AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Anatomy

The anterior rami of the spinal nerves C5 to T1 combine to form the brachial plexus. C5 and C6 merge into the upper trunk, C7 forms the middle trunk, and C8 and T1 merge to form the lower trunk. Anterior divisions from the upper and middle trunks form the lateral cord. The medial cord is the anterior division of the lower trunk. Posterior divisions from all 3 trunks form the posterior cord. Terminal branches originate from the C5 root, trunks, and cords to supply the upper extremity and shoulder girdle. The spinal nerves emerge from the vertebral foramina and pass between the anterior and middle scalenes, then between the clavicle and first rib near the coracoid and humeral head. The plexus is relatively tethered at the prevertebral fascia at its proximal aspect and by the axillary sheath in the mid arm.

Complications

A lesion of the brachial plexus can result in motor, sensory, and sympathetic disturbances. Impairments can be transient, such as in stinger or burner injuries in football players, or they may result in intractable palsy. Because of the changing arrangement of the brachial plexus as it progresses distally, injuries to it may result in diverse paralyses, anesthesias, and paresthesias, depending on the exact level of injury and the extent of injury to the various elements at that level.

Diagnosis

Brachial plexopathies may be difficult to accurately diagnose, even with a meticulous investigation. Not only does the anatomic design of the plexus pose challenges but also the types of lesions and injuries are frequently incomplete and complex. Yet, establishing a precise anatomic diagnosis and estimating the severity of the lesion is imperative for prognostic, surgical, and rehabilitative purposes.

Pathophysiology

Nerve roots may be avulsed from the cord, or the plexus may be subject to traction or compression. Any injury that increases the distance between the relatively fixed points of the prevertebral fascia and the mid forearm may injure the plexus.

Traction or compression may result in ischemia, which initially damages the vasa vasorum. Severe compression injuries can result in intraneural hematomas, which can compress adjacent nerve tissue.

Frequency

United States

The frequency varies depending on the etiology and severity of injury. Brachial plexus injuries are estimated to account for 5% of peripheral nerve injuries. However, the true occurrence of brachial plexus injuries is undetermined, primarily because of significant underreporting. Prospective studies performed at Tulane University have revealed a 7.7% incidence of stingers in a group of college football players; however, other sources report a 40% incidence (Clancy, 1977).

International

The frequency varies depending on the etiology and severity of injury.

Mortality/Morbidity

Coexistent musculoskeletal or central nervous system injury, such as spinal cord injury (SCI) or traumatic brain injury (BI), is common after violent trauma and presents a diagnostic challenge.

• Narakas reported that 80% of patients with severe traumatic brachial plexopathy had multiple trauma to the head and skeletal system.
• Root avulsion and contusions of the brachial plexus and cord are other frequent coexistent, complicating factors that pose additional diagnostic and prognostic challenges.

Race

No racial predilection is reported.

Sex

In general, traumatic brachial plexopathy is more prevalent in men than in women because of an association with violent trauma and sports.

• Certain conditions such as thoracic outlet syndrome (TOS) are statistically more common in women than in men.
• Other regional differences influence sex- and cause-related statistics.

Age

Because of an association with violent trauma and sports-related injuries, traumatic brachial plexopathy is most prevalent in male adolescents in their mid-teens and in men in their early 30s.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

History taking should include inquiry into the mechanism of injury, as well as a description of patient symptoms. Common mechanisms of injury involve cervical extension, rotation, lateral bending, and depression or hyperabduction of the shoulder.

Patients should be queried about weakness, sensory loss, paresthesias and dysesthesias and the location of symptoms in the arm.

Physical

The physician should examine the cervical spine, shoulder, clavicle, scapula, and related joints for range of motion (ROM), alignment, and tender points. A thorough neurologic examination of the upper extremity should include manual muscle testing, sensory examination, and an evaluation of deep tendon reflexes

• The site of injury can be accurately localized with a precise neurologic examination by using the correlative neuroanatomy.
• A sensory examination should include testing for light touch sensation, pinprick sensation, 2-point discrimination, vibration sensation, and proprioception.
• In an anterior dislocation of the shoulder, the sensory distribution of the axillary and musculocutaneous nerves are tested to detect nerve injury in the early stages.
• Associated problems that require prompt attention can be identified with the following:
• • Evaluation of joint instability and scapular winging
  • Auscultation to detect hemidiaphragmatic paralysis
  • Observation of patterns of muscle weakness and/or atrophy, in which the injured side is compared with the uninvolved side
  • Testing for SCI and BI

Causes

Trauma accounts for a large proportion of brachial plexopathies. The mechanism of traumatic injuries and the magnitude, rate, and direction of deforming forces ultimately determines the extent and location of the injury. Mechanisms include traction, penetrating injury, and crushing or compression.

Closed injuries, such as those caused by vehicular accidents, industrial accidents, and sports-related trauma are more common in civilian life than in military life. Violent torsion of the upper limb, either upward or downward, may damage the plexus. Gunshot wounds and knife injuries to the neck or axilla, shrapnel injuries, and blast injuries can all result in brachial plexus lesions.

Iatrogenic injuries occur during surgery, particularly in procedures involving the following: (1) neck or shoulder, (2) opening of the chest, (3) regional anesthetic blocks, and (4) placement of cannulas. Injuries to the brachial plexus of neonates may occur during birth, as a result of the strain placed on the plexus by a wide separation of the head and shoulder or by forced adduction of the shoulder joint during a difficult delivery.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Cervical radiculopathy
Traumatic root avulsion
Syringomyelia
Anterior horn cell disorders
Cerebrovascular accident (CVA)
Thoracic outlet syndrome (TOS)
Peripheral neuropathy
Entrapment syndromes of the upper extremity
Iatrogenic injury - Injection and/or block, thoracotomy, tourniquet paralysis
Sports injury - Stingers, burners
Psychogenic paralysis
Intraspinal and brachial plexus neoplasm
Myopathy
Neurodegenerative process
Toxic process - Exposure to heavy metals, synthetic hydrocarbons, alcohol
Infiltrative process
Vasculitic process - Polyarteritis nodosa (PAN), systemic lupus erythematosus (SLE), diabetes
Hemorrhagic process in the spinal cord or nerve sheath
Immunogenic process - Human immunodeficiency virus (HIV) infection, transverse myelitis
Spinal stenosis
Shoulder and scapulothoracic dislocation, fracture, tendinitis, or capsulitis

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• Electrodiagnosis has become a mainstay in the diagnostic evaluation of brachial plexopathies. Electrodiagnostic tests providing physiologic data about the continuity of pathways and of lesion type and severity. Serial testing is helpful to determine prognosis.
• While positive waves and fibrillations (which indicate axonal injury) do not appear for several weeks after injury, sensory nerve action potentials (SNAPs) can be useful within days of injury to distinguish a presynaptic lesion from a postsynaptic lesion. With postsynaptic lesions, SNAPs are absent, whereas they are present with presynaptic ganglionic lesions.
• Somatosensory evoked potentials (SSEPs) are also useful to assess proximal lesions, such as root avulsions.

Imaging Studies

• Many peripheral nerve injuries can be associated with other soft tissue or bone injuries that can be detected at radiography.
• • Radiographs of the injury site help in identifying fractures or foreign bodies. For example, fractures of the cervical spine are frequently associated with brachial plexus injuries.
  • Chest radiographs demonstrate unilateral elevation of the diaphragm in cases of phrenic nerve paralysis.
  • Midhumeral fractures are associated with radial nerve injuries, and midforearm fractures of the ulna or radius are associated with median or ulnar nerve injuries, respectively.
  • To rule out bony and ligamentous injuries, all patients with axillary nerve injury should initially undergo radiography of the shoulder and cervical spine.
• The resolution of the fine anatomic detail of soft tissue is better with MRI than with CT.
• • Conventional MRI is used to visualize both normal and abnormal peripheral nerve structures.
  • In addition, MRI can depict signal intensity changes in denervated muscle as early as 4 days after injury. With short-tau inversion recovery (STIR) techniques, signal intensity changes in the thenar muscles were depicted on MRIs of 100% of the patients with clinically advanced carpal tunnel syndrome.
  • With neuropraxic nerve injuries, the signal intensity in the innervated muscles remains normal on STIR or T2-weighted images. Therefore, after a peripheral nerve injury, early MRI of the muscle can be useful in distinguishing a neuropraxic injury from more severe axonotmesis or neurotmesis.
• Because CT and traditional MRI techniques have inherent limitations in their resolution and distinction of peripheral nerves from the surrounding structures, magnetic resonance neurography (MRN) has been developed.
• • MRN can depict both normal and abnormal peripheral nerves in various regions of the body.
  • The injured peripheral nerve can be assessed by orienting the images along the course of the damaged nerve. For example, the loss of signal intensity on T2-weighted images indicates damage to the myelin sheath.
  • In addition, loss of water content in denervated nerves of the deep muscles can be assessed with MRN when needle electromyography (EMG) is difficult to perform.
  • The predictive value of MRN in the diagnosis of peripheral nerve trauma has not yet been reliably established.
• CT can be used in the investigation of occult fractures not depicted on plain radiographs.
• With myelography, CT can be used to demonstrate root avulsion.

Other Tests

• Clinical threshold testing can be used to evaluate sensory function in peripheral nerves.
• These tests can be used to determine the level of stimulus necessary to elicit a response.
• Semmes-Weinstein monofilaments are fine filaments that exert a discrete amount of pressure on the fingertips. They are used to perform threshold testing.
• Vibratory senses can be assessed by means of clinical threshold testing with low (30-Hz) to high (256-Hz) frequencies.

Histologic Findings

At light microscopy, nerves injured with epineurectomy or a crush mechanism have widespread fiber degeneration and myelin debris in the subperineurial region. The centrofascicular areas are relatively preserved compared with the subperineurial regions. The central vessels were preserved mostly within the centrofascicular area of the injured nerve. The thickness of myelin in the axons is decreased after injury, and the internodal length becomes more variable compared with its length before injury. A loss of cross-sectional area without a loss in the muscle fiber count begins within 1 week of denervation.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Rehabilitation Program

Physical Therapy

Depending on local expertise the rehabilitation program may be undertaken with a physical therapist, and occupational therapist, or both. The goals are to preserve ROM, improve strength, and manage pain.

Patients should undergo physical therapy (PT) to maintain ROM and to optimize the recovery of motor function as muscle reinnervation occurs.

The goal of treatment is to return function to the structures supplied by the damaged nerves and to improve the patient's quality of life. Both the injured nerve and the exogenous sources of nerve injury are treated.

At the onset of injury, early mobilization and icing are used. In the subacute phase, therapy gradually progresses from passive to active motion and from assisted to active ROM, as tolerated.

Heat, ultrasonography, transcutaneous electrical nerve stimulation (TENS), interferential current stimulation, and/or electrical stimulation are used, depending on the predominant symptoms.

Cervical muscle strengthening and the correction of upper extremity muscle imbalances are included in the protocol as well.

The use of appropriate slings, the protection of extremities and joints, and the prevention of subluxation must be considered.

Cervical pillows or collars may be required for those with combined lesions of the roots and plexus.

Occupational Therapy

During occupational therapy (OT) efforts are concentrated on maintaining ROM in the shoulder; fabricating appropriate orthoses to support the function of the hand, elbow, and arm; and addressing edema control and sensory deficits, with both testing and therapy.

OT may address issues related to the patient's ability to write, type, and find alternate ways of communicating.

Additionally, OT provides help with retraining for activities of daily living (ADLs), including use of one arm techniques, adaptive equipment, and self-ranging and strengthening exercises.

Recreational Therapy

Recreational therapy should address compensatory strategies and activities that can substitute for altered or lost function in extremities that were required for recreation prior to injury.

Medical Issues/Complications

• Complications may include intractable pain syndromes, such as persistent neuropathy and complex regional pain syndrome, type 2 (CRPS II or causalgia); skin damage and infection; significant muscle atrophy; contractures and capsulitis; subluxations; sensory loss; osteopenia; heterotopic ossification; myofascial pain; and depression and anxiety.
• Bone dislocation with neurologic deficit requires prompt anatomic reduction to prevent irreversible nerve damage.
• The use of analgesics can help patients control pain from nerve injuries. Steroids may help to decrease endoneurial edema associated with nerve injury.
• Hyperbaric oxygen decreases vascular compromise of the vasa nervorum and endoneurial edema and pressure. Hyperbaric oxygen is an approved adjunctive treatment for acute traumatic ischemic reperfusion injury.
• Ciliary neurotrophic factor (CNTF), which enhances motor neuron survival both in vivo and in vitro, is currently in the investigational stage.

Surgical Intervention

Surgery is reserved for patients in whom symptoms persist despite appropriate conservative treatment. Two important issues to consider before surgery are as follows: (1) whether function can be obtained after the nerve is repaired and (2) whether the potential benefit to the patient outweighs the surgical risks, costs, and loss of productivity. Also, the timing of surgery is important.

• In clean lacerating injuries in which the nerve ends are visible in the wound or when clinical examination reveals obvious motor and sensory deficits from the laceration, immediate primary repair may be indicated.
• In blunt transections resulting from lacerations, delayed repair has a better surgical result.
• Injuries without evidence of early spontaneous recovery, such as those caused by bullets, crushing blows, traction, fractures, or injections, are explored several months after the injury.
• Brachial plexus stretches or contusions are observed for 4 months. If no evidence of recovery is present, the plexus is explored.
• Nerve or tendon transfers may be necessary for unsuccessful nerve repair.
• • Brachial plexus injuries are not always reparable. In such cases, neurotizations or nerve transfers may offer a better functional outcome.
  • Sunderland suggests 2 criteria that must be present before fascicular repair or interfascicular grafting is considered: (1) The fascicular bundle must be large enough for suturing. (2) The bundle must be sharply localized or sufficiently well defined so that it can be identified and mobilized for repair.
  • The spinal accessory or long thoracic nerve can be grafted onto distal arm nerve trunks, with some improvement in elbow flexion.
• Intraoperative care with proper axial orientation of the fascicles, hemostasis, suture material, and suture line tension leads to better outcomes. Tension of the suture line and inadequate preparation of the nerve stumps are 2 leading causes of regenerative failure across the suture site that results in poor recovery of nerve function.
• Surgical delays in excess of 5 months dramatically decrease the rate of functional return. Therefore, surgical repairs are most effective within 3 months of the injury.
• When repair does not provide adequate results, planned tendon transfers can increase extremity function.
• Rarely, in cases of a complete multilevel injury (eg, flail injury, anesthetic arm), amputation may result in a better functional outcome because the patient can use the extremity with an appropriate prosthesis. However, the result may be less cosmetically pleasing than with other approaches.

Consultations

• Consultations with an orthopedic surgeon and a neurosurgeon are considered in cases with poor neurologic and functional recovery.
• A complete multidisciplinary rehabilitation assessment is indicated. A consultation with a prosthetic specialist may be required for the fabrication of a temporary or permanent prosthetic device.
• A pain management strategy is of great importance to improve the patient's ability to cope and function and to improve his or her quality of life.

Other Treatment

• In cases of CRPS II, sympathetic (ie, stellate) blockade may be required, along with the appropriate combination of neuropathic and narcotic medications.
• For incomplete painful injuries and especially in cases of CRPS II, the use of a spinal cord stimulator on a trial basis may be beneficial. If this trial is successful, the stimulator may be implanted.
• Implantable peripheral nerve stimulators have also been successfully used in some centers.
• The use of an implantable intrathecal device (eg, pump) may be considered in cases in which oral medications, therapy, and use of a spinal cord stimulator fail.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Nonsteroidal anti-inflammatory drugs (NSAIDs) and neuropathic pain medications are most commonly used, depending on the symptoms and time since injury. During the acute phase, narcotic analgesics may also be necessary, but they should not be used for long-term pain management. Narcotic medications are also indicated in the acute postoperative period.

Neuropathic pain medications are useful for relief of dysesthetic pain, in both the acute and chronic phases. There is no drug of choice, and frequently, medications must be tried in serial fashion to find one that provides optimal relief for the patient.

Drug Category: Nonsteroidal anti-inflammatory drugs

After acute injury, NSAIDs are particularly helpful to relieve pain related to the injury, including injuries involving soft tissues such as muscles and ligaments.

Drug Category: Anticonvulsants

The use of certain anti-epileptic drugs, such as the GABA analogue gabapentin (Neurontin), has proven helpful in some cases of neuropathic pain. Anticonvulsants have central and peripheral anticholinergic effects, as well as sedative effects, and block the active reuptake of norepinephrine and serotonin. The multifactorial mechanism of analgesia could include improved sleep, an altered perception of pain, and an increased pain threshold. The efficacy of these drugs can be potentiated with concomitant use of opiates and NSAIDS. Rarely should these drugs be used in treatment of acute pain because they may require a few weeks to become effective.

Drug Category: Tricyclic antidepressants

This is a complex group of drugs that have central and peripheral anticholinergic effects, as well as sedative effects. They have central effects on pain transmission. They block the active re-uptake of norepinephrine and serotonin.

Drug Category: Analgesics

Narcotics are indicated in the acute injury period and in the postoperative period should reconstructive surgery be required. In rare cases in which patients may require long-term opioid use; these patients should use scheduled, longer-acting medications such as methadone.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Inpatient Care

• If PT is not initiated promptly after surgery, denervation can occur and result in muscle atrophy and fibrosis, joint stiffness, motor endplate atrophy, and trophic skin changes.
• Grant et al (1999) do not advocate the traditional treatment, which involves several weeks of immobilization. Instead, the use of a short period to allow healing and adequate strengthening of the repair site is advised.
• Repairs (nerve transfer/neurotization, as well as tendon transfer) are protected by means of relaxed joint posturing for about 3 weeks.
• To prevent disruption of the sutures at the repair site, the patient should avoid strenuous physical activity.
• In nerve transfers, the extremity is immobilized for 4 weeks after surgery, at which time PT is initiated.
• Postoperative clinical examinations are performed every 3 months for the first 2 years after surgery and every 6 months after that.
• At each postoperative visit, the ROM, strength, and sensation in the treated area should be tested, and results should be documented.

Further Outpatient Care

• Continuation of PT and/or OT and follow-up with a surgeon and/or orthotist may be needed.
• Vocational rehabilitation and modifications at home and/or work are also assessed.
• In some cases, repeated electrodiagnostic evaluations may be required for prognostication and further treatment planning. These tests can be used to detect early signs of muscle reinnervation several months before clinically evident muscle contractions appear.

In/Out Patient Meds

• A variety of medications may be required, mainly for the management of associated painful states.

Transfer

• When indicated, the patient may be admitted to the hospital for orthopedic or neurosurgical procedures.

Deterrence

• Measures that the patient can use to prevent setbacks and further damage include the following:
• • Protect the damaged limb from repeat injury and extremes of motion
  • Maintain the functional ROM
  • Strengthen muscles in the cervical region and limbs
  • Make appropriate modifications in the workplace and/or at home

Complications

• Late complications may include the following:
• • Pain syndromes, such as persistent neuropathy, neuroma, and CRPS II
  • Skin damage and infection
  • Significant muscle atrophy
  • Contracture and capsulitis
  • Subluxation
  • Sensory loss
  • Osteopenia
  • Heterotopic ossification
  • Myofascial pain
  • Depression and anxiety

Prognosis

• The outcome and prognosis of acute injury varies widely, depending on the type and etiology of injury and the timing of therapy.
• • The extent of injury to neural tissue and the age and medical status of the injured patient are important factors that influence the outcome.
  • Patient compliance and motivation for recovery can also have an important effect on the overall success of therapy.
• Spontaneous recovery may occur as soon as days to weeks with mild neurapraxic lesions or as late as 11 months after a gunshot wound.
• Recovery from axonotmetic injuries usually occurs over months.
• • In axonotmesis, although axons regenerate, functional recovery depends on the associated injuries, the amount of healthy proximal axon that remains after injury, and the age of the patient.
  • Recovery is usually complete unless the injury is so proximal that atrophy of the motor endplate or sensory receptor occurs before the axon can grow back to these organs.
  • In cases of a coexisting root avulsion, the above scenario of a very proximal lesion, resulting in atrophy of the motor endplate or sensory receptor, may be possible. Therefore, healing may be greatly delayed or incomplete.
• In neurotmesis, regeneration occurs, but function rarely returns to that before injury.
• Generally, the rate of spontaneous recovery after shotgun wounds is lower than with other mechanisms.
• Neural injuries associated with fractures have a greater incidence of spontaneous resolution; generally, recovery is less common with neural injuries secondary to dislocations.
• Lesions resulting from shoulder dislocations heal within 12-45 weeks, depending on severity of the dislocation, and, consequently, type and extent of the associated neural injury or injuries.

Patient Education

• Educating the patient, family, and rehabilitation team, and medical practitioners involved in the patient's postdischarge care may have several benefits.
• • It facilitates the coordination and planning of services.
  • It hastens the implementation of appropriate interventions.
  • It results in a better recovery.
• Of equal importance is addressing the associated psychological factors, with the aim of improving the following:
• • The patient's mood stability
  • The patient's coping skills
  • Family functioning
  • Pain management
  • Patient motivation
  • Patient participation in therapy
  • Overall outcome

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Failing to consider a cervical spine or SCI or a traumatic BI can delay early intervention and result in unwanted residual long-term sequelae.
• In the initial assessment after a sport-related injury, the sideline personnel and physician should maintain a healthy degree of suspicion for underlying spine injury or concussion. For example, with persistent symptoms of a burner injury, or postconcussive state, a complete assessment may be needed to prevent premature return to play.
• Overlooking a brachial plexus injury can lead to further damage that may persist.
• The precise localization of the lesion on electrodiagnostic studies and determining the appropriate prognosis can be challenging in the initial postinjury period or when multiple structures and/or levels are involved.
• Repeat study or the use of an additional imaging or other diagnostic investigation may be considered in cases with poor functional recovery.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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Article Last Updated: Apr 20, 2006