Brachial Plexus Injury (BPI)

The brachial plexus is a network of nerves that originate from the neck region and branch off to give rise to most of the nerves that control movement and sensation in the upper limbs.

Brachial plexus injury (BPI) is the umbrella term for a variety of conditions that may impair function of the brachial plexus.

The trusted experience and surgical expertise of the neurosurgeons at The Johns Hopkins Peripheral Nerve Surgery Center make us the best choice for treatment of this condition.

Symptoms
BPI may result in some of the following symptoms:

• Pain
• Loss of sensation
• Muscle weakness
• Paralysis of some or all of the muscles of the shoulder and upper limb

Some patients may experience avulsion pain (a burning, crushing type of pain) in the distribution of the injured nerves.

Causes of brachial plexus injury
Brachial plexus injury is caused by nerve injury. The majority of pediatric and adult brachial plexus injuries are caused by trauma. The most common inciting events may include:

• High-speed vehicular accidents, especially motorcycle accidents
• Blunt trauma
• Stab or gunshot wounds
• Inflammatory processes (brachial plexitis)
• Compression (for example caused by a growing tumor)
• Neuropathies

Obstetric brachial plexus palsy
Obstetric brachial plexus palsy occurs in less than one percent of live births. During delivery, the baby's shoulder may become impacted on the pubic bone causing the brachial plexus nerves to stretch or tear (shoulder dystocia). Several patterns of obstetric brachial plexus palsy have been described including Erb's Palsy and Klumpke's palsy. The prognosis for recovery depends on the pattern, complexity, and severity of injury.

Diagnosis
Due to the complex spectrum of brachial plexus injuries, a detailed and comprehensive understanding of the exact nature of injury in each patient is required for proper management.

Multiple modalities are utilized to diagnose a brachial plexus injury including:

• History taking and clinical examination
• Electrodiagnostic studies (EMG, NCV, SNAP,SSEP)
• Imaging studies (CT, MRI)

Some of these evaluations may need to be repeated on a regular basis to track the progression of recovery of function. Used in combination, these modalities provide valuable insights into the elements of the brachial plexus that have been injured and some information about the severity of the injury.

Surgical Interventions
Due to the broad spectrum of brachial plexus injuries, it is difficult to estimate the rate of spontaneous recovery. The potential for spontaneous recovery depends on the type and severity of injury. Therefore, prognosis must be assessed for each patient individually based on the type and severity of their injury, and the progression of any spontaneous recovery that may be occurring.

DREZ Procedure
At Johns Hopkins, our doctors are expertly trained in a procedure known as Doral Route Entry Zone lesioning, or DREZ for short. This highly risky procedure requires the experience and expertise of the neurosurgeons at Hopkins who have the skill and knowledge to perform this delicate surgery.

During this surgical procedure, your neurosurgeon will open the spinal canal and locate the area where the nerves have been avulsed, or pulled out from the spinal cord. Using a microscope, your neurosurgeon will remove the scarred tissue. After the damaged nerve tissue has been removed, your doctor will make a series of microscopic burns into the damaged area of the spinal cord using an electrode. Over 70 to 100 contiguous burns are made in the area in order to correct the neural pathways and stop the pain messages.

Factors in surgical interventions
The degree of functional impairment and potential for recovery depend on the mechanism, type, complexity of the brachial plexus injury, and time from injury. The most important decisions your surgeons will make is determining if and when surgical intervention should occur.

Nerve injury surgery to repair the damaged nerves is complex, requiring an expert and experienced surgeon. Proper diagnosis is essential for deciding which patients have the potential for spontaneous recovery. If it is apparent that the severity and type of injury precludes the potential for spontaneous recovery (e.g., avulsion), early surgery is indicated. Otherwise surgery is typically delayed for several months to allow for spontaneous recovery.

Length of time
Serial physical examinations and diagnostic studies play a key role in tracking the progression of recovery. After a few months, surgery is indicated if there are no signs of spontaneous recovery or if recovery has plateaued at an unacceptable functional level.

Surgical intervention serves two functions: confirmation of diagnosis and repair of injury. Several factors determine the type of intervention performed including: preoperative diagnosis, interval between injury and surgery, and intraoperative diagnosis. Procedures to restore function include neurolysis, neurotization, tendon transfers, and free muscle transfers.

Brachial Plexus Injury Recovery
Recovery of function is a lengthy process. Nerves grow at about one inch per month, so it may take several months before the first signs of recovery are apparent. Recovery progresses from muscles of the shoulder, to those of the arm, and finally the hand. Physical therapy is essential to strengthen recovering muscles and maintain flexibility of joints. Pain from surgery is usually minimal and can be managed by analgesics. Additional interventions, including the DREZ procedure, may be indicated to address avulsion pain.

The determination of whether the surgery was successful is usually not made until enough time has passed for complete reinnervation (for the nerves to grow back) and strengthening (about one and a half to two years). Recovery may continue to occur for up to four years. If there is incomplete recovery, patients should be evaluated for the further interventions. These may include muscle or tendon transfers or releases to optimize movement of the limb.