The Rise of Nerve Transfers: Tracing a National Evolution Toward the Postgrafting Era in Brachial Plexus Injury Management.

Abstract

Nerve transfers have been heralded as a "quantum leap" in peripheral nerve surgery, fundamentally altering the reconstructive paradigm over the past 2 decades. This study analyzed national trends in adult traumatic brachial plexus injury (BPI) management, tracking specialty-specific adoption of nerve transfers and comparing 30-day postoperative outcomes with traditional reconstruction. Data were extracted from the National Surgical Quality Improvement Program (2006 to 2022). Adult patients (18 years or older) with a primary BPI diagnosis, who underwent nerve reconstruction, were included. Cases were categorized by the presence of a nerve transfer using CPT code 64905. Analyses included descriptive statistics, standardized mean differences, and multivariable logistic regression. Among 544 BPI patients, 80 underwent reconstruction involving a nerve transfer. Plastic surgeons performed 60% of nerve transfers despite accounting for only 33.5% of all BPI reconstructions. Neurosurgeons had the lowest overall nerve transfer utilization but increased to a rate matching orthopedic surgeons in the final 4 years. Nerve transfers were associated with lower 30-day complication rates than traditional reconstruction (2.5% vs. 11%, P=0.034), despite being performed on patients with higher preoperative morbidity risk. In multivariable analysis, orthopedic and neurosurgeons remained significantly less likely than plastic surgeons to perform nerve transfers (OR: 0.26, P<0.001; OR: 0.18, P<0.001, respectively). Nerve transfer use in BPI reconstruction has increased steadily, with a recent increase among neurosurgeons. Despite being used in higher-risk patients, nerve transfers were associated with significantly lower short-term complication rates. These findings support continued adoption of nerve transfers and highlight their favorable safety profile.