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Long-term results of surgery for brachial plexus birth palsy.
by Kirjavainen M, Remes V, Peltonen J, Kinnunen P, Pöyhiä T, Telaranta T, Alanen M, Helenius I, Nietosvaara YThe Journal of bone and joint surgery. American volume.
Article Abstract:
BACKGROUND: The long-term results of surgical treatment of brachial plexus birth palsy have not been reported. We present the findings of a nationwide study, with a minimum five-year follow-up, of the outcomes of surgery for brachial plexus birth palsy in Finland. METHODS: Of 1,717,057 newborns, 1706 with brachial plexus birth palsy requiring hospital treatment were registered in Finland between 1971 and 1997. Of these patients, 124 (7.3%) underwent surgery on the brachial plexus at a mean age of 2.8 months (range, 0.4 to 13.2 months). The most commonly performed surgical procedure was direct neurorrhaphy after neuroma resection. One hundred and twelve patients (90%) returned for a clinical and radiographic follow-up examination after a mean of 13.3 years. Activities of daily living were recorded on a questionnaire, and the affected limb was assessed with use of joint-specific functional measures. RESULTS: Two-thirds (63%) of the patients were satisfied with the functional outcome, although one-third of all patients needed help in activities of daily living. One-third of the patients, including all nine with a clavicular nonunion from the surgical approach, experienced pain in the affected limb. All except four patients used the hand of the unaffected limb as the dominant hand. Shoulder function was moderate, with a mean Mallet score of 3.0. Both elbow and hand function were good, with a mean score on the Gilbert elbow scale of 3 and a mean Raimondi hand score of 4. Incongruence of the glenohumeral joint was noted in sixteen (16%) of the ninety-nine patients in whom it was assessed, and incongruence of the radiohumeral joint was noted in twenty-one (21%). The extent of the brachial plexus injury was found to be strongly associated with the final shoulder, elbow, and hand function in a multivariate analysis. CONCLUSIONS: Following surgical treatment of brachial plexus birth palsy, substantial numbers of the patients continued to need help performing activities of daily living and had pain in the affected limb, with the pain due to a clavicular nonunion in one-fourth of the patients. The strongest prognostic factor predicting outcome appears to be the extent of the primary plexus injury.
Long-term results of surgery for brachial plexus birth palsy.
By: Anonymous - Tue 2/27/2007 PMWhat impressed me the most about this study were the outcomes, including the 31% incidence of arm pain, average Mallet and Gilbert scores of 3, 63% satisfaction rate, and a third of patients needing assistance with ADLs. Are these outcomes unusually poor?, or perhaps acceptable considering the patients included had quite severe injuries including flail arms or no arm flexion at 3 months (not just an inability to reach the mouth by 6-9 months). Concerns include the low surgical volumes of each surgeon (even in the most experienced one), the lack of preoperative imaging, and the frequency of direct coaptations after neuroma removal, which brings up the concern of suture-site tension.
Nevertheless, I believe this is an important study that perhaps represents the "real-life", long-term outcomes of severe birth injury repairs. These results are pertinent because many babies continue to be operated on by low-volume surgeons, or young surgeons entering the field of nerve surgery; partly because of limited family resources and referral source understanding. Until statistically better outcomes are evident at higher volume centers (of note, a lack of uniformity in outcome measures is one limitation that prevents adequate comparison studies) this will likely not change.
Source: http://peripheralnervesurgery.blogspot.com/in...