Alexandra L. Mathews, Guang Yang, Kate Wan-Chu Chang and Kevin C. Chung
The effectiveness of contralateral C-7 (CC7) transfer is controversial, yet this procedure has been performed around the world to treat brachial plexus injuries. The authors performed a systematic review to study whether Asian countries reported better outcomes after CC7 transfer compared with “other” countries.
A systematic literature search using PubMed, EMBASE, and 3 Chinese databases was completed. Patient outcomes of CC7 transfer to the median and musculocutaneous (MC) nerves were collected and categorized into 2 groups: Asia and “other” countries. China was included as a subcategory of Asia because investigators in China published the majority of the collected studies. To compare outcomes among studies, we created a normalized Medical Research Council (MRC) scale.
For median nerve outcomes, Asia reported that 41% of patients achieved an MRC grade of ≥ M3 of wrist flexion compared with 62% in “other” countries. For finger flexion, Asia found that 41% of patients reached an MRC grade of ≥ M3 compared with 38% in “other” countries. Asia reported that 60% of patients achieved ≥ S3 sensory recovery, compared with 32% in “other” countries. For MC nerve outcomes, 75% of patients from both Asia and “other” countries reached M4 and M3 in elbow flexion.
Current data did not demonstrate that studies from Asian countries reported better outcomes of CC7 transfer to the median and MC nerves. Future studies should focus on comparing outcomes of different surgical strategies for CC7 transfer.
Kelly L. VanderHave, Karen Bovid, Hilary Alpert, Kate Wan-Chu Chang, Douglas J. Quint, James A. Leonard Jr. and Lynda J. S. Yang
The rate of neonatal brachial plexus palsy (NBPP) remains 0.4%–4% despite improvements in perinatal care. Among affected children, the extent of brachial plexus palsy differs greatly, as does the prognosis. Controversial elements in management include indications and timing of nerve repair as well as type of reconstruction in patients in whom function will ultimately not be recovered without surgical intervention. Differentiating preganglionic (avulsion) from postganglionic (rupture) lesions is critical because preganglionic lesions cannot spontaneously recover motor function. Distinguishing between these lesions at initial presentation based on clinical examination alone can be difficult in infants. The purpose of the present study was to determine the sensitivity of preoperative electrodiagnostic studies (EDSs) and CT myelography (CTM) in determining the presence of nerve root rupture and avulsions in infants with NBPP.
After receiving institutional review board approval, the authors conducted a retrospective review of patients referred to the Neonatal Brachial Plexus Program between 2007 and 2010. Inclusion criteria included children who underwent brachial plexus exploration following preoperative EDSs and CTM. The CTM scans were interpreted by a staff neuroradiologist, EDSs were conducted by a single physiatrist, and intraoperative findings were recorded by the operating neurosurgeon. The findings from the preoperative EDSs and CTM were then compared with intraoperative findings. The sensitivities and 95% confidence intervals were determined to evaluate performance accuracy of each preoperative measure.
Twenty-one patients (8 male amd 13 female) met inclusion criteria for this study. The sensitivity of EDSs and CTM for detecting a postganglionic rupture was 92.8% (CI 0.841–0.969) and 58.3% (CI 0.420–0.729), respectively. The sensitivity for EDSs and CTM for preganglionic nerve root avulsion was 27.8% (CI 0.125–0.509) and 72.2% (CI 0.491–0.875), respectively. In cases in which both CTM and EDSs gave concordant results, the sensitivity for both modalities combined was 50.0% (CI 0.237–0.763) for avulsion and 80.8% (CI 0.621–0.915) for rupture. Overall, EDSs were most useful in identifying ruptures, particularly in the upper plexus, whereas CTM was most sensitive in identifying avulsions in the lower plexus.
Knowledge of the spinal nerve integrity is critical for early management of patients with NBPP. Surgical management, in the form of nerve repair/reconstruction, and optimal prognostication of NBPP depend on the accurate diagnosis of the level and type of lesion. Both EDSs and CTM scans must always be interpreted in the context of a comprehensive evaluation of the patient. They provide supplemental information (in addition to the physical examination) for early detection of nerve root rupture and avulsion injuries, aiding surgical decision making and preoperative planning for NBPP. Continued advances in imaging, EDSs, and microsurgical nerve repair techniques will allow surgeons to achieve greater success for functional recovery in management of NBPP.