Many brachial plexus injuries will heal spontaneously without surgery over the course of weeks to months, especially those that are mild. However, early intervention is critical to maximize the amount of function that can be restored.
MRI neurography is helpful in diagnosing these injuries. It helps determine if the nerves are intact, where they have been injured and whether or not the injury is severe.
What is the Brachial Plexus?
The brachial plexus is the group of nerves that controls the movement and feeling of your shoulders, arms, wrists, and hands. Injury to this area can cut off the communication between your spinal cord and the parts of your arm and hand.
The spinal nerves that make up the brachial plexus are located in the neck region of your spine. They give off a branching pattern that looks like a tree, with roots and trunks. Each branching point (called a rami communicantes) connects to several roots and other rami.
Initially, the spinal nerves (incorrectly called roots in some anatomic textbooks) come out of their neural foramina in the spine, behind the vertebral arteries. They form five anterior primary rami that then give off secondary branches to their respective muscles and the skin of the shoulder. The five roots join to form trunks that are named for the part of the scapula they innervate (superior, middle, and lateral) or the first rib they lift (subclavian).
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These five nerves also form four cords (together called the infraclavicular plexus). The dorsal scapular nerve comes from the superior trunk. This nerve innervates the rhomboid and levator scapulae muscles that retract and downward rotate your scapula. The subclavian nerve comes from both the C5 and C6 nerves to innervate the subclavius muscle that elevates your first rib during respiration.
Injuries to the brachial plexus can happen in many ways. They can occur during childbirth (called neonatal brachial plexus palsy or Erb’s palsy). They can also occur in contact sports such as American football, when an athlete collides with another player and experiences cervical axial compression, flexion, or extension of the nerve roots or terminal branches.
Sometimes these injuries are not diagnosed or treated right away, which can lead to permanent damage. If the brachial plexus is injured by penetrating trauma (like a deep knife wound), surgery may be needed to reconnect the nerves.
Most of the time, brachial plexus injuries heal without surgery over weeks to months, especially in mild cases. Physical or occupational therapy can help patients with nerve and muscle recovery. In some cases, doctors will use a nerve graft to replace an injured nerve. A healthy nerve from the back of your foot or a rib is used to patch an injured nerve. Sometimes a manufactured nerve growth guide encourages nerve growth to reconnect the brachial plexus.
What are the Symptoms of a Brachial Plexus Injury?
The brachial plexus is the network of nerves that provides movement and sensation to the shoulder, arm and hand. It exits the spinal cord high in the neck, and descends down through the shoulder, arm and hand. Injuries to the brachial plexus can result from trauma, inflammation, entrapment or tumors. Most traumatic brachial plexus injuries are caused by falls, motor vehicle accidents and other activities that result in the sudden forceful pulling or stretching of the nerves. This may include contact sports like football, rugby and wrestling, or accidents involving machinery, firearms, knife wounds and even car crashes and explosions.
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Mild brachial plexus injuries are often correctable with physiotherapy and splinting. These techniques will help to restore range of motion and strengthen the muscles of the arm and hand. A more serious injury involves a rupture or complete separation of the nerve roots from the spinal cord. This causes severe weakness and loss of feeling in the arm and hand and can have a profound impact on one’s quality of life.
Injuries to the nerves of the upper plexus are called preganglionic injuries, while lower plexus injuries are called postganglionic. Symptoms of preganglionic injuries include the inability to lift the ribcage (winging of the scapula) and the lack of sensitivity of the fingertips and thumb (Klumpke Paralysis). Injuries to the postganglionic nerves of the lower brachial plexus cause muscle weakness and the loss of a sense of touch in the fingers, palm, heel and ring finger.
Patients who have a traumatic brachial plexus injury should consult a board-certified hand surgeon right away to determine the type and severity of the damage. The physician will conduct a physical examination and ask about the patient’s symptoms. Imaging with a CT scan or an MRI will also be used to determine the location and extent of the injury. Other tests include electromyography which involves inserting electrodes into the different muscles to check for electrical activity.
If the injury is severe, surgery will likely be needed to repair the damaged nerves. The surgery will involve transplanting a healthy nerve from another part of the body and sewing it between the severed ends of the nerves. The transplanted nerve acts as a scaffold to guide the injured ends of the nerves back together and re-establish nerve signals. The most common nerve to be grafted is the sural nerve which is located in the back of the leg.
What is the Diagnosis of a Brachial Plexus Injury?
The type of nerve injury you have, and how severe it is, determines your prognosis (outlook). If the nerves are just stretched or torn, the injury may heal without surgery. But if the nerves are cut or ruptured, you may need surgery to restore hand and arm function.
To diagnose your brachial plexus injury, your healthcare provider will examine your neck and shoulder, test for movement of your arm and hand and ask you about your symptoms. He or she will also order imaging tests, such as X-rays and computed tomography myelogram scan, which uses X-rays plus a dye to show the spinal nerves. Other tests may include magnetic resonance imaging (MRI), which uses a series of magnets and radio waves to take pictures of the nerves in your arm and hand.
Your doctor will need details about the time of your injury and how you injured yourself. This will help him or her find the cause of your weakness and pain. For example, did your injury happen when you were playing a contact sport like football or wrestling, or when you were in a motor vehicle accident? Did you injure your shoulder while lifting something heavy?
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During the physical exam, your doctor will compare the strength of your injured arm or hand with the strength of your unaffected arm or hand. Your surgeon will also check for any loss of sensation and the quality of your pain, which is usually dull or aching, but can be burning or stabbing.
If your injury is mild, you and your healthcare provider will likely decide not to perform surgery. Instead, you will probably have physical therapy to prevent stiffness in your shoulder and elbow. Your healthcare provider may also recommend medication to help control pain and prevent nerve damage. If the injury is severe, you will need surgery to repair your nerves. You should schedule surgery within six months after the injury, because the longer you wait for the procedure, the fewer chances there are for your nerves to recover their normal functions. Your healthcare team will discuss your options for treatment at your follow-up appointment.
What are the Treatment Options for a Brachial Plexus Injury?
The nerves that support the shoulder and arm exit the spinal cord in the neck at levels C5-C8, C7-C8 and T1-T2. If the brachial plexus is damaged, you may experience pain and loss of movement and sensation in your shoulders, arms and hands. Some brachial plexus injuries heal spontaneously, while others need surgery to restore strength and function.
Prompt examination by a healthcare provider is critical for all brachial plexus injuries. The initial examination involves a close comparison of the injured side of your body with the uninjured side to determine how much weakness and numbness you have.
Treatment for a brachial plexus injury may include:
Physical therapy, which consists of a series of exercises to stretch and strengthen your muscles. Some of these exercises are done with the help of a therapist, while others are self-directed at home. Your healthcare provider will recommend certain physical therapy stretches and exercises specific to your injury that are designed to improve the quality of your movements and reduce pain.
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In some cases, your doctor may prescribe medications to help control your symptoms. These may include anti-inflammatory drugs, muscle relaxants or corticosteroid creams. Your doctor may also recommend wearing a brace or splint to help protect the area and keep your arms and hands straight during recovery.
Many people who have a brachial plexus injury require surgery to recover the use of their arm and hand. Surgery may be necessary if the injury occurred from severe trauma, such as a penetrating wound or a car accident, or if it happened during delivery (shoulder dystocia).
Nerve repair and transfer surgeries can take months to years for movement and feeling to return. After the surgery, your health care provider will prescribe physical therapy to stretch and strengthen your muscles. Some patients may need a splint or sling for two weeks after the procedure, while others will wear it for longer periods. Some of the more sophisticated procedures for nerve repair, such as nerve grafts and tendon transfers, can have better results but also require more time to heal.
