Brachial Plexus Injury

The brachial plexus is a group or network of interlaced nerves that run from the spinal cord in the neck down the arm to carry signals from your spine to the shoulders, arms and hands. These nerves control the movement as well as provide sensation in the arm and hand.

A brachial plexus injury occurs when these nerves get stretched or compressed when your arm is pulled forcibly or stretched. In severe cases, these nerves may get ripped apart or torn away from the spinal cord. The most severe brachial plexus injuries often occur due to motor vehicle accidents.

Severe brachial plexus injuries can cause paralysis of your arm, with a loss of function and sensation, and sometimes permanent disability in the arm. These injuries may need surgical treatment to regain function of the arm or hand. Surgical procedures such as nerve grafts, nerve transfers or muscle transfers can help restore function.

Minor brachial plexus injuries also known as stingers or burners occur commonly during contact sports, such as football. These injuries may heal completely in several weeks without any treatment. Newborn infants may suffer brachial plexus injuries during birth if its shoulder gets stretched while it passes through the birth canal. Conditions such as inflammation or tumors may also affect the brachial plexus.

Signs and symptoms of a brachial plexus injury vary greatly depending upon the severity and location of the injury as well as whether there are other injuries. Often, only one arm is affected. The common symptoms of brachial plexus injury include:

• Less severe injuries: Minor injuries often occur while playing contact sports, such as football or wrestling. The brachial plexus nerves get stretched or compressed, and these injuries are called stingers or burners. These produce the following symptoms:
  • A feeling like an electric shock or a burning sensation shooting down your arm
  • Weakness or numbness in your arm
  • These symptoms often last for only a few seconds or minutes, but sometimes, may linger for several days or longer.
• More-severe injuries: More-severe symptoms result from injuries that tear away or rupture the nerves. The most serious brachial plexus injury (avulsion) occurs when the nerve root gets torn away from the spinal cord. Signs and symptoms of more-severe injuries include:
  • Weakness or not being able to use certain muscles in your hand, arm or shoulder
  • Complete loss of movement (paralysis) and sensation in the affected arm, including your shoulder and hand
  • Severe pain that lasts for a long time

When to see a doctor:

Brachial plexus injuries can eventually lead to permanent weakness or disability. Even if your injury seems minor, you may need medical attention. See your doctor if you have:

• Recurrent burners and stingers
• Weakness in any part of the arm following trauma
• Complete paralysis of the upper extremity following trauma
• Neck pain
• Symptoms in both arms
• Symptoms in upper and lower limbs

It is very important to get your brachial plexus injury evaluated and treated within six to seven months after the injury as delays in treatment can compromise the outcomes of nerve surgeries.

Various events that may cause brachial plexus injury, include:

• High-energy contact sports: Football players often experience burners or stingers, which occur when the nerves in the brachial plexus stretch beyond their limit when they collide with other players.
• Difficult childbirth: Newborn infants may sustain brachial plexus injuries due to problems during birth, such as a breech presentation or a prolonged labor. If an infant's shoulders get wedged within the birth canal, there is an increased risk of a brachial plexus palsy. Most commonly, the upper nerves are injured, a condition called Erb's palsy. Total brachial plexus birth palsy may occur when both the upper and lower nerves are damaged.
• Trauma: Several types of trauma — including motor vehicle collisions, motorcycle accidents, falls or gunshot wounds — can result in brachial plexus injuries. Stretching type of injury, which occurs when the head and neck are forced away from your shoulder is common during a fall from a motorcycle or car accident.
• Inflammation: Inflammation may cause damage to the brachial plexus. In a rare condition called Parsonage-Turner syndrome (brachial plexitis), brachial plexus inflammation occurs without trauma, and results in paralysis of some muscles of the arm.
• Tumors: Noncancerous (benign) or cancerous tumors may develop in the brachial plexus or exert pressure on the brachial plexus or may spread to these nerves resulting in damage to the brachial plexus.
• Radiation treatment: Radiation therapy may cause damage to the brachial plexus.

The traumatic brachial plexus injuries tend to occur when your shoulder is forcefully pulled while your neck stretches up and away from the injured shoulder. 

When you call to make your appointment, always ask whether you need to be prepared for the diagnostic tests for brachial plexus injury. For example, you may need to stop taking certain medications for a few days or avoid using some lotions on the day of the test.

Ask a family member or friend if possible, to come along with you to the appointment. Sometimes, it may be difficult to absorb all the information your doctor gives during an appointment. Someone who accompanies you may remember something that you have forgotten or missed.

This is particularly important when your child has a brachial plexus injury. In most children, the injury heals on its own without the need of surgery. But children who do not show any improvement during their first three to six months of life may need surgery. This means parents will have to make some difficult decisions, and it is often helpful to have a friend or family member by your side who can offer you advice and support.

Here are some suggestions to get ready for your appointment:

• Make a note of all your symptoms, including how you were injured, for how long you have had your symptoms and whether they have become worse over time.
• Make a list of all regular medications, vitamins and supplements that you take.

Do not hesitate to ask the questions that may come to your mind during the appointment.

Both children and adults with brachial plexus injuries have several options for restoring lost function. Be sure to ask your doctor about all the possibilities available to you or your child.

Your doctor will perform a comprehensive physical examination to diagnose the injury and determine whether there are any associated injuries. All the nerve groups controlled by the brachial plexus will be examined to identify the exact location of the nerve injury and its severity. In addition, your symptoms will be reviewed.

A number of tests may be done to diagnose the type and severity of brachial plexus injuries, such as:

• Electromyography (EMG): During an EMG, a needle electrode is inserted through your skin into various muscles. This test evaluates the electrical activity of your muscles during contraction and at rest. There may be a slight pain when the electrodes are inserted, but most people complete the test without much discomfort.
• Nerve conduction studies: These tests are performed as part of the EMG, and is done to measure the speed of conduction in your nerve when a small current passes through the nerve. This provides information about how well the nerve functions.
• Magnetic resonance imaging (MRI): This test employs powerful magnets and radio waves to create detailed images of your body in several different planes. It often shows the extent of the damage caused by a brachial plexus injury and can help assess the status of arteries that are important for the limb or for reconstruction of it. New methods of high-resolution MRI, known as magnetic resonance neurography, may be used.
• Computerized tomography (CT) myelography: Computerized tomography uses a series of X-rays to obtain cross-sectional images of your body. CT myelography uses a contrast material that is injected during a spinal tap to produce a detailed picture of your spinal cord and nerve roots during a CT scan. This test may be done when MRIs do not provide adequate information.
• Angiogram: An angiogram may be suggested if your doctor suspects injury of the blood vessels feeding your arm. This is an imaging test in which contrast material is injected into an artery or vein to check the condition of your blood vessels. This information is very important to plan your surgical procedure.

Treatment for brachial plexus injury depends on several factors such as the type and severity of the injury, the time elapsed since the injury, and other existing conditions. Stretched nerves may sometimes recover without any treatment. Your doctor will advise physical therapy to keep your joints and muscles working properly, maintain the range of motion, and prevent stiffness in the joints.

Sometimes, scar tissue may be formed during the healing process. To improve nerve function, surgical repair is often required for nerves that have significant surrounding scar tissue or that have been cut or torn.

Surgical repair of brachial plexus nerves should occur within six to seven months of the injury for the muscles to recover completely. Various surgical techniques are used to treat nerve injury, depending upon the type of injury and the length of time that has passed since the injury. In most procedures, an incision is made near the neck above the collarbone. If the injury extends down the brachial plexus, another incision at the front of the shoulder may be required. To repair or reconnect the nerves, surgeons make use of high-powered microscopes and small, specialized instruments.

Types of surgery.

Nerve repair: In this procedure, the surgeon will reattach the two torn ends of a cut nerve. Nerve repair is usually done in case of sharp lacerations to the nerves, such as in a knife wound.

Nerve graft: In this procedure, the damaged part of the brachial plexus is removed and replaced with sections of healthy nerves taken from another part of your body. This helps restore your arm's function as the transplanted nerve guides regrowth of the lacerated nerve and ultimately restores the nerve signals to the muscles.

Nerve transfer: This procedure is performed when the nerve root has been torn away from the spinal cord. In this situation, surgeons often take a less important nerve that is still attached to the spinal cord and reconnect it to the nerve that is injured and no longer attached to the spinal cord. In many cases, surgeons may perform this technique at a level close to the affected muscle in order to speed up recovery rather than doing a repair (nerve graft) farther from the muscle. Sometimes, doctors may perform a combination of nerve graft and nerve transfer.

Nerve tissues grow slowly, about an inch (2.5 centimeters) a month. Therefore, it may take several years to derive the full benefit of surgery. During the recovery period, you must keep your joints flexible by doing some exercises. Splints may be placed to give support and prevent your hand from curling inward.

Muscle transfer: Muscle transfer is a procedure in which your surgeon will remove a less important muscle or tendon from another part of your body, usually the thigh, and transfer it to your arm and reconnect the nerves and blood vessels supplying the muscle.

Patients who delay thier first visit to the doctor for more than 1 year after injury tend to have poor outcomes with surgical reconstruction of nerves. In such patients, surgery that focuses on reconstruction of the tendon (tendon transfer) or muscle (free-functioning muscle transfer) may be done.

A tendon transfer is a type of surgery in which the tendon of a functioning muscle is harvested and attached to a nonfunctioning muscle tendon in order to restore a specific motion or motor function.

During a free-functioning muscle transfer, a healthy muscle from one part of the body is moved to the injured area, along with its tendon, artery, vein, and nerve. Each of these structures is attached to the corresponding structures of the injured area in order to restore motion or motor function.

Pain control.

Pain from the most severe types of brachial plexus injuries has been described as a debilitating, severe crushing sensation or a constant burning. Initially, narcotic pain medications may be used, which may be changed as your recovery progresses to optimize pain relief.

Brachial plexus injury often cannot be prevented, but you may follow certain measures to reduce the risk of complications once an injury has occurred:

For yourself: Daily range-of-motion exercises and physical therapy helps prevent stiffness of your joint. Avoid getting cut or burnt as you may not feel it if you are experiencing numbness. If you are an athlete, you are at an increased risk of getting injured at the brachial plexus area. For this reason, your doctor may advise wearing a special padding to protect the area from sports injury.

For your child: If you are the parent of a child with a brachial plexus palsy, you should start exercising your child's joints and functioning muscles daily, from the time your baby is about 3 weeks old. This helps in preventing the joints from becoming permanently stiff and maintains your child's working muscles strong and healthy.

Lifestyle modifications are necessary in order to cope with brachial plexus injury.

Recovery from a brachial plexus injury takes several months as nerve regeneration occurs very slowly at the rate of about 1 mm/day. A positive mental attitude and support from your close relatives, friends, and healthcare professionals is important during recovery and rehabilitation.

During this recovery period, occupational therapists will teach the way you can make use of your unaffected arm to perform your daily activities such as eating and maintaining personal hygiene.

Physical therapy exercises of the shoulder, elbow, wrist, and fingers help to prevent stiffness, contractures, or muscle atrophy. In addition, assistive devices such as splinting or supportive bracing may be recommended to support a limp arm and joints. To prevent swelling of the affected arm that leads to pain and joint contractures, compression gloves and sleeves may be used.

Patients need to develop healthy coping skills in order to make adjustments in their lives — both in employment and daily activities —with a prospect of having a less functional arm and/or hand.

You will be at an increased risk of brachial plexus injury if you actively participate in contact sports such as football and wrestling, or unfortunately get involved in high-speed accidents.

Complications

Most brachial plexus injuries, both in children and adults, heal completely without any lasting damage. But some injuries may cause temporary or permanent problems such as:

• Pain: Damage to the nerves cause chronic pain.
• Stiffness in the joints: If there is paralysis of your hand or arm, your joints may become stiff, which makes movement difficult, even after you regain use of your limbs. For this reason, your doctor will recommend ongoing physical therapy during the recovery period.
• Loss of sensation: If you lose sensation in your arm or hand, you will be at a higher risk of burning or injuring yourself.
• Muscle atrophy: After injury of slow-growing nerves, it takes several years to heal. During this time, the affected muscles tend to break down or degenerate due to lack of use.
• Permanent disability: Even after undergoing surgery, some people may experience permanent disability that ranges from weakness in the hand, shoulder or arm to paralysis.

Your recovery from a serious brachial plexus injury is based on a number of factors, such as:

• Your age
• The type
• Location and
• Severity of the injury