From the Guidelines
For patients with brachial plexus injury, particularly those with traumatic brachial plexopathy, imaging should ideally be delayed until approximately 1 month following the trauma to accurately determine the extent of plexus injury. This approach is based on the most recent guidelines from the American College of Radiology, as outlined in the 2021 update of the ACR Appropriateness Criteria for plexopathy 1. The delay allows for the resolution of subarachnoid hemorrhage and soft-tissue edema that may obscure nerve roots and the brachial plexus itself, providing a clearer picture of the injury.
Key Considerations in Management
- The management of brachial plexus injuries depends on the severity and location of the injury, with penetrating and open injuries often requiring early surgical exploration, whereas blunt and closed injuries may be managed nonoperatively or surgically 1.
- It is crucial to differentiate between preganglionic (involving intraspinal nerve roots) and postganglionic (involving plexus lateral to the dorsal root ganglion) injuries, as the prognosis and reconstruction approaches differ significantly 1.
- Imaging plays a significant role in determining the extent of the injury, detecting associated findings such as pseudomeningocele, spinal cord edema or hemorrhage, and injuries to nearby structures that may cause extrinsic compression of the brachial plexus 1.
Treatment Approaches
- For mild injuries, conservative management including physical therapy, pain management, and possibly medications like gabapentin for nerve pain is recommended.
- More severe injuries, especially those with no improvement after conservative treatment, may require surgical intervention, including nerve grafts, nerve transfers, or tendon transfers.
- The goal of treatment is to maximize recovery and minimize permanent loss of function, emphasizing the importance of prompt medical attention and appropriate timing of interventions.
From the Research
Brachial Plexus Injury Overview
- Brachial plexus injuries are devastating life-altering events with pervasive detrimental effects on a patient's physical, psychosocial, mental, and financial well-being 2.
- The brachial plexus is a series of nerves formed by roots of cervical segments 5 to 8 (C5-C8) as well as the first thoracic nerve (T1), providing sensation and motor innervation to the skin and muscles of the chest and upper limb 3.
Diagnosis and Treatment
- The initial diagnosis of brachial plexus injury 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 techniques including neurolysis, nerve grafting, nerve transfers, free functional muscle transfers, tendon transfers, and joint arthrodesis 2.
- Therapeutic strategies for brachial plexus injury also include the introduction of survival-proactive agents with anti-oxidative stress and anti-inflammation properties to promote motor function recovery 4.
Pain Management
- Neuropathic pain following traumatic brachial plexus injury can be managed with neurolysis and oral gabapentin, providing significant pain relief and improvement in quality of life 5.
- Oral pregabalin has also been shown to prolong analgesia from brachial plexus block and increase the sensory block, making it a useful adjunct in pain management 6.
Multidisciplinary Approach
- The successful management of patients with brachial plexus injury requires a multidisciplinary team approach, including peripheral nerve surgeons, neurology, hand therapy, physical therapy, pain management, social work, and mental health 2.
- A comprehensive care team can provide patients with meaningful recovery and improve their overall well-being, despite the devastating nature of brachial plexus injuries 2, 3.