Brachial plexus injury are the injuries related to brachial plexus.
Brachial plexus injury are the injuries related to brachial plexus. Usually, partialinjuries to brachial plexus occurs when the arm is forcibly stretched, pulled or injured during an accident. There is injury of C5,6 nerve roots with or without C7 nerve root in the neck causing weakness, numbness, or loss of movement in the shoulder and elbow. The hand function is good in partial brachial plexus injuries. Deficits in shoulder stability, abduction (outward movement), external and internal rotation, as well as in elbow flexion (bending of elbow) and forearm supination (rotate forearm inward) occur in partial BPI. If C7 is involved, there will also be variable weakness in extension of elbow, wrist and fingers (straightening of elbow, wrist and finger joints).
Less common type of partial Brachial Plexus Injuries seen is lower arm type -C8, T1 injuries.Theywill present with weakness of hand muscles and finger extension, along with loss of sensation in forearm and hand. Patient may notice difference in size of both eyes (meiosis), lowering of upper eyelid (ptosis).
It is often seen more in men aged between 15-25 years. Upper brachial plexus (C5, C6) are more likely to stretch or rupture for their origin, whereas lower brachial plexus (C8, T1) avulse/detach from the spinal cord.
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 is examined thoroughly for all the movements at all his joints of the paralysed arm. Hand function is completely normal in patients with partial brachial plexus injuries of C5,6 nerve roots. If C7 nerve root is also injured, then patient might not be able to extend his elbow, wrist and fingers but finger flexion will be possible.
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 investigations. 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.
Next important factor is time interval between the accident and surgical intervention. It is said "sooner the treatment, better the outcome" in brachial plexus injuries.
Observation is done for the first 2-3 months after the accident, which gives the time for any spontaneous recovery and if present, we can wait for further 3 months. If no recovery is seen after 3 months of accident, nerve transfer surgery is done as early as possible. The nerves are explored, repaired and transferred during the surgery. Surgery can still be done for injuries within 9 months to 1 year of injury but chances of recovery would be less when compared to surgery done early at 3 months.
If nerve transfer surgery is attempted after 1 year of accident, it has been observed that chances of recovery would be very less as there's is not enough time left for nerve regeneration, so specific targeted muscle and tendon transfers are done instead of nerve transfer surgery beyond 1 year of accident.
The maximum result which a patient with full effort and physiotherapy gets in partial brachial plexus injury is that he is able to abduct (lift his arm away from the body) upto 90 degrees-120 degrees and flex the elbow (bend elbow towards the body).
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 many of the cases, nerve is also harvested from the leg for repair of partial brachial plexus injuries. 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 to muscle 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 andnerves are repairedby taking nerve graft from the legif 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.
Brachial plexus neurotisation procedure is a long surgery and usually takes about 6 to 8 hours minimum. After the surgery the patient is usually kept in the hospital for 2 days and is allowed to go home thereafter. The sutures are non dissolvable and are removed on 14 days. After that regular monthly follow up examination is mandatory to assess the progress of the repair and nerve regeneration.
The nerve regeneration occurs slowly at a rate of approximately 1 mm/day, recovery from a brachial plexus injury takes time, and patients may not experience results for several months even after successful surgery. After 1-1.5 years of surgery, if functional recovery is not possible despite all efforts, next stage surgery is planned.
Patient is advised for regular physiotherapy, TENS therapy (transcutaneous electric nerve stimulation) after the surgery.
A positive mindset and the support of family, friends, and healthcare professionals are important to recovery and rehabilitation.
The result of partial brachial plexus injuries repair is quite unpredictable and in the best of hands is around 70 to 80%. The patients may require additional surgeries in future also to target these specific functions which the patient wants to regain in his/her arm.
Indivisual results may vary from person to person.
These pictures are shown for the purpose of education only.
Best plastic surgeon, Dr. Amit Agarwal is an American Board Certified, extensively trained, and best Plastic & Aesthetic surgeon in Lucknow. He is the Chief Plastic Surgeon heading the Department of Plastic, Microvascular, and Craniofacial surgery at Vivekananda Polyclinic and Institute of Medical Sciences, Lucknow, U.P, India. He maintains a busy practice at Avadh and Nishat Hospital and his own center - Kayakriti Plastic Surgery & Dental Center. He was formerly a Consultant in the Department of Plastic Surgery and Burns at the prestigious SGPGI, Lucknow.
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This surgery does not affect the ducts or the areas of the breast involved in milk production. Thus, it does not affect the breast feeding.
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