Priorities of Treatment and Rationale (Babies Are Not Small Adults)

Brachial plexus birth injuries (BPBI) occur at a rate of 1–3 per 1000 live births. Most injuries recover spontaneously without permanent sequelae; however, about one third of patients will have lifelong lasting deficits (Malessy, Neurosurg Clin NA 20:1–14, 2009). The most severely injured infants will require primary nerve surgery to restore innervation of the arm. Global or total injuries require earlier surgery compared to upper and/or middle trunk lesions. The principal surgical techniques are nerve grafting and nerve transfers (Kozin, Nerve repair manual. Checkpoint Surgical, Beachwood, 2016). Nerve grafting requires neuroma excision back to proximal and distal viable fascicles followed by cable grafting. Nerve transfer utilizes a donor nerve that is available and expendable, which is transferred to a recipient nerve in need of axons to achieve the desired function (Clarke et al, IFSSH ezine 5:17–25, 2015). This chapter will focus on primary nerve surgery for BPBI. We acknowledge that there are multiple controversial topics regarding BPBI from diagnosis to treatment strategies. We recognize that this chapter, while informed by the collective wisdom of the plexus community, still may reflect our own center’s biases and experience.