The function of the hand after operations for obstetric injuries to the brachial plexus

Hand function outcomes following surgical treatment of complete neonatal brachial plexus palsy

PURPOSE

Although re-innervation of the hand is considered a priority in the treatment of infants with complete brachial plexus injury, there is currently a paucity of publications investigating hand function outcomes following primary nerve reconstruction in infants with neonatal brachial plexus palsy (NBPP). This study therefore aimed to evaluate hand function outcomes in a series of patients with complete NBPP.

METHODS

This retrospective case series included all patients who underwent primary nerve surgery for complete neonatal brachial plexus palsy over an 8-year period. Outcomes were assessed using the Raimond Hand Scale. Classification of grade 3 or higher indicates a functional hand (assistance in bimanual activity).

RESULTS

Nineteen patients with a complete NBPP underwent primary nerve reconstruction at a mean age of 3.7 months. Periodic clinical evaluations were performed until at least 4 years of age. According to the Raimondi hand scale, one patient did not recover (grade 0), three patients attained grade 1, four grade 2, ten grade 3, and in one grade 4. Overall hand functional recovery was achieved in 57.8% (11/19) of patients.

CONCLUSION

Sufficient recovery of hand function to perform bimanual activity tasks in patients with complete NBPP lesions is possible and should be a priority in the surgical treatment of these infants.

Recent Advances in the Treatment of Brachial Plexus Birth Injury

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Describe methods of clinical evaluation for neurologic recovery in brachial plexus birth injury. 2. Understand the role of different diagnostic imaging modalities to evaluate the upper limb. 3. List nonsurgical strategies and surgical procedures to manage shoulder abnormality. 4. Explain the advantages and disadvantages of microsurgical nerve reconstruction and distal nerve transfers in brachial plexus birth injury. 5. Recognize the prevalence of pain in this population and the need for greater sensory outcomes evaluation.

SUMMARY

Brachial plexus birth injury (BPBI) results from closed traction injury to the brachial plexus in the neck during an infant's vertex passage through the birth canal. Although spontaneous upper limb recovery occurs in most instances of BPBI, some infants do not demonstrate adequate motor recovery within an acceptable timeline and require surgical intervention to restore upper limb function. This article reviews major advances in the management of BPBI in the past decade that include improved understanding of shoulder pathology and its impact on observed motor recovery, novel surgical techniques, new insights in sensory function and pain, and global efforts to develop standardized outcomes assessment scales.

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

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

Sensory Outcome in Children Following Microsurgery for Brachial Plexus Birth Injury

PURPOSE

Studies are limited on sensory outcome in children with brachial plexus birth injury (BPBI). The purpose of this research was to evaluate the sensory function of the hand in children with BPBI who had microsurgical reconstruction of the brachial plexus.

METHODS

The sensory thresholds of children with upper and total plexus injury were evaluated with the Weinstein Enhanced Sensory Test and a test of stereognosis.

RESULTS

A total of 63 children participated (aged 10.92 ± 3.29 years), 24 (38%) of whom had abnormal sensory thresholds in the affected hand. Only 4 children had loss of protective sensation or higher thresholds. These 4 measurements were all identified in the territory of the superficial branch of the radial nerve. Twelve children with upper plexus (43%) and 12 (34%) with total plexus injury had sensory impairment in the affected hand. These proportions were not statistically different. Of all children evaluated, 18 (29%) had a lower stereognosis score in the affected hand compared with the unaffected hand. The proportions of children with impairment in stereognosis in the upper plexus group (n = 5; 18%) versus the total plexus group (n = 13; 37%) were not statistically different. Age at the time of assessment, sex, upper versus total plexus injury, number of root avulsions, subjective report of altered sensation, and Faces Pain Scale-Revised score were not related to sensory impairment in the affected hand.

CONCLUSIONS

Sensory recovery in BPBI after microsurgical reconstruction in children with total plexus injury who had reconstruction of the lower trunk had the potential to achieve sensory recovery similar to their upper plexus counterparts. A large proportion of children achieve normal sensory outcome, and those who had deficits had mild impairments.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

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).

Characteristics and outcomes of obstetric brachial plexus palsy in a single Saudi center: an experience of ten years

BACKGROUND

Obstetric brachial plexus palsy (OBPP) is considered a rare, unpredictable, and unavoidable injury of the upper limb. In this study, we presented a retrospective cohort study over a period of ten years in King Faisal Specialists Hospital and Research Centre (KFSH&RC), Riyadh, Saudi Arabia, to assess the characteristics and functional outcomes of OBPP.

METHODS

Between January 2005 and December 2015, we carried out 125 repairs of OBPP in KFSH&RC. Out of 71 girls and 54 boys, two babies died of unrelated causes, so they were excluded from the review. All medical records of the patients who attended OBPP clinic at KFSH&RC were reviewed, and relative data were extracted. Descriptive measures for categorical variables and categorical variables were presented. Student's t test and Pearson's χ² test were used. The level of statistical significance was set at P ≤ 0.05.

RESULTS

A total of 123 patients were included in the study with a mean follow-up of 6.1 ± 2.4 years. Of those, 71 (57.7%) were females. Mean age at presentation was 4.2 ± 2.7 months with a birth weight of 3965.9 ± 629.6 g. More than half of the patients (56.1%) sustained the injury in the right side, and 62 patients (50.4%) were classified as Narakas I. Most of the surgeries (96.7%) were nerve grafting. Only 32 (26.0%) patients needed one or more secondary interventions. In the last visit, the mean total score of Mallet was 16.6 ± 2.8. Also, passive external rotation in adduction improved to 38.3 ± 14.5. Last Raimondi hand function grade was 2 ± 1.

DISCUSSION

Our experience demonstrated the value of primary and secondary surgeries in patients with OBPP. Also, we presented the patterns of injury in Saudi patients presented to KFSH&RC.

Direct Nerve Sutures in (Extended) Upper Obstetric Brachial Plexus Repair

Background  In rare, selected cases of severe (extended) upper obstetric brachial plexus palsy (OBPP), after supraclavicular exposure and distal mobilization of the traumatized trunks and careful neuroma excision, we decided to perform direct nerve coaptation with tolerable tension and immobilized the affected arm positioned in adduction and 90-degree elbow flexion for three weeks.

Objectives  We present our surgical technique and preliminary results in a prospective open patient series, including 22 patients (14 right and 8 left side affected) between 2009 and 2016, operated at a mean age of 8.4 months.

Methods  Analysis of functional results after a minimum of 18 months was conducted using the British Medical Research Council (BMRC) scale.

Results  All children reached 60–90° of elbow flexion and 75° of shoulder abduction at already six months after surgery. For those patients having already passed one year post surgery, the mean active shoulder abduction reached 92°, and for those who past the 18 months 124°. We discuss the actual knowledge about nerve coaptation under “reasonable” tension including its advantages and drawbacks.

Conclusion  This technique may be indicated in preoperatively selected cases of (extended) upper OBPP and may give good functional results.

Recovery of upper extremity function following endoscopically assisted contralateral C7 transfer for obstetrical brachial plexus injury

Transfer of the contralateral C7 nerve for reconstruction of the brachial plexus in infants with obstetrical brachial plexus injury has rarely been reported. We developed a new endoscopy-assisted technique via the prevertebral (retroesophageal) route for the transfer of the contralateral C7 nerve in reconstruction of the brachial plexus. The reconstruction was performed in 20 infants (14 boys and six girls). Motor recovery was assessed using the Gilbert and Raimondi scales. The Narakas Sensory Grading System was used to evaluate hand sensation. The mean follow-up period was 45 months (SD 18.2). Of the 20 children, nine had contralateral C7 transfer to lower nerve roots, two had transfer to upper nerve roots and nine had transfer to both upper and lower roots. The postoperative shoulder and elbow functions were good or satisfactory according to the Gilbert classification in all children whose preoperative scores were poor. All patients with lower roots reconstruction (9) had satisfactory hand function. A total of 15 children had a Narakas score of S3. Our technique enables safe contralateral C7 transfer to the avulsed roots in severe obstetrical brachial plexus injury infants with a satisfactory functional recovery.

LEVEL OF EVIDENCE

Level IV.

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

Obstetric brachial plexus injuries (OBPP) are a relatively common stretch injury of the brachial plexus that occurs during delivery. Roughly 30 % of patients will not recover completely and will need a surgical repair. Two main treatment strategies have been used: primary surgery, consisting in exploring and reconstructing the affected portions of the brachial plexus within the first few months of the patient's life, and secondary procedures that include tendon or muscle transfers, osteotomies, and other orthopedic techniques. Secondary procedures can be done as the only surgical treatment of OBPP or after primary surgery, in order to minimize any residual deficits. Two things are crucial to achieving a good outcome: (1) the appropriate selection of patients, to separate those who will spontaneously recover from those who will recover only partially or not at all; and (2) a good surgical technique. The objective of the present review is to assess the published literature concerning certain controversial issues in OBPP, especially in terms of the true current state of primary and secondary procedures, their results, and the respective roles each plays in modern-day treatment of this complex pathology. Considerable published evidence compiled over decades of surgical experience favors primary nerve surgery as the initial therapeutic step in patients who do not recover spontaneously, followed by secondary surgeries for further functional improvement. As described in this review, the results of such treatment can greatly ameliorate function in affected limbs. For best results, multi-disciplinary teams should treat these patients.

Hand Sensorimotor Function in Older Children With Neonatal Brachial Plexus Palsy

BACKGROUND

Routine sensory assessments in neonatal brachial plexus palsy are infrequently performed because it is generally assumed that sensory recovery exceeds motor recovery. However, studies examining sensory function in neonatal brachial plexus palsy have produced equivocal findings. The purpose of this study was to examine hand sensorimotor function in older children with neonatal brachial plexus palsy using standard clinical and research-based measures of tactile sensibility.

METHODS

Seventeen children with neonatal brachial plexus palsy (mean age: 11.6 years) and 19 age-matched controls participated in the study. Functional assessments included grip force, monofilament testing, and hand dexterity (Nine-Hole Peg, Jebsen-Taylor Hand Function). Tactile spatial perception involving the discrimination of pin patterns and movement-enhanced object recognition (stereognosis) were also assessed.

RESULTS

In the neonatal brachial plexus palsy group, significant deficits in the affected hand motor function were observed compared with the unaffected hand. Median monofilament scores were considered normal for both hands. In contrast, tactile spatial perception was impaired in the neonatal brachial plexus palsy group. This impairment was seen as deficits in both pin pattern and object recognition accuracy as well as the amount of time required to identify patterns and objects. Tactile pattern discrimination time significantly correlated with performance on both functional assessment tests (P < 0.01).

DISCUSSION

This study provides evidence that tactile perception deficits may accompany motor deficits in neonatal brachial plexus palsy even when measures of tactile registration (i.e., monofilament testing) are normal. These results may reflect impaired processing of somatosensory feedback associated with reductions in goal-directed upper limb use and illustrate the importance of including a broader range of sensory assessments in neonatal brachial plexus palsy.

Primary Nerve Repair for Obstetrical Brachial Plexus Injury: A Meta-Analysis

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.

Donor-side morbidity after contralateral C-7 nerve transfer: results at a minimum of 6 months after surgery

OBJECT Donor-side morbidity associated with contralateral C-7 (CC7) nerve transfer remains controversial. The purpose of this study was to evaluate functional deficits in the donor limb resulting from prespinal route CC7 nerve transfer. METHODS A total of 63 patients were included. Forty-one patients had undergone CC7 nerve transfer surgery at least 6 months previously and were assigned to one of 2 groups based on the duration of postoperative follow-up. Group 1 (n = 21) consisted of patients who had undergone surgery between 6 months and 2 years previously, and Group 2 (n = 20) consisted of patients who had undergone surgery more than 2 years previously. An additional 22 patients who underwent CC7 nerve transfer surgery later than those in Groups 1 and 2 were included as a control group (Group 3). Results of preoperative testing in these patients and postoperative testing in Groups 1 and 2 were compared. Testing included subjective assessments and objective examinations. An additional 3 patients had undergone surgery more than 6 months previously but had severe motor weakness and were therefore evaluated separately; these 3 patients were not included in any of the study groups. RESULTS The revised Short-Form McGill Pain Questionnaire (SF-MPQ-2) was the only subjective test that showed a significant difference between Group 3 and the other 2 groups, while no significant differences were found in objective sensory, motor, or dexterity outcomes. The interval from injury to surgery for patients with a normal SF-MPQ-2 score in Groups 1 and 2 was significantly less than for those with abnormal SF-MFQ-2 scores (2.4 ± 1.1 months vs 4.6 ± 2.9 months, p = 0.002). The 3 patients with obvious motor weakness showed a tendency to gradually recover. CONCLUSIONS Although some patients suffered from long-term sensory disturbances, resection of the C-7 nerve had little effect on the function of the donor limb. Shortening preoperative delay time can improve sensory recovery of the donor limb.

Phrenic nerve transfer to the musculocutaneous nerve for the repair of brachial plexus injury: electrophysiological characteristics

Phrenic nerve transfer is a major dynamic treatment used to repair brachial plexus root avulsion. We analyzed 72 relevant articles on phrenic nerve transfer to repair injured brachial plexus that were indexed by Science Citation Index. The keywords searched were brachial plexus injury, phrenic nerve, repair, surgery, protection, nerve transfer, and nerve graft. In addition, we performed neurophysiological analysis of the preoperative condition and prognosis of 10 patients undergoing ipsilateral phrenic nerve transfer to the musculocutaneous nerve in our hospital from 2008 to 201 3 and observed the electromyograms of the biceps brachii and motor conduction function of the musculocutaneous nerve. Clinically, approximately 28% of patients had brachial plexus injury combined with phrenic nerve injury, and injured phrenic nerve cannot be used as a nerve graft. After phrenic nerve transfer to the musculocutaneous nerve, the regenerated potentials first appeared at 3 months. Recovery of motor unit action potential occurred 6 months later and became more apparent at 12 months. The percent of patients recovering 'excellent' and 'good' muscle strength in the biceps brachii was 80% after 18 months. At 12 months after surgery, motor nerve conduction potential appeared in the musculocutaneous nerve in seven cases. These data suggest that preoperative evaluation of phrenic nerve function may help identify the most appropriate nerve graft in patients with an injured brachial plexus. The functional recovery of a transplanted nerve can be dynamically observed after the surgery.

Neonatal brachial plexus palsy--management and prognostic factors

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.

A cross-sectional study of hand sensation in adults with conservatively treated obstetric brachial plexus lesion

AIM

Sensory function is assumed to recover almost completely in obstetric brachial plexus lesion (OBPL), and is reported to recover much better than motor function. However, there is no obvious physiological reason why this should be so. Any persistent problems with sensory innervation might contribute to disability, therefore we aimed to assess sensory dysfunction in adults resulting from OBPL.

METHOD

Adults with conservatively treated OBPL (n=17; 12 females, five males; median age 38y; lesion levels: C5-C6, n=7; C5-C7, n=7; C5-C8, n=2; C5-Th1, n=1) and 19 healthy comparison persons (10 females, nine males; median age 23y) were investigated. Sensory function was measured using Semmes-Weinstein monofilaments, two-point discrimination, object recognition, and a locognosia test.

RESULTS

Scores of the Semmes-Weinstein monofilaments and two-point discrimination, but not object recognition or locognosia, were significantly worse in those with OBPL than in those without OBPL.

INTERPRETATION

There may be systematic abnormalities in sensory function in adults with conservatively treated OBPL. The existence of these impairments and their contribution to functional impairment needs to be acknowledged.

Aspects of activities and participation of 7-8 year-old children with an obstetric brachial plexus injury

BACKGROUND

Children with an obstetric brachial plexus injury (OBPI) can experience problems in the performance of meaningful activities such as writing, bimanual activities, and participation in sports and leisure activities.

AIMS

To quantify the everyday functioning and participation of 7-8 year-old children with an OBPI, with special emphasis on writing, and to investigate associated characteristics.

METHODS

Parents of children with an OBPI were sent a self-report questionnaire regarding the school performance, writing abilities, bimanual hand use, and participation in sports and leisure activities of their child, assessed with the Vineland Adaptive Behavior Scales (VABS sub-scale writing), the ABILHAND-kids, and the Children's Assessment of Participation and Enjoyment (CAPE). Furthermore, questions were asked about socio-demographic variables, medical history, pain, and the use of assistive devices.

RESULTS

Fifty three questionnaires were filled in (response 61%). According to the parents, 66% of their children were almost completely recovered, and 58% had a near normal arm function. Most of the children preferred to use their non-involved hand. More than 45% of the children complained about pain, and 39.6% had difficulties with writing, which resulted in a mean developmental delay of 8 months on the VABS sub-scale. Children with writing problems significantly more often had neurosurgery, were living with a single parent, more often received assistance at school, and had a significantly lower ABILHAND-kids score, compared to children with no writing problems.

CONCLUSIONS

Large percentages of 7-8 year-old children with an OBPI experience difficulties with writing and have musculoskeletal pain. Restrictions in participation were less pronounced.