Commentary Journal of Hand Surgery (European Volume) 2020, Vol. 45(8) 805–806 journals.sagepub.com/home/jhs

Commentary on: C5-8 neonatal brachial plexus palsy. Operative findings, reconstructive strategy and outcome. Lombard et al. (2020) have reported their outcomes following nerve graft repair for neonatal brachial plexus palsy (NBPP) affecting the C5-8 nerve roots. They are to be congratulated on presentation of their surgical strategy and achieving long-term follow-up (mean 9.7 years, minimum 3 years) in 24 patients. The group of injuries was well defined, with inclusion based on findings at surgical exploration of the brachial plexus. They conclude that the reconstruction provides restoration of elbow flexion. There was useful hand function, this being largely provided by the intact T1 root. Unfortunately, there is no comparison with nonoperative treatment or alternative nerve repair strategies. Direct comparison with the outcomes of children treated without nerve repair is difficult because the extent of injury cannot be as well defined in non-operative cases. However, the outcomes for the elbow, shoulder and wrist can be compared with existing knowledge of the natural history of NBPP. It is known that it is rare for active elbow flexion not to recover spontaneously to a useful functional level after NBPP (Gilbert and Tassin, 1987; Hems et al., 2017; Narakas, 1987). Out of the 24 patients reported by Lombard et al., four underwent further surgery because of poor active elbow flexion and two had no elbow flexion at final follow-up. It is therefore difficult to conclude that the results of the nerve repair are better or even as good as nonoperative management. With regard to the shoulder, cases of NBPP affecting C5-8 roots (approximating to Narakas Group 3 lesions) with no biceps recovery at 4–5 months of age would be expected to have fairly poor spontaneous recovery of shoulder function (Waters, 1999).

Waters (1999) reported a mean Mallet score of 12.5 out of 20 (internal rotation was not recorded) for Narakas Group 3 or 4 cases recovering biceps function during the fifth month of age, and 9.8 for cases recovering biceps during the sixth month. Lombard et al. obtained a median score of 9.5 (out of 25) at final follow-up, representing quite poor shoulder function. It is therefore unclear if the nerve repair improved outcome. The finding of better recovery of external rotation in cases of accessory to suprascapular nerve transfer compared with nerve grafts may be a pointer to future repair strategies. Sixteen of the 24 children required secondary tendon transfer because of persisting weakness of wrist extension. The natural history for spontaneous recovery of wrist extension in cases of C5-8 NBPP is unclear. While there are cases of failure of recovery of wrist extension in NBPP, these are quite rare. Therefore, the benefit of nerve repair is doubtful. Lombard et al. have not reported the outcome for forearm rotation, which is a movement commonly affected in NBPP. Overall, the results of this study further demonstrate the need for thorough study of the natural history for spontaneous recovery after NBPP and comparative studies with surgical management. Current evidence does not support routine exploration of the plexus and nerve graft repair. The strongest indication for nerve reconstruction may be for shoulder function using nerve transfers alone, in children with biceps recovery delayed to 6 months of age or later. This approach allows spontaneous return of elbow flexion. However, clinical evidence for improved outcomes for the shoulder after repair needs to be established.

References Gilbert A, Tassin JL. Obstetrical palsy: a clinical, pathologic, and surgical review. In: Terzis JK (ed.) Microreconstruction of nerve injuries. Philadelphia, WB Saunders, 1987: 529–53.

806 Hems TEJ, Savaridas T, Sherlock DA. The natural history of recovery of elbow flexion after obstetric brachial plexus injury managed without nerve repair. J Hand Surg Eur. 2017, 42: 706–9. Lombard A, Bachy M and Fitoussi F. C5-8 neonatal brachial plexus palsy. Operative findings, reconstructive strategy and outcome. J Hand Surg Eur. 2020 (in press). Narakas AO. Obstetrical brachial plexus injuries. In: Lamb DW (ed.) The paralysed hand. Edinburgh, Churchill Livingstone, 1987: 116–35. Waters P. Comparison of the natural history, the outcome of microsurgical repair, and the outcome of operative reconstruction in brachial plexus birth palsy. J Bone Joint Surg. 1999, 81-A: 649–59.

Journal of Hand Surgery (Eur) 45(8) Tim Hems Scottish National Brachial Plexus Injury Service, Queen Elizabeth University Hospital and Royal Hospital for Children, Glasgow, UK Email: [email protected]

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