Birth Trauma of the Nervous System

1
Birth Trauma of the Nervous System

• Joseph H Piatt, Jr, MD, FAAP
• Section
• of
• Neurosurgery

2
regions

• cranial
• scalp
• skull
• intracranial
• spinal
• craniocervical
• lower cervical
• peripheral
• brachial plexus
• phrenic
• facial
• other

3
scalp injuries

• caput succedaneum
• subgaleal hematoma
• cephalohematoma

4
(No Transcript)
5
(No Transcript)
6
(No Transcript)
7
(No Transcript)
8
(No Transcript)
9
(No Transcript)
10
skull injuries

• nondisplaced linear fracture
• ping pong fracture
• diastatic fracture
• growing skull fracture
• occipital osteodiastasis

11
(No Transcript)
12
(No Transcript)
13
(No Transcript)
14
(No Transcript)
15
(No Transcript)
16
(No Transcript)
17
(No Transcript)
18
(No Transcript)
19
intracranial hemorrhage

• epidural
• subdural
• supratentorial
• infratentorial
• intraparenchymal
• cerebral
• cerebellar

20
intracranial hemorrhageNEJM 19993411709-14

• 583,340 singletons live-born to nulliparous
  mothers
• weights 2500 - 4000gm
• 1 / 3 delivered operatively

21
intracranial hemorrhageNEJM 19993411709-14
22
(No Transcript)
23
(No Transcript)
24
(No Transcript)
25
posterior fossa SDH
26
(No Transcript)
27
(No Transcript)
28
(No Transcript)
29
(No Transcript)
30
spinal cord injury

• craniocervical
• vertex
• fetal hyperextension
• lower cervical
• breech

31
(No Transcript)
32
spinal cord injuryJ Pediatr 1993122431-7

• high cervical (N 14) all vertex
• cervicothoracic (N 6) all breech
• thoracolumbar (N 2)

33
spinal cord injuryJ Pediatr 1993122431-7

• 4/14 high cervical injuries died of cranial
  trauma.
• 2/10 survivors took a breath within 24 hours and
  recovered with mild disability.
• 5/10 with apnea on day 1 and no motor recovery in
  3 mo. were permanently ventilator dependent.

34
peripheral nerve injury

• brachial plexus
• phrenic nerve
• facial nerve
• radial nerve
• many others

35
(No Transcript)
36
brachial plexus birth injury

• 11000 live births and holding
• primiparity
• macrosomia
• maternal diabetes
• shoulder dystocia
• no obvious explanation up to 50

37
brachial plexus birth injuryObstet Gynecol
199993536-40
N gt 1,000,000 live births over 2 yr
period overall rate 1.51000 about 50 of cases
assoc with shoulder dystocia
38
plexus pathology

• upper to lower gradient of severity
• rupture of C5, C6 roots or upper trunk
• upper roots infrequently avulsed
• Horner syndrome, diaphragm paralysis

39
common
uncommon
40
(No Transcript)
41
(No Transcript)
42
natural history

• NICU diagnosis - 95 recovery
• all recoveries complete within 1 yr
• bad functional outcomes if recovery has not begun
  by 3 mo
• aberrant reinnervation

43
management

• ROM exercises to prevent contractures
• investigations
• MR imaging
• EMG?
• plexus exploration
• orthopedic interventions

neurolysis nerve grafts neurotization
44
neurosurgical outcomesupper plexus
reconstructions

• neurolysis
• dubious value
• nerve grafts
• 80 gt M3
• less contracture at shoulder?
• neurotization
• 50 gt M3