Brachial Plexus Injury Treatment

The nerves that carry signals back and forth between our brains and our arms, hands and fingers form a communication conduit known as the brachial plexus. When these nerves are injured or destroyed, it causes a brachial plexus injury (BPI). Restoring movement and sensation can be a complex job and involves treating not only the nerves but also the affected muscles, bones and tendons. Successfully treating BPIs requires depth of experience in all these areas and coordination among specialists.

At Lucile Packard Children’s Hospital, our multidisciplinary team of BPI experts has decades of experience diagnosing BPIs and determining the best possible treatment strategies for patients. With access to the latest techniques and technologies, including nerve transfers and intraoperative nerve monitoring, our physicians, surgeons and therapists all focus specifically on helping children with BPIs recover motion and sensation, with the broader goal of helping them achieve the most normal life possible. Our team members work closely with each other and with patients and families. We track outcomes and adjust our methodologies to allow us to make subtle improvements that add up over time to make a huge difference for our patients.        

Wide range of severity for BPI

There is a wide range of brachial plexus injuries. The extent of a new injury is often hard to determine, so zeroing in on an accurate diagnosis, prognosis and treatment plan takes time and expertise. The course of recovery depends on how many nerves are injured, which ones are involved and how badly they are damaged. Some injuries require only time and therapy to fully resolve. Others require surgery to restore maximum range of motion. Because it is usually impossible to tell which category a new injury falls into, it is necessary to monitor patients and track changes in the injury over time.

Peripheral nerves (nerves outside the brain and spinal cord) are bundles of information-carrying neurons that are something like old-fashion phone lines. The part of each nerve that carries the electrical impulse and transmits the message (the equivalent of the phone line’s thin copper wire) is called the axon. The insulating coating around each axon is called the myelin sheath. Bunches of sheathed axons are bundled together in fascicles, which are themselves bundled together in a single nerve, the outer layer of which is called the epineurium.

Children’s axons are remarkably regenerative and, if damage is limited to the axons alone, their nerves often repair themselves within weeks or months. Even in such cases, however, therapy will help ensure that the maximum range of motion is restored. At the other end of the spectrum, if the entire nerve is severed or destroyed, only surgical reconstruction or nerve replacement can restore control of the muscles or the sensation delivered by the damaged nerve.

Diagnosis of brachial plexus injury

Most of the brachial plexus injuries we treat are birth related. If a newborn patient shows signs of complete BPI where the shoulder, arm and hand are all paralyzed, pediatricians should refer the patient to a multidisciplinary brachial plexus center, such as Lucile Packard Children’s Hospital Stanford, for evaluation. In cases of Erb’s palsy (where a child can no longer flex the elbow and loses some range of motion in the shoulder) or of Klumpke’s palsy (where the hand and wrist are paralyzed), pediatricians will sometimes track the patient’s progress for the first month or two, during which time many cases begin to resolve on their own.

In the first months after injury, parents and therapists should perform gentle range-of-motion exercises to maintain passive range of motion and avoid joint stiffness. By the time the patient is three months of age, if she can bend her elbow, move her wrist upward, and straighten her thumb and fingers, these are excellent signs that the nerves are healing on their own.

On the other hand, if the patient’s condition remains unimproved after three months of age, pediatricians should refer the patient to a center with specialized BPI expertise. In such cases, sequential exams should be performed until the child is six months old, and if elbow flexion or shoulder motion still have not recovered, surgical exploration and repair or reconstruction are probably necessary.

Older children with traumatic, infection-related or tumor-related BPIs are easier to diagnose than infants because they can report sensation and follow instructions during examination. Often, for example, a BPI causes tingling or numbness in the injured arm or hand, but it is impossible to identify such sensations in children who cannot speak. A child also may experience weakness in their upper arm or have difficulty lifting or moving it, but unless they can understand a physician’s instruction to try to move it, this can be hard to confirm.

Some common comorbidities of BPIs can also help with diagnosis. For example, ptosis (droopy eyelid) and asymmetrical pupil dilation, both resulting from associated nerve damage, are sometimes indicators of a BPI. Other occasional comorbidities are broken ribs, clavicle, or upper arm or a dislocated shoulder, resulting either from the original injury that caused the BPI or from the long-term muscle imbalance that comes with the nerve damage.

In addition to tracking recovery with serial physical exams and sometimes sonograms or MRIs, older patients may also undergo electromyograms (EMGs), which are tests that record the vitality of electrical current in muscles. EMGs can help assess nerve function and track recovery.

Brachial plexus surgery

If brachial plexus surgery is required, many centers will schedule a date for an initial exploratory operation used to plan the actual repair itself. Because our entire team works together on each child, we typically accomplish that critical exploratory procedure during the same operation as the repair or reconstruction. Combining the procedures and eliminating an additional surgery reduces the patient’s exposure to anesthesia, shortens her hospital stay, expedites recovery, and is easier on both the patient and her family.

Worldwide, nerve reconstruction is the most common surgical intervention for children with birth-related BPIs. After the extent and nature of the injury are evaluated during the exploratory part of the procedure, the damaged portions of the brachial plexus nerves are removed. Sections of nerve are then borrowed from elsewhere in the patient, typically from the patient’s legs, and grafted in place of the injured ones. This allows the axon to grow back across the injured area and restore some function to the nerve and muscle. Removing the nerve from the leg causes loss of sensation on the outside of the foot but is not disabling. Although complete recovery is rare with nerve reconstruction, the surgery usually results in a significant improvement in function.

Nerve transfer, a more recently popularized brachial plexus surgical technique, redirects a nearby intact section of nerve to the muscle that is nonfunctional due to the injury. The redirected, working nerve supplies the muscle with an alternative functioning connection to the brain. Over time, and with the help of a therapist, the patient can learn to operate the muscle with the new nerve.

Nerve transfer and nerve reconstruction take about four hours to perform, and patients typically spend another day in the hospital for observation and recovery before they are sent home.

After brachial plexus surgery

Arms are typically covered in a protective dressing for three weeks after surgery, and patients return for wound evaluation after these initial three weeks. Once they are home and recovered, patients will typically work with a therapist. Nerve recovery can take up to two years, and patients typically return for a follow-up visit approximately every three months for two years after surgery to monitor functional recovery.

Possible further surgery

As some patients grow older, their range of motion can be further improved with additional surgeries. These procedures may include:

• Joint fusions
• Cutting and repositioning of bones, known as corrective osteotomies
• Transfer of working tendons or muscles to power weak or non-working ones
• Surgical release of tight muscles or joints

Some brachial plexus injuries resolve in weeks or months. Others may cause challenges for years or even for a patient’s entire life. Working with an experienced multidisciplinary team of dedicated specialists who appreciate and employ the full spectrum of possible treatments and can adjust and optimize clinical strategies at each stage grants a huge advantage to patients. If surgery is needed, our doctors understand the full array of surgical options and the opportunities for future surgical adjustments as a patient grows older, which allows them to make the best possible decisions at each juncture while taking into account the long-term ramifications for our young patients.

Our specific expertise is repairing the brachial plexus, but our treatments embrace and nurture the entire child and family.