The treatment of brachial plexus birth palsy remains a vexing problem. There is little information on the benefits of surgical intervention after the age of ten months. This article reports the treatment of infants between 11 and 29 months of age with combined brachial plexus and shoulder surgery. Twenty-two infants with a mean age of 16 months were included. Nineteen patients were available for follow-up more than two years from surgery. All 19 patients had exploration and microsurgical neurolysis of the upper brachial plexus with bypass nerve grafting using proximal and distal end-to-side repairs. In four patients, an additional spinal accessory nerve transfer was performed. Concomitant release of any shoulder contracture was performed. Eleven patients underwent posterior capsulodesis, and all patients had injection of Botox into the shoulder internal rotator muscles. Results were assessed according to a modified Gilbert shoulder evaluation scale. At the latest follow-up, all patients had advanced by a mean of two grades. This indicates improvement in abduction and external rotation.
The author’s results support the contention that late microsurgical intervention can be beneficial in children with brachial plexus birth palsy. Simultaneous treatment of the concommitment shoulder position may be necessary. In most cases, grafting was used with an end-to-side technique to avoid deterioration following neuroma resection. There was no evidence of deterioration following this nerve reconstruction. However, the benefits of microsurgical neurolysis and end-to-side repair still remain questionable. From these results it is impossible to delineate what part of the treatment regimen led to improved results. The enhanced outcome may be solely attributed to the shoulder reconstruction and not necessarily the microsurgical treatment. Further subdivision of the results would be helpful.
J Bone Joint Surg