Recommendations for management of neonatal brachial plexus palsy: Based on clinical review

Highlights

• Brachial plexus clinics need to be multidisciplinary and include dedicated therapists with experience in the assessment of neonatal brachial plexus palsy (NBPP) and a surgeon with experience in microsurgical repair of NBPP.

• Referral of infants with NBPP to brachial plexus clinic (BPC) should occur by one month of age.

• Referrals should be triaged effectively so that all infants less than 3 months of age have at least one appointment before attending BPC to determine their diagnosis, the nature and extent of their injury and to implement appropriate assessment and management.

• Screening for comorbidities such as hip dysplasia and plagiocephaly and implementing appropriate management should occur at these initial appointments before attending BPC.

• Education of clinicians in maternity hospitals and the community are essential to ensure that infants and children with NBPP are referred in a timely manner and managed appropriately outside the clinic environment.

Abstract

Study Design

Descriptive report.

Introduction

Neonatal brachial plexus palsy (NBPP) involves a partial or total injury of the nerves that originate from spinal roots C5-C8 and T1. The reported incidence of NBPP is between 0.38 and 5.1 in 1000 births.

Purpose of the Study

This study describes the management NBPP in the first 3 years of life and to develop an assessment framework for infants with NBPP and postoperative guidelines for those undergoing primary surgery.

Methods

Retrospective medical record audit from 2012 to 2017.

Results

Of 187 children referred to brachial plexus clinic (BPC), 138 were new referrals and included in the audit. The average number of new referrals per annum was 37; average age at referral was 6.61 week; average age at first appointment was 16.9 weeks. Of the 138 infants, 104 were initially assessed by a physiotherapist before attending BPC. The most common comorbidity was plagiocephaly.

Discussion

From 2012 to 2017, birth location, birth facility, referral source, and time between referral and initial assessment have remained stable. The age at referral, age at which the child was first assessed, and the number of children who received services externally before attending the hospital all decreased. The number of children seen by a physiotherapist before attending BPC increased. An NBPP assessment framework, including critical time points for assessment, and postoperative guidelines for infants and children undergoing primary surgery were created.

Conclusions

Early referral is essential for effective management of NBPP and ideally infants should be assessed and management implemented before 3 months of age.

Introduction

Neonatal brachial plexus palsy (NBPP) involves a partial or total injury to the network of nerves that originate from spinal roots C5-T1 that is sustained during birth.¹ The injury is usually the result of shoulder obstruction during delivery leading to the need to increase the neck-shoulder angle, producing longitudinal stretching forces that exceed the neural tensile stress tolerance.² Shoulder dystocia is the main risk factor associated with NBPP, with other risk factors including having a baby with a birth weight greater than 4.5 kg and requiring an instrumental delivery.³

The reported incidence of NBPP ranges from 0.38 to 5.1 per 1000 live births.4, 5, 6, 7 A study by Chauhan et al in 2014 summarized 63 publications and noted that the rate of NBPP was comparable between the United States and other countries at 1.5 vs 1.3 per 1000 live births, and that the rate may be decreasing.⁸ The rate of not having an associated shoulder dystocia was 76% for all studies but was higher in the United States (78%) compared with other countries (47%).⁸ The variation in incidence has been related to birth weight and obstetric care, and the fact that some studies were performed in selected populations rather than nationwide data sets.⁵ In Australia, where this research was completed, there is no nationwide data set for the incidence of NBPP; however, it is postulated that the incidence could be similar at 1.3 to 1.5 per 1000 live births as reported by Chauhan 2014.⁸

Full recovery of upper limb neurological function in an infant with NBPP may occur within the first month after birth.^9,10 The rate of permanent disability (lasting more than 12 months) has been reported as 10% to 18% in the United States and 19% to 23% in other countries.⁸ Infants with more severe injuries may have residual deficits including loss of active range of movement, joint contractures, and motor deficits in their affected upper extremity.¹ These children may have varying degrees of permanent dysfunction including muscle weakness, limb length discrepancy, abnormal postures, bony deformities, and shoulder, elbow, and/or wrist contractures and dislocations.10, 11, 12 The impacts of NBPP may also affect the child's global development and family dynamics.¹²

The long-term prognosis for infants and children with NBPP is contingent on neurological recovery and the varying clinical presentations correlate with different injury types, subspecialty referral patterns, and subsequent care. Serial physical examination of children with NBPP is essential to determine the need for additional therapeutic or surgical intervention as the child grows and develops new skills.⁶ It is important that therapy starts early in infancy to prevent contractures and joint deformity in the affected limb and enhance the development of gross and fine motor skills.^6,13 Brachial plexus injuries are complex and the patterns of recovery are not yet fully known or predictable; hence, decisions regarding the best management remain challenging.² Published reports indicate the importance of early intervention for infants and close monitoring between 3 and 6 months of age to determine whether or not they will recover full function in the affected arm.^2,3,14 Although most infants recover satisfactory function spontaneously, 10% to 30% will not recover and it is widely recognized that these infants should be referred to specialized multidisciplinary centers due to the potential need for surgical intervention and ongoing musculoskeletal complications that may arise.¹⁵

The results of the International Plexus Outcome Study Group (iPluto) world-wide consensus survey noted that there was no consensus regarding the strategies to optimally treat children with NBPP.¹⁶ In particular, there is no generally accepted algorithm to decide whether nerve surgery should be performed, and if so at what age, and based on which parameters.¹⁶ In contrast to the lack of consensus reported in the iPluto project, a meta-analysis of the effect of primary nerve repair versus nonoperative management for infants and children with NBPP concluded that primary nerve repair commencing at 3 months of age reduced functional impairment compared with nonoperative management, and that residual impairment with nonoperative management is under reported in the literature.¹⁷ Children with NBPP may require primary nerve reconstruction with neuroma resection and grafts and/or nerve transfers in situations where nerve recovery has been limited.¹⁸ The rationale for early surgery is that the longer the muscles are deinnervated the worse the eventual outcome.⁶ Hale et al reports that the indications and timing of surgical intervention in cases of subtotal injury remain without consensus; in fact, the most deliberated element of brachial plexus management remains the timing of surgery for patients with extraforaminal rupture of the upper trunk injuries, where the range of injury severity and recovery is more difficult to predict.⁶ Secondary reconstructive surgery may also be recommended at a later stage but is not included in this paper as it is not part of initial management.

The aims of this study were to (i) complete a retrospective medical record audit to determine the timing and structure of assessment for infants and children with NBPP referred to our service for multidisciplinary brachial plexus clinic (BPC); (ii) develop an assessment framework for the assessment of children with NBPP to identify those that would benefit from surgical intervention in the first 3 years of life and allow consistency in the timing of assessments to improve comparison between management of infants with NBPP; (iii) create postoperative guidelines for those undergoing primary surgery.