From the Guidelines
Brachial plexus injuries should be managed based on the severity of the injury, with mild cases (neuropraxia) treated conservatively and moderate to severe cases (axonotmesis or neurotmesis) potentially requiring surgical intervention within 3-6 months of injury, as recommended by the most recent guidelines 1.
Key Considerations
- The severity of the injury determines the treatment approach, with conservative management recommended for mild cases and surgical intervention for moderate to severe cases.
- Imaging of the brachial plexus, ideally delayed until approximately 1 month following the trauma, can help determine the extent of the injury and guide treatment decisions 1.
- Differentiating between preganglionic (intraforaminal) and postganglionic (plexus) injuries is crucial for treatment planning, with noncontrast MRI being the most appropriate imaging study for this purpose in adult traumatic injury cases 1.
Treatment Approaches
- Conservative management for mild injuries (neuropraxia) includes physical therapy 3-5 times weekly for 3-6 months, pain management using medications like gabapentin or pregabalin, and NSAIDs for inflammation.
- Surgical intervention may be necessary for moderate to severe injuries (axonotmesis or neurotmesis) to repair or graft damaged nerves, with post-surgery rehabilitation typically lasting 12-24 months.
Important Factors
- Early intervention is key to maximizing functional outcomes, as prolonged denervation leads to muscle atrophy and poorer prognosis.
- Psychological support is essential for patients navigating the often lengthy recovery process.
- Complete recovery may not always be possible, especially with root avulsions from the spinal cord, and patients should be aware of the potential for slow nerve regeneration, occurring at approximately 1mm per day.
From the Research
Definition and Function of Brachial Plexus
- The brachial plexus is a series of nerves formed by roots of cervical segments 5 to 8 (C5-C8) as well as the first thoracic nerve (T1) 2.
- It functions to provide sensation and motor innervation to the skin and muscles of the chest and upper limb.
- The brachial plexus is composed of different segments: roots, trunks, divisions, and cords.
Causes and Treatment of Brachial Plexus Injury
- Injuries to the brachial plexus occur relatively frequently and are due mainly to traumatic accidents that lead to traction or compression of the nerve roots 2.
- The treatment of brachial plexus injury requires a team approach, including peripheral nerve surgeons, neurology, hand therapy, physical therapy, pain management, social work, and mental health 3.
- Several surgical treatment options are available, including neurolysis, nerve grafting, nerve transfers, free functional muscle transfers, tendon transfers, and joint arthrodesis 3.
Management of Brachial Plexus Injury
- Management of patients with brachial plexus injuries requires a multidisciplinary team approach to address all aspects of their care simultaneously 4.
- Elective amputation and prosthetic rehabilitation may be considered in some cases, with the best possibility for good prosthetic rehabilitation being the early application of prosthetic devices with intensive occupational therapy 4.
- Oral medications such as pregabalin and gabapentin may be used to manage neuropathic pain following traumatic brachial plexus injury 5, 6.
Diagnosis and Treatment Outcomes
- The initial diagnosis of brachial plexus injury includes a detailed history, comprehensive physical examination, and critical review of imaging and electrodiagnostic studies 3.
- Surgical reconstruction depends on the timing of presentation and specific injury pattern, with the goal of achieving the best possible functional outcomes for patients with brachial plexus injury 3.
- Despite the devastating nature of brachial plexus injuries, comprehensive care within a multidisciplinary team can provide patients with meaningful recovery 3.