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.
A very difficult part of brachial plexus lesions is the unexpected pain which can develop with time. Even though the nerves have been pulled out from the spinal cord connections, a chronic pain problem can develop in the area the nerves supply normally, which is the arm. As the nerves transmitting impulses to and from the spinal cord have been severed by being forcibly disconnected, the spinal cord nerves which normally receive their inputs are deprived of this. These nerves change and start transmitting signals spontaneously, generating an abnormal pain problem which can be unpleasant and persistent.
The pain is often described by the patients as burning, crushing or shooting, can be very severe and be accompanied by agonising spasms. Deafferentation pain is the name given to the type of pain which is caused by a lack of incoming (afferent) input to the nerves of the spinal cord. Conservative measures are most common in treatment and it is useful to involve a pain management team early on in management. Patients can usefully be admitted with this complex pain problem to sort out their medication and adopt a multidisciplinary approach.
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.
An experienced multidisciplinary team is necessary to manage the non-surgical care of these patients, including an occupational therapist, orthotist, physician and physiotherapist. Orthotists provide long term bracing to prevent contractures and to protect healing structures, occupational therapists work at the functional abilities of the person, physiotherapists maintain joint ranges and monitor muscle work and the physician diagnoses and sets the treatment goals. Designated specialist centres are most appropriate for surgical care as only specialists can decide on the relevance of a hugely variable condition and choose from the very large number of operative options.
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.
Healing nerves progress at an average speed of one millimetre a day, which in imperial is about an inch or so a month. This can mean a very long wait if the injury is high up in the neck like the brachial plexus and without a nerve supply the nerve endplates on the muscle can degenerate which means the muscle won't work even if the nerve grows down to it in time. Much research is continuing into nerve growth factors which might speed up the recovery of direct nerve repairs and later grafting.
A very difficult part of brachial plexus lesions is the unexpected pain which can develop with time. Even though the nerves have been pulled out from the spinal cord connections, a chronic pain problem can develop in the area the nerves supply normally, which is the arm. As the nerves transmitting impulses to and from the spinal cord have been severed by being forcibly disconnected, the spinal cord nerves which normally receive their inputs are deprived of this. These nerves change and start transmitting signals spontaneously, generating an abnormal pain problem which can be unpleasant and persistent.
The pain is often described by the patients as burning, crushing or shooting, can be very severe and be accompanied by agonising spasms. Deafferentation pain is the name given to the type of pain which is caused by a lack of incoming (afferent) input to the nerves of the spinal cord. Conservative measures are most common in treatment and it is useful to involve a pain management team early on in management. Patients can usefully be admitted with this complex pain problem to sort out their medication and adopt a multidisciplinary approach.
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.
An experienced multidisciplinary team is necessary to manage the non-surgical care of these patients, including an occupational therapist, orthotist, physician and physiotherapist. Orthotists provide long term bracing to prevent contractures and to protect healing structures, occupational therapists work at the functional abilities of the person, physiotherapists maintain joint ranges and monitor muscle work and the physician diagnoses and sets the treatment goals. Designated specialist centres are most appropriate for surgical care as only specialists can decide on the relevance of a hugely variable condition and choose from the very large number of operative options.
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.
Healing nerves progress at an average speed of one millimetre a day, which in imperial is about an inch or so a month. This can mean a very long wait if the injury is high up in the neck like the brachial plexus and without a nerve supply the nerve endplates on the muscle can degenerate which means the muscle won't work even if the nerve grows down to it in time. Much research is continuing into nerve growth factors which might speed up the recovery of direct nerve repairs and later grafting.
About the Author:
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 London.
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