What are the current trends in surgical management of brachial plexus (nerve network that conducts signals from the spinal cord to the shoulder, arm, and hand) injuries?

From the Guidelines

The current trends in surgical management of brachial plexus injuries prioritize early intervention, typically within 3-6 months of injury, to maximize functional recovery and minimize morbidity and mortality. According to the most recent and highest quality study, 1, penetrating and open injuries to the brachial plexus are often managed with early surgical exploration, whereas blunt and closed injuries may be managed nonoperatively or surgically, depending on the location and severity of the injury.

Key Considerations in Surgical Management

• Preoperative evaluation has improved with high-resolution MRI neurography and electrodiagnostic studies to precisely locate lesions, as noted in 1.
• Microsurgical techniques remain the foundation of treatment, with nerve transfers becoming increasingly preferred over traditional nerve grafting due to shorter regeneration distances and improved outcomes.
• Common transfers include spinal accessory nerve to suprascapular nerve for shoulder abduction, and intercostal nerves to musculocutaneous nerve for elbow flexion.
• Targeted muscle reinnervation is gaining popularity for pain management in complete avulsion injuries.

Recent Recommendations and Guidelines

• A study from 2020, 1, recommends emergency surgical decompression within 24 hours after the neurological deficit to improve long-term neurological recovery in patients with traumatic spinal cord injury or lumbosacral plexus injury.
• However, the most recent study, 1, provides more specific guidance on the management of brachial plexus injuries, emphasizing the importance of early intervention and individualized treatment approaches.

Emerging Trends and Technologies

• Nerve conduits and processed nerve allografts are now used for shorter nerve gaps (<3cm), reducing donor site morbidity.
• Free functioning muscle transfers, particularly the gracilis muscle, are employed for patients presenting after 12 months.
• Postoperatively, early rehabilitation protocols emphasize motor reeducation and cortical plasticity training.
• Adjunctive treatments include botulinum toxin for co-contractions and specialized bracing.
• Technological advances such as nerve stimulators and robotic-assisted microsurgery are emerging, while research into nerve growth factors and stem cell therapies shows promise for enhancing nerve regeneration.

From the Research

Current Trends in Surgical Management of Brachial Plexus Injury Patients

• The current trends in surgical management of brachial plexus injury patients involve a multidisciplinary team approach, including peripheral nerve surgeons, neurology, hand therapy, physical therapy, pain management, social work, and mental health 2.
• The initial diagnosis includes a detailed history, comprehensive physical examination, and critical review of imaging and electrodiagnostic studies 2.
• Surgical reconstruction depends on the timing of presentation and specific injury pattern, with a full spectrum of techniques including neurolysis, nerve grafting, nerve transfers, free functional muscle transfers, tendon transfers, and joint arthrodesis being utilized 2.
• The best time window for surgery is the first 3 months after injury, and the next best time is the next 3 months, as the neuromuscular junctions degenerate in 20-24 months 3.
• The presence of spontaneous fibrillations in a muscle on electromyography is an indication of denervated yet vital muscle, and the restoration of elbow flexion is a priority followed closely by restoration of shoulder abduction and stabilization 3.

Surgical Strategies and Approaches

• The various surgical strategies in brachial plexus injuries should be directed toward accomplishing the goal of restoring elbow flexion, shoulder abduction, and stabilization 3.
• Distal nerve transfers have become a preferred approach, with studies showing excellent recovery of elbow and shoulder functions 4, 5.
• Exploration of the supraclavicular brachial plexus remains a foundational component of surgical management, despite increasing utilization of distal nerve transfers, with most surgeons routinely exploring the supraclavicular brachial plexus in situations of pan-plexus and upper trunk injuries 4.
• Nerve transfers for repair of brachial plexus injuries result in excellent recovery of elbow and shoulder functions, with patients who had direct repair of brachial plexus elements in addition to nerve transfers tending to do better than those who had only nerve transfer operations 5.

Outcomes and Prognosis

• The outcomes of brachial plexus surgery have improved significantly with the advent of newer surgical techniques, especially distal nerve transfers 3.
• Global avulsion injuries have a poor outcome due to limited donor sources, whereas partial injuries have a remarkable outcome in a majority of cases 3.
• Studies have shown that nerve transfers can yield partial recovery of shoulder and elbow movements, with muscle reinnervation observed in proximal upper limb muscles 6.
• The extent of improvement is limited, and the use of spinal implants does not justify the risks involved 6.