Treatment of Brachial Plexus Injuries
The treatment of brachial plexus injuries depends critically on whether the injury is open/penetrating (requiring early surgical exploration) versus closed/blunt (which may be managed operatively or non-operatively based on severity), with complete nerve ruptures and preganglionic injuries requiring early operative intervention while incomplete injuries often recover with conservative management. 1, 2
Initial Diagnostic Evaluation
Before determining treatment, proper diagnosis is essential:
- Delay imaging for approximately 1 month after trauma to allow hemorrhage and edema to resolve and for pseudomeningocele formation, which aids in diagnosis 3, 2, 4
- MRI of the brachial plexus with dedicated protocol is the gold standard imaging modality, providing superior soft-tissue contrast to determine injury severity and location 3, 1, 2
- Electrodiagnostic studies (EMG/NCS) should be performed to assess severity and location of nerve injury, correlating with MRI findings 2
Critical Surgical Decision Points
The imaging and clinical evaluation must answer these specific questions that determine treatment:
- Is the injury preganglionic (nerve root avulsion) or postganglionic? Preganglionic injuries have worse prognosis and require different reconstruction approaches 3, 2
- Is the nerve completely ruptured or stretched but intact? Complete ruptures necessitate early operative management 3, 1, 2
- Are there associated findings like pseudomeningocele, spinal cord edema, or neuroma? These indicate more severe injury requiring surgical intervention 3
Treatment Algorithm Based on Injury Type
Open/Penetrating Injuries
- Require early surgical exploration regardless of other factors 1, 2
- Surgical options include neurolysis, nerve grafting, and nerve transfers 5
Closed/Blunt Injuries with Complete Nerve Rupture
- Early operative management is indicated due to worse prognosis 3, 1, 2
- Surgery should be performed within 3-6 months when no signs of recovery are present 6
- Surgical techniques include nerve grafting, nerve transfers, free functional muscle transfers, tendon transfers, and joint arthrodesis 5, 7
Closed/Blunt Injuries with Incomplete Nerve Damage
- Conservative management with physical therapy is appropriate initially 1, 8
- Monitor systematically for spontaneous recovery, which occurs in the majority of patients 6
- Physical therapy modalities include range of motion exercises, muscle stretching, strengthening, manual therapy, and sensory re-education 8
Preganglionic (Root Avulsion) Injuries
- Require surgical reconstruction as spontaneous recovery is unlikely 3, 2
- Reconstruction approaches differ from postganglionic injuries and must be planned accordingly 3, 2
Multidisciplinary Team Requirements
Successful management requires coordination between peripheral nerve surgeons, neurology, hand therapy, physical therapy, pain management, social work, and mental health services 5
Pain Management Considerations
- Initial surgical treatment of the paralysis—including nerve, trunk and root reconstruction, and neurolysis—is effective for treating neuropathic pain in 78% of cases 9
- Ablative or neuromodulative procedures (like dorsal root entry zone lesioning) should be reserved for refractory pain cases that do not respond to initial surgical reconstruction 9
Common Pitfalls to Avoid
- Do not perform surgery too early (before 1 month) when hemorrhage and edema obscure the true extent of injury 3, 2
- Do not delay surgery beyond 3-6 months in cases showing no recovery, as outcomes worsen with prolonged denervation 6
- Do not rely on standard cervical spine or neck MRI protocols—specialized brachial plexus protocols are required for proper evaluation 1, 4
- Do not assume all injuries require surgery—the majority of incomplete injuries recover spontaneously with conservative management 6