Extensive somatosensory innervation in infants with obstetric brachial palsy.

In the pre-operative screening of infants with obstetric brachial palsy (OBP), the results of routine electromyography are often overly optimistic when compared to the peri-operative findings. This prompted us to include investigation of the sensory innervation of these infants using the N20 (the first cortical response to a peripheral stimulation) of the somatosensory evoked potentials (SSEP). Three to seven months after birth, SSEP were recorded at the skull after stimulation of the thumb and middle finger in infants with obstetric rupture of the upper trunk or avulsion of roots C5, C6, or C7, and in whom no clinical improvement of motor function was observed in the biceps brachii and deltoid muscles. In most infants, a normal N20 could be evoked, indicating the existence of peripheral sensory pathways. From the thumb, these sensory pathways would necessarily bypass the upper trunk and dorsal roots of spinal nerves C5 and C6, and from the middle finger bypass the middle trunk and dorsal root C7, before extending into the dorsal column and projecting toward the thalamus and cerebral cortex. These data suggest that in infancy the segmental sensory innervation of the hand is more diverse than is described in most textbooks.

Management of obstetric brachial plexus lesions: state of the art and future developments.

Despite improving perinatal care the incidence of obstetric brachial plexus lesions (OBPL) has not declined. Most babies recover spontaneously. In 10-20% recovery is incomplete. To prevent lasting functional deficits early referral to specialized centers is necessary. If the biceps shows no function at 3 months, standardized clinical assessment and additional investigations must delineate the extent of a lesion. Detection of root avulsions by myelography and computed tomography combined with electrodiagnostics remains inconclusive in 15% of cases. Plexus reconstruction is performed during the 4th-6th months. Contractures or deformities are treated conservatively or by orthopedic surgery. Long-term rehabilitation is required. In future, aspects of prevention need attention. Improving imaging and neurophysiological techniques are promising for greater precision in detecting root avulsions and even spontaneous recovering nerves. Functional imaging will allow better understanding of central integration and plasticity. New pharmacological agents may promote nerve regeneration.

Obstetric antecedents of surgically treated obstetric brachial plexus injuries.

OBJECTIVE: To determine whether the anatomy of an obstetric brachial plexus lesion (OBPL) is causally related to the preceding obstetric history. DESIGN: Anatomical classification of the OBPL during reconstructive neurosurgical treatment in consecutive infants who had surgery for OBPL between 1986 and 1994 and relating these findings with the characteristics of the preceding birth. SETTING: De Wever Hospital, Heerlen, The Netherlands. SUBJECTS: All infants who had surgical treatment for OBPL between 1 April 1986 and 1 January 1994 (n = 130). RESULTS: An Erb's C5-C6 injury was preceded more frequently by a difficult breech birth (19/26 cases or 73%). In contrast, the more extensive forms of Erb's palsy classified as a C5-C7 injury or a total palsy with a C5-T1 injury were observed more frequently after complicated cephalic birth (52/59 or 88%, and 43/45 or 96%, respectively). The extent of anatomical damage as expressed by the incidence of an avulsion of one or more spinal nerves was 18/26 (69%) in Erb C5-C6, 13/59 (22%) in Erb C5-C7 and 21/45 (47%) in total C5-T1 palsy. CONCLUSION: The Erb's C5-C6 palsy, occasionally bilateral and/or complicated by phrenic nerve injury, was the most frequent form of OBPL after a breech birth. The more extensive form of Erb's palsy and the total palsy were observed more frequently after delivery in a cephalic presentation. The pure form of Erb's palsy and the total palsy were characterised by a higher incidence of nerve avulsions than the extensive form of Erb's palsy.

Computer assisted diagnosis and treatment planning of brachial plexus injuries.

PLEXUS is a computer program which has been developed to provide recommendations for diagnosis and treatment planning of brachial plexus injuries. This computer program is meant for neurologists, neurosurgeons and orthopaedic surgeons who are not experienced in the field of brachial plexus injuries. The system detects the locations and severity of brachial plexus lesions. PLEXUS also indicates whether the patient may be referred to a specialist centre for nerve surgery. In order to determine whether the advice given by the system is of expert quality, a study of its recommendations is being carried out in cooperation with four international brachial plexus experts. To investigate if the system does indeed have the capability to assist physicians in the area of brachial plexus injuries, it is being tested clinically in four hospitals in The Netherlands.

Obstetric brachial plexus lesions and their neurosurgical treatment.

The present series of 655 brachial plexus lesions includes 240 obstetric palsies. The results of neurophysiological and radiological examinations in these cases are often disappointing in regard to the evaluation of the severity of the lesion. Timing for surgery was according to the criterium of Gilbert: lack of clinical signs of recovery of the biceps at the end of the third month. Intra- and/or extraplexal neurotizations were performed in 94 children. Although only 28 children operated upon have been followed up for at least 2 years, some tentative conclusions may be drawn. A good to very good result was achieved in 10 children with an upper plexus lesion, born in cephalic presentation. In breech presentation cases, often associated with root avulsion, and in (sub)total lesions, the final result was much less.

Sensibility testing after nerve grafting.

This study attempts to establish which sensitivity test is to be preferred for final assessment of recovery of sensibility after nerve grafting. For this purpose seven sensibility tests were performed on patients who had been treated by median nerve transplantation. The findings revealed that the stereognosis test is of greater value for a final evaluation than the two-point discrimination test. This paper discusses several aspects of sensibility tests, e.g. the range of variation of the results and the degree of objectivity.

Uncommon third ventricle herniation with cyst formation as a possible result of obstructive hydrocephalus.

An adult man with an unusual cyst formation, originating from the suprapineal recess is described. The cyst may partly be caused by and may partly have contributed to aqueductstenosis.