Diaphragmatic Paralysis Associated With Neonatal Brachial Plexus Palsy

DIAPHRAGMATIC PARALYSIS ASSOCIATED WITH NEONATAL BRACHIAL PLEXUS PALSY OPTIONAL LOGO HERE

Michyla Bowerson, MD*, Virginia S. Nelson, MD**, and Lynda J.-S.Yang, MD**

*Kalamazoo Center for Medical Studies TY resident and Univ. of Michigan Medical School, **Department of Neurosurgery and ***Department of PMR Univ. of Michigan Health Systems

Background

Results

•Phrenic-nerve palsy can occur in the context of neonatal brachial plexus palsy, yet neither outcomes nor definitive treatment guidelines have been established.

•166 patients with brachial plexus palsy were evaluated during 2005-2009, the incidence of clinically significant phrenic-nerve palsy in patients with brachial plexus palsy was 2.4%.

•Diaphragmatic paralysis alone in the newborn results in significant respiratory sequelae and failure to thrive. •Neonatal brachial plexus palsy may occur concurrently with phrenic-nerve palsy. It is unknown whether the outcome of phrenic-nerve palsy is associated with the severity of brachial plexus palsy. •The incidence of this association has not been wellstudied. • Treatment guidelines remain uncertain with regard to the conservative versus surgical management of phrenicnerve palsy in the context of brachial plexus palsy.

Results

• All hemidiaphragmatic and brachial plexus palsies occurred on the right side. •75% (n = 3) of infants required diaphragm plication via thoracoscopy. Zero patients required surgical nerve repair or brachial plexus reconstruction. •In patients undergoing thoracoscopic plication, supplemental oxygen and nasogastric feeds were discontinued by 1 month postoperatively, with subsequent steady weight gain. •One patient (25%) presented with temporary respiratory distress, but did not require surgical intervention. •Risk factors for a concurrent presentation of brachial plexus palsy and phrenic-nerve palsy included breech presentation, forceps extraction, and shoulder dystocia. •Increased birth weight was not evident in these patients.

Study design •Retrospective medical record review of 166 patients with neonatal brachial plexus palsy evaluated at the University of Michigan during the period 2005-2009. •Four patients also manifested phrenic-nerve palsies. •The phrenic-nerve palsies were evident on chest x-rays as elevations of the hemidiaphragm, and were confirmed and followed by ultrasound or fluoroscopy, indicating absent or paradoxic movements of the hemidiaphragm. •Ultrasound or fluoroscopy was repeated after diaphragmatic plication. •All patients were followed in the Brachial Plexus Program at the University of Michigan, and detailed brachial plexus examinations were performed at regular intervals.

Table 1. Clinical characteristics of the four infants with phrenic nerve palsy.

Case

F

2

M

3

M

4

Case 1 2

Phrenic nerve injury R (C5, 6, 7) R (C5, 6) R (C5, 6, 7)

Gender

1

4

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Results

Table 2. Diagnosis, management, clinical course, and outcome of four infants with phrenic nerve injury. Follow up

1

Chest X-ray

Fluoroscopy at 1.5 and 5 months

2

Chest X-ray Ultrasound

Ultrasound at 10 days and 34 days

16

3

Chest X-ray

Ultrasound at 13, 26, and 30 days

0

4

Chest X-ray Ultrasound

Ultrasound at 8 days

17

Case

Case

Readmit age NG feedings Plication (day of life) (months) (months)

M

Apgar score Presentatio n at birth 1’ 5’ 10’ 4 1 4 2

9 5

Cephalic 10

8 3

4

Age off Oxygen (months)

Bicep recovery (MRC)

3

2

2

5/5

2

27

0.5

1.17

1.33

4/5

3

5, 15

0.5

1

2

4/5

4

None

None

None

None

4/5

Table 3. Epidemiological data for brachial plexus palsy and/or phrenic nerve injury in our study and in Stramrood et al.

3.6

Stramrood et al. Brachial plexus palsy and Phrenic nerve injury (N = 10)

Diagnosis

25% chest X-ray Fluoroscopy 75% chest X-ray Ultrasound

20% chest X-ray fluoroscopy 80% chest X-ray Ultrasound

% underwent Plication 75%

80%

Plication date (days after birth)

20.5

31.3

Extubation days after 1.5 plication

11.25

Respiratory condition 100% good

90% good, 10% died

Conclusions •The severity of brachial plexus palsy failed to correlate with severity of respiratory consequences. •None of the patients underwent brachial plexus nerve repair or reconstruction. •We suggest that diaphragmatic paralysis should not be overlooked during a brachial plexus examination, and diaphragmatic paralysis in the very young may require aggressive intervention before the treatment of the brachial plexus lesion. References

3.7

3.04

3.91

•Stramrood CA, Blok CA, van der Zee DC, Gerards LJ. Neonatal phrenic nerve injury due to traumatic delivery. J PerinatMed 2009;37:293-6.

R

2.87

Breech 2% presentation

25%

70%

•Al-Qattan MM, Clarke HM, Curtis CG. The prognostic value of concurrent phrenic nerve palsy in newborn children with Erb’s palsy. J Hand Surg [Br] 1998;23:225.

R

1.98 100% right

70% right, 30 % left (10% bilateral phrenic nerve only, 10% bilaterally brachial plexus palsy only)

•Al-Qattan MM. Obstetric brachial plexus palsy associated with breech delivery. Ann Plast Surg 2003;51:257-65.

53% right, Side of palsy 47 left Mode of delivery Forcep extraction

Cephalic

Spontaneous

Cephalic

Forcep extraction

Breech

30

32

Brachial Brachial plexus palsy plexus palsy and Phrenic nerve only injury (N = 4) (N = 166)

Our study (N = 4)

Stramrood et al. (N = 10)

Birth weight 4 (kg)

R

R (C5, 6, 7, T1, no Horner’s)

Total ICU days

1

Brachial Birth weight plexus palsy (kg) R

Table 4. Diagnosis, management, and outcome of infants with concurrent phrenic nerve and brachial plexus palsy in two different studies.

Method of diagnosis (day 1 of life)

Our study

3

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Spontaneous

Birth complication

Shoulder dystocia

C-section Maternal diabetes Clavicle fracture Forcep extraction

7%

0%

0%

20%

25%

Not stated

8%

0%

Not stated

10%

50%

10%

Vacuum extraction

11%

0%

20%

Shoulder dystocia

26%

25%

Not stated

•Blaauw G, Slooff ACJ, Muhlig RS. Results of surgery after breech delivery. In: Gilbert A, editor. Brachial plexus injuries. Florence, KY: Taylor & Francis, 2001:217-24. •Rennie JM. Respiratory problems of infants with neurological disease. In: Greenough A, Milner AD, editors. Neonatal respiratory disorders. London: Hodder Arnold, 2003:254. •Lemmer J, Stiller B, Heise G, et al. Postoperative phrenic nerve palsy: Early clinical implications and management. Intensive Care Med 2006;32:1227-33. •Tsugawa C, Kimura K, Nishijima E, Muraji T, Yamaguchi M. Diaphragmatic eventration in infants and children: Is conservative treatment justified? J Pediatr Surg 1997;32:1643-4.