Long-term results of multiple muscle transfer to reconstruct shoulder function in patients with birth palsy: eleven-year follow-up

We evaluated the long-term clinical results of multiple muscle transfer for reconstruction of shoulder function in 10 patients with birth palsy. Multiple muscle transfer consists mainly of Harmon's deltoid shift, Ober's biceps muscle transfer, and Hoffer's latissimus dorsi muscle transfer. The follow-up ranged from 5 to 14 years with an average of 10.5 years. Two of the 10 patients showed no improvement, one due to severely atrophied latissimus dorsi muscle, and the other who had not received Hoffer's latissimus dorsi muscle transfer. Except for these two patients, an averaged flexion and external angles were 114 degrees and 25 degrees, respectively. Harmon's deltoid shift and Hoffer's latissimus dorsi muscle transfer for reconstruction of shoulder function in patients with birth palsy have proven to be a useful method in reconstructing and maintaining the function of active elevation and external rotation of the shoulder.

Shoulder reconstruction in patients with chronic brachial plexus birth palsy. A case control study

Patients with chronic brachial plexus birth palsy and persistent peripheral neurologic deficits frequently have problems related to their shoulder. Specifically, internal rotation and adduction contractures develop because of the loss of muscle balance about the glenohumeral joint. With time, progressive and predictable deformity of the glenohumeral joint occurs. The authors reviewed their results in treating patients with persistent functional deficits with either soft tissue procedures (tendon transfers and muscle releases) or rotational humeral osteotomies based on criteria incorporating patient age and degree of glenohumeral deformity. Patients in each group were evaluated prospectively and compared with each other. In all cases, patients in both groups experienced substantial improvements in global shoulder function. In the patients in the tendon transfer group, global Mallet scores improved from an average of 9.5 to 15.6. Patients undergoing humeral osteotomies also had improvements in global Mallet score from an average of 9.5 to 15.1. This study confirms that both operations, when appropriately applied, will predictably improve shoulder function.

Comparison of the natural history, the outcome of microsurgical repair, and the outcome of operative reconstruction in brachial plexus birth palsy

BACKGROUND

The purposes of this study were to document the natural history of brachial plexus birth palsy, in relation to the recovery of biceps function, in the first six months of life; to assess the outcome after microsurgical repair of the brachial plexus in patients who had no recovery of biceps function at six months; and to compare the results of transfer of the latissimus dorsi and teres major tendons with the results of derotation osteotomy of the humerus and to compare the results of the tendon transfers and the osteotomy with the natural history of the disorder.

METHODS

Sixty-six patients (sixty-seven lesions) who had brachial plexus birth palsy were seen for an initial evaluation when they were less than three months old. The time of recovery of biceps function was recorded for each month of life for six months from the date of birth. The patients were divided into groups according to the month of life during which recovery of biceps strength was noted. A physical examination and an assessment with use of the functional criteria of Mallet were performed each month. Microsurgical repair of the brachial plexus was performed in six infants who had no evidence of biceps function within the first six months of life. Another group of twenty-seven patients were referred for evaluation of chronic neuropathy after they were six months old. A transfer of the latissimus dorsi and teres major tendons to the rotator cuff was performed in nine of these patients and a derotation osteotomy of the humerus was performed in seven because of an internal rotation contracture or functional weakness of the external rotators of the shoulder.

RESULTS

Twenty-two infants had recovery of biceps function within the first three months of life and had normal function at the time of the latest evaluation. Infants who had recovery of biceps function during the fourth, fifth, or sixth month of life later had significantly worse function, according to the criteria described by Mallet, than those who had had recovery in the first three months (p<0.005). The clinical results for the six patients who had had microsurgical repair six months after birth were significantly better (p<0.04) than those for the fifteen patients who had had recovery of biceps function in the fifth month of life. However, the results for the patients who had had repair of the brachial plexus were not found to be better than those for the eleven patients who had had recovery of biceps function in the fourth month of life. The improvement in function, as assessed with use of the Mallet criteria, after tendon transfer (p<0.001) and humeral osteotomy (p<0.0001) was significant.

CONCLUSIONS

The present study confirms the observation of Gilbert and Tassin that it is rare for infants who have recovery of biceps function after the age of three months to have complete neurological recovery. Microsurgical repair was effective in improving function in the small subgroup of patients who had no evidence of recovery of biceps function within the first six months of life.

[Electrophysiological criteria for selection of operative procedure in the treatment of late incomplete obstetrical palsy]

OBJECTIVE

Using electrophysiological method to evaluate the severity of incomplete obstetric paralysis brachial plexus injuries, and establish an electrophysiological criteria for selection of operative procedure in the treatment of cases of late stage.

METHODS

Neurolysis was performed in 16 patients, and during the operation, the neuroma at the upper trunk was discovered. The electrophysiological study was carried out before and during operation to evaluate the conducting function of neuroma. In the follow-up the operative result was analysed by Mallet test.

RESULTS

The preoperative study showed that the compound muscular active potential (CMAP) amplitude of supraspinatus deltoid and biceps were decreased more than 60% in comparison with that of the healthy side. After external neurolysis of the neuroma, by stimulation of the proximal and distal ends of the neuroma the average decrease of CMAP amplitude of the above three muscles was 37.45% +/- 20.97%, 47.85% +/- 26.23%, 47.05% +/- 21.23%, respectively and no significant improvement was observed in the shoulder and elbow function in all of the 16 cases.

CONCLUSION

When the preoperative electrophysiological study found that the CMAP amplitude decreased more than 60% in comparison with that of the healthy side, transposition of nerve or nerve grafting was indicated.

Perinatally acquired brachial plexus palsy--a persisting challenge

The aim of this investigation was to study the contemporary pattern of perinatally acquired brachial plexus palsy (BPP) in Sweden. National incidence data were collected from the Swedish Medical Birth Registry. The clinical pattern of BPP was studied in the county of Skaraborg. All children (n = 52) with confirmed neonatal BPP in 1981-89 were assessed 4-14 y after birth using routine neonatal and follow-up documentation for retrospective analysis and an assessment battery for the clinical evaluation of impairment. The mothers' recollection of the birth process was recorded by interview and compared with two control groups. The incidence of BPP in Sweden increased significantly from 1.4 per mill in 1980 to 2.3 per mill in 1994. The incidence was 45 times higher at a birthweight of > 4500 g than at a birthweight of < 3500 g. Fifty percent had a birthweight exceeding the mean +2 SD. In the Skaraborg series, half the children had normalized arm-hand function after 6 months (mean) and half had stationary impairment from 15 months (mean). Twenty-two percent of the children had severe stationary impairment of arm-hand function according to the criteria. There was no correlation between birthweight and the level of impairment. One-third of the newborn infants with BPP had neonatal care related to the difficult birth process and perinatal distress. The mothers of the children recalled the birth process as being difficult or very difficult in 77% compared with 20 and 27%, respectively, in the two control groups. This population-based investigation has revealed an unexpected increase in BPP in Sweden and has confirmed that BPP continues to be a significant cause of motor handicap in children.

Outcome of surgically treated birth-related brachial plexus injuries in twenty cases

Birth-related brachial plexus injury occurs in 0.19-2.5 per 1,000 live births, of which 70-92% improve with conservative management. With the advent of microsurgical techniques, patients who fail expectant treatment may benefit from brachial plexus exploration and reconstruction. From 1991 to 1996, 87 patients were referred to the multidisciplinary brachial plexus clinic at St. Louis Children's Hospital. Twenty patients were selected for surgical management. The average age at surgery was 10.5 months (range 3-35, median = 8), with an average follow-up of 23.9 months (range 7-45, median = 24). Two patients were lost to follow-up. Surgical procedures included neurolysis (n = 8), neurotization (n = 2), nerve grafting (n = 5), and a combination (n = 3) of the above. Two patients underwent exploration without repair. Intercostal nerves, pectoral nerves, and C4 roots were used for neurotizations, and the sural nerve was used for nerve grafting. Results from 18 patients were available for follow-up review. Fifteen patients (83% demonstrated clinical improvement postoperatively. Of the 3 patients without improvement, 2 underwent exploration without repair, and one underwent neurolysis of the axillary nerve. Of patients undergoing reconstruction, 93% had improved strength postoperatively. No subjects had worsening neurologic status, and there were no complications. These results suggest that surgery for birth-related brachial plexus injury may show favorable outcomes if patients are selected appropriately. Patients undergoing neurolysis and nerve grafting had more favorable outcomes than those undergoing neurotization.

Obstetrical brachial plexus palsy: results following neurolysis of conducting neuromas-in-continuity

Sixteen infants with conducting neuromas-in-continuity at primary brachial plexus exploration underwent microsurgical neurolysis of their lesions. For each patient, the immediate preoperative scores for individual joint movements were compared with scores at the last examination. In the Erb's palsy group (n = 9), significant improvement was seen in shoulder movements, elbow flexion, supination, and wrist extension (paired t test, p < 0.05). Clinically useful improvements in function was seen at the shoulder and elbow (Fisher's exact test, p < 0.05). In the total palsy group (n = 7), significant improvement in shoulder abduction, shoulder adduction, elbow flexion, and extension of the wrist, fingers, and thumb was seen (paired t test, p < 0.05), but there was no significant improvement in the proportion of patients with useful functional outcomes. Neurolysis in Erb's palsy improves both muscle grade and the functional ability of patients. Neurolysis does not provide useful functional recovery in patients with total plexus palsy.

Obstetric brachial plexus palsy

In a retrospective survey of 46 conservatively treated patients with obstetric brachial plexus palsy (OBPP) the following conclusions were reached. An immediate examination of the neurological status of the neonate root by root is essential for proper analysis of the course of the recovery. Mild cases with C5-C6 root injury (Erb's palsy) have a good outcome and may be treated conservatively. Intermediate cases with C5-C7 root injury with additional drop hand require close observation as early as age 3 weeks when the first electromyographic (EMG) examination is indicated. The second EMG should be performed at age 11-12 weeks. If the function of the brachial biceps muscle is lacking at age approximately 12 weeks (3 months), microsurgical intervention should be considered; such intervention definitely is required at age 5 months if the paresis in the brachial biceps muscle has not recovered. Severe cases with C5-C8 or C5-Th1 root injuries with flaccid abducted arm, wrist drop, claw hand, and possibly head tilt to the contralateral side and Horner's sign should be operated on primarily at age 1-2 months.

Palliative surgical procedures to restore shoulder function in obstetric brachial palsy. Critical analysis of Narakas' series

Dr. Narakas intended to study a series of 61 cases of shoulder sequelae of obstetric palsy. His vast experience would have enriched our clinical knowledge of this ailment. The authors carry on with that study to clarify his therapeutic approach and share the benefit of his experience.

Obstetrical palsy: early treatment and secondary procedures

Obstetrical palsy has been described since a long time. Unfortunately, until the last 20 years, few options were available to correct its sequelae. During the last two decades, there has been a regain of interest because of the possibility to microsurgically repair these lesions. Tassin in 1984 demonstrated that babies who have no recovery of the biceps function by three months of age should be operated without delay. At brachial plexus exploration, in the presence of neuroma, nerve grafting is usually necessary. In cases of root avulsion, internal or external neurotization should be performed depending on the severity of the lesions. Physiotherapy and long-term follow-up of these patients are primordial to prevent joint ankylosis and to identify the patients who will benefit from secondary surgery. Our results are presented either after early treatment or after secondary procedures. These results justify aggressive management of obstetrical brachial plexus palsy because of children's great capacity for regeneration and accommodation.

An approach to obstetrical brachial plexus injuries

The approach of one clinic to the early evaluation of the infant with an obstetrical brachial plexus palsy has been presented. The need for a reproducible and standardized grading system has been identified. The natural history of these lesions will be better understood as further studies elucidate key principles. The final goals are the precise prognostication of natural outcome and the early prediction of the need for surgical intervention.

Long-term evaluation of brachial plexus surgery in obstetrical palsy

The author reviews the long-term results of a large series of obstetrical brachial plexuses. The results of direct repair and secondary tendon transfers are reviewed.

The natural history of obstetrical brachial plexus palsy

Obstetrical brachial plexus palsy remains an unfortunate consequence of difficult childbirth. Sixty-six such patients were reviewed. Included were 28 patients (42 percent) with upper plexus involvement and 38 (58 percent) with total plexopathy. The natural history of spontaneous recovery in all of these patients has been determined using an appropriate grading mechanism. Sixty-one patients (92 percent) recovered spontaneously and five patients (8 percent) required primary brachial plexus exploration and reconstruction (median age 12 months), demonstrating that most patients do well. Additional analysis was undertaken to examine ways in which outcome might be predicted. The analysis does not consider whether or not the patient was operated upon. Good or poor recovery was determined by the spontaneous recovery observed. Discriminant analysis revealed that whereas elbow flexion at 3 months correlated well with spontaneous recovery at 12 months, when used as a single parameter it incorrectly predicted recovery in 12.8 percent of cases. Shoulder abduction was not a significant predictor of recovery. Numerous other early parameters correlated well with spontaneous recovery. When elbow flexion and elbow, wrist, thumb, and finger extension at 3 months were combined into a test score, the proportion of patients whose recovery was incorrectly predicted was reduced to 5.2 percent.

A case of neonatal spinal cord injury: magnetic resonance imaging and somatosensory evoked potentials

This is the first case report on the diagnosis of spinal cord injury due to hemorrhage during the neonatal period using magnetic resonance imaging (MRI). Somatosensory evoked potentials are also helpful in the functional demonstration of this lesion. When discrepant signs, alert consciousness and intact cranial nerves are observed in newborn babies with flaccid extremities and respiratory disturbance, the immediate carrying out of MRI is mandatory in order to differentiate spinal cord injury from hypoxic-ischemic encephalopathy, cerebral hemorrhage, and neuromuscular disease.

Palliative surgical procedures in sequelae of obstetric palsy

The authors present 28 years of combined experience with reconstructive surgery for the different sequelae of obstetric palsy. The sequelae have been classified to indicate in each case the most adequate surgical procedure.

[Clinical study of cross-reinnervation in obstetrical paralysis]

It is known that cross-reinnervation occurs when regenerating nerve fibers recombine in brachial plexus injury, especially in obstetrical paralysis. This cross-reinnervation causes abnormal contraction in many muscles simultaneously during voluntary movement. To date, however, little has been reported on its pathophysiology, severity and prognosis. In order to clarify these problems, 362 cases of obstetrical paralysis were studied clinically and electromyographically, and abnormal muscle contractions during voluntary movement were analyzed. The results are as follows; Cross-reinnervation is seen in most cases which have suffered from transection or severe injury near the transection of the nerve fibers (including that in the neural tube), and which have got recovery better than manual muscle testing grade (2) "poor". Cross-reinnervation is caused by cross-reinnervation of nerve fibers which regenerate in the wrong muscles. Muscle contraction occurring in many muscles simultaneously is different from co-ordinate movement. Other paradoxical muscle action is found besides that of contraction. Cross-reinnervation can be classified into the following types by the muscle groups showing the contraction. Deltoid m., biceps brachii m. type, Deltoid m., biceps brachii m., triceps brachii m. type, Biceps brachii m., triceps brachii m. type, Deltoid m., biceps brachii m., triceps brachii m., forearm mm. type, Deltoid m., biceps brachii m., forearm mm. type, Biceps brachii m., triceps brachii m., forearm mm. type, Triceps brachii m., forearm mm. type. Abnormal muscle activity caused by cross-reinnervation is found from 4-6 months after nerve recovery from Wallerian degeneration, and it does not improve, but physical therapy or operative treatment can bring improvement in daily activities. Clinical severity of cross-reinnervation is correlated to the severity of paralysis and in proportion to the ratio of normally recovered nerve fibers and cross-reinnervated nerve fibers. It suggests that cross-reinnervation is caused by the discordant recovery from injury of nerve fibers in the brachial plexus. The site of cross-reinnervation depends on the severity of paralysis. Usually it spreads from the 5th and 6th cervical nerve roots to the upper trunk, medial trunk, posterior cord and lastly to the lower trunk and medial cord, determined by the severity of paralysis. This agrees with the way of spreading of obstetrical paralysis.

Birth palsy: natural recovery course and combined root avulsion

Seventy-six patients with birth palsy were reviewed for type of palsy and mode of delivery. High incidences of root avulsion associated with lesser birth weight were identified in patients of breech deliveries. In 15 patients with serial neurological assessment for more than 5 years, the natural recovery course was evaluated, based on the assessment of particular key muscle and dermatomes mainly innervated by single nerve roots. Rapid and useful motor recovery was observed in upper-type palsy and the upper root levels (C5 and C6) of whole-type palsy, while poor prognosis of motor function was demonstrated in the lower root levels (C8 and D1) of whole-type palsy. Recovery of sensory function was far more predominant than recovery of motor function. Of 12 patients with root avulsion, 10 patients (27 avulsed roots) over 5 years of age were neurologically assessed. Of avulsed roots, 70.4% had useful sensory recovery and 33.3% had useful motor recovery. The patho-mechanism of those with a good prognosis in root avulsion of birth palsy is discussed, based on the findings of this series.

Dynamic properties of partially denervated muscle in children with brachial plexus birth palsy

Contraction time, time to peak rate of tension development, half-relaxation time and maximum twitch tension of partially denervated flexor carpi ulnaris muscle were measured in children with brachial plexus birth palsy. The extent of weakness of the affected muscle was assessed by expressing its maximum twitch tension as a percentage of the tension of the contralateral normal muscle. Contraction time, time to peak rate and half-relaxation time were prolonged in children with severe weakness, while in children with moderate weakness only half-relaxation time was prolonged. The contralateral normal flexor carpi ulnaris muscle showed age differences in its contractile properties, while in the affected muscle such differences were not found. This result suggests that denervation at birth impairs normal development of muscle contractile properties.

Biceps tendon rerouting and percutaneous osteoclasis in the treatment of supination deformity in obstetrical palsy

Paralytic supination deformity of the forearm, secondary to obstetrical palsy, was treated by biceps tendon rerouting in 11 children. In two patients additional pronation was obtained by subsequent percutaneous osteoclasis and rotation of the radius and ulna. Correction of the supination deformity resulted in improvement of single-handed as well as two-handed activities in all patients.