William, french 1 month old baby

[pmali]

Hi,

our baby William was born on 1st of December in the south east of France. It was quite clear that his right arm was paralysed following the delivery (the legs came first, normally a cesarean surgery was planned but the baby came two month earlier than expected).
I venture to ask some questions there because it is probably one of the most accurate forum about BP injury.

HIs shoulder and biceps are paralyzed, whereas triceps, wrist, and fingers work very well. So I guess C5-C6 are affected.

My question is: is there some possibility at that point to guess if it is only C5-C6 stretching/damage or C5-C6 avulsion?

My main fear is C5-C6 avulsion (more difficult to treat even by surgery).
Could we ask for a NMR diagnosis (to detect pseudomeningocele around C5-C6) or a electromyogram around 3 months of age?
Or do we have just to wait for his 3 months old to see if his elbow will bent?

Sorry for my poor english. Hope you could help us. We are quite stressed about the outcome of his paralysis.
But we know it will be quite a long process (and fight)
Physiotherapy will start next week.

Thanks again for your help

Pierre and Cecile

[katep]

I am sorry you had to find this forum, but glad that you are not in the dark about your son's injury. His presentation of symptoms sounds a little odd for a breech birth. Could there have been other trauma involved other than just during the delivery? (Ie, did they try to reposition him or anything like that prior to delivery)? Was his whole arm paralyzed at first, or just his shoulder and biceps? When did he regain triceps, wrist and finger function? I ask because usually, breech delivery trauma puts the most strain on the lower roots with the upper roots getting the least. The recovery of the other roots often gives a lot of clues about the level of trauma experienced over all. But if something else caused the trauma, then those assumptions may not apply.

Regarding his C5 and C6. Even if those roots are severely damaged, it is very uncommon for the C5 and C6 roots to be avulsed. The worst case is that they tear all the way through, but the rupture usually happens a distance away from the spinal cord, and can be repaired with grafting if necessary. That is because C5 and C6 typically have additional tissue that anchors them to the spine that protect the nerve roots and keep them from being pulled out of the spinal cord. The lower roots, C8 and T1, are more prone to being avulsed because they don't normally have this extra protection. In your son's case, I wouldn't expect that C5 and C6 sustained this sort of maximum damage, because the other roots appear to be relatively unaffected. With the way the geometry of the plexus is, the level of strain experienced by each of the nerve roots is usually proportional. With regular head-first deliveries, the upper roots get the most stretch while the lower ones the least, and it is reversed with a breech delivery. Since William's lower roots don't seem to have been that heavily stretched at all, the odds are fairly good that his upper roots are not that badly damaged.

Depending on the doctor, they might want an MRI but I doubt most would request one. I think with upper root avulsion being so unlikely in his case, they would probably just wait for the biceps to recover and, if not, do surgery and grafting. It is still early, but I would make sure you get him in to see someone who is capable of doing brachial plexus nerve surgery. I do think (and hope and pray) that it won't be necessary.

Kate

[pmali]

Dear Kate,

your reply is very interesting. Adtually, his wrist and fingers did not work properly just after the delivery but went it back just in a few days.
Concerning the breech delivery, It is also very interesting. Because I thought that C5-C6 were not protected by this additional tissue during breech deliveries, compared to head-first delivery. That's why C5-C6 are generally more avulsed during breech deliveries: could you confirm?
All I know is the obstetrician had to move the head at the end of the delivery. I was there but did not observed it.. Benjamin also suffered from oligoamnios, and the obstetrician hypothetized also his arm could have a bad (stretched) position during pregnancy.

Anyway I have to ask a detailed report about the delivery. We have specialized surgeons here in baby graft nerves, especially in Paris. I have to look into.

thanks a lot!

[Judy-T]

You have one of the most excellent doctors in Paris that deals with this injury. He is world reknown for his research. Here is the link: http://ubpn.org/index.php?option=com_ph ... 117&id=224
He is a very nice man , I met him at a conference years ago.
Judy OBPI 49

[katep]

I double checked and I'm so sorry.. you are correct. Breech babies, especially low birth weight breech babies, appear to have much higher odds of avulsion of the upper roots, at least as reported by a 1996 paper by Dr. Alain Gilbert in Paris:

http://web.jbjs.org.uk/cgi/reprint/78-B/2/303

The main conclusion I saw in the article was that surgery should be considered quickly if upper root avulsion is suspected. Dr. Gilbert is there at the Institut Français de la Main, and is really the pioneer of nerve surgery in this century, and while this paper does sound somewhat bleak it is almost 15 years old which is a long time with these surgeries. Advancements are being made all the time, and Gilbert is definitely part of that. It would be good if you could get your son in to see him quickly.

Kate

[katep]

Here also is a 2004 paper detailing surgical results on children who were breech deliveries with upper root lesions (mostly avulsions). There seems to be good prospects for nerve transfers (neurotization) to animate the shoulder and help return function. This paper also references another of Gilbert's which says that sometimes "partial avulsion" occurs with some recovery in up to 50% of cases. Then selective nerve transfers could be used later to reinnervate muscles that were missed by the initial recovery. I personally know of a child who had a very unique injury, with complete paralysis of his triceps (possible C7 avulsion) but otherwise good recovery of all other muscle groups, who had one of these selective nerve transfer to his triceps at almost three years old and had good results. There is good reason to hope, even if your son's upper roots are avulsed.

Kate

[pmali]

thanks for your help.
you're right, Pr Gilbert is excellent but Dr Romana (hopital Trousseau, Paris) seems also to be excellent (she was a student of Pr Gilbert) and makes surgeries quite all over the world. Do you know her?

[katep]

I don't know her. Although I've met Dr. Gilbert and corresponded via email, I wouldn't say I "know" him, either. But I'm definitely impressed with his depth and breadth of experience in treating brachial plexus injuries. If this were my child, I know I would want the most experienced person treating him, if everything else was equal. Brachial plexus injuries requiring nerve operations are themselves rare. Out of that group, breech deliveries are rare. Breech injuries with upper root avulsions are thus so rare, my feeling would be that the more cases a surgeon has seen and the more nerve transfers in these cases that surgeon has done, the better. That's just my gut feeling. Though, to be honest, I'm sure most surgeons who perform the entire range of brachial plexus nerve surgery would be capable of doing the latest, most successful nerve transfers for upper root avulsions. I would just want to be absolutely sure that they attended the big conferences and symposia on brachial plexus injuries and were following the latest developments closely, so that my child would get the benefit of all the available knowledge. I'm sure Dr. Romana does that.

Kate

[marieke]

I just wanted to say hi, and welcome. I speak French, am bilingual, so if you ever want to write in French feel free

I too was born breech and 3 months premature. My hand/writs/fingers work perfectly well, but have no hand-to-mouth, and am lacking in forward flexion and have little active external rotation. This may sound discouraging, but every baby is different and it has not stopped me from doing things.

I played clarinet in high school, was a competitive figure skater, did ballet, swam and rode my bike! I became a nurse a few years ago and love it.

J'espere que Benjamin va recouvrire plus et que les medecins peuvent l'aide le plus tot possible! Je n'ais pas eu des chirurgis quand j'etais bebe (il y a 35 ans!) mais j'ai eu une a l'age de 14 ans seulement qui m'a redonne plus de fonction

[pmali]

thanks a lot!

do you know any more articles about the degree of recovery following c5-c6 avulsion???

Pierre