eMedicine Specialties > Orthopedic Surgery > Trauma

Brachial Plexus Injuries, Traumatic: Treatment

Author: Mark R Foster, MD, PhD, FACS, President and Orthopaedic Surgeon, Orthopaedic Spine Specialists of Western Pennsylvania, PC
Coauthor(s): Christopher Chaput, MD, Assistant Professor of Orthopedic Surgery, Texas A&M Health Science Center; Consulting Surgeon, Department of Orthopedic Surgery, Scott and White Memorial Hospital; Robert A Probe, MD, Associate Professor of Orthopedic Surgery, Texas A&M University Health Science Center; Chairman, Department of Orthopedic Surgery, Scott and White Clinic and Memorial Hospital
Contributor Information and Disclosures

Updated: Sep 26, 2008

Treatment

Medical Therapy

Nonoperative treatment of brachial plexus lesions is complex and may best be addressed by an integrated multidisciplinary team that includes a skilled orthotist, occupational therapists, physical therapists, and physicians. Bracing often plays a role in preventing contractures while waiting for recovery after surgery or while waiting for recovery from neuropraxia.

Surgical Therapy

Operative care of the brachial plexus is a highly specialized field that is limited to relatively few tertiary care centers. Wide variation exists in how these injuries are addressed surgically. The availability of subspecialists with experience in the operative management of these lesions is critical if operative management is considered.

In general, the surgical options consist of nerve transfers, nerve grafting, muscle transfers, free muscle transfers, and neurolysis of scar around the brachial plexus in incomplete lesions. Advances in the field are likely to create more surgical options in the future. For example, Carlstedt obtained promising initial results with the repair of preganglionic lesions by replanting nerve rootlets directly into the spinal cord.16 This is a dramatic advance because preganglionic lesions were previously thought to be irreparable.

Related eMedicine topic:
Wound Healing, Nerve

Preoperative Details

Patient selection is key, as these injuries are very complex and vary widely. Other preoperative considerations are timing of intervention, which can be critical, and planning of the repair versus reconstructive nature of specific procedures.17

Initial evaluation centers on examination, particularly sensation and remaining motor function, but electrodiagnostic studies and imaging are integral to planning for any proposed procedure. 

Physical therapy may be important in the prevention of contractures during the period of preoperative observation. However, surgery may proceed without observation if examination and imaging demonstrate the absence of potential for spontaneous recovery.

Immediate exploration with possible end-to-end repair may be indicated in some cases of open injury caused by a sharp object. Unfortunately, blunt-force and avulsion-type injuries are more common; if such an injury is open, nerves may be tagged at debridement, but call for 3-4 weeks for demarcation for delayed repair.

Although timing is controversial for stretch injuries, a period for spontaneous recovery should be allowed. However, too lengthy a delay may result in motor end-plate failure, which typically occurs at 3-6 months.

Reconstruction details are really a matter of planning, as the variety of procedures is large and reconstruction may need to be staged. Many surgeon prioritize the elbow and then the shoulder for reconstructive procedures. The principle considerations are the root level involved and the specific deficits, particularly hand sensibility, wrist extension, finger flexion, wrist flexion, finger extension, and intrinsic function of the hand.18

Examples of nerve grafting include cable grafts of sural nerve with C5 to target shoulder abduction, C6 for elbow flexion, and C7 for elbow and wrist extension.

Intraoperative Details

Primary procedures are repair procedures; secondary procedures are reconstructive.

Open injuries, particularly high-velocity gunshot wounds, call for debridement and immediate repair when possible, or tagging of nerves for delayed repair. External neurolysis should be performed for intraoperative monitoring and electrical studies, or neurolysis alone for nerves in continuity that exhibit a nerve action potential (NAP). The NAP can demonstrate preserved axons or significant regeneration, and potential for further recovery; a neurapraxic lesion shows no NAP, as opposed to axonometric lesions (positive for NAP). Otherwise (no intraoperative NAP) nerve grafting can be done for postganglionic neuromas or neural ruptures.

Somatosensory evoked potentials (SSEPs) demonstrate continuity between the CNS and the peripheral nervous system via a dorsal root ganglion (DRG). Postganglionic lesions do not have SSEPs.

Nerve grafting or nerve transfers (neurotization) may be performed for preganglionic injury (ie, intact cell bodies in DRG) or to reduce reinnervation time, usually within 6 months of the trauma.

Postoperative Details

Expectations after surgery are not for immediate recovery, but instead for a slow process requiring significant patient and family education and involvement. Physical therapy is critical to safely maintain joint motion and suppleness, as well as supports for protection. Electrical stimulation is controversial but may at least have psychological benefit.

Follow-up

Follow-up should be prolonged, as neural recovery time is lengthy, with a regeneration rate of 1 mm per day (1 inch per month). Tendon and free muscle transfers as well as arthrodeses may be critical to restoring some function; even marginal improvements may be functionally significant.

Physical therapy and bracing often are used over the prolonged postoperative period to prevent contractures, to keep joints supple after surgery, and to reinforce the need for patience from patient and family.

Complications

Contractures related to certain types of incisions have been reported. In some exposures, the spinal accessory nerve is at risk and should be protected. More specific complications are variable and depend on the exact type of procedure performed.

Deafferentation pain can be one of the most difficult problems for the clinician to treat after brachial plexus injuries. This pain syndrome may occur after surgical repair or with conservative treatment of brachial plexus lesions. When the nerve roots are avulsed in preganglionic lesions, the cells in the dorsal column are robbed of their nerve supply. Shortly after the injury (days to weeks), spontaneous signals are generated in these cells. These spontaneous signals can result in intractable pain for the patient. Patients often report severe burning in the extremity, and they may describe the pain as shooting or crushing. Typically, the pain is severe and has a paroxysmal component.

Treatment of deafferentation pain begins with conservative measures. A pain management team should be involved early, and admission is often helpful to allow for initiation of treatment with a multidisciplinary approach.19 Antidepressants, anticonvulsants, and narcotics all may have a role, and treatments must be customized to the character of the pain and to the patient. As with other types of neurogenic pain, gabapentin has met with some success in the treatment of deafferentation pain.

Transcutaneous nerve stimulation (TNS) can be considered. TNS may work by preventing the cells in the dorsal column from sending abnormal signals proximally. TNS must be used for a prolonged period, and maximum benefit from the device may not occur for several months. For a total brachial plexus lesion (C5-T1), the stimulators are placed on the front of the chest (C3-C4 dermatome) and on the inner arm (T2 dermatome).

Acupuncture, hypnosis, biofeedback, and various desensitization protocols have been tried with mixed results.

Advances in surgical technique have renewed interest in surgical procedures to disrupt the signals generated in the dorsal reentry zone (DREZ) of the dorsal columns. Thomas and Sheehy documented good pain reduction (75% relief) in about half of the patients in their series.20 Most surgeons reserve such invasive procedures for long-standing severe pain that is refractory to conservative measures.

More on Brachial Plexus Injuries, Traumatic

Overview: Brachial Plexus Injuries, Traumatic
Workup: Brachial Plexus Injuries, Traumatic
Treatment: Brachial Plexus Injuries, Traumatic
Follow-up: Brachial Plexus Injuries, Traumatic
Multimedia: Brachial Plexus Injuries, Traumatic
References
Further Reading

References

  1. Shin AY, Spinner RJ, Steinmann SP, Bishop AT. Adult traumatic brachial plexus injuries. J Am Acad Orthop Surg. Oct 2005;13(6):382-96. [Medline].

  2. Blaauw G, Muhlig RS, Vredeveld JW. Management of brachial plexus injuries. Adv Tech Stand Neurosurg. 2008;33:201-31. [Medline].

  3. Rovak JM, Tung TH. Traumatic brachial plexus injuries. Mo Med. Nov-Dec 2006;103(6):632-6. [Medline].

  4. Akita S, Wada E, Kawai H. Combined injuries of the brachial plexus and spinal cord. J Bone Joint Surg Br. May 2006;88(5):637-41. [Medline].

  5. Webb JC, Munshi P, Saifuddin A, Birch R. The prevalence of spinal trauma associated with brachial plexus injuries. Injury. Sep 2002;33(7):587-90. [Medline].

  6. Goldie BS, Coates CJ. Brachial plexus injury: a survey of incidence and referral pattern. J Hand Surg [Br]. Feb 1992;17(1):86-8. [Medline].

  7. Narakas AO. The treatment of brachial plexus injuries. Int Orthop. 1985;9(1):29-36. [Medline].

  8. Leffert RD. Green's Operative Hand Surgery. 4th ed. New York, NY:. Churchill Livingstone;1999:1557-1587.

  9. Rohde RS, Wolfe SW. Nerve transfers for adult traumatic brachial plexus palsy (brachial plexus nerve transfer). HSS J. Feb 2007;3(1):77-82. [Medline].

  10. Moiyadi AV, Devi BI, Nair KP. Brachial plexus injuries: outcome following neurotization with intercostal nerve. J Neurosurg. Aug 2007;107(2):308-13. [Medline].

  11. Suzuki K, Doi K, Hattori Y, Pagsaligan JM. Long-term results of spinal accessory nerve transfer to the suprascapular nerve in upper-type paralysis of brachial plexus injury. J Reconstr Microsurg. Aug 2007;23(6):295-9. [Medline].

  12. Millesi H. Brachial plexus injuries. In: Chapman MW, Szabo RM, Mann RA, et al, eds. Chapman's Orthopaedic Surgery. Philadelphia, Pa:. Lippincott Williams & Wilkins;2001:1703-1720.

  13. Boome RS. The hand and upper extremity. In: Boome RS, ed. The Brachial Plexus. Vol 14. Philadelphia, Pa:. WB Saunders Co;1997:1-18.

  14. Amrami KK, Port JD. Imaging the brachial plexus. Hand Clin. Feb 2005;21(1):25-37. [Medline].

  15. Burge P. Diagnostic investigations. In: Boome RS, ed. The Brachial Plexus. Vol 14. Philadelphia, Pa:. WB Saunders Co;1997:19-29.

  16. Carlstedt TP. Spinal nerve root injuries in brachial plexus lesions: basic science and clinical application of new surgical strategies. A review. Microsurgery. 1995;16(1):13-6. [Medline].

  17. Jivan S, Kumar N, Wiberg M, Kay S. The influence of pre-surgical delay on functional outcome after reconstruction of brachial plexus injuries. J Plast Reconstr Aesthet Surg. May 15 2008;[Medline].

  18. Ahmed-Labib M, Golan JD, Jacques L. Functional outcome of brachial plexus reconstruction after trauma. Neurosurgery. Nov 2007;61(5):1016-22; discussion 1022-3. [Medline].

  19. Parry CB. Management of Deafferentation Pain. In: Boome RS, ed. The Brachial Plexus. Vol 14. Philadelphia, Pa:. WB Saunders Co;1997:165-168.

  20. Thomas DG, Sheehy JP. Dorsal root entry zone lesions (Nashold's procedure) for pain relief following brachial plexus avulsion. J Neurol Neurosurg Psychiatry. Oct 1983;46(10):924-8. [Medline].

  21. Doi K, Muramatsu K, Hattori Y, et al. Restoration of prehension with the double free muscle technique following complete avulsion of the brachial plexus. Indications and long-term results. J Bone Joint Surg Am. May 2000;82(5):652-66. [Medline].

  22. Kandenwein JA, Kretschmer T, Engelhardt M, Richter HP, Antoniadis G. Surgical interventions for traumatic lesions of the brachial plexus: a retrospective study of 134 cases. J Neurosurg. Oct 2005;103(4):614-21. [Medline].

  23. Birche R. Surgical Disorders of the Peripheral Nerves. 1st ed. Churchill Livingstone:1998:157-207.

  24. Miller MD. Review of Orthopedics. 3rd ed. Philadelphia, Pa:. WB Saunders Co;2000:519-527.

  25. Tavakkolizadeh A, Saifuddin A, Birch R. Imaging of adult brachial plexus traction injuries. J Hand Surg [Br]. Jun 2001;26(3):183-91. [Medline].

Further Reading

For a further review of adult traumatic brachial plexus injuries, see Shin et al. 1

Plexopathy .
American College of Radiology.  2006.  13 pages.  NGC:005539
 

Keywords

traumatic brachial plexus injury, lesions of the brachial plexus, supraclavicular injuries, upper plexus injuries, lower plexus injuries, shoulder injuries

Contributor Information and Disclosures

Author

Mark R Foster, MD, PhD, FACS, President and Orthopaedic Surgeon, Orthopaedic Spine Specialists of Western Pennsylvania, PC
Mark R Foster, MD, PhD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Physical Society, Christian Medical & Dental Society, Eastern Orthopaedic Association, North American Spine Society, Orthopaedic Research Society, and Pennsylvania Orthopaedic Society
Disclosure: Nothing to disclose.

Coauthor(s)

Christopher Chaput, MD, Assistant Professor of Orthopedic Surgery, Texas A&M Health Science Center; Consulting Surgeon, Department of Orthopedic Surgery, Scott and White Memorial Hospital
Christopher Chaput, MD is a member of the following medical societies: Texas Medical Association
Disclosure: Nothing to disclose.

Robert A Probe, MD, Associate Professor of Orthopedic Surgery, Texas A&M University Health Science Center; Chairman, Department of Orthopedic Surgery, Scott and White Clinic and Memorial Hospital
Robert A Probe, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Medical Association, American Orthopaedic Foot and Ankle Society, AO Foundation, Orthopaedic Trauma Association, and Texas Medical Association
Disclosure: Stryker Orthopaedics Consulting fee Consulting

Medical Editor

Jeffrey L Visotsky, MD, Assistant Professor, Department of Clinical Orthopedic Surgery, Northwestern University
Jeffrey L Visotsky, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association for Hand Surgery, American College of Physician Executives, American College of Surgeons, American Medical Association, American Society for Surgery of the Hand, Arthroscopy Association of North America, Chicago Medical Society, and Illinois State Medical Society
Disclosure: Depuy Consulting fee Speaking and teaching; Pegasus Honoraria Board membership

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Samuel Agnew, MD, FACS, Associate Professor, Departments of Orthopedic Surgery and Surgery, Chief of Orthopedic Trauma, University of Florida at Jacksonville; Consulting Surgeon, Department of Orthopedic Surgery, McLeod Regional Medical Center
Samuel Agnew, MD, FACS is a member of the following medical societies: American Association for the Surgery of Trauma, American College of Surgeons, Orthopaedic Trauma Association, and Southern Orthopaedic Association
Disclosure: Nothing to disclose.

CME Editor

Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital
Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association of Physicians of Indian Origin, American College of International Physicians, and American College of Surgeons
Disclosure: Nothing to disclose.

Chief Editor

Mary Ann E Keenan, MD, Professor, Vice Chair for Graduate Medical Education, Department of Orthopedic Surgery, University of Pennsylvania School of Medicine; Chief of Neuro-Orthopedics Program, Department of Orthopedic Surgery, Hospital of the University of Pennsylvania
Mary Ann E Keenan, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, American Society for Surgery of the Hand, and Orthopaedic Rehabilitation Association
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.