Surgical Reconstruction of Isolated Upper Trunk Brachial Plexus Birth Injuries in the Presence of an Avulsed C5 or C6 Nerve Root.

BACKGROUND: Avulsion of either the C5 or C6 root with intact middle and lower trunks in brachial plexus birth injury is rare. In these cases, only 1 proximal root is available for intraplexal reconstruction. The purpose of the present study was to determine the outcomes of these patients when single-root reconstruction was balanced across the anterior and posterior elements of the upper trunk. METHODS: We performed a retrospective cohort study of prospectively collected data for patients with brachial plexus birth injury who underwent primary nerve reconstruction between 1993 and 2014. Patients were included who had isolated upper-trunk injuries with intact middle and lower trunks. The study group had avulsion of either the C5 or C6 root. The control group had neuroma-in-continuity or ruptures of the upper trunk. Outcomes were assessed with use of the Active Movement Scale and the Brachial Plexus Outcome Measure. The Wilcoxon signed-rank test was utilized to evaluate changes across treatment. RESULTS: Ten patients with brachial plexus birth injury were included in the avulsion cohort. Surgical reconstruction entailed neuroma resection and nerve grafting from the single available root balanced across all distal targets with or without spinal accessory-to-suprascapular nerve transfer. Significant improvements were observed across treatment for both the avulsion and control groups in terms of shoulder abduction, shoulder flexion, external rotation, elbow flexion, and supination. At a mean follow-up of 54.5 ± 8.8 months, patients in the avulsion group achieved Active Movement Scale scores of 6.8 ± 0.4 for elbow flexion and 6.5 ± 0.9 for shoulder flexion and abduction, with lesser recovery observed in external rotation (3.3 ± 2.8). All patients available for Brachial Plexus Outcome Measure assessments demonstrated functional movement. CONCLUSIONS: In the setting of avulsion of 1 upper-trunk root, nerve reconstruction by grafting of the upper trunk from the other upper-trunk root provides improved movement, high Active Movement Scale scores, and satisfactory function according to the Brachial Plexus Outcome Measure. These data provide support for a strategy that ensures the entire upper trunk is adequately reconstructed in the setting of upper-trunk lesions. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Surgical Reconstruction of Isolated Upper Trunk Brachial Plexus Birth Injuries in the Presence of an Avulsed C5 or C6 Nerve Root.

BACKGROUND: Avulsion of either the C5 or C6 root with intact middle and lower trunks in brachial plexus birth injury is rare. In these cases, only 1 proximal root is available for intraplexal reconstruction. The purpose of the present study was to determine the outcomes of these patients when single-root reconstruction was balanced across the anterior and posterior elements of the upper trunk. METHODS: We performed a retrospective cohort study of prospectively collected data for patients with brachial plexus birth injury who underwent primary nerve reconstruction between 1993 and 2014. Patients were included who had isolated upper-trunk injuries with intact middle and lower trunks. The study group had avulsion of either the C5 or C6 root. The control group had neuroma-in-continuity or ruptures of the upper trunk. Outcomes were assessed with use of the Active Movement Scale and the Brachial Plexus Outcome Measure. The Wilcoxon signed-rank test was utilized to evaluate changes across treatment. RESULTS: Ten patients with brachial plexus birth injury were included in the avulsion cohort. Surgical reconstruction entailed neuroma resection and nerve grafting from the single available root balanced across all distal targets with or without spinal accessory-to-suprascapular nerve transfer. Significant improvements were observed across treatment for both the avulsion and control groups in terms of shoulder abduction, shoulder flexion, external rotation, elbow flexion, and supination. At a mean follow-up of 54.5 ± 8.8 months, patients in the avulsion group achieved Active Movement Scale scores of 6.8 ± 0.4 for elbow flexion and 6.5 ± 0.9 for shoulder flexion and abduction, with lesser recovery observed in external rotation (3.3 ± 2.8). All patients available for Brachial Plexus Outcome Measure assessments demonstrated functional movement. CONCLUSIONS: In the setting of avulsion of 1 upper-trunk root, nerve reconstruction by grafting of the upper trunk from the other upper-trunk root provides improved movement, high Active Movement Scale scores, and satisfactory function according to the Brachial Plexus Outcome Measure. These data provide support for a strategy that ensures the entire upper trunk is adequately reconstructed in the setting of upper-trunk lesions. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

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.

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.

Pain in children following microsurgical reconstruction for obstetrical brachial plexus palsy.

PURPOSE: To determine the prevalence and characteristics of pain experienced by children who have had microsurgical reconstruction for obstetrical brachial plexus palsy (OBPP). METHODS: A prospective case series study was conducted of 65 children aged 6 to 18 years with a diagnosis of OBPP and who had microsurgery at less than 12 months of age with nerve grafting or transfer. A total of 28 patients (43%) had upper OBPP and 37 (57%) had total OBPP. We evaluated pain using the Faces Pain Scale-Revised and the Adolescent Pediatric Pain Tool. Sensory symptoms in the affected limb were also collected. Mean age was 11.0 ± 3.3 years. RESULTS: We evaluated 65 children. The point prevalence of pain (pain at the time of assessment) was 25%. The reported lifetime prevalence of pain (experienced anytime during life) was 66%. A total of 71% reported that the affected extremity felt different at least once in their lifetime. Average intensity of those with pain (n = 43) was 40 ± 19 mm on a 100-mm visual analog scale. Seventy percent of children reported that symptoms occurred every day or at least once a week. Anatomical distribution of pain was throughout the affected upper extremity irrespective of the severity of injury, with the exception of children with upper plexus injuries who did not report pain in their hand. Words typically used to describe neuropathic or musculoskeletal symptoms were chosen by the children to represent their pain. CONCLUSIONS: Children with OBPP who had microsurgical reconstruction commonly reported pain. These symptoms were typically frequent but were episodic and low in intensity. The descriptions of the type of pain include terms typical of both neuropathic and musculoskeletal origins. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Extending the indications for primary nerve surgery in obstetrical brachial plexus palsy.

PURPOSE: This study identifies a small subset of patients with obstetrical brachial plexus palsy who, while they do not meet common surgical indications, may still benefit from primary nerve surgery. METHODS: Between April 2004 and April 2009, 17 patients were offered primary nerve surgery despite not meeting the standard surgical indications of the authors. The authors performed a retrospective analysis of these 17 patients using prospectively collected data. RESULTS: This group of 17 patients were identified as having poor shoulder function at about 9 months of age despite passing the Cookie Test. Fourteen patients underwent surgical intervention and three families declined surgery. All patients in the operative group regained some active external rotation after surgery. Five patients in this group have required further interventions. Two of the three patients for whom surgery was declined have had no subsequent spontaneous improvement in active external rotation. DISCUSSION: The commonly used indications for primary nerve surgery in obstetrical brachial plexus palsy may not adequately identify all patients who may benefit from surgical intervention. Patients who pass the Cookie Test but have poor spontaneous recovery of active shoulder movements, particularly external rotation, may still benefit from primary nerve surgery.

Botulinum toxin for the treatment of motor imbalance in obstetrical brachial plexus palsy.

BACKGROUND: Residual muscle imbalance is a common problem affecting obstetrical brachial plexus palsy patients. The goal of this study was to examine the efficacy of botulinum toxin type A (Botox) in improving this muscle imbalance. METHODS: The authors retrospectively reviewed obstetrical brachial plexus palsy patients treated with Botox for muscle imbalance as an isolated procedure. Outcomes were the change in Active Movement Scale scores from pre-Botox scores to scores at 1 month after Botox and 1 year after Botox. RESULTS: Twenty-seven patients were included, 19 treated for shoulder imbalance and eight treated for elbow imbalance. Active Movement Scale scores (mean±SD) for shoulder external rotation improved from 0.6±1.0 before Botox to 2.6±2.14 (p<0.01) at 1 month after Botox, and declined to 1.3±1.2 (p<0.01) at 1 year after Botox. Scores for elbow flexion were 3.3±2.1 before Botox, unchanged at 4.4±1.8 (p=0.07) 1 month after Botox, and improved to 5.8±0.5 (p<0.01) at 1 year after Botox. Scores for elbow supination were 2.9±1.7 before Botox and 3.4±1.5 (p=0.2) at 1 month after Botox, and improved to 3.9±2.0 (p<0.01) at 1 year after Botox. CONCLUSIONS: Botox for shoulder movement imbalance produces improvement in external rotation that is not sufficiently sustained over time to be of clinical benefit. However, Botox for elbow movement imbalance produces a sustained and clinically useful improvement. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The brachial plexus outcome measure: development, internal consistency, and construct validity.

PURPOSE: The purpose of this article was to report the development of a new assessment tool, the Brachial Plexus Outcome Measure (BPOM) and the evaluation of its internal consistency and construct validity. METHODS: A retrospective case series of children aged 4-19 years with obstetrical brachial plexus palsy (OBPP) was conducted. Intraclass coefficients were calculated for the BPOM Activity Scale items. Correlation between the Active Movement Scale (AMS) and BPOM Activity Scale scores were conducted to determine the convergent validity. RESULTS: The BPOM Activity Scale items (N=306) had good internal consistency (Cronbach's α=0.87). A strong correlation between the BPOM Activity Scale and AMS (n=284) was found (r=0.71, p=0.001, α=0.05). CONCLUSIONS: The BPOM Activity Scale demonstrates good internal consistency and construct validity as a discriminative functional outcome measure in children with OBPP. LEVEL OF EVIDENCE: IV.

Radial nerve palsy in the newborn: a case series.

BACKGROUND: Peripheral nerve palsies of the upper extremities presenting at birth can be distressing for families and care providers. It is therefore important to be able to identify patients whose diagnosis is compatible with full recovery so that their families can be reassured. METHODS: We conducted a retrospective review of all infants presenting with weakness of the upper extremity to our clinic between July 1995 and September 2009. We also conducted a review of the current literature. RESULTS: During the study period, 953 infants presented to our clinic. Of these patients, 25 were identified as having isolated radial nerve palsy (i.e., a radial nerve palsy in isolation with good shoulder function and intact flexion of the elbow). Seventeen infants (68.0%) had a subcutaneous nodule representing fat necrosis in the inferior posterolateral portion of the affected arm. Full recovery occurred in all patients within a range of one week to six months, and 72.0% of the patients (18/25) had fully recovered by the time they were two months old. INTERPRETATION: Although the outcome of obstetrical brachial plexus palsy is highly variable, isolated radial nerve palsy in the newborn carries a uniformly favourable prognosis.

Suprascapular nerve reconstruction in obstetrical brachial plexus palsy: spinal accessory nerve transfer versus C5 root grafting.

BACKGROUND: The purpose of this study was to determine whether there is any difference in external rotation following reconstruction of the suprascapular nerve using nerve grafts from the proximal C5 root or nerve transfer using the spinal accessory nerve. METHODS: External rotation was assessed using the Active Movement Scale immediately before surgery and 3 years postoperatively. Patients with less than 3 years of follow-up were excluded. For patients who underwent secondary shoulder surgery before the 3-year follow-up, the Active Movement Scale score before shoulder surgery was used as the outcome. RESULTS: One-hundred-six patients underwent nerve grafting, while 71 patients underwent spinal accessory nerve transfer. The spinal accessory nerve transfer group had a greater proportion of patients with total plexus palsies, more avulsions, and an earlier age at surgery (p < 0.001). In the C5 nerve graft group, the mean Active Movement Scale score increased from 0.4 to 2.2 (p < 0.001). In the nerve transfer group, the mean score increased from 0.2 to 3.0 (p < 0.001). Preoperatively, the C5 nerve graft group had significantly better scores than the nerve transfer group (p = 0.03). Postoperatively, there was no significant difference between treatments (p = 0.1). Further statistical analysis failed to demonstrate a significant advantage of one surgical treatment over the other. CONCLUSIONS: There was no difference in external rotation after suprascapular nerve reconstruction with either nerve grafting from the proximal C5 root or spinal accessory nerve transfer. The choice of suprascapular nerve reconstruction can be selected depending on specific requirements of the individual lesion.

Final results of grafting versus neurolysis in obstetrical brachial plexus palsy.

BACKGROUND: The authors previously showed that neurolysis in obstetrical brachial plexus palsy resulted in improved function in some patients at 1 year's follow-up. In this study, the hypothesis that the long-term outcome of neuroma-in-continuity resection and nerve grafting yields better results than neurolysis was tested. METHODS: Obstetrical brachial plexus palsy patients treated with primary nerve surgery with a minimum follow-up of 4 years were studied. Patients were classified as undergoing neurolysis (n = 16) or resection and grafting (n = 92) and separated into Erb's or total palsy groups. The Active Movement Scale was used for patient evaluation. Changes in Active Movement Scale scores were analyzed using the Wilcoxon signed rank test. Fifteen movements were tested, and the proportion of patients in each group with scores deemed functionally useful (6 or 7) was compared using McNemar's exact test. RESULTS: After 4 years' follow-up, Erb's palsy neurolysis patients showed no improvement in function. Conversely, Erb's palsy grafting patients had improved function in seven movements. Total palsy neurolysis patients showed no improvement in function, whereas grafted patients showed improved function in 11 of 15 movements. CONCLUSIONS: Early improvements in function produced by neurolysis in Erb's palsy were not sustained over time. Neuroma-in-continuity resection and nerve grafting for both Erb's and total palsy produced significant improvements in Active Movement Scores and in the proportion of patients demonstrating functionally useful scores. Neurolysis as a complete surgical treatment for obstetrical brachial plexus palsy should be abandoned in favor of neuroma resection and nerve grafting.

Evaluation of elbow flexion as a predictor of outcome in obstetrical brachial plexus palsy.

BACKGROUND: The purpose of this study was to answer two questions. First, are there obstetrical brachial plexus palsy patients with no elbow flexion at 3 months who go on to recover useful upper extremity function without surgical intervention? Second, are there patients with evidence of elbow flexion at 3 months who do benefit from brachial plexus reconstruction? METHODS: The authors retrospectively reviewed a sample drawn from 253 consecutive patients at The Hospital for Sick Children obstetrical brachial plexus database from 1993 to 1996. Inclusion criteria were examination at age 3 months and either complete spontaneous recovery or repeated examination after age 3 years. Two hundred nine patients satisfied the inclusion criteria. Patients were distributed into four groups: group A, no elbow flexion at age 3 months (operative management); group B, elbow flexion present at 3 months (operative management); group C, no elbow flexion at age 3 months (nonoperative management); and group D, elbow flexion present at 3 months (nonoperative management). RESULTS: Groups A, B, and C showed significant intragroup improvements in both elbow flexion (p < 0.0001) and total limb motion scores (the sum of 15 individual joint motions) (p < 0.0001) with time. No differences were noted among groups A, B, and C for either elbow flexion or total limb motion scores at final follow-up. CONCLUSIONS: Early elbow flexion alone is not a sufficient criterion to recommend a nonoperative approach. In addition, spontaneous recovery of useful upper extremity function has been observed in a carefully selected subset of patients without elbow flexion at 3 months.

Pediatric Evaluation of Disability Inventory: its application to children with obstetric brachial plexus palsy.

PURPOSE: A standardized method of measurement of self-care ability in children with obstetric brachial plexus palsy (OBPP) has not been universally adopted. A study was conducted to determine if the Pediatric Evaluation of Disability Inventory (PEDI) was able to discriminate between the self-care ability of children with OBPP and their peers and distinguish between those with differing severities of OBPP. METHODS: The PEDI self-care domain results for 45 children with OBPP (30 without hand impairment, 15 with hand impairment) were reviewed retrospectively. RESULTS: The group performance of children without hand impairment was within 1 SD above the mean. The group performance of children with hand impairment was more than 2 SDs below the mean. The difference between the 2 groups was statistically significant. CONCLUSIONS: In this study children without hand impairment did not have a self-care activity limitation as measured by the PEDI. A deficit in self-care ability was found in those with hand impairment. The PEDI was able to differentiate between the performances of reported self-care activities of children with differing severities of OBPP; however, it was unable to discriminate between those without hand impairment and their peers. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic, Level II.