OBSTETRICAL BRACHIAL PLEXUS INJURIES

Once any more dangerous conditions have been identified and stabilized, the assessment and possible treatment of the brachial plexus injury can begin. Major areas of concern to the patient are likely to be management of the pain, which can be chronic and extreme, and which does not generally respond well to many painkillers. Those painkillers which are found to be effective often have serious and debilitating side effects.  In addition, the patient often has concerns about life after the accident, whether those concerns are related to employment, finances, relationships, self-image or just performing simple tasks with one hand, especially if the dominant arm is injured. Most injured people have concerns in all these areas. There is a period of adjustment to the psychological effects of the damaged limb, which can be very hard on the sufferer and their families. Finding knowledgeable support is a priority in all cases.

Brachial plexus injuries can happen in many ways. They can be divided into two categories, open or closed injuries. One of the most common causes of a closed injury is a motorcycle accident. It is surmised that following impact, the rider hits the ground, often continues to slide and a brachial plexus injury is caused when the helmeted head is forced away from the point of the shoulder, causing violent traction to the brachial plexus. Closed injuries are usually caused by traction or compression of the brachial plexus, and can be caused by sports injuries, car accidents, falls or radiotherapy, to name a few. Open injuries such as knife wounds or cuts, including surgery, can also cause injury to the brachial plexus.

Brachial plexus injuries need referral to a specialist as soon as possible upon detection. The type and extent of injury is ascertained by clinical evaluation utilizing EMG, seeking out sensory and motor changes in the affected limb, MRI (magnetic resonance imaging) scan and possibly CT Myelogram where contrast dye is injected into the spine and scanned to see if there is leakage from the spine or other indicators of damage.  Surgical exploration may be scheduled to physically examine the extent of injury. The types of injury range from mild lesion (stretch) to tears and neuromas (scar tissue that builds up around damaged area) rupture and avulsion (nerve root being pulled from the spine).

Some mild injuries recover quite quickly and spontaneously. Some may benefit from nerve graft surgery (typically at 3 to 6 months post trauma), the donor nerve being taken from the patient’s leg or other possible site and grafted in place of the damaged brachial plexus nerve(s). After nerve surgery the recovery time frame is months to possibly years, although denervated paralyzed muscle tissue will atrophy and may not be receptive to nerve impulses after a period of time. It should be emphasized that just as the many possible complex variations of the injury occur, so does the rate and extent of recovery for each individual patient. As a general rule the smaller fine control muscles in the hand are in the most danger of being lost as the regeneration of damaged nerves is slow, about 1 inch or 3 centimeters a month. Therefore, by the time any nerve recovery reaches the patient’s hand, atrophy may have resulted in lost function.  Some injuries unfortunately do not respond to treatment and are so severe that they are permanent.

Besides the nerve grafting and scar tissue removal surgeries available as a possible option, there are other surgical techniques which can be utilized long after the initial period of injury. These include muscle and tendon release surgery. 

Pain can be the most limiting factor in rehabilitation of patients with a brachial plexus injury. It has been observed that pain following avulsions is particularly severe, and has been described, by those affected, variously as crushing, constant burning and even ‘like putting your hand in a deep fat fryer’ or into a vise. An almost unbearable feeling of pressure can build up in the affected limb. However, some people with less severe injuries also report serious pain. In these cases it has been described as being of a different nature to that experienced from avulsions, and is mainly felt when the injury is recovering. It has been reported that 90% of the patients who have avulsions to one or more nerve roots have severe pain.

Management of the pain is difficult. One possibility is electrical stimulation (TNS or TENS) for pain relief. In one study, it was found that of 158 patients, 100 gained significant pain relief as a result of the stimulation. Some of those had experienced pain for a very long time before the stimulation. Some patients report no easing of pain with this method. The ‘pain gate’ theory (the idea that occupation of the patient in tasks etc will ‘block’ the pain impulses in the brain) is often advised, and can be effective. For this reason, if at all possible, it is often best for the patient to return to work or take up another occupation as soon as is practicable. Good results have been reported from use of a chiropractor, massage and other alternatives to drug based analgesia. For extreme cases, surgery of various kinds is sometimes advised. These surgeries include nerve block surgeries, insertion of a pump delivering painkillers direct to the area affected and ablative surgeries, which involve the burning of nerve endings. Surgeries of this kind would normally be undertaken after referral to a specialist pain clinic. Details of these and other methods of dealing with chronic pain may be found from the link to www.pain.com found below in Further Information. It is advisable to discuss your options with a brachial plexus injury specialist and it may be helpful to discuss the surgery with others who have experienced it.

ANALGESIC DRUGS

Rather than to list effective drugs, especially since different brand names are used internationally, it is simpler to state that, in most cases, opiates are used immediately post trauma, and in some cases continue to be used for some time afterwards. Due to the undesirable side effects of both these and anti-inflammatory drugs, the patient needs to keep pursuing other methods of pain relief, especially if the pain becomes protracted or chronic. Anti-depressants and anti-convulsants have been used, though, again, if long-term use is contemplated, the side effects need to be considered. However, it is a fact that long term or chronic pain often leads to depression and tricyclic anti-depressants are front line treatments for chronic neuropathic pain. Talking with other people who are injured can often help, although all these injuries are different and what works for one might not work for another. Severe pain has been reported as reducing greatly over the years, though pain flare ups still occur many years post trauma, including reports from some patients who have had amputations (phantom limb pain). In most cases, the pain ceases to be a major issue within the recovery timeframe.

As well as traditional physical therapy there are other treatments known to work well for patients; Hydro or aqua-therapy in a heated pool is an excellent way to loosen and stretch muscles. The heat and the hydrostatic pressure of the water offer great benefit.  Massage therapy and chiropractic treatment bring relief to many patients. Any muscle motor recovery from previously paralyzed muscle will need strengthening work for a long time after re-innervation. It is important that the patient develops a long-term view of Brachial Plexus injury rehabilitation.

SENSATION/MOVEMENT IN THE AFFECTED ARM

Most brachial plexus injuries result in a completely ‘flail’ arm immediately after the injury happens, with little or no movement detectable. As recovery occurs, the sensation and motor functions of the affected limb may gradually return. Some injuries are less severe and virtually complete recovery may occur in these cases.

If sensory function is at all impaired, the patient will need to be extremely careful that the affected limb is not inadvertently damaged. Tables similar to those below are commonly used by doctors to evaluate the level of function in patients.

TABLE ONE: MOTOR FUNCTION

M0      No muscular contraction

M1      Return of perceptible contraction in the proximal muscles

M2      Return of perceptible contraction in both proximal and distal muscles

M3      Return of function in both proximal and distal muscles of such a degree that all
            important muscles are able to act against resistance

M4      Return of function as in M3; in addition, all synergic and independent  
            movements are possible

M5      Complete recovery

S0     Absence of sensibility in the autonomous area

S1     Recovery of deep cutaneous pain sensibility within the autonomous area of the 
         nerve

S2     Return of some degree of superficial cutaneous pain and tactile sensibility within 
         the autonomous area of the nerve

S3     Return of superficial cutaneous pain and tactile sensibility throughout the 
         autonomous area, with disappearance of any previous over response

S3+   As S3; in addition some recovery of 2 point discrimination within the 
         autonomous area

S4     Complete recovery

LONG TERM ISSUES FACING ADULTS WITH BRACHIAL PLEXUS INJURIES

Because the unaffected arm has done double duty for so many years, it ages more quickly and is prone to stress-related injuries, such as tendonitis, bursitis, carpal tunnel syndrome and muscle injury.  Arthritis is reported in both the affected and unaffected arms and shoulders.  It is imperative for an adult with such an injury to be aware of this and not to overuse either the affected or unaffected arm.  They may need to learn to ask for help whenever possible in order to avoid such injuries.

It is important to understand that even in its mildest forms, a brachial plexus injury is truly life changing. Many people with these injuries have periods of depression and while this could be considered a normal reaction to any traumatic event, the ongoing nature of the injury may cause the depression to become serious or prolonged. In addition, worries about self-image, relationships and finances are likely to be causing extra anxiety. The patient will need to learn to share his or her problems with friends or family, and seek medical help where necessary.  The depression can be more limiting than the injury, it is important to realize it will pass and seek help where necessary.  As time passes and the patient gains acceptance and becomes accustomed to the life changes wrought by the injury, such periods of depression become fewer. 

www.ubpn.org

www.nabd.org.uk

www.independentliving.org

www.pain.com