When a baby’s nerves tear away from spinal cord during birth

A photo showing a baby with a birth brachial injury

Birthing is a delicate process suspended between hope and uncertainty. This moment calls for the medical personnel to be extra careful. Possible complications are not just limited to the mother; infants also face imminent danger.  

Among these dangers is Birth Brachial Plexus Palsy (BBPP), a condition that can rob a child of movement in their arm. It can render a tiny limp to never move, turning what should be a milestone that brings joy into frustrations and sometimes tears.

Dr Dorsi Jowi, a consultant plastic and reconstructive surgeon and hand specialist, was the lead surgeon during the first successful BBPP surgery at the Kenyatta National Hospital on a four-year-old girl recently. 

She explains the brachial plexus as a network of nerves that supply the upper limb. She says that it comes from the upper part of the spinal cord, in the neck and gives both movement and sensation to the arm.

In birth brachial plexus injuries, these vital nerves are stretched, ruptured or even torn away from the spinal cord, most often during the birthing process itself, particularly if the delivery is complicated or the baby is larger than average.

She says: “The majority of the causes are usually difficult labours, especially with bigger babies, whereas the baby passes through the birth canal, the neck and shoulder might be pulled in opposite directions. This causes a traction injury to the nerves.”

She says that this type of injury may present itself immediately at birth. She notes that with brachial plexus injuries, you will notice almost immediately that the baby is not able to move their affected limb. An observant paediatrician or parent may notice one arm remains motionless or held unnaturally close to the body while the other moves freely.

While the diagnosis is often immediate, the road to recovery is more complex. “Surgery is not always done at birth. Our first job is to assess the child and find out which level of the brachial plexus has been injured,” Dr Dorsi notes. “Not all injuries require surgery, and about 80 per cent will recover, although that recovery is rarely full functional recovery."

The surgical decision depends upon the type and extent of nerve damage, which may be: Neuropraxia, which is stretching with no actual severing of the nerve and usually heals with therapy alone; Rupture, where the nerve is torn but still attached to the spinal cord; and avulsion where the nerve is completely torn away from the spinal cord.

“In cases of rupture, surgery may involve finding the two ends and directly repairing them. If the gap is too wide, we use a 'nerve graft'—borrowing a nerve from elsewhere in the body to bridge it,” Dr Dorsi explains. For avulsion, where direct repair is impossible, surgeons may perform a “nerve transfer” using donor nerves from other areas.

On treatment, Dr Dorsi says that it is a multidisciplinary path. “It is always a team approach,” says Dr Dorsi. “We work alongside physiotherapists, occupational therapists, paediatricians and neurologists. Selecting a procedure depends on factors like the type of injury, severity and how much function is returning over the first few months.”

She says that surgical intervention is usually considered between four and nine months of age if there’s no meaningful recovery. “The earlier we do the surgery, the better the outcomes, but even at two or four years old, we may still help by releasing tight muscles or performing additional operations,” Dr Dorsi adds.

While nerve surgery can never offer a 100 per cent guarantee, the potential for life-changing improvement is real.

“One of the main improvements is the ability to lift the shoulder and bend the elbow. That alone transforms what the child can do; it means they can reach, grab and do activities that would otherwise be impossible,” Dr. Dorsi says.

She says families can expect functional improvement of 80–90 per cent, particularly when diligent post-surgical physiotherapy is paired with the operation. She adds that recovery is never ‘full function,’ but physiotherapy and consistent care can make an enormous difference.

Dr Dorsi, however, says that not all children with BBPP require surgery. For milder injuries, physiotherapy is key. Stretching and exercising the limb helps maintain flexibility in joints and strength in muscles. Even children who undergo surgery need ongoing non-surgical management to increase function.

Despite the technological advancement, this surgery still has its barriers. “The surgery itself is costly and lengthy, often taking about six hours. The specialised equipment, the surgical expertise and the need for a pediatric anesthesiologist all make it more expensive. In Kenya, there are currently only two or three specialists trained to do this kind of surgery."

Late referrals and lack of awareness among both the public and healthcare providers mean many children simply miss the window when surgery is most effective.

“We want families and professionals to know there is an option for nerve surgery in infancy that can make a huge difference. If you see a baby with this condition, refer them to a specialist early,” urges Dr Dorsi.

For families facing this daunting diagnosis, the path ahead requires courage, commitment and hope. With the advancement in surgery and the dedication of interdisciplinary teams, many children affected by birth brachial plexus palsy can look to the future with hope that it can be corrected.