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Owens WR, Mohan VC, Quirarte DM, Bovill JD, Nguyen GT, Northcutt II JH, Nguyen JL, Pederson WC. A Multidisciplinary Approach to Brachial Plexus Birth Injury: An Overview and Institutional Experience. Semin Plast Surg 2025; 39:69-74. [PMID: 40406644 PMCID: PMC12094837 DOI: 10.1055/s-0045-1808270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2025]
Abstract
Without early diagnosis and intervention, brachial plexus birth injuries (BPBIs) can result in permanent upper extremity debilitation. Previously, BPBI was treated by single-specialty surgeons; however, given the complexity of the injury, BPBIs necessitate multidisciplinary team care. Common specialists involved within brachial plexus injury clinics include radiologists, physical medicine and rehabilitation physicians, occupational therapists, nerve surgeons, and shoulder surgeons. Care plans are meticulously designed by all team members, and depending on injury severity and clinical course, patients may undergo treatment including range-of-motion exercises, splinting, botulinum toxin injections, nerve surgery, or shoulder surgery. The objective of this article is to highlight and discuss key providers within BPBI clinics and describe the BPBI experience here at Texas Children's Hospital.
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Affiliation(s)
- Winston R. Owens
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
- Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas
| | - Vamsi C. Mohan
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
- Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas
| | - Diego M. Quirarte
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
- Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas
| | - John D. Bovill
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Gabrielle T. Nguyen
- Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, Texas
- Department of Physical Medicine and Rehabilitation, Texas Children's Hospital, Houston, Texas
| | - James H. Northcutt II
- Department of Physical and Occupational Therapy, Texas Children's Hospital, Houston, Texas
| | - Jenny Lee Nguyen
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
- Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas
| | - William C. Pederson
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
- Division of Plastic Surgery, Department of Surgery, Texas Children's Hospital, Houston, Texas
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Shah MM, Mammen JJ, Jain M, Ponugoti G, Naik N, Patel T, Rubaiath T, Vijay P. Midterm Outcomes of Shoulder Dislocations in Brachial Plexus Birth Injuries Treated With Injection Botulinum Toxin A. J Pediatr Orthop 2025; 45:e492-e495. [PMID: 39894942 DOI: 10.1097/bpo.0000000000002917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2025]
Abstract
BACKGROUND Shoulder dislocation can be seen early in infancy and can be diagnosed by shoulder ultrasound. Botulinum toxin injection in the internal rotators of the shoulder can be used to as an adjunct to relieve the internal rotation contracture. The aim of this study was to evaluate the intermediate-term outcomes of shoulder dislocations treated with injection botulinum toxin and to identify the factors determining the outcomes of the procedure. METHODS Eighty-six children with ultrasound diagnosed shoulder dislocation underwent injection BTX-A between 2011 and 2022. Children who underwent nerve surgeries and the ones with inadequate follow-up were excluded. Sixty-two children were followed up for a mean duration of 36 months. Injection botulinum toxin A 2 U/kg body weight was injected each into the subscapularis and the pectoralis major. After manual stretching of contracted anterior soft tissue and shoulder capsule, a shoulder spica was applied for 3 weeks. Hospital for Sick Children Active Movement Scale (HSC-AMS) score and active and passive shoulder was recorded before and after the procedure and the requirement for further interventions was noted. RESULTS Outcomes were divided into 3 categories: group A-27 (44%) children who did not require any further surgery in our follow-up period; group B-27 (44%) needed further procedure for recurrence of IR contracture; and group C-8 (12%) developed external rotation contracture later. Children in group A had statistically significant higher preinjection HSC-AMS score for elbow flexion and shoulder abduction than the other groups. Children in group C had greater passive external rotation and weak elbow extension and wrist dorsiflexion as compared with the other 2 groups. CONCLUSIONS Injection botulinum toxin A is effective in treating shoulder dislocations in children with early recruitment of C5 to 6 muscles, while children with involvement of C7 muscles may develop an external rotation contracture subsequently, hence this procedure should be avoided. LEVEL OF EVIDENCE Level IV-therapeutic.
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Affiliation(s)
- Maulin M Shah
- Department of Pediatric Orthopedics, Orthokids Clinic
| | | | | | | | | | - Tejas Patel
- C/NDT, AT(WST), Sparsh Pediatric Rehabilitation Clinic, Ahmedabad, Gujarat, India
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O’Shea G, Patel SS, Mailey BA. Brachial Plexus Birth Injury: Treatment and Interventions. Plast Surg (Oakv) 2025:22925503241301719. [PMID: 39811497 PMCID: PMC11726498 DOI: 10.1177/22925503241301719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2024] [Revised: 09/29/2024] [Accepted: 10/15/2024] [Indexed: 01/16/2025] Open
Abstract
Introduction: Brachial plexus birth injury (BPBI) is a condition affecting newborns and involves damage to the nerve fibers compromising the brachial plexus during birth. Although most newborns recover spontaneously, a large subset require surgery to regain function, and others will have permanent disability despite intervention. Deciding when to pursue surgical intervention remains a challenge for clinicians treating BPBI. Methods: A comprehensive search of the literature was conducted using PubMed, Scopus, and MEDLINE databases. A total of 24 primary and secondary sources were chosen for inclusion following full-text assessments. All sources were analyzed to provide a comprehensive review on the development of BPBI treatments and interventions over time. Results: Spontaneous recovery can be achieved in many cases of BPBI, but most patients require physical therapy and other forms of treatment to avoid muscle imbalance and prevent contracture formation. In addition to physical therapy, the most common non-surgical interventions include botulinum toxin injections and splinting. In cases requiring surgery, clinicians may use several tests and diagnostic imaging to aid in decision making. Common surgical interventions for BPBI include nerve grafting, nerve transfers, and muscle and tendon transfers. Conclusion: Most newborns recover from BPBI within the first 3 months of life. However, some require treatment to restore optimal function. In general, non-surgical interventions should be the primary course of treatment, and surgery should be avoided unless the patient is deemed unable to recover with any other treatment.
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Affiliation(s)
- Grace O’Shea
- Division of Plastic and Reconstructive Surgery, Saint Louis University Hospital, St. Louis, MO, USA
| | - Sonia S. Patel
- Saint Louis University School of Medicine, St. Louis, MO, USA
| | - Brian A. Mailey
- Division of Plastic and Reconstructive Surgery, Saint Louis University Hospital, St. Louis, MO, USA
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Khabyeh-Hasbani N, O’Brien DM, Meisel EM, Koehler SM. Current Concepts in Brachial Plexus Birth Injuries: A Comprehensive Narrative Review. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e6083. [PMID: 39175516 PMCID: PMC11340930 DOI: 10.1097/gox.0000000000006083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 06/24/2024] [Indexed: 08/24/2024]
Abstract
Background Brachial plexus birth injury (BPBI) encompasses a spectrum of upper extremity paralysis cases following childbirth. The etiology of BPBI is multifactorial, involving maternal, obstetric, and neonatal associative factors. Despite opportunities for spontaneous recovery, recent literature demonstrates that a significant proportion of infants experience residual deficits and functional limitations as they age. Understanding the complex anatomy of the brachial plexus, clinical presentations of the pathology, diagnostic workup, current treatment options, and common secondary sequelae is instrumental for appropriate management of BPBI. Methods Following a comprehensive search strategy used by the authors to identify relevant literature relating to the progression, patho-anatomy, clinical presentation, management, and treatment of BPBI, this comprehensive narrative review outlines current approaches to assess, manage, and advance BPBI care. Results We advocate for prompt referral to specialized multicenter brachial plexus clinics for accurate diagnosis, timely intervention, and individualized patient-centered assessment. Further research is needed to elucidate mechanisms of injury, refine diagnostic protocols, and optimize long-term outcomes. Conclusions Collaboration between healthcare providers and families is paramount in providing comprehensive care for infants with BPBI. This review offers insights into the current understanding and management of BPBI, highlighting the importance of tailored approaches and intraoperative decision-making algorithms to optimize functional outcomes.
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Affiliation(s)
- Nathan Khabyeh-Hasbani
- From the Department of Orthopaedic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, N.Y
| | - Devon M. O’Brien
- Department of Orthopaedic Surgery, Children’s Hospital of Los Angeles, Los Angeles, Calif
| | - Erin M. Meisel
- Department of Orthopaedic Surgery, Children’s Hospital of Los Angeles, Los Angeles, Calif
| | - Steven M. Koehler
- From the Department of Orthopaedic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, N.Y
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Domeshek LF, Zuo KJ, Letourneau S, Klar K, Anthony A, Ho ES, Hopyan S, Clarke HM, Davidge KM. Surgery for internal rotation contracture in infancy may obviate the need for brachial plexus nerve reconstruction: early experience. J Shoulder Elbow Surg 2024; 33:291-299. [PMID: 37479177 DOI: 10.1016/j.jse.2023.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 05/22/2023] [Accepted: 06/13/2023] [Indexed: 07/23/2023]
Abstract
BACKGROUND Shoulder internal rotation contracture and subluxation in the first year of life has long been recognized in some patients with brachial plexus birth injury (BPBI). Surgical management of shoulder pathology has traditionally been undertaken following nerve reconstruction as necessary. In some patients; however, shoulder pathology may impair or obscure functional neuromuscular recovery of the upper extremity. As a proof of concept, we report a highly selected subset of patients with BPBI in whom shoulder surgery undertaken before one year of age obviated the need for neuroma resection and nerve grafting. METHODS A retrospective review was performed of all patients with upper trunk BPBI who underwent shoulder surgery before one year of age from 2015 to 2018. Upper extremity motor function was evaluated with preoperative and postoperative Active Movement Scale scores, Cookie tests, and the requirement for subsequent neuroma resection and nerve grafting. RESULTS Fifteen patients with BPBI meeting the inclusion criteria underwent shoulder surgery (including a subscapularis slide and tendon transfers of the teres major and latissimus dorsi muscles) before 1 year of age. Preoperatively, no patients of the appropriate age passed the Cookie test for elbow flexion. Thirteen patients either passed the Cookie test or scored Active Movement Scale score 7 for elbow flexion at or before the last available follow-up undertaken at a median age of 3.4 [1.4, 5.2] years. One of those 13 patients underwent single fascicular distal nerve transfer to improve elbow flexion before subsequently passing the Cookie test. Two patients did not have sufficient follow-up to assess elbow flexion. CONCLUSION Although the exact role of shoulder surgery in infancy for BPBI remains to be defined, the findings from this study provide proof of concept that early, targeted surgical treatment of the shoulder may obviate the need for brachial plexus nerve reconstruction in a highly selected group of infants with BPBI.
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Affiliation(s)
- Leahthan F Domeshek
- Division of Plastic and Reconstructive Surgery, The Hospital for Sick Children and the Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Kevin J Zuo
- Division of Plastic and Reconstructive Surgery, The Hospital for Sick Children and the Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Sasha Letourneau
- Division of Plastic and Reconstructive Surgery, The Hospital for Sick Children and the Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Karen Klar
- Department of Rehabilitation, The Hospital for Sick Children, Toronto, ON, Canada
| | - Alison Anthony
- Department of Rehabilitation, The Hospital for Sick Children, Toronto, ON, Canada
| | - Emily S Ho
- Department of Rehabilitation, The Hospital for Sick Children, Toronto, ON, Canada
| | - Sevan Hopyan
- Division of Orthopedic Surgery, The Hospital for Sick Children and the Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Howard M Clarke
- Division of Plastic and Reconstructive Surgery, The Hospital for Sick Children and the Department of Surgery, University of Toronto, Toronto, ON, Canada.
| | - Kristen M Davidge
- Division of Plastic and Reconstructive Surgery, The Hospital for Sick Children and the Department of Surgery, University of Toronto, Toronto, ON, Canada
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Serbin R, Waters PM, Lewis D, Gaston G, Loeffler B. Shoulder Reconstruction for Brachial Plexus Birth Injuries: An In-Depth Review and Case-Based Update. JOURNAL OF THE PEDIATRIC ORTHOPAEDIC SOCIETY OF NORTH AMERICA 2023; 5:784. [PMID: 40432931 PMCID: PMC12088157 DOI: 10.55275/jposna-2023-784] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Indexed: 05/29/2025]
Abstract
Brachial plexus birth injuries can result in significant shoulder dysfunction with limitations in range of motion, decreased strength, and risk of glenohumeral joint deformity. This comprehensive review examines current approaches for management of the shoulder including surgical reconstruction following these injuries. Serial clinical exams and selective imaging are critical to determine optimal timing of surgery based on recovery potential and joint pathology. Biceps recovery is monitored monthly from birth and, if absent by 5-6 months, serves as an indication for nerve reconstruction with nerve grafting, transfers, or both. Glenohumeral contracture, deformity, and dislocation commonly occur in infancy and are assessed by exam, ultrasound, and MRI scan. Procedural intervention is indicated when there is loss of passive external rotation, active motor weakness, and/or glenohumeral deformity/dislocation is present. Contracture release and joint reduction to center the humeral head on the glenoid is performed early when there are limitations in passive external rotation not resolved with therapy. Glenoid remodeling can occur when reduction is performed early (6 months to 2-3 years). Surgical options include (1) extraarticular contracture releases (e.g., botox, subscapularis slide) and closed reduction, (2) intraarticular arthroscopic/open release and reduction, and (3) contracture release/joint reduction combined with tendon transfers (latissimus-teres major most common). The lower trapezius transfer is increasingly used for active external rotation as it spares internal rotation strength and has an excellent line of pull reproducing that of the infraspinatus. For advanced joint deformity, humeral/ glenoid osteotomies are utilized. A nuanced, individualized approach is required considering the child's deficits, pathoanatomy, and age in a case-based manner. Open communication between providers and families is imperative to optimize care. This review provides a comprehensive analysis of current shoulder reconstruction approaches following brachial plexus birth injuries. Key Concepts•Failure of biceps recovery by 5-6 months for extraforaminal injuries (C5-C6; C5-C6-C7) indicates nerve surgery intervention between 5-9 months using nerve grafting, transfers, or a combination to restore function in the shoulder (and as for indicated elbow, forearm, and wrist).•Glenohumeral joint complications such as contracture, deformity, and dislocation often emerge during early infancy to the first 2-3 years due to incomplete recovery. Physical exams focus on the progressive limitations of external rotation (ER), and advanced imaging (ultrasound or MRI) is needed when passive ER falls below 30 degrees and/or there's posterior humeral head prominence.•In cases of glenohumeral deformity and dislocation, it's crucial to center and stabilize the humeral head on the glenoid during reduction. Early intervention (6 months to 2-3 years) can result in glenoid remodeling.•Surgical options range from extraarticular contracture releases, such as botox and subscapularis slide, to intraarticular arthroscopic or open release and reduction. Depending on patient age and deformity severity, reduction surgeries can be standalone or combined with tendon transfers. It's vital to adopt a patient-tailored, stepwise approach during surgery.•The latissimus dorsi-teres major transfer restores active external rotation, while the lower trapezius offers an alternative for active ER that preserves internal rotation strength. In situations with pronounced deformities in older patients, glenoid and humeral osteotomies can be performed.
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Affiliation(s)
- Ryan Serbin
- Atrium Health Carolinas Medical Center, Department of Orthopaedic Surgery, Charlotte, NC
| | - Peter M. Waters
- Atrium Health Carolinas Medical Center, Department of Orthopaedic Surgery, Charlotte, NC
- OrthoCarolina Hand Center, Charlotte, NC
- Boston Children's Hospital, Boston, MA
| | - Daniel Lewis
- Atrium Health Carolinas Medical Center, Department of Orthopaedic Surgery, Charlotte, NC
- OrthoCarolina Hand Center, Charlotte, NC
| | - Glenn Gaston
- Atrium Health Carolinas Medical Center, Department of Orthopaedic Surgery, Charlotte, NC
- OrthoCarolina Hand Center, Charlotte, NC
| | - Bryan Loeffler
- Atrium Health Carolinas Medical Center, Department of Orthopaedic Surgery, Charlotte, NC
- OrthoCarolina Hand Center, Charlotte, NC
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Cawthorn TR, Hopyan S, Clarke HM, Davidge KM. Management of Brachial Plexus Birth Injury: The SickKids Experience. Semin Plast Surg 2023; 37:89-101. [PMID: 37503532 PMCID: PMC10371415 DOI: 10.1055/s-0043-1769930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
This article describes the approach utilized by the multidisciplinary team at Sick Kids Hospital to evaluate and treat patients with brachial plexus birth injury (BPBI). This approach has been informed by more than 30 years of experience treating over 1,800 patients with BPBI and continues to evolve over time. The objective of this article is to provide readers with a practical overview of the Sick Kids approach to the management of infants with BPBI.
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Affiliation(s)
- Thomas R. Cawthorn
- Division of Plastic & Reconstructive Surgery, Sick Kids Hospital, Toronto, Ontario, Canada
| | - Sevan Hopyan
- Division of Orthopedic Surgery, Sick Kids Hospital, Toronto, Ontario, Canada
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Howard M. Clarke
- Division of Plastic & Reconstructive Surgery, Sick Kids Hospital, Toronto, Ontario, Canada
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Kristen M. Davidge
- Division of Plastic & Reconstructive Surgery, Sick Kids Hospital, Toronto, Ontario, Canada
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
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Zuo KJ, Ho ES, Hopyan S, Clarke HM, Davidge KM. Recent Advances in the Treatment of Brachial Plexus Birth Injury. Plast Reconstr Surg 2023; 151:857e-874e. [PMID: 37185378 DOI: 10.1097/prs.0000000000010047] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
LEARNING OBJECTIVES After studying this article, the participant should be able to: 1. Describe methods of clinical evaluation for neurologic recovery in brachial plexus birth injury. 2. Understand the role of different diagnostic imaging modalities to evaluate the upper limb. 3. List nonsurgical strategies and surgical procedures to manage shoulder abnormality. 4. Explain the advantages and disadvantages of microsurgical nerve reconstruction and distal nerve transfers in brachial plexus birth injury. 5. Recognize the prevalence of pain in this population and the need for greater sensory outcomes evaluation. SUMMARY Brachial plexus birth injury (BPBI) results from closed traction injury to the brachial plexus in the neck during an infant's vertex passage through the birth canal. Although spontaneous upper limb recovery occurs in most instances of BPBI, some infants do not demonstrate adequate motor recovery within an acceptable timeline and require surgical intervention to restore upper limb function. This article reviews major advances in the management of BPBI in the past decade that include improved understanding of shoulder pathology and its impact on observed motor recovery, novel surgical techniques, new insights in sensory function and pain, and global efforts to develop standardized outcomes assessment scales.
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Affiliation(s)
- Kevin J Zuo
- From the Divisions of Plastic, Reconstructive, and Aesthetic Surgery
| | - Emily S Ho
- From the Divisions of Plastic, Reconstructive, and Aesthetic Surgery
- Division of Plastic and Reconstructive Surgery, The Hospital for Sick Children
| | - Sevan Hopyan
- From the Divisions of Plastic, Reconstructive, and Aesthetic Surgery
- Orthopedic Surgery, Department of Surgery, University of Toronto
| | - Howard M Clarke
- From the Divisions of Plastic, Reconstructive, and Aesthetic Surgery
- Division of Plastic and Reconstructive Surgery, The Hospital for Sick Children
| | - Kristen M Davidge
- From the Divisions of Plastic, Reconstructive, and Aesthetic Surgery
- Division of Plastic and Reconstructive Surgery, The Hospital for Sick Children
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The Effectiveness and Safety of Botulinum Neurotoxin in Obstetric Brachial Plexus Injury: A Systematic Review and Meta-Analysis. Healthcare (Basel) 2022; 10:healthcare10122419. [PMID: 36553943 PMCID: PMC9778416 DOI: 10.3390/healthcare10122419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 11/26/2022] [Accepted: 11/28/2022] [Indexed: 12/04/2022] Open
Abstract
Obstetric brachial plexus injury, also known as neonatal brachial plexus injury, is not unusual in newborns. Given the lack of a comprehensive synthesis of the available data on the effectiveness of botulinum neurotoxin (BoNT) in treating children with obstetric brachial plexus injury, we conducted a systematic review and meta-analysis. We searched PubMed, Embase, Web of Science, and Cochrane databases from inception to 25 November 2022. Outcomes were function of the shoulder and elbow joints, muscle power of the deltoid, biceps brachii and triceps brachii, and the recurrence rate of subluxation or dislocation after reduction of the shoulder joint after BoNT application. Meta-regression was conducted to assess the moderator effect of age. We included 11 case series and 2 cohort studies. Passive range of motion of shoulder external rotation (standardized mean difference [SMD], 0.678; 95% confidence interval [95%CI], 0.423 to 0.934), Active Movement Scale for shoulder external rotation (SMD, 0.47; 95%CI, 0.131 to 0.808), and active range of motion of elbow extension (SMD, 2.445; 95%CI, 1.556 to 3.334) increased significantly after BoNT. However, the modified Gilbert scale for shoulder abduction (SMD, 1.239; 95% CI, -0.2 to 2.678), the Toronto score for active elbow flexion (SMD, 1.099; 95% CI, -0.053 to 2.252), muscle power of deltoid (SMD, 0.675; 95% CI, -0.599 to 1.949), biceps brachii (SMD, 0.225; 95% CI, -0.633 to 1.083), and triceps brachii (SMD, 1.354; 95% CI, -1.493 to 4.202) did not reach statistical significance. The moderator effect of age was not significant (p = 0.88). Meta-analysis was not done for recurrence rate of subluxation or dislocation due to insufficient data. In conclusion, our data support BoNT use in patients with obstetric brachial plexus injury. However, definite conclusions cannot be drawn due to small sample size and the lack of randomized controlled trials. More research is warranted to clarify the effectiveness of BoNT in patients with obstetric brachial plexus injury by using standardized injection protocols and outcome measurements.
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McNeely MM, Chang KWC, Smith BW, Justice D, Daunter AK, Yang LJS, McGillicuddy JE. Knowledge of neonatal brachial plexus palsy among medical professionals in North America. Childs Nerv Syst 2021; 37:3797-3807. [PMID: 34406450 DOI: 10.1007/s00381-021-05310-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 07/24/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE Early referral of neonatal brachial plexus palsy (NBPP) patients to multidisciplinary clinics is critical for timely diagnosis, treatment, and improved functional outcomes. In Saudi Arabia, inadequate knowledge regarding NBPP is a reason for delayed referral. We aimed to evaluate the knowledge of North American healthcare providers (HCPs) regarding the diagnosis, management, and prognosis of NBPP. METHODS A 12-question survey regarding NBPP was distributed via electronic and paper formats to North American providers from various referring and treating specialties. NBPP knowledge was compared between Saudi Arabian vs. North American providers, referring vs. treating specialties, academic vs. community hospitals, and providers with self-reported confidence vs. nonconfidence in NBPP knowledge. RESULTS Of the 273 surveys collected, 45% were from referring providers and 55% were from treating providers. Saudi Arabian and North American HCPs demonstrated similar NBPP knowledge except for potential etiologies for NBPP and surgery timing. In North America, referring and treating providers had similar overall knowledge of NBPP but lacked familiarity with its natural history. A knowledge gap existed between academic and community hospitals regarding timing of referral/initiation of physical/occupational therapy (PT/OT) and Horner's syndrome. Providers with self-reported confidence in treating NBPP had greater knowledge of types of NBPP and timing for PT/OT initiation. CONCLUSIONS Overall, North American providers demonstrated adequate knowledge of NBPP. However, both eastern and western physicians remain overly optimistic in believing that most infants recover spontaneously. This study revealed a unique and universal knowledge gap in NBPP diagnosis, referral, and management worldwide. Continuous efforts to increase NBPP knowledge are indicated.
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Affiliation(s)
- Molly M McNeely
- School of Medicine, University of Michigan, Ann Arbor, MI, USA
| | | | - Brandon W Smith
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Denise Justice
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | - Alecia K Daunter
- Physical Medicine & Rehabilitation, University of Michigan, Ann Arbor, MI, USA
| | - Lynda J-S Yang
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
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Vova JA, Green MM, Brandenburg JE, Davidson L, Paulson A, Deshpande S, Oleszek JL, Inanoglu D, McLaughlin MJ. A consensus statement on the use of botulinum toxin in pediatric patients. PM R 2021; 14:1116-1142. [PMID: 34558213 DOI: 10.1002/pmrj.12713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 08/12/2021] [Accepted: 09/10/2021] [Indexed: 11/10/2022]
Abstract
Botulinum toxin has been used in medicine for the past 30 years. However, there continues to be controversy about the appropriate uses and dosing, especially in the pediatric population. A panel of nine pediatric physiatrists from different regions and previous training programs in the United States were nominated based on institutional reputation and botulinum toxin (BoNT) experience. Based on a review of the current literature, the goal was to provide the rationale for recommendations on the administration of BoNT in the pediatric population. The goal was not only to review safety, dosing, and injection techniques but also to develop a consensus on the appropriate uses in the pediatric population. In addition to upper and lower limb spasticity, the consensus also provides recommendations for congenital muscular torticollis, cervical dystonia, sialorrhea, and brachial plexus palsies.
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Affiliation(s)
- Joshua A Vova
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Michael M Green
- University of Utah/Primary Children's Hospital, Salt Lake City, Utah, USA
| | | | - Loren Davidson
- University of California Davis, Sacramento, California, USA
| | - Andrea Paulson
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Gillette Children's Specialty Healthcare, Minneapolis, Minnesota, USA
| | - Supreet Deshpande
- Gillette Children's Specialty Healthcare, Minneapolis, Minnesota, USA
| | | | - Didem Inanoglu
- Children's Health Specialty Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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12
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Chen HY, Blackwell SC, Yang LJS, Mendez-Figueroa H, Chauhan SP. Neonatal brachial plexus palsy: associated birth injury outcomes, hospital length of stay and costs. J Matern Fetal Neonatal Med 2021; 35:5736-5744. [PMID: 33632043 DOI: 10.1080/14767058.2021.1892066] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To compare the birth injury outcomes and hospital length of stay and costs among newborns delivered at 34-42 weeks with neonatal brachial plexus palsy (NBPP) versus those without. STUDY DESIGN We conducted a retrospective, cross-sectional study using data from the National Inpatient Sample to identify all newborns hospitalizations that occurred in the U.S. between 2016 and 2017. We included non-anomalous single liveborn delivered in-hospital at 34-42 weeks. The newborns with NBPP were identified by International Classification of Diseases, 10th Revision, Clinical Modification codes. Birth injury outcomes, and hospital length of stay and hospital costs were examined. A multivariable Poisson regression model with robust error variance was used to examine the association between NBPP and birth injury outcomes. A multivariable generalized linear regression model was used to examine the association between NBPP and hospital length of stay and hospital costs. RESULTS Of 7,019,722 non-anomalous single liveborn delivered at 34-42 weeks in the U.S. from 2016 to 2017, the rate of NBPP (n = 6695) was 0.95 per 1000 newborn hospitalizations. After multivariable regression adjustment, compared to newborns without NBPP, the risk of the composite birth injury outcome was 2.91 (95% CI 2.61-3.25) times higher in those with NBPP. Similar results of an increased risk among newborns with NBPP were observed in all individual birth injury outcomes. Compared to newborns without NBPP, after adjustment, the hospital length of stay was 1.48 (95% IC 1.38-1.59) times higher and the hospital costs were 2.21 (95% CI 1.97-2.48) times higher in those with NBPP. CONCLUSIONS Among newborns delivered at 34-42 weeks, the risk of associated birth injuries, hospital length of stay and costs, were significantly higher in newborns with NBPP than those without.
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Affiliation(s)
- Han-Yang Chen
- Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Sean C Blackwell
- Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Lynda J-S Yang
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | - Hector Mendez-Figueroa
- Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Suneet P Chauhan
- Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
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Narendran LM, Mendez-Figueroa H, Chauhan SP, Folh KL, Grobman WA, Chang K, Yang L, Blackwell SC. Predictors of neonatal brachial plexus palsy subsequent to resolution of shoulder dystocia. J Matern Fetal Neonatal Med 2021; 35:5443-5449. [PMID: 33541167 DOI: 10.1080/14767058.2021.1882982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE The objective was to ascertain factors among deliveries complicated by shoulder dystocia (SD) and neonatal brachial plexus palsy (NBPP). METHODS At 11 hospitals, deliveries complicated by SD were identified. The inclusion criteria were vaginal delivery of non-anomalous, singleton at 34-42 weeks. Adjusted odds ratios (aOR) with 95% confidence intervals (CI) were calculated. Receiver operating characteristic (ROC) curves were created to evaluate the predictive value of the models for NBPP. RESULTS Of the 62,939 individuals who delivered vaginally, 1,134 (1.8%) had SD and met other inclusion criteria. Among the analytic cohort, 74 (6.5%) had NBPP. The factor known before delivery which was associated with NBPP was diabetes (aOR = 3.87; 95% CI = 2.13-7.01). After delivery, the three factors associated with NBPP were: (1) birthweight of at least 4000 g (aOR = 1.83; 95% CI = 1.05-3.20); (2) calling for help during the SD (aOR = 4.09, 95% CI = 2.29-7.30), and (3) the duration of SD ≥120 sec (aOR = 2.47, 95% CI = 1.30-4.69). The AUC under the ROC curve for these independent factors was 0.79 (95% CI = 0.77 - 0.82). CONCLUSIONS Few factors were identified that were associated with NBPP after SD, but they could not reliably predict which neonates will experience the complication.
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Affiliation(s)
- Leena M Narendran
- Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Hector Mendez-Figueroa
- Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Suneet P Chauhan
- Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Kendra L Folh
- Quality and Safety Department, Children's Memorial Herman Hospital, Houston, TX, USA
| | - William A Grobman
- Department of Obstetrics and Gynecology, Northwestern University, Chicago, IL, USA
| | - Kate Chang
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | - Lynda Yang
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | - Sean C Blackwell
- Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
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14
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Singh AK, Manske MC, James MA. Outcomes of Botulinum Toxin Injection for Shoulder Internal Rotation Contractures in Infants with Brachial Plexus Birth Injury. J Hand Surg Am 2020; 45:1186.e1-1186.e6. [PMID: 32753228 DOI: 10.1016/j.jhsa.2020.06.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 05/07/2020] [Accepted: 06/16/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE Shoulder internal rotation contractures (IRC) are common sequela of brachial plexus birth injuries (BPBI). Botulinum toxin A (BTX-A) injection into targeted muscles has been described to facilitate functional improvement at the shoulder joint and prevent glenohumeral dysplasia. The purpose of this study was to assess the outcomes of BTX-A injections on shoulder IRC in children with BPBI. METHODS We conducted a retrospective analysis of 47 children with shoulder IRC due to BPBI, who were treated with BTX-A. Shoulder passive external rotation in adduction and Active Movement Scale external rotation scores were recorded before and after BTX-A injection. We also recorded the number of children who underwent secondary surgical balancing procedures to improve shoulder motion after BTX-A injection. RESULTS Mean age at the time of injection was 12 months (range, 5-23 months). Subjects demonstrated a significant increase in passive external rotation of 46° (range, 10° to 90) at 4 months; an average improvement of 18° (range, -30° to 80°) persisted at 11 months after injection. A total of 28 patients (60%) underwent subsequent external rotation tendon transfer. At 5-year follow-up, 7 patients (15%) had adequate functional shoulder range of motion and did not undergo external rotation tendon transfer. CONCLUSIONS Botulinum toxin A injections result in improvement in IRC due to BPBI, which is sustained beyond the expected half-life of 3 months. As many as 15% of patients who have this treatment avoid external rotation tendon transfer. TYPE OF STUDY/LEVEL OF EVIDENCE Diagnostic IV.
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Affiliation(s)
- Avreeta K Singh
- Department of Orthopaedics, University of California Davis Medical Center, Sacramento, CA.
| | - M Claire Manske
- Department of Orthopaedics, University of California Davis Medical Center, Sacramento, CA; Department of Orthopaedics, Shriners Hospital for Children Northern California, Sacramento, CA
| | - Michelle A James
- Department of Orthopaedics, University of California Davis Medical Center, Sacramento, CA; Department of Orthopaedics, Shriners Hospital for Children Northern California, Sacramento, CA
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Yeves-Lite A, Zuil-Escobar JC, Martínez-Cepa C, Romay-Barrero H, Ferri-Morales A, Palomo-Carrión R. Conventional and Virtual Reality Mirror Therapies in Upper Obstetric Brachial Palsy: A Randomized Pilot Study. J Clin Med 2020; 9:jcm9093021. [PMID: 32961793 PMCID: PMC7563545 DOI: 10.3390/jcm9093021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 09/07/2020] [Accepted: 09/17/2020] [Indexed: 12/16/2022] Open
Abstract
The abilities of children diagnosed with Obstetric Brachial Palsy (OBP) are limited by brachial plexus injuries. Thus, their participation in the community is hindered, which involves a lower quality of life due to worse performance in activities of daily living as a consequence of the functional limitations of the affected upper limb. Conventional Mirror Therapy (Conventional MT) and Virtual Therapy improve the affected upper limb functionality. Therefore, the aim of this study was to compare the effects of Conventional MT and Virtual Reality MT on the spontaneous use of the affected upper limb and quality of life of children with upper Obstetric Brachial Palsy between 6 and 12 years of age. A randomized pilot study was performed. Twelve children were randomly assigned to perform Conventional Mirror Therapy or Virtual Reality Mirror Therapy for four weeks. Ten children completed the treatment. Two assessments (pre/post-intervention) were carried out to assess the spontaneous use of the affected upper limb and the quality of life using the Children’s Hand-use Experience Questionnaire (CHEQ) and the Pediatric Quality of Life Inventory Generic Core Scales (PedsQL TM 4.0), respectively. There was a statistically significant increment in spontaneous use, observed in independent tasks (p = 0.02) and in the use of the affected hand with grasp (p = 0.04), measured with the CHEQ, for the Virtual Reality MT group. There were no statistically significant changes (p > 0.05) for the Conventional MT group in the spontaneous use of the affected upper limb. Regarding the quality of life, statistically significant changes were obtained in the Physical and Health activity categories of the parents’ questionnaire (p = 0.03) and in the total score of the children’s questionnaire (p = 0.04) in the Virtual Reality MT group, measured using the PedsQL TM 4.0. Statistically significant changes were not obtained for the quality of life in the Conventional MT group. This study suggests that, compared to Conventional MT, Virtual Reality MT would be a home-based therapeutic complement to increase independent bimanual tasks using grasp in the affected upper limb and improve the quality of life of children diagnosed with upper OBP in the age range of 6–12 years.
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Affiliation(s)
- Alba Yeves-Lite
- San-José Institute Foundation, Avda. de la Hospitalidad, s/n, 28054 Madrid, Spain;
| | - Juan Carlos Zuil-Escobar
- Department of Physiotherapy, Faculty of Medicine, CEU-San Pablo University, Urb. Montepríncipe, s/n., 28668 Madrid, Spain
- Correspondence: (J.C.Z.-E.); (C.M.-C.)
| | - Carmen Martínez-Cepa
- Department of Physiotherapy, Faculty of Medicine, CEU-San Pablo University, Urb. Montepríncipe, s/n., 28668 Madrid, Spain
- Correspondence: (J.C.Z.-E.); (C.M.-C.)
| | - Helena Romay-Barrero
- Department of Nursing, Physiotherapy and Occupational Therapy, Faculty of Physiotherapy and Nursing, University of Castilla-La Mancha, 45071 Toledo, Spain; (H.R.-B.); (A.F.-M.); (R.P.-C.)
| | - Asunción Ferri-Morales
- Department of Nursing, Physiotherapy and Occupational Therapy, Faculty of Physiotherapy and Nursing, University of Castilla-La Mancha, 45071 Toledo, Spain; (H.R.-B.); (A.F.-M.); (R.P.-C.)
| | - Rocío Palomo-Carrión
- Department of Nursing, Physiotherapy and Occupational Therapy, Faculty of Physiotherapy and Nursing, University of Castilla-La Mancha, 45071 Toledo, Spain; (H.R.-B.); (A.F.-M.); (R.P.-C.)
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Morscher MA, Thomas MD, Sahgal S, Adamczyk MJ. Onabotulinum toxin type A injection into the triceps unmasks elbow flexion in infant brachial plexus birth palsy: A retrospective observational cohort study. Medicine (Baltimore) 2020; 99:e21830. [PMID: 32846828 PMCID: PMC7447388 DOI: 10.1097/md.0000000000021830] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Brachial plexus birth palsy (BPBP) is a neurologic injury that can result in mild to full paralysis of the affected upper extremity. In severe cases, nerve surgery is often performed before age 1 year. Several studies report gains in elbow flexion with onabotulinum toxin type A (OBTT-A) injections to the triceps; however, its use in infants is not widely reported. The purpose of this study is to present our experience using these injections before 6 months of age to therapeutically unmask elbow flexion and diagnostically guide surgical decision making.This is a retrospective observational cohort study. The cohort included infants with BPBP who received OBTT-A injection to the triceps before age 6 months. Indications for the injections include trace elbow flexion and palpable co-contraction of the biceps and triceps. Elbow flexion was evaluated using the Toronto Test score. Therapeutic success was defined as an increase in post-injection scores. These scores were then used diagnostically as an indication for surgery if the infant did not achieve full elbow flexion by 8 months. A treatment algorithm for OBTT-A triceps injection was developed based on all treatment options offered to infants with elbow flexion deficits seen in the clinic.Of the 12 infants that received OBTT-A triceps injections, 10 (83%) had improved Toronto test elbow flexion scores post-injection. Gains in elbow flexion once attained were maintained. Of the 9 OBTT-A infants with at least 2 years follow-up, 4 achieved full elbow flexion without surgery; the remainder after surgery. No complications with OBTT-A injections were noted and patients were followed on average 6 years. The average age at time of injection was 4 months (range: 2-5 months). Compared to other treatments given, OBTT-A infants tended to present with more elbow flexion than the 4 infants requiring immediate surgical intervention and less elbow flexion than the 16 infants treated conservatively.OBTT-A injection to the triceps in infants with BPBP before 6 months of age therapeutically improved elbow flexion and diagnostically guided surgical decisions when full elbow flexion was not achieved by 8 months of age with no known complications.
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Affiliation(s)
| | | | - Suneet Sahgal
- Rehabilitation Services, The Children's Center Rehabilitation Hospital, Bethany, OK
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17
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Doty MS, Chauhan SP, Chang KWC, Al-Hafez L, McGovern C, Yang LJS, Blackwell SC. Persistence and Extent of Neonatal Brachial Plexus Palsy: Association with Number of Maneuvers and Duration of Shoulder Dystocia. AJP Rep 2020; 10:e42-e48. [PMID: 32140291 PMCID: PMC7056399 DOI: 10.1055/s-0040-1705140] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 11/15/2019] [Indexed: 11/23/2022] Open
Abstract
Objective The main objective of this article is to determine if persistence of neonatal brachial plexus palsy (NBPP) following shoulder dystocia was associated with maneuvers used or duration of impacted shoulder. Study Design Retrospective review of children with NBPP and documented shoulder dystocia. Student t -tests and chi-squared tests were used to compare outcomes when shoulder dystocia resolved with > 3 versus ≤ 3 maneuvers or duration > versus ≤ 120 seconds. Relative risk (RR) with 95% confidence intervals (CI) was calculated. Results Among 46 children with NBPP and shoulder dystocia, incidence of persistence was significantly higher at 2 years of age when > 3 versus ≤ 3 maneuvers were used (100 vs. 62%; RR: 1.6, 95% CI: 1.2-2.2). When resolution of impacted shoulder lasted >120 versus ≤ 120 seconds, NBPP at 2 years was significantly more likely (100 vs. 63%; RR: 1.6, 95% CI: 1.1-2.2). Injury to all five nerves of the brachial plexus was more likely if standard deviation lasted > 120 versus ≤ 120 seconds (RR: 2.2; 95% CI: 1.03-4.6). Conclusion Though the number of maneuvers used and duration of shoulder dystocia are associated with persistence of NBPP, the retrospective nature of the study of a selective cohort precludes recommendations changing the current management of shoulder dystocia.
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Affiliation(s)
- Morgen S Doty
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Suneet P Chauhan
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Kate W-C Chang
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Leen Al-Hafez
- Department of Obstetrics and Gynecology, Houston Methodist Hospital, Houston, Texas
| | - Connie McGovern
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Lynda J-S Yang
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Sean C Blackwell
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas
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18
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De Groef A, Devoogdt N, Van Kampen M, De Hertogh L, Vergote M, Geraerts I, Dams L, Van der Gucht E, Debeer P. The effectiveness of Botulinum Toxin A for treatment of upper limb impairments and dysfunctions in breast cancer survivors: A randomised controlled trial. Eur J Cancer Care (Engl) 2019; 29:e13175. [PMID: 31571329 DOI: 10.1111/ecc.13175] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 07/30/2019] [Accepted: 09/04/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To examine the effectiveness of a single Botulinum Toxin A (BTX-A) infiltration in the pectoralis major muscle, in addition to a standard physical therapy (PT) programme on upper limb impairments and dysfunctions after breast cancer treatment. METHODS Fifty breast cancer patients with persistent pain 3 months after finishing treatment participated in a double-blinded randomised controlled trial. The intervention group received a single BTX-A infiltration. The control group received a placebo (saline) infiltration. Within one week after the infiltration, all patients attended an individual PT programme (12 sessions) during the first 3 months. Outcome parameters were active shoulder range of motion, upper limb strength, scapular statics and shoulder function. Measures were taken before the intervention, at 1, 3 (i.e. after the intervention) and 6 months follow-up. RESULTS No differences between groups were found for all outcome parameters over the course of 6 months. However, overall beneficial effects of the PT for active forward flexion shoulder range of motion and shoulder function were found in both groups. CONCLUSION A single Botulinum Toxin A (BTX-A) infiltration in the pectoralis major muscle, in addition to a PT programme cannot be recommended to treat upper limb impairments and dysfunctions after breast cancer treatment.
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Affiliation(s)
- An De Groef
- Department of Rehabilitation Sciences, University Hospitals Leuven, Leuven, Belgium.,Department of Physical Medicine and Rehabilitation, KU Leuven - University of Leuven, Leuven, Belgium
| | - Nele Devoogdt
- Department of Rehabilitation Sciences, University Hospitals Leuven, Leuven, Belgium.,Department of Physical Medicine and Rehabilitation, KU Leuven - University of Leuven, Leuven, Belgium.,Department of Vascular Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Marijke Van Kampen
- Department of Rehabilitation Sciences, University Hospitals Leuven, Leuven, Belgium.,Department of Physical Medicine and Rehabilitation, KU Leuven - University of Leuven, Leuven, Belgium
| | - Laura De Hertogh
- Department of Rehabilitation Sciences, University Hospitals Leuven, Leuven, Belgium.,Department of Physical Medicine and Rehabilitation, KU Leuven - University of Leuven, Leuven, Belgium
| | - Margot Vergote
- Department of Rehabilitation Sciences, University Hospitals Leuven, Leuven, Belgium.,Department of Physical Medicine and Rehabilitation, KU Leuven - University of Leuven, Leuven, Belgium
| | - Inge Geraerts
- Department of Rehabilitation Sciences, University Hospitals Leuven, Leuven, Belgium.,Department of Physical Medicine and Rehabilitation, KU Leuven - University of Leuven, Leuven, Belgium
| | - Lore Dams
- Department of Rehabilitation Sciences and Physiotherapy, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Elien Van der Gucht
- Department of Rehabilitation Sciences, University Hospitals Leuven, Leuven, Belgium.,Department of Physical Medicine and Rehabilitation, KU Leuven - University of Leuven, Leuven, Belgium
| | - Philippe Debeer
- Department of Development and Regeneration, Orthopaedics, University Hospitals Leuven, Leuven, Belgium.,Institute for Orthopaedic Research and Training, KU Leuven - University of Leuven, Leuven, Belgium
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19
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Vu K, Kowalske K. Botulinum Toxin A for Improving Lack of Ankle Dorsiflexion Range of Motion After Major Burns-A Retrospective Chart Review. Arch Phys Med Rehabil 2019; 101:S50-S54. [PMID: 31437426 DOI: 10.1016/j.apmr.2019.07.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 07/12/2019] [Accepted: 07/16/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To review the effectiveness of botulinum toxin A (BTX-A) for treating the loss of maximum ankle dorsiflexion range of motion after burn injury. DESIGN Retrospective chart review. SETTING Large urban burn center. PARTICIPANTS Patients (3-51 y) with major burn injury and loss of ankle dorsiflexion range while hospitalized (N=5). INTERVENTION BTX-A treatment in addition to standard care. MAIN OUTCOME MEASURES Maximum ankle dorsiflexion range of motion at time of treatment, 1 month and 3 months posttreatment. RESULTS Patients' total burn area ranged from 18% to 95%, and time from injury to BTX-A injection (80-125 units) was 19-93 days. Ankle range at the time of injection was -10 to -50 degrees, and all patients had improved ankle range at 1 month postinjection (-30 to +10 degrees). At 3 months postinjection, 3 participants had neutral ranges of motion that were relatively improved compared to preinjection ranges. Patients with additional complications or severe injury showed regression toward preinjection maximum ankle dorsiflexion range of motion. CONCLUSION This retrospective study examines BTX-A as a potential tool for treating ankle plantar flexion contractures post major burn injury after failed conservative treatment. Initial review shows some patients may benefit from these injections, but more systematically designed studies are required to assess effectiveness. If effective, further investigation will be needed to validate and standardize treatment protocols, establish dosing, and assess long-term effectiveness in those with burn injury or severe complications.
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Affiliation(s)
- Kevin Vu
- Department of Physical Medicine and Rehabilitation, UT Southwestern Medical Center Dallas, Dallas, TX
| | - Karen Kowalske
- Department of Physical Medicine and Rehabilitation, UT Southwestern Medical Center Dallas, Dallas, TX.
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20
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Long-Term Outcomes of Brachial Plexus Reconstruction with Sural Nerve Autograft for Brachial Plexus Birth Injury. Plast Reconstr Surg 2019; 143:1017e-1026e. [DOI: 10.1097/prs.0000000000005557] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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21
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Utility of ultrasound-guided injection of botulinum toxin type A for muscle imbalance in children with obstetric brachial plexus palsy: description of the procedure and action protocol. NEUROLOGÍA (ENGLISH EDITION) 2019. [DOI: 10.1016/j.nrleng.2018.12.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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22
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External Rotation Predicts Outcomes After Closed Glenohumeral Joint Reduction With Botulinum Toxin Type A in Brachial Plexus Birth Palsy. J Pediatr Orthop 2018; 38:32-37. [PMID: 26886458 DOI: 10.1097/bpo.0000000000000735] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Few studies have investigated outcomes after adjunct botulinum toxin type A (BTX-A) injections into the shoulder internal rotator muscles during shoulder closed reduction and spica cast immobilization in children with brachial plexus birth palsy. The purpose of this study was to report success rates after treatment and identify pretreatment predictors of success. METHODS Children with brachial plexus birth palsy who underwent closed glenohumeral joint reduction with BTX-A and casting were included. Minimum follow-up was 1 year. Included patients did not receive concomitant shoulder surgery nor undergo microsurgery within 8 months. Records were reviewed for severity of palsy, age, physical examination scores, passive external rotation (PER), and subsequent orthopaedic procedures (repeat injections, repeat reduction, shoulder tendon transfers, and humeral osteotomy). Treatment success was defined in 3 separate ways: no subsequent surgical reduction, no subsequent closed or surgical reduction, and no subsequent procedure plus adequate external rotation. RESULTS Forty-nine patients were included. Average age at time of treatment was 11.5 months. Average follow-up was 21.1 months (range, 1 to 9 y). Thirty-two patients (65%) required repeat reduction (closed or surgical). Only 16% of all patients obtained adequate active external rotation without any subsequent procedure. Increased PER (average 41±14 degrees, odds ratio=1.21, P=0.01) and Active Movement Scale external rotation (average 1.3, odds ratio=2.36, P=0.02) predicted optimal treatment success. Limited pretreatment PER (average -1±17 degrees) was associated with treatment failure. Using the optimal definition for success, all patients with pretreatment PER>30 degrees qualified as successes and all patients with PER<15 degrees were treatment failures. CONCLUSIONS Pretreatment PER>30 degrees can help identify which patients are most likely to experience successful outcomes after shoulder closed reduction with BTX-A and cast immobilization. However, a large proportion of these patients will still have mild shoulder subluxation or external rotation deficits warranting subsequent intervention. LEVEL OF EVIDENCE Level IV-therapeutic.
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Abstract
BACKGROUND The Mallet scale, Active Movement Scale (AMS), and Toronto Test are validated for use in children with brachial plexus birth palsy (BPBP). However, the inability to compare these evaluation systems has led to difficulty gauging treatment efficacy and interpreting available literature in which multiple scoring systems are reported. Given the critical importance of physical examination, we compared 3 scoring systems to clarify statistical relationships between current validated evaluation methods. METHODS The medical records of children with BPBP treated at a single institution over a 14-year period were retrospectively reviewed. Modified Mallet, AMS, and Toronto scores were recorded throughout the entire period. Data were included if at least 2 complete scoring systems were documented during the same examination session. Spearman correlation coefficients were calculated for all composite and subscore combinations. A concordance table was constructed for select variables found to be highly correlated. RESULTS Total single-session score combinations were as follows: 157 Mallet and AMS, 325 AMS and Toronto, and 143 Mallet and Toronto. Composite AMS and Toronto scores were found to have a strong correlation (r=0.928, P<0.001). A concordance table comparing these variables revealed that a Toronto score of 3.5 is concordant to an AMS score of 45. Modified Mallet scores had only a moderate correlation with composite AMS (r=0.512, P<0.001) and Toronto (r=0.458, P<0.001) scores. Specifically regarding the modified Mallet score, maneuvers requiring external rotation had stronger correlations with the composite modified Mallet score than maneuvers highlighting internal rotation. CONCLUSIONS Modified Mallet scores do not correlate well with AMS or Toronto scores and should be utilized separately when managing children with BPBP. Similarly, AMS and Toronto scores are inadequate to guide clinical decisions for which the literature cites Mallet scores as outcome measures, and vice versa. Lastly, Mallet scores should incorporate an isolated internal rotation component to adequately assess midline function. LEVEL OF EVIDENCE Diagnostic level III.
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García Ron A, Gallardo R, Huete Hernani B. Utility of ultrasound-guided injection of botulinum toxin type A for muscle imbalance in children with obstetric brachial plexus palsy: Description of the procedure and action protocol. Neurologia 2017; 34:215-223. [PMID: 28347577 DOI: 10.1016/j.nrl.2016.12.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Revised: 12/01/2016] [Accepted: 12/20/2016] [Indexed: 10/19/2022] Open
Abstract
INTRODUCTION Obstetric brachial plexus palsy (OBPP) usually has a favourable prognosis. However, nearly one third of all severe cases have permanent sequelae causing a high level of disability. In this study, we explore the effectiveness of ultrasound-guided injection of botulinum toxin A (BoNT-A) and describe the procedure. PATIENTS AND METHODS We designed a prospective, descriptive study including patients with moderate to severe OBPP who were treated between January 2010 and December 2014. We gathered demographic data, type of OBPP, and progression. Treatment effectiveness was assessed with the Active Movement Scale (AMS), the Mallet classification, and video recordings. RESULTS We gathered a total of 14 133 newborns, 15 of whom had OBPP (1.6 per 1000 live births). Forty percent of the cases had severe OBPP (0.4/1000), a dystocic delivery, and APGAR scores < 5; mean weight was 4038g. Mean age at treatment onset was 11.5 months. The muscles most frequently receiving BoNT-A injections were the pronator teres, subscapularis, teres major, latissimus dorsi, and pectoralis major. All the patients who completed the follow-up period (83%) experienced progressive improvements: up to 3 points on the AMS and a mean score of 19.5 points out of 25 on the Mallet classification at 2 years. Treatment improved muscle function and abnormal posture in all cases. Surgery was avoided in 3 patients and delayed in one. Adverse events were mild and self-limited. CONCLUSIONS Due to its safety and effectiveness, BoNT-A may be used off-label as an adjuvant to physical therapy and/or surgery in moderate to severe OBPP. Ultrasound may increase effectiveness and reduce adverse effects.
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Affiliation(s)
- A García Ron
- Unidad de Neuropediatría, Instituto del Niño y del Adolescente. Hospital Clínico San Carlos, Madrid, España.
| | - R Gallardo
- Residente de Neuropediatría, H.U. Infanta Cristina. Parla, Madrid, España
| | - B Huete Hernani
- Servicio de Pediatría, Unidad de Neuropediatría, H.U. Infanta Cristina, Parla, Madrid, España
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Abstract
Brachial plexus birth palsy (BPBP) is an upper extremity paralysis that occurs due to traction injury of the brachial plexus during childbirth. Approximately 20 % of children with brachial plexus birth palsy will have residual neurologic deficits. These permanent and significant impacts on upper limb function continue to spur interest in optimizing the management of a problem with a highly variable natural history. BPBP is generally diagnosed on clinical examination and does not typically require cross-sectional imaging. Physical examination is also the best modality to determine candidates for microsurgical reconstruction of the brachial plexus. The key finding on physical examination that determines need for microsurgery is recovery of antigravity elbow flexion by 3-6 months of age. When indicated, both microsurgery and secondary shoulder and elbow procedures are effective and can substantially improve functional outcomes. These procedures include nerve transfers and nerve grafting in infants and secondary procedures in children, such as botulinum toxin injection, shoulder tendon transfers, and humeral derotational osteotomy.
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Affiliation(s)
- Kristin L Buterbaugh
- Division of Orthopaedic Surgery, Perelman School of Medicine at the University of Pennsylvania, The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Wood Building Room 2307, Philadelphia, PA, 19104-4318, USA
| | - Apurva S Shah
- Division of Orthopaedic Surgery, Perelman School of Medicine at the University of Pennsylvania, The Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Wood Building Room 2307, Philadelphia, PA, 19104-4318, USA.
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Chauhan SP, Chang KWC, Ankumah NAE, Yang LJS. Neonatal brachial plexus palsy: obstetric factors associated with litigation. J Matern Fetal Neonatal Med 2016; 30:2428-2432. [DOI: 10.1080/14767058.2016.1252745] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Suneet P. Chauhan
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX, USA and
| | - Kate W-C. Chang
- Department of Neurosurgery and Brachial Plexus Program, University of Michigan, Ann Arbor, MI, USA
| | - Nana-Ama Esi Ankumah
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX, USA and
| | - Lynda J-S. Yang
- Department of Neurosurgery and Brachial Plexus Program, University of Michigan, Ann Arbor, MI, USA
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Arthroscopic treatment for internal contracture of the shoulder secondary to brachial plexus birth palsy: report of a case series and review of the literature. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2015; 25:1121-9. [DOI: 10.1007/s00590-015-1670-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Accepted: 06/29/2015] [Indexed: 10/23/2022]
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Michaud LJ, Louden EJ, Lippert WC, Allgier AJ, Foad SL, Mehlman CT. Use of Botulinum Toxin Type A in the Management of Neonatal Brachial Plexus Palsy. PM R 2014; 6:1107-19. [PMID: 24798262 DOI: 10.1016/j.pmrj.2014.05.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2013] [Revised: 03/10/2014] [Accepted: 05/01/2014] [Indexed: 10/25/2022]
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Chauhan SP, Blackwell SB, Ananth CV. Neonatal brachial plexus palsy: incidence, prevalence, and temporal trends. Semin Perinatol 2014; 38:210-8. [PMID: 24863027 DOI: 10.1053/j.semperi.2014.04.007] [Citation(s) in RCA: 94] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Epidemiological knowledge of the incidence, prevalence, and temporal changes of neonatal brachial plexuses palsy (NBPP) should assist the clinician, avert unnecessary interventions, and help formulate evidence-based health policies. A summary of 63 publications in the English language with over 17 million births and 24,000 NBPPs is notable for six things. First, the rate of NBPP in the US and other countries is comparable: 1.5 vs. 1.3 per 1000 total births, respectively. Second, the rate of NBPP may be decreasing: 0.9, 1.0 and 0.5 per 1,000 births for publications before 1990, 1990-2000, and after 2000, respectively. Third, the likelihood of not having concomitant shoulder dystocia with NBPP was 76% overall, though it varied by whether the publication was from the US (78%) vs. other countries (47%). Fourth, the likelihood of NBPP being permanent (lasting at least 12 months) was 10-18% in the US-based reports and 19-23% in other countries. Fifth, in studies from the US, the rate of permanent NBPP is 1.1-2.2 per 10,000 births and 2.9-3.7 per 10,000 births in other nations. Sixth, we estimate that approximately 5000 NBPPs occur every year in the US, of which over 580-1050 are permanent, and that since birth, 63,000 adults have been afflicted with persistent paresis of their brachial plexus. The exceedingly infrequent nature of permanent NBPP necessitates a multi-center study to improve our understanding of the antecedent factors and to abate the long-term sequela.
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Affiliation(s)
- Suneet P Chauhan
- Department of Obstetrics and Gynecology, University of Texas, Houston, TX.
| | - Sean B Blackwell
- Department of Obstetrics and Gynecology, University of Texas, Houston, TX
| | - Cande V Ananth
- Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, NY; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
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