What specialist should a patient with a brachial plexus injury be referred to for evaluation?

Specialist Referral for Brachial Plexus Injury Evaluation

Patients with brachial plexus injuries should be referred to a peripheral nerve surgeon (neurosurgeon, plastic surgeon, or orthopedic surgeon with specialized training in peripheral nerve surgery) for comprehensive evaluation and management. 1

Primary Specialist Options

First-Line Specialist:

• Peripheral nerve surgeon with expertise in brachial plexus reconstruction, who may be:
  • Neurosurgeon
  • Plastic surgeon
  • Orthopedic surgeon

These specialists have the training necessary to evaluate the complex anatomy of the brachial plexus and determine appropriate surgical interventions when needed.

Supporting Specialists:

As part of a multidisciplinary approach, the following specialists may also be involved:

1. Neurologist - For electrodiagnostic studies and non-surgical management 2
2. Radiologist - For specialized imaging interpretation (MRI brachial plexus is gold standard) 1
3. Physical/Occupational Therapist - For rehabilitation 3
4. Pain Management Specialist - For addressing neuropathic pain 2

Timing of Referral

• Immediate referral for penetrating or open injuries requiring early surgical exploration 1
• Within 1 month for blunt/closed injuries to allow for:
  • Resolution of hemorrhage and edema
  • Development of pseudomeningocele (if present)
  • Optimal imaging conditions 1

Diagnostic Workup Prior to Specialist Referral

1. MRI of the brachial plexus (gold standard - 84% sensitivity, 91% specificity)

   • Should be delayed until approximately 1 month post-injury
   • Should include T1-weighted, T2-weighted, and fat-saturated T2-weighted or STIR sequences 1

2. CT myelography (alternative when MRI is contraindicated)

   • Useful for detecting traumatic cervical nerve root avulsions
   • Limited to evaluating preganglionic nerve root injury 4

Rationale for Specialist Selection

The American College of Radiology guidelines emphasize that brachial plexus injuries require specialized evaluation to determine:

1. Whether the injury is preganglionic (involving intraspinal nerve roots) or postganglionic (involving plexus lateral to the dorsal root ganglion) 4
2. Whether nerve integrity is maintained or complete rupture has occurred 4
3. Appropriate surgical candidates (optimal window for intervention is within 1-3 months post-injury) 1

Clinical Pearls

• Early identification and referral are critical, as the optimal window for surgical intervention is within 1-3 months post-injury 1
• Brachial plexus injuries may be overlooked in complex trauma cases with vascular and orthopedic injuries 5
• The peripheral nerve surgeon will determine the need for procedures such as nerve grafting, nerve transfers, or free functional muscle transfers based on injury pattern 6
• Surgical repair offers the best chance for functional recovery in patients with significant deficits 1

By referring patients with brachial plexus injuries to a peripheral nerve surgeon with specialized training, you ensure they receive the most appropriate evaluation and treatment options for optimal functional outcomes.