Intercostal Nerve Transfer in Management of Biceps and Triceps Cocontraction in Spontaneously Recovered Obstetric Brachial Plexus Palsy

Abstract

Background Obstetric brachial plexus palsy is caused by traction during birth. Most patients regain useful function with spontaneous recovery. In some cases, cross reinnervation occurs between the biceps and triceps muscles. In these cases, smooth active motion of the elbow joint is impaired by simultaneous biceps and triceps muscle contraction. The biceps and triceps muscle cocontraction could be treated by botulinum toxin type A injection, tendon transfer of the triceps to biceps, and intercostal nerves transfer to the musculocutaneous nerve (MCN) or to the motor branch of the radial nerve to the triceps muscle. Patients and Methods We present 16 cases (10 males and 6 females) with biceps and triceps cocontraction in spontaneously recovered obstetric brachial plexus palsy patients. They were treated by 3 intercostal nerves transfer to MCN without exploration of the remaining plexus. The mean age at surgery was 40.6 months (range, 24–65 months). Preoperative electromyography was done in all cases to confirm biceps and triceps cocontraction and to assess the contractile status of both muscles. Results The mean postoperative follow-up period was 51.7 months (range, 27–64 months). At the final follow-up, elbow flexion was graded 3 in 1 patient, grade 4 in 3 patients, grade 6 in 9 patients, and grade 7 in 3 patients using the 7-point Toronto scale. The mean active range of motion of the elbow (against gravity) increased from 38 degrees preoperatively (range, 0–75 degrees) to 96.8 °̊ at the final follow-up (range, 60–140 degrees). Conclusions Intercostal nerves transfer to MCN for management of biceps, and triceps cocontraction in spontaneously recovered obstetric brachial plexus injury is a good option with minimal morbidity and high success rate.

Surgical timing in neonatal brachial plexus palsy: A PRISMA‐IPD systematic review

“…The results of this systematic review suggest a negative correlation between age at brachial plexus microsurgery and Mallet sub- et al, 2019;Sénès et al, 2015). Our results for Mallet hand-to-mouth subscore indicate that if microsurgery cannot be completed by 6 months of age due to unavoidable circumstances, surgery can possibly be delayed for up to 9 months of age and still provide significant functional improvement in supination.…”

“…There was no significant correlation between age (6.31 ± 3.33 months) and Mallet subscore for shoulder abduction (3.41 ± 0.82, ρ = −0.09, n = 91, p = .41) (Azzi et al, 2018 ; Blaauw et al, 2006 ; Ghanghurde et al, 2016 ; Gibon et al, 2016 ; Gosk et al, 2010 ; Grossman et al, 2004 ; Malessy & Pondaag, 2014 ; Terzis & Kostas, 2005 ; Terzis & Kostas, 2008 ; Xu et al, 2000 ) or between age (7.92 ± 5.62 months) and MRC subscore for elbow flexion (3.65 ± 0.79, ρ = −0.10, n = 119, p = .29) (Chuang et al, 2005 ; Ghanghurde et al, 2016 ; Gibon et al, 2016 ; Lin et al, 2011 ; Luo et al, 2011 ; Malessy & Pondaag, 2014 ; Meyer, 1986 ; Noaman et al, 2004 ; Siqueira et al, 2012 ; Xu et al, 2000 ). There was also no significant correlation between age (16.85 ± 13.93 months) and AMS subscore for elbow flexion (5.72 ± 1.76, ρ = −0.16, n = 81, p = 1.14) (Al‐Qattan & Al‐Kharfy, 2014 ; Argenta et al, 2016 ; Figueiredo Rde et al, 2016 ; Little et al, 2014 ; Mencl et al, 2015 ; Murison et al, 2017 ; Semaya et al, 2019 ) and between age (10.37 ± 0.82 months) and AMS subscore for external rotation (4.96 ± 1.95, ρ = −0.04, n = 26, p = .84) (Argenta et al, 2016 ; Bade et al, 2014 ; Mencl et al, 2015 ).…”

“…Our review showed similar results to Bauer et al as age was not found to be a significant predictor of surgical outcomes in terms of AMS scale subscores. Other studies have shown that intercostal nerve transfers and neurotization can be attempted in older children until 5–6 years of age (Semaya et al, 2019 ; Sénès et al, 2015 ). Our results for Mallet hand‐to‐mouth subscore indicate that if microsurgery cannot be completed by 6 months of age due to unavoidable circumstances, surgery can possibly be delayed for up to 9 months of age and still provide significant functional improvement in supination.…”

Intercostal Nerve Transfer for Biceps Reinnervation in Obstetrical Brachial Plexus Palsy: A Preferred Reporting Items for Systematic Reviews and Meta-Analysis for Individual Patient Data Systematic Review using Individualized Fusion and Comparison to Supraclavicular Exploration and Nerve Grafting

“…19 Data gath ered from two texts of patients undergoing ICN transfers present an average Toronto score of 6.4 ± 1.2. 20,21 The regression value between SENG and ICN transfers when comparing MRC scores is MRC scores is 0.3821 (standard error 0.4590, p = 0.2551). The regression value between SENG and ICN transfers when comparing Toronto scores is 0.7154 (standard error 0.8487, p = 0.2188).…”

Intercostal nerve transfer in management of biceps and triceps co‐contraction in brachial plexus birth palsy

“…In our study, the main aim was to separate the innervation of the triceps from the biceps rather than intentionally weaken the triceps. However, inadvertent weakening of the triceps may have occurred during the process (Bertelli & Ghizoni, 2011), the addition of ICN transfer surgery can provide further benefits by reestablishing muscle balance and improving selective muscle activation (Semaya et al, 2019).…”