Child's Nervous System

, Volume 35, Issue 2, pp 349–354 | Cite as

Outcomes from primary surgical reconstruction of neonatal brachial plexus palsy in 104 children

  • Mario G. SiqueiraEmail author
  • Carlos Otto Heise
  • Gustavo C. Alencar
  • Roberto S. Martins
  • Luciano Foroni
Original Article



The outcome from microsurgical reconstruction of neonatal brachial plexus palsy (NBPP) varies, and comparison between different series is difficult, given the differences in preoperative evaluation, surgical strategies, and outcome analysis. To evaluate our results, we reviewed a series of children who underwent surgical treatment in a period of 14 years.


We made a retrospective review of 104 cases in which microsurgical repair of the brachial plexus was performed. Strength was graded using the Active Movement Scale. Whenever possible, upper palsies underwent surgery 4 to 6 months after birth and total lesions around 3 months. The lesions were repaired, according to the type of injury: neurolysis, nerve grafting, nerve transfer, or a combination of techniques. The children were followed for at least 24 months.


The majority of cases were complete lesions (56/53.8%). Erb’s palsy was present in 10 cases (9.6%), and 39 infants (37.5%) presented an extended Erb’s palsy. The surgical techniques applied were neurolysis (10.5%), nerve grafts (25.9%), nerve transfers (34.6%), and a combination of grafts and transfers (30.7%). The final outcome was considered poor in 41.3% of the cases, good in 34.3%, and excellent in 24%. A functional result (good plus excellent) was achieved in 58.3% of the cases.


There is no consensus regarding strategies for treatment of NBPP. Our surgical outcomes indicated a good general result comparing with the literature. However, our results were lower than the best results reported. Maybe the explanation is our much higher number of total palsy cases (53.8% vs. 25% in the literature).


Neonatal brachial plexus palsy Brachial plexus reconstruction Nerve grafts Nerve transfers 



  1. 1.
    Al-Qattan MM (2000) The outcome of Erb’s palsy when the decision to operate is made at 4 months of age. Plast Reconstr Surg 106:1461–1465CrossRefGoogle Scholar
  2. 2.
    Al-Qattan MM (2002) Oberlin’s ulnar nerve transfer to the biceps nerve in Erb’s birth palsy. Plast Reconstr Surg 109:405–407CrossRefGoogle Scholar
  3. 3.
    Al-Qattan MM (2003) Obstetric brachial plexus injuries. J Am Soc Surg Hand 3:41–54CrossRefGoogle Scholar
  4. 4.
    Al-Qattan MM, El-Sayed AA, Al-Kharfy TM, Al-Jurayyan NA (1996) Obstetrical brachial plexus injury in newborn babies delivered by cesarean section. J Hand Surg Br 21:263–265CrossRefGoogle Scholar
  5. 5.
    Bain JR, Dematteo C, Gjertsen D, Hollenberg RD (2009) Navigating the gray zone: a guideline for surgical decision making in obstetrical brachial plexus injuries. J Neurosurg Pediatr 3:173–180CrossRefGoogle Scholar
  6. 6.
    Birch R, Ahad N, Kono H, Smith S (2005) Repair of obstetric brachial plexus palsy. Results in 100 children. J Bone Joint Surg Br 87:1089–1095CrossRefGoogle Scholar
  7. 7.
    Buterbaugh KL, Shah AS (2016) The natural history and management of brachial plexus palsy. Curr Rev Musculoskelet Med 9:418–426CrossRefGoogle Scholar
  8. 8.
    Chauhan SP, Blackwell SB, Ananth CV (2014) Neonatal brachial plexus palsy: incidence, prevalence, and temporal trends. Semin Perinatol 38:210–218CrossRefGoogle Scholar
  9. 9.
    Chuang DC, Mardini S, Ma HS (2005) Surgical strategy for infant obstetrical brachial plexus palsy: experiences at Chang Gung Memorial Hospital. Plast Reconstr Surg 116:132–142CrossRefGoogle Scholar
  10. 10.
    Clarke HM, Curtis CG (1995) An approach to obstetrical brachial plexus injuries. Hand Clin 11:563–581Google Scholar
  11. 11.
    Curtis C, Stephens D, Clarke HM, Andrews D (2002) The active movement scale: an evaluative tool for infants with obstetrical brachial plexus palsy. J Hand Surg Am 27:470–478CrossRefGoogle Scholar
  12. 12.
    El-Gammal TA, Fathi NA (2002) Outcomes of surgical treatment of brachial plexus injuries using nerve grafting and nerve transfers. J Reconstr Microsurg 18:7–15CrossRefGoogle Scholar
  13. 13.
    El-Sayed AA, Al-Qattan M, Clarke HM, Curtis CG (1996) Incidence of Klumpke’s birth palsy: comparison between two decades. Can J Plast Surg 4:1–6CrossRefGoogle Scholar
  14. 14.
    Foad SL, Mehlman CT, Ying J (2008) The epidemiology of neonatal brachial plexus palsy in the United States. J Bone Joint Surg Am 90:1258–1264CrossRefGoogle Scholar
  15. 15.
    Garg R, Merrell GA, Hillstrom HJ, Wolfe SW (2011) Comparison of nerve transfers and nerve grafting for traumatic upper plexus palsy: a systematic review and analysis. J Bone Joint Surg Am 93:819–829CrossRefGoogle Scholar
  16. 16.
    Gilbert A (1995) Long-term evaluation of brachial plexus surgery in obstetrical palsy. Hand Clin 11:583–594Google Scholar
  17. 17.
    Gilbert A, Tassin JL (1984) Surgical repair of the brachial plexus in obstetric paralysis. Chirurgie 110:70–75Google Scholar
  18. 18.
    Gilbert A, Whitaker I (1991) Obstetrical brachial plexus lesions. J Hand Surg Br 16:489–491CrossRefGoogle Scholar
  19. 19.
    Gilbert WM, Nesbitt TS, Danielsen B (1999) Associated factors in 1611 cases of brachial plexus injury. Obstet Gynecol 93:536–540Google Scholar
  20. 20.
    Gilchrist DK (1967) A stockinette-Velpeau for immobilization of the shoulder-girdle. J Bone Joint Surg Am 49:750–751CrossRefGoogle Scholar
  21. 21.
    Haerle M, Gilbert A (2004) Management of complete obstetric brachial plexus lesions. J Pediatr Orthop 24:194–200CrossRefGoogle Scholar
  22. 22.
    Heise CO, Siqueira MG, Martins RS, Gherpelli JL (2007) Clinical electromyography correlation in infants with obstetric brachial plexopathy. J Hand Surg 32:999–910CrossRefGoogle Scholar
  23. 23.
    Heise CO, Siqueira MG, Martins RS, Gherpelli JL (2009) Motor nerve conduction studies in obstetric brachial plexopathy for a selection of patients with poor outcome. J Bone Joint Surg Am 91:1729–1737CrossRefGoogle Scholar
  24. 24.
    Heise CO, Martins RS, Siqueira MG (2015) Neonatal brachial plexus palsy: a permanent challenge. Arq Neuropsiquiatr 73:803–808CrossRefGoogle Scholar
  25. 25.
    Heise CO, Siqueira MG, Martins RS, Foroni LH, Sterman-Neto H (2017) Distal nerve transfer versus supraclavicular nerve grafting : comparison of elbow flexion outcome in neonatal brachial plexus palsy with C5-C7 involvement. Childs Nerv Syst 33:1571–1574CrossRefGoogle Scholar
  26. 26.
    Hentz VR, Meyer RD (1991) Brachial plexus microsurgery in children. Microsurgery 12:175–185CrossRefGoogle Scholar
  27. 27.
    Hoeksma AF, ter Steeg AM, Nelissen RG, van Ouwerkerk WJ, Lankhorst GJ, de Jong BA (2004) Neurological recovery in obstetric brachial plexus injuries: an historical cohort study. Dev Med Child Neurol 46:76–83CrossRefGoogle Scholar
  28. 28.
    Joyner B, Soto M, Adam HM (2006) Brachial plexus injury. Pediatr Rev 27:238–239CrossRefGoogle Scholar
  29. 29.
    Kawai H, Tsuyuguchi Y, Masada K, Kawabata H, Ono K, Yamamoto K, Tada K (1989) Identification of the lesion in brachial plexus injuries with root avulsion: a comprehensive assessment by means of preoperative findings, myelography, surgical exploration and intraoperative diagnosis. Neuro Orthop 7:15–23Google Scholar
  30. 30.
    Kennedy R (1903) Suture of the brachial plexus in birth paralysis of the upper extremity. Br Med J 1:298–301CrossRefGoogle Scholar
  31. 31.
    Kirjavainen M, Remes V, Peltonen J, Kinnunen P, Pöyhiä T, Telaranta T, Alanen M, Helenius I, Nietosvaara Y (2007) Long-term results of surgery for brachial plexus birth palsy. J Bone Joint Surg Am 89:18–26CrossRefGoogle Scholar
  32. 32.
    Kirjavainen M, Remes V, Peltonen J, Rautakorpi S, Helenius I, Nietosvaara Y (2008) The function of the hand after operations for obstetric injuries to the brachial plexus. J Bone Joint Surg Br 90:349–355CrossRefGoogle Scholar
  33. 33.
    La Scala GC, Rice SB, Clarke HM (2003) Complications of microsurgical reconstruction of obstetrical brachial plexus palsy. Plast Reconstr Surg 111:1383–1388CrossRefGoogle Scholar
  34. 34.
    Laurent JP, Lee R, Shenaq S, Parke JT, Solis IS, Kowalik L (1993) Neurosurgical correction of upper brachial plexus birth injuries. J Neurosurg 79:197–203CrossRefGoogle Scholar
  35. 35.
    Lin JC, Schwentker-Colizza A, Curtis CG, Clarke HM (2009) Final results of grafting versus neurolysis in obstetrical brachial plexus palsy. Plast Reconstr Surg 123:939–948CrossRefGoogle Scholar
  36. 36.
    Maillet M, Romana C (2009) Complete obstetric brachial plexus palsy: surgical improvement to recover a functional hand. J Child Orthop 3:101–108CrossRefGoogle Scholar
  37. 37.
    Michelow B, Clarke H, Curtis C, Zuker RM, Seifu Y, Andrews DF (1994) The natural history of obstetrical brachial plexus palsy. Plast Reconstr Surg 93:675–681CrossRefGoogle Scholar
  38. 38.
    Narakas AO (1981) Obstetrical brachial plexus injuries. Orthop Clin N Am 12:303–322Google Scholar
  39. 39.
    Narakas AO (1986) Injuries to the brachial plexus. In: Bora F (ed) The pediatric upper extremity: diagnosis and management. WB Saunders, Philadelphia, pp 247–258Google Scholar
  40. 40.
    Narakas AO (1987) Obstetric brachial plexus injuries. In: Lamb DW (ed) The paralysed hand. Churchill Livingstone, Edinburgh, pp 116–135Google Scholar
  41. 41.
    Nehme A, Kany J, Sakes-de-Gauzy J, Charlet JP, Dautel G, Cahuzac JP (2002) Obstetrical brachial palsy. Prediction of outcome in upper root injuries. J Hand Surg Br 27:9–12CrossRefGoogle Scholar
  42. 42.
    Noaman HH, Shiha AE, Bahm J (2004) Oberlin’s ulnar nerve transfer to the bíceps motor nerve in obstetric brachial plexus palsy: indications, and good and bad results. Microsurgery 24:182–187CrossRefGoogle Scholar
  43. 43.
    Pondaag W, Malessy MJA (2006) Recovery of hand function following nerve grafting and transfer in obstetric brachial plexus lesions. J Neurosurg 105(1 Suppl):33–40Google Scholar
  44. 44.
    Pondaag W, Malessy MJA (2018) Outcome assessment for brachial plexus birth injury. Results from the iPluto world-wide consensus survey. J Orthop Res 36:2533–2541CrossRefGoogle Scholar
  45. 45.
    Pondaag W, Malessy MJ, van Dijk JG, Thomeer RT (2004) Natural history of obstetric brachial plexus palsy: a systematic review. Dev Med Child Neurol 46:138–144CrossRefGoogle Scholar
  46. 46.
    Sarac C, Duijnisveld BJ, van der Weide A, Schoones JW, Malessy MJ, Nelissen RG, Vlieland TP (2015) Outcome measures used in clinical studies on neonatal brachial plexus palsy: a systematic literature review using the international classification of functioning, disability and health. J Pediatr Rehabil Med 8:167–185CrossRefGoogle Scholar
  47. 47.
    Shenaq SM, Kim JYS, Armenta AH, Nath RK, Cheng E, Jedrysiak A (2004) The surgical treatment of obstetric brachial plexus palsy. Plast Reconstr Surg 113:54–67CrossRefGoogle Scholar
  48. 48.
    Siqueira MG, Socolovsky M, Heise CO, Martins RS, Di Masi G (2012) Efficacy and safety of Oberlin’s procedure in the treatment of brachial plexus birth palsy. Neurosurgery 71:1156–1161CrossRefGoogle Scholar
  49. 49.
    Smith N, Rowan P, Benson L, Ezaki M, Carter PR (2004) Neonatal brachial plexus palsy. Outcome of absent biceps function at three months of age. J Bone Joint Surg 86:2163–2170CrossRefGoogle Scholar
  50. 50.
    Strombeck C, Krumlinde-Sundholm L, Forssberg H (2000) Functional outcome at 5 years in children with obstetric brachial plexus palsy with and without microsurgical reconstruction. Dev Med Child Neurol 42:148–157CrossRefGoogle Scholar
  51. 51.
    Terzis JK, Kokkalis ZT (2008) Shoulder function following primary axillary nerve reconstruction in obstetrical brachial plexus patients. Plast Reconstr Surg 122:1457–1469CrossRefGoogle Scholar
  52. 52.
    Tse R, Kozin SH, Malessy MJ, Clarke HM (2015) International Federation of Societies for surgery of the hand committee report: the role of nerve transfers in the treatment of neonatal brachial plexus palsy. J Hand Surg Am 40:1246–1259CrossRefGoogle Scholar
  53. 53.
    Van Dijk JG, Pondaag W, Buitenhuis SM, Van Zwet EW, Malessy MJ (2012) Needle electromyography at 1 month predicts paralysis of elbow flexion at 3 months in obstetric brachial plexus lesions. Dev Med Child Neurol 54:753–758CrossRefGoogle Scholar
  54. 54.
    Vredeveld JW (2001) Clinical neurophysiological investigations. In: Gilbert A (ed) Brachial plexus injuries. Martin-Dunitz, London, pp 39–44Google Scholar
  55. 55.
    Waters PM (1997) Obstetric brachial plexus injuries: evaluation and management. J Am Acad Orthop Surg 5:205–214CrossRefGoogle Scholar
  56. 56.
    Waters PM (1999) 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 Am 81:649–659CrossRefGoogle Scholar
  57. 57.
    Waters PM (2005) Update on management of pediatric brachial plexus palsy. J Pediatr Orthop B 14:233–244CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Peripheral Nerve Surgery Unit, Department of NeurosurgeryUniversity of São Paulo Medical SchoolSão PauloBrazil
  2. 2.Clinical Neurophysiology, Department of NeurologyUniversity of São Paulo Medical SchoolSão PauloBrazil

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