By Mr Tom Quick
Consultant Orthopaedic Surgeon
A 19th-century Bavarian doctor, Wilhelm Heinrich Erb, gave his name to a nerve injury which happens to babies during birth. Erb’s Palsy is a weakness of shoulder and elbow muscles.
Arm nerves come from the spine in the lower neck at C5, C6, C7, C8 and T1. These nerves come together at a major junction called the brachial plexus. During birth, as the child squeezes out of the mother’s pelvis, the neck can be over-stretched damaging the nerves. Injury can be mild, recovering rapidly and completely, nerves can be partially or totally snapped, or pulled clean from the spinal cord.
Nerve injury in BBPP
In babies, a brachial plexus injury is very different to that in an adult. Newborns' nerves are more stretchy and the causing force is much less and more gradual than, say, in a car crash. Nerve injury in BBPP is usually a 'neuroma in continuity'. This means that not all the nerve cells are completely damaged and many can regrow naturally. When the damage is too great, the injured area may have to be cut out and replaced with nerve grafts.
To work out if surgery is necessary, rigorous assessment is crucial. We use repeated clinical examinations alongside neurophysiology, which is like medical circuit testing. With this combination, we can determine the stage of recovery and the likely condition of the nerves and their connections to the arm muscles.
We classify our findings into three groups:
- The outcome will be great without surgery
- The outcome may not be perfect but surgery won't help
- Surgery is likely to improve the outcome
Primary Brachial Plexus surgery
This is an operation on the nerves of the brachial plexus in the neck. It entails an exploration, then, if the evidence supports that removing damaged nerves or re-routing others will help, I carry on and do just that.
I make a cut in the neck just above the collar bone. Next, I free the brachial plexus nerves from the scar tissue which forms after damage. Then, I re-test the nerves to be absolutely sure that we have the most up-to-date information before carrying on.
The nerves may be recovering well and now that they are released from scar tissue, I might decide to do no more and simply close up the wound.
Sometimes, the damage is so bad that I might have to take nerves from your child’s leg and graft them into the brachial plexus, or reroute some other undamaged nerves from nearby.
It is important to understand that if this operation is necessary, the results will not be instantaneous - not like re-wiring a light bulb and flicking a switch. It is more like attaching a hosepipe to a tap, and then having to wait until the water can flow down the whole length. In nerve surgery, cells take time to regenerate. Improvement may not show for many months, with full recovery taking years.
The Shoulder in BBPP
The most common problem after BBPP involves the shoulder. Injury varies within each nerve root, so recovery of differing parts can be uneven. When one muscle pulls more strongly than its opposite number, it can lead to abnormal development, then partial and eventually full dislocation of the shoulder joint.
In the Peripheral Nerve Unit at the RNOH, Mr Tom Quick, and his colleagues, Mr Michael Fox and Dr Marco Sinisi are leaders in performing an operation called an anterior release which corrects this at an early stage. If your child is 4-6 years old, we often have to use a special operation - glenoplasty – which we developed here at the RNOH. This is where the bone of the shoulder joint is reshaped to improve function.
The Forearm and Hand
When the lower arm and hand are also affected, physiotherapy will help. In addition, operations such as joint releases, tendon transfers, nerve transfers and bone realignment can be carried out.
Emily's Story - Erb's Palsy
For more information please contact the Royal National Orthopaedic Hospital Private Patient Unit: 020 8909 5712/13