Management of Birth Brachial Plexus Injury Including Use of Distal Nerve Transfers.

Birth Brachial plexus injury continues to remain a problem despite significant care from obstetricians to prevent it. Many children show spontaneous recovery but a significant proportion do not have adequate recovery. This review article discusses, etiology, assessment, investigations and overall strategy to treat the condition. Surgical strategy consists of primary intraplexal repair as the standard of care but of late the distal nerve transfers used in adult plexus injuries are increasingly being used in infants too. We discuss the history, current usage and pros and cons of distal nerve transfers, the usage of Botulinum Toxin and finally given an overall algorithm for the management.

Relationships Between 3 Classification Systems in Brachial Plexus Birth Palsy.

BACKGROUND: The Mallet scale, Active Movement Scale (AMS), and Toronto Test are validated for use in children with brachial plexus birth palsy (BPBP). However, the inability to compare these evaluation systems has led to difficulty gauging treatment efficacy and interpreting available literature in which multiple scoring systems are reported. Given the critical importance of physical examination, we compared 3 scoring systems to clarify statistical relationships between current validated evaluation methods. METHODS: The medical records of children with BPBP treated at a single institution over a 14-year period were retrospectively reviewed. Modified Mallet, AMS, and Toronto scores were recorded throughout the entire period. Data were included if at least 2 complete scoring systems were documented during the same examination session. Spearman correlation coefficients were calculated for all composite and subscore combinations. A concordance table was constructed for select variables found to be highly correlated. RESULTS: Total single-session score combinations were as follows: 157 Mallet and AMS, 325 AMS and Toronto, and 143 Mallet and Toronto. Composite AMS and Toronto scores were found to have a strong correlation (r=0.928, P<0.001). A concordance table comparing these variables revealed that a Toronto score of 3.5 is concordant to an AMS score of 45. Modified Mallet scores had only a moderate correlation with composite AMS (r=0.512, P<0.001) and Toronto (r=0.458, P<0.001) scores. Specifically regarding the modified Mallet score, maneuvers requiring external rotation had stronger correlations with the composite modified Mallet score than maneuvers highlighting internal rotation. CONCLUSIONS: Modified Mallet scores do not correlate well with AMS or Toronto scores and should be utilized separately when managing children with BPBP. Similarly, AMS and Toronto scores are inadequate to guide clinical decisions for which the literature cites Mallet scores as outcome measures, and vice versa. Lastly, Mallet scores should incorporate an isolated internal rotation component to adequately assess midline function. LEVEL OF EVIDENCE: Diagnostic level III.

International Federation of Societies for Surgery of the Hand Committee report: the role of nerve transfers in the treatment of neonatal brachial plexus palsy.

Nerve transfers have gained popularity in the treatment of adult brachial plexus palsy; however, their role in the treatment of neonatal brachial plexus palsy (NBPP) remains unclear. Brachial plexus palsies in infants differ greatly from those in adults in the patterns of injury, potential for recovery, and influences of growth and development. This International Federation of Societies for Surgery of the Hand committee report on NBPP is based upon review of the current literature. We found no direct comparisons of nerve grafting to nerve transfer for primary reconstruction of NBPP. Although the results contained in individual reports that use each strategy for treatment of Erb palsy are similar, comparison of nerve transfer to nerve grafting is limited by inconsistencies in outcomes reported, by multiple confounding factors, and by small numbers of patients. Although the role of nerve transfers for primary reconstruction remains to be defined, nerve transfers have been found to be effective and useful in specific clinical circumstances including late presentation, isolated deficits, failed primary reconstruction, and multiple nerve root avulsions. In the case of NBPP more severe than Erb palsy, nerve transfers alone are inadequate to address all of the deficits and should only be considered as adjuncts if maximal re-innervation is to be achieved. Surgeons who commit to care of infants with NBPP need to avoid an over-reliance on nerve transfers and should also have the capability and inclination for brachial plexus exploration and nerve graft reconstruction.

Incidence and prognosis of neonatal brachial plexus palsy with and without clavicle fractures.

OBJECTIVE: To report the incidence of neonatal brachial plexus palsy with and without ipsilateral clavicle fracture in a population of newborns and to compare the prognosis between these subgroups. METHODS: This was a retrospective review of 3,739 clavicle fractures and 1,291 brachial plexus palsies in neonates over a 24-year period from a geographically defined health care system with reference to county-wide population data. RESULTS: A referral clinic for children with brachial plexus palsies evaluated 1,383 neonates, of whom 320 also had ipsilateral clavicular fracture. As a result of referral patterns within the region, it is likely that this represents nearly all infants from the area with persistent brachial plexus injury after 2 months of age. Among the children evaluated without concomitant clavicular fracture, 72% resolved spontaneously (154/214); among those with concomitant clavicular fracture, 74% healed spontaneously (55/74). Limiting the analysis to neonates delivered at Parkland Memorial Hospital and assuming that those neonates with a discharge diagnosis of brachial plexus injury with or without clavicular fracture who did not present to the referral brachial plexus injury clinic had complete resolution, 94.4% without clavicular fracture resolved and 98.1% with clavicular fracture resolved (P=.005). CONCLUSIONS: The risk of persistent neurologic deficit from a birth-related brachial plexus palsy is lower than what has been reported, and the presence of a clavicle fracture may improve the likelihood of recovery. LEVEL OF EVIDENCE: III.

[Differential diagnostics of diseases of the brachial plexus]. / Differenzialdiagnose von Erkrankungen des Plexus brachialis.

Progressive, atrophic, asymmetrically distributed flaccid paresis of arm and hand muscles represents a frequent symptom of neuromuscular diseases that can be attributed to injury of the arm nerves, the plexus or the cervical roots. A timely and exact diagnosis is mandatory; however, the broad spectrum of differential diagnoses often represents a diagnostic challenge. A large variety of neuromuscular disorders need to be considered, encompassing autoimmune mediated inflammatory neuropathic conditions, such as multifocal motor neuropathy, as well as chronic degenerative and nerve compression disorders. This review provides an overview of the most frequent disorders of the upper plexus and cervical roots and summarizes the characteristic clinical features as well as electrodiagnostic and laboratory test results. In addition the diagnostic value of magnetic resonance imaging and sonography is discussed.

Is the term "obstetrical brachial plexus palsy" obsolete? An international survey to assess consensus among peripheral nerve surgeons.

BACKGROUND: Brachial plexus injury diagnosed following delivery often causes lifelong disability and frequently results in litigation. While there is no universally accepted name for this condition, the term 'obstetrical brachial plexus palsy' (OBPP) is commonly used worldwide. The difficulty with the term 'OBPP' lies with the use of the word 'obstetrical', which some have construed to imply obstetrical malpractice even if none occurred. Many regions, especially in the United States, are suffering increasing obstetrician shortages, sometimes as a result of unsustainable liability insurance premiums. We wanted to determine whether surgeons felt that an alternative to the term 'OBPP' was more appropriate. METHODS: We surveyed peripheral nerve surgeons worldwide to determine the appropriateness of the term 'OBPP' and alternative terms. RESULTS: The majority of US-based surgeons (94%) preferred alternative terms, such as 'neonatal brachial plexus palsy'. However, only 53% of surgeons from other regions preferred alternative terms. This difference was statistically significant (p < 0.0002). CONCLUSIONS: More precise and descriptive alternatives to the term 'OBPP' are available and acceptable to many surgeons. An alternative to 'OBPP' may improve communication between practitioners, families and the legal system, especially in the United States. Our peripheral nerve organisations may be able to provide further leadership on this matter.

Our experience with surgical treatment of perinatal brachial plexus palsy--results in different types of lesions.

INTRODUCTION: Perinatal brachial plexus palsies can be divided into upper (C5-C6), upper-middle (C5-C6-C7) and total injuries (C5-Th1). The study aimed to evaluate the results of surgical repair in the different types of palsies. MATERIAL AND METHODS: The patient population comprised 80 children who underwent primary repair of the brachial plexus (external neurolysis, internal neurolysis, direct neurorrhaphy, nerve grafts, extraanatomical intraplexus reconstruction, extraanatomical extraplexus reconstruction). 31 patients were additionally subjected to 39 tenomioplasty procedures. Widely recognised assessment scales were used to evaluate the outcome of surgical treatment of different types of palsies in 70 patients. RESULTS: Good and very good post-operative function of the glenohumeral and elbow joints was demonstrated in all patients with upper palsy. In the group of upper-middle injuries, 61.5% of patients presented good and very good function of the shoulder joint and 76.9% had good function of the elbow. In subjects with total brachial plexus palsy, good function of the glenohumeral was demonstrated by 51.2%, good function of the elbow by 61% and 53.6% presented with a functionally useful hand. CONCLUSIONS: 1. While surgical repair may be indicated in brachial plexus injuries at all levels, it is usually inevitable in total and upper-middle palsies. 2. The surgical outcome depends on the extent of baseline damage to the brachial plexus, with the best prognosis in insolated upper palsies.

[Current concepts in perinatal brachial plexus palsy: Part 1: early phase]. / Conceptos actuales en la parálisis braquial perinatal: Parte 1: etapa temprana.

The incidence of perinatal brachial palsy is similar to that of other frequent conditions in children's orthopedics. The treatment has been traditionally conservative with pediatric follow-up and consultations with various specialists to deal with its sequelae. Its natural history and treatment are controversial. Sequelaes tend to appear earlier each time, so that it should be attended to in checkups and taken into consideration in therapeutic tactics at the same time as nerve repair. This paper includes an analysis of its clinical classification and nerve recovery parameters, essential to decide when to start an exploration of the plexus.

Intraoperative decision making by electrophysiological detection of the origin of thoracodorsal nerve in the C7 nerve root transfer procedure.

The objective of this article is to discuss the significance of predicting the injury degree of the thoracodorsal nerve by intraoperative electrophysiological examination in the C7 nerve root transfer for brachial plexus injury. Each trunk of the brachial plexus followed by each bundle of C7 was stimulated before the contralateral C7 was disconnected. The ratio of the origination of thoracodorsal nerve controlling the latissimus dorsi muscle was evaluated. The highest ratio of the origination of thoracodorsal nerve controlling the latissimus dorsi muscle was in the middle trunk of the brachial plexus. In the middle trunk, the highest ratio was the posterior division. In the posterior division, the internal fascicles were the predominant ones. The intraoperative electrophysiological examination can precisely locate the origin of the dominated nerve of latissimus dorsi muscle. It is recommended for safety to direct the operative procedure selection in the C7 transfer.

Narakas classification of obstetric brachial plexus palsy revisited.

Narakas classified babies with obstetric palsy into four groups: upper Erb's, extended Erb's, total palsy, and total palsy with a Horner. Over the last 15 years, it was noted at our obstetric palsy clinic that good spontaneous recovery in newborns with extended Erb's palsy (C5, C6, C7 injury) was more likely if they recovered active wrist extension against gravity before 2 months of age. A hypothesis was made that newborns with extended Erb's palsy (Narakas Group II) may be subclassified into two groups according to this 'early recovery of wrist extension.' In a retrospective study of 581 cases with strict inclusion criteria, the hypothesis was found to be true: patients with extended Erb's and 'early recovery of wrist extension' have significantly higher percentages of good spontaneous recovery of limb function than those with extended Erb's and 'no early recovery of wrist extension' (P<0.0001 by chi-squared test).

Controversies in the diagnosis and treatment of pediatric brachial plexus injuries.

Brachial plexus injuries have a steady occurrence in the pediatric population from a variety of sources. The various approaches taken to diagnosing and treating this injury have long been fraught with controversy. This has been compounded with advances in medical technology and surgical techniques. Our paper attempts to give a short discussion of the epidemiology of brachial plexus injuries and delineate the specific controversies that exist in diagnosis and treatment.

Brachial plexus traction injury: quantification of sensory abnormalities.

OBJECTIVE: Stretch injury to the brachial plexus may occur following traumatic flexion-extension of the cervical spine often seen in motor vehicle accidents or falls. Radiologic and conventional nerve conduction studies are negative in many cases. The present study was undertaken in an attempt to simplify, standardize, and quantify the positive and negative sensory abnormalities that are most often seen during the clinical examination. METHODS: Quantitation of thresholds for thermal detection and pain, vibration, pressure pain and elevated arm stress test was performed in a series of 38 patients with the clinical picture of brachial plexus traction injury as well as a group of age and sex matched control subjects. RESULTS: Significant decreases in all evoked pain thresholds, except for heat pain, along with increases in sensory detection thresholds were found in the patient group compared with controls. DISCUSSION: Quantification of sensory findings may greatly facilitate and substantiate the diagnosis of this type of injury. The data are consistent with the hypothesis that brachial plexus traction injury causes dysfunction of small sensory fiber systems and results in a form of neuropathic pain.

Management of obstetrical brachial plexus palsy with early plexus microreconstruction and late muscle transfers.

Birth brachial plexus injury usually affects the upper roots. In most cases, spontaneous reinnervation occurs in a variable degree. This aberrant reinnervation leaves characteristic deformities of the shoulder, elbow, forearm, wrist, and hand. Common sequelae are the internal rotation and adduction deformity of the shoulder, elbow flexion contractures, forearm supination deformity, and lack of wrist extension and finger flexion. Nowadays, the strategy in the management of obstetrical brachial plexus palsy focuses in close follow-up of the baby up to 3-6 months and if there are no signs of recovery, microsurgical repair is indicated. Nonetheless, palliative surgery consisting of an ensemble of secondary procedures is used to further improve the overall function of the upper extremity in patients who present late or fail to improve after primary management. These secondary procedures include transfers of free vascularized and neurotized muscles. We present and discuss our experience in treating early and/or late obstetrical palsies utilizing the above-mentioned microsurgical strategy and review the literature on the management of brachial plexus birth palsy.

[Value of MRI in diagnosis of obstetrical brachial plexus palsy pre-ganglionic injury].

OBJECTIVE: To evaluate the value of MRI in diagnosis of obstetrical brachial plexus palsy pre-ganglionic injury. METHODS: From November 2006 to February 2008, 10 patients with obstetrical brachial plexus palsy were treated, 8 males and 2 females, aged from 2 months to 3 years (11.4 months on average). There were 7 cases of left side and 3 of right side. According to Tassin classification, 2 cases were type II, 6 type III and 2 type IV. All patients were performed MRI examinations before the operation, whose results were compared with those of exploration during the operation. RESULTS: MRI examinations showed 1 patient was normal and 9 patients had post-traumatic spinalmeningolcele. The 6 patients had displacement of spinal cord (4 towards the healthy side and 2 towards the sick side), 6 had deformity of spinal cord, and 2 had avulsed nerve root thickening. MRI detected 19 nerve roots were positive, 16 were true positive and 3 false positive in surgical exploration. MRI detected 6 nerve roots were negative, 4 were true negative and 2 false negative in surgical exploration. The sensitivity, specificity and accuracy of MRI in diagnosis of obstetrical brachial plexus palsy pre-ganglionic injury were 84.2%, 80.0% and 83.3%, respectively. There were significant differences in the results by preoperative MRI examinations and by exploration during the operation (P < 0.05). CONCLUSION: MRI can show pre-ganglionic injury of brachial plexus of the patients with obstetrical brachial plexus palsy and can supply references for early diagnosis and operation time. MRI can be routinely conducted as a preoperative examination.

Brachial plexus injury during open heart surgery--controlled prospective study.

BACKGROUND: Postoperative brachial plexus injury is often reported because the brachial plexus is stretched by sternotomy and the use of sternal retractors during open heart surgery. In many studies, brachial plexus injuries have been demonstrated by postoperative electrophysiological studies in susceptible patients. In this study, we estimated the incidence, severity, and type of brachial plexus injuries by routine preoperative and postoperative electrophysiological studies of patients undergoing open heart surgery. METHODS: Patients undergoing coronary artery bypass grafting (CABG) surgery (Group 1), heart valve surgery (Group 2), or peripheral vascular surgery (Group 3) were included in the investigation. Electrophysiological studies of both upper extremities were performed five days before and three weeks after the operation. RESULTS: Peripheral nerve problems were found preoperatively in 23 of the 112 patients (21 %). These problems persisted, but similar findings were obtained postoperatively from the left upper extremities of six of the 42 CABG (14 %) and two of the 24 heart valve (8 %) patients who had had normal preoperative evaluations. The patients with injured nerves were older and had undergone longer operation times. There were no differences between the patients with injured nerves and the others with respect to mammary artery harvesting or other operative variables. CONCLUSIONS: There are no reports in the literature of routine preoperative and postoperative electrophysiological studies in large patient groups to evaluate brachial plexus injury during open heart surgery. It is known that heart surgery sometimes causes partial brachial plexus injury, especially in the lower trunk. However, these peripheral nerve problems are usually not considered clinically important and are not investigated. Patients undergoing open heart surgery must be closely followed up for peripheral nerve injury during the postoperative period.

Whiplash injury. TOS and double crush syndrome. Forensic medical aspects.

In this article the author wants to specify that the whiplash syndrome is underestimated, even by the specialists. In particular the complications aren't taken into correct consideration, above all if they concern the brachial plexus, especially regarding the TOS syndrome and double-crush syndrome. This is a problem also among the experts who have to make an evaluation in the field of insurance.

Planning brachial plexus surgery: treatment options and priorities.

Brachial plexus injuries are devastating and usually result from high-energy trauma in young patients. Clinicians treating brachial plexus injuries need to recognize the pattern of injury presenting in each patient. Most injuries can be described as either supraclavicular or infraclavicular. The specific injury is determined by means ofa precise workup, including careful physical examination, electrodiagnostic studies, and imaging studies; a thorough workup is essential for successful preoperative planning. Priorities need to be identified and matched with available resources in each patient. A growing number of good treatment alternatives are available. Finally,counseling patients toward realistic expectations isa critical component of preparation for surgery.

Direct plexus repair by grafts supplemented by nerve transfers.

This article reviews the Louisiana State University Health Sciences Center experience with direct repair of brachial plexus lacerations, gunshot wounds, and stretch/contusive/avulsive injuries. In the stretch category, limited outcomes with direct repair have led to addition of nerve transfers rather than their exclusive use. It is important to per-form direct plexus repair in conjunction with nerve transfers in the same patient when-ever possible. The intent of such a "pants-over-vest" approach is to maximize axonal input to denervated structures.

Brachial plexopathies: classification, causes, and consequences.

The brachial plexus, which is the most complex structure of the peripheral nervous system, supplies most of the upper extremity and shoulder. The high incidence of brachial plexopathies reflects its vulnerability to trauma and the tendency of disorders involving adjacent structures to affect it secondarily. The combination of anatomic, pathophysiologic, and neuromuscular knowledge with detailed clinical and ancillary study evaluations provides diagnostic and prognostic information that is important to clinical management. Since most brachial plexus disorders do not involve the entire brachial plexus but, rather, show a regional predilection, a regional approach to assessment of plexopathies is necessary.

Management of complete obstetric brachial plexus lesions.

From 1978 to 2002, the authors have operated on 723 babies for obstetric brachial plexus repair. Complete paralyses and associated root ruptures and avulsions are severe, and the results cannot be evaluated before the end of growth. A series of 73 patients operated on from 1978 to 1994 were followed with a mean follow-up of 6.4 years. Secondary operations (mainly on the shoulders) were necessary 123 times. Although the results show that the shoulders and elbows did not do as well as in upper-type lesions, the results at the level of the hand were encouraging, showing 75% useful results after 8 years, even in patients with avulsion injuries of the lower roots. These results demonstrate the usefulness of early exploration and repair of the obstetric plexus.