Christine G. Curtis

The natural history of obstetrical brachial plexus palsy.

Obstetrical brachial plexus palsy remains an unfortunate consequence of difficult childbirth. Sixty-six such patients were reviewed. Included were 28 patients (42 percent) with upper plexus involvement and 38 (58 percent) with total plexopathy. The natural history of spontaneous recovery in all of these patients has been determined using an appropriate grading mechanism. Sixty-one patients (92 percent) recovered spontaneously and five patients (8 percent) required primary brachial plexus exploration and reconstruction (median age 12 months), demonstrating that most patients do well. Additional analysis was undertaken to examine ways in which outcome might be predicted. The analysis does not consider whether or not the patient was operated upon. Good or poor recovery was determined by the spontaneous recovery observed. Discriminant analysis revealed that whereas elbow flexion at 3 months correlated well with spontaneous recovery at 12 months, when used as a single parameter it incorrectly predicted recovery in 12.8 percent of cases. Shoulder abduction was not a significant predictor of recovery. Numerous other early parameters correlated well with spontaneous recovery. When elbow flexion and elbow, wrist, thumb, and finger extension at 3 months were combined into a test score, the proportion of patients whose recovery was incorrectly predicted was reduced to 5.2 percent.

Obstetrical brachial plexus palsy: results following neurolysis of conducting neuromas-in-continuity.

&NA; Sixteen infants with conducting neuromas‐in‐continuity at primary brachial plexus exploration underwent microsurgical neurolysis of their lesions. For each patient, the immediate preoperative scores for individual joint movements were compared with scores at the last examination. In the Erbs palsy group (n = 9), significant improvement was seen in shoulder movements, elbow flexion, supination, and wrist extension (paired t test, p < 0.05). Clinically useful improvement in function was seen at the shoulder and elbow (Fishers exact test, p < 0.05). In the total palsy group (n = 7), significant improvement in shoulder abduction, shoulder adduction, elbow flexion, and extension of the wrist, fingers, and thumb was seen (paired t test, p < 0.05), but there was no significant improvement in the proportion of patients with useful functional outcomes. Neurolysis in Erbs palsy improves both muscle grade and the functional ability of patients. Neurolysis does not provide useful functional recovery in patients with total plexus palsy. (Plast. Reconstr. Surg. 97: 974, 1996.)

Klumpke's birth palsy. Does it really exist?

Erb’s palsy is the most common obstetric brachial plexus injury followed by total plexus palsy. The distribution of Klumpke’s birth palsy with modern obstetric practice is unknown. In this paper, we studied the distribution of Klumpke’s birth palsy in our series of 235 consecutive cases of obstetrical brachial plexus injury and determined the incidence of this type of palsy to be 0.6% as cited in the English literature over the last decade.

Neuroma-in-continuity resection: early outcome in obstetrical brachial plexus palsy.

&NA; The short‐term effect of neuroma‐in‐continuity resection in obstetrical brachial plexus palsy was evaluated to test the hypothesis that the neuroma does not contribute to useful limb function. Twenty‐six patients with obstetrical brachial plexus palsy underwent resection of the neuroma‐in‐continuity and interpositional nerve grafting, and 17 patients underwent neurolysis only. The preoperative and postoperative active movement scores were recorded using an eight‐point scale for 15 joint motions in each patient. Data analysis examined the change in total limb motion scores over time within patients undergoing neuroma‐in‐continuity resection and a comparison with those patients undergoing neurolysis. Compared with preoperative assessment, limb motion scores after neuroma resection were significantly decreased at 6 weeks, not significantly different by 3 months, and significantly improved at 12 months postoperatively. In comparison to patients undergoing neurolysis only, limb motion scores after neuroma resection were not significantly different at 3, 6, and 12 months postoperatively. These findings are unlikely to be accounted for by axonal regeneration across interpositional nerve grafts. Nerve regeneration or recovery in the nongrafted segment of the plexus must be sufficient to reproduce preoperative motion. Resection of the neuromas‐in‐continuity in obstetrical brachial plexus palsy does not significantly diminish motor activity. (Plast. Reconstr. Surg. 102: 1555, 1998.)

Final results of grafting versus neurolysis in obstetrical brachial plexus palsy.

Background: The authors previously showed that neurolysis in obstetrical brachial plexus palsy resulted in improved function in some patients at 1 year’s follow-up. In this study, the hypothesis that the long-term outcome of neuroma-in-continuity resection and nerve grafting yields better results than neurolysis was tested. Methods: Obstetrical brachial plexus palsy patients treated with primary nerve surgery with a minimum follow-up of 4 years were studied. Patients were classified as undergoing neurolysis (n = 16) or resection and grafting (n = 92) and separated into Erb’s or total palsy groups. The Active Movement Scale was used for patient evaluation. Changes in Active Movement Scale scores were analyzed using the Wilcoxon signed rank test. Fifteen movements were tested, and the proportion of patients in each group with scores deemed functionally useful (6 or 7) was compared using McNemar’s exact test. Results: After 4 years’ follow-up, Erb’s palsy neurolysis patients showed no improvement in function. Conversely, Erb’s palsy grafting patients had improved function in seven movements. Total palsy neurolysis patients showed no improvement in function, whereas grafted patients showed improved function in 11 of 15 movements. Conclusions: Early improvements in function produced by neurolysis in Erb’s palsy were not sustained over time. Neuroma-in-continuity resection and nerve grafting for both Erb’s and total palsy produced significant improvements in Active Movement Scores and in the proportion of patients demonstrating functionally useful scores. Neurolysis as a complete surgical treatment for obstetrical brachial plexus palsy should be abandoned in favor of neuroma resection and nerve grafting.

The Prognostic Value of Concurrent Horner’s Syndrome in Total Obstetric Brachial Plexus Injury

The prognostic value of concurrent Horner’s syndrome in infants with total birth palsy was investigated. The records of 48 cases with total palsy were reviewed. Poor spontaneous return of the motor function of the limb was found for both with and without concurrent Horner’s syndrome. Fisher’s exact test (P=0.02) indicated that the presence of concurrent Horner’s syndrome is a significant prognostic factor for poor spontaneous recovery of the limb.

The prognostic value of concurrent clavicular fractures in newborns with obstetric brachial plexus palsy

This study investigates the prognostic value of concurrent clavicular fractures in newborn babies with obstetric brachial plexus palsy. The records of 183 consecutive newborn babies with brachial plexus birth injury from 1988 to 1993 were reviewed retrospectively. Poor outcome, specifically insufficient spontaneous return of motor function of the limb necessitating primary brachial plexus surgery, was assessed for infants both with and without concurrent clavicular fractures. 13 newborn babies had concurrent clavicular fractures, and of these two required primary brachial plexus surgery. On the other hand, surgery was required for 43 of the remaining 170 infants with intact clavicles. Using Fisher’s exact test, P = 0.2. Concurrent clavicular fractures in newborns with obstetrical brachial plexus palsy have no prognostic value in predicting spontaneous recovery.

Suprascapular nerve reconstruction in obstetrical brachial plexus palsy: spinal accessory nerve transfer versus C5 root grafting.

Background: The purpose of this study was to determine whether there is any difference in external rotation following reconstruction of the suprascapular nerve using nerve grafts from the proximal C5 root or nerve transfer using the spinal accessory nerve. Methods: External rotation was assessed using the Active Movement Scale immediately before surgery and 3 years postoperatively. Patients with less than 3 years of follow-up were excluded. For patients who underwent secondary shoulder surgery before the 3-year follow-up, the Active Movement Scale score before shoulder surgery was used as the outcome. Results: One-hundred-six patients underwent nerve grafting, while 71 patients underwent spinal accessory nerve transfer. The spinal accessory nerve transfer group had a greater proportion of patients with total plexus palsies, more avulsions, and an earlier age at surgery (p < 0.001). In the C5 nerve graft group, the mean Active Movement Scale score increased from 0.4 to 2.2 (p < 0.001). In the nerve transfer group, the mean score increased from 0.2 to 3.0 (p < 0.001). Preoperatively, the C5 nerve graft group had significantly better scores than the nerve transfer group (p = 0.03). Postoperatively, there was no significant difference between treatments (p = 0.1). Further statistical analysis failed to demonstrate a significant advantage of one surgical treatment over the other. Conclusions: There was no difference in external rotation after suprascapular nerve reconstruction with either nerve grafting from the proximal C5 root or spinal accessory nerve transfer. The choice of suprascapular nerve reconstruction can be selected depending on specific requirements of the individual lesion.

Evaluation of elbow flexion as a predictor of outcome in obstetrical brachial plexus palsy

Background: The purpose of this study was to answer two questions. First, are there obstetrical brachial plexus palsy patients with no elbow flexion at 3 months who go on to recover useful upper extremity function without surgical intervention? Second, are there patients with evidence of elbow flexion at 3 months who do benefit from brachial plexus reconstruction? Methods: The authors retrospectively reviewed a sample drawn from 253 consecutive patients at The Hospital for Sick Children obstetrical brachial plexus database from 1993 to 1996. Inclusion criteria were examination at age 3 months and either complete spontaneous recovery or repeated examination after age 3 years. Two hundred nine patients satisfied the inclusion criteria. Patients were distributed into four groups: group A, no elbow flexion at age 3 months (operative management); group B, elbow flexion present at 3 months (operative management); group C, no elbow flexion at age 3 months (nonoperative management); and group D, elbow flexion present at 3 months (nonoperative management). Results: Groups A, B, and C showed significant intragroup improvements in both elbow flexion (p < 0.0001) and total limb motion scores (the sum of 15 individual joint motions) (p < 0.0001) with time. No differences were noted among groups A, B, and C for either elbow flexion or total limb motion scores at final follow-up. Conclusions: Early elbow flexion alone is not a sufficient criterion to recommend a nonoperative approach. In addition, spontaneous recovery of useful upper extremity function has been observed in a carefully selected subset of patients without elbow flexion at 3 months.

Quality of life in childhood immune thrombocytopenia: international validation of the kids' ITP tools.

The Kids ITP Tools (KIT) is a disease‐specific measure of health‐related quality of life for children with immune thrombocytopenia (ITP). To facilitate use in international trials it has been cross‐culturally adapted for France, Germany, the United Kingdom and Uruguay. This study assessed the validity and reliability of the translated KIT in comparison to generic quality of life measures.