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Missouri BPI Specialists/Clinics
Gregory H. Borschel, M.D.
When was your Brachial Plexus Injury Clinic established? 2006 Identify what specialties related to brachial plexus injuries are represented by practitioners working in your clinic including physical/occupational therapists, if any. Pediatric Plastic and Reconstructive Surgery, Physical Therapy, Occupational Therapy, Orthopedic surgery, Pediatric Neuroradiology, Pediatric Neurology, Physical Therapy, Social Work, Pediatric Plastic and Reconstructive Surgery Nursing Specialists, Anesthesiology / Pain Management. What do you/your clinic specialize in treating? obstetrical brachial plexus injuries and pediatric traumatic brachial plexus injuries Indicate the total number of brachial plexus patients you/your clinic has evaluated since your establishment: Number of children (Obstetrical brachial plexus injuries): 12 Number of children (Trauma or other brachial plexus injuries): 8 Number of adults (Obstetrical brachial plexus injuries): 0 Number of adults (Trauma or other brachial plexus injuries): 0 State your philosophy regarding evaluation, referral and treatment of obstetrical brachial plexus injuries in children. It is important to evaluate infants with this problem as early as possible. Ideally, at St. Louis Children’s Hospital /Washington University in St. Louis, we prefer to see them in the newborn nursery or within the first two weeks of life. At that time specialized exercises are begun. The next visit would be at age one month in our combined multidisciplinary brachial plexus clinic, where the infant would be seen by the therapists and the surgeon at the same time. At the one month visit additional exercises are begun. In rare, severe cases, surgery may be recommended as early as one month. However, in most cases, the need for surgery is determined at age three months using the Toronto Test Score. In some cases, if improvements can be made using isolated selective nerve transfers, these would be performed at around age three to five months of age. In some instances surgery would be performed at age six months or as late as nine months, depending on the degree of movement in the arm and the particular needs of the child. Prior to the operation, I prefer to obtain either an MRI or a CT myelogram to guide our management. I also order a diaphragm ultrasound before operation. Electrical studies (EMG) are not necessary for infants. The operations usually take between 5 and 10 hours. The infants typically stay in the hospital for two days. If the family lives far away then I usually advise staying in St. Louis for several days, then letting me check the wound at around one week after the operation. I will usually place the child’s arm in a soft sling for about three weeks. Usually range of motion therapy can be continued for the wrist and fingers and thumb during this time. Then at three weeks after the operation, range of motion therapy for the elbow and shoulder can begin again. The results of surgery can be seen usually within four to six months. Recovery continues until around age three or four, at which point the results can be considered more or less “final” from a nerve recovery standpoint. If there are other improvements that can be made that would benefit the child, such as limitations of shoulder, elbow or wrist motion, then we may advise parents to consider additional operations. We continue to follow all of our patients into adulthood. Sometimes, other issues may arise as the children grow older. They may wish to participate in certain activities that require additional movements that may be able to be improved with therapy or surgery. Occasionally pain can be an issue in the older children – and this may be treatable. State you/your clinic philosophy regarding evaluation, referral and treatment of trauma or other brachial plexus injuries in children In the case of an older child with a brachial plexus injury, either from a gunshot wound, motor vehicle accident or other injury, again we prefer to see patients as early as possible after injury. Lung, brain or spinal cord injuries may require stabilization at the referring hospital prior to transfer. A detailed examination of the sensory and motor function of the arm is carried out. Depending on the level and nature of the injury, nerve grafting or nerve transfers may help in improving recovery. Usually in cases of closed injury (such as car crashes) we would not perform surgery before three months after the injury. In these cases electrical studies (EMG) can be quite helpful, as well as MRI, CT, and diaphragm ultrasound. If there is an open injury then surgical exploration and nerve grafting with or without nerve transfers may be warranted before three months. These operations usually take about five to eight hours to complete. The children are usually in the hospital for about two days after the operation. Depending on what kind of operation is done, a soft sling or a splint may be applied after the operation. Range of motion therapy is very important before and after the operation. We will usually resume therapy shortly after the operation. Results will continue to improve for about two or three years after the operation. In some cases of severe injury, muscle transplants, combined with nerve transfers, may provide the best outcome. In these cases we use the gracilis muscle (a long, thin “extra” muscle from the inner thigh). Pain from such injuries can sometimes be significant. When appropriate, surgery can sometimes improve the pain, and certain medications can also help. We also have pain specialists available with a specific interest in this problem at our institution. State you/your clinic philosophy regarding evaluation, referral and treatment of obstetrical brachial plexus injuries in adults. There are two major issues that sometimes need to be addressed in adult patients with this type of nerve injury. First, pain can sometimes be an issue, and sometimes this becomes worse with age. The reasons for this are not well understood. However, sometimes it can be improved. Second, certain movements may become worse with age. Sometimes these can be improved surgically. State your philosophy regarding pain management and brachial plexus injuries. Pain control begins at the time of the first visit. This is a very important issue. For infants, we take care to accomplish therapy exercises with a minimal amount of discomfort. For the most part, the infants become used to the exercises with time (and so do the parents). After operations the infants receive pain medication through the IV and also by mouth to minimize pain. When they go home they have prescriptions for narcotic pain medication, but often parents do not need to give anything stronger than Tylenol after a few days. As these children grow up, they typically do not have issues with pain. However, they sometimes do, and in these cases we try to determine if there is a surgical way to improve the pain or if certain medications can help in reducing discomfort. In cases of older children with traumatic brachial plexus injuries, such as car crashes, pain can sometimes be a major issue. In these cases we will often begin certain medications to try to help minimize the discomfort, and we will often have our pain specialists in the Department of Anesthesiology see the children as well. Indicate research efforts (include dates please) conducted by you specific to brachial plexus injuries. We performed a review of infants with brachial plexus palsy to try to determine the importance of elbow flexion in making the decision to operate. This study will be published in 2007. We wrote a review of evaluative and surgical techniques for brachial plexus injury in infants. This work will be published in 2007. Our laboratory is investigating alternatives to the use of nerve grafts for brachial plexus reconstruction. We have published numerous studies on the basic science related to nerve injury as well as new approaches to nerve healing that may help children with these problems. Do you accept any national/governmental payment for services or are you enrolled in any state medicaid plans? Please provide information on these plans and include which states you are enrolled in for medicaid services. This web page lists the insurances which are accepted at our clinic: http://webserver01.bjc.org/sfnet/slch/PhysicianProfile.asp?DrNo='1034247' We have been able to treat children from many states, including Arkansas, Florida, Georgia, Illinois, Indiana, Kansas, Kentucky, Missouri, Mississippi, New Hampshire, Tennessee, Texas, Virginia, Washington and others. For more information, call my secretary, Carrie. Her number is 314-747-1193. |
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