A traumatic injury to the brachial plexus (nerves that conduct signals to the shoulder, arm and hand) can have devastating consequences, including loss of function and chronic pain, for an otherwise healthy, active patient. Fortunately, new advances in nerve surgery can yield marked improvement in movement and function in the shoulder, elbow and hand while simultaneously diminishing pain.
Early recognition and treatment of this injury, along with the recent advances that have been made in microsurgical reconstruction, have greatly improved outcomes for patients. Injuries for which restoring function would have been impossible only two decades ago are now being treated with nerve reconstruction, increasing the possibility of a return to an active productive life. The Center for Brachial Plexus and Traumatic Nerve Injury at Hospital for Special Surgery in New York City leads a multidisciplinary approach to expertly treat injuries of the brachial plexus and peripheral nerves.
New advances in nerve surgery can yield marked improvement in movement and function in the shoulder, elbow and hand while simultaneously diminishing pain.
Injuries to the brachial plexus should be evaluated as soon as possible. A physician can help the patient decide on the need for more diagnostic procedures and discuss the likelihood of spontaneous recovery, and the timing of surgery, if indicated. Ideally, if surgery is required, it should be completed within six months of the date of injury.
If you have been diagnosed with a traumatic brachial plexus injury, you may call our office directly. If you are not certain whether you may have injured your brachial plexus, you should check with your primary care provider or a neurologist.
A team of physicians, nurses, research personnel, and specialized hand therapists evaluates each patient and continues to work with him or her throughout the course of treatment. Specialized testing may be required, including computerized tomography (CT), myelography, magnetic resonance imaging (MRI), and neurodiagnostic testing. A physician at the Center will fully evaluate each patient before advanced imaging or neurodiagnostic tests are ordered, so that a customized approach can be mapped, and unnecessary or duplicate testing avoided.
Surgery for a brachial plexus injury can range from 3 to 12 hours, depending on the complexity of the case. Patients can expect to restrict their activities for at least four weeks following surgery; therapy for the upper extremity may be necessary for several months while nerves and muscles recover.
Most patients are discharged the day following surgery. However, in some cases, the procedure may be done on an outpatient basis.
The nerve that is transplanted is usually taken from an uninjured muscle in the same area as the non-working muscle. It’s important to understand that the entire nerve is not transferred; only a portion is moved, so that function and sensation are not affected in uninjured areas. On occasion, a nerve graft from the leg is used if more nerve tissue is required. (Scott W. Wolfe, MD has presented his success using bioabsorbable nerve conduits; tiny chambers that span gaps between damaged nerves, and allow nerves to grow and repair injured nerves.)
The appearance of scars may vary. The incisions can be a few inches in length and occasionally quite extensive, depending on the degree of injury. Plastic surgical techniques are used to close the incisions to minimize scarring. Some examples of postsurgical scars are below.
Examples of postsurgical scarring after brachial plexus repair
Surprisingly little pain is associated with surgery for brachial plexus injuries. If needed, pain management specialists at HSS have extensive experience in helping patients feel comfortable throughout their recovery.
For most patients, relief from the pain associated with brachial plexus injury (as distinguished from postsurgical pain) is achieved at one or two years following surgery, although in some cases a longer period of time may elapse before the pain is controlled. For those individuals who continue to experience pain beyond this period, the orthopedic surgeon may make a referral to a neurosurgeon, who may recommend an additional surgery on the spinal cord known as Dorsal Route Entry Zone lesioning (DREZ). DREZ involves the removal of scar tissue and the use of an electrode on the damaged area of the spinal cord to stop pain messages from being sent to the brain.
No, as long as a patient does not experience another injury to the area.
Physical therapy for the upper extremity is essential. The program usually begins before any surgical intervention and continues for many months following surgery. Pool therapy is particularly important and biofeedback may also be helpful.
Risks associated with surgery to repair a brachial plexus injury include failure to improve, tingling or diminished strength in areas of the hand or forearm (generally temporary), and post-surgical stiffness. The surgery can be long, and the resulting pressure to certain areas of the body can cause temporary pain; great efforts are made to pad these areas with special gelpads during surgery.
When the injury is incomplete, it is prudent to wait to see if a brachial plexus injury will improve spontaneously. In many cases, this recovery does occur and surgery is not needed. Often the nerve injury cannot be fully appreciated immediately, and may be overshadowed by life-threatening injuries of the skull and brain, abdomen, or fractures and dislocations of the shoulder and arm. In more serious cases, repair of critical blood vessels to the arm may be necessary for the limb to survive, and nerve repair is planned as a subsequent, elective procedure.