Complications of microsurgical reconstruction of obstetrical brachial plexus palsy

The Outcome of Spinal Accessory Nerve Transfer to the Musculocutaneous Nerve in Birth Brachial Plexus Palsy

PURPOSE

Patients with brachial plexus birth injury with limited intraplexal donors require the use of extraplexal donors. Concern regarding the potential for respiratory problems resulting from the harvest of intercostal nerves or the phrenic nerve suggests the need for other options. Transfer of the spinal accessory nerve (SAN) is one option for restoring elbow flexion in adult patients; however, there are few reports of the results of this transfer in brachial plexus birth injury. This study aimed to report the result of SAN transfer to the musculocutaneous nerve (MCN) in brachial plexus birth injury.

METHODS

Patients who had undergone SAN to MCN nerve transfer were included in this study. Patients were classified according to Narakas classification. The chart was reviewed for the time for recovery of elbow flexion according to the Active Movement Scale (AMS).

RESULTS

Eleven patients underwent SAN to MCN transfers with interpositional sural nerve grafts. Mean birthweight was 4,070 grams (range: 3,300-4,670). Mean time to operation was 6.5 months (range: 4-10). Of the 11 patients, two were of Narakas type 3, whereas the others were of type 4. One patient did not recover elbow flexion and underwent later tendon transfer, whereas the other 10 patients reached AMS grade M6 recovery. The median time for AMS grade M1 elbow flexion recovery was eight months (interquartile range: 6.2-8.8) and for AMS grade M5 was 26 months (interquartile range: 14.2-36.5).

CONCLUSIONS

Spinal accessory nerve to MCN transfer with an interposition nerve graft is a viable option for restoring elbow flexion. However, long-term outcomes of this procedure have yet to be fully demonstrated.

TYPE OF STUDY/LEVEL OF EVIDENCE

Case series IV.

Management of Brachial Plexus Birth Injury: The SickKids Experience

This article describes the approach utilized by the multidisciplinary team at Sick Kids Hospital to evaluate and treat patients with brachial plexus birth injury (BPBI). This approach has been informed by more than 30 years of experience treating over 1,800 patients with BPBI and continues to evolve over time. The objective of this article is to provide readers with a practical overview of the Sick Kids approach to the management of infants with BPBI.

Elbow flexion in neonatal brachial plexus palsy: a meta-analysis of graft versus transfer

BACKGROUND

Functional elbow flexion recovery is one of the main goals of neonatal brachial plexus palsy (NBPP) reconstruction. The current neurosurgical treatment options include nerve grafting and nerve transfer.

OBJECTIVE

The present study sought to examine the literature for comparison of functional elbow flexion recovery in NBPP following nerve grafting or nerve transfer. We conducted a systematic literature review and meta-analysis according to PRISMA guidelines. A search was conducted on Pubmed/Medline and Cochrane for eligible studies published until November of 2018. Odd ratios (OR) and 95% confidence intervals (CI) were calculated to compare functional elbow flexion outcomes between nerve graft and nerve transfer. A random effects model meta-analysis was conducted. A Medical Research Council (MRC) score ≥ 3 or Active Movement Scale (AMS) ≥ 5 was considered a functional recovery of elbow flexion.

RESULTS

The present study included 194 patients from 1990 to 2015 across five observational trials. Only pediatric patients with obstetric brachial plexus injury were included. The mean patient age at surgery varied between studies from 5.7 months to 11.9 months and mean follow-up from 12 to 70 months. No complications or cases of donor site morbidity were reported. From the included studies, 118 patients were reported with MRC or AMS scoring usable for odd ratio comparison. Functional recovery occurred with nerve transfer in 95.2% of patients (n = 59/62) and with nerve grafting in 96.4% of patients (n = 54/56). Overall, the outcomes for elbow flexion between the groups appeared similar (OR 1.15, 95% CI 0.19-7.08, I² 2.9%).

CONCLUSION

Comparing nerve grafting and nerve transfer for NBPP, there is no statistically significant difference in functional elbow flexion recovery.

Outcomes from primary surgical reconstruction of neonatal brachial plexus palsy in 104 children

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).

An Update on the Management of Neonatal Brachial Plexus Palsy-Replacing Old Paradigms: A Review

IMPORTANCE

Neonatal brachial plexus palsy (NBPP) can result in persistent deficits for those who develop it. Advances in surgical technique have resulted in the availability of safe, reliable options for treatment. Prevailing paradigms include, "all neonatal brachial plexus palsy recovers," "wait a year to see if recovery occurs," and "don't move the arm." Practicing by these principles places these patients at a disadvantage. Thus, the importance of this review is to provide an update on the management of NBPP to replace old beliefs with new paradigms.

OBSERVATIONS

Changes within denervated muscle begin at the moment of injury, but without reinnervation become irreversible 18 to 24 months following denervation. These time-sensitive, irreversible changes are the scientific basis for the recommendations herein for the early management of NBPP and put into question the old paradigms. Early referral has become increasingly important because improved outcomes can be achieved using new management algorithms that allow surgery to be offered to patients unlikely to recover sufficiently with conservative management. Mounting evidence supports improved outcomes for appropriately selected patients with surgical management compared with natural history. Primary nerve surgery options now include nerve graft repair and nerve transfer. Specific indications continue to be elucidated, but both techniques offer a significant chance of restoration of function.

CONCLUSIONS AND RELEVANCE

Mounting data support both the safety and effectiveness of surgery for patients with persistent NBPP. Despite this support, primary nerve surgery for NBPP continues to be underused. Surgery is but one part of the multidisciplinary care of NBPP. Early referral and implementation of multidisciplinary strategies give these children the best chance of functional recovery. Primary care physicians, nerve surgeons, physiatrists, and occupational and physical therapists must partner to continue to modify current treatment paradigms to provide improved quality care to neonates and children affected by NBPP.

Retropharyngeal Contralateral C7 Nerve Transfer to the Lower Trunk for Brachial Plexus Birth Injury: Technique and Results

PURPOSE

Brachial plexus birth injuries with multiple nerve root avulsions present a particularly difficult reconstructive challenge because of the limited availability of donor nerves. The contralateral C7 has been described for brachial plexus reconstruction in adults but has not been well-studied in the pediatric population. We present our technique and results for retropharyngeal contralateral C7 nerve transfer to the lower trunk for brachial plexus birth injury.

METHODS

We performed a retrospective review. Any child aged less than 2 years was included. Charts were analyzed for patient demographic data, operative variables, functional outcomes, complications, and length of follow-up.

RESULTS

We had a total of 5 patients. Average nerve graft length was 3 cm. All patients had return of hand sensation to the ulnar nerve distribution as evidenced by a pinch test, unprompted use of the recipient limb without mirror movement, and an Active Movement Scale (AMS) of at least 2/7 for finger and thumb flexion; one patient had an AMS of 7/7 for finger and thumb flexion. Only one patient had return of ulnar intrinsic hand function with an AMS of 3/7. Two patients had temporary triceps weakness in the donor limb and one had clinically insignificant temporary phrenic nerve paresis. No complications were related to the retropharyngeal nerve dissection in any patient. Average follow-up was 3.3 years.

CONCLUSIONS

The retropharyngeal contralateral C7 nerve transfer is a safe way to supply extra axons to the severely injured arm in brachial plexus birth injuries with no permanent donor limb deficits. Early functional recovery in these patients, with regard to hand function and sensation, is promising.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic V.

Complications in Surgery for Brachial Plexus Birth Injury: Avoidance and Treatment

Brachial plexus birth injuries are rare, with treatment and follow-up often required from infancy until skeletal maturity. We review complications that may occur related to primary nerve surgery or secondary musculoskeletal procedures, and discuss how these may be avoided.

Intravenous Access in Infants Undergoing Bilateral Sural Nerve Grafts for Primary Brachial Plexus Exploration

Background:

Intravenous access (IVA) in infants undergoing primary brachial plexus exploration may be difficult. Both lower limbs are prepared and draped for sural nerve graft harvesting. The injured upper limb is also prepared and draped and is not available for IVA. In difficult IVA from the remaining upper limb, we have been using one of the feet for IVA. The infection rate and problems of intravenous infusions in this setting have never been studied in the literature. This study documents the infection rate and problems of intravenous infusions in these infants when a foot (within the sterile field) is used for IVA.

Methods:

This is a retrospective study of 63 consecutive infants undergoing primary brachial plexus exploration, and in whom IVA was obtained from one of the feet. Infection rate and problems of intravenous infusions were recorded.

Results:

No surgical wound infection and no infection of the IVA site were noted. There were no instances of accidental dislodgement of the intravenous cannula and no instances of extravasation.

Conclusion:

The use of one of the feet (within the sterile filed) for IVA is safe and acceptable in infants undergoing primary brachial plexus exploration and bilateral sural nerve grafting.

The use of the phrenic nerve communicating branch to the fifth cervical root for nerve transfer to the suprascapular nerve in infants with obstetric brachial plexus palsy

Traditionally, suprascapular nerve reconstruction in obstetric brachial plexus palsy is done using either the proximal C5 root stump or the spinal accessory nerve. This paper introduces another potential donor nerve for neurotizing the suprascapular nerve: the phrenic nerve communicating branch to the C5 root. The prevalence of this communicating branch ranges from 23% to 62% in various anatomical dissections. Over the last two decades, the phrenic communicating branch was used to reconstruct the suprascapular nerve in 15 infants. Another 15 infants in whom the accessory nerve was used to reconstruct the suprascapular nerve were selected to match the former 15 cases with regard to age at the time of surgery, type of palsy, and number of avulsed roots. The results showed that there is no significant difference between the two groups with regard to recovery of external rotation of the shoulder. It was concluded that the phrenic nerve communicating branch may be considered as another option to neurotize the suprascapular nerve.

Iatrogenic burn caused by an operating microscope: case report

We present a patient who experienced a burn from an operating microscope during surgery for a brachial plexus birth palsy, a literature review, and recommendations on how to avoid such injuries.

Obstetrical brachial plexus palsy

SUMMARY

In this article, the authors review their approach to evaluation, operative management, and reconstructive technique. Brachial plexus injuries in the newborn are usually managed nonoperatively. The timing and indications for primary surgery vary significantly between institutions. The motor examination is used to determine which infants would benefit from operative management. Patients are selected based on established criteria, such as the Toronto Test Score, applied at age 3 months. However, some cases are initially less clear, and we may recommend delaying operative management until age 6 months or as late as age 9 months if the child fails the cookie test. Neuroma excision, sural nerve grafting, and nerve transfers are performed when indicated by clinical motor examination. The use of selective motor nerve transfers, either in combination with nerve grafting or alone, has allowed nerve coaptations to be performed closer to the neuromuscular junction, which may further improve regeneration. Children undergoing primary surgery experience low rates of perioperative morbidity, and they experience gains in motor function until 3 or 4 years postoperatively, at which point recovery stabilizes.

Management of brachial plexus injuries

Most brachial plexus lesions are traction injuries sustained during birth, but in adolescents and older people they are usually caused by traffic accidents or following a fall in the home. A minority are the result of penetrating injury after civilian assault or trauma encountered during wartime. Birth palsy cases (obstetric brachial plexus palsy) and the remaining cases (traumatic briachial plexus palsy) are viewed differently with regard to treatment and outcome and so these two groups are usually discussed in separate chapters. In this paper we treat both groups in parallel because as far as primary (= nerve) surgery is concerned, many treatment problems and solutions are present in both groups and are therefore comparable.