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Scientific Articles   |    
Mechanisms and Risk Factors of Brachial Plexus Injury in the Treatment of Early-Onset Scoliosis with Distraction-Based Growing Implants
Elizabeth R.A. Joiner, BS1; Lindsay M. Andras, MD1; David L. Skaggs, MD, MMM1
1 Children’s Orthopaedic Center, Children’s Hospital Los Angeles, 4650 Sunset Boulevard, Mailstop 69, Los Angeles, CA 90027
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Investigation performed at the Children’s Orthopaedic Center, Children’s Hospital Los Angeles, Los Angeles, California



Disclosure: One or more of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of an aspect of this work. In addition, one or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Copyright © 2013 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2013 Nov 06;95(21):e161 1-7. doi: 10.2106/JBJS.M.00222
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Abstract

Background: 

Brachial plexus injuries have been reported in association with distraction-based instrumentation for early-onset scoliosis. The purpose of this study was to describe brachial plexus injuries associated with distraction-based spine instrumentation with rib anchors and the mechanisms and risk factors responsible.

Methods: 

We performed a retrospective single-center review of a consecutive series of forty-one patients with early-onset scoliosis who underwent distraction-based instrumentation with rib anchors from 2000 to 2011.

Results: 

Four (10%) of the forty-one patients experienced an intraoperative brachial plexus injury. Three mechanisms of brachial plexus injuries were identified: (1) injury of the brachial plexus by the first rib being pushed superiorly by rib-anchored growing instrumentation, (2) direct injury to the brachial plexus by the superior pole of the retracted scapula, and (3) injury of the brachial plexus when the scapula was moved inferiorly during Sprengel deformity reconstruction. The last two mechanisms are independent of spinal instrumentation. Two patients had neurological symptoms or neuromonitoring signal changes when the arm was in the adducted position but not when the arm was abducted. All patients had complete neurological recovery.

Conclusions: 

Patients with Sprengel deformity appear to be at increased risk for brachial plexus injury when undergoing distraction-based spine instrumentation with rib anchors. Injury to the brachial plexus can occur with scapular elevation alone, presumably by direct compression of the superior end of the scapula on the brachial plexus. Brachial plexus injuries may be “hidden” during monitoring of an arm in shoulder abduction but symptomatic with shoulder adduction, as the brachial plexus is draped over the elevated first rib.

Level of Evidence: 

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

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    References

    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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