The hand is supplied by a group of nerves coming from the spinal cord at the level of the neck.  It is fairly fixed at the site where they leave the spinal cord and below where they enter into the arm.  Any injury which increases the distance between the neck and the shoulder has the risk of injuring the brachial plexus of nerves. This commonly happens when people fall off the motor cycles. Sudden deceleration with high kinetic energy  can  cause  severe  brachial plexus injuries.  Total plexus lesions tear  off  all roots from the spinal cord. THE RESULT COULD BE DEVASTATING- the whole of the upper limb may become flail with no sensation or a group of muscles may not work, thereby resulting in permanent paralysis to that side of the limb .

 The diagnosis of brachial plexus  is based on clinical and special  investigations to know  the exact level of the lesion.  Microsurgical techniques, have improved  the prognosis of nerve injuries  dramatically. It  has brought about a more aggressive attitude in brachial plexus management. The Hand and Microsurgery Department of Ganga Hospital is happy to dedicate itself to the care of this challenging problem. 

    The injury could be stretch of the nerves or total rupture. If the level of injury is outside the bony spinal canal, repair of the nerves may be possible. If the injury happens inside the  bony spinal canal direct repair of the nerves is not possible. Even in such cases salvage of function by rerouting of nerves (neurotisation), or tendon transfers may be done.  The field of Brachial plexus injuries is one of the newer  frontiers of Hand Surgery.  The advent of microsurgery has dramatically improved the results in many patients.  From a situation of uniform gloom, we have now reached the stage of guarded optimism. The Hand unit of Ganga Hospital is actively involved in managing such problems.

When should the patient be first seen?

It is better to be under the care of the expert team from the beginning.  If it could be confirmed that the injury is inside the bony spinal canal, rehabilitative surgery could be done early.  Good clinical examination and investigations like CT myelogram and nerve conduction studies are usually done.  Otherwise a waiting period of 3 to 4 months is appropriate. Then a detailed clinical examination is done followed if necessary by a fresh set of investigations.  Better results are obtained if  nerve surgery is done within 6 months from injury. If the patient is seen later, tendon transfers or free muscle transfers after nerve grafts can be done. 

Are operations worthwhile?

    In most cases yes. As a general rule, one can recommend the repair of nerve lesions as early as possible, as this ensures better outcome.  There is a saying, ‘For those who have nothing, a little is a lot’.  Results of Brachial Plexus surgery must be evaluated on those lines.  In most cases it is possible to stabilize the shoulder, restore elbow flexion, to establish protective sensation. It is  a marked improvement for the patient and beyond any expectation even a few years ago. Nerve recovery may proceed for many  months.  It is important to have regular physiotherapy  till recovery , which is around 9 months to one year in most cases.

What are the types of Surgery ?

1.  Direct Nerve Surgery
2.  Tendon Transfers

1.  Direct Nerve Surgery
     Direct Nerve Surgery consists of exploring the brachial plexus and depending on the intraoperative finding one of the following can be carried out

a. Neurolysis : Consists of freeing the Nerves caught in the scar(fig. )
b. Direct repair : When the ends are cleanly cut like in a stab injury they can be directly repaired
c. Primary Nerve Grafts : When the gap is more the cut ends can be joined by nerve grafts (fig.i to iii)
d. Neurotisation : When all roots are avulsed, nerves such as spinal accessory, phrenic , intercostal can be used to neurotise important nerves responsible for specific functions in the upper limb.

Surgery and good rehabilitation programmes result in a good assisting hand to the other hand. Whether requiring surgery or not, every patient with Brachial plexus injury needs proper evaluation of an expert team, counseling and rehabilitaion.

    The increased incidence of road traffic accidents in our city roads has resulted in higher frequency of brachial plexus injuries. The highly convenient means of transportation in our overcrowded cities, the scooter and motorcycles are the main cause of  these injuries. Though it is neither practical or sensible to attempt to restrict their use, safe driving and due precautions can bring down the incidence of this devastating injuries. For those unfortunate few who end up with these injuries microsurgery offers a ray of hope.