Use of intercostal nerves for neurotization of the musculocutaneous nerve in infants with birth-related brachial plexus palsy

OBJECT: The use of intercostal nerves (ICNs) for the neurotization of the musculocutaneous nerve (MCN) in adult patients with traumatic brachial plexus palsy has been well described. However, its use for brachial plexus palsy in infants has rarely been reported. The authors surgically created 31 ICN-MCN communications for birth-related brachial plexus palsy and present the surgical results. METHODS: Thirty-one neurotizations of the MCN, performed using ICNs, were conducted in 30 patients with birth-related brachial plexus palsy. In most cases other procedures were combined to reconstruct all upper-extremity function. The mean patient age at surgery was 5.8 months and the mean follow-up period was 5.2 years. Intercostal nerves were transected 1 cm distal to the mammary line and their stumps were transferred to the axilla, where they were coapted directly to the MCN. Two ICNs were used in 26 cases and three ICNs in five cases. The power of the biceps muscle of the arm was rated Grade M4 in 26 (84%) of 31 patients. In the 12 patients who underwent surgery when they were younger than 5 months of age, all exhibited a grade of M4 (100%) in their biceps muscle power. These results are better than those previously reported in adults. CONCLUSIONS: Neurotization of the MCN by surgically connecting ICNs is a safe, reliable, and effective procedure for reconstruction of the brachial plexus in patients suffering from birth-related palsy.     

Intercostal nerve transfer in infants with obstetric brachial plexus palsy

The use of intercostal nerve (ICN) transfer to repair brachial plexus lesions associated with root avulsions is a well known procedure in adults. However, there is a paucity of reports on the use of ICN in infants with obstetrical brachial plexus palsy (OBPP). This study included 46 infants with obstetric brachial plexus palsy who underwent 62 neurotization procedures. Clinically, 2 cases had upper trunk injury, 19 had upper-middle trunk injury, 3 had lower trunk injury, and 22 had total palsy. The average age at surgery was 14 months. Twelve patients underwent surgery younger than 6 months of age, 11 patients at 6 to <9 months, 9 patients at 9-12 months, and 14 patients at >12 months. The average follow-up period was 49 months. ICN transfer resulted in 76% satisfactory (good and excellent) outcome, and was best for restoration of elbow flexion (93.5%). Functional results were best when the operation was done before the age of 9 months; however, the difference between age groups was statistically insignificant. Functional results were also independent of the extent of the original injury. Nine children had preoperative and postoperative CT chest scans. All the nine children developed basal pulmonary atelectasis postoperatively. Pulmonary atelectasis was mostly ipsilateral and was not correlated to the patient age (months), or the duration of anesthesia (in minutes). We conclude that, intercostals nerve transfer is an effective procedure for restoration of function in infants with OBPP and root avulsions. The procedure is associated with variable degree of ipsilateral pulmonary atelectasis.     

Phrenic nerve transfer for brachial plexus motor neurotization

We report a series of 164 patients who underwent phrenic neurotization to elements of the brachial plexus with root avulsion injuries. Recipient nerves included musculocutaneous nerve in 125 patients (78 direct neurotizations and 48 with intervening autograft), median nerve in 10 patients, and a variety of other nerves in 28 patients. Sixty-five patients presented a follow-up period of 2 or more years. Of this group, 55 patients (84.6%) achieved a recovery of M-3 or better. We observed no long-term deleterious effects on respiratory function.     

Finger movement at birth in brachial plexus birth palsy

AIM: To investigate whether the finger movement at birth is a better predictor of the brachial plexus birth injury. METHODS: We conducted a retrospective study reviewing pre-surgical records of 87 patients with residual obstetric brachial plexus palsy in study 1. Posterior subluxation of the humeral head (PHHA), and glenoid retroversion were measured from computed tomography or Magnetic resonance imaging, and correlated with the finger movement at birth. The study 2 consisted of 141 obstetric brachial plexus injury patients, who underwent primary surgeries and/or secondary surgery at the Texas Nerve and Paralysis Institute. Information regarding finger movement was obtained from the patient’s parent or guardian during the initial evaluation. RESULTS: Among 87 patients, 9 (10.3%) patients who lacked finger movement at birth had a PHHA > 40%, and glenoid retroversion < -12°, whereas only 1 patient (1.1%) with finger movement had a PHHA > 40%, and retroversion < -8° in study 1. The improvement in glenohumeral deformity (PHHA, 31.8% ± 14.3%; and glenoid retroversion 22.0°± 15.0°) was significantly higher in patients, who have not had any primary surgeries and had finger movement at birth (group 1), when compared to those patients, who had primary surgeries (nerve and muscle surgeries), and lacked finger movement at birth (group 2), (PHHA 10.7% ± 15.8%; Version -8.0°± 8.4°, P = 0.005 and P = 0.030, respectively) in study 2. No finger movement at birth was observed in 55% of the patients in this study group. CONCLUSION: Posterior subluxation and glenoid retroversion measurements indicated significantly severe shoulder deformities in children with finger movement at birth, in comparison with those lacked finger movement. However, the improvement after triangle tilt surgery was higher in patients who had finger movement at birth.     

Extraplexual neurotization of brachial plexus

The authors reviewed 62 neurotizations of the brachial plexus in 71 patients performed between 1974 and 1989. The nerves used were the accessory, the motor or sensory branches of the cervical plexus, and the intercostals. Twenty-five suprascapular nerves, 19 musculocutaneous, 4 medial roots of the median nerve, and 12 lateral roots of the median nerve were neurotized. The authors concluded that useful results can be achieved using extraplexual neurotizations. © 1994 Wiley-Liss, Inc.     

Axillary nerve neurotization with the anterior deltopectoral approach in brachial plexus injuries

Combined neurotization of both axillary and suprascapular nerves in shoulder reanimation has been widely accepted in brachial plexus injuries, and the functional outcome is much superior to single nerve transfer. This study describes the surgical anatomy for axillary nerve relative to the available donor nerves and emphasize the salient technical aspects of anterior deltopectoral approach in brachial plexus injuries. Fifteen patients with brachial plexus injury who had axillary nerve neurotizations were evaluated. Five patients had complete avulsion, 9 patients had C5, six patients had brachial plexus injury pattern, and one patient had combined axillary and suprascapular nerve injury. The long head of triceps branch was the donor in C5,6 injuries; nerve to brachialis in combined nerve injury and intercostals for C5‐T1 avulsion injuries. All these donors were identified through the anterior approach, and the nerve transfer was done. The recovery of deltoid was found excellent (M5) in C5,6 brachial plexus injuries with an average of 134.4° abduction at follow up of average 34.6 months. The shoulder recovery was good with 130° abduction in a case of combined axillary and suprascapular nerve injury. The deltoid recovery was good (M3) in C5‐T1 avulsion injuries patients with an average of 64° shoulder abduction at follow up of 35 months. We believe that anterior approach is simple and easy for all axillary nerve transfers in brachial plexus injuries. © 2012 Wiley Periodicals, Inc. Microsurgery, 2012.     

Surgical treatment of brachial plexus birth palsy.

Brachial plexus birth palsy remains a challenging condition. In the 1000 infants followed from 1977 to 1988, functional results were much improved over those obtained by observation only, if surgical exploration and repair were performed when no clinical recuperation of biceps function occurred by three months of age. Recovery is slow, and comprehensive follow-up study of reconstructed and conservatively managed children is required to prevent joint contractures. Children who will benefit from palliative procedures such as tendon transfers must also be identified.     

Posterior shoulder dislocation in infants with neonatal brachial plexus palsy

BACKGROUND: Glenoid dysplasia and posterior shoulder subluxation with resultant shoulder stiffness is a well-recognized complication in infants with neonatal brachial plexus palsy. It is generally considered to be the result of a slowly progressive glenohumeral deformation secondary to muscle imbalance, physeal trauma, or both. Recent publications about infantile posterior shoulder dislocation have suggested that the onset of dysplasia occurs at an earlier age than has been previously recognized. The prevalence of early dislocation in infants with this disorder has not been previously reported, to our knowledge. METHODS: We studied 134 consecutive infants with neonatal brachial plexus palsy who were seen at our institution over a period of two years. All infants were examined at monthly intervals to assess neurological recovery and the status of the upper extremity until recovery occurred or a treatment plan was established. The type of brachial plexus involvement was classified. Specific clinical signs associated with subluxation and dislocation were recorded. These included asymmetry of skin folds of the axilla or the proximal aspect of the arm, apparent shortening of the humeral segment, a palpable asymmetric fullness in the posterior region of the shoulder, or a palpable click during shoulder manipulation. The infants who were identified as having these clinical signs were evaluated with ultrasonographic imaging studies. RESULTS: Eleven (8%) of the 134 infants had a posterior shoulder dislocation. The mean age at the time of diagnosis was six months (range, three to ten months). There was no correlation between the occurrence of dislocation and the type of initial neurological deficit. A rapid loss of passive external rotation between monthly examinations indicated a posterior shoulder dislocation. CONCLUSIONS: Posterior shoulder dislocation can occur earlier (before the age of one year) and more rapidly in infants with neonatal brachial plexus palsy than has been appreciated previously. As with developmental dysplasia of the hip, a high index of suspicion, recognition of clinical signs, and the use of ultrasonography will allow the diagnosis to be established. Following early diagnosis, attention should be focused on improving the stability and congruency of the shoulder joint.     

Humeral retroversion and shoulder muscle changes in infants with internal rotation contractures following brachial plexus birth palsy

AIM To examine humeral retroversion in infants who sustained brachial plexus birth palsy(BPBI) and suffered from an internal rotation contracture. Additionally, the role of the infraspinatus(IS) and subscapularis(SSc) muscles in the genesis of this bony deformation is explored.METHODS Bilateral magnetic resonance imaging(MRI) scans of 35 infants(age range: 2-7 mo old) with BPBI were retrospectively analyzed. Retroversion was measured according to two proximal axes and one distal axis(transepicondylar axis). The proximal axes were:(1) the perpendicular line to the borders of the articular surface(humeral centerline); and(2) the longest diameter through the humeral head. Muscle cross-sectional areas of the IS and SSc muscles were measured on the MRI-slides representing the largest muscle belly. The difference in retroversion was correlated with the ratio of muscle-sizes and passive external rotation measurements.RESULTS Retroversion on the involved side was significantly decreased, 1.0° vs 27.6°(1) and 8.5° vs 27.2°(2),(P 0.01), as compared to the uninvolved side. The size of the SSc and IS muscles on the involved side was significantly decreased, 2.26 cm2 vs 2.79 cm2 and 1.53 cm2 vs 2.19 cm2, respectively(P 0.05). Furthermore, the muscle ratio(SSc/IS) at the involved side was significantly smaller compared to the uninvolved side(P = 0.007).CONCLUSION Even in our youngest patient population, humeral retroversion has a high likelihood of being decreased. Altered humeral retroversion warrants attention as a structural change in any child being evaluated for the treatment of an internal rotation contracture.     

External rotation humeral osteotomy for brachial plexus birth palsy

In patients with brachial plexus birth palsy, persistent muscular imbalance across the developing shoulder results in progressive glenohumeral dysplasia, characterized by increased glenoid retroversion, humeral head flattening, and posterior subluxation of the humeral head. Soft-tissue procedures-such as tendon transfers and musculotendinous lengthenings--will provide limited functional improvements in the setting of advanced glenohumeral deformity. For patients with internal rotation contracture and external rotation weakness associated with severe glenohumeral dysplasia, external rotation osteotomy of the humerus may be used to improve global shoulder function. The purpose of this article is to review the history, indications, and surgical technique of external rotation humeral osteotomy for patients with brachial plexus birth palsy.     

Long-term results of surgery for brachial plexus birth palsy

BACKGROUND: The long-term results of surgical treatment of brachial plexus birth palsy have not been reported. We present the findings of a nationwide study, with a minimum five-year follow-up, of the outcomes of surgery for brachial plexus birth palsy in Finland. METHODS: Of 1,717,057 newborns, 1706 with brachial plexus birth palsy requiring hospital treatment were registered in Finland between 1971 and 1997. Of these patients, 124 (7.3%) underwent surgery on the brachial plexus at a mean age of 2.8 months (range, 0.4 to 13.2 months). The most commonly performed surgical procedure was direct neurorrhaphy after neuroma resection. One hundred and twelve patients (90%) returned for a clinical and radiographic follow-up examination after a mean of 13.3 years. Activities of daily living were recorded on a questionnaire, and the affected limb was assessed with use of joint-specific functional measures. RESULTS: Two-thirds (63%) of the patients were satisfied with the functional outcome, although one-third of all patients needed help in activities of daily living. One-third of the patients, including all nine with a clavicular nonunion from the surgical approach, experienced pain in the affected limb. All except four patients used the hand of the unaffected limb as the dominant hand. Shoulder function was moderate, with a mean Mallet score of 3.0. Both elbow and hand function were good, with a mean score on the Gilbert elbow scale of 3 and a mean Raimondi hand score of 4. Incongruence of the glenohumeral joint was noted in sixteen (16%) of the ninety-nine patients in whom it was assessed, and incongruence of the radiohumeral joint was noted in twenty-one (21%). The extent of the brachial plexus injury was found to be strongly associated with the final shoulder, elbow, and hand function in a multivariate analysis. CONCLUSIONS: Following surgical treatment of brachial plexus birth palsy, substantial numbers of the patients continued to need help performing activities of daily living and had pain in the affected limb, with the pain due to a clavicular nonunion in one-fourth of the patients. The strongest prognostic factor predicting outcome appears to be the extent of the primary plexus injury.     

The evaluation and treatment of children with brachial plexus birth palsy

The Andrew J. Weiland Medal is presented by the American Society for Surgery of the Hand to a mid-career researcher dedicated to advancing patient care in the field of hand surgery. The Weiland Medal for 2010 was presented to the author at the annual meeting of the American Society for Surgery of the Hand. The purpose of this article is to present a decade of research directed at establishing and building evidence in support of effective treatment of adolescents and children impaired by nerve injury. The primary beneficiaries of this effort are children affected by brachial plexus injury. The research goals have been to better understand their underlying problems, improve their lives via advanced diagnostic and surgical techniques, and, by applying appropriate outcome measures, better appreciate the changes to their lives brought about by therapeutic interventions.     

Hypoglossal nerve transfer in obstetric brachial plexus palsy.

A cost-benefit analysis was performed of hypoglossal nerve transfer in six patients with obstetric brachial palsy taking into account the factors donor site morbidity and extent of recovery. Hypoglossal nerve transfer was employed in four children for elbow flexion only; in two patients for elbow flexion as well as for elbow extension. The transfer was part of an extended brachial plexus reconstruction for treatment of obstetric brachial plexus palsy. After a mean post-operative interval of 52 months (SD+/-8.1), two professional speech therapists investigated late donor site morbidity by analyzing elementary and communicative functions. The functional result for the arm was assessed using the Mallet scale and by performing a physical examination. Following hypoglossal nerve transfer, early donor site morbidity was significant causing great anxiety in the parents. Late donor site morbidity consisted of serious oral problems in a number of the children. They also showed clear associated movements in the arm during mouth/tongue activity. Recovery of powerful volitional elbow flexion was achieved in four cases only. We do not believe that the sacrifice of such an important function as exerted by the hypoglossal nerve is balanced by the gain demonstrated in our series.     

Living-donor nerve transplantation for global obstetric brachial plexus palsy

The first reported case of live-donor nerve transplantation is presented, performed in an 8-month-old infant with global obstetric brachial plexus palsy (OBPP) and four root avulsions who had undergone prior sural nerve autografting at 3 months. Cross-chest C7 nerve transfer and temporary tacrolimus/prednisone immunosuppression were utilized. Acute rejection was prevented, with no observable complications from the immunosuppressive medications, ipsilateral deficits resulting from the use of the contralateral C7 root as a donor nerve, or untoward effects on growth and development occurring over a 2-year follow-up period. Although some return of sensory and motor responses on nerve conduction studies was documented, the failure to observe a clinically significant functional improvement in the affected limb directly attributable to the transplant may have been due to performing the procedure too late and/or inadequate follow-up. Results of additional cases performed earlier than in this patient with longer follow-up will need to be evaluated to determine whether the procedure proves to be a viable therapeutic option for treatment of global OBPP with four or five root avulsions.