A Historical Perspective on Brachial Plexus Palsy Management: From Ancient Civilizations to the Modern Era.

Evidence of brachial plexus palsies and potential therapies have been identified by investigators across cultures and civilizations. It could be argued that there are early records of brachial plexus injuries in not only literary work but also paintings, sculptures, and ancient medical texts. The compiled ancient evidence in this review provides a historical framework of brachial plexus palsies and potential management techniques that have been utilized from ancient to modern time.

Knowledge of neonatal brachial plexus palsy among medical professionals in North America.

PURPOSE: Early referral of neonatal brachial plexus palsy (NBPP) patients to multidisciplinary clinics is critical for timely diagnosis, treatment, and improved functional outcomes. In Saudi Arabia, inadequate knowledge regarding NBPP is a reason for delayed referral. We aimed to evaluate the knowledge of North American healthcare providers (HCPs) regarding the diagnosis, management, and prognosis of NBPP. METHODS: A 12-question survey regarding NBPP was distributed via electronic and paper formats to North American providers from various referring and treating specialties. NBPP knowledge was compared between Saudi Arabian vs. North American providers, referring vs. treating specialties, academic vs. community hospitals, and providers with self-reported confidence vs. nonconfidence in NBPP knowledge. RESULTS: Of the 273 surveys collected, 45% were from referring providers and 55% were from treating providers. Saudi Arabian and North American HCPs demonstrated similar NBPP knowledge except for potential etiologies for NBPP and surgery timing. In North America, referring and treating providers had similar overall knowledge of NBPP but lacked familiarity with its natural history. A knowledge gap existed between academic and community hospitals regarding timing of referral/initiation of physical/occupational therapy (PT/OT) and Horner's syndrome. Providers with self-reported confidence in treating NBPP had greater knowledge of types of NBPP and timing for PT/OT initiation. CONCLUSIONS: Overall, North American providers demonstrated adequate knowledge of NBPP. However, both eastern and western physicians remain overly optimistic in believing that most infants recover spontaneously. This study revealed a unique and universal knowledge gap in NBPP diagnosis, referral, and management worldwide. Continuous efforts to increase NBPP knowledge are indicated.

Compression neuropathies of the forearm: anatomy, clinical features and management.

The upper limb consists of four major parts: a girdle formed by the clavicle and scapula, the arm, the forearm and the hand. Peripheral nerve lesions of the upper limb are divided into lesions of the brachial plexus or the nerves arising from it. Lesions of the nerves arising from the brachial plexus are further divided into upper (proximal) or lower (distal) lesions based on their location. Peripheral nerves in the forearm can be compressed in various locations and by a wide range of pathologies. A thorough understanding of the anatomy and clinical presentations of these compression neuropathies can lead to prompt diagnosis and management, preventing possible permanent damage. This article discusses the aetiology, anatomy, clinical presentation and surgical management of compressive neuropathies of the upper limb.

Anatomy, Imaging, and Pathologic Conditions of the Brachial Plexus.

The brachial plexus is an intricate anatomic structure with an important function: providing innervation to the upper extremity, shoulder, and upper chest. Owing to its complex form and longitudinal course, the brachial plexus can be challenging to conceptualize in three dimensions, which complicates evaluations in standard orthogonal imaging planes. The components of the brachial plexus can be determined by using key anatomic landmarks. Applying this anatomic knowledge, a radiologist should then be able to identify pathologic appearances of the brachial plexus by using imaging modalities such as MRI, CT, and US. Brachial plexopathies can be divided into two broad categories that are based on disease origin: traumatic and nontraumatic. In the traumatic plexopathy group, there are distinct imaging findings and management methods for pre- versus postganglionic injuries. For nontraumatic plexopathies, having access to an accurate patient history is often crucial. Knowledge of the timing of radiation therapy is critical to diagnosing post-radiation therapy brachial plexopathy. In acute brachial neuritis, antecedent stressors occur within a specific time frame. Primary and secondary tumors of the brachial plexus are not uncommon, with the most common primary tumors being peripheral nerve sheath tumors. Direct extension and metastasis from primary malignancies such as breast and lung cancer can occur. Although diagnosing a brachial plexus anomaly is potentially perplexing, it can be straightforward if it is based on foundational knowledge of anatomy, imaging findings, and pathologic features. ©RSNA, 2020.

Team Approach: Management of Brachial Plexus Birth Injury.

Brachial plexus birth injury is an upper-extremity paralysis that occurs from a traction injury to the brachial plexus during birth. Approximately 10% to 30% of children with a brachial plexus birth injury have residual neurologic deficits with associated impact on upper-limb function. Management of brachial plexus birth injuries with a multidisciplinary team allows optimization of functional recovery while avoiding unnecessary intervention. Early occupational therapy should be initiated with a focus on range of motion and motor learning. The need for microsurgical reconstruction of the brachial plexus can be predicted based on early physical examination findings, and reconstruction is generally performed at 3 to 9 months of age. The majority of children with residual neurologic deficits develop associated glenohumeral dysplasia. These children may require secondary procedures, including botulinum toxin injection, subscapularis and pectoralis lengthening, shoulder capsular release, shoulder tendon transfer, and humeral osteotomy.

Role of tacrolimus in return of hand function after brachial plexus injury in a lung transplantation patient.

We report a patient who has been on tacrolimus for bilateral lung transplantation and presented with a brachial plexus injury (BPI), with unusual improvement of lower trunk innervated hand function. The lower trunk injury with resultant left hand paralysis had developed after his sternotomy 18 months ago. He has been treated with tacrolimus as part of his immunosuppression protocol since the surgery, without severe side effects. Physical examination at 18 months demonstrated unusual excellent grip pattern and full opposition of his thumb with slight claw deformity of his ulnar two digits. While the neurotoxic effects of tacrolimus are more emphasised, the neuroregenerative properties have been recently explored. The recovery in this patient is unique and unusual after BPI and is most likely as a result of the low dose tacrolimus treatment.

Photobiomodulation After Neurotization (Oberlin Procedure) in Brachial Plexus Injury: A Randomized Control Trial.

Objective: To investigate effect of photobiomodulation (PBM) on nerve regeneration after neurotization with the Oberlin Procedure (ulnar fascicle to motor branch to biceps) to restore elbow flexion in patients with brachial plexus injury. Materials and methods: This prospective randomized controlled trial was conducted with 14 patients with high brachial plexus injury who underwent neurotization with the Oberlin Procedure to restore elbow flexion. The patients were randomly allocated to two groups of equal numbers: control group and PBM group. In this study, the PBM used has a wavelength of 808 nm, 50 mW power, continuous mode emission, 4 J/cm2 dosimetry, administered daily for 10 consecutive days, with an interval of 2 days (weekends). The outcome of surgery was assessed after 1, 2, 3, and 6 months. The nonparametric Mann-Whitney U-test and chi-square test were utilized to compare the results between both groups. Results: After 3 months postoperatively, more patients in the PBM group had demonstrated signs of reinnervation and the mean muscle power was significantly higher in the PBM group. No adverse effects resulted from the administration of PBM. Conclusions: PBM is a treatment modality that can improve nerve regeneration after neurotization with the Oberlin Procedure.

Treatment of radiation-induced brachial plexopathy with omentoplasty

Radiation-induced brachial plexus neuropathy (RIBPN) is a rare and delayed non-traumatic injury to the brachial plexus, which occurs following radiation therapy to the chest wall, neck, and/or axilla in previously treated patients with cancer. The incidence of RIBPN is more common in patients treated for carcinoma of the breast and Hodgkin lymphoma. With the improvement in radiation techniques, the incidence of injury to the brachial plexus following radiotherapy has dramatically reduced. The currently reported incidence is 1.2% in women irradiated for breast cancer. The progression of symptoms is gradual in about two-thirds of cases; the patients may initially present with paresthesia followed by pain, and later progress to motor weakness in the affected limb. We present the case of a 68-year-old female patient with breast cancer submitted to surgery, chemotherapy, and radiotherapy in the year 2000. Eighteen years later, she developed symptoms and signs compatible with RIBPN and was successfully submitted to omentoplasty for pain control. Omentoplasty is an alternative treatment for RIBPN refractory to conservative treatment, which seems to be effective in improving neuropathic pain. However, postoperative worsening of the motor strength is a real possibility, and all candidates for this type of surgery must be informed about the risk of this complication.

Indirect Cost of Traumatic Brachial Plexus Injuries in the United States.

BACKGROUND: Traumatic brachial plexus injuries (BPIs) disproportionately affect young, able-bodied individuals. Beyond direct costs associated with medical treatment, there are far-reaching indirect costs related to disability and lost productivity. Our objective was to estimate per-patient indirect cost associated with BPI. METHODS: We estimated indirect costs as the sum of (1) short-term wage loss, (2) long-term wage loss, and (3) disability payments. Short-term (6-month) wage loss was the product of missed work days and the average earnings per day. The probability of return to work was derived from a systematic review of the literature, and long-term wage loss and disability payments were estimated. Monte Carlo simulation was used to perform a sensitivity analysis of long-term wage loss by varying age, sex, and return to work simultaneously. Disability benefits were estimated from U.S. Social Security Administration data. All cost estimates are in 2018 U.S. dollars. RESULTS: A systematic review of the literature demonstrated that the patients with BPI had a mean age of 26.4 years, 90.5% were male, and manual labor was the most represented occupation. On the basis on these demographics, our base case was a 26-year-old American man working as a manual laborer prior to BPI, with an annual wage of $36,590. Monte Carlo simulation estimated a short-term wage loss of $22,740, a long-term wage loss of $737,551, and disability benefits of $353,671. The mean total indirect cost of traumatic BPI in the Monte Carlo simulations was $1,113,962 per patient over the post-injury lifetime (median: $801,723, interquartile range: $22,740 to $2,350,979). If the probability of the patient returning to work at a different, lower-paying job was doubled, the per-patient total indirect cost was $867,987. CONCLUSIONS: BPI can have a far-reaching economic impact on both individuals and society. If surgical reconstruction enables patients with a BPI to return to work, the indirect cost of this injury decreases. LEVEL OF EVIDENCE: Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The Multidisciplinary Approach to the Diagnosis and Management of Nonobstetric Traumatic Brachial Plexus Injuries.

OBJECTIVE: Nonobstetric traumatic brachial plexus injuries can result in significant morbidity and chronic disability if not managed in a timely manner. Functional arm recovery is possible, but it requires a multidisciplinary approach toward the diagnosis and management of such injuries. CONCLUSION: This article provides an overview of the clinical, electrophysiology, and diagnostic imaging knowledge needed for accurate imaging interpretation and to participate in multidisciplinary discussions aimed at expediting optimal patient management.

Sensibility of the Hand in Children With Conservatively or Surgically Treated Upper Neonatal Brachial Plexus Lesion.

BACKGROUND: The aim of this study was to assess the sensibility of the hand in children with a neonatal brachial plexus palsy (NBPP) involving the C5 and C6, and to correlate results with dexterity. METHODS: Fifty children with NBPP (30 after nerve surgery, mean age 9.8 years) and 25 healthy controls (mean age 9.6 years) were investigated. Sensibility was assessed with two-point discrimination and Semmes-Weinstein monofilaments. Dexterity was evaluated with a single item from the Movement Assessment Battery for Children-2. We compared the affected side with the nondominant hand of the control group. RESULTS: The sensibility in the first and second fingers was significantly diminished in the NBPP for both two-point discrimination (P = 0.005 and P = 0.014, respectively) and monofilament test (P < 0.001). Dexterity was significantly lower in the NBPP group than in control group, corrected for age (P = 0.023). There was a significant difference toward decreasing hand function with decreasing sensibility according to the Semmes-Weinstein test for the thumb (Jonckheere-Terpstra nonparametric trend test, P = 0.036). CONCLUSIONS: The sensibility of the thumb and index finger in children with an upper plexus lesion (either surgically or conservatively treated) is diminished. The decreased sensibility has a negative impact on hand function. Appreciation of diminished hand function in patients with NBPP involving C5 and C6 is important to optimize treatment.

Active Range of Motion Over Time in Patients With Obstetrical Brachial Plexus Palsy: A 10-Year Analysis.

PURPOSE: In our experience, and from the personal report of others, children with obstetrical brachial plexus palsy appear to lose some of their initially recovered active range of motion over the time in both operated and nonsurgical patients. This study investigates whether such a diminution of active movement occurs over time. METHODS: We performed a retrospective analysis of data from our obstetrical brachial plexus clinic. Between 1991 and 2000, 139 patients with a minimum follow-up of 10 years were included in the study. Patients were divided into a nonsurgical group (n = 42) and a group who underwent either primary or secondary brachial plexus reconstruction or both (n = 97). Fifteen joint movements were assessed at 2, 4 to 6, and 9 to 11 years of age and at later final follow-up using the Active Movement Scale. Repeated measures analysis using age at each visit as the repeated measures covariate was undertaken. RESULTS: Active movement scores were not diminished when patients were evaluated at the 10-year follow-up visit. CONCLUSIONS: The suggested loss of active range of motion over time is not demonstrated at 10-year follow-up. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic III.

Extrarenal rhabdoid tumor presented with an immobile arm in a one-year-old boy.

Infants with an immobile arm may be easily overlooked in primary care settings. Differential diagnoses include injuries, infections, neuropathies, ischemia and rarely, neoplasms. We report the case of a one-year-old boy with weakness in his left arm after minor trauma with a diagnosis of brachial plexus palsy initially. After rehabilitation for 2months, his weakness progressed to unsteady gait and quadriparesis. MRI revealed a huge solid tumor in the left supraclavicular fossa, which also involved the left brachial plexus, upper thoracic cavity, and left paravertebral space with invasion into the spinal canal. Microscopically, the medium-large polygonal tumor cells had an eccentric eosinophilic cytoplasm and immunostaining showed a loss of nuclear INI1 expression. Array comparative genomic hybridization of the tumor tissue confirmed a segmental deletion at chromosome region 22q11.23 involving the SMARCB1 gene. The final diagnosis was cervical paravertebral malignant rhabdoid tumor with intraspinal epidural and intradural invasion, a rare case of extrarenal extracranial rhabdoid tumor (ERRT). The intraspinal part of the tumor was resected followed by interval-compressed chemotherapy with vincristine-doxorubicin-cyclophosphamide alternating with ifosfamide-etoposide (VDC/IE). The tumor showed very good partial response to four cycles of chemotherapy with gradual recovery of neurological symptoms. ERRT is a very rare and aggressive tumor that mainly occurs in infants and children and may manifest with vague neurological symptoms when it involves the spinal cord and/or peripheral nerves. A neoplasm such as ERRT originating from or involving the brachial plexus should be considered in the differential diagnosis of an immobile arm in infancy.

Obstetrical brachial plexus injury (OBPI): Canada's national clinical practice guideline.

OBJECTIVE: The objective of this study was to establish an evidence-based clinical practice guideline for the primary management of obstetrical brachial plexus injury (OBPI). This clinical practice guideline addresses 4 existing gaps: (1) historic poor use of evidence, (2) timing of referral to multidisciplinary care, (3) Indications and timing of operative nerve repair and (4) distribution of expertise. SETTING: The guideline is intended for all healthcare providers treating infants and children, and all specialists treating upper extremity injuries. PARTICIPANTS: The evidence interpretation and recommendation consensus team (Canadian OBPI Working Group) was composed of clinicians representing each of Canada's 10 multidisciplinary centres. OUTCOME MEASURES: An electronic modified Delphi approach was used for consensus, with agreement criteria defined a priori. Quality indicators for referral to a multidisciplinary centre were established by consensus. An original meta-analysis of primary nerve repair and review of Canadian epidemiology and burden were previously completed. RESULTS: 7 recommendations address clinical gaps and guide identification, referral, treatment and outcome assessment: (1) physically examine for OBPI in newborns with arm asymmetry or risk factors; (2) refer newborns with OBPI to a multidisciplinary centre by 1 month; (3) provide pregnancy/birth history and physical examination findings at birth; (4) multidisciplinary centres should include a therapist and peripheral nerve surgeon experienced with OBPI; (5) physical therapy should be advised by a multidisciplinary team; (6) microsurgical nerve repair is indicated in root avulsion and other OBPI meeting centre operative criteria; (7) the common data set includes the Narakas classification, limb length, Active Movement Scale (AMS) and Brachial Plexus Outcome Measure (BPOM) 2 years after birth/surgery. CONCLUSIONS: The process established a new network of opinion leaders and researchers for further guideline development and multicentre research. A structured referral form is available for primary care, including referral recommendations.

Humeral Retroversion in Children with Shoulder Internal Rotation Contractures Secondary to Upper-Trunk Neonatal Brachial Plexus Palsy.

BACKGROUND: The most common sequela of neonatal brachial plexus palsy is an internal rotation contracture of the shoulder that impairs function and leads to skeletal deformation of the glenohumeral joint. Treatment options include release, transfers, and humeral osteotomy, all ultimately striving for better function through increased external rotation. Prior studies have shown that neonatal brachial plexus palsy alters humeral retroversion but with conflicting findings. We studied retroversion in children with internal rotation contractures from neonatal brachial plexus palsy to clarify its effect on version and surgical planning. METHODS: Bilateral shoulder and elbow magnetic resonance imaging scans of 21 children with neonatal brachial plexus palsy were retrospectively analyzed. Retroversion referenced to the transepicondylar line at the elbow was measured with respect to 2 different proximal reference axes, the longest diameter of an axial cut of the proximal part of the humerus (the skew axis) and the line perpendicular to the articular surface (the humeral center line). Glenoid version and glenohumeral morphology type (concentric glenoid, posterior-concentric glenoid, biconcave, or pseudoglenoid) were also determined. All geometric variables were assessed for correlation with patient age and the severity of the internal rotation contracture. RESULTS: Retroversion on the involved side was decreased at 6° compared with 19° (p = 0.003), as measured between the skew axis and transepicondylar line. Retroversion referenced to the humeral center line was also decreased at -2° (anteversion) compared with 20° (p < 0.001). Patient age was inversely correlated with retroversion, but was only significant for the skew axis (r = -0.497, p = 0.022), decreasing in linear regression by 2.4° per year (p = 0.038). Humeral retroversion did not correlate with the severity of the internal rotation contracture, glenoid version, or glenoid morphology type. CONCLUSIONS: Humeral retroversion is likely to be less on the affected side in children with internal rotation contractures from upper trunk neonatal brachial plexus palsy and merits consideration in surgical planning. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Transferencia de la cabeza larga del tríceps para la flexión del codo en secuela de lesiones del plexo braquial / Transfer of the long head of triceps for elbow flexion in braquial plexus sequelae

Resumen: La anatomía neurovascular independiente de la cabeza larga del tríceps braquial y su idoneidad como un colgajo muscular libre han sido ampliamente estudiadas. En cambio, la trasposición de esta porción del tríceps para mejorar la flexión de codo ha sido descrita pocas veces. Se describen en este artículo dos casos de secuela de lesión del plexo braquial, en los que se realizó trasposición únicamente de la cabeza larga del tríceps. Se logró mejorar la flexión del codo y se conservó la extensión del mismo.

Abstract: The independent neurovascular anatomy of the long head of the triceps brachii and its suitability as a free muscle transfer have been extensively studied. Instead muscle transposition of the long head of the triceps brachii to enhance elbow flexion has been rarely described. We describe in this paper two cases of injury of brachial plexus sequel in which transposition was performed only on the long head of the triceps. The elbow flexion was improved, the extension was preserved.

Clinical impact of magnetic resonance neurography in patients with brachial plexus neuropathies.

OBJECTIVE: To study the impact of brachial plexus MR neurography (MRN) in the diagnostic thinking and therapeutic management of patients with suspected plexopathy. METHODS: MRN examinations of adult brachial plexuses over a period of 18 months were reviewed. Relevant data collection included-patient demographics, clinical history, pre-imaging diagnostic impression, pre-imaging treatment plan, post-imaging diagnosis, post-imaging treatment plan, surgical notes and electrodiagnostic (ED) results. Impact of imaging on the pre-imaging clinical diagnosis and therapeutic management were classified as no change, mild change or substantial change. RESULTS: Final sample included 121 studies. The common aetiologies included inflammatory in 31 (25.6%) of 121 patients, trauma in 29 (23.9%) of 121 patients and neoplastic in 26 (21.5%) of 121 patients. ED tests were performed in 47 (38.8%) of 121 patients and these showed concordance with MRN findings in 31 (66.0%) of 47 patients. Following MRN, there was change in the pre-imaging clinical impression for 91 (75.2%) of 121 subjects, with a mild change in diagnosis in 57 (47.1%) of 121 patients and a substantial change in 34 (28.0%) of 121 patients. 19 (15.7%) of 121 patients proceeded to therapies that would not have been performed in the same manner without the information obtained from MRN. CONCLUSION: MRN of the brachial plexus significantly impacts clinical decision-making and should be routinely performed in suspected brachial plexopathy. Advances in knowledge: MRN significantly impacts the diagnostic thinking and therapeutic management of patients with suspected brachial plexopathy. MRN not only provides concordant information to ED tests in majority of cases, but also supplements with additional diagnostic data in patients who are ED negative.

Neonatal Brachial Plexus Palsy in Children Aged 0 to 2.5 Years; Parent-Perceived Family Impact, Quality of Life, and Upper Extremity Functioning.

BACKGROUND: To investigate whether parents perceive impact of neonatal brachial plexus palsy on family and quality of life and upper extremity functioning in children less than 2.5 years. METHODS: This cross-sectional study used the PedsQL Family Impact Module (36 items/one total/four scales/scores 0 to 100), TNO-AZL (Dutch Organisation of Applied Natural Science and Academic Hospital Leiden) Preschool Children Quality of Life (43 items/12 scales/scores 0 to 100) and 21 upper extremity functioning questions. Associations between neonatal brachial plexus palsy/patient characteristics and family impact, perceived quality of life, and upper extremity functioning were investigated using regression analysis. RESULTS: Parents of 59 children (median age, 18 months) participated, 49 with C5-C6/C5-C7 lesions. Median Family Impact Module and TNO-AZL Preschool Children Quality of Life scores were 81.3 to 100.0/100.0 and 78.6 to 100.0/100.0. TNO-AZL Preschool Children Quality of Life scores did not differ significantly to healthy references except for stomach, skin, communication, and motor functioning problems. Parents reported around three upper extremity functioning problems. Greater lesion extent, lower age, still being in follow-up, and right-sided lesions were associated with greater family impact (P < 0.01 to P < 0.1). No clinically relevant associations were found for perceived quality of life. Greater lesion extent and nerve surgery history were associated with more upper extremity functioning problems (P < 0.01). Problems were associated with parental worrying (P < 0.05). CONCLUSIONS: Parents perceive having a child with neonatal brachial plexus palsy as impacting on their family depending on the side and severity of the lesion, treatment history, still being in follow-up, and age. They perceive the child's quality of life as relatively normal and not significantly different to healthy peers. However, parents noticed upper extremity functioning problems which increased parental worrying. Health care specialists should take these findings into account to better inform or counsel parents in an early stage during treatment.

A Thematic Analysis of Online Discussion Boards for Brachial Plexus Injury.

PURPOSE: Patients with brachial plexus injury (BPI) and their family members contribute to Internet discussion groups dedicated to BPI. We hypothesized that a thematic analysis of posts from BPI Internet discussion groups would reveal common themes related to the BPI patient experience, providing topics for patient education and counseling. METHODS: Internet discussion boards were identified using the search term "brachial plexus injury support group" in Google, Bing, and Yahoo! search engines. Two discussion boards had substantially more posts than other Web sites and were chosen for analyses. Posts from January 1, 2015, through January 1, 2016, were examined. Using an iterative and established process, 2 investigators (M.T.M. and C.J.D) independently analyzed each post using thematic analysis in 3 steps (open coding, axial coding, and selective coding) to determine common themes. In this process, each post was reviewed 3 times. RESULTS: A total of 328 posts from the 2 leading discussion boards were analyzed. Investigators reached a consensus on themes for all posts. One central theme focused on emotional aspects of BPI. Four other central themes regarding information support were identified: BPI disease, BPI treatment, recovery after BPI treatment, and process of seeking care for BPI. CONCLUSIONS: Examination of posts on Internet support groups for BPI revealed recurring concerns, questions, and opinions of patients and their family members. The most common themes related to disease information, treatment, recovery, and the emotional element of BPI. CLINICAL RELEVANCE: These findings provide a helpful starting point in refining topics for patient education and support that are targeted on patients' interests and concerns.