Nerve Transfer in Delayed Obstetrical Palsy Repair

Abstract

Objective When root avulsions are detected in children suffering from obstetrical brachial plexus palsy (OBPP), neurotization procedures of different nerve trunks are commonly applied in primary brachial plexus repair, to connect distally the nerves of the upper limbs using healthy nerve structures. This article aims to outline our experience of neurotization procedures in OBPP, which involves nerve transfers in the event of delayed repair, when a primary repair has not occurred or has failed. In addition, we propose the opportunity for late repair, focusing on extending the time limit for nerve surgery beyond that which is usually recommended. Although, according to different authors, the time limit is still unclear, it is generally estimated that nerve repair should take place within the first months of life. In fact, microsurgical repair of OBPP is the technique of choice for young children with the condition who would otherwise have an unfavorable outcome. However, in certain cases the recovery process is not clearly defined so not all the patients are direct candidates for primary nerve surgery.

Methods In the period spanning January 2005 through January 2011, among a group of 105 patients suffering from OBPP, ranging from 1 month to 7 years of age, the authors have identified a group of 32 partially recovered patients. All these patients underwent selective neurotization surgery, which was performed in a period ranging from 5 months to 6.6 years of age.

Results Late neurotization of muscular groups achieved considerable functional recovery in these patients, who presented with reduced motor function during early childhood. The said patients, with the exception of five, would initially have avoided surgery because they had not met the criteria for nerve surgery.

Conclusion We have concluded that the execution of late nerve surgical procedures can be effective in children affected by OBPP.

Keywords

nerve transfer - neurotization - obstetrical brachial plexus palsy - delayed nerve repair

• References

• 1 El-Gammal TA, El-Sayed A, Kotb MM, Saleh WR, Ragheb YF, el-Refai O. Delayed selective neurotization for restoration of elbow and hand functions in late presenting obstetrical brachial plexus palsy. J Reconstr Microsurg 2014; 30 (4) 271-274
• 2 Michelow BJ, Clarke HM, Curtis CG, Zuker RM, Seifu Y, Andrews DF. The natural history of obstetrical brachial plexus palsy. Plast Reconstr Surg 1994; 93 (4) 675-680 , discussion 681
• 3 Waters PM. Obstetric brachial plexus injuries: evaluation and management. J Am Acad Orthop Surg 1997; 5 (4) 205-214
• 4 Tse R, Marcus JR, Curtis CG, Dupuis A, Clarke HM. Suprascapular nerve reconstruction in obstetrical brachial plexus palsy: spinal accessory nerve transfer versus C5 root grafting. Plast Reconstr Surg 2011; 127 (6) 2391-2396
• 5 van Ouwerkerk WJ, Uitdehaag BM, Strijers RL , et al. Accessory nerve to suprascapular nerve transfer to restore shoulder exorotation in otherwise spontaneously recovered obstetric brachial plexus lesions. Neurosurgery 2006; 59 (4) 858-867 , discussion 867–869
• 6 Pondaag W, de Boer R, van Wijlen-Hempel MS, Hofstede-Buitenhuis SM, Malessy MJ. External rotation as a result of suprascapular nerve neurotization in obstetric brachial plexus lesions. Neurosurgery 2005; 57 (3) 530-537 , discussion 530–537
• 7 Waters PM. Comparison of the natural history, the outcome of microsurgical repair, and the outcome of operative reconstruction in brachial plexus birth palsy. J Bone Joint Surg Am 1999; 81 (5) 649-659
• 8 Terzis JK, Kostas I. Outcomes with suprascapular nerve reconstruction in obstetrical brachial plexus patients. Plast Reconstr Surg 2008; 121 (4) 1267-1278
• 9 Terzis JK, Kokkalis ZT. Shoulder function following primary axillary nerve reconstruction in obstetrical brachial plexus patients. Plast Reconstr Surg 2008; 122 (5) 1457-1469
• 10 Suzuki K, Doi K, Hattori Y, Pagsaligan JM. Long-term results of spinal accessory nerve transfer to the suprascapular nerve in upper-type paralysis of brachial plexus injury. J Reconstr Microsurg 2007; 23 (6) 295-299
• 11 Yamada T, Doi K, Hattori Y, Hoshino S, Sakamoto S, Arakawa Y. Long thoracic nerve neurotization for restoration of shoulder function in C5-7 brachial plexus preganglionic injuries: case report. J Hand Surg Am 2010; 35 (9) 1427-1431
• 12 Doi K, Sakai K, Kuwata N, Ihara K, Kawai S. Reconstruction of finger and elbow function after complete avulsion of the brachial plexus. J Hand Surg Am 1991; 16 (5) 796-803
• 13 Terzis JK, Kokkalis ZT. Restoration of elbow extension after primary reconstruction in obstetric brachial plexus palsy. J Pediatr Orthop 2010; 30 (2) 161-168
• 14 Goubier JN, Teboul F, Khalifa H. Reanimation of elbow extension with intercostal nerves transfers in total brachial plexus palsies. Microsurgery 2011; 31 (1) 7-11
• 15 Noaman HH, Shiha AE, Bahm J. Oberlin's ulnar nerve transfer to the biceps motor nerve in obstetric brachial plexus palsy: indications, and good and bad results. Microsurgery 2004; 24 (3) 182-187
• 16 Oberlin C, Béal D, Leechavengvongs S, Salon A, Dauge MC, Sarcy JJ. Nerve transfer to biceps muscle using a part of ulnar nerve for C5-C6 avulsion of the brachial plexus: anatomical study and report of four cases. J Hand Surg Am 1994; 19 (2) 232-237
• 17 Kawabata H, Shibata T, Matsui Y, Yasui N. Use of intercostal nerves for neurotization of the musculocutaneous nerve in infants with birth-related brachial plexus palsy. J Neurosurg 2001; 94 (3) 386-391
• 18 Little KJ, Zlotolow DA, Soldado F, Cornwall R, Kozin SH. Early functional recovery of elbow flexion and supination following median and/or ulnar nerve fascicle transfer in upper neonatal brachial plexus palsy. J Bone Joint Surg Am 2014; 96 (3) 215-221
• 19 Lin H, Hou C, Chen D. Contralateral C7 transfer for the treatment of upper obstetrical brachial plexus palsy. Pediatr Surg Int 2011; 27 (9) 997-1001
• 20 Lin H, Hou C, Chen D. Modified C7 neurotization for the treatment of obstetrical brachial plexus palsy. Muscle Nerve 2010; 42 (5) 764-768
• 21 Battiston B, Lanzetta M. Reconstruction of high ulnar nerve lesions by distal double median to ulnar nerve transfer. J Hand Surg Am 1999; 24 (6) 1185-1191
• 22 Mallet J. Paralysie obstetricale. Rev Chir Orthop Reparatrice Appar Mot 1972; 58 (Suppl. 01) 166-168
• 23 Mackinnon SE, Dellon AL. Surgery of the Peripheral Nerve. New York, NY: Thieme; 1988
• 24 Raimondi P. Evaluation of results in obstetrical brachial plexus palsy: the hand. In: Proceedings of the International Meeting of Obstetrical Brachial Plexus Palsy; Heerlen, The Netherlands; 1993
• 25 Pagnotta A, Haerle M, Gilbert A. Long-term results on abduction and external rotation of the shoulder after latissimus dorsi transfer for sequelae of obstetric palsy. Clin Orthop Relat Res 2004; (426) 199-205
• 26 Gilbert A, Tassin JL. Surgical repair of the brachial plexus in obstetric paralysis [in French]. Chirurgie 1984; 110 (1) 70-75
• 27 El-Gammal TA, Abdel-Latif MM, Kotb MM , et al. Intercostal nerve transfer in infants with obstetric brachial plexus palsy. Microsurgery 2008; 28 (7) 499-504
• 28 Raimbault J. Electrical assessment of muscle denervation. In: Terzis J, , ed. Microreconstruction of Nerve Injuries. Philadelphia, PA: WB Saunders; 1987: 211-221