The evidence for nerve repair in obstetric brachial plexus palsy revisited

Abstract

Strong scientific validation for nerve reconstructive surgery in infants with Obstetric Brachial Plexus Palsy is lacking, as no randomized trial comparing surgical reconstruction versus conservative treatment has been performed. A systematic review of the literature was performed to identify studies that compare nerve reconstruction to conservative treatment, including neurolysis. Nine papers were identified that directly compared the two treatment modalities. Eight of these were classified as level 4 evidence and one as level 5 evidence. All nine papers were evaluated in detail to describe strong and weak points in the methodology, and the outcomes from all studies were presented. Pooling of data was not possible due to differences in patient selection for surgery and outcome measures. The general consensus is that nerve reconstruction is indicated when the result of nerve surgery is assumedly better than the expected natural recovery, when spontaneous recovery is absent or severely delayed. The papers differed in methodology on how the cut-off point to select infants for nerve reconstructive surgical therapy should be determined. The justification for nerve reconstruction is further discussed.

Figure 1

Bar diagram comparing conservative (C) with surgical (S) results. Each bar shows the percentage of patients that attain Mallet score II/III/IV. Divided into infants with C5-C6 lesions and C5-C6-C7 lesions. Reconstructed from Figure 5 in Gilbert's paper [6].

Figure 2

End stage of proximal functions from Boom and Kaye's data. y-axis: MRC score; x-axis: composition of groups 1 to 4 depends on the month of first recovery, compared with surgical group (S); small dots represent a patient, and large dots represent the mean score, with error bars of 1 standard deviation; graph reconstructed from Table 1 [3].

Figure 3

Proportion of patients with upper trunk lesions that reach a AMS score of 6 or 7. ∗ signifies statistical difference between preoperative and postoperative scores. Reconstructed from the original data in Clarke's paper [8].

Figure 4

Proportion of patients with total lesions that reach a AMS score of 6 or 7. ∗ signifies statistical difference between preoperative and postoperative scores. Reconstructed from the original data in Clarke's paper [8].

Figure 5

End stage of proximal functions from Waters' data. y-axis: Mallet subscore; composition of groups 1 to 6 depends on the month of first recovery, compared with surgical group (S); small dots represent a patient, and large dots represent the mean score, with error bars of 1 standard deviation; graph reconstructed from published individual patient data [9].

Figure 6

End stage of proximal functions from Al-Qattan's data. y-axis: active movement scale; composition of groups 2 to 4 depends on the month of first recovery, compared with surgical group (S); small dots represent a patient, and large dots represent the mean score, with error bars of 1 standard deviation; graph reconstructed from published individual patient data [10].

Figure 7

Bar diagram comparing conservative therapy (C) with neurolysis (N) and reconstruction (R). Each bar shows the percentage of patients that attain Mallet score II/III/IV/V; for the C and N groups Mallet subscores for abduction, external rotation, and hand to mouth were available; for the R group only a global Mallet score was available; reconstructed from Xu's data [11].

Figure 8

Recovery of shoulder movements. y-axis: attained result as percentage of the maximum score of range of motion (ROM); the median value is depicted as well as the 25th–75th percentiles; redrawn from Strömbeck's Figure 3(a) [12].

Figure 9

Recovery of distal movements. y-axis: attained results as percentage of the maximum score of range of motion (ROM); the median value is depicted as well as the 25th–75th percentiles; redrawn from Strömbeck's Figure 5(c) [12].

Figure 10

Results from the Louisiana series (n = 151 from 1995 to 2001) [13].