The brachial plexus is a complex network of nerves between the shoulders and neck. These nerves control the activity of the muscles in the chest, shoulder, arms and hands, as well as the sensation (sensation) in the upper extremities. Five nerves which begin of the spinal cord (C5, C6, C7, C8, T1) join each other and branch to make the brachial plexus. Injury to them is named as brachial plexus injuries.

Dr Rajendra S Gujjalanavar has special interest and expertise in the management of brachial plexus injury. Treatment involves multidisciplinary team approach including:

1. plastic surgeon
2. occupational therapist
3. physical medicine
4. pain specialist.

Brachial Plexus injuries occur in two groups of individuals.

• Obstetric brachial plexus palsy (OBPP) occurs when the child suffers Brachial Plexus injury (Birth Brachial Plexus Palsy) during childbirth, commonly called as Erb’s Palsy.
• Adult brachial Plexus Injury occurs due to violent forces that occur during injuries like motor cycle accidents.

The pathology, the philosophy of management and therefore the outcome achieved are very different in both the groups. Hence they are dealt with separately.

Birth Brachial Plexus Injury

During the birth process, the nerves of brachial plexus may suffer from excessive stretch causing injury to the nerves. This may be due to several causes like the passage being narrower for the dimensions of the baby or to a condition called shoulder dystocia. This means that there is difficulty in delivery of shoulder after head comes out, in this process of the delivery of the shoulder the nerves in the neck may suffer from stretch injury.

What happens when the brachial plexus is injured?

During the birth process, the nerves of brachial plexus may suffer from excessive stretch causing injury to the nerves. This may be due to several causes like the passage being narrower for the dimensions of the baby or to a condition called shoulder dystocia. This means that there is difficulty in delivery of shoulder after head comes out, in this process of the delivery of the shoulder the nerves in the neck may suffer from stretch injury.

What are the different types of injuries?

Two types of injuries:

• Rupture means the nerve is injured after it has come out from spinal cord beyond the bony vertebral column.
• Avulsion means nerve cables have been pulled out of the spinal cord.

The implication is that in case of rupture, the injured nerve can be joined back but when there is avulsion, the injured nerve cannot be joined back to the spinal cord. Recovery and surgical options are better with rupture. Even with avulsion injury in children, some function can be still restored by joining some working adjacent nerve to the injured nerve.

Why do deformities occur in Birth Brachial Plexus Palsy children?

Bones of babies grow at a rapid rate. Normally, growing bones and joints are pulled by various muscles from all sides. In case of brachial plexus injury, some muscles are working and some may be paralyzed. So, there is an unequal pull on the growing bones and joints leading to various deformities.

When will take baby to doctor?

It is ok to consult the doctor by about 6 weeks. The doctor would examine the child and record the recovery and will explain to you the prognosis and further management.

What is treatment for OBPP?

Botox causes temporary weakness of muscles. In babies with partial recovery from brachial plexus injury there can be imbalance between muscles and it may cause some deformities or may restrict some movements. Botox is used to correct these imbalances and improve the movements. In some children the consequences could produce lasting improvement.

What surgery is done for OBPP?

If at 6 months baby doesn’t recover the maximum range movement as doctors want, then there is severe injury to the brachial plexus nerves. Doctors approach the brachial plexus through the neck, to see the status of the nerves. If the nerves are found damaged and the ends are available an effort is made to repair them. The injured nerves will have a gap between the two damaged ends, the nerve from the leg is taken to bridge the gap. The leg will have no functional deficiencies as this is a dispensable nerve (sural nerve) and children can normally run and play like any other child after the nerve is removed. Sometimes good nerves to may not be available to connect at all. In that case cross connections with nearby working nerves to produce the movement in shoulder and elbow. This operation is called nerve transfer . Advances in anesthesia has made operation safe for children.

The child is unable to lift the upper limb (at the shoulder) what can be done for this?

Difficulty to lift arm can be due to the weakness of lifting muscles, too strong opposite pull from neighboring muscles or mostly a combination of the two .In older children release the tightness of the contracted muscles by surgery or make them weak by Botox injection.

What is Mod Quad operation?

Mod Quad is a operation where muscle release and rebalancing done to improve the shoulder movements. It improves lifting of the arm in children who are unable to lift the arm due to the tight muscles in armpit. The tight contracting muscles in the axilla (armpit) are relaxed and pressure on a nerve is released. Muscles also are transferred to achieve balance as per the necessity of the kid . Usually after this operation arm are often made to lift overhead and therefore the children are ready to perform the overhead activities much easily.

Adult Brachial Plexus Injury

An adult brachial plexus palsy is usually the results of trauma to the neck area. The mechanism usually is traction injury to the brachial plexus nerves causing damage to the nerves and a loss of function.

When to visit doctor with brachial plexus palsy?

Initial evaluation is important as early as possible (not before one month after injury but no later than 3-6 months) so as to be ready to provide appropriate care and interventions. Outcomes depend on severity of the injury to the brachial plexus and the timing of presentation and intervention.

What Happens in a Brachial Plexus Palsy?

A Brachial Plexus Palsy (BPP) affects the nerves of brachial plexus which are passing from the neck to the arm. These are the nerves that trigger movement from the shoulder right down to the fingers. The most common explanation for brachial plexus injury is stretching, compressing, or tearing of the nerves which will end in scar formation. Some injuries may heal without much disabilities, others may result in disability if not treated promptly. Depending on the type of brachial plexus injuries, symptoms can occur within upper limb ( shoulder, elbow, and/or hand and fingers). These symptoms include loss of feeling, loss of control , limited or no active range of motion and pain.

How to diagnose adult brachial plexus palsy?

Diagnosis is mainly by clinical examination supported by nerve conduction studies, MRI, x-rays etc.

How to treat brachial plexus injury?

Nerves that have been only stretched may recover without further treatment. Your doctor may recommend physiotherapy to stay your joints and muscles working properly, maintain range of motion, and stop stiff joints. Surgery to repair plexus brachialis nerves should generally occur within six months after the injury.

What are surgical options for brachial plexus injury?

1. Microsurgery- Microsurgery is recommended to repair damaged nerves if healing is still insufficient 3 to 6 months after injury. This operation usually consists of a combination of nerve grafting and nerve transfer procedures. It is best performed between 3 and 9 months after injury and is usually not useful over 1 year.
2. Tendon transfer- Tendon transfer involves separating the tendon from its normal ligament and reuniting it. This procedure allows a healthy muscle to help a weak or damaged muscle return to its desired function. Tendon transfer is usually done around the shoulder to improve the ability to lift the arm, but can be done in the forearm, wrist or arm.
3. Free muscle transfer is an extensive operation, usually using the muscles of the legs, that requires reconnection of blood vessels and nerves under a microscope. It is performed only when there are no local muscles in the arm or arm to replace the dysfunctional muscles.

What are the aftercare for brachial plexus surgery?

After surgery patient needs regularly physiotherapy, occupational therapy, and nerve stimulation till complete recovery. Frequent follow-ups could also be required and patient/family commitment regarding the recommendations are crucial for maximum functional outcomes.

Peripheral Nerve Injury

Peripheral nerves send messages from your brain and spinal cord to the remainder of your body, helping you are doing things like sensing that your feet are cold and moving your muscles so that you can walk. A nerve injury can affect your brain’s ability to communicate together with your muscles and organs. Damage to the peripheral nerves is named peripheral neuropathy.

It’s important to start treatment for a peripheral nerve injury as soon as possible. Early diagnosis and treatment helps in preventing complications and permanent damage. Dr Rajendra S Gujjalanavar is specialized in nerve injury management.

What are the Symptoms?

You may experience symptoms that range from mild to significantly limiting your daily activities. Your symptoms often depend upon which nerve fibers are affected:

• Motor nerves- Muscle weakness, cramps and uncontrollable muscle twitching.
• Sensory nerves- Numbness or tingling in your hands or feet, trouble sensing pain or changes in temperature.
• Autonomic nerves excessive -Sweating, changes in blood pressure, the inability to tolerate heat and gastrointestinal symptoms.You may experience a variety of symptoms depending on type of nerve injured.

When to see a doctor?

If you experience weakness, tingling, numbness or a complete loss of feeling in a limb, see your doctor to work out the cause. It’s important to treat peripheral nerve injuries early.

How nerve injury happens?

These can be caused by either sharp trauma, or blunt trauma or medical conditions like carpel tunnel syndrome or autoimmune disease like rheumatoid arthritis etc.

How diagnosis nerve injury done?

Your doctor will review your medical record , ask about any accidents or previous surgeries, and discuss your symptoms with you. Your doctor also will conduct a physical and neurological examination. If your neurological examination shows signs of a nerve injury, your doctor may recommend diagnostic tests, which can include: Electromyography (EMG),Nerve conduction study, Magnetic resonance imaging (MRI).

How is nerve injury treated?

Your doctor will determine your treatment depending on nerve injury:

1. If a nerve is injured but not cut, injury is more likely to heal. You may need physiotherapy and rest to the affected area until it’s healed. Nerves recovers slowly and maximal recovery may take weeks to months.
2. If your injury is caused by a medical condition, your doctor will treat the underlying condition.
3. Injuries during which the nerve has been completely cut requires surgical management and treatment options are nerve repair, nerve graft, nerve transferor tendon transfer depending on type of and duration of injury.

What are the aftercare for brachial plexus surgery?

After surgery patient needs regularly physiotherapy, occupational therapy, and nerve stimulation till complete recovery. Frequent follow-ups could also be required and patient/family commitment regarding the recommendations are crucial for maximum functional outcomes.