Obstetric brachial plexus palsy: 20 years’ experience at a tertiary center in Turkey

Abstract

Aim: The aim of this study was to examine cases of obstetric brachial plexus palsy OBPP treated over 20 years at a single tertiary center Material and Method: We retrospectively reviewed 777 cases of OBPP who were observed at the Pediatric Neurology Department at Istanbul Medical Faculty between March 1989 and December 2010 The patients were evaluated in terms of demographic characteristics treatment methods surgical approaches complications and functional levels according to Narakas Clasification Scale Results: Out of a total of 777 OBPP patients 393 were female and 384 were male The mean birth weight was 3968 9 g Three of the patients were siblings OBPP was bilateral in 3 patients; right sided in 463 patients and left sided in 311 patients In terms of concomitant conditions 82 patients had torticollis 62 had Horner rsquo;s syndrome 47 had broken clavicle 3 had broken humerus 3 had cerebral palsy and 1 had facial paralysis According to the Narakas classification 430 patients 55 were evaluated as stage 1 OBPP 219 28 5 were evaluated as stage 2 66 8 5 were evaluated as stage 3 and 62 8 were evaluated as stage 4 One third of the patients 33 underwent Vojta and neurodevelopmental therapy in addition to routine physiotherapy Complete recovery was observed in 439 56 of all patients in 66 of the patients with stage 1 OBPP in 56 of the patients with stage 2 OBPP in 35 of the patients with stage 3 OBPP and in 18 of the patients with stage 4 OBPP Botulinum Toxin Type A was applied in 97 cases; 30 patients underwent primary nerve surgery and 94 underwent multiple surgical procedures 25 of them required a second surgery and 15 required a third surgery Various joint contractures were seen in 200 patients Conclusions: Despite physiotherapy Botulinum Toxin Type A application and surgical intervention one out of three patients had difficulty using their arm and developed contractures and disabilities that affected their every day life In conclusion OBPP continues to be a severe problem leading to functional impairment and disability Turk Arch Ped 2013; 48: 13 6

Keywords

• Botulinum toxin type A, Narakas classification, obstetric brachial plexus palsy, physiotherapy, torticollis

Doğumsal brakiyal pleksus felçli olgularımız: tek merkezin 20 yıllık deneyimi

Abstract

Amaç: Doğumsal brakiyal pleksus felci tanısı alan olgularımızın klinik özelliklerini ve izlem sonuçlarını ortaya koymaktır. 

Gereç ve Yöntem: Çalışmada Mart 1989 ile Aralık 2010 tarihleri arasında İstanbul Üniversitesi İstanbul Tıp Fakültesi Çocuk Nörolojisi Bilim Dalı rsquo;nda izlenen 777 olgunun demografik özellikleri uygulanan tedavi yöntemleri ve cerrahi yaklaşımları ortaya çıkan komplikasyonlar ve Narakas sınıflamasına göre iyileşme düzeyleri geriye dönük olarak değerlendirildi. 

Bulgular: Doğumsal brakiyal pleksus paralizili 777 hastanın 393 rsquo;ü kız 384 rsquo;ü erkek idi Ortalama doğum kiloları 3968 9 gramdı Üç olgu aynı anneden doğan kardeşlerdi Paralizi 463 hastada sağ 311 hastada sol ve üç hastada iki taraflı olarak gelişmişti Brakiyal pleksus paralizisine ek olarak olguların 82 39;sinde tortikolis 62 39;sinde Horner sendromu 47 39;sinde klavikula kırığı üçünde humerus kırığı üçünde beyin felci ve birinde yüz felci saptandı Narakas sınıflamasına göre 430 55 olgu evre 1 219 28 5 olgu evre 2 66 8 5 olgu evre 3 ve 62 8 olgu evre 4 olarak değerlendirildi Olguların 33 rsquo;üne Vojta ve geleneksel tedavi yaklaşımları 67 rsquo;sine ise sadece geleneksel fizyoterapi yaklaşımı uygulandı Tüm olguların 439 rsquo;unda 56 tam iyileşme sağlandı Narakas rsquo;a göre evre 1 olan olguların 66 rsquo;sında evre 2 olguların 56 rsquo;sında evre 3 olguların 35 rsquo;inde ve evre 4 olguların 18 rsquo;inde tam iyileşme sağlandı Olguların 97 rsquo;sine botilinum toksin A 30 olguya birincil sinir cerrahisi ve 94 olguya ikincil cerrahi uygulandı Bu olgulardan 25 rsquo;i ikinci kez 15 rsquo; i üçüncü kez cerrahi girişim geçirdi İki yüz olguda çeşitli düzeylerde eklem kontraktürleri gelişti.

Çıkarımlar: Düzenli fizyoterapi botilinum toksin A uygulaması ve cerrahi girişimlere rağmen olguların üçte birinde kolda kullanım zorluğu kontraktür ve özürlerin oluştuğu gözlendi Sonuç olarak doğumsal brakiyal pleksus felci işlevsel yetersizlikle sonuçlanan ve özür bırakan önemli bir sorun olmaya devam etmektedir.

Keywords

• Botilinum toksin A
• doğumsal brakiyal pleksus felci
• fizyoterapi
• Narakas sınıflandırması
• tortikolis

References

1. Yılmaz K, Çalışkan M, Oge E, Aydınlı N, Tunacı M, Özmen M. Clinical assessment, MRI, and EMG in congenital brachial plexus palsy. Pediatr Neurol 1999; 21(4): 705-10.
2. Walsh JM, Kandamany N, Ni Shuibhne N, Power H, Murphy JF, O’Herlihy C. Neonatal brachial plexus injury: comparison of incidence and antecedents between 2 decades. Am J Obstet Gynecol 2011; 204(4): 324.e1-6.
3. Foad SL, Mehlman CT, Ying J. The epidemiology of neonatal brachial plexus palsy in the United States. J Bone Joint Surg Am 2008; 90(6): 1258Backe B, Magnussen EB, Johansen OJ, Sellaeg G, Russwurm H. Obstetric brachial plexus palsy: a birth injury not explained by the known risk factors. Acta Obstet Gynecol Scand 2008; 87(10): 1027-32.
4. Hoeksma AF, Wolf H, Oei SL. Obstetric brachial plexus injuries: incidence, natural course and shoulder contracture. Clin Rehabil 2000; 14(5): 523-6.
5. Doğum istatistikleri 2001-2008 sonuçları. T.C Başbakanlık Türkiye İstatistik Kurumu Haber Bülteni, 2009: 180.
6. Hale HB, Bae DS, Waters PM. Current concepts in the management of brachial plexus birth palsy. J Hand Surg Am 2010; 35(2): 322-31. Bager B. Perinatally acquired brachial plexus palsy--a persisting challenge. Acta Paediatr 1997; 86(11): 1214-9.
7. Eng GD, Binder H, Getson P, O’Donnell R. Obstetrical brachial plexus palsy (OBPP) outcome with conservative management. Muscle Nerve 1996; 19(7): 884-91.
8. Sebastin SJ, Chung KC. Pathogenesis and management of deformities of the elbow, wrist, and hand in late neonatal brachial plexus palsy. J Pediatr Rehabil Med 2011; 4(2): 119-30.

9. Mollberg M, Hagberg H, Bager B, Lilja H, Ladfors L. High birthweight and shoulder dystocia: the strongest risk factors for obstetrical brachial plexus palsy in a Swedish population-based study. Acta Obstet Gynecol Scand 2005; 84(7): 654-9.
10. Inglis SR, Feier N, Chetiyaar JB, et al. Effects of shoulder dystocia training on the incidence of brachial plexus injury Am J Obstet Gynecol 2011; 204(4): 322.e1-6.
11. Foad SL, Mehlman CT, Ying J. The epidemiology of neonatal brachial plexus palsy in the United States. J Bone Joint Surg Am 2008; 90(6): 1258Ballock RT, Song KM. The prevalence of nonmuscular causes of torticollis in children. J Pediatr Orthop 1996; 16(4): 500-4.
12. Hervey-Jumper SL, Justice D, Vanaman MM, Nelson VS, Yang LJ. Torticollis associated with neonatal brachial plexus palsy. Pediatr Neurol 2011; 45(5): 305-10.
13. Gordon M, Rich H, Deutschberger J, Green M. The immediate and long-term outcome of obstetric birth trauma. I. Brachial plexus paralysis. Am J Obstet Gynecol 1973; 117(1): 51-6.
14. Hardy AE. Birth injuries of the brachial plexus: incidence and prognosis. J Bone Joint Surg Br 1981; 63-B(1): 98-101.
15. Sibi ński M, Synder M. Obstetric brachial plexus palsy--risk factors and predictors. Ortop Traumatol Rehabil 2007; 9(6): 569-76.
16. Smith NC, Rowan P, Benson LJ, Ezaki M, Carter PR. Neonatal brachial plexus palsy. Outcome of absent biceps function at three months of age. J Bone Joint Surg Am 2004; 86-A(10): 2163-70.
17. Aydın A, Mersa B, Erer M, Özkan T, Özkan S. Early results of nerve surgery in obstetrical brachial plexus palsy. Acta Orthop Traumatol Turc 2004; 38: 170-7.
18. Suenaga N, Minami A, Kaneda K. Long-term results of multiple muscle transfer to reconstruct shoulder function in patients with birth palsy: eleven year follow up. J Pediatr Orthop 1999; 19(5): 669-71.
19. Cohen G, Rampal V, Aubart-Cohen F, Seringe R, Wicart P. Brachial plexus birth palsy shoulder deformity treatment using subscapularis release combined to tendons transfer. Orthop Traumatol Surg Res 2010; 96(4): 334-9.