1
|
Hems T. Questions regarding natural history and management of obstetric brachial plexus injury. J Hand Surg Eur Vol 2021; 46:796-799. [PMID: 34210206 DOI: 10.1177/17531934211027117] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Tim Hems
- Scottish National Brachial Plexus Injury Service, Queen Elizabeth University Hospital and Royal Hospital for Children, Glasgow, UK
| |
Collapse
|
2
|
Elnaggar RK. Integrated Electromyography: Discriminant Analysis and Prediction of Recovery 3 to 6 Years After Brachial Plexus Birth Injury. Pediatr Phys Ther 2020; 32:120-128. [PMID: 32150027 DOI: 10.1097/pep.0000000000000684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To assess the recovery likelihood, 3 to 6 years after brachial plexus birth injury (BPBI), and predict the functional recovery from integrated electromyography (IEMG). METHODS Thirty children with BPBI limited to C5-C6 lesion participated. Maximal electromyography activity of deltoid and biceps brachii was measured at entry. Shoulder and elbow functions were assessed at the baseline and at 4 intervals across 2 years. RESULTS Shoulder and elbow function significantly changed across the follow-up period. Shoulder and elbow functions were significantly dependent on deltoid and biceps brachii muscles' IEMG level, respectively, with the groups showing higher IEMG achieving better recovery. The deltoid and biceps IEMG explained a portion of the improvement in shoulder and elbow function over 2 years. CONCLUSION Recovery of the shoulder and elbow function continues 3 to 6 years after BPBI. IEMG may partially explain variation in the prognosis for children with BPBI.
Collapse
Affiliation(s)
- Ragab K Elnaggar
- Department of Physical Therapy for Pediatrics, Faculty of Physical Therapy, Cairo University, Giza, Egypt
| |
Collapse
|
3
|
Looven R, Le Roy L, Tanghe E, Broeck C, Muynck M, Vingerhoets G, Pitt M, Vanderstraeten G. Early electrodiagnosis in the management of neonatal brachial plexus palsy: A systematic review. Muscle Nerve 2019; 61:557-566. [DOI: 10.1002/mus.26762] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Revised: 10/22/2019] [Accepted: 11/12/2019] [Indexed: 11/10/2022]
Affiliation(s)
- Ruth Looven
- Child Rehabilitation Centre, Department of Physical and Rehabilitation MedicineGhent University Hospital Ghent Belgium
| | - Laura Le Roy
- Department of Rehabilitation Sciences and PhysiotherapyGhent University Ghent Belgium
| | - Emma Tanghe
- Department of Rehabilitation Sciences and PhysiotherapyGhent University Ghent Belgium
| | - Christine Broeck
- Department of Rehabilitation Sciences and PhysiotherapyGhent University Ghent Belgium
| | - Martine Muynck
- Child Rehabilitation Centre, Department of Physical and Rehabilitation MedicineGhent University Hospital Ghent Belgium
| | - Guy Vingerhoets
- Department of Experimental PsychologyFaculty of Psychological and Educational Sciences, Ghent University Ghent Belgium
| | - Matthew Pitt
- Department of Clinical NeurophysiologyGreat Ormond Street Hospital for Children NHS Trust London UK
| | | |
Collapse
|
4
|
Burnier M, Le Hanneur M, Cambon-Binder A, Belkheyar Z. Isolated open anterior shoulder release in brachial plexus birth palsy. J Shoulder Elbow Surg 2019; 28:1347-1355. [PMID: 30981548 DOI: 10.1016/j.jse.2018.12.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 12/18/2018] [Accepted: 12/20/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND In children with brachial plexus birth palsy (BPBP), a shoulder joint internal contracture is commonly observed, which may result in glenohumeral osseous deformities and posterior joint subluxation. The purpose of this retrospective study was to evaluate the impact of an isolated anterior shoulder release on osteoarticular disorders and assess the subsequent clinical improvements. METHODS Forty consecutive BPBP patients with glenohumeral dysplasia underwent an open anterior shoulder release. Shoulder scans (ie, magnetic resonance imaging preoperatively and computed tomography postoperatively) were conducted to assess glenoid version and the percentage of the humeral head anterior to the middle of the glenoid fossa. Clinical data including analytical shoulder range of motion and modified Mallet scores were collected. RESULTS After a mean follow-up period of 23 months, glenoid version and the percentage of the humeral head anterior to the middle of the glenoid fossa significantly improved from -32° and 18%, respectively, to mean postoperative values of -12° (P < .001) and 45% (P < .001), respectively. Passive and active external rotation increased from -2° and -43°, respectively, to 76° (P < .001) and 54° (P < .001), respectively. The mean modified Mallet score significantly improved from 14.2 to 21.4 points (P < .001). In 8 children with satisfactory passive motion, a latissimus dorsi transfer was performed secondarily to obtain satisfactory active motion. CONCLUSION In BPBP patients with glenohumeral deformities, isolated open anterior release of the shoulder induces significant remodeling of the joint, reducing posterior joint subluxation and improving both passive and active shoulder ranges of motion. Additional latissimus transfer remains mandatory in selected cases to achieve satisfactory function.
Collapse
Affiliation(s)
- Marion Burnier
- Department of Hand and Upper Limb Surgery, Hôpital Edouard Herriot, Lyon, France; Department of Orthopedics, Service of Hand Surgery, Clinique du Mont Louis, Paris, France.
| | - Malo Le Hanneur
- Department of Orthopedics and Traumatology, Service of Hand, Upper Limb and Peripheral Nerve Surgery, Georges Pompidou European Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Adeline Cambon-Binder
- Department of Orthopedics and Traumatology, Service of Hand Surgery, Saint Antoine Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Zoubir Belkheyar
- Department of Orthopedics, Service of Hand Surgery, Clinique du Mont Louis, Paris, France
| |
Collapse
|
5
|
Outcomes from primary surgical reconstruction of neonatal brachial plexus palsy in 104 children. Childs Nerv Syst 2019; 35:349-354. [PMID: 30610478 DOI: 10.1007/s00381-018-04036-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 12/17/2018] [Indexed: 10/27/2022]
Abstract
PURPOSE The outcome from microsurgical reconstruction of neonatal brachial plexus palsy (NBPP) varies, and comparison between different series is difficult, given the differences in preoperative evaluation, surgical strategies, and outcome analysis. To evaluate our results, we reviewed a series of children who underwent surgical treatment in a period of 14 years. METHODS We made a retrospective review of 104 cases in which microsurgical repair of the brachial plexus was performed. Strength was graded using the Active Movement Scale. Whenever possible, upper palsies underwent surgery 4 to 6 months after birth and total lesions around 3 months. The lesions were repaired, according to the type of injury: neurolysis, nerve grafting, nerve transfer, or a combination of techniques. The children were followed for at least 24 months. RESULTS The majority of cases were complete lesions (56/53.8%). Erb's palsy was present in 10 cases (9.6%), and 39 infants (37.5%) presented an extended Erb's palsy. The surgical techniques applied were neurolysis (10.5%), nerve grafts (25.9%), nerve transfers (34.6%), and a combination of grafts and transfers (30.7%). The final outcome was considered poor in 41.3% of the cases, good in 34.3%, and excellent in 24%. A functional result (good plus excellent) was achieved in 58.3% of the cases. CONCLUSIONS There is no consensus regarding strategies for treatment of NBPP. Our surgical outcomes indicated a good general result comparing with the literature. However, our results were lower than the best results reported. Maybe the explanation is our much higher number of total palsy cases (53.8% vs. 25% in the literature).
Collapse
|
6
|
Hems TEJ, Savaridas T, Sherlock DA. The natural history of recovery of elbow flexion after obstetric brachial plexus injury managed without nerve repair. J Hand Surg Eur Vol 2017. [PMID: 28627963 DOI: 10.1177/1753193417712924] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
UNLABELLED In this study, we report the outcome for spontaneous recovery of elbow flexion in obstetric brachial plexus injury managed without nerve reconstruction. Excluding those with transient paralysis, our records revealed 152 children with obstetric brachial plexus injury born before our unit routinely offered brachial plexus reconstruction. Five had had nerve repairs. Of the remainder, only one patient had insufficient flexion to reach their mouth. Elbow flexion started to recover clinically at a mean age of 4 months for Narakas Group 1, 6 months for Group 2, 8 months for Group 3 and 12 months for Group 4. The mean active range of elbow flexion, in 44 cases, was 138°. The mean isometric elbow flexion strength, in 39 patients, was 63% (range 23%-100%) of the normal side. It appears to be rare for elbow flexion not to recover spontaneously, although recovery occurs later in more severe injuries. It is doubtful if nerve reconstruction can improve elbow flexion above the likely spontaneous recovery in babies with obstetric brachial plexus injuries. LEVEL OF EVIDENCE II.
Collapse
Affiliation(s)
- T E J Hems
- Scottish National Brachial Plexus Injury Service, Queen Elizabeth University Hospital and Royal Hospital for Children, Glasgow, UK
| | - T Savaridas
- Scottish National Brachial Plexus Injury Service, Queen Elizabeth University Hospital and Royal Hospital for Children, Glasgow, UK
| | - D A Sherlock
- Scottish National Brachial Plexus Injury Service, Queen Elizabeth University Hospital and Royal Hospital for Children, Glasgow, UK
| |
Collapse
|
7
|
Abzug JM, Kozin SH, Waters PM. Open Glenohumeral Joint Reduction and Latissimus Dorsi and Teres Major Tendon Transfers for Infants and Children Following Brachial Plexus Birth Palsy. Tech Hand Up Extrem Surg 2017; 21:30-36. [PMID: 28448306 DOI: 10.1097/bth.0000000000000150] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Glenohumeral dysplasia can occur in brachial plexus birth palsy due to an imbalance of muscle forces. Most commonly this occurs in C5-C6 injuries where the shoulder external rotators are weak compared with the shoulder internal rotators. Treatment of the dysplasia with open reduction of the glenohumeral joint in combination with rebalancing the muscles can improve the development of the joint. Furthermore, the tendon transfer can improve shoulder function by decreasing the internal rotation forces about the shoulder while increasing the external rotation forces. This paper describes the indications, contraindications, and technique of performing an open glenohumeral joint reduction and latissimus dorsi and teres major tendon transfers for brachial plexus birth palsy.
Collapse
Affiliation(s)
- Joshua M Abzug
- *Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD †Shriners Hospital for Children, Philadelphia, PA ‡Children's Hospital Boston, Boston, MA
| | | | | |
Collapse
|
8
|
Grossman JAI, DiTaranto P, Yaylali I, Alfonso I, Ramos LE, Price AE. Shoulder Function Following Late Neurolysis and Bypass Grafting for Upper Brachial Plexus Birth Injuries. ACTA ACUST UNITED AC 2016; 29:356-8. [PMID: 15234499 DOI: 10.1016/j.jhsb.2004.03.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2003] [Accepted: 03/08/2004] [Indexed: 10/26/2022]
Abstract
Eleven children ranging in age from 9 to 21 months underwent late nerve reconstruction for persistent shoulder paralysis following an upper brachial plexus birth injury. Only neurolysis was performed in three patients. Neurolysis and nerve grafting bypassing the neuroma with proximal and distal end-to-side repairs was performed in the other eight. All patients were followed for 2 or more years. Two patients underwent a secondary procedure before their final follow-up evaluation. All infants demonstrated significant improvement when assessed by a modified Gilbert shoulder motion scale.
Collapse
|
9
|
|
10
|
Coroneos CJ, Voineskos SH, Coroneos MK, Alolabi N, Goekjian SR, Willoughby LI, Farrokhyar F, Thoma A, Bain JR, Brouwers MC. Obstetrical brachial plexus injury: burden in a publicly funded, universal healthcare system. J Neurosurg Pediatr 2016; 17:222-229. [PMID: 26496634 DOI: 10.3171/2015.6.peds14703] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECT The aim of this study was to determine the volume and timing of referrals for obstetrical brachial plexus injury (OBPI) to multidisciplinary centers in a national demographic sample. Secondarily, we aimed to measure the incidence and risk factors for OBPI in the sample. The burden of OBPI has not been investigated in a publicly funded system, and the timing and volume of referrals to multidisciplinary centers are unknown. The incidence and risk factors for OBPI have not been established in Canada. METHODS This is a retrospective cohort study. The authors used a demographic sample of all infants born in Canada, capturing all children born in a publicly funded, universal healthcare system. OBPI diagnoses and corresponding risk factors from 2004 to 2012 were identified and correlated with referrals to Canada's 10 multidisciplinary OBPI centers. Quality indicators were approved by the Canadian OBPI Working Group's guideline consensus group. The primary outcome was the timing of initial assessment at a multidisciplinary center, "good" if assessed by the time the patient was 1 month of age, "satisfactory" if by 3 months of age, and "poor" if thereafter. Joinpoint regression analysis was used to determine the OBPI incidence over the study period. Odds ratios were calculated to determine the strength of association for risk factors. RESULTS OBPI incidence was 1.24 per 1000 live births, and was consistent from 2004 to 2012. Potential biases underestimate the level of injury identification. The factors associated with a very strong risk for OBPI were humerus fracture, shoulder dystocia, and clavicle fracture. The majority (55%-60%) of OBPI patients identified at birth were not referred. Among those who were referred, the timing of assessment was "good" in 28%, "satisfactory" in 66%, and "poor" in 34%. CONCLUSIONS Shoulder dystocia was the strongest modifiable risk factor for OBPI. Most children with OBPI were not referred to multidisciplinary care. Of those who were referred, 72% were assessed later than the target quality indicator of 1 month that was established by the national guideline consensus group. A referral gap has been identified using quality indicators at clinically relevant time points; this gap should be addressed with the use of knowledge tools (e.g., a clinical practice guideline) to target variations in referral rates and clinical practice. Interventions should guide the referral process.
Collapse
Affiliation(s)
| | - Sophocles H Voineskos
- Division of Plastic Surgery and.,Departments of 2 Clinical Epidemiology & Biostatistics
| | - Marie K Coroneos
- Department of Obstetrics and Gynecology, University of Toronto, Ontario, Canada
| | | | | | | | | | - Achilleas Thoma
- Division of Plastic Surgery and.,Departments of 2 Clinical Epidemiology & Biostatistics
| | | | - Melissa C Brouwers
- Departments of 2 Clinical Epidemiology & Biostatistics.,Oncology, McMaster University, Hamilton, Ontario, Canada; and
| | | |
Collapse
|
11
|
Abstract
BACKGROUND Nerve repair may be effective in improving function following obstetrical brachial plexus injury. No previous review has directly compared nerve repair to nonoperative management for similar patients, and no previous analysis has been adequately powered to determine whether nerve repair reduces impairment. METHODS Electronic databases were searched (MEDLINE, Embase, CINAHL, and Cochrane Central). Eligible studies were randomized controlled trials, observational studies, and case series (n > 9); included patients younger than 2 years undergoing nerve repair or nonoperative management of obstetrical brachial plexus injury; and reported functional impairment. Two reviewers independently screened articles using objective a priori criteria. Bias was assessed for each study. Overall quality of evidence was evaluated for each outcome. RESULTS Among nine cohort studies including 222 patients, nerve repair significantly reduced functional impairment compared with nonoperative management (relative risk, 0.58; 95 percent CI, 0.43 to 0.79; p < 0.001; I = 0 percent; absolute risk reduction, 19 percent; number needed to treat, six). Findings are consistent with comparison of similar patients from case series. With operative management, no deaths were reported; major adverse events were reported in 1.5 percent, and minor adverse events were reported in 5.0 percent of cases. Among demographic (all severities) samples managed nonoperatively, residual impairment remains in 27 percent (19 to 36 percent). CONCLUSIONS Nerve repair reduces functional impairment in obstetrical brachial plexus injury. Nonoperative management in patients with a deficit at 3 months of age leads to a high proportion of functional impairment. Mortality is not a common risk of modern pediatric microsurgical nerve repair. Residual impairment with nonoperative management is underestimated in the reported literature. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
Collapse
|
12
|
Abstract
Successful treatment of patients with neonatal brachial plexus palsy (NBPP) begins with a thorough understanding of the anatomy of the brachial plexus and of the pathophysiology of nerve injury via which the brachial plexus nerves stretched in the perinatal period manifest as a weak or paralyzed upper extremity in the newborn. NBPP can be classified by systems that can guide the prognosis and the management as these systems are based on the extent and severity of nerve injury, anatomy of nerve injury, and clinical presentation. Serial physical examinations, supplemented by a thorough maternal and perinatal history, are critical to the formulation of the treatment plan that relies upon occupational/physical therapy and rehabilitation management but may include nerve reconstruction and secondary musculoskeletal surgeries. Adjunctive imaging and electrodiagnostic studies provide additional information to guide prognosis and treatment. As research improves not only the technical aspects of NBPP treatment but also the ability to assess the activity and participation as well as body structure and function of NBPP patients, the functional outcomes for affected infants have an overall optimistic prognosis, with the majority recovering adequate functional use of the affected arm. Of importance are (i) early referral to interdisciplinary specialty clinics that can provide up-to-date advances in clinical care and (ii) increasing research/awareness of the psychosocial and patient-reported quality-of-life issues that surround the chronic disablement of NBPP.
Collapse
Affiliation(s)
- Lynda J-S Yang
- Department of Neurosurgery, University of Michigan, 1500 E. Medical Center Dr, Room 3552 TC, Ann Arbor, MI 48109-5338.
| |
Collapse
|
13
|
Ali ZS, Bakar D, Li YR, Judd A, Patel H, Zager EL, Heuer GG, Stein SC. Utility of delayed surgical repair of neonatal brachial plexus palsy. J Neurosurg Pediatr 2014; 13:462-70. [PMID: 24483255 DOI: 10.3171/2013.12.peds13382] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Neonatal brachial plexus palsy (NBPP) represents a significant health problem with potentially devastating consequences. The most common form of NBPP involves the upper trunk roots. Currently, primary surgical repair is performed if clinical improvement is lacking. There has been increasing interest in "early" surgical repair of NBPPs, occurring within 3-6 months of life. However, early treatment recommendations ignore spontaneous recovery in cases of Erb's palsy. This study was undertaken to evaluate the optimal timing of surgical repair in this group with respect to quality of life. METHODS The authors formulated a decision analytical model to compare 4 treatment strategies (no repair or repair at 3, 6, or 12 months of life) for infants with persistent NBPPs. The model derives data from a critical review of published studies and projects health-related quality of life and quality-adjusted life years over a lifetime. RESULTS When evaluating the quality of life of infants with NBPP, improved outcomes are seen with delayed surgical repair at 12 months, compared with no repair or repair at early and intermediate time points, at 3 and 6 months, respectively. ANOVA showed that the differences among the 4 groups are highly significant (F = 8369; p < 0.0001). Pairwise post hoc comparisons revealed that there are highly significant differences between each pair of strategies (p < 0.0001). Meta-regression showed no evidence of improved outcomes with more recent treatment dates, compared with older ones, for either nonsurgical or for surgical treatment (p = 0.767 and p = 0.865, respectively). CONCLUSIONS These data support a delayed approach of primary surgical reconstruction to optimize quality of life. Early surgery for NBPPs may be an overly aggressive strategy for infants who would otherwise demonstrate spontaneous recovery of function by 12 months. A randomized, controlled trial would be necessary to fully elucidate the natural history of NBPP and determine the optimal time point for surgical intervention.
Collapse
Affiliation(s)
- Zarina S Ali
- Department of Neurosurgery, University of Pennsylvania; and
| | | | | | | | | | | | | | | |
Collapse
|
14
|
Philandrianos C, Baiada A, Salazard B, Benaïm J, Casanova D, Magalon G, Legré R. [Management of upper obstetrical brachial plexus palsy. Long-term results of non-operative treatment in 22 children]. ANN CHIR PLAST ESTH 2011; 58:327-35. [PMID: 21665347 DOI: 10.1016/j.anplas.2011.05.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2011] [Accepted: 05/07/2011] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Treatment of obstetrical brachial plexus palsy (OBPP) is always debated, especially for upper plexus palsy. Some authors perform early surgical treatment in case of absence of biceps contraction at the age of 3 months. Others prefer to wait until the age of 6 months before considering a surgical procedure when no suspicion of root avulsion is found. We think that a conservative approach with intensive rehabilitation program can obtain good functional outcome for patients who will recover biceps function spontaneously between 3 and 6 months, and that it is not necessary to perform surgery at 3 months. To argue our choice, we have compared the long-term outcome of two groups of children with upper OBPP conservatively treated regarding the age of biceps recovery (before or after 3 months). PATIENTS AND METHODS Twenty-two patients with non operated upper roots birth palsy, followed in Timone's Hospital of Marseille by a multidisciplinary team, have recovered a biceps contraction between 1 and 8 months and were retrospectively included in this study. All children underwent an intensive rehabilitation program since birth, performed by a specialized physiotherapist. Patients were reviewed, and their shoulder function was assessed using Mallet score. The score was analysed regarding the age of biceps recovery. RESULTS The mean follow up was 8.2 years. Nine children recovered a biceps contraction at 3 months of age or before; the mean global Mallet score was 4.11. Thirteen children recovered a biceps contraction after 3 months of age (between 3 and 8 months); the mean global Mallet score was 3.92. The difference was not statistically significant. CONCLUSION This study shows that global shoulder function is comparable for two groups. The children who did not recover a biceps contraction at 3 months of age had a global shoulder function as good as the one who recovered biceps function earlier. We think our intensive rehabilitation program allowed us to avoid a useless early surgery. Surgical plexus treatment was indicated for children who did not have biceps contraction after 6 months of age.
Collapse
Affiliation(s)
- C Philandrianos
- Service de chirurgie plastique, hôpital Nord, chemin des Bourelly, Marseille, France.
| | | | | | | | | | | | | |
Collapse
|
15
|
Pondaag W, Allen RH, Malessy MJA. Correlating birthweight with neurological severity of obstetric brachial plexus lesions. BJOG 2011; 118:1098-103. [DOI: 10.1111/j.1471-0528.2011.02942.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
16
|
Abstract
Shoulder dystocia and brachial plexus injury occur in 0.5% to 1.5% of all births. Risk factors for both include maternal obesity, excessive prenatal weight gain, maternal diabetes, protracted labor, and fetal macrosomia. These factors are involved in only about 50% of births complicated by shoulder dystocia or brachial plexus injury. Shoulder dystocia has a low recurrence rate (9.8%-16.7%), although history of previous shoulder dystocia is the most reliable predictor of occurrence. Brachial plexus injury is the most common morbidity associated with shoulder dystocia, but 50% of newborns who present with this injury were not subject to shoulder dystocia at birth. Most brachial plexus injuries are transient, although 5% to 22% become permanent. Shoulder dystocia followed by permanent brachial plexus injury or mental impairment is one of the leading causes of malpractice allegations. Prompt assessment and management of shoulder dystocia and preparation to maximize the efficiency of shoulder dystocia maneuvers are critical. Documentation of the appropriate use of maneuvers to relieve shoulder dystocia demonstrates standard of care practice, thereby decreasing the potential for successful malpractice allegations.
Collapse
Affiliation(s)
- Cecilia M Jevitt
- University of South Florida College of Nursing, Tampa, FL 33544, USA.
| |
Collapse
|
17
|
Current concepts in the management of brachial plexus birth palsy. J Hand Surg Am 2010; 35:322-31. [PMID: 20141905 DOI: 10.1016/j.jhsa.2009.11.026] [Citation(s) in RCA: 155] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2009] [Accepted: 11/27/2009] [Indexed: 02/02/2023]
Abstract
Brachial plexus birth palsy, although rare, may result in substantial and chronic impairment. Physiotherapy, microsurgical nerve reconstruction, secondary joint corrections, and muscle transpositions are employed to help the child maximize function in the affected upper extremity. Many present controversies regarding natural history, microsurgical treatment, and secondary shoulder reconstructive surgery remain unresolved in infants with brachial plexus birth palsies. Recent literature has enhanced our understanding of the pathoanatomy and natural history of the injury as well as the surgical indications, expected outcomes, and complications; this literature has led to improved care of these patients. Based on the present evidence, recommendations for both microsurgery and shoulder reconstruction with tendon transfer and arthroscopic and open reductions are presented.
Collapse
|
18
|
Foad SL, Mehlman CT, Foad MB, Lippert WC. Prognosis following neonatal brachial plexus palsy: an evidence-based review. J Child Orthop 2009; 3:459-63. [PMID: 19885693 PMCID: PMC2782065 DOI: 10.1007/s11832-009-0208-3] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2009] [Accepted: 09/19/2009] [Indexed: 02/03/2023] Open
Abstract
PURPOSE The spontaneous recovery rate of neonatal brachial plexus palsy (NBPP) is often cited as 75-95%. However, recent reports have found the recovery rate to be much lower. The purpose of this study was to perform an evidence-based review aimed at summarizing the available English language information regarding prognosis following NBPP based on the Narakas classification. METHODS A Medline database search was performed to identify articles that focused on the natural history, outcome, prognosis, or conservative treatment of neonatal brachial plexus birth injury from 1966 to 2006. Twenty-four articles were identified. The articles were graded according to the Oxford Evidence Based Grading Scale and data regarding sample size, follow up, study purpose, Narakas grouping, Mallet scale, and recovery of function at 3 and 6 months were extracted. Of the 24 articles, 11 were included for review. Data analysis included odds ratios and percent recovery. RESULTS Of the 11 studies, only one was given a grade of a Level I study, three were given a grade of Level II, and seven were given a grade of Level IV. Sixty-four percent of infants classified as Narakas I and II had spontaneous recovery of biceps function at 3 months of age and only 9% of the Narakas III and IV group had recovery. Sixty-five percent of the Narakas I and II group had complete recovery at 6 months of age and only 14% of the Narakas III and IV group had recovery. The odds of biceps recovery at 3 months of age for the Narakas I and II group was 19 times higher compared to the III and IV group. The odds of complete recovery were 11 times higher for the Narakas I and II group compared to the III and IV group. CONCLUSION The quality of the literature regarding the prognosis of neonatal brachial plexus injury is poor. Based on the Narakas classification, recovery better for NBPP classified as Narakas I and II.
Collapse
Affiliation(s)
- Susan L. Foad
- />Division of Orthopaedics, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, MLC 9018, Cincinnati, OH 45229 USA
| | - Charles T. Mehlman
- />Division of Orthopaedics, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, MLC 2017, Cincinnati, OH 45229 USA
| | - Mohab B. Foad
- />Department of Orthopaedic Surgery, University of Cincinnati Medical Center, P.O. Box 670212, Cincinnati, OH 4267-0212 USA
| | - William C. Lippert
- />Division of Orthopaedics, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, MLC 9018, Cincinnati, OH 45229 USA
| |
Collapse
|
19
|
Heise CO, Siqueira MG, Martins RS, Gherpelli JLD. Motor nerve-conduction studies in obstetric brachial plexopathy for a selection of patients with a poor outcome. J Bone Joint Surg Am 2009; 91:1729-37. [PMID: 19571096 DOI: 10.2106/jbjs.h.00542] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The criteria and timing for nerve surgery in infants with obstetric brachial plexopathy remain controversial. Our aim was to develop a new method for early prognostic assessment to assist this decision process. METHODS Fifty-four patients with unilateral obstetric brachial plexopathy who were ten to sixty days old underwent bilateral motor-nerve-conduction studies of the axillary, musculocutaneous, proximal radial, distal radial, median, and ulnar nerves. The ratio between the amplitude of the compound muscle action potential of the affected limb and that of the healthy side was called the axonal viability index. The patients were followed and classified in three groups according to the clinical outcome. We analyzed the receiver operating characteristic curve of each index to define the best cutoff point to detect patients with a poor recovery. RESULTS The best cutoff points on the axonal viability index for each nerve (and its sensitivity and specificity) were <10% (88% and 89%, respectively) for the axillary nerve, 0% (88% and 73%) for the musculocutaneous nerve, <20% (82% and 97%) for the proximal radial nerve, <50% (82% and 97%) for the distal radial nerve, and <50% (59% and 97%) for the ulnar nerve. The indices from the proximal radial, distal radial, and ulnar nerves had better specificities compared with the most frequently used clinical criterion: absence of biceps function at three months of age. CONCLUSIONS The axonal viability index yields an earlier and more specific prognostic estimation of obstetric brachial plexopathy than does the clinical criterion of biceps function, and we believe it may be useful in determining surgical indications in these patients.
Collapse
Affiliation(s)
- Carlos O Heise
- University of São Paulo Medical School Clinics Hospital, São Paulo, Brazil.
| | | | | | | |
Collapse
|
20
|
Nath RK, Liu X. Nerve reconstruction in patients with obstetric brachial plexus injury results in worsening of glenohumeral deformity: a case-control study of 75 patients. ACTA ACUST UNITED AC 2009; 91:649-54. [PMID: 19407301 DOI: 10.1302/0301-620x.91b5.21878] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Whereas a general trend in the management of obstetric brachial plexus injuries has been nerve reconstruction in patients without spontaneous recovery of biceps function by three to six months of age, many recent studies suggest this may be unnecessary. In this study, the severity of glenohumeral dysplasia and shoulder function and strength in two groups of matched patients with a C5-6 lesion at a mean age of seven years (2.7 to 13.3) were investigated. One group (23 patients) underwent nerve reconstruction and secondary operations, and the other (52 patients) underwent only secondary operations for similar initial clinical presentations. In the patients with nerve reconstruction shoulder function did not improve and they developed more severe shoulder deformities (posterior subluxation, glenoid version and scapular elevation) and required a mean of 2.4 times as many operations as patients without nerve reconstruction. This study suggests that less invasive management, addressing the muscle and bone complications, is a more effective approach. Nerve reconstruction should be reserved for those less common cases where the C5 and C6 nerve roots will not recover.
Collapse
Affiliation(s)
- R K Nath
- Texas Nerve and Paralysis Institute, Houston, Texas 77030, USA.
| | | |
Collapse
|
21
|
Abstract
Traction injury to the brachial plexus sustained during the birth process that results in impaired neuromuscular function of the upper extremity continues to occur despite advances in modern obstetric care. The most common pattern of injury usually results in motor weakness of shoulder external rotation, leading to internal rotation contractures and subsequent deformity of the skeletally immature glenohumeral joint. Understanding of these deformities and effective surgical intervention have advanced greatly over the past decade. Restoration of balance between internal and external rotation forces around the shoulder has great potential for remodeling of the glenohumeral joint in the young child. Arthroscopic-directed release of the contracture, with select use of latissimus dorsi transfer to provide external rotation power, has proved to be effective for many children with these contractures.
Collapse
|
22
|
Terzis JK, Kostas I. Outcomes with suprascapular nerve reconstruction in obstetrical brachial plexus patients. Plast Reconstr Surg 2008; 121:1267-1278. [PMID: 18349646 DOI: 10.1097/01.prs.0000305537.74910.bf] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Restoration of shoulder abduction is very important following obstetrical brachial plexus paralysis. The purpose of this report is to present the authors' experience of suprascapular nerve reconstruction in 53 cases of obstetrical brachial plexus palsy. METHODS From 1978 to 2002, 170 children with obstetrical brachial plexus palsy were seen at the authors' institution. One hundred nine children underwent surgical treatment, and 53 of them had suprascapular nerve reconstruction. RESULTS The overall results were good or excellent in 96 percent of patients for the supraspinatus muscle and 75 percent for the infraspinatus muscle. The overall mean postoperative muscle grading was 3.71 +/- 0.7 for the supraspinatus muscle and 2.94 +/- 0.8 for the infraspinatus muscle (p < 0.05). By using the Mallet score, 23 patients (46 percent) achieved Mallet grade III and 24 patients (48 percent) achieved Mallet grade IV shoulder abduction function. Evaluating external rotation function, 21 patients (42 percent) achieved Mallet grade III and 20 patients (40 percent) achieved Mallet grade IV. Early surgery (<6 months) yielded significantly better results than late surgery (>6 months). CONCLUSIONS Suprascapular nerve neurotization is a worthwhile procedure and is a high priority in upper limb reanimation for restoration of glenohumeral joint stability, shoulder abduction, and external rotation. Concomitant neurotization of the axillary nerve yields improved outcomes in shoulder abduction function. The best results are seen in patients with high severity scores, when only the upper two roots are involved, and when direct neurotization of the suprascapular nerve is performed within 6 months after the injury.
Collapse
Affiliation(s)
- Julia K Terzis
- Norfolk, Va. From the Department of Surgery, Division of Plastic and Reconstructive Surgery, Eastern Virginia Medical School and International Institute of Reconstructive Microsurgery
| | | |
Collapse
|
23
|
Zafeiriou DI, Psychogiou K. Obstetrical brachial plexus palsy. Pediatr Neurol 2008; 38:235-42. [PMID: 18358400 DOI: 10.1016/j.pediatrneurol.2007.09.013] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2007] [Revised: 07/30/2007] [Accepted: 09/24/2007] [Indexed: 10/22/2022]
Abstract
Obstetrical brachial plexus palsy, one of the most complex peripheral nerve injuries, presents as an injury during the neonatal period. The majority of the children recover with either no deficit or a minor functional deficit, but it is almost certain that some will not regain adequate limb function. These few cases must be managed in an optimal way. Considerable medical and legal debate has surrounded the etiologic factors of this traumatic lesion, and obstetricians are often considered responsible for the injury. According to recent studies, spontaneous endogenous forces may contribute substantially to this type of neonatal trauma. All obstetric circumstances that predispose to brachial plexus damage and that could be anticipated should be assessed. Correct diagnosis is necessary for the accurate estimation of prognosis and treatment. The most important aspect of therapy is timely recognition and referral, to prevent the various possible sequelae affecting the shoulder, elbow, or forearm. Since the early 1990s, research has increased the understanding of obstetrical brachial plexus palsy. Further research is needed, focused on developing strategies to predict brachial injury. This review focuses on emerging data relating to obstetrical brachial plexus palsy and discusses the present controversies regarding natural history, prognosis, and treatment in infants with brachial plexus birth palsies.
Collapse
|
24
|
Uysal H, Demir SO, Oktay F, Selcuk B, Akyüz M. Extremity shortness in obstetric brachial plexus lesion and its relationship to root avulsion. J Child Neurol 2007; 22:1377-83. [PMID: 18174555 DOI: 10.1177/0883073807307103] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
A total of 73 patients with obstetric brachial plexus palsy and extremity shortness were evaluated clinically, electrophysiologically, and with cervical magnetic resonance imaging. Patients were separated into groups according to age and the level of lesion. The differences of the length of the humerus, ulna, radius, and the second and fifth metacarpal bones were significant between the involved and uninvolved extremities. The difference in shortness increased in relation to the age of the groups and stabilized to approximately 10% in the groups aged 4 to 8 years and 8+ years. A significant relationship was observed between bone length differences and lesion levels. Differences in bone lengths were statistically significant in patients with avulsion in the group aged 8+ years. Extremity shortness appears to be related to avulsion and the level of lesion. The effect of avulsion on extremity shortness gradually increases with age. Finally, root avulsion can be an important factor in extremity shortness of obstetric brachial plexus palsy patients.
Collapse
Affiliation(s)
- Hilmi Uysal
- Department Akdeniz University Hospital, Antalya, Turkey.
| | | | | | | | | |
Collapse
|
25
|
Evaluation of Elbow Flexion as a Predictor of Outcome in Obstetrical Brachial Plexus Palsy. Plast Reconstr Surg 2007; 120:1585-1590. [DOI: 10.1097/01.prs.0000282104.56008.cb] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
26
|
Les présentations cliniques. OSTÉOPATHIE PÉDIATRIQUE 2007. [PMCID: PMC7271215 DOI: 10.1016/b978-2-84299-917-9.50007-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
|
27
|
Heise CO, Gherpelli JLD. Prognostic relevance of risk factors for obstetrical brachial plexopathy. ARQUIVOS DE NEURO-PSIQUIATRIA 2006; 64:30-4. [PMID: 16622549 DOI: 10.1590/s0004-282x2006000100007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
We did a case-control study to verify if the birthweight, forceps delivery or perinatal asphyxia have any significant effect on the prognosis of obstetrical brachial plexopathy. Group A was composed of 25 infants who completely recovered at the age of 6 months. Group B was composed of 21 infants who were still not able to remove a blindfold from the face with the affected limb in the sitting position at the age of 12 months. There was no statistical difference of the median birthweight or median first minute Apgar score between the groups. There was also no relation between birthweight higher than 4000g, first minute Apgar score lower than 6 or forceps delivery with a poor prognosis.
Collapse
Affiliation(s)
- Carlos O Heise
- Ambulatório de Neurologia do Desenvolvimento, Clínica Neurológica, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil.
| | | |
Collapse
|
28
|
O'Brien DF, Park TS, Noetzel MJ, Weatherly T. Management of birth brachial plexus palsy. Childs Nerv Syst 2006; 22:103-12. [PMID: 16320018 DOI: 10.1007/s00381-005-1261-y] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2005] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The indications for surgical repair of congenital brachial plexus palsy are controversial. Our objective was to determine the results of early brachial plexus surgery following obstetric-induced brachial plexus palsy. METHODS We performed a retrospective analysis of the outcome of 58 cases of brachial plexus surgery. The indication for operation consisted of the presence of less than antigravity strength in the biceps, triceps, and deltoid muscle groups at 6 months of age. Data gathered prospectively, previously, showed the likelihood of improvement with less than antigravity strength in these cases to be poor. RESULTS Follow-up data were obtained on 52 of the 58 cases. Overall mean follow-up was 2 years. Twelve patients had more than 3 years follow-up (mean 5.5 years, range 3-11.5 years). Significant improvement was seen in all injury patterns i.e., C5-C6, C5-C7, and C5-C8, T1. Greater than antigravity strength in the biceps, triceps, and deltoid muscle groups was seen in the majority of cases at follow-up. CONCLUSIONS Repair of obstetrical brachial plexus palsy in children at 6 months of age that is based on less than antigravity strength in the biceps, triceps, and deltoid muscle groups produces improvement in functional capabilities. Children with obstetrical brachial plexus palsy should be referred soon after birth to a center that specializes in the treatment of this type of palsy.
Collapse
Affiliation(s)
- Donncha F O'Brien
- Department of Neurosurgery, St. Louis Children's Hospital, School of Medicine, Washington University in St. Louis, St. Louis, MO, USA
| | | | | | | |
Collapse
|
29
|
Benjamin K. Part 2. Distinguishing physical characteristics and management of brachial plexus injuries. Adv Neonatal Care 2005; 5:240-51. [PMID: 16202966 DOI: 10.1016/j.adnc.2005.06.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Brachial plexus injuries (BPI) are usually readily apparent at or shortly after birth. Failure of caregivers to recognize and appropriately treat BPI may contribute to the risk of life-long neuromuscular dysfunction for the infant and represents a serious medical-legal liability for the delivery provider. This article is the second in a series on BPI and provides a standard classification and a systematic guide to physical examination of the infant with suspected BPI. Conditions that mimic BPI are discussed along with diagnostic studies used to confirm this disorder. The natural history and predictors of outcome are presented along with a sample treatment protocol. Pictures and video clips are provided to enhance the reader's understanding of the consequences of this injury and the potential for improvement with surgical treatment. Useful Internet resources for parents, focused discharge planning, and guidelines for appropriate monitoring and follow-up are provided. Advantages of early referral and management by a multidisciplinary team at a brachial plexus specialty center are discussed.
Collapse
Affiliation(s)
- Kathleen Benjamin
- Department of Neonatology, The Children's Hospital, Denver, CO 80218, USA.
| |
Collapse
|
30
|
Heise CO, Gonçalves LR, Barbosa ER, Gherpelli JLD. Botulinum toxin for treatment of cocontractions related to obstetrical brachial plexopathy. ARQUIVOS DE NEURO-PSIQUIATRIA 2005; 63:588-91. [PMID: 16172705 DOI: 10.1590/s0004-282x2005000400006] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Botulinum toxin type A was recently introduced for treatment of biceps - triceps muscle cocontraction, which compromises elbow function in children with obstetrical brachial plexopathy. This is our preliminary experience with this new approach. Eight children were treated with 2 - 3 U/kg of botulinum toxin injected in the triceps (4 patients) and biceps (4 patients) muscle, divided in 2 or 3 sites. All patients submitted to triceps injections showed a long-lasting improvement of active elbow flexion and none required new injections, after a follow-up of 3 to 18 months. Three of the patients submitted to biceps injections showed some improvement of elbow extension, but none developed anti-gravitational strength for elbow extension and the effect lasted only three to five months. One patient showed no response to triceps injections. Our data suggest that botulinum toxin can be useful in some children that have persistent disability secondary to obstetrical brachial plexopathy.
Collapse
Affiliation(s)
- Carlos O Heise
- Department of Neurology, University of São Paulo Medical School, São Paulo, SP, Brazil.
| | | | | | | |
Collapse
|
31
|
Benjamin K. Part 1. Injuries to the brachial plexus: mechanisms of injury and identification of risk factors. Adv Neonatal Care 2005; 5:181-9. [PMID: 16084476 DOI: 10.1016/j.adnc.2005.03.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Upper-arm weakness (paresis) or paralysis indicates peripheral-nerve damage to the brachial plexus, a network of lower cervical and upper thoracic spinal nerves supplying the arm, forearm, and hand. Physical findings reflect muscle paralysis from spinal nerve roots. The mechanism of injury includes maternal, obstetric, and infant factors that apply traction on or compression to the anatomically vulnerable brachial plexus. Nerve regeneration can occur if nerve tissue components are preserved. Recovery is affected by multiple factors, including the type and site of injury, intervention timing, and developmental factors. The majority of injuries recover in days or months; however, residual deficits can persist. Part 1 of 2 of this article provides an overview of the neurophysiology of peripheral-nerve damage and nerve regeneration. The multifactorial etiology of brachial plexus injuries will be reviewed. Photographs and on-line video clips will enhance the description of the brachial plexus injury classifications and illustrate mechanisms of shoulder dystocia and obstetric relief maneuvers. A systematic approach to the physical examination will be explored in Part 2. Serial evaluation of motor function recovery is essential and is accomplished by appropriate referrals and follow-up. Part 2 will also describe treatment options and discuss anticipatory parent guidance.
Collapse
|
32
|
Pitt M, Vredeveld JW. The role of electromyography in the management of the brachial plexus palsy of the newborn. Clin Neurophysiol 2005; 116:1756-61. [PMID: 16000255 DOI: 10.1016/j.clinph.2005.04.022] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2005] [Revised: 04/26/2005] [Accepted: 04/27/2005] [Indexed: 11/24/2022]
Abstract
Despite being the foremost examination in the management of traumatic nerve damage electromyography (EMG) has an uncertain and ill-defined role in the investigation of brachial plexus palsy of the newborn (BPPN). This may be because EMG, which is used most commonly several months after birth, fails to answer adequately two of the most important questions posed by this condition: its aetiology and the likely prognosis. In this review, we contend that EMG has important contributions to the solution of both of these questions but only if the timing of the investigation is altered. Used early on in the first few days after birth, EMG can separate the rare palsies that occurred during the intrauterine period from those caused by events at the time of birth, and thus have an important role in directing the investigations of the aetiology more appropriately. EMG alone would still not be able to determine which of the perinatal events were responsible. If the EMG is then repeated before reinnervation complicates interpretation, it seems probable that it would identify accurately those cases, where neurotmesis and avulsion have occurred, much earlier than 3 months of age, the crucial age in the clinical assessment of BPPN for consideration for surgery. This might have very important implications for the future directions of treatment.
Collapse
Affiliation(s)
- Matthew Pitt
- Department of Clinical Neurophysiology, Great Ormond Street Hospital for Sick Children, NHS Trust, Great Ormond Street, London WC1N 3QH, UK.
| | | |
Collapse
|
33
|
Abstract
This is a prospective study of 107 repairs of obstetric brachial plexus palsy carried out between January 1990 and December 1999. The results in 100 children are presented. In partial lesions operation was advised when paralysis of abduction of the shoulder and of flexion of the elbow persisted after the age of three months and neurophysiological investigations predicted a poor prognosis. Operation was carried out earlier at about two months in complete lesions showing no sign of clinical recovery and with unfavourable neurophysiological investigations. Twelve children presented at the age of 12 months or more; in three more repair was undertaken after earlier unsuccessful neurolysis. The median age at operation was four months, the mean seven months and a total of 237 spinal nerves were repaired. The mean duration of follow-up after operation was 85 months (30 to 152). Good results were obtained in 33% of repairs of C5, in 55% of C6, in 24% of C7 and in 57% of operations on C8 and T1. No statistical difference was seen between a repair of C5 by graft or nerve transfer. Posterior dislocation of the shoulder was observed in 30 cases. All were successfully relocated after the age of one year. In these children the results of repairs of C5 were reduced by a mean of 0.8 on the Gilbert score and 1.6 on the Mallett score. Pre-operative electrodiagnosis is a reliable indicator of the depth of the lesion and of the outcome after repair. Intra-operative somatosensory evoked potentials were helpful in the detection of occult intradural (pre-ganglionic) injury.
Collapse
Affiliation(s)
- R Birch
- PNI Unit, The Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, Middlesex HA7 4LP, UK.
| | | | | | | |
Collapse
|
34
|
Abstract
Birth injuries of the brachial plexus are fairly common, but the majority of affected newborns make quick recoveries without any specific intervention. A minority suffer more severe injuries that lead to varying degrees of life-long disability. Happily, modern microsurgical techniques permit reconstruction of certain plexus injuries and, in carefully selected patients, can restore voluntary activity to target muscle groups. To what degree reanimation of paralyzed muscles improves function and quality of life for these children is a more important matter that has not yet been addressed at the level of modern standards of evidence. Brachial plexus reconstruction is only a first step in the multidisciplinary process needed to optimize long-term functional outcomes for severely affected infants.
Collapse
Affiliation(s)
- Joseph H Piatt
- Section of Neurosurgery, St. Christopher's Hospital for Children, Erie Avenue at Front Street, Philadelphia, PA 19134, USA; Department of Pediatrics, Drexel University College of Medicine, Philadelphia, PA 19134, USA
| |
Collapse
|
35
|
Abstract
Brachial plexus injuries (B.p.i.) are lesions occurring more and more frequently due to high velocity road and sport traumas. They are severe lesions with disabling sequelae. Surgical procedures and results could greatly be improved in the last 2 decades. Although the anatomy of brachial plexus is well known, less known are the functional maps of the various brachial plexus elements. In this paper treatment modalities for obstetrical, traumatic (adult) and actinic B.p.i. are being described too.
Collapse
Affiliation(s)
- G A Brunelli
- Director Foundation for Research on Spinal Cord Lesions, University of Brescia, Brescia, Italy.
| |
Collapse
|
36
|
Korak KJ, Tam SL, Gordon T, Frey M, Aszmann OC. Changes in spinal cord architecture after brachial plexus injury in the newborn. ACTA ACUST UNITED AC 2004; 127:1488-95. [PMID: 15175226 DOI: 10.1093/brain/awh155] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Obstetric brachial plexus palsy is a devastating birth injury. While many children recover spontaneously, 20-25% are left with a permanent impairment of the affected limb. So far, concepts of pathology and recovery have focused on the injury of the peripheral nerve. Proximal nerve injury at birth, however, leads to massive injury-induced motoneuron loss in corresponding motoneuron pools and therefore limits the extent of functional recovery. In the present study, the role of spinal cord plasticity after injury and recovery from obstetric brachial plexus lesions was investigated. A selective injury to spinal roots C5 and C6 was induced in newborn Sprague-Dawley rats, leading to motoneuron loss in corresponding motoneuron pools. Recovery of extremity function was evaluated with different behavioural paradigms. Permanent changes of adjacent motoneuron pools were quantitatively evaluated by retrograde tracing and functional muscle testing. We report that the adjacent C7 motoneuron contribution to biceps muscle innervation increased four-fold after upper trunk lesions in newborns, thus compensating for the injury-induced motoneuron loss. These results indicate that, in obstetric brachial plexus palsy, changes in spinal cord architecture are an integral part not only of primary pathology but also of the subsequent recovery process. While present treatment is directed towards the restoration of neural continuity, future treatment strategies must recognize and take advantage of CNS participation in the injury and recovery process.
Collapse
Affiliation(s)
- Klaus J Korak
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University Clinics of Vienna School of Medicine, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | | | | | | | | |
Collapse
|
37
|
Abstract
Birth injuries of the brachial plexus are fairly common, but most affected newborns make quick recoveries without any specific intervention. A minority suffer more severe injuries that lead to varying degrees of life-long disability. Modem microsurgical techniques permit reconstruction of certain plexus injuries and, in carefully selected patients, can restore voluntary activity to target muscle groups. The degree to which reanimation of paralyzed muscles improves function and quality of life for these children is a more important matter that has not yet been addressed using modern standards of evidence. Brachial plexus reconstruction is only a first step in the multidisciplinary process needed to optimize long-term functional outcomes for severely affected infants.
Collapse
Affiliation(s)
- Joseph H Piatt
- Section of Neurosurgery, St. Christopher's Hospital for Children, Erie Avenue at Front Street, Philadelphia, PA 19134-1095, USA.
| |
Collapse
|
38
|
DiTaranto P, Campagna L, Price AE, Grossman JAI. Outcome following nonoperative treatment of brachial plexus birth injuries. J Child Neurol 2004; 19:87-90. [PMID: 15072099 DOI: 10.1177/08830738040190020101] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Ninety-one infants who sustained a brachial plexus birth injury were treated with only physical and occupational therapy. The children were evaluated at 3-month intervals and followed for a minimum of 2 years. Sixty-three children with an upper or upper-middle plexus injury recovered good to excellent shoulder and hand function. In all of these children, critical marker muscles recovered M4 by 6 months of age. Twelve infants sustained a global palsy, with critical marker muscles remaining at M0-M1 at 6 months, resulting in a useless extremity. Sixteen infants with upper and upper-middle plexus injuries failed to recover greater than M1-M2 deltoid and biceps by 6 months, resulting in a very poor final outcome. These data provide useful guidelines for selection of infants for surgical reconstruction to improve ultimate outcome.
Collapse
Affiliation(s)
- Patricia DiTaranto
- Department of Orthopedics, Hospital Materno Infantil, Mar del Plata, Argentina
| | | | | | | |
Collapse
|
39
|
Pitt M, Vredeveld JW. Chapter 27 The role of electromyography in the management of obstetric brachial plexus palsies. ACTA ACUST UNITED AC 2004; 57:272-9. [PMID: 16106625 DOI: 10.1016/s1567-424x(09)70363-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Affiliation(s)
- Matthew Pitt
- Department of Clinical Neurophysiology, Great Ormond Street Hospital for Sick Children NHS Trust, Great Ormond Street, London WC1N 3QH, UK.
| | | |
Collapse
|
40
|
Heise CO, Lorenzetti L, Marchese AJT, Gherpelli JLD. Motor conduction studies for prognostic assessment of obstetrical plexopathy. Muscle Nerve 2004; 30:451-5. [PMID: 15372436 DOI: 10.1002/mus.20121] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Early prognostic assessment of obstetrical brachial plexopathies (OBP) would facilitate rational selection of infants for brachial plexus surgery. We performed bilateral motor nerve conduction studies (MNCS) of axillary, musculocutaneous, radial, median, and ulnar nerves in 33 babies (age 10-60 days) with OBP in order to compare the amplitude of compound muscle action potentials (CMAPs). All babies were followed up until 6 months of age and the outcome was classified according to muscle strength and arm function. A CMAP amplitude reduction of more than 90%, compared to the unaffected side, predicted severe weakness of the corresponding root level (p < 0.01). Our results indicate that MNCS are a useful tool for very early prognostic assessment of OBP.
Collapse
Affiliation(s)
- Carlos O Heise
- Department of Neurology, University of São Paulo Medical School, Brazil.
| | | | | | | |
Collapse
|
41
|
|
42
|
|