Quantifying Patient-Initiated Upper Extremity Movement After Surgical Reconstruction for Adult Pan-Brachial Plexus Injury

BACKGROUND AND OBJECTIVES

Determining functional recovery in adult patients with traumatic pan-brachial plexus injury (pBPI) is hampered by the fact that most outcome measures are collected in the clinical setting and may not reflect arm use in the real world. This study's objectives were to demonstrate the feasibility of using wearable motion sensor technology to quantify spontaneous arm movement in adult patients with pBPI after surgical reconstruction and report the time and intensity with which the affected arm was used.

METHODS

Twenty-nine patients with pBPI who underwent surgical reconstruction at least 2 years prior were included in this study. Study participants wore an accelerometer on bilateral arms for 7 days. The vector time (VT) and magnitude with which each arm moved were collected and divided by the same values collected from the uninjured arm to generate a ratio (VT and vector magnitude [VM], respectively) to quantify differences between the arms. Correlations between VT, VM, and patient demographic and physician-elicited clinical measures were calculated. Patients were enrolled at Chang Gung Memorial Hospital, Linkou Medical Center, Taiwan, and data analysis was performed at the University of Michigan.

RESULTS

Twelve patients had pan-avulsion injuries, and 17 patients had C5 rupture with C6-T1 avulsion injuries. All underwent nerve reconstruction with contralateral C7 or ipsilateral C5 nerve roots as donors. At mean 7.3 years after surgery, the mean VT ratio was 0.54 ± 0.13 and the mean VM ratio was 0.30 ± 0.13. Both VT and VM ratios were significantly correlated with patient employment and movements at the elbow and forearm.

CONCLUSION

Wearable motion detection technology can capture spontaneous, real-world movements of the arm in patients who have undergone surgical reconstruction for pBPI. Despite severe injuries, these patients are able to use their affected arm 50% of the time and with 30% of the intensity of their unaffected arm, which is positively correlated with return to work after injury. These data support the use of surgical reconstruction for pBPI.

G. Carl Huber (1865-1934): A Michigan Pioneer in Peripheral Nerve Injury and Regeneration

The treatment of peripheral nerve injuries has seen tremendous innovations over the past century. Dr Gotthelf Carl Huber, an American immigrant and early experimental pioneer in the field of peripheral nerve injury, created a foundation of scientific knowledge for these advancements. At the beginning of his career, Huber published novel work in peripheral nerve injury, supporting the concept of Wallerian degeneration and demonstrating the use of nerve grafting for repair. As his scientific career evolved into other research areas at the University of Michigan, Huber's impact extended far beyond just the study of peripheral nerve injury. Because of the external forces of the First World War, Dr Huber's focus returned to translational projects concentrated on the treatment of neuromas and war time peripheral nerve injuries. Huber's scientific impact in the field of peripheral nerve injury and repair came as a result of his incredible work ethic, mentorship, and tremendous leadership qualities; through this, his work still influences clinical practice today, a century later.

Early referral to multidisciplinary specialty centers to optimize outcomes in children with neonatal brachial plexus palsy

AIM

To demonstrate the trajectory of long-term recovery of upper-extremity movement and determine optimal timing of evaluation at multidisciplinary specialty centers in children with neonatal brachial plexus palsy (NBPP).

METHOD

All children with conservatively managed NBPP seen at one institution from 2005 to 2020 were considered for inclusion. The cohort was divided according to age at formal evaluation (≤30 or > 30 days). Active range of motion (AROM) for shoulder and elbow movements collected at each appointment were compared in local age windows between early and late cohorts. Locally estimated scatterplot smoothing was used to demonstrate the trajectory of recovery for the overall cohort.

RESULTS

More than 13 000 prospectively collected data points for 429 children (220 males, 209 females) were analysed. Elbow flexion improved to nearly full AROM for both groups over the course of the study. Shoulder abduction, forward flexion and external rotation, and forearm supination improved for the entire cohort, although greater absolute improvement, particularly at the shoulder, was seen in the early cohort (age at formal evaluation ≤30 days). AROM for elbow extension remained roughly stable for the early cohort but decreased for the late cohort (age at formal evaluation >30 days). AROM for forearm pronation decreased over time for both cohorts.

INTERPRETATION

Our data demonstrate good long-term functional recovery for children with conservatively managed NBPP. However, early referral to multispecialty brachial plexus centers may optimize outcomes.

WHAT THIS PAPER ADDS

Many children with conservatively managed neonatal brachial plexus palsy have good long-term shoulder and elbow outcomes. Early referral to multidisciplinary clinics may maximize long-term shoulder and elbow recovery and optimize outcomes.

Implications of median sensory study to the thumb and deltoid/biceps motor unit recruitment on identifying C6 root avulsion in upper neonatal brachial plexus palsy

INTRODUCTION/AIMS

Anatomic representation suggests that a median sensory nerve conduction study recording the thumb (median D1 NCS) may effectively assess upper neonatal brachial plexus palsy (NBPP). We sought to determine the feasibility of technique, establish reference data, and assess its ability to: (a) identify focal upper plexus lesions; and (b) identify C6 root avulsion. In a secondary analysis, we explored the association between absence/presence of motor unit action potentials (MUAPs) during needle electromyography (EMG) of the deltoid and biceps brachii muscles and C6 avulsion status.

METHODS

A retrospective chart review was performed of surgical patients with severe upper NBPP who ultimately underwent surgical reconstruction (between 2017 and 2020). Median D1 sensory nerve action potential (SNAP) amplitude ranges were determined in affected and contralateral limbs and analyzed by C6 root avulsion status. Also, presence/absence of MUAPs during EMG of the deltoid and biceps brachii was compared between C6 avulsion patients and controls.

RESULTS

Thirty-eight patients were included in our analysis. A median D1 NCS study was readily performed, showing a contralateral limb mean amplitude of 27.42 μV (range, 3.8-54.7 μV). Most patients had a low ipsilateral median D1 SNAP amplitude, regardless of C6 avulsion status. Detectable MUAPs in either deltoid or biceps brachii on EMG were atypical in C6 root avulsion.

DISCUSSION

The median D1 NCS identifies upper NBPP, but does not distinguish C6 avulsions from post-ganglionic lesions, likely due to the frequent co-occurrence of post-ganglionic axonal disruption. The presence of MUAPs on deltoid/biceps brachii EMG suggests C6 avulsion is unlikely.

Knowledge of neonatal brachial plexus palsy among medical professionals in North America

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.

Neonatal brachial plexus palsy: associated birth injury outcomes, hospital length of stay and costs

OBJECTIVE

To compare the birth injury outcomes and hospital length of stay and costs among newborns delivered at 34-42 weeks with neonatal brachial plexus palsy (NBPP) versus those without.

STUDY DESIGN

We conducted a retrospective, cross-sectional study using data from the National Inpatient Sample to identify all newborns hospitalizations that occurred in the U.S. between 2016 and 2017. We included non-anomalous single liveborn delivered in-hospital at 34-42 weeks. The newborns with NBPP were identified by International Classification of Diseases, 10th Revision, Clinical Modification codes. Birth injury outcomes, and hospital length of stay and hospital costs were examined. A multivariable Poisson regression model with robust error variance was used to examine the association between NBPP and birth injury outcomes. A multivariable generalized linear regression model was used to examine the association between NBPP and hospital length of stay and hospital costs.

RESULTS

Of 7,019,722 non-anomalous single liveborn delivered at 34-42 weeks in the U.S. from 2016 to 2017, the rate of NBPP (n = 6695) was 0.95 per 1000 newborn hospitalizations. After multivariable regression adjustment, compared to newborns without NBPP, the risk of the composite birth injury outcome was 2.91 (95% CI 2.61-3.25) times higher in those with NBPP. Similar results of an increased risk among newborns with NBPP were observed in all individual birth injury outcomes. Compared to newborns without NBPP, after adjustment, the hospital length of stay was 1.48 (95% IC 1.38-1.59) times higher and the hospital costs were 2.21 (95% CI 1.97-2.48) times higher in those with NBPP.

CONCLUSIONS

Among newborns delivered at 34-42 weeks, the risk of associated birth injuries, hospital length of stay and costs, were significantly higher in newborns with NBPP than those without.

Quantifying Real-World Upper-Limb Activity Via Patient-Initiated Movement After Nerve Reconstruction for Upper Brachial Plexus Injury

BACKGROUND

A critical concept in brachial plexus reconstruction is the accurate assessment of functional outcomes. The current standard for motor outcome assessment is clinician-elicited, outpatient clinic-based, serial evaluation of range of motion and muscle power. However, discrepancies exist between such clinical measurements and actual patient-initiated use. We employed emerging technology in the form of accelerometry-based motion detectors to quantify real-world arm use after brachial plexus surgery.

OBJECTIVE

To evaluate (1) the ability of accelerometry-based motion detectors to assess functional outcome and (2) the real-world arm use of patients after nerve transfer for brachial plexus injury, through a pilot study.

METHODS

Five male patients who underwent nerve transfer after brachial plexus injury wore bilateral motion detectors for 7 d. The patients also underwent range-of-motion evaluation and completed multiple patient-reported outcome surveys.

RESULTS

The average age of the recruits was 41 yr (±17 yr), and the average time from operation was 2 yr (±1 yr). The VT (time of use ratio) for the affected side compared to the unaffected side was 0.73 (±0.27), and the VM (magnitude ratio) was 0.63 (±0.59). VT strongly and positively correlated with shoulder flexion and shoulder abduction: 0.97 (P = .008) and 0.99 (P = .002), respectively.

CONCLUSION

Accelerometry-based activity monitors can successfully assess real-world functional outcomes after brachial plexus reconstruction. This pilot study demonstrates that patients after nerve transfer are utilizing their affected limbs significantly in daily activities and that recovery of shoulder function is critical.

Persistence and Extent of Neonatal Brachial Plexus Palsy: Association with Number of Maneuvers and Duration of Shoulder Dystocia

Objective  The main objective of this article is to determine if persistence of neonatal brachial plexus palsy (NBPP) following shoulder dystocia was associated with maneuvers used or duration of impacted shoulder. Study Design  Retrospective review of children with NBPP and documented shoulder dystocia. Student t -tests and chi-squared tests were used to compare outcomes when shoulder dystocia resolved with > 3 versus ≤ 3 maneuvers or duration > versus ≤ 120 seconds. Relative risk (RR) with 95% confidence intervals (CI) was calculated. Results  Among 46 children with NBPP and shoulder dystocia, incidence of persistence was significantly higher at 2 years of age when > 3 versus ≤ 3 maneuvers were used (100 vs. 62%; RR: 1.6, 95% CI: 1.2-2.2). When resolution of impacted shoulder lasted >120 versus ≤ 120 seconds, NBPP at 2 years was significantly more likely (100 vs. 63%; RR: 1.6, 95% CI: 1.1-2.2). Injury to all five nerves of the brachial plexus was more likely if standard deviation lasted > 120 versus ≤ 120 seconds (RR: 2.2; 95% CI: 1.03-4.6). Conclusion  Though the number of maneuvers used and duration of shoulder dystocia are associated with persistence of NBPP, the retrospective nature of the study of a selective cohort precludes recommendations changing the current management of shoulder dystocia.

Erratum: Persistence of Neonatal Brachial Plexus Palsy among Nulliparous Versus Parous Women

[This corrects the article DOI: 10.1055/s-0038-1677051.].

An Update on the Management of Neonatal Brachial Plexus Palsy-Replacing Old Paradigms: A Review

IMPORTANCE

Neonatal brachial plexus palsy (NBPP) can result in persistent deficits for those who develop it. Advances in surgical technique have resulted in the availability of safe, reliable options for treatment. Prevailing paradigms include, "all neonatal brachial plexus palsy recovers," "wait a year to see if recovery occurs," and "don't move the arm." Practicing by these principles places these patients at a disadvantage. Thus, the importance of this review is to provide an update on the management of NBPP to replace old beliefs with new paradigms.

OBSERVATIONS

Changes within denervated muscle begin at the moment of injury, but without reinnervation become irreversible 18 to 24 months following denervation. These time-sensitive, irreversible changes are the scientific basis for the recommendations herein for the early management of NBPP and put into question the old paradigms. Early referral has become increasingly important because improved outcomes can be achieved using new management algorithms that allow surgery to be offered to patients unlikely to recover sufficiently with conservative management. Mounting evidence supports improved outcomes for appropriately selected patients with surgical management compared with natural history. Primary nerve surgery options now include nerve graft repair and nerve transfer. Specific indications continue to be elucidated, but both techniques offer a significant chance of restoration of function.

CONCLUSIONS AND RELEVANCE

Mounting data support both the safety and effectiveness of surgery for patients with persistent NBPP. Despite this support, primary nerve surgery for NBPP continues to be underused. Surgery is but one part of the multidisciplinary care of NBPP. Early referral and implementation of multidisciplinary strategies give these children the best chance of functional recovery. Primary care physicians, nerve surgeons, physiatrists, and occupational and physical therapists must partner to continue to modify current treatment paradigms to provide improved quality care to neonates and children affected by NBPP.

Depression and Anxiety in Traumatic Brachial Plexus Injury Patients Are Associated With Reduced Motor Outcome After Surgical Intervention for Restoration of Elbow Flexion

BACKGROUND

Depression has been associated with poor outcomes in neurosurgical patients, including increased pain, poorer functional recovery, delayed return to work, and decreased patient satisfaction. No reports exist regarding an association of psychiatric diagnoses with outcomes after brachial plexus reconstruction. As outcomes and patient satisfaction become increasingly important to payers and physician reimbursement, assessing modifiable preoperative risk factors for their association with poor outcome and patient satisfaction is imperative.

OBJECTIVE

To analyze patients undergoing brachial plexus reconstruction to assess the relationship of depression/anxiety with functional outcome.

METHODS

Data were collected retrospectively on all patients who underwent brachial plexus reconstruction to restore elbow flexion between 2005 and 2013. Elbow flexion, graded via the Medical Research Council scale, was assessed at latest follow-up. Multiple variables, including the presence of Axis I psychiatric diagnoses, were assessed for their association with the dichotomous outcome of Medical Research Council scale score ≥3 (antigravity) vs <3 elbow flexion. Standard statistical methods were used.

RESULTS

Thirty-seven patients met inclusion criteria. The median postsurgical follow-up time was 21 months. Operations included neurolysis (n = 3), nerve graft repair (n = 6), and nerve transfer (n = 28). Depression was present in 10 of 37 patients (27%). Of variables tested, only depression was associated with poor elbow flexion outcome (odds ratio: 6.038; P = .04).

CONCLUSION

Preoperative depression is common after brachial plexus injury. The presence of depression is associated with reduced elbow flexion recovery after reconstruction. Our data suggest assessment and treatment of preoperative mental health is important in designing a comprehensive postoperative management plan to optimize outcomes and patient satisfaction.

ABBREVIATIONS

MRC, Medical Research CouncilTBI, traumatic brain injury.

Intraoperative Ultrasound for Peripheral Nerve Applications

Offering real-time, high-resolution images via intraoperative ultrasound is advantageous for a variety of peripheral nerve applications. To highlight the advantages of ultrasound, its extraoperative uses are reviewed. The current intraoperative uses, including nerve localization, real-time evaluation of peripheral nerve tumors, and implantation of leads for peripheral nerve stimulation, are reviewed. Although intraoperative peripheral nerve localization has been performed previously using guide wires and surgical dyes, the authors' approach using ultrasound-guided instrument clamps helps guide surgical dissection to the target nerve, which could lead to more timely operations and shorter incisions.

Interrater reliability of electrodiagnosis in neonatal brachial plexopathy

INTRODUCTION

We investigated interrater reliability of overall assessment of nerve root lesions by electrodiagnostic testing (EDX) in neonatal brachial plexus palsy (NBPP).

METHODS

Two blinded, board-certified reviewers retrospectively reviewed de-identified EDX data from 37 infants with NBPP for 2005-2012. Only nerve conduction and electromyography needle data were included. The examiners independently assigned 1 of 4 nerve root lesion categories: (1) pre-ganglionic lesion (avulsion), (2) post-ganglionic lesion (rupture), (3) normal, or (4) "unable to determine." Simple percentage agreement, the Cohen kappa statistic representing interrater reliability for each nerve root (C5-T1), and overall kappa between examiners were evaluated.

RESULTS

Interrater reliabilities were substantial to almost perfect for each nerve root except C5. Considering all nerve roots, overall interrater reliability was substantial (kappa = 0.62); simple percentage agreement was 75% (138/185).

CONCLUSIONS

Interrater reliability of nerve root assessment by EDX for infants with NBPP was high for C6-T1 root levels, but less reliable for C5 because of technical factors. Muscle Nerve 55: 69-73, 2017.

The current role of diagnostic imaging in the preoperative workup for refractory neonatal brachial plexus palsy

INTRODUCTION

Despite recent improvements in perinatal care, the incidence of neonatal brachial plexus palsy (NBPP) remains relatively common. CT myelography is currently considered to be the optimal imaging modality for evaluating nerve root integrity. Recent improvements in MRI techniques have made it an attractive alternative to evaluate nerve root avulsions (preganglionic injuries).

AIM

We demonstrate the utility of MRI for the evaluation of normal and avulsed spinal nerve roots. We also show the utility of ultrasound in providing useful preoperative evaluation of the postganglionic brachial plexus in patients with NBPP.

Persistence of Neonatal Brachial Plexus Palsy Associated with Maternally Reported Route of Delivery: Review of 387 Cases

Objective The factors associated with persistent neonatal brachial plexus palsy (PNBPP) are unknown. Our objectives are to compare PNBPP at 1 and 2 years in children delivered via vaginal delivery (VD) versus cesarean delivery (CD) and in children delivered via VD with or without reported shoulder dystocia (SD). Study Design Retrospective cohort of children diagnosed with neonatal brachial plexus palsy (NBPP). Maternally reported delivery history and presence of SD were recorded with Student t-test, chi-square test, and odds ratio (OR) with 95% confidence intervals (CI) calculated for comparisons. Results Of 387 cases of NBPP, 8% (30) delivered via CD. Rates of PNBPP were higher in the VD group at 1 and 2 years (60% of CD and 85% of VD; OR, 0.26; 95% CI, 0.11-0.62 at 1 year; 33% of CD and 73% of VD; OR, 0.15; 95% CI, 0.05-0.39 at 2 years). There was no difference in PNBPP in women with VD with or without maternally reported SD (87 vs. 85%, p = 0.68 at 1 year; 64 vs. 61%, p = 0.61 at 2 years). Conclusion PNBPP is possible with CD, and there is no difference in PNBPP in VD with or without maternally reported SD. A prospective study is warranted to ascertain associative factors.

Home-based movement therapy in neonatal brachial plexus palsy: A case study

STUDY DESIGN

Case report.

INTRODUCTION

The value of movement-based therapy in peripheral nerve injury conditions such as neonatal brachial plexus palsy (NBPP) is unclear.

PURPOSE OF THE STUDY

To determine the effectiveness of a home-based movement therapy program in a 17 year old female patient with a right NBPP pan-plexopathy.

METHODS

Home training consisted of arm reaching and object manipulation tasks using devices which recorded performance. Training occurred for 1 h/day, 5 days/week for 6 weeks with periodic webcam supervision. Pre- and post clinical, functional and kinematic assessments were performed in a laboratory setting.

RESULTS

Following training, shoulder flexion and elbow extension active range of motion increased by 13° and 9°, respectively, and functional ability also improved. Reach movement duration decreased significantly with a concomitant improvement in movement coordination.

CONCLUSIONS

These results demonstrate that movement therapy has the potential to improve motor function in NBPP years after the initial insult.

LEVEL OF EVIDENCE

4.

Utility of ultrasound in noninvasive preoperative workup of neonatal brachial plexus palsy

BACKGROUND

Ultrasound has been utilized in the evaluation of compressive and traumatic peripheral nerve pathology.

OBJECTIVE

To determine whether US can provide comprehensive evaluation of the post-ganglionic brachial plexus in the setting of neonatal brachial plexus palsy and whether this information can be used to guide preoperative nerve reconstruction strategies.

MATERIALS AND METHODS

In this retrospective cohort study, preoperative brachial plexus ultrasonography was performed in 52 children with neonatal brachial plexus palsy who were being considered for surgery. The 33 children who had surgery compose the patient cohort. The presence and location of post-ganglionic neuromas were evaluated by US and compared to the surgical findings. US evaluation of shoulder muscle atrophy was conducted as an indirect way to assess the integrity of nerves. Finally, we correlated glenohumeral joint laxity to surgical and clinical management.

RESULTS

Ultrasound correctly identified 21 of 25 cases of upper trunk and middle trunk neuroma involvement (84% sensitivity for each). It was 68% sensitive and 40% specific in detection of lower trunk involvement. US identified shoulder muscle atrophy in 11 of 21 children evaluated; 8 of these 11 went on to nerve transfer procedures based upon the imaging findings. US identified 3 cases of shoulder joint laxity of the 13 children evaluated. All 3 cases were referred for orthopedic evaluation, with 1 child undergoing shoulder surgery and another requiring casting.

CONCLUSION

Ultrasound can provide useful preoperative evaluation of the post-ganglionic brachial plexus in children with neonatal brachial plexus palsy.

Sonography of Common Peripheral Nerve Disorders With Clinical Correlation

Sonography is now considered an effective method to evaluate peripheral nerves. Low cost, high resolution, the ability to image an entire limb in a short time, and dynamic assessment are several of the positive attributes of sonography. This article will review the normal appearance of peripheral nerves as shown with sonography. In addition, the most common applications for sonography of the peripheral nerves will be reviewed, which include entrapment neuropathies, intraneural ganglion cyst, nerve trauma, and peripheral nerve sheath tumors. Clinical information related to nerve disorders is also included, as it provides valuable information that can be obtained during sonographic examinations, increasing diagnostic accuracy.

Hand Sensorimotor Function in Older Children With Neonatal Brachial Plexus Palsy

BACKGROUND

Routine sensory assessments in neonatal brachial plexus palsy are infrequently performed because it is generally assumed that sensory recovery exceeds motor recovery. However, studies examining sensory function in neonatal brachial plexus palsy have produced equivocal findings. The purpose of this study was to examine hand sensorimotor function in older children with neonatal brachial plexus palsy using standard clinical and research-based measures of tactile sensibility.

METHODS

Seventeen children with neonatal brachial plexus palsy (mean age: 11.6 years) and 19 age-matched controls participated in the study. Functional assessments included grip force, monofilament testing, and hand dexterity (Nine-Hole Peg, Jebsen-Taylor Hand Function). Tactile spatial perception involving the discrimination of pin patterns and movement-enhanced object recognition (stereognosis) were also assessed.

RESULTS

In the neonatal brachial plexus palsy group, significant deficits in the affected hand motor function were observed compared with the unaffected hand. Median monofilament scores were considered normal for both hands. In contrast, tactile spatial perception was impaired in the neonatal brachial plexus palsy group. This impairment was seen as deficits in both pin pattern and object recognition accuracy as well as the amount of time required to identify patterns and objects. Tactile pattern discrimination time significantly correlated with performance on both functional assessment tests (P < 0.01).

DISCUSSION

This study provides evidence that tactile perception deficits may accompany motor deficits in neonatal brachial plexus palsy even when measures of tactile registration (i.e., monofilament testing) are normal. These results may reflect impaired processing of somatosensory feedback associated with reductions in goal-directed upper limb use and illustrate the importance of including a broader range of sensory assessments in neonatal brachial plexus palsy.

Prevalence of Posterior Shoulder Subluxation in Children With Neonatal Brachial Plexus Palsy After Early Full Passive Range of Motion Exercises

BACKGROUND

Children with neonatal brachial plexus palsy (NBPP) are often prescribed shoulder range of motion (ROM) exercises; however, the extent and timing of exercise implementation remains controversial in the context of shoulder joint integrity. The association of ROM exercises to delayed posterior shoulder subluxation (PSS) is unknown.

OBJECTIVE

To determine prevalence of PSS in children with NBPP who began full passive ROM exercises before 6 months of age, and characteristics associated with development or absence of PSS in children.

DESIGN

Cross-sectional study.

SETTING

Tertiary care NBPP referral center.

PARTICIPANTS

Forty-six children with NBPP, aged 24-57 months, who began full ROM exercises before 6 months of age.

METHODS

One radiologist conducted bilateral shoulder ultrasound (US) on each child to evaluate for PSS. One occupational therapist evaluated each child clinically for PSS using defined parameters without knowledge of US results.

MAIN OUTCOME MEASURES

By US, 20% of children had PSS; 46% had PSS by clinical examination. Shoulder active ROM limitations and history of shoulder surgery were associated with presence of PSS. Extent of NBPP was not associated with PSS.

RESULTS

Nine of 46 children (20%) met US criteria for PSS; α angle was 58° ± 21° (mean ± standard deviation [SD]). Twenty-one children (46%) met clinical criteria. Mean age at examination was 35 ± 10 months. Shoulder active ROM (P ≤ .004) was associated with PSS, whereas passive ROM was not (P ≥ .08). History of secondary shoulder surgery and primary nerve graft repair were associated with PSS (P = .04). Extent of NBPP by Narakas classification was not associated with PSS (P = .48).

CONCLUSIONS

Early use of full-arc passive ROM home exercise program is not associated with increased prevalence of PSS in children with NBPP compared to prevalence of PSS in published literature. We suggest careful clinical examination, based on defined criteria, provides a reasonable screening examination for evaluating PSS that can be confirmed by noninvasive US.

Medical treatment decision making after total avulsion brachial plexus injury: a qualitative study

OBJECT

Complete avulsion traumatic brachial plexus injuries (BPIs) can be treated using nerve and musculoskeletal reconstruction procedures. However, these interventions are most viable within certain timeframes, and even then they cannot restore all lost function. Little is known about how patients make decisions regarding surgical treatment or what impediments they face during the decision-making process. Using qualitative methodology, the authors aimed to describe how and why patients elect to pursue or forego surgical reconstruction, identify the barriers precluding adequate information transfer, and determine whether these patients are satisfied with their treatment choices over time.

METHODS

Twelve patients with total avulsion BPIs were interviewed according to a semi-structured guide. The interview transcripts were qualitatively analyzed using the systematic inductive techniques of grounded theory to identify key themes related to the decision-making process and long-term satisfaction with decisions.

RESULTS

Four decision factors emerged from our analysis: desire to restore function, perceived value of functional gains, weighing the risks and costs of surgery, and having concomitant injuries. Lack of insurance coverage (4 patients), delayed diagnosis (3 patients), and insufficient information regarding treatment (4 patients) prevented patients from making informed decisions and accessing care. Three individuals, all of whom had decided against reconstruction, had regrets about their treatment choices.

CONCLUSIONS

Patients with panplexus avulsion injuries are missing opportunities for reconstruction and often not considering the long-term outcomes of surgery. As more Americans gain health insurance coverage, it is very likely that the number of patients able to pursue reconstruction will increase. The authors recommend implementing clinical pathways to help patients meet critical points in care within the ideal timeframe and using a patient- and family-centered care approach combined with patient decision aids to foster shared decision making, increase access to information, and improve patient satisfaction with decisions. These measures could greatly benefit patients with BPI while reducing costs, improving efficiency, and generating better outcomes.

High prevalence of early language delay exists among toddlers with neonatal brachial plexus palsy

AIM

An association of language impairment with neonatal brachial plexus palsy has not been reported in the literature. The current treatment paradigm for neonatal brachial plexus palsy focuses on upper extremity motor recovery with little formal assessment of other aspects of development, such as language. We performed a cross-sectional pilot study to investigate early language delay prevalence in toddlers with neonatal brachial plexus palsy and potential neonatal brachial plexus palsy-related factors involved.

METHOD

Twenty toddlers with neonatal brachial plexus palsy were consecutively recruited (12 males and eight females; mean age, 30 months). Preschool Language Scale Score (4th edition), demographics, and socioeconomic status were collected. Neonatal brachial plexus palsy-related factors such as palsy side, treatment type, Narakas grade, muscle Medical Research Council score, and Raimondi hand score were reported. Student t test, chi-square test, or Fisher exact test were applied. Statistical significance level was established at P < 0.05.

RESULTS

Of study participants, 30% had language delay, whereas the prevalence of language delay in the population with normal development in this age range was approximately 5-15%.

INTERPRETATION

We observed high language delay prevalence among toddlers with neonatal brachial plexus palsy. Although our subject sample is small, our findings warrant further study of this phenomenon. Early identification and timely intervention based on type of language impairment may be critical for improving communication outcome in this population.

Neonatal brachial plexus palsy--management and prognostic factors

Successful treatment of patients with neonatal brachial plexus palsy (NBPP) begins with a thorough understanding of the anatomy of the brachial plexus and of the pathophysiology of nerve injury via which the brachial plexus nerves stretched in the perinatal period manifest as a weak or paralyzed upper extremity in the newborn. NBPP can be classified by systems that can guide the prognosis and the management as these systems are based on the extent and severity of nerve injury, anatomy of nerve injury, and clinical presentation. Serial physical examinations, supplemented by a thorough maternal and perinatal history, are critical to the formulation of the treatment plan that relies upon occupational/physical therapy and rehabilitation management but may include nerve reconstruction and secondary musculoskeletal surgeries. Adjunctive imaging and electrodiagnostic studies provide additional information to guide prognosis and treatment. As research improves not only the technical aspects of NBPP treatment but also the ability to assess the activity and participation as well as body structure and function of NBPP patients, the functional outcomes for affected infants have an overall optimistic prognosis, with the majority recovering adequate functional use of the affected arm. Of importance are (i) early referral to interdisciplinary specialty clinics that can provide up-to-date advances in clinical care and (ii) increasing research/awareness of the psychosocial and patient-reported quality-of-life issues that surround the chronic disablement of NBPP.

High-resolution MRI evaluation of neonatal brachial plexus palsy: A promising alternative to traditional CT myelography

BACKGROUND AND PURPOSE

Despite recent improvements in perinatal care, the incidence of neonatal brachial plexus palsy remains relatively common. CT myelography is currently considered to be the optimal imaging technique for evaluating nerve root integrity. Recent improvements in MR imaging techniques have made it an attractive alternative to evaluate nerve root avulsions (preganglionic injuries). We aim to demonstrate utility of MR imaging in the evaluation of normal and avulsed spinal nerve roots.

MATERIALS AND METHODS

All study patients with clinically diagnosed neonatal brachial plexus palsy underwent MR imaging by use of a high-resolution, heavily T2-weighted (driven equilibrium) sequence. MR imaging findings were reviewed for presence of nerve root avulsion from C5-T1 and for presence of pseudomeningocele. The intraoperative findings were reviewed and compared with the preoperative MR imaging findings.

RESULTS

Thirteen patients (9 male, 4 female) underwent MR imaging; 6 patients underwent nerve reconstruction surgery, during which a total of 19 nerve roots were evaluated. Eight avulsions were noted at surgery and in the remainder, the nerve injury was more distal (rupture/postganglionic injury). Six of the 8 nerve root avulsions identified at surgery were at C5-6 level, whereas 1 nerve root avulsion was identified at C7 and C8 levels, respectively. The overall sensitivity and specificity of MR imaging for nerve root avulsions was 75% and 82%, respectively.

CONCLUSIONS

Our preliminary results demonstrate that high-resolution MR imaging offers an excellent alternative to CT myelography for the evaluation of neonatal brachial plexus palsy with similar sensitivity compared with CT myelography.

Deficits in elbow position sense in neonatal brachial plexus palsy

BACKGROUND

In neonatal brachial plexus palsy, sensory recovery is thought to exceed motor recovery with little attention paid to long-term assessment of proprioceptive ability. However, there is growing evidence that reduced somatosensory function frequently accompanies motor deficits as a result of activity-dependent changes in the central nervous system. Given the importance of proprioception in everyday motor activities, this study was designed to investigate position sense about the elbow joint in neonatal brachial plexus palsy.

METHODS

A convenience sample of seven individuals with neonatal brachial plexus palsy aged 9-17 years and in seven control individuals aged 10-16 years were recruited for the study. An elbow position matching task was used in which passive displacement of the forearm (reference arm) was reproduced with the same or opposite arm. In both conditions, matching was performed in the absence of vision and required utilization of position-related proprioceptive feedback.

RESULTS

Position-matching errors were significantly greater for the affected versus the unaffected arm when reproducing a reference position with the same arm. When matching was performed using the opposite arm, errors were dependent upon which arm served as the reference arm. When the unaffected arm served as the reference position, affected arm matching errors were not significantly different from control values. However, in the reverse situation, in which the unaffected arm relied on reference feedback from the affected arm, matching errors doubled compared with control values.

CONCLUSIONS

These results provide evidence that position sense is impaired in neonatal brachial plexus palsy and illustrate the importance of assessing proprioception in this population.

Home exercise DVD promotes exercise accuracy by caregivers of children and adolescents with brachial plexus palsy

OBJECTIVE

To evaluate the accuracy of home exercise performance by caregivers of children with neonatal brachial plexus palsy (NBPP) who use digital versatile disc (DVD) guidance.

DESIGN

Prospective cohort study.

SETTING

Brachial Plexus Clinic at the University of Michigan.

PARTICIPANTS

Seventy-six adult caregivers of a consecutive cohort of pediatric patients with NBPP.

METHODS

Caregivers received the Home Exercise Program for Brachial Plexus Palsy DVD and an initial demonstration of correct hand placement and movement patterns by 1 of 2 occupational therapists. At times A, B, and C (approximately 3, 6, and 12 months), caregiver accuracy in exercise performance at each joint and standard measurements of arm function were recorded.

MAIN OUTCOME MEASUREMENTS

Caregiver accuracy in correct hand placement and movement pattern during exercise performance was evaluated with use of a dichotomy scale (yes/no) at each joint. Active and passive range of motion were assessed as indicators of arm function.

RESULTS

The mean patient age was 38 months, and the median Narakas score was 2. No significant difference in exercise accuracy for all upper extremity joints between the initial evaluation and times A, B, and C or between individual times was observed, except at the shoulder (98.9% initially to 88.3% at time A; P = .0002) and elbow (100% initially to 96.6% at time A; P = .04). Regarding arm function, an increase in active range of motion for shoulder flexion, elbow flexion, forearm supination, wrist extension, and finger flexion was observed during the study period.

CONCLUSIONS

Shoulder and elbow exercises may be more complex, requiring more frequent performance review with the caregiver. However, the home exercise DVD may benefit patients with NBPP and their caregivers and may provide an adjunct to formal therapy sessions.

Surgical decompression improves symptoms of late peroneal nerve dysfunction after TKA

Acute peroneal nerve palsy is a well-known complication of total knee arthroplasty (TKA) that causes a neurological deficit typically seen within hours or days postoperatively. Peroneal nerve dysfunction presents more subtlely than peroneal nerve palsy, with decreased knee range of motion, lateral knee pain, or both following TKA. The diagnosis of peroneal nerve dysfunction may not be suspected for weeks, months, or even years after TKA. Electromyography and nerve conduction studies can support the diagnosis. Historically, peroneal nerve palsy following TKA has been treated nonoperatively but has had an unsatisfactory rate of complete recovery. Recently, a few reports have demonstrated that patients with either peroneal nerve palsy or dysfunction after TKA have had excellent results with surgical decompression of the peroneal nerve.The authors describe a 63-year-old woman who reported transient episodes of lateral knee and leg pain for years after undergoing TKA. She eventually underwent electromyography and nerve conduction studies that indicated a diagnosis of peroneal nerve dysfunction. Approximately 10 years after the TKA, she underwent surgical decompression of the peroneal nerve and has done well since, with significant pain relief and an increased activity level.This case supports the recent literature describing peroneal nerve dysfunction as an uncommon but surgically treatable cause of lateral knee pain following TKA. Increased awareness of the condition and its facile treatment via surgical decompression may result in improved outcomes years after TKA.

A systematic review of nerve transfer and nerve repair for the treatment of adult upper brachial plexus injury

Nerve reconstruction for upper brachial plexus injury consists of nerve repair and/or transfer. Current literature lacks evidence supporting a preferred surgical treatment for adults with such injury involving shoulder and elbow function. We systematically reviewed the literature published from January 1990 to February 2011 using multiple databases to search the following: brachial plexus and graft, repair, reconstruction, nerve transfer, neurotization. Of 1360 articles initially identified, 33 were included in analysis, with 23 nerve transfer (399 patients), 6 nerve repair (99 patients), and 4 nerve transfer + proximal repair (117 patients) citations (mean preoperative interval, 6 ± 1.9 months). For shoulder abduction, no significant difference was found in the rates ratio (comparative probabilities of event occurrence) among the 3 methods to achieve a Medical Research Council (MRC) scale score of 3 or higher or a score of 4 or higher. For elbow flexion, the rates ratio for nerve transfer vs nerve repair to achieve an MRC scale score of 3 was 1.46 (P = .03); for nerve transfer vs nerve transfer + proximal repair to achieve an MRC scale score of 3 was 1.45 (P = .02) and an MRC scale score of 4 was 1.47 (P = .05). Therefore, for elbow flexion recovery, nerve transfer is somewhat more effective than nerve repair; however, no particular reconstruction strategy was found to be superior to recover shoulder abduction. When considering nerve reconstruction strategies, our findings do not support the sole use of nerve transfer in upper brachial plexus injury without operative exploration to provide a clear understanding of the pathoanatomy. Supraclavicular brachial plexus exploration plays an important role in developing individual surgical strategies, and nerve repair (when donor stumps are available) should remain the standard for treatment of upper brachial plexus injury except in isolated cases solely lacking elbow flexion.

Laparoscopic triple neurectomy for intractable groin pain: technical report of 3 cases

BACKGROUND

Neuropathic groin pain can be a severely debilitating condition. Triple neurectomy of the ilioinguinal, iliohypogastric, and genitofemoral nerves is a viable treatment option.

OBJECTIVE

To present our initial experience with the laparoscopic retroperitoneal approach to triple neurectomy.

METHODS

Three patients (33 to 48 years of age) presented with chronic groin pain of 3 to 7 years' duration. The discomfort manifested in the ilioinguinal, iliohypogastric, and genitofemoral nerve distributions and severely affected their lifestyles, resulting in multiple unsuccessful medical and surgical treatments without symptomatic relief. Because the patients failed other modes of treatment, they underwent a laparoscopic retroperitoneal triple neurectomy.

RESULTS

Three patients underwent a triple neurectomy from November 2006 to May 2009. All patients reported debilitating chronic groin pain and underwent prior treatments ranging from anesthetic blocks to orchiectomy without lasting relief. The first case illustrates the anatomic variation of the genitofemoral nerve and the importance of transecting both branches for adequate symptomatic relief. The remaining cases demonstrate successful transection of all 3 nerves with significant pain relief at 10 months to 3 years of follow-up. No major complications were encountered.

CONCLUSION

This technique provides several advantages in the treatment of chronic groin pain. The retroperitoneal approach provides a facile method to reach the nerves in 1 stage and provides a dissection field free of previous scars. As a laparoscopic technique, benefits include small incision sites with small scars, less postoperative pain, and shorter hospitalizations and/or same-day discharges with effective relief of groin pain.

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.

Severe obstetric brachial plexus palsies can be identified at one month of age

OBJECTIVE

To establish whether severe obstetric brachial plexus palsy (OBPP) can be identified reliably at or before three months of age.

METHODS

Severe OBPP was defined as neurotmesis or avulsion of spinal nerves C5 and C6 irrespective of additional C7-T1 lesions, assessed during surgery and confirmed by histopathological examination. We first prospectively studied a derivation group of 48 infants with OBPP with a minimal follow-up of two years. Ten dichotomous items concerning active clinical joint movement and needle electromyography of the deltoid, biceps and triceps muscles were gathered at one week, one month and three months of age. Predictors for a severe lesion were identified using a two-step forward logistic regression analysis. The results were validated in two independent cohorts of OBPP infants of 60 and 13 infants.

RESULTS

Prediction of severe OBPP at one month of age was better than at one week and at three months. The presence of elbow extension, elbow flexion and of motor unit potentials in the biceps muscle correctly predicted whether lesions were mild or severe in 93.6% of infants in the derivation group (sensitivity 1.0, specificity 0.88), in 88.3% in the first validation group (sensitivity 0.97, specificity 0.76) and in 84.6% in the second group (sensitivity of 1.0, specificity 0.66).

INTERPRETATION

Infants with OBPP with severe lesions can be identified at one month of age by testing elbow extension, elbow flexion and recording motor unit potentials (MUPs) in the biceps muscle. The decision rule implies that children without active elbow extension at one month should be referred to a specialized center, while children with active elbow extension as well as active flexion should not. When there is active elbow extension, but no active elbow flexion an EMG is needed; absence of MUPs in the biceps muscle is an indication for referral.

Wilhelm Heinrich Erb, M.D. (1840 to 1921): a historical perspective on Erb's palsy

Erb's palsy is well known to physicians across medical specialties, and its clinical manifestations present a formidable challenge to reconstructive surgeons. Although the condition is well established, knowledge pertaining to its namesake, Wilhelm Heinrich Erb, is rather obscure in the existing scientific literature. Erb was influential not only through his description of classic brachial plexus palsy involving the superior (or upper) roots, but also by his indelible contributions to our understanding of peripheral nerve physiology, deep tendon reflexes, and the muscular dystrophies. Erb's contributions to medicine transcend specialty boundaries. In this article, the authors seek to convey his scientific achievements and the character of the man through translation of his German manuscripts. These texts, complemented by the existing English literature, provide a unique perspective on Wilhelm Heinrich Erb's contribution to medicine. The authors will also emphasize his role in describing and clarifying the nature of Erb's palsy.

Limb preference in children with obstetric brachial plexus palsy

Brachial plexus palsy affects children differently than adults. In children with obstetric brachial plexus palsy, motor development must depend on nervous system adaptation. Previous studies report sensory plasticity in these children. This noninvasive study provides support for neural plasticity (the general ability of the brain to reorganize neural pathways based on new experiences) in children with obstetric brachial plexus palsy by considering upper limb preference. As in the general population, we expect that 90% of children would prefer their right upper limb. However, only 17% of children affected by right obstetric brachial plexus palsy prefer the right upper limb for overall movement; children with left obstetric brachial plexus palsy did not significantly differ from the general population in upper limb preference. This study also provides the first evidence of a significant correlation between actual task performance and select obstetric brachial plexus palsy outcome measurement systems, thereby justifying the routine use of these outcome measurement systems as a reflection of the practical utility of the affected limb to the patient.