Thanks very much. Good morning. I don't have any conflicts to disclose related to the topic of this presentation. My charge, as I interpreted it, was to talk about the assessment of the infant with a pediatric brachial plexus birth palsy. So just by way of introduction, things we all know together, despite advances in obstetrics, brachial plexus birth palsy continues to occur in about 100,000 live births. More recent information reminds us that while the vast majority of infants have spontaneous recovery, perhaps 30% will have persistent neurologic deficits and upper limb impairment. And all of us are interested in the microsurgery that is appropriate and beneficial for these infants and children with these persistent deficits. But assessments in the infant can be challenging, and indications, techniques, and timing continue to be a bit variable from surgeon to surgeon. So we'll try to touch on these. We take a big step back and think about what the goals of early assessment are, early infantile assessment. I think that we would all acknowledge that the number one goal is to make the right diagnosis, not just make the right diagnosis, but provide some characterization of the pattern and extent of injury. I think we all would agree that an upper trunk neuropraxic injury is going to be very different than the multilevel root avulsions. I think early assessment also allows us to engage our colleagues, particularly our physical therapists, neurologists, physiatrists, whatever your colleague may be in your particular practice situation who are invaluable team members in the care of even the infants. It allows us to establish some rapport with the family in what can oftentimes be a very emotionally charged situation. And ultimately what we wish to do is to predict recovery and determine which of these infants are going to go on to benefit from surgical intervention. So I would argue that the preferred age of first evaluation is roughly one to two months of age. At this time, the diagnosis is a bit easier to come by. Pseudoparalysis from fracture, for example, will have sorted itself out, and typically syndromic associations or other central nervous system disorders have also become more apparent. And an earlier assessment at one to two months of age allows for serial evaluations that will help us in our ability to prognosticate. So what to assess? I think we're all familiar with the elements of the physical examination. Starts with the eyes, always starts with the eyes. Looking for ptosis, meiosis, and anhydrosis is helpful in the situation of patients with Horner-type lesions. Looking for scapular winging in the infant's back, as well as any asymmetric or aberrant respiratory motions that might suggest a phrenic nerve injury and hemiplegic-phragmatic paralysis, all thought to be poor prognostic signs. And then literally through a comprehensive evaluation, we can look at the active motion of the upper limb, both spontaneously in a stimulated fashion using rattles, toys, etc., using the infantile reflexes if need be. Careful assessment of passive motion as well is important, perhaps more gently than is depicted in the lower right-hand part of the screen, to assess particularly shoulder motion in those patients with upper trunk lesions. And again, this allows us to get a better understanding of where the child is at that particular time. We, like many other centers, will utilize a physical examination form that we fill out in every visit to help characterize and document these assessments. Then we would advocate serial visits, perhaps every 4 to 6 weeks in the first 6 to 12 months of life, to help chart out and mark out neurologic recovery, active motion recovery, in hopes that we can continue to risk stratify these infants using, I should say, partnering with our therapists and other colleagues, allows for multiple examiners, which can be extremely helpful, particularly in the borderline or not-so-clear-cut cases. And I think that we, like all of you, will continue to use BICEPS, the Toronto Test Score and the Cookie Test, as some assessments. We'll touch on those just briefly. So antigravity BICEPS has been talked about by many and often, and this is used to help prognosticate who is going to develop spontaneous recovery and which infants and children might benefit from surgical intervention. I think we're going to have a talk following this by David, who's going to chat a bit about the optimal timing of this. We know that BICEPS, antigravity BICEPS function alone, may inaccurately predict recovery in perhaps 12% of cases. And this work comes from Mitchell and colleagues. They've instructed us that the addition of looking at elbow extension, wrist extension, thumb extension, and digital extension may improve our ability to prognosticate and predict recovery. And those colleagues have then come up with a so-called Toronto Test Score, depicted here, and have utilized this score in their decision-making analysis, particularly early in life. And then there's the so-called Cookie Test, described by Clark and others, typically described as asking the child to bring his hand to the mouth, his or her hand to the mouth at nine months of age, with the shoulder adducted, with trying to limit compensatory neck flexion. And again, I think the significance of the Cookie Test will be discussed later in this session. Aside from those particular assessments, charting and evaluating all active motion is important. And so the folks at SickKids have come up with the Active Movement Scale, which has been found to be both valid and reliable, assessing 15 different active movements and grading them on a scale of 0 to 7, depending on the arc of passive motion. There are some surgeons and centers who use additional ancillary testing, be it radiographic imaging or electrophysiologic studies. I'll just touch upon this for a moment. These are not things that we currently utilize at our particular center for some of the reasons that I hope to elucidate. So CT scans, traditional CT myography have been utilized. However, the specificity and sensitivity continue to be a little bit limited. And prior studies have demonstrated that even in the presence of diverticuli or pseudomeningoceles, intraoperative findings don't necessarily correlate with these imaging studies in perhaps half of cases. MRI and MRI myelograms are a bit better. They can help us, hopefully, distinguish between avulsion and extraforaminal lesions, as well as to characterize the levels of involvement. But again, oftentimes inconclusive in up to 15% of cases, 1 out of 6 or 1 out of 7. And it's not yet clear whether these additional imaging studies provide much benefit over careful preoperative examination and careful intraoperative inspection. Electrodiagnostic tests have been evaluated in the past and the challenge with these is oftentimes they will underestimate the severity involvement and overestimate the potential for recovery. Traditional studies have demonstrated that preoperative findings do not necessarily match with intraoperative findings. And depending on the center in which you work at, the accessibility to a neurophysiologist who can perform these studies in an appropriate fashion may be variable. I would just point out this interesting study from 2000 by Redveld. My apologies for the pronunciation, colleagues in the Netherlands, comparing infantile brachial plexus birth palsy and adult traumatic brachial plexus injuries in which there was confirmed C5 or C6 avulsion or rupture injuries inspected at the time of surgical exploration. Interestingly, many of the children had relatively little pathologic activity on their presurgical electrodiagnostic tests and had some preserved reflex activity. These authors posited or theorized that there may be, indeed, some luxury innervation and some plasticity and in some situations C7 may help contribute to early biceps and deltoid innervation, which can further cloud the picture. So do electric diagnostic studies help us answer the question of which infant will have neuroautomatic or avulsion-type injuries? EMG studies are probably insufficient. Perhaps there's a role for CMAPs or other seromotor evaluations in the future. I look forward to our discussion about this. And finally, circling back to the role of physical therapists, occupational therapists, and our other colleagues, I think that this is beneficial and should be instituted early in life to maintain passive range of motion, potentially utilize splinting for joint contractures. It certainly allows for additional observers, oftentimes brutally honest and objective observers, to help us in our decision making. And families find all our partners as invaluable resources as they think not only about the present but also about the future. I'm not going to talk about indications for surgeries. I know that that's a topic for David to address next. But hopefully that was a nice introduction to the topic and stimulated some thoughts about assessment. Thank you.

assessment

infants

brachial plexus birth palsy

early intervention

physical therapists