All Disorders National Institute of Neurological Disorders and Stroke Adult post traumatic Brachial plexus injury is unfortunately a rather common injury brachial young adults.
In India the most common scenario is of a young man injured in injury motorcycle accident. Results have been discussed and analysed to get an idea of factors influencing final recovery. It appears that time from injury and number of roots involved are most crucial.
Adult brachial plexus injury: evaluation and management.Brachial plexus injury BPI is one of the most devastating injuries from the point of view of the patient.
Potentially this can lead to brachial, economic hardship, depression and in plexus instances even suicidal urges. The typical patient is a young male who has had an plexus while riding a two wheeler where he has been thrown off the vehicle and suffered traction between neck and shoulder damaging his plexus to varying degrees. It is therefore vital that this very valuable segment of our population is functionally restored as early as adult to the best of adult ability.
With modern techniques in hand and microsurgery, this is very much feasible provided the injury is treated in time. There are techniques available for late referrals too, but early commencement of treatment makes a huge difference to the eventual outcome.
Research and Experimental Treatment Options. What are the causes and plexus factors for RIBP. How is RIBP diagnosed. How is RIBP treated. These resources may adult The discussion boards at BreastCancer. The site is public, so you can read posts without registering. If you'd like to injury the discussion, registration is quick and free. Participants offer one another encouragement, coping tips, and information about any new directions brachial RIBP research and treatment, as well as a comfortable and understanding forum for airing the frustrations and grief of living with this condition.Injury to one phrenic nerve leads to paralysis of the ipsilateral diaphragm, often leading to symptoms of dyspnea, which may improve with time. If both phrenic.
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If patient has a flail upper limb then all roots are involved. Table 1 summarizes this description. It is important to note loss of sensation and often what patient perceives as altered sensation. However on rigorous sensory testing these areas too are often anesthetic. Dry skin is a give away for affected dermatomes due to loss of sudomotor function.
Brachial plexus injury in adults: Diagnosis and surgical treatment strategiesTable 2 summarizes some easy rules of the thumb.
In case of fracture clavicle it is likely to result in a post ganglionic injury and also may be associated with a subclavian artery injury which will impact future free functional muscle transfers FFMT especially in a flail upper limb as the donor vessels may be compromised or limited. Multiple limb fractures and head injury will affect the outcome only if they delay plexus surgery beyond 3 to 6 months.
In case of humerus fractures, the clinician should be alerted about the existence of an additional radial nerve injury which is then difficult to diagnose. The brachial plexus is the network of nerves that sends signals from your spinal cord to your shoulder, arm and hand. A brachial plexus injury occurs when these nerves are stretched, compressed, or in the most serious cases, ripped apart or torn away from the spinal cord. Minor brachial plexus injuries, known as stingers or burners, are common in contact sports, such as football. Babies sometimes sustain brachial plexus injuries during birth. Other conditions, such as inflammation or tumors, may affect the brachial plexus. The most severe brachial plexus injuries usually result from auto or motorcycle accidents. Horner's sign indicates a very proximal usually Pre Ganglionic type of lesion and signals the need for aggressive early management of the plexus injury with multi staged reconstruction including FFMT amongst other things.
This of course pre supposes the existence of an excellent electro diagnostic department in your center which unfortunately is not always the case. The following things can be determined by Edx:. Imaging gives valuable information about the lesion as also about the associated injuries.
Adult brachial plexus injury Dr. Nath is a specialist in brachial plexus injury and erb's palsy treatment surgery. Dr. Nath is a former Assistant Professor of the Department of Surgery and Division of Plastic Surgery and Department of Neurosurgery. Also affiliated with the Texas Medical Center in Houston and the Texas Medical School Northwestern University Medical School Chicago IL. The brachial plexus is a group of nerves that come from the spinal cord in the neck and travel down the arm (see Figure 1). These nerves control the muscles of the shoulder, elbow, wrist and hand, as well as provide feeling in the arm.Some modalities are listed below and this can be a subject of a review article in itself. There are several papers discussing these modalities. Currently MRI is considered very useful, at least in the adults.
Although there are reports of the use of MR scans the author does not routinely perform MR scans every time he sees a patient, although patients often already have one when seen by a hand and plastic surgeon. Clinical exam and electro physiology can give very adequate evidence of the status of the plexus and the indication for surgery.
Surgery especially for obstetric plexus injuries was pioneered by Kennedy ,[ 31 ] Sever [ 32 ] and Wyeth and Sharpe in However Sever's results and paper describing cases were a damper for future work for almost 50 years. Herbert Seddon revived interest in the field after world war II. Any brachial plexus injury which has not shown substantial spontaneous recovery in 3 months deserves to be explored.
Timing is crucial due to the eventual loss of neuro muscular end plates at 20 to 24 months after denervation. Operation can be performed in days or weeks to get the maximum out of any possible nerve transfers. In partial injuries especially of the upper plexus, a maximum period of 3 months is worthwhile to look for improved CMAP's of donor nerves and resolve the neuropraxia part in functioning roots.
Indian data from the Post Graduate thesis of two of my students[ 40 , 41 ] clearly demonstrate that the first three months are the best period followed by 3 to 6 months after injury. Age too impacts results. Young patients at or around 20 years show rapid recovery with higher gain of strength.
People over 40 are thought to show reduced results; however, they still show adequately good results to justify surgery at any age unless medical factors make the person unfit for reconstruction. Bhatia AG[ 42 ] has shown documented consistent good results of nerve reconstruction in people over 50 in a sample size of 38 cases.
Age range was and median age Pre-op delay was few days to 12 months. The results showed a similar percentage of greater than M3 power as in younger people. Typically the exposure is both above and below the clavicle to get at the entire plexus and its nerve [ Figure 1 ]. A detailed paper[ 43 ] is available discussing the approach and its technical details. In obstetric plexus cases, it is often necessary to ostetomize the clavicle to get a good exposure;[ 43 ] however, in adult cases except for the truly retro clavicular injury we do not always osteotomize the clavicle.
Whenever feasible depending on timing, surgery for nerve repair takes precedence over all other procedures since time is of the essence. As soon as other injuries are dealt with primarily the patient should have the earliest possible nerve repair.
Secondary procedures are done after nerve repairs or in very late cases as a substitute to restore function. Either way all patients can be offered some treatment at all stages. In cases of post ganglionic injury where donor roots are available, the root stumps are joined to distal targets which may be trunks, cords or individual nerves with the help of autologous nerve grafts.
These may be free grafts or vascularized grafts. In general short grafts do better than long grafts; however, such a choice is not always available. Nerves not arising from the plexus are used as donor nerves. Some authors use phrenic nerve. Their data and conclusions are reproduced below.
Their series is of on 16 patients with brachial palsy 15 total and 1 partial, where it was used for axillary nerve. The observations have been as under. Based on these observations, in his opinion, phrenic nerve is not an expendable nerve.
During young age, a majority of them may remain asymptomatic. However with advancing age and in high demand situations pulmonary infections , they will be more prone to develop respiratory complications. Essentially the concept is to use the fascicles or branches of a functioning distal nerve to re innervate a denervated muscle or group of muscles. The donor nerve typically suffers very little functional deficit but the recepient muscle being nearby compared to intra plexal neurotization in neck gets quickly innervated and functional.
Typically this is a dream win—win situation, some examples:. Pioneered by Gu et al. This is a paradigm changing procedure where either the full or half contralateral C7 root from the normal side is harvested and connected to the target nerves on the affected side.
In situations where there is global avulsion on the affected side this is a vital new technique which offers promise.
For older adults we prefer to use the contralateral C7 to get either the lateral cord or the posterior cord innervated for more proximal muscle function and the results are reliable. The author has discussed the BBPI strategies elsewhere in detail. Thus potentially total reconstruction up to and including the hand intrinsic muscles is feasible even in an all 5 root injury if operated in time.
This is rarely feasible in an adult total palsy. For all injuries we will discuss strategies for intra plexal repair and other nerve transfers simultaneously.
Currently the Oberlin and Somsak transfers are gaining popularity even in post ganglionic injuries amongst many surgeons due to the much higher chances of success especially in older patients and delayed repairs.
For post ganglionic injuries it will remain similar to C5C6 injury in cases of early surgery on a young patient. For cases with pre ganglionic injury or older patient or late repair the strategy is:.
Videos of results are available in the online version. Elbow flexion restored using Oberlin's Technique a Ulnar nerve fascicle coapted to musculocutaneous nerve b Result showing elbow flexion restored using Oberlin's Technique b Clinical result. If patient is young and operated early. In late cases or if C7 is not available then distal nerve transfers are possible:. Figure 5 shows results in such a case. The commoner injury is a pre ganglionic total avulsion.
In these cases a multi staged strategy is employed by the author. The author uses a different strategy as follows:. Stage II 3 months following stage I: Simultaneously use one ICN for triceps if C7 is on lateral cord. Tendon transfers to improve hand function for grasping, shoulder fusion if shoulder is unstable.
Using computer mouse is also possible. Fine function like buttoning a shirt, writing, typing etc. Figures 6 shows a result of secondary procedures:. Functional restoration after reconstruction of flail upper limb a Elbow flexion b Functional restoration after reconstruction of flail upper limb b Fingers flexing against resistance using Gracilis c Functional restoration after reconstruction of flail upper limb c Finger flexion after Opp C7 transfer to median. Babhulkar and Thatte[ 41 ] analyzed a small subset of the data in Bombay Hospital over a 4 year period where at least 2 years approx.
This was a prospective study of adult patients with either total or partial traumatic brachial plexopathy between August and May studied at Bombay Hospital Institute of Medical Sciences, Mumbai. The aim was to evaluate the outcome of surgical management of brachial plexus injury patients with a follow up of minimum two years along with social and emotional impact over patients of brachial plexus injury. Patients were treated with a combination of neurolysis 79 patients , neurotization 84 patients or nerve grafting 29 patients according to intra-operative findings.
The youngest patient was of 18 years with mean of The mean time interval between injury and surgery was 5. The average post operative follow up was Patients subsequently may have got free functional muscle transfers in severe cases but this was not factored into the assessment.
Pure nerve repair results are analysed. All the factors studied in our series delay in operation, number of avulsed roots, type and level of injury and use of nerve graft except age of the patient affected the outcome on univariate analysis. On multimodal regression analysis, delay in operation P value 0. We conclude that these complex injuries require tailored approach for improved prognosis.
Multiple factors impart important influence on the outcome of brachial plexus surgery, only factors like delay in operation and number of avulsed roots significantly affected the outcome of surgery in our series. FFMT using Gracilis has added a very valuable tool to enhance results in cases of flail upper limb.
In the past these patients had no hope of really getting a usable upper limb following pure nerve repair. It is therefore important to offer this option to the global avulsion patients right at the outset and outline a comprehensive program of sequential surgery and rehab to avoid depression.
Though social and emotional assessment was not done using any standardized index, it showed that poor outcome was associated with dissatisfaction, depression and impact on the career. The main frustration of brachial plexus surgeons is the patient with avulsed roots—no usable proximal donor axons.
Some groups[ 58 — 65 ] are now trying to reimplant the avulsed roots into the spinal cord with the hope of reconnecting with the tracts coming from and going to the CNS.
They have had partial success but they seem to work that too partially only if done very early, like in the first few weeks after injury. Workers in basic biology are reporting something more fascinating in non mammalian animals; two groups working on the sea cucumber an echinoderm [ 66 ] and the Zebra fish[ 67 ] have shown amazing regeneration of the nervous system.
The main cell responsible is the equivalent of the mammalian radial glial cell which manages to help the organism in regeneration and bridging the gap. In mammals too the glia come in at the site of an injury but currently appear to remain static there and in fact hinder regeneration to some extent. The key will lie in up regulation of genes like her National Center for Biotechnology Information , U.
Ann Indian Acad Neurol. Thatte , Sonali Babhulkar , and Amita Hiremath. Author information Article notes Copyright and License information Disclaimer.
This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3. This article has been cited by other articles in PMC. Abstract Adult post traumatic Brachial plexus injury is unfortunately a rather common injury in young adults. Brachial plexus injury, adult, surgical strategy. Introduction Brachial plexus injury BPI is one of the most devastating injuries from the point of view of the patient.
History One of the earliest descriptions of injuries to the brachial plexus can be found in Homer's Iliad,[ 1 ] but it was not until this past century that attempts at reconstruction were reported. Etiology and pathophysiology In the majority of cases treated by the author as also elsewhere in the world, the main etiology remains vehicular accident typically on a two wheeler. A list of common etiologies is given below: Industrial trauma—weight falling on shoulder from a height, being dragged inside a machine by the arm.
Iatrogenic injury, either deliberate as in tumor surgery involving nerve roots or accidental while operating in the posterior triangle of the neck. Pathophysiology of pre and post ganglionic lesions This is perhaps the most important distinction in the pathology of brachial plexus injury.
Broadly speaking for the surgeon, there are three different kinds of lesions: Neuropraxia—reversible rapidly in weeks, rarely reaches the surgeon. Externally intact looking nerves Sunderland type two or three injury — axonotomesis —not to be resected in the neck but distal transfers may be needed if progress is poor.
Neuroma in continuity—represents a post ganglionic lesion Sunderland Type III and IV axonotomessis and requires surgical repair after excision of the neuroma.
Rarely is the neuroma conductive, if it is a neurolysis may suffice. Rupture—Post Ganglionic lesion neurotomessis sunderland typeV , amenable to intra plexal nerve repair. Avulsion—Pre Ganglionic lesion, typically that root has to be abandoned as a source of regenerating axon. Classification as per site Brachial Plexus injuries can be classified in various ways: Patient evaluation Consists of: A detailed history and noting the date of injury.
Complete clinical examination Muscle charting and note muscle wasting. Muscle charting As a simple thumb rule C5C6 represent the shoulder and elbow function, mainly of the deltoid and the biceps. Table 1 Summary of root wise motor function. Open in a separate window. Sensory evaluation It is important to note loss of sensation and often what patient perceives as altered sensation.
Table 2 Summary of sensory innervation. The following things can be determined by Edx: Type of lesion, i. Compound motor action potential CMAP of important nerves like the ulnar and median which are potential donor nerves in upper plexus injuries. Imaging Imaging gives valuable information about the lesion as also about the associated injuries. Plain X-rays for fractures and raised diaphragm phrenic nerve injury.
CT myelography to determine the root status—not really done now but was the gold standard a few years ago. Surgery for brachial plexus injury Surgery especially for obstetric plexus injuries was pioneered by Kennedy ,[ 31 ] Sever [ 32 ] and Wyeth and Sharpe in Indications for surgery and timing Any brachial plexus injury which has not shown substantial spontaneous recovery in 3 months deserves to be explored.
Surgical Exposure Typically the exposure is both above and below the clavicle to get at the entire plexus and its nerve [ Figure 1 ]. Marking for typical exposure of supra and infra clavicular plexus. Treatment Strategy Broadly surgery for these is divided in two broad categories: Surgery for nerve repair. Surgery of the nerves Broadly divided into: Three patients with weak or nonfunctional spinal accessory nerve underwent simultaneous unilateral transfer of phrenic nerve to the suprascapular nerve and three intercostal nerves to the musculocutaneous nerve.
These patients also remained symptom free in the post operative period. Pulmonary function tests in postoperative period exhibited a significant reduction in vital capacity, total lung capacity, forced vital capacity, and forced expiratory volume in 1 s.
These patients were followed up for a period of 28 to 36 months. Minor brachial plexus injuries, known as stingers or burners, are common in contact sports, such as football.
Babies sometimes sustain brachial plexus injuries during birth. Other conditions, such as inflammation or tumors, may affect the brachial plexus. The most severe brachial plexus injuries usually result from auto or motorcycle accidents. Severe brachial plexus injuries can leave your arm paralyzed, with a loss of function and sensation.
Surgical procedures such as nerve grafts, nerve transfers or muscle transfers can help restore function. A cross-section of spine shows how nerve roots are connected to the spinal cord. The most severe type of nerve injury is an avulsion A , where the nerve roots are torn away from the spinal cord. Less severe injuries involve a stretching B of the nerve fibers or a rupture C , where the nerve is torn into separate pieces. Signs and symptoms of a brachial plexus injury can vary greatly, depending on the severity and location of your injury.
Usually only one arm is affected. Minor damage often occurs during contact sports, such as football or wrestling, when the brachial plexus nerves get stretched or compressed.
These are called stingers or burners, and can produce the following symptoms:. These symptoms usually last only a few seconds or minutes, but in some people may linger for days or longer. More-severe symptoms result from injuries that seriously injure or even tear or rupture the nerves. The most serious brachial plexus injury avulsion occurs when the nerve root is torn from the spinal cord. Brachial plexus injuries can cause permanent weakness or disability.
Even if yours seems minor, you may need medical care. See your doctor if you have:. Damage to the upper nerves that make up the brachial plexus tends to occur when your shoulder is forced down while your neck stretches up and away from the injured shoulder.
The lower nerves are more likely to be injured when your arm is forced above your head. Participating in contact sports, particularly football and wrestling, or being involved in high-speed motor-vehicle accidents increases your risk of brachial plexus injury.
Given enough time, many brachial plexus injuries in both children and adults heal with little if any lasting damage.
SHOULDER - Brachial Plexus Injury / Erb's Palsy - one arm - Brachial Girl
Brachial plexus injury - Symptoms and causes - Mayo Clinic The pain from brachial plexus injuries results from injury to the spinal cord where the nerve rootlets are avulsed from the cord. In addition, injuries nearer the spinal cord may cause a burning numbness, which is called paresthesias or dysesthesias. Abstract Adult traumatic brachial plexus injuries are devastating, and they are occurring with inc. Adult brachial plexus injury