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Virally Mediated Brachial Plexus Neuritis: A Case Series and Surgical Algorithm
Anthony Thanh Vu, MD; Emily Louden, MPH; Melissa Miller, RN, BSN; Ann Schwentker, MD; Kevin Yakuboff, MD
Cincinnati Children's Medical Center, Cincinnati, OH

Introduction: Virally mediated brachial plexus neuritis can cause acute flaccid paralysis of the upper extremity. It involves the proximal musculature with no sensory deficits. Recently, there has been an outbreak in our region with several patients referred to our center for treatment. Review of the literature and CDC reports suggest that late recovery is not expected. While there have been proposed surgical strategies, there is currently no established surgical algorithm. Following our early experience with the contralateral-C7 (cC7) transfer for brachial plexus birth palsy, we have developed a treatment algorithm for this patient population.

Materials & Methods: We retrospectively reviewed our database for all children diagnosed with suspected virally mediated brachial plexus neuritis over the past 12 months. Demographics, clinical course, Mallet scores, magnetic resonance imaging (MRIs), and electromyography (EMG) results were reviewed. A surgical algorithm was created based on our experience.

Results: We had a total of four patients in our series, all with a preceding viral-like upper respiratory illness. Average age at diagnosis was 4.5 years. All patients presented with a flaccid shoulder and elbow with shoulder subluxation and some useful hand and wrist function. A viral work-up was performed on three patients but no causative species was identified. Three patients had abnormal findings on cervical spine MRI. Because of poor recovery, all patients have been scheduled for surgery within 9 months of presentation. Our algorithm is based on early intervention in cases where there is no clinical improvement seen within 6-9 months from onset of paralysis. Nerve transfers for shoulder function include spinal accessory to suprascapular nerve. Radial to axillary nerve transfer is generally not available because of poor or absent triceps function. Nerve transfers for elbow function include intercostals to the musculocutaneous nerve or the cC7 to the upper trunk. Although our patients had some recovery of hand function, this was incomplete in all children, thus an Oberlin or double fascicular transfer is not recommended. In the case of severe hand deficit, we only recommend using cC7 to the lower trunk if the patient is under 2 years old.

Conclusions: Brachial neuritis must be considered in the differential of an acute, painless, flaccid extremity. Work up includes EMG, MRI, and viral serologies. Our proposed algorithm is based on early intervention after determining that adequate recovery is not likely, usually within 6-9 months post-injury.


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