Brachial Plexus Injury

The brachial plexus is a network of intertwined nerves that begins at the neck (the cervical region in the spinal cord) and crosses the upper chest to the armpit that are responsible for sending signals from the spine to the shoulders, arms and hands and for controlling movement and sensation in these limps. An injury to this network, such as from cut, damage, pressure, stress or being forcefully pulled or stretched too far, can disrupt these functions, leading to weakness, sensory loss and varying degrees of paralysis.

In Cuba treatment for a brachial plexus injury typically includes a multidisciplinary team of neurologists, orthopedic surgeons, neurosurgeons, and physical medicine and rehabilitation specialists and involves physical therapy, pain management, and, in severe cases, surgical intervention to repair or graft damaged nerves with the goal of restoring as much function and sensation as possible to the affected shoulder, arm, and hand, alleviate pain, and prevent further complications.

When left untreated a number of complications can develop, including:

• Permanent weakness
• Paralysis of the arm.
• Chronic pain.
• Loss of sensation.
• Muscle atrophy.
• Significant impairment in the ability to perform daily activities.

Types of Brachial Plexus Injuries

The brachial plexus has five anatomic sections. Injuries to the brachial plexus can occur in one or more of these areas:

• Spinal nerves.
• Trunks.
• Divisions.
• Cords.
• Branches.

Brachial plexus injuries vary greatly in severity, depending on the type of injury and the amount of force involved. The main types of brachial plexus injuries include:

• Stretch (neuropraxia): This is the mildest form of brachial plexus injury, commonly caused by stretching or compression of the nerves without tearing. This type of injury often results from sudden trauma, such as sports injuries or falls. This happens when a brachial plexus nerve mildly stretches, which damages the protective covering of the nerve.
• Rupture: This happens when a more forceful stretch of a brachial plexus nerve causes it to tear partially or fully. This type of injury typically results from a high-impact trauma, such as a motorcycle or car accident, and can lead to significant functional impairment if not treated properly.
• Avulsion: This is the most severe type of brachial plexus injury whereby nerve roots are completely torn from the spinal cord. These types of injuries are caused by extreme trauma and can lead to significant and permanent disability if not addressed.

Causes of Brachial Plexus Injuries

Brachial plexus injuries can occur due to different reasons, including:

• Forceful trauma: High-impact accidents such as car crashes or motorcycle accidents, gunshot wounds can cause the brachial plexus to stretch, compress, or tear.
• Athletic injuries: Contact sports like football or wrestling can lead to brachial plexus injuries, often referred to as “stingers” or “burners.”
• Birth Injuries: Difficult births, particularly those involving excessive pulling on the infant’s shoulders, can result in brachial plexus injuries.
• Tumours and Radiation Therapy: Growths near the brachial plexus or radiation treatment for cancers can damage the nerves.
• Inflammatory Conditions: Certain conditions like brachial neuritis can cause inflammation of the brachial plexus.
• Medical trauma: A nerve is cut during a surgical procedure, or damaged by an injection or the positioning of the body during surgery.

Symptoms of Brachial Plexus Injuries

Pain from a brachial plexus injury can range from mild to severe and may be temporary or chronic, depending on the injury’s type and extent. For example, a mildly stretched nerve might cause pain for about a week, whereas a ruptured nerve can lead to severe, long-lasting pain that may necessitate physical therapy and potentially surgery.

• Weakness, numbness or paralysis: In the shoulder, arm, or hand.
• Loss of Sensation: Tingling or numbness in the arm or hand.
• Pain: Intense pain, often described as a burning or electric shock sensation.
• Muscle Atrophy: Wasting away of the muscles in the arm or hand.

Diagnosis of Brachial Plexus Injuries

A comprehensive evaluation is necessary for diagnosing brachial plexus injuries. This may include:

• Physical Examination: Assessing muscle strength and sensation and assessing other injuries.
• Electrodiagnostic Tests: These tests, including electromyograms and nerve conduction studies, measure nerve conduction and muscle signals. They help confirm the diagnosis of a brachial plexus injury, pinpoint the location of the nerve damage, determine its severity, and assess the rate of nerve recovery.
• X-rays: Images of the neck, chest, shoulder and arm to rule out associated bone fractures, especially since brachial plexus injuries typically happen from traumatic injuries.
• Computed tomographic (CT) scan: CT scan is considered the most reliable test for detecting spinal nerve avulsion (pull out) injuries.

Treatment of Brachial Plexus Injuries

There are two main types of treatment for brachial plexus injuries, nonsurgical and surgical.

Non-Surgical Options

Physical therapy: The goal of physiotherapy for brachial plexus injuries is to restore as much function as possible to the affected shoulder, arm, and hand, alleviate pain, improve range of motion, strengthen muscles, enhance sensory perception, and enable the patient to perform daily activities independently and efficiently. Included are:

• Range of motion exercises.
• Strengthening exercises.
• Sensory re-education.
• Manual therapy.
• Joint mobilization.
• Soft tissue mobilization.
• Hydrotherapy exercises.
• Occupational therapy.
• Cold and heat therapy.

Surgical Options

Surgical treatment aims for brachial plexus injuries are to restore function, relieve pain, repair nerve damage, improve mobility, prevent further damage and enhance quality of life.

Surgical intervention for brachial plexus injuries is indicated when there is:

• Severe nerve damage.
• Lack of improvement after 3-6 months of conservative treatment.
• Chronic pain.
• Nerve compression.
• Associated injuries

There are several surgical treatments for brachial plexus injuries depending on the type and severity of the injury and the amount of time that has passed since the injury.

• Nerve repair: This procedure involves meticulously suturing the torn ends of the affected nerves to restore their continuity and facilitate natural healing and regeneration. This surgical procedure is performed when nerves are cleanly severed and can be directly reconnected without undue tension.
• Nerve grafts: This procedure is used to repair brachial plexus injuries by bridging the gap between the severed ends of a damaged nerve with a segment of a healthy nerve taken from another part of the body. This procedure is essential when the nerve ends cannot be directly reconnected without tension.
• Nerve transfers: This procedure is carried out by rerouting functional nerves from less critical muscles to reinnervate muscles or areas that have lost their nerve supply. This procedure is employed when the damaged nerves cannot regenerate or when immediate restoration of function is needed.
• Neurolysis: This surgical procedure is carried out to remove scar tissue or adhesions that are compressing or entrapping the nerves. This process involves meticulously dissecting around the affected nerves to free them from surrounding fibrous tissue, which can impede nerve function and cause pain.
• Tendon transfers: This is a surgical procedure used to in cases where nerve repair or regeneration is not feasible and involves detaching a tendon from its original attachment and reattaching it to a different location to compensate for the impaired muscle, thereby restoring movement and strength to the affected limb.
• Brachial plexus reconstruction: This is an advanced surgical approach that combines multiple techniques, including nerve grafts, nerve transfers, and muscle or tendon transfers for severe or complex brachial plexus injuries.

It’s important to know that depending on the severity of the injury, surgery may not be able to return your arm or hand to its abilities before the injury.