Faculty Bibliography

We retrospectively reviewed 26 patients who underwent reconstruction of the shoulder for a medial rotation contracture after birth injury of the brachial plexus. Of these, 13 patients with a mean age of 5.8 years (2.8 to 12.9) received an injection of botulinum toxin type A into the pectoralis major as a surgical adjunct. They were matched with 13 patients with a mean age of 4.0 years (1.9 to 7.2) who underwent an identical operation before the introduction of botulinum toxin therapy to our unit. Pre-operatively, there was no significant difference (p = 0.093) in the modified Gilbert shoulder scores for the two groups. Post-operatively, the patients who received the botulinum toxin had significantly better Gilbert shoulder scores (p = 0.012) at a mean follow-up of three years (1.5 to 9.8). It appears that botulinum toxin type A produces benefits which are sustained beyond the period for which the toxin is recognised to be active. We suggest that by temporarily weakening some of the power of medial rotation, afferent signals to the brain are reduced and cortical recruitment for the injured nerves is improved

BACKGROUND: Detailed evaluation of a brachial plexus birth injury is important for treatment planning. OBJECTIVE: To determine the diagnostic performance of MRI and MR myelography in infants with a brachial plexus birth injury. MATERIALS AND METHODS: Included in the study were 31 children with perinatal brachial plexus injury who underwent surgical intervention. All patients had cervical and brachial plexus MRI. The standard of reference was the combination of intraoperative (1) surgical evaluation and (2) electrophysiological studies (motor evoked potentials, MEP, and somatosensory evoked potentials, SSEP), and (3) the evaluation of histopathological neuronal loss. MRI findings of cord lesion, pseudomeningocele, and post-traumatic neuroma were correlated with the standard of reference. Diagnostic performance characteristics including sensitivity and specificity were determined. RESULTS: From June 2001 to March 2004, 31 children (mean age 7.3 months, standard deviation 1.6 months, range 4.8-12.1 months; 19 male, 12 female) with a brachial plexus birth injury who underwent surgical intervention were enrolled. Sensitivity and specificity of an MRI finding of post-traumatic neuroma were 97% (30/31) and 100% (31/31), respectively, using the contralateral normal brachial plexus as the control. However, MRI could not determine the exact anatomic area (i.e. trunk or division) of the post-traumatic brachial plexus neuroma injury. Sensitivity and specificity for an MRI finding of pseudomeningocele in determining exiting nerve injury were 50% and 100%, respectively, using MEP, and 44% and 80%, respectively, using SSEP as the standard of reference. MRI in infants could not image well the exiting nerve roots to determine consistently the presence or absence of definite avulsion. CONCLUSION: In children younger than 18 months with brachial plexus injury, the MRI finding of pseudomeningocele has a low sensitivity and a high specificity for nerve root avulsion. MRI and MR myelography cannot image well the exiting nerve roots to determine consistently the presence or absence of avulsion of nerve roots. The MRI finding of post-traumatic neuroma has a high sensitivity and specificity in determining the side of the brachial plexus injury but cannot reveal the exact anatomic area (i.e. trunk or division) involved. The information obtained is, however, useful to the surgeon during intraoperative evaluation of spinal nerve integrity for reconstruction

The purpose of this report is to discuss the association of brachial plexus palsy and congenital deformations. We reviewed all charts of patients less than 1 year of age with obstetrical brachial plexus palsy evaluated by one of the authors (IA) between January 1998 and October 2005 at Miami Children's Hospital Brachial Plexus Center. Of 158 patients with obstetrical brachial plexus palsy, 7 had deformations (4.4%). Deformations were present in 32% of patients delivered by cesarean section, but in only 2% of patients delivered vaginally. The deformations were ipsilateral, involving the chest in two patients, distal arms in two patients, proximal arm in one patient, ear in one patient, and the leg in one patient. All patients with deformations had unilateral Erb's palsies. None had a history of maternal uterine malformation. Two presumptive mechanisms of injury, one causing the deformation (compressive forces) and one causing brachial plexus palsy at the time of delivery (traction forces), were present in all cases. The higher incidence of deformation in patients with obstetrical brachial plexus palsy born by cesarean sections and the presence of two presumptive mechanisms in all of the cases presented here raises the possibility that fetal deformations are a risk factor for obstetrical brachial plexus palsy

Over a 5-year-period, 26 infants underwent a partial transfer of the spinal accessory nerve into the suprascapular nerve using a nerve graft, as part of the repair of a brachial plexus birth injury. At a minimum follow-up of 2.5 years, all children had shoulder function of Grade 4 or better using a modified Gilbert Scale. Average lateral rotation was measured at 53 degrees

Obstetrical brachial plexus injury occurs when the forces preventing the stretch of the brachial plexus are overcome by the forces stretching it. This report describes an 8-day-old male delivered by uncomplicated cesarean section with right obstetrical brachial plexus palsy and congenital arm atrophy. The patient had a history of decreased right arm movement detected by fetal ultrasound at 18 to 20 weeks of gestation. The purpose of this article is to report that stretching of brachial plexus at birth sufficient to produce a plexus injury may occur in a patient with a vulnerable plexus even in the absence of traction during delivery

Eleven children ranging in age from 9 to 21 months underwent late nerve reconstruction for persistent shoulder paralysis following an upper brachial plexus birth injury. Only neurolysis was performed in three patients. Neurolysis and nerve grafting bypassing the neuroma with proximal and distal end-to-side repairs was performed in the other eight. All patients were followed for 2 or more years. Two patients underwent a secondary procedure before their final follow-up evaluation. All infants demonstrated significant improvement when assessed by a modified Gilbert shoulder motion scale