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Neonatal Brachial Plexus Palsies with Neurotmesis C5 and Avulsion C6: Supraclavicular Reconstruction Strategies and Outcome
Martijn J.A. Malessy, PhD; Willem Pondaag, PhD
Leiden University Medical Center, Leiden, Netherlands
Background: Anatomical reconstruction is not possible in severe upper Neonatal Brachial Plexus Palsies (NBPP) with neurotmesis C5 and avulsion C6. Reconstruction strategies for the restoration of elbow flexion and shoulder function in this specific upper NBPP lesion type are not well defined and outcome is unclear.
Methods: Between 1990 and 2008, nerve surgery was performed in 421 NBPP patients. Thirty-five infants had a neurotmetic lesion C5, and avulsion or intraforaminal neurotmesis C6, irrespective of C7. The C8, T1 functions were intact. Nerve surgery was based on three hierarchical steps: First, restoration of elbow flexion was aimed after by intraplexal reconstruction from proximal stump C5 to C6 or the anterior division of the superior trunk (ST); Second, shoulder function reanimation was pursued by reconnecting the suprascapular nerve (SSN) and, third the distal stump C5 or posterior division ST was used as a target.
Results: For elbow flexion, intraplexal transfer of either the C6 anterior root filaments or the entire C6 nerve to C5 was performed in 18 of 35 patients. Direct coaptation was technically possible in 16 of 18 infants. In the remaining 17 infants, two to four grafts were used from C5 to fully cover the cross-sectional area of the anterior division ST (mean graft length 2.7 cm., SD ±0.5 cm.). For shoulder function, an extra-intraplexal nerve transfer of the accessory to the SSN was used in 29 infants. Five times grafting from C5 to the SSN was applied. It was possible to lead out one to three additional grafts from C5 to the posterior division ST in 21 patients. After a mean follow-up of 5.7 years (median 4.8), all infants reached biceps muscle recovery of at least MRC 4. Mallet grade IV Abduction was obtained in 22 (63%), and external rotation recovered in 11 (30%) of patients.
Conclusions: In severe upper NBPP with C6 avulsion, restoration of good elbow flexion as first priority can be obtained with intraplexal reconstruction from C5. Shoulder function recovery is, however, limited.
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