Quantifying Patient-Initiated Upper Extremity Movement After Surgical Reconstruction for Adult Pan-Brachial Plexus Injury.

BACKGROUND AND OBJECTIVES: Determining functional recovery in adult patients with traumatic pan-brachial plexus injury (pBPI) is hampered by the fact that most outcome measures are collected in the clinical setting and may not reflect arm use in the real world. This study's objectives were to demonstrate the feasibility of using wearable motion sensor technology to quantify spontaneous arm movement in adult patients with pBPI after surgical reconstruction and report the time and intensity with which the affected arm was used. METHODS: Twenty-nine patients with pBPI who underwent surgical reconstruction at least 2 years prior were included in this study. Study participants wore an accelerometer on bilateral arms for 7 days. The vector time (VT) and magnitude with which each arm moved were collected and divided by the same values collected from the uninjured arm to generate a ratio (VT and vector magnitude [VM], respectively) to quantify differences between the arms. Correlations between VT, VM, and patient demographic and physician-elicited clinical measures were calculated. Patients were enrolled at Chang Gung Memorial Hospital, Linkou Medical Center, Taiwan, and data analysis was performed at the University of Michigan. RESULTS: Twelve patients had pan-avulsion injuries, and 17 patients had C5 rupture with C6-T1 avulsion injuries. All underwent nerve reconstruction with contralateral C7 or ipsilateral C5 nerve roots as donors. At mean 7.3 years after surgery, the mean VT ratio was 0.54 ± 0.13 and the mean VM ratio was 0.30 ± 0.13. Both VT and VM ratios were significantly correlated with patient employment and movements at the elbow and forearm. CONCLUSION: Wearable motion detection technology can capture spontaneous, real-world movements of the arm in patients who have undergone surgical reconstruction for pBPI. Despite severe injuries, these patients are able to use their affected arm 50% of the time and with 30% of the intensity of their unaffected arm, which is positively correlated with return to work after injury. These data support the use of surgical reconstruction for pBPI.

Recovery of Shoulder, Elbow, and Forearm Movement After Nerve Reconstruction for Neonatal Brachial Plexus Palsy.

BACKGROUND AND OBJECTIVES: There is a relative dearth of published data with respect to recovery of upper extremity movement after nerve reconstruction for neonatal brachial plexus palsy (NBPP). This study aimed to demonstrate long-term recovery of active range of motion (AROM) at the shoulder, elbow, and forearm after nerve reconstruction for NBPP and to compare that with patients managed nonoperatively. METHODS: We interrogated a prospectively collected database of all patients evaluated for NBPP at a single institution from 2005 to 2020. AROM measurements for shoulder, elbow, and forearm movements were collected at every visit up to 5 years of follow-up and normalized between 0 and 1. We used generalized estimated equations to predict AROM for each movement within local age windows over 5 years and compared the operative and nonoperative cohorts at each age interval. RESULTS: In total, >13 000 collected datapoints representing 425 conservatively and 99 operatively managed children were included for analysis. At 5 years, absolute recovery of AROM after nerve reconstruction was ∼50% for shoulder abduction and forward flexion, ∼65% for shoulder external rotation, and ∼75% for elbow flexion and forearm supination, with ∼20% loss of elbow extension AROM. Despite more limited AROM on presentation for the operative cohort, at 5 years, there was no significant difference between the groups in AROM for shoulder external rotation, elbow extension, or forearm supination, and, in Narakas grade 1-2 injury, shoulder abduction and forward flexion. CONCLUSION: We demonstrate recovery of upper extremity AROM after nerve surgery for NBPP. Despite more severe presenting injury, operative patients had similar recovery of AROM when compared with nonoperative patients for shoulder external rotation, elbow extension, forearm supination, and, for Narakas grade 1-2 injury, shoulder abduction and forward flexion.

Impact of Timing of Primary Nerve Surgery on Shoulder, Forearm, and Elbow Recovery in Neonatal Brachial Plexus Palsy.

BACKGROUND AND OBJECTIVES: Neonatal brachial plexus palsy (NBPP) almost universally affects movement at the shoulder, elbow, and forearm. Timing of nerve reconstruction surgery to optimize long-term outcomes remains unknown. This study aimed to determine if timing of nerve reconstruction affects long-term recovery of an active range of motion (AROM) at the shoulder, elbow, and forearm in NBPP. METHODS: We interrogated a prospectively collected database of all patients with NBPP who underwent primary nerve surgery at a single tertiary referral center between 2005 and 2020. The cohort was divided into those who underwent surgery at ≤6 or >6 months old and ≤9 or >9 months old. AROM for shoulder abduction, forward flexion, and external rotation, elbow flexion and extension, and forearm supination were collected at each visit. RESULTS: Ninety-nine children were included in the analysis; 28 underwent surgery at ≤6 months old, 71 at >6 months, 74 at ≤9 months, and 25 at >9 months. There was no difference in AROM at 5 years for any of the movements between the ≤6- and >6-month groups. The ≤9-month group had significantly better shoulder forward flexion and elbow extension AROM than the >9-month group at a 5-year follow-up and better forearm supination at up to a 15-year follow-up. Patients who presented earlier were more likely to have earlier operations. CONCLUSION: Surgery before 9 months may improve long-term upper extremity recovery in NBPP. Early referral should be encouraged to optimize timing of operative intervention.

Developing interdisciplinary research teams in neurosurgery: key elements to success in brachial plexus and peripheral nerve surgery.

The highest-impact medical literature is increasingly produced by interdisciplinary teams. The field of neurosurgery, which involves complex pathologies and recoveries, is particularly amenable to interdisciplinary research approaches. However, research in the medical context regarding the characteristics of effective teams, as well as how to develop and maintain interdisciplinary teams, remains lacking. Here, the authors used the business literature to identify the characteristics of effective teams. They then used the University of Michigan Brachial Plexus and Peripheral Nerve Program, founded under the leadership of the late Dr. Lynda Yang, as a case study for how these principles can be applied to build and operationalize a successful interdisciplinary team. They suggest that these same techniques can be used to create interdisciplinary research groups in other areas of neurosurgery.

Implications of median sensory study to the thumb and deltoid/biceps motor unit recruitment on identifying C6 root avulsion in upper neonatal brachial plexus palsy.

INTRODUCTION/AIMS: Anatomic representation suggests that a median sensory nerve conduction study recording the thumb (median D1 NCS) may effectively assess upper neonatal brachial plexus palsy (NBPP). We sought to determine the feasibility of technique, establish reference data, and assess its ability to: (a) identify focal upper plexus lesions; and (b) identify C6 root avulsion. In a secondary analysis, we explored the association between absence/presence of motor unit action potentials (MUAPs) during needle electromyography (EMG) of the deltoid and biceps brachii muscles and C6 avulsion status. METHODS: A retrospective chart review was performed of surgical patients with severe upper NBPP who ultimately underwent surgical reconstruction (between 2017 and 2020). Median D1 sensory nerve action potential (SNAP) amplitude ranges were determined in affected and contralateral limbs and analyzed by C6 root avulsion status. Also, presence/absence of MUAPs during EMG of the deltoid and biceps brachii was compared between C6 avulsion patients and controls. RESULTS: Thirty-eight patients were included in our analysis. A median D1 NCS study was readily performed, showing a contralateral limb mean amplitude of 27.42 µV (range, 3.8-54.7 µV). Most patients had a low ipsilateral median D1 SNAP amplitude, regardless of C6 avulsion status. Detectable MUAPs in either deltoid or biceps brachii on EMG were atypical in C6 root avulsion. DISCUSSION: The median D1 NCS identifies upper NBPP, but does not distinguish C6 avulsions from post-ganglionic lesions, likely due to the frequent co-occurrence of post-ganglionic axonal disruption. The presence of MUAPs on deltoid/biceps brachii EMG suggests C6 avulsion is unlikely.

Quantifying long-term upper-limb activity using wearable motion sensors after nerve reconstruction for neonatal brachial plexus palsy.

OBJECTIVE: Standard, physician-elicited clinical assessment tools for the evaluation of function after nerve reconstruction for neonatal brachial plexus palsy (NBPP) do not accurately reflect real-world arm function. Wearable activity monitors allow for the evaluation of patient-initiated, spontaneous arm movement during activities of daily living. In this pilot study, the authors demonstrate the feasibility of using body-worn sensor technology to quantify spontaneous arm movement in children with NBPP 10 years after nerve reconstruction and report the timing and magnitude of recovered arm movement. METHODS: Eight children with NBPP who underwent brachial plexus reconstruction approximately 10 years prior were recruited to take part in this single-institution prospective pilot study. Per the treatment protocol of the authors' institution, operated patients had severe, nonrecovering nerve function at the time of surgery. The patients were fitted with an activity monitoring device on each of the affected and unaffected arms, which were worn for 7 consecutive days. The duration (VT) and power (VM) with which each arm moved during the patient's normal daily activities were extracted from the accelerometry data and ratios comparing the affected and unaffected arms were calculated. Demographic data and standard physician-elicited clinical measures of upper-extremity function were also collected. RESULTS: Three children underwent nerve grafting and transfer and 5 children underwent graft repair only. The mean (± SD) active range of motion was 98° ± 53° for shoulder abduction, 130° ± 24° for elbow flexion, and 39° ± 34° for shoulder external rotation. The median Medical Research Council grade was at least 2.5 for all muscle groups. The median Mallet grade was at least 2 for all categories, and 13.5 total. The VT ratio was 0.82 ± 0.08 and the VM ratio was 0.53 ± 0.12. CONCLUSIONS: Wearable activity monitors such as accelerometers can be used to quantify spontaneous arm movement in children who underwent nerve reconstruction for NBPP at long-term follow-up. These data more accurately reflect complex, goal-oriented movement needed to perform activities of daily living. Notably, despite severe, nonrecovering nerve function early in life, postsurgical NBPP patients use their affected arms more than 80% of the time that they use their unaffected arms, paralleling results in patients with NBPP who recovered spontaneously. These data represent the first long-term, real-world evidence to support brachial plexus reconstruction for patients with NBPP.

MRI evaluation of nerve root avulsion in neonatal brachial plexus palsy: understanding the presence of isolated dorsal/ventral rootlet disruption.

OBJECTIVE: The evaluation, treatment, and prognosis of neonatal brachial plexus palsy (NBPP) continues to have many areas of debate, including the use of ancillary testing. Given the continued improvement in imaging, it is important to revisit its utility. Nerve root avulsions have historically been identified by the presence of pseudomeningoceles or visible ruptures. This "all-or-none" definition of nerve root avulsions has many implications for the understanding and management of NBPP, especially as characterization of the proximal nerve root as a potential donor remains critical. This study examined the ability of high-resolution MRI to more specifically define the anatomy of nerve root avulsions by individually examining the ventral and dorsal rootlets as they exit the spinal cord. METHODS: This is a retrospective review of patients who had undergone brachial plexus protocol MRI for clinical evaluation of NBPP at a single institution. Each MR image was independently reviewed by a board-certified neuroradiologist, who was blinded to both established diagnosis/surgical findings and laterality. Each dorsal and ventral nerve rootlet bilaterally from C5 to T1 was evaluated from the spinal cord to its exit in the neuroforamen. Each rootlet was classified as avulsed, intact, or undeterminable. RESULTS: Sixty infants underwent brachial plexus protocol MRI from 2010 to 2018. All infants were included in this study. Six hundred individual rootlets were analyzed. There were 49 avulsed nerve rootlets in this cohort. Twenty-nine (59%) combined dorsal/ventral avulsions involved both the ventral and dorsal rootlets, and 20 (41%) were either isolated ventral or isolated dorsal rootlet avulsions. Of the isolated avulsion injuries, 13 (65%) were dorsal only, meaning that the motor rootlets were intact. CONCLUSIONS: A closer look at nerve root avulsions with MRI demonstrates a significant prevalence (approximately 41%) of isolated dorsal or ventral nerve rootlet disruptions. This finding implies that nerve roots previously labeled as "avulsed" but with only isolated dorsal (sensory) rootlet avulsion can yet provide donor fascicles in reconstruction strategies. A majority (99%) of the rootlets can be clearly visualized with MRI. These findings may significantly impact the clinical understanding of neonatal brachial plexus injury and its treatment.

Nerve graft versus nerve transfer for neonatal brachial plexus: shoulder outcomes.

OBJECTIVE: The decision-making in neonatal brachial plexus palsy (NBPP) treatment continues to have many areas in need of clarification. Graft repair was the gold standard until the introduction of nerve transfer strategies. Currently, there is conflicting evidence regarding outcomes in patients with nerve grafts versus nerve transfers in relation to shoulder function. The objective of this study was to further define the outcomes for reconstruction strategies in NBPP with a specific focus on the shoulder. METHODS: A cohort of patients with NBPP and surgical repairs from a single center were reviewed. Demographic and standard clinical data, including imaging and electrodiagnostics, were gathered from a clinical database. Clinical data from physical therapy evaluations, including active and passive range of motion, were examined. Statistical analysis was performed on the available data. RESULTS: Forty-five patients met the inclusion criteria for this study, 19 with graft repair and 26 with nerve transfers. There were no significant differences in demographics between the two groups. Understandably, there were no patients in the nerve grafting group with preganglionic lesions, resulting in a difference in lesion type between the cohorts. There were no differences in preoperative shoulder function between the cohorts. Both groups reached statistically significant improvements in shoulder flexion and shoulder abduction. The nerve transfer group experienced a significant improvement in shoulder external rotation, from -78° to -28° (p = 0.0001), whereas a significant difference was not reached in the graft group. When compared between groups, there appeared to be a trend favoring nerve transfer in shoulder external rotation, with the graft patients improving by 17° and the transfer patients improving by 49° (p = 0.07). CONCLUSIONS: In NBPP, patients with shoulder weakness experience statistically significant improvements in shoulder flexion and abduction after graft repair or nerve transfer, and patients with nerve transfers additionally experience significant improvement in external rotation. With regard to shoulder external rotation, there appear to be some data supporting the use of nerve transfers.

Persistence and Extent of Neonatal Brachial Plexus Palsy: Association with Number of Maneuvers and Duration of Shoulder Dystocia.

Objective The main objective of this article is to determine if persistence of neonatal brachial plexus palsy (NBPP) following shoulder dystocia was associated with maneuvers used or duration of impacted shoulder. Study Design Retrospective review of children with NBPP and documented shoulder dystocia. Student t -tests and chi-squared tests were used to compare outcomes when shoulder dystocia resolved with > 3 versus ≤ 3 maneuvers or duration > versus ≤ 120 seconds. Relative risk (RR) with 95% confidence intervals (CI) was calculated. Results Among 46 children with NBPP and shoulder dystocia, incidence of persistence was significantly higher at 2 years of age when > 3 versus ≤ 3 maneuvers were used (100 vs. 62%; RR: 1.6, 95% CI: 1.2-2.2). When resolution of impacted shoulder lasted >120 versus ≤ 120 seconds, NBPP at 2 years was significantly more likely (100 vs. 63%; RR: 1.6, 95% CI: 1.1-2.2). Injury to all five nerves of the brachial plexus was more likely if standard deviation lasted > 120 versus ≤ 120 seconds (RR: 2.2; 95% CI: 1.03-4.6). Conclusion Though the number of maneuvers used and duration of shoulder dystocia are associated with persistence of NBPP, the retrospective nature of the study of a selective cohort precludes recommendations changing the current management of shoulder dystocia.

The Presence and Persistence of Unrealistic Expectations in Patients Undergoing Nerve Surgery.

BACKGROUND: Unrealistic expectations of the outcomes of peripheral nerve surgery reduce patient satisfaction. Most clinicians can recall patients with unrealistic expectations despite verbal preoperative education. OBJECTIVE: To assess patients' baseline level of understanding regarding nerve surgery and appropriate expectations. Additionally, we tested the effect of a written, preoperative educational handout on the patients' retention of knowledge. METHODS: This cross-sectional survey recruited patients scheduled to undergo peripheral nerve surgery at a single institution in 2016 to 2017. During the preoperative visit, a specialized nurse practitioner reviewed perioperative protocols, risks and benefits of the surgery, and postoperative care. Patients immediately completed a survey to assess their preoperative understanding of the verbally reviewed information. During the same visit, an additional written handout was given to patients in a randomized fashion. At their first postoperative visit, all patients completed the survey again. RESULTS: A total of 60 patients (mean age 52 yr) were enrolled of which 62% were male. Immediately following verbal instruction, 31% of patients had erroneous (unrealistic) expectations regarding pain, 30% had erroneous expectations regarding postoperative motor outcome, and 41% had erroneous expectations regarding the timing of postoperative recovery. There was no significant difference between patients who received the written handout vs those who did not, on retesting in the postoperative period. CONCLUSION: Patients undergoing peripheral nerve procedures demonstrated a high baseline level of unrealistic expectations despite standard in-person verbal counseling by specialty providers. A written handout did not have clear benefit in the retention of preoperative surgical teaching. Further investigation into more effective preoperative patient counseling is needed.

Erratum: Persistence of Neonatal Brachial Plexus Palsy among Nulliparous Versus Parous Women.

[This corrects the article DOI: 10.1055/s-0038-1677051.].

Persistence of Neonatal Brachial Plexus Palsy among Nulliparous Versus Parous Women.

Objective Our objective was to compare persistence of neonatal brachial plexus palsy (NBPP) at 1 and 2 years in children of nulliparous versus parous women. Study Design We conducted a retrospective cohort study of children diagnosed with NBPP followed at the University of Michigan, Interdisciplinary Brachial Plexus Program (UM-BPP). Self-reported demographics, delivery history, including birth weight (BW) < versus ≥ 9 lbs, and presence of shoulder dystocia (SD) were recorded. Student's t -test and Chi-square test with odds ratio (OR) with 95% confidence intervals (CI) were calculated for comparisons of maternal, neonatal, and peripartum characteristics. Results Of 337 children with NBPP, 43% (146) were of nulliparas and 57% (191) of multiparas. At 1 year, children with persistent NBPP were similar in both groups (87% vs. 88%, aOR 1.357, 95% CI: 0.297-6.208). Persistent NBPP was not significantly different among nulliparous and multiparous women at 2 years (97% vs. 92% respectively, aOR 0.079, 95% CI: 0.006-1.050). Conclusion In one of the largest cohorts of NBPP, maternal parity did not influence the likelihood of NBPP persistence at 1 and 2 years.

Quantifying Real-World Upper-Limb Activity Via Patient-Initiated Movement After Nerve Reconstruction for Upper Brachial Plexus Injury.

BACKGROUND: A critical concept in brachial plexus reconstruction is the accurate assessment of functional outcomes. The current standard for motor outcome assessment is clinician-elicited, outpatient clinic-based, serial evaluation of range of motion and muscle power. However, discrepancies exist between such clinical measurements and actual patient-initiated use. We employed emerging technology in the form of accelerometry-based motion detectors to quantify real-world arm use after brachial plexus surgery. OBJECTIVE: To evaluate (1) the ability of accelerometry-based motion detectors to assess functional outcome and (2) the real-world arm use of patients after nerve transfer for brachial plexus injury, through a pilot study. METHODS: Five male patients who underwent nerve transfer after brachial plexus injury wore bilateral motion detectors for 7 d. The patients also underwent range-of-motion evaluation and completed multiple patient-reported outcome surveys. RESULTS: The average age of the recruits was 41 yr (±17 yr), and the average time from operation was 2 yr (±1 yr). The VT (time of use ratio) for the affected side compared to the unaffected side was 0.73 (±0.27), and the VM (magnitude ratio) was 0.63 (±0.59). VT strongly and positively correlated with shoulder flexion and shoulder abduction: 0.97 (P = .008) and 0.99 (P = .002), respectively. CONCLUSION: Accelerometry-based activity monitors can successfully assess real-world functional outcomes after brachial plexus reconstruction. This pilot study demonstrates that patients after nerve transfer are utilizing their affected limbs significantly in daily activities and that recovery of shoulder function is critical.

Comparative accuracies of electrodiagnostic and imaging studies in neonatal brachial plexus palsy.

OBJECTIVEThe incorporation of ancillary testing in the preoperative setting for patients with neonatal brachial plexus palsy (NBPP) remains controversial, but the recommendation for early nerve reconstruction when a baby has a preganglionic lesion at the lower nerve roots is generally accepted. At some specialty centers, nerve surgeons use preoperative electrodiagnostic testing (EDX) and imaging to aid in lesion localization and the preoperative planning of the nerve reconstruction. EDX and imaging have been evaluated for their abilities to detect pre- and postganglionic lesions, but their accuracies have never been compared directly in the same set of patients. The aim of the present study was to evaluate the accuracy of imaging and EDX in an NBPP population.METHODSA retrospective review was conducted of 54 patients with operative NBPP seen between 2007 and 2017. The patients underwent EDX and imaging: EDX was performed, and the results were reviewed by board-certified electrodiagnosticians, and imaging was reviewed by board-certified neuroradiologists. The gold standard was considered to be the findings at surgical exploration. Descriptive and analytical statistics were utilized to compare the accuracies of imaging and EDX.RESULTSThe mean age at surgery was 6.94 mos (± 4 mos). Fifteen patients (28%) were Narakas grade I-II, and 39 (72%) were Narakas grade III-IV. For all nerve roots, the overall accuracy of detecting preganglionic lesions was 74% for EDX and 69% for imaging. The overall sensitivity of detecting preganglionic lesions by EDX was 31%, but the specificity was 90%. The overall sensitivity of detecting preganglionic lesions by imaging was 66%, and the overall specificity was 70%. However, at C8, EDX was 37.5% sensitive and 87.5% specific, whereas imaging was 67.7% sensitive but only 29.4% specific.CONCLUSIONSEDX outperformed imaging with regard to specificity and accuracy of identifying preganglionic injuries. This finding is especially relevant in the lower nerve roots, given that lower plexus preganglionic lesions are an accepted indication for early intervention.

Effect of fascicle composition on ulnar to musculocutaneous nerve transfer (Oberlin transfer) in neonatal brachial plexus palsy.

OBJECTIVE Neonatal brachial plexus palsy (NBPP) continues to be a problematic occurrence impacting approximately 1.5 per 1000 live births in the United States, with 10%-40% of these infants experiencing permanent disability. These children lose elbow flexion, and one surgical option for recovering it is the Oberlin transfer. Published data support the use of the ulnar nerve fascicle that innervates the flexor carpi ulnaris as the donor nerve in adults, but no analogous published data exist for infants. This study investigated the association of ulnar nerve fascicle choice with functional elbow flexion outcome in NBPP. METHODS The authors conducted a retrospective study of 13 cases in which infants underwent ulnar to musculocutaneous nerve transfer for NBPP at a single institution. They collected data on patient demographics, clinical characteristics, active range of motion (AROM), and intraoperative neuromonitoring (IONM) (using 4 ulnar nerve index muscles). Standard statistical analysis compared pre- and postoperative motor function improvement between specific fascicle transfer (1-2 muscles for either wrist flexion or hand intrinsics) and nonspecific fascicle transfer (> 2 muscles for wrist flexion and hand intrinsics) groups. RESULTS The patients' average age at initial clinic visit was 2.9 months, and their average age at surgical intervention was 7.4 months. All NBPPs were unilateral; the majority of patients were female (61%), were Caucasian (69%), had right-sided NBPP (61%), and had Narakas grade I or II injuries (54%). IONM recordings for the fascicular dissection revealed a donor fascicle with nonspecific innervation in 6 (46%) infants and specific innervation in the remaining 7 (54%) patients. At 6-month follow-up, the AROM improvement in elbow flexion in adduction was 38° in the specific fascicle transfer group versus 36° in the nonspecific fascicle transfer group, with no statistically significant difference (p = 0.93). CONCLUSIONS Both specific and nonspecific fascicle transfers led to functional recovery, but that the composition of the donor fascicle had no impact on early outcomes. In young infants, ulnar nerve fascicular dissection places the ulnar nerve at risk for iatrogenic damage. The data from this study suggest that the use of any motor fascicle, specific or nonspecific, produces similar results and that the Oberlin transfer can be performed with less intrafascicular dissection, less time of surgical exposure, and less potential for donor site morbidity.

Prediction Algorithm for Surgical Intervention in Neonatal Brachial Plexus Palsy.

BACKGROUND: Neonatal brachial plexus palsy (NBPP) results in reduced function of the affected arm with profound ramifications on quality of life. Advances in surgical technique have shown improvements in outcomes for appropriately selected patients. Patient selection, however, remains difficult. OBJECTIVE: To develop a decision algorithm that could be applied at the individual patient level, early in life, to reliably predict persistent NBPP that would benefit from surgery. METHODS: Retrospective review of NBPP patients was undertaken. Maternal and neonatal factors were entered into the C5.0 statistical package in R (The R Foundation). A 60/40 model was employed, whereby 60% of randomized data were used to train the decision tree, while the remaining 40% were used to test the decision tree. The outcome of interest for the decision tree was a severe lesion meeting requirements for surgical candidacy. RESULTS: A decision tree prediction algorithm was generated from the entered variables. Variables utilized in the final decision tree included presence of Horner's syndrome, presence of a pseudomeningocele, Narakas grade, clavicle fracture at birth, birth weight >9 lbs, and induction or augmentation of labor. Sensitivity of the decision tree was 0.71, specificity 0.96, positive predictive value 0.94, negative predictive value 0.79, and F1 score 0.81. CONCLUSION: We developed a decision tree prediction algorithm that can be applied shortly after birth to determine surgical candidacy of patients with NBPP, the first of its kind utilizing only maternal and neonatal factors. This conservative decision tree can be used to offer early surgical intervention for appropriate candidates.

Oberlin transfer compared with nerve grafting for improving early supination in neonatal brachial plexus palsy.

OBJECTIVE The use of nerve transfers versus nerve grafting for neonatal brachial plexus palsy (NBPP) remains controversial. In adult brachial plexus injury, transfer of an ulnar fascicle to the biceps branch of the musculocutaneous nerve (Oberlin transfer) is reportedly superior to nerve grafting for restoration of elbow flexion. In pediatric patients with NBPP, recovery of elbow flexion and forearm supination is an indicator of resolved NBPP. Currently, limited evidence exists of outcomes for flexion and supination when comparing nerve transfer and nerve grafting for NBPP. Therefore, the authors compared 1-year postoperative outcomes for infants with NBPP who underwent Oberlin transfer versus nerve grafting. METHODS This retrospective cohort study reviewed patients with NBPP who underwent Oberlin transfer (n = 19) and nerve grafting (n = 31) at a single institution between 2005 and 2015. A single surgeon conducted intraoperative exploration of the brachial plexus and determined the surgical nerve reconstruction strategy undertaken. Active range of motion was evaluated preoperatively and postoperatively at 1 year. RESULTS No significant difference between treatment groups was observed with respect to the mean change (pre- to postoperatively) in elbow flexion in adduction and abduction and biceps strength. The Oberlin transfer group gained significantly more supination (100° vs 19°; p < 0.0001). Forearm pronation was maintained at 90° in the Oberlin transfer group whereas it was slightly improved in the grafting group (0° vs 32°; p = 0.02). Shoulder, wrist, and hand functions were comparable between treatment groups. CONCLUSIONS The preliminary data from this study demonstrate that the Oberlin transfer confers an advantageous early recovery of forearm supination over grafting, with equivalent elbow flexion recovery. Further studies that monitor real-world arm usage will provide more insight into the most appropriate surgical strategy for NBPP.

Patient-perceived surgical indication influences patient expectations of surgery for degenerative spinal disease.

OBJECTIVE: Patients frequently have misconceptions regarding diagnosis, surgical indication, and expected outcome following spinal surgery for degenerative spinal disease. In this study, we sought to understand the relationship between patient-perceived surgical indications and patient expectations. We hypothesized that patients reporting appendicular symptoms as a primary surgical indication would report a higher rate of having expectations met by surgery compared to those patients reporting axial symptoms as a primary indication. METHODS: Questionnaires were administered to patients who had undergone surgery for degenerative spinal disease at 2 tertiary care institutions. Questions assessed perception of the primary indication for undergoing surgery (radicular versus axial), whether the primary symptom improved after surgery, and whether patient expectations were met with surgery. Outcomes of interest included patient-reported symptomatic improvement following surgery and expectations met by surgery. Various factors were assessed for their relationship to these outcomes of interest. RESULTS: There were 151 unique survey respondents. Respondents were nearly split between having a patient-perceived indication for surgery as appendicular symptoms (55.6%) and axial symptoms (44.4%). Patient-perceived surgical indication being appendicular symptoms was the only factor predictive of patient-reported symptomatic improvement in our logistic regression model (OR 2.614; 95% CI 1.218-5.611). Patient-perceived surgical indication being appendicular symptoms (OR 3.300; 95% CI 1.575-6.944) and patient-reported symptomatic improvement (OR 33.297; 95% CI 12.186-90.979) were predictive of patients reporting their expectations met with surgery in both univariate and multivariate logistic regression modeling. CONCLUSIONS: We found that patient-reported appendicular symptoms as the primary indication for surgery were associated with a higher rate of both subjective improvement following surgery and having expectations met by surgery. Studies such as ours point to the fact that while performing technically superlative operations is paramount, it may be equally important to address other factors that help determine patient perception of the surgery experience.

Neonatal brachial plexus palsy: obstetric factors associated with litigation.

OBJECTIVE: Our objective was to compare characteristics between neonatal brachial plexus palsy (NBPP) cases that were litigated versus those that were not. STUDY DESIGN: From May to December 2012, the University of Michigan Interdisciplinary Brachial Plexus Program surveyed 51 consecutive families whose children were treated for NBPP. Obstetric data was self-reported. Unless NBPP resolved, children were followed for at least two years. Student's t-test and Chi-square test with odds ratio and 95% confidence intervals were calculated. RESULTS: Among 51 families surveyed, obstetric data were available for 98% (n = 50). Litigation was pursued by 48% (n = 24). Comparing families that litigated versus those that did not, there were no differences in demographics, peripartum characteristics, operative versus spontaneous vaginal birth, shoulder dystocia in current pregnancy (65% versus 54%; p = 0.56) or birth weight above 9 lbs. The number of children having brachial nerve surgery was significantly higher among families that litigated (46%) versus those that did not (8%; p = 0.002). CONCLUSION: Though there were no differences in peripartum events, almost 1 out of 2 children managed by interdisciplinary team had concomitant litigation. The only factor associated with litigation was having brachial nerve surgery. Efforts are warranted to avert NBPP and mitigate litigations.