1
|
Noor MS, Khabyeh-Hasbani N, Behbahani M, Koehler SM. Advancing glenohumeral dysplasia treatment in brachial plexus birth injury: the end-to-side spinal accessory to suprascapular nerve transfer technique. Childs Nerv Syst 2024; 40:1159-1167. [PMID: 38353693 DOI: 10.1007/s00381-023-06270-y] [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: 12/13/2023] [Accepted: 12/23/2023] [Indexed: 03/28/2024]
Abstract
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.
Collapse
Affiliation(s)
- Md Sibat Noor
- Department of Orthopaedic Surgery, Montefiore Medical Center, Bronx, NY, USA
| | | | - Mandana Behbahani
- Department of Neurosurgery, Montefiore Medical Center, Bronx, NY, USA
| | - Steven M Koehler
- Department of Orthopaedic Surgery, Montefiore Medical Center, Bronx, NY, USA.
| |
Collapse
|
2
|
Mendiratta D, Levidy MF, Chu A, McGrath A. Rehabilitation protocols in neonates undergoing primary nerve surgery for upper brachial plexus palsy: A scoping review. Microsurgery 2024; 44:e31154. [PMID: 38376241 DOI: 10.1002/micr.31154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 12/24/2023] [Accepted: 02/01/2024] [Indexed: 02/21/2024]
Abstract
INTRODUCTION Surgical management is recommended in patients with severe neonatal brachial plexus palsy (NBPP) within the first 6 months of age to regain best possible function. Rehabilitation post-surgery remains relatively unexplored. This is a scoping review that explores, which rehabilitation modalities exist and how they vary for different microsurgical approaches in NBPP. MATERIALS AND METHODS A systematic search was conducted to include articles about upper trunk obstetric brachial plexus nerve microsurgery in pediatric patients that made mention of rehabilitation protocols. The aims of rehabilitation modalities varied and were grouped: "passive" movement to prevent joint contracture or stiffness, "active" or task-oriented movement to improve motor function, or "providing initial motor recovery". Surgical approach was described as either exploration of the brachial plexus (EBP) or nerve transfer without root exploration (NTwoRE). Technique was categorized into transfers and non-transfers. RESULTS Thirty-six full-text articles were included. Initiation of rehabilitation was 22.26 days post-surgery. Twenty-eight studies were EBP, and six were NTwoRE. Of studies classifiable by aims, nine were "passive", nine were "active", and five were "providing initial motor recovery". Only 27.7% of EBP studies mentioned active therapy, while 75.0% of NTwoRE studies mentioned active therapy. The average age of patients in the EBP procedure category was 7.70 months, and NTwoRE was 17.76 months. Within transfers, the spinal accessory to suprascapular group was more likely to describe an active shoulder exercise therapy, whereas contralateral C7 group was more likely to describe "initial motor recovery", especially through the use of electrostimulation. All articles on electrostimulation recommended 15-20-minute daily treatment. CONCLUSION Information on rehabilitation is limited post-nerve surgery in NBPP. However, when mentioned, the aims of these therapies vary with respect to surgical approach and technique. The type of therapy to employ may be a multifaceted decision, involving factors such as patient age, initial deformity, and goals of the care team.
Collapse
Affiliation(s)
- Dhruv Mendiratta
- Department of Orthopaedics, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Michael F Levidy
- Department of Orthopaedics, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Alice Chu
- Department of Orthopaedics, 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
| |
Collapse
|
3
|
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.
Collapse
|
4
|
Velásquez-Girón E, Zapata-Copete JA. Nerve Graft and Nerve Transfer for Improving Elbow Flexion in Children with Obstetric Palsy. A Systematic Review. Rev Bras Ortop 2021; 56:705-710. [PMID: 34900097 PMCID: PMC8651435 DOI: 10.1055/s-0041-1729586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 12/17/2020] [Indexed: 10/29/2022] Open
Abstract
Obstetric brachial plexus palsy is a rather common injury in newborns, caused by traction to the brachial plexus during labor. In this context, with the present systematic review, we aimed to explore the use of nerve graft and nerve transfer as procedures to improve elbow flexion in children with obstetric palsy. For the present review, we followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We searched the MEDLINE, EMBASE, LILACS, The Cochrane Central Register of Controlled Trials, Web of Science, Wholis and SCOPUS databases. Predetermined criteria defined the following requirements for inclusion of a study: Clinical trials, quasi-experiments, and cohort studies that performed nerve graft and nerve transfer in children (≤ 3 years old) with diagnosis of obstetric palsy. The risk of bias in nonrandomized studies of interventions assessment tool was used for nonrandomized studies. Out of seven studies that used both procedures, three of them compared the procedures of nerve graft with nerve transfer, and the other four combined them as a reconstructive method for children with obstetric palsy. According to the Medical Research Council grading system, both methods improved equally elbow flexion in the children. Overall, our results showed that both techniques of nerve graft and nerve transfer are equally good options for nerve reconstruction in cases of obstetric palsy. More studies approaching nerve reconstruction techniques in obstetric palsy should be made, preferably randomized clinical trials, to validate the results of the present systematic review.
Collapse
Affiliation(s)
- Eduardo Velásquez-Girón
- Seção de Cirurgia Ortopédica de Mão, Departamento de Cirurgia, Universidad del Valle, Cali, Colômbia
| | - James A Zapata-Copete
- Departamento de Cirurgia, Seção de Cirurgia Plástica, Universidad del Valle, Cali, Colômbia
| |
Collapse
|
5
|
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.
Collapse
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
| |
Collapse
|
6
|
Nath RK, Somasundaram C. Long-term Improvements of Neuroplasty and Scalene Muscle Resection in LTN-injured Winged Scapula Patients. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3408. [PMID: 33680659 PMCID: PMC7929713 DOI: 10.1097/gox.0000000000003408] [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: 09/15/2020] [Accepted: 12/10/2020] [Indexed: 11/25/2022]
Abstract
Injuries to the long thoracic nerve, which directly branches off of the C6, C7, and C8 brachial plexus nerve roots, can cause scapular winging and affect shoulder movements. Long thoracic nerve injuries resulting from accidents, violence, or overuse can be severe lesions requiring challenging surgeries. We evaluated the long-term functional outcomes of neuroplasty and the scalene muscle resection procedures in patients with long thoracic nerve injury and winging scapula. Methods All 15 patients who underwent scalene muscle resection with decompression and neurolysis of the long thoracic nerve in a single institution to treat winged scapula and limited shoulder movements between March 2007 and May 2020 with follow-up over 2 years were included in the study. Results Shoulder abduction and arm flexion improved significantly to 158 ± 52 degrees and 165 ± 53 degrees from a mean of 108 ± 54 degrees and 104 ± 52 degrees (P < 0.02) over 2 years after surgery (mean 3.4 years). Overall, there was a significant reduction in the scapular winging, as assessed by estimating the decrease in the angle between the scapular plane and the posterior chest wall. The extent of the score greatly improved post-surgically from a mean of 1.2 ± 0.4 to 3.5 ± 0.9 (range 1-4; 1-severe, 2-moderate, 3-mild, and 4-minimal) (P < 0.01). Conclusion The improvement in shoulder movements and reduced scapular winging was significant and stable over 2 years of surgery in 81% of our study patients.
Collapse
Affiliation(s)
- Rahul K Nath
- Texas Nerve and Paralysis Institute, Research Division, Houston, Tex
| | | |
Collapse
|
7
|
Looven R, Le Roy L, Tanghe E, Broeck C, Muynck M, Vingerhoets G, Pitt M, Vanderstraeten G. Early electrodiagnosis in the management of neonatal brachial plexus palsy: A systematic review. Muscle Nerve 2019; 61:557-566. [DOI: 10.1002/mus.26762] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Revised: 10/22/2019] [Accepted: 11/12/2019] [Indexed: 11/10/2022]
Affiliation(s)
- Ruth Looven
- Child Rehabilitation Centre, Department of Physical and Rehabilitation MedicineGhent University Hospital Ghent Belgium
| | - Laura Le Roy
- Department of Rehabilitation Sciences and PhysiotherapyGhent University Ghent Belgium
| | - Emma Tanghe
- Department of Rehabilitation Sciences and PhysiotherapyGhent University Ghent Belgium
| | - Christine Broeck
- Department of Rehabilitation Sciences and PhysiotherapyGhent University Ghent Belgium
| | - Martine Muynck
- Child Rehabilitation Centre, Department of Physical and Rehabilitation MedicineGhent University Hospital Ghent Belgium
| | - Guy Vingerhoets
- Department of Experimental PsychologyFaculty of Psychological and Educational Sciences, Ghent University Ghent Belgium
| | - Matthew Pitt
- Department of Clinical NeurophysiologyGreat Ormond Street Hospital for Children NHS Trust London UK
| | | |
Collapse
|
8
|
Long-Term Outcomes of Brachial Plexus Reconstruction with Sural Nerve Autograft for Brachial Plexus Birth Injury. Plast Reconstr Surg 2019; 143:1017e-1026e. [DOI: 10.1097/prs.0000000000005557] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
9
|
Ray WZ, Mahan MA, Guo D, Guo D, Kliot M. An update on addressing important peripheral nerve problems: challenges and potential solutions. Acta Neurochir (Wien) 2017; 159:1765-1773. [PMID: 28500566 DOI: 10.1007/s00701-017-3203-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Accepted: 04/24/2017] [Indexed: 12/31/2022]
Abstract
From time to time it is thoughtful and productive to review a medical field and reflect upon what are the major issues that need to be addressed and what is being done to do so. This review article is not meant to be all-inclusive but rather focuses on four evolving areas in the field of peripheral nerve disorders and treatments: (1) nerve surgery under ultrasound guidance using a new ultra-minimally invasive thread technique; (2) evolving magnetic resonance imaging (MRI) and ultrasound imaging techniques that are helping to both diagnose and treat a variety of peripheral nerve problems including entrapment neuropathies, traumatic nerve injuries, and masses arising from nerves; (3) promoting recovery after nerve injury using electrical stimulation; and (4) developing animal models to reproduce a severe nerve injury (neurotmetic grade in continuity) that requires a surgical intervention and repair. In each area we first describe the current challenges and then discuss new and emerging techniques and approaches. It is our hope that this article will bring added attention and resources to help better address peripheral nerve problems that remain a challenge for both patients and physicians.
Collapse
Affiliation(s)
- Wilson Z Ray
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Mark A Mahan
- Department of Neurosurgery, University of Utah, Salt Lake City, UT, 84132, USA
| | - Danzhu Guo
- BayCare Clinic, Green Bay, WI, 54303, USA
| | | | - Michel Kliot
- Department of Neurosurgery, Stanford University School of Medicine, Palo Alto, CA, 94304, USA.
| |
Collapse
|
10
|
Luszawski J, Marcol W, Mandera M. The components of shoulder and elbow movements as goals of primary reconstructive operation in obstetric brachial plexus lesions. Neurol Neurochir Pol 2017; 51:366-371. [PMID: 28711374 DOI: 10.1016/j.pjnns.2017.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2017] [Accepted: 06/22/2017] [Indexed: 11/15/2022]
Abstract
Most of the cases of obstetric brachial plexus lesions (OBPL) show satisfactory improvement with conservative management, but in about 25% some surgical treatment is indicated. The present paper analyzes the effects of primary reconstructive surgeries in aspect of achieving delineated intraoperatively goals. Children operated before the age of 18 months with follow-up period longer than 1 year were selected. Therapeutic goals established during the operation were identified by analysis of initial clinical status and operative protocols. The elementary movement components in shoulder and elbow joints were classified by assessing range of motion, score in Active Movement Scale and modified British Medical Research Council scale of muscle strength. The effect was considered satisfactory when some antigravity movement was possible, and good when strength exceeded M3 or antigravity movement exceeded half of range of passive movement. In 13 of 19 patients most of established goals were achieved at good level, in 2 at satisfactory level. Remaining 4 patients showed improvement only in some aspects of extremity function. In 2 patients improvement in some movements was accompanied by worsening of other movements. The analysis of results separated into individual components of movements showed that goals were achieved in most of the cases, simultaneously clearly indicating which damaged structures failed to provide satisfactory function despite being addressed intraoperatively. The good results were obtained mainly by regeneration through grafts implanted after resection of neuroma in continuity, which proves that this technique is safe in spite of unavoidable temporary regression of function postoperatively.
Collapse
Affiliation(s)
- Jerzy Luszawski
- Department of Pediatric Neurosurgery, University Hospital No. 6, Medical University of Silesia, Medyków 16, 40-752 Katowice, Poland.
| | - Wiesław Marcol
- Department of Physiology, Medical University of Silesia, Medyków 18, 40-752 Katowice, Poland
| | - Marek Mandera
- Department of Pediatric Neurosurgery, School of Public Health, Medical University of Silesia, Piekarska 18, 41-902 Bytom, Poland
| |
Collapse
|
11
|
Vliet ACV, Tannemaat MR, Duinen SGV, Verhaagen J, Malessy MJ, Winter FD. Human Neuroma-in-Continuity Contains Focal Deficits in Myelination. J Neuropathol Exp Neurol 2015. [DOI: 10.1097/nen.0000000000000229] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
|
12
|
Affiliation(s)
- Willem Pondaag
- Leiden University Medical Center, Leiden, The Netherlands
| | | |
Collapse
|
13
|
Van Heest AE, Andrisevic E, Agel J. Neurolysis and upper trunk brachial plexus birth palsy. Response. J Neurosurg Pediatr 2014; 14:324-7. [PMID: 25133490 DOI: 10.3171/2014.3.peds14163] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
|
14
|
Pondaag W, Malessy MJA. Letters to the editor: Neurolysis and upper trunk brachial plexus birth palsy. J Neurosurg Pediatr 2014:1-3. [PMID: 24995820 DOI: 10.3171/ped.2014.0.0.peds14163] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Willem Pondaag
- Leiden University Medical Center, Leiden, The Netherlands
| | | |
Collapse
|