Tests and Procedures for Brachial Plexus

An injury to the brachial plexus can cut off all communication between your spinal cord at the neck to your arm, wrist, and hand. This can lead to a loss of function, sensation, paralysis of the arm, or chronic pain.

Pain from severe brachial plexus injuries can be described as severe, crushing, burning, or debilitating. Nerves regrow slowly after trauma or injury. However, it can take several years to heal. If medications aren’t helping with pain, your medical professional may recommend a surgical procedure to interrupt the pain signals.

Coming to the correct diagnosis for a brachial plexus injury requires a deep understanding of the anatomy of the core nerves that make up the brachial plexus and the corresponding responsibilities of each nerve. The five nerves that comprise the brachial plexus and their functions are as follows:

1. Axillary nerve - Begins at the nerve root but a majority of its fibers are located under the armpit. It controls the innervation (supply of nerves) for the teres minor and deltoid muscles.
2. Median nerve - Begins at the spinal cord and innervates major muscles in the upper arm and hand.
3. Musculocutaneous nerve - Starts at the nerve root and controls the flexing of upper arm muscles at both the shoulder and elbow.
4. Radial nerve - Originates from the nerve root and is responsible for various muscles in the upper arm, elbow, forearm and hand.
5. Ulnar nerve - Begins at the bottom of the neck and signals the fine motor functioning of the fingers.

Using a variety of physical examination techniques and the patient’s detailed description of symptoms and responses to different pressures can indicate which nerves are injured. This will inform which area will be examined further with more sophisticated diagnostic tests. These tests include:

• X-ray of your shoulder and neck.
• EMG: Electromyography (EMG) is a test that evaluates the electrical activity and function of your muscles and nerves. This test may include a nerve conduction study to measure the speed of electrical activity passing through the nerve.
• MRI: Magnetic resonance imaging (MRI) uses a magnetic field and radio waves to produce detailed images of the body. New methods of high-resolution MRI, known as magnetic resonance neurography, may be used.
• Computerized tomography (CT) myelography: a series of X-rays to obtain cross-sectional images of the body. May be used to produce a detailed picture of the spinal cord and nerve roots during the scan.
• Because injuries to this group of nerves can range in severity and symptoms, there are varying degrees of diagnoses and treatment plans to address it.

Brachial Plexus Neuropraxia (Stretch)

Neuropraxia events occur when nerves are stretched to the point of excess, leading to an injury. Sometimes referred to as burners or stingers, these injuries typically come with an electric shock sensation. Compression neuropraxia happens most often and is typically seen in older patients. Traction neuropraxia is less common and occurs when the nerve structure is pulled downward. Traction neuropraxia is more often seen in adolescent and young adult patients.

Brachial Plexus Rupture

If a brachial plexus stretch is forceful enough to cause nerves to tear, you may have a rupture, which can lead to arm weakness, extreme pain, and may even render some muscles in the shoulder and arm unusable. Surgery can often treat this diagnosis.

Brachial Plexus Avulsion

In some cases, the brachial plexus nerves can be separated from the spinal cord completely, resulting in severe pain, permanent weakness, loss of sensation, and even paralysis. These severe cases, known as brachial plexus avulsion, are typically seen following severe trauma from a car or motorcycle accident.

Brachial Plexus Neuroma

Sometimes the brachial plexus nerves are injured during surgery from a cut or trauma during a procedure. Scar tissue, known as a neuroma, can build up around the damaged nerve. This can cause pain in the area of the neuroma and will require surgical intervention to repair. Treating brachial plexus neuromas includes surgically removing the scarred nerve tissue.

Brachial Plexus Injury at Birth

Every one or two out of a thousand births results in obstetric brachial plexus injury. In infants, brachial plexus injuries can occur during childbirth. This is common in larger babies whose heads get stretched away from their shoulders during birth, as well as in breech babies and in cases where labor lasts a very long time.

Some milder forms of brachial plexus injury may self-resolve in a matter of days. Nerves that have been stretched may not need further treatment to recover. Conservative measures for brachial plexus injury treatment may include:

Medication to reduce inflammation - Inflammation is a natural response to injuries, but can encourage infection or result in lessened mobility in excess. Anti-inflammatory medications, ice, compression, and rest will reduce this excess swelling and allow for improved nerve communication.

Physical therapy - Physical therapy is a highly effective approach for restoring strength and mobility to a patient’s arm that has experienced a mild brachial plexus injury or who is recovering from brachial plexus surgery. Stretches and strength exercises will reestablish the connection between the nerve and the impacted area and help the patient return to utilizing their arm, elbow, or hand with greater dexterity and confidence.

Physical therapy may be recommended to maintain joint and muscle function and range of motion, as well as prevent stiff joints. Your doctor may also prescribe anti-inflammatory medications.

For more severe cases, brachial plexus injury treatment may require surgery. If your nerves have been torn, ripped, or ruptured away from the spinal cord, you may be at risk for permanent weakness or disability from your injury if not treated.

Surgical Procedures

Brachial plexus surgeries can help restore nerve function when the brachial plexus nerves have been severely damaged.

The surgeons at the Institute for Advanced Reconstruction are among the few or only experts worldwide who perform all aspects of brachial plexus surgeries. Our surgical experts have helped countless patients with brachial plexus and other injuries restore movement and sensation to their shoulders, arms, and hands.

Depending on the nature and severity of your brachial plexus  injury, your surgeon may recommend  one or more of the following nerve-related surgical treatment options:

Neurolysis

Neurolysis removes scar tissue from damaged nerve endings through the use of chemical or physical agents. By removing targeted nerve fibers, the pain signals sent from the nerve to the brain get interrupted to provide pain relief.  For less severe cases, relief from pain and numbness or tingling may be felt immediately. For more severe cases, you may experience a reduction in pain, numbness, or tingling that continues to improve over time.

This procedure typically takes about an hour and can be done under general anesthesia or local anesthesia. Patients are usually released the same day after a 1 to 2 hour recovery period. It can take one to six weeks for patients to return to full normal activities after neurolysis treatment.

Nerve Graft

A nerve graft connects two damaged parts of a nerve by using a transplanted piece of nerve to bridge the gap. The transplanted piece of nerve may come from somewhere within your body (autograft) or may come from an outside donor source (cadaver allograft) and is then sterilized and processed to ensure it can be safely implanted in your body. By bridging the gap between two damaged nerves, a pathway is provided that allows for the nerve to regrow. A nerve graft often happens in combination with a nerve transfer procedure.

A nerve graft is typically an outpatient procedure done under general anesthesia. It can take 1 to 4 hours to complete and patients are usually released the same day or the day after the procedure. Your surgeon may recommend that you wear a sling or splint to immobilize your limb for a few weeks. Full recovery may take many months to regain movement and sensation in the affected area as the nerve endings regrow.

Nerve Transfer

A nerve transfer or transplant is the process of taking a nerve that’s functioning from a different part of the body and rerouting it to a non-functioning nerve to allow for new nerve growth over time. This procedure may be performed at the same time as a nerve graft, which uses the transplanted nerve to bridge the gap between two damaged nerve sections. When a nerve transfer is done without a graft, a surgeon will take a healthy nerve nearby the affected one, cut it, and connect the healthy functioning nerve to the damaged nerve. Think of it as throwing a railroad switch and changing the directions of the track, except in this case, your surgeon is redirecting the electrical activity to the recipient nerve.

A nerve transfer is typically an outpatient procedure done under general anesthesia. It can take 1 to 4 hours to complete and patients are usually released the day of, or the day after the procedure. There are two parts to recovery: the initial post-surgical recovery, which can take a few weeks for post-surgical healing, and the nerve regrowth process, which can take months or longer. Nerves regrow at a rate of about one inch per month. Regaining full function and eliminating pain and numbness can take time as those nerves slowly regrow.

Muscle Transfer

For some brachial plexus injuries, a muscle or tendon transfer procedure may be required to fully restore feeling and function to a limb. This procedure removes a tendon or muscle from one part of the body, such as your thigh, and then transfers it to another, like the arm. The nerves and blood vessels that supply the muscle are then reconnected.

A muscle or tendon transfer is typically an outpatient procedure done under general anesthesia. It can take 2 to 6 hours to complete and patients are usually released the day of, or the day after surgery. After surgery, you may be required to wear a splint or a brace for 1 to 2 months as your muscles and tendons heal into their new position. Physical therapy will usually be a part of your recovery process to rebuild strength and mobility in the affected transferred muscle and tendon. 

Most facilities do not have the individual or team expertise to enact these comprehensive treatment plans. Fortunately, the Institute for Advanced Reconstruction has some of the most decorated surgeons in the world, such as Dr. Andrew Elkwood, who specializes in brachial plexus repair, with the support of his surgical team.