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Brachial Plexus Surgery

What is brachial plexus surgery?

Brachial plexus surgery is a surgery performed to treat brachial plexus injuries.

What is the brachial plexus?

The brachial plexus is a network of nerves that originates at the spinal cord near the neck and passes down your upper arm from under your collar bone. It consists of 5 nerve roots:

  • 4 nerve roots from the lower cervical segment of the spinal cord: C5, C6, C7 and C8
  • 1 nerve root from the first thoracic spinal cord segment known as T1

These nerves join to form the upper, middle and lower trunks of the brachial plexus, which split into nerves that supply your upper limbs, controlling your shoulder, elbow, wrist and hand. An injury to any part of these nerves can stop signals to and from the brain and may partially or completely paralyze your arms. Brachial plexus injuries can occur in both infants during child birth and adults due trauma to the brachial plexus.

Types of brachial plexus?

The types of brachial plexus injury may include:

  • Neurapraxia: minimally stretched nerves or stretched nerves that are not torn
  • Nerve rupture: Overstretched nerve that is torn
  • Avulsion of nerves-nerves detached from the spinal cord

Diagnosis of brachial plexus

Your doctor will first take your medical history, conduct a clinical examination and wherever necessary, order tests to complete the diagnosis of brachial plexus injury.

Imaging tests such as magnetic resonance imaging (MRI) and computerized tomography (CT), using a contrast dye, may be ordered to visualise the nerve damage.

Your doctor may ask for

  • Nerve conduction studies determines the speed of nerve impulses. The time taken for impulses to pass from one electrode to the other is assessed and recorded.
  • Electromyography (EMG) to evaluate the muscle response of your injured arm. Your doctor will insert small electrodes into the muscle and ask you to contract that muscle. This records the electrical activity of the contracted muscles and determines the ability of the muscles to respond when its nerves are stimulated.

Indications of brachial plexus surgery

Minor injuries of the brachial plexus such as neurapraxia may recover on their own without any therapy, but surgery is necessary for treatment of nerve rupture or nerve avulsion.

Your doctor may recommend surgery after 3 months in case of partial paralysis or anytime within 2 months in case of complete paralysis. Delaying the surgery beyond a specified time may increase the risk of muscle atrophy, thus diminishing the chances of recovery.

Brachial plexus surgery

Several surgical options are available depending on the patient’s condition. The type of brachial plexus surgery will differ for infants and adults. Some of the common techniques followed include:

Nerve surgery

  • Nerve graft surgery involves replacing the damaged section of the nerve with a nerve section removed from another part of the body.
  • Neurotization or nerve transfer surgery is performed to connect the lower end of the damaged nerve to a less important upper end of an intact nerve from the spinal cord.
  • Direct neurorrhaphy involves identifying the damaged nerves and directly suturing the two cut ends of the damaged nerve back together.

Musculo-skeletal surgery

  • Contracture release is a surgery that corrects tightness of the shoulder joint the develops in some children because of decreased mobility.
  • Muscle or tendon transfer surgery may be necessary if the arm muscles have deteriorated. This involves transfer of a muscle or tendon from another part of your body to the damaged part of your arm.
  • Capsulorraphy surgery can be performed to place the head of the humerus, the bone of the upper arm, back into the shoulder joint in order to treat shoulder dislocation or joint instability caused by muscle weakness. 
  • Osteotomy involves cutting the bones of the upper arm or forearm and reorienting them in a better position.

Risks and complications of brachial plexus surgery

As with any surgery, there are risks involved.  Associated risks of nerve reconstruction surgery may include:

  • Bleeding
  • Infection
  • Some tingling and weakness in areas from which nerves have been borrowed to reconstruct the damage nerves
  • Failure to improve

What to expect after brachial plexus surgery

After the surgery you will have to wear a sling for the first few weeks to protect your arm and aid in wound healing. Your doctor may prescribe medications to relieve pain. Physical therapy involving range of motion exercises for the elbow, shoulder and hand may be advised a few weeks later. You also may be instructed to perform strengthening exercises after your arm movements are regained.

Downtime of brachial plexus surgery

Various factors that influence recovery after brachial plexus surgery are: 

  • Location and extent of the injury
  • Age
  • Time of interval between the injury and surgery

In case of infants, mild injury to the brachial plexus may resolve within 3 to 6 months, whereas severe injuries may require treatment for over a year and regular follow-ups.

In case of adults, it may take more than a year to achieve complete improvement after surgery. Younger patients recover faster, whereas recovery is slower (and usually incomplete) in patients over 45 to 50 years of age.

Prognosis of brachial plexus surgery

The prognosis of brachial plexus surgery in infants is best when treatment is started within 4 weeks of birth. Infants with stretch or neuropraxia injuries and upper brachial plexus injuries generally have a good prognosis.

Adults with injury to the C5 and/or C6 nerves generally experience near complete recovery.

Patients with complete paralysis and injury to the C5, C6 and C7 nerves may experience difficulty in achieving complete recovery to the original extent.

Patients with complete paralysis (C5,6,7,8 and T1) usually cannot expect complete recovery.

Providers

Affiliations

  • Texas Orthopedic Hospital
  • Joe W. King Orthopedic Institute
  • American Academy of Orthopaedic Surgeons
  • The American Board of Orthopaedic Surgery