Brachial Plexus Surgery Group of India

FOR PUBLIC

Injuries to the Brachial Plexus are increasingly common in road traffic accidents. They are notorious because it causes paralysis of the affected upper limb. Many are not aware of this condition and they are not getting the proper guidance. The community has to be enlightened about this disabling condition. It is with this view we have opened this website.Brachial Plexus is a plexus of nerves that emerge from the spinal cord in the neck on both sides and supply the muscles of the upper limb. The roots that emerge from the cord are called C5,C6,C7,C8 and T1. These roots unite to form trunks and the trunks into divisions and these divisions unite and divide into cords which give off the various nerves to the muscles of shoulder, elbow, wrist and hand. Broadly C5,C6 take care of shoulder and elbow. C8 , T1 take care of wrist and hand. C7 participate in all.

Thus in a variety of ways the plexus may be damaged. Unfortunately all types of damage can be seen in one plexus as shown below.

This Brachial Plexus can be injured even in a new born during normal delivery when excess force is applied in delivering the child.

The diagnosis and management of these problems are not straight forward and need expert guidance. Early diagnosis is very important. If the patient notices inability to move the whole of the upper limb or part of it and the skin feels numb, following a major accident, he should inform he doctor immediately. Three types can damage can occur.

1. Total Paralysis of upper limb (or)
2. Shoulder and Elbow Paralysis (or)
3. Hand and Forearm Paralysis.

Once the paralysis occurs the patient should seek the guidance of a Reconstructive Hand Surgeon. For diagnosing the type and level of damage X-Rays, Electrophysiological studies and Imaging studies may have to be done. If under the supervision of a surgeon there is no improvement in 6-8 weeks time or the improvement stops at the end of 3-4 months active surgical intervention should be considered. The nature of surgery at the initial stages is to open up the Plexus and assess the level and nature of damage and then proceed with Nerve Reconstruction.

In the new born the same paralysis can occur as mentioned earlier. If the children are not able to bend the elbow in 3 months time or if there are absolutely no signs of recovery in 10 - 12 weeks, surgical intervention is the choice. In the waiting period, under the supervision of the surgeons, it is very important to keep all the upper limb joints mobile by regular exercises and electrical stimulation of the muscles to maintain the muscle nutrition by the physiotherapist. Sometimes splinting may have to be done to prevent contractures.

On opening the plexus if the nerves are compressed by scar, the treatment is removal of the scar under the operating microscope and the surgery is called as “Neurolysis” and one can expect good recovery in these cases.

A 40year old lady with stretch injury of the right Brachial Plexus, following Neurolysis at the end of 6 months – almost full recovery.

If the nerves are divided and the cut ends are available, they can be joined either by direct suturing if the gap is minimal. This is called as Direct Repair. If the nerves are stretched and replaced by dense scar then we have to remove the scared segment. If the gap is more than 2 to 3cms and the cut ends have to be connected by nerves taken from the leg and the cut ends will be bridged and this is called as “Nerve Grafting”.

This boy with birth injury to right plexus following removal of the scar and Nerve grafting at the age of 1 year. – He had very good recovery following surgery and seen now at the age of 8 years as a late follow up.

The taking of nerves from the back of legs will not cause any disability.

If the nerves are pulled out from the spinal cord these nerves have to be connected to new nerves. This is called as “Nerve Crossing”. These donor nerves may be from the neighbourhood in the neck and chest or from the same Plexus. In the recent times we borrow from the opposite side plexus without any damage to the other side.

In patients who come after 1 ½ - 2 Years or later after the original injury the Nerve Reconstruction is not possible because the muscles get atrophied. In these situations one has to depend on the working muscles in the upper limb to take up the function of the paralysed muscles. This is called as "Muscle Transfer". If no muscle is available in the same limb or in the nearby chest wall one has to bring in muscle from the thigh by Microvascular Surgery. Hence the importance of early diagnosis and early surgery. As on today the following are the guidelines to be kept in mind.

1. Early surgery gives better results
2. More the delay, poorer will be the recovery
3. Stiff joints do not fare well.
4. Preferably patients` below 40 to 50 yrs.

A lot of research is being done all over the globe on nerve regeneration. Unless the factors that enhance nerve regeneration are found, the results of nerve surgery will be unpredictable in a large percentage of cases. The factors that will improve nerve regeneration are not clear. They grow only 1mm/day after an initial lag phase of 20 – 30 days. And once they reach their respective destination, they act on the muscle to produce contraction and joint movement. For this the muscle also must be in good shape when the nerve arrives. It has been proved that after 1 year, the muscle goes in for irreversible damage and thereafter it fails to respond to any command coming through the nerve.

Since the Brachial Plexus Injuries affect the youth of our country in large numbers, it should be considered as a national problem. We must give top priority and proper line of management. It is with a view to improve the results and to pool the resources and technical expertise of all those surgeons interested in this field, we have formed the

“Brachial Plexus Surgery Group of India”.