Treatment of Obstetrical Brachial Plexus Injuries: Experience in Osaka

ABSTRACT

Early surgical intervention in obstetrical brachial plexus palsy started with sophisticated microsurgery techniques about 20 years ago. However, the indication for the operation is still controversial. A new classification of obstetrical brachial plexus palsy is advocated to establish systematic surgical planning. It is based on the mode of delivery and type of paralysis at 1 month old. It consists of four main types: type I, vertex delivery-upper type palsy; type II, vertex delivery-total type palsy, incomplete; type III, vertex delivery-total type palsy, complete; type IV, breech delivery-upper type palsy. Two types are added to cover the whole spectrum of this condition. Type O is neurapraxia and is clinically unimportant. Type V is a miscellaneous type, which should be considered individually. Most of the cases are classified into one of the four main types. The first priority for reconstruction is given to upper root function in types I and IV, posterior cord function in type II, and hand function in type III. The surgical procedure is intraplexal neurotizations in type I, and a combination of intraplexal and extraplexal neurotizations is a choice in types II and III. In type IV, extraplexal neurotizations are necessary. Surgical results are also discussed briefly in this article.

Birth palsy - obstetrical paralysis - Erb's palsy - brachial plexus - neurotization

REFERENCES

• 1 Sandmire H F, DeMott R K. Erb's palsy: concepts of causation.  Obstet Gynecol. 2000;  95 941-942
• 2 Alder J B, Patterson R L. Erb's palsy. Long-term results of the treatment in eighty-eight cases.  J Bone Joint Surg Am. 1967;  49 1052-1063
• 3 Gordon M, Rich H, Deutschberger J D, Green M. The immediate and long-term outcome of obstetric birth trauma.  Am J Obstet Gynecol. 1973;  117 51-56
• 4 Tan K L. Brachial palsy.  J Obstet Gynaecol Br Commonw. 1973;  80 60-62
• 5 Greenwald A G, Schute P C, Shiveley J L. Brachial plexus birth palsy: a 10-year report on the incidence and prognosis.  J Pediatr Orthop. 1984;  4 689-692
• 6 Specht E E. Brachial plexus palsy in the newborn. Incidence and prognosis.  Clin Orthop. 1975;  110 32-34
• 7 Bager B. Perinatally acquired brachial plexus palsy-a persisting challenge.  Acta Paediatr. 1997;  86 1214-1219
• 8 Kennedy R. Suture of the brachial plexus in birth paralysis of the upper extremity.  Br Med J. 1903;  1 298-301
• 9 Sever J W. Obstetric paralysis: report of eleven hundred cases.  JAMA. 1925;  85 1862-1865
• 10 Saha A K. Surgery of the Paralysed and Frail Shoulder. Copenhagen; Munksgaard 1967
• 11 Zancolli E A. Paralytic supination contracture of the forearm.  J Bone Joint Surg Am. 1967;  49 1275-1284
• 12 Zancolli E A, Mitre H. Latissimus dorsi transfer to restore elbow flexion.  J Bone Joint Surg Am. 1973;  55 1265-1275
• 13 Alanen M, Halonen J P, Katevuo K, Vilkki P. Early surgical exploration and epineural repair in birth brachial palsy.  Z Kinderchir. 1986;  41 335-337
• 14 Boome R S, Kaye J C. Obstetric traction injuries of the brachial plexus. Natural history, indications for surgical repair and results.  J Bone Joint Surg Br. 1988;  70 571-576
• 15 Gilbert A, Khouri N, Carlioz H. Exploration chirurgicale du plexus brachial dans la paralysie obstétricale.  Rev Chir Orthop Reparatrice Appar Mot. 1980;  66 33-42
• 16 Kawabata H, Masada K, Tsuyuguchi Y, Kawai K, Ono K, Tada K. Early microsurgical reconstruction in birth palsy.  Clin Orthop. 1987;  215 233-242
• 17 Meyer R D. Treatment of adult and obstetrical brachial plexus injuries.  Orthopedics. 1986;  9 899-903
• 18 Narakas A O. Obstetrical brachial plexus injuries. In: Lamb DW The Paralysed Hand. Edinburgh, UK; Churchill Livingstone 1987: 116-135
• 19 Terzis J K, Liberson W T, Levine R. Obstetrical brachial plexus palsy.  Hand Clin. 1986;  2 773-786
• 20 Zancolli E A, Zancolli E R. Palliative surgical procedures in sequelae of obstetrical palsy.  Hand Clin. 1988;  4 643-669
• 21 Al-Qattan M M, Clarke H M, Curtis C G. Klumpke's birth palsy. Does it really exist?.  J Hand Surg [Br]. 1995;  20 19-23
• 22 Brunelli G A, Brunelli G R. A fourth type of brachial plexus lesion: the intermediate (C7) palsy.  J Hand Surg [Br]. 1991;  16 492-494
• 23 Tassin J L. Paralysies obstétricales du plexus brachial: Evolution spontanée, résultats des intervensions réparatrices précoces [thesis]. VII: Université Paris 1983
• 24 Gilbert A. Long-term evaluation of brachial plexus surgery in obstetrical palsy.  Hand Clin. 1995;  11 583-594
• 25 Waters P M. 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
• 26 Chuang D CC, Ma H S, Wei F C. A new strategy of muscle transposition for treatment of shoulder deformity caused by obstetric brachial plexus palsy.  Plast Reconstr Surg. 1998;  101 686-694
• 27 Chuang D CC. Palliative reconstruction for late obstetric brachial plexus palsy with deformities of shoulder, elbow, or forearm and hand.  J Perinat Med. 2003;  31(suppl 1) 55
• 28 Al-Qattan M M, Clarke H M, Curtis C G. The prognostic value of concurrent Horner's syndrome in total obstetric brachial plexus injury.  J Hand Surg [Br]. 2000;  25 166-167
• 29 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;  94 386-391
• 30 Laurent J P. Neurosurgical correction of upper brachial plexus birth injuries.  J Neurosurg. 1993;  79 197-203
• 31 Alanen M, Ryoppy S, Varho T. Twenty-six early operations in brachial birth palsy.  Z Kinderchir. 1990;  45 136-139
• 32 Kawabata H, Kawai H, Masatomi T, Yasui N. Accessory nerve neurotization in infants with brachial plexus birth palsy.  Microsurgery. 1994;  15 768-772
• 33 Slooff A C. Obstetric brachial plexus lesions and their neurosurgical treatment.  Clin Neurol Neurosurg. 1993;  95(suppl) S73-77
• 34 Clarke H M, Al-Qattan M M, Curti C G, Zuker R M. Obstetrical brachial plexus palsy: results following neurolysis of conducting neuromas-in-continuity.  Plast Reconstr Surg. 1996;  97 974-982
• 35 Kawabata H. Brachial plexus surgery in obstetrical paralysis. In: Kawai H, Kawabata H Brachial Plexus Palsy. Singapore; World Scientific Publishing 2000: 302-319
• 36 Kawabata H, Miki K, Kitano M, Yoshida A. Surgical results in birth palsy with breech presentation [in Japanese].  J Jpn Soc Surg Hand. 2002;  19 716-719