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Original Research

Outcomes of Brachial Plexus Neurolysis in 40 Patients With Obstetric Brachial Plexus Injury

Rahul K. Nath, MD
Chandra Somasundaram, PhD
Keywords
January 2025
1937-5719
ePlasty 2025;25:e4
© 2024 HMP Global. All Rights Reserved.
Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of ePlasty or HMP Global, their employees, and affiliates.

Abstract

Background. Severe traction injury to the brachial plexus (BP) during childbirth can induce the formation of intraneural scar tissue or neuroma in continuity. This can lead to nerve entrapment and demyelination, which inhibit axonal transport to the target muscles. Secondary complications include muscle weakness, contractures, joint deformity, and altered limb growth with prolonged and persistent disability. These patients find difficulty performing activities of daily living. BP neurolysis is one of the multistage reconstructive procedures in patients with obstetric brachial plexus injury (OBPI). The successful outcome of BP neurolysis is reported in patients with OBPI. We report improvements in all Mallet functional movements, including forearm supination angle (the Nath-modified Mallet), in 40 OBPI patients after BP neurolysis. 

Methods. Forty OBPI patients (25 female and 15 male with a mean age of 14 years, range 2-25 years; 29 on the right and 11 on the left) underwent BP neurolysis and follow-up evaluations with the lead author and surgeon (RKN). All these patients had undergone multiple previous surgeries, such as primary exploration, Botox, nerve transfer, humeral or forearm osteotomy, wrist tendon transfer, mod Quad, triangle tilt, and biceps tendon lengthening. Patients’ pre- and postoperative shoulder functions were evaluated by the surgeon in the clinic and from photos/videos. These functional movements include shoulder abduction, external rotation, hand-to-mouth movement, hand-to-neck movement, and hand-to-spine movement, which score from 1 (no movement) to 5 (normal movement). In addition to the Mallet functional movements, the supination angle (the angle between the midline of the body and the tangential line to the palm with arms straight; neutral = 0, full supination = 90°, full pronation = −90°) was also evaluated and scored using the Nath-modified Mallet before and after BP neurolysis.

Results. Of the 40 patients in this report, 37 (93%) achieved a Mallet grade of 5/5 (n = 23, 58%) or 4/5 (n = 14, 35%) in shoulder abduction after BP neurolysis. The other 3 patients had a Mallet grade of 3/5 (90 degrees) postoperatively in shoulder abduction. There was statistically highly significant improvement after BP neurolysis in shoulder abduction (3.9 ± 0.7 to 4.5 ± 0.6, P < .0001), external rotation (2.9 ± 1.0 to 3.8 ± 1.1, P < .0001), hand-to-mouth (4.2 ± 0.7 to 4.5 ± 0.7, P < .03), hand-to-neck (3.6 ± 0.8 to 4.2 ± 0.8, P < .0001), hand-to-spine (2.9 ± 1.1 to 3.4 ± 1.2, P < .004), forearm supination (3.8 ±1.1 to 4.2 ±1.0, P < .0001), the Nath-modified total Mallet score (21 ± 3.1 to 25 ± 3.3, P < .0001), including supination angle (40.5 ± 48.8 to 56.3 ± 41.6, P < .001). Improvement in the Nath-modified total Mallet functions was weakly associated with follow-up time after BP neurolysis (R = 0.17, P = .0003).

Conclusions. Among the 40 patients, 37 (93%) achieved a Mallet grade of 5/5 or 4/5 in shoulder abduction after surgery with a mean follow-up of 2 years. All upper-limb functional movements improved significantly as BP neurolysis improves axonal transport to the target muscles after surgically removing the external and internal scarring of the upper trunk and its terminal branches. Additionally, neurolysis decompresses the BP from external compression by the surrounding connective tissues and densely scarred scalene muscles. Thus, it can provide these patients with an effective and rapid functional recovery. These children and their parents are pleased with the progress and increased ability to perform their activities of daily living after surgery.

Introduction

Obstetric brachial plexus injury (OBPI) is rare (0.5-2.6 in 1000)1 yet the most frequent type of birth injury that results from traumatic stretching of the brachial plexus during childbirth. Spontaneous recovery is common, with only 10% to 30% of patients having prolonged and persistent disability,2 leading to secondary complications including persistent muscle weakness, contractures, joint deformity, and altered limb growth,3 and these patients find difficulties with the activity of daily living (ADL).4

Severe traction injury to the brachial plexus (BP) in these patients induces the formation of intraneural scar tissue or neuroma in continuity5-7 that can cause nerve entrapment and axon demyelination and inhibit axonal transport.8 The regenerating nerve fibers from the proximal injury site to send motor signal conduction to the distal target muscles can be compromised by (1) intraneural scar or neuroma formation by the excessive proliferation of fibroblasts, which produce axon growth inhibitory proteins and scar-associated proteins such as semaphorins 3A (sema3A) and 3F (sema3F), as shown in neuroma tissue in permanent OBPI; 9 (2) poor axonal movement and abnormal branching patterns; and (3) axonal crosstalk of regenerating nerve fibers.

Scar formation at the site of nerve lesion is deleterious to functional recovery. Treatment of OBPI is multifaceted, focused on repairing nerve injury and preventing and treating secondary musculoskeletal deformities. Neurolysis is indicated to remove scar tissue, treat hampered axonal growth, and transport to the target muscles. Studies have shown a significant improvement in upper-limb functional movements after microsurgical neurolysis in OBPI.5,6,10-27 Wells et al28 recently reported that the proportion of OBPI patients treated with neurolysis alone had no significant change in 3 decades.

Here, we report the outcomes of BP neurolysis in 40 OBPI patients with an average age of 14 years old (2-25) who had undergone multiple previous surgeries, including nerve, muscle, and bony surgical procedures.

Methods and Materials

Forty OBPI patients (25 female and 15 male with a mean age of 14 years, range 2-25; 29 on the right and 11 on the left) underwent BP neurolysis and follow-up evaluations with the lead author and surgeon (RKN). All these patients had undergone multiple previous surgeries, such as primary exploration, Botox, nerve transfer, humeral or forearm osteotomy, wrist tendon transfer, mod Quad, triangle tilt, and biceps tendon lengthening (Table 1). Patients' pre- and postoperative shoulder functions were evaluated by the surgeon in the clinic and from photo/video records. We adopted the Mallet grading system to evaluate the patients’ all upper-limb functional movements. These functional movements include shoulder abduction, external rotation, hand-to-mouth movement, hand-to-neck movement, and hand-to-spine movement, which score from 1 (no movement) to 5 (normal movement). In addition to the Mallet functional movements,29 the supination angle (the angle between the midline of the body and the tangential line to the palm with arms straight; neutral = 0, full supination = 90°, full pronation = −90°) was also evaluated and scored using the Nath-modified Mallet30-33 (shown in Figure 1): full pronation −90°, grade 1; supination angle (<-30°), grade 2; supination angle (-30 to 30°), grade 3; supination angle (>30 to 80°), grade 4; and supination angle (>80°), grade 5.

Table 1

Table 1-1

Table1-2

Abd, abduction; BP, brachial plexus; BTL, biceps tendon lengthening; ER, external rotation; F, female; FO, forearm osteotomy; HM, hand-to-mouth; HN, hand-to-neck; HS, hand-to-spine; HO, humeral osteotomy L, left; M, male; MQ, mod Quad; NT, nerve transfer; R, right; SNG, sural nerve grafting; Sup, supination; TT, triangle tilt

Figure 1

Figure 1. The Nath-modified Mallet evaluation of function and arm appearance. Supination and the resting position are assessed in addition to the traditional modified Mallet grading. The total Nath-modified Mallet score is calculated from the scores for shoulder abduction, external rotation, hand to mouth, hand to the neck, hand to spine, and supination, giving a maximum score of 30. Angles for abduction and forearm supination are measured from video stills. The Nath-modified scoring method is reported in detail33 as the modified Mallet system in the literature.

Other investigators reported the Nath-modified scoring method in detail33 as one of the modified Mallet grading systems in the literature. Twenty-nine patients had upper and middle plexus injuries, 4 had C5-C8, and 7 had total plexus (C5-T1) injuries.

Surgical technique

The patient was brought to the operating room, where they underwent general anesthesia. The injured side of the neck and arm was prepped and draped in the usual sterile fashion. An initial incision was created over the area where the upper trunk of the brachial exited through the anterior scalene muscle, about 2 cm superior to the upper clavicular border. A dense scar in the neck required extra care to dissect to reach the affected nerves in this region. The upper trunk of the brachial plexus was identified deep within the scalene fat pad. The fat pad was retracted, and the underlying upper trunk of the brachial plexus was identified. It appeared to have quite a thick epineurial scar consistent with the injury to the upper trunk and its terminal branches, including the anterior and posterior divisions and suprascapular nerve. The posterior divisions of the upper trunk and suprascapular nerve appeared most affected. The thickened epineurium of the anterior division was externally neurolyzed through microsurgical technique and high magnification. Subsequently, the posterior division similarly underwent external neurolysis. The suprascapular nerve was externally neurolyzed through a microsurgical technique. 

The anterior scalene muscle was densely scarred, impinging the upper trunk. Consequently, the muscle was surgically freed to alleviate the compression on the upper trunk. The substance of the upper trunk was entered, and the perineurium was dissected through microsurgical technique and high magnification. Major fascicle groups of the posterior division were separated, and an internal scar was removed by internal neurolysis. Subsequently, the suprascapular nerve was treated similarly by separating the fascicles and performing internal neurolysis. Internal neurolysis was also performed on the anterior division. Direct electrical stimulation improved the conduction to the biceps and shoulder muscles following surgery, based on intraoperative monitoring.

Subsequently, another incision was created in the medial upper arm, where the neurovascular bundle of the arm was located. A sharp and blunt dissection revealed the median, ulnar, and radial nerves. All were noted to be scarred and compressed, with poor electrical conductivity. The median, ulnar, and radial nerves underwent external neurolysis, followed by internal neurolysis.  

In summary, direct electrical stimulation improved the conduction to the muscles innervated by all operated muscles after surgery, based on intraoperative monitoring measured in the operating room by a third-party electrophysiology team. Blood loss was minimal, and there were no complications.

Statistical analyses

Excel 2013 (Microsoft Corp) was used to analyze descriptive statistical data and generate graphs. Paired Student t tests were conducted to determine if differences between preoperative and postoperative modified Mallet scores for each function were statistically significant. The P values were two-tailed and considered significant if they were less than or equal to .05. We used the Pearson correlation coefficient to assess the associations between the follow-up time and the surgical outcomes.

Results

Among the 40 patients in this report, 37 (93%) achieved a Mallet grade of 5/5 (n = 23, 58%) or 4/5 (n = 14, 35%) in shoulder abduction after BP neurolysis. The other 3 patients had a Mallet grade of 3/5 (90 degrees) postoperatively in shoulder abduction. The mean shoulder abduction angle was 148 ± 30 after BP neurolysis, improved from 125 ± 29 degrees. There was statistically highly significant improvement after BP neurolysis in shoulder abduction (3.9 ± 0.7 to 4.5 ± 0.6, P < .0001), external rotation (2.9 ± 1.0 to 3.8 ± 1.1, P < .0001), hand-to-mouth (4.2 ± 0.7 to 4.5 ± 0.7, P < .03), hand-to-neck (3.6 ± 0.8 to 4.2 ± 0.8, P < .0001), hand-to-spine (2.9 ± 1.1 to 3.4 ± 1.2, P < .004), forearm supination (3.8 ±1.1 to 4.2 ±1.0, P < .0001), the Nath-modified total Mallet score30-33(21 ± 3.1 to 25 ± 3.3, P < .0001), including supination angle (40.5 ± 48.8 to 56.3 ± 41.6, p<0.001) 30-32 (Tables 1 and 2; Figures 1-7). The Mallet score for hand-to-spine remained unchanged in 13 patients. Thirty-one of 40 patients (78%) achieved a Mallet score of 4 or 5/5 in ER postoperatively. Fourteen patients with a Mallet score of 2/5 for ER preoperatively improved to 4 or 5/5 after neurolysis.

Table 2

Table 2

Figure 2

Figure 2. Nath-modified total Mallet functions, including forearm supination, before and after BP neurolysis in 40 patients with OBPI.

Figure 3

Figure 3. The Nath-modified total Mallet functions, including forearm supination, before and after BP neurolysis in 40 patients with OBPI.

Figure 4

Figure 4. A mean of forearm supination and the other classical Mallet functional movements before and after BP neurolysis in 40 patients with OBPI.

Figure 5

Figure 5. Shoulder abduction angle before and after BP neurolysis in 40 patients with OBPI.

Figure 6

Figure 6. External rotation and hand-to-neck movement before and after BP neurolysis in 40 patients with OBPI.

Figure 7

Figure 7. Nath-modified Mallet functional movements of a 3-year-old male patient before BP neurolysis (upper panel) and images of the same patient 3.8 years after BP neurolysis with significant improvement to near-normal functional movements (lower panel).

Improvements in patients with C5-T1 injury after BP neurolysis

External rotation and hand-to-spine or back movements significantly improved from a Mallet grade of 2 to 4 in patient 6 in Table 1. Hand-to-neck movements improved from a Mallet score of 3 to 5 in patient 15 in Table 1. Patient 22 in Table 1 improved all upper-limb functional movements except supination and hand-to-spine.

We found that the postoperative follow-up time was weakly associated with improvement in the Nath-modified total Mallet functions (R = 0.17, P = .0003). There were no significant postoperative complications in any of the patients in this report.

Figure 7 shows representative patient images of the Nath-modified Mallet functional movements of a 3-year-old male patient before BP neurolysis and pictures of the same patient 3.8 years after BP neurolysis, with significant improvement to near-normal functional movements.

Discussion

Though the injury patterns are significantly different in OBPI and traumatic brachial plexus injury (TBPI) patients, neuroma, or scar formation at the site of the lesion resulting from nerve injury and compression by surrounding connective tissue and scarred scalene muscles, is similar. Decompression and BP neurolysis are performed on both obstetric and adult TBPI and long-thoracic nerve injuries.5,6,10-27,35,36 Studies have demonstrated that neurolysis improved nerve conduction,36,37 muscle grade, and functional movements in OBPI patients.5,6,10-28 We and other investigators 35, 36 have demonstrated rapid recovery and long-term improvements in upper-limb functions after neurolysis in patients with long-thoracic nerve injury35,36 and neurogenic thoracic outlet syndrome.38. The postoperative follow-up time was weakly associated with improved total modified Mallet functions in OBPI patients in this report.

Chin et al20 showed that about two-thirds of surgically treated OBPI patients (22 of 32) underwent neurolysis alone, which resulted in good recovery of abduction and elbow flexion but poor recovery of external rotation. Postoperatively, 78% of patients in our report achieved a Mallet score of 4 or 5/5 in external rotation.

Clarke et al11 reported that neurolysis alone showed functional recovery in patients with upper trunk injury but not in patients with total plexus injury (C5-T1). In contrast to those findings, El-Gammal et al26showed that OBPI patients with lower trunk palsy also achieved a total Raimondi score after neurolysis. Further, these authors26 recently performed neurolysis in 57.6 % (n = 15) of OBPI patients and demonstrated functional recovery in shoulder abduction, external rotation, and elbow flexion in 4 of 6 late-presenting cases.

Andrisevic et al13 reported that 14 of 16 OBPI patients achieved elbow flexion, and 11 of 16 patients regained shoulder abduction after neurolysis performed in infants with neuroma-in-continuity with over 50% conduction. 

Among the 40 patients in this report, 37 (93%) achieved a Mallet grade of 5/5 (n = 23, 58%) or 4/5 (n = 14, 35%) in shoulder abduction after BP neurolysis. The other 3 patients had a Mallet grade of 3/5 (90 degrees) postoperatively in shoulder abduction.

Functional recovery is weeks to months in complete axonal and demyelinating injuries. Nine patients with less than 6-month postoperative follow-ups in our report show that functional recovery was not due to the completion of nerve regeneration but was reversed once the compression was relieved by nerve decompression and internal and external neurolysis of the densely formed scar tissue. By directly measuring the nerve conduction before and after surgical procedures, we found that the nerve conduction improved after the decompression and neurolysis.36,37

In addition, McComas39-41 demonstrated that neurapraxic injuries could be rapidly reversed once the compression was relieved by neurolysis, as the conduction is obstructed at the site of compression caused by neural fibrosis.6,42 In these clinical situations, peripheral nerves may remain anatomically intact; however, since lesions in continuity can be reversed even after prolonged paralysis through decompression and neurolysis, signal conduction may be compromised due to slowed axonal transport by chemical factors.9,34

Limitations

A limitation of this work is that it is a retrospective study.

Conclusions

Among the patients, 37 (93%) achieved a Mallet grade of 5/5 or 4/5 in shoulder abduction after surgery with a mean follow-up of 2 years. All upper limb functional movements improved significantly as BP neurolysis improves axonal transport to the target muscles after surgically removing the external and internal scarring of the upper trunk and its terminal branches. Additionally, neurolysis decompresses the BP from external compression by the surrounding connective tissues and densely scarred scalene muscles. Thus, it can provide these patients with an effective and rapid functional recovery. These children and their parents are pleased with the progress and increased ability to perform their activities of daily living after surgery.

Acknowledgments

Authors: Rahul K. Nath, MD; Chandra Somasundaram, PhD

Affiliation: Texas Nerve and Paralysis Institute, Houston, Texas

Correspondence: Rahul K. Nath, MD; rnath@drnathmedical.com

We thank the patients and their families who participated in this study.

Informed consent: Patients were treated ethically in compliance with the Helsinki Declaration. Documented informed consent was obtained for all patients. The patient provided written consent to use the images in this report.

Disclosures: The authors disclose no relevant financial or nonfinancial interests.

References

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Versatility of the Anterolateral Thigh Free Flap: The Four Seasons Flap Michele Di Candia, MD,a Kwok Lie,b Devor Kumiponjera, MRCS, MBChB,a Jeremy Simcock, MBChB, FRACS (Plast), MD,a George C. Cormack, MBChB, MA, FRCS (Ed),a and...
Versatility of the...
03/05/2012
ePlasty
Literature Review
CASE REPORT Persistent Seromas in Abdominal Free Flap Donor Sites After Postmastectomy Breast Reconstruction Surgery: Case Reports and Literature Review
03/06/2013
CASE REPORT Persistent Seromas in Abdominal Free Flap Donor Sites After Postmastectomy Breast Reconstruction Surgery: Case Reports and Literature Review Abtin Sadeghi, BA (Hons),a and Charles Malata, BSc (HB), LRCP, MRCS, FRCS...
CASE REPORT Persistent Seromas in Abdominal Free Flap Donor Sites After Postmastectomy Breast Reconstruction Surgery: Case Reports and Literature Review Abtin Sadeghi, BA (Hons),a and Charles Malata, BSc (HB), LRCP, MRCS, FRCS...
CASE REPORT Persistent...
03/06/2013
ePlasty
Sacral Pressure Ulcer
09/02/2013
Sacral Pressure Ulcer Paul J. Therattil, BA, Craig Pastor, MD, and Mark S. Granick, MD Department of Surgery, Division of Plastic Surgery, New Jersey Medical School, University of Medicine and Dentistry of New Jersey,...
Sacral Pressure Ulcer Paul J. Therattil, BA, Craig Pastor, MD, and Mark S. Granick, MD Department of Surgery, Division of Plastic Surgery, New Jersey Medical School, University of Medicine and Dentistry of New Jersey,...
Sacral Pressure...
09/02/2013
ePlasty

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