The outcome of Erb's palsy when the decision to operate is made at 4 months of age

Since the establishment of the obstetrical brachial plexus clinic in Saudi Arabia, the author has designed a prospective study in which the indication for brachial plexus surgery in infants with Erb's palsy was the lack of active elbow flexion against gravity at 4 months of age. Forty-three infants were included in the study and were distributed among four groups: group A (n = 20) included infants who had active elbow flexion at the initial assessment or at 2 months of age; group B (n = 9) included infants who had active elbow flexion at 3 months of age; group C (n = 11) included infants who had active elbow flexion at 4 months of age; and group D (n = 3) included infants who did not have active elbow flexion at 4 months of age. At the final follow-up, all children in group A demonstrated complete spontaneous recovery of the motor power of the limb. All children in group B also had satisfactory spontaneous recoveries, and none required secondary corrective procedures. Five of the 11 patients in group C had satisfactory spontaneous recoveries. The remaining six children in group C had good recovery of elbow flexion but a poor recovers of shoulder function. Finally, all three patients who did not have elbow flexion at 4 months of age (group D) underwent surgical exploration and reconstruction of the brachial plexus, using nerve grafts. The results of this prospective study are discussed, along with the controversial issue regarding the timing of primary plexus surgery in Erb's palsy.     

Surgical strategy for improving forearm and hand function in late obstetric brachial plexus palsy

For the purpose of treatment, obstetric brachial plexus palsy can be subdivided into two distinct phases: initial obstetric brachial plexus palsy, and late obstetric brachial plexus palsy. In the latter, nerve surgery is no longer practical, and treatment often requires palliative surgery to improve function of the shoulder, elbow, forearm, and hand. Late obstetric brachial plexus palsy in the forearm and hand includes weakness or absence of wrist or metacarpophalangeal or interphalangeal joint extension; weakness or absence of finger flexion; forearm supination, or less commonly pronation contracture; ulnar deviation of the wrist; dislocation of the radial or ulnar head; thumb instability; or sensory disturbance of the hand. Palliative reconstruction for these forearm and hand manifestations is more difficult than for the shoulder or elbow because of the lack of powerful regional muscles for transfer. This report reviews the authors' experience performing more than 100 surgical procedures in 54 patients over a 9-year period (between 1988 and 1997) with a minimum of 2 years' follow-up. Surgical treatment is highly individualized, but the optimal age for forearm and hand reconstruction is usually later than for shoulder and elbow reconstruction because of the requirement for a preoperative exercise program. Multiple procedures for forearm and hand function were often performed on any given patient. Frequently, these were done simultaneously with reconstructive procedures for improving shoulder and/or elbow function. Traditional tendon transfer techniques do not provide satisfactory reconstruction for those deformities. Many of the authors' patients required more complex techniques such as nerve transfer and functioning free-muscle transplantation to augment traditional techniques of tendon and/or bone management. Sensory disturbance of the forearm and hand in late obstetric brachial plexus palsy seems a minor problem and further sensory reconstruction is unnecessary.     

Qualitative dermatoglyphic traits in brachial plexus palsy

It has been considered for many years that the cause of perinatal brachial plexus palsy (PBPP) is excessive lateral traction applied to the fetal head at delivery, in association with anterior shoulder dystocia, but this do not explain all cases of brachial plexus palsy. The incidence found in several family members could be suggestive for inheritance with variable expression. The aim of this study was to prove early found confirmations of genetic predisposition for PBPP In the previous studies, the quantitative dermatoglyphic analysis showed some differences in digito-palmar dermatoglyphs between patients with PBPP and healthy controls. Now this qualitative analysis will try to determine hereditary of those diseases. We analyzed digito-palmar dermatoglyphics from 140 subjects (70 males and 70 females) diagnosed with PBPP and 400 phenotypically healthy adults (200 males and 200 females) from Zagreb area as control group. The results of Chi-square test showed statistically significant differences for frequencies of patterns on fingers in females between the groups observed. Statistically significant differences were found on palms in III and IV interdigital areas in both males and females and in thenar and I interdigital area only in females. As it was found in previous researches on quantitative dermatoglyphic traits, more differences are found between females with PBPP and control group, than between males. The fact, that the main presumed cause of PBPP is obstetrical trauma, it could be associated with congenital variability in formation of brachial plexus.     

Radial nerve palsy in the newborn: a case series

Background:

Peripheral nerve palsies of the upper extremities presenting at birth can be distressing for families and care providers. It is therefore important to be able to identify patients whose diagnosis is compatible with full recovery so that their families can be reassured.

Methods:

We conducted a retrospective review of all infants presenting with weakness of the upper extremity to our clinic between July 1995 and September 2009. We also conducted a review of the current literature.

Results:

During the study period, 953 infants presented to our clinic. Of these patients, 25 were identified as having isolated radial nerve palsy (i.e., a radial nerve palsy in isolation with good shoulder function and intact flexion of the elbow). Seventeen infants (68.0%) had a subcutaneous nodule representing fat necrosis in the inferior posterolateral portion of the affected arm. Full recovery occurred in all patients within a range of one week to six months, and 72.0% of the patients (18/25) had fully recovered by the time they were two months old.

Interpretation:

Although the outcome of obstetrical brachial plexus palsy is highly variable, isolated radial nerve palsy in the newborn carries a uniformly favourable prognosis.Peripheral nerve palsies in the newborn are uncommon and usually involve the brachial plexus or facial nerve.¹ Isolated radial nerve palsy in the newborn is a rare phenomenon and may be misdiagnosed as obstetrical brachial plexus palsy. It is important to differentiate between these two conditions, as the management and prognosis of each diagnosis are different. Over the last three decades, multiple reports of small numbers of patients with radial nerve palsy present at birth have been published.^2–6 This paper presents the largest single series of this lesion currently documented in the literature.     

Predictive value of computed tomographic myelography in obstetrical brachial plexus palsy

Preoperative radiologic studies to detect root avulsions of the brachial plexus caused by birth trauma are considered useful in assisting with surgical planning for reconstruction. In this study, the predictive value of computed tomographic (CT) myelography in detecting nerve root avulsions at our institution was determined. Sixty-three consecutive patients with an obstetrical brachial plexus palsy who had had both preoperative CT myelography and reconstructive surgery were selected. All CT myelograms were analyzed post hoc by a single neuroradiologist in a manner blind to the surgical findings. At each root level of the brachial plexus, the presence of a pseudomeningocele was noted along with the presence or absence of rootlets within each identified pseudomeningocele. Extraforaminal root avulsions later determined at surgery were reviewed by a single surgeon in a manner blind to the radiographic results. Surgical and radiographic findings were then compared at each corresponding root level. A total of 281 roots were examined. The sensitivity, specificity, positive predictive value, and likelihood ratio for root avulsions with pseudomeningoceles were 0.63, 0.85, 0.40, and 4.2, respectively. For pseudomeningoceles for which rootlets traversing the sac could not be identified, these values were 0.37, 0.98, 0.74, and 18.5, respectively. The presence of pseudomeningoceles with or without rootlets was not a sensitive indicator of root avulsions. Root avulsions were better predicted by identifying the absence of rootlets in a pseudomeningocele. This absence on CT myelography may be used to suggest an extraforaminal root avulsion due to its high specificity and high likelihood ratio.     

Outcomes of scapula stabilization in obstetrical brachial plexus palsy: a novel dynamic procedure for correction of the winged scapula

Among the late consequences of obstetrical brachial plexus palsy is winging of the scapula, a functional and aesthetic deformity. This article introduces a novel surgical procedure for the dynamic correction of this clinical entity that involves the dynamic transfer of the contralateral trapezius muscle and/or rhomboid muscles and anchoring to the affected scapula. In more severe cases of scapula winging, the contralateral latissimus dorsi muscle may also need to be transferred to achieve dynamic scapula stabilization. The outcomes of this novel surgical procedure were analyzed in relation to the effect on abduction, external rotation, growth of the scapula, and distance of the scapula from the posterior midline. The results were analyzed in 26 patients who underwent this procedure and had adequate follow-up. The mean patient age was 6.39 years. Fourteen (54 percent) had a diagnosis of Erb palsy, and 12 (46 percent) had a diagnosis of global paralysis. All 26 patients had an additional secondary procedure performed prior to or simultaneously with the scapula stabilization procedure. In 19 patients, the contralateral trapezius was transferred and anchored to the medial border of the winged scapula alone, but in seven cases the underlying rhomboid major was transferred along with the trapezius muscle to provide sufficient scapula stabilization. In five cases in which the scapula winging was severe, the contralateral latissimus dorsi muscle was transferred at a second stage. After this procedure, all patients demonstrated improved scapula symmetry. The mean increase in abduction was 18 degrees (p < 0.001), the mean increase in external rotation was 19 degrees (p < 0.001), and the mean increase in anterior flexion was 12 degrees (p = 0.015). The improvement of the relative position of the winged scapula on the posterior thorax was analyzed by measuring the distance of the inferior angle of both scapulae from the midline, then calculating the difference between normal and affected sides and comparing this value before and after the scapula stabilization procedure. This value preoperatively was 3.24 cm; postoperatively it decreased to 0.36 cm (p < 0.001), demonstrating a statistically significant improvement.     

The reconstructive strategy for improving elbow function in late obstetric brachial plexus palsy.

Children with previously untreated obstetric brachial plexus palsy frequently have abnormal elbow function because of motor recovery with aberrant reinnervation, or because of paresis or paralysis. From 1988 to 1997 (9-year period), 62 children with obstetric brachial plexus palsy with resulting elbow deformity underwent various methods of palliative reconstruction to improve elbow function. For motor recovery with aberrant reinnervation, release of aberrantly reinnervated antagonistic muscles and augmentation of paretic muscles form the basis of surgical intervention. The surgical procedures included triceps-to-biceps transfer, biceps-to-triceps transfer, brachialis-to-triceps transfer, or combined biceps- and brachialis-to-triceps transfer. Choice of procedures was individualized and randomly determined on the basis of the degree and pattern of aberrant reinnervation between elbow flexors and extensors. In patients' motor recovery with paresis or paralysis, persistently weak elbow flexion was salvaged with a functioning free muscle transplantation or Steindler's flexorplasty, or regional shoulder muscle transfer. In addition, patients with aberrant reinnervation between shoulder abductors and elbow flexors underwent anterior deltoid-to-biceps transfer with a fascia lata graft. All patients had a minimum follow-up of 2 years. Results are assessed and discussed and a reconstructive algorithm is recommended. In general, reconstruction of elbow extension should precede that of elbow flexion. Biceps-to-triceps transfer with preservation of an intact brachialis muscle, or brachialis-to-triceps transfer with preservation of an intact biceps, allows 50 percent of these patients to achieve acceptable elbow flexion and extension in a single-stage procedure.     

Technical note: the humeral canal approach to the brachial plexus

Many variations to the axillary approach to the brachial plexus have been described. However, the success rate varies depending on the approach used and on the definition of success. Recent work describes a new approach to regional anaesthesia of the upper limb at the humeral/brachial canal using selective stimulation of the major nerves. This report outlines initial experience with this block, describing the technique and results in 50 patients undergoing hand and forearm surgery. All patients were assessed for completeness of motor and sensory block. The overall success rate was 90 percent. Motor block was present in 80 percent of patients. Completion of the block was necessary in 5 patients. Two patients required general anaesthesia. The preponderance of ulnar deficiencies agrees with previously published data on this technique. No complications were described. Initial experience confirms the high success rate described using the Dupré technique. This technically straightforward approach with minimal complications can be recommended for regional anaesthesia of the upper limb.     

The developing shoulder has a limited capacity to recover after a short duration of neonatal paralysis

Mechanical stimuli are required for the proper development of the musculoskeletal system. Removal of muscle forces during fetal or early post-natal timepoints impairs the formation of bone, tendon, and their attachment (the enthesis). The goal of the current study was to examine the capacity of the shoulder to recover after a short duration of neonatal rotator cuff paralysis, a condition mimicking the clinical condition neonatal brachial plexus palsy. We asked if reapplication of muscle load to a transiently paralyzed muscle would allow for full recovery of tissue properties. CD-1 mice were injected with botulinum toxin A to paralyze the supraspinatus muscle from birth through 2 weeks and subsequently allowed to recover. The biomechanics of the enthesis was determined using tensile testing and the morphology of the shoulder joint was determined using microcomputed tomography and histology. A recovery period of at least 10 weeks was required to achieve control properties, demonstrating a limited capacity of the shoulder to recover after only two weeks of muscle paralysis. Although care must be taken when extrapolating results from an animal model to the human condition, the results of the current study imply that treatment of neonatal brachial plexus palsy should be aggressive, as even short periods of paralysis could lead to long-term deficiencies in enthesis biomechanics and shoulder morphology.     

Brachial plexus injury.

A 28-year-old man shot himself in the left posterior triangle of the neck with a shotgun. At the initial operation secondary repair of the resultant brachial plexus injury was decided upon in view of the difficulty in assessing lesions in continuity at this point after injury. The patient had total brachial plexus palsy. Nine weeks after the injury sensory and motor function were returning and the only element of the brachial plexus not showing evidence of nerve fibre continuity was the musculocutaneous nerve. Sural nerve autografts were sutured between the trimmed proximal and distal stumps of this nerve. By 4 months after the injury there was further improvement in both sensory and motor function, and by 18 months there was sensation in the autonomous zones of both median and ulnar nerves and good return of muscle power.     

Clinical and neuropathological study about the neurotization of the suprascapular nerve in obstetric brachial plexus lesions

Background

The lack of recovery of active external rotation of the shoulder is an important problem in children suffering from brachial plexus lesions involving the suprascapular nerve. The accessory nerve neurotization to the suprascapular nerve is a standard procedure, performed to improve shoulder motion in patients with brachial plexus palsy.

Methods

We operated on 65 patients with obstetric brachial plexus palsy (OBPP), aged 5-35 months (average: 19 months). We assessed the recovery of passive and active external rotation with the arm in abduction and in adduction. We also looked at the influence of the restoration of the muscular balance between the internal and the external rotators on the development of a gleno-humeral joint dysplasia. Intraoperatively, suprascapular nerve samples were taken from 13 patients and were analyzed histologically.

Results

Most patients (71.5%) showed good recovery of the active external rotation in abduction (60°-90°). Better results were obtained for the external rotation with the arm in abduction compared to adduction, and for patients having only undergone the neurotization procedure compared to patients having had complete plexus reconstruction. The neurotization operation has a positive influence on the glenohumeral joint: 7 patients with clinical signs of dysplasia before the reconstructive operation did not show any sign of dysplasia in the postoperative follow-up.

Conclusion

The neurotization procedure helps to recover the active external rotation in the shoulder joint and has a good prevention influence on the dysplasia in our sample. The nerve quality measured using histopathology also seems to have a positive impact on the clinical results.     

三通道电刺激仪的研制及对臂丛神经损伤的临床疗效

目的:研制可用于臂丛神经损伤治疗的三通道电刺激仪,并且将之应用于临床臂丛神经损伤患者,观察该仪器治疗臂丛神经损伤的临床效果。方法:由主控模块、显示模块、键盘模块、三个通道的电刺激发生器模块以及电源模块组成系统,可以连续交替释放脉冲刺激,针对不同神经和肌肉,选择不同的刺激位点。将60例臂丛神经损伤术后的患者随机分成试验组(30例)和对照组(30例),试验组术后第三周使用三通道电刺激仪治疗,对照组不做处理,患者术后随访6-12月后,观察患者上肢肩部、肘部功能恢复情况。结果:试验组治疗后上臂丛、全臂丛、下臂丛的肩部、肘部功能均好于治疗前,差异明显,均有统计学意义(P0.05);试验组上臂丛、全臂丛、下臂丛的肩部、肘部治疗效果均显著优于对照组,差异有统计学意义(P0.05)。结论:三通道电刺激仪可以有效地促进臂丛神经损伤后上肢功能的康复,可以对三组神经和肌肉交替进行电刺激,使用方便,并且便于携带,患者较为满意。     

B超声引导下肋锁间隙与喙突入路连续臂丛神经阻滞对Barton骨折术后镇痛效果比较

目的:比较超声引导下肋锁间隙与喙突两种入路连续臂丛神经阻滞对Barton骨折手术患者术后的镇痛效果。方法:选择择期行Barton骨折手术患者60例,随机分为肋锁间隙入路连续臂丛神经阻滞组(A组,n=30)和喙突入路连续锁骨下臂丛神经阻滞组(B组,n=30)。两组均在超声引导下进行臂丛神经阻滞,同时留置神经阻滞导管,麻醉后2小时经神经阻滞导管连接无线电子镇痛泵。记录手术过程中神经深度、麻醉操作时间,并评估麻醉效果;记录术后第一次追加药物时间;记录麻醉后6 h、12 h、18 h、24 h、36 h、48 h静息及运动状态VAS评分;记录术后第一天和第二天镇痛泵有效按压次数及补救镇痛情况;记录患者满意度及并发症发生情况。结果:与B组相比,A组神经深度明显减浅(P<0.05),麻醉操作时间显著缩短(P<0.05),术后第一次追加药物时间延长(P<0.05),麻醉后12 h、18 h、24 h、36 h静息及运动状态VAS评分较低(P<0.05),术后第一天有效按压次数明显减少(P<0.05),患者满意度评分高(P<0.05),误穿血管发生率明显减少(P<0.05)。结论:超声引导下肋锁间隙入路与喙突入路连续锁骨下臂丛神经阻滞均可安全有效用于Barton骨折手术术后镇痛;但肋锁间隙连续臂丛神经阻滞术后镇痛效果更好,且具有神经阻滞深度浅、操作时间更短、阻滞效果更好、患者满意度更高及并发症更少等优点。     

Motor grading of elbow flexion – is Medical Research Council grading good enough?

We present a new surgical technique for a pedicled teres major muscle transfer to improve shoulder abduction and flexion in children with sequelae of obstetric brachial plexus palsy. In addition, we provide the clinical outcome in the first 17 operated children.     

Validity of median nerve somatosensory evoked potentials in the diagnosis of supraclavicular brachial plexus lesions

Experience with median nerve SEPs in the diagnosis of brachial plexus lesions is analysed in 49 patients selected from a total material of 264 cases with brachial plexus problems tested by SEP techniques. Median nerve SEPs were always compared with the results of SEPs after stimulation of at least one other nerve relevant to the site of the lesion as suspected clinically and electromyographically. All patients presented with unilateral brachial plexus problems and all root lesions were verified by clinical presentation, EMG studies, myelogram or surgery. There were 19 brachial plexus injuries, 13 cases with cervical spondylopathic rediculopaties without myelopathy and 7 patients presented brachial plexopathy with systemic cancer. It was found that median nerve SEPs were always normal in injuries of upper trunk and root avulsions confined to one or two root levels. Median nerve SEPs were abnormal in multiple trunk lesions and multiple root avulsions. In patients with spondylopathic radiculopathies median nerve SEPs were normal apart from one case where involvement of multiple roots was present. Median nerve SEPs were useful in assessing patients presenting brachial plexus problems in the presence of systematic cancer apart from cases where lower trunk involvement was present.In general, median nerve SEPs are useful if they are combined with SEP testing of other nerves anatomically more closely related to the problem as outlined clinically and electromyographically.     

The surgical treatment of brachial plexus injuries in adults

Posttraumatic brachial plexus palsy is a severe injury primarily affecting young individuals at the prime of their life. The devastating neurological dysfunction inflicted in those patients is usually lifelong and creates significant socioeconomic issues. During the past 30 years, the surgical repair of these injuries has become increasingly feasible. At many centers around the world, leading surgeons have introduced new microsurgical techniques and reported a variety of different philosophies for the reconstruction of the plexus. Microneurolysis, nerve grafting, recruitment of intraplexus and extraplexus donors, and local and free-muscle transfers are used to achieve optimal outcomes. However, there is yet no consensus on the priorities and final goals of reconstruction among the various centers.     

Spontaneous pneumothorax: outpatient management with intercostal tube drainage.

In a series of 104 episodes of pneumothorax 75 percent of episodes were managed successfully on an outpatient basis by observation (23.1 percent) or by intercostal tube drainage using a flutter valve (51.9 percent). The patients for whom this treatment was not successful were admitted to hospital; 17 of them (16.3 percent of 104) were treated surgically. Bleb suturing with a stapling device and dry sponge abrasion of the pleura was the operation of choice.     

Nerve Transfer in Delayed Obstetrical Palsy Repair

Objective

 When root avulsions are detected in children suffering from obstetrical brachial plexus palsy (OBPP), neurotization procedures of different nerve trunks are commonly applied in primary brachial plexus repair, to connect distally the nerves of the upper limbs using healthy nerve structures. This article aims to outline our experience of neurotization procedures in OBPP, which involves nerve transfers in the event of delayed repair, when a primary repair has not occurred or has failed. In addition, we propose the opportunity for late repair, focusing on extending the time limit for nerve surgery beyond that which is usually recommended. Although, according to different authors, the time limit is still unclear, it is generally estimated that nerve repair should take place within the first months of life. In fact, microsurgical repair of OBPP is the technique of choice for young children with the condition who would otherwise have an unfavorable outcome. However, in certain cases the recovery process is not clearly defined so not all the patients are direct candidates for primary nerve surgery.

Methods

 In the period spanning January 2005 through January 2011, among a group of 105 patients suffering from OBPP, ranging from 1 month to 7 years of age, the authors have identified a group of 32 partially recovered patients. All these patients underwent selective neurotization surgery, which was performed in a period ranging from 5 months to 6.6 years of age.

Results

 Late neurotization of muscular groups achieved considerable functional recovery in these patients, who presented with reduced motor function during early childhood. The said patients, with the exception of five, would initially have avoided surgery because they had not met the criteria for nerve surgery.

Conclusion

 We have concluded that the execution of late nerve surgical procedures can be effective in children affected by OBPP.