Department of Neurosurgery, University of Michigan, Ann Arbor.
Department of Physical Medicine and Rehabilitation, University of Michigan, Ann Arbor.
JAMA Pediatr. 2018 Jun 1;172(6):585-591. doi: 10.1001/jamapediatrics.2018.0124.
Neonatal brachial plexus palsy (NBPP) can result in persistent deficits for those who develop it. Advances in surgical technique have resulted in the availability of safe, reliable options for treatment. Prevailing paradigms include, "all neonatal brachial plexus palsy recovers," "wait a year to see if recovery occurs," and "don't move the arm." Practicing by these principles places these patients at a disadvantage. Thus, the importance of this review is to provide an update on the management of NBPP to replace old beliefs with new paradigms.
Changes within denervated muscle begin at the moment of injury, but without reinnervation become irreversible 18 to 24 months following denervation. These time-sensitive, irreversible changes are the scientific basis for the recommendations herein for the early management of NBPP and put into question the old paradigms. Early referral has become increasingly important because improved outcomes can be achieved using new management algorithms that allow surgery to be offered to patients unlikely to recover sufficiently with conservative management. Mounting evidence supports improved outcomes for appropriately selected patients with surgical management compared with natural history. Primary nerve surgery options now include nerve graft repair and nerve transfer. Specific indications continue to be elucidated, but both techniques offer a significant chance of restoration of function.
Mounting data support both the safety and effectiveness of surgery for patients with persistent NBPP. Despite this support, primary nerve surgery for NBPP continues to be underused. Surgery is but one part of the multidisciplinary care of NBPP. Early referral and implementation of multidisciplinary strategies give these children the best chance of functional recovery. Primary care physicians, nerve surgeons, physiatrists, and occupational and physical therapists must partner to continue to modify current treatment paradigms to provide improved quality care to neonates and children affected by NBPP.
新生儿臂丛神经麻痹（NBPP）可能会导致那些患有该病的人持续存在缺陷。手术技术的进步为治疗提供了安全可靠的选择。目前流行的范式包括“所有新生儿臂丛神经麻痹都会恢复”、“等待一年看是否会恢复”和“不要动手臂”。按照这些原则进行治疗会使这些患者处于不利地位。因此，本综述的重要性在于提供 NBPP 管理的最新信息，用新的范式取代旧的观念。
失神经肌肉内的变化在损伤发生时就开始了，但如果没有神经再支配，在失神经后 18 至 24 个月就会变得不可逆转。这些时间敏感的、不可逆转的变化是本文中推荐 NBPP 早期管理的科学依据，也对旧的观念提出了质疑。早期转诊变得越来越重要，因为使用新的管理算法可以改善结果，为那些通过保守治疗不太可能充分恢复的患者提供手术治疗的机会。越来越多的证据支持对于经过适当选择的患者，手术治疗比自然史治疗有更好的结果。目前，神经外科手术的选择包括神经移植修复和神经转移。具体的适应证仍在进一步阐明，但这两种技术都提供了恢复功能的重要机会。
越来越多的数据支持对持续性 NBPP 患者进行手术的安全性和有效性。尽管有这些支持，对 NBPP 的主要神经手术仍然未得到充分利用。手术只是 NBPP 多学科治疗的一部分。早期转诊和实施多学科策略，使这些儿童有最好的机会恢复功能。初级保健医生、神经外科医生、物理治疗师和职业治疗师必须合作，继续修改当前的治疗模式，为受 NBPP 影响的新生儿和儿童提供更好的优质护理。
