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Assessment of Preoperative Active Movement Scale Scores in Discordant Brachial Plexus Birth Injuries
Clark Jia-Long Chen, MD
1; Connor Hickey, MD
2; Christopher S Crowe, MD
3; Eugene D Park, MD
4; Scott H Kozin, MD
5; Dan A. Zlotolow, MD
51Einstein Healthcare Network, Philadelphia, PA; 2Albert Einstein Healthcare Network, Philadelphia, PA; 3University of Washington, Seattle, WA; 4Shriners Children's Philadelphia, Philadelphia, PA; 5Shriners Hospitals for Children, Philadelphia, PA
Background:
Brachial Plexus Birth Injury (BPBI) is a significant neonatal condition resulting in upper extremity paralysis due to traction injury of the brachial plexus during childbirth. Accurate assessment of preoperative Active Movement Scale (AMS) scores is essential for surgical planning. However, the variability between physical exam and intraoperative findings affects the accuracy in which we can classify injuries preoperatively.
Objective:
This study aims to evaluate the preoperative AMS scores among patients with BPBI in which preoperative prediction did not match intraoperative injury findings, to describe common trends.
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). Nerve roots were intact, avulsed, ruptured, partially avulsed, and partially ruptured. AMS scores were compared across injuries and correlated with surgical predictions.
Results:
Out of 135 concordant patients, we identified 7 A-A's (avg AMS: 61.43), 33 B-B's (average AMS: 44.48), 1 C-C (average AMS: 46.00), and 94 D-D's (average AMS: 24.63) (Table 1). The overall average preoperative AMS for the concordant group was 35.79 with an ANOVA of p < 0.001. For the discordant undercall group, there were 19 patients, (average AMS: 53.89, SD: 17.23), with the following variations of discordance: A-B, A-C, B-C, and B-D, with ANOVA p=0.568. For the overcall group, there were 8 patients (average AMS: 47.14, SD: 7.20) that had the following variations of discordance: B-A, D-B, and D-C, with ANOVA p=0.666.
A detailed breakdown of discordant injuries showed partial rupture was the most common type of nerve root injury leading an undercall of BPBI (Figure 1).
Conclusion:
Partial rupture injuries often lead to undercalling the true extent of BPBI, highlighting the need for more accurate identification to improve surgical planning and outcomes. Additionally, distinct AMS scores for Injuries A, B, C, and D contribute to preoperative and intraoperative discordance by having similar AMS scores. Addressing these discrepancies can enhance preoperative assessments and optimize surgical strategies.
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