Brachial Plexus injury and treatment - Dr. Leena Jain
The brachial plexus is a network of nerves in the neck that arise from the highest section of the spinal cord. From the shoulder to the fingertips, this plexus provides sensory and motor (movement) information to the upper limb.
The brachial plexus network can be affected by blunt trauma, penetrating damage, falling weight on the shoulder region, or dragging injury to the neck/shoulder region. When the brachial plexus is injured, the affected upper limb loses feeling and movement, making it limp and flail.
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| Brachial Plexus Injury |
Nature of injury
Some brachial plexus injuries are self-limiting, and the patient may recover to near-normal or normal nerve function depending on the amount of the lesion.
However, frequently, patients experience injuries to all of the nerves in the plexus, resulting in chronic impairment with no chance of spontaneous recovery—patients with global palsy present with the affection of a single nerve of the complete plexus of nerves.
Patients are frequently unable to raise their arm above their head, bend their elbow to eat, or curl their fingers into a fist. Surgery is the only way to restore hand function in all of these situations of severe and extensive brachial plexus injuries.
Diagnosis
The diagnosis of a brachial plexus injury, according to Dr. Leena Jain, a plastic surgeon in Bandra, is critical. The following conditions necessitated brachial plexus surgery for a full recovery:
- Nerves in the brachial plexus are ripped, severely stretched, or severed due to neck and shoulder trauma.
- Neurofibromas, schwannomas, and other nerve tumors of the brachial plexus
The plastic surgeon will perform a thorough examination to determine which nerves have been affected, the extent of the damage, the location of the damage, and the availability of donor nerves for transplant. Electromyography and nerve conduction investigations are then used to assess the condition of the nerves.
The Plastic Surgeons next devise a strategy for deciding whether to do nerve transfers or muscle transfers. A medical examination entails:
- An in-depth examination of your medical history
- Symptoms and how they affect daily life and quality of life
- Physical examination to compare the affected and unaffected sides in terms of pain, sensation, and motor function.
- The function of the chest is evaluated.
- MRI and Ultrasound examinations are used to visualize the injury, its location, and extent.
- EMG is used to assess nerve function and to determine which nerves should be repaired.
Brachial plexus surgery planning and scheduling
Only penetrating injuries involving damaged nerves allow for immediate scheduling of brachial plexus surgery. If the injury is caused by crushing or stretching, it is best to schedule the brachial plexus surgery later.
The patient's recovery from the damage is monitored for at least 2-3 months to see whether there is any evidence of spontaneous recovery; otherwise, surgery is indicated.
To establish the state of healing, EMG tests and physical therapy are recommended at regular intervals.
If extra nerves are available or a few nerves remain undamaged, brachial plexus surgery is recommended to restore sensation and movement if nerve transfers fail to regain sensation and movement. For the optimum results, this procedure should be performed three to six months following the accident.
Delaying surgery for more than a year is not recommended since the afflicted muscles in this area begin to shrink permanently, a condition known as atrophy. Once they become atrophic, the only option is to transfer muscles or tendons.
Types of surgeries for treating Brachial plexus nerve injury:
Various operations are available to treat brachial plexus problems.
The goal of brachial plexus surgery is to restore sensation and restore motor function in the hand, elbow, arm, and shoulder.
The plastic surgeon will assess the amount of the nerve injury, its location, and type, as well as the patient's current health status. The impact of injuries on one's quality of life and ability to work is also considered.
Your surgeon may suggest the following procedures:
- Repair of the Brachial Plexus Nerve: The Brachial Plexus Nerve Heal operation is performed by the surgeon to repair the cut or torn nerve. Sewing the ends together and approximating them is the technique. Small, specialized equipment and a microscope are used in this procedure.
- Decompression and Neurolysis of the Brachial Plexus: Decompression surgery is used to relieve the pressure on a compressed nerve. This surgery also treats the loss of function and the symptoms that come with it. The adhesions or scar tissues in and around the wounded nerve are removed during neurolysis surgery.
- Surgery for Nerve Grafting: This procedure is used to remove a nerve that has been damaged or is highly scarred. Because the wounded nerve cannot send impulses from the brain to the hand and arm, the patient is paralyzed. The injured brain is removed and replaced with a nerve transplant from an expendable sensory nerve by the plastic surgeon. The sural nerve in the leg could be used as a source for the graft. As the nerve graft replaces the injured nerve, this surgery forms a bridge that serves as a pathway for nerve regeneration.
- Surgery to Transfer Nerves: The goal of nerve transfer surgery is to transfer healthy working nerves to the branches of the brachial plexus that supply the relevant upper limb muscles, allowing new nerves to regenerate and activate the muscles. This operation is the most effective way to restore muscle and skin movement and sensation, and it should be done within a year after the injury.The timing of a nerve transfer procedure is critical, as restoring nerve supply is necessary before irreversible atrophy sets in. The practicality of nerve transfer surgery is also determined by the location of the damage and the type of affected nerve.
The nerves that are employed in these treatments are as follows:
- The front of the shoulder's medial pectoral nerve
- Underneath the ribs is the intercostal nerve.
- The accessory nerve of the spine
- The thoracodorsal nerve is a branch of the thoracodorsal nerve.
- The arm's musculocutaneous nerve
Surgical Tendon Transfer
Tendon transfer is the most dependable approach for regaining movement after a brachial plexus injury in some circumstances, especially if a long period has passed since the damage. When nerve transfers and nerve grafting are not possible, this option is seriously considered. Performing tendon transfer procedures is not time-consuming.
A paralyzed tendon is joined to an expendable and functioning tendon during tendon transfer surgery. The working tendon will try to restore movement in the upper extremity by acting on the paralyzed tendon. Only partial brachial plexus injuries with tendons available for transfer make this viable.
Transplantation of Functional Muscle
If a long period has gone after the brachial plexus damage, a functional muscle transplant is the best option. In that scenario, nerve repair, grafting, and transfer are also impossible.
To restore elbow flexion with or without finger extension, an extrinsic muscle is usually transferred to the damaged muscle in the upper extremity.
It takes 3-4 months for some recovery and 8-10 months for functional recovery, which includes the restoration of elbow bending or flexion.
After around 6 months, a second muscle can be transferred to restore finger flexion. The muscle employed is the gracilise muscle from the thigh, and it does not affect thigh function.
To re-establish blood flow, the surgeon uses a microscope to link minute blood arteries from the transplanted muscle to muscles in the axilla or neck. Similarly, a neighboring neuron is connected to the transplanted muscle's nerve to provide motor functionality.
Dr. Leena Jain is a well-known microsurgeon and hand surgeon in Mumbai who treats brachial plexus injuries.
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