Total obstetric brachial plexus palsy: Results and strategy of microsurgical reconstruction

Abstract

From 2000 to 2006, 35 infants with total obstetric brachial plexus palsy underwent brachial plexus exploration and reconstruction. The mean age at surgery was 10.8 months (range 3-60 months), and the median age was 8 months. All infants were followed for at least 2.5 years (range 2.5-7.3 years) with an average follow-up of 4.2 years. Assessment was performed using the Toronto Active Movement scale. Surgical procedures included neurolysis, neuroma excision and interposition nerve grafting and neurotization, using spinal accessory nerve, intercostals and contralateral C7 root. Satisfactory recovery was obtained in 37.1% of cases for shoulder abduction; 54.3% for shoulder external rotation; 75.1% for elbow flexion; 77.1% for elbow extension; 61.1% for finger flexion, 31.4% for wrist extension and 45.8% for fingers extension. Using the Raimondi score, 18 cases (53%) achieved a score of three or more (functional hand). The mean Raimondi score significantly improved postoperatively as compared to the preoperative mean: 2.73 versus 1, and showed negative significant correlation with age at surgery. In total, obstetrical brachial plexus palsy, early intervention is recommended. Intercostal neurotization is preferred for restoration of elbow flexion. Tendon transfer may be required to improve external rotation in selected cases. Apparently, intact C8 and T1 roots should be left alone if the patient has partial hand recovery, no Horner syndrome, and was operated early (3- or 4-months old). Apparently, intact nonfunctioning lower roots with no response to electrical stimulation, especially in the presence of Horner syndrome, should be neurotized with the best available intraplexal donor.

Results of nerve reconstructions in treatment of obstetrical brachial plexus injuries

“…When statistically analyzed, our results for group 1 and 2 seem similar, with the exception of shoulder abduction, but not statistically significantly. The results of global shoulder recovery and elbow flexion in the present study and also in a number of published series are good [3,9,13,21,32]. In contrast, the results with regard to external rotation were poor; successful results were achieved in 50 % in group 1 and 25 % in group 2.…”

“…Pondag et al, in a series of 86 patients, found that only 20 % achieved more than 20 degrees of true glenohumeral external rotation [23]. El-Gammal et al found 34 % and 54 % after tendon transfers [9]. No difference in final external rotation was found between patients who underwent nerve grafting from the proximal stump of C5 and patients who underwent spinal accessory nerve transfer [23,30].…”

“…Although the indication and timing of surgery remain controversial among authors [2,9,13,21,32], we believe that the optimal indication and timing of surgery in cases of total palsy with impaired hand function are within the first 3 months of age. In cases of upper brachial plexus injuries, within the first 4 months is acceptable if there is no useful elbow flexion.…”

The natural history and management of brachial plexus birth palsy

“…Nerve grafting can result in improved motor function and sensibility. Although difficult to compare due to variable indications and scoring systems, studies have consistently demonstrated significant functional gains in elbow flexion in patients who undergo surgery between 3 and 9 months [14,51,52]. Nerve transfers have gained popularity over the past decade.…”

Traumatic Brachial Plexus Injuries: Epidemiological Study at two Egyptian Centers over 2 Years

“…Many studies that were published by other Egyptian centers 2,5,6 showed the incidence and management of those cases, however, in this study we focus only on the traumatic type of the BPI. This study has been designed to evaluate the epidemiological, clinical, and outcome of traumatic brachial plexus injuries in our institutions.…”