Motor Nerve Transfers in Complete and Incomplete Brachial Plexus Injuries: A State-of-the-Art Review
Round 1
Reviewer 1 Report
Comments and Suggestions for AuthorsDear Authors,
The subject of the manuscript in very interesting
The manuscript is defined as a "state-of-the-art review", but does not describe any literature search strategy. The authors do not specify how they searched, nor the databases consulted (PubMed, Embase, Cochrane, etc.).
The search keywords are not mentioned, nor the time interval studied. The inclusion/exclusion criteria or the total number of articles identified and included are not known.
I consider it necessary to add "Materials and Methods" and "Discussion" sections
The comparison of functional outcomes with the surgical techniques used is not discussed as regards surgery, the timing of its indication, the effects of performing the surgery or its timing are not discussed the discussion of functional outcomes and comparison of techniques
Authors should also pay attention to the instructions for authors regarding manuscript writing
Best regards
Author Response
Dear Reviewer #1,
We sincerely thank you for your constructive comments and for highlighting several important aspects that significantly improved the quality and clarity of our manuscript. We carefully revised the manuscript according to your suggestions, and the modifications are detailed below.
Comment 1: “The manuscript is defined as a ‘state-of-the-art review’, but does not describe any literature search strategy. The authors do not specify how they searched, nor the databases consulted (PubMed, Embase, Cochrane, etc.). The search keywords are not mentioned, nor the time interval studied. The inclusion/exclusion criteria or the total number of articles identified and included are not known.”
Response 1: We thank the Reviewer for this important observation. To address this concern, we added a detailed “Materials and Methods” section describing the methodology of the review in a comprehensive and transparent manner. Specifically, we now report:
- the databases consulted (PubMed/MEDLINE, Embase, Cochrane Library, Scopus, and Web of Science);
- the literature search strategy and the main keywords used;
- the time interval considered;
- the inclusion and exclusion criteria adopted;
- the study selection process.
In addition, we included a PRISMA flowchart illustrating the screening and selection process of the studies, as well as a summary table showing the distribution of the included articles according to the different reconstructive subgroups discussed in the review.
We believe that these additions substantially improved the methodological transparency and reproducibility of the manuscript.
Comment 2: “I consider it necessary to add ‘Materials and Methods’ and ‘Discussion’ sections.”
Response 2: We added both a dedicated “Materials and Methods” section and a comprehensive “Discussion” section, together with a final “Conclusions” section.
The newly added Discussion critically summarizes the evolution of nerve transfer strategies in brachial plexus injury reconstruction, highlighting:
- the progressive shift from proximal nerve reconstruction toward selective distal neurotization;
- the increasing role of intraplexal nerve transfers;
- the current indications for extraplexal donor nerves;
- the persistent limitations in distal functional reconstruction, particularly regarding intrinsic hand function;
- the heterogeneity and limitations of the currently available literature.
We also discussed future perspectives and ongoing challenges in the field of motor nerve transfer surgery.
Comment 3: “The comparison of functional outcomes with the surgical techniques used is not discussed as regards surgery, the timing of its indication, the effects of performing the surgery or its timing are not discussed the discussion of functional outcomes and comparison of techniques.”
Response 3: We expanded the “Discussion” section by including additional considerations regarding functional outcomes and the evolution of surgical strategies described in the literature. In particular, we discussed:
- the rationale behind the increasing preference for distal intraplexal nerve transfers over proximal reconstruction techniques;
- the impact of regeneration distance and surgical timing on functional outcomes;
- the relative advantages and limitations of intraplexal versus extraplexal donor strategies;
- the modern “function-oriented” reconstructive approach based on patient-specific functional priorities;
- the persistent challenges associated with reliable restoration of intrinsic hand function.
However, we would like to emphasize that the primary aim of the present review was not to perform a comparative meta-analysis of surgical outcomes or establish the superiority of specific techniques, but rather to provide a comprehensive and structured overview of the currently available motor nerve transfer strategies described in the literature. Due to the substantial heterogeneity among the included studies, variability in outcome measures, and inconsistent follow-up durations, a standardized quantitative comparison between techniques was not feasible.
Comment 4: “Authors should also pay attention to the instructions for authors regarding manuscript writing.”
Response 4: We thank the Reviewer for this observation. We carefully revised the manuscript structure, formatting, and organization in accordance with the journal’s Instructions for Authors. In particular, we added the required methodological sections and improved the overall clarity and consistency of the manuscript.
We would like to sincerely thank the Reviewer again for the insightful comments and suggestions, which greatly contributed to improving the quality, clarity, and scientific rigor of our manuscript.
Reviewer 2 Report
Comments and Suggestions for Authorsoverall well written in a structured aooroach
more represntation of state of art review book chapter rather tha systematic review.
section 3 - spelling - should be winging of scapula
Best to give some evidence of PROM based papers - intraplexal vs extraplexal
Author Response
Dear Reviewer #2,
We sincerely thank you for your positive evaluation of our manuscript and for your constructive suggestions. We carefully considered all your comments and revised the manuscript accordingly.
Comment 1: “Overall well written in a structured approach.”
Response 1: We sincerely appreciate the Reviewer’s positive feedback regarding the structure and overall quality of the manuscript.
Comment 2: “More representation of state-of-the-art review book chapter rather than systematic review.”
Response 2: We agree that the manuscript was originally conceived as a comprehensive state-of-the-art overview aimed at systematically organizing currently available motor nerve transfer strategies rather than as a formal quantitative systematic review or meta-analysis.
To improve methodological clarity and better align the manuscript with review standards, we substantially revised the manuscript by adding a dedicated “Materials and Methods” section, explicitly describing the literature search strategy, databases consulted, inclusion and exclusion criteria, and study selection process according to PRISMA guidelines. We also included a PRISMA flowchart and summary tables to improve transparency and reproducibility.
We believe these modifications better clarify the scope and methodological framework of the present review.
Comment 3: “Section 3 - spelling - should be winging of scapula.”
Response 3: We thank the Reviewer for identifying this typographical error. The spelling has been corrected accordingly throughout the manuscript.
Comment 4: “Best to give some evidence of PROM based papers - intraplexal vs extraplexal.”
Response 4: We appreciate the Reviewer’s valuable suggestion regarding patient-reported outcome measures (PROMs). We agree that PROM-based comparisons between intraplexal and extraplexal nerve transfer strategies represent an important and clinically relevant topic.
However, the primary objective of the present review was to provide a comprehensive anatomical and surgical overview of currently available donor–recipient motor nerve transfer strategies for upper-limb reinnervation in brachial plexus injuries, rather than to perform a comparative outcome-based analysis. Given the considerable heterogeneity of the available literature, including differences in outcome measures, surgical indications, follow-up duration, and reporting methods, we considered a focused PROM-based comparison to be beyond the intended scope of the current manuscript.
Nevertheless, we acknowledge the importance of functional and patient-reported outcomes in evaluating reconstructive success and have further emphasized in the Discussion section the need for future studies with standardized outcome reporting and higher-quality comparative evidence.
We sincerely thank the Reviewer again for the helpful comments and suggestions, which contributed to improving the clarity and overall quality of the manuscript.
Reviewer 3 Report
Comments and Suggestions for AuthorsThis ia a chapter in a book, not a review paper.
The essentials of review paper are not present.
No aim of work, no methodology and no results.
Author Response
Dear Reviewer #3,
We sincerely thank you for your comments and for highlighting important methodological aspects of the manuscript. We carefully revised the article in response to your observations, and the modifications are detailed below.
Comment 1: “This is a chapter in a book, not a review paper.”
Response 1: The manuscript was originally conceived as a comprehensive state-of-the-art overview intended to systematically organize the currently available motor nerve transfer strategies for upper-limb reconstruction in brachial plexus injuries. We acknowledge that the initial version lacked several structural elements typically expected in a review article.
To address this concern, we substantially revised the manuscript by incorporating the essential methodological components of a structured review. In particular, we added dedicated “Materials and Methods,” “Discussion,” and “Conclusions” sections, together with a PRISMA flowchart and summary tables, in order to improve methodological transparency and overall scientific structure.
We believe these revisions have significantly strengthened the manuscript and better aligned it with the standards of a review paper.
Comment 2: “The essentials of review paper are not present.”
Response 2: We thank the Reviewer for this important comment. In response, we comprehensively revised the manuscript to include the key elements required for a review article. Specifically, we added:
- a clearly defined aim of the study in the Introduction;
- a detailed “Materials and Methods” section describing:
- the databases consulted,
- the search strategy and keywords,
- the inclusion and exclusion criteria,
- the study selection process;
- a PRISMA flowchart illustrating article identification and screening;
- summary tables organizing the included studies according to reconstructive targets and donor-recipient strategies;
- a structured “Discussion” section critically summarizing the current literature and its limitations;
- a final “Conclusions” section.
These additions were specifically intended to improve the methodological rigor, clarity, and reproducibility of the review.
Comment 3: “No aim of work, no methodology and no results.”
Response 3: The revised manuscript now clearly states the aim of the work in the Introduction, namely to provide a comprehensive state-of-the-art overview of currently available motor nerve transfer strategies for upper-limb reinnervation in brachial plexus injuries.
In addition, we introduced a dedicated “Materials and Methods” section detailing the review methodology according to PRISMA principles, including databases searched, search terms, eligibility criteria, and study selection procedures.
We also added a Results section summarizing the number and types of included studies and categorizing the reconstructive strategies according to recipient nerve and functional target. These data are further illustrated through the PRISMA flowchart and supplementary summary tables.
We believe that these revisions have substantially improved the scientific structure and completeness of the manuscript.
We sincerely thank the Reviewer again for the constructive criticism, which helped us significantly improve the quality, organization, and methodological rigor of the manuscript.
Round 2
Reviewer 1 Report
Comments and Suggestions for AuthorsDear Authors,
The authors followed the review's recommendations
Best regrads,
