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Total obstetric brachial plexus palsy: results and strategy of microsurgical reconstruction
Tarek A El-Gammal1, Amr El-Sayed, Mohamed M Kotb
1Department of Orthopedics and Traumatology, Reconstructive Microsurgery Unit, Assiut University School of Medicine, Assiut 71526, Egypt. tarek_elgammal@yahoo.com
Insights
Early surgical intervention for obstetric brachial plexus palsy improves outcomes. Reconstruction techniques like intercostal neurotization for elbow flexion and nerve grafting show promising results in infants, with earlier surgery correlating to better functional recovery.
Area of Science:
- Pediatric Surgery
- Neurology
- Orthopedics
Background:
- Obstetric brachial plexus palsy (OBPP) is a significant birth injury affecting infant arm function.
- Surgical reconstruction aims to restore nerve function and improve limb use in affected children.
- Limited data exists on long-term functional outcomes following various surgical interventions for OBPP.
Purpose of the Study:
- To evaluate the functional outcomes of surgical exploration and reconstruction in infants with total obstetric brachial plexus palsy.
- To identify the efficacy of different surgical techniques, including neurotization and nerve grafting.
- To determine the correlation between age at surgery and functional recovery in OBPP patients.
Main Methods:
- Retrospective analysis of 35 infants with total OBPP undergoing brachial plexus exploration and reconstruction between 2000-2006.
- Surgical procedures included neurolysis, neuroma excision, interposition nerve grafting, and neurotization (spinal accessory, intercostals, contralateral C7).
- Functional assessment using the Toronto Active Movement scale and Raimondi score, with a minimum 2.5-year follow-up.
Main Results:
- Satisfactory recovery rates varied by function: elbow flexion (75.1%), elbow extension (77.1%), finger flexion (61.1%), shoulder abduction (37.1%), and external rotation (54.3%).
- 53% of patients achieved a functional hand (Raimondi score ≥ 3), with significant postoperative improvement (mean 2.73 vs. 1 preoperatively).
- Earlier age at surgery showed a significant negative correlation with functional outcomes.
Conclusions:
- Early surgical intervention is crucial for optimizing functional recovery in obstetric brachial plexus palsy.
- Intercostal neurotization is effective for restoring elbow flexion; tendon transfers may aid external rotation.
- Specific guidelines are proposed for managing intact nerve roots based on recovery, Horner's syndrome, and age at surgery.
Abstract:
From 2000 to 2006, 35 infants with total obstetric brachial plexus palsy underwent brachial plexus exploration and reconstruction. The mean age at surgery was 10.8 months (range 3-60 months), and the median age was 8 months. All infants were followed for at least 2.5 years (range 2.5-7.3 years) with an average follow-up of 4.2 years. Assessment was performed using the Toronto Active Movement scale. Surgical procedures included neurolysis, neuroma excision and interposition nerve grafting and neurotization, using spinal accessory nerve, intercostals and contralateral C7 root. Satisfactory recovery was obtained in 37.1% of cases for shoulder abduction; 54.3% for shoulder external rotation; 75.1% for elbow flexion; 77.1% for elbow extension; 61.1% for finger flexion, 31.4% for wrist extension and 45.8% for fingers extension. Using the Raimondi score, 18 cases (53%) achieved a score of three or more (functional hand). The mean Raimondi score significantly improved postoperatively as compared to the preoperative mean: 2.73 versus 1, and showed negative significant correlation with age at surgery. In total, obstetrical brachial plexus palsy, early intervention is recommended. Intercostal neurotization is preferred for restoration of elbow flexion. Tendon transfer may be required to improve external rotation in selected cases. Apparently, intact C8 and T1 roots should be left alone if the patient has partial hand recovery, no Horner syndrome, and was operated early (3- or 4-months old). Apparently, intact nonfunctioning lower roots with no response to electrical stimulation, especially in the presence of Horner syndrome, should be neurotized with the best available intraplexal donor.
