Nerve Lesions in Neonates & Children

Obstetric Brachial Plexus Palsy (OBPP or Birth palsy)

Although the last decade has shown a relative reduction in the frequency of obstetric brachial plexus palsies, we still see quite a few of these neonates as well as children or young adults from the past decades with aftermaths of OBPP. Obese mothers with overweight babies form a special risk group. Spontaneous assisted births in such a cohort might lead to OBPP.  Most of the time the palsy in babies is recognised by the mothers. The involved arm of the baby with OBPP is found to be in a typically internally rotated and extended position, usually termed as “policeman tip receiving position”. Birth palsies may involve just the upper two nerve roots (Erb’s Palsy) or the upper three (Extended Upper OBPP) or the lower two roots or the entire brachial plexus. In the majority of the cases, it is a lesion in continuity of the upper trunk of the brachial plexus. However, modern MRI imaging methods have shown that root avulsions in neonates are more common than previously thought.

In cases of simple stretch injury to the upper element, the recovery of function is quite rapid under physiotherapy measures. In such cases one can visually observe (as opposed to EMG) improvements in or restoration of elbow flexion, shoulder abduction and other functions within a span of two to three months (approximately 50-60% of all OBPP babies show a spontaneous improvement of function without surgery). In persistent palsy irrespective of physical therapy, or if an initial improvement has come to a still stand, surgical correction should be considered in the individual case.

In any case (surgery or not) the baby with OBPP should preferentially be observed both by a brachial plexus surgeon and physical therapists in order not to neglect the correct moment to operate, when the indication is there. Thus the care of OBPP is, without doubt, an interdisciplinary one. The prognosis of primary brachial plexus reconstruction in babies is quite different from adults: the chances of regaining almost all useful functions of the arm is high.

Baby-Plexus OBPP-RESULTS Handfunction-OBPP

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One of the frequent residues of OBPP, irrespective of operation or not, is the failed recovery of the external rotation of the shoulder joint. As the child grows, there is a deficit of raising the arm above head level. However, unlike adults, children compensate their functional loss using other muscles. In this case they use the paravertebral muscles to bend their whole upper part of the body to bring the involved arm above head level, albeit with quite a difficulty. This compensatory movement leads to a misbalanced development of the vertebral column and thus to scoliosis and further vertebral problems in childhood and adulthood. Thus secondary correction is preferable in such children. The strategy depends on the suppleness of the shoulder joint itself: (a) with a supple joint, an additional motor is provided for the external rotation via transfer of the conjoint tendon of Latissimus dorsi and teres major to an external rotation position of the humerus (L’Episcopo Tendon Transfer). (b) with a stiff and unsupple joint, correction osteotomies provide a solution to improve over head movement of the arm. Some examples are illustrated as follows.

Scoliosis-Ext-Rot-Palsy Episcopo-Transfer-OBPP Rotationsosteotomie-text

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Möbius and Möbius-like Syndromes:
Congenital facial palsy in the new born owing to non-development of the facial nerve nuclei in the brain stem and/or non-development of mimic muscles is termed Möbius Syndrome. As a rule babies with Möbius Syndrome show bilateral facial palsy with an inability to smile or show other emotional expression. Usually parents notice this developmental anomaly at a time point starting from several weeks to several months after the child was born.

Quite a few other conditions, including unilateral facial palsy in the new born (which is identified much earlier by the parents) are termed Möbius-like Syndromes.

In the majority of the cases of Möbius and Möbius-like syndromes, the treatment is surgical and aimed at proper eye-lid closure and oral commissural excursion using static, as well as dynamic microsurgical methods such as free muscle transfer. As in any other case of peripheral nerve lesion, an individual evaluation of the children is necessary to titrate the required treatment strategy.


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