la paralisi ostetrica: timing e chirurgia primaria delle …

LA PARALISI OSTETRICA:

TIMING E CHIRURGIA

PRIMARIA DELLE POPB

Pierluigi Tos, Paolo Titolo

UOD Microchirurgia – UOC Traumatologia MuscoloscheletricaASO Città della Salute e della Scienza di Torino

CTO Trauma Center Torino – [email protected] TO

mailto:[email protected]

1764 Obstetrical brachial palsy described by Smellie.

1874 Wilhelm H. Erb described brachial plexus paralysis in adults which involved the upper roots and described certain types of “delivery paralysis”. He credited Duchenne for describing the brachial palsy following delivery in affected newborns 1955.

1885 Augusta Klumpke first described the clinical picture resulting from injury to lower roots.

BACKGROUND

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ETIOLOGY

Stretch, tear, compression or avulsion of the nerves usually after forceful lateral deviation of the head from the shoulders during delivery.

Recent studies suggest intrinsic forces (uterine contractions)

EPIDEMIOLOGYIncidence of brachial plexus palsy is reported to affect

0.5 to 1.9 per 1000 live births (Bar et al 2001)

90% ERB- DUCHENNE PALSY

• Most common on the right side because the most common delivery presentation is left occiput anterior vertex.

• Associated with: pre and gestational diabetesolder maternal ageincreased BW (body weith),LGA (macrosomia)

• Newborns with BP injuries have a higher incidence of low Apgar scores of less than 7 at 1 and 5 mins and of asphyxia than matched controls

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Risk factor Odds ratio 95% Confidence interval

Maternal weight > 90 kg 1.3 0.2-62.6

Postdate pregnancy 1.8 0.9-3.9

Diabetes 3.2 1.6-6.3

Fetal macrosomia• 4000–4500 • >4500 • >5000

9.617.9 45.2

6.2-14.910.3-31.315.8-128.8

Assisted delivery• Low-forceps • Mid-forceps• Vacuum extractor • Cesarean delivery

3.73.717.20.5

2.0-7.05.7-59.35.1-58.20.1-1.9

Prolonged second stage of Labor 8.3 4.0-17.3

Shoulder dystocia 340.5 46.9-897.3

Epidural anesthesia 2.0 1.2-3.5

Use of Oxytocin 3.7 1.1-2.6

Application of fundal pressure 27.5 4.0-1163.4

RISK FACTORS

ANATOMY

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UPPER PALSY

Internal rotationNo elbow flexion

Good finger flexion

CLINICAL FEATURESCOMPLETE PALSY

Flail arm Horner’s syndrome

Horner’s Syndrome

usually means avulsion of T1

Lack of movement of the affected arm usually leads to referral for orthopaedic opinion

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FRACTURE CLAVICLE FRACTURE HUMERUS

DIFFERENTIAL DIAGNOSIS

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SHOULDER DISLOCATION

UPPER HUMERAL EPIPHYSOLYSIS

DIFFERENTIAL DIAGNOSIS

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TYPE OF INJURIES

PREGANGLIO

NICROOT

AVULSION

POSTGANGLIO

NIC

SEDDON SEDDON SUNDERLANDSUNDERLAND

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TYPE OF INJURIES

PREGANGLIO

NICROOT

AVULSIONNO DIRECT REPAIR !!!!!NEROTIZATION

POORER RESULTS

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ROOT AVULSIONAlso referred to as pre-ganglionic injury

In C5-C6 post-ganglionic lesion is more frequent than avulsion because the nerve is firmly

attached to the cervical spine

At lower levels connections between the spinal nerve and the transverse process are absent and root avulsions

are more common

In subsequent order rupture generally takes place at:A. the fibrous connections (1)

between nerve and foramenB. the dura (2) C. and the rootlets(3)

DRG – dorsal root ganglionB – bony foramenSC – spinal cord

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TYPE OF INJURIES

POSTGANGLIO

NIC

SEDDON SEDDON SUNDERLANDSUNDERLAND

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CLASSIFICATION of NERVE LESIONS

(Seddon -Sunderland)

1° grado - NEUROAPRASSIA (blocco di conduzione reversibile)

2° grado - ASSONOTMESI (assoplasma interrotto - degenerazione Valleriana)

3° grado - NEUROTMESI (l’endonervio è interrotto)

4° grado - NEUROTMESI (anche il perinervio è interrotto)

5° grado - NEUROTMESI (interruzione completa del nervo) TO

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SEDDON SEDDON INJURIESINJURIES

NeuropraxiaNeuropraxia: : simple simple stretching of the nervestretching of the nerve

Mild AxonotmesisMild Axonotmesis: : rupture of a few axonsrupture of a few axons

NeurotmesisNeurotmesis: : complete complete disruption of the nerve disruption of the nerve

TYPE OF INJURIES

DEGREE SPONTANEOUSRECOVERY

COSA ACCADE A MONTE

nella sintesi di proteine utili alla RICOSTRUZIONE ASSONALE

nella sintesi di proteine della TRASMISSIONE SINAPTICA

DEGENERAZIONE ASSONALE fino al 1°/2° nodo di Ranvier

CORPOCELLULARE

MONCONEPROSSIMALE

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“NORMALE” “IN RIGENERAZIONE”

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COSA ACCADE A VALLE

DEGENERAZIONE VALLERIANA

scomparsa del cilindrasse

PROLIFERAZIONE cellule di

SCHWANN (cordoni di Büngner -

“tubi endoneurali”)

SCOMPARSA delle PLACCHE MOTRICI

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RIGENERAZIONE

FORMAZIONE delCONO di CRESCITA

COLLATERAL SPROUTING

EMANAZIONE di PSEUDOPODI e

ADESIONE alla MEMBRANA

BASALEdelle CELLULE di

SCHWANNTO

ACCRESCIMENTO

con una VELOCITÀ

di 1-2 mm/die

RIGENERAZIONE

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CRESCITA dell’ASSONEE

PASSAGGIO DELLA ZONA DI LESIONE

RIGENERAZIONE

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CRESCITA DELL’ASSONE LUNGO i“TUBI ENDONEURALI” A VALLE

RIPRISTINO DI UN CORRETTO CONTATTOCON GLI ORGANI BERSAGLIO

RIGENERAZIONE

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TIMING DELLA RICOSTRUZIONE

FATTORI LIMITANTI

ADULTO- MUSCOLO

- degenera con il tempo

- distanza- NERVO MONCONE DISTALE

- perde cellule Schwann

- Fibrosi intraneurale

BAMBINO- RIORGANIZZAZIONE

CEREBRALE- DISTURBO NELLA CRESCITA OSTEOARTICOLARE- PSICOLOGIA GENITORI

-SCARSA PLASTICITA’ CEREBRALE- NEUROMA >FIBROSI

- NEUROMA < FIBROSI

DIFFERENCES BETWEEN ADULT BRACHIAL PLEXUS

LESIONS AND OBPLTRAUMA MECHANISM less velocity (compared to a motor vehicle accident) probably longer in duration

a true rupture of the nerves (Sunderland V) is seldom seen, a neuroma-in-continuity is usually found

PERIPHERAL NERVE LESION AND REGENERATIONAxonal outgrowth was shown to be superior in young compared to adults

In neuroma-incontinuity SURPRISINGLY LARGE NUMBER OF AXONS GROW ACROSS THE LESION SITE (although infants show no clinical recovery at 6 months) probably because axons in younger have a more penetrable basal lamina tube encasing

Axonal outgrowth through the neuroma might explain the lack of sustained atrophy in OBPL, which is a typical in adult

Shorter regeneration distance between the level of injury and the target organ. CO-

CONTRACTIONS

Biceps and Triceps cocontraction

Breathing ArmTO

DIFFERENCES ON RECONSTRUCTION

STRATEGIES in total palsy

ADULTS CHILDPRIORITY

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RECONSTRUCTION STRATEGIESNarakas et al.

• Group I classic upper trunk lesion C5-6

• Group II extended upper trunk lesion C5-7

• Group III flail extremity

• Group IV flail extremity + Horner’s syndrome

46%

30%

20%

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Group I• Erb’s palsy Posture of adduction and inward rotation at the

shoulder with extension and pronation at the elbow and flexion of the fingers of the hand

• Absence of shoulder abduction and external rotation, elbow flexion, and forearm supination.

• Spontaneous recovery 90%

classic upper trunk lesion C5-6

(Klumpke= absent grasp reflex)

Group II

with the absence of wrist and digital extension added to the limitations noted in

group I

extended upper trunk lesion C5-7

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CLASSIC “WAITER'S TIP”

EXAMINATIONGENERAL EXAMINATION:Head shape and size

Eyes: conjugate movements, Horner’s

Neck: control in supported sitting and prone, range limitations actively or passively

Chest: respiratory pattern, chest movement symmetry

Legs: range of motion, tone, movement pattern

Unaffected arm: range of motion passively and actively, strength

AFFECTED ARM:Resting position

Passive range of motion

Active range of motion in supine and sitting or supported sitting

StrengthEvidence of pain

INFANT REFLEXES:Moro: symmetry

Asymmetrical tonic neck reflex (ATNR)

Palmar grasp

FEEDING:Sucking, swallowing

INTERACTION WITH ENVIRONMENT:Vision, hearing, touch

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Passive External rotation of the shoulder • In adduction• At 90° of abduction

stabilizing the scapula against the thorax to assess glenohumeral joint motion and stability.

Palpation of the humeral headwithin the posterior soft spot, may indicate posterior glenohumeral joint subluxation or

dislocation.

Assess Dynamic instability and degree of scapular winging

Muscle tightness of the pectoralis major, lattisimus dorsi, and teres major is evaluated with direct palpation. Presence of any contracture

EVALUATION OF AFFECTED ARM: KEY POINTS

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External shoulder rotation. The upper arm was held in internal rotation and adduction, with the elbow at 90° flexion; the hand lay on the child’s abdomen. External rotation was presentwhen the forearm was lifted from the abdomen without active elbow extension.

Elbow flexion. With the arm extended, flexion was present when the forearm and hand were lifted while the upper arm remained static.

Supination. With the elbow passively or actively held in 90° flexion, active rotation of the distal forearm was considered supination, regardless of flexion or extension of the wrist. When forearm rotation was effected by wrist extension and gravity, supination was considered absent.

Active elbow extension. With the upper arm in 90° anteflexion, active elbow extension was present if the flexed forearm could be extended regardless of the end point of the range of motion.

EVALUATION OF AFFECTED ARM: ACTIVE MOTION

TONIC NECK REFLEX

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MORO REFLEX

spreading out the arms (abduction)unspreading the arms (adduction)

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http://www.answers.com/topic/arm

http://www.answers.com/topic/anatomical-terms-of-motion

http://www.answers.com/topic/anatomical-terms-of-motion

PALMAR GRASP

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ptosis, myosis, enophthalmos, anhidrosis

TRICKS

Flessione con supinazione Flessione senza supinazione

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Bahm, J; Ocampo-Pavez, C; Disselhorst-Klug, C; Sellhaus, B; Weis, J

Obstetric Brachial Plexus Palsy: Current Treatment Strategy, Long-Term Results, and PrognosisDtsch Arztebl Int 2009; 106(6): 83-90, DOI: 10.3238/arztebl.2009.0083

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ASSESSING SHOULDER FUNCTIONMALLET SCORE

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ASSESSING ELBOW AND HAND FUNCTION

DIAGNOSIS

Evaluation can be undertaken by multiple modes of

Imaging

EMG - 1 mth Useful for more precise diagnosis NOT FOR PROGNOSIS

MRI / TC / MIELO TCRarely necessary, useful in suspicion of upper roots

avulsion

Chest X ray / Real time Ultra Sonography TO

PROGNOSIS AND NATURAL HISTORY

it is important to determine whether the injury is preganglionic or

postganglionic

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• It has previously been reported that up to 92% of patients with BPBP have mild injury and spontaneous recovery within the first 2 months of life. Laurent JP, J Neurosurg 1993;79:197–203

• Other authors suggest a much lower recovery rate with only 66% of affected children recovering completely and 10% to 15% left with considerable permanent weakness. Hoeksma AFDev Med Child Neurol 2004;46:76–83; Pondaag W, Dev Med Child Neurol 2004;46:138 –144.

• The varying degrees of clinical presentation and recovery correlate with different injury types, subspecialty referral patterns, and subsequentcare


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Cases in which the return of biceps function occurs

after 3 months rarely have complete recovery

Waters PM. 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;81A:649–659.

Complete recovery occurs only if motor function is present at no later than 6

months of age

Global shoulder function worsens with increasing delay in return of biceps

function


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Other authors port that patients who regained biceps function between 4 and 6 months of age were able to achieve global shoulder function with secondary tendon transfers (comparable to the function of

those who underwent microsurgical procedures at 3 months)

routinely used return of biceps function at 9 months of age

Waters PM. / Al-Qattan MM

Clarke and Curtis


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In a series no child with full recovery of motor function had complete palsy or

nerve root avulsion

Muscle imbalance develops rapidly, and

soft tissue contracture contributes to deformity and joint

incongruence early in the neonatal period


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THERAPY / ( SURGERY ) SHOULD START IMMEDIATELY IN INFANCY

PREVENTION OF CONTRACTURE AND JOINT DEFORMITY ABOUT THE SHOULDER

SCAPULAR STABILIZATION AND PASSIVE GLENOHUMERAL MOBILIZATION IN ALL PLANES IS

NECESSARY ON A FREQUENT BASIS.

SUPERVISED HOME PROGRAM WITH PROFESSIONAL MONITORING.

CORTICAL RECOGNITION AND INTEGRATION OF THE AFFECTED LIMB IS PROMOTED.


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When should the repair be done ?

FOR MOST SURGEONS : 3 MONTHS

FOR OTHERS : 6 – 9 MONTHS

FOR SOME DEPENDING ON THE VARIATIONSOF AN ASSESSMENT SCALE

INDICATION AND TIMING

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Is there a difference in results between 3 and 6 months ?

Probably notThen the problem is whether the decisionwill be more precise at 3 or 6 months andsince it has not been proven, it is better

to make the decision early


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A very serious argument is psychological:

The more signs of recovery , even non significant for the end-result , the more difficult

it is for the family to take their decision

The choice is between an early operation with the risk of an excessive indication or a late

decision which will induce some refusal from the families


AS THERE HAS BEEN NO PROOF OF A BETTER PRECISION IF THE

CHOICE IS DELAYED , AND AS WE ALL BELIEVE THAT EARLY

SURGERY ALLOWS BETTER RECOVERY , MY CHOICE HAS

BEEN A DECISION AT 3 MONTHS


• General consensus:– No surgery for upper plexus injuries who recovery

of biceps by 3 months – reconstruction at 3 months for global lesions and

Horner’s syndrome

•Some argument:– Early intervention in patients with initial fail

extremity with some recovery of biceps, but no significant hand or forearm recovery

•Most controversial element:– Timing of surgery for patients with rupture-type injuries,

in which there are varying degrees of severity of injury and recovery

INDICATION AND TIMINGMicrosurgical intervention aims to improve

function without the expectation of full recover

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GILBERT ABSOLUTE INDICATION FOR EARLY OPERATION AT 3 MONTH

COMPLETE PALSY

Horner’s syndrome

UPPER PALSY

no biceps at 3 months


poorer shoulder outcomes at 5 years and increased likelihood for secondary procedures in patients who regained biceps function after 3

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THE EXACT TIMING IS STILL UNKNOWNWHAT WE SUGGEST

We consider absent or significantly impaired hand function, in the context of a flail arm at birth, to be an

absolute indication for nerve surgery as soon as the infant reaches the age of 3 months

surgery to NBPP patients who demonstrate no spontaneous recovery of shoulder external

rotation and elbow flexion/forearm supination by 3–4 months of age

If the presence of true shoulder and elbow movements is DOUBTFUL, we proceed with

SURGICAL EXPLORATION, because the POTENTIAL BENEFITS FROM REPAIRING

NEUROTMETIC LESIONS GENERALLY OUTWEIGH THE RISKS OF NEGATIVE

EXPLORATION

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WHAT WE SUGGEST

LEIDEN THREE ITEM TEST 1

At 1 month:-Elbow extension-Elbow flexion-EMG of the biceps

Prediction of severe OBPP at 1 month of age was better than at 1 week and at 3 months.

Correct prediction whether lesions were mild or severe in 93.6% of infants

try to ASSESS SEVERITY OF THE BRACHIAL PLEXUS LESION(S) AS EARLY AS POSSIBLE for surgical and

psychosocial reasons

2011

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Prediction of severe OBPP at 1 month

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STRUTTURA DEDICATA

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RECONSTRUCTION STRATEGIES

• Group I

• Group II extended upper trunk lesion C5-7

• Group III flail extremity

• Group IV


Group IN C5, C6

• C5 -SSC• C5- PDUT (for

shoulder)• C6- ADUT( for biceps) Or

• 11° to SSC

C5

C6


Group I N C5, A C6

Neuroma C5

sovrascapular

Dorsal root ganglion C6

Anterior root filaments C6


Group IN C5, A C6

C5

C6


Group IAC5, AC6

• SAN to SCC• MPN to MCN

Oberlain technique carry potential risks for the growing hand

(Breech presentation)


Group III – C5 C6 C7 C8 T1

• C5 -SSC• C5- PDUT (for

shoulder)• C5- ADUT (for biceps)

• C6 C8

Median nerve

Ulnar nerve

N C5-C6, A C7-C8-T1

LATE REINNERVATION – LATE NEUROTIZATIONS

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RESULTS of LATE NEUROTIZATIONS

GILBERT – RAIMONDI 2013TO

NBPP is not a static processAs the child grows up, a variety of

secondary deformities of the extremities occur.

The extent and severity of these secondary deformities is related to– the severity of the initial plexus lesion– the age of the child at presentation,– the degree of recovery of muscle function.

SEQUELE

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SEQUELE

La spalla è l’articolazione più colpitaIl gomito, avambraccio, polso, e mano

sviluppano deformità invalidanti

Esiti più frequenti:dismetria arti (accentuata dalla deformità in flessione del gomito)

(72%) deformità di rotazione interna della spalla

(62%) deformità di flessione del gomito (69%) deformità di supinazione avambraccio (29%) deformità di pronazione avambraccio(27%) deviazione ulnare del polso vari tipi di paralisi delle dita

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da 1 anno a 2 annise eccessiva intrarotazione

non ostante esercizi favorenti la extrarotazione ed, eventualmente, per

proporre un

intervento di release del muscolo sottoscapolare

TIMING – SEQUELEinterventi palliativi

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dopo i 2 annieventuali

interventi correttivi muscolari per

migliorare la funzione di spalla

dopo i 4 anni - adolescenza valutare deformità ossee ed articolari, da ulteriori procedure chirurgiche potrebbero

rendersi convenienti – ostotomie, etc

TIMING - SEQUELE

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CONCLUSIONI

LA PARALISI SEVERA VA RIFERITA TEMPESTIVAMENTE (1 mese) e

OPERATA PRECOCEMENTE – 3 MESI

STRETTI CONTROLLO CLINICI PER VALUTARE INSORGERE DI

DEFORMITA’ / FKT – CHIRURGIA

CHIRUGHI SPECIALIZZATI CHE CONOSCANO LE CURE

SUCCESSIVE / TRASFERIMENTI TENDINEI E MUSCOLARI

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Trauma Center TORINO - ITALY

Reconstructive Microsurgery Unit

Ortopaedics DepartmentCity of Health and Science

TorinoCTO Hospital – Trauma

Center Torino Italy

Pierluigi Tos

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la paralisi ostetrica: timing e chirurgia primaria delle …

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