Recovery of Elbow Flexion After Intercostal Nerve Transfer in Older Adults
Overview
This retrospective case series evaluated outcomes of intercostal nerve (ICN) to musculocutaneous nerve (MCN) transfer in four elderly patients (≥60 years) with complete brachial plexus injuries. Early surgery within 2 months enabling direct coaptation yielded meaningful elbow flexion recovery, whereas delayed reconstruction beyond 5 months with grafting resulted in poor outcomes.
Background
Restoration of elbow flexion is critical in managing complete traumatic brachial plexus injuries, especially when proximal donor nerves are unavailable. ICN-to-MCN nerve transfer is a well-established technique to reinnervate the biceps muscle. However, elderly patients are underrepresented in outcome studies, and the impact of aging on nerve transfer success remains unclear. This study addresses this gap by analyzing clinical outcomes and perioperative factors influencing recovery in patients aged 60 years and older.
Data Highlights
Patient
Age
Time to Surgery
Coaptation Strategy
Elbow Flexion Outcome (MRC Grade)
1
>60
<2 months
Direct neurorrhaphy (no graft)
M4 (useful elbow flexion)
2-4
>60
>5 months
With nerve graft
M0–M2 (limited/absent recovery)
Key Findings
Elderly patients represented less than 1.6% of over 250 ICN-to-MCN transfers performed.
All patients were male with complete brachial plexus avulsion from motorcycle accidents.
Early reconstruction within 2 months allowed direct tension-free coaptation and resulted in M4 elbow flexion strength.
Delayed surgery beyond 5 months, requiring nerve grafts, was associated with poor functional recovery (M0–M2).
Preserved muscle bulk, normal testosterone levels, and adherence to rehabilitation correlated with better outcomes.
Chronological age alone should not contraindicate ICN-to-MCN transfer, but the therapeutic window narrows with age.
Clinical Implications
Clinicians should consider early surgical intervention for elderly patients requiring ICN-to-MCN transfer to maximize functional recovery. Direct tension-free nerve coaptation without grafting is preferable when feasible. Careful patient selection including assessment of muscle quality and commitment to postoperative rehabilitation is essential to optimize outcomes in this population.
Conclusion
ICN-to-MCN transfer remains a viable reconstructive option for restoring elbow flexion in selected elderly patients. Early surgery and modifiable perioperative factors significantly influence the likelihood of meaningful functional recovery.
References
Clinical Experience Overview, 2024 -- Recovery of Elbow Flexion Following Intercostal Nerve Transfer in Older Adults
