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United Kingdom BPI Specialists/Clinics
Mr. Rolfe Birch, FRCS, Orthopaedic Surgeon
When was your Brachial Plexus Injury Clinic established? The Peripheral Nerve Injury Unit was established at the Royal National Orthopaedic Hospital in 1948 by Professor Sir Herbert Seddon and it grew from the work of the Medical Research Council Special Committee which embraced the treatment of these injuries incurred during the two World Wars. I know that there was a vast amount of work done by colleagues in the USA during these periods, and the report of Woodhall and of Beebe is the North American equivalent to the Report of the MRC Special Committee. I think that the foundation of modern treatment of injuries to the brachial plexus lay with the observations made by George Bonney in 1954 and then hy him with Roger Gilliatt in 1958 which described pre and post-ganglionic injury and which set the ground for modern neurophysiological investigative work. In the 1970's George Bonney implemented a policy of urgent or emergency treatment for severe injuries in the adult and a policy of urgent primary repair of nerves and vessels when there was associated arterial lesion. I joined him in 1979 at St. Mary's Hospital, London, and continued that work. The Unit from St. Mary's was transferred to the Royal National Orthopaedic Hospital in 1991. Six years ago we were joined here by Mr. Thomas Carlstedt from the Karolinska Hospital, whose work in re-connection of the central nervous system to the peripheral nervous system is widely and properly acclaimed. Identify what specialties related to brachial plexus injuries are represented by practitioners working in your clinic including physical/occupational therapists, if any. Radiology, Neurophysiology, Pain Service, Orthotics. Full Rehabilitation Team. What do you/your clinic specialize in treating?
Indicate the total number of brachial plexus patients you/your clinic has evaluated since your establishment: Number of children (Obstetrical brachial plexus injuries): 1500 since 1989 Number of children (Trauma or other brachial plexus injuries): 100 since 1979 Number of adults (Obstetrical brachial plexus injuries): a handful only Number of adults (Trauma or other brachial plexus injuries): 3000 since 1979 State your philosophy regarding evaluation, referral and treatment of obstetrical brachial plexus injuries. Our understanding of OBP has been greatly enhanced by the completion of the National Incidence Survey which will shortly be published and this has given valuable information about the natural history of this disorder. Our own studies have shown that the majority of children go on to a very high level of recovery spontaneously, that about 10% of children should be considered for operations upon the plexus itself and that about 25% of children run into very real problems with secondary deformities of the shoulder, most especially, posterior dislocation of the shoulder. We will shortly be publishing work which confirms the importance of neurophysiological work in defining the prognosis of the lesion in individual cases, and this work, started by Dr. Shelagh Smith over ten years ago, is, I think, one of the most important advances that we have seen in this field. To summarise our approach: first establish prognosis; next, where necessary, improve that prognosis by appropriate re-innervation; next be constantly on the alert for the development of secondary contracture, most especially that relating to the shoulder; finally, adequate, which means prolonged, review of the children up to at least the age of seven and deferring secondary reconstructive operations till about that age. This last does represent a change, we have found that musculo-tendinous transfers are very difficult to get right in the younger child. Our experience with the adult presenting with a OBP problems are so scanty that I can offer no concrete suggestions save to say that operation in such cases is only very rarely indicated. State your philosophy regarding evaluation, referral and treatment of trauma or other brachial plexus. Operation is indicated to establish diagnosis and so prognosis, then to improve that prognosis by nerve repair, nerve transfer or other means. Such operation is an emergency in open wounds or whether there is associated arterial injury. It is urgent where the clinical evidence points to major disruption of the brachial plexus. The case for urgent explorations is greatly strengthened by two further facts: the first is the biological imperative, the proof that the central pool of neurones will die after separation from their axons at a proximal level and the next relates to changes distally, to increasing technical difficulty in definition of nerve stumps and of deterioration within those distal stumps and within the target organs. State your philosophy regarding pain management and brachial plexus injuries. The question of pain is central to the handling of plexus lesions, and we have recently published work proving that re-innervation of the limb relieves pain. This alone justifies action even in those cases where the lesion is a most severe one. Above all, the whole process of operation and repair must be seen as an integral, indeed essential, part of the whole process of rehabilitation. The aim of that rehabilitation is to support the patient back into a normal daily life, to their proper work or to different work or to study. That process cannot begin unless diagnosis is established early and with precision. It is in this context that the approach to "reconstructive" operations is wholly different from that in OBP, appropriate reconstructive operations should be planned as soon as the neurological prognosis is known. Indicate research efforts (include dates please) conducted by you specific to brachial plexus injuries. The main thrust of current research work relates to the following: Regeneration between the central and the peripheral nervous system; pain; prognosis in OBP and the role of ancillary investigations; results of interventions. Indicate any other facts that you feel would help families and individuals understand your practice. We must emphasize that the treatment of these injuries should be taken as an urgent matter and that it should be set within a framework of the proper treatment of patients who have suffered severe injury. We have long argued the case within the United Kingdom for the establishment of Regional Centres capable of handling such cases and have taken active steps to train and to promote the establishment of such Centres. We suggest that a population base of about 5 million is about right. It is not our practice to accept direct "self referrals", in this country referrals come to us from orthopaedic surgeons and colleagues in other disciplines who are aware of our methods and approach; on occasion referrals will be accepted from General practitioners. |
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