Active Movement Scale Scores Impact Surgical Decision Making in Perinatal Brachial Plexus Palsy
Anne E Glenney, BA1, Casey Zhang, BA1, Meeti Mehta, BA1, Alexander Comerci, BA1, Hilary Liu, BA1, Yusuf Surucu, MD1, Elizabeth A. Moroni, MD, MHA1, Kacey Marra, PhD2 and Alexander J Davit III, MD3, 1University of Pittsburgh Medical Center, Pittsburgh, PA, 2Department of Plastic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, 3Department of Plastic Surgery, University of Pittsburgh Medical Center / Children's Hospital of Pittsburgh, Pittsburgh, PA
Background: Perinatal brachial plexus palsy (PBPP) is an exceedingly rare condition that poses challenges to treating providers. While most cases resolve without surgical intervention, evaluating upper-extremity motor power in infants represents a clinical challenge, and it is difficult to predict which patients will go on to require surgical management. The Active Movement Scale (AMS) is a validated scale that provides a quantifiable assessment of upper-extremity strength in infants. Our study describes trends in AMS scores over time in PBPP patients to better understand the relationship between AMS scores, management, and outcomes in PBPP patients.
Methods: A retrospective review of patients with brachial plexus injury presenting to our institution between 2008 and 2020 was conducted. Patients were included if they had a diagnosis of PBPP and a minimum of three recorded AMS scores. Variables collected included demographic information, birth history, presence of risk factors (e.g., shoulder dystocia, maternal diabetes), AMS scores, operative management, and outcomes.
Results: 173 patients with brachial plexus injury presented to our institution between 2008 and 2020. 57 patients met inclusion criteria; 17 patients required surgery at an average of 7 months old. The average AMS score at initial presentation for non-surgical patients was 85.0. On long-term follow up (on average at 17 months), non-surgical patients demonstrated a significant improvement in AMS, to an average 101.6 (p<0.001). Patients who required surgery had significantly lower pre-operative AMS scores than non-surgical patients, with an average score of 41.3 at initial presentation (p<0.001). Following surgery, patients’ AMS scores increased significantly to an average of 74.6 (p<0.001). Notably, each one-point increase in initial AMS score was associated with a 9.88% reduction in likelihood of surgery (p=0.004). There was no significant difference in the rate of improvement of AMS scores between non-operative and operative patients pre-operatively (p=0.287).
Conclusion: Initial AMS scores may predict the likelihood of requiring surgery, with lower initial AMS scores associated with significantly higher risk of requiring operative intervention. However, there was no significant difference in the pre-operative rate of improvement of AMS scores between patients managed surgically compared to non-surgically. This finding suggests that function at initial presentation, rather than rate of improvement over the first year of life, is predictive of future surgery. These results have implications on practice management, suggesting that a higher index of suspicion for requiring surgical management should be maintained for PBPP patients with low initial AMS scores.
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