Prospective study of recovery following neonatal brachial plexus injury

Advancing glenohumeral dysplasia treatment in brachial plexus birth injury: the end-to-side spinal accessory to suprascapular nerve transfer technique

PURPOSE

Brachial plexus birth injury (BPBI) is a common injury with the spectrum of disease prognosis ranging from spontaneous recovery to lifelong debilitating disability. A common sequela of BPBI is glenohumeral dysplasia (GHD) which, if not addressed early on, can lead to shoulder dysfunction as the child matures. However, there are no clear criteria for when to employ various surgical procedures for the correction of GHD.

METHODS

We describe our approach to correcting GDH in infants with BPBIs using a reverse end-to-side (ETS) transfer from the spinal accessory to the suprascapular nerve. This technique is employed in infants that present with GHD with poor external rotation (ER) function who would not necessitate a complete end-to-end transfer and are still too young for a tendon transfer. In this study, we present our outcomes in seven patients.

RESULTS

At presentation, all patients had persistent weakness of the upper trunk and functional limitations of the shoulder. Point-of-care ultrasounds confirmed GHD in each case. Five patients were male, and two patients were female, with a mean age of 3.3 months age (4 days-7 months) at presentation. Surgery was performed on average at 5.8 months of age (3-8.6 months). All seven patients treated with a reverse ETS approach had full recovery of ER according to active movement scores at the latest follow-up. Additionally, ultrasounds at the latest follow-up showed a complete resolution of GHD.

CONCLUSION

In infants with BPBI and evidence of GHD with poor ER, end-to-end nerve transfers, which initially downgrade function, or tendon transfers, that are not age-appropriate for the patient, are not recommended. Instead, we report seven successful cases of infants who underwent ETS spinal accessory to suprascapular nerve transfer for the treatment of GHD following BPBI.

Three-Dimensional Upper Limb Movement Analysis in Children and Adolescents With Brachial Plexus Birth Injury: A Systematic Review

BACKGROUND

To synthesize the current evidence on clinical use of three-dimensional upper limb movement analysis (3D-ULMA) in children and adolescents with brachial plexus birth injury (BPBI).

METHODS

MEDLINE, Embase, and Web of Science were searched for relevant studies up to April 2022. An automatic e-mail alert was installed to ensure no eligible article was missed. Articles evaluating 3D-ULMA in children and adolescents with BPBI were included. Covidence web-based platform was used for blind screening of eligible articles. Twenty-one observational studies with a final sample size of 609, encompassing 493 BPBI cases, met the inclusion criteria. Data were extracted using a custom form to support standardized extraction conforming to the Cochrane Checklist of items. Risk of bias was assessed using the Newcastle-Ottawa Scale, the Strengthening the Reporting of Observational Studies in Epidemiology checklist, and a specifically established quality assessment form for kinematic analysis studies.

RESULTS

Study setups differed, including six different types of kinematic devices. Twelve studies used the (modified) Mallet positions for their 3D-ULMA. Throughout the studies, 3D-ULMA was used for various purposes. The Newcastle-Ottawa Scale scored 16 articles with five stars or more, indicating fair to moderate quality.

CONCLUSIONS

This systematic review summarizes the different 3D-ULMA kinematic devices, test protocols, and their clinical use for BPBI. The use of 3D-ULMA provides valuable, objective, and quantified data to clinicians with regard to movement strategies; it complements existing clinical scales and can be implemented to evaluate effectiveness of therapy interventions. Implications for future research and clinical practice are discussed.

The Relationship Between Elbow Flexion Postures and Overhead Reaching in Birth Brachial Plexus Injuries

PURPOSE

The aim of this study was to investigate the effect of alterations in muscle length of the biceps in various elbow postures during shoulder elevation and muscle activation.

METHODS

Participants aged 5 years and older with a birth brachial plexus injury were asked to perform elevation shoulder (abduction and flexion) in 7 elbow conditions. Surface electromyography was applied to bilateral biceps and triceps.

RESULTS

Peak shoulder elevation was present in the immobilized 20° elbow posture. Muscle activity of the triceps and biceps was impacted by the elbow posture via immobilization.

CONCLUSIONS

Elbow postures in elongated postures, via immobilization, may result in higher shoulder elevation due to increased passive forces when there is an altered muscle state of the biceps in this population. Clinicians should consider the optimal elbow joint posture (<30°) to improve overhead reaching in this population.

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.

Glenohumeral abduction contractures after residual neonatal brachial plexus injury

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

Functional outcomes of infants with Narakas grade 1 birth-related brachial plexus palsy undergoing neurotization compared with infants who did not require surgery

PURPOSE

This study aimed to investigate the functional outcomes of infants who underwent neurotization for shoulder abduction and elbow flexion in Narakas grade 1 birth-related brachial plexus palsy (BRBPP) and compare this cohort to children who progressed past the point of needing intervention.

METHODS

A cohort study was conducted at a single center between 1999 and 2010. Two-hundred and eight infants were identified with BRBPP that presented for neurosurgical care as infants. Of those, 38 (18 %) received neurosurgical intervention with approximate 2-year follow-up. Only infants undergoing cranial nerve XI to suprascapular nerve neurotization for shoulder abduction (SA) weakness and medial pectoral nerve to musculocutaneous nerve neurotization for elbow flexion (EF) weakness were included. In addition, 30 infants who improved past the need for surgical intervention and had been followed for close to 24 months were identified for comparison. Descriptive statistics and exploratory analysis were performed using SAS 9.2 and JMP 9.0.2.

RESULTS

Shoulder abduction For SA, there were no differences in age at presentation between the operative (6-9 months) and non-operative (5-9 months) groups (p = 0.99). Infants in the operative cohort had significantly worse initial function (p = 0.008). At 2-year follow-up, the two groups had become similar (p = 1.0). Elbow flexion For EF, there were no differences in age at presentation between the operative (6-8 months) and non-operative (5-8.5 months) groups (p = 0.98). Infants in the operative cohort had significantly worse initial function (p = 0.002). At 2-year follow-up, those two groups had become similar (p = 0.26).

CONCLUSIONS

Infants undergoing neurotization for Narakas grade 1 brachial plexus injury had similar long-term function to those who had improved and never required surgery. The preoperative exam findings were significantly different between the intervened and non-intervened groups, while the postoperative exam findings were not.

Primary Nerve Repair for Obstetrical Brachial Plexus Injury: A Meta-Analysis

BACKGROUND

Nerve repair may be effective in improving function following obstetrical brachial plexus injury. No previous review has directly compared nerve repair to nonoperative management for similar patients, and no previous analysis has been adequately powered to determine whether nerve repair reduces impairment.

METHODS

Electronic databases were searched (MEDLINE, Embase, CINAHL, and Cochrane Central). Eligible studies were randomized controlled trials, observational studies, and case series (n > 9); included patients younger than 2 years undergoing nerve repair or nonoperative management of obstetrical brachial plexus injury; and reported functional impairment. Two reviewers independently screened articles using objective a priori criteria. Bias was assessed for each study. Overall quality of evidence was evaluated for each outcome.

RESULTS

Among nine cohort studies including 222 patients, nerve repair significantly reduced functional impairment compared with nonoperative management (relative risk, 0.58; 95 percent CI, 0.43 to 0.79; p < 0.001; I = 0 percent; absolute risk reduction, 19 percent; number needed to treat, six). Findings are consistent with comparison of similar patients from case series. With operative management, no deaths were reported; major adverse events were reported in 1.5 percent, and minor adverse events were reported in 5.0 percent of cases. Among demographic (all severities) samples managed nonoperatively, residual impairment remains in 27 percent (19 to 36 percent).

CONCLUSIONS

Nerve repair reduces functional impairment in obstetrical brachial plexus injury. Nonoperative management in patients with a deficit at 3 months of age leads to a high proportion of functional impairment. Mortality is not a common risk of modern pediatric microsurgical nerve repair. Residual impairment with nonoperative management is underestimated in the reported literature.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Outcome in adolescence of brachial plexus birth palsy. 69 individuals re-examined after 10–20 years

BACKGROUND AND PURPOSE

The frequency and severity of a permanent lesion after brachial plexus birth palsy (BPBP) and its impact on activities of daily living are not well documented. We therefore investigated the outcome of BPBP in adolescents, regarding arm function and consequences for activity and participation.

PARTICIPANTS AND METHODS

Of 30,574 babies born at St. Olavs University Hospital in 1991-2000, 91 had BPBP (prevalence 3 per 1,000), and 69 of these individuals were examined at a median age of 14 (10-20) years. The examination included the modified Mallet classification, range of motion, shoulder rotation and grip strength, Assisting Hand Assessment, and Canadian Occupational Performance Measure. Of the 22 subjects who were not examined, 3 could not be traced and 19 reported having no problems in the affected arm.

RESULTS

At follow-up, 17 adolescents had a permanent lesion (i.e. individual Mallet subscore below 4) with a median Mallet total score of 15 (9-19), while 52 had good or normal shoulder function (median Mallet total score 25 (23-25)). All participants with a permanent lesion had reduced active shoulder rotation (≤15°), 16 had elbow extension deficit, and 10 had subnormal grip strength. External rotation was considerably weaker in the affected shoulder. In addition, they had ineffective use of the affected arm in bimanual activities. Even so, all except 1 were independent in activities of daily living, although 15 experienced minor difficulties.

INTERPRETATION

Every fourth to fifth child with BPBP had a permanent lesion as an adolescent. External rotation was the most impaired movement. Despite ineffective use of the affected arm in bimanual activities, all of the participants except one were independent in activities of daily living.

Utility of delayed surgical repair of neonatal brachial plexus palsy

OBJECT

Neonatal brachial plexus palsy (NBPP) represents a significant health problem with potentially devastating consequences. The most common form of NBPP involves the upper trunk roots. Currently, primary surgical repair is performed if clinical improvement is lacking. There has been increasing interest in "early" surgical repair of NBPPs, occurring within 3-6 months of life. However, early treatment recommendations ignore spontaneous recovery in cases of Erb's palsy. This study was undertaken to evaluate the optimal timing of surgical repair in this group with respect to quality of life.

METHODS

The authors formulated a decision analytical model to compare 4 treatment strategies (no repair or repair at 3, 6, or 12 months of life) for infants with persistent NBPPs. The model derives data from a critical review of published studies and projects health-related quality of life and quality-adjusted life years over a lifetime.

RESULTS

When evaluating the quality of life of infants with NBPP, improved outcomes are seen with delayed surgical repair at 12 months, compared with no repair or repair at early and intermediate time points, at 3 and 6 months, respectively. ANOVA showed that the differences among the 4 groups are highly significant (F = 8369; p < 0.0001). Pairwise post hoc comparisons revealed that there are highly significant differences between each pair of strategies (p < 0.0001). Meta-regression showed no evidence of improved outcomes with more recent treatment dates, compared with older ones, for either nonsurgical or for surgical treatment (p = 0.767 and p = 0.865, respectively).

CONCLUSIONS

These data support a delayed approach of primary surgical reconstruction to optimize quality of life. Early surgery for NBPPs may be an overly aggressive strategy for infants who would otherwise demonstrate spontaneous recovery of function by 12 months. A randomized, controlled trial would be necessary to fully elucidate the natural history of NBPP and determine the optimal time point for surgical intervention.

Psychometric properties of outcome measures for children and adolescents with brachial plexus birth palsy: a systematic review

AIM

The aim of this review was to evaluate the psychometric properties of outcome measures used to quantify upper limb function in children and adolescents with brachial plexus birth palsy (BPBP).

METHOD

Eleven electronic databases were searched to identify studies on the effects of conservative management to improve upper limb function in young people with BPBP. Outcome measures used in these studies were extracted and used in a subsequent search to identify studies that evaluated the psychometric properties of these measures. The methodological quality of these studies was rated using a standardized critical appraisal tool.

RESULTS

Thirty-three outcome measures and 12 psychometric studies were identified. Nine outcome measures had some psychometric evidence, which was variable in quality. The outcome measures which seem to have the most robust psychometric properties include the Active Movement Scale, Assisting Hand Assessment, Pediatric Evaluation of Disability Index, and the Pediatric Outcomes Data Collection Instrument.

INTERPRETATION

Further research is required to determine the psychometric properties of outcome measures used for children and adolescents with BPBP. Caution is required when interpreting the results of commonly used outcome measures in this population owing to their relatively unknown psychometric properties.

Prognostic value of thumb pain sensation in birth brachial plexopathy

OBJECTIVE: To evaluate the prognostic value of absent thumb pain sensation in newborns and young infants with birth brachial plexopathy. METHODS: We evaluated 131 patients with birth brachial plexopathy with less than two months of age. Pain sensation was evoked by thumb nail bed compression to evaluate sensory fibers of the upper trunk (C6). The patients were followed-up monthly. Patients with less than antigravity elbow flexion at six months of age were considered to have a poor outcome. RESULTS: Thirty patients had absent thumb pain sensation, from which 26 showed a poor outcome. Sensitivity of the test was 65% and specificity was 96%. CONCLUSION: Evaluation of thumb pain sensation should be included in the clinical assessment of infants with birth brachial plexopathy.

Torticollis associated with neonatal brachial plexus palsy

We investigate the incidence of torticollis associated with neonatal brachial plexus palsy, whether the severity of brachial plexus palsy affects outcomes and the rate of recovery. We performed a retrospective review of 128 consecutive neonatal brachial plexus palsy patients evaluated at the University of Michigan from 2005-2009. Patients were followed for at least 3 months, with regular physical examinations and imaging. Forty-three percent presented concurrently with torticollis. Significant differences were evident in mean age at first brachial plexus examination, suggesting that patients with concurrent torticollis present earlier for clinical examination. Recovery from torticollis was evident in 62% of patients by 23 ± 12 weeks with conservative management. No statistically significant differences were evident between torticollis and nontorticollis groups after reviewing their severity of neonatal brachial plexus palsy (Narakas score), recovery from neonatal brachial plexus palsy (biceps function at 6 months), need for nerve repair or reconstructive procedures, or infant, maternal, or other factors associated with labor. Results suggest that although torticollis occurs with increased frequency in children with brachial plexus palsy, its presence is not related to severity and does not affect the probability of recovery from brachial plexus palsy. Conservative management for torticollis yields reasonable recovery.

Range of motion and strength after surgery for brachial plexus birth palsy

BACKGROUND

There is little information about the range of motion (ROM) and strength of the affected upper limbs of patients with permanent brachial plexus birth palsy.

PATIENTS AND METHODS

107 patients who had brachial plexus surgery in Finland between 1971 and 1998 were investigated in this population-based, cross-sectional, 12-year follow-up study. During the follow-up, 59 patients underwent secondary procedures. ROM and isometric strength of the shoulders, elbows, wrists, and thumbs were measured. Ratios for ROM and strength between the affected and unaffected sides were calculated.

RESULTS

61 patients (57%) had no active shoulder external rotation (median 0° (-75-90)). Median active abduction was 90° (1-170). Shoulder external rotation strength of the affected side was diminished (median ratio 28% (0-83)). Active elbow extension deficiency was recorded in 82 patients (median 25° (5-80)). Elbow flexion strength of the affected side was uniformly impaired (median ratio 43% (0-79)). Median active extension of the wrist was 55° (-70-90). The median ratio of grip strength for the affected side vs. the unaffected side was 68% (0-121). Patients with total injury had poorer ROM and strength than those with C5-6 injury. Incongruity of the radiohumeral joint and avulsion were associated with poor strength values.

INTERPRETATION

ROM and strength of affected upper limbs of patients with surgically treated brachial plexus birth palsy were reduced. Patients with avulsion injuries and/or consequent joint deformities fared worst.

Obstetric brachial plexus palsy: a prospective, population-based study of incidence, recovery, and residual impairment at 18 months of age

AIM

The aim of this investigation was to study the incidence of obstetric brachial plexus palsy (OBPP), to prospectively follow the recovery process, to assess the functional outcome at 18 months of age, and to find early prognostic indicators.

METHOD

Of the 38 749 children born between 1999 and 2001 in western Sweden, 114 (70 males, 44 females) had an OBPP. Ninety-eight children were examined on six occasions at up to 18 months of age. Muscle strength, range of motion, hand preference, and functional abilities were noted, and the severity of the OBPP was classified.

RESULTS

The incidence of OBPP was 2.9 per 1000 live births, and the incidence of persisting OBPP was 0.46 per 1000. At 3 months of age, the predictive value of regained elbow flexion for complete recovery was 100%, 99% of shoulder external rotation, and 96% of forearm supination. Most of the 18 children with persisting OBPP could perform functional activities but asymmetries were noted. Five children had a mild, 11 had a moderate, and two had a severe impairment. Three had undergone nerve surgery, one with a mild and two with a severe persisting impairment.

INTERPRETATION

Most children with an OBPP recover completely. Muscle strength at 3 months of age can be used to predict outcome.

Prognosis following neonatal brachial plexus palsy: an evidence-based review

PURPOSE

The spontaneous recovery rate of neonatal brachial plexus palsy (NBPP) is often cited as 75-95%. However, recent reports have found the recovery rate to be much lower. The purpose of this study was to perform an evidence-based review aimed at summarizing the available English language information regarding prognosis following NBPP based on the Narakas classification.

METHODS

A Medline database search was performed to identify articles that focused on the natural history, outcome, prognosis, or conservative treatment of neonatal brachial plexus birth injury from 1966 to 2006. Twenty-four articles were identified. The articles were graded according to the Oxford Evidence Based Grading Scale and data regarding sample size, follow up, study purpose, Narakas grouping, Mallet scale, and recovery of function at 3 and 6 months were extracted. Of the 24 articles, 11 were included for review. Data analysis included odds ratios and percent recovery.

RESULTS

Of the 11 studies, only one was given a grade of a Level I study, three were given a grade of Level II, and seven were given a grade of Level IV. Sixty-four percent of infants classified as Narakas I and II had spontaneous recovery of biceps function at 3 months of age and only 9% of the Narakas III and IV group had recovery. Sixty-five percent of the Narakas I and II group had complete recovery at 6 months of age and only 14% of the Narakas III and IV group had recovery. The odds of biceps recovery at 3 months of age for the Narakas I and II group was 19 times higher compared to the III and IV group. The odds of complete recovery were 11 times higher for the Narakas I and II group compared to the III and IV group.

CONCLUSION

The quality of the literature regarding the prognosis of neonatal brachial plexus injury is poor. Based on the Narakas classification, recovery better for NBPP classified as Narakas I and II.

Motor nerve-conduction studies in obstetric brachial plexopathy for a selection of patients with a poor outcome

BACKGROUND

The criteria and timing for nerve surgery in infants with obstetric brachial plexopathy remain controversial. Our aim was to develop a new method for early prognostic assessment to assist this decision process.

METHODS

Fifty-four patients with unilateral obstetric brachial plexopathy who were ten to sixty days old underwent bilateral motor-nerve-conduction studies of the axillary, musculocutaneous, proximal radial, distal radial, median, and ulnar nerves. The ratio between the amplitude of the compound muscle action potential of the affected limb and that of the healthy side was called the axonal viability index. The patients were followed and classified in three groups according to the clinical outcome. We analyzed the receiver operating characteristic curve of each index to define the best cutoff point to detect patients with a poor recovery.

RESULTS

The best cutoff points on the axonal viability index for each nerve (and its sensitivity and specificity) were <10% (88% and 89%, respectively) for the axillary nerve, 0% (88% and 73%) for the musculocutaneous nerve, <20% (82% and 97%) for the proximal radial nerve, <50% (82% and 97%) for the distal radial nerve, and <50% (59% and 97%) for the ulnar nerve. The indices from the proximal radial, distal radial, and ulnar nerves had better specificities compared with the most frequently used clinical criterion: absence of biceps function at three months of age.

CONCLUSIONS

The axonal viability index yields an earlier and more specific prognostic estimation of obstetric brachial plexopathy than does the clinical criterion of biceps function, and we believe it may be useful in determining surgical indications in these patients.

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

OBJECT

In the literature, the best recommendations are imprecise as to the timing and selection of infants with obstetrical brachial plexus injury (OBPI) for surgical intervention. There is a gray zone (GZ) in which the decision as to the benefits and risks of surgery versus no surgery is not clear. The authors propose to describe this category, and they have developed a guideline to assist surgical decision-making within this GZ.

METHODS

The authors first performed a critical review of the medical literature to determine the existence of a GZ in other clinical publications. In those reports, 47-89% of infants with OBPI fell within such a GZ. Complete recovery in those reported patients ranged from 9 to 59%. Using a prospective inception cohort design, all infants referred to the OBPI Clinic at McMaster Children's Hospital were systematically evaluated up to 3 years of age. The Active Movement Scale scores were compared for surgical and nonsurgical groups of infants in the GZ to identify any important trends that would guide surgical decision-making.

RESULTS

In the authors' population of infants with OBPI, 81% fell within the GZ, of whom 44% achieved complete recovery. Mean scores differed significantly between surgery and no surgery groups in terms of total Active Movement Scale score and shoulder abduction and flexion at 6 months. Elbow flexion and external rotation differed at 3 months.

CONCLUSIONS

There is compelling evidence that there is a group of infants with OBPI in whom the assessment of the risk/benefit ratio for surgical versus nonsurgical treatment is not evident. These infants reside within what the authors have called the GZ. Based on their results, a guideline was derived to assist clinicians working with infants with OBPI to navigate the GZ.

Lack of effectiveness of primary conservative management for infants with brachial plexus birth palsy

PURPOSE

Brachial plexus birth palsy (BPBP) is the most common peripheral nerve injury in children (prevalence <5.1 per 1000 live births) and conservative management is routinely used to manage them. We have previously systematically reviewed studies investigating primary conservative management, published between 1992 and 2002, and found these to be inconclusive. The aim of this review was to update our previous systematic review to include studies published between 2002 and 2008, synthesise the data thus obtained with that of our previous review and create an up-to-date body of evidence for conservative management of infants with BPBP.

PROCEDURES

Fifteen databases were searched systematically for quantitative studies (randomised controlled trials, comparative studies, case series), published in English between January 2002 and June 2008 inclusive. Studies were excluded if they investigated infants who, in their first two years of life, underwent microsurgical repair of the brachial plexus, surgical management of secondary deformities or received other treatments traditionally delivered by surgeons, such as Botulinum toxin injections. The eligibility of each study identified from the database searches was evaluated against the inclusion criteria by two independent reviewers. These studies were then critically appraised for level of evidence using the National Health and Medical Research Council of Australia Hierarchy of Evidence and methodological quality using the Critical Review Form - Quantitative Studies. Data pertaining to the demographic characteristics of study participants, treatments received, main results and outcome measures used were also extracted. Where any disagreement between reviewers occurred, consensus was reached by discussion. Data from the recently published studies were narratively synthesised and then combined with the data gained from our previous systematic review to create a body of evidence on primary conservative management for BPBP infants.

RESULTS

Four publications, representing three studies (one comparative study, two case series), were sourced. Methodological quality scores of these studies ranged from 6 to 12 (maximum =16). The current body of evidence (publications from 1992 to 2008) therefore comprises 11 studies, four using a comparative design and seven using a case series design. Six of the 11 studies were classified as being of "poor" methodological quality (score <8). Conservative management mainly consisted of exercise therapy, although splinting, massage and dynamic traction were also used. All studies lacked a clear definition of conservative management sufficient to allow replication of the treatment in a clinical setting. A variety of outcome measures were used, limiting comparability of the studies. Data from the three case studies suggests that conservative management may be more effective in infants with upper and middle plexus injuries compared with total plexus palsy. However, the different outcome measures used and lack of comparison groups limit the strength of this finding.

CONCLUSIONS

The body of evidence investigating the use of primary conservative management of infants with BPBP remains inconclusive. The studies published to date are limited in number, level of evidence and methodological quality. Further, a variety of outcome instruments, with limited psychometric properties, have been used to investigate management techniques which do not mirror those of contemporary clinical practice.

The function of the hand after operations for obstetric injuries to the brachial plexus

Hand function was evaluated in 105 patients who had been operated on in early infancy for brachial plexus birth palsy. The mean follow-up after surgery was for 13.4 years (5.0 to 31.5). Fine sensation, stereognosis, grip and pinch strength and the Raimondi scale were recorded.

Fine sensation was normal in 34 of 49 patients (69%) with C5–6 injury, 15 of 31 (48%) with C5–7 and in 8 of 25 (32%) with total injury. Loss of protective sensation or absent sensation was noted in some palmar areas of the hand in 12 of 105 patients (11%). Normal stereognosis was recorded in 88 of the 105 patients (84%), whereas only 9 of the 105 (9%) had normal grip strength. The mean Raimondi scale scores were 4.57 (3 to 5) (C5–6), 4.26 (1 to 5) (C5–7) and 2.16 (0 to 5) in patients with total injury.

The location of impaired sensation was related to the distribution of the root injury. Avulsion type of injury correlated with poor recovery of hand function.

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 results of surgery for brachial plexus birth palsy

BACKGROUND

The long-term results of surgical treatment of brachial plexus birth palsy have not been reported. We present the findings of a nationwide study, with a minimum five-year follow-up, of the outcomes of surgery for brachial plexus birth palsy in Finland.

METHODS

Of 1,717,057 newborns, 1706 with brachial plexus birth palsy requiring hospital treatment were registered in Finland between 1971 and 1997. Of these patients, 124 (7.3%) underwent surgery on the brachial plexus at a mean age of 2.8 months (range, 0.4 to 13.2 months). The most commonly performed surgical procedure was direct neurorrhaphy after neuroma resection. One hundred and twelve patients (90%) returned for a clinical and radiographic follow-up examination after a mean of 13.3 years. Activities of daily living were recorded on a questionnaire, and the affected limb was assessed with use of joint-specific functional measures.

RESULTS

Two-thirds (63%) of the patients were satisfied with the functional outcome, although one-third of all patients needed help in activities of daily living. One-third of the patients, including all nine with a clavicular nonunion from the surgical approach, experienced pain in the affected limb. All except four patients used the hand of the unaffected limb as the dominant hand. Shoulder function was moderate, with a mean Mallet score of 3.0. Both elbow and hand function were good, with a mean score on the Gilbert elbow scale of 3 and a mean Raimondi hand score of 4. Incongruence of the glenohumeral joint was noted in sixteen (16%) of the ninety-nine patients in whom it was assessed, and incongruence of the radiohumeral joint was noted in twenty-one (21%). The extent of the brachial plexus injury was found to be strongly associated with the final shoulder, elbow, and hand function in a multivariate analysis.

CONCLUSIONS

Following surgical treatment of brachial plexus birth palsy, substantial numbers of the patients continued to need help performing activities of daily living and had pain in the affected limb, with the pain due to a clavicular nonunion in one-fourth of the patients. The strongest prognostic factor predicting outcome appears to be the extent of the primary plexus injury.

Augmentation of partially regenerated nerves by end-to-side side-to-side grafting neurotization: experience based on eight late obstetric brachial plexus cases

OBJECTIVE

The effect of end-to-side neurotization of partially regenerated recipient nerves on improving motor power in late obstetric brachial plexus lesions, so-called nerve augmentation, was investigated.

METHODS

Eight cases aged 3-7 years were operated upon and followed up for 4 years (C5,6 rupture C7,8 T1 avulsion: 5; C5,6,7,8 rupture T1 avulsion: 1; C5,6,8 T1 rupture C7 avulsion: 1; C5,6,7 rupture C8 T1 compression: one 3 year presentation after former neurotization at 3 months). Grade 1-3 muscles were neurotized. Grade 0 muscles were neurotized, if the electromyogram showed scattered motor unit action potentials on voluntary contraction without interference pattern. Donor nerves included: the phrenic, accessory, descending and ascending loops of the ansa cervicalis, 3rd and 4th intercostals and contralateral C7.

RESULTS

Superior proximal to distal regeneration was observed firstly. Differential regeneration of muscles supplied by the same nerve was observed secondly (superior supraspinatus to infraspinatus regeneration). Differential regeneration of antagonistic muscles was observed thirdly (superior biceps to triceps and pronator teres to supinator recovery). Differential regeneration of fibres within the same muscle was observed fourthly (superior anterior and middle to posterior deltoid regeneration). Differential regeneration of muscles having different preoperative motor powers was noted fifthly; improvement to Grade 3 or more occurred more in Grade 2 than in Grade 0 or Grade 1 muscles. Improvements of cocontractions and of shoulder, forearm and wrist deformities were noted sixthly. The shoulder, elbow and hand scores improved in 4 cases.

LIMITATIONS

The sample size is small. Controls are necessary to rule out any natural improvement of the lesion. There is intra- and interobserver variability in testing muscle power and cocontractions.

CONCLUSION

Nerve augmentation improves cocontractions and muscle power in the biceps, pectoral muscles, supraspinatus, anterior and lateral deltoids, triceps and in Grade 2 or more forearm muscles. As it is less expected to improve infraspinatus power, it should be associated with a humeral derotation osteotomy and tendon transfer. Function to non improving Grade 0 or 1 forearm muscles should be restored by muscle transplantation.

LEVEL OF EVIDENCE

Level IV, prospective case series.

Prognostic relevance of risk factors for obstetrical brachial plexopathy

We did a case-control study to verify if the birthweight, forceps delivery or perinatal asphyxia have any significant effect on the prognosis of obstetrical brachial plexopathy. Group A was composed of 25 infants who completely recovered at the age of 6 months. Group B was composed of 21 infants who were still not able to remove a blindfold from the face with the affected limb in the sitting position at the age of 12 months. There was no statistical difference of the median birthweight or median first minute Apgar score between the groups. There was also no relation between birthweight higher than 4000g, first minute Apgar score lower than 6 or forceps delivery with a poor prognosis.

Management of birth brachial plexus palsy

INTRODUCTION

The indications for surgical repair of congenital brachial plexus palsy are controversial. Our objective was to determine the results of early brachial plexus surgery following obstetric-induced brachial plexus palsy.

METHODS

We performed a retrospective analysis of the outcome of 58 cases of brachial plexus surgery. The indication for operation consisted of the presence of less than antigravity strength in the biceps, triceps, and deltoid muscle groups at 6 months of age. Data gathered prospectively, previously, showed the likelihood of improvement with less than antigravity strength in these cases to be poor.

RESULTS

Follow-up data were obtained on 52 of the 58 cases. Overall mean follow-up was 2 years. Twelve patients had more than 3 years follow-up (mean 5.5 years, range 3-11.5 years). Significant improvement was seen in all injury patterns i.e., C5-C6, C5-C7, and C5-C8, T1. Greater than antigravity strength in the biceps, triceps, and deltoid muscle groups was seen in the majority of cases at follow-up.

CONCLUSIONS

Repair of obstetrical brachial plexus palsy in children at 6 months of age that is based on less than antigravity strength in the biceps, triceps, and deltoid muscle groups produces improvement in functional capabilities. Children with obstetrical brachial plexus palsy should be referred soon after birth to a center that specializes in the treatment of this type of palsy.

Entrapment neuropathy contributing to dysfunction after birth brachial plexus injuries

Although surgical treatment of brachial plexus birth palsy has yielded encouraging results, persistent inability to abduct and elevate the shoulder is common even in children with excellent return of arm and hand function. The reason for deltoid weakness in the afflicted children is not completely understood and may be multifactorial. Clinical observations, including a pattern of position-dependent weakness, suggest that primary nerve damage may not be the sole cause. The authors performed a retrospective chart study to investigate the outcome of surgical treatment to augment shoulder function in a series of 10 children (ages 9 months to 8 years) with inadequate external rotation of the shoulder and inability to actively raise the arm beyond 90 degrees from a birth brachial plexus injury. At follow-up 6 months after surgery, increased shoulder range of motion was noticed in all, with significantly increased abduction/elevation in 8 of the 10 children. Analysis of data, including pre- and postoperative functional testing and intraoperative electrophysiologic monitoring, led to the conclusion that secondary compression of the axillary nerve in the quadrangular space is a separate and common reason for impairment in children with brachial plexus birth palsy and persistent weakness of the deltoid muscle and may provide an important reason for early intervention.

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.

Effectiveness of primary conservative management for infants with obstetric brachial plexus palsy

BACKGROUND

Obstetric brachial plexus palsy, a complication of childbirth, occurs in 1-3 per 1000 live births internationally. Traction and/or compression of the brachial plexus is thought to be the primary mechanism of injury and this may occur in utero, during the descent through the birth canal or during delivery. This results in a spectrum of injuries that vary in severity, extent of damage and functional use of the affected upper limb. Most infants receive treatment, such as conservative management (physiotherapy, occupational therapy) or surgery; however, there is controversy regarding the most appropriate form of management. To date, no synthesised evidence is available regarding the effectiveness of primary conservative management for obstetric brachial plexus palsy.

OBJECTIVES

The objective of this review was to systematically assess the literature and present the best available evidence that investigated the effectiveness of primary conservative management for infants with obstetric brachial plexus palsy.

SEARCH STRATEGY

A systematic literature search was performed using 14 databases: TRIP, MEDLINE, CINAHL, AMED, Web of Science, Proquest 5000, Evidence Based Medicine Reviews, Expanded Academic ASAP, Meditext, Science Direct, Physiotherapy Evidence Database, Proquest Digital Dissertations, Open Archives Initiative Search Engine, Australian Digital Thesis Program. Those studies that were reported in English and published over the last decade (July 1992 to June 2003) were included in this review.

SELECTION CRITERIA

Quantitative studies that investigated the effectiveness of primary conservative management for infants with obstetric brachial plexus palsy were eligible for inclusion in this review. This excluded studies that solely investigated the effect of primary surgery for these infants, management of secondary deformities and the investigation of the effects of pharmacological agents, such as botulinum toxin.

DATA COLLECTION AND ANALYSIS

Two independent reviewers assessed the eligibility of each study for inclusion into the review, the study design used and its methodological quality. Where any disagreement occurred, consensus was reached by discussion. Studies were assessed for clinical homogeneity by considering populations, interventions and outcomes. Where heterogeneity was present, synthesis was undertaken in a narrative format.

RESULTS

Eight studies were included in the review. Most were ranked low on the Hierarchy of Evidence (no randomised controlled trials were found), and had only fair methodological quality. Conservative management was variable and could consist of active or passive exercise, splints or traction. All studies lacked a clear description of what constituted conservative management, which would not allow the treatment to be replicated in the clinical setting. A variety of outcome instruments were used, none of which had evidence of validity, reliability or sensitivity to detect change. Furthermore, less severely affected infants were selected to receive conservative management. Therefore, it is difficult to draw conclusions regarding the effectiveness of conservative management for infants with obstetric brachial plexus palsy.

CONCLUSIONS

There is scant, inconclusive evidence regarding the effectiveness of primary conservative intervention for infants with obstetric brachial plexus palsy. Further research should be directed to develop outcome instruments with sound psychometric properties for infants with obstetric brachial plexus palsy and their families. These outcome instruments should then be used in well-designed comparative studies.

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.

Motor conduction studies for prognostic assessment of obstetrical plexopathy

Early prognostic assessment of obstetrical brachial plexopathies (OBP) would facilitate rational selection of infants for brachial plexus surgery. We performed bilateral motor nerve conduction studies (MNCS) of axillary, musculocutaneous, radial, median, and ulnar nerves in 33 babies (age 10-60 days) with OBP in order to compare the amplitude of compound muscle action potentials (CMAPs). All babies were followed up until 6 months of age and the outcome was classified according to muscle strength and arm function. A CMAP amplitude reduction of more than 90%, compared to the unaffected side, predicted severe weakness of the corresponding root level (p < 0.01). Our results indicate that MNCS are a useful tool for very early prognostic assessment of OBP.

Patient safety events during pediatric hospitalizations

OBJECTIVE

Our objective was to describe potential patient safety events for hospitalized children, using the patient safety indicators (PSIs), and examine associations with these events.

METHODS

PSI algorithms, developed by researchers at the Agency for Healthcare Research and Quality to identify potential in-hospital patient safety problems using administrative data, were applied to 3.8 million discharge records for children under 19 years from 22 states in the 1997 Healthcare Cost and Utilization Project. Prevalence of PSI events and associations with patient-level and hospital-level characteristics, length of stay, in-hospital mortality, and total charges were examined.

RESULTS

The prevalence of pediatric patient safety events is significant with the highest rate found for birth trauma at 1.5 cases per every 100 births. The majority of these events for birth trauma consist of long bone and skull fractures, excluding the clavicle. Compared with records without PSI events, discharges with PSI events had 2- to 6-fold longer lengths of stay, 2- to 18-fold higher rates of in-hospital mortality, and 2- to 20-fold higher total charges. Bivariate and multivariate analyses found that all PSI events except birth trauma were directly associated with factors related to greater severity of illness and large urban teaching institutions. Birth trauma, however, was directly associated with black and Hispanic ethnicity but was not consistently associated with technologically sophisticated teaching institutions.

CONCLUSIONS

The prevalence of birth trauma and other potential patient safety events for hospitalized children is high and comparable to hospitalized adults. These events are associated with increased length of stay, in-hospital mortality, and total charges. Associated factors differ significantly for birth trauma compared with other PSI events. Institutional application of the PSIs may be useful to identify processes of care that warrant further evaluation as the health care industry tackles the problem of patient safety, particularly for children.

Inhibition of caspases promotes long-term survival and reinnervation by axotomized spinal motoneurons of denervated muscle in newborn rats

We examined whether (1) a pan-caspase inhibitor, Boc-D-FMK, exerts long-term neuroprotective effects on spinal motoneurons (MNs) after root avulsion in neonatal rats and (2) whether the rescued spinal MNs regenerate their axons into a peripheral nerve (PN) graft and reinnervate a previously denervated target muscle. Eight weeks after root avulsion, 67% of spinal MNs remained in the Boc-D-FMK-treated group, whereas all MNs died in the sham control group. By 12 weeks postinjury, however, all Boc-D-FMK treated MNs died. In the regeneration experiment, a PN graft was implanted at different times after injury. The animals were allowed to survive for 4 weeks following the operation. Without caspase inhibition, MNs did not regenerate at any time point. In animals treated with Ac-DEVD-CHO, a caspase-3-specific inhibitor, and Boc-D-FMK, 44 and 62% of MNs, respectively, were found to regenerate their axons into a PN graft implanted immediately after root avulsion. When the PN graft was implanted 2 weeks after injury, however, MNs failed to regenerate following Ac-DEVD-CHO treatment, whereas 53% of MNs regenerated their axons into the graft after treatment with Boc-D-FMK. No regeneration was observed when a PN graft was implanted later than 2 weeks after injury. In the reinnervation study, injured MNs and the target biceps muscle were reconnected by a PN bridge implanted 2 weeks after root avulsion with administration of Boc-D-FMK. Eight weeks following the operation, 39% of MNs reinnervated the biceps muscle. Morphologically normal synapses and motor endplates were reformed in the muscle fibers. Collectively, these data provide evidence that injured neonatal motoneurons can survive and reinnervate peripheral muscle targets following inhibition of caspases.

Development of the regenerative capacity of postnatal axotomized rat spinal motoneurons

The present study examined whether a peripheral nerve (PN) graft can rescue developing motoneurons from degeneration and determined when immature motoneurons begin to express a regenerative capacity. Transplantation of a PN graft was unable to rescue motoneurons from degeneration if spinal root avulsion was performed in animals younger than P14. However, this procedure did enhance motoneuron survival when root avulsion was performed at P14 or later. Immature (P1 or P7) motoneurons were unable to regenerate their axons into the transplanted PN graft following root avulsion, whereas in older animals (P14-P28) motoneurons were able to regenerate axons into the PN graft. The percentage of regenerated motoneurons increased from P21 to P28 and was similar to that of adult animals. Therefore, the regenerative capacity of rat spinal motoneurons first begins at about P14, which seems to be critical.