Examination of Brachial Plexus Injury

• Immediately after the accident due to any reason, patient must be thoroughly examined to rule out any fracture at the site of injury or injury to other parts of body, such as head, spinal cord or chest injury.
• Level of consciousness of the patient after the accident should be enquired for and whether he/she was able/not able to lift his limb after accident and had/ had not any sensation then, which can be a clue for planning management later.

Due to very less awareness, often patient roams around and reach the right person quite late after the injury. So Plastic surgeons trained in Brachial plexus surgery are the ones who should be consulted for management of such cases. Dr Amit Agarwal specializes and have expertise of more than 11 years in the field of brachial plexus injury management and is well aware of all aspects of treatment.

After patient has recovered from the other injuries, patient will be advised for regular physiotherapy and, explained to examine himself as per the features described below and follow up is done every month. If no recovery is perceived, patient will undergo few diagnostic investigation. Chest radiographs, Magnetic Resonance Neurography of Brachial Plexus, Pulmonary function tests (PFT), Electromyelography (EMG) and Nerve Conduction Studies (NCSs) are done to confirm the diagnosis, localize and characterize the nerve lesion.

SurgicalProcedure of Nerve Repair/ Transfer for Complete BPI

The surgery is done under General Anaesthesia and patient is admitted a day before surgery in the hospital. Routine blood investigations are done, Pre-anaesthetic checkup is done, and Informed written consent form is signed before surgery. In most of the cases, nerve is also harvested from the leg for repair of complete brachial plexusinjuries.It does not create any deficit in the leg apart from mild sensory abnormality in the outer aspect of the ankle region which subsides overtime.

The procedure is best done within a golden time period, within 3-5 months of the injury, to reactivate the paralyzed muscle(s) early, effectively, and successfully tomuscle strength to grade 4 power.

Nerve repair

Nerve repair is done in cases of rupture of nerves. Brachial plexus is explored, ruptured nerves are identified, scarred portion of the nerves are removed and nerve repair is done by taking nerve graft from different parts of the body. Usually, Nerve repair is possible in upper brachial plexus rupture as the lower trunks are avulsed from the spinal cord making nerve repairs impossible. Incision is given in the neck region above the level of clavicle. Muscles are dissected and the nerves are explored. Neuroma Is excised from the upper brachial plexus andnerves are repairedby taking nerve graft from the leg if the proximal nerve roots are healthy.

Additionally spinal accessory nerve is transferred to the supra scapular nerve torestore initiation of the shoulder abduction movement. This is a very vital transfer done in all Brachial Plexus Injuries.

Nerve Transfer

Nerve transfer is a surgical option that intentionally divides a physiologically active nerve (with low donor morbidity) and transfers it to a distal more important but irreparable paralytic nerve of the brachial plexus.

• Intraplexus (within the plexus) Nerve Transfer
  Usually,Intraplexus nerve transfer is applicable in cases of avulsionofnerve from the spinal cord, in which at least one of the spinal nerves is a rupture injury and still available for transfer—not to its original pathway, but to other more important nerves. Intraplexus nerve transfer is individualized depending upon the intraoperative findings, the surgeon's philosophy, and the patient's condition and requirements
• Extraplexus(outside the plexus) Nerve transfer
  Extraplexusnerve transfer involves the transfer of a neighbouring nerve (from the same side or opposite neck) to the avulsed brachial plexus for the neurotization of a paralytic nerve. The reported donor nerves in common use are mostly aimed at motor re-innervation. These include the
  • phrenic (Ph) nerve,
  • spinal accessory (XI) nerve (accessed by an anterior neck approach),
  • deep motor branches of the cervical plexus (cervical motor branches; CMBs), hypoglossal nerve (XII), and the
  • contralateral C7 (CC7) spinal nerve
  • intercostal nerves.
  • Extraplexus sensory nerve transfer, such as supraclavicular sensory nerves to the median nerve transfer, is sometimes used to provide sensation to the paralytic hand.

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