Dr. Leena Jain, a leading Plastic Surgeon in Mumbai, treats brachial plexus injuries. She is an expert microsurgeon with considerable experience in hand reconstruction. In this blog, she gives an insight on the treatment of brachial plexus injuries.
The brachial plexus is a network of nerves arising from the uppermost part of the spinal cord located in the neck. This plexus transmits sensory and motor (movement) signals to the upper limb- from shoulder to fingers.
Blunt trauma, penetrating injury, fall of weight on the shoulder region or dragging injury to the neck/ shoulder to the neck and/or shoulder region can affect the brachial plexus network. Brachial plexus injury causes loss of sensation and movement in the affected upper limb making it limp and flail.
Presentation of brachial plexus injury:
Depending upon the extent of injury, some brachial plexus injuries are self-limiting and the patient may recover to near normal or normal functioning of the affected nerve functions.
However, more often than not, patients do sustain injury to all the nerves in the plexus causing permanent damage with no scope of spontaneous recovery. Here the patients present with affection of a single nerve of the entire plexus of nerves causing global palsy.
Patients are often unable to move their arm above their head, nor bend elbow to eat, neither can they curl their fingers into a fist. In all these cases of severe and extensive brachial plexus injuries, surgery is the only option to restore hand function..
Dr. Leena Jain, a brachial plexus surgeon in Mumbai, states that diagnosing the brachial plexus injury is very important. Patients with the following conditions required brachial plexus surgery to recover well -
- Neck and shoulder trauma injuries resulting in torn or severely stretched nerves or severed nerves in the brachial plexus
- Nerve tumors of the brachial plexus i.e., neurofibromas, schwannomas, and so on.
The plastic surgeon will conduct an in-depth examination to know which nerves are injured, the extent of damage, location, availability of donor nerves for transfer. Status of nerves is then evaluated using Electromyography and nerve conduction studies.
A plan is then drawn in place by the Plastic Surgeons to decide on nerve transfers or transfer of functioning muscle. The medical examination involves
- An in-depth history of health condition
- Symptoms and their impact on normal activities and quality of life
- Physical examination to study the pain, sensation, and motor function on comparing the affected and the unaffected side.
- Chest function is assessed
- Imaging studies – MRI and Ultrasound to view the injury, its location, and extent
- EMG for nerve function and decision which nerves can be chosen for repair
Planning and scheduling brachial plexus surgery
Immediate scheduling of brachial plexus surgery is possible only in case of penetrating injuries where the nerves are severed. Scheduling the brachial plexus surgery later is advised if the injury is due to crushing or stretching.
The patient’s recovery from the injury is observed for a minimum of 2-3 months for any signs of spontaneous recovery otherwise surgical intervention is required.
EMG tests and physical therapy are advised at regular intervals to determine the state of recovery
Brachial plexus surgery is advised to restore sensation and movement in case of poor or no recovery using nerve transfers if spare nerves are available or a few nerves remain undamaged. This surgery is advised three to six months after the injury for best results.
Delaying the surgery for more than one year is not recommended as the affected muscles in this region start to shrink permanently, this condition is referred to as atrophy, and once they become atrophic then the treatment involves transferring muscles or tendons..
Various surgeries to treat brachial plexus condition
The focus of the brachial plexus surgery is to establish the motor function of the hand, elbow, arm, and shoulder along with restoring sensation.
The plastic surgeon will take an overview of the extent of nerve injury, location and type, and an overview of the existing health condition of the patient. Also, the impact of injury affecting the quality and work of life is also considered.
Procedures your surgeon might recommend are:
Brachial Plexus Nerve Repair
The surgeon performs the Brachial Plexus Nerve Repair surgery to repair the cut or torn nerve. The procedure involves sewing the ends together and reconnecting them. This surgery is done using small, specialized instruments and a microscope.
Brachial Plexus Decompression and Neurolysis
Decompression surgery is performed to treat a compressed nerve and release the pressure. This surgery also addresses the loss of function and associated symptoms. The surgery also known as neurolysis removes the adhesions or scar tissues in and around the injured nerve.
Nerve Grafting Surgery
This surgery is performed to remove an injured or severely scarred nerve. The injured nerve cannot carry signals from the brain to the hand and arm; hence, the patient is in a paralytic condition.
The plastic surgeon removes the damaged brain and replaces it with a nerve graft of an expendable sensory nerve. The graft could be taken from the sural nerve in the leg. This procedure creates a bridge that becomes a passage for nerve regeneration as the nerve graft replaces the damaged nerve.
Nerve Transfer Surgery
The aim of the nerve transfer surgery is to transfer healthy functioning nerves to the branches of brachial plexus which are involved in supplying the corresponding upper limb muscles so new nerves regenerate along this pathway and activate the muscles.
This surgery proves to be the best option to restore movement and sensation to muscles and skin and is best done within a year of injury.
The timing is the key feature of a nerve transfer surgery, as restoring nerve supply is essential before the onset of irreversible atrophy. Also, the location of the injury and the type of injured nerve determines the feasibility of nerve transfer surgery.
Nerves used in these procedures are,
- The medial pectoral nerve in the front of the shoulder
- The intercostal nerve under the ribs
- The spinal accessory nerve
- The thoracodorsal nerve
- The musculocutaneous nerve in the arm
- Other nerves in the forearm and hand
Tendon Transfer Surgery
In certain conditions especially if a considerable time has passed after the injury, tendon transfer is the most reliable option for restoring movement after a brachial plexus injury. This option is given serious thought when nerve transfers and nerve grafting are not possible. There is no time constraint for performing tendon transfer surgeries.
The tendon transfer surgery is performed on a paralyzed tendon and an expendable and functioning tendon is attached. The functioning tendon will act upon the paralyzed tendon and attempt to restore movement in the upper extremity. This is possible only in partial brachial plexus injuries where tendons are available for transfer.
Functional Muscle Transplant
Functional muscle transplant is ideal if a considerable time has passed after the occurrence of brachial plexus injury. Also, it is impossible to perform nerve repair, grafting, and transfer in that condition.
Mostly, a nonessential muscle is transplanted to the impaired muscle in the upper extremity to restore elbow flexion with or without finger extension.
This procedure takes about 3-4 months to show some recovery and about 8-10 months for functional recovery that is restoration of elbow bending or flexion.
A second muscle can be transferred about 6 months later to restore finger flexion. The muscle used is one from the thigh called gracilis muscle , using this does not affect any thigh function.
The surgeon uses a microscope, and tiny blood vessels of the transplanted muscle are used to connect to muscles in the axilla or neck to restore the blood flow. Similarly, a nearby nerve is connected to provide motor functionality to the nerve of the transplanted muscle.
One of the prominent Microsurgeon and Hand surgeons in Mumbai, Dr. Leena Jain provides treatment for brachial plexus injuries