Building a Comprehensive Pediatric Brachial Plexus Program – The Nuts and Bolts of an Interdisciplinary Model
Raymond Tse, MD1, Sarah Lewis2, Heidi Allen3, Marisa Osorio, DO4 and Jason Jio4
1Division of Plastic Surgery, Seattle Children's Hospital, Seattle, WA, 2Physical Therapy, Seattle Children's Hospital, Seattle, WA, 3 Occupational Therapy, Seattle Children's Hospital, Seattle, WA, 4 Seattle Children's Hospital, Seattle, WA
Treatment of complex medical problems has been shown to be better in concentrated centers with access to interdisciplinary care. While infants with brachial plexus palsies have primary nerve deficits, growth and development lead to downstream effects on musculoskeletal function, overall appearance, and psychosocial health. The purpose of this presentation is to describe the principles used to build an interdisciplinary pediatric brachial plexus program and to report on the early measureable outcomes using this model. Guiding principles included: team composition, team management, communication, cultural competence, psychological/social services, and outcome assessment. Based upon protocols for management of the nerve, musculoskeletal system, and psychosocial needs, appropriate supporting experts were recruited. In turn these collaborating specialists created protocols for CT myelography, frozen section nerve pathology, and shoulder ultrasonography. During the first 3 years of this program, 207 children were assessed. Each child was administered a physical therapy program if there were persistent deficits. Two infants required ongoing pediatrician care for CNS, lung, and cardiac sequelae of birth. Surgical indications were according to the Toronto protocol and 20 infants underwent brachial plexus exploration and/or reconstruction for Narakas I (n=2), Narakas II (n=6), Narakas III (n=3), Narakas IV (n=8), and Klumpke (n=1) type palsies. The mean number of nerve root avulsions identified on exploration was 0 for Narakas I, 0 for Narakas II, 1.5 for Narakas III, and 2.25 for Narakas IV. Of 21 avulsed nerve roots identified on exploration, 18 were detected pre-operatively by myelography. Of 127 presumed normal nerve ends submitted for frozen section, 26 were re-cut further from the lesion due to poor histologic appearance. Shoulder ultrasounds were performed on infants who were older than 3 months and who a clinical examination suspicious of glenohumeral subluxation. Nine infants were confirmed to have significant subluxation requiring closed reduction and casting and temporary chemodenervation. All children over 2 years of age were assessed for psychosocial coping. Eighteen children were identified to participated in a group therapy program to help facilitate psychosocial adjustment. Measures of quality of life increased for all children involved. There are currently no guidelines for the composition and function of brachial plexus programs. The experience developing a program to address nerve, musculoskeletal, and psychosocial needs at our institution is presented. Future studies are required to determine if this interdisciplinary model results in better outcomes or greater patient satisfaction.
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