Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts.
Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, Boston, Massachusetts.
J Bone Joint Surg Am. 2020 Feb 5;102(3):194-204. doi: 10.2106/JBJS.18.01312.
Infants with more severe brachial plexus birth injury (BPBI) benefit from primary nerve surgery to improve function. The timing of the surgery, however, is controversial. The Treatment and Outcomes of Brachial Plexus Injury (TOBI) study is a multicenter prospective study with the primary aim of determining the optimal timing of this surgical intervention. This study compared outcomes evaluated 18 to 36 months after "early" microsurgery (at <6 months of age) with the outcomes of "late" microsurgery (at >6 months of age).
Of 216 patients who had undergone microsurgery, 118 were eligible for inclusion because they had had a nerve graft and/or transfer followed by at least 1 physical examination during the 18 to 36-month interval after the microsurgery but before any secondary surgery. Patients were grouped according to whether the surgery had been performed before or after 6 months of age. Postoperative outcomes were measured using the total Active Movement Scale (AMS) score as well as the change in the AMS score. To address hand reinnervation, we calculated a hand function subscore from the AMS hand items and repeated the analysis only for the subjects with a Narakas grade of 3 or 4. Our hypothesis was that microsurgery done before 6 months of age would lead to better clinical outcomes than microsurgery performed after 6 months of age.
Eighty subjects (68%) had early surgery (at a mean age of 4.2 months), and 38 (32%) had late surgery (at a mean age of 10.7 months and a maximum age of 22.0 months). Infants who underwent early surgery presented earlier in life, had more severe injuries at baseline, and had a significantly lower postoperative AMS scores in the unadjusted analysis. However, when we controlled for the severity of the injury, the difference in the AMS scores between the early and late surgery groups was not significant. Similarly, when we restricted our multivariable analysis to patients with a Narakas grade-3 or 4 injury, there was no significant difference in the postoperative AMS hand subscore between the early and late groups.
This study suggests that surgery earlier in infancy (at a mean age of 4.2 months) does not lead to better postoperative outcomes of BPBI nerve surgery than when the surgery is performed later in infancy (mean age of 10.7 months).
Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.
患有更严重臂丛神经出生损伤（BPBI）的婴儿受益于初级神经手术以改善功能。然而，手术的时机存在争议。《臂丛神经损伤治疗和结果（TOBI）研究》是一项多中心前瞻性研究，主要目的是确定这种手术干预的最佳时机。这项研究比较了“早期”显微镜手术（<6 个月龄）后 18 至 36 个月的结果与“晚期”显微镜手术（>6 个月龄）后的结果。
在接受显微镜手术的 216 名患者中，有 118 名符合纳入标准，因为他们在显微镜手术后 18 至 36 个月内（即显微镜手术后，且在任何二次手术之前）至少进行了一次体格检查，并接受了神经移植和/或转移。根据手术是在 6 个月龄之前还是之后进行，将患者分为两组。术后结果使用总主动运动评分（AMS）评分以及 AMS 评分的变化来衡量。为了评估手再神经支配，我们从 AMS 手部项目中计算了一个手部功能子评分，并仅对 Narakas 分级为 3 或 4 的患者重复了该分析。我们的假设是，6 个月龄之前的显微镜手术比 6 个月龄之后的显微镜手术会产生更好的临床结果。
80 名患者（68%）接受了早期手术（平均年龄为 4.2 个月），38 名患者（32%）接受了晚期手术（平均年龄为 10.7 个月，最大年龄为 22.0 个月）。接受早期手术的婴儿在生命早期出现，基线损伤更严重，且未矫正分析中术后 AMS 评分明显较低。然而，当我们控制损伤的严重程度时，早期手术组和晚期手术组之间 AMS 评分的差异并不显著。同样，当我们将多变量分析限制在具有 Narakas 分级 3 或 4 损伤的患者时，早期组和晚期组之间的术后 AMS 手部亚评分没有显著差异。
这项研究表明，婴儿期（平均年龄为 4.2 个月）早期手术并不会比婴儿期后期（平均年龄为 10.7 个月）手术导致更好的 BPBI 神经手术后结果。
预后 II 级。请参阅作者说明以获取完整的证据水平描述。
