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Siqueira MG, Heise CO, Martins RS, Zaccariotto M, Pessa M, Sterman-Neto H. Hand function outcomes following surgical treatment of complete neonatal brachial plexus palsy. Childs Nerv Syst 2024; 40:1455-1459. [PMID: 38183435 DOI: 10.1007/s00381-023-06269-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 12/22/2023] [Indexed: 01/08/2024]
Abstract
PURPOSE Although re-innervation of the hand is considered a priority in the treatment of infants with complete brachial plexus injury, there is currently a paucity of publications investigating hand function outcomes following primary nerve reconstruction in infants with neonatal brachial plexus palsy (NBPP). This study therefore aimed to evaluate hand function outcomes in a series of patients with complete NBPP. METHODS This retrospective case series included all patients who underwent primary nerve surgery for complete neonatal brachial plexus palsy over an 8-year period. Outcomes were assessed using the Raimond Hand Scale. Classification of grade 3 or higher indicates a functional hand (assistance in bimanual activity). RESULTS Nineteen patients with a complete NBPP underwent primary nerve reconstruction at a mean age of 3.7 months. Periodic clinical evaluations were performed until at least 4 years of age. According to the Raimondi hand scale, one patient did not recover (grade 0), three patients attained grade 1, four grade 2, ten grade 3, and in one grade 4. Overall hand functional recovery was achieved in 57.8% (11/19) of patients. CONCLUSION Sufficient recovery of hand function to perform bimanual activity tasks in patients with complete NBPP lesions is possible and should be a priority in the surgical treatment of these infants.
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Affiliation(s)
- Mario Gilberto Siqueira
- Peripheral Nerve Surgery Unit, Department of Neurosurgery, University of São Paulo Medical School, Rua Dr. Enéas Carvalho de Aguiar 255, 05403-000, São Paulo, SP, Brazil.
| | - Carlos Otto Heise
- Peripheral Nerve Surgery Unit, Department of Neurosurgery, University of São Paulo Medical School, Rua Dr. Enéas Carvalho de Aguiar 255, 05403-000, São Paulo, SP, Brazil
- Clinical Neurophysiology, Department of Neurology, University of São Paulo Medical School, São Paulo, SP, Brazil
| | - Roberto Sergio Martins
- Peripheral Nerve Surgery Unit, Department of Neurosurgery, University of São Paulo Medical School, Rua Dr. Enéas Carvalho de Aguiar 255, 05403-000, São Paulo, SP, Brazil
| | - Monise Zaccariotto
- Peripheral Nerve Surgery Unit, Department of Neurosurgery, University of São Paulo Medical School, Rua Dr. Enéas Carvalho de Aguiar 255, 05403-000, São Paulo, SP, Brazil
| | - Mariana Pessa
- Occupational Therapy, Department of Orthopedic Surgery, University of São Paulo Medical School, São Paulo, SP, Brazil
| | - Hugo Sterman-Neto
- Peripheral Nerve Surgery Unit, Department of Neurosurgery, University of São Paulo Medical School, Rua Dr. Enéas Carvalho de Aguiar 255, 05403-000, São Paulo, SP, Brazil
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Long-Term Results of Microsurgical Brachial Plexus Reconstruction in Late-Presenting Cases of Brachial Plexus Birth Injury. J Hand Surg Am 2023; 48:126-133. [PMID: 36539318 DOI: 10.1016/j.jhsa.2022.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 10/22/2022] [Accepted: 11/09/2022] [Indexed: 12/23/2022]
Abstract
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.
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Srinivasan N, Mahajan J, Gupta S, Shah YM, Shafei J, Levidy MF, Abdelmalek G, Pant K, Jain K, Zhao C, Chu A, McGrath A. Surgical timing in neonatal brachial plexus palsy: A PRISMA-IPD systematic review. Microsurgery 2022; 42:381-390. [PMID: 35147253 PMCID: PMC9305151 DOI: 10.1002/micr.30871] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 11/23/2021] [Accepted: 01/28/2022] [Indexed: 12/05/2022]
Abstract
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.
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Affiliation(s)
- Nivetha Srinivasan
- Department of Orthopedic Surgery, Rutgers-New Jersey Medical School, Newark, New Jersey, USA
| | - Jasmine Mahajan
- Department of Orthopedic Surgery, Rutgers-New Jersey Medical School, Newark, New Jersey, USA
| | - Shivani Gupta
- Department of Orthopedic Surgery, Rutgers-New Jersey Medical School, Newark, New Jersey, USA
| | - Yash M Shah
- Department of Orthopedic Surgery, Rutgers-New Jersey Medical School, Newark, New Jersey, USA
| | - Jasmine Shafei
- Department of Orthopedic Surgery, Rutgers-New Jersey Medical School, Newark, New Jersey, USA
| | - Michael F Levidy
- Department of Orthopedic Surgery, Rutgers-New Jersey Medical School, Newark, New Jersey, USA
| | - George Abdelmalek
- Department of Orthopedic Surgery, Rutgers-New Jersey Medical School, Newark, New Jersey, USA
| | - Krittika Pant
- Department of Orthopedic Surgery, Rutgers-New Jersey Medical School, Newark, New Jersey, USA
| | - Kunj Jain
- Department of Orthopedic Surgery, Rutgers-New Jersey Medical School, Newark, New Jersey, USA
| | - Caixia Zhao
- Department of Orthopedic Surgery, Rutgers-New Jersey Medical School, Newark, New Jersey, USA
| | - Alice Chu
- Department of Orthopedic Surgery, Rutgers-New Jersey Medical School, Newark, New Jersey, USA
| | - Aleksandra McGrath
- Department of Clinical Sciences, Umeå University, Umeå, Sweden.,Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden
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Hamant LG, Adelson PD, Kang P, Brown SD, Arango JI. Comparison of autograft versus allograft in the surgical repair of pediatric obstetrical brachial plexus injuries. J Neurosurg Pediatr 2020; 26:318-326. [PMID: 32534482 DOI: 10.3171/2020.4.peds2033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 04/08/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The goal of this study was to determine the functional efficacy of acellular processed nerve allograft (ALG) as compared to sural nerve autograft (AUG) harvested at time of surgery for children with obstetrical brachial plexus injury (OBPI). METHODS A retrospective review of records was performed in patients who underwent surgical repair of OBPI between 2009 and 2015 at Phoenix Children's Hospital. Patients were grouped based on the type of nerve graft used (AUG using the patient's own sural nerve or decellularized processed cadaveric nerve ALG) and compared in terms of motor strength, British Medical Research Council score, functionality (Mallet scale score), surgical time, rate of complications, and need for further intervention. RESULTS A total of 52 records were identified meeting study criteria. Sural nerve AUG was used in 22 cases and ALG in 30 cases. Changes from pre- to postsurgical assessment of motor strength were significant for all muscle groups measured except for elbow extension for both groups. All Mallet scores increased significantly. No significant differences were observed in motor strength and functional components between groups. Interventions using ALG had shorter operative times than those performed using AUG. No significant difference was observed in terms of need for further intervention. Two patients (9%) in the AUG group developed stitch abscesses at the harvest site, whereas there were no infectious complications reported in the ALG group. CONCLUSIONS These findings suggest equivalence in terms of muscle strength and functional outcomes between the use of AUG and ALG for patients with OBPI. However, the less invasive character of ALG repair decreases surgical time and risk of complications.
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Affiliation(s)
| | - P David Adelson
- 1Phoenix Children's Hospital and
- 2Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, Arizona
- 3Mayo Clinic School of Medicine, Rochester, Minnesota; and
- 4University of Arizona, College of Medicine-Phoenix, Arizona
| | - Paul Kang
- 4University of Arizona, College of Medicine-Phoenix, Arizona
| | - S Danielle Brown
- 2Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, Arizona
| | - Jorge I Arango
- 2Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, Arizona
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Haninec P, Hradecky J, Mencl L. Lower subscapular nerve transfer for axillary nerve repair in upper brachial plexus palsy. Acta Neurochir (Wien) 2020; 162:135-139. [PMID: 31713155 DOI: 10.1007/s00701-019-04122-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Accepted: 10/24/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND The potential to utilize the lower subscapular nerve for brachial plexus surgery has been suggested in many anatomical studies. However, we know of no studies in the literature describing the use of the lower subscapular nerve for axillary nerve reconstruction to date. This study aimed to examine the effectiveness of this nerve transfer in patients with upper brachial plexus palsy. METHODS Of 1340 nerve reconstructions in 568 patients with brachial plexus injury performed by the senior author (P.H.), a subset of 18 patients underwent axillary nerve reconstruction using the lower subscapular nerve and constitutes the patient group for this study. The median age was 48 years, and the median time between trauma and surgery was 6 months. A concomitant radial nerve injury was found in 8 patients. RESULTS Thirteen patients completed a minimum follow-up period of 24 months. Successful deltoid recovery was defined as (1) muscle strength MRC grade ≥ 3, (2) electromyographic signs of reinnervation, and (3) increase in deltoid muscle mass. Axillary nerve reconstruction was successful in 9 of 13 patients, which represents a success rate of 69.2%. No significant postoperative weakness of shoulder internal rotation or adduction was observed after transecting the lower subscapular nerve. CONCLUSIONS The lower subscapular nerve can be used as a safe and effective neurotization tool for upper brachial plexus injury, having a success rate of 69.2% for axillary nerve repair. Our technique presents a suitable alternative for patients with concomitant radial nerve injury.
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Affiliation(s)
- Pavel Haninec
- Department of Neurosurgery, 3rd Faculty of Medicine, Charles University Hospital Kralovske Vinohrady, Srobarova 50, 100 34, Prague, Czech Republic
| | - Jan Hradecky
- Department of Neurosurgery, 3rd Faculty of Medicine, Charles University Hospital Kralovske Vinohrady, Srobarova 50, 100 34, Prague, Czech Republic
| | - Libor Mencl
- Department of Neurosurgery, 3rd Faculty of Medicine, Charles University Hospital Kralovske Vinohrady, Srobarova 50, 100 34, Prague, Czech Republic.
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Triplanar Humeral Osteotomy for Restoration of Midline Function in Patients With Brachial Plexus Birth Palsy. Tech Hand Up Extrem Surg 2017; 21:48-54. [PMID: 28394871 DOI: 10.1097/bth.0000000000000156] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Brachial plexus birth palsy resolves spontaneously in a majority of patients, however, others may have serious permanent dysfunction. Although nerve transfers or grafts are early options for treatment, many children have residual deficits or present too late for such procedures. In these patients, rotational osteotomy of the humerus may restore improved function and motion. Unfortunately, traditional humeral osteotomies only provide correction in a single plane, therefore appropriate correction of the typical residual deformity is incomplete. Here, we describe a novel technique for obtaining a calculated correction in 3 planes using a single osteotomy of the humerus on the basis of a mathematical equation. Nine patients are described here with an average of 35.4 months follow-up. Corrections were obtained in adduction, extension, and either internal or external rotation depending on the initial deformity and Modified Mallet scores were collected for each patient. There was 1 case of transient radial nerve palsy with no long-term complications overall.
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