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Doubts in obstetric brachial palsy

This FAQ are born from our team’s experience during our work in helping brachial plexus paralysis patient’s healing and sharing with them and their parents all the journey.

Globalised neurologic injury

How is it possible, in this century, with all the scientific advances than children born with brachial plexus palsy?

Obstetrical brachial plexus palsy is an uncommon injury compared with other pathologies. Its frequency is 0,005 of each 1000 newborn. Despite the medical improvements, this frequency remains constant as much in developed countries as to others. Humans own nature, biology and morphology determines impossible eradication of this illness.

In developing societies, with less medical and technological advances, incidence rate increases, but perinatal morbidity and mortality, nutritional problems and other neurologic injuries reduce real incidence in long term survivors, to a similar frequency.

A low frequency shouldn’t mean less information.

Why don’t they give us information about what happens to our child?

A low frequency pathology implies that health professionals have less opportunities to treat and work with this kind of injuries. Even in specific specialty centres experience gathered over the years is of few cases compared to other pathologies.

Where and how to get information?

Dr Muset got his specialisation in the nineties, and his advice and surgical practice are due to 20 years of professional surgical dedication, and his experience gathered in surgical cases of other 20 years of follow up.

His surgical view, advice, prognosis and treatments are supported by his own results, compared and updated through scientific specific activities of few groups confirming long patient series operated worldwide.

It’s understandable that information provided to patient would be imprecise, in terms of specific answers for exact prognosis, safety in treatment or results.

Only from experience and full dedication we turn low frequency pathology into our habitual work, and high complexity techniques in safety routine, not only in risk control but also in reach results.

What is happening to my child? Has it solution?

Obstetrical brachial palsy is a brachial plexus injury, with partial or complete limb function. It is caused by nerves rupture from medulla in the neck on their way to the arm.

There are three kind of injures:
C5-C6 roots injury: affecting abduction and external rotation of the shoulder and elbow flexion.

The baby has a drooping arm, is able to move the hand and stretch out the arm but can’t flex the elbow so the baby is not able to raise the arm and can’t move the hand to the mouth.

C5-C6-C7 roots injury: add disability of stretch out the arm and raise the wrist, in addition to lack of abduction, external rotation and elbow flexion.

Total palsy: The baby is not able to move the arm nor the hand.

The early control (first month) and strict follow up (month by month) allow establishing injury prognosis and optimal time or need of surgical treatment.

If evolution is not satisfactory surgical indication is absolutely essential to obtain the best results. The optimal age for microsurgical reconstruction is around 3 months old.

Is the injury reparable if it is serious?

Superspecialization in neural and vascular microsurgery fields in obstetrical brachial plexus injuries allow us  to offer patient safety and confidence in the treatment, even in more complex lesions with nerve roots avulsions (complete disconnection from medulla).

Treatment in this type of injuries is technically complex. Medical team must be trained and qualified for choosing the most suitable treatment strategy after clinical assessment.

Neurophysiological intraoperative complementary tests are not useful in babies because they produce a big number of false positives and negatives. Experience is the only element which allows us to decide the most appropriate microsurgical repair in each case. Each patient is different and unique. Obstetrical paralysis is the only type of paralysis in wich microsurgical reconstruction can achieve hand and proximal arm function reinnervation.

Surgery and post-operative 

¿How long would be the surgery? Is it dangerous? 

Surgical procedures protocol is essential and necessary. It is achieve through experience. Anatomical variations, injury identification and roots quality may slow down unnecessarily the results, which derive from the decision taking insecurity.

Surgical plan must be established as a priority based on clinical exploration and surgical technique, and must be carried out rapidity.

Prolonged anaesthetic time and open wounds in 3 months old baby may have an effect on the postoperative.

Surgical time in C5-C6-C7 vary between 60 and 120 minutes, and total paralysis vary between 120 and 165 minutes.

Surgical procedure in obstetrical brachial plexus paralysis is technically difficult and must be executed perfectly to assure good results. Vital risk is not considered despite it is done in 3 months old babies, considering that no vital structures are affected.
Surgical infection is one of the complications associated in all surgical procedures. Dr Muset has had only 2 patients with a post-operative infection, in his experience and practice achieved in more than 350 microsurgical reconstructions and 400 secondary procedures. One of the infections was resolved with antibiotic therapy. The second patient required a new operation with surgical wound clean and intravenous antibiotic. Final results were not compromised in none of them, and the evolution was satisfactory.

Do the baby has to wear cast during postoperative? 

Parents decision of going through a surgery in a baby is very important. The main goal is obtain good results and recovery of a paralytic limb. Generally, it is the first big family decision, in a time of life that should be of highest happiness.

Surgeon decision when pointing out surgical procedure implies high responsibility obligation. Microsurgical reconstruction is a delicate procedure, acting on fragile neural structures which have to be protected from traction and extreme positions.

Dr. Muset and his team now assume no unnecessary surgical risk of interruption of primary microsurgical repair once finished surgery. Therefore we generally consider essential wearing cephalothoracic immobilisation in our patients.

¿How hospitalisation is?

Patients safety is a priority in our surgical practice, and is essential for babies. Our brachial plexus palsy patients are treated in collaborator tertiary care and university hospitals, with all paediatric support needed to assure procedure safety.

Hospitality during hospitalisation is different between medical institutions, according to their philosophy and related with health insurance types in our country.

Anaesthetic and paediatric teams have extensive experience and professional solvency. Work during the years facilitate, make automatic and improve efficiency levels.

2 or 3 days of admission are generally needed. First night is usually (but not always) the most uncomfortable. Second day of stay, once paediatric control and surgeon visit are done, calm the family.

Dr Muset’s nurse and personal secretary make things convenient and give the the family information, social and official support. All the procedures are personalised.

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