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Abstract
Upper roots palsy is the most common type of injury occurring in 73-86% of cases. It is usually easily detected immediately following birth. In such cases, the arm is not actively moving but the passive range of motion is equal on both limbs. The arm is internally rotated at the shoulder and the forearm is pronated. The elbow is extended in C5-C6 palsy and if C7 is involved it may be slightly flexed. The wrist may be flexed [the classic “Waiter’s Tip” posture]. Fingers may be flexed with failure of extension.
This study included 74 patients with upper OBPP who were furtherly subdivided into two main groups (Group I and Group II). The main comparison held between Group (I) and Group (IIa) revealed a highly significant difference between both groups regarding the functional recovery at the level of the shoulder and elbow. Good recovery was reported in a total of 63.69% of cases of Group (I) while in Group (IIa) this was detected in 9.1% only (P<0.001). This difference found to be at the side of plexus exploration and reconstruction was nearly similar to other reports done in this field. So, in a properly selected patient plexus exploration can be justified and predicted to result in, at least, a satisfactory limb function.
Optimal timing for surgical intervention is still a matter of great controversy although the indication for surgery is clear in Upper OBPP (weak or absent deltoid and biceps muscles function). Lesion severity is also a contributing factor. This work proved that if the roots are suspected to be ruptured or avulsed, exploration of the plexus is required and is best done between 4-6 months of age. Those with less severe injury (e.g. conducting neuroma in continuity), may show clinical improvement. So, they require more time before a decision can be made as regards the need for surgery. Another philosophical point is that, if we waited too long, the decision will be very difficult, as some recovery have occurred. Surgical exploration will restart the recovery from ZERO with loss of the function post-operative. So, it will be very difficult for the parents to accept an immediate loss for the hope of a hypothetical late recovery.
In our work, cable nerve grafting is found superior to other modalities used during plexus repair although it takes a longer duration to show its results (depending on the length of the journey) (P-Value < 0.05). But it can provide nerve fibers of good quality that can provide a suitable media for the roots of the plexus to grow rapidly and smoothly with minimal scaring.
This study confirmed that improvement in deltoid and biceps muscles is detectable around 6 months after surgery, although some infants show improvements earlier. This earlier improvement occurs when we do neurolysis or nerve transposition (neurotization). Muscle strength will increase gradually over the next 18 months. Improvement of the forearm and hand muscles is detectable around 8 months and continues for another 3-4 years till completed.
Finally by comparing the results of functional recovery in Group (I) and Group (II), it is found that the difference in functional recovery was statistically significant at the side of the operated group. Most of patients in the non-operated group were suffering from defective abduction and defective external rotation at the level of the shoulder and extension deficit at the level of the elbow.