eMedicine Specialties > Physical Medicine and Rehabilitation > Plexopathy
Traumatic Brachial Plexopathy: Treatment & Medication
Updated: Sep 25, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Rehabilitation Program
Physical Therapy
Depending on local expertise, the rehabilitation program may be undertaken with a physical therapist and/or an occupational therapist. The goals are to preserve ROM, improve strength, and manage pain.
Patients should undergo physical therapy to maintain ROM and to optimize the recovery of motor function as muscle reinnervation occurs.
The goal of treatment is to return function to the structures supplied by the damaged nerves and to improve the patient's quality of life. The injured nerve and the exogenous sources of nerve injury are treated.
At the onset of injury, early mobilization and icing are used. In the subacute phase, therapy gradually progresses from passive to active motion and from assisted to active ROM, as tolerated.
Heat, ultrasonography, transcutaneous electrical nerve stimulation (TENS), interferential current stimulation, and/or electrical stimulation are used, depending on the predominant symptoms.
Cervical muscle strengthening and the correction of upper extremity muscle imbalances are included in the protocol as well.
The use of appropriate slings, the protection of extremities and joints, and the prevention of subluxation must be considered.
Cervical pillows or collars may be required for patients with combined lesions of the roots and plexus.
Occupational Therapy
During occupational therapy efforts are concentrated on maintaining ROM in the shoulder; fabricating appropriate orthoses to support the function of the hand, elbow, and arm; and addressing edema control and sensory deficits, with testing and therapy.
Occupational therapy may address issues related to the patient's ability to write, type, and find alternate ways of communicating.
Additionally, occupational therapy provides help with retraining for activities of daily living (ADLs), including the use of 1-arm techniques, adaptive equipment, and self-ranging and strengthening exercises.
Recreational Therapy
Recreational therapy should address compensatory strategies and activities that can substitute for altered or lost function in extremities that were required for recreation prior to injury.
Medical Issues/Complications
- Complications may include intractable pain syndromes, such as persistent neuropathy and complex regional pain syndrome type 2 (CRPS II or causalgia), skin damage and infection, significant muscle atrophy, contractures and capsulitis, subluxations, sensory loss, osteopenia, heterotopic ossification, myofascial pain, and depression and anxiety.
- Bone dislocation with neurologic deficit requires prompt anatomic reduction to prevent irreversible nerve damage.
- The use of analgesics can help patients control pain from nerve injuries. Steroids may help to decrease endoneurial edema associated with nerve injury.
- Hyperbaric oxygen decreases vascular compromise of the vasa nervorum, as well as endoneurial edema and pressure. Hyperbaric oxygen is an approved adjunctive treatment for acute traumatic ischemic reperfusion injury.
- Ciliary neurotrophic factor (CNTF), which enhances motor neuron survival in vivo and in vitro, is in the investigational stage.
Surgical Intervention
Surgery is reserved for patients in whom symptoms persist despite appropriate conservative treatment.6,14,15,16 Two important issues to consider before surgery are as follows: (1) whether function can be obtained after the nerve is repaired and (2) whether the potential benefit to the patient outweighs the surgical risks, costs, and loss of productivity. The timing of surgery is important as well.17
Other factors to consider are as follows:
- In clean lacerating injuries in which the nerve ends are visible in the wound or when clinical examination reveals obvious motor and sensory deficits from the laceration, immediate primary repair may be indicated.
- In blunt transections resulting from lacerations, delayed repair has a better surgical result.
- Injuries without evidence of early spontaneous recovery, such as those caused by bullets, crushing blows, traction, fractures, or injections, are explored several months after the injury.
- Brachial plexus stretches or contusions are observed for 4 months. If no evidence of recovery is present, the plexus is explored.
- Nerve or tendon transfers may be necessary if nerve repair is unsuccessful.18
- Brachial plexus injuries are not always reparable. In such cases, neurotizations or nerve transfers may offer a better functional outcome.
- Sunderland suggests 2 criteria that must be present before fascicular repair or interfascicular grafting is considered:
- The fascicular bundle must be large enough for suturing.
- The bundle must be sharply localized or sufficiently well defined so that it can be identified and mobilized for repair.
- The spinal accessory or long thoracic nerve can be grafted onto distal arm nerve trunks, with some improvement in elbow flexion.
- Intraoperative care with proper axial orientation of the fascicles, hemostasis, suture material, and suture line tension leads to better outcomes. Tension of the suture line and inadequate preparation of the nerve stumps are 2 leading causes of regenerative failure across the suture site (resulting in poor recovery of nerve function).
- Surgical repairs are most effective within 3 months of the injury.19 Surgical delays in excess of 5 months dramatically decrease the rate of functional return.
- When repair does not provide adequate results, planned tendon transfers can increase extremity function.
- Rarely, in cases of a complete multilevel injury (eg, flail injury, anesthetic arm), amputation may result in a better functional outcome, because the patient can use the extremity with an appropriate prosthesis. However, the result may be less cosmetically pleasing than would that obtained with other approaches.
Related eMedicine article:
Hand, Brachial Plexus Surgery
Consultations
- Consultations with an orthopedic surgeon and a neurosurgeon are considered in cases in which there has been poor neurologic and functional recovery.
- A complete multidisciplinary rehabilitation assessment is indicated.20 A consultation with a prosthetic specialist may be required for the fabrication of a temporary or permanent prosthetic device.
- A pain management strategy is of great importance in improving the patient's ability to cope and function and in improving his/her quality of life.
Other Treatment
- In cases of CRPS II, sympathetic (ie, stellate) blockade may be required, along with the appropriate combination of neuropathic and narcotic medications.
- For incomplete, painful injuries, and especially in cases of CRPS II, the use of a spinal cord stimulator on a trial basis may be beneficial. If this trial is successful, the stimulator may be implanted.
- Implantable peripheral nerve stimulators have also been successfully used in some centers.
- The use of an implantable intrathecal device (eg, pump) may be considered in cases in which the employment of oral medications, therapy, and a spinal cord stimulator fail.
Medication
Nonsteroidal anti-inflammatory drugs (NSAIDs) and neuropathic pain medications are most commonly used in the treatment of traumatic brachial plexopathy, depending on the symptoms and the length of time since the injury's occurrence. During the acute phase, narcotic analgesics may also be necessary, but they should not be used for long-term pain management. Narcotic medications are also indicated in the acute postoperative period.
Neuropathic pain medications are useful for the relief of dysesthetic pain in the acute and chronic phases. There is no drug of choice, and medications often must be tried in serial fashion to find one that provides optimal relief for the patient.
Nonsteroidal anti-inflammatory drugs
After acute injury, NSAIDs are particularly helpful in relieving pain related to the injury, including injuries involving soft tissues, such as muscles and ligaments.
Celecoxib (Celebrex)
Inhibits primarily COX-2. COX-2 is considered an inducible isoenzyme, induced during pain and inflammatory stimuli. Inhibition of COX-1 may contribute to NSAID GI toxicity. At therapeutic concentrations, COX-1 isoenzyme is not inhibited; thus, GI toxicity may be decreased. Seek the lowest dose for each patient.
Adult
200 mg/d PO qd; alternatively, 100 mg PO bid
Pediatric
Not established
Coadministration with fluconazole may increase celecoxib plasma concentrations because of inhibition of celecoxib metabolism; coadministration with rifampin may decrease celecoxib plasma concentrations
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
May cause fluid retention and peripheral edema; caution in compromised cardiac function, hypertension, conditions predisposing patient to fluid retention; caution in severe heart failure and hyponatremia (may cause deterioration in circulatory hemodynamics); NSAIDs may mask usual signs of infection; caution in existing controlled infections; evaluate symptoms and signs suggesting liver dysfunction or abnormal liver laboratory results
Naproxen (Naprosyn, Aleve)
For relief of mild to moderate pain; naproxen inhibits inflammatory reactions and pain by reducing the activity of cyclooxygenase, which decreases prostaglandin synthesis.
Adult
500 mg PO followed by 250 mg PO q6-8h; not to exceed 1.25 g/d
Pediatric
<2 years: Not established
>2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d
Coadministration with aspirin increases risk of serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when patient is taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug
Anticonvulsants
The use of certain antiepileptic drugs, such as the GABA analogue gabapentin (Neurontin), has proven helpful in some cases of neuropathic pain. Anticonvulsants have central and peripheral anticholinergic effects, as well as sedative effects, and block the active reuptake of norepinephrine and serotonin. The multifactorial mechanism of analgesia could include improved sleep, an altered perception of pain, and an increased pain threshold. The efficacy of these drugs can be potentiated with the concomitant use of opiates and NSAIDS. Rarely should these drugs be used in the treatment of acute pain, because they may require a few weeks to become effective.
Gabapentin (Neurontin)
Has anticonvulsant properties and antineuralgic effects; however, the exact mechanism of action is unknown. Gabapentin is structurally related to GABA, but it does not interact with GABA receptors. Titration to effect can take place over several days (300 mg on day 1, 300 mg bid on day 2, and 300 mg tid on day 3).
Adult
Day 1: 100 mg PO tid or 300 mg qhs
Day 2: 400 mg PO tid over 3 d and titrate prn; not to exceed 1200 mg PO qid
Pediatric
<12 years: Not established
>12 years: Administer as in adults
Antacids may significantly reduce bioavailability (administer at least 2 h following antacids); may significantly increase norethindrone levels
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in severe renal disease
Tricyclic antidepressants
This is a complex group of drugs that have central and peripheral anticholinergic effects, as well as sedative effects. They have central effects on pain transmission. Tricyclic antidepressants block the active reuptake of norepinephrine and serotonin.
Nortriptyline (Pamelor)
Has demonstrated effectiveness in the treatment of chronic pain. By inhibiting the reuptake of serotonin and/or norepinephrine by the presynaptic neuronal membrane, this drug increases the synaptic concentration of these neurotransmitters in the central nervous system. Pharmacodynamic effects, such as the desensitization of adenyl cyclase and the down-regulation of beta-adrenergic receptors and serotonin receptors, also appear to play a role in nortriptyline's mechanisms of action.
Adult
25 mg PO tid/qid; not to exceed 150 mg/d
Pediatric
<25 kg: Not established
25-35 kg: 10-20 mg/d PO
35-54 kg: 25-35 mg/d PO
>54 kg: Administer as in adults
Cimetidine may increase nortriptyline levels when used concurrently; may increase prothrombin time in patients taking warfarin
Documented hypersensitivity; narrow-angle glaucoma; do not administer to patients that have taken MAOIs in past 14 days
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in cardiac conduction disturbances and history of hyperthyroidism, renal or hepatic impairment; because of pronounced effects in cardiovascular system, best to avoid in elderly
Doxepin (Sinequan, Adapin)
Inhibits histamine and acetylcholine activity; doxepin has proven useful in the treatment of various forms of depression associated with chronic and neuropathic pain.
Adult
10-150 mg/d PO qhs or divided bid/tid
Pediatric
<12 years: Not recommended
>12 years: 25-50 mg/d PO qhs or bid/tid; increase gradually to 100 mg/d
Decreases antihypertensive effects of clonidine but increases effects of sympathomimetics and benzodiazepines; effects of desipramine increase with phenytoin, carbamazepine, and barbiturates
Documented hypersensitivity; urinary retention; acute recovery phase following myocardial infarction; glaucoma
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in cardiovascular disease, conduction disturbances, seizure disorders, urinary retention, hyperthyroidism, and patients receiving thyroid replacement
Analgesics
Narcotics are indicated in the acute injury period and in the postoperative period should reconstructive surgery be required. In rare cases in which patients require long-term opioid use, these patients should use scheduled, longer-acting medications, such as methadone.
Methadone (Dolophine)
Used in the management of severe pain. Methadone inhibits ascending pain pathways, diminishing the perception of and response to pain.
Adult
2.5-10 mg PO/IM/SC q3-8h prn; increase to a maintenance dose of 5-20 mg q6-8h
Pediatric
0.7 mg/kg/d PO/IM/SC divided q4-6h prn, not to exceed 10 mg/dose
Phenytoin, rifampin, and pentazocine may decrease blood levels; phenothiazines, tricyclic antidepressants, MAOIs, and CNS depressants may increase the toxicity
Documented hypersensitivity; bronchial asthma or increased intracranial pressure
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in severe liver disease; titrate dose slowly because of relatively long half-life
Oxycodone (OxyContin, Roxicodone, OxyIR)
Indicated for the relief of moderate to severe pain.
Adult
Immediate release: 5 mg PO q6h prn
Controlled release: 10 mg PO bid
Pediatric
Immediate release:
<6 years: Not established
6-12 years: 1.25 mg PO q6h prn
>12 years: 2.5 mg PO q6h prn
Controlled release: Not established
Phenothiazines may antagonize analgesic effects; MAOIs, general anesthesia, CNS depressants, and tricyclic antidepressants may increase toxicity
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in COPD, emphysema, and renal insufficiency
Oxycodone and acetaminophen (Percocet)
Drug combination indicated for the relief of moderate to severe pain.
Adult
1-2 tab or cap PO q4-6h prn pain
Pediatric
0.05-0.15 mg/kg/dose oxycodone PO; not to exceed 5 mg/dose of oxycodone PO q4-6h prn
Phenothiazines may decrease analgesic effects of this medication; toxicity increases with coadministration of either CNS depressants or tricyclic antidepressants
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Duration of action may increase in the elderly; be aware of total daily dose of acetaminophen patient is receiving; not to exceed 4000 mg of acetaminophen per 24 h; higher doses may cause liver toxicity
Fentanyl citrate (Duragesic)
Potent narcotic analgesic with much shorter half-life than morphine sulfate. Fentanyl citrate is the DOC for conscious sedation analgesia. It is ideal for analgesic action of short duration during anesthesia and for the immediate postoperative period.
Fentanyl citrate is excellent for pain management and sedation with short duration (30-60 min); it is easy to titrate. The drug is easily and quickly reversed with naloxone.
After the initial dose, subsequent doses should not be titrated more frequently than q3h or q6h thereafter.
When the transdermal dosage form used, controlled with 72-h dosing intervals effective in most patients. However, some patients require 48-h dosing intervals.
Adult
Emergency: 0.5-2 mcg/kg/dose IV/IM
Analgesia: 0.5-1 mcg/kg/dose IV/IM q30-60min
Transdermal: Apply a 25 mcg/h system q48-72h
Pediatric
<2 years: 2-3 mcg/kg/dose IV/IM q30-60min
2-12 years: 1-2 mcg/kg/dose IV/IM q60min
>12 years: Administer as in adults
Phenothiazines may antagonize analgesic effects of opiate agonists; TCAs may potentiate adverse effects of fentanyl when both drugs used concurrently
Documented hypersensitivity; hypotension or potentially compromised airway where it would be difficult to establish rapid airway control
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in hypotension, respiratory depression, constipation, nausea, emesis, and urinary retention; idiosyncratic reaction, known as chest wall rigidity syndrome, may require neuromuscular blockade to increase ventilation
Hydrocodone and acetaminophen (Lorcet)
Drug combination indicated for moderate to severe pain.
Adult
1-2 tab or cap PO q4-6h prn pain
Pediatric
<12 years: 10-15 mg/kg/dose based on acetaminophen PO q4-6h prn; not to exceed 2.6 g/d acetaminophen
>12 years: 750 mg acetaminophen PO q4h; not to exceed 10 mg hydrocodone bitartrate per dose or 5 doses/24 h
Coadministration with phenothiazines may decrease analgesic effects; toxicity increases with CNS depressants or tricyclic antidepressants
Documented hypersensitivity; high altitude cerebral edema (HACE) or elevated intracranial pressure (ICP)
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Tablets contain metabisulfite, which may cause hypersensitivity; caution in patients dependent on opiates, because substitution may result in acute opiate-withdrawal symptoms; caution in severe renal or hepatic dysfunction
Tramadol (Ultram)
Inhibits ascending pain pathways, altering perception of and response to pain. Tramadol also inhibits the reuptake of norepinephrine and serotonin.
Adult
50-100 mg PO q4-6h; not to exceed 400 mg/d
Pediatric
Not established
Significantly decreases effects of carbamazepine, cimetidine increases toxicity, risk of serotonin syndrome with coadministration of antidepressants
Documented hypersensitivity; opioid-dependent patients; concurrent use of MAOI or within 14 days; use of SSRIs, TCAs, opioids, acute alcohol intoxication
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Can cause dizziness, nausea, constipation, sweating, pruritus; additive sedation with alcohol and TCAs; abrupt discontinuation can precipitate opioid withdrawal symptoms; adjust dose in liver disease, myxedema, hypothyroidism, hypoadrenalism; pregnancy, breast-feeding; seizure; development of tolerance or dependency with extended use
More on Traumatic Brachial Plexopathy |
| Overview: Traumatic Brachial Plexopathy |
| Differential Diagnoses & Workup: Traumatic Brachial Plexopathy |
 Treatment & Medication: Traumatic Brachial Plexopathy |
| Follow-up: Traumatic Brachial Plexopathy |
| References |
| « Previous Page | Next Page » |
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Further Reading
Keywords
traumatic brachial plexopathy, brachial plexus, brachial, plexopathy, peripheral neuropathy, peripheral nerve injury, thoracic outlet syndrome, brachial plexus injury, brachial plexus injuries, traumatic brachial plexus injury, brachial plexus neuropathy, brachial plexus lesion, stinger injury, stingers, burner injury
