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  • Updated 02.02.2017
  • Released 02.08.2002
  • Expires For CME 02.02.2020

Brachial plexus injuries

Introduction

Overview

The brachial plexus is a network of nerves that control the 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. Diagnosis and treatment of brachial plexus injuries is slowly evolving. Imaging modalities, such as magnetic resonance neurography and ultrasonography, are increasingly used for evaluation of brachial plexus injuries. The novel approach of bionic reconstruction has reached clinical arena, and its utility remains to be determined.

Key points

• Motor vehicle accidents and gunshot wounds are the most common traumatic insults causing brachial plexus injuries and these patients frequently have other associated trauma.

• Symptoms of brachial plexus injury include varying degrees of upper extremity pain, weakness, sensation changes, and diminished reflexes.

• Diagnostic tools include: CT myelogram for the evaluation of root injury, particularly associated root avulsions, MRI for the evaluation of the plexus distal to the spinal foramina, and EMG/nerve conduction studies for confirming localization and assessing extent of axonal injury.

• Mechanism of injury, time since injury, type of injury (preganglionic or postganglionic), and associated injuries are all important factors to consider when determining a treatment option.

• Surgical exploration with early surgical repair, delayed surgical repair, tendon and nerve transfer, and root transfers are potential treatment options.

Historical note and terminology

Injuries are as old as human evolution. Neurologic injury is described in mythological war stories and in the modern era following the world wars. The devastating nature of upper limb injuries was described by Homer in Iliad and by Thucydides in History of the Peloponnesian War. Historically, it was the chariot drivers and warriors who had sustained these injures. Flaubert gave an anatomical description of avulsed roots in 1827 (87). Thorburn performed direct repair of the brachial plexus injured in an industrial accident and reported the intraoperative findings (89). The early operative reports and results on brachial plexus injuries and birth injuries of the brachial plexus were not encouraging due to high mortality and morbidity rates. Experience with open brachial plexus injuries during British World War II also had disappointing results, leading to a conclusion that these injuries may not be routinely explored, thus, proposing a conservative attitude in the management of plexus injuries.

Seddon proposed his method of interposition nerve grafts for traction injuries (71). Subsequent interest in the surgical treatment of plexus trauma was revived with the introduction of magnification and illumination, along with sustained efforts by Millesi of Austria and Narakas of Switzerland (60; 63). An aggressive operative approach was proposed by surgeons with claims that improvement following surgical treatment is the direct result of disrupting the natural history following perineural and intraneural scarring and the destruction of nerve fibers. Millesi has promoted sequential microsurgical procedures of external neurolysis, internal neurolysis, and autologous grafting. Kline utilized the electrophysiological studies combined with preoperative clinical details, as well as intraoperative neuroelectrophysiological measurements to define the operative methodology (49).

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