Wednesday, January 31, 2007

Long-term results of surgery for brachial plexus birth palsy.

(J Bone Joint Surg Am. 2007 Jan;89(1):18-26)


1 comment:

Coordinator said...

This study present the long-term (13 year) results of 112 children operated on for severe birth brachial plexus injury over a 26-year period by 11 surgeons in Finland. The indications for surgery were a flail arm at 2 months or no elbow flexion at 3 months. 8/11 surgeons performed less than 10 procedures during the study period, with the most experienced surgeon (39 operations) frequently performing direct coaptations after neuroma removal. The majority of babies did not undergo preopreative CT myelography or MRI. The follow-up evaluations were thorough, including functional evaluation of the shoulder, elbow, and hand, as well as a number of quality-of-life evaluations. Only 10% of patients were lost to follow-up.

What impressed me the most about this study were the outcomes, including the 31% incidence of arm pain, average Mallet and Gilbert scores of 3, 63% satisfaction rate, and a third of patients needing assistance with ADLs. Are these outcomes unusually poor?, or perhaps acceptable considering the patients included had quite severe injuries including flail arms or no arm flexion at 3 months (not just an inability to reach the mouth by 6-9 months). Concerns include the low surgical volumes of each surgeon (even in the most experienced one), the lack of preoperative imaging, and the frequency of direct coaptations after neuroma removal, which brings up the concern of suture-site tension.

Nevertheless, I believe this is an important study that perhaps represents the "real-life", long-term outcomes of severe birth injury repairs. These results are pertinent because many babies continue to be operated on by low-volume surgeons, or young surgeons entering the field of nerve surgery; partly because of limited family resources and referral source understanding. Until statistically better outcomes are evident at higher volume centers (of note, a lack of uniformity in outcome measures is one limitation that prevents adequate comparison studies) this will likely not change.