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Nerve Surgery - Primary Surgery
The protocols at The Nath Brachial Plexus Institute are based on our experience with thousands of children with brachial plexus injuries seen in the last 8 years.. Generally, if there is continued significant shoulder and/ or elbow weakness by the age of 4 to 6 months of age, and certainly, if there is significant weakness in the biceps muscle by 6 months of age, we believe that surgical exploration is indicated.
The
intraoperative nerve testing then defines the specific
procedure used to improve arm function. It is
very important to note that in 12 to 18 months following
injury, denervated muscles will not accept a new nerve
supply, and remain paralyzed or weak permanently. Because
nerves only grow back at one inch per month, time is
of the essence in managing these and any other nerve
injuries. Bone deformity can accompany longstanding
paralysis of any limb in growing children.
Specific nerve surgeries that we use are: nerve scar excision (neurolysis), nerve grafting, nerve transfer and neurotization. It is sometimes necessary to perform tendon lengthening procedures in infancy in conjunction with the nerve procedures. These procedures are complex and must be used judiciously in order not to burn bridges for future reconstructive options.
Additionally, wrist, finger and thumb movements are often affected, leading to problems with hand grasp and finger pinch. A series of tendon/ muscle transfers can help to achieve excellent function with these injuries as well.
The basic principle is that some strong muscles and tendons can be re-routed to strengthen weaker functions by sewing the transferred tendons into the paralyzed ones.
Each child of course is very different in terms of type of injury, level of function, age at presentation, and many other elements which are addressed individually; it is often possible that patients require a combination of protocols for optimal recovery, in our experience.
If
your child has weakness of shoulder, elbow, and/ or
hand by the age of 3 to 4 months, we strongly
recommend consultation with a surgical specialist with
extensive experience in obstetric brachial plexus injury.
If your child has no movement in any part of the arm by 3 months, we strongly recommend surgery at or before 3 months.
We have found this series
of steps to offer optimal results. The specifics
of application to each child is highly individual,
however, and of course other centers may have different
management protocols.
EMG's are ideally done
at 4 to 6 weeks of age to set a baseline for further
evaluation in the future. Similarly, an MRI
around that time can be done to determine whether
root avulsion (tearing of the roots from the spinal
cord) is present, although this test overall is less
important than a good EMG examination. The EMG should
then be repeated around 3 to 4 months of age to see
if improvement has occurred electrically, and to correlate
with the physical examination. Generally speaking,
if there is not full movement of all elements of the
arm (shoulder, elbow, hand) by 3 to 4 months, serious
consideration for operative exploration should be
initiated. If there is no elbow flexion by 6 months
of age, surgery is definitely recommended.
Some modifications to these general rules are:
continuing improvement in arm function by 4 to 6 months will delay or contraindicate surgery at that time, but if improvement stops later, surgery might be indicated, as in the next item below;
patients who arrive at our clinic well after 9 to 12 months of age with continuing elbow weakness and other deficits will require 2-level reconstruction, at the level of the nerve roots and in the axilla with appropriate nerve transfers and releases;
patients who are seen after 2 years of age for the first time are best managed with nerve releases and muscle/ tendon transfers.
This website is intended as an informational resource only for families and patients suffering from
peripheral nerve injuries. No attempt to provide specific medical advice is intended. It is not intended to infer that surgery is always the best choice for a particular nerve injury.
You should always contact a specialist directly for diagnosis and treatment of your
specific problem, and a second opinion is always a good idea.
