The findings in paediatric obstetric brachial palsy differ from those in older patients: a suggested explanation

Brachial Plexus Birth Injury: A Review of Neurology Literature Assessing Variability and Current Recommendations

BACKGROUND

Publications regarding the epidemiology and management of brachial plexus birth injury (BPBI) were evaluated to investigate treatment guidelines for children with BPBI.

METHODS

A search of neurology literature from 1990 to 2019 was performed using PubMed, Scopus, and Medline. Data including incidence, risk factors, spontaneous recovery rates, imaging studies, treatment recommendations, and indications and timing for surgery were collected.

RESULTS

A total of 46 total studies were reviewed. Reported incidence rates for BPBI ranged from 0.3 to 3 per 1000 births. Spontaneous recovery rates had an average reported range from 66% to 75%. Physical and occupational therapy were recommended in 37% of articles. Computed tomographic myelogram and magnetic resonance imaging of the brachial plexus were the most commonly recommended imaging studies for BPBI. Timelines for surgical interventions ranged from age three to nine months. Early referral was recommended in 28% of the articles included in the review.

CONCLUSIONS

Given the inconsistencies in spontaneous recovery rates, imaging recommendations, and timing of referral, establishing consistent clinical guidelines for patients with BPBI is crucial for management. Early referral to specialists for evaluation and treatment may improve outcomes in children with BPBI.

Contralateral C7 transfer via both ulnar nerve and medial antebrachial cutaneous nerve to repair total brachial plexus avulsion: a preliminary report

Aim: After brachial plexus injuries, sacrifice of the contralateral C7 (cC7) root from the non-injured side is well tolerated and various schemes to innervate the injured side from the cC7 root have been used. Objective: To demonstrate the surgical outcomes from transferring the cC7 to the affected side via both the ulnar nerve and medial antebrachial cutaneous nerve (MACN).Methods: A retrospective study of 16 adult patients sustaining total brachial plexus avulsion who underwent this procedure. The British Medical Research Council (MRC) grading system and the disabilities of the arm, shoulder, and hand (DASH) questionnaire scoring were used to evaluate the recovery.Results: About 68.75% of the patients achieved functional recovery of elbow flexion to M3 or better and 43.75% achieved motor recovery of wrist and finger flexion to M3 or better. Sensation in the median nerve territory recovered to S2 or better in 68.75%. The DASH scores after surgery were significantly lower than those before surgery.Conclusions: cC7 transfer via both ulnar and MACNs is an effective and safe procedure in patients sustaining total injuries of brachial plexus.

Outcome of Finger Extension After Nerve Transfer to Repair C7-T1 Brachial Plexus Palsy in Rats: Comparative Study of the Supinator Motor Branch Transfer to the Posterior Interosseous Nerve and the Contralateral C7 Transfer to the Lower Trunk

BACKGROUND

Functional recovery following supinator motor branch transfer requires further investigation.

OBJECTIVE

To compare the outcome of finger extension after supinator motor branch transfer or contralateral C7 (cC7) transfer in C7-T1 brachial plexus palsies in rats.

METHODS

In this study, 120 adult rats underwent C7-T1 nerve root avulsion and received different nerve transfer repairs: group A, cC7 nerve transfer to the lower trunk; group B, supinator motor branch nerve transfer to the posterior interosseous nerve (PIN); and group C, no repair. The ethology of the rats, latency and amplitude of the compound muscle action potential from the PIN, muscle mass and muscle fiber cross-sectional area of the extensor digitorum communis and extensor carpi ulnaris, and number of myelinated nerve fibers in the PIN were examined postoperatively.

RESULTS

There was no finger extension in group C. We observed finger extension in groups A and B 50.2 ± 5.66 and 13.1 ± 2.08 days postoperatively, respectively. Finger extension restoration in group B was greater than that in group A at 4, 8, and 12 weeks postoperatively ( P < .05). Sixteen weeks after surgery, the recovery rate of the myelinated nerve fibers in group A was marginally higher than that in group B, but the difference was not significant. Of the other measured values, group B showed a greater and significant improvement compared to group A ( P < .05).

CONCLUSION

Supinator motor branch transfer allows for faster recovery and is a more effective procedure for restoring finger extension in C7-T1 brachial plexus palsies.

Neonatal Magnetic Resonance Imaging Without Sedation Correlates With Injury Severity in Brachial Plexus Birth Palsy

PURPOSE

Which infants with brachial plexus birth palsy (BPBP) should undergo microsurgical plexus reconstruction remains controversial. The current gold standard for the decision for plexus reconstruction is serial clinical examinations, but this approach obviates the possibility of early surgical treatment. We hypothesize that a new technique using 3-dimensional volumetric proton density magnetic resonance imaging (MRI) without sedation can evaluate the severity of BPBP injury earlier than serial clinical examinations.

METHODS

Infants were prospectively enrolled prior to 12 weeks of age and imaged using 3 Tesla MRI without sedation. Clinical scores were collected at all visits. The imaging findings were graded based on the number of injured levels and the severity of each injury, and a radiological score was calculated. All infants were followed at least until the decision for surgery was made based on clinical examination.

RESULTS

Nine infants completed the MRI scan and clinical follow-up. The average Toronto score at presentation was 4.4 out of 10 (range, 0-8.2); the average Active Movement Scale score was 50 out of 105 (range, 0-86). Four infants required surgery: 2 because of a flail limb and Horner syndrome and 2 owing to failure to recover antigravity elbow flexion by age 6 months. Radiological scores ranged from 0 to 18 out of a maximum score of 25. The average radiological score for those infants who required surgery was 12 (range, 6.5-18), whereas the average score for infants who did not require surgery was 3.5 (range, 0-8).

CONCLUSIONS

Three-dimensional proton density MRI can evaluate spinal nerve roots in infants without the need for radiation, contrast agents, or sedation. These data suggest that MRI can help determine the severity of injury earlier than clinical examination in infants with BPBP, although further study of a larger sample of infants with varying severity of disease is necessary.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic II.

The Towel Test: A Useful Technique for the Clinical and Electromyographic Evaluation of Obstetric Brachial Plexus Palsy

The towel test consists of covering an infant’s face with a towel and seeing if he/she can remove it with either arm. In this study it has been used to aid the clinical and electromyographic assessment of 21 infants with obstetric brachial plexus palsy. At 2 to 3 months, none of the 21 infants succeeded in removing the towel, either with their normal or affected arm. At 6 months, all the infants succeeded in removing the towel with their normal arm, but 11 could not with their affected arm, and the same was observed at a further assessment at 9 months. The towel test is a reliable technique for evaluating children with obstetric brachial plexus injuries.

Congenital subaxial cervical subluxation presenting as a bilateral Erb's palsy: surgical management, rehabilitation, and outcome

INTRODUCTION

Subaxial spine injuries during infancy are uncommon.

CASE REPORT

We present the case of an infant referred to our brachial plexus clinic with proximal weakness of both arms noted immediately following a complicated breech delivery. Nerve conduction studies were consistent with bilateral proximal upper plexus injury; however, radiological evaluation revealed a C4-C5 subluxation and MRI features of bilateral C5 root avulsions. He was immobilized in a cervical-body orthosis and underwent open reduction and posterior C4-C5-C6 fixation at 10 weeks age using luque rods, sublaminar wires, and rib graft. The spine was immobilized in a custom molded cervicothoracic brace for a total of 3 months, and a home exercise program prescribed. Follow-up radiographic evaluation showed good posterior bony fusion by 2 months but persistent bilateral proximal upper limb weakness with reduced compound motor action potential (CMAP) amplitudes of the axillary and musculocutaneous nerves. Bilateral supraclavicular exploration and C5 root neurotization using the ipsilateral C7 nerve roots were performed at 7 months of age. Voluntary biceps activity followed by voluntary external rotation with gravity eliminated was noted within the next 2-3 months. He progressed to develop near normal motor control of bilateral upper limbs within 1 year.

CONCLUSIONS

We wish to report this rare entity and our favorable outcome using a strategy of early spinal stabilization and neurotization repair to restore function following proximal nerve root injury.

Comparative study of intercostal nerve transfer to lower trunk and contralateral C7 root transfer in repair of total brachial plexus injury in rats

AIM

The aim of this study is to compare the treatment outcome of nerve transfer using intercostal nerves (ICNs) or contralateral C7 (cC7) root in rats.

METHODS

Ninety adult Sprague-Dawley rats were randomly divided into three groups of 30 each: group A (cC7 root transfer), group B (ICNs transfer), and group C (control). Electrophysiological examination, muscle tension test, neuromorphology, and muscle fiber cross-sectional area measurements obtained from the three groups were compared to evaluate neurotization outcome 4, 8, and 12 weeks postoperatively.

RESULTS

Median nerve regeneration and the flexor digitorum superficialis (FDS) muscle functional recovery of group B were worse than group A from comparison of both groups' parameters.

CONCLUSIONS

Neurotization of ICNs to the lower trunk is difficult to replace cC7 root transfer to the median nerve for restoration of hand function in total brachial plexus injury (BPI). Therefore, at present, the more important implication of the comparative study is that traditional cC7 root transfer remains the mainstay strategy to repair forearm flexor muscle function.

Clinical and neurobiological advances in promoting regeneration of the ventral root avulsion lesion

Root avulsions due to traction to the brachial plexus causes complete and permanent loss of function. Until fairly recent, such lesions were considered impossible to repair. Here we review clinical repair strategies and current progress in experimental ventral root avulsion lesions. The current gold standard in patients with a root avulsion is nerve transfer, whereas reimplantation of the avulsed root into the spinal cord has been performed in a limited number of cases. These neurosurgical repair strategies have significant benefit for the patient but functional recovery remains incomplete. Developing new ways to improve the functional outcome of neurosurgical repair is therefore essential. In the laboratory, the molecular and cellular changes following ventral root avulsion and the efficacy of intervention strategies have been studied at the level of spinal motoneurons, the ventral spinal root and peripheral nerve, and the skeletal muscle. We present an overview of cell-based pharmacological and neurotrophic factor treatment approaches that have been applied in combination with surgical reimplantation. These interventions all demonstrate neuroprotective effects on avulsed motoneurons, often accompanied with various degrees of axonal regeneration. However, effects on survival are usually transient and robust axon regeneration over long distances has as yet not been achieved. Key future areas of research include finding ways to further extend the post-lesion survival period of motoneurons, the identification of neuron-intrinsic factors which can promote persistent and long-distance axon regeneration, and finally prolonging the pro-regenerative state of Schwann cells in the distal nerve.

Long-term outcome of accessory nerve to suprascapular nerve transfer in obstetric brachial plexus lesion: functional, morphological, and electrophysiological results

PURPOSE

An accessory to suprascapular nerve (XIN-SSN) transfer is considered in patients with obstetric brachial plexus lesion who fail to recover active shoulder external rotation. The aim of this study was to evaluate the quality of extraplexal suprascapular nerve neurotization and to perform a detailed analysis of the infraspinatus muscle (IM) and shoulder external rotation.

METHODS

A XIN-SSN transfer was performed in 14 patients between 2000 and 2007. Patients had been operated at the age of 3.7 ± 2.8 years. Follow-up examinations were conducted up to 8.5 ± 2.5 years. Magnetic resonance imaging was performed to investigate muscle trophism. Fatty muscle degeneration of the IM was classified according to the Goutallier classification. We conducted nerve conduction velocity studies of the suprascapular nerve and needle electromyography of the IM to assess pathologic spontaneous activity and interference patterns. Active glenohumeral shoulder external rotation and global shoulder function were evaluated using the Mallet score.

RESULTS

Postoperatively, growth of the IM increased equally on the affected and unaffected sides, although significant differences of muscle thickness persisted over time. There was only grade 1 or 2 fatty degeneration pre- and postoperatively. Electromyography of the IM revealed a full interference pattern in all except one patient, and there was no pathological spontaneous activity. Glenohumeral external rotation as well as global shoulder function increased significantly.

CONCLUSION

Our results indicate that the anastomosis after XIN-SSN transfer is functional and that successful reinnervation of the infraspinatus muscle may enable true glenohumeral active external rotation.

Results of nerve reconstructions in treatment of obstetrical brachial plexus injuries

BACKGROUND

The aim of this study was to evaluate the results achieved using various surgical techniques in patients with partial and total obstetrical brachial plexus palsy.

METHODS

From 2000 to 2013, 33 patients with obstetrical brachial plexus injury underwent surgery. Twenty had follow-up periods greater than 24 months and met the criteria for inclusion in the study. All patients were evaluated using the Active Movement Scale.

RESULTS

The outcomes of different nerve reconstructive procedures including nerve transfers, nerve grafting after neuroma resection and end-to-side neurorrhaphy are presented. The overall success rate in upper plexus birth injury was 80 % in shoulder abduction, 50 % in external rotation and 81.8 % in elbow flexion with median follow-ups of 36 months. Success rate in complete paralysis was 87 % in finger and thumb flexion, 87 % in shoulder abduction and 75 % in elbow flexion; the median follow-up was 46 months. Useful reanimation of the hand was obtained in both patients who underwent end-to-side neurotization.

CONCLUSION

Improved function can be obtained in infants with obstetrical brachial plexus injury with early surgical reconstruction.

Clinical assessment of the infant and child following perinatal brachial plexus injury

STUDY DESIGN

Literature review.

INTRODUCTION

After perinatal brachial plexus injury (PBPI), clinicians play an important role in injury classification as well as the assessment of recovery and secondary conditions. Early assessment guides the initial plan of care and influences follow-up and long-term outcome.

PURPOSE

To review methods used to assess, classify and monitor the extent and influence of PBPI with an emphasis on guidelines for clinicians.

METHODS

We use The International Classification of Functioning, Disability, and Health (ICF) model to provide a guide to assessment after PBPI for rehabilitation clinicians.

DISCUSSION

With information gained from targeted assessments, clinicians can design interventions to increase the opportunities infants and children have for optimal recovery and to attain skills that allow participation in areas of interest.

Total ipsilateral C7 root neurotization to the upper trunk for isolated C5-C6 avulsion in obstetrical brachial plexus palsy: a preliminary technical report

BACKGROUND

C5-C6 root avulsion in obstetrical brachial plexus palsy (OBPP) is a rare injury with poor prognosis usually associated with breech delivery. The treatment is challenging and requires high microsurgical skills. The triple nerve transfer (spinal accessory nerve, ulnar fascicles, and triceps long or lateral head branch) represents the gold standard treatment. The total ipsilateral C7 nerve root neurotization is a promising technique, which has never been described in OBPP.

OBJECTIVE

The total ipsilateral C7 nerve root is used as a neurotizer transferred to the upper trunk as an alternative method to other intra- or extra-plexual reconstruction techniques.

METHODS

During brachial plexus surgical exploration, an intraoperative neurostimulation was performed to confirm the integrity of C7 and the lesion of C5 and C6. The entire C7 nerve root and the upper trunk are cut. The C7 root was transferred to the upper trunk with a fibrin sealant.

RESULT

This technique was easily performed with a single approach and avoided intercalated nerve grafts. The C7 nerve root provided a large number of nerve fibers with an adequate diameter to be transferred to the upper trunk. We illustrated this technique with a typical case of a child at 8 years of follow-up.

CONCLUSION

The total ipsilateral transfer of the C7 root to the upper trunk is a viable alternative procedure for newborns with C5-C6 avulsion.

Bone age in children with obstetrical brachial plexus palsy: effect of peripheral nerve injury on skeletal maturation

The purpose of this retrospective study was to analyze the effect of peripheral nerve injury on the skeletal maturation process. The bone ages of the affected and unaffected hand-wrists of 42 children with obstetrical brachial palsy were determined according to the Greulich and Pyle atlas. In 23 patients, the bone ages of the both sides were identical (bone-age-symmetrical group), in 19 patients the bone age of the affected side was delayed (bone-age-delayed group). The mean bone age of the affected side was delayed 0.48 ± 0.25 years that of the unaffected side (P = .000), and the delay of bone age was inversely correlated with chronological age (R (2) = .45, P < .02) in the bone-age-delayed group. Skeletal retardation can be recognized after appearance of ossification centers by plain radiography, dating from the third month of life, in early infancy. Thus, bone age determination method might be helpful for predicting potential future limb shortness.

Modified Quad surgery significantly improves the median nerve conduction and functional outcomes in obstetric brachial plexus nerve injury

Background

Nerve conduction studies or somatosensory evoked potentials (SSEPs) have become an important tool in the investigation of peripheral nerve lesions, and is sensitive in detecting brachial plexus nerve injury, and other nerve injuries.

To investigate whether the modified Quad surgical procedure improves nerve conductivity and functional outcomes in obstetric brachial plexus nerve injury (OBPI) patients.

Methods

All nerves were tested with direct functional electrical stimulation. A Prass probe was used to stimulate the nerves, and recording the response, the compound motor action potential (CMAP) in the muscle. SSEP monitoring was performed pre- and post modified Quad surgery, stimulating the median and ulnar nerves at the wrist, the radial nerve over the dorsum of the hand, recording the peripheral, cervical and cortical responses. All patients have had the modified Quad surgery (n = 19). The modified Quad surgery is a muscle release and transfer surgery with nerve decompressions. All patients were assessed preoperatively and postoperatively by evaluating video recordings of standardized movements, the modified Mallet scale to index active shoulder movements.

Results

The cervical responses were significantly lower in amplitude in the affected arm than the un-affected arm. The median nerve conduction was significantly improved from 8.04 to 9.26 (P < 0.022) post-operatively. The shoulder abduction was also significantly improved (pre-op 30° ± 23.3 to 143° ± 33.7, p < 0.0001), with a mean follow-up of 43 months after the modified Quad surgery in these patients.

Conclusion

Median nerve conduction, and shoulder abduction were significantly improved in OBPI children, who have undergone the modified Quad procedure with neuroplasty, internal microneurolysis and tetanic stimulation of the median nerve.

Needle electromyography at 1 month predicts paralysis of elbow flexion at 3 months in obstetric brachial plexus lesions

AIM

Treatment decisions in obstetric brachial plexus lesions are often based on clinical paralysis of elbow flexion at 3 months of age, when electromyography (EMG) is misleading because motor unit potentials (MUPs) occur in clinically paralytic muscles. We investigated whether EMG at 1 week or 1 month identifies infants with flexion paralysis at 3 months, allowing early referral.

METHOD

Forty-eight infants (27 females, 21 males) were prospectively studied. The presence or absence of flexion paralysis at around 1 week (median 9 d; range 5-17d), 1 month (median 31 d; range 24-53 d), and 3 months of age (median 87 d; range 77-106 d) was noted for clinical (shoulder external rotation, elbow flexion, extension, and supination) and EMG parameters (denervation activity, MUPs and polyphasic MUPs in the deltoid, biceps, and triceps muscles).

RESULTS

At 1 month, the absence of biceps MUPs had a sensitivity of 95% for later flexion paralysis, and absence of deltoid MUPs had a sensitivity of 100% for flexion paralysis; the false-positive rates for the same findings were 21% and 33% respectively. EMG at 3 months was highly misleading as MUPs were seen in 19 of 20 clinically paralytic biceps muscles.

INTERPRETATION

EMG at 1 month can identify severe cases of flexion paralysis for early referral EMG of the biceps at 3 months is highly misleading; the discrepancy between the EMG and clinical testing may be due to abnormal axonal branching and aberrant central motor control.

Functional contribution of T1 to the brachial plexus in infants

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.

Modified C-7 neurotization in the treatment of brachial plexus avulsion injury

Object

Contralateral C-7 transfer is often used in patients with brachial plexus avulsion injury. Traditionally, the contralateral C-7 root has only been transferred to a single nerve, such as the median or radial nerve. In this study, the authors aimed to evaluate the efficacy of contralateral C-7 transfer to 2 different recipient nerves in patients with brachial plexus avulsion injuries.

Methods

Between 2004 and 2008, 10 patients with brachial plexus root avulsions underwent nerve reconstruction using a modified C-7 neurotization technique. In this procedure, the contralateral C-7 root was transferred via vascularized ulnar nerve grafts to both the musculocutaneous nerve and the median nerve on the affected side.

Results

The strength of the biceps muscles increased to M3 or M4 in 6 patients and to M2 in 2 patients. The median nerve transfers led to regained motor function and strength of the wrist and finger flexors with improvement to M3 in 5 patients. Seven patients showed notable gains of sensory function (≥ S3).

Conclusions

Contralateral C-7 transfer to 2 different recipient nerves is a feasible and efficient approach in patients with brachial plexus avulsion injuries when the donor nerve is limited.

Contralateral C7 transfer for the treatment of upper obstetrical brachial plexus palsy

PURPOSE

The use of contralateral C7 is seldom indicated in infants with obstetrical brachial plexus palsy (OBPP). The purpose of this study was to evaluate the value of contralateral C7 transfer in infants with upper OBPP in order to define the application and outcome of this transfer in these infants more optimally.

METHODS

Over a 5-year period, 15 infants with upper brachial plexus injuries underwent transfer of the contralateral C7 as part of the primary surgical reconstruction. The common trunk of the contralateral C7 root was transferred to the upper trunk or lateral cord on the affected side with nerve graft. The efficacy of the surgery and effects of patient age at the time of nerve transfer were analyzed.

RESULTS

Patients were followed up for a mean duration of 46.8 months. Noteworthy function (≥M2+) was gained in 11 of 15 patients, and sensory function (≥S3, MRC grading system) was gained in all patients. Age was not the factor related to the outcome of this surgery.

CONCLUSIONS

Contralateral C7 transfer is an effective procedure for the restoration of upper limb function in infants with OBPP and root avulsions.

Radial nerve palsy in the newborn: a case series

BACKGROUND

Peripheral nerve palsies of the upper extremities presenting at birth can be distressing for families and care providers. It is therefore important to be able to identify patients whose diagnosis is compatible with full recovery so that their families can be reassured.

METHODS

We conducted a retrospective review of all infants presenting with weakness of the upper extremity to our clinic between July 1995 and September 2009. We also conducted a review of the current literature.

RESULTS

During the study period, 953 infants presented to our clinic. Of these patients, 25 were identified as having isolated radial nerve palsy (i.e., a radial nerve palsy in isolation with good shoulder function and intact flexion of the elbow). Seventeen infants (68.0%) had a subcutaneous nodule representing fat necrosis in the inferior posterolateral portion of the affected arm. Full recovery occurred in all patients within a range of one week to six months, and 72.0% of the patients (18/25) had fully recovered by the time they were two months old.

INTERPRETATION

Although the outcome of obstetrical brachial plexus palsy is highly variable, isolated radial nerve palsy in the newborn carries a uniformly favourable prognosis.

Perinatal brachial plexus palsy

BACKGROUND

Perinatal brachial plexus palsy (PBPP) is a flaccid paralysis of the arm at birth that affects different nerves of the brachial plexus supplied by C5 to T1 in 0.42 to 5.1 infants per 1000 live births.

OBJECTIVES

To identify antenatal factors associated with PBPP and possible preventive measures, and to review the natural history as compared with the outcome after primary or secondary surgical interventions.

METHODS

A literature search on randomized controlled trials, systematic reviews and meta-analyses on the prevention and treatment of PBPP was performed. EMBASE, Medline, CINAHL and the Cochrane Library were searched until June 2005. Key words for searches included 'brachial plexus', 'brachial plexus neuropathy', 'brachial plexus injury', 'birth injury' and 'paralysis, obstetric'.

RESULTS

There were no prospective studies on the cause or prevention of PBPP. Whereas birth trauma is said to be the most common cause, there is some evidence that PBPP may occur before delivery. Shoulder dystocia and PBPP are largely unpredictable, although associations of PBPP with shoulder dystocia, infants who are large for gestational age, maternal diabetes and instrumental delivery have been reported. The various forms of PBPP, clinical findings and diagnostic measures are described. Recent evidence suggests that the natural history of PBPP is not all favourable, and residual deficits are estimated at 20% to 30%, in contrast with the previous optimistic view of full recovery in greater than 90% of affected children. There were no randomized controlled trials on nonoperative management. There was no conclusive evidence that primary surgical exploration of the brachial plexus supercedes conservative management for improved outcome. However, results from nonrandomized studies indicated that children with severe injuries do better with surgical repair. Secondary surgical reconstructions were inferior to primary intervention, but could still improve arm function in children with serious impairments.

CONCLUSIONS

It is not possible to predict which infants are at risk for PBPP, and therefore amenable to preventive measures. Twenty-five per cent of affected infants will experience permanent impairment and injury. If recovery is incomplete by the end of the first month, referral to a multidisciplinary team is necessary. Further research into prediction, prevention and best mode of treatment needs to be done.

Modified C7 neurotization for the treatment of obstetrical brachial plexus palsy

Contralateral C7 transfer is used rarely in infants with obstetrical brachial plexus palsy (OBPP). We aimed to determine the efficacy of contralateral C7 transfer to two different recipient nerves in infants with OBPP. Between 2001 and 2005, 9 infants with brachial plexus root avulsions underwent nerve reconstruction using a modified C7 neurotization technique. In this procedure, the contralateral C7 root was transferred to both the musculocutaneous nerve and the median nerve on the affected side. The strength of the biceps muscles increased to M3 or M4 in 7 patients and to M2 in 2 patients. The median nerve transfers led to regained motor function and strength of wrist and finger flexors with improvement to M3 or M4 in 5 patients. All patients showed notable gains of sensory function. Contralateral C7 transfer to two different recipient nerves is a feasible and efficient approach in infants with OBPP.

Electromyography, nerve action potential, and compound motor action potentials in obstetric brachial plexus lesions: validation in the absence of a "gold standard"

OBJECTIVE

Obstetric brachial plexus lesions (OBPLs) are caused by traction to the brachial plexus during labor. Typically, in these lesions, the nerves are usually not completely ruptured but form a "neuroma-in-continuity." Even in the most severe OBPL lesions, at least some axons will pass through this neuroma-in-continuity and reach the tubes distal to the lesion site. These axons may be particularly prone to abnormal branching and misrouting, which may explain the typical feature of co-contraction. An additional factor that may reduce functional regeneration is that improper central motor programming may occur. Surgery should be restricted to severe cases in which spontaneous restoration of function will not occur, i.e., in neurotmesis or root avulsions. A major problem is how to predict whether function will be best after spontaneous nerve outgrowth or after nerve reconstructive surgery. When a decision has been made to perform an early surgical exploration, what to do with the neuroma-in-continuity can be a problem. The intraoperative appraisal is difficult and depends on experience, but even in experienced hands, misjudgment can be made.

METHODS

We performed an observational study to assess whether early electromyography (at the age of 1 month) is able to predict severe lesions. Additionally, the value of intraoperative nerve action potential and compound motor action potentials was investigated.

RESULTS

Severe cases of OBPL can be identified at 1 month of age on the basis of clinical findings and needle electromyography of the biceps. This outcome needs independent validation, which is currently in progress. Nerve action potential and compound motor action potential recordings show statistically significant differences on the group level between avulsion, neurotmesis, axonotmesis, and normal. For the individual patient, a clinically useful cutoff point could not be found. Intraoperative nerve action potential and compound motor action potential recordings do not add to the decision making during surgery.

CONCLUSION

The absence of a "gold standard" for the assessment of the severity of the OBPL lesion makes prognostic studies of OBPL complex. The currently available assessment strategies used to obtain the best possible solutions are discussed.

MR imaging findings in brachial plexopathy with thoracic outlet syndrome

The BPL is a part of the peripheral nervous system. Many disease processes affect the BPL. In this article, on the basis of 60 patients, we reviewed MR imaging findings of subjects with brachial plexopathy. Different varieties of BPL lesions are discussed.

Obstetric brachial plexus palsy: treatment strategy, long-term results, and prognosis

BACKGROUND

Obstetric brachial plexus palsy is rare, but the limb impairments are manifold and often long-lasting. Physiotherapy, microsurgical nerve reconstruction, secondary joint corrections, and muscle transpositions are employed with success. The role of conservative and operative treatment options should be regularly reviewed.

METHODS

Selective literature review (evidence levels 3 and 4) and analysis of personal clinical operative and scientific experience over the past 15 years.

RESULTS

Children with upper and total plexus palsy displaying nerve root avulsions and/or -ruptures are treated today by early primary nerve reconstruction in the first few months of life followed by secondary corrections, with good functional results. The late complications, with muscle weakness, impaired motion patterns, and joint dysplasia, are often underrated.

CONCLUSIONS

The potential for scientific analysis is limited, due to the rarity and interindividual variability of the lesions and the varying effects on function and growth. Expectations and compliance are different in every patient. Surgical techniques are not yet standardized. Knowledge of the consequences for joint growth and congruence is inadequate. Today, functional improvement can be achieved by surgery in most clinical manifestations of obstetric brachial plexus palsy, within the framework of an interdisciplinary treatment concept.

Lyme disease--current state of knowledge

BACKGROUND

Lyme disease is the most frequent tick-borne infectious disease in Europe. The discovery of the causative pathogen Borrelia burgdorferi in 1982 opened the way for the firm diagnosis of diseases in several clinical disciplines and for causal antibiotic therapy. At the same time, speculation regarding links between Borrelia infection and a variety of nonspecific symptoms and disorders resulted in overdiagnosis and overtreatment of suspected Lyme disease.

METHOD

The authors conducted a selective review of the literature, including various national and international guidelines.

RESULTS

The spirochete Borrelia burgdorferi sensu lato is present in approximately 5% to 35% of sheep ticks (Ixodes ricinus) in Germany, depending on the region. In contrast to North America, different genospecies are found in Europe. The most frequent clinical manifestation of Borrelia infection is erythema migrans, followed by neuroborreliosis, arthritis, acrodermatitis chronica atrophicans, and lymphocytosis benigna cutis. Diagnosis is made on the basis of the clinical symptoms, and in stages II and III by detection of Borrelia-specific antibodies. In adults erythema migrans is treated with doxycycline, in children with amoxicillin. The standard treatment of neuroborreliosis is third-generation cephalosporins.

CONCLUSIONS

After appropriate antibiotic therapy, the outcome is favorable. In approximately 95% of cases neuroborreliosis is cured without long-term sequelae. When chronic borreliosis is suspected, other potential causes of the clinical syndrome must be painstakingly excluded.

RESULTS OF END-TO-SIDE NERVE COAPTATION IN SEVERE OBSTETRIC BRACHIAL PLEXUS LESIONS

OBJECTIVE

Options for nerve repair are limited in brachial plexus lesions with multiple root avulsions because an insufficient number of proximal nerve stumps are available to serve as lead-out for nerve grafts. End-to-side nerve repair might be an alternative surgical technique for repair of such severe lesions. In this technique, an epineurial window is created in a healthy nerve, and the distal stump of the injured nerve is coapted to this site. Inconsistent results of end-to-side nerve repairs in traumatic nerve lesions in adults have been reported in small series. This article evaluates the results of end-to-side nerve repair in obstetric brachial plexus lesions and reviews the literature.

METHODS

A retrospective analysis was performed of 20 end-to-side repairs in 12 infants. Evaluation of functional recovery of the target muscle was performed after at least 2 years of follow up (mean, 33 mo).

RESULTS

Five repairs failed (25%). Seven times (35%) good function (Medical Research Council at least 3) of the target muscle occurred in addition to eight partial recoveries (40%). In the majority of patients, however, the observed recovery cannot be exclusively attributed to the end-to-side repair. The reinnervation may be based on axonal outgrowth through grafted or neurolyzed adjacent nerves. It seems likely that recovery was solely based on the end-to-side repair in only two patients. No deficits occurred in donor nerve function.

CONCLUSION

This study does not convincingly show that the end-to-side nerve repair in infants with an obstetric brachial plexus lesion is effective. Its use cannot be recommended as standard therapy.

Magnetic resonance neurography in children with birth-related brachial plexus injury

BACKGROUND

Magnetic resonance neurography (MRN) enables visualization of peripheral nerves. Clinical examination and electrodiagnostic studies have been used in the evaluation of birth-related brachial plexus injury. These are limited in their demonstration of anatomic detail and severity of injury.

OBJECTIVE

We investigated the utility of MRN in evaluating birth-related brachial plexus injury in pediatric patients, and assessed the degree of correlation between MRN findings and physical examination and electromyographic (EMG) findings.

MATERIALS AND METHODS

The MRN findings in 11 infants (age 2 months to 20 months) with birth-related brachial plexus injury were evaluated. A neuroradiologist blinded to the EMG and clinical examination findings reviewed the images. Clinical history, examination, EMG and operative findings were obtained.

RESULTS

All infants had abnormal imaging findings on the affected side: seven pseudomeningoceles, six neuromas, seven abnormal nerve T2 signal, four nerve root enlargement, and two denervation changes. There was greater degree of correlation between MRN and physical examination findings (kappa 0.6715, coefficient of correlation 0.7110, P < 0.001) than between EMG and physical examination findings (kappa 0.5748, coefficient of correlation 0.5883, P = 0.0012).

CONCLUSION

MRN in brachial plexus trauma enables localization of injured nerves and characterization of associated pathology. MRN findings demonstrated a statistically significant correlation with physical examination and EMG findings, and might be a useful adjunct in treatment planning.

Management of brachial plexus injuries

Most brachial plexus lesions are traction injuries sustained during birth, but in adolescents and older people they are usually caused by traffic accidents or following a fall in the home. A minority are the result of penetrating injury after civilian assault or trauma encountered during wartime. Birth palsy cases (obstetric brachial plexus palsy) and the remaining cases (traumatic briachial plexus palsy) are viewed differently with regard to treatment and outcome and so these two groups are usually discussed in separate chapters. In this paper we treat both groups in parallel because as far as primary (= nerve) surgery is concerned, many treatment problems and solutions are present in both groups and are therefore comparable.

Clinical-electromyography correlation in infants with obstetric brachial plexopathy

PURPOSE

The real utility of needle electromyography (EMG) for evaluation of infants with obstetric brachial plexopathy remains controversial. The objective of this paper is to evaluate how EMG correlates with clinical evaluation of these patients.

METHODS

We performed EMG in 41 infants (42 arms) with severe obstetric brachial plexopathy who were from 3 to 12 months of age. We correlated the EMG interference pattern with the clinical assessment of infraspinatus, deltoid, biceps, triceps, and extensor digitorum communis muscles.

RESULTS

Motor unit potentials were always present, and abnormal spontaneous activity was not common in proximal muscles. The correlation between EMG interference pattern and clinical assessment was not good, except for extensor digitorum communis. EMG showed higher scores than clinical evaluation for infraspinatus, deltoid, and biceps muscles. Respiratory synkinesis was present in 19 patients, or 45% of the affected arms, and it could involve any muscle innervated from C5 to T1.

CONCLUSIONS

Needle EMG fails to estimate or overestimates clinical recovery in proximal muscles in this age group.

Long-term follow-up of children with obstetric brachial plexus palsy II: neurophysiological aspects

The aim of this study was to examine long-term neurophysiological outcomes and sensory function in patients with obstetric brachial plexus palsy (OBPP). The same 70 children/adolescents examined in part I: functional aspects (35 males, 35 females; age range 7-20y, mean 13y 6mo [SD 4y 3mo], median 13y) were examined with neurophysiological methods at 3 to 7 months and at 7 to 20 years of age. Thirteen of the 70 participants underwent nerve reconstruction before 1 year of age. Electromyography (EMG) was performed on deltoid and first interossei muscles; Quantitative Sensory Test was used for C6 and C8 dermatomes. Tests for functional sensibility and 2-point discrimination for C6 and C8 were performed. This study shows that considerable EMG changes can be observed in OBBP, even in those fully recovered. EMG changes in the deltoid were shown to deteriorate over time, and sensibility is considerably less affected than motor function.

Motor Evoked Potentials After Transcranial Magnetic Stimulation Support Hypothesis of Coexisting Central Mechanism in Obstetric Brachial Palsy

Six infants with obstetric brachial palsy, ranging from 4 to 7 months of age, were investigated. One was suspected of having extensive brachial plexus lesions and five were suspected of having a unilateral lesion of both roots C5 and C6. All were referred to our center to investigate the possibility for reconstructive surgery. In all infants, even at this age, transcranial magnetic stimulation resulted in motor evoked potentials (MEP) in the biceps (in one, in the brachioradial) muscles. Averaging could not be done because of the intraindividual variation in latency. The MEP was easier to recognize if evoked when the infant had the arm bent. In all five infants suspected of upper brachial plexus lesion with avulsion of both roots C5 and C6 and/or complete rupture of the upper trunk, proven in four, an MEP on the lesioned side could be evoked. Combined with earlier investigations showing (almost) normal EMG and somatosensory evoked potentials in infants with upper plexus lesion, this leads us to the conclusion that the paralysis of these infants cannot only be attributed to the peripheral axonal damage alone but that central plasticity must also play an important role. As this is a slow process, some infants might not yet be able to use the paralytic muscles. Some theoretic issues are discussed.

Contralateral C7 transfer for the treatment of brachial plexus root avulsions in children - a report of 12 cases

PURPOSE

To retrospectively determine the risks and benefits of contralateral C7 nerve root transfer in infants and children.

METHODS

In 12 infants and children with brachial plexus root avulsions from birth injury or other trauma, the common trunk of the contralateral C7 root was transferred to the trunk, division, cord, or nerve branch(es) on the affected side with 2 different types of interposition grafts. The surgery was performed in 1 stage for 5 patients and in 2 stages for 7 patients.

RESULTS

Patients were followed up for a mean of 42 months, with a minimum of 21 months. Noteworthy function (> or = M2+, modified British Medical Research Council grading system) was gained in 10 of 12 patients and sensory function (> or = S3, British Medical Research Council grading system) was gained in all patients. Improvements in strength and sensation were accompanied by little synchronous motion and sensibility changes in the donor limb in 7 children, to whom the repaired nerves were those innervating the shoulder and/or elbow or both the musculocutaneous and median nerves. In addition to slight damage to the sensory function of the median nerve, 2 infants also had temporarily reduced shoulder abduction on the healthy side.

CONCLUSIONS

For contralateral C7 transfer in infants and children with brachial plexus root avulsions, the deficit created by the procedure is minimal and motor and sensory function is gained. Transfer of the contralateral C7 root to different nerves for a child may improve the quality of functional recovery.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic, Level IV.

Role of intraoperative neurophysiology in primary surgery for obstetrical brachial plexus palsy (OBPP)

OBJECTIVE

Management of conducting neuroma-in-continuity in primary surgery for obstetrical brachial plexus palsy (OBPP) is still discussed controversially. We present our experience with intraoperative neurophysiological recordings in the management of lesions in continuity in OBPP.

METHODS

A series of ten children with lesions in continuity of the upper brachial plexus is presented. Due to recordable compound nerve action potentials (CNAPs) and muscle response to motor stimulation across the neuroma, five children underwent external neurolysis of neuroma only (neurolysis group). Due to lack of recordable CNAPs or muscle response, resection of neuroma and interpositional nerve grafting were performed in another five children (resection and grafting group). Functional recovery after at least 30 months of follow-up was assessed.

RESULTS

There was a marked difference in functional recovery between the neurolysis and the resection and grafting group. Especially, recovery of shoulder function was disappointing after external neurolysis of conducting neuroma-in-continuity. At the end of follow-up, results of shoulder and elbow function after resection of neuroma followed by interpositional nerve grafting were better without exception.

CONCLUSION

Intraoperative neurophysiological recordings face certain difficulties when used in small children with OBPP. Due to overoptimistic assessment of prognosis after intraoperative CNAP recordings and motor stimulation, the functional results after neurolysis of conducting neuroma-in-continuity are disappointing. Resection of neuroma-in-continuity, conducting or not, offers the best opportunity for maximal functional recovery of the compromised upper limb in OBPP. The role of intraoperative neurophysiological techniques should be confined to the diagnosis of root avulsions.

The role of electromyography in the management of the brachial plexus palsy of the newborn

Despite being the foremost examination in the management of traumatic nerve damage electromyography (EMG) has an uncertain and ill-defined role in the investigation of brachial plexus palsy of the newborn (BPPN). This may be because EMG, which is used most commonly several months after birth, fails to answer adequately two of the most important questions posed by this condition: its aetiology and the likely prognosis. In this review, we contend that EMG has important contributions to the solution of both of these questions but only if the timing of the investigation is altered. Used early on in the first few days after birth, EMG can separate the rare palsies that occurred during the intrauterine period from those caused by events at the time of birth, and thus have an important role in directing the investigations of the aetiology more appropriately. EMG alone would still not be able to determine which of the perinatal events were responsible. If the EMG is then repeated before reinnervation complicates interpretation, it seems probable that it would identify accurately those cases, where neurotmesis and avulsion have occurred, much earlier than 3 months of age, the crucial age in the clinical assessment of BPPN for consideration for surgery. This might have very important implications for the future directions of treatment.

Update on management of pediatric brachial plexus palsy

This manuscript will review the literature and focus on the present controversies regarding natural history, microsurgical treatment, and secondary shoulder reconstructive surgery in infants with brachial plexus birth palsies. Surgical indications, expected outcomes and complications will be addressed. The controversy regarding microsurgery timing in extra-foraminal ruptures will be addressed in detail. The developments in assessment and care of glenohumeral deformity with magnetic resonance imaging scans, arthroscopic and open reductions, and tendon transfers about the shoulder will be discussed. Recommendations for microsurgery and shoulder reconstruction will be based on the present evidence from the literature.

Update on management of pediatric brachial plexus palsy

This manuscript will review the literature and focus on the present controversies regarding the natural history, microsurgical treatment, and secondary shoulder reconstructive surgery in infants with brachial plexus birth palsies. Surgical indications, expected outcomes, and complications will be addressed. The controversy regarding the timing of microsurgery in extraforaminal ruptures will be addressed in detail. The developments in assessment and care of glenohumeral deformity with magnetic resonance imaging scans, arthroscopic and open reductions, and tendon transfers about the shoulder will be discussed. Recommendations for microsurgery and shoulder reconstruction will be based on the present evidence from the literature.

Birth injuries of the brachial plexus

Birth injuries of the brachial plexus are fairly common, but the majority of affected newborns make quick recoveries without any specific intervention. A minority suffer more severe injuries that lead to varying degrees of life-long disability. Happily, modern microsurgical techniques permit reconstruction of certain plexus injuries and, in carefully selected patients, can restore voluntary activity to target muscle groups. To what degree reanimation of paralyzed muscles improves function and quality of life for these children is a more important matter that has not yet been addressed at the level of modern standards of evidence. Brachial plexus reconstruction is only a first step in the multidisciplinary process needed to optimize long-term functional outcomes for severely affected infants.

Changes in spinal cord architecture after brachial plexus injury in the newborn

Obstetric brachial plexus palsy is a devastating birth injury. While many children recover spontaneously, 20-25% are left with a permanent impairment of the affected limb. So far, concepts of pathology and recovery have focused on the injury of the peripheral nerve. Proximal nerve injury at birth, however, leads to massive injury-induced motoneuron loss in corresponding motoneuron pools and therefore limits the extent of functional recovery. In the present study, the role of spinal cord plasticity after injury and recovery from obstetric brachial plexus lesions was investigated. A selective injury to spinal roots C5 and C6 was induced in newborn Sprague-Dawley rats, leading to motoneuron loss in corresponding motoneuron pools. Recovery of extremity function was evaluated with different behavioural paradigms. Permanent changes of adjacent motoneuron pools were quantitatively evaluated by retrograde tracing and functional muscle testing. We report that the adjacent C7 motoneuron contribution to biceps muscle innervation increased four-fold after upper trunk lesions in newborns, thus compensating for the injury-induced motoneuron loss. These results indicate that, in obstetric brachial plexus palsy, changes in spinal cord architecture are an integral part not only of primary pathology but also of the subsequent recovery process. While present treatment is directed towards the restoration of neural continuity, future treatment strategies must recognize and take advantage of CNS participation in the injury and recovery process.

Birth injuries of the brachial plexus

Birth injuries of the brachial plexus are fairly common, but most affected newborns make quick recoveries without any specific intervention. A minority suffer more severe injuries that lead to varying degrees of life-long disability. Modem microsurgical techniques permit reconstruction of certain plexus injuries and, in carefully selected patients, can restore voluntary activity to target muscle groups. The degree to which reanimation of paralyzed muscles improves function and quality of life for these children is a more important matter that has not yet been addressed using modern standards of evidence. Brachial plexus reconstruction is only a first step in the multidisciplinary process needed to optimize long-term functional outcomes for severely affected infants.