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Controversies in Neurology
July 2006

Surgery for Brachial Plexus Palsy: Does Timing Matter?

Author Affiliations

Author Affiliation: Wake Forest University School of Medicine, Winston-Salem, NC. Dr Roach is now with Ohio State University School of Medicine, Columbus.


E. S.RoachMD

Arch Neurol. 2006;63(7):1034-1035. doi:10.1001/archneur.63.7.1034

The art of medicine consists of amusing the patient while nature cures the disease.—Voltaire

Once as a resident I was chided by an attending for not seeing a patient with Bell palsy the same day she was referred. Bell palsy is hardly an emergency, I countered. True, he said, but if you wait too long the weakness will resolve before you begin steroids and the patient will not keep the appointment. Sound business advice, but poor science.

Like patients with Bell palsy, most babies with brachial plexus injury recover spontaneously, making it difficult to prove that a particular therapy is effective or to pinpoint the optimal timing of treatment—if it does work. Seventy-five (88%) of 85 affected babies in 1 report had fully recovered by 1 year of age, leaving only 10 (12%) with persistent dysfunction.1 In another series, half of the babies were dysfunctional at age 6 months but only 2% were severely disabled by 1 year of age.2 Proving that a treatment works at all is difficult when the majority of the patients improve spontaneously and many of the individuals who undergo treatment improve but do not fully recover.3 Showing that earlier therapy is superior to later treatment is even more challenging.