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Reevaluating the Impact of Horner's Syndrome on Diagnosis Accuracy in Brachial Plexus Birth Injury
Clark Jia-Long Chen, MD
1; Christopher S Crowe, MD
2; Connor Hickey, MD
3; Eugene D Park, MD
4; Scott H Kozin, MD
5; Dan A. Zlotolow, MD
51Einstein Healthcare Network, Philadelphia, PA; 2University of Washington, Seattle, WA; 3Albert Einstein Healthcare Network, Philadelphia, PA; 4Shriners Children's Philadelphia, Philadelphia, PA; 5Shriners Hospitals for Children, Philadelphia, PA
Background:
Brachial Plexus Birth Injury (BPBI) results from trauma to the brachial plexus nerves during childbirth, causing motor and sensory dysfunction in the affected limb. However, the relevance of a Horner's (HS) syndrome in BPBI remains unclear, as there are anatomic differences between neonates and adults in the stellate ganglion communicating rami with the brachial plexus
7. The C7 nerve root is most closely associated with the sympathetic chain
Objective:
This study aims to evaluate HS among patients with BPBI in which preoperative prediction did not match intraoperative injury findings and describe common trends in discordance.
Methods:
A retrospective analysis was conducted on a cohort of 162 BPBI patients treated at a single institution between 2004 and 2023. Patients were categorized into three groups based on the concordance of their preoperative AMS scores with intraoperative findings: concordant, undercall and overcall. Together, undercall and overcall make up the discordant group. The SHRINeRs classification for BPBI was used, in which Injury A(C5-6), B(C5-7), C(C5-8), and D (C5-T1). Presence of HS was identified on initial consolation visit with ptosis and myosis.
Results:
Among the 135 concordant cases, 37% had HS, with a notable prevalence in group DD (54%). In contrast, 27 discordant cases had a lower HS prevalence (19%, p=0.103). Specifically, undercall injuries were significant (p<0.001), with 100% accuracy in nerve roots A-B and B-C. Overcall injuries, primarily involving suspected global injuries, were associated with HS in 63% of cases. Notably, injuries to C7 frequently led to HS, contributing to overcall patterns. The ANOVA analysis of preoperative AMS scores for discordant cases showed no significant differences, indicating challenges in distinguishing true intermediate injury types (p=0.413). These findings suggest that HS, especially in C7 injuries, complicates accurate preoperative assessment, leading to diagnostic discrepancies, and that discordant overcall Injury D patterns (p=0.008).
Conclusion:
The presence of a C7 injury influenced most discordant overcall events in which a complete paralysis (C5-T1) was assumed due to the presence of HS. Less emphasis on HS may help decrease these discrepancies in the search for an optimized preoperative assessment.
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