Peripheral Nerve Decompression for Pain Relief in the Setting of Previous Obstetrical Brachial Plexus Injury: A Retrospective Case Series

Peripheral Nerve Decompression for Pain Relief in the Setting of Previous Obstetrical Brachial Plexus Injury: A Retrospective Case Series | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Peripheral Nerve Decompression for Pain Relief in the Setting of Previous Obstetrical Brachial Plexus Injury: A Retrospective Case Series Jessica Gormley, Pavlo Isak, Deborah Gjertsen, James R Bain This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3842970/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 08 Mar, 2024 Read the published version in Child's Nervous System → Version 1 posted 7 You are reading this latest preprint version Abstract Purpose In children with previous obstetrical brachial plexus injury (OBPI) upper extremity pain is present in 45 to 66% of patients. Recent literature reports this as musculoskeletal or neuropathic in nature. The purpose of the study is to demonstrate that peripheral nerve decompression and neurolysis may be an effective treatment for patients with upper extremity pain in the context of previous OBPI. Methods A retrospective chart review was performed on patients undergoing peripheral nerve decompression and neurolysis after OBPI by senior author. The primary outcome assessed was pain and secondary outcome measure was range of motion of the wrist and elbow. Outcome measures were assessed preoperatively as well as at their subsequent follow-up. Results Six patients were included, with a mean age of 14 years old at time of decompression. Three patients underwent median nerve, two patients underwent ulnar nerve and one patient underwent posterior interosseous nerve decompression. There was a substantial improvement in pain post-operatively, demonstrated by reduction or resolution of subjective pain in all patients and resolution of Tinel’s sign. There was a modest improvement in range of motion. Conclusion This study demonstrates an improvement in subjective pain and range of motion after decompression and neurolysis in OBPI patients with peripheral neuropathy. Appropriate identification of this pathology through routine follow-up with a multidisciplinary clinic allows for early recognition and symptom relief. Future research should focus on assessment and treatment of pain in this population on a larger scale. Brachial plexus Pain Peripheral nerves Decompression surgical Figures Figure 1 Introduction Obstetrical brachial plexus injury (OBPI) is a neurological injury sustained during labour and delivery resulting in unilateral deficits of the affected limb.[ 1 ] The incidence lies between 1.6 and 2.6 per 1000 live births, with common risk factors being shoulder dystocia, macrosomia and comorbid birthing trauma.[ 2 , 3 ] The large majority of OBPIs are transient but surgical reconstruction is indicated for root avulsions and injury patterns with a low likelihood of spontaneous recovery.[ 4 , 5 ] Despite extensive research into the initial management of these injuries, there is limited evidence to support long-term evaluation and management in this patient population.[ 6 ] For this reason, chronic pain following OBPI remains poorly understood, controversial, and vastly under-recognized. In adults who suffer traumatic brachial plexus injury similar to OBPI, debilitating neuropathic and chronic pain is well documented in the literature.[ 7 , 8 ] However, the pediatric population experiences and expresses pain differently, and consideration for these differences is required to obtain accurate information in this group.[ 6 ] Previous studies have demonstrated the incidence of upper extremity pain in this population ranges from 45 to 66% throughout childhood, with the typical presentation being frequent, episodic and of low-to-moderate intensity.[ 6 , 9 ] However, some patients encounter severe pain that limits their functional abilities.[ 6 ] When assessing the quality of pain in these children, the characterization is consistent with musculoskeletal and neuropathic pain patterns.[ 6 , 9 , 10 ] A recent study by Ho et al. reported 21 descriptions used by this population that were suggestive of a neuropathic origin, such as “tingling,” “pins and needles,” “asleep,” “numbness,” “twitches” and “shooting pain.”[ 6 , 10 ] Because studies have only begun to understand the nature of pain in this cohort of patients, a detailed recommendation for optimal management has yet to be determined. The aim of our retrospective study is to demonstrate that peripheral nerve decompression and neurolysis may be an effective treatment for patients with upper extremity pain in the context of previous OBPI. The secondary outcome measure is range of motion of the wrist and elbow in the affected limb pre- and post-operatively. Materials and Methods Patient Population A retrospective chart review was performed on patients undergoing peripheral nerve decompression and neurolysis after OBPI by the senior author between September 2014 and October 2019. This study was approved by the institution’s research ethics board before initiation. The study included all patients within this time frame presenting with neuropathic symptoms consistent with a peripheral nerve distribution that required decompression, in the context of previous OBPI. Nerve compression was confirmed with ultrasonography (US) or electromyography with nerve conduction velocity (EMG-NCV) before the time of operation. Patients were excluded if there was inadequate reporting of pre- and post-operative pain or range of motion, as outcome measures were unable to be assessed. There were six patients who met the inclusion criteria of this study. Objectives The primary outcome measure of the study is upper extremity pain before and after peripheral nerve decompression and neurolysis. Pain scores were reported by patients subjectively both descriptively and using a 10-point scale pre- and post-operatively and assessed clinically using Tinel’s sign over the affected nerve. The secondary outcome was pre and post-operative range of motion of the wrist and elbow. Outcome scores for range of motion were assigned using the Active Movement Scale (AMS), which ranges from a grade of 0 to 7 based on range of motion with or without the force of gravity. Clinical assessment of outcome measures was completed at their pre-operative clinic visit as well as at their two-week post-operative and subsequent follow-up. Statistical Analysis Our analysis and results are presented in a descriptive fashion. For categorical data we used frequencies and percentages. For continuous data we used means with standard deviation and range. Operative Technique All patients were placed on the operating table in supine position, and a tourniquet was placed on the affected extremity distal to the axilla. After the induction of general anesthetic, the limb was exsanguinated, and the tourniquet was inflated. For patients undergoing median nerve decompression, a curvilinear incision along the proximal volar forearm was made. A tight lacterus fibrosis was identified and divided in all cases, ensuring adequate protection of the biceps tendon, brachial artery and cephalic vein. Pronator teres was identified and released if found to be compressive. The median nerve was identified and circumferential neurolysis was performed from the distal arm to proximal forearm for complete decompression. In the patients that required concomitant anterior interosseous nerve (AIN) decompression, the AIN was identified distally, and fasciotomy of the overlying tissue was completed. For patients undergoing ulnar nerve decompression, an incision between the medial epicondyle and olecranon was made. Once the ulnar nerve was identified through dissection, fascial release of identifiable compressive forces including triceps fascia, medial intermuscular septum, medial antebrachial fascia and fascial bands of the flexor carpi ulnaris (FCU) was completed. Circumferential neurolysis and transposition of the ulnar nerve was performed. Finally, for the patient undergoing posterior interosseous nerve (PIN) decompression an incision was made in the interval between brachioradialis and extensor carpi radialis longus (ECRL). A fasciotomy between these two muscles was completed and deep in this interval the PIN was identified. Fascial release of the compressive ECRB and supinator muscles was performed until adequate decompression both proximally and distally was achieved. In all cases, the affected arm’s passive range of motion of the elbow and wrist was assessed intra-operatively. Once hemostasis was achieved, a two-layer closure of the wound was completed. The incision was dressed appropriately, and follow-up was scheduled for two-weeks postoperatively. Results Patient Characteristics There were six patients who met the inclusion criteria of this study, with all six patients being female (100.0%). In four of the six cases (66.7%) the left upper extremity was affected, with the remaining two being the right upper extremity. In terms of the initial management of their OBPI, two cases were non-operative (33.3%). For those who required operative management, two patients had their initial operation at 6-months of age, one patient at 52-months, and one patient’s age was not recorded. The details of their initial management, as well as additional procedures required, can be found in Table 1 . Table 1 Patient demographics of initial management for OBPI Patient Number Gender Affected side Age at time of first operation Initial Management of OBPI Additional Procedures 1 Female Left 6 months C5-6 neuroma excision with NG, C7 neurolysis Pronator teres tendon transfer to ECRB 2 Female Right Not applicable Non-operative None 3 Female Left 4 years 4 months Oberlin transfer: ulnar motor fascicles FCU to musculocutaneous motor fascicles of biceps brachii None 4 Female Right Not applicable Non-operative Botox injection for muscle contracture 5 Female Left Not recorded Brachial plexus reconstruction, specific technique not recorded Free muscle transfer gracilis to FPL/FDP and tenolysis of adhesions 6 Female Left 6 months C5-C6 neurolysis None NG; nerve graft, ECRB; extensor carpi radialis brevis, FCU; flexor carpi ulnaris, FPL; flexor pollicis longus, FDP; flexor digitorum profundus. With respect to the decompression and neurolysis procedure, the mean age at the time of operation was 14 years old (SD 2.76, range 9–16). Three patients (50.0%) required median nerve decompression, with two of the three undergoing concomitant AIN decompression, two patients (33.3%) required ulnar nerve decompression and transposition, and one patient (16.7%) underwent PIN decompression. The details of patient demographics and management can be found in Table 2 . Table 2 Patient demographics and outcome measures for peripheral nerve decompression Patient Number Age Site of decompression Subjective Pain (pre) Subjective Pain (post) AMS grade (pre) AMS grade (post) 1 14 Left median nerve Significant pain in forearm; Pain on pronation and flexion; Positive Tinel. Significant improvement in pain; Tinel NR. Wrist ext: 3 Elbow ext: 5 Wrist ext: 5 Elbow ext: 6 2 16 Right posterior interosseous nerve Significant pain at elbow and forearm (5–7/10); Pain on pronation; Uncomfortable paresthesia; Positive Tinel. Resolution of pain; Resolution of paresthesia; Negative Tinel. Elbow ext: 2 Elbow ext: 5 3 9 Left ulnar nerve Significant pain at elbow; Uncomfortable paresthesia; Positive Tinel. Significant improvement in pain (3–4/10); Significant improvement of paresthesia; Tinel NR. Wrist ext: 4 Elbow ext: 5 Wrist ext: 5 Elbow extension: 6 4 16 Right median and anterior interosseous nerve Significant pain in forearm and wrist; Pain with carrying; Uncomfortable paresthesia; Positive Tinel. Significant improvement in pain; Negative Tinel. Wrist flex: 6 Elbow ext: 6 Wrist flex: 6 Elbow ext: 6 5 13 Left ulnar nerve Significant pain at elbow; Uncomfortable paresthesia; Positive Tinel. Resolution of pain; Significant improvement of paresthesia; Tinel NR. NR NR 6 16 Left median and anterior interosseous nerve Significant pain in forearm (7/10); Uncomfortable paresthesia; Positive Tinel. Resolution of pain; Resolution of paresthesia; Tinel NR. NR Elbow ext: 6 AMS; active movement scale, NR; not recorded, ext; extension, flex; flexion. Pain Scores All six patients reported significant pain in their extremity pre-operatively and five patients reported uncomfortable paraesthesia. Post-operatively all patients reported significant improvement or resolution of their pain (6/6, 100%) and paresthesia (5/5, 100%). In the two patients that reported pre-operative pain scores using a 10-point scale, the mean score was 6.5 (SD 0.7, range 6–7). In both of these patients, complete resolution of pain was reported. All six patients had a positive Tinel’s sign pre-operatively, with two patients (33.3%) reported to have a negative Tinel’s post-operatively and in four patients (66.7%) assessment of Tinel’s sign was not recorded after their operation. Additional details on pain scores can be found in Table 2 . Range of Motion The mean pre-operative AMS grade for the wrist and elbow was 4.3 (SD 1.5, range 3–6) and 4.5 (SD 1.7, range 2–6) respectively. The mean post-operative AMS grade for the wrist was 5.3 (SD 0.6, range 5–6) and elbow was 5.8 (SD 0.4, range 5–6). The mean improvement across patients in wrist and elbow AMS was 1 (SD 1.0, range 0–2) and 1.25 (SD 1.3, range 0–3) respectively. The detailed breakdown of AMS grading for each patient can be found in Table 2 . Intraoperative Findings Intra-operative findings of tight and fibrotic changes in fascia and overlying muscle were consistent across all patients. In the three patients undergoing median nerve decompression, a tight lacterus fibrosis was identified. For the single patient undergoing PIN decompression, a tight and fibrotic supinator was identified. Finally, for the two patients undergoing ulnar nerve decompression and transposition the pathologic changes were variable, demonstrating thickened triceps fascia, medial intermuscular septum, FCU fascial bands and medial antebrachial fascia. Intraoperative photographs were taken for one patient undergoing right median and AIN decompression (Fig. 1 A-C). Discussion The patients involved in this study represent the diverse nature of OBPI, with variable severity of presentation, pathology and initial management. All patients were initially treated according to the current OBPI clinical guidelines and continued to be followed for routine assessment of function.[ 5 ] All six patients presented with a new complaint of neuropathic pain in a distinct peripheral nerve distribution, with a positive Tinel’s sign over the site of maximal compression, with confirmation on imaging or EMG. Overall there was a substantial improvement in pain post-operatively, which was demonstrated by a reduction in subjective reports of pain in all patients and resolution of Tinel’s sign when assessed post-operatively. There was a modest improvement in range of motion, with a mean improvement of the AMS grade by 1 and 1.25 for the wrist and elbow respectively. The improvement in range of motion of the elbow is likely secondary to pain relief and removal of fibrotic tissue enabling greater mobility in the affected extremity. The site of decompression in all cases was distal to the innervation of the common extensors and flexors of the elbow, and therefore the improved mobility would not be secondary to increased motor unit recruitment. The onset of symptoms of peripheral neuropathy in this population occurred during the pubertal growth spurt period, with the mean age being 14 years old (range 9–16). During this time, one would expect accelerated growth of musculoskeletal structures.[ 11 ] However, in patients with previous OBPI, deficiencies in musculotendinous growth from fibrotic changes to the affected extremity have been observed secondary to their primary plexopathy.[ 12 ] These pathologic changes in growth can lead to compression of the peripheral nerves with worsening symptomology as the patient continues to grow. Intra-operative findings of fibrotic changes were consistent across all patients, with the site of pathologic changes varying based on the peripheral nerve affected. In all patients undergoing median nerve decompression, a tight lacterus fibrosis was identified and divided. For the single patient undergoing PIN decompression, a tight, pale and fibrotic supinator was identified and released. Finally, for those undergoing ulnar nerve decompression and transposition, the pathologic changes varied widely and fascial release of any identifiable compressive forces (ie. triceps fascia, medial intermuscular septum, medial antebrachial fascia or fascial bands of the flexor carpi ulnaris) was completed. This study demonstrates that in patients with previous OBPI not all symptoms originate from their initial injury and that secondary insult may occur. Identifying a new onset of musculoskeletal or neuropathic pain in the pediatric population continues to be an issue, as the expression of pain is different and far less supported in the literature.[ 6 ] This challenge is worsened in the context of OBPI where residual deficits of the affected extremity may be present.[ 6 ] When a patient is presenting with a new symptom complex, a detailed history and physical examination should be completed, and diagnostic tests can be used to confirm the underlying pathology once localized. US or EMG-NCV can be used for diagnosis in the context of focal peripheral nerve deficits, based on availability of resources and patient tolerance for EMG-NCV.[ 13 , 14 ] The patients involved in this study were identified through follow-up assessment which further highlights the need for serial visits throughout the entire childhood from a multi-disciplinary team including both a physiotherapist and peripheral nerve surgeon.[ 5 ] Compression neuropathies are exceedingly rare in the general pediatric population and continue to remain under-recognized but follow-up by specialists in the field allow for greater recognition of new symptomology and identification of underlying issues for this population.[ 15 ] Early recognition of peripheral neuropathy in our study allowed for improvement in pain and function from their baseline in all patients. Limitations of this study include the lack of a control group, small sample size and poor availability of data. Given the retrospective nature of this study, we were only able to report information on pain and range of motion from data recorded in the patient’s medical chart. All patients had subjective reports of pain, but few reported pre- and post-operative scores using a validated scale, which limited our ability for a pooled analysis and introduced availability bias. Future research should focus on improving recognition of peripheral neuropathy as a source of pain in this patient population through serial visits to a multidisciplinary clinic. To improve the strength of conclusions that are able to be drawn on this topic, a large-scale prospective study on decompression and neurolysis for peripheral neuropathy in the context of OBPI should be completed using validated scales across all participants. Conclusion This study identifies compressive peripheral neuropathy as a source of pain in patients with previous OBPI and demonstrates a significant improvement in subjective pain and moderate improvement in range of motion after decompression and neurolysis. Appropriate identification of this pathology through routine follow-up with a multidisciplinary clinic, thorough clinical examinations and appropriate diagnostic tests allows for early recognition and symptom relief in this cohort of patients. Future research should focus on assessment and treatment of peripheral neuropathy in the context of previous OBPI for pain management on a larger scale. Declarations Funding: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Declaration of Conflicting Interests: Disclosures include J.R.B. is a medical consultant for Epineuron. No product use, conflict of interest, promotion of products or involvement in this publication. Ethics: This study was performed in line with the principles of the Declaration of Helsinki. This study was approved by the Hamilton Integrated Research Ethics Board (HIREB) before initiation (2020-12818-C). Author Contribution All authors contribute to conception and design of the study, completed critical manuscript revisions for important intellectual content, provided final approval of the version to be published and agreed to act as guarantor of the work to ensure that questions regarding any aspect of it, are appropriately investigated and resolved. J.G. and P.I. extracted data from patient's chart, completed data analysis and interpretation of data, prepared figures 1 a through c and tables 1 and 2 and wrote the main manuscript text. References Tan KL (1973) Brachial palsy. J Obstet Gynaecol Br Commonw 80:60–62 Coroneos CJ, Voineskos SH, Coroneos MK et al (2015) Primary nerve repair for obstetrical brachial plexus injury: A meta-analysis. Plast Reconstr Surg 136:765–779. 10.1097/PRS.0000000000001629 Foad SL, Mehlman CT, Ying J (2008) The epidemiology of neonatal brachial plexus palsy in the United States. J Bone Jt Surg - Ser A 90:1258–1264. 10.2106/JBJS.G.00853 Pondaag W, Malessy MJA, Van Dijk JG, Thomeer RTWM (2004) Natural history of obstetric brachial plexus palsy: A systematic review. Dev Med Child Neurol 46:138–144. 10.1017/S0012162204000258 Coroneos CJ, Voineskos SH, Christakis MK et al (2017) Obstetrical brachial plexus injury (OBPI): Canada’s national clinical practice guideline. BMJ Open 7:e014141. 10.1136/bmjopen-2016-014141 Ho ES, Curtis CG, Clarke HM (2015) Pain in Children following microsurgical reconstruction for obstetrical brachial plexus palsy. J Hand Surg Am 40:1177–1183. 10.1016/j.jhsa.2015.02.003 Bruxelle J, Travers V, Thiebaut JB (1988) Occurrence and treatment of pain after brachial plexus injury. Clin Orthop Relat Res 237:87–95. 10.1097/00003086-198812000-00013 Bertelli JA, Ghizoni MF, Loure Iro Chaves DP (2011) Sensory disturbances and pain complaints after brachial plexus root injury: A prospective study involving 150 adult patients. Microsurgery 31:93–97. 10.1002/micr.20832 Spaargaren E, Ahmed J, Van Ouwerkerk WJR, De Groot V, Beckerman H (2011) Aspects of activities and participation of 7–8 year-old children with an obstetric brachial plexus injury. Eur J Paediatr Neurol 15:345–352. 10.1016/j.ejpn.2011.03.008 Jacob E, Mack AK, Savedra M, Van Cleve L, Wilkie DJ (2014) Adolescent pediatric pain tool for multidimensional measurement of pain in children and adolescents. Pain Manag Nurs 15:694–706. 10.1016/j.pmn.2013.03.002 Neu CM, Rauch F, Rittweger J, Manz F, Schoenau E (2002) Influence of puberty on muscle development at the forearm. Am J Physiol - Endocrinol Metab 283:103–107. 10.1152/ajpendo.00445.2001 Coroneos CJ, Maizlin ZV, Dematteo C, Gjertsen D, Bain JR (2015) Popeye muscle’ morphology in OBPI elbow flexion contracture. J Plast Surg Hand Surg 49:327–332. 10.3109/2000656X.2015.1049543 Kang PB (2007) : Pediatric nerve conduction studies and EMG. In: The Clinical Neurophysiology Primer. 369–89.10.1007/978-1-59745-271-7_22 Domkundwar S, Autkar G, Khadilkar SV, Virarkar M (2017) Ultrasound and EMG–NCV study (electromyography and nerve conduction velocity) correlation in diagnosis of nerve pathologies. J Ultrasound 20:111–122. 10.1007/s40477-016-0232-3 Costales JR, Socolovsky M, Sánchez Lázaro JA, Costales DR (2019) Peripheral nerve injuries in the pediatric population: a review of the literature. Part II: entrapment neuropathies. Child’s Nerv Syst 35:37–45. 10.1007/s00381-018-3975-7 Additional Declarations Competing interest reported. Disclosures include J.R.B. is a medical consultant for Epineuron. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3842970","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":266073421,"identity":"0f7fae85-dc95-4c20-9956-67a5474abc01","order_by":0,"name":"Jessica Gormley","email":"data:image/png;base64,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","orcid":"","institution":"McMaster University","correspondingAuthor":true,"prefix":"","firstName":"Jessica","middleName":"","lastName":"Gormley","suffix":""},{"id":266073422,"identity":"dcec5663-f5ed-4b79-a0ab-37c079c8a0d2","order_by":1,"name":"Pavlo Isak","email":"","orcid":"","institution":"McMaster University","correspondingAuthor":false,"prefix":"","firstName":"Pavlo","middleName":"","lastName":"Isak","suffix":""},{"id":266073423,"identity":"0083f4c4-9a77-4e2e-a49e-0e3270b59e9b","order_by":2,"name":"Deborah Gjertsen","email":"","orcid":"","institution":"McMaster Children’s Hospital, McMaster University","correspondingAuthor":false,"prefix":"","firstName":"Deborah","middleName":"","lastName":"Gjertsen","suffix":""},{"id":266073424,"identity":"979b0f24-295f-4b46-9482-221b8358fd41","order_by":3,"name":"James R Bain","email":"","orcid":"","institution":"McMaster University","correspondingAuthor":false,"prefix":"","firstName":"James","middleName":"R","lastName":"Bain","suffix":""}],"badges":[],"createdAt":"2024-01-07 16:14:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3842970/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3842970/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00381-024-06348-1","type":"published","date":"2024-03-08T15:01:12+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":49491195,"identity":"1b709718-3da4-4efd-a6c3-da36fe1f5eeb","added_by":"auto","created_at":"2024-01-11 18:20:35","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":12460833,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ea\u003c/strong\u003eIntra-operative photograph prior to right median and AIN decompression\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eb\u003c/strong\u003e Intra-operative photograph prior to right median and AIN decompression\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ec\u003c/strong\u003e Intra-operative photograph after right median and AIN decompression\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-3842970/v1/5362f90182274cb0254cd838.png"},{"id":52432248,"identity":"b9ab2be8-786c-4ba4-acef-a2042ec032f7","added_by":"auto","created_at":"2024-03-11 15:11:39","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1188953,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3842970/v1/a90058bc-6ba8-4204-b851-dd1e27f4167e.pdf"}],"financialInterests":"Competing interest reported. Disclosures include J.R.B. is a medical consultant for Epineuron. No product use, conflict of interest, promotion of products or involvement in this publication.","formattedTitle":"Peripheral Nerve Decompression for Pain Relief in the Setting of Previous Obstetrical Brachial Plexus Injury: A Retrospective Case Series","fulltext":[{"header":"Introduction","content":"\u003cp\u003eObstetrical brachial plexus injury (OBPI) is a neurological injury sustained during labour and delivery resulting in unilateral deficits of the affected limb.[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] The incidence lies between 1.6 and 2.6 per 1000 live births, with common risk factors being shoulder dystocia, macrosomia and comorbid birthing trauma.[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] The large majority of OBPIs are transient but surgical reconstruction is indicated for root avulsions and injury patterns with a low likelihood of spontaneous recovery.[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] Despite extensive research into the initial management of these injuries, there is limited evidence to support long-term evaluation and management in this patient population.[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] For this reason, chronic pain following OBPI remains poorly understood, controversial, and vastly under-recognized.\u003c/p\u003e \u003cp\u003eIn adults who suffer traumatic brachial plexus injury similar to OBPI, debilitating neuropathic and chronic pain is well documented in the literature.[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] However, the pediatric population experiences and expresses pain differently, and consideration for these differences is required to obtain accurate information in this group.[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] Previous studies have demonstrated the incidence of upper extremity pain in this population ranges from 45 to 66% throughout childhood, with the typical presentation being frequent, episodic and of low-to-moderate intensity.[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] However, some patients encounter severe pain that limits their functional abilities.[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] When assessing the quality of pain in these children, the characterization is consistent with musculoskeletal and neuropathic pain patterns.[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] A recent study by Ho et al. reported 21 descriptions used by this population that were suggestive of a neuropathic origin, such as \u0026ldquo;tingling,\u0026rdquo; \u0026ldquo;pins and needles,\u0026rdquo; \u0026ldquo;asleep,\u0026rdquo; \u0026ldquo;numbness,\u0026rdquo; \u0026ldquo;twitches\u0026rdquo; and \u0026ldquo;shooting pain.\u0026rdquo;[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] Because studies have only begun to understand the nature of pain in this cohort of patients, a detailed recommendation for optimal management has yet to be determined.\u003c/p\u003e \u003cp\u003eThe aim of our retrospective study is to demonstrate that peripheral nerve decompression and neurolysis may be an effective treatment for patients with upper extremity pain in the context of previous OBPI. The secondary outcome measure is range of motion of the wrist and elbow in the affected limb pre- and post-operatively.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatient Population\u003c/h2\u003e \u003cp\u003eA retrospective chart review was performed on patients undergoing peripheral nerve decompression and neurolysis after OBPI by the senior author between September 2014 and October 2019. This study was approved by the institution\u0026rsquo;s research ethics board before initiation. The study included all patients within this time frame presenting with neuropathic symptoms consistent with a peripheral nerve distribution that required decompression, in the context of previous OBPI. Nerve compression was confirmed with ultrasonography (US) or electromyography with nerve conduction velocity (EMG-NCV) before the time of operation. Patients were excluded if there was inadequate reporting of pre- and post-operative pain or range of motion, as outcome measures were unable to be assessed. There were six patients who met the inclusion criteria of this study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eObjectives\u003c/h2\u003e \u003cp\u003eThe primary outcome measure of the study is upper extremity pain before and after peripheral nerve decompression and neurolysis. Pain scores were reported by patients subjectively both descriptively and using a 10-point scale pre- and post-operatively and assessed clinically using Tinel\u0026rsquo;s sign over the affected nerve. The secondary outcome was pre and post-operative range of motion of the wrist and elbow. Outcome scores for range of motion were assigned using the Active Movement Scale (AMS), which ranges from a grade of 0 to 7 based on range of motion with or without the force of gravity. Clinical assessment of outcome measures was completed at their pre-operative clinic visit as well as at their two-week post-operative and subsequent follow-up.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eOur analysis and results are presented in a descriptive fashion. For categorical data we used frequencies and percentages. For continuous data we used means with standard deviation and range.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eOperative Technique\u003c/h2\u003e \u003cp\u003eAll patients were placed on the operating table in supine position, and a tourniquet was placed on the affected extremity distal to the axilla. After the induction of general anesthetic, the limb was exsanguinated, and the tourniquet was inflated.\u003c/p\u003e \u003cp\u003eFor patients undergoing median nerve decompression, a curvilinear incision along the proximal volar forearm was made. A tight lacterus fibrosis was identified and divided in all cases, ensuring adequate protection of the biceps tendon, brachial artery and cephalic vein. Pronator teres was identified and released if found to be compressive. The median nerve was identified and circumferential neurolysis was performed from the distal arm to proximal forearm for complete decompression. In the patients that required concomitant anterior interosseous nerve (AIN) decompression, the AIN was identified distally, and fasciotomy of the overlying tissue was completed.\u003c/p\u003e \u003cp\u003eFor patients undergoing ulnar nerve decompression, an incision between the medial epicondyle and olecranon was made. Once the ulnar nerve was identified through dissection, fascial release of identifiable compressive forces including triceps fascia, medial intermuscular septum, medial antebrachial fascia and fascial bands of the flexor carpi ulnaris (FCU) was completed. Circumferential neurolysis and transposition of the ulnar nerve was performed.\u003c/p\u003e \u003cp\u003eFinally, for the patient undergoing posterior interosseous nerve (PIN) decompression an incision was made in the interval between brachioradialis and extensor carpi radialis longus (ECRL). A fasciotomy between these two muscles was completed and deep in this interval the PIN was identified. Fascial release of the compressive ECRB and supinator muscles was performed until adequate decompression both proximally and distally was achieved.\u003c/p\u003e \u003cp\u003eIn all cases, the affected arm\u0026rsquo;s passive range of motion of the elbow and wrist was assessed intra-operatively. Once hemostasis was achieved, a two-layer closure of the wound was completed. The incision was dressed appropriately, and follow-up was scheduled for two-weeks postoperatively.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003ePatient Characteristics\u003c/h2\u003e \u003cp\u003eThere were six patients who met the inclusion criteria of this study, with all six patients being female (100.0%). In four of the six cases (66.7%) the left upper extremity was affected, with the remaining two being the right upper extremity. In terms of the initial management of their OBPI, two cases were non-operative (33.3%). For those who required operative management, two patients had their initial operation at 6-months of age, one patient at 52-months, and one patient\u0026rsquo;s age was not recorded. The details of their initial management, as well as additional procedures required, can be found in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatient demographics of initial management for OBPI\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient Number\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAffected side\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAge at time of first operation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eInitial Management of OBPI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAdditional Procedures\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLeft\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eC5-6 neuroma excision with NG, C7 neurolysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePronator teres tendon transfer to ECRB\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNot applicable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNon-operative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLeft\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 years 4 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOberlin transfer: ulnar motor fascicles FCU to musculocutaneous motor fascicles of biceps brachii\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNot applicable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNon-operative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBotox injection for muscle contracture\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLeft\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNot recorded\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eBrachial plexus reconstruction, specific technique not recorded\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eFree muscle transfer gracilis to FPL/FDP and tenolysis of adhesions\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLeft\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eC5-C6 neurolysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eNG; nerve graft, ECRB; extensor carpi radialis brevis, FCU; flexor carpi ulnaris, FPL; flexor pollicis longus, FDP; flexor digitorum profundus.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eWith respect to the decompression and neurolysis procedure, the mean age at the time of operation was 14 years old (SD 2.76, range 9\u0026ndash;16). Three patients (50.0%) required median nerve decompression, with two of the three undergoing concomitant AIN decompression, two patients (33.3%) required ulnar nerve decompression and transposition, and one patient (16.7%) underwent PIN decompression. The details of patient demographics and management can be found in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatient demographics and outcome measures for peripheral nerve decompression\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient Number\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSite of decompression\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSubjective Pain (pre)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSubjective Pain (post)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAMS grade (pre)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eAMS grade (post)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLeft median nerve\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSignificant pain in forearm;\u003c/p\u003e \u003cp\u003ePain on pronation and flexion;\u003c/p\u003e \u003cp\u003ePositive Tinel.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSignificant improvement in pain;\u003c/p\u003e \u003cp\u003eTinel NR.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eWrist ext: 3\u003c/p\u003e \u003cp\u003eElbow ext: 5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eWrist ext: 5\u003c/p\u003e \u003cp\u003eElbow ext: 6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRight posterior interosseous nerve\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSignificant pain at elbow and forearm (5\u0026ndash;7/10);\u003c/p\u003e \u003cp\u003ePain on pronation;\u003c/p\u003e \u003cp\u003eUncomfortable paresthesia;\u003c/p\u003e \u003cp\u003ePositive Tinel.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eResolution of pain;\u003c/p\u003e \u003cp\u003eResolution of paresthesia;\u003c/p\u003e \u003cp\u003eNegative Tinel.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eElbow ext: 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eElbow ext: 5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLeft ulnar nerve\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSignificant pain at elbow;\u003c/p\u003e \u003cp\u003eUncomfortable paresthesia;\u003c/p\u003e \u003cp\u003ePositive Tinel.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSignificant improvement in pain (3\u0026ndash;4/10);\u003c/p\u003e \u003cp\u003eSignificant improvement of paresthesia; \u003c/p\u003e \u003cp\u003eTinel NR.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eWrist ext: 4\u003c/p\u003e \u003cp\u003eElbow ext: 5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eWrist ext: 5\u003c/p\u003e \u003cp\u003eElbow extension: 6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRight median and anterior interosseous nerve\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSignificant pain in forearm and wrist;\u003c/p\u003e \u003cp\u003ePain with carrying;\u003c/p\u003e \u003cp\u003eUncomfortable paresthesia;\u003c/p\u003e \u003cp\u003ePositive Tinel.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSignificant improvement in pain;\u003c/p\u003e \u003cp\u003eNegative Tinel.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eWrist flex: 6\u003c/p\u003e \u003cp\u003eElbow ext: 6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eWrist flex: 6\u003c/p\u003e \u003cp\u003eElbow ext: 6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLeft ulnar nerve\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSignificant pain at elbow;\u003c/p\u003e \u003cp\u003eUncomfortable paresthesia;\u003c/p\u003e \u003cp\u003ePositive Tinel.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eResolution of pain;\u003c/p\u003e \u003cp\u003eSignificant improvement of paresthesia;\u003c/p\u003e \u003cp\u003eTinel NR.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eNR\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLeft median and anterior interosseous nerve\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eSignificant pain in forearm (7/10);\u003c/p\u003e \u003cp\u003eUncomfortable paresthesia;\u003c/p\u003e \u003cp\u003ePositive Tinel.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eResolution of pain; \u003c/p\u003e \u003cp\u003eResolution of paresthesia;\u003c/p\u003e \u003cp\u003eTinel NR.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eElbow ext: 6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eAMS; active movement scale, NR; not recorded, ext; extension, flex; flexion.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003ePain Scores\u003c/h2\u003e \u003cp\u003eAll six patients reported significant pain in their extremity pre-operatively and five patients reported uncomfortable paraesthesia. Post-operatively all patients reported significant improvement or resolution of their pain (6/6, 100%) and paresthesia (5/5, 100%). In the two patients that reported pre-operative pain scores using a 10-point scale, the mean score was 6.5 (SD 0.7, range 6\u0026ndash;7). In both of these patients, complete resolution of pain was reported. All six patients had a positive Tinel\u0026rsquo;s sign pre-operatively, with two patients (33.3%) reported to have a negative Tinel\u0026rsquo;s post-operatively and in four patients (66.7%) assessment of Tinel\u0026rsquo;s sign was not recorded after their operation. Additional details on pain scores can be found in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section3\"\u003e \u003ch2\u003eRange of Motion\u003c/h2\u003e \u003cp\u003eThe mean pre-operative AMS grade for the wrist and elbow was 4.3 (SD 1.5, range 3\u0026ndash;6) and 4.5 (SD 1.7, range 2\u0026ndash;6) respectively. The mean post-operative AMS grade for the wrist was 5.3 (SD 0.6, range 5\u0026ndash;6) and elbow was 5.8 (SD 0.4, range 5\u0026ndash;6). The mean improvement across patients in wrist and elbow AMS was 1 (SD 1.0, range 0\u0026ndash;2) and 1.25 (SD 1.3, range 0\u0026ndash;3) respectively. The detailed breakdown of AMS grading for each patient can be found in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eIntraoperative Findings\u003c/h2\u003e \u003cp\u003eIntra-operative findings of tight and fibrotic changes in fascia and overlying muscle were consistent across all patients. In the three patients undergoing median nerve decompression, a tight lacterus fibrosis was identified. For the single patient undergoing PIN decompression, a tight and fibrotic supinator was identified. Finally, for the two patients undergoing ulnar nerve decompression and transposition the pathologic changes were variable, demonstrating thickened triceps fascia, medial intermuscular septum, FCU fascial bands and medial antebrachial fascia. Intraoperative photographs were taken for one patient undergoing right median and AIN decompression (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e1\u003c/span\u003eA-C).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe patients involved in this study represent the diverse nature of OBPI, with variable severity of presentation, pathology and initial management. All patients were initially treated according to the current OBPI clinical guidelines and continued to be followed for routine assessment of function.[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] All six patients presented with a new complaint of neuropathic pain in a distinct peripheral nerve distribution, with a positive Tinel\u0026rsquo;s sign over the site of maximal compression, with confirmation on imaging or EMG. Overall there was a substantial improvement in pain post-operatively, which was demonstrated by a reduction in subjective reports of pain in all patients and resolution of Tinel\u0026rsquo;s sign when assessed post-operatively. There was a modest improvement in range of motion, with a mean improvement of the AMS grade by 1 and 1.25 for the wrist and elbow respectively. The improvement in range of motion of the elbow is likely secondary to pain relief and removal of fibrotic tissue enabling greater mobility in the affected extremity. The site of decompression in all cases was distal to the innervation of the common extensors and flexors of the elbow, and therefore the improved mobility would not be secondary to increased motor unit recruitment.\u003c/p\u003e \u003cp\u003eThe onset of symptoms of peripheral neuropathy in this population occurred during the pubertal growth spurt period, with the mean age being 14 years old (range 9\u0026ndash;16). During this time, one would expect accelerated growth of musculoskeletal structures.[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] However, in patients with previous OBPI, deficiencies in musculotendinous growth from fibrotic changes to the affected extremity have been observed secondary to their primary plexopathy.[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] These pathologic changes in growth can lead to compression of the peripheral nerves with worsening symptomology as the patient continues to grow. Intra-operative findings of fibrotic changes were consistent across all patients, with the site of pathologic changes varying based on the peripheral nerve affected. In all patients undergoing median nerve decompression, a tight lacterus fibrosis was identified and divided. For the single patient undergoing PIN decompression, a tight, pale and fibrotic supinator was identified and released. Finally, for those undergoing ulnar nerve decompression and transposition, the pathologic changes varied widely and fascial release of any identifiable compressive forces (ie. triceps fascia, medial intermuscular septum, medial antebrachial fascia or fascial bands of the flexor carpi ulnaris) was completed.\u003c/p\u003e \u003cp\u003eThis study demonstrates that in patients with previous OBPI not all symptoms originate from their initial injury and that secondary insult may occur. Identifying a new onset of musculoskeletal or neuropathic pain in the pediatric population continues to be an issue, as the expression of pain is different and far less supported in the literature.[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] This challenge is worsened in the context of OBPI where residual deficits of the affected extremity may be present.[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] When a patient is presenting with a new symptom complex, a detailed history and physical examination should be completed, and diagnostic tests can be used to confirm the underlying pathology once localized. US or EMG-NCV can be used for diagnosis in the context of focal peripheral nerve deficits, based on availability of resources and patient tolerance for EMG-NCV.[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] The patients involved in this study were identified through follow-up assessment which further highlights the need for serial visits throughout the entire childhood from a multi-disciplinary team including both a physiotherapist and peripheral nerve surgeon.[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] Compression neuropathies are exceedingly rare in the general pediatric population and continue to remain under-recognized but follow-up by specialists in the field allow for greater recognition of new symptomology and identification of underlying issues for this population.[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] Early recognition of peripheral neuropathy in our study allowed for improvement in pain and function from their baseline in all patients.\u003c/p\u003e \u003cp\u003eLimitations of this study include the lack of a control group, small sample size and poor availability of data. Given the retrospective nature of this study, we were only able to report information on pain and range of motion from data recorded in the patient\u0026rsquo;s medical chart. All patients had subjective reports of pain, but few reported pre- and post-operative scores using a validated scale, which limited our ability for a pooled analysis and introduced availability bias. Future research should focus on improving recognition of peripheral neuropathy as a source of pain in this patient population through serial visits to a multidisciplinary clinic. To improve the strength of conclusions that are able to be drawn on this topic, a large-scale prospective study on decompression and neurolysis for peripheral neuropathy in the context of OBPI should be completed using validated scales across all participants.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study identifies compressive peripheral neuropathy as a source of pain in patients with previous OBPI and demonstrates a significant improvement in subjective pain and moderate improvement in range of motion after decompression and neurolysis. Appropriate identification of this pathology through routine follow-up with a multidisciplinary clinic, thorough clinical examinations and appropriate diagnostic tests allows for early recognition and symptom relief in this cohort of patients. Future research should focus on assessment and treatment of peripheral neuropathy in the context of previous OBPI for pain management on a larger scale.\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of Conflicting Interests:\u003c/strong\u003e Disclosures include J.R.B. is a medical consultant for Epineuron. No product use, conflict of interest, promotion of products or involvement in this publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was performed in line with the principles of the Declaration of Helsinki. This study was approved by the Hamilton Integrated Research Ethics Board (HIREB) before initiation (2020-12818-C).\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAll authors contribute to conception and design of the study, completed critical manuscript revisions for important intellectual content, provided final approval of the version to be published and agreed to act as guarantor of the work to ensure that questions regarding any aspect of it, are appropriately investigated and resolved. J.G. and P.I. extracted data from patient's chart, completed data analysis and interpretation of data, prepared figures 1 a through c and tables 1 and 2 and wrote the main manuscript text.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eTan KL (1973) Brachial palsy. J Obstet Gynaecol Br Commonw 80:60\u0026ndash;62\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCoroneos CJ, Voineskos SH, Coroneos MK et al (2015) Primary nerve repair for obstetrical brachial plexus injury: A meta-analysis. Plast Reconstr Surg 136:765\u0026ndash;779. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/PRS.0000000000001629\u003c/span\u003e\u003cspan address=\"10.1097/PRS.0000000000001629\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFoad SL, Mehlman CT, Ying J (2008) The epidemiology of neonatal brachial plexus palsy in the United States. 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Child\u0026rsquo;s Nerv Syst 35:37\u0026ndash;45. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00381-018-3975-7\u003c/span\u003e\u003cspan address=\"10.1007/s00381-018-3975-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"childs-nervous-system","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"cnsy","sideBox":"Learn more about [Child's Nervous System](http://link.springer.com/journal/381)","snPcode":"381","submissionUrl":"https://submission.nature.com/new-submission/381/3","title":"Child's Nervous System","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Brachial plexus, Pain, Peripheral nerves, Decompression, surgical","lastPublishedDoi":"10.21203/rs.3.rs-3842970/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3842970/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eIn children with previous obstetrical brachial plexus injury (OBPI) upper extremity pain is present in 45 to 66% of patients. Recent literature reports this as musculoskeletal or neuropathic in nature. The purpose of the study is to demonstrate that peripheral nerve decompression and neurolysis may be an effective treatment for patients with upper extremity pain in the context of previous OBPI.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA retrospective chart review was performed on patients undergoing peripheral nerve decompression and neurolysis after OBPI by senior author. The primary outcome assessed was pain and secondary outcome measure was range of motion of the wrist and elbow. Outcome measures were assessed preoperatively as well as at their subsequent follow-up.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eSix patients were included, with a mean age of 14 years old at time of decompression. Three patients underwent median nerve, two patients underwent ulnar nerve and one patient underwent posterior interosseous nerve decompression. There was a substantial improvement in pain post-operatively, demonstrated by reduction or resolution of subjective pain in all patients and resolution of Tinel\u0026rsquo;s sign. There was a modest improvement in range of motion.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThis study demonstrates an improvement in subjective pain and range of motion after decompression and neurolysis in OBPI patients with peripheral neuropathy. Appropriate identification of this pathology through routine follow-up with a multidisciplinary clinic allows for early recognition and symptom relief. Future research should focus on assessment and treatment of pain in this population on a larger scale.\u003c/p\u003e","manuscriptTitle":"Peripheral Nerve Decompression for Pain Relief in the Setting of Previous Obstetrical Brachial Plexus Injury: A Retrospective Case Series","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-01-11 18:20:31","doi":"10.21203/rs.3.rs-3842970/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-01-23T17:14:05+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-01-19T23:25:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"ee10d3e1-afde-4bc7-8105-72a968b0655f","date":"2024-01-17T21:33:09+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-01-17T16:43:57+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-01-09T09:58:10+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-01-09T09:58:10+00:00","index":"","fulltext":""},{"type":"submitted","content":"Child's Nervous System","date":"2024-01-07T16:12:46+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"childs-nervous-system","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"cnsy","sideBox":"Learn more about [Child's Nervous System](http://link.springer.com/journal/381)","snPcode":"381","submissionUrl":"https://submission.nature.com/new-submission/381/3","title":"Child's Nervous System","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"46910a64-7d9e-42e6-8b38-5e43dbbed244","owner":[],"postedDate":"January 11th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-03-11T15:09:00+00:00","versionOfRecord":{"articleIdentity":"rs-3842970","link":"https://doi.org/10.1007/s00381-024-06348-1","journal":{"identity":"childs-nervous-system","isVorOnly":false,"title":"Child's Nervous System"},"publishedOn":"2024-03-08 15:01:12","publishedOnDateReadable":"March 8th, 2024"},"versionCreatedAt":"2024-01-11 18:20:31","video":"","vorDoi":"10.1007/s00381-024-06348-1","vorDoiUrl":"https://doi.org/10.1007/s00381-024-06348-1","workflowStages":[]},"version":"v1","identity":"rs-3842970","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3842970","identity":"rs-3842970","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}