Neonatal brachial plexus palsy – Historical perspective

Abstract

Neonatal brachial plexus palsy (NBPP), frequently but not always associated with difficulty in the newborn’s passage down the birth canal, has likely been occurring for many centuries. The first recorded case of NBPP in the medical literature was reported in 1768 by William Smellie [1], a prominent British obstetrician. In the latter half of the 19th century, Duchene [2] and Erb [3] described and localized the lesions causing the proximal upper extremity weakness in the deltoid and biceps to the 5th and 6th cervical nerve roots. In 1885, Klumpke described a lower brachial plexus palsy with profound hand weakness and preservation of proximal strength and associated ipsilateral Horner’s syndrome, which she localized to the 8th cervical and 1st thoracic nerve roots [4]. Although the anatomy and probable etiology were thus established, treatment was largely expectant, supported by bracing and physical therapy. Kaiser Wilhelm of Germany, born during this time period (1895) with left NBPP, was treated only with extensive, even, stressful, and painful therapy to improve his function [5]. These modalities failed, leaving him with an embarrassingly shortened, weak, and withered forearm and hand. Wilhelm blamed the English doctor who attended his birth (his mother was a daughter of Queen Victoria) and consequently developed a hostility to the English, which may have played a role in the decisions leading up to World War I. The tragic consequences of this condition for this involved individual may thus be seen to have far reaching consequences. Surgical intervention was initially described by Kennedy [6] and Taylor [7] in the United States in the first decade of the 20th century. Direct suture repair was performed in these cases and in patients in several other reports. Results were initially described as favorable, but morbidity was high. In 1925, Sever reported on 1100 cases and determined that good outcomeswere not common and that a number of cases were worsened by surgery [8,9]. As a consequence, the conservative attitude regarding NBPP treatment predominated for the next several decades, awaiting and expecting some degree of recovery. In those children who did not recover well, secondary musculoskeletal procedures were occasionally used in an attempt to improve function. Brachial plexus exploration and repair were very rarely performed. Therewas, and still is, considerable controversy over the percentage of neonatal brachial plexus palsy patients who go on to a functionally acceptable spontaneous recovery. Clearly, infants with an upper plexus (Erb’s palsy) acquired perinatally who develop antigravity biceps or deltoid function by 3–4 months seem to progress to an excellent recovery. Those infants who do not meet these criteria are presumed to have a more widespread involvement of the brachial plexus and a more serious degree of injury. Their spontaneous outcome is significantly less functional. The standard regimen of physical therapy, bracing, subsequent bone