Brachial plexus is an intricate network of nerves formed by the coalesce of C5-C8 cervical and T1 thoracic roots from the spinal cord. The nerves arising from this complex network subsequently provide the movements and sensation to the entire upper limb. Injuries to the brachial plexus can be very disabling as they cause paralysis of the movement of the upper limb and preclude effective use of the upper limb. These injuries are caused by high velocity trauma like road traffic accident or fall from height. In India, two wheelers accident are the commonest cause and 90% of our patients have been victim of fall from two wheelers. Consequently, young adults are commonly affected with this injury. These injuries are ‘life altering’ as they may result in substantial physical disability, psychological distress and socioeconomic hardship. However, with the recent advances in the treatment of these injuries most of these patients can be helped and made better to an extent that they can lead an active and productive life and still achieve their future goal they aspired to before the injury.
The signs and symptoms vary greatly depending on the severity and location of the injury. An electric shock like feeling radiating down the arm with temporary weakness is seen with the mild injuries. Complete lack of movement, loss of sensation, severe pain and permanent weakness point toward a more severe form of injury.
The extent of spontaneous recovery following a brachial plexus injury is variable and unpredictable. It requires frequent and thorough clinical examination over the first three months after injury to look for the signs of recovery. 90% to 100% of mild stretch injuries (pure neurapraxia) would recover within this period. During this period, the patient will be asked to follow a physiotherapy protocol to keep the joints supple, prevent stiffness and strengthen the working muscles. The patient might be asked to undergo radiological (X-rays of chest and cervical spine, MRI) and electrodiagnostic (NCV, EMG) investigations to look for associated injuries and to define the extent and level of the brachial plexus injury.
Surgery is treatment of choice in patients who have not shown any spontaneous recovery in first 6-10 weeks. If there is some spontaneous recovery, observation period could be extended but surgical intervention should not be overly delayed as the outcome of nerve surgery is inferior if surgery is done after 6 months from the time of injury. Ideally, a global brachial plexus palsy needs surgery at about 2 months and partial brachial plexus injury at about 3 months in absence of any spontaneous recovery. Patients with complete plexus avulsion injuries where the chances of spontaneous recovery are low, surgery can be done with exploration and reconstruction at an earlier period between four to six weeks.
The goal of surgical management is to restore the lost motor function i.e. to regain movements. The specific aim of the surgery would differ with the extent of injury the patient has, nevertheless, any restoration of movement will greatly improve activities of daily living and thereby quality of life. However, the surgeon and the patient must understand that the limb function may not return to pre-injury levels following the surgery.
Nerve regeneration happens slowly (1mm/day) and results following surgery takes a long time to be seen clinically. Surgeries performed beyond six months are associated with less favorable outcomes as the motor endplates of the target muscles start degenerating following denervation.
More than half of these patients with brachial plexus injury experience disturbing neuropathic pain. Nerve surgery often does not directly address the pain as the cause is at the spinal cord and brain level, but studies have shown that there is some reduction of pain following exploration of brachial plexus and neurolysis. It can be reduced to some extent with pharmacological measures (antidepressants amitryptaline, anticonvulsants- gabapentin, pregabalin) and intractable pain not responding to the pharmacological measures may need surgical procedures as last resort (dorsal root entry zone ablation) for some relief.
The surgical procedures can be any of the following depending on the type and severity of the injury:
Post-OP after 1 year
Restoration of elbow flexion in a patient with C5,6,7 palsy. Note the wrist and finger extension after tendon transfers
Spinal accessory nerve to musculocutaneous nerve transfer- Pre-op and Post-op after 1 year
Post- operative management: Patients who underwent nerve surgery are advised for total immobilisation of the extremity for four weeks following which joint mobility exercises and electrical stimulation are started. They are provided printouts about the therapy and charting of the electrical stimulation to done twice a day. Patients who undergo trapezius transfer are immobilised in a shoulder abduction splint for two months and the started-on physiotherapy thereafter. Patients undergoing tendon transfers are asked to review the hospital for supervised physiotherapy sessions at one-month post-surgery.
Results of trapezius transfer and wrist arthrodesis
Free functioning muscle transfer for finger flexion with results after 1 year
In summary, brachial plexus injuries are complex with variable extent, severity and presentation. They need detailed assessment and planning by the experienced team. The surgical options needed for a given patient also vary immensely needing expertise in Orthopedics, plastic surgery and Microsurgery. Brachial plexus Surgery team at Ganga hospital provides a comprehensive ‘complete’ solution to all the brachial plexus related problems. With experience of managing more than 2000
patients with brachial plexus injury this team is world renown in this field of Hand and Reconstructive Microsurgery.
Brachial plexus injuries are surely ‘life changing’ injuries but surely with the growing expertise in this field for almost all the patients with this injury there is hope!