Traumatic Brachial Plexopathy Treatment & Management

Physical Therapy

Depending on local expertise, a 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.

A literature review by de Santana Chagas et al found that in adults with brachial plexus injury, physical therapy most often involved kinesiotherapy (such as ROM exercises, muscle stretching, and strengthening techniques), electrothermal treatment, phototherapy, manual therapy, and sensory reeducation. ^[28]

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.

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.

Surgery is reserved for patients in whom symptoms persist despite appropriate conservative treatment. ^{[3, 4, 5, 6, 7, 8, 29]} 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. ^[30]

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. ^{[31, 32]}

Brachial plexus injuries are not always reparable. In such cases, neurotizations or nerve transfers may offer a better functional outcome. ^[9]

Sunderland suggests 2 criteria that must be present before fascicular repair or interfascicular grafting is considered ^[33] :

• 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.

A literature review by Ali et al indicated that in adult upper trunk brachial plexus injuries, the Oberlin nerve transfer procedure is more effective in restoring elbow flexion than nerve grafting or combined grafting/transfer techniques. The study also found that nerve transfer in general is more effective than grafting or combined procedures in restoring shoulder abduction. ^[34]

A literature review by Vernon Lee et al indicated that in patients with traumatic brachial plexus injury, the type of nerve transfer they undergo affects the likelihood of whether they will attain elbow flexion of grade 4 (M4) or higher on the (British) Medical Research Council scale of 0-5. Patients who underwent double Oberlin transfer or two intercostal nerve transfers seemed more likely to achieve M4 or greater than did those treated with other techniques, such as single Oberlin, thoracodorsal, or phrenic transfer or three intercostal nerve transfers. The investigators also found evidence that in patients with complete traumatic brachial plexus injury (pan-plexus injury), the chance of reaching M4 or higher was reduced by 7% for each month that surgery was delayed post injury. Individuals in the study were aged 16 years or above. ^[35]

Intraoperative care with proper axial orientation of the fascicles, hemostasis, suture material, and suture line tension leads to better outcomes in brachial plexus surgery. 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).

Although there has been controversy over whether brachial plexus reconstruction can effectively restore elbow function in patients over age 50 years who have sustained traumatic brachial plexus injury, a report by Gillis et al indicated that such surgery can benefit these individuals. In the study, patients in this age group underwent nerve grafting, nerve transfer, or free functional muscle transfer, with an average 24-month follow-up. While no cohort members demonstrated a Medical Research Council flexion grade as high as M3 preoperatively, the majority of patients reached M3 or above postoperatively, although better results were achieved with nerve transfer than with muscle transfer. ^{[36, 37]}

Surgical repairs are most effective within 3 months of the injury. ^[38] Surgical delays in excess of 5 months dramatically decrease the rate of functional return. (However, a study by Wang et al reported that strength and range of motion for the shoulder and elbow continued to improve beyond 2-3 years postsurgery in adult patients who underwent nerve reconstruction for brachial plexus injury. ^[39] )

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 Medscape Drugs & Diseases article:

Brachial Plexus Hand Surgery

See the list below:

• 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. ^[40] 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.

See the list below:

• 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.