American Society for Peripheral Nerve

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Functional Outcome following Single-Root Reconstruction of the Upper Trunk in Erb's Palsy
Kristen Davidge, MD, MSc1; Emily Ho, BSc, OT2; Howard M. Clarke, MD, PhD, FRCS(C)2
1Division of Plastic Surgery, University of Toronto, Toronto, ON, Canada; 2Division of Plastic Surgery, Hospital for Sick Children, Toronto, ON, Canada

Background: Obstetric brachial plexus palsy (OBPP) commonly presents with isolated upper trunk paralysis, but avulsion of either the C5 or C6 root is rare. In these situations, only one root is available for intraplexal reconstruction of the upper trunk. The purpose of this study was to determine the functional outcome of patients with Erb’s palsy, who required single-root reconstruction of the upper trunk.

Methods: We performed a retrospective cohort study of patients with OBPP undergoing a primary nerve operation between 1993 and 2009. All data was collected prospectively. Patients were included if they had isolated upper trunk injuries (C7, C8 and T1 intact) and avulsion of either the C5 or C6 nerve root. Functional outcome was assessed using the Active Movement Scale (AMS) at a minimum follow-up of 4 years. Post-operative movement in patients with single-root reconstruction of the upper trunk was then compared to a control group of patients where two roots were available for upper trunk reconstruction (n=18), using the Wilcoxon rank-sum test.

Results: Ten patients with OBPP (7 female, 9 unilateral) were included in the final cohort. Average birth weight was 8.9 ± 1.5 pounds, and mean age at surgery was 10.4 ± 0.9 months. The C6 root was avulsed in 9 patients (90%), and the C5 root in 1 patient. Surgical reconstruction of the upper trunk entailed neuroma resection and interpositional nerve grafting from the single available root (mean number of sural nerve cables, 6 ± 1). At a mean follow-up of 10.1 ± 5.0 years, all patients achieved AMS scores of 7/7 for elbow flexion. Average scores for shoulder abduction, shoulder flexion, and forearm supination were 6.0 ± 1.7, 6.0 ± 1.7, and 5.8 ± 1.9 respectively. The poorest recovery was seen in external rotation of the shoulder, with a mean AMS score of 2.9 ± 2.2. Post-operative AMS scores at 4 years follow-up did not significantly differ between patients undergoing single- versus two-root reconstruction of the upper trunk.

Conclusions: Reconstruction of the upper trunk via interpositional nerve grafting from a single nerve root for C5 or C6 avulsions can restore excellent elbow flexion and good shoulder function. Functional recovery in this patient group is similar to that which can be achieved when two donor nerve roots are available for grafting. Active external rotation remains difficult to achieve in all cases of C5-C6 injuries requiring operative intervention.

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