BRACHIAL PLEXUS INJURY

The brachial plexus comprises a group of nerves that branch out of the from the cervical spinal cord in the neck and go down the arm to supply the muscles that move the shoulder, elbow, wrist and fingers, as well as provide sensation in the upper limb. Minor brachial plexus injuries, generally due to stretching of the nerve in injury will completely recover in several weeks. Severe injuries, if accompanied by root avulsion, may lead to permanent weakness of a part or the whole limb.

Stretching of the brachial plexus typically occurs to a motorcyclist in a road traffic accident where his head and neck is turned away from the shoulder resulting in stretching or avulsion of one or several nerve roots of the brachial plexus. It can also be seen in neonates resulting from forceps delivery causing brachial plexus injury in some cases.

 

SYMPTOMS
  • Weakness of part or whole of the upper limb involved (pan-plexus injury)

  • Numbness and tingling in the limb

  • Pain in the limb, which can be severe at times.

INVESTIGATIONS
  1. MRI (Magnetic Resonance Imaging) of the Brachial Plexus will show the plexus injury as well as nerve root avulsion. MRI of the cervical spine will also rule out cervical spine injury.

  2. X-ray of the chest (AP view) may show hemidiaphragm paralysis from phrenic nerve involvement, or fractures of the clavicle or humerus.

  3. Electromyography(EMG) / Nerve conduction studies (NCV) will show the muscles and nerves involved in the injury as well as monitor recovery.

 
TREATMENT OPTIONS
  1. Physiotherapy - Minor brachial plexus injuries with no root avulsion can recover with time (weeks/months) and therapy. These are the ones which have been demonstrated by tests to have continuity in the nerve and progressive NCV has shown an improvement. 

  2. Surgical Management –

    • Neurosurgeons specialized in brachial plexus injuries will decide the best time to operate on serious injuries, unlikely to recover on its own. Surgical options include nerve transfers, nerve grafting, muscle transfers and neurolysis of scar around the brachial plexus.

    • The National Institute for Health and Care Excellence (NICE) recommends that phrenic nerve transfer may be considered as a treatment option.

    • In neonates, surgery is recommended as an early intervention, as outcome is best if repair is undertaken within three months