Torticollis associated with neonatal brachial plexus palsy

Disease spectrum of torticollis in children and diagnostic flowchart: A retrospective, single-centre study

AIM

To describe the disease spectrum of torticollis in Chinese children and to improve its diagnostic flowchart.

METHODS

A retrospective analysis was conducted at the Rehabilitation Department of Beijing Children's Hospital from 2017 to 2021. Patients were diagnosed and referred based on a diagnostic flowchart of torticollis. Detailed patient data were collected from the outpatient electronic medical record system.

RESULTS

A total of 2047 patients met the inclusion criteria. The top five conditions were congenital muscular torticollis (CMT) (76.6%), cerebral palsy (5.1%), ocular torticollis (4.7%), brachial plexus injury (1.9%) and atlantoaxial rotary subluxation (1.3%). CMT was most common in 0-2 year olds, cerebral palsy in 3-5 year olds, and atlantoaxial rotary subluxation in 7-12 year olds. The top five referral departments were orthopaedics, ophthalmology, otolaryngology, head and neck surgery, neurology and neurosurgery.

CONCLUSIONS

The disease spectrum of torticollis in children and the diagnostic flowchart provide important references for diagnosing torticollis, which necessitates multidisciplinary collaboration.

Promoting Recovery Following Birth Brachial Plexus Palsy

Neonatal brachial plexus palsies (NBPP) occur in 1.74 per 1000 live births with 20% to 30% having persistent deficits. Dysfunction can range from mild to severe and is correlated with the number of nerves involved and the degree of injury. In addition, there are several comorbidities and musculoskeletal sequelae that directly impact the overall functional development. This review addresses the nonsurgical and surgical management options and provides guidance for pediatricians on monitoring and when to refer for specialty care.

Comorbidities in Infants and Children with Neonatal Brachial Plexus Palsy: A Scoping Review to Inform Multisystem Screening

AIMS

The scoping review was undertaken to explore comorbidities in infants and children with neonatal brachial plexus palsy (NBPP). The purpose of the review was to inform physical and occupational therapy screening of multiple body systems during the examination of children with NBPP.

METHODS

EBSCO Discovery and EMBASE electronic databases were searched for reports published between January 1996 and September 2021 describing comorbidities in children with NBPP between birth and 18 years. Key data pertaining to comorbidity prevalence, risk factors, clinical features, and associated outcomes were extracted and charted by one researcher and confirmed by a second researcher.

RESULTS

Thirty-six articles were included in the scoping review. Fourteen comorbidities were identified across the musculoskeletal, neurological, cardiopulmonary, and integumentary systems and the communication domain. The most prevalent comorbidities were clavicle fractures, plagiocephaly, torticollis, high body mass index, and language delays. The least prevalent comorbidity was facial nerve palsy.

CONCLUSIONS

Physical and occupational therapists can use knowledge of comorbidities in infants and children with NBPP for multisystem screening during the examination. A thorough history can identify risk factors for comorbidities. Detection of comorbidities during screening allows for timely specialty referrals to optimize care.

Art and Pediatric Orthopaedics: "Arm-twisting" by Wyspianski, the Poet, Actor, and Artist

Stanislaw Wyspianski, a multifaceted Polish artist painted "A Girl with a Red Hat", which portrays a young girl with an obviously deformed right upper limb. The pattern of deformities is suggestive of either athetoid hemiplegic cerebral palsy or Erb's palsy.

Cervical Dystonia Mimics: A Case Series and Review of the Literature

Background

Cervical dystonia is mostly idiopathic in nature. However, a small subset of cases are mimics, leading to diagnostic pitfalls. There is paucity of literature on pseudodystonias affecting the cervical region.

Method

We performed a retrospective review of patients attending a movement disorders clinic over a period of 7 years (2012–2018). Among them, those who were considered to have mimics of cervical dystonia based upon clinical and supportive investigations were included.

Results

Six out of 2,412 patients (0.24%) were diagnosed as cervical dystonia mimics and the causes included isolated neck extensor myopathy (2), craniovertebral junction anomalies (2), sternocleidomastoid fibrosis (1) and post traumatic sequelae (1). Among these patients, three patients had received various treatments for cervical dystonia, including botulinum toxin injections.

Discussion

Mimics of isolated cervical dystonia are rare. A high degree of suspicion and proper diligent clinical assessment assists management and prognostication.

Body Weight at Birth: The Only Risk Factor Associated with Contralateral Clavicular Fracture in Patients with Congenital Muscular Torticollis

To date and to the best of our knowledge, there have been limited studies on the risk factor of clavicle fracture combined with congenital muscular torticollis (CMT), despite it being the most common fracture in newborns. So, the aim of this study was to investigate the risk factors associated with clavicular fracture combined with CMT, and its effect on prognosis. In this study, a total of 134 infants with CMT were included. The risk factors associated with clavicular fracture combined with CMT were analyzed. To analyze the correlation between the clinical parameters and the clavicular fracture in patients with CMT, demographic data, such as body weight at birth, maternal age, gender, gestational age, delivery method, sternocleidomastoid (SCM) thickness of ipsilateral side, its ratio between the ipsilateral and contralateral side, and the first visitation date after birth were evaluated. In the results of this study, the clavicular fracture was found in 15 of 134 patients with CMT (19%). In multivariate logistic analysis, the body weight at birth was the only significant parameter for predicting clavicular fracture in patients with CMT (p-value < 0.05). However, there was no significant difference of treatment duration between CMT infants with or without clavicular fracture. In infants with CMT, the area under the ROC curve of the body weight at birth for predicting clavicular fracture was 0.659 (95% CI, 0.564–0.745.; p < 0.05). The optimal cut-off value obtained from the maximum Youden index J was 3470 g (sensitivity: 57.14%, specificity: 75.76%), and the odd ratio of clavicular fracture in patients with CMT increased by 1.244 times for every 100 g of body weight at birth. In conclusion, birth weight appears to be a clinical predictor of clavicular fracture in infants with CMT. More studies and discussions are needed on whether any screening should be recommended for detecting the concurrent clavicular fracture in subjects with CMT.

An Update on the Management of Neonatal Brachial Plexus Palsy-Replacing Old Paradigms: A Review

IMPORTANCE

Neonatal brachial plexus palsy (NBPP) can result in persistent deficits for those who develop it. Advances in surgical technique have resulted in the availability of safe, reliable options for treatment. Prevailing paradigms include, "all neonatal brachial plexus palsy recovers," "wait a year to see if recovery occurs," and "don't move the arm." Practicing by these principles places these patients at a disadvantage. Thus, the importance of this review is to provide an update on the management of NBPP to replace old beliefs with new paradigms.

OBSERVATIONS

Changes within denervated muscle begin at the moment of injury, but without reinnervation become irreversible 18 to 24 months following denervation. These time-sensitive, irreversible changes are the scientific basis for the recommendations herein for the early management of NBPP and put into question the old paradigms. Early referral has become increasingly important because improved outcomes can be achieved using new management algorithms that allow surgery to be offered to patients unlikely to recover sufficiently with conservative management. Mounting evidence supports improved outcomes for appropriately selected patients with surgical management compared with natural history. Primary nerve surgery options now include nerve graft repair and nerve transfer. Specific indications continue to be elucidated, but both techniques offer a significant chance of restoration of function.

CONCLUSIONS AND RELEVANCE

Mounting data support both the safety and effectiveness of surgery for patients with persistent NBPP. Despite this support, primary nerve surgery for NBPP continues to be underused. Surgery is but one part of the multidisciplinary care of NBPP. Early referral and implementation of multidisciplinary strategies give these children the best chance of functional recovery. Primary care physicians, nerve surgeons, physiatrists, and occupational and physical therapists must partner to continue to modify current treatment paradigms to provide improved quality care to neonates and children affected by NBPP.

Rare Concurrence of Congenital Muscular Torticollis and a Malignant Tumor in the Same Sternocleidomastoid Muscle

While congenital muscular torticollis (CMT) can occur along with other conditions, such as clavicle fracture or brachial plexus injury, these conditions exist outside the sternocleidomastoid muscle (SCM). We present a rare case with concurrence of CMT and a malignant tumor inside the same SCM, along with serial clinical and radiological findings of the atypical features of CMT. The malignant tumor was in fact a low-grade fibromyxoid sarcoma. To the best of our knowledge, the current case is the first of a concurrent condition of CMT inside the SCM. This case suggests that concurrent conditions could exist either inside or outside the SCM with CMT. Therefore, a thorough evaluation of SCM is required when subjects with CMT display atypical features, such as the increase of mass or poor response to conservative therapy. In that case, appropriate imaging modalities, such as ultrasonogram or magnetic resonance imaging, are useful for differential diagnosis.

Contralateral Involvement of Congenital Muscular Torticollis and Clavicular Fracture

Congenital muscular torticollis (CMT) is known to concur with some conditions such as developmental dysplasia of the hip or brachial plexus injury, which gives us some insights for pathogenesis of CMT. Although clavicular fracture is the most common fracture in newborns, little is known about concurrence of CMT and clavicular fracture. Our clinical experience led us to realize that concurrence of CMT and clavicular fracture tended to occur on the contralateral side for each other rather than the ipsilateral side. This study aimed to verify contralateral concurrence of CMT and clavicular fracture. This is a retrospective cohort study in a tertiary hospital, including 996 subjects with CMT. Concurrent clavicular fracture was found in 20 of 996 subjects with CMT, with the concurrence rate being 2.01%. Concurrent clavicular fracture and clavicular fracture occurred on the contralateral side for each other in 18 subjects (90%) rather than the ipsilateral side. This contralateral concurrence between side of CMT and clavicular fracture was significant (P = 0.001), with an odds ratio of 81 (P = 0.0032). Concurrent clavicular fracture and clavicular fracture seem to occur significantly more on the contralateral side for each other. Underlying mechanism for consistent contralateral concurrence needs to be verified in the near future.

High prevalence of cranial asymmetry exists in infants with neonatal brachial plexus palsy

PURPOSE

This study aimed to: 1) evaluate the prevalence of cranial asymmetry (positional plagiocephaly) in infants with neonatal brachial plexus palsy (NBPP); 2) examine the association of patient demographics, arm function, and NBPP-related factors to positional plagiocephaly; and 3) determine percentage of spontaneous recovery from positional plagiocephaly and its association with arm function.

METHODS

Infants < 1 year of age with NBPP and no previous exposure to plagiocephaly cranial remolding therapy or surgical intervention were recruited for this prospective cross-sectional study. Positional plagiocephaly (diagonal difference) measurements were captured using a fiberglass circumferential mold of the cranium. Included infants were divided into 2 groups: 1) those with positional plagiocephaly at most recent evaluation (plagio group), including infants with resolved positional plagiocephaly (plagio-resolved subgroup); and 2) those who never had positional plagiocephaly (non-plagio group). Standard statistics were applied.

RESULTS

Eighteen of 28 infants (64%) had positional plagiocephaly. Delivery type might be predictive for plagiocephaly. Infants in the non-plagio group exhibited more active range of motion than infants in the plagio group. All other factors had no significant correlations.

CONCLUSIONS

A high prevalence of positional plagiocephaly exists among the NBPP population examined. Parents and physicians should encourage infants to use their upper extremities to change position and reduce chance of cranial asymmetry.

High prevalence of early language delay exists among toddlers with neonatal brachial plexus palsy

AIM

An association of language impairment with neonatal brachial plexus palsy has not been reported in the literature. The current treatment paradigm for neonatal brachial plexus palsy focuses on upper extremity motor recovery with little formal assessment of other aspects of development, such as language. We performed a cross-sectional pilot study to investigate early language delay prevalence in toddlers with neonatal brachial plexus palsy and potential neonatal brachial plexus palsy-related factors involved.

METHOD

Twenty toddlers with neonatal brachial plexus palsy were consecutively recruited (12 males and eight females; mean age, 30 months). Preschool Language Scale Score (4th edition), demographics, and socioeconomic status were collected. Neonatal brachial plexus palsy-related factors such as palsy side, treatment type, Narakas grade, muscle Medical Research Council score, and Raimondi hand score were reported. Student t test, chi-square test, or Fisher exact test were applied. Statistical significance level was established at P < 0.05.

RESULTS

Of study participants, 30% had language delay, whereas the prevalence of language delay in the population with normal development in this age range was approximately 5-15%.

INTERPRETATION

We observed high language delay prevalence among toddlers with neonatal brachial plexus palsy. Although our subject sample is small, our findings warrant further study of this phenomenon. Early identification and timely intervention based on type of language impairment may be critical for improving communication outcome in this population.

Neonatal brachial plexus palsy--management and prognostic factors

Successful treatment of patients with neonatal brachial plexus palsy (NBPP) begins with a thorough understanding of the anatomy of the brachial plexus and of the pathophysiology of nerve injury via which the brachial plexus nerves stretched in the perinatal period manifest as a weak or paralyzed upper extremity in the newborn. NBPP can be classified by systems that can guide the prognosis and the management as these systems are based on the extent and severity of nerve injury, anatomy of nerve injury, and clinical presentation. Serial physical examinations, supplemented by a thorough maternal and perinatal history, are critical to the formulation of the treatment plan that relies upon occupational/physical therapy and rehabilitation management but may include nerve reconstruction and secondary musculoskeletal surgeries. Adjunctive imaging and electrodiagnostic studies provide additional information to guide prognosis and treatment. As research improves not only the technical aspects of NBPP treatment but also the ability to assess the activity and participation as well as body structure and function of NBPP patients, the functional outcomes for affected infants have an overall optimistic prognosis, with the majority recovering adequate functional use of the affected arm. Of importance are (i) early referral to interdisciplinary specialty clinics that can provide up-to-date advances in clinical care and (ii) increasing research/awareness of the psychosocial and patient-reported quality-of-life issues that surround the chronic disablement of NBPP.

Utility of delayed surgical repair of neonatal brachial plexus palsy

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.

Torticollis

Torticollis refers to a twisting of the head and neck caused by a shortened sternocleidomastoid muscle, tipping the head toward the shortened muscle, while rotating the chin in the opposite direction. Torticollis is seen at all ages, from newborns to adults. It can be congenital or postnatally acquired. In this review, we offer a new classification of torticollis, based on its dynamic qualities and pathogenesis. All torticollis can be classified as either nonparoxysmal (nondynamic) or paroxysmal (dynamic). Causes of nonparoxysmal torticollis include congenital muscular; osseous; central nervous system/peripheral nervous system; ocular; and nonmuscular, soft tissue. Causes of paroxysmal torticollis are benign paroxysmal; spasmodic (cervical dystonia); Sandifer syndrome; drugs; increased intracranial pressure; and conversion disorder. The description, epidemiology, clinical presentation, evaluation, treatment, and prognosis of the most clinically significant types of torticollis follow.