Obstetrical Brachial Plexus Paralysis, Part 2

The mission of these two issues (Parts 1 and 2) of Seminars in Plastic Surgery is to assemble and disseminate worldwide knowledge and experience of the microsurgical management of obstetrical brachial plexus injury. Toward this goal, experts in the field from well-established centers around the world have been invited to contribute. Despite stringent time restrictions, the vast majority of authors responded enthusiastically to this call. To all these contributors, I am eternally grateful.

Contributors were asked to present their institutional experiences, including their concepts, approaches, and outcomes. Experiences with both primary and secondary reconstruction were considered.

Authors were invited on the basis of their recognized contributions to the treatment of the obstetrical brachial plexus lesion. Furthermore, I invited contributions from past fellows or colleagues who have trained at Eastern Virginia Medical School and at the International Institute of Reconstructive Microsurgery in Norfolk, Virginia, or with whom I have enjoyed scientific collaboration over the last 20 years.

The first issue (Part 1) enlisted institutional experiences from Saudi Arabia; Boston, Massachusetts; Aachen, Germany; The Netherlands; Taipei, Taiwan; Miami, Florida; Palo Alto, California; Osaka, Japan; Istanbul, Turkey; and Norfolk Virginia; along with a call for multicenter prospective study.

This second issue (Part 2) starts with the French contribution, from Paris, France, which is primarily a historical review of people that described this condition; it includes a colorful lengthy segment on Duchenne's life and contributions and smaller reports on subsequent investigators.

The next contribution is from Amsterdam, The Netherlands. The authors share their experience with preoperative imaging investigations in obstetrical brachial plexus paralysis with the use of high-strength magnetic resonance scanners, which allow imaging of plexus structures in some detail.

This is followed by the experience of the Norfolk Center in the use of electrophysiological and radiological (computer tomography myelography) preoperative testing to detect root avulsions.

The Baylor experience, describing the current management in Houston, Texas, of the obstetrical paralysis lesion, is reported next.

This is followed by two contributions from Norfolk describing shoulder abduction and external rotation results with suprascapular nerve neurotization, followed by the authors' experience with intercostal nerve neurotization for global plexopathies.

The next report describes the experience of the Neurosurgery Division at Toronto with nerve transfers for severe obstetrical brachial plexus paralysis.

The second volume (part 2) concludes with two contributions form colleagues from Greece on secondary reconstruction at the shoulder, elbow, and hand.

There is a wide diversity of opinions and approaches to the surgical treatment of the obstetrical brachial plexus lesion. No attempts have been made to critique the content of the submitted reports. Communications with authors were limited to requests for additional information to clarify concepts for our readers.

This is the first time that readers have had such a unique opportunity to be exposed to experiences from recognized international centers on the topic of obstetrical brachial plexus paralysis.

This paralysis has varied severity presentations and is influenced by an array of factors including prolonged labor, large gestational size, breech presentation, and difficult delivery assisted with or without instrumentation.

Despite recent advances in obstetrics, incidences remain the same. There is great diversity of opinion regarding the optimal timing for surgery, with persistent neurological deficits after 3-5 months generally accepted as indication for surgery. Compounding the clinical dilemma is the absence of a standard internationally accepted evaluation system in measuring outcomes. The experiences presented here are based on retrospective series by talented microsurgeons who provide useful clinical information on the subject. The different patterns of injury, the individual surgical approaches, and the often nonstandardized evaluation systems used make comparisons among centers difficult. It is hoped that these early efforts will lead to a scientific, evidence-based approach to the management of these crippling lesions.