The nerves throughout our body are like a telecommunications system carrying messages between the brain and the rest of the body. As the American Society for Surgery of the Hand explains, “Some nerves carry messages from the brain to muscles to make the body move. Other nerves carry messages about pain, pressure, or temperature from the body to the brain. Many small fibers are bundled inside each nerve to carry the messages. There is an outer layer that insulates and protects the nerves. Sometimes, nerves can be damaged.”
What is the Brachial Plexus?
The brachial plexus is a network of nerves that extends from the spinal cord in the neck, under the collarbone and down the arm. These nerves control the shoulder, arm, elbow, wrist and hand. An injury to the brachial plexus can cause significant pain and disability. In severe cases, people can lose the use of their arm and hand.
It usually takes a really bad accident, such as a high-impact car or motorcycle crash, or a very serious sports injury, to cause serious damage to the brachial plexus. We tend to see more young adults with this injury. In the spring and summer, it’s not uncommon to see a patient who has fallen off an all-terrain vehicle. In the winter, we may see someone who had a snowmobile accident.
Diagnosis of a Brachial Plexus Injury
The diagnosis is based on the patient’s medical history, a description of the accident and the physical exam. We sometimes order a nerve conduction test or a CT scan with myelogram, in which a dye is injected into the sac around nerve roots so we can get a good picture of what’s going on.
The damage often results from a “stretch” injury: imagine that the brachial plexus nerves are like spaghetti or rubber bands that get stretched or pulled apart. Some less severe injuries will get better on their own. Patients usually start seeing improvement within the first three months of an injury, although it may take a year or more for a full recovery.
For a severe, debilitating brachial plexus injury, surgery is often the best option to improve function. It is recommended that patients and their doctors wait three months after the injury to see if healing takes place. After three months, if a patient continues to experience significant pain and disability, surgery is often considered. However, it is best that a patient see an expert in brachial plexus injuries as soon as possible after the injury.
Brachial Plexus Surgery
Nerve reconstruction is considered when the nerves are so severely damaged they cannot recover on their own. We have found that it is best to perform the surgery between three and six months after the injury occurs. This is the “golden window” for the best outcome.
There are different types of surgeries depending on the nature of the injury, and a complex nerve reconstruction surgery could take 12 hours or more. It’s important to choose a physician specializing in this type of surgery.
One way surgeons can reconstruct nerves is by performing a nerve transfer to restore function. They carefully dissect out portions, or fascicles, of nearby healthy nerves called “donor nerves,” and transfer these fascicles to the injured nerves to restore electrical connectivity and enable nerve regeneration.
The other option is a nerve graft, in which we take healthy nerve tissue from another part of the body to replace a segment of a damaged nerve. One common procedure entails taking a portion of the sural nerve, which runs up the back of the leg, and moving it to the arm area to bridge a gap between two nerve endings.
After surgery, patients usually go to physical therapy. A full recovery is typically a lengthy process and may take two or more years.
New Tool to Assess Surgical Outcomes and Help Patients
The sudden nature of a brachial plexus injury can lead to emotional distress and a loss of independence, which can be overwhelming to patients. They may be unable to go to work or attend school and, understandably, many suffer from depression. The goal of treatment is to improve function, decrease pain, help patients cope and restore their quality of life.
HSS recently developed the first-ever patient questionnaire to measure the physical and emotional impact of brachial plexus injury. The survey also seeks to assess patients’ treatment expectations and the outcomes of surgery.
We are always seeking to improve patient care, and we believe the questionnaire will enable us to more completely understand the disability and recovery from this complex condition. It also fosters the discussion of realistic patient expectations, which are necessary to maintain motivation and ensure long-term participation in rehabilitation after surgery. We believe the questionnaire will also assist patients as they make plans for school, work and other commitments.
We ask individuals to complete questionnaires both before and after treatment, and this will enable us to learn what matters most to patients and see if we achieved their goals.
Center for Brachial Plexus and Traumatic Nerve Injury at HSS
At our Center for Brachial Plexus and Traumatic Nerve Injury, we see men and women of all ages, from all over the world. Our multi-disciplinary team includes orthopedic surgeons, physiatrists, neurologists, radiologists, psychiatrists, pathologists, rheumatologists, pain management specialists, anesthesiologists, physical therapists, occupational therapists and social workers.
Dr. Steve K. Lee is an Associate Attending Orthopedic Surgeon at Hospital for Special Surgery. At HSS, he holds a number of leadership positions such as Research Director of the HSS Center for Brachial Plexus and Traumatic Nerve Injury where he is involved with cutting edge research in clinical outcomes and basic science for the improvement of care of the patient with devastating nerve injuries.