title: A systematic review of brachial plexus surgery for birth-related brachial plexus injury.
abstract: OBJECTIVE
  Brachial plexus injury complicates 0.6-2.6 per 1,000 live births. Surgery is sometimes advocated for patients who fail to improve with conservative management. We reviewed the available literature on birth-related brachial plexus palsy in order to provide recommendations for surgical management, using evidence-based criteria.
  
  
  METHODS
  Studies were identified by searching Medline (1966-2002) and the Cochrane Library using the terms brachial plexus, neonate or infant, surgery and natural history. The reference lists of relevant articles were also reviewed. The search was restricted to articles published in English. Each article was classified according to its methodology. Management recommendations were suggested based on the results of the studies identified and the degree of certainty of the available literature.
  
  
  RESULTS
  Twenty-three papers were selected for detailed analysis. There are no randomized controlled trials that have investigated the role of brachial plexus surgery in the management of birth-related brachial plexus palsy. Two prospective studies of relevance were found, one describing the natural history of birth-related brachial plexus injury and one evaluating surgery for these patients. The remainder consisted of retrospective case series. Outcomes from surgical series are generally favorable (level III and V evidence). Direct comparison with the natural history could not be inferred from the series reviewed given the lack of controls.
  
  
  CONCLUSIONS
  There is no conclusive evidence showing a benefit of surgery over conservative management approaches in the treatment of patients with birth-related brachial plexus injuries. Surgery remains a valid practice option given the level III and V evidence suggesting a possible benefit of surgery.
authors.affiliation: Division of Neurosurgery, Department of Surgery, QEII Health Sciences Centre, Dalhousie University, Halifax, NS, Canada.
authors.forename: P Daniel
authors.initials: PD
authors.lastname: McNeely
authors.forename: James M
authors.initials: JM
authors.lastname: Drake
mesh_terms: D001720:Birth Injuries / Q000601:surgery*; D001917:Brachial Plexus / Q000293:injuries* / Q000601:surgery; D002675:Child, Preschool; D019317:Evidence-Based Medicine; D005500:Follow-Up Studies; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D009460:Neurologic Examination; D010043:Outcome and Process Assessment, Health Care; D012189:Retrospective Studies