Michaud Linda J, Louden Emily J, Lippert William C, Allgier Allison J, Foad Susan L, Mehlman Charles T
Division of Physical Medicine and Rehabilitation, Brachial Plexus Center, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH∗
Division of Pediatric Orthopaedic Surgery, Brachial Plexus Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH†.
PM R. 2014 Dec;6(12):1107-19. doi: 10.1016/j.pmrj.2014.05.002. Epub 2014 May 2.
To evaluate functional outcomes and the impact on surgical interventions after the use of botulinum neurotoxin type A (BoNT-A) for muscle imbalance, cocontractions, or contractures with neonatal brachial plexus palsy.
A retrospective cohort study.
A brachial plexus center in a tertiary children's hospital.
Fifty-nine patients with neonatal brachial plexus palsy (75 injection procedures, 91 muscles and/or muscle groups) received BoNT-A injections (mean age at injection, 36.2 months; range, 6-123 months; 31 boys; 30 right-sided injuries, 28 left-sided injuries, 1 bilateral injury).
Data collected retrospectively from medical records, from procedure notes and clinic visits before BoNT-A use, at ≤6 months follow-up (BoNT-A active [BA]) and at ≥7 months follow-up (BoNT-A not active [BNA]) included demographics, injection indication, side, and site(s), previous surgical history, occupational therapy and/or physical therapy plan, and outcome measurements.
Outcomes assessed before and after injections included active and passive range of motion, Mallet and Toronto scores, parent comments about arm function, preinjection surgical considerations, and postinjection surgical history.
Injection procedures included 51 to shoulder internal rotators, 15 triceps, 15 pronator teres, 9 biceps, and 1 flexor carpi ulnaris. Active and passive shoulder external rotation (SER) range of motion improved after shoulder internal rotator injections (P = .0003 and P = .002, respectively), as did Mallet scores with BA; the latter were sustained with BNA. Surgical intervention was averted, modified, or deferred after BoNT-A in 45% (n = 20) under surgical consideration before BoNT-A. Active elbow flexion improved in 67% (P = .005), sustained BNA (P = .004) after triceps injections; 2 of 7 patients averted surgery. Active supination improved with BA (P = .002), with gains sustained BNA (P = .016). Passive elbow extension improved after biceps injections by an average 17° (P = .004) BA, although not sustained BNA.
BoNT-A is an effective adjunct to therapy and surgery in managing muscle imbalance, cocontractions, and contractures in neonatal brachial plexus palsy. Use of BoNT-A can result in averting, modifying, or deferring surgical interventions in a number of affected children.
评估A型肉毒杆菌毒素（BoNT-A）用于治疗新生儿臂丛神经麻痹的肌肉失衡、共同收缩或挛缩后，其功能结局以及对手术干预的影响。
一项回顾性队列研究。
一家三级儿童医院的臂丛神经中心。
59例新生儿臂丛神经麻痹患者（共进行75次注射操作，涉及91块肌肉和/或肌肉群）接受了BoNT-A注射（注射时的平均年龄为36.2个月；范围为6 - 123个月；31名男孩；30例右侧损伤，28例左侧损伤，1例双侧损伤）。
从病历中回顾性收集的数据，包括BoNT-A使用前的手术记录、操作记录和门诊就诊情况，在≤6个月随访时（BoNT-A起效期[BA]）以及≥7个月随访时（BoNT-A非起效期[BNA]），这些数据包括人口统计学信息、注射指征、部位和位点、既往手术史、职业治疗和/或物理治疗计划以及结局测量指标。
注射前后评估的结局包括主动和被动活动范围、马利特（Mallet）评分和多伦多评分、家长对上肢功能的评价、注射前的手术考量以及注射后的手术史。
注射操作涉及51次注射到肩部内旋肌、15次注射到肱三头肌、15次注射到旋前圆肌、9次注射到肱二头肌以及1次注射到尺侧腕屈肌。肩部内旋肌注射后，主动和被动肩部外旋（SER）活动范围均有所改善（分别为P = 0.0003和P = 0.002），BA期的马利特评分也有所改善；BNA期仍维持改善状态。在BoNT-A注射前考虑手术的患者中，45%（n = 20）的手术干预得以避免、调整或推迟。肱三头肌注射后，67%的患者主动肘关节屈曲得到改善（P = 0.005），BNA期仍维持改善状态（P = 0.004）；7例患者中有2例避免了手术。BA期主动旋后功能得到改善（P = 0.002），BNA期改善程度得以维持（P = 0.016）。肱二头肌注射后，BA期被动肘关节伸展平均改善17°（P = 0.004），但BNA期未维持改善。
BoNT-A是治疗新生儿臂丛神经麻痹肌肉失衡、共同收缩和挛缩的有效治疗和手术辅助手段。使用BoNT-A可使许多受影响儿童避免、调整或推迟手术干预。
