Novel, composite MRI score may help assess brachial plexus birth injury in infants
Key takeaways:
- A novel, composite score based on MRI findings may aid in surgical decision-making for patients with brachial plexus birth injury.
- MRI may help assess surgical indications faster than traditional evaluation.
A protocol of non-contrast MRI without sedation may aid in surgical decision-making regarding infants with brachial plexus birth injury, according to results of a prospective multicenter study in the Journal of Bone and Joint Surgery.
“Babies are not small adults when it comes to brachial plexus injuries,” Andrea S. Bauer, MD, associate professor of orthopedic surgery at Boston Children’s Hospital, told Healio. “The overall burden of injury to the brachial plexus can be quantified on MRI and used to predict the likelihood of nerve surgery earlier than we can make the decision clinically.”
Bauer and colleagues from the Non-Anesthetized Plexus Technique for Infant MRI Evaluation (NAPTIME) study used non-contrast MRI without sedation to assess the need for reconstructive nerve surgery in 65 infants (aged 28 days to 120 days) with brachial plexus birth injury (BPBI).
“The MRI was interpreted via the NAPTIME score, a compiled score of injury burden throughout the plexus, including both preganglionic and postganglionic injuries,” Bauer and colleagues wrote in the study. “All of the subjects were evaluated with routine clinical examinations up to 6 months of age, by which time the treating surgeon determined whether to offer nerve surgery. Surgeons were blinded to the MRI results.”
Bauer and colleagues then assessed the utility of the NAPTIME score to aid surgical decision-making.
“The NAPTIME score might distinguish which infants will meet the criteria for reconstructive nerve surgery earlier than when the decision can be made clinically,” they wrote.
Overall, Bauer and colleagues found 18 patients (28%) met the criteria for surgery on clinical evaluation. They found the interrater reliability of the NAPTIME score was moderate, with a score of 0.703 (95% CI, 0.582-0.818).
Among patients who met the criteria for surgery, the median NAPTIME score was 16.2. Among patients who did not meet the criteria for surgery, the median NAPTIME score was 7.
Bauer and colleagues found the NAPTIME score predicted meeting the criteria for surgery, with an estimated area under the curve of 0.812 (95% CI, 0.688-0.936). They found a NAPTIME score of more than 13 correlated with a 0.94 specificity and a 0.61 sensitivity for surgical indication.
“There is more work to be done in this field, but in the near term, I think we will see a lot of pediatric brachial plexus centers start to use this non-sedated MRI technique, and, in the long term, hopefully the understanding of all the different possible patterns of injury can help us to tailor surgery in a more patient-specific way,” Bauer said.
Perspective
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We read the article entitled “Early MRI can predict the indication for surgery in brachial plexus birth injury” with great interest, as predicting which infants will benefit from early surgical intervention remains a very controversial issue. While MRI is often used during the workup of birth-related brachial plexus injuries, the quality and, therefore, the utility of the scan is variable.
Using non-sedated rapid MRI, which is commonly used in pediatric patients with hydrocephalus and other intracranial and spine pathology, to analyze the integrity of the brachial plexus and determine the need for early surgical intervention is a novel technique that avoids the need for sedation, contrast agents and radiation exposure. While the results of the study suggest that infants with higher NAPTIME scores met the criteria for surgery more often, it is unclear whether proceeding with earlier operative intervention is beneficial in terms of infant outcomes. Further study of surgical outcomes of early vs. late surgery as predicted by NAPTIME scoring would be of great importance.
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