Waters P M
Department of Orthopaedic Surgery, Children's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA.
J Bone Joint Surg Am. 1999 May;81(5):649-59. doi: 10.2106/00004623-199905000-00006.
The purposes of this study were to document the natural history of brachial plexus birth palsy, in relation to the recovery of biceps function, in the first six months of life; to assess the outcome after microsurgical repair of the brachial plexus in patients who had no recovery of biceps function at six months; and to compare the results of transfer of the latissimus dorsi and teres major tendons with the results of derotation osteotomy of the humerus and to compare the results of the tendon transfers and the osteotomy with the natural history of the disorder.
Sixty-six patients (sixty-seven lesions) who had brachial plexus birth palsy were seen for an initial evaluation when they were less than three months old. The time of recovery of biceps function was recorded for each month of life for six months from the date of birth. The patients were divided into groups according to the month of life during which recovery of biceps strength was noted. A physical examination and an assessment with use of the functional criteria of Mallet were performed each month. Microsurgical repair of the brachial plexus was performed in six infants who had no evidence of biceps function within the first six months of life. Another group of twenty-seven patients were referred for evaluation of chronic neuropathy after they were six months old. A transfer of the latissimus dorsi and teres major tendons to the rotator cuff was performed in nine of these patients and a derotation osteotomy of the humerus was performed in seven because of an internal rotation contracture or functional weakness of the external rotators of the shoulder.
Twenty-two infants had recovery of biceps function within the first three months of life and had normal function at the time of the latest evaluation. Infants who had recovery of biceps function during the fourth, fifth, or sixth month of life later had significantly worse function, according to the criteria described by Mallet, than those who had had recovery in the first three months (p<0.005). The clinical results for the six patients who had had microsurgical repair six months after birth were significantly better (p<0.04) than those for the fifteen patients who had had recovery of biceps function in the fifth month of life. However, the results for the patients who had had repair of the brachial plexus were not found to be better than those for the eleven patients who had had recovery of biceps function in the fourth month of life. The improvement in function, as assessed with use of the Mallet criteria, after tendon transfer (p<0.001) and humeral osteotomy (p<0.0001) was significant.
The present study confirms the observation of Gilbert and Tassin that it is rare for infants who have recovery of biceps function after the age of three months to have complete neurological recovery. Microsurgical repair was effective in improving function in the small subgroup of patients who had no evidence of recovery of biceps function within the first six months of life.
本研究的目的是记录出生后六个月内臂丛神经产瘫的自然病程，及其与肱二头肌功能恢复的关系；评估六个月时肱二头肌功能未恢复的患者接受臂丛神经显微外科修复后的疗效；比较背阔肌和大圆肌腱转移与肱骨旋转截骨术的结果，并将肌腱转移和截骨术的结果与该疾病的自然病程进行比较。
66例（67处损伤）臂丛神经产瘫患者在三个月龄以内接受了初次评估。从出生之日起，记录六个月内每月肱二头肌功能的恢复时间。根据记录到肱二头肌力量恢复的月龄将患者分组。每月进行体格检查并采用马利特功能标准进行评估。对出生后头六个月内无肱二头肌功能迹象的6例婴儿实施了臂丛神经显微外科修复。另一组27例患者在六个月龄后因慢性神经病变前来接受评估。其中9例患者接受了背阔肌和大圆肌腱向肩袖的转移术，7例因肩内旋挛缩或肩外旋肌功能薄弱接受了肱骨旋转截骨术。
22例婴儿在出生后的头三个月内肱二头肌功能恢复，且在最近一次评估时功能正常。根据马利特标准，在出生后第四、五或六个月内肱二头肌功能恢复的婴儿，其功能明显差于在头三个月内恢复的婴儿（p<0.005）。出生后六个月接受显微外科修复的6例患者的临床结果明显优于在出生后第五个月肱二头肌功能恢复的15例患者（p<0.04）。然而，未发现接受臂丛神经修复的患者的结果优于在出生后第四个月肱二头肌功能恢复的11例患者。根据马利特标准评估，肌腱转移（p<0.001）和肱骨截骨术后（p<0.0001）功能改善显著。
本研究证实了吉尔伯特和塔森的观察结果，即三个月龄后肱二头肌功能恢复的婴儿很少能完全神经功能恢复。显微外科修复对于出生后头六个月内无肱二头肌功能恢复迹象的一小部分患者的功能改善有效。
