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When and how to operate on a child with BPBP. Its severity. Types of surgery

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MInitial management of newborns with congenital brachial plexus palsy

When a baby is born with a BPBP, it is advisable to begin with passive movements (movements that we do or a physical therapist does to our child) of the joints that do not move, to prevent both joint stiffness and deformities. The MOST important movement is the shoulder external rotation (Figure 9), in order to avoid internal rotation contracture of the shoulder and the further development of deformity of the shoulder (glenohumeral dysplasia).
 

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Figure 9. With one hand we fixate the scapula to the thorax. With the other hand we fixate the arm to the chest, we flex the elbow to 90 ° and perform external rotation of the shoulder (by moving his hand out).


When to operate? Types of nerve injury and indications for surgery

The indications for surgical intervention depend on the type of injury and number of injured nerve roots. At birth, nerves can be injured in the spine (avulsion injury) or in the neck (rupture injury).

Avulsions are not capable of spontaneous regeneration and therefore require surgery at an early stage (3 months old). They are more frequent in total brachial plexus palsies and breech deliveries. Associated paralysis of the diaphragm and the Claude Bernard Horner sign (Figure 10) indicate avulsion of the superior and inferior cervical nerve roots respectively.
 

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Figure 10. Claude Bernard Horner sign. The drooping of the eyelid and a less-opened pupil indicate an inferior cervical nerve root avulsion of the brachial plexus.


In the ruptures, according to the severity of the injury, the nerve can regenerate spontaneously, reinnervate the muscle and restore movement. The best way to assess the severity is periodically checking the recovery of certain movements. The indication for surgery is based on the recovery of elbow flexion AGAINST GRAVITY.

The most scientifically valid strategy is to do surgery if the baby does not recover elbow flexion at 5 months of age. There are several surgeons who indicate surgery at 3 months but their results are not better than those operating at 5 months; and they operate 85% more children!!

In 90% of babies with BPBP, spontaneous regeneration is successful, restoring elbow flexion before 5 months of age, therefore they do not require nerve surgery (although 10% of these may require surgery for the development of secondary deformities in the shoulder (glenohumeral dysplasia)).
 

When is the most severe the BPBP?

The severity of brachial plexus birth palsy is greater in these situations:

  • Several cervical nerve roots affected.
     
  • Late recovery of elbow flexion.
     
  • Avulsion injuries.
     

Types of nerve repair surgeries performed in the brachial plexus palsy

A-Neuroma resection and nerve grafting

At the point of the nerve injury, a scar called neuroma forms. The neuroma should be "removed" and the missing piece of nerve "bypass it" with nerve grafts that serve as a conduit for axons to cross and reinnervate the muscles (Figure 3). Usually the graft is obtained from the leg (sural nerve).

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Figure 11. The neuroma has been removed, and a “bypass” using nerve grafts from the leg has been created..


Since nerve regeneration has a speed of 1 mm per day after nerve repair, the farther the muscle distance from the neck, the longer we will have to wait until reinnervation takes place, enabling muscle contractility. Sequentially, the shoulder will move first (4 to 6 months) followed by the elbow (6 months). In total brachial plexus palsies the hand is also affected, thus requiring 1.5-2 years to recover hand motion.


B-Nerve transfers

Its main indication is avulsion injuries.

It consists in connecting two different nerves. The donor nerve can be sacrificed without causing significant impact, and donates axons to the nerve responsible for innervating the muscle. For instance, the trapezium nerve (spinal accessory nerve) can be cut and connected to the suprascapular nerve to restore shoulder movement or part of the ulnar nerve can be connected to the biceps nerve to restore elbow flexion (Oberlin transfer).
 

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Figure 12. Spinal accessory nerve transfer (1) to the suprascapular nerve (3), to reinnervate shoulder muscles and regain movement in his shoulder. Trapezium (2), external rotators muscles of the shoulder (3).

 

Surgery Outcomes


Taking into account the above mentioned indications (avulsions and non-recovery of elbow flexion at the age of 5 months), the outcome of surgery is better than the result of spontaneous regeneration. However, with surgery, full recovery of function is not expected. In C5-C6 palsy, 80% of children achieve nearly complete shoulder and elbow motion. In C5-C7 palsy results are slightly worse, but children get an acceptable function of the limb. The results are worse in total brachial plexus palsy, but we can get a useful hand in 70% of cases.

Obstetric brachial palsy
Brachial Plexus Birth Palsy: Definition and Mechanisms of Injury:
Risk of brachial plexus birth palsy. Necessary diagnostic tests.
BPBP treatment: physical therapy and surgery
Shoulder problems in children with BPBP
Prevention and Risk of IRCS and DGH
Diagnosis and Treatment of Shoulder Dysplasia
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