Purpose
Which infants with brachial plexus birth palsy (BPBP) should undergo microsurgical
plexus reconstruction remains controversial. The current gold standard for the decision
for plexus reconstruction is serial clinical examinations, but this approach obviates
the possibility of early surgical treatment. We hypothesize that a new technique using
3-dimensional volumetric proton density magnetic resonance imaging (MRI) without sedation
can evaluate the severity of BPBP injury earlier than serial clinical examinations.
Methods
Infants were prospectively enrolled prior to 12 weeks of age and imaged using 3 Tesla
MRI without sedation. Clinical scores were collected at all visits. The imaging findings
were graded based on the number of injured levels and the severity of each injury,
and a radiological score was calculated. All infants were followed at least until
the decision for surgery was made based on clinical examination.
Results
Nine infants completed the MRI scan and clinical follow-up. The average Toronto score
at presentation was 4.4 out of 10 (range, 0–8.2); the average Active Movement Scale
score was 50 out of 105 (range, 0–86). Four infants required surgery: 2 because of
a flail limb and Horner syndrome and 2 owing to failure to recover antigravity elbow
flexion by age 6 months. Radiological scores ranged from 0 to 18 out of a maximum
score of 25. The average radiological score for those infants who required surgery
was 12 (range, 6.5–18), whereas the average score for infants who did not require
surgery was 3.5 (range, 0–8).
Conclusions
Three-dimensional proton density MRI can evaluate spinal nerve roots in infants without
the need for radiation, contrast agents, or sedation. These data suggest that MRI
can help determine the severity of injury earlier than clinical examination in infants
with BPBP, although further study of a larger sample of infants with varying severity
of disease is necessary.
Type of study/level of evidence
Diagnostic II.
Key words
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References
- Natural history of obstetric brachial plexus palsy: a systematic review.Dev Med Child Neurol. 2004; 46: 138-144
- 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: 649-659
- Surgical repair of the brachial plexus in obstetric paralysis.Chirurgie. 1984; 110 ([in French]): 70-75
- Neurotization in brachial plexus injuries: indication and results.Clin Orthop Relat Res. 1988; 237: 43-56
- The results of surgical repair in brachial plexus injuries.J Bone Joint Surg Br. 1982; 64: 54-66
- Surgical treatment of brachial plexus injuries.Br J Neurosurg. 1993; 7: 491-500
- Normal brachial plexus: MR imaging.Radiology. 1987; 165: 763-767
- Cervical nerve root avulsion in brachial plexus injuries: magnetic resonance imaging classification and comparison with myelography and computerized tomography myelography.J Neurosurg. 2002; 96: 277-284
- The role of somatosensory evoked potentials and nerve conduction studies in the surgical management of brachial plexus injuries.J Bone Joint Surg Br. 1980; 62: 492-496
- Gomes dos Santos JB, Faloppa F. Brachial plexus injuries: diagnosis performance and reliability of everyday tools.Hand Surg. 2014; 19: 7-11
- Usefulness of myelography in brachial plexus injuries.J Hand Surg Br. 1989; 14: 59-64
- The findings in paediatric obstetric brachial palsy differ from those in older patients: a suggested explanation.Dev Med Child Neurol. 2000; 42: 158-161
- Obstetric lesions of the brachial plexus.Muscle Nerve. 2001; 24: 1451-1461
- Polyneural innervation in the psoas muscle of the developing rat.Muscle Nerve. 1998; 21: 1058-1063
- Predictive value of computed tomographic myelography in obstetrical brachial plexus palsy.Plast Reconstr Surg. 2000; 106: 971-977
- The diagnostic value of CT myelography, MR myelography, and both in neonatal brachial plexus palsy.AJNR Am J Neuroradiol. 2014; 35: 1425-1432
- The Active Movement Scale: an evaluative tool for infants with obstetrical brachial plexus palsy.J Hand Surg Am. 2002; 27: 470-478
- The natural history of obstetrical brachial plexus palsy.Plast Reconstr Surg. 1992; 93 (discussion 681): 675-680
- Navigating the gray zone: a guideline for surgical decision making in obstetrical brachial plexus injuries.J Neurosurg Pediatr. 2009; 3: 173-180
- Injuries of the brachial plexus and neighboring peripheral nerves in vertebral fractures and other trauma of the cervical spine [in German].Orthopade. 1987; 16: 81-86
- Imaging in the newborn: infant immobilizer obviates the need for anesthesia.Isr Med Assoc J. 2011; 13: 663-665
- Non-sedated rapid volumetric proton density MRI predicts neonatal brachial plexus birth palsy functional outcome.J Neuroimaging. 2016; 27: 248-254
Article info
Publication history
Published online: March 18, 2017
Accepted:
January 29,
2017
Received:
August 24,
2016
Footnotes
No benefits in any form have been received or will be received related directly or indirectly to the subject of this article.
Identification
Copyright
© 2017 by the American Society for Surgery of the Hand. All rights reserved.
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