Neonatal Brachial Plexus Palsy Research Articles

188 Timing of Nerve Reconstruction Surgery to Optimize Long-Term Recovery at the Elbow and Forearm in Neonatal Brachial Plexus Palsy

INTRODUCTION: Restoration of elbow flexion is highly prioritized in nerve reconstruction for neonatal brachial plexus palsy (NBPP). Elbow extension and forearm supination are also frequently impacted in NBPP. Timing of surgical reconstruction for optimal outcomes at the elbow and forearm remains unknown. METHODS: We interrogated a prospectively collected database of all children with NBPP who underwent nerve reconstruction at a single center between 2005-2020. AROM was collected for elbow flexion and extension and forearm supination at every clinic visit and normalized between 0 and 1. The cohort was divided into those with surgery =6 months old, 6-9 months old, and >9 months old. We compared elbow and forearm AROM in local age windows between the groups using a regression model expressing the expected AROM as a linear function. Significant differences between the groups were identified using a Wald test. RESULTS: Of 99 included children 28 had surgery =6 months old, 46 had surgery between 6-9 months, and 25 had surgery >9 months. At ∼13 years follow up, there was no difference in recovery of AROM for elbow flexion between the groups. For elbow extension, mean normalized AROM was significantly worse when comparing the >9 month and =6 month group (0.41 vs 0.84, p < 0.001). For forearm supination, the =6 month group had significantly better AROM than the 6-9 month (0.57 vs 0.77, p = 0.02) and >9 month (0.46 vs 0.77, p < 0.001) groups. Children who presented earlier had surgery at a younger age. CONCLUSIONS: Earlier surgery may result in better long-term recovery of elbow extension and surgery =6 months of age may yield the best outcomes for forearm supination. Early referral may help optimize timing of nerve surgery.

Rehabilitation protocols in neonates undergoing primary nerve surgery for upper brachial plexus palsy: A scoping review.

Surgical management is recommended in patients with severe neonatal brachial plexus palsy (NBPP) within the first 6 months of age to regain best possible function. Rehabilitation post-surgery remains relatively unexplored. This is a scoping review that explores, which rehabilitation modalities exist and how they vary for different microsurgical approaches in NBPP. A systematic search was conducted to include articles about upper trunk obstetric brachial plexus nerve microsurgery in pediatric patients that made mention of rehabilitation protocols. The aims of rehabilitation modalities varied and were grouped: "passive" movement to prevent joint contracture or stiffness, "active" or task-oriented movement to improve motor function, or "providing initial motor recovery". Surgical approach was described as either exploration of the brachial plexus (EBP) or nerve transfer without root exploration (NTwoRE). Technique was categorized into transfers and non-transfers. Thirty-six full-text articles were included. Initiation of rehabilitation was 22.26 days post-surgery. Twenty-eight studies were EBP, and six were NTwoRE. Of studies classifiable by aims, nine were "passive", nine were "active", and five were "providing initial motor recovery". Only 27.7% of EBP studies mentioned active therapy, while 75.0% of NTwoRE studies mentioned active therapy. The average age of patients in the EBP procedure category was 7.70 months, and NTwoRE was 17.76 months. Within transfers, the spinal accessory to suprascapular group was more likely to describe an active shoulder exercise therapy, whereas contralateral C7 group was more likely to describe "initial motor recovery", especially through the use of electrostimulation. All articles on electrostimulation recommended 15-20-minute daily treatment. Information on rehabilitation is limited post-nerve surgery in NBPP. However, when mentioned, the aims of these therapies vary with respect to surgical approach and technique. The type of therapy to employ may be a multifaceted decision, involving factors such as patient age, initial deformity, and goals of the care team.

Hand function outcomes following surgical treatment of complete neonatal brachial plexus palsy.

Although re-innervation of the hand is considered a priority in the treatment of infants with complete brachial plexus injury, there is currently a paucity of publications investigating hand function outcomes following primary nerve reconstruction in infants with neonatal brachial plexus palsy (NBPP). This study therefore aimed to evaluate hand function outcomes in a series of patients with complete NBPP. This retrospective case series included all patients who underwent primary nerve surgery for complete neonatal brachial plexus palsy over an 8-year period. Outcomes were assessed using the Raimond Hand Scale. Classification of grade 3 or higher indicates a functional hand (assistance in bimanual activity). Nineteen patients with a complete NBPP underwent primary nerve reconstruction at a mean age of 3.7months. Periodic clinical evaluations were performed until at least 4years of age. According to the Raimondi hand scale, one patient did not recover (grade 0), three patients attained grade 1, four grade 2, ten grade 3, and in one grade 4. Overall hand functional recovery was achieved in 57.8% (11/19) of patients. Sufficient recovery of hand function to perform bimanual activity tasks in patients with complete NBPP lesions is possible and should be a priority in the surgical treatment of these infants.

Investigating the effect of anatomical variations in the response of the neonatal brachial plexus to applied force: Use of a two-dimensional finite element model.

The brachial plexus is a set of nerves that innervate the upper extremity and may become injured during the birthing process through an injury known as Neonatal Brachial Plexus Palsy. Studying the mechanisms of these injuries on infant cadavers is challenging due to the justifiable sensitivity surrounding testing. Thus, these specimens are generally unavailable to be used to investigate variations in brachial plexus injury mechanisms. Finite Element Models are an alternative way to investigate the response of the neonatal brachial plexus to loading. Finite Element Models allow a virtual representation of the neonatal brachial plexus to be developed and analyzed with dimensions and mechanical properties determined from experimental studies. Using ABAQUS software, a two-dimensional brachial plexus model was created to analyze how stresses and strains develop within the brachial plexus. The main objectives of this study were (1) to develop a model of the brachial plexus and validate it against previous literature, and (2) to analyze the effect of stress on the nerve roots based on variations in the angles between the nerve roots and the spinal cord. The predicted stress for C5 and C6 was calculated as 0.246 MPa and 0.250 MPa, respectively. C5 and C6 nerve roots experience the highest stress and the largest displacement in comparison to the lower nerve roots, which correlates with clinical patterns of injury. Even small (+/- 3 and 6 degrees) variations in nerve root angle significantly impacted the stress at the proximal nerve root. This model is the first step towards developing a complete three-dimensional model of the neonatal brachial plexus to provide the opportunity to more accurately assess the effect of the birth process on the stretch within the brachial plexus and the impact of biological variations in structure and properties on the risk of Neonatal Brachial Plexus Palsy.

Impact of Timing of Primary Nerve Surgery on Shoulder, Forearm, and Elbow Recovery in Neonatal Brachial Plexus Palsy

BACKGROUND AND OBJECTIVES: Neonatal brachial plexus palsy (NBPP) almost universally affects movement at the shoulder, elbow, and forearm. Timing of nerve reconstruction surgery to optimize long-term outcomes remains unknown. This study aimed to determine if timing of nerve reconstruction affects long-term recovery of an active range of motion (AROM) at the shoulder, elbow, and forearm in NBPP. METHODS: We interrogated a prospectively collected database of all patients with NBPP who underwent primary nerve surgery at a single tertiary referral center between 2005 and 2020. The cohort was divided into those who underwent surgery at ≤6 or >6 months old and ≤9 or >9 months old. AROM for shoulder abduction, forward flexion, and external rotation, elbow flexion and extension, and forearm supination were collected at each visit. RESULTS: Ninety-nine children were included in the analysis; 28 underwent surgery at ≤6 months old, 71 at >6 months, 74 at ≤9 months, and 25 at >9 months. There was no difference in AROM at 5 years for any of the movements between the ≤6- and >6-month groups. The ≤9-month group had significantly better shoulder forward flexion and elbow extension AROM than the >9-month group at a 5-year follow-up and better forearm supination at up to a 15-year follow-up. Patients who presented earlier were more likely to have earlier operations. CONCLUSION: Surgery before 9 months may improve long-term upper extremity recovery in NBPP. Early referral should be encouraged to optimize timing of operative intervention.

Exploring structural brain changes in children with neonatal brachial plexus palsy: a voxel-based morphometry analysis

BACKGROUND: Obstetric brachial plexus palsy (OBPP) is paralysis of the upper limb resulting from nerve injury during vaginal delivery. Although current treatment approaches frequently lead to complete reinnervation of the limb, some patients show long-term motor deficits. These impairments may result from upper limb disuse that causes structural brain changes. AIM: This study aimed to compare deep gray matter volumes between children with OBPP and healthy controls. METHODS: We analyzed the structural magnetic resonance imaging results of 46 children with OBPP (n=24, mean age — 10.20, of whom 12 were girls) and healthy age-matched controls (n=22, mean age — 9.63, of whom 10 were girls) using a voxel-based morphometry technique in SPM12 package (Statistical Parametric Mapping) in MATLAB R2019b. To minimize false discoveries, we used a stringent procedure to control the family-wise error rate. RESULTS: We found volumetric brain differences between children with OBPP and healthy controls (all FWE-corrected p 0.005). Children with OBPP had significantly lower gray matter volumes in the left amygdala, bilateral hippocampus, and right entorhinal cortex. CONCLUSION: Integrating our findings with previous work, we speculate that the amygdala–hippocampus–entorhinal cortex complex might play a significant role in motor disorders.

Brain plasticity and age after restoring elbow flexion with distal nerve transfers in neonatal brachial plexus palsy and nonneonatal traumatic brachial plexus injury using the plasticity grading scale.

Ulnar and/or median nerve fascicle to musculocutaneous nerve (MCN) transfers are used to restore elbow flexion following severe neonatal and nonneonatal brachial plexus injuries (BPIs). Restoring volitional control requires plastic changes in the brain. To date, whether the potential for plasticity is influenced by a patient's age remains unknown. Patients who had presented with a traumatic upper (C5-6 or C5-7) BPI were divided into two groups: neonatal brachial plexus palsies (NBPPs) and nonneonatal traumatic BPIs (NNBPIs). Both groups underwent ulnar or median nerve transfers to the MCN for elbow flexion restoration between January 2002 and July 2020. Only those who attained a British Medical Research Council strength rating of 4 were reviewed. The primary comparison between the two groups was the plasticity grading scale (PGS) score to determine the level of independence of elbow flexion (target) from forearm motor muscle movement (donors). The authors also assessed patient compliance with rehabilitation using a 4-point Rehabilitation Quality Scale. Bivariable and multivariable analyses were used to identify intergroup differences. In total, 66 patients were analyzed: 22 with NBPP (mean age at surgery 10 months) and 44 with NNBPI (age range at surgery 3-67 years, mean 30.2 years; mean time to surgery 7 months, p < 0.001). All NBPP patients obtained a PGS grade of 4 at the final follow-up versus just 47.7% of NNBPI patients (mean 3.27, p < 0.001). On ordinal regression analysis, after nature of the injury was excluded because of excessive collinearity with age, age was the only significant predictor of plasticity (β = -0.063, p = 0.003). Median rehabilitation compliance scores were not statistically different between the two groups. The extent of plastic changes that occur for patients to regain volitional control over elbow flexion after upper arm distal nerve transfers following BPI is influenced by patient age, with complete plastic rewiring more likely in younger patients and virtually ubiquitous in infants. Older patients should be informed that elbow flexion after an ulnar or median nerve fascicle transfer to the MCN might require simultaneous wrist flexion.

Forearm and elbow secondary surgical procedures in neonatal brachial plexus palsy: a systematic scoping review

IntroductionNeonatal Brachial plexus palsy (NBPP) is an injury during delivery that can lead to loss of motor function and limited range of motion in patients due to damage of nerves in the brachial plexus. This scoping review aims to explore types of procedures performed and assess outcomes of forearm and elbow secondary surgery in pediatric patients. MethodsSearches of PubMed, Cochrane, CINAHL, Web of Sciences and Scopus were completed to obtain studies describing surgical treatment of elbow and forearm in pediatric patients with NBPP. 865 abstracts and titles were screened by two independent reviewers resulting in 295 full text papers; after applying of inclusion and exclusion criteria 18 articles were included. The level of evidence of this study is level IV. Results10 main procedures were performed to regain function of the forearm and elbow in neonatal brachial plexus birth palsy patients. Procedures had different aims, with supination contracture (6) and elbow flexion restoration (5) being the most prevalent. The variance between pre-and postoperative soft tissue and bony procedures outcomes decreased and showed improvement with respect to the aim of each procedure category. For soft tissue procedures, a statistically significant increase was found between pre- and postoperative values for active elbow flexion, passive supination, and active supination. For bony procedures, there was a statistically significant decrease between pre- and postoperative values of passive and active supination. ConclusionsOverall, all procedures completed in the assessed articles of this study were successful in their aim. Bony procedures, specifically osteotomies, were found to have a wider range of results, whereas soft tissue procedures were found to be more consistent and reproducible with respect to their outcomes. Bony and soft tissue procedures were found vary in their aims and outcomes. This study indicates the need for further research to augment knowledge about indications and long-term benefits to each procedure.

Outcomes of humeral osteotomies versus soft-tissue procedures in secondary surgical procedures for neonatal brachial plexus palsy: a meta-analysis.

Secondary surgical procedures can be used in brachial plexus birth injury to correct shoulder movement imbalances. This study compares outcomes of the two secondary surgical procedure types: humeral osteotomies and soft tissue procedures. Outcome measures assessed included active and passive internal and external rotation, active and passive abduction and adduction, active and passive flexion and extension, percentage of the humeral head anterior to the middle glenoid fossa, glenoid version, and Mallet Score. Nineteen full-text articles were included in the analysis. Humeral osteotomies resulted in a loss of internal rotation postoperatively (-15.94°). Active internal rotation was not evaluated for soft tissue procedures. All other assessed outcomes were improved postoperatively for bony and soft tissue procedures. Bony procedures exhibited a greater degree of active external rotation postoperatively when compared to soft tissue procedures (+67° vs. +40°). Both bony and soft tissue procedures Improve shoulder function in children with neonatal brachial plexus palsy, however, soft tissue procedures showed greater consistency in outcomes. Level of Evidence: IV.

Recovery of Shoulder, Elbow, and Forearm Movement After Nerve Reconstruction for Neonatal Brachial Plexus Palsy.

There is a relative dearth of published data with respect to recovery of upper extremity movement after nerve reconstruction for neonatal brachial plexus palsy (NBPP). This study aimed to demonstrate long-term recovery of active range of motion (AROM) at the shoulder, elbow, and forearm after nerve reconstruction for NBPP and to compare that with patients managed nonoperatively. We interrogated a prospectively collected database of all patients evaluated for NBPP at a single institution from 2005 to 2020. AROM measurements for shoulder, elbow, and forearm movements were collected at every visit up to 5 years of follow-up and normalized between 0 and 1. We used generalized estimated equations to predict AROM for each movement within local age windows over 5 years and compared the operative and nonoperative cohorts at each age interval. In total, >13 000 collected datapoints representing 425 conservatively and 99 operatively managed children were included for analysis. At 5 years, absolute recovery of AROM after nerve reconstruction was ∼50% for shoulder abduction and forward flexion, ∼65% for shoulder external rotation, and ∼75% for elbow flexion and forearm supination, with ∼20% loss of elbow extension AROM. Despite more limited AROM on presentation for the operative cohort, at 5 years, there was no significant difference between the groups in AROM for shoulder external rotation, elbow extension, or forearm supination, and, in Narakas grade 1-2 injury, shoulder abduction and forward flexion. We demonstrate recovery of upper extremity AROM after nerve surgery for NBPP. Despite more severe presenting injury, operative patients had similar recovery of AROM when compared with nonoperative patients for shoulder external rotation, elbow extension, forearm supination, and, for Narakas grade 1-2 injury, shoulder abduction and forward flexion.

Translation, reliability, and validity of the Brazilian-Portuguese version of the Brachial Plexus Outcome Measure scale (BPOM-Br)

Purpose To translate and investigate inter-rater reliability, internal consistency, content validity, and construct validity of the Brazilian-Portuguese Version of the Brachial Plexus Outcome Measure Scale (BPOM-Br). Material and methods The translation followed international guidelines. Inter-rater reliability was tested with 51 individuals with Neonatal Brachial Plexus Palsy (NBPP), aged between 4 to 16 years old. To determine concurrent construct validity, children were also assessed with the Mallet Scale. Statistical analysis included Bland-Altman, Intraclass Correlation Coefficient (ICC), Floor and Ceiling and effect, and Pearson correlation. Results The majority of the sample consisted of children with upper NBPP (75.2%), mean age of 8.9 years old. BPOM-Br showed appropriate content validity (comprehensiveness) according to rehabilitation professionals. It also showed excellent inter-rater reliability (ICC = 0.90) and internal consistency (α = 0.91). Bland-Altman analysis showed bias close to zero. Finally, BPOM-Br showed overall significant positive correlations with the Mallet scale items (rs= 0.31 to 0.78 p < 0.05), indicating adequate concurrent validity. Conclusions BPOM-Br is a consistent, reliable, and valid instrument to assess activity of school-aged children with NBPP. IMPLICATIONS FOR REHABILITATION The Brazilian-Portuguese Version of the Brachial Plexus Outcome Measure Scale (BPOM-Br) presents understandable items and no ceiling and floor effects. The BPOM-Br provides a valid and reliable version for use in Brazilian school-aged children with neonatal brachial plexus palsy. It is important to promote its use both in clinical practice and in research as a specific evaluation of activity domain.

Validity and reliability of the Turkish version of the hand-use-at-home questionnaire for children with unilateral cerebral palsy and neonatal brachial plexus palsy

Purpose To translate the Hand-Use-at-Home questionnaire (HUH), assesses the amount of spontaneous use of the affected hand in children with 18 bimanual activities, into Turkish and examine its validity and reliability on children with neonatal brachial plexus palsy (NBPP) or unilateral cerebral palsy (UCP). Materials and methods The HUH was translated and cross-culturally adapted to Turkish and administered to children with NBPP (n = 25) and UCP (n = 42) between 3 and 10 years. The psychometric analyses included reliability by internal consistency (Cronbach’s alpha) and test/retest reliability (intraclass correlation coefficient, ICC) structural validity was evaluated with exploratory factor analysis, and construct validity was investigated by matching the HUH with the Pediatric Outcome Data Collection Instrument Upper Extremity Scale (PODCI) (NBPP only), and Children’s Hand-Use Experience Questionnaire (CHEQ) (UCP only). Results HUH showed excellent test–retest reliability (ICC2,1 = 0.988 Cl (0.977–0.992)), excellent internal consistency (Cronbach’s-α = 0.989), and moderate correlation with CHEQ (rs = 0.558) in UCP and high correlation with PODCI Scale (rs = 0.789) in NBPP group. The HUH had low and moderate correlation respectively lesion-extent levels (r=-0.457) in NBPP and 5 Manual Ability Classification System levels (r=-0.688) in the UCP group. Conclusion The HUH is a valid and reliable tool to assess the amount of spontaneous use of the affected hand in Turkish children with NBPP and UCP.

Brain plasticity in neonatal brachial plexus palsies: quantification and comparison with adults' brachial plexus injuries.

To compare two populations of brachial plexus palsies, one neonatal (NBPP) and the other traumatic (NNBPP) who underwent different nerve transfers, using the plasticity grading scale (PGS) for detecting differences in brain plasticity between both groups. To be included, all patients had to have undergone a nerve transfer as the unique procedure to recover one lost function. The primary outcome was the PGS score. We also assessed patient compliance to rehabilitation using the rehabilitation quality scale (RQS). Statistical analysis of all variables was performed. A p ≤ 0.050 set as criterion for statistical significance. A total of 153 NNBPP patients and 35 NBPP babies (with 38 nerve transfers) met the inclusion criteria. The mean age at surgery of the NBPP group was 9months (SD 5.42, range 4 to 23months). The mean age of NNBPP patients was 22years (SD 12years, range 3 to 69). They were operated around sixth months after the trauma. All transfers performed in NBPP patients had a maximum PGS score of 4. This was not the case for the NNBPP population that reached a PGS score of 4 in approximately 20% of the cases. This difference was statistically significant (p < 0.001). The RQS was not significantly different between groups. We found that babies with NBPP have a significantly greater capacity for plastic rewiring than adults with NNBPP. The brain in the very young patient can process the changes induced by the peripheral nerve transfer better than in adults.

Early referral to multidisciplinary specialty centers to optimize outcomes in children with neonatal brachial plexus palsy.

To demonstrate the trajectory of long-term recovery of upper-extremity movement and determine optimal timing of evaluation at multidisciplinary specialty centers in children with neonatal brachial plexus palsy (NBPP). All children with conservatively managed NBPP seen at one institution from 2005 to 2020 were considered for inclusion. The cohort was divided according to age at formal evaluation (≤30 or > 30 days). Active range of motion (AROM) for shoulder and elbow movements collected at each appointment were compared in local age windows between early and late cohorts. Locally estimated scatterplot smoothing was used to demonstrate the trajectory of recovery for the overall cohort. More than 13 000 prospectively collected data points for 429 children (220 males, 209 females) were analysed. Elbow flexion improved to nearly full AROM for both groups over the course of the study. Shoulder abduction, forward flexion and external rotation, and forearm supination improved for the entire cohort, although greater absolute improvement, particularly at the shoulder, was seen in the early cohort (age at formal evaluation ≤30 days). AROM for elbow extension remained roughly stable for the early cohort but decreased for the late cohort (age at formal evaluation >30 days). AROM for forearm pronation decreased over time for both cohorts. Our data demonstrate good long-term functional recovery for children with conservatively managed NBPP. However, early referral to multispecialty brachial plexus centers may optimize outcomes. Many children with conservatively managed neonatal brachial plexus palsy have good long-term shoulder and elbow outcomes. Early referral to multidisciplinary clinics may maximize long-term shoulder and elbow recovery and optimize outcomes.

Neuromuscular Electrical Stimulation for Infants with Neonatal Brachial Plexus Palsy: A Pilot Study

Background: Biceps recovery is a critical determinant for treatment decision-making in patients with neonatal brachial plexus palsy (NBPP). One treatment intervention used by therapists is neuromuscular electrical stimulation (NMES), but its use remains controversial. This study’s aim was to determine the effect and safety of NMES on biceps function in infants with NBPP compared to standard therapy.

Utilizing International Classification of Diseases Codes to Identify Shoulder Dystocia and Neonatal Brachial Plexus Injury

BackgroundThe utilization of International Classification of Diseases, Ninth or Tenth Revision, (ICD-9/10) coding to identify the incidence of disease is frequently performed in medical research. This study attempts to assess the validity of using ICD-9/10 codes to identify patients with shoulder dystocia (SD) with concurrent neonatal brachial plexus palsy (NBPP). MethodsThis retrospective cohort study examined patients evaluated at the University of Michigan Brachial Plexus and Peripheral Nerve Program (UM-BP/PN) from 2004 to 2018. We reported the percentage of patients with reported NBPP ICD-9/10 and SD ICD-9/10 discharged at birth who were later diagnosed with NBPP by a specialty clinic by interdisciplinary faculty and staff utilizing physical evaluations and ancillary testing such as such as electrodiagnostics and imaging. The relationship of reported NBPP ICD-9/10, SD ICD-9/10, extent of NBPP nerve involvement, and NBPP persistence at age two years were examined via chi-square or Fischer exact test. ResultsOf the 51 mother-infant dyads with complete birth discharge records evaluated at the UM-BP/PN, 26 (51%) were discharged without an ICD-9/10 code documenting NBPP; of these 26 patients, only four had ICD-9/10 documentation of SD at discharge, which left 22 patients with no ICD-9/10 code documentation of either SD or NBPP (43%). Patients with pan-plexopathy were more likely to be discharged with an NBBP ICD-9/10 code than those infants with upper nerve involvement (77% vs 39%, P < 0.02). ConclusionUse of ICD-9/10 codes for the identification of NBPP appears to undercount the true incidence. This underestimation is more pronounced for milder forms of NBPP.

147 The Impact of Tming of Primary Nerve Surgery on Shoulder Recovery in Neonatal Brachial Plexus Palsy

INTRODUCTION: Neonatal brachial plexus palsy (NBPP) almost universally impacts shoulder abduction, forward flexion, and external rotation. While nerve reconstruction options are available for restoration of these movement, the outcomes for nerve surgery for shoulder have lagged behind those at other joints. Operative timing is a potentially modifiable variable but remains controversial. METHODS: We interrogated a prospective database of all patients with NBPP who underwent primary nerve surgery at a single tertiary referral center between 2005-2020. The cohort was divided into those who underwent surgery ≤6 months old, 6-9 months old, and &gt;9 months old. AROM for shoulder abduction, forward flexion, and external rotation was plotted over time for each group and a logistic regression and 95% confidence interval fit to each plot to visualize both absolute and rate of recovery of AROM for each group. RESULTS: 99 children with 2196 AROM measurements were included in the analysis with average follow-up of 46 months. 26 underwent surgery ≤6 months old, 47 between 6-9 months, and 26 &gt;9 months old. Those who underwent surgery ≤9 months old had more rapid and better overall recovery of shoulder abduction and forward flexion than those who had surgery &gt;9 months. Timing of operation did not clearly impact recovery of external rotation. Patients who presented to a multidisciplinary clinic earlier were more likely to have earlier operations. CONCLUSIONS: Surgery prior to 9 months old may improve long-term recovery of shoulder AROM in NBPP. Early referral should be encouraged to optimize timing of operative intervention.

Electrodiagnosis and Imaging Studies in Neonatal Brachial Plexus Palsy: Comparative study

Electrodiagnosis and Imaging Studies in Neonatal Brachial Plexus Palsy: Comparative study

Supraclavicular approach for neonatal brachial plexus palsy.

Neonatal brachial plexus palsy describes injury to the brachial plexus in the perinatal period, resulting in motor and sensory deficits of the upper arm. Nerve reconstruction, including graft repair and nerve transfers, can be used to restore function in patients whose injury does not respond to conservative management. Despite the availability of these techniques, 30%-40% of children have lifelong disability, reflecting a 10-fold underutilization of surgery. Here, the authors demonstrate a supraclavicular approach for brachial plexus exploration, as well as a spinal accessory to suprascapular nerve transfer for restoration of shoulder abduction and external rotation. The video can be found here: https://stream.cadmore.media/r10.3171/2022.10.FOCVID22109.

Quality of upper extremity skills and disability inventory via manual ability classification in children with neonatal brachial plexus palsy

Purpose The aim of study was to investigate the relationship between upper extremity skill quality and disability inventory according to manual ability classification system in children with neonatal brachial plexus palsy (NBPP). Materials and methods Children with NBPP were included between the ages of 4–7.5 years. Children were classified in Manual Ability Classification System (MACS). Upper extremity skill quality was evaluated with Quality of Upper Extremity Skills Test (QUEST), disability status was assessed with Pediatric Evaluation of Disability Inventory (PEDI). Results Total of 63 children (girls:31/boys:32), and mean age was 6.32 ± 1.73 years. 37 (58.73%) of children were at MACS Level-2. According to MACS classification, significant differences were noted in PEDI scores (p = 0.001), dissociated movements (p = 0.016) and grasp (p = 0.002) domains of QUEST. However, no significant differences between QUEST total scores (p = 0.079). PEDI (ROC; AuC = 0.762) and QUEST total score (ROC; AuC = 0.714) were sensitive to difference between groups across MACS in children with NBPP. Conclusion The PEDI and QUEST are sensitive in distinguishing the disability of children with NBPP at different MACS levels. Assessment of children with NBPP is not limited to functionality, disability, and quality of movement, it is multidimensional. Outcomes measures studies of movement’s quality in children with NBPP are needed.