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High Sensitivity of EDX In Neonatal Brachial Plexus Palsy (NBPP) Warrants Increased Use In Pre-Operative Planning Of Nerve Reconstruction Strategies
Mary Catherine Spires, MD1; Kate Wan-Chu Chang, MA, MS2; Lynda Yang, MD, PHD2; (1)University of Michigan, Ann Arbor, MI 48104, MI, (2)University of Michigan, Ann Arbor, MI

Introduction: Use of electrodiagnostic testing (EDX) for surgical decision-making in NBPP (incidence of 1-4/1000 live births) is controversial. Despite high inter-rater reliability for assessing the NBPP lesions (pre- vs post-ganglionic), EDX is routinely used less than imaging - and consequently less for planning the strategy for nerve reconstruction. Therefore, the purposes of this study are (1) to determine the sensitivity of EDX and (2) to compare the sensitivity of EDX with that of imaging in NBPP. Methods: We conducted a retrospective review of infants with NBPP from 2007 to 2017 at a single institution. Infants who underwent both pre-operative EDX and imaging (CT-myelogram, MRI) were included in the study. The findings of pre-operative EDX and imaging were compared to the surgical findings (gold standard) regarding NBPP nerve root pre-ganglionic and post-ganglionic lesions. Sensitivities of EDX vs. imaging were reported to evaluate performance accuracy of each pre-operative diagnostic tool. Results: Fifty-four infants (mean age of 6.9 months) were included in the study; the majority were female (57%), Caucasian (63%), and Narakas II-IV (72%). EDX demonstrated significant higher overall sensitivity for detecting post-ganglionic lesion at all nerve root levels: at C7, EDX demonstrated 92% sensitivity vs. imaging (73%, P=0.006); at C8, EDX was 88% sensitive vs. imaging (29%, P=0.008); at C5, EDX was 88% sensitive compared to imaging (84%, P=0.7); similarly, at C6, EDX was 97% sensitive vs. imaging (85%, p=0.23). For pre-ganglionic lesion that are detectable on imaging by the presence of pseudomeningoceles, the sensitivity of imaging at C5 was only 43% (compared to EDX at 14%, P=0.7). Likewise, C6 was similarly disappointing with sensitivity of 57% (compared to EDX at 39%, P=0.23). Imaging had expected higher sensitivities than EDX at C7 (EDX: 30% vs. imaging: 83%, P=0.006) and C8 (EDX: 38% vs. imaging: 67%, P=0.008) levels. Conclusions: We demonstrate that EDX has an overall high sensitivity in demonstrating post-ganglionic lesions in NBPP, and therefore, EDX is essential for pre-operative planning of nerve reconstruction strategies. Because EDX was poorly reputed as a surgical planning tool due to its reported poor ability to prognosticate, no prior study had addressed the sensitivity of EDX in determining the location/severity of individual nerve root lesions. We suggest that these results warrant the increased use of EDX in strategizing surgery.

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