The most difficult injuries to manage are those caused by severe stretch or traction as there is no obvious guide to what has occurred inside. Doing surgery early might interfere with normal recovery while leaving surgery for too long can allow important parts of the nervous system to degenerate without connections. Nerve avulsion can be surgically approached after three to six weeks or if natural recovery does not occur as expected then surgery can be approached at 3 to 6 months. If the nerve has been cut then repair can be attempted, whilst if it has been avulsed then grafting can be performed. To speed up recovery a nerve transfer may be used.
Intractable arm pain is one of the very difficult parts of the brachial plexus lesion injury picture, a chronic and disabling problem which can come on with time. A severe pain problem can develop in the arm despite the fact that the nerves have been ripped out and are not connected any longer to the spinal cord. However the nerves in the spinal cord expect inputs from the arm nerves and when they don't get them they start reacting abnormally to this deprivation, generating a particularly unpleasant pain problem in the arm.
Patients typically describe the pain as shooting, crushing or burning, severe or coming on in severe spasms. This kind of pain is referred to as deafferentation pain, which refers to the rupture causing a loss of incoming (afferent) signals to the nervous system. Treatment of deafferentation pain starts with conservative measures. A pain management team specialises in these conditions and early involvement would be helpful, even admission to allow treatment to be started with a multidisciplinary approach. Many drugs can be used apart from the morphine chemicals and some may be helpful in suppressing this neuropathic pain.
TENS, transcutaneous nerve stimulation, is a physical modality for pain control which sends signals into the spinal cord to affect the pain gating system and may be useful in some cases. It can take a long time for an effect to be forthcoming and for the best outcome to be clear. There are a list of other treatments for brachial plexus lesions, none of them with much demonstrable success, including CBT (cognitive behavioural therapy), biofeedback, acupuncture, desensitisation and hypnosis. Due to the varied nature of the presenting symptoms a multidisciplinary team is vital to manage the patient over time.
Nonoperative treatment is complex and best managed by the dedicated multidisciplinary team which might include a physiotherapist, occupational therapist, physician and orthotist. The physician can manage the diagnosis and monitor the recovery, the orthotist will provide braces to prevent joint contracture, the occupational therapist will teach functional use and the physiotherapist will maintain joint ranges and encourage normal muscle use. Surgical care is highly specialised and should be undertaken only by specialists in designated centres with experience. Because the injuries vary so greatly the choice to intervene or not and the procedures to be chosen if surgery is to be attempted are very varied.
How brachial plexus lesions progress with time is uncertain because of the high level of variability in the injury mechanisms and anatomical structures affected. The age of the patient and the surgery chosen also affect outcome greatly. Using a working muscle to do the work of a denervated one can increase function, and the sural nerve in the leg is often used as a graft, typically performed at 3-6 months after the injury. Replacing the avulsed nerves back into the spinal cord has been performed, which if it worked would be a dramatic demonstration that central nerves could repair, but this is not yet a routine procedure.
Healing nerves progress at an average speed of one millimetre a day, which in imperial is about an inch or so a month. This can mean a very long wait if the injury is high up in the neck like the brachial plexus and without a nerve supply the nerve endplates on the muscle can degenerate which means the muscle won't work even if the nerve grows down to it in time. Much research is continuing into nerve growth factors which might speed up the recovery of direct nerve repairs and later grafting. - 16004
Intractable arm pain is one of the very difficult parts of the brachial plexus lesion injury picture, a chronic and disabling problem which can come on with time. A severe pain problem can develop in the arm despite the fact that the nerves have been ripped out and are not connected any longer to the spinal cord. However the nerves in the spinal cord expect inputs from the arm nerves and when they don't get them they start reacting abnormally to this deprivation, generating a particularly unpleasant pain problem in the arm.
Patients typically describe the pain as shooting, crushing or burning, severe or coming on in severe spasms. This kind of pain is referred to as deafferentation pain, which refers to the rupture causing a loss of incoming (afferent) signals to the nervous system. Treatment of deafferentation pain starts with conservative measures. A pain management team specialises in these conditions and early involvement would be helpful, even admission to allow treatment to be started with a multidisciplinary approach. Many drugs can be used apart from the morphine chemicals and some may be helpful in suppressing this neuropathic pain.
TENS, transcutaneous nerve stimulation, is a physical modality for pain control which sends signals into the spinal cord to affect the pain gating system and may be useful in some cases. It can take a long time for an effect to be forthcoming and for the best outcome to be clear. There are a list of other treatments for brachial plexus lesions, none of them with much demonstrable success, including CBT (cognitive behavioural therapy), biofeedback, acupuncture, desensitisation and hypnosis. Due to the varied nature of the presenting symptoms a multidisciplinary team is vital to manage the patient over time.
Nonoperative treatment is complex and best managed by the dedicated multidisciplinary team which might include a physiotherapist, occupational therapist, physician and orthotist. The physician can manage the diagnosis and monitor the recovery, the orthotist will provide braces to prevent joint contracture, the occupational therapist will teach functional use and the physiotherapist will maintain joint ranges and encourage normal muscle use. Surgical care is highly specialised and should be undertaken only by specialists in designated centres with experience. Because the injuries vary so greatly the choice to intervene or not and the procedures to be chosen if surgery is to be attempted are very varied.
How brachial plexus lesions progress with time is uncertain because of the high level of variability in the injury mechanisms and anatomical structures affected. The age of the patient and the surgery chosen also affect outcome greatly. Using a working muscle to do the work of a denervated one can increase function, and the sural nerve in the leg is often used as a graft, typically performed at 3-6 months after the injury. Replacing the avulsed nerves back into the spinal cord has been performed, which if it worked would be a dramatic demonstration that central nerves could repair, but this is not yet a routine procedure.
Healing nerves progress at an average speed of one millimetre a day, which in imperial is about an inch or so a month. This can mean a very long wait if the injury is high up in the neck like the brachial plexus and without a nerve supply the nerve endplates on the muscle can degenerate which means the muscle won't work even if the nerve grows down to it in time. Much research is continuing into nerve growth factors which might speed up the recovery of direct nerve repairs and later grafting. - 16004
About the Author:
Jonathan Blood Smyth is a Superintendent Physiotherapist at an NHS hospital in the South-West of the UK. He specialises in orthopaedic conditions and looking after joint replacements as well as managing chronic pain. Visit the website he edits if you are looking for physiotherapists in London.
