Doc-to-Doc: Brachial Plexus Injuries
Catherine Curtin, MD is Assistant Professor of Plastic Surgery at Stanford University . She specializes in peripheral nerve injuries and hand surgery. To contact Dr. Curtin about speaking engagements please call 650-725-2766 or email pgrier@stanford.edu. For patient referrals, please call the Referring Physician Resource Center at 866.742-4811.
Brachial plexus injuries present with a wide variety of upper limb deficits. The prognosis for these injuries is variable because of the differences in the severity of the nerve damage. The least severe type of injury will spontaneously recover in about four weeks with supportive treatment of the arm with a sling and gentle range of motion exercises. However, if at a month there is still a neuro-defect, the patient by definition has a more severe injury and a referral to a more specialized center is warranted. Management of a more severe brachial plexus injury involves a combination of watchful waiting, therapy, and surgical interventions.
More severe peripheral nerve injuries fall into two categories: axonotomesis and neurotemesis. In the first, the axons are damaged but the nerve is still in continuity. These injuries can heal and recovery may be possible without surgery. In the second, the nerve is disrupted and will not recover. Differentiating between axonotomesis and neurotemesis injuries is challenging and requires sequential physical exams to assess improvements in motor function, EMG to evaluate re-innervation of the muscles, and sometimes diagnostic studies such as MRI. The complicating factor to this management strategy is the limited time window when surgical interventions will be effective. If a muscle is disconnected from its nerve for much greater than a year, the muscle permanently “forgets” how to function and will never respond to nerve impulses again. This puts time pressure on the brachial plexus team to decide if surgical intervention is the best treatment option.
For those injuries that require surgery a mixture of techniques are utilized. Surgery often begins with exploration and monitoring of the nerves to assess the damage. The reconstruction consists of a combination of nerve grafting and nerve transfers. Nerve transfers are a newer technique which has greatly improved the surgical results. In this technique, the surgeon takes a nearby undamaged or “live” nerve and connects it to the de-innervated muscle. This greatly shortens the distance the axons need to heal and reconnects the muscle to the nervous system before permanent changes occur. Amazingly the brain learns how to move the muscle through this different neural pathway.
Brachial plexus injuries can have devastating consequences with loss of function and pain. With newer surgical techniques, we can achieve improved functional results. The caveat is that treatment needs to be initiated before permanent changes occur.
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