Neonatal Brachial Plexus Palsy

2018 ◽  
Author(s):  
Raymond Tse ◽  
Angelo B. Lipira
Keyword(s):  
Brachial Plexus ◽  
Multiple Root ◽  
Surgical Reconstruction ◽  
Delayed Presentation ◽  
Brachial Plexus Palsy ◽  
Nerve Reconstruction ◽  
Nerve Transfers ◽  
Neonatal Brachial Plexus Palsy ◽  
Severity Of Injury ◽  
Technical Details

Neonatal brachial plexus palsy occurs in approximately 1 in 1000 live births. The extent of involvement and severity of injury are variable. The chapter discusses assessment, nonsurgical treatment, and surgical treatment of neonatal brachial plexus palsy. The approach to surgical exploration is detailed and a number of scenarios are presented so that the principles of primary nerve reconstruction (including nerve graft and nerve transfers) can be illustrated. The scenarios include upper plexus injury, pan-plexus injury, multiple root avulsions, isolated deficits, delayed presentation, and failed reconstruction. Technical details of nerve grafting and nerve transfers are described. Secondary musculoskeletal consequences of brachial plexus palsy are also discussed, including strategies for prevention and options for secondary surgical reconstruction.

Ultrasonography for neonatal brachial plexus palsy

2014 ◽  
Vol 14 (5) ◽  
pp. 527-531 ◽  
Author(s):  
Jacob Rahul Joseph ◽  
Michael A. DiPietro ◽  
Deepak Somashekar ◽  
Hemant A. Parmar ◽  
Lynda J. S. Yang
Keyword(s):  
Brachial Plexus ◽  
Functional Results ◽  
Operative Management ◽  
Brachial Plexus Palsy ◽  
Nerve Reconstruction ◽  
Nerve Roots ◽  
Unaffected Side ◽  
Neonatal Brachial Plexus Palsy ◽  
Preoperative Mapping ◽  
Supraclavicular Fossa

Ultrasonography has previously been reported for use in the evaluation of compressive or traumatic peripheral nerve pathology and for its utility in preoperative mapping. However, these studies were not performed in infants, and they were not focused on the brachial plexus. The authors report a case in which ultrasonography was used to improve operative management of neonatal brachial plexus palsy (NBPP). An infant boy was born at term, complicated by right-sided shoulder dystocia. Initial clinical evaluation revealed proximal arm weakness consistent with an upper trunk injury. Unlike MRI or CT myelography that focus on proximal nerve roots, ultrasonography of the brachial plexus in the supraclavicular fossa was able to demonstrate a small neuroma involving the upper trunk (C-5 and C-6) and no asymmetry in movement of the diaphragm or in the appearance of the rhomboid muscle when compared with the unaffected side. However, the supra- and infraspinatus muscles were significantly asymmetrical and atrophied on the affected side. Importantly, ultrasound examination of the shoulder revealed posterior glenohumeral laxity. Instead of pursuing the primary nerve reconstruction first, timely treatment of the shoulder subluxation prevented formation of joint dysplasia and formation of a false glenoid, which is a common sequela of this condition. Because the muscles innervated by proximal branches of the cervical nerve roots/trunks were radiographically normal, subsequent nerve transfers were performed and good functional results were achieved. The authors believe this to be the first report describing the utility of ultrasonography in the surgical treatment planning in a case of NBPP. Noninvasive imaging, in addition to thorough history and physical examination, reduces the intraoperative time required to determine the extent and severity of nerve injury by allowing improved preoperative planning of the surgical strategy. Inclusion of ultrasonography as a preoperative modality may yield improved outcomes for children with NBPP.

scholarly journals Oberlin transfer compared with nerve grafting for improving early supination in neonatal brachial plexus palsy

2018 ◽  
Vol 21 (2) ◽  
pp. 178-184 ◽  
Author(s):  
Kate W. C. Chang ◽  
Thomas J. Wilson ◽  
Miriana Popadich ◽  
Susan H. Brown ◽  
Kevin C. Chung ◽  
...  
Keyword(s):  
Brachial Plexus ◽  
Elbow Flexion ◽  
Nerve Grafting ◽  
Brachial Plexus Palsy ◽  
Nerve Reconstruction ◽  
Early Recovery ◽  
Treatment Groups ◽  
Neonatal Brachial Plexus Palsy ◽  
Significant Difference ◽  
Transfer Group

OBJECTIVEThe use of nerve transfers versus nerve grafting for neonatal brachial plexus palsy (NBPP) remains controversial. In adult brachial plexus injury, transfer of an ulnar fascicle to the biceps branch of the musculocutaneous nerve (Oberlin transfer) is reportedly superior to nerve grafting for restoration of elbow flexion. In pediatric patients with NBPP, recovery of elbow flexion and forearm supination is an indicator of resolved NBPP. Currently, limited evidence exists of outcomes for flexion and supination when comparing nerve transfer and nerve grafting for NBPP. Therefore, the authors compared 1-year postoperative outcomes for infants with NBPP who underwent Oberlin transfer versus nerve grafting.METHODSThis retrospective cohort study reviewed patients with NBPP who underwent Oberlin transfer (n = 19) and nerve grafting (n = 31) at a single institution between 2005 and 2015. A single surgeon conducted intraoperative exploration of the brachial plexus and determined the surgical nerve reconstruction strategy undertaken. Active range of motion was evaluated preoperatively and postoperatively at 1 year.RESULTSNo significant difference between treatment groups was observed with respect to the mean change (pre- to postoperatively) in elbow flexion in adduction and abduction and biceps strength. The Oberlin transfer group gained significantly more supination (100° vs 19°; p < 0.0001). Forearm pronation was maintained at 90° in the Oberlin transfer group whereas it was slightly improved in the grafting group (0° vs 32°; p = 0.02). Shoulder, wrist, and hand functions were comparable between treatment groups.CONCLUSIONSThe preliminary data from this study demonstrate that the Oberlin transfer confers an advantageous early recovery of forearm supination over grafting, with equivalent elbow flexion recovery. Further studies that monitor real-world arm usage will provide more insight into the most appropriate surgical strategy for NBPP.

Utility of delayed surgical repair of neonatal brachial plexus palsy

2014 ◽  
Vol 13 (4) ◽  
pp. 462-470 ◽  
Author(s):  
Zarina S. Ali ◽  
Dara Bakar ◽  
Yun R. Li ◽  
Alex Judd ◽  
Hiren Patel ◽  
...  
Keyword(s):  
Quality Of Life ◽  
Brachial Plexus ◽  
Spontaneous Recovery ◽  
Surgical Repair ◽  
Surgical Reconstruction ◽  
Brachial Plexus Palsy ◽  
Improved Outcomes ◽  
Neonatal Brachial Plexus Palsy ◽  
Life Years

Object Neonatal brachial plexus palsy (NBPP) represents a significant health problem with potentially devastating consequences. The most common form of NBPP involves the upper trunk roots. Currently, primary surgical repair is performed if clinical improvement is lacking. There has been increasing interest in “early” surgical repair of NBPPs, occurring within 3–6 months of life. However, early treatment recommendations ignore spontaneous recovery in cases of Erb's palsy. This study was undertaken to evaluate the optimal timing of surgical repair in this group with respect to quality of life. Methods The authors formulated a decision analytical model to compare 4 treatment strategies (no repair or repair at 3, 6, or 12 months of life) for infants with persistent NBPPs. The model derives data from a critical review of published studies and projects health-related quality of life and quality-adjusted life years over a lifetime. Results When evaluating the quality of life of infants with NBPP, improved outcomes are seen with delayed surgical repair at 12 months, compared with no repair or repair at early and intermediate time points, at 3 and 6 months, respectively. ANOVA showed that the differences among the 4 groups are highly significant (F = 8369; p < 0.0001). Pairwise post hoc comparisons revealed that there are highly significant differences between each pair of strategies (p < 0.0001). Meta-regression showed no evidence of improved outcomes with more recent treatment dates, compared with older ones, for either nonsurgical or for surgical treatment (p = 0.767 and p = 0.865, respectively). Conclusions These data support a delayed approach of primary surgical reconstruction to optimize quality of life. Early surgery for NBPPs may be an overly aggressive strategy for infants who would otherwise demonstrate spontaneous recovery of function by 12 months. A randomized, controlled trial would be necessary to fully elucidate the natural history of NBPP and determine the optimal time point for surgical intervention.

scholarly journals Successful Nerve Transfers for Traumatic Brachial Plexus Palsy in a Septuagenarian

Hand ◽  
2016 ◽  
Vol 11 (4) ◽  
pp. NP30-NP33 ◽  
Author(s):  
Parker H. Johnsen ◽  
Scott W. Wolfe
Keyword(s):  
Brachial Plexus ◽  
Older Patients ◽  
Nerve Transfer ◽  
Elbow Flexion ◽  
The Elderly ◽  
Suprascapular Nerve ◽  
Brachial Plexus Palsy ◽  
Nerve Reconstruction ◽  
Post Injury ◽  
Nerve Transfers

Background: Conventional wisdom and the available literature demonstrate compromised outcomes following nerve reconstruction for traumatic brachial plexus palsy in the elderly. We present a 74-year-old male who was reconstructed with multiple nerve transfers for brachial plexus palsy after a ski accident. Methods: Triceps to axillary nerve transfer, spinal accessory to suprascapular nerve transfer, and ulnar to musculocutaneous nerve transfer were performed 16 weeks post injury. Results: At 11 years post-op, the patient could abduct to 65° and forward flex at M4 strength, limited only by painful glenohumeral arthritis. Elbow flexion was M5- at both the biceps and brachialis, and bulk and tone were nearly symmetrical with the opposite side. Eleven-year electrodiagnostic studies demonstrated reinnervation and improved motor unit recruitment all affected muscles. Conclusion: This case questions the widely held dogma that older patients who undergo brachial plexus reconstruction do poorly. Given the short reinnervation distance and optimal donor nerve health, nerve transfers may be an excellent option for healthy older patients with traumatic brachial plexus palsy.

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

2019 ◽  
Vol 35 (2) ◽  
pp. 349-354 ◽  
Author(s):  
Mario G. Siqueira ◽  
Carlos Otto Heise ◽  
Gustavo C. Alencar ◽  
Roberto S. Martins ◽  
Luciano Foroni
Keyword(s):  
Brachial Plexus ◽  
Surgical Reconstruction ◽  
Brachial Plexus Palsy ◽  
Neonatal Brachial Plexus Palsy

scholarly journals The Evidence for Nerve Repair in Obstetric Brachial Plexus Palsy Revisited

2014 ◽  
Vol 2014 ◽  
pp. 1-11 ◽  
Author(s):  
Willem Pondaag ◽  
Martijn J. A. Malessy
Keyword(s):  
Conservative Treatment ◽  
Brachial Plexus ◽  
Nerve Repair ◽  
Treatment Modalities ◽  
Surgical Reconstruction ◽  
Brachial Plexus Palsy ◽  
Nerve Reconstruction ◽  
Obstetric Brachial Plexus Palsy ◽  
Obstetric Brachial Plexus ◽  
Nerve Surgery

Strong scientific validation for nerve reconstructive surgery in infants with Obstetric Brachial Plexus Palsy is lacking, as no randomized trial comparing surgical reconstruction versus conservative treatment has been performed. A systematic review of the literature was performed to identify studies that compare nerve reconstruction to conservative treatment, including neurolysis. Nine papers were identified that directly compared the two treatment modalities. Eight of these were classified as level 4 evidence and one as level 5 evidence. All nine papers were evaluated in detail to describe strong and weak points in the methodology, and the outcomes from all studies were presented. Pooling of data was not possible due to differences in patient selection for surgery and outcome measures. The general consensus is that nerve reconstruction is indicated when the result of nerve surgery is assumedly better than the expected natural recovery, when spontaneous recovery is absent or severely delayed. The papers differed in methodology on how the cut-off point to select infants for nerve reconstructive surgical therapy should be determined. The justification for nerve reconstruction is further discussed.

scholarly journals Comparative accuracies of electrodiagnostic and imaging studies in neonatal brachial plexus palsy

2019 ◽  
Vol 23 (1) ◽  
pp. 119-124 ◽  
Author(s):  
Brandon W. Smith ◽  
Kate W. C. Chang ◽  
Lynda J. S. Yang ◽  
Mary Catherine Spires
Keyword(s):  
Brachial Plexus ◽  
Preoperative Planning ◽  
Brachial Plexus Palsy ◽  
Nerve Reconstruction ◽  
Nerve Roots ◽  
Electrodiagnostic Testing ◽  
Neonatal Brachial Plexus Palsy ◽  
Age At Surgery ◽  
The Mean ◽  
Lesion Localization

OBJECTIVEThe incorporation of ancillary testing in the preoperative setting for patients with neonatal brachial plexus palsy (NBPP) remains controversial, but the recommendation for early nerve reconstruction when a baby has a preganglionic lesion at the lower nerve roots is generally accepted. At some specialty centers, nerve surgeons use preoperative electrodiagnostic testing (EDX) and imaging to aid in lesion localization and the preoperative planning of the nerve reconstruction. EDX and imaging have been evaluated for their abilities to detect pre- and postganglionic lesions, but their accuracies have never been compared directly in the same set of patients. The aim of the present study was to evaluate the accuracy of imaging and EDX in an NBPP population.METHODSA retrospective review was conducted of 54 patients with operative NBPP seen between 2007 and 2017. The patients underwent EDX and imaging: EDX was performed, and the results were reviewed by board-certified electrodiagnosticians, and imaging was reviewed by board-certified neuroradiologists. The gold standard was considered to be the findings at surgical exploration. Descriptive and analytical statistics were utilized to compare the accuracies of imaging and EDX.RESULTSThe mean age at surgery was 6.94 mos (± 4 mos). Fifteen patients (28%) were Narakas grade I–II, and 39 (72%) were Narakas grade III–IV. For all nerve roots, the overall accuracy of detecting preganglionic lesions was 74% for EDX and 69% for imaging. The overall sensitivity of detecting preganglionic lesions by EDX was 31%, but the specificity was 90%. The overall sensitivity of detecting preganglionic lesions by imaging was 66%, and the overall specificity was 70%. However, at C8, EDX was 37.5% sensitive and 87.5% specific, whereas imaging was 67.7% sensitive but only 29.4% specific.CONCLUSIONSEDX outperformed imaging with regard to specificity and accuracy of identifying preganglionic injuries. This finding is especially relevant in the lower nerve roots, given that lower plexus preganglionic lesions are an accepted indication for early intervention.

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