Controversies in NTOS: What Is the Evidence Supporting Brachial Plexus Neurolysis and Wrapping

The motor and sensory deficits of NTOS may be due in part to neurologically active, fibrotic tissue surrounding the brachial plexus. The pathophysiologic mechanism behind the formation of this tissue begins with an inciting traumatic event or repetitive mechanical tension leading to an inflammatory environment promoting Schwann cell activation and neural ingrowth. Surgical treatment of NTOS should target this fibrotic tissue and includes brachial plexus neurolysis as well as human amnion membrane wrapping. To date, no significant randomized controlled trials or large retrospective studies have been performed to assess their efficacy in the NTOS population. However, treatment of athletes with NTOS, recurrent NTOS patients, and those with traumatic brachial plexus injuries has included brachial plexus neurolysis and shows promising results. Wrapping with human amnion membrane has been proven to decrease the formation of scar tissue in animal models. Small series involving neurolysis and wrapping of peripheral nerves in entrapment syndromes have also shown positive results. Human amnion wrapping is currently being employed in the treatment of at least 100 NTOS patients, and 1 year results have revealed a significant decrease in rates of recurrence.