Evaluation
When patients enter the program, they are first screened to determine the extent of the injury. Based on their age at the time of entry, they may begin medical therapy or may be in need of electrodiagnostic and imaging studies. Because the majority of patients do not need surgery, only those that fail to recover according to specified criteria, and have completed a full work-up by non-surgical doctors, are referred to the surgical team.
Non-surgical Treatment
Approximately 70-80 percent of brachial plexus palsies are diagnosed as a mild stretch type. Patients are able to recover without surgery by following a series of daily stretches and exercises. The prescribed exercises are taught by trained team occupational therapists.
Surgical Treatment
In a limited percentage of children surgery is required for optimal outcome. These children will have one of the three more severe degrees of injury mentioned. Each type of injury requires a different surgical treatment. It is very important to know whether the injury is a neuroma, rupture, or avulsion.
Prior to surgery, two tests are run to determine the type of injury. The first is an electromyography (EMG). In this test the pediatric neurologist makes a direct recording of the arm nerves and muscles. This helps to establish a pattern of what areas of the arm are affected. The second test produces an image of the brachial plexus. Using advanced technology a picture of the plexus is taken to physically show nerve damage and give information as to the type of injury. Neither test is 100 percent accurate which often means the exact nature of the injury, and its severity, are difficult to diagnose until the actual surgery.
During the surgery the brachial plexus is exposed using a special incision to allow a complete view. Next, direct electrical testing of nerves is done to confirm the extent of injury to each of the three major parts of the plexus. Ruptured nerves are then treated by taking a nerve graft, typically from a sensory nerve in the legs, to repair the damaged ends. (Taking nerves from the legs for grafting only creates a small area of numbness on the side of the foot and a scar on the back of the leg. Future development or coordination of the leg is not usually affected.) In some severe cases, an end is not available to connect to and a more delicate procedure must be done. In these cases, there is the possibility of using nerve transplant tissue to complete the surgery.
Surgery takes from six to 12 hours. Following surgery, the patient remains in the hospital for several days to be monitored by a special pediatric nursing staff. Typically, the patient is discharged after a few days wearing simple bandages around the neck, shoulder and arm area.
If brachial plexus treatment is not completed before six months of age, children between six months and 12 months of age can be considered for direct surgery on the brachial plexus on a case by case basis. After 12 months of age, it is very difficult to achieve a meaningful degree of recovery. Most children seen after this time frame will do better with secondary surgeries such as tendon transfer surgery.
Post-surgical Care
Two weeks after the operation, the patient sees the surgeon to make sure the arm is properly healing. Therapy for the arm typically begins a week after the first office visit. Long term follow-up visits at the pediatric neurology clinic are then scheduled at months 1, 3, 6, 12, 18, and 24 post-surgery. Children who have traveled from abroad to come to our program can arrange for some or most of their follow-up to occur in their local communities by doctors who are able to stay in touch with our specialists.
Staff
Physicians in the program are full-time teaching faculty from the University of Texas Medical School at Houston who have specialty training in pediatric nerve injuries. Members of the medical advisory team represent the departments of pediatric and general neurology, neonatology, obstetrics, radiology, and hand/microsurgery. Representatives from each department have designed a structured and detailed protocol for evaluation and treatment of every child based on the most current published medical literature.
Physicians:
Idris S. Gharbaoui, MD
Dr. Gharbaoui has trained in Morocco, France and Houston. He received his Medical Doctor's Degree with Honors in 1987 and completed his Specialty in General Surgery and Orthopedics in 1991 at Mohamed V University in Rabat, Morocco. He subsequently received University Diplomas in Hand and Upper Limb Surgery, Juridical Expertise of Disabilities, and Microsurgical Techniques at Pierre et Marie Curie University and René Descartes University in Paris. In 1991 and 1992, he completed fellowships in hand surgery and pediatric hand surgery at Trousseau Children's Hospital in Paris and Institut Français de la main, also in Paris. More recently, he completed fellowships in orthopaedic hand surgery, plastic hand surgery and pediatric hand surgery at Baylor College of Medicine, Houston. Dr. Gharbaoui's specialties include:
- Peripheral Nerve Surgery and Brachial Plexus Injuries
- Repair of Birth and Traumatic Hand and Upper Extremity Injuries
- Hand and Upper Extremity Surgery
- Microsurgery and Replantation
Pedro Mancias, M.D.
About Brachial Plexus Palsy
Brachial plexus palsy is an injury to nerves in the neck and shoulder region affecting an arm. The brachial plexus is a group of nerves that have a complex intermingling to eventually form the nerves that innervate the shoulder, arm, forearm, and hand. The brachial plexus starts as 5 nerve roots exiting the spinal cord in the neck (5 cervical and thoracic root). After making various connections the plexus produces 5 major nerves and many minor nerves that give muscle function and (sensation) to the shoulder, arm and hand. The brachial plexus can basically be divided into 3 regions: upper, middle, and lower trunks. Other terms you may have seen include Erb's Palsy which is an upper plexus injury. Klumpke's palsy is lower plexus palsy. The upper plexus controls raising the shoulder and bending the elbow. The middle plexus controls muscles in the forearm that help the hand to open and close. The lower plexus controls muscles in the hand itself that give dexterity and fine coordination.
Brachial plexus palsies that occur at birth are commonly associated with a stretch type of injuries. They are not caused by any one factor but rather the interaction of many factors taken together. Injuries to the brachial plexus can occur to any part of the plexus or to the entire plexus. Injuries usually follow familiar patterns. The most common injury involves only the upper plexus. The next common injury involves the upper and middle plexus followed by injury to the whole plexus. The least common injury is to the lower plexus alone.
Injuries to nerves can vary in severity. The least severe is a stretch injury that affects the insulation around the nerves and temporarily stops the nerve from working but will recover on its own with no surgery. Fortunately, 70-80 percent of plexus injuries are this type. The next more severe injury is a stretch on the nerves that makes enough scar tissue that recovery may be affected without surgery to help. More severe is a rupture of the nerve where surgery is required to directly attach the ends back together or grafted. The most severe injury is called an avulsion where the nerve actually has been pulled out from the spinal cord. This type of injury cannot be repaired directly and surgical substitution of a different nerve must be made.
Contact Us
For more information regarding our program or to make an appointment, call 832-325-7151.
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