Delayed Selective Neurotization for Restoration of Elbow and Hand Functions in Late Presenting Obstetrical Brachial Plexus Palsy

Abstract

The published experience of obstetrical brachial plexus palsy (OBPP) cases with poor recovery and late neurosurgical intervention are sparse. This study included 19 cases who presented after the age of 1 year with poor recovery of elbow and/or hand function and electrophysiological evidence of reinnervation. Age at surgery averaged 41 months, and the follow-up averaged 50 months. Distal neurotization was performed for restoration of elbow flexion in 11 cases, elbow extension in 3 cases, and finger flexion and/or sensibility in 5 cases. Active elbow flexion increased from an average of 2.7 to 91.8 degrees with an average gain of 89 degrees. Active elbow extension increased from an average of 10 to 56.7 degrees with an average gain of 46.7 degrees. Although, three out of five cases (60%) showed satisfactory recovery of finger flexion, all cases scored<2 using Raimondi score. Four cases gained protective sensation and one case gained discriminative sensation. The results of neurotization in late OBPP are variable. The best and most consistent results are obtained by necrotizing the biceps by the intercostal nerves or, in selected cases, by the flexor carpi ulnaris fascicle of the ulnar nerve. Delayed neurotization is the only way to recover sensory function in the hand.