Upper brachial plexus nerve transfers under wide awake anesthesia (WALANT)- surgical technique.

Background: Upper brachial plexus injuries often necessitate complex nerve transfers, which are traditionally performed under general anesthesia (GA). In patients with polytrauma or significant comorbidities, GA may present additional perioperative risks. The Wide Awake Local Anesthesia No Tourniquet (WALANT) technique offers a potential alternative by enabling nerve transfers under local anesthesia with real-time patient feedback and without the need for sedation or airway management. Methods: We describe the application of the WALANT technique in a 15-year-old male patient with a C5-C6 brachial plexus avulsion injury. The procedure involved the use of diluted lidocaine with epinephrine for regional infiltration in the supraclavicular and upper arm regions, followed by three targeted nerve transfers: ulnar fascicle to musculocutaneous nerve (for elbow flexion), radial nerve branch to axillary nerve (for shoulder abduction), and spinal accessory to suprascapular nerve. The surgery was performed without sedation, allowing continuous intraoperative feedback. Results: The patient remained cooperative and comfortable throughout the procedure. Intraoperative nerve stimulation and real-time feedback facilitated precise fascicular selection and coaptation. At 6-month follow-up, the patient achieved MRC Grade 3 shoulder abduction and elbow flexion, with no donor-site deficits. EMG confirmed early reinnervation in the biceps and deltoid. Conclusions: WALANT may be a safe and effective alternative for selected cases of upper brachial plexus reconstruction, particularly in patients where general anesthesia poses additional risk. It enables accurate fascicular identification and intraoperative functional assessment while reducing recovery time and healthcare resource use. Further studies are warranted to evaluate its broader applicability and outcomes in peripheral nerve surgery. Level of evidence: IV.