Ask the Expert: Brachial Plexus Injuries
Dr. Joseph Feinberg, Physiatrist-in-Chief at Hospital for Special Surgery, answers readers’ questions on brachial plexus injuries.
Q1. What are different types of brachial plexus injuries?
The brachial plexus is group of nerves that are formed as the nerves (cervical roots) exit the cervical spine (neck region) and travel through the upper chest region behind the clavicle (collar bone) to the shoulder. Brachial plexus injuries can be complete or partial. They are classified as pre ganglionic (when closer to the spinal cord), post ganglionic (when further from the spinal cord), supraclavicular (above the collar bone) and infraclavicular (below the collar bone). Injuries to different parts of the plexus will affect different parts of the upper limb (i.e. shoulder, arm, forearm, hand).
Q2. How are brachial plexus injuries caused?
The brachial plexus is usually injured from a high velocity stretch to the nerves (i.e., motorcycle or bicycle accident, diving accident, collision in sports, fall from a height), direct trauma from a penetrating object (i.e., stab wound, gunshot) or from a fracture in the shoulder area. The brachial plexus can also be injured from compression of the nerves. This can occur in a more repetitive chronic manner as in the thoracic outlet syndrome or from a growing mass like a tumor.
Q3. What are common symptoms of brachial plexus injuries?
Common symptoms of brachial plexus injuries include weakness, possible paralysis, numbness, loss of sensation and pain in the upper limb.
Q4. How are these injuries treated?
Brachial plexus injuries are treated both surgically and non-surgically depending on the degree of injury, the functional losses and the likelihood of recovery. Surgical treatments include decompression of the nerves, direct nerve repair, nerve transfers and nerve grafting. In some cases, tendon transfers are performed to restore function. Some injuries will require a period of observation before surgery is felt necessary. Surgical treatments are often performed months after the injury.
Q5. How does physical therapy help with rehabilitation?
Physical and occupational therapy play an important role in both the surgical and non-surgical cases. Treatments will include exercises to maintain or improve motion and exercises to help strengthen certain muscle groups. Special therapy approaches are often needed to re-educate the use of certain muscle groups following nerve and/or tendon transfers. This is known as cognitive retraining. Biofeedback can often be helpful. Therapists will also help prevent patients from developing mal-substitution patterns. Splints are sometimes fabricated to protect certain structures or used to maximize function. Different modalities such as electrical stimulation are used for pain control.
Q6. How are brachial plexus injuries evaluated and diagnosed?
Brachial plexopathies are diagnosed by obtaining a history of the injury (includes mechanism of injury), performing a comprehensive physical exam and then ordering the necessary diagnostic tests. Nerve testing is performed by an experienced Electromyographer (physiatrist or neurologist). This test is called an electrodiagnostic test also know as an EMG. Imaging tests can include an MRI,a CT myelogram and sometime an ultrasound study.
For more information, please visit: http://www.hss.edu/condition-list_brachial-plexus-injury.asp
Dr. Joseph Feinberg is Physiatrist-in-Chief and specializes in brachial plexus and peripheral nerve injuries and disorders. He is Co-Medical Director at Center for Brachial Plexus and Traumatic Nerve Injury. He is currently the team physician for St. Peters College. Dr. Feinberg is the editor of a book titled Peripheral Nerve Injuries in the Athlete, published by Human Kinetics. Dr. Feinberg is part of a medical team called F.O.C.O.S. (Foundation of Orthopedics and Complex Spine) that travels to Ghana to treat patients with orthopaedic and neurological disorders.