The prerequisites and clinical outcomes of ipsilateral C7 nerve root transfer to the upper trunk for adult C5-C6 brachial plexus injuries.

PURPOSE: Although ipsilateral C7 nerve transfer is used for the treatment of C5-C6 brachial plexus injuries, accurately evaluating the functional quality of the donor nerve (ipsilateral C7 nerve root) is difficult, especially when the C7 nerve root is slightly injured. The purpose of this study was to determine the indicators to evaluate the quality of the ipsilateral C7 nerve and assess the clinical outcomes of this procedure. METHODS: This study employed the following three indicators to assess the quality of the ipsilateral C7 nerve: (1) the muscle strength and electrophysiological status of the latissimus dorsi, triceps brachii, and extensor digitorum communis; (2) the sensibility of the radial three digits, especially the index finger; and (3) the intraoperative appearance, feel and electrophysiological status of the ipsilateral C7 nerve root. Transfer of the ipsilateral C7 nerve root to the upper trunk was implemented only when the following three tests were conducted, the criteria were met, and the clinical outcomes were assessed in eight patients with C5-C6 brachial plexus injuries. RESULTS: Patients were followed-up for an average of 90 ± 42 months. At the final follow-up, all eight patients achieved recovery of elbow flexion, with five and three patients scoring M4 and M3, respectively, according to the Medical Research Council scoring. The shoulder abduction range of motor recovery averaged 86 ± 47° (range, 30°-170°), whereas the shoulder external rotation averaged 51 ± 26° (range, 15°-90°). CONCLUSION: Ipsilateral C7 nerve transfer is a reliable and effective option for the functional reconstruction of the shoulder and elbow after C5-C6 brachial plexus injuries when the three prerequisites are met.

Jitter patterns in conventional concentric needle electromyography recordings of regenerating motor units.

BACKGROUND: The time interval between two potential components of the same motor unit potential (MUP) is measured for jitter analysis. Enhanced jitter is generally thought to result from impaired neuromuscular transmission as occurs in myasthenia gravis or during reinnervation. METHODS: Within a database of conventional video-electromyography (EMG) recordings 4 MUP with peculiar jitter patterns were identified. In 1 spontaneously discharging MUP, massive and chaotic jitter was seen with a mean consecutive difference (MCD) of 9.3 ms. In 2 spontaneously discharging MUP a certain potential subgroup jittered relative to the other part(s) of the MUP (MCD 2.0 and 3.3 ms). A jittering satellite was detected in a fourth voluntarily recruited MUP (MCD 0.6 ms). RESULTS: These different jitter patterns recorded with conventional EMG technique may mainly result from dysmyelination. CONCLUSIONS: A new look at the contribution of dysmyelination to abnormal jitter is also warranted in single fiber EMG recordings.

Examination of the human motor endplate after brachial plexus injury with two-photon microscopy.

INTRODUCTION: After traumatic nerve injury, neuromuscular junction remodeling plays a key role in determining functional outcomes. Immunohistochemical analyses of denervated muscle biopsies may provide valuable prognostic data regarding clinical outcomes to supplement electrodiagnostic studies. METHODS: We performed biopsies on nonfunctioning deltoid muscles in two patients after gunshot wounds and visualized the neuromuscular junctions using two-photon microscopy with immunohistochemistry. RESULTS: Although the nerves in both patients showed evidence of acute Wallerian degeneration, some of the motor endplates were intact but exhibited significantly decreased surface area and volume. Both patients exhibited substantial recovery of motor function over several weeks postinjury. DISCUSSION: Two-photon microscopic assessment of neuromuscular junction integrity and motor endplate morphometry in muscle biopsies provided evidence of partial sparing of muscle innervation. This finding supported the clinical judgment that eventual recovery would occur. With further study, this technique may help to guide operative decisionmaking after traumatic nerve injuries.

Primary cancer location predicts predominant level of brachial plexopathy.

BACKGROUND: Changes in radiation therapy practice and cancer incidence bring into question prior evidence suggesting that radiation therapy predominantly injures the brachial plexus upper trunk, while tumor invasion typically injures the lower trunk. METHODS: We reviewed electrodiagnostic brachial plexopathy reports in cancer survivors for predominant trunk involvement, injury mechanism (tumor invasion vs radiation), and primary cancer location. RESULTS: Fifty-six cases of cancer-associated brachial plexopathy were identified. There was no relationship between injury mechanism and brachial plexus injury level. However, primary cancer location superior/inferior to the clavicle increased the odds of predominantly upper/lower trunk involvement by a factor of 60.0 (95% confidence interval: 7.9, 1401, respectively). CONCLUSIONS: Cancers superior/inferior to the clavicle increase the likelihood of predominantly upper/lower trunk plexopathy, respectively, regardless plexus injury mechanism. These findings contrast with older work, possibly due to more precise radiation therapy techniques and increased incidence of radiosensitive head and neck cancers.

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

Neonatal brachial plexus palsy (NBPP) is a prominent form of newborn morbidity with a potentially disabling persistence. Neurosurgical intervention is indicated in select NBPP patients. Early prognostic assessment would facilitate rational selection of those infants for surgery. We conducted a systematic literature review to determine the prognostic value of early electrodiagnosis (EDx) in NBPP. We included 16 observational studies with a total sample size of 747 children. Risk of bias and quality of evidence were rated. Wide variation was found in EDx techniques, outcome algorithms, and decisionmaking. Nevertheless, the most methodologically sound studies support the use of EDx, at standardized time-frames, as a key prognostic modality for complementing clinical judgment and neuroimaging. An accurate knowledge of the underlying anatomy of the nerve injury helps to counsel families and to guide reconstructive strategy.

Low interrater reliability of brachial plexus MRI in chronic inflammatory neuropathies.

INTRODUCTION: Magnetic resonance imaging of the brachial plexus shows nerve thickening in approximately half of the patients with chronic inflammatory demyelinating polyneuropathy (CIDP) and multifocal motor neuropathy (MMN). The reliability of qualitative evaluation of brachial plexus MRI has not been studied previously. METHODS: We performed an interrater study in a retrospective cohort of 19 patients with CIDP, 17 patients with MMN, and 14 controls. The objective was to assess interrater variability between radiologists by using a predefined scoring system that allowed the distinction of no, possible, or definite nerve thickening. RESULTS: Raters agreed in 26 of 50 (52%) brachial plexus images; κ-coefficient was 0.30 (SE 0.08, 95% confidence interval 0.14-0.46, P < .0005). DISCUSSION: Our results provide evidence that interrater reliability of qualitative evaluation of brachial plexus MRI is low. Objective criteria for abnormality are required to optimize the diagnostic value of MRI for inflammatory neuropathies.

Backpack palsy and other brachial plexus neuropathies in the military population.

Brachial plexus neuropathy is often seen in the military population, especially due to pressure (backpack palsy, BPP) or idiopathic (neuralgic amyotrophy, NA). We aimed to gain insight in the disease characteristics of soldiers with brachial plexus neuropathies in the Dutch military population and to compare disease characteristics between patients with BPP and NA. In this retrospective chart review study we aimed to include all patients with brachial plexus neuropathy, who presented in the Joint Military Hospital between 1 January, 2011 and 31 December, 2016. We calculated the incidence of NA and BPP and Chi-square tests or Student t tests were performed for differences in patient characteristics between NA and BPP. We included 127 patients, 63 with BPP, 45 with NA, 10 with traumatic brachial plexus neuropathy, and 9 with other plexopathy. The incidence of brachial plexus neuropathy was 50/100 000 person years overall, 25/100 000 person years for BPP, and 18/100 000 person years for NA. Patients in the BPP group differed from the NA with regard to pain (BPP 41% vs NA 93%, P = .000), atrophy (13% BPP vs 29% NA, P = .049), and sensory symptoms (83% BPP vs 44% NA, P = .000). In the BPP group 90% had incomplete recovery and in the NA group 78%. Our study showed a high incidence of BPP and NA in the military population and suggests recovery is not so benevolent as previously thought. Future research is necessary to improve insight and outcome of military patients with brachial plexus neuropathies.

Anatomic Variation of the Phrenic Nerve and Brachial Plexus Encountered during 100 Supraclavicular Decompressions for Neurogenic Thoracic Outlet Syndrome with Associated Postoperative Neurologic Complications.

BACKGROUND: The objective of this study was to characterize phrenic nerve and brachial plexus variation encountered during supraclavicular decompression for neurogenic thoracic outlet syndrome and to identify associated postoperative neurologic complications. METHODS: A multicenter retrospective review was performed to evaluate anatomic variation of the phrenic nerve and brachial plexus from November 2010 to July 2018. After initial characterization, the following two groups were identified: variant anatomy (VA) group and standard anatomy (SA) group. Complications were analyzed and compared between the two groups. RESULTS: In total, 105 patients were identified, and 100 patients met inclusion criteria. Any anatomic variation of the standard course or configuration of the phrenic nerve and/or brachial plexus was encountered in 47 (47%) patients. Phrenic nerve anatomic variations were identified in 28 (28%) patients. These included 9 duplicated nerves, 6 lateral accessory nerves, 8 medial displacement, and 5 lateral displacement. Brachial plexus anatomic variation was found in 34 (34%) patients. The most common variant configuration of a fused middle and inferior trunk was identified in 25 (25%) patients. Combined phrenic nerve and brachial plexus anatomic variation was demonstrated in 15 (15%) patients. The VA and SA groups consisted of 47 and 53 patients, respectively. Transient phrenic nerve injury with postoperative elevation of the ipsilateral hemidiaphragm was documented in 3 (6.4%) patients in the VA group and 6 (11.3%) patients in the SA group (P = 0.49). Permanent phrenic nerve injury was identified in 1 (2.1%) patient in the VA group (P = 0.47) and none in the SA group. Transient brachial plexopathy was encountered in 1 (1.9%) patient in the SA group (P = 1.0) with full recovery to normal function. CONCLUSIONS: Anatomic variability of the phrenic nerve and brachial plexus are encountered more frequently than previously reported. While the incidence of nerve injury is low, surgeons operating within the thoracic aperture should be familiar with variant anatomy to reduce postoperative complications.

Recovery of shoulder abduction in traumatic brachial plexus palsy: a systematic review and meta-analysis of nerve transfer versus nerve graft.

Brachial plexus palsy is a surgically manageable condition. Re-animating the shoulder is a high priority for restoring upper extremity function. Methods for reinnervating injured nerves include the transfer of a healthy nerve or fascicle distal to the site of injury, or grafting a healthy sensory nerve to restore motor function. Studies aiming to compare these two techniques for restoring shoulder abduction have yielded conflicting results. We conducted a systematic review and meta-analysis following the PRISMA guidelines. We reviewed the PubMed database for studies comparing nerve transfer and nerve grafting for shoulder abduction published by December 2018. Outcomes using the Medical Research Scale (MRC) for muscle strength were assessed using a random effects model meta-analysis. Five studies comprising a total of 212 patients (n = 158, nerve transfer; n = 54, nerve grafts) were used for the analysis. The rate of functional recovery of shoulder function was slightly better for nerve transfer (n = 114/158, 72%) than for nerve graft patients (n = 36/54, 67%). However, this was not statistically significant (OR 1.34, 95% CI 0.27-6.72, I2 = 62.9%). Nerve transfer and grafting are similarly effective in terms of shoulder abduction. Future prospective studies are needed to validate our results and identify the optimal shoulder re-animation strategy in patients with brachial plexus injuries.

What Range of Motion is Achieved 5 Years After External Rotationplasty of the Shoulder in Infants with an Obstetric Brachial Plexus Injury?

BACKGROUND: Obstetric brachial plexus injuries result from traction injuries during delivery, and 30% of these children have persisting functional limitations related to an external rotation deficit of the shoulder. Little is known about the long-term effect of soft-tissue procedures of the shoulder in patients with obstetric brachial plexus injuries. QUESTIONS/PURPOSES: (1) After soft-tissue release for patients with passive external rotation less than 20° and age younger than 2 years and for patients older than 2 years with good external rotation strength, what are the improvements in passive external rotation and abduction arcs at 1 and 5 years? (2) For patients who underwent staged tendon transfer after soft-tissue release, what are the improvements in active external rotation and abduction arcs at 1 and 5 years? (3) For patients with passive external rotation less than 20° and no active external rotation, what are the improvements in active external rotation and abduction arcs at 1 and 5 years? METHODS: This was a retrospective analysis of a longitudinally maintained institutional database. Between 1996 and 2009, 149 children underwent a soft-tissue procedure of the shoulder for an internal rotation contracture. The inclusion criteria were treatment with an internal contracture release and/or tendon transfer, a maximum age of 18 years at the time of surgery, and a minimum follow-up period of 2 years. Six patients were older than 18 years at the time of surgery and 31 children were seen at our clinic until 1 year postoperatively, but because they had good clinical results and lived far away from our center, these children were discharged to physical therapists in their hometown for annual follow-up. Thus, 112 children (59 boys) were available for analysis. Patients with passive external rotation less than 20° and age younger than 2 years and patients older than 2 years with good external rotation strength received soft-tissue release only (n = 37). Of these patients, 17 children did not have adequate active external rotation, and second-stage tendon transfer surgery was performed. For patients with passive external rotation less than 20° with no active external rotation, single-stage contracture release with tendon transfer was performed (n = 68). When no contracture was present (greater than 20° of external rotation) but the patient had an active deficit (n = 7), tendon transfer alone was performed; this group was not analyzed. A functional assessment of the shoulder was performed preoperatively and postoperatively at 6 weeks, 3 months, and annually thereafter and included abduction, external rotation in adduction and abduction, and the Mallet scale. RESULTS: Internal contracture release resulted in an improvement in passive external rotation in adduction and abduction of 29° (95% confidence interval, 21 to 38; p < 0.001) and 17° (95% CI, 10 to 24; p < 0.001) at 1 year of follow-up and 25° (95% CI, 15-35; p < 0.001) and 15° (95% CI, 7 to 24; p = 0.001) at 5 years. Because of insufficient strength of the external rotators after release, 46% of the children (17 of 37) underwent an additional tendon transfer for active external rotation, resulting in an improvement in active external rotation in adduction and abduction at each successive follow-up visit. Patients with staged transfers had improved active function; improvements in active external rotation in adduction and abduction were 49° (95% CI, 28 to 69; p < 0.05) and 45° (95% CI, 11 to 79; p < 0.001) at 1 year of follow-up and 38° (95% CI, 19 to 58; p < 0.05) and 23° (95% CI, -8 to 55; p < 0.001) at 5 years. In patients starting with less than 20° of passive external rotation and no active external rotation, after single-stage contracture release and tendon transfer, active ROM was improved. Active external rotation in adduction and abduction were 75° (95% CI, 66 to 84; p < 0.001) and 50° (95% CI, 43 to 57; p < 0.001) at 1 year of follow-up and 65° (95% CI, 50 to 79; p < 0.001) and 40° (95% CI, 28 to 52; p < 0.001) at 5 years. CONCLUSION: Young children with obstetric brachial plexus injuries who have internal rotation contractures may benefit from soft-tissue release. When active external rotation is lacking, soft-tissue release combined with tendon transfer improved active external rotation in this small series. Future studies on the degree of glenohumeral deformities and functional outcome might give more insight into the level of increase in external rotation. LEVEL OF EVIDENCE: Level III, therapeutic study.

Perineural spread to the brachial plexus: a focused review of proposed mechanisms and described pathologies.

BACKGROUND: Perineural spread (PNS) is an emerging mechanism for progressive, non-traumatic brachial plexopathy. We aim to summarize the pathologies (tumor and infection) shown to have spread along or to the brachial plexus, and identify the proposed mechanisms of perineural spread. METHODS: A focused review of the literature was performed pertaining to pathologies with identified perineural spread to the brachial plexus. RESULTS: We summarized pathologies currently reported to have PNS in the brachial plexus and offer a structure for understanding and describing these pathologies with respect to their interaction with the peripheral nervous system. CONCLUSIONS: Perineural spread is an underrepresented entity in the literature, especially regarding the brachial plexus. It can occur via a primary or secondary mechanism based on the anatomy, and understanding this mechanism helps to support biopsies of sacrificial nerve contributions, leading to more effective and timely treatment plans for patients.

Acupuncture Induces Reduction in Limbic-Cortical Feedback of a Neuralgia Rat Model: A Dynamic Causal Modeling Study.

Background: Neuropathic pain after brachial plexus avulsion remained prevalent and intractable currently. However, the neuroimaging study about neural mechanisms or etiology was limited and blurred. Objective: This study is aimed at investigating the effect of electroacupuncture on effective connectivity and neural response in corticolimbic circuitries during implicit processing of nociceptive stimulus in rats with brachial plexus pain. Methods: An fMRI scan was performed in a total of 16 rats with brachial plexus pain, which was equally distributed into the model group and the electroacupuncture group. The analysis of task-dependent data determined pain-related activation in each group. Based on those results, several regions including AMY, S1, and h were recruited as ROI in dynamic causal modeling (DCM) analysis comparing evidence for different neuronal hypotheses describing the propagation of noxious stimuli in regions of interest and horizontal comparison of effective connections between the model and electroacupuncture groups. Results: In both groups, DCM revealed that noxious stimuli were most likely driven by the somatosensory cortex, with bidirectional propagation with the hypothalamus and amygdala and the interactions in them. Also, the 3-month intervention of acupuncture reduced effective connections of h-S1 and AMY-S1. Conclusions: We showed an evidence that a full connection model within the brain network of brachial plexus pain and electroacupuncture intervention reduces effective connectivity from h and AMY to S1. Our study for the first time explored the relationship of involved brain regions with dynamic causal modeling. It provided novel evidence for the feature of the organization of the cortical-limbic network and the alteration caused by acupuncture.

Teres major transfer to restore external rotation of shoulder in Erb palsy patients.

BACKGROUND: The lack of external rotation and shoulder abduction as sequelae of obstetric brachial plexus palsy requires a release of the subscapularis muscle associated with tendon transfer of the internal rotator of the shoulder. The aim of this study was to present the results of a teres major transfer to the infraspinatus tendon. METHODS: This study included 20 patients (9 boys and 11 girls) with a mean age of 3 years 8 months (range, 1.5-14 years). The average follow-up time was 42 months (range, 12-48 months) to determine whether external rotation weakness and internal rotation contracture sequelae were managed by anterior release of the subscapularis and teres major tendon transfer to the infraspinatus tendon. RESULTS: We found marked improvement in shoulder abduction from 67° before surgery to 158° after surgery. We also found marked improvements in active external rotation from 8° before surgery to 85° after surgery and in passive external rotation from 0° preoperatively to 72° postoperatively. Two cases showed a loss of the last degrees of internal rotation, but this improved after physiotherapy. CONCLUSIONS: Anterior release of the subscapularis tendon with a teres major transfer to the infraspinatus tendon significantly improves shoulder function in Erb palsy patients with internal rotation contracture.

Elbow flexion reconstruction with nerve transfer or grafting in patients with brachial plexus injuries: A systematic review and comparison study.

INTRODUCTION: Posttraumatic brachial plexus (BP) palsy was used to be treated by reconstruction with nerve grafts. For the last two decades, nerve transfers have gained popularity and believed to be more effective than nerve grafting. The aim of this systematic review was to compare elbow flexion restoration with nerve transfers or nerve grafting after traumatic BP injury. METHODS: PRISMA-IPD structure was used for 52 studies included. Patients were allocated as C5-C6 (n = 285), C5-C6-C7 (n = 150), and total BP injury (n = 245) groups. In each group, two treatment modalities were compared, and effects of age and preoperative interval were analyzed. RESULTS: In C5-C6 injuries, 93.1% of nerve transfer patients achieved elbow flexion force ≥M3, which was significantly better when compared to 69.2% of nerve graft patients (p < 0.001). For improved outcomes of nerve transfer patients, shorter preoperative interval was a significant factor in all injury patterns (p < 0.001 for C5-C6 injuries and total BP injuries, p = 0.018 for C5-C6-C7 injuries), and young age was a significant factor in total BP injury pattern (p = 0.022). CONCLUSIONS: Our analyses showed that nerve transfers appear superior to nerve graftings especially in patients with a C5-C6 injury. Unnecessary delays in surgery must be prevented, and younger patients may have more chance for better recovery. LEVEL OF EVIDENCE: Level II.

Assessment of Motor Repertoire in 3- to 5-Month-Old Infants With Obstetric Brachial Plexus Lesion.

PURPOSE: The aim of this study was to define the movement characteristics and postures of infants with obstetric brachial plexus lesion. METHODS: The study group included 20 infants with obstetric brachial plexus lesion and a control group of 20 infants with normal neurological outcome, aged 9 to 17 weeks postterm. Infants were evaluated by global and detailed general movements assessment. RESULTS: There were no significant differences between the motor optimality scores of the 2 groups. However, there were some differences in terms of concurrent movements and the posture. Infants with obstetric brachial plexus lesion demonstrated more excitement bursts, head rotation, hand-knee contact, rolling, and few finger posture and postural asymmetry, and performed jerky movements when compared with the control group. CONCLUSIONS: Obstetric brachial plexus lesion did not affect the quality of fidgety movements of the infants but leads to compensatory movements in concurrent movements on the unaffected sides.

Suprascapular neuropathy: A review of 87 cases.

INTRODUCTION: Suprascapular neuropathy (SSN) is rare, with an estimated prevalence of 4.3% in patients with shoulder pain. METHODS: This retrospective chart review included patients with SSN seen during a 16-year period. Demographics and clinical information were recorded. Descriptive statistics, including percentages, means, and standard deviations, were computed for the variables of interest for all patients. RESULTS: Of 87 patients included in this study, trauma (n = 27) was the most common cause of SSN, followed by neuralgic amyotrophy (n = 21). Fifty-seven patients had isolated SSN. Others had SSN associated with axillary neuropathy (23 patients), brachial plexopathy (3 patients), and long thoracic, radial, or spinal accessory neuropathy (1 patient each). DISCUSSION: SSN is commonly associated with axillary neuropathy. Trauma remains the most common cause of SSN. Electrodiagnostic findings aid in the initial diagnosis and may indicate the need for close clinical follow-up based on the severity of the axonal injury.

Administration of Curcumin Alleviates Neuropathic Pain in a Rat Model of Brachial Plexus Avulsion.

BACKGROUND/AIMS: Brachial plexus avulsion (BPA) generally causes a chronic persistent pain that lacks efficacious treatment. Curcumin has been found to possess anti-inflammatory abilities. However, little is known about the mechanisms and effects of curcumin in an animal model of BPA. METHODS: Mechanical withdrawal thresholds (MWT) were examined by von Frey filaments. Cold allodynia was tested by the acetone spray test. The levels of tumor necrosis factor-α (TNF-α) and interleukin (IL)-6 in rat spinal cords were analyzed by the enzyme-linked immunosorbent assay, and the expression levels of c-Fos and nerve growth factor (NGF) were measured by Western blot. The expression level of glial fibrillary acidic protein (GFAP) was observed by immunofluorescence and Western blot. RESULTS: After curcumin treatment, the MWT showed a significant increase when compared to the BPA group on both hind paws. A remarkable decrease of paw-withdrawal response frequency was observed compared with the BPA group. In addition, curcumin treatment significantly decreased the levels of TNF-α and IL-6 in rat spinal cords that were exceedingly upregulated in the BPA group. The protein levels of c-Fos and NGF were decreased by treatment with curcumin compared with the corresponding protein levels in the BPA group. Besides, curcumin reduced the number of GFAP positive cells and GFAP expression. CONCLUSIONS: Our findings suggest that curcumin significantly extenuates the BPA-induced pain and inflammation by reducing the expression level of proinflammatory cytokines and pain-associated proteins and inhibiting the activity of astrocytes.

Scapular Stabilization Limits Glenohumeral Stretching in Children With Brachial Plexus Injuries.

PURPOSE: To quantify the effects of scapular stabilization on scapulothoracic and glenohumeral (GH) stretching. METHODS: Motion capture data during external rotation and abduction with and without scapular stabilization were collected and analyzed for 26 children with brachial plexus birth palsy. These positions were performed by an experienced occupational therapist and by the child's caretaker. Scapulothoracic and GH joint angular displacements were compared between stretches with no stabilization, stabilization performed by the therapist, and stabilization performed by the caretaker. The relationship between the age and ability of the therapist and caretaker to perform the stretches with scapular stabilization was also assessed. RESULTS: During external rotation there were no significant differences in either the scapulothoracic or GH joint during stabilization by either the therapist or the caretaker. During abduction, both scapulothoracic and GH joint angular displacements were statistically different. Scapulothoracic upward rotation angular displacement significantly decreased with scapular stabilization by the therapist and caretaker. Glenohumeral elevation angular displacement significantly decreased with scapular stabilization performed by the therapist and caretaker. There were only weak correlations between age and the differences in scapulothoracic and GH joint angular displacement performed by both the therapist and the caretaker. CONCLUSIONS: The findings of this study indicate that scapular stabilization may be detrimental to passive stretching of the GH joint in children, as demonstrated by a reduced stretch. Based on the findings of this study, we have changed our practice to recommend passive stretches without scapular stabilization for children aged 5 years and older with brachial plexus birth palsy. In infants and children aged less than 5 years, we now recommend stretching with and without scapular stabilization until the effect of scapular stabilization is objectively assessed in these age groups. LEVEL OF EVIDENCE/TYPE OF STUDY: Therapeutic IV.

Free Reverse Gracilis Muscle Combined With Steindler Flexorplasty for Elbow Flexion Reconstruction After Failed Primary Repair of Extended Upper-Type Paralysis of the Brachial Plexus.

PURPOSE: To report the clinical outcomes of elbow flexion reconstruction using a reverse free gracilis muscle flap plus Steindler flexorplasty in patients with previously failed reconstruction of extended upper-type brachial plexus paralysis. METHODS: Twenty-four male patients were reoperated upon an average of 45 months (SD, ± 45 months) after brachial plexus repair. The gracilis tendon was secured to the acromion, and the muscle belly was sutured to the biceps distal tendon. Vascular repair was performed preferentially end to end to the radial artery and cephalic vein. Nerve repair was achieved by coapting the nerve to the gracilis to motor fascicles of the median or ulnar nerve. The medial epicondyle was osteotomized, proximally advanced by 4 to 5 cm and secured to the anterior side of the humerus. RESULTS: Active elbow flexion was restored in 23 of 24 patients. Sixteen patients ultimately achieved M4 strength, among whom 6 had full range of motion (ROM), and the remaining 10 recovered an average of 110° (95% confidence interval [95% CI], 100°-120°) of elbow flexion. Seven patients exhibited M3 elbow flexion strength recovery, which was associated with weaker hands and incomplete ROM, averaging 94° (95% CI, 86°-102°). There was, on average, a 10° (95% CI, 4.4°-15.6°). elbow flexion contracture. Among the 16 patients with M4 level recovery of elbow flexion, supination was partially restored in 12. CONCLUSIONS: In patients previously operated upon, using a reversed free gracilis muscle flap in association with a Steindler procedure is effective as salvage surgery to restore elbow flexion and partial supination. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Sensory Outcome in Children Following Microsurgery for Brachial Plexus Birth Injury.

PURPOSE: Studies are limited on sensory outcome in children with brachial plexus birth injury (BPBI). The purpose of this research was to evaluate the sensory function of the hand in children with BPBI who had microsurgical reconstruction of the brachial plexus. METHODS: The sensory thresholds of children with upper and total plexus injury were evaluated with the Weinstein Enhanced Sensory Test and a test of stereognosis. RESULTS: A total of 63 children participated (aged 10.92 ± 3.29 years), 24 (38%) of whom had abnormal sensory thresholds in the affected hand. Only 4 children had loss of protective sensation or higher thresholds. These 4 measurements were all identified in the territory of the superficial branch of the radial nerve. Twelve children with upper plexus (43%) and 12 (34%) with total plexus injury had sensory impairment in the affected hand. These proportions were not statistically different. Of all children evaluated, 18 (29%) had a lower stereognosis score in the affected hand compared with the unaffected hand. The proportions of children with impairment in stereognosis in the upper plexus group (n = 5; 18%) versus the total plexus group (n = 13; 37%) were not statistically different. Age at the time of assessment, sex, upper versus total plexus injury, number of root avulsions, subjective report of altered sensation, and Faces Pain Scale-Revised score were not related to sensory impairment in the affected hand. CONCLUSIONS: Sensory recovery in BPBI after microsurgical reconstruction in children with total plexus injury who had reconstruction of the lower trunk had the potential to achieve sensory recovery similar to their upper plexus counterparts. A large proportion of children achieve normal sensory outcome, and those who had deficits had mild impairments. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.