If there is little to no improvement through physical and occupational therapy by three months of age, a baby should be reevaluated, and neurosurgery may be recommended. It is important to move forward with neurosurgery before your child reaches one year, to assure the best possible outcome.
Other surgeries related to improving functioning of tendons or muscles, and even bones, may be recommended for older infants (two to four years old) depending on outcomes from therapy and neurosurgery.
If neuromas have developed (clumps of nerve tissue caused by nerves trying to heal and reconnect) a neurosurgeon may remove scarring along the nerve pathway, called (neurolysis) and graft the two ends of the nerve with a nerve taken from another location.
The neurosurgery team at Children’s National Hospital uses the most sophisticated intra-operative monitoring techniques to assure the best possible outcomes during reconstruction of delicate nerves and tissue. Intra-operative monitoring includes the use of EMG and somatosensory response to identify and test the nerves to be repaired. After this surgery, your baby will need to keep his or her arm and shoulder in a sling, so it remains immobile for several weeks.
Since the introduction of early and effective therapy for newborns with brachial plexus injuries, surgery of tendons, muscles and bones may not be necessary, or may be done later in life. If nerves are repaired early in life, they can regenerate and other structures will not be compromised. If surgery is required, it may be recommended for older infants, aged four to six.
In some cases connective tissues between muscle and bone that have been compromised due to nerve damage can be repaired through a tendon transfer. The surgeon separates the tendon from its normal attachment and reattaches it in a different place. This can be helpful in improving shoulder and wrist motion, as well as elbow position and hand grip.
Tendon transfers are generally performed when your child is older: at about three to four years old. Physical therapy may continue indefinitely after surgery.
In some cases, if function of the arm has been severely compromised, it is possible to realign the arm bone surgically by turning it and/or transferring muscles so the child can turn his or her shoulder. Severe elbow, wrist and hand constrictions can sometimes be treated with muscle and tendon releases.
Low current electrical stimulation can help strengthen weak muscles. Children must be old enough and aware enough to report discomfort and to cooperate with a physical therapist to use this approach. Outcomes indicate that electrical stimulation may be an important additional therapy.