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Injury of brachial plexus — Clinical Guidelines

Overview

Brachial plexus injuries involve damage to the network of nerves that conducts signals from the spine to the shoulder, arm, and hand, often resulting from trauma or obstetric complications. These injuries can lead to significant motor and sensory deficits in the affected limb.

Diagnosis

Clinical assessment focusing on motor and sensory deficits 6 10.

Imaging studies such as MRI or CT myelography to visualize nerve damage and associated injuries 8.

Electromyography (EMG) and nerve conduction studies to assess nerve function and severity 3.

Grading systems like the Seddon classification (neuropraxia, axonotmesis, neurotmesis) to evaluate injury extent 3.

Management

Early Rehabilitation and Physical Therapy: Essential for recovery, focusing on maintaining joint mobility and muscle strength 6 17.

Surgical Intervention: Indicated for severe injuries (e.g., neurotmesis) where nerve repair or grafting can improve outcomes, especially within 5.3 months post-injury 14.

Pain Management: Multimodal approach including NSAIDs, opioids, and neuropathic pain medications; dorsal root entry zone (DREZ) coagulation for refractory pain 13 18.

Neuromuscular Electrical Stimulation: To prevent muscle atrophy and maintain muscle tone 17.

Special Populations

Pediatrics: Early referral to multidisciplinary care is crucial for optimal outcomes in brachial plexus birth palsy 3.

Pregnancy: Simulation training programs like PROMPT aim to reduce obstetric brachial plexus injuries through improved obstetric care 1.

Comorbidities: Management strategies should consider additional health issues, though specific guidelines are sparse in provided abstracts 2.

Key Recommendations

Early Multidisciplinary Referral: Essential for infants and children with brachial plexus injuries to ensure timely and coordinated care (Evidence: Strong 3).

Surgical Nerve Repair Within Optimal Timeframes: For severe injuries, surgical intervention within 5.3 months post-injury improves functional outcomes (Evidence: Moderate 14).

Incorporate Early Rehabilitation: Focus on physical therapy and rehabilitation to maintain joint mobility and muscle strength (Evidence: Moderate 6 17).

Consider DREZ Coagulation for Refractory Pain: For patients with intractable pain post-brachial plexus avulsion, DREZ coagulation may be beneficial (Evidence: Weak 13 18).

References

1 Yau CWH, Lenguerrand E, Morris S, Draycott T, Pizzo E. A model-based cost-utility analysis of multi-professional simulation training in obstetric emergencies. PloS one 2021. link 2 Nayak A, D'Souza A, Bhat AK, Rao A, Acharya AM. Role of Early Referral and Surgical Intervention in Brachial Plexus Birth Palsy: Awareness Among Obstetricians and Pediatricians in a Teaching Hospital. International quarterly of community health education 2020. link 3 Coroneos CJ, Voineskos SH, Christakis MK, Thoma A, Bain JR, Brouwers MC. Obstetrical brachial plexus injury (OBPI): Canada's national clinical practice guideline. BMJ open 2017. link 4 Barrington MJ, Gledhill SR, Kluger R, Clarke AL, Wong DM, Davidson H et al.. A Randomized Controlled Trial of Ultrasound Versus Nerve Stimulator Guidance for Axillary Brachial Plexus Block. Regional anesthesia and pain medicine 2016. link 5 Brogan DM, Carofino BC, Kircher MF, Spinner RJ, Elhassan BT, Bishop AT et al.. Prevalence of rotator cuff tears in adults with traumatic brachial plexus injuries. The Journal of bone and joint surgery. American volume 2014. link 6 van Dongen R, Cohen SP, van Kleef M, Mekhail N, Huygen F. 22. Traumatic plexus lesion. Pain practice : the official journal of World Institute of Pain 2011. link 7 Arcas-Bellas JJ, Cassinello F, Cercós B, del Valle M, Leal V, Alvarez-Rementería R. Delayed quadriparesis after an interscalene brachial plexus block and general anesthesia: a differential diagnosis. Anesthesia and analgesia 2009. link 8 Tender GC, Kline DG. The infraclavicular approach to the brachial plexus. Neurosurgery 2008. link 9 van Geffen GJ, Rettig HC, Koornwinder T, Renes S, Gielen MJ. Ultrasound-guided training in the performance of brachial plexus block by the posterior approach: an observational study. Anaesthesia 2007. link 10 Duff SV, Dayanidhi S, Kozin SH. Asymmetrical shoulder kinematics in children with brachial plexus birth palsy. Clinical biomechanics (Bristol, Avon) 2007. link 11 Weinberg J, Rokito S, Silber JS. Etiology, treatment, and prevention of athletic "stingers". Clinics in sports medicine 2003. link00057-1) 12 Perris TM, Watt JM. The road to success: a review of 1000 axillary brachial plexus blocks. Anaesthesia 2003. link 13 Samii M, Bear-Henney S, Lüdemann W, Tatagiba M, Blömer U. Treatment of refractory pain after brachial plexus avulsion with dorsal root entry zone lesions. Neurosurgery 2001. link 14 Bonnard C, Anastakis DJ, van Melle G, Narakas AO. Isolated and combined lesions of the axillary nerve. A review of 146 cases. The Journal of bone and joint surgery. British volume 1999. link 15 Berman JS, Birch R, Anand P. Pain following human brachial plexus injury with spinal cord root avulsion and the effect of surgery. Pain 1998. link00220-0) 16 Ochiai N, Nagano A, Yamamoto S, Nakagawa T, Shibata K. Tenodesis of extensor digitorum in treatment of brachial plexus injuries involving C5, 6, 7 and 8 nerve roots. Journal of hand surgery (Edinburgh, Scotland) 1995. link80132-9) 17 Parry CB. Thoughts on the rehabilitation of patients with brachial plexus lesions. Hand clinics 1995. link 18 Thomas DG. Brachial plexus injury: deafferentation pain and dorsal root entry zone (DREZ) coagulation. Clinical neurology and neurosurgery 1993. link90035-f) 19 Freedlander E. Brachial plexus cord compression by the tendon of a pedicled latissimus dorsi flap. British journal of plastic surgery 1986. link90123-2)

Injury of brachial plexus