Treatment Options for Brachial Plexus Injury
Initial Diagnostic Evaluation
MRI of the brachial plexus with a dedicated protocol is the gold standard first-line imaging test and should be obtained in all suspected cases. 1, 2, 3 This provides superior soft-tissue contrast and spatial resolution compared to all other modalities, with 81% sensitivity, 91% specificity, and 88% accuracy. 3
Critical Diagnostic Determinations
The imaging and clinical evaluation must answer three key questions that directly determine treatment approach:
Preganglionic vs. postganglionic injury: Preganglionic injuries (nerve root avulsions within the spinal canal) have worse prognosis and different reconstruction options than postganglionic injuries (plexus damage lateral to the dorsal root ganglion). 2, 3 MRI can identify pseudomeningoceles as surrogate markers for root avulsion. 3
Complete rupture vs. stretch injury: Complete nerve disruptions require early operative management, while stretch injuries (neurapraxia or axonotmesis) often recover spontaneously. 2, 4, 5
Open/penetrating vs. closed/blunt injury: Penetrating and open injuries typically require early surgical exploration, while blunt and closed injuries may be managed operatively or non-operatively depending on severity. 2, 6
Imaging Protocol Specifications
Delay imaging until approximately 1 month post-trauma to allow resolution of hemorrhage and edema and for pseudomeningocele formation. 2, 3
Use dedicated brachial plexus MRI protocol (not standard neck/chest/spine MRI) including orthogonal views through oblique planes of the plexus, T1-weighted, T2-weighted, fat-saturated T2-weighted sequences, and STIR sequences. 2, 3
Add IV contrast for suspected tumors, inflammatory conditions, or post-radiation changes. 1, 3
If MRI is contraindicated, CT neck with IV contrast offers the next highest level of anatomic visualization. 1
Electrodiagnostic Studies
- Perform EMG/NCS to assess severity and location of nerve injury, correlating with MRI findings of abnormal intraneural signal and active radiculopathy. 2
Treatment Algorithm Based on Injury Type
Open/Penetrating Injuries
Emergency surgical exploration is indicated for open wounds, including gunshot wounds, penetrating trauma, and vascular injuries. 2, 6, 4 In one surgical series, 78% of patients with open wounds recovered to Grade 3 or better function (proximal muscles against resistance, distal muscles against gravity) following surgical repair. 4
Closed/Blunt Injuries with Complete Nerve Disruption
Surgical intervention should be performed within 3-6 months when no signs of spontaneous recovery are present. 5 Operative procedures include:
Nerve grafting: Primary surgical technique for complete disruptions, used in 81% of surgical cases in one large series. 4
Neurotization (nerve transfer): Used in 47% of surgical cases, particularly important for preganglionic injuries where proximal nerve stumps are unavailable. 4
End-to-end anastomosis: Used in 5% of cases when nerve ends can be approximated without tension. 4
Neurolysis alone: Reserved for 12% of cases with incomplete injuries and evidence of nerve continuity. 4
Among patients with C5-C6 stretch injuries repaired by nerve grafting, 100% recovered useful arm function. 4 Overall, 58% of patients with stretch injuries recovered to Grade 3 or better level following surgical treatment. 4
Closed/Blunt Injuries with Incomplete Disruption
Conservative management with systematic monitoring is appropriate initially, as the majority of these injuries resolve spontaneously. 5 Operative treatment is ultimately required in only 13-18% of patients. 5
Rehabilitation Protocol During Spontaneous Recovery Period
Physical therapy should begin immediately and includes:
Kinesiotherapy: Range of motion exercises, muscle stretching, and strengthening exercises to prevent contractures and maintain joint mobility. 7, 8
Sensory re-education strategies: To address sensory deficits and promote cortical reorganization. 7, 8
Electrothermal and phototherapy: Adjunctive modalities to reduce pain and promote tissue healing. 8
Manual therapy: To maintain soft tissue mobility and prevent adhesions. 8
Neuroelectromagnetic stimulation: May promote nerve regeneration and muscle activation. 7
Rehabilitation intervention is beneficial during all stages of recovery including the spontaneous recovery period, postoperative period, and sequelae period. 7
Postoperative Rehabilitation
Following surgical repair, rehabilitation focuses on:
Maintaining range of motion during nerve regeneration phase (typically 3-6 months before motor recovery begins). 7
Management of postoperative edema and pain. 7
Special Considerations and Common Pitfalls
Risk Factors for Poor Outcomes
Older patient age: Elderly patients have higher rates of neurological complications and slower recovery. 5
Higher energy trauma: High-energy injuries and multitrauma victims have worse prognosis. 5
Longer time to reduction: In dislocation-related injuries, delayed reduction increases nerve injury risk. 5
C5-T1 complete injuries: Pan-plexus injuries have worse outcomes than isolated upper trunk injuries. 4
Critical Imaging Pitfalls
Do not order standard cervical spine, neck, chest, or spine MRI protocols - these are inadequate for proper brachial plexus evaluation and will miss critical pathology. 2, 3
Do not rely on CT cervical spine alone - it cannot visualize preganglionic nerve roots and has limited soft-tissue contrast resolution. 1, 2
Do not image too early - hemorrhage and edema in the acute phase obscure nerve anatomy and prevent accurate assessment. 2, 3
Surgical Timing Considerations
The median interval from trauma to operation in surgical series is 7 months, but surgery should ideally occur within 3-6 months when no recovery is evident. 4, 5 Earlier intervention (within 3 months) may be beneficial for complete disruptions identified on imaging. 5
Associated Injuries
59% of brachial plexus injury patients have associated major trauma requiring coordinated multidisciplinary management. 4 Emergency surgery for vascular repair may be necessary in 18% of cases. 4