Brachial Plexus
Brachial plexus injuries are challenging issues. They are a physical and social travesty for the patients and their loved ones. Additionally, they are challenging to treat, for the peripheral nerve surgeon as well as the physical therapists. Due to the technical challenges and the long road to recovery not many surgeons perform brachial plexus operations.
Why is it important to see a brachial plexus or peripheral nerve surgeon for your operation as opposed to a surgeon who is willing to do a brachial plexus or nerve operation?
Patients with a brachial plexus or peripheral nerve injuries require special attention, and a significant investment of both time and effort of their care team. Improvements are slow, and can take up to a year and a half to two years to reach the peak of recovery. During that time the patient will need to be an active participant in splinting, physiotherapy, muscle stimulation therapy. Ideally the entire care team will work in concert and in close communication with each other.
How were brachial plexus injuries treated historically?
For a long time, patients were offered only physiotherapy with expectant recovery of function. Scans and electrophysiological studies were frequently done, but no active surgical effort was made to repair the damaged nerves or plexus. If the patient recovered overtime they were considered lucky. If not, the magnitude of the injury was stated as the cause and the patient’s only remaining option was to adjust to life with their deficits. Eventually tendon transfers were used to augment the patients abilities, however in order for that to work there must be a working motor tendon unit.
What are the current trends in brachial plexus surgery?
A) Nerve laceration, or Neuroma: The level if the injury can be anywhere outside the spinal canal from the neck to the axilla. In such situations a direct repair or a bridging graft of the nerve maybe possible. In those circumstances good results are often possible.
B) Nerve root avulsion: In these cases direct nerve repair or bridging is not feasible. In these cases we take a functioning nerve as a donor nerve and connect it to the healthy end of the avulsed nerve. In this case we may or may not be sacrificing one function (less critical) in order to restore a critical function. The simplest way to think of it is if one two electronics are plugged into a wall via two separate extension cords and a fuse blows on one of the outlets we can then plug our most important appliance into the working extension cord. In order to do that we unplug the other appliance.
Overly Simplified into two types of injuries.
When should the patient be seen?
Regardless of the type of injury timing is important. Once a nerve is repaired it must regrow from the site of injury to the target, which may either be a muscle or a sensory receptor. Once the repair happens, it takes approximately 3 weeks to cross the suture line and then grows at a rate of 1 mm per day until it reaches the target. So if the distance from the injury to the muscle is 30cm the patient can expect it to take one year before they begin to see signs of recovery. So if a patient presents 6 months after an injury, we are already looking at one and a half years from injury to the earliest signs of recovery. After 18 months the motor end plates begin to atrophy. Once that occurs the opportunity for meaningful muscle recovery is lost. HOWEVER THAT DOES NOT MEAN WE ARE OUT OF OPTIONS.
Returning to the question at hand. We should see the patient as soon as possible. The patient can be appropriately assessed as to which nerves are working and which are not. A therapy plan can be put in place and while waiting for return of function a rapport can be established as well as a plan for the event that the nerves do not spontaneously recover.