The role of subscapularis muscle denervation in the pathogenesis of shoulder internal rotation contracture after neonatal brachial plexus palsy: a study in a rat model

Results of spinal accessory nerve to suprascapular nerve transfers in children with brachial plexus birth injury

Shoulder external rotation after brachial plexus birth injury can be restored by transfer of the spinal accessory nerve to the suprascapular nerve, or more distally to its infraspinatus branch. We studied the outcome of these nerve transfers in 52 patients with a minimum postoperative follow-up of 12 months (mean 7.3 years). The median postoperative improvement in shoulder external rotation was 120° (interquartile range [IQR] 45-135) after anterior and 110° (IQR 83-120) after dorsal spinal accessory nerve transfer to the suprascapular nerve main trunk, and 110° (IQR 80-125) after transfer to the infraspinatus branch. Patients operated after 20 months obtained external rotation ≥90° less frequently. The results of this study suggest that a decision about distal nerve transfer for shoulder external rotation is recommended at 1.5 years of age.Level of evidence: III.

The Putti Sign Following Residual Brachial Plexus Birth Injury: Prevalence and Significance

BACKGROUND

The Putti sign, a common deformity and complaint in children with brachial plexus birth injury (BPBI), stems from a glenohumeral (GH) abduction contracture. Despite recent clinical studies offering insights into this deformity, none have explored the prevalence of the Putti sign or its correlation with GH abduction contractures.

METHODS

We conducted a prospective analysis of 238 patients (median age 7.5 years; range, 4.1-16.2) with residual BPBI seen in the clinic from December 2019 to December 2022. Epidemiological data, including demographics, palsy levels, modified Mallet scale sum, surgical history, and presence/absence of the Putti sign and glenohumeral adduction angle (GHADD), were collected. Patients were categorized into 4 age groups: 0 to 5 years (n=67), 6 to 10 years (n=102), 11 to 15 years (n=53), and 16 years and older (n=16). Results were expressed as medians (minimum-maximum), with frequency comparisons done using Pearson's chi-square analysis. Mann-Whitney U and Kruskal-Wallis tests were used for quantitative variable comparison, and receiver operating characteristic (ROC) analysis determined the threshold GHADD angle for Putti sign appearance.

RESULTS

Main findings included: (1) 27% of patients with residual BPBI exhibited the Putti sign, (2) confirmed correlation between the Putti sign and GH adduction contractures, (3) Putti sign manifestation with GHADD angle measuring less than -5° because to abduction contracture, and (4) association between this deformity and reduced activities requiring external rotation. No significant differences in Putti sign prevalence were found across age groups.

CONCLUSIONS

Our study underscores the common occurrence of the Putti sign in children with residual BPBI. It is important to note that we highlight its functional significance beyond cosmetic concerns. Contrary to prior literature, our analysis reveals functional impairment associated with the Putti sign. Although no age-based differences in Putti sign prevalence were observed, patients aged 0 to 5 years and 11 to 15 years showed more severe glenohumeral abduction contractures, possibly due to growth spurts.

LEVEL OF EVIDENCE

Diagnosis IV.

Subscapularis impairment on magnetic resonance imaging is correlated with functional limitations in neonatal brachial plexus palsy

PURPOSE

The relationship between functional shoulder deficits in children with neonatal brachial plexus palsy (NBPP) and magnetic resonance imaging (MRI) shoulder abnormalities was evaluated.

METHODS

Shoulder function was assessed in 16 children (mean age: 5.8 years; range: 3-12 years) with NBPP based on shoulder rotator muscle strength, as measured using an isokinetic dynamometer and the modified Mallet score. The thickness and fatty infiltration of the subscapularis and infraspinatus muscles, and the morphology of the glenoid on MRI, were also determined.

RESULTS

The highest subscapularis fatty infiltration subgroup of NBPP patients promoted the highest alteration muscle thickness and modified Mallet score.

CONCLUSIONS

In NBPP children, subscapularis impairments play a major role in the functional limitations. This study of pediatric NBPP patients highlighted the value of adding an examination of the muscles to routine MRI assessment of bone parameters in the shoulders of NBPP children.

TRIAL REGISTRATION

NCT03440658.

The Relative Efficacy of Available Proteasome Inhibitors in Preventing Muscle Contractures Following Neonatal Brachial Plexus Injury

BACKGROUND

Contractures following neonatal brachial plexus injury (NBPI) are associated with growth deficits in denervated muscles. This impairment is mediated by an increase in muscle protein degradation, as contractures can be prevented in an NBPI mouse model with bortezomib (BTZ), a proteasome inhibitor (PI). However, BTZ treatment causes substantial toxicity (0% to 80% mortality). The current study tested the hypothesis that newer-generation PIs can prevent contractures with less severe toxicity than BTZ.

METHODS

Unilateral brachial plexus injuries were surgically created in postnatal (5-day-old) mice. Following NBPI, mice were treated with either saline solution or various doses of 1 of 3 different PIs: ixazomib (IXZ), carfilzomib (CFZ), or marizomib (MRZ). Four weeks post-NBPI, mice were assessed for bilateral passive range of motion at the shoulder and elbow joints, with blinding to the treatment group, through an established digital photography technique to determine contracture severity. Drug toxicity was assessed with survival curves.

RESULTS

All PIs prevented contractures at both the elbow and shoulder (p < 0.05 versus saline solution controls), with the exception of IXZ, which did not prevent shoulder contractures. However, their efficacies and toxicity profiles differed. At lower doses, CFZ was limited by toxicity (30% to 40% mortality), whereas MRZ was limited by efficacy. At higher doses, CFZ was limited by loss of efficacy, MRZ was limited by toxicity (50% to 60% mortality), and IXZ was limited by toxicity (80% to 100% mortality) and loss of efficacy. Comparisons of the data on these drugs as well as data on BTZ generated in prior studies revealed BTZ to be optimal for preventing contractures, although it, too, was limited by toxicity.

CONCLUSIONS

All of the tested second-generation PIs were able to reduce NBPI-induced contractures, offering further proof of concept for a regulatory role of the proteasome in contracture formation. However, the narrow dose ranges of efficacy for all PIs highlight the necessity of precise proteasome regulation for preventing contractures. Finally, the substantial toxicity stemming from proteasome inhibition underscores the importance of identifying muscle-targeted strategies to suppress protein degradation and prevent contractures safely.

CLINICAL RELEVANCE

Although PIs offer unique opportunities to establish critical mechanistic insights into contracture pathophysiology, their clinical use is contraindicated in patients with NPBI at this time.

Nerve Tracing in Juvenile Rats: A Feasible Model for the Study of Brachial Plexus Birth Palsy and Cocontractions?

Brachial plexus birth injuries cause diminished motor function in the upper extremity. The most common sequel is internal rotation contracture. A number of these patients also suffer from cocontractions, preventing the use of an otherwise good passive range of motion in the shoulder. One theory behind the co-contracture problem is that injured nerve fibers grow into distal support tissue not corresponding to the proximal support tissue, resulting in reinnervation of the wrong muscle groups. To further elucidate this hypothesis, we used rat neonates to investigate a possible model for the study of cocontractions in brachial plexus birth injuries. Five-day-old rats were subjected to a crush injury to the C5-C6 roots. After a healing period of 4 weeks, the infraspinatus muscle was injected with Fluoro-Gold. A week later, the animals were perfused and spinal cords harvested and sectioned. Differences in the uptake of Fluoro-Gold and NeuN positive cells of between sides of the spinal cord were recorded. We found a larger amount of Fluoro-Gold positive cells on the uninjured side, while the injured side had positive cells dispersed over a longer area in the craniocaudal direction. Our findings indicate that the method can be used to trace Fluoro-Gold from muscle through a neuroma. Our results also indicate that a neuroma in continuity somewhat prevents the correct connection from being established between the motor neuron pool in the spinal cord and target muscle and that some neurons succumb to a crushing injury. We also present future research ideas.

The role of sympathetic innervation in neonatal muscle growth and neuromuscular contractures

Neonatal brachial plexus injury (NBPI), a leading cause of pediatric upper limb paralysis, results in disabling and incurable muscle contractures that are driven by impaired longitudinal growth of denervated muscles. A rare form of NBPI, which maintains both afferent and sympathetic muscle innervation despite motor denervation, protects against contractures. We have previously ruled out a role for NRG/ErbB signaling, the predominant pathway governing antegrade afferent neuromuscular transmission, in modulating the formation of contractures. Our current study therefore investigated the contributions of sympathetic innervation of skeletal muscle in modulating NBPI-induced contractures. Through chemical sympathectomy and pharmacologic modification with a β2 -adrenergic agonist, we discovered that sympathetic innervation alone is neither required nor sufficient to modulate contracture formation in neonatal mice. Despite this, sympathetic innervation plays an intriguing sex-specific role in mediating neonatal muscle growth, as the cross-sectional area (CSA) and volume of normally innervated male muscles were diminished by ablation of sympathetic neurons and increased by β-adrenergic stimulation. Intriguingly, the robust alterations in CSA occurred with minimal changes to normal longitudinal muscle growth as determined by sarcomere length. Instead, β-adrenergic stimulation exacerbated sarcomere overstretch in denervated male muscles, indicating potentially discrete regulation of muscle width and length. Future investigations into the mechanistic underpinnings of these distinct aspects of muscle growth are thus essential for improving clinical outcomes in patients affected by muscle disorders in which both length and width are affected.

Glenohumeral abduction contractures after residual neonatal brachial plexus injury

Glenohumeral abduction contractures are common in patients with neonatal brachial plexus injury, but little has been previously published about them. We conducted a retrospective analysis of data prospectively collected from 205 consecutive children (108 female) of mean age 9.6 years with neonatal brachial plexus injury (C5-C6, 58%; C5-C7, 29%; C5-T1, 14%). Most children (69%) showed a glenohumeral abduction contracture, it being more common in those with upper neonatal brachial plexus injury.Level of evidence: III.

Timing of proteasome inhibition as a pharmacologic strategy for prevention of muscle contractures in neonatal brachial plexus injury

Neonatal brachial plexus injury (NBPI) causes disabling and incurable contractures, or limb stiffness, which result from proteasome-mediated protein degradation impairing the longitudinal growth of neonatally denervated muscles. We recently showed in a mouse model that the 20S proteasome inhibitor, bortezomib, prevents contractures after NBPI. Given that contractures uniquely follow neonatal denervation, the current study tests the hypothesis that proteasome inhibition during a finite window of neonatal development can prevent long-term contracture development. Following neonatal forelimb denervation in P5 mice, we first outlined the minimum period for proteasome inhibition to prevent contractures 4 weeks post-NBPI by treating mice with saline or bortezomib for varying durations between P8 and P32. We then compared the ability of varying durations of longer-term proteasome inhibition to prevent contractures at 8 and 12 weeks post-NBPI. Our findings revealed that proteasome inhibition can be delayed 3-4 days after denervation but is required throughout skeletal growth to prevent contractures long term. Furthermore, proteasome inhibition becomes less effective in preventing contractures beyond the neonatal period. These therapeutic effects are primarily associated with bortezomib-induced attenuation of 20S proteasome β1 subunit activity. Our collective results, therefore, demonstrate that temporary neonatal proteasome inhibition is not a viable strategy for preventing contractures long term. Instead, neonatal denervation causes a permanent longitudinal growth deficiency that must be continuously ameliorated during skeletal growth. Additional mechanisms must be explored to minimize the necessary period of proteasome inhibition and reduce the risk of toxicity from long-term treatment.

The Effect of Distal Transfer of the Spinal Accessory Nerve to the Suprascapular Nerve on the Shoulder Reanimation in Spontaneously Partially Recovered Obstetric Brachial Plexus Lesion

BACKGROUND

Spontaneous recovery of elbow flexion in obstetric brachial plexus palsy at 4 to 6 months of age is sufficient to exclude the child from the early microsurgical intervention. However, lack of complete active external rotation of shoulder is a common finding in such cases despite ongoing other arm and shoulder functions. Nerve transfer is proposed to manage such cases before the age of 18 months.

AIM

The aim of this study was to study the distal transfer of the spinal accessory nerve to the suprascapular nerve through posterior approach and its effect on the shoulder reanimation in patients with obstetric brachial plexus lesion who had spontaneously recovered biceps function but not shoulder function before the age of 18 months.

PATIENTS AND METHODS

This prospective study included 20 patients admitted to Elhadra University Hospital with obstetric brachial plexus lesion aged between 10 and 18 months with spontaneous recovery of biceps function, weak active shoulder abduction grade 4 or grade 5 and deficient active shoulder external rotation. All patients were assessed preoperative and postoperative by Active Movement Scale.

RESULTS

Active shoulder external rotation improved in all patients at the end of follow-up period, whereas the shoulder abduction improved in 80%. Early surgery in patient younger than 16 months shows better results.

CONCLUSIONS

The distal transfer of spinal accessory nerve to suprascapular nerve is an effective method for active shoulder abduction and external rotation recovery in spontaneously recovered elbow flexion in obstetric brachial plexus lesions. Better results are obtained in patients younger than 16 months old. Early transfer balances the forces around the shoulder joint, preventing shoulder internal rotation contracture.

Proteasome inhibition preserves longitudinal growth of denervated muscle and prevents neonatal neuromuscular contractures

Muscle contractures are a prominent and disabling feature of many neuromuscular disorders, including the 2 most common forms of childhood neurologic dysfunction: neonatal brachial plexus injury (NBPI) and cerebral palsy. There are currently no treatment strategies to directly alter the contracture pathology, as the pathogenesis of these contractures is unknown. We previously showed in a mouse model of NBPI that contractures result from impaired longitudinal muscle growth. Current presumed explanations for growth impairment in contractures focus on the dysregulation of muscle stem cells, which differentiate and fuse to existing myofibers during growth, as this process has classically been thought to control muscle growth during the neonatal period. Here, we demonstrate in a mouse model of NBPI that denervation does not prevent myonuclear accretion and that reduction in myonuclear number has no effect on functional muscle length or contracture development, providing definitive evidence that altered myonuclear accretion is not a driver of neuromuscular contractures. In contrast, we observed elevated levels of protein degradation in NBPI muscle, and we demonstrate that contractures can be pharmacologically prevented with the proteasome inhibitor bortezomib. These studies provide what we believe is the first strategy to prevent neuromuscular contractures by correcting the underlying deficit in longitudinal muscle growth.

Relationship between neuropathy proximal to the suprascapular nerve and rotator cuff tear in a rodent model

BACKGROUND

Rotator cuff tears are believed to coexist with cervical spine lesions. In cases of preexisting neuropathy, such as cervical spine lesions, fatty degeneration has likely already occurred due to the neuropathy. In these cases, rotator cuff tear is thought to occur easily because of preexisting extensive fatty degeneration and degeneration of the tendons due to neuropathy. This study aimed to evaluate the effects of paralysis due to neuropathy proximal to the suprascapular nerve on the supraspinatus and infraspinatus tendons using a rat model of brachial plexus paralysis.

METHODS

This study included fifteen, 8-week-old Sprague-Dawley rats. The left shoulder was included in the paralysis group and the contralateral shoulder constituted the sham group. Biomechanical testing (evaluated maximum tear force, maximum displacement and Young's modulus) (n = 10) and histological analyses (n = 5) (using the Bonar scale) were performed at 12 weeks postoperatively to confirm the degeneration of the tendon.

RESULTS

The mean maximum tear force was significantly lower in the paralysis group than in the sham group (P = 0.008), indicating that rotator cuff tears occurred with a lower force in the paralysis group. Additionally, the average Young's modulus was significantly greater in the paralysis group than in the sham group (P = 0.003), indicating that the rotator cuff muscle became hard and inflexible in the paralysis group. The Bonar scales of the histological analyses were significantly higher in the paralysis group (total score = 7.04 ± 0.61) than the sham group (total score = 0) (p < 0.0001).

CONCLUSIONS

If neuropathy of proximal to the suprascapular nerve, such as cervical spine or brachial plexus lesion, exists, weakness and degeneration of the rotator cuff tendon and stiffness of the rotator cuff muscle develop. Neuropathy is likely a cause of rotator cuff tears.

The Effect of Scapular Position on Magnetic Resonance Imaging Measurements of Glenohumeral Dysplasia Caused by Neonatal Brachial Plexus Palsy

PURPOSE

Neonatal brachial plexus palsy (NBPP) frequently causes glenohumeral dysplasia. Quantification of this dysplasia on magnetic resonance imaging can determine the need for and the success of nonsurgical or surgical intervention. However, we hypothesize that the variable position of the scapula on the thorax between affected and unaffected shoulders affects dysplasia measurements.

METHODS

Magnetic resonance imaging studies were analyzed from 19 NBPP patients (ages 0.8-18 years; median, 2.4 years) without prior shoulder surgery. Three reviewers measured the glenoid version angle (GVA) and percentage of humeral head anterior to the midscapular line (PHHA) on standard axial images ("thoracic axial") and on reformatted axial images aligned perpendicular to the scapular plane ("scapular axial"), which corrects for scapulothoracic position. Scapular tilt and protraction were measured to assess their impact on the difference between thoracic and scapular GVA and PHHA measurements. Intra- and interrater reliability were calculated for GVA and PHHA on both views.

RESULTS

The GVA of the affected shoulder was significantly greater on thoracic than on scapular images, by an average of 5° and as much as 34°. The PHHA was significantly less in the affected shoulders on thoracic than on scapular images, by an average of 5% and as much as 33% of humeral head width. The difference in GVA, but not PHHA, between thoracic and scapular axial images in the affected shoulder correlated with scapular tilt. Unaffected shoulders showed no significant difference in GVA or PHHA between thoracic and scapular axial images. Interrater reliability ranged from fair to substantial and did not differ between thoracic and scapular images.

CONCLUSIONS

Thoracic axial images overestimate the severity of glenohumeral dysplasia in NBPP, owing at least in part to the variable position of the scapula on the thorax. This confounding effect must be considered in interpretation of axial quantitative measures of glenohumeral dysplasia in NBPP.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic III.

Botulinum Toxin Injection for Internal Rotation Contractures in Brachial Plexus Birth Palsy. A Minimum 5-Year Prospective Observational Study

BACKGROUND

Brachial plexus birth palsy is frequently associated with internal rotation contractures of the shoulder as a result of muscle imbalance. The purpose of this study is to assess the effect of botulinum toxin A (BTX-A) injection in the subscapular (SC) muscle on external rotation and the need for tendon transfer for external rotation of the shoulder.

METHODS

A prospective comparative study was performed including 15 consecutive patients treated with BTX-A and a historic control group of 67 patients with mean age 30 months (SD 10). The BTX-A injection (2 IU/kg body weight) was performed immediately following MRI under general anesthesia in the SC muscle. Passive external rotation, the need for tendon transfer surgery, glenohumeral deformity, and muscle degeneration were evaluated. The hazard ratio for no relapse of internal rotation contracture after BTX-A injection compared with no BTX-A injection was calculated.

RESULTS

In the BTX-A group, the passive external rotation in adduction increased from -1 degree (95% CI, -10 to 8) to 32 degrees (95% CI, 17-46) at 3 months and 6 patients were indicated for surgery compared with a decline from -2 degrees (95% CI, -7 to 3) to -11 degrees (95% CI, -17 to -6) in the control group with 66 indications for surgery. At 5 years of follow-up, 10 patients in the BTX-A group were indicated for surgery with a hazard ratio of 4.0 (95% CI, 1.9 to 8.4).

CONCLUSIONS

BTX-A injection in the SC muscle of brachial plexus birth palsy patients can reduce internal rotation contractures and subsequently the need for tendon transfer surgery. At 5 years of follow-up a relapse was seen in 67% of the patients treated with BTX-A. Because at MRI less SC degeneration was found in the good responders on BTX-A treatment, this group seems to be the best target group. Further research is needed on patient selection for BTX-A injection including glenohumeral deformity, SC degeneration, as well as doses of BTX-A to be used.

LEVEL OF EVIDENCE

Level II-prospective comparative study.