Botulinum toxin for treatment of cocontractions related to obstetrical brachial plexopathy

Abstract

-Botulinum toxin type A was recently introduced for treatment of biceps -triceps muscle cocontraction, which compromises elbow function in children with obstetrical brachial plexopathy. This is our preliminary experience with this new approach. Eight children were treated with 2 -3 U/kg of botulinum toxin injected in the triceps (4 patients) and biceps (4 patients) muscle, divided in 2 or 3 sites. All patients submitted to triceps injections showed a long-lasting improvement of active elbow flexion and none re q u i red new injections, after a follow-up of 3 to 18 months. Three of the patients submitted to biceps injections showed some improvement of elbow extension, but none developed anti-gravitational stre n g t h for elbow extension and the effect lasted only three to five months. One patient showed no response to triceps injections. Our data suggest that botulinum toxin can be useful in some children that have persistent disability secondary to obstetrical brachial plexopathy.KEY WORDS: botulinum toxin type A, obstetric paralysis, drug therapy.Toxina botulínica para tratamento das co-contrações relacionadas à plexopatia braquial obstétrica RESUMO -A toxina botulínica do tipo A foi introduzida recentemente para o tratamento das co-contrações e n t re os músculos biceps e triceps, que comprometem a função do cotovelo nas crianças com plexopatia braquial obstétrica. Apresentamos nossa experiência preliminar com esta abordagem. Oito crianças foram tratadas com 2 -3 U/kg de toxina botulínica injetada nos músculos triceps (4 pacientes) e biceps (4 pacientes), divididas em 2 ou 3 sítios. Todos os pacientes submetidos a injeções no triceps apresentaram melhora persistente da flexão do cotovelo e nenhum precisou de novas aplicações após seguimento de 3 a 18 meses. Três pacientes submetidos a aplicações no biceps apresentaram melhora na extensão do cotovelo, mas nenhum adquiriu força antigravitacional e o efeito durou apenas 3 a 5 meses. Um paciente não re s p o n d e u às injeções. Nossos dados sugerem que a toxina botulínica pode ser útil no tratamento de algumas crianças com seqüelas de plexopatia braquial obstétrica. PALAVRAS-CHAVE: toxina botulínica tipo A, paralisia obstétrica, terapia por drogas.The incidence of obstetrical brachial plexopathy (OBP) in developed countries is around 0.15% and has not been reduced despite progress in obst e t r i c s 1 . Upper brachial plexus lesions (C5-C6) are almost always present in OBP, either in isolated form, or in association with middle (C7) and lower (C8-T1) brachial plexus lesions 2 . Most of the patients with OBP will fully recover after a few m o n t h s 3 , but 5% to 25% will remain handicapped 1,3 . Treatment of OBP patients includes one or more of the followings: physiotherapy, re c o n s t ru c t i v e plexus surg e ry and correction of secondary deformities. The use of botulinum toxin type A (BTA ) was recently introduced to treat biceps -triceps muscle cocontractions and improve the functional performance of these children 4,5 . This is a re p o rt of...

Indications and effects of botulinum toxin A for obstetric brachial plexus injury: a systematic literature review

“…studies. Neurosurgical treatment of the brachial plexus was only mentioned by Heise et al., 23 with neurosurgical plexus neurolysis in two of four cases. Basciani and Intiso 17,18 used a plaster cast as additional treatment.…”

“…After applying the inclusion and exclusion criteria and completing the secondary search by reviewing the reference lists of other related papers, 10 full‐text papers and six congress abstracts were included. Table I gives an overview of all 16 studies, their study designs, and levels of evidence 17–32 …”

“…In 72 children, the brachialis and brachioradialis muscles were also treated 18,20 . On average, the age of the children was 4 to 5 years in the Desiato and Risina 20 and Basciani and Intiso 17,18 studies, and 2 years in the Heise et al 23 . and Johnstone et al 25 .…”

Elbow flexion restoration using pedicled latissimus dorsi transfer in seven cases

“…On the contrary, Zancolli reports post-operative nerve conduction studies showing absence of triceps contractions during latissimus dorsi contraction [5]. Botulinum toxin injection in triceps muscle should help the central command to distinguish elbow flexion from extension [20].…”

Improvement in abduction of the shoulder after reconstructive soft-tissue procedures in obstetric brachial plexus palsy

“…6 Recent evidence supports the conservative management of apparent muscle imbalances, using botulinum toxin to treat biceps/triceps co-contraction. 7,8 Children with even a mild neurological deficit at the age of three months have a higher risk of long-term dysfunction of the upper limb. 6 The most important secondary deformities associated with injury to the upper plexus are related to the resultant weakness of the deltoid and external rotators of the shoulder.…”