Severe Obstetric Brachial Plexus Palsies Can Be Identified at One Month of Age

Martijn J A Malessy,Willem Pondaag,Lynda J.-S Yang,Sonja M Hofstede-Buitenhuis,Saskia Le Cessie,J Gert Van Dijk,Mel B Feany

doi:10.1371/journal.pone.0026193

Martijn J A Malessy, Willem Pondaag + Show 5 more

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https://doi.org/10.1371/journal.pone.0026193

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Abstract

ObjectiveTo establish whether severe obstetric brachial plexus palsy (OBPP) can be identified reliably at or before three months of age.MethodsSevere OBPP was defined as neurotmesis or avulsion of spinal nerves C5 and C6 irrespective of additional C7-T1 lesions, assessed during surgery and confirmed by histopathological examination. We first prospectively studied a derivation group of 48 infants with OBPP with a minimal follow-up of two years. Ten dichotomous items concerning active clinical joint movement and needle electromyography of the deltoid, biceps and triceps muscles were gathered at one week, one month and three months of age. Predictors for a severe lesion were identified using a two-step forward logistic regression analysis. The results were validated in two independent cohorts of OBPP infants of 60 and 13 infants.ResultsPrediction of severe OBPP at one month of age was better than at one week and at three months. The presence of elbow extension, elbow flexion and of motor unit potentials in the biceps muscle correctly predicted whether lesions were mild or severe in 93.6% of infants in the derivation group (sensitivity 1.0, specificity 0.88), in 88.3% in the first validation group (sensitivity 0.97, specificity 0.76) and in 84.6% in the second group (sensitivity of 1.0, specificity 0.66).InterpretationInfants with OBPP with severe lesions can be identified at one month of age by testing elbow extension, elbow flexion and recording motor unit potentials (MUPs) in the biceps muscle. The decision rule implies that children without active elbow extension at one month should be referred to a specialized center, while children with active elbow extension as well as active flexion should not. When there is active elbow extension, but no active elbow flexion an EMG is needed; absence of MUPs in the biceps muscle is an indication for referral.

Highlights

Obstetric brachial plexus palsy (OBPP) almost always involves traction of the C5 and C6 nerve roots, resulting in weakness of shoulder function and elbow flexion
Lack of biceps function has been reported as an indication for nerve surgery [10], [11]
We aimed to develop assessment guidelines to help primary and secondary care physicians identify severe OBPP as early as possible

Summary

Introduction

Obstetric brachial plexus palsy (OBPP) almost always involves traction of the C5 and C6 nerve roots, resulting in weakness of shoulder function and elbow flexion. Life-long functional impairment occurs in 20–30% of cases [7]. Mild lesions cannot be distinguished reliably from severe lesions in the perinatal period; only time reveals whether or not spontaneous recovery will occur. Identification of severe cases facilitates early referral to specialized centers, where the need for reconstructive nerve surgery can be assessed. Mild cases may be referred unnecessarily while severe cases may be referred too late for nerve surgery that is more effective when performed early [8]. Severity (based primarily on biceps function [9]) is usually assessed at 3 months of age. Caretakers are often presented with overly optimistic assessments or no prediction at all, leading to parental distress [19] and treatment delays

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