Intercostal nerve transfer for elbow flexion in elderly brachial plexus injury shows limited recovery in small series

IntroductionRestoration of elbow flexion is a primary goal in the surgical management of complete traumatic brachial plexus injuries (BPIs). When proximal donor nerves are unavailable, intercostal nerve (ICN) transfer to the musculocutaneous nerve (MCN) represents a well-established reconstructive option. However, elderly patients are markedly underrepresented in published series, and outcomes in this population remain poorly defined. The objective of this study was to evaluate clinical outcomes of ICN-to-MCN transfer in elderly patients and to identify perioperative factors associated with meaningful functional recovery.MethodsA retrospective case series was conducted. Over a 30-year period, four consecutive patients aged over 60 years who underwent ICN-to-MCN transfer for complete traumatic brachial plexus avulsion were identified. Demographic characteristics, surgical timing, coaptation strategy, and functional outcomes were analyzed.ResultsElderly patients accounted for less than 1.6% of more than 250 ICN-to-MCN transfers performed during the study period. All patients were male and sustained complete brachial plexus injuries following motorcycle accidents. One patient who underwent early reconstruction within 2 months of trauma, allowing direct neurorrhaphy without grafting, achieved useful elbow flexion (M4). This patient demonstrated preserved muscle bulk, normal testosterone levels, and strong adherence to postoperative motor rehabilitation. In contrast, delayed surgery beyond 5 months, particularly when nerve grafts were required, resulted in limited or absent recovery (M0–M2).ConclusionsICN-to-MCN transfer remains a viable reconstructive option in carefully selected elderly patients. Favorable outcomes are influenced by modifiable factors, particularly earlier reconstruction, feasibility of tension-free coaptation, preserved muscle quality, and structures postoperative rehabilitation. While chronological age alone should not be considered a contraindication, the therapeutic window for successful nerve transfer is substantially narrower in older individuals.