Surgery - Brachial Plexus Lesions

Surgery - Brachial Plexus Lesions

The most difficult injuries to manage are those caused by severe stretch or traction as there is no obvious guide to what has occurred inside. Doing surgery early might interfere with normal recovery while leaving surgery for too long can allow important parts of the nervous system to degenerate without connections. Nerve avulsion can be surgically approached after three to six weeks or if natural recovery does not occur as expected then surgery can be approached at 3 to 6 months. If the nerve has been cut then repair can be attempted, whilst if it has been avulsed then grafting can be performed. To speed up recovery a nerve transfer may be used.

Intractable arm pain is one of the very difficult parts of the brachial plexus lesion injury picture, a chronic and disabling problem which can come on with time. A severe pain problem can develop in the arm despite the fact that the nerves have been ripped out and are not connected any longer to the spinal cord. However the nerves in the spinal cord expect inputs from the arm nerves and when they don't get them they start reacting abnormally to this deprivation, generating a particularly unpleasant pain problem in the arm.

Patients typically describe the pain as shooting, crushing or burning, severe or coming on in severe spasms. This kind of pain is referred to as deafferentation pain, which refers to the rupture causing a loss of incoming (afferent) signals to the nervous system. Treatment of deafferentation pain starts with conservative measures. A pain management team specialises in these conditions and early involvement would be helpful, even admission to allow treatment to be started with a multidisciplinary approach. Many drugs can be used apart from the morphine chemicals and some may be helpful in suppressing this neuropathic pain.

Physical treatments include transcutaneous nerve stimulation (TENS), a battery powered electrical device which inputs signals into the central nervous system which may interfere with normal pain transmission at the level of the spinal cord. TENS has to be used over a long period and it may be months before maximum benefit occurs. Many other treatments have been tried with very variable and not very impressive results including desensitisation, cognitive behavioural therapy, acupuncture, hypnosis and biofeedback. A multidisciplinary team is vital to deal with the many problems whilst either waiting for recovery or undergoing surgical reconstruction of some kind.

Nonoperative treatment is complex and best managed by the dedicated multidisciplinary team which might include a physiotherapist, occupational therapist, physician and orthotist. The physician can manage the diagnosis and monitor the recovery, the orthotist will provide braces to prevent joint contracture, the occupational therapist will teach functional use and the physiotherapist will maintain joint ranges and encourage normal muscle use. Surgical care is highly specialised and should be undertaken only by specialists in designated centres with experience. Because the injuries vary so greatly the choice to intervene or not and the procedures to be chosen if surgery is to be attempted are very varied.

Prognosis after brachial plexus injury is difficult to predict because the way the incident occurs and the exact details of the injury can be so variable, with the person's age and the surgical choices also affecting the outcome. Function can be improved by transferring a working muscle to do the work of the muscles no longer functioning, and nerve grafting using the leg sural nerve is now performed mostly three to six months after the injury. Nerve roots which have been pulled out from the spinal cord have been surgically replaced without predictable results yet, but success would indicate the possibility of central nervous system healing.

Nerves heal at an average speed of about an inch a month, or one millimetre a day, which means that if the nerve injury is a long way from the muscle it needs to supply it will take a very long time to get there. The connecting endplates on the muscles may degenerate before the nerves have a chance to grow down to them. Nerve growth factors are the subject of much research to increase the rate of recovery of nerve repairs and grafting.

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Jonathan Blood Smyth is a Superintendent Physiotherapist at an NHS hospital in the South-West of the UK. He specialises in orthopaedic conditions and looking after joint replacements as well as managing chronic pain. Visit the website he edits if you are looking for physiotherapists in Lancashire.