Neurolysis alone as the treatment for neuroma-in-continuity with more than 50% conduction in infants with upper trunk brachial plexus birth palsy

2014 ◽  
Vol 13 (2) ◽  
pp. 229-237 ◽  
Author(s):  
Emily Andrisevic ◽  
Marshall Taniguchi ◽  
Michael D. Partington ◽  
Julie Agel ◽  
Ann E. Van Heest
Keyword(s):  
Brachial Plexus ◽  
External Rotation ◽  
Severe Disease ◽  
Treatment Algorithm ◽  
Elbow Flexion ◽  
Functional Improvement ◽  
Shoulder Abduction ◽  
Active Movement ◽  
Nerve Injuries

Object The debate addressed in this article is that of surgical treatment methods for a neuroma-in-continuity. The authors of this study chose to test the hypothesis that more severe nerve injuries, as distinguished by < 50% conduction across a neuroma-in-continuity, could be treated with neuroma resection and grafting, whereas less severe nerve injuries, with > 50% conduction across the neuroma, could be treated with neurolysis alone. Methods The goal of this study was to compare preoperative and postoperative Active Movement Scale (AMS) scores in children with upper trunk brachial plexus birth injuries treated with neurolysis alone if the neuroma's conductivity was > 50% on intraoperative nerve testing. Seventeen patients (7 male, 10 female) met the criteria for inclusion in this study. Surgery was done when the patients were an average of 10 months old (range 6–19 months). The authors analyzed AMS scores from the preoperative assessment, 1-year postoperative follow-up visit, and subsequent follow-up assessment as close to 3 years after surgery as possible (referred to in this paper as > 2-year postoperative scores). Results Comparison of preoperative and 1-year follow-up data showed significant improvement in shoulder abduction, flexion, external rotation, and internal rotation; elbow flexion and supination; and wrist extension. Comparison of preoperative findings and results of assessment at > 2-year follow-up showed significant improvement in shoulder abduction, flexion, external rotation; and elbow flexion and supination. At final follow-up, useful function (AMS score of 6 or 7) was achieved for elbow flexion in 14 of 16 patients, shoulder flexion in 11 of 15 patients, shoulder abduction in 11 of 16 patients, and shoulder external rotation in 5 of 15 patients. Conclusions This report indicates that there is a subgroup of patients who can benefit clinically, with functional improvement of shoulder and elbow function, from treatment with neurolysis alone for upper trunk lesions demonstrating more than 50% conduction across the neuroma on intraoperative nerve testing. Patients with less than 50% conduction, indicating more severe disease, are treated with nerve resection and grafting in the authors' treatment algorithm.

Functional outcomes of tendon transfer for brachial plexus birth palsy using the Hoffer technique

2020 ◽  
Vol 102-B (2) ◽  
pp. 246-253 ◽  
Author(s):  
Ram K. Alluri ◽  
Nina Lightdale-Miric ◽  
Erin Meisel ◽  
Gina Kim ◽  
Jesse Kaplan ◽  
...  
Keyword(s):  
Risk Factors ◽  
Brachial Plexus ◽  
Functional Outcomes ◽  
External Rotation ◽  
Shoulder Abduction ◽  
Active Movement ◽  
Brachial Plexus Birth Palsy ◽  
Derotational Osteotomy ◽  
Birth Palsy

Aims To describe and analyze the mid-term functional outcomes of a large series of patients who underwent the Hoffer procedure for brachial plexus birth palsy (BPBP). Methods All patients who underwent the Hoffer procedure with minimum two-year follow-up were retrospectively reviewed. Active shoulder range of movement (ROM), aggregate modified Mallet classification scores, Hospital for Sick Children Active Movement Scale (AMS) scores, and/or Toronto Test Scores were used to assess functional outcomes. Subgroup analysis based on age and level of injury was performed. Risk factors for subsequent humeral derotational osteotomy and other complications were also assessed. A total of 107 patients, average age 3.9 years (1.6 to 13) and 59% female, were included in the study with mean 68 months (24 to 194) follow-up. Results All patients demonstrated statistically significant improvement in all functional outcomes and active shoulder abduction and external rotation ROM (p < 0.001). Patients < 2.5 years of age had higher postoperative AMS, abduction ROM and strength scores, and aggregate postoperative Toronto scores (p ≤ 0.035) compared to patients ≥ 2.5 years old. There were 17 patients (16%) who required a subsequent humeral derotational osteotomy; lower preoperative AMS external rotation scores and external rotation ROM were predictive risk factors (p ≤ 0.016). Conclusion Patients with BPBP who underwent the Hoffer procedure demonstrated significant improvement in postoperative ROM, strength, and functional outcome scores at mid-term follow-up. Patients younger than 2.5 years at the time of surgery generally had better functional outcomes. Limited preoperative external rotation strength and ROM were significantly associated with requirement for subsequent humeral derotational osteotomy. In our chort significant improvements in shoulder function were obtained after the Hoffer procedure for BPBP. Cite this article: Bone Joint J 2020;102-B(2):246–253.

Navigating the gray zone: a guideline for surgical decision making in obstetrical brachial plexus injuries

2009 ◽  
Vol 3 (3) ◽  
pp. 173-180 ◽  
Author(s):  
James R. Bain ◽  
Carol DeMatteo ◽  
Deborah Gjertsen ◽  
Robert D. Hollenberg
Keyword(s):  
Decision Making ◽  
Brachial Plexus ◽  
External Rotation ◽  
Elbow Flexion ◽  
Complete Recovery ◽  
Shoulder Abduction ◽  
Active Movement ◽  
Gray Zone ◽  
Surgical Decision ◽  
Surgical Decision Making

Object In the literature, the best recommendations are imprecise as to the timing and selection of infants with obstetrical brachial plexus injury (OBPI) for surgical intervention. There is a gray zone (GZ) in which the decision as to the benefits and risks of surgery versus no surgery is not clear. The authors propose to describe this category, and they have developed a guideline to assist surgical decision-making within this GZ. Methods The authors first performed a critical review of the medical literature to determine the existence of a GZ in other clinical publications. In those reports, 47–89% of infants with OBPI fell within such a GZ. Complete recovery in those reported patients ranged from 9 to 59%. Using a prospective inception cohort design, all infants referred to the OBPI Clinic at McMaster Children's Hospital were systematically evaluated up to 3 years of age. The Active Movement Scale scores were compared for surgical and nonsurgical groups of infants in the GZ to identify any important trends that would guide surgical decision-making. Results In the authors' population of infants with OBPI, 81% fell within the GZ, of whom 44% achieved complete recovery. Mean scores differed significantly between surgery and no surgery groups in terms of total Active Movement Scale score and shoulder abduction and flexion at 6 months. Elbow flexion and external rotation differed at 3 months. Conclusions There is compelling evidence that there is a group of infants with OBPI in whom the assessment of the risk/benefit ratio for surgical versus nonsurgical treatment is not evident. These infants reside within what the authors have called the GZ. Based on their results, a guideline was derived to assist clinicians working with infants with OBPI to navigate the GZ.

C5-8 neonatal brachial plexus palsy. Operative findings, reconstructive strategy and outcome

2020 ◽  
Vol 45 (8) ◽  
pp. 798-804
Author(s):  
Aude Lombard ◽  
Manon Bachy ◽  
Frank Fitoussi
Keyword(s):  
Brachial Plexus ◽  
External Rotation ◽  
Elbow Flexion ◽  
Active Movement ◽  
Brachial Plexus Palsy ◽  
Level Of Evidence ◽  
Neonatal Brachial Plexus Palsy ◽  
Brachial Plexus Repair ◽  
Operative Findings

From 1998 to 2014, we performed primary brachial plexus repair in 260 children with neonatal brachial plexus palsy. Thirty-three presented with a C5-8 palsy and 24 were reviewed for this study. The surgical strategy was to focus on repairing the upper trunk. Secondary surgical procedures were performed in 21 patients, mainly for shoulder external rotation deficit or weak wrist extension. After a mean follow-up of 9.7 years (range 3 to 19), the median Mallet score for the shoulder was 9.5 and the mean Raimondi score for the hand was 3.3. Median active movement scale was 5, 7 and 5.5 for the deltoid, biceps and triceps, respectively. We conclude that primary C5-8 brachial plexus reconstruction provides restoration of elbow flexion and most patients have a sensitive and functional hand. We also found that secondary surgery to improve shoulder and wrist function is often necessary, which should initially be explained to the family. Level of evidence: IV

Analysis of human acellular nerve allograft combined with contralateral C7 nerve root transfer for restoration of shoulder abduction and elbow flexion in brachial plexus injury: a mean 4-year follow-up

2020 ◽  
Vol 132 (6) ◽  
pp. 1914-1924 ◽  
Author(s):  
Liang Li ◽  
Jiantao Yang ◽  
Bengang Qin ◽  
Honggang Wang ◽  
Yi Yang ◽  
...  
Keyword(s):  
Brachial Plexus ◽  
Nerve Root ◽  
Functional Outcomes ◽  
Elbow Flexion ◽  
Shoulder Abduction ◽  
Allograft Reconstruction ◽  
Acellular Nerve Allograft ◽  
The Mean ◽  
Monofilament Test

OBJECTIVEHuman acellular nerve allograft applications have increased in clinical practice, but no studies have quantified their influence on reconstruction outcomes for high-level, greater, and mixed nerves, especially the brachial plexus. The authors investigated the functional outcomes of human acellular nerve allograft reconstruction for nerve gaps in patients with brachial plexus injury (BPI) undergoing contralateral C7 (CC7) nerve root transfer to innervate the upper trunk, and they determined the independent predictors of recovery in shoulder abduction and elbow flexion.METHODSForty-five patients with partial or total BPI were eligible for this retrospective study after CC7 nerve root transfer to the upper trunk using human acellular nerve allografts. Deltoid and biceps muscle strength, degree of shoulder abduction and elbow flexion, Semmes-Weinstein monofilament test, and static two-point discrimination (S2PD) were examined according to the modified British Medical Research Council (mBMRC) scoring system, and disabilities of the arm, shoulder, and hand (DASH) were scored to establish the function of the affected upper limb. Meaningful recovery was defined as grades of M3–M5 or S3–S4 based on the scoring system. Subgroup analysis and univariate and multivariate logistic regression analyses were conducted to identify predictors of human acellular nerve allograft reconstruction.RESULTSThe mean follow-up duration and the mean human acellular nerve allograft length were 48.1 ± 10.1 months and 30.9 ± 5.9 mm, respectively. Deltoid and biceps muscle strength was grade M4 or M3 in 71.1% and 60.0% of patients. Patients in the following groups achieved a higher rate of meaningful recovery in deltoid and biceps strength, as well as lower DASH scores (p < 0.01): age < 20 years and age 20–29 years; allograft lengths ≤ 30 mm; and patients in whom the interval between injury and surgery was < 90 days. The meaningful sensory recovery rate was approximately 70% in the Semmes-Weinstein monofilament test and S2PD. According to univariate and multivariate logistic regression analyses, age, interval between injury and surgery, and allograft length significantly influenced functional outcomes.CONCLUSIONSHuman acellular nerve allografts offered safe reconstruction for 20- to 50-mm nerve gaps in procedures for CC7 nerve root transfer to repair the upper trunk after BPI. The group in which allograft lengths were ≤ 30 mm achieved better functional outcome than others, and the recommended length of allograft in this procedure was less than 30 mm. Age, interval between injury and surgery, and allograft length were independent predictors of functional outcomes after human acellular nerve allograft reconstruction.

Clinical findings in C5-C6 and C5-C7 root palsies with brachial plexus traction lesions

2012 ◽  
Vol 38 (3) ◽  
pp. 237-241 ◽  
Author(s):  
J. A. Bertelli ◽  
M. F. Ghizoni
Keyword(s):  
Brachial Plexus ◽  
External Rotation ◽  
Elbow Flexion ◽  
Clinical Findings ◽  
Hand Strength ◽  
Shoulder Abduction ◽  
Finger Extension ◽  
Root Injury ◽  
Flexion Extension

Stretch injuries of the C5-C7 roots of the brachial plexus traditionally have been associated with palsies of shoulder abduction/external rotation, elbow flexion/extension, and wrist, thumb, and finger extension. Based on current myotome maps we hypothesized that, as far as motion is concerned, palsies involving C5-C6 and C5-C7 root injuries should be similar. In 38 patients with upper-type palsies of the brachial plexus, we examined for correlations between clinical findings and root injury level, as documented by CT tomomyeloscan. Contrary to commonly held beliefs, C5-C7 root injuries were not associated with loss of extension of the elbow, wrist, thumb, or fingers, but residual hand strength was much lower with C5-C7 vs C5-C6 lesions.

scholarly journals Pronator Quadratus to Extensor Carpi Radialis Brevis Nerve Transfer in C5–C7 or C5–C8 Brachial Plexus Injuries for Independent Wrist Extension

2020 ◽  
Vol 53 (01) ◽  
pp. 036-041
Author(s):  
Anil Bhatia ◽  
Mahmoud Salama
Keyword(s):  
Brachial Plexus ◽  
Nerve Transfer ◽  
Elbow Flexion ◽  
Shoulder Abduction ◽  
Wrist Extension ◽  
Pronator Quadratus ◽  
Motor Branch ◽  
Nerve Surgery ◽  
Extensor Carpi Radialis

Abstract Background Patients with lesions affecting C7 and C8 roots (in addition to C56) demonstrate loss of independent wrist dorsiflexion in addition to loss of shoulder abduction and elbow flexion. Traditionally, this deficit has been addressed using tendon transfers after useful function at the shoulder and elbow has been restored by primary nerve surgery. Confidence with nerve transfer techniques has prompted attempts to replace this method by incorporating procedures for wrist dorsiflexion in the primary operation itself. Aim The objective of this study was to report the results of pronator quadratus motor branch transfers to the extensor carpi radialis brevis motor branch to reconstruct wrist extension in C5–C8 root lesions of the brachial plexus. Patients and Methods Twenty-three patients, average age 30 years, with C5–8 root injuries underwent operations an average of 4.7 months after their accident. Extrinsic extension of the fingers and thumb was weak or absent in two cases while the remaining 18 patients could open their hand actively. The patients lacked independent wrist extension when they were examined with the fingers flexed as the compensatory action of the extrinsic finger extensors was removed. The average follow-up was 21 months postoperative with the minimal follow-up period was at least 12 months. Results Successful reinnervations of the extensor carpi radialis brevis (ECRB) were demonstrated in all patients. In 17 patients, wrist extension scored M4, and in 3 patients it scored M3. Conclusions The pronator quadratus (PQ) to ECRB nerve transfer in C5–C7 or C5–C8 brachial plexus injuries for independent wrist extension reconstruction gives consistently good results with minimal donor morbidity.

NERVE TRANSFER SURGERY FOR ADULT BRACHIAL PLEXUS INJURY

Neurosurgery ◽  
2009 ◽  
Vol 65 (suppl_4) ◽  
pp. A55-A62 ◽  
Author(s):  
Olawale A.R. Sulaiman ◽  
Daniel D. Kim ◽  
Clint Burkett ◽  
David G. Kline
Keyword(s):  
Brachial Plexus ◽  
Research Council ◽  
Medical Research Council ◽  
Nerve Transfer ◽  
Elbow Flexion ◽  
Shoulder Abduction ◽  
Nerve Transfers ◽  
Direct Repair ◽  
Grade 3

Abstract OBJECTIVE To review the clinical outcomes in our patients who have undergone nerve transfer operations for brachial plexus reconstruction at the Louisiana State University (LSU) over a 10-year period. A secondary objective is to compare clinical outcomes in patients who had only nerve transfer operations as compared with patients whose nerve transfers were supplemented with direct repair of brachial plexus elements. METHODS Retrospective review of the medical records, imaging, and electrodiagnostic studies (electromyographic and nerve conduction studies) of patients with brachial plexus injuries who underwent nerve transfer operations at LSU over a period of 10 years. RESULTS A total of 81 patients were treated between 1995 to 2005 at the LSU Health Sciences Center; 7 of these patients were lost to follow-up, leaving 74 patients, with an average follow-up of 3.5 years, for review. We evaluated recovery of elbow flexion and shoulder abduction. Ninety percent of patients with medial pectoral to musculocutaneous nerve transfers recovered to LSU grade 2 (Medical Research Council grade 3), and 60% of those patients with intercostal to musculocutaneous nerve transfer regained similar strength in elbow flexion. Shoulder abduction recovery to LSU grade 2 (Medical Research Council grade 3) after spinal accessory to suprascapular and/or thoracodorsal to axillary nerve transfer, was 95% and 36%, respectively. There was a tendency for better motor recovery when nerve transfer operations were combined with direct repair of plexus elements. CONCLUSION Nerve transfers for repair of brachial plexus injuries result in excellent recovery of elbow and shoulder functions. Patients who had direct repair of brachial plexus elements in addition to nerve transfers tended to do better than those who had only nerve transfer operations.

Functional contribution of T1 to the brachial plexus in infants

2011 ◽  
Vol 37 (3) ◽  
pp. 237-243 ◽  
Author(s):  
A. Fattah ◽  
C. G. Curtis ◽  
A. M. R. Agur ◽  
H. M. Clarke
Keyword(s):  
Brachial Plexus ◽  
Upper Limb ◽  
External Rotation ◽  
Physiological Activity ◽  
Arm Movement ◽  
Elbow Flexion ◽  
Early Postoperative Period ◽  
Active Movement ◽  
Anatomical Dissection ◽  
Obstetrical Brachial Plexus Palsy

To determine the contribution of the T1 root to movements of the upper limb in infancy, 40 infants presenting with obstetrical brachial plexus palsy who underwent resection and reconstruction of all brachial plexus roots with the exception of the T1 root were assessed in the early postoperative period. The movements of the limb were recorded using the Hospital for Sick Children active movement scale and demonstrated considerable variability. All movements of the upper limb were observed in this group with the exception of external rotation of the shoulder and elbow flexion. Classical accounts of the function of T1 have limited its activity to the small muscles of the hand and were based on anatomical dissection, brachial plexus injuries and electrical stimulation. By contrast, this study isolated the physiological activity of T1 and analysed the functional contribution of this root to arm movement. We show a greater than generally recognized contribution of T1 to the function of the upper limb in infants.

scholarly journals Results of Sever- L’ Episcopo procedure for obstetric brachial plexus palsy

2016 ◽  
Vol 3 (1) ◽  
pp. 50
Author(s):  
Karthi Sundar V. ◽  
Anil Kumar S.V.
Keyword(s):  
Brachial Plexus ◽  
External Rotation ◽  
Social Stigma ◽  
Functional Results ◽  
Functional Improvement ◽  
Brachial Plexus Palsy ◽  
Obstetric Brachial Plexus Palsy ◽  
Obstetric Brachial Plexus ◽  
Teres Major

<p class="abstract"><strong>Background:</strong> The reported incidence of obstetric brachial plexus palsy (OBPP) varies from 0.3 to 2.5 per 1000 live births<strong></strong>resulting in internal rotation deformity and weak abduction of the involved side shoulder<span lang="EN-IN">.</span></p><p class="abstract"><strong>Methods:</strong> To retrospectively analyse the functional results of the Sever- L‘ Episcopo procedure for OBPP with a minimum follow-up of 2 years to a maximum of 13 years using modified Mallet scoring system for shoulder.<strong></strong></p><p class="abstract"><strong>Results:</strong> A significant improvement in the range of abduction and the restoration of external rotation of shoulder was achieved with Sever- L’Episcopo procedure<span lang="EN-IN">. </span></p><p class="abstract"><strong>Conclusions:</strong> The results of secondary reconstruction of a dysfunctional shoulder by means of a Lattismus dorsi &amp; Teres major transfer as described by Sever- L’Episcopo is definitely beneficial. However this procedure will improve, but will not normalize, function. Apart from functional improvement this procedure corrects a deformity thereby easing the psycho-social stigma associated with it<span lang="EN-IN">.</span></p>

Glenohumeral fusion in adults with sequelae of obstetrical brachial plexus injury: a report of eight cases

2018 ◽  
Vol 44 (3) ◽  
pp. 248-255
Author(s):  
Zoubir Belkheyar ◽  
Amar Belkacem Djeffel ◽  
Adeline Cambon-Binder
Keyword(s):  
Brachial Plexus ◽  
Brachial Plexus Injury ◽  
External Rotation ◽  
Shoulder Abduction ◽  
Level Of Evidence ◽  
Flexor Muscles ◽  
Obstetric Brachial Plexus ◽  
Brachial Plexus Paralysis ◽  
Shoulder Arthrodesis

The purpose of this study was to assess the outcomes of glenohumeral fusion performed in adulthood in patients with poor recovery after obstetric brachial plexus injury. We reviewed eight patients with obstetrical brachial plexus injury who had undergone shoulder arthrodesis. The mean age was 28 years (range 16 to 55). All of the patients had active periscapular and elbow flexor muscles. At an average follow-up of 20 months, the active range of abduction and external rotation of the affected shoulder was 67° (range 50° to 85°) and 21° (range 0° to 40°), respectively. All of the patients were satisfied with the outcome of the intervention. Fusion was obtained between 3 and 6 months, and none of the patients experienced residual pain. Shoulder fusion improved the active shoulder abduction and external rotation in adults with residual obstetrical brachial plexus paralysis. Level of evidence: IV

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