ORIGINAL ARTICLE Outcomes from primary surgical reconstruction of neonatal brachial plexus palsy in 104 children Mario G. Siqueira 1 & Carlos Otto Heise 1,2 & Gustavo C. Alencar 1 & Roberto S. Martins 1 & Luciano Foroni 1 Received: 5 November 2018 /Accepted: 17 December 2018 # Springer-Verlag GmbH Germany, part of Springer Nature 2019 Abstract Purpose The outcome from microsurgical reconstruction of neonatal brachial plexus palsy (NBPP) varies, and comparison between different series is difficult, given the differences in preoperative evaluation, surgical strategies, and outcome analysis. To evaluate our results, we reviewed a series of children who underwent surgical treatment in a period of 14 years. Methods We made a retrospective review of 104 cases in which microsurgical repair of the brachial plexus was performed. Strength was graded using the Active Movement Scale. Whenever possible, upper palsies underwent surgery 4 to 6 months after birth and total lesions around 3 months. The lesions were repaired, according to the type of injury: neurolysis, nerve grafting, nerve transfer, or a combination of techniques. The children were followed for at least 24 months. Results The majority of cases were complete lesions (56/53.8%). Erb’ s palsy was present in 10 cases (9.6%), and 39 infants (37.5%) presented an extended Erb’ s palsy. The surgical techniques applied were neurolysis (10.5%), nerve grafts (25.9%), nerve transfers (34.6%), and a combination of grafts and transfers (30.7%). The final outcome was considered poor in 41.3% of the cases, good in 34.3%, and excellent in 24%. A functional result (good plus excellent) was achieved in 58.3% of the cases. Conclusions There is no consensus regarding strategies for treatment of NBPP. Our surgical outcomes indicated a good general result comparing with the literature. However, our results were lower than the best results reported. Maybe the explanation is our much higher number of total palsy cases (53.8% vs. 25% in the literature). Keywords Neonatal brachial plexus palsy . Brachial plexus reconstruction . Nerve grafts . Nerve transfers Introduction Neonatal brachial plexus palsy (NBPP) is an unpredictable complication of childbirth. Despite full awareness of the prob- lem and advances in obstetrics, the incidence of NBPP re- mains around 1.5 cases for every 1000 live births, with a range from 0.5 to 5 [8, 14, 19, 27]. These differences in incidence may depend on the type of obstetric care and the average birth weight of neonates in different geographical regions [57]. Half of the patients present one or more perinatal risk factors, which include macrosomia (birth weight over 4 kg), shoulder dystocia, previous deliveries resulting in NBPP, multiparous pregnancies, assisted delivery (vacuum or forceps), and breech presentation [27, 55]. The extent of brachial plexus injury and consequently its prognosis differ greatly. The pre- vious belief that the majority of children affected (up to 92% [34]) have mild injury, and spontaneous recovery has been replaced by a more realistic view in which the recovery rate is now acknowledged to be much lower, such that only 66% of the patients achieve complete recovery, while 10 to 15% pres- ent some permanent weakness [27, 45]. Although a large number of these patients recover spontaneously to reach a normal or near-normal degree of functioning, surgical treat- ment may be necessary when the lesion is more severe, to avoid persistent neurological symptoms and deficiencies in upper limb development. The first surgical repair for NBPP was recorded early in the twentieth century [30], but the unfavorable outcomes from this and in other early reports made most surgeons skeptical about the long-term results from this type of treatment. It was only in 1981 that Narakas [38] published the first good results from the * Mario G. Siqueira mgsiqueira@uol.com.br 1 Peripheral Nerve Surgery Unit, Department of Neurosurgery, University of São Paulo Medical School, São Paulo, SP, Brazil 2 Clinical Neurophysiology, Department of Neurology, University of São Paulo Medical School, São Paulo, SP, Brazil Child's Nervous System https://doi.org/10.1007/s00381-018-04036-5