Brachial Plexus Atlanta

Brachial Plexus at Atlanta Plastic Surgery. Doctor Ann Schwentker, M.D. performs Brachial Plexus Surgery at Atlanta Plastic Surgery. She currently sees patients at our Piedmont and Northside Hospital locations along with Children’s Hospital of Atlanta at Scottish Rite (CHOA). Her practice provides coverage for Georgia and the Southeast United States for brachial plexus injuries. Please contact her or her Assistant, Lori, at 404-351-1155 lponder@atlplastic.com to schedule an appointment.

In a difficult birth, when the baby's shoulders become lodged behind the mother's pelvic bone, the brachial plexus can become stretched and damaged. Such babies may be born with an arm that is limp or twisted in an awkward position. With impaired control of the bicep, the arm may be unable to bend at the elbow. The baby may have a dropped wrist or be unable to open and close his fingers.

Most cases involve only a partial loss of movement, and function may return spontaneously in the first month of life. Other children benefit from physical and occupational therapy. If they attain normal function of the arm in the first three months of life, they usually have no further problems.

But about 10 percent of babies born with brachial plexus damage will not recover. They need reconstructive surgery to reroute nerves. With brachial plexus injury occurring in about two or three of every 1,000 live births, a substantial number of children will need surgical intervention. By promptly identifying infants with significant damage and providing timely treatment, Dr Schwentker at Atlanta Plastic Surgery has been able to give children greater functional use of their arms. Some may attain near-normal range of motion, while others adapt to remaining impairments without a significant impact on their daily lives.

Neurosurgeons from Children’s Hospital of Atlanta often are called into the neonatal nursery to perform the initial assessment. Impairment in arm mobility, usually on the right side, may be readily apparent. For example, babies typically will bend their elbows and put their hands above their shoulders in a “touchdown” position. Children with a damaged brachial plexus may keep one arm slightly bent and still while the other arm moves freely. In a severe case, the fingers of one hand may be curled but unable to flex open and closed. At the Children’s Center for Facial Nerve and Brachial Plexus Reconstruction, children are monitored every month or two for signs of functional improvement.

How long to watch and wait for functional improvement depends on the severity of the brachial plexus damage. If the hands are involved and the child shows signs of Horner Syndrome – ptosis and myosis – this indicates a disruption in the sympathetic nerve system. The T1 nerve, which is vital for hand movement, has been avulsed and is not likely to improve without surgical intervention. In these cases, surgical reconstruction often takes place at 3 months of age. Other patients may wait as long as 9 months before undergoing reconstruction. Early intervention minimizes muscle atrophy from disuse and takes advantage of the infant’s more malleable and immature nervous system. Most brachial plexus repairs will occur before the child is 1 year old.

There are three types of nerve injury that can occur: neuropraxia, rupture and avulsion.

The first, neuropraxia, can lead to a neuroma or scar tissue around a nerve or between nerve cells that interrupts the nerve signal. In less severe cases, surgeons can strip off external scar tissue to restore the connection. Often, however, the scar tissue must be cut out, and the neural pathway reconstructed with a nerve graft. The nerve impulses essentially get lost in the neuroma, and the grafts provide a pathway for new nerve growth to the muscle.

A rupture in the nerve leads to poor conduction and likewise requires repair with a graft. If the nerve root is avulsed from the spinal cord, it cannot be reimplanted. An extra-anatomic reconstruction of the plexus reroutes the nerves. The plasticity of the infant’s brain enables the child to adapt to these new pathways.

Brachial plexus damage also can involve one or more of the C5, C6, C7, C8 and T1 nerves, with each affecting different muscle movements and sensation. For example, injury to the upper brachial plexus (C5 and C6) has been called Erb-Duchenne palsy, or Erb’s palsy. It affects the shoulder and upper arm, causing the child’s arm to be rotated inward with the wrist flexed. The child cannot lift his arm over his head or grip with his fingers.

Magnetic Resonance Imaging (MRI) provides some valuable information about nerve damage for pre-surgical evaluation, and functional assessments indicate which nerves are damaged and the extent of the damage. Ultimately, the course of treatment may be altered based on what is observed during the surgery itself.

In one recent case, a 3-month-old child with very little shoulder motion was referred to the center. He was unable to bend his elbow, lift his wrist, or open his fingers or thumb. His arm was internally rotated and his fingers were curled inward. If his fingers were manually unfurled, then released, they returned to their closed position. His arm had been in this position since birth, and in three months he had shown no improvement. His muscles would progressively atrophy with disuse until new neural pathways could be constructed.

MRI revealed a neuroma affecting four nerve roots. A fifth nerve had been avulsed. Electromyograms (EMGs) are not performed because they do not distinguish between an avulsion and a rupture – injuries that occur inside the spine or extraforaminally. In fact, even the MRI provides only a general guide for surgery; clinical judgment during surgery is required to determine how to reconstruct the pathways.

Surgery began with removal of the infant’s sural nerves, which control sensation only to a small patch along the side of the foot. A missing sural nerve does not affect walking, athletics or any other functional use of the foot.

A V-shaped incision was then made above the clavicle and the phrenic nerve was carefully set aside to reveal the brachial plexus. The C5, C6 and C7 nerves were embedded in a ball of scar tissue, and the C8 nerve was avulsed. Electrical stimulation of the nerve indicated that the C8 was not functional. Scar tissue was removed and the sural nerves were used to create grafts to make new pathways.

Because new nerve growth will occur at a rate of about 1mm per month through the grafts, the patient’s progress will be monitored for 18 months to two years, to determine the success of the procedure. Initially, the child may appear to have a functional setback. The injured nerves may have provided partial connections that have been disrupted by surgery. However, only surgery can provide further improvement in functionality.

Brachial plexus surgery has limitations, which are carefully explained to parents. In most cases, children will progress and have a useful, functioning arm – but they will not have a “normal” arm. For example, they may gain antigravity strength – the ability to bend against gravity – but not normal strength or normal range of motion.

The arm may be bent slightly at the elbow and incapable of completely straightening out. In some cases, patients are referred to an orthopaedic surgeon who can perform additional procedures to reconfigure tendons or muscles to enable the child to straighten the arm or to alter the range of motion. At least 25 percent of patients will need additional surgery to maximize their function. Patients also will need significant physical therapy, and parents will be taught how to guide their child in range-of-motion exercises.

The prognosis of reconstructive surgery patients is significantly better than that of patients who receive only physical and occupational therapy and do not undergo reconstructive surgery. One study, which has not yet been published, involved a review of 100 cases spanning 15 years from the University of Toronto Hospital for Sick Children. Patients who had brachial plexus reconstructive surgery gained more muscle, more muscle movement and a greater ability to move their joints at least half the normal range against gravity. All of the children with Erb’s palsy (a less severe injury) who had reconstructive surgery regained useful function of the arm. Conversely, no patients with total palsy and hand involvement recovered useful hand function if they did not have surgery, while surgical patients demonstrated some functional improvement. Physicians at Children’s are tracking patients and expect to be able to demonstrate similar results.

As results such as these are reported in the medical literature, brachial plexus reconstruction will receive more recognition as an important intervention for children injured during birth.