Brachial plexus injury

Brachial plexus injuries most commonly result from motor vehicle accidents, gunshot or stab wounds, contact sports accidents, or falls.

Injury may involve a portion of the plexus (partial injury) or all 5 nerve roots (pan-plexus injury). Partial and pan-plexus brachial plexus injuries both have potential surgical treatment options; however, the prognosis for pan-plexus injuries is limited. More extensive injuries may require multiple major operations, while partial injuries can often be corrected in a single operation.

Brachial plexus injuries can be ruptures (roots still connected to the spinal cord) or avulsions (roots detached from the spinal cord). Nerve transfer techniques, which can be successfully applied to both ruptures and avulsions, are often the treatment of choice for microsurgical repair. However, there are situations in which graft repair of brachial plexus injuries is indicated, particularly in pan-plexus injuries where there are limited nerve transfer options.

An injury that does not show signs of improvement within 3 months will often require major surgical reconstruction. The speed of nerve regeneration after spontaneous recovery or nerve repair is about 1 mm per day (1 inch per month).

Given the time frame to permanent paralysis (about 1-2 years), surgical repair is best carried out by 3-6 months after injury.

Brachial plexus injuries are usually caused by trauma to the roots of the plexus as they exit the cervical spine.[1]Nath RK, Lyons AB, Bietz G. Physiological and clinical advantages of median nerve fascicle transfer to the musculocutaneous nerve following brachial plexus root avulsion injury. J Neurosurg. 2006;105:1-5. http://www.ncbi.nlm.nih.gov/pubmed/17405252?tool=bestpractice.com This most commonly occurs in road traffic accidents, falls from height, and may also be due to iatrogenic injury.[2]Kaiser R, Waldauf P, Ullas G, et al. Epidemiology, etiology, and types of severe adult brachial plexus injuries requiring surgical repair: systematic review and meta-analysis. Neurosurg Rev. 2020 Apr;43(2):443-52. http://www.ncbi.nlm.nih.gov/pubmed/30014280?tool=bestpractice.com ​ Inflammatory, neoplastic, and compressive causes are also possible.[3]Moghekar AR, Moghekar AR, Karli N, et al. Brachial plexopathies: etiology, frequency, and electrodiagnostic localization. J Clin Neuromuscul Dis. 2007;9:243-7. http://www.ncbi.nlm.nih.gov/pubmed/17989587?tool=bestpractice.com The effects of the injury can include paralysis and loss of sensation of the upper extremity, and pain. The specific clinical presentation will depend on the roots involved and the degree of injury to each root.[Figure caption and citation for the preceding image starts]: Left brachial plexusFrom the collection of the Texas Nerve and Paralysis Institute, Dr Rahul Nath, Founder and Medical Director; used with permission [Citation ends].