By Ibani Kapur, Farooq Ali Khan, Abhishek Kumar, Raamesh Gowri Raghavan and Sukant Khurana
Introduction and Epidemiological data
A neurologic injury affecting the complex network of nerves that control the muscles of the upper limb is referred to as Brachial Plexus Injury. This network, is a network of nerve fibers which begin in the root of the neck and enter the upper arm. The anterior rami(divisions) of the cervical spinal nerves C5, C6, C7 and C8, and the first thoracic spinal nerve, T1 form the plexus.(4) According to reports, over the last fifty years the incidence of this injury has increased. Spinal cord injuries should not be confused with injury to the brachial plexus. These occur 10–20 times more frequently compared to those of spinal cord injuries.(1)
Although, a major percentage of brachial plexus injury can be accounted to motorcycle accidents as is reported for UK(2), another type of this injury is encountered during childbirth. This category of brachial plexus injury is called Obstetric type brachial plexus injury and is more common than Downs Syndrome or Muscular Dystrophy(2). Also called Neonatal brachial plexus palsy, it is caused due to injury to one or more cervical or thoracic nerve roots (C5-T1).(5)
There are a range of techniques available today, that are relied upon. The route to be followed for the treatment depends largely upon the severity as well as precise location of the injury. Accordingly, the non-operative or the surgical route would be followed. In adults particularly, the mechanism of injury observed is either crush type which is caused due to direct trauma to the neck and upper extremity , traction of the plexus or compression of plexus due to adjacent tissue elements that have been injured.(6)
Statistics
Neonatal BPI- 80–85 percent cases are mild and children recover within first two months
Births from years 1997,2000 and 2003 were studied. Out of 11,555,823 live births 17,334 had Brachial Plexus Injury. However, rate decreased from 1.7 per 1000 live births in 1997 to 1.3 per 1000 live births in 2003.(8)
Risk factors associated with neonatal brachial plexus are:
· Fetal Macrosomia
· Gestational Diabetes
· Shoulder Dystocia
Incidence of BPI is 1 in 1000 births.(9)
UK,India — young males injured in motorcycle accidents is a more common cause of BPI among adults.(1)
The incidence of BPI after shoulder dystocia was observed to be 26.3 %(7)
Probability of a neonate with shoulder dystocia is 11.11 percent higher than that without.(7)
Shoulder Dystocia is a condition wherein the obstetrician is required to deliver an infant without applying any force so as to prevent a permanent injury. Birth weight and mode of delivery are to be considered for shoulder dystocia. Once there is occurrence of shoulder dystocia , between 8 to 20 percent of infants experience brachial plexus damage. Since some births require extreme pressure for delivery while others do not, formal diagnosis can be reported of shoulder dystocia on this basis. Studies prove that diabetes mellitus is associated with an extra risk of shoulder dystocia.(7)
Causes
· Traction — as briefly mentioned earlier, is a very common cause of traumatic type of brachial plexus injury. Traction forces can lead to stretching , rupture or avulsion of the nerve root. When the nerve root is avulsed, only one end is available to the surgeon thereby making repair difficult. Avulsion of C5-T1 occurs majorly in casualties of motorcycle accidents.(2)
· Penetrating injury — which involves gunshot or puncture wounds
· Birth Palsy- Obstetric type Brachial Plexus injury involving the upper brachial plexus is referred to as erb. However, the lower brachial plexus being affected is a rare case.
Management of Brachial Plexus Injury
There are two procedures that can be opted for on the advent of this uncertain disorder
· Non operative management is a conservative technique wherein some amount of mobility can be achieved with the help of physiotherapy and rehabilitation.
· Conservative management involves drugs which can help ease neuropathic pain. Antiepileptic drugs like Gabapentin (15 dollars per 100 mg) and carbamazepine or antidepressants such as amitriptyline(10). Initial stages can involve usage of NSAIDs and opoid drugs but will not be helpful to a great extent.
Operative or surgical route can involve (11)
· Neurolysis
· Nerve grafting
· Neurotization
The lesions caused to the brachial plexus can be classified as (11)
· Preganglionic
· Postganglionic
· combination of the two
Preganglionic lesion is one where there is avulsion of nerve roots. In this case, repair is difficult. Therefore, nerve grafting is used. The donor nerve used for this purpose is called an intercostal nerve.
Fibrin glue is a new technique to obtain a single structured nerve
Avulsion of roots can be easily predicted if there is Horners syndrome or presence of phrenic palsy
Preferred route for infants — Reconstructive surgery
Postganglionic lesion involves the nerve structure distal to sensory ganglion. In this case, when lesion is non degenerative nerve grafting is used. If fascicles are intact, conservative management is followed.
New Treatment techniques and its Demographic studies
· C-7(C77) Transfer Technique
Brachial Plexus root avulsion Injury treatment involves C-7(C77) transfer technique.
CC7 transfer to musculocutaneous (MC) nerve for treatment in Asia as well as countries like Egypt,Belgium,US,France,Austria and Brazil was conducted.
C7 which also refers to the seventh cervical nerve, in many cases was used to reconstruct nerves besides the musculocutaneous nerve. However, in this study the focus lies on these two nerves.(13)
Demographic statistics
Total of 154 patients with traumatic BPI were subjected to contralateral C-7 transfer to the MC nerve. Outcome was reported in 118 patients from Asian countries and 36 from other countries.(13)
33 studies were carried out of which 26 were from Asian countries, ninety percent being males and mean age of twenty four years. The average preoperative time of seven months was reported by Asian authors while other countries reported a much longer duration of eleven months.(13)
· Bionic Hand Reconstruction
A relatively new technique can be used in cases where restoration of hand functions is difficult to achieve. An algorithm for bionic hand construction was conceived. This new technique involves selective nerve and muscle transfer combined with amputation of the functionless hand, and its replacement with a prosthetic device.(18)
Demographic statistics
Between 2011 and 2015, a total of 34 patients with post traumatic global brachial plexopathies consulted Center for Advanced Restoration of Extremity Function. In 65% of the patients motorcycle accidents accounted for the BPI. In 18 patients (53%), primary and secondary BP reconstructions alone restored sufficient hand and arm function. However, in 16 patients (47%) the neurological injury was so severe that distal function could not be achieved with biological means alone and bionic reconstruction was necessary to restore adequate hand function.(18)
Social Media
It was a subject of discussion for quite some time about Martin Sheen suffering from Erb’s Palsy
Case Studies
1) Patient- 58 year old man
Complication- Intractable pain in the left arm after sustaining a Brachial Plexus Injury in a motorcycle accident 32 years earlier
Physical Symptoms
· Lack of movement in upper extremity
· Burning pain
· Hyperalgesia which refers to extreme sensitivity to pain
Pain Rating- 9 on a scale of 0 to 10 on the Numeric Rating Scale
Tests-
· Electromyography (EMG) showed an incomplete left BPI
· Nerve Conduction Study(NCS) proved no evoked potential in any of the nerves sampled
Medication-
· Hydromorphone — 16 mg/day
· tramadol- 150mg/day
· gabapentin- 2400mg/day
2) Patient — A 15 year old boy
Complication- Afflicted with injury to the upper brachial plexus preceding a motor accident ,
Hornets syndrome,
no injury to the lungs was observed from CT — Myelography.
A duration of 3 weeks post injury, avulsion of nerve roots C5 — C7 and injuries to spinal roots C8-T1 was observed
Procedure adopted- Multiple nerve transfers ,3 weeks after injury
Procedure
· the terminal part of the accessory nerve was transferred to the suprascapular nerve
· the second and third intercostal nerves transferred (the upper intercostal via two radial nerve grafts) to the axillary nerve
· the fourth to sixth intercostal nerves were transferred (the two lower via three radial nerve grafts) to the musculocutaneous nerve. Postoperatively, he trained under the supervision of a physiotherapist with experience in rehabilitation of patients with BPI.(12)
Time period for activation of muscles infra and supraspinatus- 21 months after surgery
Muscle chosen as donor muscle — Gracilis muscle
This muscle is used for functioning free muscle transplantation (FFMT)
Post-operative complications included pneumonia and delayed wound healing after treatment with antibiotics.
EMG after a year of surgery revealed no denervation activity in the gracilis muscle innervated by phrenic nerve
Elbow function was not completely restored, some activity in the movement of fingers and thumb was achieved but not sufficient for daily functioning. This can be attributed to the non avulsion of c8 and t1 roots(12).
Costs of Selected Opioids (14)
Real Life Stories
“Samantha’s arm was completely paralyzed,” said Cindy, Samantha’s grandmother and legal guardian. “She had no movement, her arm had dislocated at her shoulder and just hung there. It was totally useless to her.””
Samantha underwent nerve transfer surgery performed by Kevin Yakuboff, MD, plastic and reconstructive surgeon. During this procedure, Dr. Yakuboff transferred three healthy nerves to replace the damaged ones to help generate re-growth.
Cindy is amazed at her granddaughter’s recovery. “Samantha is my miracle girl,” she says. “She’s come a long way.
“You would never know by looking at her today all that she has been through.” The only noticeable sign of her brachial plexus injury is a scar, which is covered by her clothes. Otherwise, Cindy says other children do not know that Samantha ever had a problem with her arm.
Before surgery, she had absolutely no movement in her arm. Now Samantha can perform important everyday tasks, such as getting dressed and feeding herself. It has also given her more opportunities to experience the world around her. Samantha likes to dance, cheerlead and swim — all activities she could not do before her surgery. “Now she can do almost anything she wants,” said Cindy.(17)
Imaging Techniques
Myelography — standard myelography is available in most hospitals for understanding the level of the injury. It is often used along with CT Myelography but found to be more sensitive in evaluation of root avulsions at the C8 and T1 nerves
Anatomic and physiologic changes observed due to the injury are recorded using MRI.(16)
New techniques including MR myelography, diffusion-weighted neurography, and Bezier surface reformation can be useful in the evaluation and management of BPI
Bezier surface reformation — Entire nerve roots are demonstrated on a single image, and suspected injured roots are easily compared with roots on the contralateral side.
This comprehensive image will help physicians grasp the location and extent of injuries and reduce the need for repeated observation of numerous axial images (16)
Recovery
Recovery of function after a brachial plexus injury 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.(15)
Recovery progresses from the 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 pain medications.(15)
Summary
The outcome of brachial plexus injury in one’s life is devastating as it can affect several aspects of the life of the patient suffering from it. Some areas affected include employment , financial and or physical dependence on others, altering residence and so on.(3)
However, giving up and losing hope should never be an option. United Brachial Plexus Network, inc is a noteworthy platform which provides information on as well as prevention and treatment of Brachial plexus injury. It also encourages unity among families suffering from this unpredictable fate.
REFERENCES
(1) United Brachial Plexus Network, Inc. 1.781.315.6161
Brachial Plexus Injury Awareness QUICK FACTS ABOUT BRACHIAL PLEXUS INJURIES
(2)PERIPHERAL NERVE DISORDERS Brachial plexus injury
Sultan Hassan Simon Kay
(3) Compensation by the Uninjured Arm After Brachial Plexus Injury
Carol A. Mancuso, Steve K. Lee, Christopher J. Dy, Zoe A. Landers, Zina Model, and Scott W. Wolfe
(4)http://teachmeanatomy.info/upper-limb/nerves/brachial-plexus/
(5)The Epidemiology of Neonatal Brachial Plexus Palsy in the United States
Susan L. Foad, MPH, Charles T. Mehlman, DO, MPH, and Jun Ying, PhD
(6)The Surgical Treatment of Brachial Plexus Injuries in Adults
Julia K. Terzis, M.D., Ph.D., and Konstantinos C. Papakonstantinou, M.D., Ph.D.
(7)Shoulder Dystocia and Brachial Plexus Injury: A Population-Based Study
Magnus Christofferssona Hakan Rydhstroemb Departments of Obstetrics and Gynecology, Central Hospital, Kalmar, and Helsingborg Hospital, Helsingborg, Sweden
(8)The Epidemiology of Neonatal Brachial Plexus Palsy in the United States
Susan L. Foad, MPH, Charles T. Mehlman, DO, MPH, and Jun Ying, PhD
Investigation performed at the Division of Pediatric Orthopaedic Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, and the Division of General Internal Medicine, Department of Internal Medicine, University of Cincinnati College of Medicine, Institute for the Study of Health, Cincinnati, Ohio
(9) paediatrics in review
(10) Treatment Options for Brachial Plexus Injuries
Vasileios I. Sakellariou, Nikolaos K. Badilas, Nikolaos A. Stavropoulos, George Mazis, Helias K. Kotoulas, Stamatios Kyriakopoulos, Ioannis Tagkalegkas, and Ioannis P.Sofianos
(11) Brachial Plexus Injury: Clinical Manifestations, Conventional Imaging Findings, and the Latest Imaging Techniques
Takeharu Yoshikawa, MD, PhD Naoto Hayashi, MD, PhD Shinichi Yamamoto, MD, PhD Yasuhito Tajiri, MD, PhD Naoki Yoshioka, MD, PhD Tomohiko Masumoto, MD, PhD Harushi Mori, MD Osamu Abe, MD, PhD Shigeki Aoki, MD, PhD Kuni Ohtomo, MD, PhD
(12) Rehabilitation, Using Guided Cerebral Plasticity, of a Brachial Plexus Injury Treated with Intercostal and Phrenic Nerve Transfers
Dahlin LB, Andersson G, Backman C, Svensson H, Björkman A
(13) A systematic review of outcomes of contralateral C-7 transfer for the treatment of traumatic brachial plexus injury: an international comparison
alexandra l. mathews, bs, guang Yang, md,Kate wan-chu chang, ma, ms,3 and Kevin c. chung, md
(16)Brachial Plexus Injury: Clinical Manifestations, Conventional Imaging Findings, and the Latest Imaging Techniques
Takeharu Yoshikawa, MD, PhD Naoto Hayashi, MD, PhD Shinichi Yamamoto, MD, PhD Yasuhito Tajiri, MD, PhD Naoki Yoshioka, MD, PhD Tomohiko Masumoto, MD, PhD Harushi Mori, MD Osamu Abe, MD, PhD Shigeki Aoki, MD, PhD Kuni Ohtomo, MD, PhD
(17)https://www.cincinnatichildrens.org/patients/care/stories/patient-stories/brachial-plexus/samantha-b
(18)Algorithm for bionic hand reconstruction in patients with global brachial plexopathies
Laura A. Hruby, MD, Agnes Sturma, MSc, Johannes A. Mayer, MD, Anna Pittermann, PhD, Stefan Salminger, MD, and Oskar C. Aszmann, MD, PhD
Christian Doppler Laboratory for Restoration of Extremity Function; Department of Physical Medicine and Rehabilitation; and Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna; and Master Degree Program, Health Assisting Engineering, University of Applied Sciences FH Campus, Vienna, Austria
(19) Ultrasound‑guided peripheral nerve stimulation for neuropathic pain after brachial plexus injury: two case reports Jung Hyun Kim ,Sang Ho Shin, Young Rong Lee, Hyo Seon LeeJin Young Chon Choon, Ho Sung Sung Jin Hong Ji ,Young Lee, Ho Sik Moon
Dr. Sukant Khurana runs an academic research lab and several tech companies. He is also a known artist, author, and speaker. You can learn more about Sukant at www.brainnart.com or www.dataisnotjustdata.com and if you wish to work on biomedical research, neuroscience, sustainable development, artificial intelligence or data science projects for public good, you can contact him at skgroup.iiserk@gmail.com or by reaching out to him on linkedin https://www.linkedin.com/in/sukant-khurana-755a2343/.