Neurolysis alone as the treatment for neuroma-in-continuity with more than 50% conduction in infants with upper trunk brachial plexus birth palsy

Abstract

<jats:sec> <jats:title>Object</jats:title> <jats:p>The debate addressed in this article is that of surgical treatment methods for a neuroma-in-continuity. The authors of this study chose to test the hypothesis that more severe nerve injuries, as distinguished by &lt; 50% conduction across a neuroma-in-continuity, could be treated with neuroma resection and grafting, whereas less severe nerve injuries, with &gt; 50% conduction across the neuroma, could be treated with neurolysis alone.</jats:p></jats:sec> <jats:sec> <jats:title>Methods</jats:title> <jats:p>The goal of this study was to compare preoperative and postoperative Active Movement Scale (AMS) scores in children with upper trunk brachial plexus birth injuries treated with neurolysis alone if the neuroma's conductivity was &gt; 50% on intraoperative nerve testing. Seventeen patients (7 male, 10 female) met the criteria for inclusion in this study. Surgery was done when the patients were an average of 10 months old (range 6–19 months). The authors analyzed AMS scores from the preoperative assessment, 1-year postoperative follow-up visit, and subsequent follow-up assessment as close to 3 years after surgery as possible (referred to in this paper as &gt; 2-year postoperative scores).</jats:p></jats:sec> <jats:sec> <jats:title>Results</jats:title> <jats:p>Comparison of preoperative and 1-year follow-up data showed significant improvement in shoulder abduction, flexion, external rotation, and internal rotation; elbow flexion and supination; and wrist extension. Comparison of preoperative findings and results of assessment at &gt; 2-year follow-up showed significant improvement in shoulder abduction, flexion, external rotation; and elbow flexion and supination. At final follow-up, useful function (AMS score of 6 or 7) was achieved for elbow flexion in 14 of 16 patients, shoulder flexion in 11 of 15 patients, shoulder abduction in 11 of 16 patients, and shoulder external rotation in 5 of 15 patients.</jats:p></jats:sec> <jats:sec> <jats:title>Conclusions</jats:title> <jats:p>This report indicates that there is a subgroup of patients who can benefit clinically, with functional improvement of shoulder and elbow function, from treatment with neurolysis alone for upper trunk lesions demonstrating more than 50% conduction across the neuroma on intraoperative nerve testing. Patients with less than 50% conduction, indicating more severe disease, are treated with nerve resection and grafting in the authors' treatment algorithm.</jats:p></jats:sec>

Early electrodiagnosis in the management of neonatal brachial plexus palsy: A systematic review

“…Most studies were completed in Europe, followed by three studies performed in Asia and South America . Three studies were conducted in the United States …”

“…All studies are prone to selection bias by including a nonrandom sample of the NBPP population. Six studies included a surgery group, five included a slow recovery or severe group, and five included NBPP children referred to a tertiary center . In two studies the population was restricted to upper trunk lesions.…”

“…None of the included studies adopted preoperative, and only one intraoperative, somatosensory evoked potentials (SEPs). Three studies performed intraoperative NCS, with Chin et al utilizing a combination of intraoperative NCS, EMG, and gross motor response to stimulation. The timing of the first (preoperative) EDx intervention varied from 5 days to 14 months after birth.…”

“…Two studies provided only the mean value, ranging from 2.6 weeks to 31 days, and one study did not mention the exact timing. Intraoperative EDx ranged from 3 months to 19 months after birth. Strömbeck et al and Yilmaz et al performed serial EDx by conducting a second intervention later in time.…”

The management of neuropathic pain from neuromas in the upper limb: surgical techniques and future directions

“…[31,32] A study of neurolysis alone in upper trunk brachial plexus neuroma-in-continuity revealed a functional improvement following neurolysis alone in cases where there was more than 50% conduction demonstrated intraoperatively across the nerve. [33] Opponents of neurolysis alone, however, warn of the risks of segmental revascularization and significant scar formation. [34] This has led to the development of techniques designed to prevent recurrent scarring such as wrapping the nerve in a variety of protective substances.…”