Chapter 228 - Birth Brachial Plexus Injury

Front 1

birth brachial plexus injury (BBPI), arises from an injury to one or more of the cervical and thoracic nerve roots ?

Back 1

C5-T1

Front 2

Erb-Duchenne nerves? Muscles?

Back 2

C5-C6 +/- C7

deltoid, biceps, coracobrachialis, and brachioradialis

Front 3

least common pattern of injury in BBPI = ? Nerves ?

Back 3

Klumpke - C8/T1

Front 4

the presumed etiology of BBPI is ?

Back 4

difficult childbirth with application of excessive lateral traction forces to the nerves during delivery

Front 5

Settings that BBPI occurs?

Back 5

Shoulder dystocia

Arm hyperextention in breech birth

Front 6

Trauma to the upper roots of the plexus typically takes place in a ?? delivery with ??? when the neck is ??? with the arm in ??? to free the shoulder from the pubic arch

Back 6

vertex - Shoulder dystocia - laterally flexed - adduction

Front 7

Because of the more common ??? presentation of the descending fetus, ??? lesions occur more frequently

Back 7

left occiput anterior - Right-sided

Front 8

injury to the posterior shoulder, may occur when that shoulder is lodged on the ??? during the birthing process.

Back 8

maternal sacral promontory

Front 9

Bilateral injuries have been reported with ??? presentation

Back 9

Breech

Front 10

BBPI risk factors

Back 10

These include maternal characteristics such as obesity and excessive maternal weight gain, primiparity, grand multiparity, gestational diabetes, and advanced maternal age (>35 years) and labor-related factors such as shoulder dystocia, prolonged second stage of labor, vaginal breech delivery, instrument (vacuum)–assisted vaginal delivery, and epidural analgesia.

Front 11

The most important fetal trait is ?

Back 11

macrosomia (birth weight > 4500 g)

Front 12

neurapraxia? Sunderland I

Back 12

physiologic block of nerve conduction within the affected axons without loss of axonal continuity; full recovery is generally observed in days to weeks.

Front 13

Axonotmesis (Sunderland classifications II through IV) ?

Back 13

loss of continuity of the axon and its myelin sheath butwith preservation of the epineurium and perineurium; walleriandegeneration and scar formation occur, but recovery may takeplace without surgical intervention if the axons successfully growback to reach the target muscle

Front 14

Neurotmesis (Sunderland V) ?

Back 14

total severance or disruption of the entire nerve fiber;recovery from this injury is not possible without timely surgicaltreatment

Front 15

these insults have been referred to asstretch (Sunderland I), varying degrees of rupture (Sunderland IIthrough V), and avulsion.

Back 15

.

Front 16

More clinically relevant than .... is the ..... of the brachial plexus injury

Back 16

pathologic severity - anatomic localization

Front 17

four major patterns of injury in BBPI

(Most common+Rarest+least favorable outcome?) - Nerves? Muscles? waiter's Tip? Claw hand?

Back 17

-The first and most common is a purely upperbrachial plexus lesion affecting C5 and C6 nerve roots (Erb’spalsy) and causing weakness of only the deltoid and bicepsmuscles

-Thesecond presentation is that of an injury involving the C5, C6, andC7 roots. The arm is internally rotated and adducted at theshoulder, the elbow is extended, the forearm is pronated, and the wrist is flexed with fingers extended, resulting in the “waiter’s tip”posture

Hint 17

Front 18

Horner?Flaccid?Skin involvment?

Back 18

-total brachial plexus injuryinvolving the C5 through T1 roots; it is the most devastatinginjury to the brachial plexus with the least favorable outcome. Affected newborns manifest flaccid, insensate paralysis of theentire arm and hand with pale or mottled skin due to vasomotorimpairment; Horner’s syndrome (ptosis, myosis, enophthalmos,and anhidrosis) may or may not be seen
-The final and exceedingly rare pattern of injury is that of Klumpke’s palsy due todamage of the lower roots, C8 and T1. The clinical featuresinclude a “claw hand” posture and Horner’s syndrome and areseen in less than 1% of cases of BBPI

Front 19

Supraclavicular injury VS infraclavicular injury?

Back 19

supraclavicular, affecting the roots and/or trunks,or infraclavicular, involving plexal lesions distal to the level of the cords

Front 20

Preganglionic lesion

Horner?

Nerves+muscle?

Back 20

Preganglionic lesions are avulsions from the spinalcord that cause denervation weakness in all muscles supplied bythe injured root (motor cell bodies in the spinal cord), althoughnerve conduction is intact (sensory cell bodies in the dorsal rootganglion). Damage to the nerves arising in proximity to the ganglion, including the phrenic (elevated hemidiaphragm), long thoracic (winged scapula), dorsal scapular (absence of rhomboid),suprascapular (rotator cuff), and thoracodorsal (latissimus dorsi)nerves, or the presence of Horner’s syndrome (preganglionicsympathetic fibers to the eye join the sympathetic chain from theT1 spinal nerve resulting in mydriasis and ptosis) suggest a significant preganglionic injury

Front 21

Postganglionic lesion

Back 21

Postganglionicruptures generally result in delay of sensory conduction andparalysis of target muscles innervated by the trunk level andbeyond; in such lesions, there is sufficient proximal and distalnerve components relative to the site of injury for surgical repairand reconstruction

Front 22

A common pattern of injury is .... rupture of the roots and trunks in the supraclavicularcompartment (Erb’s palsy) and .... avulsion in theinfraclavicular compartment

Back 22

postganglionic -preganglionic

Front 23

Back 23

.

Front 24

Factorsthat portend a worse prognosis include

Back 24

total plexopathy andlower plexus injury, Horner’s syndrome, and multiple root avulsions

Front 25

Infants who gain partial antigravity strength in upper trunk innervated muscles within thefirst 2 months are likely to progress to complete recovery overthe next 2 years, whereas those who do not gain antigravitystrength by 5- or 6 months after birth are unlikely to recovercompletely without surgical intervention

Back 25

.

Front 26

The infant who demonstrates no signs of recovery and has a persistently .... at .... of age has totalpalsy with an unfavorable long-term prognosis

Back 26

flaccid arm - 2 months

Front 27

For all infants, we use the modified andsimplified..... ,and for patients older than 2 years who are able to cooperate, weuse the .... to document functional changes inthe shoulder and arm

Back 27

British Medical Research Council scale (BMRC 0-5)
Mallet classification

Front 28

BBPI DDX?

Back 28

Suspected associated injuries like rib,spine, clavicle, or humerus fracture and observed asymmetry ofchest wall expansion should be clarified with inspiratory andexpiratory plain radiographs. Fractures of the humerus andclavicle—the bone most commonly broken during delivery—cancause compression of the brachial plexus and a pseudoparalysisthat mimics true BBPI. Other differential diagnoses arecongenital aplasia of brachial plexus nerve roots, congenital varicella of the upper extremity, umbilical cord palsy, and intrauterinemaladaptation palsy

Front 29

Physical therapy in the form of .... is initiated at home within the ...., andthe patient returns to the clinic ....

Back 29

passive range of motion exercises - first month - 4 weeks after birth

Front 30

If, at .... age, the aforementioned musclesstill have not recovered antigravity strength, brachial plexusexploration with repair is recommended

Back 30

6 months of

Front 31

cookie test? when?

Back 31

At some institutions, surgical decisionmaking is further delayed until 9 months of age
-With the affected armadducted against the chest wall, the infant attempts to bring alightweight cookie to the mouth with elbow flexion; if the childaccomplishes this action without flexing the neck more than 45degrees, nonsurgical management is generally recommended.

Front 32

patients in whom nerve injury on examination raises concernabout phrenic nerve injury should undergo ..... tolook for an ....

Back 32

chest radiography - elevated hemidiaphragm

Front 33

If a patient is presented with BBPI without evidence of obstetric trauma and an intrauterine injury is considered, ... isperformed within .... following delivery to assess for denervation and clarify the timing of the event

Back 33

EMG - a week

Front 34

When surgical intervention is proposed, EMG and nerve conduction studies areundertaken in some centers ... after birth

Back 34

3 months

Front 35

When the decision is made to proceed with brachial plexusexploration, we use ..... to look for .... as markers fornerve ... and for any sign of spinal cord injury

Back 35

T1- and T2-weighted fast spin echo cervical MRI sequences
pseudomeningoceles - root avulsion

Front 36

.... is an invasive alternative to MRI thatprovides better ..... but requires general anesthesia, lumbar puncture, intrathecal administration of a contrast agent, and radiation exposure

Back 36

CT myelography - delineation of nerve roots and intervertebral foramina

Front 37

Many writerscite Gilbert and Tassin’s classic study of 44 children with BBPIin which the recovery of the .... muscles at ... of ageserved as the indicator for expected spontaneous recovery

Back 37

biceps - 3 months

Front 38

surgery if not recovery after?

Back 38

recommending surgical exploration at 3 months if sufficient improvement has not occurred

Front 39

recognizable surgery benefits may not appear for up to ?

Back 39

6 months

Front 40

Surgery is performed with the patient under ... anesthesia achieved with a .... neuromuscular agent to permitintraoperative electrical stimulation

Back 40

general - short-acting

Front 41

The incision for thesupraclavicular(erb) begins .... andfollows the .... to the ...; if a combined approach is indicated, the incision is extended laterally along the .... and ...

Back 41

-two fingerbreadths beneath the mastoid tip
- posterior border of the sternocleidomastoid muscle
-midpoint of the clavicle
-superior border of the clavicle to the deltopectoral groove
-curved inferiorly to the anterior axillary fold

Front 42

Once the incision is made through the skin and platysma muscle for the supraclavicular approach, the flaps are raised and a layer of fibrofatty tissue overlying the brachial plexus ..... to the .... is elevated with sharp dissection. The.... muscle is divided, and the transverse cervical vessels are retracted or cauterized

Back 42

Posterior - SCM muscle - omohyoid

Front 43

Once the incision is made through the skin and platysma muscle for the supraclavicular approach, the flaps are raised and a layer of fibrofatty tissue overlying the brachial plexus ..... to the .... is elevated with sharp dissection. The.... muscle is divided, and the transverse cervical vessels are retracted or cauterized

Back 43

Posterior - SCM muscle - omohyoid

Front 44

Dissection continues down to the clavicle with subsequent division of the... and clavicular ..... Although some surgeons routinely perform a clavicular osteotomy to improve exposure for combined approaches, others connect the supraclavicular and infraclavicular plexal elements through...

Back 44

subclavius muscle - periosteum - subclavicular blunt dissection

Front 45

Once the incision is made through the skin and platysma muscle for the supraclavicular approach, the flaps are raised and a layer of fibrofatty tissue overlying the brachial plexus ..... to the .... is elevated with sharp dissection. The.... muscle is divided, and the transverse cervical vessels are retracted or cauterized

Back 45

Posterior - SCM muscle - omohyoid

Front 46

Dissection continues down to the clavicle with subsequent division of the... and clavicular ..... Although some surgeons routinely perform a clavicular osteotomy to improve exposure for combined approaches, others connect the supraclavicular and infraclavicular plexal elements through...

Back 46

subclavius muscle - periosteum - subclavicular blunt dissection

Front 47

if necessary, the... may be dissected from the clavicle with preservation of the .... in order to expose the .... of the brachial plexus.

Back 47

clavicular portion of the pectoralis major muscle - pectoral nerve - Cords

Front 48

Once the incision is made through the skin and platysma muscle for the supraclavicular approach, the flaps are raised and a layer of fibrofatty tissue overlying the brachial plexus ..... to the .... is elevated with sharp dissection. The.... muscle is divided, and the transverse cervical vessels are retracted or cauterized

Back 48

Posterior - SCM muscle - omohyoid

Front 49

Dissection continues down to the clavicle with subsequent division of the... and clavicular ..... Although some surgeons routinely perform a clavicular osteotomy to improve exposure for combined approaches, others connect the supraclavicular and infraclavicular plexal elements through...

Back 49

subclavius muscle - periosteum - subclavicular blunt dissection

Front 50

if necessary, the... may be dissected from the clavicle with preservation of the .... in order to expose the .... of the brachial plexus.

Back 50

clavicular portion of the pectoralis major muscle - pectoral nerve - Cords

Front 51

The first goal is to reveal the ...., which requires identification of both the... along the ... and the... arising from the ....; the latter may be seen at the...?

Back 51

-C5 and C6 nerve roots and upper trunk

-phrenic nerve / ant scalene muscle

-spinal accessory nerve / C4 root

-posterior junction of the upper and middle thirds of the SCN muscle

Front 52

The upper trunk neuroma is likely to be readily apparent, and the C5 root is identified by tracing of the most superficial portion of the upper trunk toward the neural foramen.... is then divided and partially resected to provide access to the C6 through T1 nerve roots; care must be taken during exposure of the T1 root, given its proximity to the...

Back 52

-The anterior scalene muscle

-pleura and subclavian vessels

Front 53

The upper trunk neuroma is likely to be readily apparent, and the C5 root is identified by tracing of the most superficial portion of the upper trunk toward the neural foramen.... is then divided and partially resected to provide access to the C6 through T1 nerve roots; care must be taken during exposure of the T1 root, given its proximity to the...

Back 53

-The anterior scalene muscle

-pleura and subclavian vessels

Front 54

The .... and ... nerves will be located arising from the ... root and upper trunk, respectively; the .... nerve will be found under the upper trunk above the .... muscle

Back 54

-Dorsal scapular / suprascapular / C5

-long thoracic / middle scalene

Front 55

The upper trunk neuroma is likely to be readily apparent, and the C5 root is identified by tracing of the most superficial portion of the upper trunk toward the neural foramen.... is then divided and partially resected to provide access to the C6 through T1 nerve roots; care must be taken during exposure of the T1 root, given its proximity to the...

Back 55

-The anterior scalene muscle

-pleura and subclavian vessels

Front 56

The .... and ... nerves will be located arising from the ... root and upper trunk, respectively; the .... nerve will be found under the upper trunk above the .... muscle

Back 56

-Dorsal scapular / suprascapular / C5

-long thoracic / middle scalene

Front 57

Infraclavicular exposure is achieved by dissection along the... with subsequent division of the... at its insertion into the .... and at the...; the cephalic vein is preserved, and marking sutures are used in the pectoralis major to facilitate closure. At this point, the .... of the brachial plexus as well as the..... nerves may be identified.

Back 57

-deltopectoral groove

-pectoralis major / humerus / midpoint of the pectoralis minor

-Cords / median, ulnar, musculocutaneous, and axillary

Front 58

Traditionally, we have harvested autologous... grafts through bilateral open posterior lower leg... incisions

now use ..., a...

Back 58

-sural nerve / stepladder

-Avance, decellularized and sterile extracellular matrix processed from donor human peripheral nerve tissue

Front 59

Surgical options for the treatment of neonatal brachial plexus palsy include?

Back 59

-neurolysis, complete or partial resection of the neuroma, and repair by nerve grafting with or without intraplexus and/or extraplexus nerve transfers

Front 60

External neurolysis alone is employed when?

Back 60

-neural elements show evidence of mild t tion injury without disruption of the perineurial sheath

Front 61

External neurolysis alone is employed when?

Back 61

-neural elements show evidence of mild t tion injury without disruption of the perineurial sheath

Front 62

Laurent and coworkers depend on the intraoperative assessment of... across a neuroma to determine whether to perform neurolysis or neuroma resection and nerve grafting; a drop in CMAP of more than 50% leads to resection, and a drop of less than 50% results in neurolysis

Back 62

-compound muscle action potentials (CMAPs)

Front 63

External neurolysis alone is employed when?

Back 63

-neural elements show evidence of mild t tion injury without disruption of the perineurial sheath

Front 64

Laurent and coworkers depend on the intraoperative assessment of... across a neuroma to determine whether to perform neurolysis or neuroma resection and nerve grafting; a drop in CMAP of more than 50% leads to resection, and a drop of less than 50% results in neurolysis

Back 64

-compound muscle action potentials (CMAPs)

Front 65

Generally, if the root or trunk is ruptured and electrical stimulation up to 10 milliamperes generates no or minimal muscle contraction, the neuroma is resected

Back 65

.

Front 66

External neurolysis alone is employed when?

Back 66

-neural elements show evidence of mild t tion injury without disruption of the perineurial sheath

Front 67

Laurent and coworkers depend on the intraoperative assessment of... across a neuroma to determine whether to perform neurolysis or neuroma resection and nerve grafting; a drop in CMAP of more than 50% leads to resection, and a drop of less than 50% results in neurolysis

Back 67

-compound muscle action potentials (CMAPs)

Front 68

Generally, if the root or trunk is ruptured and electrical stimulation up to 10 milliamperes generates no or minimal muscle contraction, the neuroma is resected

Back 68

.

Front 69

The primary objective of surgery for Erb’s or upper trunk palsy is to restore .... and ... muscle functions

Back 69

Shoulder - biceps

Front 70

External neurolysis alone is employed when?

Back 70

-neural elements show evidence of mild t tion injury without disruption of the perineurial sheath

Front 71

Laurent and coworkers depend on the intraoperative assessment of... across a neuroma to determine whether to perform neurolysis or neuroma resection and nerve grafting; a drop in CMAP of more than 50% leads to resection, and a drop of less than 50% results in neurolysis

Back 71

-compound muscle action potentials (CMAPs)

Front 72

Generally, if the root or trunk is ruptured and electrical stimulation up to 10 milliamperes generates no or minimal muscle contraction, the neuroma is resected

Back 72

.

Front 73

The primary objective of surgery for Erb’s or upper trunk palsy is to restore .... and ... muscle functions

Back 73

Shoulder - biceps

Front 74

-If only a single nerve root stump is accessible, it is grafted to the .... nerve

-All nerve grafts should be prepared ... longer than the measured defect length

Back 74

-Musculocutaneous

-10% to 15%

Front 75

External neurolysis alone is employed when?

Back 75

-neural elements show evidence of mild t tion injury without disruption of the perineurial sheath

Front 76

Laurent and coworkers depend on the intraoperative assessment of... across a neuroma to determine whether to perform neurolysis or neuroma resection and nerve grafting; a drop in CMAP of more than 50% leads to resection, and a drop of less than 50% results in neurolysis

Back 76

-compound muscle action potentials (CMAPs)

Front 77

Generally, if the root or trunk is ruptured and electrical stimulation up to 10 milliamperes generates no or minimal muscle contraction, the neuroma is resected

Back 77

.

Front 78

The primary objective of surgery for Erb’s or upper trunk palsy is to restore .... and ... muscle functions

Back 78

Shoulder - biceps

Front 79

-If only a single nerve root stump is accessible, it is grafted to the .... nerve

-All nerve grafts should be prepared ... longer than the measured defect length

Back 79

-Musculocutaneous

-10% to 15%

Front 80

Neurorrhaphy is performed with...

Back 80

-9-0 Prolene epineurial sutures combined with fibrin glue

Front 81

External neurolysis alone is employed when?

Back 81

-neural elements show evidence of mild t tion injury without disruption of the perineurial sheath

Front 82

Laurent and coworkers depend on the intraoperative assessment of... across a neuroma to determine whether to perform neurolysis or neuroma resection and nerve grafting; a drop in CMAP of more than 50% leads to resection, and a drop of less than 50% results in neurolysis

Back 82

-compound muscle action potentials (CMAPs)

Front 83

Generally, if the root or trunk is ruptured and electrical stimulation up to 10 milliamperes generates no or minimal muscle contraction, the neuroma is resected

Back 83

.

Front 84

The primary objective of surgery for Erb’s or upper trunk palsy is to restore .... and ... muscle functions

Back 84

Shoulder - biceps

Front 85

-If only a single nerve root stump is accessible, it is grafted to the .... nerve

-All nerve grafts should be prepared ... longer than the measured defect length

Back 85

-Musculocutaneous

-10% to 15%

Front 86

Neurorrhaphy is performed with...

Back 86

-9-0 Prolene epineurial sutures combined with fibrin glue

Front 87

When transfer of the spinal accessory nerve to the suprascapular nerve is used to reinnervate the infraspinatus and supraspinatus muscles, care must be taken to section the nerve distal to the first branch to the .... muscle in order to avoid a significant motor deficit.

Back 87

Trapezius

Front 88

External neurolysis alone is employed when?

Back 88

-neural elements show evidence of mild t tion injury without disruption of the perineurial sheath

Front 89

Laurent and coworkers depend on the intraoperative assessment of... across a neuroma to determine whether to perform neurolysis or neuroma resection and nerve grafting; a drop in CMAP of more than 50% leads to resection, and a drop of less than 50% results in neurolysis

Back 89

-compound muscle action potentials (CMAPs)

Front 90

Generally, if the root or trunk is ruptured and electrical stimulation up to 10 milliamperes generates no or minimal muscle contraction, the neuroma is resected

Back 90

.

Front 91

The primary objective of surgery for Erb’s or upper trunk palsy is to restore .... and ... muscle functions

Back 91

Shoulder - biceps

Front 92

-If only a single nerve root stump is accessible, it is grafted to the .... nerve

-All nerve grafts should be prepared ... longer than the measured defect length

Back 92

-Musculocutaneous

-10% to 15%

Front 93

Neurorrhaphy is performed with...

Back 93

-9-0 Prolene epineurial sutures combined with fibrin glue

Front 94

When transfer of the spinal accessory nerve to the suprascapular nerve is used to reinnervate the infraspinatus and supraspinatus muscles, care must be taken to section the nerve distal to the first branch to the .... muscle in order to avoid a significant motor deficit.

Back 94

Trapezius

Front 95

Restoration of shoulder abduction may also be achieved with a neurotization procedure that joins the... to the...

-This operation can be performed through either a... or ... approach

Back 95

-long head of the triceps motor branch of the radial nerve

-anterior portion of the axillary nerve

-transaxillary / posterior

Front 96

TransAxilary approach

Back 96

-an incision is made through the axilla to the split between the biceps and triceps muscles, where the radial nerve branch of the long head of the triceps is localized, followed by identification of the axillary nerve medial to the tendon of the latissimus dorsi

Front 97

TransAxilary approach

Back 97

-an incision is made through the axilla to the split between the biceps and triceps muscles, where the radial nerve branch of the long head of the triceps is localized, followed by identification of the axillary nerve medial to the tendon of the latissimus dorsi

Front 98

Posterior approach

Back 98

-the patient must be prone; an incision is made along the posterior arm from the lateral border of the scapula down the posterior deltoid and lateral border of the long head of the triceps. The lateral cutaneous brachial nerve is followed to the axillary nerve and the quadrangular space is defined; once the long and lateral heads of the triceps are split, the distinct motor branches of the radial nerve are identified with direct nerve stimulation, and neurorrhaphy is performed as previously described.

Front 99

Complications

Back 99

-loss of preoperative muscle strength, injury to the phrenic nerve with diaphragmatic paralysis, cerebrospinal fluid leak, pneumothorax, thoracic duct injury (left-sided approach only), injury to the carotid and subclavian arteries or jugular and subclavian veins, pseudoarthrosis of the clavicle in the setting of clavicular osteotomy, and wound infection.

Front 100

Postoperative Care

Discharge?

Sling for how long?

Revisit?

Back 100

1-2 D

3W

3M

Front 101

Recovery typically begins within.... after surgical intervention and may continue until the patient is....

Back 101

-2 to 10 months / 5 years old

Front 102

Recovery typically begins within.... after surgical intervention and may continue until the patient is....

Back 102

-2 to 10 months / 5 years old

Front 103

-the objectives of the procedure are as follows:?

Back 103

1/stabilization of the shoulder through reinnervation of the supraspinatus and deltoid muscles;

2/restoration of elbow flexion with reactivation of the biceps muscle;

3/ improvement of median nerve sensory function in cases of lower or total palsies for future secondary reconstruction procedures.

Front 104

patients with a total plexus palsy, microsurgical exploration and repair should be undertaken by .... of age.

Back 104

3M