Thanks, Michael. I'd like to thank the chairs of the session for inviting me to speak this morning. I'm from a long way away, Melbourne, and I can't operate the machine here. We're fighting. So my charge was to speak about indications and planning, and it's a pretty controversial area, largely. This is a difficult group of patients, in a sense, because of the atrogenic nature of the injury, and they're often fairly suspicious and concerned about the prospect of you inflicting further, potentially further, insult upon them. So it takes a bit of time and planning, and I'd support Don in the idea of early assessment, particularly to establish a rapport with the families. I think that's critical. So in terms of the natural history of the condition, we see these babies, or the babies that are seen in the labour ward and present with a flaccid arm, and they're reassured by a somewhat overly optimistic obstetrician and midwife that everything's going to get better. The nerves have just had a little bit of a stretch, and it's all going to be fine. And then they turn up in your clinic, and things aren't fine. So there is some support for the concept that a large proportion of these kids will get better and regain normal function, particularly if those have started to recover their bicep function by less than six weeks. They are likely to go on and make a good recovery. But there is also the other group at the other end of the spectrum who have the total palsy and may have a Horner sign indicating significant lower trunk injury as well, and they're almost guaranteed to have a poor recovery without intervention. The difficulty is the group in the middle between these two, and that's where the controversy in terms of the surgical indication still lies, I think. As Don said, there's a significant residual deficit in at least 30% of these children, and it's beholden upon us to try and prognosticate which of these groups are going to end up with this deficit and therefore potentially benefit from surgery. And the main avenues to establishing this prognosis is with the initial assessment, assessing the extent of the lesion, and then with serial examination after that, assessing the tempo of recovery. Other factors that help with this is there have been papers that have used the predictor of birth weight and also whether the birth was a breach or vertex presentation. And I would echo Don's feelings about imaging and neurophysiology. We don't use imaging as an indicator for the indication for surgery. We use it as a tool once the decision's been made to proceed with surgery. We think it helps with planning in terms of identifying pre-ganglionic injury, but in terms of making a decision based on whether the MRI shows injury or not, we rely upon our clinical judgment. And neurophysiology, again, we think probably overestimates the scope for recovery, but I know there are plenty of centres that do rely upon it and use it as part of their algorithm. So if we're talking about surgery, and I won't go into this in detail because Scott is going to speak about this, I'm sure, very eloquently, but there are basically two aspects to this. One is the concept of nerve reconstruction, and we're talking about a nerve injury, and so therefore if we're worried that these kids aren't going to get better, it makes good sense to do something to rewire them and therefore restore function, balance around joints, stimulate stimulus to growth, afferent sensory capacity for the developing cortex. But the other issue here I think that needs to be considered is the musculoskeletal reconstruction. You need to be keeping an eye on these children from the beginning, from the point of view of their shoulder and elbow, from the point of view of joint contracture and subluxation, because early surgery may be required to address that. And a stiff joint, the best nerve reconstruction in the world won't fix a stiff joint, so that's an important aspect of it as well. In terms of nerve reconstruction, again, going to go over this quickly, the options here are to either perform a neuralysis, which I think probably has a limited role, and the preferred, once the decision has been made to pull the trigger, so to speak, is to proceed with a nerve reconstruction. And I'm not sure that I've done a case where I've been convinced that once the decision has been made to proceed with surgery, I'm not sure that my operating findings have ever justified just doing a neuralysis alone, but I guess that's coming. In terms of reconstruction, there are options of graft reconstruction, resection, and replacing the neuroma with graft, or else using nerve transfer, which Scott will talk about. And then, in terms of designing your operation, how are you going to go about it? Are you going to reconstruct it as an anatomical type of distribution of grafting and transfers, or are you going to be selective in your distal targeting? But to get to the specifics here for a moment, the total palsy group, it's well accepted, I think, that surgery is the preferred option and should be probably done as early as possible. The difficulty here relates to the operative plan. Usually, these kids have got multiple avulsions, such as this child here, and that means that you're going to have a paucity of available proximal axons, and you're going to need to prioritize which distal targets receive what axons. And whether you direct your proximal axons down to the hand to restore sensation and function in the hand, and then rely upon extra plexal transfers for proximal function, or whether you try and just spread things out, is the decision to be made there. For the upper trunk, I won't go over all of this in great detail, but the controversy here is that because there is some function left in the limb, which of these kids are going to get better adequately by themselves? Tassana Gilbert promoted the idea that the absent bicep at three months meant that surgery was indicated. Howard Clark, as we've heard, extended this in his papers and has a sort of objective score threshold at the three-month mark, which basically is an involvement of the C567 nerve root domains, and those that fail to progress surgery at six months or a cookie test at nine months as the sort of final hurdle to cross, if you like. Peter Waters' prospective study showed us that there were patients who do recover bicep function after three months who do go on to make an adequate recovery, and so that hurdle can be pushed back a bit. And I think this is probably where we would be situated, that the absence of biceps at four to five months is relevant. More recently, Jorg Barm and also Van Uykerk and his group have been doing selective suprascapular nerve transfers for a deficit of active external rotation, and I think this is the next step in the textbook, if you like, or the recipe book. And that is attractive in the sense that a selective transfer by a dorsal approach is a relatively limited operation and makes good sense in terms of the complicated problem of the shoulder and restoring balance to that. But whether that versus a later musculoskeletal operation with tendon transfers is better, that's the controversy to come. In terms of operative plan for the upper trunk palsy, again, it's a matter of assessing what nerve routes are available, whether the baby is born breach or vertex I think is useful. Breach babies often have a poor quality proximal route and may benefit from a nerve transfer, and I think Scott's going to speak to us more about that. As I said, imaging helps. Intraoperative neurophysiology also helps evaluate that, but we don't use that. We prefer to rely upon our macroscopic assessment, but that maybe more relates to a lack of resource. And then, again, the question is whether you use grafts or transfer to restore your function. I just would like to quickly emphasize this musculoskeletal aspect of the care of these patients, because it's not all just about the nerves. And for babies who present with joint subluxation or joint contracture, they need early treatment. It's important to restore the joint to prevent the secondary dysplasia or to try and limit that at least. In the slightly older child who's made their maximum motor recovery, a persistent palsy may be an indication for a secondary tendon transfer, or in the older child with a fixed deformity, a more orthopedic approach of osteotomy or arthrodesis may be warranted. So if we talk about the shoulder, that's a pretty big topic in itself and probably doesn't do it justice to skip through this, but you can end up with problems with joint internal rotation, contracture, which can be dealt with effectively with subscapular side or tenotomies. You can have weakness of abduction, external rotation in particular can be dealt with with tendon transfer. Scapular instability is a bit more complex and beyond my inadequate brain. And what we really want to try and avoid is the persistent joint deformity. If you go down to the elbow, the elbow contracture usually can be dealt with effectively with a splint. A failure of reconstruction such as happened in this poor little kid, who was one of my patients, that can be dealt with by secondary muscle transfer. And this little bloke ended up with a free gracilis innervated by his overland transfer and came and ended up a bit better than this. A subluxation of the proximal radial joint needs to be addressed and the supination deformity can be addressed by other osteotomy or tendon transfer. And then once you get down to the hand, the issues we have in the, this is usually in the more severe group, where there's persistent wrist instability or a failure of recovery of grasp or pinch. And that's a complicated problem because there aren't many donors available to sort that out. And that's where I come from. Thank you very much. Applause

brachial plexus injuries

indications and planning

surgery

nerve reconstruction

musculoskeletal reconstruction