Obstetric brachial plexus palsy: reviewing the literature comparing the results of primary versus secondary surgery

Brain plasticity in neonatal brachial plexus palsies: quantification and comparison with adults' brachial plexus injuries

PURPOSE

To compare two populations of brachial plexus palsies, one neonatal (NBPP) and the other traumatic (NNBPP) who underwent different nerve transfers, using the plasticity grading scale (PGS) for detecting differences in brain plasticity between both groups.

METHODS

To be included, all patients had to have undergone a nerve transfer as the unique procedure to recover one lost function. The primary outcome was the PGS score. We also assessed patient compliance to rehabilitation using the rehabilitation quality scale (RQS). Statistical analysis of all variables was performed. A p ≤ 0.050 set as criterion for statistical significance.

RESULTS

A total of 153 NNBPP patients and 35 NBPP babies (with 38 nerve transfers) met the inclusion criteria. The mean age at surgery of the NBPP group was 9 months (SD 5.42, range 4 to 23 months). The mean age of NNBPP patients was 22 years (SD 12 years, range 3 to 69). They were operated around sixth months after the trauma. All transfers performed in NBPP patients had a maximum PGS score of 4. This was not the case for the NNBPP population that reached a PGS score of 4 in approximately 20% of the cases. This difference was statistically significant (p < 0.001). The RQS was not significantly different between groups.

CONCLUSION

We found that babies with NBPP have a significantly greater capacity for plastic rewiring than adults with NNBPP. The brain in the very young patient can process the changes induced by the peripheral nerve transfer better than in adults.

Virtual Reality for Upper Limb Rehabilitation in Patients With Obstetric Brachial Palsy: Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Obstetric brachial palsy (OBP) is a pathology caused by complications during childbirth because of cervical spine elongation, affecting the motor and sensory innervation of the upper limbs. The most common lesion occurs on the C5 and C6 nerve branches, known as Erb-Duchenne palsy. The least common lesion is when all nerve roots are affected (C5-T1), which has the worst prognosis. Virtual reality (VR) is commonly used in neurological rehabilitation for the evaluation and treatment of physical deficits.

OBJECTIVE

This systematic review aims to assess the efficacy of VR in the rehabilitation of upper limb function in patients with OBP.

METHODS

A search was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2020 guidelines in several scientific databases-PubMed, Web of Science, PEDro, Cochrane, MEDLINE, Scopus, and CINAHL-without language or date restrictions and including articles published up to April 2023. The inclusion criteria were established according to the population, intervention, comparison, outcome, and study (PICOS) design framework: children aged <18 years diagnosed with OBP, VR therapy used in addition to conventional therapy or isolated, VR therapy compared with conventional therapy, outcomes related to OBP rehabilitation therapy, and randomized controlled trials (RCTs). The PEDro scale was used to assess the methodological quality of the RCTs, and the Cochrane Collaboration tool was used to assess the risk of bias. The Review Manager statistical software (version 5.4; The Cochrane Collaboration) was used to conduct the meta-analysis. The results were synthesized through information extraction and presented in tables and forest plots.

RESULTS

In total, 5 RCTs were included in this systematic review, with 3 (60%) providing information for the meta-analysis. A total of 138 participants were analyzed. All the studies used semi-immersive or nonimmersive VR systems. The statistical analysis showed no favorable results for all outcomes except for the hand-to-mouth subtest of the Mallet scoring system (functional activity; standardized mean difference -0.97, 95% CI -1.67 to -0.27; P=.007).

CONCLUSIONS

The evidence for the use of VR therapy for upper limb rehabilitation outcomes in patients with OBP was insufficient to support its efficacy and strongly recommend its use. Nevertheless, scientific literature supports the use of VR technologies for rehabilitation as it provides several advantages, such as enhancing the patient's motivation, providing direct feedback, and focusing the patient's attention during the intervention. Thus, the use of VR for upper limb rehabilitation in patients with OBP is still in its first stages. Small sample sizes; limited long-term analysis; lack of testing of different doses; and absence of International Classification of Functioning, Disability, and Health-related outcomes were present in the included RCTs, so further research is needed to fully understand the potential of VR technologies as a therapeutic approach for patients with OBP.

TRIAL REGISTRATION

PROSPERO CRD42022314264; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=314264.

Examination of Upper Extremity Length Discrepancy in Patients with Obstetric Brachial Plexus Paralysis

Since the natural course of obstetric brachial plexus palsy is variable, several problems are encountered. One important question, in considering patients with OBPP under observation in outpatient clinical settings, is whether children will have length discrepancies in their arms. The aim of this study was to determine differences in the length of the affected extremity, in comparison to the opposite upper extremity. As such, 45 patients, aged 6 months to 18 years, with unilateral brachial plexus palsy developed due to obstetric reasons, were included in the study. Affected and healthy side humerus, ulna, radius, 2nd metacarpal and 5th metacarpal lengths were evaluated according to gender, age, side, Narakas classification, primary and secondary surgery. Statistically significant differences were found in the change rates of affected/healthy humerus, radius, 2nd metacarpal and 5th metacarpal lengths according to age (93%, 95%, 92%, 90% and 90%, respectively). Affected/healthy change rates of ulna, radius, 2nd metacarpal and 5th metacarpal lengths were found to differ statistically (p < 0.05) according to the Narakas classification variable (94%, 92%, 95%, 94% and 94%, respectively). There were no statistically significant differences in the ratios of affected/healthy change in the lengths of the humerus, ulna, radius and 5th metacarpal compared to the primary surgery (p > 0.05). The ratios of affected/healthy change in ulna, radius and 5th metacarpal lengths were found to differ statistically (p < 0.05) according to secondary surgeries (93%, 91%, 91% and 92%, respectively). Joint and bone deformities and bone shortening were observed after changes that occurred in the postnatal and growing periods due to obstetric brachial plexus palsy. Every increase in function to be gained in the upper extremity musculature was also potentially able to reduce problems, such as shortness.

Long-Term Results of Microsurgical Brachial Plexus Reconstruction in Late-Presenting Cases of Brachial Plexus Birth Injury

PURPOSE

The role of primary surgery in delayed presenting cases of brachial plexus birth injury is still debated. The purpose of this study was to evaluate the results of brachial plexus reconstruction performed at the age of ≥12 months.

METHODS

Twenty-nine cases were included. Five cases had upper (C5-6) palsy, 4 had upper/middle (C5-7), and 20 had total (C5-8 and T1) palsy.

RESULTS

The age at the time of primary surgery was an average of 15.6 months. The brachial plexus was formally explored and neurolysis, grafting, and neurotization were used in different combinations. Exploration revealed that 27% of the roots were avulsed and 32% were ruptured. The follow-up was an average of 7.9 years. Generally, the best functional recovery was elbow flexion followed by shoulder external rotation. Satisfactory shoulder abduction (≥6 on the Toronto Active Movement Scale [TAMS]) was achieved in 31% of cases. The abduction range was an average of 79° ± 35°; 50° in upper palsy, 103° in upper/middle palsy, and 82° in total palsy. Shoulder external rotation ≥6 on the TAMS was achieved in 62% of cases. External rotation range was an average of 58° ± 29°; 78° in upper palsy, 68° in upper/middle palsy, and 52° in total palsy. Elbow flexion and extension of ≥6 on the TAMS were achieved in 69% and 58% of cases, respectively. Wrist flexion and finger flexion of ≥6 on the TAMS were achieved in 35% and 12.5%, whereas wrist and finger extension of >6 on the TAMS were achieved in 25% and 4% of cases, respectively.

CONCLUSION

In the delayed presentation of brachial plexus birth injury, brachial plexus reconstruction results in good functional recovery of elbow flexion and shoulder external rotation but modest functional recovery of finger flexion and wrist extension. The rate of functional recovery of the elbow flexion was similar following nerve grafting and transfer. Nerve transfer for shoulder external rotation should be considered even in infants with available roots for grafting.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Pediatric Shoulder Arthroscopy is Effective and Most Commonly Indicated for Instability, Obstetric Brachial Plexus Palsy, and Partial Rotator Cuff Tears

Purpose

The purpose of this review was to systematically evaluate the literature on pediatric shoulder arthroscopy and outline its indications, outcomes, and complications.

Methods

This systematic review was carried out in accordance with PRISMA guidelines. PubMed, Cochrane Library, ScienceDirect, and OVID Medline were searched for studies reporting the indications, outcomes, or complications in patients undergoing shoulder arthroscopy under the age of 18 years. Reviews, case reports, and letters to the editor were excluded. Data extracted included surgical techniques, indications, preoperative and postoperative functional and radiographic outcomes, and complications. The methodological quality of included studies was evaluated using the Methodological Index for Non-Randomized Studies (MINORS) tool.

Results

Eighteen studies, with a mean MINORS score of 11.4/16, were identified, including a total of 761 shoulders (754 patients). Weighted average age was 13.6 years (range, 0.83-18.8 years) with a mean follow-up time of 34.6 months (range, 6-115). As part of their inclusion criteria, 6 studies (230 patients) recruited patients with anterior shoulder instability and 3 studies recruited patients with posterior shoulder instability (80 patients). Other indications for shoulder arthroscopy included obstetric brachial plexus palsy (157 patients) and rotator cuff tears (30 patients). Studies reported a significant improvement in functional outcomes for arthroscopy indicated for shoulder instability and obstetric brachial plexus palsy. A significant improvement was also noted in radiographic outcomes and range of motion for obstetric brachial plexus palsy patients. The overall rate of complication ranged from 0% to 25%, with 2 studies reporting no complications. The most common complication was recurrent instability (38 patients of 228 [16.7%]). Fourteen of the 38 patients (36.8%) underwent reoperation.

Conclusion

Among pediatric patients, shoulder arthroscopy was indicated most commonly for instability, followed by brachial plexus birth palsy, and partial rotator cuff tears. Its use resulted in good clinical and radiographic outcomes with limited complications.

Level of Evidence

Systematic review of Level II to IV studies.

Brachial Plexus Birth Injury: A Review of Neurology Literature Assessing Variability and Current Recommendations

BACKGROUND

Publications regarding the epidemiology and management of brachial plexus birth injury (BPBI) were evaluated to investigate treatment guidelines for children with BPBI.

METHODS

A search of neurology literature from 1990 to 2019 was performed using PubMed, Scopus, and Medline. Data including incidence, risk factors, spontaneous recovery rates, imaging studies, treatment recommendations, and indications and timing for surgery were collected.

RESULTS

A total of 46 total studies were reviewed. Reported incidence rates for BPBI ranged from 0.3 to 3 per 1000 births. Spontaneous recovery rates had an average reported range from 66% to 75%. Physical and occupational therapy were recommended in 37% of articles. Computed tomographic myelogram and magnetic resonance imaging of the brachial plexus were the most commonly recommended imaging studies for BPBI. Timelines for surgical interventions ranged from age three to nine months. Early referral was recommended in 28% of the articles included in the review.

CONCLUSIONS

Given the inconsistencies in spontaneous recovery rates, imaging recommendations, and timing of referral, establishing consistent clinical guidelines for patients with BPBI is crucial for management. Early referral to specialists for evaluation and treatment may improve outcomes in children with BPBI.

Surgical timing in neonatal brachial plexus palsy: A PRISMA-IPD systematic review

Background

Neonatal brachial plexus palsy (NBPP) is a serious complication of high‐risk deliveries with controversy surrounding timing of corrective nerve surgery. This review systematically examines the existing literature and investigates correlations between age at time of upper trunk brachial plexus microsurgery and surgical outcomes.

Methods

A systematic screening of PubMed, Cochrane, Web of Science, and CINAHL databases using PRISMA‐IPD guidelines was conducted in January 2020 to include full‐text English papers with microsurgery in upper trunk palsy, pediatric patients. Spearman rank correlation analysis and two‐tailed t‐tests were performed using individual patient data to determine the relationship between mean age at time of surgery and outcome as determined by the Mallet, Medical Research Council (MRC), or Active Movement Scale (AMS) subscores.

Results

Two thousand nine hundred thirty six papers were screened to finalize 25 papers containing individual patient data (n = 256) with low to moderate risk of bias, as assessed by the ROBINS‐I assessment tool. Mallet subscore for hand‐to‐mouth and shoulder abduction, AMS subscore for elbow flexion and external rotation, and MRC subscore for elbow flexion were analyzed alongside the respective age of patients at surgery. Spearman rank correlation analysis revealed a significant negative correlation (ρ = −0.30, p < .01, n = 89) between increasing age (5.50 ± 2.09 months) and Mallet subscore for hand‐to‐mouth (3.43 ± 0.83). T‐tests revealed a significant decrease in Mallet hand‐to‐mouth subscores after 6 months (p < .05) and 9 months (p < .05) of age. No significant effects were observed for Mallet shoulder abduction, MRC elbow flexion, or AMS elbow flexion and external rotation.

Conclusion

The cumulative evidence suggests a significant negative correlation between age at microsurgery and Mallet subscores for hand‐to‐mouth. However, a similar correlation with age at surgery was not observed for Mallet shoulder abduction, MRC elbow flexion, AMS external rotation, and AMS elbow flexion subscores.

Case Report: Bionic Reconstruction in an Adult With Obstetric Brachial Plexus Injury

Introduction: Many adults who had a severe Narakas IV obstetric brachial plexus injury (OBPI) suffer from extensive impairments in daily living due to limited hand-arm function. The dramatic loss of axonal support at this very early age of development often render the entire extremity a biologic wasteland and reconstructive methods and therapies often fail to recover any functional hand use. In this scenario bionic reconstruction, including an elective amputation and a subsequent prosthetic fitting, may enable functional improvement in adults suffering from the consequences of such severe brachial plexus injuries. We here describe our experience in treating such patients and lay out the surgical rational and rehabilitation protocol exemplified in one patient.

Case Presentation/Methods: A 27-year-old adult with a unilateral OBPI contacted our center. He presented with globally diminished function of the affected upper extremity with minimal hand activity, resulting in an inability to perform various tasks of daily living. No biological reconstructive efforts were available to restore meaningful hand function. An interdisciplinary evaluation, including a psychosocial assessment, was used to assess eligibility for bionic reconstruction. Before the amputation and after the prosthetic fitting functional assessments and self-reported questionnaires were performed.

Results: One month after the amputation and de-rotation osteotomy of the humerus the patient was fitted with a myoelectric prosthesis. At the 1.5 year-follow-up assessment, the patient presented with a distinct improvement of function: the ARAT improved from 12 to 20 points, SHAP score improved from 8 to 29, and the DASH value improved from 50 to 11.7. The average wearing times of the prosthesis were 5 to 6 h per day (on 4–5 days a week).

Discussion: The options for adults suffering from the consequences of severe OBPIs to improve function are limited. In selected patients in whom the neurological deficit is so severe that biologic hand function is unsatisfactory, an elective amputation and subsequent restoration of the hand with mechatronic means may be an option. The follow-up results indicate that this concept can indeed lead to solid hand function and independence in daily activities after amputation, subsequent prosthetic fitting, and rehabilitation.

Effect of arthroscopic shoulder release on shoulder mobility and bone deformity following brachial plexus birth injury: a systematic review and meta-analysis

BACKGROUND

Specific information to guide clinical practice is lacking for the effects of arthroscopic release on bone and joint deformities, as well as the additional benefits of tendon transfer, in children with brachial plexus birth injury. The aims of this study were (1) to evaluate changes in shoulder mobility and bone and joint deformity, (2) to evaluate the effect of release with and without tendon transfer on the same outcomes, and (3) to evaluate the perioperative and long-term complications.

METHODS

We conducted a systematic review and meta-analysis. Four databases were searched using relevant inclusion and exclusion criteria from inception until May 2020. The quality of articles was evaluated using the Methodological Index for Non-randomized Studies (MINORS) scale. Data regarding patients, interventions, and clinical and radiologic outcomes were reported.

RESULTS

Thirteen articles were included: 6 of low quality and 7 of moderate quality separated into 17 studies (266 children). The mean follow-up duration was 32.4 months (standard deviation, 15.2 months). Arthroscopic release significantly improved the Mallet score (standardized mean difference [SMD], 3.1 [95% confidence interval (CI), 1.5-4.7]; P < .001) and passive external rotation (SMD, 3.6 [95% CI, 2.3-4.9]; P = .02). The percentage of humeral head anterior (SMD, 1.3 [95% CI, 0.7-1.9]; P = .003) and glenoid retroversion (SMD, 1.4 [95% CI, 0.9-2]; P = .01) also improved. Descriptive analysis of the data suggested that concomitant tendon transfer further improved mobility. Recurrence of internal-rotation contracture was reported in 8 of 157 children.

DISCUSSION

This systematic review showed that arthroscopic release effectively improves both shoulder mobility and bone deformity, with few complications in young children with brachial plexus birth injury. As such, it seems reasonable to propose a stepwise approach starting with a release without transfer.

Brachial Plexus Injury Surgical Service in Time of Coronavirus Disease 2019 Pandemic Experience from a Single Tertiary Orthopaedic Hospital in Indonesia

BACKGROUND: Brachial plexus injury (BPI) is one of the most devastating nerve injuries to the extremities. BPI in adults is an increasingly common clinical problem due to road traffic accident. Injury patterns, the timing of surgery, priority on the recovery of function, and patient’s understanding about the expectations of the prognosis are things that are important to consider before deciding on surgical management. The coronavirus pandemic coronavirus disease 2019 (COVID-19) has significantly affected all sectors, one of which is a surgical practice both in terms of medical personnel and equipment, also patient perceptions of hospital services. AIM: This study will analyze epidemiological data on BPI patients who underwent surgery during the COVID-19 pandemic. METHODS: A retrospective descriptive study of BPI profile in Prof. Soeharso Orthopedic Hospital before (2019) and during (2020) the COVID-19 pandemic. Demographic data, the total number of surgery, type of surgical procedure, and patient origin were collected. We compared to the same period in 2019 before pandemic started. RESULTS: In the data obtained from patients treated or undergoing BPI surgery before pandemic (March 1, 2019 to December 31, 2019) and during the pandemic (March 1, 2020 to December 31, 2020), Indonesia first confirms case was on March 2, 2020, until today. There were 51 and 43 cases, respectively. Panplexal type before the pandemic there were 27 patients (52%), and during the pandemic were 20 patients (46%), the upper type before: during the pandemic was 24 (48%): 23 (54%), and lower type 0 cases. Primary reconstruction before: during the pandemic was 26 (55%): 27 (62%) case, and secondary reconstruction before: during the pandemic was 25 (49%): 16 (38%) case, respectively. CONCLUSION: COVID-19 pandemic has no significant effect in the term of the number of BPI surgery performed. Better outcome in BPI surgery is influenced by the timing of the operation, therefore primary reconstruction remains the main choice for BPI patients with safety concern or health protocols. Pre-operative screening applied in our hospital includes laboratory examination, chest radiograph, and polymerase chain reaction swab test. Surgical personnel using personal protective equipment such as protective suit, face shield, google, shoes and medical mask during the COVID-19 pandemic. Patients with significant axon loss and limited clinical recovery are considered “urgent”, as surgery should be performed within 6 months or sooner (depending upon the distance to recipient’s muscle) to avoid irreversible muscle atrophy and degradation of motor endplates.

Evidence that nerve surgery improves functional outcome for obstetric brachial plexus injury

The majority of children with obstetric brachial plexus injury show some degree of spontaneous recovery. This review explores the available evidence for the use surgical brachial plexus repair to improve outcome. So far, no randomized trial has been performed to evaluate the usefulness of nerve repair. The evidence level of studies comparing surgical treatment with non-surgical treatment is Level IV at best. The studies on natural history that are used for comparison with surgical series are also, unfortunately, of too low quality. Among experts, however, the general agreement is that nerve reconstruction is indicated when spontaneous recovery is absent or severely delayed at specific time points. A major obstacle in comparing or pooling obstetric brachial plexus injury patient series, either surgical or non-surgical, is the use of many different outcome measures. A requirement for multicentre studies is consensus on how to assess and report outcome, both concerning motor performance and functional evaluation.

Conjoint muscle transfer and subscapularis slide in brachial plexus birth palsy: Clinical outcomes in shoulder functions

Background

Shoulder deformity and inadequate shoulder function in brachial plexus birth palsy (BPBP) occur due to imbalance between the shoulder abductors, external rotators, adductors and internal rotators. This is due to cross innervation of the regenerating axons and subsequent target muscle innervation. These lead to internal rotation deformity along with glenohumeral dysplasia. Conjoint muscle transfer in the form of latissimus dorsi and teres major muscle combined with release and slide of subscapularis muscle improves shoulder functions. This study aims to evaluate the outcomes of shoulder function after a simultaneous conjoint muscle transfer and subscapularis slide in the management of BPBP.

Methods

18 children with BPBP, who presented with shoulder deformity and inadequate shoulder functions, underwent conjoint muscle transfer along with subscapularis muscle slide. At 18 months, shoulder functions were assessed preoperatively and postoperatively using Mallet score system and range of motions. Statistical analysis was performed to ascertain if the outcomes were statistically significant.

Results

Mean age was 4.64 years with a mean preoperative Mallet score of 10.89 ± 1.60 and mean postoperative Mallet score of 16.22 ± 1.86. At 18 months, mean gain in shoulder abduction at 18 months was 57.22 ± 16.11° with external rotation of 26.66 ± 7.67°. All children showed improvement in shoulder functions. There was no correlation between the clinical outcomes and age of the child.

Conclusion

This procedure was effective in improving shoulder functions in a cohort of patients. The long-term effect of this procedure, however, remains to be evaluated by further follow-up and with similar such studies.

Health-care use and information needs of children with neonatal brachial plexus palsy: A cross-sectional survey among 465 Dutch patients

To investigate health-care use (HCU) and information needs of children aged 0-18 years with neonatal brachial plexus palsy (NBPP), a cross-sectional study was performed. Patients and/or parents seen in our NBPP clinic were invited to complete a survey comprising questions on HCU due to NBPP and current information needs. Outcomes were described for three age-groups (0-1/2-9/10-18 years), based on follow-up status (early/late/no-discharge). Four hundred sixty-five parents/patients participated (59 in the 0-1, 226 in the 2-9, and 180 in the 10-18-year group). Two hundred ninety-three patients had C5-C6 lesions, 193 were discharged from follow-up, 83 of whom categorized as 'early discharged' (<1 year of age). Over the past year, 198 patients had contact with the expert team (49 in the 0-1, 81 in the 2-9, and 68 in the 10-18-year group) and 288 with at least one other health-care professional (53 in the 0-1, 133 in the 2-9, and 102 in the 10-18-year group). Of the 83 patients discharged early, 34 reported health-care use. Two hundred twenty-eight participants reported current information needs of whom 23 were discharged early. HCU and information needs of Dutch children with NBPP remains considerable even in children who were discharged. Stricter follow-up and information provision for these patients is needed.

Rehabilitation of Neonatal Brachial Plexus Palsy: Integrative Literature Review

This integrative literature review has been carried out with the aim of analyzing the scientific literature aimed at identifying and describing existing rehabilitation treatments/therapies for neonatal brachial plexus palsy (NBPP). NBPP is a frequent consequence of difficult birthing, and it impairs the function of the brachial plexus in newborns. This is why knowledge on rehabilitation strategies deserves special attention. The data collection was carried out in January 2019, in the EBSCOhost and BVS (Biblioteca Virtual em Saúde) platforms, in the CINAHL Complete, MEDLINE Complete, LILACS and PubMed databases. Thirteen articles were included in this integrative literature review, based on a literature search spanning title, abstract and full text, and considering the inclusion criteria. Two main treatments/therapies for NBPP rehabilitation were identified: conservative treatment and surgical treatment. Conservative treatment includes teamwork done by physiatrists, physiotherapists and occupational therapists. These professionals use rehabilitation techniques and resources in a complementary way, such as electrostimulation, botulinum toxin injection, immobilizing splints, and constraint induced movement therapy of the non-injured limb. Professionals and family members work jointly. Surgical treatment includes primary surgeries, indicated for children who do not present any type of spontaneous rehabilitation in the first three months of life; and secondary surgeries, recommended in children who after primary surgery have some limitation of injured limb function, or in children who have had some spontaneous recovery, yet still have significant functional deficits. Treatment options for NBPP are defined by clinical evaluation/type of injury, but regardless of the type of injury, it is unanimous that conservative treatment is always started as early as possible. It should be noted that there was no evidence in the literature of other types of rehabilitation and techniques used in clinical practice, such as preventive positioning of contractures and deformities, hydrotherapy/aquatic therapy, among others, so we consider there is a need for further studies at this level in this area.

The Homuncular Jigsaw: Investigations of Phantom Limb and Body Awareness Following Brachial Plexus Block or Avulsion

Many neuropsychological theories agree that the brain maintains a relatively persistent representation of one’s own body, as indicated by vivid “phantom” experiences. It remains unclear how the loss of sensory and motor information contributes to the presence of this representation. Here, we focus on new empirical and theoretical evidence of phantom sensations following damage to or an anesthetic block of the brachial plexus. We suggest a crucial role of this structure in understanding the interaction between peripheral and central mechanisms in health and in pathology. Studies of brachial plexus function have shed new light on how neuroplasticity enables “somatotopic interferences”, including pain and body awareness. Understanding the relations among clinical disorders, their neural substrate, and behavioral outcomes may enhance methods of sensory rehabilitation for phantom limbs.

Caring for a Child With an Obstetric Brachial Plexus Injury: A Metaphor Analysis

PURPOSE

The purpose of this study was to examine the metaphors used by mothers to describe their experiences caring for their children with obstetric brachial plexus injuries.

DESIGN AND METHODS

A secondary qualitative data analysis was conducted from the primary data set of a phenomenological study of mothers' experiences caring for their children with obstetric brachial plexus injuries. The type of secondary qualitative data analysis approach used was analytic expansion. Metaphor Identification Procedure was used to analyze the corpus of 132 pages of typed transcription.

RESULTS

This metaphorical analysis yielded seven metaphors mothers used to describe their experiences caring for their children with obstetric brachial plexus injuries. These metaphors portrayed mothers' lives as involving a heavy weight, a maze, a juggling act, a simmering pot, a dagger to the heart, a rollercoaster, and a constant battle.

CONCLUSION

The seven metaphors helped women express what they could not completely capture using only medical jargon and provide valuable insight for clinicians. Using secondary qualitative data analysis to mine for any metaphors in a primary data set gives researchers another valuable and creative opportunity to discover new knowledge from the data they had previously collected.

PRACTICE IMPLICATIONS

Specific interventions can be developed to target each of these seven metaphors to help mothers in their daily care for their children with obstetric brachial plexus injuries.

Distal nerve transfer versus supraclavicular nerve grafting: comparison of elbow flexion outcome in neonatal brachial plexus palsy with C5-C7 involvement

PURPOSE

Ulnar and median nerve transfers to arm muscles have been used to recover elbow flexion in infants with neonatal brachial plexus palsy, but there is no direct outcome comparison with the classical supraclavicular nerve grafting approach.

METHODS

We retrospectively analyzed patients with C5-C7 neonatal brachial plexus palsy submitted to nerve surgery and recorded elbow flexion recovery using the active movement scale (0-7) at 12 and 24 months after surgery. We compared 13 patients submitted to supraclavicular nerve grafting with 21 patients submitted to distal ulnar or median nerve transfer to biceps motor branch. We considered elbow flexion scores of 6 or 7 as good results.

RESULTS

The mean elbow flexion score and the proportion of good results were better using distal nerve transfers than supraclavicular grafting at 12 months (p < 0.01), but not at 24 months. Two patients with failed supraclavicular nerve grafting at 12 months showed good elbow flexion recovery after ulnar nerve transfers.

CONCLUSION

Distal nerve transfers provided faster elbow flexion recovery than supraclavicular nerve grafting, but there was no significant difference in the outcome after 24 months of surgery. Patients with failed supraclavicular grafting operated early can still benefit from late distal nerve transfers. Supraclavicular nerve grafting should remain as the first line surgical treatment for children with neonatal brachial plexus palsy.

Obstetrical Brachial Plexus Palsy

Obstetrical brachial plexus palsy is a disorder of the peripheral nervous system and occurs in as many as 0.4% of infants born. It is associated with shoulder dystocia, use of mechanical extraction, and macrosomia; it occurs more frequently in infants born by vaginal delivery. The unilateral injury to the brachial plexus complex occurs during the delivery phase as lateral traction is applied to the head to permit shoulder clearance. The infant typically presents in the delivery room with decreased active movements of the affected arm and asymmetrical primitive reflex responses. The severity of nerve involvement can range from a stretch injury to complete avulsion. While full recovery is possible, prognosis is variable and up to 35% of children may have some degree of life-long functional impairment of the affected limb.

Evidence of the Effectiveness of Primary Brachial Plexus Surgery in Infants With Obstetric Brachial Plexus Palsy-Revisited

A recent systematic review questioned the effectiveness of primary surgery in infants with obstetric brachial plexus palsy. At our center, the indication for primary surgery in infants with upper Erb’s obstetric palsy is the lack of active elbow flexion at age 4 months. The current study compares the outcome of motor recovery in 2 groups of infants with upper Erb’s palsy: one group (n = 9) treated surgically between age 4 and 5 months, and another group (n = 9) treated conservatively despite the lack of active elbow flexion at age 4 months. The only reason for not doing the surgery in the latter group was refusal by the parents. The scores of motor recovery were collected at the 2-year follow-up visit, and they were significantly better in the surgical group. The study demonstrates the effectiveness of primary surgery in infants with upper Erb’s obstetric palsy compared to conservative management.

Utility of ultrasound-guided injection of botulinum toxin type A for muscle imbalance in children with obstetric brachial plexus palsy: Description of the procedure and action protocol

INTRODUCTION

Obstetric brachial plexus palsy (OBPP) usually has a favourable prognosis. However, nearly one third of all severe cases have permanent sequelae causing a high level of disability. In this study, we explore the effectiveness of ultrasound-guided injection of botulinum toxin A (BoNT-A) and describe the procedure.

PATIENTS AND METHODS

We designed a prospective, descriptive study including patients with moderate to severe OBPP who were treated between January 2010 and December 2014. We gathered demographic data, type of OBPP, and progression. Treatment effectiveness was assessed with the Active Movement Scale (AMS), the Mallet classification, and video recordings.

RESULTS

We gathered a total of 14 133 newborns, 15 of whom had OBPP (1.6 per 1000 live births). Forty percent of the cases had severe OBPP (0.4/1000), a dystocic delivery, and APGAR scores < 5; mean weight was 4038g. Mean age at treatment onset was 11.5 months. The muscles most frequently receiving BoNT-A injections were the pronator teres, subscapularis, teres major, latissimus dorsi, and pectoralis major. All the patients who completed the follow-up period (83%) experienced progressive improvements: up to 3 points on the AMS and a mean score of 19.5 points out of 25 on the Mallet classification at 2 years. Treatment improved muscle function and abnormal posture in all cases. Surgery was avoided in 3 patients and delayed in one. Adverse events were mild and self-limited.

CONCLUSIONS

Due to its safety and effectiveness, BoNT-A may be used off-label as an adjuvant to physical therapy and/or surgery in moderate to severe OBPP. Ultrasound may increase effectiveness and reduce adverse effects.