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Leblebicioğlu G, Pondaag W. Brachial plexus birth injury: advances and controversies. J Hand Surg Eur Vol 2024; 49:747-757. [PMID: 38366382 DOI: 10.1177/17531934241231173] [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] [Indexed: 02/18/2024]
Abstract
While there is considerable spontaneous recovery in most cases of brachial plexus birth injury, many children are left with significant problems that may lead to lifelong functional limitations, loss of work and social isolation. Detailed treatment with the right strategy can provide very valuable improvement in function. Over the past few years, the clinical approach to brachial plexus birth palsy has entered a new era in both diagnostic and surgical treatment methods. This article reviews four areas of management, the role of imaging in defining the severity of the injury, the optimal timing of for nerve exploration and reconstruction in appropriate cases, the advantages and potential complications of nerve transfers, and the role of physiotherapy. Available evidence is considered. Although it is difficult to make clear and precise inferences on a subject where there are many variables and considerable uncertainties, some currently accepted views will be summarized.Level of evidence: V.
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Affiliation(s)
| | - Willem Pondaag
- Department of Neurosurgery/Leiden Nerve Center, Leiden University Medical Center, Leiden, The Netherlands
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2
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Liu DS, Miller P, Rothenberg A, Vuillermin C, Waters PM, Bauer AS. Early Elbow Flexion Contracture Predicts Shoulder Contracture in Infants with Brachial Plexus Birth Injury. J Pediatr 2024; 264:113739. [PMID: 37717907 DOI: 10.1016/j.jpeds.2023.113739] [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] [Received: 05/19/2023] [Revised: 08/19/2023] [Accepted: 09/13/2023] [Indexed: 09/19/2023]
Abstract
OBJECTIVE To determine if children who present with an elbow flexion contracture (EFC) from brachial plexus birth injury (BPBI) are more likely to develop shoulder contracture and undergo surgical treatment. STUDY DESIGN Retrospective review of children <2 years of age with BPBI who presented to a single children's hospital from 1993 to 2020. Age, elbow and shoulder range of motion (ROM), imaging measurements, and surgical treatment and outcome were analyzed. Patients with an EFC of ≥10° were included in the study sample. Data from 2445 clinical evaluations (1190 patients) were assessed. The final study cohort included 72 EFC cases matched with 230 non-EFC controls. Three patients lacked sufficient follow-up data. RESULTS There were 299 included patients who showed no differences between study and control groups with respect to age, sex, race, ethnicity, or functional score. Patients with EFC had 12° less shoulder range of motion (95% CI, 5°-20°; P < .001) and had 2.5 times the odds of shoulder contracture (OR, 2.5; 95% CI, 1.3-4.7; P = .006). For each additional 5° of EFC, the odds of shoulder contracture increased by 50% (OR, 1.5; 95% CI, 1.2-1.8; P < .001) and odds of shoulder procedure increased by 62% (OR, 1.62; 95% CI, 1.04-2.53; P = .03). Sensitivity of EFC for predicting shoulder contracture was 49% and specificity was 82%. CONCLUSIONS In patients with BPBI <2 years of age, presence of EFC can be used as a screening tool in identifying shoulder contractures that may otherwise be difficult to assess. Prompt referral should be arranged for evaluation at a BPBI specialty clinic, because delayed presentation risks worsening shoulder contracture and potentially more complicated surgery.
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Affiliation(s)
- David S Liu
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, MA
| | - Patricia Miller
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, MA
| | - Anna Rothenberg
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, MA
| | - Carley Vuillermin
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, MA
| | - Peter M Waters
- Department of Orthopaedic Surgery, Atrium Health, Charlotte, NC
| | - Andrea S Bauer
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, MA.
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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: 4] [Impact Index Per Article: 4.0] [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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Long-Term Results of Microsurgical Brachial Plexus Reconstruction in Late-Presenting Cases of Brachial Plexus Birth Injury. J Hand Surg Am 2023; 48:126-133. [PMID: 36539318 DOI: 10.1016/j.jhsa.2022.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 10/22/2022] [Accepted: 11/09/2022] [Indexed: 12/23/2022]
Abstract
PURPOSE The role of primary surgery in delayed presenting cases of brachial plexus birth injury is still debated. The purpose of this study was to evaluate the results of brachial plexus reconstruction performed at the age of ≥12 months. METHODS Twenty-nine cases were included. Five cases had upper (C5-6) palsy, 4 had upper/middle (C5-7), and 20 had total (C5-8 and T1) palsy. RESULTS The age at the time of primary surgery was an average of 15.6 months. The brachial plexus was formally explored and neurolysis, grafting, and neurotization were used in different combinations. Exploration revealed that 27% of the roots were avulsed and 32% were ruptured. The follow-up was an average of 7.9 years. Generally, the best functional recovery was elbow flexion followed by shoulder external rotation. Satisfactory shoulder abduction (≥6 on the Toronto Active Movement Scale [TAMS]) was achieved in 31% of cases. The abduction range was an average of 79° ± 35°; 50° in upper palsy, 103° in upper/middle palsy, and 82° in total palsy. Shoulder external rotation ≥6 on the TAMS was achieved in 62% of cases. External rotation range was an average of 58° ± 29°; 78° in upper palsy, 68° in upper/middle palsy, and 52° in total palsy. Elbow flexion and extension of ≥6 on the TAMS were achieved in 69% and 58% of cases, respectively. Wrist flexion and finger flexion of ≥6 on the TAMS were achieved in 35% and 12.5%, whereas wrist and finger extension of >6 on the TAMS were achieved in 25% and 4% of cases, respectively. CONCLUSION In the delayed presentation of brachial plexus birth injury, brachial plexus reconstruction results in good functional recovery of elbow flexion and shoulder external rotation but modest functional recovery of finger flexion and wrist extension. The rate of functional recovery of the elbow flexion was similar following nerve grafting and transfer. Nerve transfer for shoulder external rotation should be considered even in infants with available roots for grafting. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Prevalence of perinatal factors in infants with brachial plexus birth injuries and their association with injury severity. J Perinatol 2022; 43:578-583. [PMID: 36585508 DOI: 10.1038/s41372-022-01594-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 12/16/2022] [Accepted: 12/21/2022] [Indexed: 01/01/2023]
Abstract
OBJECTIVES To determine the prevalence of perinatal factors associated with brachial plexus birth injury (BPBI) in affected infants and their relationship with BPBI severity. STUDY DESIGN Retrospective study of BPBI infants prospectively enrolled in a multicenter registry. The prevalence of perinatal factors was calculated. Infants were stratified by injury severity and groups were compared to determine the association of severity and perinatal factors. RESULTS Seven-hundred-ninety-six BPBI infants had a mean 4.2 ± 1.6 perinatal factors. Nearly all (795/796) reported at least one factor, including shoulder dystocia(96%), no clavicle fracture (91%), difficult delivery(84%), parity >1(61%) and birthweight >4000 g(55%). Ten-percent (74/778) had Horner's syndrome and 28%(222/796) underwent nerve surgery. Birth asphyxia and NICU admission were significantly associated with injury severity. CONCLUSIONS NICU admission and asphyxia were associated with BPBI severity. An improved understanding of the relationship between perinatal factors and BPBI severity may be used to guide early referral to BPBI providers and support prevention efforts.
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Catena N, Baldrighi C, Jester A, Soldado F, Farr S. Microsurgery in pediatric upper limb reconstructions: An overview. J Child Orthop 2022; 16:241-255. [PMID: 35992521 PMCID: PMC9382710 DOI: 10.1177/18632521221106390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 05/13/2022] [Indexed: 02/03/2023] Open
Abstract
The use of microsurgery has spread during the last decades, making resolvable many complex defects considered hitherto inapproachable. Although the small vessel diameter in children was initially considered a technical limitation, the increase in microsurgical expertise over the past three decades allowed us to manage many pediatric conditions by means of free tissue transfers. Pediatric microsurgery has been shown to be feasible, gaining a prominent place in the treatment of children affected by limb malformations, tumors, nerve injuries, and post-traumatic defects. The aim of this current concepts review is to describe the more frequent pediatric upper limb conditions in which the use of microsurgical reconstructions should be considered in the range of treatment options.
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Affiliation(s)
- Nunzio Catena
- Reconstructive Surgery and Hand Surgery
Unit, IRCCS Istituto Giannina Gaslini, Genova, Italy,Nunzio Catena, Reconstructive Surgery and
Hand Surgery Unit, IRCCS Istituto Giannina Gaslini, Largo G. Gaslini 5, 16121
Genova, Italy.
| | - Carla Baldrighi
- Children’s Hand and Upper Limb Service,
Department of Plastic Surgery, Birmingham Children’s Hospital NHS Foundation Trust,
Birmingham, UK
| | - Andrea Jester
- Children’s Hand and Upper Limb Service,
Department of Plastic Surgery, Birmingham Children’s Hospital NHS Foundation Trust,
Birmingham, UK
| | - Francisco Soldado
- Pediatric Hand, Nerve and Microsurgery
Institute, Vall d’Hebron Instituto de Oncologia, Barcelona, Spain
| | - Sebastian Farr
- Pediatric Orthopedics and Foot and
Ankle Surgery, Orthopedic Hospital Speising, Vienna, Austria
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Brachial Plexus Birth Injury: Trends in Early Surgical Intervention over the Last Three Decades. Plast Reconstr Surg Glob Open 2022; 10:e4346. [PMID: 35620493 DOI: 10.1097/gox.0000000000004346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 03/23/2022] [Indexed: 11/25/2022]
Abstract
Early surgical management of brachial plexus birth injury has advanced owing to targeted surgical techniques and increases in specialty-centers and multi-institutional collaboration. This study seeks to determine trends in the early surgical management of BPBI over the last 30 years. Methods A systematic review was performed through MEDLINE (PubMed) identifying studies limited to the early surgical management of BPBI from 1990 to current. Patients treated after 1 year of age (ie, tendon transfers and secondary reconstructive efforts) were excluded. Diagnostic tests, age of intervention, surgical treatment modalities, and outcome scoring systems were extrapolated and compared so as to determine trends in management over time. Results Seventeen studies met criteria, summating a total of 883 patients. The most commonly reported physical examination classifications were the Mallet and AMS scoring systems. Most patients underwent neuroma excision and sural nerve autografting (n = 618, 70%) when compared with primary nerve transfers (148, 16.8%), primary nerve transfer with autografting combinations (59, 6.7%), or neurolysis alone (58, 6.6%). There was no significant change in the proportion of patients treated with sural nerve grafting, combination graft and transfer procedures, or isolated neurolysis over time. However, there has been a significant increase in the proportion of patients treated with primary nerve transfer procedures (τ b = 0.668, P < 0.01) over time. Conclusion Although neuroma excision and sural nerve autografting has been the historic gold-standard treatment for brachial plexus birth injury, peripheral nerve transfers have become increasingly utilized for surgical management.
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8
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Lin JS, Samora JB. Brachial Plexus Birth Injuries. Orthop Clin North Am 2022; 53:167-177. [PMID: 35365261 DOI: 10.1016/j.ocl.2021.11.003] [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: 02/02/2023]
Abstract
Brachial plexus birth injuries (BPBIs) are typically traction type injuries to the newborn that occur during the delivery process. Although the incidence of these injuries has overall decreased from 1.5 to around 0.9 per 1000 live births in the United States over the past 2 decades, these injuries remain common, with incidence holding fairly steady from 2008 to 2014. Shoulder dystocia is the strongest identified risk factor, imparting a 100-fold greater risk. The newborn's shoulder is caught behind the mother's pubic bone, and traction performed on the child during delivery results in injury to the brachial plexus. Other risk factors associated with BPBI include macrosomia (birthweight > 4.5 kg), heavy for gestational age infants, birth hypoxia, gestational diabetes, and forceps or vacuum-assisted delivery. Breech presentation has also been described as a risk factor in the past, but there have been more recent data that challenge this association.
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Affiliation(s)
- James S Lin
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, 700 Children's Drive, T2E- A2700, Columbus, OH 43205, USA
| | - Julie Balch Samora
- Department of Orthopaedics, The Ohio State University Wexner Medical Center, 700 Children's Drive, T2E- A2700, Columbus, OH 43205, USA; Department of Orthopedic Surgery, Nationwide Children's Hopsital, Columbus, OH, USA.
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Srinivasan N, Mahajan J, Gupta S, Shah YM, Shafei J, Levidy MF, Abdelmalek G, Pant K, Jain K, Zhao C, Chu A, McGrath A. Surgical timing in neonatal brachial plexus palsy: A PRISMA-IPD systematic review. Microsurgery 2022; 42:381-390. [PMID: 35147253 PMCID: PMC9305151 DOI: 10.1002/micr.30871] [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: 08/03/2021] [Revised: 11/23/2021] [Accepted: 01/28/2022] [Indexed: 12/05/2022]
Abstract
Background Neonatal brachial plexus palsy (NBPP) is a serious complication of high‐risk deliveries with controversy surrounding timing of corrective nerve surgery. This review systematically examines the existing literature and investigates correlations between age at time of upper trunk brachial plexus microsurgery and surgical outcomes. Methods A systematic screening of PubMed, Cochrane, Web of Science, and CINAHL databases using PRISMA‐IPD guidelines was conducted in January 2020 to include full‐text English papers with microsurgery in upper trunk palsy, pediatric patients. Spearman rank correlation analysis and two‐tailed t‐tests were performed using individual patient data to determine the relationship between mean age at time of surgery and outcome as determined by the Mallet, Medical Research Council (MRC), or Active Movement Scale (AMS) subscores. Results Two thousand nine hundred thirty six papers were screened to finalize 25 papers containing individual patient data (n = 256) with low to moderate risk of bias, as assessed by the ROBINS‐I assessment tool. Mallet subscore for hand‐to‐mouth and shoulder abduction, AMS subscore for elbow flexion and external rotation, and MRC subscore for elbow flexion were analyzed alongside the respective age of patients at surgery. Spearman rank correlation analysis revealed a significant negative correlation (ρ = −0.30, p < .01, n = 89) between increasing age (5.50 ± 2.09 months) and Mallet subscore for hand‐to‐mouth (3.43 ± 0.83). T‐tests revealed a significant decrease in Mallet hand‐to‐mouth subscores after 6 months (p < .05) and 9 months (p < .05) of age. No significant effects were observed for Mallet shoulder abduction, MRC elbow flexion, or AMS elbow flexion and external rotation. Conclusion The cumulative evidence suggests a significant negative correlation between age at microsurgery and Mallet subscores for hand‐to‐mouth. However, a similar correlation with age at surgery was not observed for Mallet shoulder abduction, MRC elbow flexion, AMS external rotation, and AMS elbow flexion subscores.
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Affiliation(s)
- Nivetha Srinivasan
- Department of Orthopedic Surgery, Rutgers-New Jersey Medical School, Newark, New Jersey, USA
| | - Jasmine Mahajan
- Department of Orthopedic Surgery, Rutgers-New Jersey Medical School, Newark, New Jersey, USA
| | - Shivani Gupta
- Department of Orthopedic Surgery, Rutgers-New Jersey Medical School, Newark, New Jersey, USA
| | - Yash M Shah
- Department of Orthopedic Surgery, Rutgers-New Jersey Medical School, Newark, New Jersey, USA
| | - Jasmine Shafei
- Department of Orthopedic Surgery, Rutgers-New Jersey Medical School, Newark, New Jersey, USA
| | - Michael F Levidy
- Department of Orthopedic Surgery, Rutgers-New Jersey Medical School, Newark, New Jersey, USA
| | - George Abdelmalek
- Department of Orthopedic Surgery, Rutgers-New Jersey Medical School, Newark, New Jersey, USA
| | - Krittika Pant
- Department of Orthopedic Surgery, Rutgers-New Jersey Medical School, Newark, New Jersey, USA
| | - Kunj Jain
- Department of Orthopedic Surgery, Rutgers-New Jersey Medical School, Newark, New Jersey, USA
| | - Caixia Zhao
- Department of Orthopedic Surgery, Rutgers-New Jersey Medical School, Newark, New Jersey, USA
| | - Alice Chu
- Department of Orthopedic Surgery, Rutgers-New Jersey Medical School, Newark, New Jersey, USA
| | - Aleksandra McGrath
- Department of Clinical Sciences, Umeå University, Umeå, Sweden.,Department of Surgical and Perioperative Sciences, Umeå University, Umeå, Sweden
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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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11
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Pulos N, Shaughnessy WJ, Spinner RJ, Shin AY. Brachial Plexus Birth Injuries: A Critical Analysis Review. JBJS Rev 2021; 9:01874474-202106000-00003. [PMID: 34102666 DOI: 10.2106/jbjs.rvw.20.00004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
» The incidence of brachial plexus birth injury (BPBI) in the United States is declining and now occurs in <1 per 1,000 births. » The gold standard for predicting the need for early intervention remains serial examination. » Early treatment of BPBI with reconstructive surgery requires the ability to perform both interposition nerve grafting and nerve transfers. » Given the heterogeneity of lesions, the evidence is largely limited to retrospective comparative studies and case series.
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Affiliation(s)
- Nicholas Pulos
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Robert J Spinner
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota.,Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota
| | - Alexander Y Shin
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
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12
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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: 0] [Impact Index Per Article: 0] [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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13
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Elvan Ö, Aktekin M, Kayan G. Microsurgical anatomy of the spinal cord in human fetuses. Surg Radiol Anat 2020; 42:951-960. [PMID: 32418124 DOI: 10.1007/s00276-020-02498-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 05/07/2020] [Indexed: 01/09/2023]
Abstract
PURPOSE To determine the microsurgical features of the spinal cord and ventral and dorsal rootlets in fetal period. METHODS Twelve formalin-fixed fetuses (six females and six males) with a mean gestational age of 27.0 ± 2.04 weeks (range between 25 and 32 weeks) were dissected to evaluate morphological properties of the spinal cord and rootlets. RESULTS Length and width of each spinal cord segment, number of dorsal and ventral rootlets, length of dorsal root entry and ventral root exit zones of each spinal nerve, spinal cord termination level, and the whole spinal cord length were determined in all fetuses. Contrary to previous reports, the number of ventral rootlets was always more than that of dorsal rootlets in all segments. No statistically significant gender difference was found for all parameters. Rootlet number and segment width in cervical region were larger than those of thoracic, while the lengths of dorsal root entry and ventral root exit zones in thoracic region were longer than those of cervical. In lumbar region, dorsal and ventral rootlet numbers were increasing again, while lengths of dorsal root entry and ventral root exit zones were decreasing. Number of dorsal and ventral rootlets of C5 and C6 segments was statistically higher than other cervical segments. The mean spinal cord length was found as 105.55 ± 11.30 mm and there was a positive significant relationship with gestational age. Conus medullaris level was detected between L1 and L3 segments. CONCLUSION Detailed microsurgical data about the fetal spinal cord and the dorsal and ventral rootlets presented in this study provide significant information which may be essential during surgical interventions in early postnatal period and childhood targeting the spinal cord and spinal nerve roots.
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Affiliation(s)
- Özlem Elvan
- School of Health, Mersin University, Çiftlikköy Campus, Yenişehir, 33343, Mersin, Turkey.
| | - Mustafa Aktekin
- Department of Anatomy, School of Medicine, Mersin University, Mersin, Turkey
| | - Gülden Kayan
- Department of Anatomy, School of Medicine, Mersin University, Mersin, Turkey
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14
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Ahluwalia R, Rocque BG, Shannon CN, Blount JP. The impact of imposed delay in elective pediatric neurosurgery: an informed hierarchy of need in the time of mass casualty crisis. Childs Nerv Syst 2020; 36:1347-1355. [PMID: 32435890 PMCID: PMC7239607 DOI: 10.1007/s00381-020-04671-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 05/08/2020] [Indexed: 11/25/2022]
Abstract
SARS-CoV-2 COVID-19, coronavirus, has created unique challenges for the medical community after national guidelines called for the cancellation of all elective surgery. While there are clear cases of elective surgery (benign cranial cosmetic defect) and emergency surgery (hemorrhage, fracture, trauma, etc.), there is an unchartered middle ground in pediatric neurosurgery. Children, unlike adults, have dynamic anatomy and are still developing neural networks. Delaying seemingly elective surgery can affect a child's already vulnerable health state by further impacting their neurocognitive development, neurologic functioning, and potential long-term health states. The purpose of this paper is to demonstrate that "elective" pediatric neurosurgery should be risk-stratified, and multi-institutional informed guidelines established.
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Affiliation(s)
- Ranbir Ahluwalia
- Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA.
- Florida State University College of Medicine, 1115 W Call St., Tallahassee, FL, 32304, USA.
| | - Brandon G Rocque
- Department of Neurosurgery, University of Alabama at Birmingham, Children's of Alabama, Birmingham, AL, USA
| | - Chevis N Shannon
- Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jeffrey P Blount
- Department of Neurosurgery, University of Alabama at Birmingham, Children's of Alabama, Birmingham, AL, USA
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