Complete obstetric brachial plexus palsy: surgical improvement to recover a functional hand

Objective   Complete obstetrical brachial plexus palsy remains a difficult situation for the child and his/her family. The quality of spontaneous reinnervation is rarely good and always leads to a non-sensitive and non-functional hand, even if abduction of the shoulder and elbow flexion do spontaneously recover. The aim of this study was to assess the results from nerve reconstruction in cases of complete palsy and to demonstrate the effect of a change in surgical technique on the outcome of hand function. Methods   Thirty pediatric patients with complete obstetric brachial plexus palsy were operated on in our department between 1987 and 2003. Twenty-five of these patients were clinically reviewed and evaluated by a physiotherapist and a surgeon (not the surgeon who performed the surgery). Functional assessment was based on the Gilbert shoulder score, the Gilbert–Raimondi score for elbow function and the Raimondi hand score. All children underwent a nerve reconstruction as graft and/or intra- or extra-plexual neurotization. Our neural surgical strategy changed between 1995 and 1996 to one that addresses the function of the hand and the wrist. A secondary surgical intervention was required in 18 cases. The most frequent procedures were a radial rotation osteotomy and a tendon transfer restoring wrist extension. Results   Mean follow-up was 7 years and 10 months. Among children operated on with the first surgical strategy—the pre-1995–1996 period—hand function was good in three cases, satisfactory in four cases and unsatisfactory in one case. Among children for whom the second surgical strategy was used—1995–1996 and later—hand function was good or very good in eight cases, satisfactory in four cases and unsatisfactory in two cases. When the 25 patients were assessed for shoulder function, the functional result was good or very good in 12 cases, satisfactory in seven cases and unsatisfactory in six cases. In terms of elbow function, the results were good or very good in 14 cases, satisfactory in eight cases and unsatisfactory in three cases. All hands recovered sensation to a certain degree. Conclusion   The surgical results are encouraging in terms of shoulder and elbow function, but not as good for hand function. With the change in neural surgical strategy in 1995–1996, when more focus was placed on the hand (second surgical strategy), the results on hand function improved relative to those obtained with the first surgical strategy. It must also be noted that hand recovery requires more time, which may partially explain why functional results are not as good for the hand as for the shoulder and elbow. These results demonstrate that early surgical exploration is useful in complete obstetrical brachial plexus palsies and that there is a need for neural reconstruction of the lower trunk.     

Management of obstetrical brachial plexus palsy with early plexus microreconstruction and late muscle transfers

Birth brachial plexus injury usually affects the upper roots. In most cases, spontaneous reinnervation occurs in a variable degree. This aberrant reinnervation leaves characteristic deformities of the shoulder, elbow, forearm, wrist, and hand. Common sequelae are the internal rotation and adduction deformity of the shoulder, elbow flexion contractures, forearm supination deformity, and lack of wrist extension and finger flexion. Nowadays, the strategy in the management of obstetrical brachial plexus palsy focuses in close follow-up of the baby up to 3-6 months and if there are no signs of recovery, microsurgical repair is indicated. Nonetheless, palliative surgery consisting of an ensemble of secondary procedures is used to further improve the overall function of the upper extremity in patients who present late or fail to improve after primary management. These secondary procedures include transfers of free vascularized and neurotized muscles. We present and discuss our experience in treating early and/or late obstetrical palsies utilizing the above-mentioned microsurgical strategy and review the literature on the management of brachial plexus birth palsy.     

Secondary reanimation procedures in late obstetrical brachial plexus palsy patients

The varying degrees of spontaneous reinnervation that occur in untreated obstetrical brachial plexus palsy leave characteristic deformities of the shoulder, elbow, forearm, wrist, and hand. Common sequelae are internal rotation and adduction deformity of the shoulder, elbow flexion contractures, forearm supination deformity, and lack of wrist extension and finger flexion. Early microsurgical reconstruction of the affected plexus leads to a more rewarding overall function of the upper arm, but residual deformities might appear later which are similar, although less serious, than those observed in untreated cases. Secondary procedures of the shoulder, elbow, forearm, and hand will improve the appearance and function of the upper extremity in late cases of obstetrical brachial plexus. Careful preoperative planning is mandatory and a multistage approach should be applied, depending on the type of palsy and the age of the patient.     

Use of intercostal nerves for different target neurotization in brachial plexus reconstruction

Intercostal nerve transfer is a valuable procedure in devastating plexopathies. Intercostal nerves are a very good choice for elbow flexion or extension and shoulder abduction when the intraplexus donor nerves are not available. The best results are obtained in obstetric brachial plexus palsy patients, when direct nerve transfer is performed within six months from the injury. Unlike the adult posttraumatic patients after median and ulnar nerve neurotization with intercostal nerves, almost all obstetric brachial plexus palsy patients achieve protective sensation in the hand and some of them achieve active wrist and finger flexion. Use in combination with proper muscles, intercostal nerve transfer can yield adequate power to the paretic upper limb. Reinnervation of native muscles (i.e., latissimus dorsi) should always be sought as they can successfully be transferred later on for further functional restoration.     

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.     

Oberlin's ulnar nerve transfer to the biceps motor nerve in obstetric brachial plexus palsy: indications, and good and bad results

We present 7 children with obstetric brachial plexus palsy treated by transferring two motor fascicles out of the ulnar nerve to the biceps nerve. Three were male, and 4 were female. The left-side brachial plexus was affected in 4 patients, and the right side in 3 patients. All children had vaginal delivery; two of them presented with shoulder dystocia. The average birth weight was 4300 g (range, 3620-5500 g). Average age at time of operation was 16 months (range, 11-24 months). The indication for the operation was absent active elbow flexion with active shoulder abduction against gravity in 4 cases, and no biceps function and bad shoulder function in 3 cases. Oberlin's ulnar nerve transfer was done in 4 cases without brachial plexus exploration in those children with good shoulder function, and exploration of the brachial plexus was performed in the other 3 cases with bad shoulder function. The average follow-up was 19 months (range, 13-30 months). Five children had biceps muscle >or=M(3) with active elbow flexion against gravity, and 2 children had biceps muscle 相似文献   

Osteotomy of the Humerus to Improve External Rotation in Nine Patients with Brachial Plexus Palsy

Malfunction of the infraspinatus muscle and teres minor muscle illustrate the typical clinical picture in patients with brachial plexus palsy. The arm hangs down in an inwardly rotated position and elbow flexion is hindered by striking of the lower arm against the thorax. Between 1995 and 2000, we have done external rotational osteotomy of the humerus for nine patients with brachial plexus palsy. The mean age of the patients at the time of operation was 29 years (range 15 to 42). The mean follow-up time was 24 (6 to 69) months. Preoperatively, the patients all had appreciable deficits of external rotation (mean deficit 37°, range 10° to 70°). As a result of osteotomy, external rotation was improved in all patients, the mean increase being 42° (range 25° to 60°). All patients were subjectively content with the improved position of the arm and its function. They were able to move their hands to their faces without striking the lower arm against the chest on elbow flexion, or without compensatory evasive movement of the shoulder.     

Our experience with triceps nerve reconstruction in patients with brachial plexus injury

Although elbow extension is facilitated by gravity, triceps muscle provides elbow joint stability; in patients with brachial plexus injuries stable elbow is necessary for obtaining useful hand function. This study presents the senior author's experience with triceps nerve reconstruction and the functional results in patients with brachial plexus injuries. Outcomes were analyzed in relation to denervation time, severity score, length of the interposition nerve graft and donor nerves used. One hundred and sixty two patients with brachial plexus injury had triceps nerve neurotization and elbow extension recovery between 1978 and 2006. The mean patient's age was 25.45 ± 9.90 years and the mean denervation time was 16.90 ± 26.95 months. Two hundred and thirty two motor donors were used in 156 patients; 6 patients underwent neurolysis; 86 intercostal nerves were transferred in 41 patients. Interposition nerve grafts were used in 130 patients. Results were good or excellent in 31.65% of patients. The age of patients and the severity of the brachial plexus lesion are among the factors that significantly influenced functional results. Intraplexus motor donors are always preferable achieving better functional outcomes than extraplexus donors. Intercostal nerves and the posterior division of contralateral C7 proved preferred donors for elbow extension restoration in multiple avulsions. Although it is difficult to restore strong elbow extension, triceps nerve reconstruction is suggested in brachial plexus management, since it provides elbow stability. Satisfactory elbow extension strength was restored in young patients with high severity score.     

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.     

背阔肌双极移位重建产瘫儿童屈肘肌功能

目的：介绍和评价背阔肌双极移位重建臂丛神经产伤后屈肘肌功能障碍的手术方法和结果。方法：从1992年6月-2002年6月，本科共收治分娩性臂丛神经损伤病人36例，其中采取背阔肌双极移位治疗臂丛神经产伤后屈肘肌功能障碍10例，男4例，女6例，手术时平均年龄为7(5—12)岁，2例息儿在术后1年因肩关节连枷而行肩关节固定术。结果：本组10例病人术后平均随访3(1．5—6)年，肘关节屈曲肌力达到4级以上，手触嘴的功能均恢复，无神经血管束损伤等手术并发症。结论：臂丛神经产伤引起的屈肘肌功能障碍严重影响患儿的生活和学习能力，需要手术治疗。本组选择的背阔肌双极移位，具有操作相对简便、符合生物力学、并发症少和结果确实的优点，因此是一种值得推荐的手术方法。     

Neurophysiologic and clinical outcome following medial pectoral to long thoracic nerve transfer for scapular winging: a case report

The use of nerve transfers (neurotization) in the reconstruction of nerve palsy is not new, but its clinical efficacy is still largely based on reports of successful restoration of elbow flexion and shoulder abduction following brachial plexus avulsion. Although its potential application extends beyond the brachial plexus, little has been written about additional indications or associated postoperative outcomes. The case described in this report illustrates yet another indication for which neurotization may be a useful technique. Medial pectoral nerve transfer to the long thoracic nerve was performed via an 11-cm sural nerve graft to treat scapular winging 4 months following nerve injury caused during axillary node dissection. Neurophysiologic and clinical outcome 18 months postoperatively revealed successful reinnervation of the serratus anterior muscle, decreased scapular winging, and symptomatic improvement from the patient's perspective.     

A systematic review of nerve transfer and nerve repair for the treatment of adult upper brachial plexus injury

Nerve reconstruction for upper brachial plexus injury consists of nerve repair and/or transfer. Current literature lacks evidence supporting a preferred surgical treatment for adults with such injury involving shoulder and elbow function. We systematically reviewed the literature published from January 1990 to February 2011 using multiple databases to search the following: brachial plexus and graft, repair, reconstruction, nerve transfer, neurotization. Of 1360 articles initially identified, 33 were included in analysis, with 23 nerve transfer (399 patients), 6 nerve repair (99 patients), and 4 nerve transfer + proximal repair (117 patients) citations (mean preoperative interval, 6 ± 1.9 months). For shoulder abduction, no significant difference was found in the rates ratio (comparative probabilities of event occurrence) among the 3 methods to achieve a Medical Research Council (MRC) scale score of 3 or higher or a score of 4 or higher. For elbow flexion, the rates ratio for nerve transfer vs nerve repair to achieve an MRC scale score of 3 was 1.46 (P = .03); for nerve transfer vs nerve transfer + proximal repair to achieve an MRC scale score of 3 was 1.45 (P = .02) and an MRC scale score of 4 was 1.47 (P = .05). Therefore, for elbow flexion recovery, nerve transfer is somewhat more effective than nerve repair; however, no particular reconstruction strategy was found to be superior to recover shoulder abduction. When considering nerve reconstruction strategies, our findings do not support the sole use of nerve transfer in upper brachial plexus injury without operative exploration to provide a clear understanding of the pathoanatomy. Supraclavicular brachial plexus exploration plays an important role in developing individual surgical strategies, and nerve repair (when donor stumps are available) should remain the standard for treatment of upper brachial plexus injury except in isolated cases solely lacking elbow flexion.     

Bilateral elbow flexion reconstruction with functioning free muscle transfer for obstetric brachial plexus palsy

A child suffered a bilateral obstetric brachial plexus palsy involving the C5 and C6 nerve roots. Abduction of the shoulder joints had recovered by 1 year, but elbow flexion did not recover on either side. Free gracilis muscle transfers were performed on both sides, at an interval of 6 months, to achieve elbow flexion. The spinal accessory nerve was used as the donor nerve.     

产瘫后肩关节内旋挛缩畸形的手术治疗

目的：介绍用肩胛下肌起点剥离术及前路松解术，治疗产瘫后肩关节内旋挛缩后遗症的方法及疗效。方法：对３６例经盂肱角测定、肩关节中立位被动外旋及Ｘ线诊断为肩关节内旋挛缩的患儿，采用肩胛下肌起点剥离或止点延长、关节复位及继发性畸形纠正等手术进行治疗。用Ｍａｌｅｔ评分及Ｇｉｌｂｅｒｔ分级两项定量评价系统来评价术前、术后功能。结果：术后随访半年，３２例有效，有效率为８８．８％。年龄愈小疗效愈佳。４例无效者，３例术前无屈肘功能，提示臂丛上干恢复差；１例肩胛下肌止点切断后未作重建。结论：肩胛下肌起点剥离术或前路松解术，是治疗产瘫后肩内旋挛缩的有效方法，疗效与患儿年龄及臂丛上干的恢复程度密切相关     

Function of the upper limb after surgery for obstetric brachial plexus palsy

We reviewed a consecutive series of 33 infants who underwent surgery for obstetric brachial plexus palsy at a mean age of 4.7 months. Of these, 13 with an upper palsy and 20 with a total palsy were treated by nerve reconstruction. Ten were treated by muscle transfer to the shoulder or elbow, and 16 by tendon transfer to the hand. The mean postoperative follow-up was 4 years 8 months. Ten of the 13 children (70%) with an upper palsy regained useful shoulder function and 11 (75%) useful elbow function. Of the 20 children with a total palsy, four (20%) regained useful shoulder function and seven (35%) useful elbow function. Most patients with a total palsy had satisfactory sensation of the hand, but only those with some preoperative hand movement regained satisfactory grasp. The ability to incorporate the palsied arm and hand into a co-ordinated movement pattern correlated with the sensation and prehension of the hand, but not with shoulder and elbow function.     

Functional contribution of T1 to the brachial plexus in infants

To determine the contribution of the T1 root to movements of the upper limb in infancy, 40 infants presenting with obstetrical brachial plexus palsy who underwent resection and reconstruction of all brachial plexus roots with the exception of the T1 root were assessed in the early postoperative period. The movements of the limb were recorded using the Hospital for Sick Children active movement scale and demonstrated considerable variability. All movements of the upper limb were observed in this group with the exception of external rotation of the shoulder and elbow flexion. Classical accounts of the function of T1 have limited its activity to the small muscles of the hand and were based on anatomical dissection, brachial plexus injuries and electrical stimulation. By contrast, this study isolated the physiological activity of T1 and analysed the functional contribution of this root to arm movement. We show a greater than generally recognized contribution of T1 to the function of the upper limb in infants.     

Osteotomy of the humerus to improve external rotation in nine patients with brachial plexus palsy.

Malfunction of the infraspinatus muscle and teres minor muscle illustrate the typical clinical picture in patients with brachial plexus palsy. The arm hangs down in an inwardly rotated position and elbow flexion is hindered by striking of the lower arm against the thorax. Between 1995 and 2000, we have done external rotational osteotomy of the humerus for nine patients with brachial plexus palsy. The mean age of the patients at the time of operation was 29 years (range 15 to 42). The mean follow-up time was 24 (6 to 69) months. Preoperatively, the patients all had appreciable deficits of external rotation (mean deficit 37 degrees, range 10 degrees to 70 degrees). As a result of osteotomy, external rotation was improved in all patients, the mean increase being 42 degrees (range 25 degrees to 60 degrees). All patients were subjectively content with the improved position of the arm and its function. They were able to move their hands to their faces without striking the lower arm against the chest on elbow flexion, or without compensatory evasive movement of the shoulder.     

Nerve repairs for traumatic brachial plexus palsy with root avulsion

Thirty-six patients with traumatic brachial plexus lesions and root avulsions were treated surgically between 1972 and 1986 and were followed for more than 24 months (average, 42.6 months). Neurotization of the musculocutaneous nerve with intercostal nerves or the spinal accessory nerve resulted in satisfactory elbow flexion in 21 of the 33 cases (64%). Combined nerve repairs (i.e., intercostal and spinal accessory neurotization of the terminal branch of the brachial plexus in combination with nerve grafts from the upper spinal nerves of the brachial plexus) created a useful function in at least one functional level of the upper limb for 11 of the 15 cases so treated. Nerve repairs resulted in stability of the shoulder and elbow function controllable with a sensible hand for patients with root avulsion injury of the brachial plexus.     

Glenohumeral arthrodesis in upper and total brachial plexus palsy. A comparison of functional results

We have compared the functional outcome after glenohumeral fusion for the sequelae of trauma to the brachial plexus between two groups of adult patients reviewed after a mean interval of 70 months. Group A (11 patients) had upper palsy with a functional hand and group B (16 patients) total palsy with a flail hand. All 27 patients had recovered active elbow flexion against resistance before shoulder fusion. Both groups showed increased functional capabilities after glenohumeral arthrodesis and a flail hand did not influence the post-operative active range of movement. The strength of pectoralis major is a significant prognostic factor in terms of ultimate excursion of the hand and of shoulder strength. Glenohumeral arthrodesis improves function in patients who have recovered active elbow flexion after brachial plexus palsy even when the hand remains paralysed.     

Accessory nerve neurotization in infants with brachial plexus birth palsy

We report the surgical results of 13 accessory nerve neurotizations in brachial plexus birth palsy. The mean age at operation was 5.9 months. The accessory nerve was transferred to three C5 roots, to three C6 roots, to four posterior division of the middle trunks, to one musculocutaneous nerve, and to two suprascapular nerves. Sixty-seven percent of the cases acquired M4 or more in the deltoid muscle, 88% in the infraspinatus muscle, and 100% in the biceps brachii muscle. Twenty-five percent of the cases acquired M4 or more in the triceps brachii muscle and the wrist extensor muscles. These results were much better than formerly reported for adult cases by other authors. No functional compromise of the trapezius muscle was noted. The accessory nerve neurotization can be used safely and effectively in neurosurgical reconstruction of the brachial plexus palsy in infants. © 1994 Wiley-Liss, Inc.