Timing of Nerve Surgery in Brachial Plexus Birth Palsy: Results of the Prospective Multi-center TOBI Study
Andrea S. Bauer, MD1; Leslie Kalish, ScD2; Peter M. Waters, MD1; (1)Department of Orthopedic Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, (2)Harvard University, Boston, MA
Introduction: It is well-accepted that infants with severe brachial plexus birth palsy (BPBP) benefit from primary nerve surgery. The timing of surgery, however, remains controversial, with recommendations ranging from 3 to 9 months of life. The Treatment and Outcomes of Brachial plexus Injuries (TOBI) study is a multi-center prospective study, begun in 2003, with the primary aim to determine the optimal timing of this surgical intervention.
Materials and Methods: Of 201 patients who underwent microsurgery, 111 were eligible for inclusion based on enrollment during the first year of life, with at least one complete examination 18 to 30 months after microsurgery but before any secondary surgery. Severity of the injury was measured as the presence or absence of a Horner's syndrome as well as by the preoperative Active Movement Scale (AMS) score. Surgical timing was dichotomized as before or after 6 months of life. Postoperative outcomes were measured using the total AMS score, as well with an AMS hand function subscore, created by adding the scores for finger flexion, finger extension, thumb flexion, and thumb extension.
Results: Sixty-eight percent of subjects had surgery before 6 months (mean 4.0 months), while 32% had late surgery at a mean of 10.8 months. Patients with early microsurgery tended to enroll in TOBI earlier and were more likely to have Horner's syndrome but were otherwise similar to those with late microsurgery. The baseline total AMS score averaged 29.3 for the early group, versus 48.8 for the late group (p=0.0005). When controlled for injury severity, there was no difference in AMS scores between the early and late surgery groups. However, baseline AMS score remained significant, with a 1-point increase in baseline total AMS score predicting a 0.25-point increase in postoperative AMS score.
We used the AMS hand function subscore to address whether early surgery might be better for reinnervation of the hand. Infants in the early surgery group had significantly lower hand function scores at baseline than the infants in the late surgery group, but there was no significant difference in the postoperative AMS hand subscore outcome between the early and late surgery groups.
Conclusions: Earlier surgery does not lead to better postoperative outcomes in BPBP nerve surgery, in contradiction to the consensus on adult nerve injuries. This is perhaps related to the unique neurophysiology of the newborn. Further study is needed to determine whether other factors are important in the decision for surgical timing.
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