Brachial plexus injuries are complex. How nerves are injured and to what degree vary widely from patient to patient. This makes diagnosing it much more challenging.
At the Center for Brachial Plexus and Traumatic Nerve Injury (CBPTNI), our tailored, patient-specific treatment schedule is intended to provide comprehensive medical information about your brachial plexus injury and deliver the best care possible for your condition. In addition to a thorough history-taking and physical examination by our doctors and physician’s assistants, most patients will undergo a number of diagnostic tests prior to and following their initial visit.
When coming in for an appointment with us, the following is a general guide to help you understand what to expect and how to prepare in advance.
Diagnostic Tests to Expect
Typically, if you were injured in a violent accident such as a car, ATV or motorcycle collision, you may require a Computerized Tomography scan with Myelogram (CT Myelogram). During a CT Myelogram, contrast dye is injected into the spinal canal before the CT scan. The CT scan gives precise information about the alignment and integrity of your spinal vertebrae. The myelogram contrast dye allows us to identify the nerve roots (or nerve origins) as they exit the spine and helps detect any fluid leaks from the spinal canal. Where there is a leak, there is likely a partial tear or complete tearing off of the nerve root from the spinal cord, something we call a nerve root avulsion. Not only does this identify where the injury is, but it also informs the doctor which nerves are still intact at the spine. This is especially useful if intact nerves are needed for a nerve reconstruction procedure. This procedure will likely be done in advance of your appointment with your doctor.
Another key test is called the electromyography (EMG), or electro-diagnostic testing. Though some patients may already have had an EMG ahead of time, your doctor will likely have you repeat the test as our specialists have developed specific EMG protocols to provide pinpoint accuracy about your brachial plexus injury. Similar to the CT myelogram, this test helps identify which nerves are injured, and which are available as potential donors for reconstructive nerve transfer surgery. Multiple nerves will be tested to see how fast they are communicating the electrical signal, whether the signal is reaching the muscle, and how well the muscle is responding. All of these details are helpful for your surgeon to determine which nerves may recover on their own with time, and which are unlikely to improve. Be prepared for the test to take 90 – 120 minutes and potentially for some moderate physical discomfort during testing, possible anxiety about needle insertion and increased physical sensitivity where needles were inserted following the test.
Lastly, your doctor may also order an MRI or ultrasound. These imaging tests can be very useful when surgery is being considered to better understand the anatomy of your injury. If your EMG results indicate that the nerve is injured and the CT myelogram shows the nerve is not torn at the spinal cord, an MRI or ultrasound will be helpful in determining exactly where the nerve is injured, and whether it was crushed, stretched, or torn. Though potentially stressful for patients who experience anxiety in confined spaces, MRIs cause minimal physical discomfort. The MRI may be anywhere from 85 – 120 minutes; your ultrasound should be 90 minutes or less.
*Not all of these tests need to be performed on the same day. We’ll work with your availability to get all tests done before your doctor’s appointment.
Your Medical Team
After you’ve undergone our diagnostic tests, you will have a consultation and physical exam with your doctor, where he or she will examine your affected arm and identify which muscle groups (shoulder, elbow, forearm, wrist, fingers, etc.) are affected, and how. Your doctor will also review the test results with you to give you an idea of your prognosis and, if surgery is necessary, a detailed description of the procedure. On the other hand, if your test results do not show the need for immediate surgical intervention, your doctor may have you wait 6 – 8 weeks before coming back to the office with another EMG to see if you have improved.
Brachial plexus injuries are associated with increased psychological distress and our mental well-being plays a crucial role in recovery from injury—both emotionally and physically. Studies have shown that mental well-being may enhance physical healing. In support of your recovery, a social worker will meet with you to assess how you are coping with your condition. Questions will explore changes you have noticed in yourself, your mood, your self-esteem, your behaviors and how you interact in your world. Other questions will assess the quality of your support system (i.e., partners, family, friends, colleagues, and mental-health providers), daily stressors and stress-relievers, and, if applicable, psychiatric history. The social worker may also provide information about common psychological responses to brachial plexus injury; identify when seeking counseling might be recommended; and note how to implement daily adjustments to improve your current quality of life. Meeting with the social worker is usually part of your consultation appointment and may take an additional 10-30 minutes depending upon what questions or concerns you may have about mental health and brachial plexus injury.
Our research coordinators will also meet with you as part of your consultation to identify if you are interested in participating in the CBPTNI’s ongoing research registry to collect data on your recovery. Participation may provide helpful information for our doctors to optimize treatment options for future patients and is entirely anonymous so that none of your personal health information is shared with anyone outside of our immediate research personnel. Should you be interested, the research coordinator will fully explain to you what participation entails and what you may expect. Whether you accept or decline to participate in research will not impact on the care you receive at CBPTNI. Depending upon whether you would like to participate, you may expect this to take 5-20 minutes.
Sustaining a brachial plexus injury can be a life-altering event, and for many, the next steps may be unclear. Knowing what comes next and what options there are to further your care helps to put you in control of your recovery, and ultimately your future.
Schneider K. Rancy, BA is an office and clinical research assistant at Hospital for Special Surgery. As part of the research team on the Hand and Upper Extremity Service, he conducts research on distal radius fracture fixation, patterns of degenerative and inflammatory arthritis of the wrist, salvage procedures for wrist reconstruction, and long-term motor outcomes following nerve and brachial plexus reconstruction.
Zoe A. Landers, LCSW is a licensed social worker at the Center for Brachial Plexus and Traumatic Nerve Injury (CBPTNI) who evaluates and facilitates treatment for brachial plexus injury patients experiencing psychological and psychosocial stressors following injury. Ms. Landers has actively participated in research with the CBPTNI multidisciplinary team to develop a deeper understanding of the psychosocial and psychological impact of brachial plexus injury. Findings from this research have been presented at major hand and upper extremity orthopedic conferences.