Obstetrical Brachial Plexus Palsy

Abstract

In this article, the authors review their approach to evaluation, operative management, and reconstructive technique. Brachial plexus injuries in the newborn are usually managed nonoperatively. The timing and indications for primary surgery vary significantly between institutions. The motor examination is used to determine which infants would benefit from operative management. Patients are selected based on established criteria, such as the Toronto Test Score, applied at age 3 months. However, some cases are initially less clear, and we may recommend delaying operative management until age 6 months or as late as age 9 months if the child fails the cookie test. Neuroma excision, sural nerve grafting, and nerve transfers are performed when indicated by clinical motor examination. The use of selective motor nerve transfers, either in combination with nerve grafting or alone, has allowed nerve coaptations to be performed closer to the neuromuscular junction, which may further improve regeneration. Children undergoing primary surgery experience low rates of perioperative morbidity, and they experience gains in motor function until 3 or 4 years postoperatively, at which point recovery stabilizes.

Obstetrical brachial plexus injury: burden in a publicly funded, universal healthcare system

“…While evidence is not sufficient to support specific nonoperative physical therapy protocols with referral at 1 month, 10,18,63 there is growing evidence to support operative nerve repair beginning at 3 months of age. 19 Canadian OBPI surgeons indicate preference for early referral 4,7,12 to allow for serial assessment by a multidisciplinary team, with indications for nerve repair beginning at 3 months. 7,12 The consensus group supported a conservative approach to referral, where centers can assess a proportion of children making a good recovery versus a patient with a delayed referral presenting with sequelae beyond ideal operative windows.…”

“…19 Canadian OBPI surgeons indicate preference for early referral 4,7,12 to allow for serial assessment by a multidisciplinary team, with indications for nerve repair beginning at 3 months. 7,12 The consensus group supported a conservative approach to referral, where centers can assess a proportion of children making a good recovery versus a patient with a delayed referral presenting with sequelae beyond ideal operative windows.…”

“…One month was chosen as the timeframe for a "good" designation based upon an existing algorithm for referral 44 and a previous national position statement. 4 Neuropraxic injuries are expected to completely recover by 1 month; 4,7,12,66 beyond 1 month, recovery is not expected to be complete. 4 The selection of 3 months for a "satisfactory" designation was based upon our meta-analysis 18 and existing surgical algorithms, 7,12 which support operative indications beginning at 3 months.…”

The Diagnostic Value of CT Myelography, MR Myelography, and Both in Neonatal Brachial Plexus Palsy

“…Indications for surgical treatment followed the protocol developed at the Toronto Hospital for Sick Children 9 and were based on clinical examination: flail arm and persistent Horner syndrome at 1 month of age; composite active movement scale score for elbow flexion, elbow extension, wrist extension, finger extensions, and thumb extension of Ͻ3.5/10 at 3 months of age; no clinical progression at 6 months of age; and failed "cookie test" (the child has to bring the hand to the mouth) at 9 months of age. One infant with isolated lower plexus palsy underwent exploration at 9 months of age because of lack of clinical recovery.…”

“…While 70%-90% of infants are treated with therapy alone, 10%-30% have indications for surgical treatment. [8][9][10][11] Nerve injuries distal to the intervertebral foramen can be reconstructed by using nerve grafts, whereas intraforaminal nerve root avulsions require nerve transfer. While both partial and complete nerve root avulsions are described, 12,13 there is no clear consensus on the surgical approach to partial nerve root avulsions.…”