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Birth Trauma of the Nervous System

Birth Trauma of the Nervous System. Joseph H Piatt, Jr, MD, FAAP Section of Neurosurgery. regions. cranial scalp skull intracranial spinal craniocervical lower cervical peripheral brachial plexus phrenic facial other. scalp injuries. caput succedaneum

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Birth Trauma of the Nervous System

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

  5. intracranial hemorrhage • epidural • subdural • supratentorial • infratentorial • intraparenchymal • cerebral • cerebellar

  6. intracranial hemorrhageNEJM 1999;341:1709-14 • 583,340 singletons live-born to nulliparous mothers • weights 2500 - 4000gm • ~ 1 / 3 delivered operatively

  7. intracranial hemorrhageNEJM 1999;341:1709-14

  8. posterior fossa SDH

  9. spinal cord injury • craniocervical • vertex • fetal hyperextension • lower cervical • breech

  10. spinal cord injuryJ Pediatr 1993;122:431-7 • high cervical (N = 14) all vertex • cervicothoracic (N = 6) all breech • thoracolumbar (N = 2)

  11. spinal cord injuryJ Pediatr 1993;122:431-7 • 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.

  12. peripheral nerve injury • brachial plexus • phrenic nerve • facial nerve • radial nerve • many others

  13. brachial plexus birth injury • ~ 1:1000 live births and holding • primiparity • macrosomia • maternal diabetes • shoulder dystocia • no obvious explanation up to 50%

  14. brachial plexus birth injuryObstet Gynecol 1999;93:536-40 N > 1,000,000 live births over 2 yr period overall rate 1.5:1000 about 50% of cases assoc with shoulder dystocia

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

  16. common uncommon

  17. 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

  18. management • ROM exercises to prevent contractures • investigations • MR imaging • EMG? • plexus exploration • orthopedic interventions neurolysis nerve grafts neurotization

  19. neurosurgical outcomes:upper plexus reconstructions • neurolysis • dubious value • nerve grafts • ~80% > M3 • less contracture at shoulder? • neurotization • ~50% > M3

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