What are the management options for brachial plexus injuries?

Brachial Plexus Injuries: Management Overview

Initial Diagnostic Evaluation

For suspected brachial plexus injury, obtain MRI of the brachial plexus with and without IV contrast using a dedicated protocol—this is the gold standard imaging modality and should be delayed approximately 1 month post-trauma to allow hemorrhage and edema resolution. 1, 2, 3

Key Diagnostic Steps

• Perform electrodiagnostic studies (EMG/NCS) to assess severity and location of nerve injury, correlating with MRI findings 2
• Determine if injury is preganglionic (involving intraspinal nerve roots, worse prognosis) versus postganglionic (involving plexus lateral to dorsal root ganglion)—this fundamentally changes reconstruction approach 2
• Assess nerve continuity: complete ruptures require early operative management while stretched-but-intact nerves may recover 2
• Look for pseudomeningoceles on MRI as surrogate markers for root avulsion 3

Critical Imaging Pitfall

• Standard neck, chest, or spine MRI protocols are inadequate—you must order a dedicated brachial plexus protocol with orthogonal views through oblique planes of the plexus, including T1, T2, fat-saturated T2/STIR, and fat-saturated T1 postcontrast sequences 1, 2, 3

Surgical Management Algorithm

Immediate Surgical Exploration Indicated For:

• Penetrating or open injuries 2, 4
• Subclavian artery damage 4
• Clinical or imaging evidence of root avulsion 4
• Total-type injury 4

Delayed Exploration (3 months) For:

• Upper-type injuries without preganglionic signs—observe for 3 months, then explore if no recovery 4
• During exploration, record spinal cord evoked potential (ESCP) or somatosensory evoked potential (SEP) to determine injury site 4

Surgical Techniques Based on Injury Pattern:

• Nerve grafting: indicated for ruptures in roots with positive ESCP/SEP, in trunk, or in cord—achieves >M3 power in infraspinatus (70%), deltoid (70%), and biceps (70%) when exploration extends distally 4
• Intercostal nerve transfer: recommended for root avulsion to restore elbow flexion—achieves >M3 elbow flexion in 70% of patients, with best results in patients <30 years old operated within 6 months 4
• Neurolysis, nerve transfers, free functional muscle transfers, tendon transfers, and joint arthrodesis are additional options depending on specific injury pattern 5, 6

Timing Considerations:

• Operate within 6 months for favorable outcomes in shoulder and elbow function restoration 6
• Best results for intercostal nerve transfer occur in patients younger than 30 years receiving surgery within 6 months 4

Non-Operative/Rehabilitation Management

Physical Therapy Modalities:

• Kinesiotherapy: range of motion exercises, muscle stretching, and strengthening 7
• Electrothermal and phototherapy 7
• Manual therapy and sensory re-education strategies 7
• Dynamic assist orthosis for muscle reeducation—provides graded system to prevent myostatic contractures, minimize atrophy, facilitate muscle fiber recruitment 8

Conservative Management Indications:

• Parsonage-Turner syndrome (neuralgic amyotrophy): managed conservatively with physical therapy to maintain range of motion and monitoring for recovery 1
• Upper-type injuries without preganglionic signs: initial 3-month observation period 4

Multidisciplinary Team Requirements

Successful management requires coordination between peripheral nerve surgeons, hand therapists, physical therapists, pain management specialists, mental health providers, and social workers to address the profound physical, psychosocial, mental, and financial impacts. 5, 6

Prevention of Perioperative Brachial Plexus Injury

Positioning Guidelines:

• Limit arm abduction to 90° in supine patients 9
• Use padded armboards to decrease upper extremity neuropathy risk 9
• Place chest rolls under dependent lateral thorax in laterally positioned patients 9
• Avoid shoulder braces in steep head-down position 9
• Periodically assess upper extremity position during procedures 9

Preoperative Risk Assessment:

• Screen for body habitus, preexisting neurologic symptoms, diabetes mellitus, peripheral vascular disease, alcohol dependency, and arthritis 9
• Perform simple postoperative assessment of extremity nerve function in PACU for early recognition 9

Prognostic Factors

• Complete nerve ruptures have worse outcomes and require early operative intervention 2
• Motor recovery of hand function remains poor even after intercostal nerve transfer, though protective sensation can be restored in median nerve distribution 4
• Forearm muscle recovery after nerve grafting is very poor 4
• Hand function restoration remains challenging in complete brachial plexus injuries 6