Neonatal phrenic nerve injury due to traumatic delivery

Unilateral diaphragmatic paralysis and complete brachial plexus injury in a complex birth injury: A rare case report mimicking Tarlov cyst and review of literature

The rare occurrence of Tarlov cysts in pediatric patients, particularly in the context of complex birth injuries, necessitates thorough evaluation and tailored management approaches. A comprehensive understanding of the clinical significance and optimal treatment strategies for this unique combination is crucial to ensure effective and individualized care for affected children.

Fluorographic findings of diaphragmatic paralysis with spontaneous recovery

BACKGROUND

Postoperative diaphragmatic paralysis is an unavoidable complication of cardiovascular surgery. Although diaphragmatic plication, as a surgical treatment, can be performed, spontaneous recovery is possible. We aimed to identify differences in fluorographic findings of diaphragmatic paralysis between pediatric patients with and without spontaneous recovery within 1 year of intrathoracic surgery.

METHODS

Ten children, who had been followed-up for at least 1 year post-surgery and who had not received diaphragmatic plication were included and classified into those with or without spontaneous recovery. The presence or absence of the paradoxical movement of the diaphragm and mediastinum was evaluated based on fluorographic findings. Fisher's exact test was used to compare the presence or absence of paradoxical movement between the groups.

RESULTS

Eight patients experienced spontaneous recovery. The mean ± standard deviation time to spontaneous recovery was 150 ± 114 days (range, 18-338 days). In the spontaneous recovery group, no patient had paradoxical movement of the mediastinum, and a significant between-group difference was observed in the presence of the paradoxical movement of the mediastinum (present/absent in patients with vs. without spontaneous recovery: 0/8 vs. 2/0, P = 0.02). There was no significant between-group difference in paradoxical movement of the diaphragm (present/absent in patients with vs. without spontaneous recovery: 1/7 vs. 2/0, P = 0.07). Pediatric patients without paradoxical movement of the mediastinum spontaneously recovered within 1 year of intrathoracic surgery.

CONCLUSIONS

Pediatric patients without paradoxical movement of the mediastinum, based on fluorography findings, spontaneously recovered within 1 year of surgery. The timing of spontaneous recovery varied between cases.

Circumferential shoulder laceration after posterior axilla sling traction: a case report of severe shoulder dystocia

BACKGROUND

Shoulder dystocia is an unpredictable and potentially catastrophic complication of vertex vaginal delivery. Posterior axilla sling traction (PAST) has recently been proposed as a method to resolve severe shoulder dystocia when commonly used techniques have failed.

CASE PRESENTATION

A 33-year-old woman (gravida 5, para 0) at 35 weeks, 1 day gestation underwent induction of labor for poorly controlled type 2 diabetes mellitus. Delivery of the large-for-gestational-age infant (4,060 g) was complicated by intractable shoulder dystocia, relieved at 3 minutes with PAST, resulting in a deep, circumferential laceration of the fetal posterior shoulder and contralateral phrenic nerve palsy.

CONCLUSIONS

PAST provides a potentially lifesaving option during intractable shoulder dystocia. Simulation or education about the technique facilitates its use when standard maneuvers fail. It is important to disseminate information about potential complications associated with these novel maneuvers.

A Rare Case of Contralateral Diaphragm Paralysis following Birth Injury with Brachial Plexus Palsy: A Case Report and Review of the Literature

Clinical History. A 4.4 kg male was born to a 25-year-old, G2P1, nondiabetic woman at 39 and 5/7 weeks. Delivery was complicated by shoulder dystocia requiring forceps-assisted vaginal delivery, resulting in left arm Erb's palsy secondary to left brachial plexus injury. He was born with low muscle tone and bradycardia and subsequently required intubation for poor respiratory effort. He was extubated on day one of life but continued to be tachypneic and have borderline oxygen saturation, requiring intensive care. Chest radiographs demonstrated a progressive clearing of his lung fields, consistent with presumptively diagnosed meconium aspiration. However, a persistent elevation of the right hemidiaphragm was noted, and his tachypnea and increased work of breathing continued. Focused ultrasound of the diaphragm was performed, confirming decreased motion of the right hemidiaphragm. Following a multidisciplinary discussion, thoracoscopic right diaphragm plication was performed on the 33rd day of life. He was extubated postoperatively and subsequently weaned to room air with a notable decrease in tachypnea over 48 hours. He was discharged on postoperative day 12 and continues to thrive at 6 months of age without respiratory embarrassment. Purpose. Ipsilateral phrenic nerve injury with diaphragm paralysis from shoulder dystocia during vaginal delivery is a recognized phenomenon. Herein, we present a case of contralateral diaphragm paralysis in order to draw attention to the clinician that this discordance is possible. Key Points. According to Raimbault et al., clinical management of newborns who experience birth injury is a multidisciplinary effort. According to Fitting and Grassino, though most cases of phrenic nerve injuries are ipsilateral to shoulder dystocia brachial plexus palsy, contralateral occurrence is possible and should be considered. According to Waters, diaphragm plication is a safe and effective operation.

Diaphragmatic paralysis after phrenic nerve injury in newborns

BACKGROUND

Phrenic nerve injury (PNI) from birth trauma is a recognized phenomenon, generally occurring with ipsilateral brachial plexus palsy (BPP). In severe cases, PNI results in diaphragm paresis (DP) and respiratory insufficiency. Surgical diaphragmatic plication (SDP) is a potential management strategy for patients with PNI and DP, but timing and outcomes associated with SDP have not been rigorously studied.

METHODS

Records from 49 tertiary United States pediatric hospitals in the Pediatric Health Information System from 2004 to 2018 were analyzed. The study cohort included patients diagnosed with BPP from birth trauma who were documented to have PNI or DP. Patients who underwent congenital cardiac operations were excluded.

RESULTS

A total of 5832 patients were identified with BPP from birth trauma during the study period, 122 (2%) of whom were found to have concomitant DP. Of those, 65 (53%) were male, 39 (32%) were infants of diabetic mothers, 80 (65%) required mechanical ventilation, and 33 (27%) underwent SDP. SDP was performed at a median (range) age of 36 (7-95) days. Median (range) total and postoperative hospital lengths of stay (LOS) were 34 (6-180) and 15 (4-132) days, respectively. There was also an observed increase in post-operative LOS with increase in age at operation.

CONCLUSION

Neonatal DP is rare and is managed with SDP in a minority of instances. Age at repair affects total and postoperative length of stay, proxies for resource utilization and morbidity. Repair prior to 45 days of life appears to result in a shorter postoperative hospital stay. This analysis will help guide surgeons with respect to indications and operative timing for infant DP.

TYPE OF STUDY

Retrospective Comparative Study.

LEVEL OF EVIDENCE

Level III.

Delivery room emergencies due to birth injuries

Delivery room emergencies due to birth injuries are serious, usually unexpected, and can be distressing situations that necessitate immediate action to reduce neonatal morbidity and prevent neonatal mortality. Birth injuries requiring immediate, urgent care in the delivery room are uncommon, hence knowledge of obstetric risk factors and prenatal conditions linked to birth injury is an important first step in the management of affected neonates. Furthermore, immediate recognition of injury and quick action upon delivery is essential in order to achieve the best possible outcomes. This chapter briefly reviews the known risk factors associated with birth injury, and then discusses the identification and management of specific injuries that may require immediate treatment in the delivery room, or hasty management within hours after birth.

Diaphragmatic paralysis in young children: A literature review

Diaphragmatic paralysis (DP) is a rare cause of respiratory distress in young children. In the first years of life, the main cause is phrenic nerve injury after cardiothoracic surgery or obstetrical trauma. DP usually presents as respiratory distress. Asymmetrical thorax elevation, difficulty weaning from mechanical ventilation, pulmonary atelectasis, and repeated pulmonary infections are other suggestive signs or complications. DP is usually suspected on chest X-ray showing abnormal hemidiaphragm elevation. Although fluoroscopy was considered the gold standard for DP confirmation, it has gradually been replaced by ultrasound, which can be done at the bedside. Some electrophysiological tools may be useful for a better characterization of phrenic nerve injury and chance of recovery. The management of DP is mainly based on clinical severity. In mild asymptomatic cases, DP may only require close monitoring. In more severe cases, adequate ventilatory support and/or surgical diaphragmatic plication may be needed. Electrophysiological tools may help clinicians assess the ideal timing for diaphragmatic plication.

Rare case of a newborn baby with left-sided Erb's palsy and a contralateral/right-sided paralysis of the diaphragm

Brachial plexus birth injury (BPBI) and phrenic nerve injury can sometimes occur concurrently in neonates following difficult deliveries like breech presentation, shoulder dystocia, forceps or vacuum extraction. Phrenic nerve palsy should be suspected in a newborn with respiratory distress and an elevated hemidiaphragm on the imaging studies in presence of the associated risk factors. The right side is affected more often than the left side and most of it is associated with BPBI. We present here a rare case of a newborn baby with a left-sided Erb's palsy and a contralateral/right-sided diaphragmatic paralysis who recovered from the persistent respiratory distress and feeding difficulties following plication of the diaphragm. The left-sided Erb's palsy also fully recovered at follow-up examination.

Erb's palsy complicating a case of annular pancreas

We report an unusual presentation of annular pancreas with pneumoperitoneum in a newborn with an associated left sided Erb's palsy. The neurological deficit caused considerable confusion in the diagnosis and unexpected complications after surgery. We highlight the importance of clinical examination and the complications that an Erb's palsy can cause. This unusual triad of Erb's palsy, eventration of diaphragm and annular pancreas has hitherto not been described in literature.

Early Thoracoscopic Plication of Diaphragm in a Newborn with Brachial Plexus Palsy and Concurrent Phrenic Nerve Palsy

Phrenic nerve palsy is a rare cause of respiratory distress in a newborn. When conservative measures fail to achieve adequate ventilation, then early surgical plication has been found to be associated with good outcome. We report a case of neonate with phrenic nerve palsy in whom an early thoracoscopic diaphragmatic plication was done.

The prognostic value of concurrent phrenic nerve palsy in newborn babies with neonatal brachial plexus palsy

PURPOSE

To investigate the prognostic value of concurrent phrenic nerve palsy for predicting spontaneous motor recovery in neonatal brachial plexus palsy.

METHODS

We reviewed the records of 366 neonates with brachial plexus palsy. The clinical and follow-up data of patients with and without phrenic nerve palsy were compared.

RESULTS

Of 366 newborn babies with neonatal brachial plexus palsy, 21 (6%) had concurrent phrenic nerve palsy. Sixteen of these neonates had upper-type palsy and 5 had total-type palsy. Poor spontaneous motor recovery was observed in 13 neonates with concurrent phrenic nerve palsy (62%) and in 129 without concurrent phrenic nerve palsy (39%). Among neonates born via vertex delivery, poor motor recovery was observed in 7 of 9 (78%) neonates with concurrent phrenic nerve palsy and 115 of 296 (39%) without concurrent phrenic nerve palsy.

CONCLUSIONS

Concurrent phrenic nerve palsy in neonates with brachial plexus palsy has prognostic value in predicting poor spontaneous motor recovery of the brachial plexus, particularly after vertex delivery.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Rowland Payne syndrome in a neonate as a consequence of birth trauma

Background: The syndrome of Rowland Payne is a rare triad of unilateral Horner syndrome, ipsilateral vocal cord paralysis, and ipsilateral paralysis of the hemidiaphragm.

Case: A healthy newborn was noted to have right ptosis, a weak hoarse cry, and stridor immediately following delivery with forceps. Pupillary miosis on the same side as the ptosis was observed. Chest X-ray showed elevation of the right diaphragmatic dome. A diagnosis of Rowland Payne syndrome was made. Neuroimaging did not reveal any structural mass lesions. The hoarseness and stridor resolved within 1 month without intervention. The Horner syndrome improved but did not disappear completely.

Conclusion: In the few reported cases in the literature, the cause of Rowland Payne syndrome has been a malignant lesion of the anterior neck disrupting the oculosympathetic nerve, the vagus nerve, and the phrenic nerve. This is the first report of Rowland Payne syndrome in a neonate. We did not find any malignancy or compressive lesion to account for his symptoms and signs. We suggest that shearing forces at the lower neck at the level of the clavicle caused stretching and mechanical injury to these motor nerves or their branches. In this report of Roland Payne syndrome related to birth trauma, the prognosis was favorable.

Phrenic nerve palsy: A rare cause of respiratory distress in newborn

Birth injury is defined as an impairment of a newborn's body function or structure due to adverse influences that occurred at birth. Phrenic nerve palsy may result from birth trauma during a traumatic neonatal delivery from a stretch injury due to lateral hyperextension of the neck at birth. This could be a rare cause of respiratory distress in the newborn period with irregular respiration. Respiratory distress due to phrenic nerve damage leading to paralysis of the ipsilateral diaphragm may require continuous positive airway pressure or mechanical ventilation and if unresponsive, surgical plication of diaphragm. Herein, we report a case of phrenic nerve palsy in a newborn presenting with respiratory distress.

Phrenic nerve palsy associated with birth trauma--case reports and a literature review

Phrenic nerve palsy is a peripheral nerve disorder caused by excessive cervical extension due to birth trauma or cardiac surgery. We describe two new patients with phrenic nerve palsy associated with birth trauma. Both patients exhibited profound dyspnea and general hypotonia immediately after birth. A chest roentgenogram and fluoroscopy revealed elevation of the diaphragm, leading to a diagnosis of phrenic nerve palsy associated with birth trauma. Since they had intermittently exhibited dyspnea and recurrent infection, we performed video-assisted thoracoscopic surgery (VATS) plication in both cases, at an early and a late stage, respectively. Both patients subsequently exhibited a dramatic improvement in dyspnea and recurrent respiratory infection. Interestingly, the late stage operated infant exhibited spontaneous recovery at 7 months with cessation of mechanical ventilation once. However, this recovery was transient and subsequently led to an increased ventilation volume demand, finally resulting in surgical treatment at 15 months. Histological examination of the diaphragm at this time showed grouped muscle atrophy caused by phrenic nerve degeneration. To our knowledge, this is the first pathologically proven report of grouped muscle atrophy of the diaphragm due to phrenic nerve degeneration, suggesting that partial impairment of phrenic nerves resulted in respiratory dysfunction with incomplete recovery. We conclude that recently developed VATS plication is a safe and effective treatment for infants with phrenic nerve palsy, and should be considered as a surgical treatment at an early period.

Respiratory distress in a one-month-old child suffering brachial plexus palsy

This paper describes a one-month-old girl presenting with respiratory and growth failure due to diaphragmatic paralysis associated with left brachial plexus palsy after forceps delivery. Despite continuous positive pressure ventilation and nasogastric feeding, the situation did not improve and a laparoscopic diaphragmatic plication had to be performed. When dealing with a child born with brachial plexus palsy, one must think of this possible association and if necessary proceed to the complementary radiological examinations. The treatment must avoid complications like feeding difficulties and failure to thrive, respiratory infections or atelectasis. It includes intensive support and a good evaluation of the prognosis of the lesion to decide the best moment for a surgical therapy.

Diaphragmatic paralysis among very low birth weight infants following ligation for patent ductus arteriosus

Management of diaphragmatic paralysis (DP) among newborn infants remains controversial, especially for very low birth weight (VLBW) infants following ligation for patent ductus arteriosus (PDA). This study aimed to characterize the impact of DP after PDA ligation among VLBW infants. Clinical characteristics of DP cases treated with either diaphragmatic plication or conservative methods were described as well. The medical records of VLBW infants who underwent PDA ligation in Chang Gung Memorial Hospital between January 2000 and December 2011 were retrospectively reviewed, and DP was suspected if postligation chest X-rays showed an elevation of the left diaphragm as confirmed by a chest ultrasonograph. For each DP case, three other infants that received PDA ligation with proximate birth dates and who were closely matched in terms of gestational age (±1 week) and birth weight (±10 %) were selected as the control group. A total of eight preterm infants were diagnosed as having DP and 24 infants were selected as the control group. The affected infants usually presented with respiratory distress and extubation failure. The study demonstrated that, among our patient population, DP was associated with a significantly longer duration of ventilator dependency (56.1 ± 16.0 vs. 29.8 ± 17.7 days, p = 0.001) and a higher incidence of severe bronchopulmonary dysplasia (87.5 vs. 23 %, p = 0.002). For selective infants with DP-related ventilatory failure after PDA ligation, surgical plication may facilitate extubation. Diaphragmatic paralysis should be evaluated carefully among VLBW infants receiving PDA ligation because of its adverse impact on ventilator dependency and correlation to a higher incidence of severe bronchopulmonary dysplasia.

Diaphragmatic paralysis associated with neonatal brachial plexus palsy

Phrenic nerve palsy can occur in the context of neonatal brachial plexus palsy, yet neither outcomes nor definitive treatment guidelines have been established. Diaphragmatic paralysis alone in the newborn results in significant respiratory sequelae and failure to thrive. Reviewing the available literature revealed little information about the incidence of phrenic nerve palsy associated with neonatal brachial plexus palsy, or whether outcomes are associated with the severity of the brachial plexus palsy. Of patients with brachial plexus palsy evaluated during 2005-2009 (n = 166) at our institution, a minority (2.4%; n = 4) had clinically significant diaphragmatic palsy. Of these, a majority (75%; n = 3) manifested respiratory complications sufficient to warrant diaphragmatic plication. The severity of brachial plexus palsy failed to correlate with severity of respiratory consequences. None of the patients underwent nerve repair or reconstruction. We suggest that diaphragmatic paralysis should not be overlooked during a brachial plexus examination, and diaphragmatic paralysis in the very young may require aggressive intervention before the treatment of brachial plexus palsy.