Non-Sedated Rapid Volumetric Proton Density MRI Predicts Neonatal Brachial Plexus Birth Palsy Functional Outcome.

BACKGROUND AND PURPOSE: The current prognostic biomarker of functional outcome in brachial plexus birth palsy is serial clinical examination throughout the first 6 months of age. This can delay surgical treatment and prolong parental anxiety in neonates who will recover spontaneously. A potentially superior biomarker is a volumetric proton density MRI performed at clinical presentation and within the first 12 weeks of life, providing a high spatial and contrast resolution examination in 4 minutes. METHODS: Nine neonates ranging in age from 4 to 9 weeks who presented with brachial plexus birth palsy were enrolled. All subjects underwent non-sedated 3 Tesla MRI with Cube Proton Density MRI sequence at the same time as their initial clinical visit. Serial clinical examinations were conducted at routine 4 week intervals and the functional performance scores were recorded. MRI findings were divided into pre-ganglionic and post-ganglionic injuries and a radiological scoring system (Shriners Radiological Score) was developed for this study. RESULTS: Proton Density MRI was able to differentiate between pre-ganglionic and post-ganglionic injuries. Radiological scores (Shriners Radiological Score) correlated better with functional performance at 6 months of age (P = .022) than the initial clinical examinations (Active Movement Scale P = .213 and Toronto P = .320). CONCLUSIONS: Rapid non-sedated volumetric Cube Proton Density MRI protocol performed at initial clinical presentation can accurately grade severity of brachial plexus birth palsy injury and predict functional performance at 6 months of age.

Correlation between clinical findings and CT scan parameters for shoulder deformities in birth brachial plexus palsy.

PURPOSE: The shoulder is the most common site of secondary deformities after birth brachial plexus palsy. The severity and the pattern of deformity vary in patients and have implications for clinical decision making. This study aimed to find the correlation between clinical findings and computed tomography (CT) scan parameters for these deformities. METHODS: This prospective study included 75 patients aged 3 to 23 years. The clinical parameters included age, extent of involvement (nerve roots affected), degree of shoulder abduction, active and passive external rotation, and Mallet score. These were correlated with 3 CT scan parameters: elevation of the scapula above the clavicle, relative glenoid version, and percentage of the humeral head anterior to the scapular line. RESULTS: There was a significant correlation between lack of active and passive external rotation and relative glenoid version and humeral head subluxation. There was a significant correlation between active abduction and elevation of the scapula above the clavicle. There was no significant correlation between age or Mallet score with any of the CT scan parameters. CONCLUSIONS: These results suggest that presence of active and passive external rotation beyond 10° is associated with significantly lesser shoulder deformity irrespective of the degree of shoulder abduction. Hence, a patient with more than 10° external rotation does not need a screening CT scan evaluation regardless of the degree of shoulder abduction present. Conversely, a lack of external rotation beyond 10° strongly suggests relative glenoid retroversion and posterior subluxation of the humeral head and should be considered a clinical indicator of shoulder deformation. TYPE STUDY/LEVEL OF EVIDENCE: Diagnostic II.

Intraobserver and interobserver reliability of two ultrasound measures of humeral head position in infants with neonatal brachial plexus palsy.

BACKGROUND: Ultrasonographic evaluation of the hip in infants is considered both reliable and reproducible in the diagnosis of developmental dysplasia of the hip. Ultrasonographic evaluation of the shoulder in infants has been reported as a valuable diagnostic aid in dysplastic development following neonatal brachial plexus palsy. To our knowledge, there has been no study of the intraobserver reproducibility and interobserver reliability of sonography of the shoulder in infants with and without suspected posterior shoulder dislocation. METHODS: Two identical but randomly ordered sets of the same deidentified sonographic images of shoulders in infants were given to radiologists, pediatric orthopaedists and orthopaedic residents, and fellows with varying degrees of experience in the evaluation of shoulder pathology in infants, who measured the position of the humeral head relative to the axis of the scapula. Intraobserver reproducibility and interobserver reliability of the measurements were assessed. RESULTS: For the position of the humeral head with respect to the glenoid in both normal and abnormal conditions, the Pearson correlation coefficient for intraobserver reproducibility was 0.91 and the intraclass correlation coefficient for interobserver reliability was 0.875. For estimating the percentage of the humeral head posterior to the axis of the scapula, the Pearson correlation was 0.85 and the intraclass correlation coefficient was 0.77. CONCLUSIONS: Ultrasonographic examination of the shoulder in infants to assess for the position of the humeral head with respect to the scapula showed high intraobserver reproducibility and interobserver reliability. It is recommended as a reliable technique for evaluating shoulder position in infants with neonatal brachial plexus palsy.

Scapular deformity in obstetric brachial plexus palsy: a new finding.

While most obstetric brachial plexus palsy patients recover arm and hand function, the residual nerve weakness leads to muscle imbalances about the shoulder which may cause bony deformities. In this paper we describe abnormalities in the developing scapula and the glenohumeral joint. We introduce a classification for the deformity which we term Scapular Hypoplasia, Elevation and Rotation. Multiple anatomic parameters were measured in bilateral CT images and three-dimensional CT reconstruction of the shoulder girdle of 30 obstetric brachial plexus palsy patients (age range 10 months-10.6 years). The affected scapulae were found to be hypoplastic by an average of 14% while the ratio of the height to the width of the body of scapula (excluding acromion) were not significantly changed, the acromion was significantly elongated by an average of 19%. These parameters as well as subluxation of the humeral head (average 14%) and downward rotation in the scapular plane were found to correlate with the area of scapula visible over the clavicle. This finding provides a classification tool for diagnosis and objective evaluation of the bony deformity and its severity in obstetric brachial plexus palsy patients.

Tendon transfer around the shoulder in obstetric brachial plexus paralysis: clinical and computed tomographic study.

One hundred nine obstetrical palsy patients with defective shoulder abduction and external rotation had subscapularis release and transfer of teres major to infraspinatus with or without pedicle transfer of the clavicular head of pectoralis major to deltoid. The age at surgery averaged 67 months (11-192) and follow-up averaged 36 months (12-80). Thirty-nine cases had follow-up CT scan of both shoulders. Improvement of abduction averaged 64 degrees and that of external rotation 50 degrees, 100% and 290% gain, respectively. Both negatively correlated with the age at surgery (P < 0.001), and were significantly higher in patients operated younger than 4 years. On computed tomographic scans, the degree of glenoid retroversion positively correlated (P < 0.001) with the age at surgery, and was significantly higher in patients operated older than 4 years. The degree of posterior subluxation showed no significant difference between different ages. There was no significant difference between the operated and normal sides in patients operated younger than 4years with regard to glenoid retroversion and in those operated younger than 2 years with regard to posterior subluxation. The operation is useful for correction of defective shoulder abduction and external rotation in obstetric palsy. It is best performed before the age of 2 to get maximal improvement in motion and prevent secondary bone changes. Between the ages of 2 and 4, it also resulted in significant improvement in motion and prevented glenoid retroversion, but not posterior subluxation. After the age of 4, the improvement in motion was not significant and secondary bone changes were not prevented.

Ultrasound diagnosis of shoulder congruity in chronic obstetric brachial plexus palsy.

Ultrasound (US) was used to determine the congruity of the shoulder in 22 children with a deformity of the shoulder secondary to chronic obstetric brachial plexus palsy. There were 11 boys and 11 girls with a mean age of 4.75 years (0.83 to 13.92). The shoulder was scanned in the axial plane using a posterior approach with the arm internally rotated. The humeral head was classified as being either congruent or incongruent. The US appearance was compared with that on clinical examination and related to the intraoperative findings. All 17 shoulders diagnosed as incongruent on US were found to be incongruent at operation, whereas three diagnosed as congruent by US were found to be incongruent at operation. The diagnostic accuracy of US for the identification of shoulder incongruity was 82% when compared with the findings at surgery. US is a valuable, but not infallible tool, for the detection of incongruity of the shoulder.

Nerve root avulsion of birth palsy: comparison of myelography with CT myelography and somatosensory evoked potential.

Findings at myelography and computed tomographic (CT) myelography were reviewed in 21 patients (22 limbs) with birth palsy; nerve root shadows were the focus of this study. Myelography demonstrated 51 completely avulsed roots (78%) and 14 incompletely avulsed roots (22%). A traumatic meningocele was detected at 38 roots on myelograms and 51 roots on CT myelograms. Thirteen avulsed roots (eight completely and five incompletely avulsed roots) (20%) were not associated with a meningocele. In nine patients who underwent brachial plexus exploration, myelographic findings were compared with root somatosensory evoked potential (SEP). SEP was not induced at 22 of 25 completely avulsed roots and was induced at all seven incompletely avulsed roots. Myelography and SEP were consistent in 29 of 32 roots (91%). It is concluded that myelography is indispensable for preoperative evaluation of cervical nerve root avulsion of birth palsy, because CT myelography is not sensitive to nerve root avulsion without a traumatic meningocele, and SEP cannot enable one to discriminate incomplete avulsion from intact roots.

[Myelography for nerve root avulsion in birth palsy].

Myelography and CT myelography (CTM) were reviewed in 18 cases of birth palsy with clinically suspected avulsion injury. Root-somatosensory evoked potential (root-SEP) was also reviewed for myelographic evaluation of the nerve root avulsion in birth palsy. Root-SEP is not induced in case of avulsed nerve roots, but is induced in case of both normal and incompletely avulsed roots. Myelography demonstrated 58 abnormal nerve roots in 18 cases (19 limbs); 45 (78%) complete and 13 (22%) incomplete nerve root avulsions. Each of complete and incomplete avulsions was defined as total absence and partial presence of rootlets on myelography, respectively. Traumatic meningoceles were detected at 46 roots (79%) on myelography and/or CTM; 35 roots on myelography and 45 roots on CTM. CTM could not detect only a very small meningocele at one root. At 11 roots CTM was superior to myelography in delineating a meningocele because CTM is sensitive to a poorly enhanced meningocele. CTM, however, could not diagnose nerve root avulsions so accurately as myelography, since myelography detected 12 (7 completely and 5 incompletely) avulsed roots without meningocele, whereas CTM could not delineate the nerve roots clearly. Thus, myelography is indispensable to evaluate nerve root avulsions without meningocele. Root-SEP was examined in 9 patients who underwent brachial plexus exploration. SEP was negative at 22/25 roots with complete avulsion and was positive at 7/7 roots with myelographically incomplete avulsion, regardless of presence or absence of any traumatic meningocele.(ABSTRACT TRUNCATED AT 250 WORDS)

Posterior dislocation of the shoulder associated with obstetric brachial plexus palsy.

Four cases of posterior dislocation of the shoulder at birth in association with obstetric brachial plexus palsy are presented. Review of the literature suggests that this association is not generally recognised. All cases were diagnosed late; two were treated by open reduction, one by humeral osteotomy and one managed conservatively.

[Evaluation of CT myelography and conventional myelography for avulsion injury of nerve root--18 cases of birth palsy].

CT myelography (CTM) and conventional myelography were reviewed in 18 cases of birth palsy with clinically suspected avulsion injury. A traumatic meningocele was detected in 45 roots by CTM, and in 35 roots by myelography. CTM misinterpreted only one root with a very small meningocele. CTM was superior to myelography in delineating a traumatic meningocele, because CTM is sensitive to a poorly enhanced meningocele. On the other hand, CTM missed 9 avulsed roots without a meningocele. By myelography, these 9 roots were diagnosed as 6 roots of complete avulsion injury and 3 roots of incomplete avulsion. Myelography is indispensable in evaluating nerve root avulsion.

[Myelography in obstetrical paralysis of the brachial plexus]. / La mielografia nelle paralisi ostetriche del plesso brachiale.

The use of myelography in obstetric palsies of brachial plexus is aimed at diagnosing root avulsion. This kind of lesion appears as the disappearance of the slightly transparent nerve roots which might be combined either with pseudomeningocele or with deformation of radicular pouch. In our study we considered 69 operated patients who had previously undergone myelography. In 74.2% of cases myelographic findings were confirmed at surgery. False positives and false negatives were 9.7% and 3.2%, respectively. Incorrect diagnoses were made in 12.9% of cases, because of misread lesions and incorrect evaluation of their location, usually at the cervico-dorsal junction. No side-effects were observed. Myelography appears thus to be extremely useful for both the preoperative evaluation and the choice of surgery in newborn children with obstetric palsy of the brachial plexus.

Arthrography in evaluation of birth injuries of the shoulder.

Birth injuries of the shoulder and proximal humerus of infants can be difficult to evaluate on plain radiographs because of lack of ossification in the proximal humeral epiphysis. We here describe arthrography of the infant shoulder and advocate it as a useful diagnostic procedure in the evaluation of humeral fractures and brachial palsies. Two infants with birth injuries of the shoulder are described. The value of dynamic fluoroscopic evaluation of the injured joint in conjunction with arthrography is illustrated in evaluation of a brachial plexus palsy.

Computerized axial tomography in obstetrical paralysis of the brachial plexus.

For the past two years we have been using CT scan of the shoulders and humeri for all our patients affected with obstetrical paralysis of the upper limb, in addition to the routine clinical, electromyographic and radiographic examinations, thus integrating all the results. It opens up new perspectives in the study of the pathological anatomy of the shoulder and the upper extremity in obstetrical paralysis and has proved essential in the study of the following parameters: declination angle of the humerus; shape of the humeral head; joint congruence of the shoulder; orientation of the scapula. The non-invasiveness, tolerability, and precisation of this method have produced interesting results in 23 patients.

[Birth palsy of the brachial plexus--surgical exploration and attempted repair in twenty one cases (author's transl)]. / Exploration chirurgicale du plexus brachial dans la paralysie obstétricale. Constatations anatomiques chez 21 malades opérés.

Twenty one cases of birth palsy of the brachial plexus have been explored surgically. The patients were aged from seven weeks to nine years. The results of pre-operative examination are described and myelography is considered to be especially important. It was found that ruptures of the upper roots at the junction of C5-C6 were frequent and could be repaired by nerve graft. Avulsion from the spinal cord was more frequent in the lower roots. It is concluded that surgical exploration and attempted repair should be done early, preferably at the age of two or three months in cases of absence of spontaneous recovery.