Search

Acute flaccid myelitis (AFM) is a devastating neurological condition in children manifesting as acute limb weakness, paralysis, or both. Despite increased awareness of AFM following the initiation of U.S. surveillance in 2014, no consensus exists for its treatment. The purpose of this systematic review is to summarize the most current knowledge regarding AFM epidemiology, etiology, clinical features, diagnosis, and supportive and operative management, focusing on the promise of nerve transfers for this disease.The authors systematically reviewed the literature based on PRISMA guidelines using multiple databases to search the keywords ("acute flaccid myelitis"), ('acute flaccid myelitis'/exp OR 'acute flaccid myelitis'), and (Acute AND flaccid AND myelitis). Original articles were included if the studies reported on (1) the diagnosis of AFM and (2) patient-specific data regarding epidemiology, etiology, clinical features, diagnostic features, or management of AFM.Of 843 articles initially identified, 99 were included in this review. The precise etiology and pathophysiologic mechanism of AFM is yet to be definitively determined, but AFM is strongly associated with non-polio enterovirus infections. Clinical presentation typically comprises preceding viral prodrome, pleocytosis, spinal cord lesions on T2 MRI, and acute onset of flaccid weakness/paralysis with hyporeflexia in at least one extremity. Supportive care includes medical therapy and rehabilitation, though patients treated conservatively often have persistent neurological deficits. Early studies of nerve transfer for AFM have shown favorable outcomes for patients with persistent weakness.Supportive care and physical therapy are the foundation of a multi-disciplinary approach to managing AFM. However, for patients with persistent limb weakness, nerve transfer has shown promise for improving function, particularly in distal muscle groups. When evaluating a patient for nerve transfer, surgeons must consider potential spontaneous recovery, patient selection, donor nerve availability, recipient nerve appropriateness, and procedure timing.

OBJECTIVE Cervical nerve 5 palsy can occur following surgery for cervical spine pathology. The prognosis of C5 palsy is generally favorable, and most patients recover useful function. However, some patients do not recover useful strength. Nerve transfers are a potential effective treatment of postoperative severe C5 palsy. This study aimed to further delineate the natural history of recovery from postoperative C5 palsy, determine whether lack of recovery at specific time points predicts poor recovery prognosis, and thereby determine a reasonable time point for referral to a complex peripheral nerve specialist. METHODS The authors conducted a retrospective review of 72 patients who underwent surgery for cervical spondylosis and stenosis complicated by C5 palsy. Medical Research Council (MRC) motor strength grades were recorded preoperatively; immediately postoperatively; at discharge; and at 2 weeks, 3 months, 6 months, and 12 months postoperatively. Univariate and multivariate logistic regression models were used to identify demographic and clinical risk factors associated with recovery of useful strength after severe C5 palsy. RESULTS The mean patient age was 62.5 years, and 36.1% of patients were female. Thirty patients (41.7%) experienced severe C5 palsy with less than antigravity strength (MRC grade 2 or less) at discharge. Twenty-one (70%) of these patients recovered useful strength (MRC grade 3 or greater) at 12 months postoperatively, and 9 patients (30%) did not recover useful strength at 12 months. Of those patients with persistent severe C5 palsy at 3 months postoperatively, 50% recovered useful strength at 12 months. Of those patients with persistent severe C5 palsy at 6 months postoperatively, 25% recovered useful strength at 12 months. No patient with MRC grade 0 or 1 strength at 6 months postoperatively recovered useful strength. A history of diabetes was associated with the occurrence of severe C5 palsy. On multivariate analysis, female sex was associated with recovery of useful strength. CONCLUSIONS Most patients with severe C5 palsy recover useful strength in their C5 myotome within 12 months of onset. However, at 3 months postoperatively, patients with persistent severe C5 palsy had only a 50% chance of recovering useful strength by 12 months. Lack of recovery of useful strength at 3 months postoperatively is a reasonable time point for referral to a complex peripheral nerve center to establish care and to determine candidacy for nerve transfer surgery if severe C5 palsy persists.

OBJECTIVE Standard, physician-elicited clinical assessment tools for the evaluation of function after nerve reconstruction for neonatal brachial plexus palsy (NBPP) do not accurately reflect real-world arm function. Wearable activity monitors allow for the evaluation of patient-initiated, spontaneous arm movement during activities of daily living. In this pilot study, the authors demonstrate the feasibility of using body-worn sensor technology to quantify spontaneous arm movement in children with NBPP 10 years after nerve reconstruction and report the timing and magnitude of recovered arm movement. METHODS Eight children with NBPP who underwent brachial plexus reconstruction approximately 10 years prior were recruited to take part in this single-institution prospective pilot study. Per the treatment protocol of the authors’ institution, operated patients had severe, nonrecovering nerve function at the time of surgery. The patients were fitted with an activity monitoring device on each of the affected and unaffected arms, which were worn for 7 consecutive days. The duration (VT) and power (VM) with which each arm moved during the patient’s normal daily activities were extracted from the accelerometry data and ratios comparing the affected and unaffected arms were calculated. Demographic data and standard physician-elicited clinical measures of upper-extremity function were also collected. RESULTS Three children underwent nerve grafting and transfer and 5 children underwent graft repair only. The mean (± SD) active range of motion was 98° ± 53° for shoulder abduction, 130° ± 24° for elbow flexion, and 39° ± 34° for shoulder external rotation. The median Medical Research Council grade was at least 2.5 for all muscle groups. The median Mallet grade was at least 2 for all categories, and 13.5 total. The VT ratio was 0.82 ± 0.08 and the VM ratio was 0.53 ± 0.12. CONCLUSIONS Wearable activity monitors such as accelerometers can be used to quantify spontaneous arm movement in children who underwent nerve reconstruction for NBPP at long-term follow-up. These data more accurately reflect complex, goal-oriented movement needed to perform activities of daily living. Notably, despite severe, nonrecovering nerve function early in life, postsurgical NBPP patients use their affected arms more than 80% of the time that they use their unaffected arms, paralleling results in patients with NBPP who recovered spontaneously. These data represent the first long-term, real-world evidence to support brachial plexus reconstruction for patients with NBPP.

Anatomic representation suggests that a median sensory nerve conduction study recording the thumb (median D1 NCS) may effectively assess upper neonatal brachial plexus palsy (NBPP). We sought to determine the feasibility of technique, establish reference data, and assess its ability to: (a) identify focal upper plexus lesions; and (b) identify C6 root avulsion. In a secondary analysis, we explored the association between absence/presence of motor unit action potentials (MUAPs) during needle electromyography (EMG) of the deltoid and biceps brachii muscles and C6 avulsion status.A retrospective chart review was performed of surgical patients with severe upper NBPP who ultimately underwent surgical reconstruction (between 2017 and 2020). Median D1 sensory nerve action potential (SNAP) amplitude ranges were determined in affected and contralateral limbs and analyzed by C6 root avulsion status. Also, presence/absence of MUAPs during EMG of the deltoid and biceps brachii was compared between C6 avulsion patients and controls.Thirty-eight patients were included in our analysis. A median D1 NCS study was readily performed, showing a contralateral limb mean amplitude of 27.42 μV (range, 3.8-54.7 μV). Most patients had a low ipsilateral median D1 SNAP amplitude, regardless of C6 avulsion status. Detectable MUAPs in either deltoid or biceps brachii on EMG were atypical in C6 root avulsion.The median D1 NCS identifies upper NBPP, but does not distinguish C6 avulsions from post-ganglionic lesions, likely due to the frequent co-occurrence of post-ganglionic axonal disruption. The presence of MUAPs on deltoid/biceps brachii EMG suggests C6 avulsion is unlikely.

OBJECTIVEThe aim of this study was to examine the role of intraoperative neuromonitoring (IONM) during resection of benign peripheral nerve sheath tumors in achieving gross-total resection (GTR) and in reducing postoperative neurological complications.METHODSData from consecutive adult patients who underwent resection of a benign peripheral nerve sheath tumor at 7 participating institutions were combined. Propensity score matching was used to balance covariates. The primary outcomes of interest were the association between IONM and GTR and the association of IONM and the development of a permanent postoperative neurological complication. The secondary outcomes of interest were the association between IONM and GTR and the association between IONM and the development of a permanent postoperative neurological complication in the subgroup of patients with tumors involving a motor or mixed nerve. Univariate and multivariate logistic regression were then performed on the propensity score–matched samples to assess the ability of the independent variables to predict the outcomes of interest.RESULTSA total of 337 patients who underwent resection of benign nerve sheath tumors were included. In multivariate analysis, the use of IONM (OR 0.460, 95% CI 0.199–0.978; p = 0.047) was a significant negative predictor of GTR, whereas none of the variables, including IONM, were associated with the occurrence of a permanent postoperative neurological complication. Within the subgroup of motor/mixed nerve tumors, in the multivariate analysis, IONM (OR 0.263, 95% CI 0.096–0.723; p = 0.010) was a significant negative predictor of a GTR, whereas IONM (OR 3.800, 95% CI 1.925–7.502; p < 0.001) was a significant positive predictor of a permanent postoperative motor deficit.CONCLUSIONSOverall, 12% of the cohort had a permanent neurological complication, with new or worsened paresthesias most common, followed by pain and then weakness. The authors found that formal IONM was associated with a reduced likelihood of GTR and had no association with neurological complications. The authors believe that these data argue against IONM being considered standard of care but do not believe that these data should be used to universally argue against IONM during resection of benign nerve sheath tumors.

OBJECTIVE Postoperative C5 palsy (C5P) is a well-recognized and often-delayed complication of cervical spine surgery. Most patients recover within 6 months of onset, but the prognosis of severe cases is poor. The clinical significance and natural history of mild versus severe C5P appear to differ substantially, but palsy severity and recovery have been poorly characterized in the literature. METHODS Owing to the varying prognoses and expanding treatment options such as nerve transfer surgery to reconstruct the C5 myotome, this systematic review attempted to describe how C5P severity is classified and how C5P and its recovery are defined, with the aim of proposing a postoperative C5P scale to support clinical decision-making. PubMed was searched for articles in English published since 2000 that offer a clear definition of postoperative C5P or its recovery. Only articles reporting exclusively on C5 palsy for patients undergoing surgery for degenerative disease were included. A single reviewer screened titles and abstracts and reviewed the full text of relevant articles, with consultation as needed from a second reviewer. Data collected included postoperative C5P definitions, classification of C5P severity, and definition and/or classification of C5P recovery. Qualitative analysis was performed. RESULTS Full-text reviews were conducted of 98 of 272 articles identified and screened, and 43 met the inclusion criteria. Postoperative C5P was most commonly defined as a reduction in deltoid muscle strength by ≥ 1 grade using manual muscle testing (MMT), with potential biceps involvement also noted by some studies. The few studies that stratified C5P on the basis of severity unanimously characterized severe C5P as MMT grade ≤ 2. Nine studies reported on C5P recovery. Deltoid muscle strength improvement of MMT grade 5 commonly defined complete recovery, with no MMT improvement considered partial recovery. CONCLUSIONS This review identified clear discrepancies in the definitions of C5P and its recovery, leading to heterogeneity in its evaluation and management. With the emergence of therapeutic procedures for severe C5P, standardization of the definitions of C5P and its recovery is critical. The authors propose MMT grades of 4, 3, and ≤ 2 to classify C5P as mild, moderate, and severe, respectively, and grades of 5, 4, and 3 to classify recovery as complete, sufficient, and useful, respectively.

Early referral of neonatal brachial plexus palsy (NBPP) patients to multidisciplinary clinics is critical for timely diagnosis, treatment, and improved functional outcomes. In Saudi Arabia, inadequate knowledge regarding NBPP is a reason for delayed referral. We aimed to evaluate the knowledge of North American healthcare providers (HCPs) regarding the diagnosis, management, and prognosis of NBPP. A 12-question survey regarding NBPP was distributed via electronic and paper formats to North American providers from various referring and treating specialties. NBPP knowledge was compared between Saudi Arabian vs. North American providers, referring vs. treating specialties, academic vs. community hospitals, and providers with self-reported confidence vs. nonconfidence in NBPP knowledge. Of the 273 surveys collected, 45% were from referring providers and 55% were from treating providers. Saudi Arabian and North American HCPs demonstrated similar NBPP knowledge except for potential etiologies for NBPP and surgery timing. In North America, referring and treating providers had similar overall knowledge of NBPP but lacked familiarity with its natural history. A knowledge gap existed between academic and community hospitals regarding timing of referral/initiation of physical/occupational therapy (PT/OT) and Horner’s syndrome. Providers with self-reported confidence in treating NBPP had greater knowledge of types of NBPP and timing for PT/OT initiation. Overall, North American providers demonstrated adequate knowledge of NBPP. However, both eastern and western physicians remain overly optimistic in believing that most infants recover spontaneously. This study revealed a unique and universal knowledge gap in NBPP diagnosis, referral, and management worldwide. Continuous efforts to increase NBPP knowledge are indicated.

The goal of this survey-based study was to evaluate the current practice patterns of clinicians who assess patients with peripheral nerve pathologies and to assess variance in motor grading on the Medical Research Council (MRC) scale using example case vignettes. An electronic survey was distributed to clinicians who regularly assess patients with peripheral nerve pathology. Survey sections included (1) demographic data, (2) vignettes where respondents were asked to assess on the MRC scale, and (3) assessment of practice patterns regarding the use of patient-reported outcome measures. Inter-rater reliability statistics were calculated for the application of the MRC scale on example vignettes. There were 109 respondents. There was significant dispersion in motor grading seen on the example vignettes. For the raw responses grading the example vignettes on the MRC scale, Krippendorff’s alpha was 0.788 (95% CI 0.604, 0.991); Gwet’s AC2 was 0.808 (95% CI 0.683, 0.932); Fleiss’ kappa was 0.416 (95% CI 0.413, 0.419). Most respondents reported not utilizing any patient-reported outcome measures across peripheral nerve pathologies. Our data show that there is significant disagreement among providers when applying the MRC scale. It is important for us to reassess our current tools for patient evaluation in order to improve upon both clinical evaluation and outcomes reporting. Consensus guidelines for outcomes reporting are needed, and domains outside of manual muscle testing should be included.

To compare the birth injury outcomes and hospital length of stay and costs among newborns delivered at 34-42 weeks with neonatal brachial plexus palsy (NBPP) versus those without.We conducted a retrospective, cross-sectional study using data from the National Inpatient Sample to identify all newborns hospitalizations that occurred in the U.S. between 2016 and 2017. We included non-anomalous single liveborn delivered in-hospital at 34-42 weeks. The newborns with NBPP were identified by International Classification of Diseases, 10th Revision, Clinical Modification codes. Birth injury outcomes, and hospital length of stay and hospital costs were examined. A multivariable Poisson regression model with robust error variance was used to examine the association between NBPP and birth injury outcomes. A multivariable generalized linear regression model was used to examine the association between NBPP and hospital length of stay and hospital costs.Of 7,019,722 non-anomalous single liveborn delivered at 34-42 weeks in the U.S. from 2016 to 2017, the rate of NBPP (Among newborns delivered at 34-42 weeks, the risk of associated birth injuries, hospital length of stay and costs, were significantly higher in newborns with NBPP than those without.

The objective was to ascertain factors among deliveries complicated by shoulder dystocia (SD) and neonatal brachial plexus palsy (NBPP).At 11 hospitals, deliveries complicated by SD were identified. The inclusion criteria were vaginal delivery of non-anomalous, singleton at 34-42 weeks. Adjusted odds ratios (aOR) with 95% confidence intervals (CI) were calculated. Receiver operating characteristic (ROC) curves were created to evaluate the predictive value of the models for NBPP.Of the 62,939 individuals who delivered vaginally, 1,134 (1.8%) had SD and met other inclusion criteria. Among the analytic cohort, 74 (6.5%) had NBPP. The factor known before delivery which was associated with NBPP was diabetes (aOR = 3.87; 95% CI = 2.13-7.01). After delivery, the three factors associated with NBPP were: (1) birthweight of at least 4000 g (aOR = 1.83; 95% CI = 1.05-3.20); (2) calling for help during the SD (aOR = 4.09, 95% CI = 2.29-7.30), and (3) the duration of SD ≥120 sec (aOR = 2.47, 95% CI = 1.30-4.69). The AUC under the ROC curve for these independent factors was 0.79 (95% CI = 0.77 - 0.82).Few factors were identified that were associated with NBPP after SD, but they could not reliably predict which neonates will experience the complication.

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

Neonatal brachial plexus palsy (NBPP) results in muscle weakness and impaired somatosensory function of the arm. Current functional assessment is primarily based on clinician-elicited measurements including muscle strength and range of motion. To what extent these measures are representative of real-world arm movement is unclear.To determine the feasibility of using body-worn accelerometers to remotely assess arm movements in children with NBPP.Prospective criterion validity study of accelerometry versus clinician assessment.Academic medical center.Nine adolescents with NBPP and nine age- and gender-matched control adolescents participated in the study. All were enrolled in school and participated in community activities.Not applicable.Standard clinician-elicited measurements were collected. For assessing spontaneous arm movements, participants wore activity monitors during all waking hours for 7 days. Results were expressed as ratios of affected to unaffected arm motion for duration and magnitude and correlated with traditional clinic-based assessments. Spearman correlations were used to determine relationships between accelerometry results and traditional assessments. A p value.05 was considered statistically significant.Accelerometry measurements of arm motion and traditional clinical assessments.Compared to control ratios, duration of arm movement and magnitude ratios were reduced in the NBPP group, particularly for arm magnitude due to reduced affected arm movement and an increase in unaffected arm movement. Ratios were highly correlated with shoulder function and, to a lesser extent, with elbow function.Real-world arm use is an appropriate outcome measure that reflects functional recovery. This study demonstrates the feasibility of wearable technology to quantify duration and intensity of spontaneous arm movement in children with NBPP. Accelerometry also allows for the association between traditional clinician-elicited assessment measures and spontaneous arm movements, demonstrating the importance of the shoulder as a focus of treatment in NBPP.

Early referral of neonatal brachial plexus palsy (NBPP) patients to multidisciplinary clinics is critical for timely diagnosis, treatment, and improved functional outcomes. In Saudi Arabia, inadequate knowledge regarding NBPP is a reason for delayed referral. We aimed to evaluate the knowledge of North American healthcare providers (HCPs) regarding the diagnosis, management, and prognosis of NBPP.A 12-question survey regarding NBPP was distributed via electronic and paper formats to North American providers from various referring and treating specialties. NBPP knowledge was compared between Saudi Arabian vs. North American providers, referring vs. treating specialties, academic vs. community hospitals, and providers with self-reported confidence vs. nonconfidence in NBPP knowledge.Of the 273 surveys collected, 45% were from referring providers and 55% were from treating providers. Saudi Arabian and North American HCPs demonstrated similar NBPP knowledge except for potential etiologies for NBPP and surgery timing. In North America, referring and treating providers had similar overall knowledge of NBPP but lacked familiarity with its natural history. A knowledge gap existed between academic and community hospitals regarding timing of referral/initiation of physical/occupational therapy (PT/OT) and Horner's syndrome. Providers with self-reported confidence in treating NBPP had greater knowledge of types of NBPP and timing for PT/OT initiation.Overall, North American providers demonstrated adequate knowledge of NBPP. However, both eastern and western physicians remain overly optimistic in believing that most infants recover spontaneously. This study revealed a unique and universal knowledge gap in NBPP diagnosis, referral, and management worldwide. Continuous efforts to increase NBPP knowledge are indicated.

Determining the exact location of dural violation after traumatic pre-ganglionic (avulsion) injury of the brachial plexus with associated progressively enlarging pseudomeningocele is critical for treatment, but current imaging by MR and CT myelogram remains inadequate as there are often only indirect imaging features. We present a case of a 25-year-old man with history of motorcycle accident and left brachial plexus injury, who was found to have an extensive anterior epidural CSF collection, resulting in the contralateral neurologic deficit. Surgical treatment relies upon the identification of the site of the dural violation. On dynamic CT myelogram images, a thin hyperdense line of contrast was seen, representing "CSF flow jet" extravasating into the pseudomeningocele. Subsequent laminectomy and foraminotomy revealed a left avulsed nerve root and a dural tear at the site localized on the CT myelogram. To our knowledge, this is the first case of using dynamic CT myelography to visualize "CSF flow jet," revealing the exact location of dural violation resulting in the expanding pseudomeningocele, providing crucial information for perioperative planning.

OBJECTIVEPatients with cervical spinal cord injury (SCI)/tetraplegia consistently rank restoring arm and hand function as their top functional priority to improve quality of life. Motor nerve transfers traditionally used to treat peripheral nerve injuries are increasingly used to treat patients with cervical SCIs. In this article, the authors present early results of a prospective clinical trial using nerve transfers to restore upper-extremity function in tetraplegia.METHODSParticipants with American Spinal Injury Association (ASIA) grade A–C cervical SCI/tetraplegia were prospectively enrolled at a single institution, and nerve transfer(s) was performed to improve upper-extremity function. Functional recovery and strength outcomes were independently assessed and prospectively tracked.RESULTSSeventeen participants (94.1% males) with a median age of 28.4 years (range 18.2–76.3 years) who underwent nerve transfers at a median of 18.2 months (range 5.2–130.8 months) after injury were included in the analysis. Preoperative SCI levels ranged from C2 to C7, most commonly at C4 (35.3%). The median postoperative follow-up duration was 24.9 months (range 12.0–29.1 months). Patients who underwent transfers to median nerve motor branches and completed 18- and 24-month follow-ups achieved finger flexion strength Medical Research Council (MRC) grade ≥ 3/5 in 4 of 15 (26.7%) and 3 of 12 (25.0%) treated upper limbs, respectively. Similarly, patients achieved MRC grade ≥ 3/5 wrist flexion strength in 5 of 15 (33.3%) and 3 of 12 (25.0%) upper limbs. Among patients who underwent transfers to the posterior interosseous nerve (PIN) for wrist/finger extension, MRC grade ≥ 3/5 strength was demonstrated in 5 of 9 (55.6%) and 4 of 7 (57.1%) upper limbs 18 and 24 months postoperatively, respectively. Similarly, grade ≥ 3/5 strength was demonstrated in 5 of 9 (55.6%) and 4 of 7 (57.1%) cases for thumb extension. No meaningful donor site deficits were observed. Patients reported significant postoperative improvements from baseline on upper-extremity–specific self-reported outcome measures.CONCLUSIONSMotor nerve transfers are a promising treatment option to restore upper-extremity function after SCI. In the authors’ experience, nerve transfers for the reinnervation of hand and finger flexors showed variable functional recovery; however, transfers for the reinnervation of arm, hand, and finger extensors showed a more consistent and meaningful return of strength and function.

OBJECTIVE Nerve transfers are increasingly being utilized in the treatment of chronic tetraplegia, with increasing literature describing significant improvements in sensorimotor function up to years after injury. However, despite technical advances, clinical outcomes remain heterogenous. Preoperative electrodiagnostic testing is the most direct measure of nerve health and may provide prognostic information that can optimize preoperative patient selection. The objective of this study in patients with spinal cord injury (SCI) was to determine various zones of injury (ZOIs) via electrodiagnostic assessment (EDX) to predict motor outcomes after nerve transfers in tetraplegia. METHODS This retrospective review of prospectively collected data included all patients with tetraplegia from cervical SCI who underwent nerve transfer at the authors’ institution between 2013 and 2020. Preoperative demographic data, results of EDX, operative details, and postoperative motor outcomes were extracted. EDX was standardized into grades that describe donor and recipient nerves. Five zones of SCI were defined. Motor outcomes were then compared based on various zones of innervation. RESULTS Nineteen tetraplegic patients were identified who underwent 52 nerve transfers targeting hand function, and 75% of these nerve transfers were performed more than 1 year postinjury, with a median interval to surgery following SCI of 24 (range 8–142) months. Normal recipient compound muscle action potential and isolated upper motor neuron injury on electromyography (EMG) were associated with greater motor recovery. When nerve transfers were stratified based on donor EMG, greater motor gains were associated with normal than with abnormal donor EMG motor unit recruitment patterns. When nerve transfers were separated based on donor and recipient nerves, normal flexor donors were more crucial than normal extensor donors in powering their respective flexor recipients. CONCLUSIONS This study elucidates the relationship of the preoperative innervation zones in SCI patients to final motor outcomes. EDX studies can be used to tailor surgical therapies for nerve transfers in patients with tetraplegia. The authors propose an algorithm for optimizing nerve transfer strategies in tetraplegia, whereby understanding the ZOI and grade of the donor/recipient nerve is critical to predicting motor outcomes.

Infants that develop a neonatal brachial plexus palsy are subject to more than just a focal nerve injury. In this chapter we discuss injuries that both occur simultaneously with the NBPP and also develop along with the nerve injury over time. In order to appreciate the full impact that this has on an individual’s life, we have to look at more factors than neurological motor recovery. Through this chapter you will learn about physical, anatomic, respiratory, sensory, cognitive, and psychosocial injuries that can impact the overall outcome for children with neonatal brachial plexus palsy. With a better understanding of the multiple issues that may arise within this population, we hope to be able to care for them in a more comprehensive way.

OBJECTIVE The evaluation, treatment, and prognosis of neonatal brachial plexus palsy (NBPP) continues to have many areas of debate, including the use of ancillary testing. Given the continued improvement in imaging, it is important to revisit its utility. Nerve root avulsions have historically been identified by the presence of pseudomeningoceles or visible ruptures. This “all-or-none” definition of nerve root avulsions has many implications for the understanding and management of NBPP, especially as characterization of the proximal nerve root as a potential donor remains critical. This study examined the ability of high-resolution MRI to more specifically define the anatomy of nerve root avulsions by individually examining the ventral and dorsal rootlets as they exit the spinal cord. METHODS This is a retrospective review of patients who had undergone brachial plexus protocol MRI for clinical evaluation of NBPP at a single institution. Each MR image was independently reviewed by a board-certified neuroradiologist, who was blinded to both established diagnosis/surgical findings and laterality. Each dorsal and ventral nerve rootlet bilaterally from C5 to T1 was evaluated from the spinal cord to its exit in the neuroforamen. Each rootlet was classified as avulsed, intact, or undeterminable. RESULTS Sixty infants underwent brachial plexus protocol MRI from 2010 to 2018. All infants were included in this study. Six hundred individual rootlets were analyzed. There were 49 avulsed nerve rootlets in this cohort. Twenty-nine (59%) combined dorsal/ventral avulsions involved both the ventral and dorsal rootlets, and 20 (41%) were either isolated ventral or isolated dorsal rootlet avulsions. Of the isolated avulsion injuries, 13 (65%) were dorsal only, meaning that the motor rootlets were intact. CONCLUSIONS A closer look at nerve root avulsions with MRI demonstrates a significant prevalence (approximately 41%) of isolated dorsal or ventral nerve rootlet disruptions. This finding implies that nerve roots previously labeled as “avulsed” but with only isolated dorsal (sensory) rootlet avulsion can yet provide donor fascicles in reconstruction strategies. A majority (99%) of the rootlets can be clearly visualized with MRI. These findings may significantly impact the clinical understanding of neonatal brachial plexus injury and its treatment.

OBJECTIVEThe decision-making in neonatal brachial plexus palsy (NBPP) treatment continues to have many areas in need of clarification. Graft repair was the gold standard until the introduction of nerve transfer strategies. Currently, there is conflicting evidence regarding outcomes in patients with nerve grafts versus nerve transfers in relation to shoulder function. The objective of this study was to further define the outcomes for reconstruction strategies in NBPP with a specific focus on the shoulder.METHODSA cohort of patients with NBPP and surgical repairs from a single center were reviewed. Demographic and standard clinical data, including imaging and electrodiagnostics, were gathered from a clinical database. Clinical data from physical therapy evaluations, including active and passive range of motion, were examined. Statistical analysis was performed on the available data.RESULTSForty-five patients met the inclusion criteria for this study, 19 with graft repair and 26 with nerve transfers. There were no significant differences in demographics between the two groups. Understandably, there were no patients in the nerve grafting group with preganglionic lesions, resulting in a difference in lesion type between the cohorts. There were no differences in preoperative shoulder function between the cohorts. Both groups reached statistically significant improvements in shoulder flexion and shoulder abduction. The nerve transfer group experienced a significant improvement in shoulder external rotation, from −78° to −28° (p = 0.0001), whereas a significant difference was not reached in the graft group. When compared between groups, there appeared to be a trend favoring nerve transfer in shoulder external rotation, with the graft patients improving by 17° and the transfer patients improving by 49° (p = 0.07).CONCLUSIONSIn NBPP, patients with shoulder weakness experience statistically significant improvements in shoulder flexion and abduction after graft repair or nerve transfer, and patients with nerve transfers additionally experience significant improvement in external rotation. With regard to shoulder external rotation, there appear to be some data supporting the use of nerve transfers.

Objective The main objective of this article is to determine if persistence of neonatal brachial plexus palsy (NBPP) following shoulder dystocia was associated with maneuvers used or duration of impacted shoulder. Study Design Retrospective review of children with NBPP and documented shoulder dystocia. Student t-tests and chi-squared tests were used to compare outcomes when shoulder dystocia resolved with > 3 versus ≤ 3 maneuvers or duration > versus ≤ 120 seconds. Relative risk (RR) with 95% confidence intervals (CI) was calculated. Results Among 46 children with NBPP and shoulder dystocia, incidence of persistence was significantly higher at 2 years of age when > 3 versus ≤ 3 maneuvers were used (100 vs. 62%; RR: 1.6, 95% CI: 1.2–2.2). When resolution of impacted shoulder lasted >120 versus ≤ 120 seconds, NBPP at 2 years was significantly more likely (100 vs. 63%; RR: 1.6, 95% CI: 1.1–2.2). Injury to all five nerves of the brachial plexus was more likely if standard deviation lasted > 120 versus ≤ 120 seconds (RR: 2.2; 95% CI: 1.03–4.6). Conclusion Though the number of maneuvers used and duration of shoulder dystocia are associated with persistence of NBPP, the retrospective nature of the study of a selective cohort precludes recommendations changing the current management of shoulder dystocia.

Background A critical concept in brachial plexus reconstruction is the accurate assessment of functional outcomes. The current standard for motor outcome assessment is clinician-elicited, outpatient clinic-based, serial evaluation of range of motion and muscle power. However, discrepancies exist between such clinical measurements and actual patient-initiated use. We employed emerging technology in the form of accelerometry-based motion detectors to quantify real-world arm use after brachial plexus surgery. Objective To evaluate (1) the ability of accelerometry-based motion detectors to assess functional outcome and (2) the real-world arm use of patients after nerve transfer for brachial plexus injury, through a pilot study. Methods Five male patients who underwent nerve transfer after brachial plexus injury wore bilateral motion detectors for 7 d. The patients also underwent range-of-motion evaluation and completed multiple patient-reported outcome surveys. Results The average age of the recruits was 41 yr (±17 yr), and the average time from operation was 2 yr (±1 yr). The VT (time of use ratio) for the affected side compared to the unaffected side was 0.73 (±0.27), and the VM (magnitude ratio) was 0.63 (±0.59). VT strongly and positively correlated with shoulder flexion and shoulder abduction: 0.97 (P = .008) and 0.99 (P = .002), respectively. Conclusion Accelerometry-based activity monitors can successfully assess real-world functional outcomes after brachial plexus reconstruction. This pilot study demonstrates that patients after nerve transfer are utilizing their affected limbs significantly in daily activities and that recovery of shoulder function is critical.

Background Neonatal brachial plexus palsy (NBPP) occurs in 1–4/1000 live births, and those with palsies of the upper trunk can suffer permanent loss of elbow flexion. One option for restoring elbow flexion comprises nerve transfer from an ulnar nerve fascicle to the musculocutaneous nerve branch to biceps, also known as the Oberlin procedure. Although outcomes are encouraging, the timing of surgical intervention from the time of injury continues to be controversial. Methods We performed a retrospective review of infants with NBPP who underwent Oberlin transfer procedure. Outcome measures included active range of motion and muscle power (MRC grade) at serial examinations up to 12 months. Results We demonstrate a positive trend in outcomes of elbow flexion and supination in patients intervened on earlier rather than later. Conclusions The optimal timing in the use of Oberlin transfer in the NBPP population is not well defined. Our study is the first to focus on ulnar to musculocutaneous nerve transfer timing in NBPP, and we demonstrate a positive trend in functional outcomes with earlier surgery.

Ultrasound-guided carpal tunnel release was performed on 14 patients (18 wrists) using dynamic expansion of the transverse safe zone. Our patient population included able-bodied patients and those with impairments. The first 8 cases (12 wrists) underwent the procedure in an operating room, the remainder in an outpatient setting. No complications occurred, and all patients were able to immediately resume use of their hands without therapy. Improvements in the Quick Form of the Disabilities of the Arm, Shoulder, and Hand Index and Boston Carpal Tunnel Questionnaire at 3 months were comparable to results reported with mini-open and endoscopic release. Our results show that ultrasound-guided carpal tunnel release can be safely and effectively performed in an outpatient setting.

The prevalence of carpal tunnel syndrome (CTS) in patients with postpolio syndrome occurs at a rate of 22%. Irrespective of those with CTS, 74% of postpolio patients weight bear through their arms for ambulation or transfers. As open carpal tunnel release is performed along the weight-bearing region of the wrist, their functional independence may be altered while recovering. This case demonstrates that ultrasound-guided carpal tunnel release was successfully performed in a patient with postpolio syndrome allowing him to immediately weight bear through his hands after the procedure so he could recover at home. LEVEL OF EVIDENCE: V.

Background Neonatal brachial plexus palsy (NBPP) results in reduced function of the affected arm with profound ramifications on quality of life. Advances in surgical technique have shown improvements in outcomes for appropriately selected patients. Patient selection, however, remains difficult. Objective To develop a decision algorithm that could be applied at the individual patient level, early in life, to reliably predict persistent NBPP that would benefit from surgery. Methods Retrospective review of NBPP patients was undertaken. Maternal and neonatal factors were entered into the C5.0 statistical package in R (The R Foundation). A 60/40 model was employed, whereby 60% of randomized data were used to train the decision tree, while the remaining 40% were used to test the decision tree. The outcome of interest for the decision tree was a severe lesion meeting requirements for surgical candidacy. Results A decision tree prediction algorithm was generated from the entered variables. Variables utilized in the final decision tree included presence of Horner's syndrome, presence of a pseudomeningocele, Narakas grade, clavicle fracture at birth, birth weight >9 lbs, and induction or augmentation of labor. Sensitivity of the decision tree was 0.71, specificity 0.96, positive predictive value 0.94, negative predictive value 0.79, and F1 score 0.81. Conclusion We developed a decision tree prediction algorithm that can be applied shortly after birth to determine surgical candidacy of patients with NBPP, the first of its kind utilizing only maternal and neonatal factors. This conservative decision tree can be used to offer early surgical intervention for appropriate candidates.

Peripheral neuropathies are not uncommon, and the diagnostic evaluation includes a clinical assessment and electrophysiologic studies as well as diagnostic imaging. Magnetic resonance imaging (MRI) and high-resolution ultrasound (HRUS) are of special importance in providing the surgeon with information in the context of nerve trauma, entrapment, and nerve involvement by tumors. Peripheral neuropathy about the knee can occur in the context of associated knee pathology such as trauma, as part of a systemic disease, or as an isolated finding. In this review, we discuss the role of MRI and HRUS in the evaluation of peripheral neuropathy and present imaging examples of peripheral neuropathy involving the knee.

OBJECTIVEPatients with cervical spinal cord injury (SCI)/tetraplegia consistently rank restoring arm and hand function as their top functional priority to improve quality of life. Motor nerve transfers traditionally used to treat peripheral nerve injuries are increasingly being used to treat patients with cervical SCIs. In this study, the authors performed a systematic review summarizing the published literature on nerve transfers to restore upper-extremity function in tetraplegia.METHODSA systematic literature search was conducted using Ovid MEDLINE 1946–, Embase 1947–, Scopus 1960–, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and clinicaltrials.gov to identify relevant literature published through January 2019. The authors included studies that provided original patient-level data and extracted information on clinical characteristics, operative details, and strength outcomes after nerve transfer procedures. Critical review and synthesis of the articles were performed.RESULTSTwenty-two unique studies, reporting on 158 nerve transfers in 118 upper limbs of 92 patients (87 males, 94.6%) were included in the systematic review. The mean duration from SCI to nerve transfer surgery was 18.7 months (range 4 months–13 years) and mean postoperative follow-up duration was 19.5 months (range 1 month–4 years). The main goals of reinnervation were the restoration of thumb and finger flexion, elbow extension, and wrist and finger extension. Significant heterogeneity in transfer strategy and postoperative outcomes were noted among the reports. All but one case report demonstrated recovery of at least Medical Research Council grade 3/5 strength in recipient muscle groups; however, there was greater variation in the results of larger case series. The best, most consistent outcomes were demonstrated for restoration of wrist/finger extension and elbow extension.CONCLUSIONSMotor nerve transfers are a promising treatment option to restore upper-extremity function after SCI. Flexor reinnervation strategies show variable treatment effect sizes; however, extensor reinnervation may provide more consistent, meaningful recovery. Despite numerous published case reports describing good patient outcomes with nerve transfers, there remains a paucity in the literature regarding optimal timing and long-term clinical outcomes with these procedures.

Our objective was to compare characteristics between neonatal brachial plexus palsy (NBPP) cases that were litigated versus those that were not.From May to December 2012, the University of Michigan Interdisciplinary Brachial Plexus Program surveyed 51 consecutive families whose children were treated for NBPP. Obstetric data was self-reported. Unless NBPP resolved, children were followed for at least two years. Student's t-test and Chi-square test with odds ratio and 95% confidence intervals were calculated.Among 51 families surveyed, obstetric data were available for 98% (n = 50). Litigation was pursued by 48% (n = 24). Comparing families that litigated versus those that did not, there were no differences in demographics, peripartum characteristics, operative versus spontaneous vaginal birth, shoulder dystocia in current pregnancy (65% versus 54%; p = 0.56) or birth weight above 9 lbs. The number of children having brachial nerve surgery was significantly higher among families that litigated (46%) versus those that did not (8%; p = 0.002).Though there were no differences in peripartum events, almost 1 out of 2 children managed by interdisciplinary team had concomitant litigation. The only factor associated with litigation was having brachial nerve surgery. Efforts are warranted to avert NBPP and mitigate litigations.

Introduction: We investigated interrater reliability of overall assessment of nerve root lesions by electrodiagnostic testing (EDX) in neonatal brachial plexus palsy (NBPP). Methods: Two blinded, board-certified reviewers retrospectively reviewed de-identified EDX data from 37 infants with NBPP for 2005–2012. Only nerve conduction and electromyography needle data were included. The examiners independently assigned 1 of 4 nerve root lesion categories: (1) pre-ganglionic lesion (avulsion), (2) post-ganglionic lesion (rupture), (3) normal, or (4) “unable to determine.” Simple percentage agreement, the Cohen kappa statistic representing interrater reliability for each nerve root (C5–T1), and overall kappa between examiners were evaluated. Results: Interrater reliabilities were substantial to almost perfect for each nerve root except C5. Considering all nerve roots, overall interrater reliability was substantial (kappa = 0.62); simple percentage agreement was 75% (138/185). Conclusions: Interrater reliability of nerve root assessment by EDX for infants with NBPP was high for C6–T1 root levels, but less reliable for C5 because of technical factors. Muscle Nerve 55: 69–73, 2017

Background Currently, no published, validated patient-reported outcome (PRO) measures of health-related quality of life (HRQOL) exist for use with neonatal brachial plexus palsy (NBPP). NBPP is a debilitating condition that occurs during the perinatal period, resulting in paralysis/paresis and loss of sensation in the affected arm. Commonly used NBPP measures are not comprehensive and do not fully account for clinically meaningful changes in function or progression of the disorder. Objective To evaluate important components of HRQOL for children with NBPP and identify where new PRO measures are needed. Design Eleven focus groups comprising children with NBPP (4), family members (6), and professional providers (1) to assess HRQOL. Setting Brachial plexus clinic. Participants Children with NBPP, their parents, and professional providers. Inclusion Criteria Children 7-17 years old with NBPP; parents/caregivers at least 18 years of age; professionals with ≥2 years' experience providing NBPP clinical care; ability to read and speak English fluently. Methods Focus group sessions were recorded, transcribed verbatim, and deidentified. Qualitative frequency analysis identified different aspects of HRQOL relevant to NBPP. This analysis expands on the grounded-theory approach to qualitative analysis, including development of a domain framework, open and axial coding, selective coding, and descriptive analysis. The resulting HRQOL domain framework (and frequency analysis) was then compared to the domain framework for existing PRO measures (PROMIS and Neuro-QoL) to identify components of HRQOL where new PRO measures are needed for NBPP. Main Outcome Measures Not applicable. Results Although many physical, social, and emotional health domains were captured by existing PRO measures, some significant NBPP-specific topics emerged from qualitative analysis—functionality, sensory, physical appearance, arm/hand compensation and preference, explaining functionality/appearance to others, and self-esteem and body image concerns. Conclusions Development of sensitive and specific measures capturing arm/hand function and body image would improve the clinical care of patients with NBPP. Level of Evidence Not applicable.

Background Routine sensory assessments in neonatal brachial plexus palsy are infrequently performed because it is generally assumed that sensory recovery exceeds motor recovery. However, studies examining sensory function in neonatal brachial plexus palsy have produced equivocal findings. The purpose of this study was to examine hand sensorimotor function in older children with neonatal brachial plexus palsy using standard clinical and research-based measures of tactile sensibility. Methods Seventeen children with neonatal brachial plexus palsy (mean age: 11.6 years) and 19 age-matched controls participated in the study. Functional assessments included grip force, monofilament testing, and hand dexterity (Nine-Hole Peg, Jebsen-Taylor Hand Function). Tactile spatial perception involving the discrimination of pin patterns and movement-enhanced object recognition (stereognosis) were also assessed. Results In the neonatal brachial plexus palsy group, significant deficits in the affected hand motor function were observed compared with the unaffected hand. Median monofilament scores were considered normal for both hands. In contrast, tactile spatial perception was impaired in the neonatal brachial plexus palsy group. This impairment was seen as deficits in both pin pattern and object recognition accuracy as well as the amount of time required to identify patterns and objects. Tactile pattern discrimination time significantly correlated with performance on both functional assessment tests ( P Discussion This study provides evidence that tactile perception deficits may accompany motor deficits in neonatal brachial plexus palsy even when measures of tactile registration (i.e., monofilament testing) are normal. These results may reflect impaired processing of somatosensory feedback associated with reductions in goal-directed upper limb use and illustrate the importance of including a broader range of sensory assessments in neonatal brachial plexus palsy.

Objective The factors associated with persistent neonatal brachial plexus palsy (PNBPP) are unknown. Our objectives are to compare PNBPP at 1 and 2 years in children delivered via vaginal delivery (VD) versus cesarean delivery (CD) and in children delivered via VD with or without reported shoulder dystocia (SD). Study Design Retrospective cohort of children diagnosed with neonatal brachial plexus palsy (NBPP). Maternally reported delivery history and presence of SD were recorded with Student t -test, chi-square test, and odds ratio (OR) with 95% confidence intervals (CI) calculated for comparisons. Results Of 387 cases of NBPP, 8% (30) delivered via CD. Rates of PNBPP were higher in the VD group at 1 and 2 years (60% of CD and 85% of VD; OR, 0.26; 95% CI, 0.11–0.62 at 1 year; 33% of CD and 73% of VD; OR, 0.15; 95% CI, 0.05–0.39 at 2 years). There was no difference in PNBPP in women with VD with or without maternally reported SD (87 vs. 85%, p = 0.68 at 1 year; 64 vs. 61%, p = 0.61 at 2 years). Conclusion PNBPP is possible with CD, and there is no difference in PNBPP in VD with or without maternally reported SD. A prospective study is warranted to ascertain associative factors.

Patients presenting with enlarging fibrofatty masses in the extremities pose an interesting dilemma to clinicians, as the differential diagnosis in such cases ranges from benign to malignant, and from lesions optimally managed operatively to those managed nonoperatively. The differential diagnosis includes benign lipoma, liposarcoma, lipoblastoma, and fibrolipomatous hamartoma (lipomatosis) of the nerves. The authors present the case of a 14-year-old girl with an enlarging fibrofatty mass of the forearm, initially thought, based on diagnostic imaging, to be a fibrolipomatous hamartoma of the median nerve, but found to be a lipoblastoma without direct nerve involvement based on histopathological examination of the operative specimen. This case serves to illustrate the diagnostic predicament that can exist with such masses. The authors advocate the need to establish a tissue diagnosis while having a contingency plan for each of the diagnostic possibilities because the management of each lesion is markedly different. In this report, the authors consider the differential diagnosis of fibrofatty masses of the extremities that the peripheral nerve surgeon may encounter, and they highlight the significant differences in management strategies for each possible diagnosis.

Ultrasound has been utilized in the evaluation of compressive and traumatic peripheral nerve pathology. To determine whether US can provide comprehensive evaluation of the post-ganglionic brachial plexus in the setting of neonatal brachial plexus palsy and whether this information can be used to guide preoperative nerve reconstruction strategies. In this retrospective cohort study, preoperative brachial plexus ultrasonography was performed in 52 children with neonatal brachial plexus palsy who were being considered for surgery. The 33 children who had surgery compose the patient cohort. The presence and location of post-ganglionic neuromas were evaluated by US and compared to the surgical findings. US evaluation of shoulder muscle atrophy was conducted as an indirect way to assess the integrity of nerves. Finally, we correlated glenohumeral joint laxity to surgical and clinical management. Ultrasound correctly identified 21 of 25 cases of upper trunk and middle trunk neuroma involvement (84% sensitivity for each). It was 68% sensitive and 40% specific in detection of lower trunk involvement. US identified shoulder muscle atrophy in 11 of 21 children evaluated; 8 of these 11 went on to nerve transfer procedures based upon the imaging findings. US identified 3 cases of shoulder joint laxity of the 13 children evaluated. All 3 cases were referred for orthopedic evaluation, with 1 child undergoing shoulder surgery and another requiring casting. Ultrasound can provide useful preoperative evaluation of the post-ganglionic brachial plexus in children with neonatal brachial plexus palsy.

This book presents cases in peripheral nerve surgery divided into four distinct areas of pathology: entrapment and inflammatory neuropathies, peripheral nerve pain syndromes, peripheral nerve tumors, and peripheral nerve trauma. Each chapter also presents pearls for the accurate diagnosis of, successful treatment of, and effective complication management for each clinical entity. The latter three focus areas will be especially helpful to neurosurgeons preparing to sit for the American Board of Neurological Surgery oral examination, which bases scoring on the three areas. Finally, each chapter contains a review of the medical evidence and expected outcomes, which is helpful for counseling patients and setting accurate expectations. Rather than exhaustive reference lists, the authors provide selected references recommended to deepen understanding.

Background Unrealistic expectations of the outcomes of peripheral nerve surgery reduce patient satisfaction. Most clinicians can recall patients with unrealistic expectations despite verbal preoperative education. Objective To assess patients' baseline level of understanding regarding nerve surgery and appropriate expectations. Additionally, we tested the effect of a written, preoperative educational handout on the patients' retention of knowledge. Methods This cross-sectional survey recruited patients scheduled to undergo peripheral nerve surgery at a single institution in 2016 to 2017. During the preoperative visit, a specialized nurse practitioner reviewed perioperative protocols, risks and benefits of the surgery, and postoperative care. Patients immediately completed a survey to assess their preoperative understanding of the verbally reviewed information. During the same visit, an additional written handout was given to patients in a randomized fashion. At their first postoperative visit, all patients completed the survey again. Results A total of 60 patients (mean age 52 yr) were enrolled of which 62% were male. Immediately following verbal instruction, 31% of patients had erroneous (unrealistic) expectations regarding pain, 30% had erroneous expectations regarding postoperative motor outcome, and 41% had erroneous expectations regarding the timing of postoperative recovery. There was no significant difference between patients who received the written handout vs those who did not, on retesting in the postoperative period. Conclusion Patients undergoing peripheral nerve procedures demonstrated a high baseline level of unrealistic expectations despite standard in-person verbal counseling by specialty providers. A written handout did not have clear benefit in the retention of preoperative surgical teaching. Further investigation into more effective preoperative patient counseling is needed.

OBJECTIVENeonatal brachial plexus palsy (NBPP) continues to be a problematic occurrence impacting approximately 1.5 per 1000 live births in the United States, with 10%–40% of these infants experiencing permanent disability. These children lose elbow flexion, and one surgical option for recovering it is the Oberlin transfer. Published data support the use of the ulnar nerve fascicle that innervates the flexor carpi ulnaris as the donor nerve in adults, but no analogous published data exist for infants. This study investigated the association of ulnar nerve fascicle choice with functional elbow flexion outcome in NBPP.METHODSThe authors conducted a retrospective study of 13 cases in which infants underwent ulnar to musculocutaneous nerve transfer for NBPP at a single institution. They collected data on patient demographics, clinical characteristics, active range of motion (AROM), and intraoperative neuromonitoring (IONM) (using 4 ulnar nerve index muscles). Standard statistical analysis compared pre- and postoperative motor function improvement between specific fascicle transfer (1–2 muscles for either wrist flexion or hand intrinsics) and nonspecific fascicle transfer (> 2 muscles for wrist flexion and hand intrinsics) groups.RESULTSThe patients’ average age at initial clinic visit was 2.9 months, and their average age at surgical intervention was 7.4 months. All NBPPs were unilateral; the majority of patients were female (61%), were Caucasian (69%), had right-sided NBPP (61%), and had Narakas grade I or II injuries (54%). IONM recordings for the fascicular dissection revealed a donor fascicle with nonspecific innervation in 6 (46%) infants and specific innervation in the remaining 7 (54%) patients. At 6-month follow-up, the AROM improvement in elbow flexion in adduction was 38° in the specific fascicle transfer group versus 36° in the nonspecific fascicle transfer group, with no statistically significant difference (p = 0.93).CONCLUSIONSBoth specific and nonspecific fascicle transfers led to functional recovery, but that the composition of the donor fascicle had no impact on early outcomes. In young infants, ulnar nerve fascicular dissection places the ulnar nerve at risk for iatrogenic damage. The data from this study suggest that the use of any motor fascicle, specific or nonspecific, produces similar results and that the Oberlin transfer can be performed with less intrafascicular dissection, less time of surgical exposure, and less potential for donor site morbidity.

Importance Neonatal brachial plexus palsy (NBPP) can result in persistent deficits for those who develop it. Advances in surgical technique have resulted in the availability of safe, reliable options for treatment. Prevailing paradigms include, “all neonatal brachial plexus palsy recovers,” “wait a year to see if recovery occurs,” and “don’t move the arm.” Practicing by these principles places these patients at a disadvantage. Thus, the importance of this review is to provide an update on the management of NBPP to replace old beliefs with new paradigms. Observations Changes within denervated muscle begin at the moment of injury, but without reinnervation become irreversible 18 to 24 months following denervation. These time-sensitive, irreversible changes are the scientific basis for the recommendations herein for the early management of NBPP and put into question the old paradigms. Early referral has become increasingly important because improved outcomes can be achieved using new management algorithms that allow surgery to be offered to patients unlikely to recover sufficiently with conservative management. Mounting evidence supports improved outcomes for appropriately selected patients with surgical management compared with natural history. Primary nerve surgery options now include nerve graft repair and nerve transfer. Specific indications continue to be elucidated, but both techniques offer a significant chance of restoration of function. Conclusions and Relevance Mounting data support both the safety and effectiveness of surgery for patients with persistent NBPP. Despite this support, primary nerve surgery for NBPP continues to be underused. Surgery is but one part of the multidisciplinary care of NBPP. Early referral and implementation of multidisciplinary strategies give these children the best chance of functional recovery. Primary care physicians, nerve surgeons, physiatrists, and occupational and physical therapists must partner to continue to modify current treatment paradigms to provide improved quality care to neonates and children affected by NBPP.

OBJECTIVEThe incorporation of ancillary testing in the preoperative setting for patients with neonatal brachial plexus palsy (NBPP) remains controversial, but the recommendation for early nerve reconstruction when a baby has a preganglionic lesion at the lower nerve roots is generally accepted. At some specialty centers, nerve surgeons use preoperative electrodiagnostic testing (EDX) and imaging to aid in lesion localization and the preoperative planning of the nerve reconstruction. EDX and imaging have been evaluated for their abilities to detect pre- and postganglionic lesions, but their accuracies have never been compared directly in the same set of patients. The aim of the present study was to evaluate the accuracy of imaging and EDX in an NBPP population.METHODSA retrospective review was conducted of 54 patients with operative NBPP seen between 2007 and 2017. The patients underwent EDX and imaging: EDX was performed, and the results were reviewed by board-certified electrodiagnosticians, and imaging was reviewed by board-certified neuroradiologists. The gold standard was considered to be the findings at surgical exploration. Descriptive and analytical statistics were utilized to compare the accuracies of imaging and EDX.RESULTSThe mean age at surgery was 6.94 mos (± 4 mos). Fifteen patients (28%) were Narakas grade I–II, and 39 (72%) were Narakas grade III–IV. For all nerve roots, the overall accuracy of detecting preganglionic lesions was 74% for EDX and 69% for imaging. The overall sensitivity of detecting preganglionic lesions by EDX was 31%, but the specificity was 90%. The overall sensitivity of detecting preganglionic lesions by imaging was 66%, and the overall specificity was 70%. However, at C8, EDX was 37.5% sensitive and 87.5% specific, whereas imaging was 67.7% sensitive but only 29.4% specific.CONCLUSIONSEDX outperformed imaging with regard to specificity and accuracy of identifying preganglionic injuries. This finding is especially relevant in the lower nerve roots, given that lower plexus preganglionic lesions are an accepted indication for early intervention.

OBJECTIVEThe use of nerve transfers versus nerve grafting for neonatal brachial plexus palsy (NBPP) remains controversial. In adult brachial plexus injury, transfer of an ulnar fascicle to the biceps branch of the musculocutaneous nerve (Oberlin transfer) is reportedly superior to nerve grafting for restoration of elbow flexion. In pediatric patients with NBPP, recovery of elbow flexion and forearm supination is an indicator of resolved NBPP. Currently, limited evidence exists of outcomes for flexion and supination when comparing nerve transfer and nerve grafting for NBPP. Therefore, the authors compared 1-year postoperative outcomes for infants with NBPP who underwent Oberlin transfer versus nerve grafting.METHODSThis retrospective cohort study reviewed patients with NBPP who underwent Oberlin transfer (n = 19) and nerve grafting (n = 31) at a single institution between 2005 and 2015. A single surgeon conducted intraoperative exploration of the brachial plexus and determined the surgical nerve reconstruction strategy undertaken. Active range of motion was evaluated preoperatively and postoperatively at 1 year.RESULTSNo significant difference between treatment groups was observed with respect to the mean change (pre- to postoperatively) in elbow flexion in adduction and abduction and biceps strength. The Oberlin transfer group gained significantly more supination (100° vs 19°; p < 0.0001). Forearm pronation was maintained at 90° in the Oberlin transfer group whereas it was slightly improved in the grafting group (0° vs 32°; p = 0.02). Shoulder, wrist, and hand functions were comparable between treatment groups.CONCLUSIONSThe preliminary data from this study demonstrate that the Oberlin transfer confers an advantageous early recovery of forearm supination over grafting, with equivalent elbow flexion recovery. Further studies that monitor real-world arm usage will provide more insight into the most appropriate surgical strategy for NBPP.