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Leblebicioğlu G, Pondaag W. Brachial plexus birth injury: advances and controversies. J Hand Surg Eur Vol 2024; 49:747-757. [PMID: 38366382 DOI: 10.1177/17531934241231173] [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] [Indexed: 02/18/2024]
Abstract
While there is considerable spontaneous recovery in most cases of brachial plexus birth injury, many children are left with significant problems that may lead to lifelong functional limitations, loss of work and social isolation. Detailed treatment with the right strategy can provide very valuable improvement in function. Over the past few years, the clinical approach to brachial plexus birth palsy has entered a new era in both diagnostic and surgical treatment methods. This article reviews four areas of management, the role of imaging in defining the severity of the injury, the optimal timing of for nerve exploration and reconstruction in appropriate cases, the advantages and potential complications of nerve transfers, and the role of physiotherapy. Available evidence is considered. Although it is difficult to make clear and precise inferences on a subject where there are many variables and considerable uncertainties, some currently accepted views will be summarized.Level of evidence: V.
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Affiliation(s)
| | - Willem Pondaag
- Department of Neurosurgery/Leiden Nerve Center, Leiden University Medical Center, Leiden, The Netherlands
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Singh DK, Kumar N, Bhayana A, Altamash M, Sharma A, Agarwal A. A pentavalent approach for the evaluation of traumatic brachial plexopathy on MRI: correlation of macropattern and micropattern. Br J Radiol 2023; 96:20220913. [PMID: 36752595 PMCID: PMC10230398 DOI: 10.1259/bjr.20220913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 01/20/2023] [Accepted: 01/24/2023] [Indexed: 02/09/2023] Open
Abstract
Macropattern analysis of traumatic brachial plexopathy (TBP) by Magnetic Resonance Imaging (MRI) encompasses localization of injured segments and determination of the severity of injury. The micropattern analysis implies the correlation of the MRI features of TBP with Sunderland's grading of the nerve injury, thereby guiding the management protocol. This review article presents a simplified novel pentavalent approach for the radiological anatomy of brachial plexus, MRI acquisition protocol for the evaluation of brachial plexus, cardinal imaging signs of TBP, and their correlation with Sunderland's microanatomical grading.
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Affiliation(s)
- Dharmendra Kumar Singh
- Department of Radiodiagnosis, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Nishith Kumar
- Department of Radiodiagnosis, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Aanchal Bhayana
- Department of Radiodiagnosis, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Mohd. Altamash
- Department of Radiodiagnosis, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Anuradha Sharma
- Department of Radiodiagnosis, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Anuj Agarwal
- Department of Radiodiagnosis, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
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Grahn P, Pöyhiä T, Nietosvaara Y. Permanent Brachial Plexus Birth Injury: Helsinki Shoulder Protocol. Semin Plast Surg 2023; 37:108-116. [PMID: 37503533 PMCID: PMC10371410 DOI: 10.1055/s-0043-1768940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
Passive shoulder exercises from birth and ultrasound screening from 3 to 12 months. Botox is given to shoulder internal rotators and a bracing commenced, if alpha-angle exceeds 30°, or passive shoulder external rotation is below 70 degrees. Plexus reconstruction is recommended to children with root avulsion(s) on magnetic resonance imaging or 3-month Toronto Test Score < 3.5. Specific neurotization is recommended to children without avulsions, but lack of progress in healing. Shoulder dysplasia was diagnosed in 49% of 270 patients with permanent brachial plexus birth injury in our catchment area from 1995 to 2021. The age at detection of shoulder dysplasia dropped from mean 5.4 years in children born before 2000 to mean 3.9 months in children born after 2009. Botox was given to 57% of the patients born after 2009. Rate of shoulder relocation decreased from 28 to 7% while mean active shoulder external rotation in adduction increased from 2 to 46°.
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Affiliation(s)
- Petra Grahn
- Department of Pediatric Orthopedics and Traumatology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Tiina Pöyhiä
- Department of Radiology, HUS Diagnostic Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Yrjänä Nietosvaara
- Department of Pediatric Orthopedics and Traumatology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Department of Pediatric Surgery, University of Eastern Finland and Kuopio University Hospital, Kuopio, Finland
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Ulmann ETE, Malessy MJA, Nagels J, Pondaag W. Shoulder Internal Rotation Contracture Formation in Surgically Managed C5, C6 Brachial Plexus Birth Injuries: Neurotmetic Lesions Fare Worse Than Avulsions. J Bone Joint Surg Am 2022; 104:2008-2015. [PMID: 36083976 DOI: 10.2106/jbjs.22.00373] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND A typical feature in infants with severe C5-C6 brachial plexus birth injury (BPBI) requiring nerve repair is the formation of shoulder internal rotation contracture (IRC). The underlying pathophysiological mechanism is unknown, and the sequelae can be difficult to treat. The severity of the IRC differs among children. C5-C6 lesions are heterogeneous at the root level. Our null hypothesis was that the type of root-level lesion (axonotmesis or neurotmesis versus avulsion) was not associated with the extent of IRC formation over time in children with upper-trunk BPBI. METHODS We performed a retrospective analysis of all patients with upper-trunk BPBI who underwent primary surgery of the C5 and/or C6 spinal nerves between 1990 and 2020 and had follow-up of at least 2 years. The primary outcome was passive shoulder external rotation (ER) in adduction at 1, 3, 5, 7, and 15 years of age. The secondary outcome was whether additional shoulder surgery was performed. The relationship between the nature of the C5-C6 lesion and IRC formation was analyzed using linear mixed models. The Kaplan-Meier method was used to estimate the cumulative risk of secondary shoulder procedures. RESULTS In total, 322 patients were analyzed; mean follow-up was 7.2 ± 4.6 years. The C5-C6 root lesion type was significantly related to the passive range of ER (overall test in linear mixed model, p = 0.007). Children with avulsion of C5 and C6 (n = 21) had, on average, 18° (95% confidence interval [CI], 6.3° to 30°) less IRC formation than those with neurotmesis of C5 and C6 (n = 175) and 17° (2.9° to 31°) less than those with neurotmesis of C5 and avulsion of C6 (n = 34). IRC formation did not differ between the neurotmesis C5-C6 and neurotmesis C5-avulsion C6 groups. Secondary shoulder procedures were performed in 77 patients (10-year risk, 28% [95%CI, 23% to 34%]). CONCLUSIONS Shoulder IRC formation in infants with BPBI with surgically treated C5-C6 lesions occurs to a lesser degree if the C5 root is avulsed than when C5 is neurotmetic. This finding provides insight into the possible causative pathoanatomy and may ultimately lead to strategies to mitigate IRC. LEVEL OF EVIDENCE Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Eva T E Ulmann
- Department of Neurosurgery, Leiden Nerve Center, Leiden University Medical Center, Leiden, the Netherlands
| | - Martijn J A Malessy
- Department of Neurosurgery, Leiden Nerve Center, Leiden University Medical Center, Leiden, the Netherlands
| | - Jochem Nagels
- Department of Orthopedic Surgery, Leiden Nerve Center, Leiden University Medical Center, Leiden, the Netherlands
| | - Willem Pondaag
- Department of Neurosurgery, Leiden Nerve Center, Leiden University Medical Center, Leiden, the Netherlands
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Hardie C, Brooks J, Wade R, Teh I, Bourke G. Diagnostic accuracy of magnetic resonance imaging for nerve injury in obstetric brachial plexus injury: protocol for systematic review and meta-analysis. Syst Rev 2022; 11:173. [PMID: 35987695 PMCID: PMC9392905 DOI: 10.1186/s13643-022-02037-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 07/28/2022] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Early and accurate clinical diagnosis of the extent of obstetric brachial plexus injury (OBPI) is challenging. The current gold standard for delineating the nerve injury is surgical exploration, and synchronous reconstruction is performed if indicated. Magnetic resonance imaging (MRI) is a non-invasive method of assessing the anatomy and severity of nerve injury in OBPI but the diagnostic accuracy is unclear. The primary objective of this review is to determine the diagnostic accuracy of MRI in comparison to surgical brachial plexus exploration for detecting root avulsion in children under 5 with OBPI. The secondary objectives are to determine its' diagnostic accuracy for detecting nerve abnormality and detecting pseudomeningocele(s) in this group. METHODS This review will be conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA).We will include studies reporting the accuracy of MRI (index test) compared to surgical exploration (reference standard) in detecting any of the three target conditions (root avulsion, any nerve abnormality and pseudomeningocele) in children under five with OBPI. Case reports and studies where the number of true positives, false positives, true negatives and false negatives cannot be derived will be excluded. We plan to search PubMed, Embase and CENTRAL for relevant studies from database inception to 15 June 2022. We will also search grey literature (medRxiv, bioRxiv and Google Scholar) and perform forward and backward citation chasing. Screening and full-text assessment of eligibility will be conducted by two independent reviewers, who will then both extract the relevant data. The QUADAS-2 tool will be used to assess methodological quality and risk of bias of included studies by two reviewers independently. The following test characteristics for the target conditions will be extracted: true positives, false positives, true negatives and false negatives. Estimates of sensitivity and specificity with 95% confidence intervals will be shown in forest plots for each study. If appropriate, summary sensitivities and specificities for target conditions will be obtained via meta-analyses using a bivariate model. DISCUSSION This study will aim to clarify the diagnostic accuracy of MRI for detecting nerve injury in OBPI and define its clinical role. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42021267629.
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Affiliation(s)
- Claire Hardie
- Leeds Institute for Medical Research, University of Leeds, Leeds, UK
- Department of Plastic and Reconstructive Surgery, Leeds Teaching Hospitals Trust, Leeds, UK
| | - James Brooks
- Leeds Institute for Medical Research, University of Leeds, Leeds, UK
| | - Ryckie Wade
- Leeds Institute for Medical Research, University of Leeds, Leeds, UK
- Department of Plastic and Reconstructive Surgery, Leeds Teaching Hospitals Trust, Leeds, UK
| | - Irvin Teh
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Grainne Bourke
- Leeds Institute for Medical Research, University of Leeds, Leeds, UK
- Department of Plastic and Reconstructive Surgery, Leeds Teaching Hospitals Trust, Leeds, UK
- Department of Integrative Medical Biology, University of Umea, Umeå, Sweden
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Lao Q, Jia Y, Zhao K, Liu K, Feng J. Value of High-Resolution MRI in the Diagnosis of Brachial Plexus Injury in Infants and Young Children. Int J Gen Med 2022; 15:5673-5680. [PMID: 35755861 PMCID: PMC9215839 DOI: 10.2147/ijgm.s362738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 06/13/2022] [Indexed: 11/26/2022] Open
Abstract
Purpose To investigate the value of high-resolution MRI based on 3D-short inversion time inversion recovery sampling perfection with application-optimized contrasts (3D-STIR SPACE) sequence for the diagnosis of brachial plexus injury in infants and young children. Methods Physical examination, electromyography (EMG) and MRI data of 26 children with brachial plexus injury were retrospectively analyzed. Sensitivity, specificity, and accuracy were calculated for the three tests. The agreement among these examinations was analyzed with the Kappa test. P<0.05 was considered statistically significant. Results Of the 26 children, 3 cases had normal MRIs, 23 cases had unilateral brachial plexus injury diagnosed with MRI, and a total of 73 nerve roots and/or sheaths were involved. Among the 23 cases with aberrant MRI findings, there were 19 cases of nerve root thickening (42 nerve roots), 4 cases of nerve root sleeve expansion (5 nerve roots), 17 cases of pseudomeningeal cysts (34 nerve roots), 2 cases of nerve root loosening (2 nerve roots), 8 cases of nerve root dissection (11 nerve roots), 19 cases with increased nerve signal (43 nerve roots), and 9 cases with an increased signal of the muscles on the affected side. As for the diagnosis of brachial plexus injury, the sensitivity and the accuracy of physical examination, EMG and MRI were 0.92, 0.86, and 0.88, respectively. The agreement between MRI and physical examination was substantial (κ=0.780, P=0.000), as did the agreement between MRI and EMG (κ=0.611, P=0.005). Conclusion High-resolution MRI based on 3D-STIR SPACE sequence plays a role in the diagnosis and evaluation of brachial plexus injury in infants and young children. It can accurately identify the injured nerve and characterize related pathological alterations. Besides EMG and physical examination, it can be used as a valuable tool for screening and monitoring of brachial plexus injury in infants and children.
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Affiliation(s)
- Qun Lao
- Department of Radiology, Hangzhou Children's Hospital, Hangzhou, People's Republic of China
| | - Yuzhu Jia
- Department of Radiology, Tongde Hospital of Zhejiang Province, Hangzhou, People's Republic of China
| | - Kaiyu Zhao
- Department of Radiology, Hangzhou Children's Hospital, Hangzhou, People's Republic of China
| | - Kun Liu
- Department of Radiology, The Second Affiliated Hospital and Yuying Children's Hospital, Wenzhou Medical University, Wenzhou, People's Republic of China
| | - Jianju Feng
- Department of Radiology, Zhuji Affiliated Hospital of Shaoxing University, Shaoxing, People's Republic of China
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González-Mantilla P, Abril A, Bedoya MA. Brachial Plexus Birth Palsy: Practical Concepts for Radiologists. Semin Musculoskelet Radiol 2022; 26:182-193. [PMID: 35609579 DOI: 10.1055/s-0042-1742392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Brachial plexus birth palsy (BPBP) is classified as a preganglionic or postganglionic injury based on the site of injury. Most patients recover spontaneously and are followed up with clinical evaluation; however, permanent sequelae are not uncommon. For patients with persistent neurologic deficits, clinical and radiologic evaluation is crucial. Untreated BPBP can progress to significant sequelae, such as muscle contractures and glenohumeral dysplasia (GHD). Timely characterization of these entities based on different imaging modalities is a high priority for optimal patient outcomes. We describe the anatomy and pathogenesis, as well as the different imaging modalities involved in the evaluation and classification of BPBP and GHD.
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Affiliation(s)
| | - Angela Abril
- Geisinger Autism & Developmental Medicine Institute, Lewisburg, Pennsylvania
| | - Maria Alejandra Bedoya
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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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
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