AAHS - Early Clinical and Radiographic Predictors of Surgical Intervention in Neonatal Brachial Plexus Palsy

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Early Clinical and Radiographic Predictors of Surgical Intervention in Neonatal Brachial Plexus Palsy
Jessica R Ong, MD, PhD^¹, Theodore Hyman, MD^², Saige Teti, BS^², Liara Ortiz Ocasio, BS^², Danny Chamaa, BS^², Abdallah Feroze, MD^², Athena Zhang, MD^², Robert F Keating, MD^², Albert K Oh, MD^²; Gary F Rogers, MD, JD, MBA, LLM, MPH^²
(¹)MedStar Georgetown University Hospital, Washington, DC, (²)Children's National Hospital, Washington, DC

Introduction

Neonatal brachial plexus palsy (NBPP) presents as weakness or flaccid paralysis of the upper extremity following perinatal injury to the C5-T1 nerve roots¹. While many patients experience spontaneous recovery, up to 30% require surgical reconstruction to optimize function². However, accurately predicting which patients will require surgery remains challenging. This study aims to identify early clinical and radiographic predictors of surgical intervention in NBPP through a retrospective multi-surgeon cohort.

Methods and Materials

A retrospective review of patients with NBPP was conducted between 2008-2024. Patients were included if they had Active Movement Scale (AMS) scores at baseline and two follow-up scores within 6 months of presentation. Demographics, injury location, radiographic findings, operative details, and pre/post-operative AMS scores were recorded. Logistic regressions were used to identify factors associated with eventual need for surgery.

Results

N=73 patients with NBPP were included, n=25 who eventually received operative treatment, and n=48 who did not. Presence or absence of a pseudomeningocele on MRI was the strongest predictor of eventual need for surgery, with PPV=0.75, NPV=0.86, and OR 16.6 (CI 2.0-255, p=0.02). Initial AMS scores less than 4 for shoulder flexion and elbow extension were moderately predictive of need for surgery (PPV=0.43 for each) but had high negative predictive value (NPV 1.0 and 0.9, respectively). Similarly, lack of a greater than 2-point improvement in these AMS scores within 3 months of presentation had moderate PPV (0.41 for shoulder flexion, 0.47 for elbow flexion) but high NPV (0.80 for both). NPV and PPV for lack of a >2-point improvement in these scores at 6 months were similar to those at 3 months.

Conclusion

In a large cohort of patients with NBPP, presence of a pseudomeningocele on MRI was the strongest predictor of eventual need for surgery among characteristics tested. Good initial motor function and strong recovery within 3 months of presentation predicted non-operative treatment, though poor motor function and recovery were only moderately predictive of surgery. The extent of motor improvement at 6 months was not significantly more predictive than at 3 months. Assessing these characteristics may allow earlier and more accurate treatment planning, affording earlier surgery to infants who need it, and avoiding unnecessary risk to those who do not.

References

Shah V, et al. The evaluation and management of neonatal brachial plexus palsy. Paediatr Child Health. 2021;26(8):493-497
Govindan M, Burrows HL. Neonatal Brachial Plexus Injury. Pediatr Rev. 2019;40(9):494-496

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