Examination of Brachial Plexus Injury

• Immediately after the accident due to any reason, patient must be thoroughly examined to rule out any fracture at the site of injury or injury to other parts of body, such as head, spinal cord or chest injury.
• Level of consciousness of the patient after the accident should be enquired for and whether he/she was able/not able to lift his limb after accident or bend his /her elbow and had/had not any sensation then, which can be a clue for planning management later.

Due to very less awareness, often patient roams around and reach the right person quite late after the injury. So Plastic surgeons trained in Brachial plexus surgery are the ones who should be consulted for management of such cases. Dr Amit Agarwal specializes and have expertise of more than 11 years in the field of brachial plexus injury management and is well aware of all aspects of treatment.

After patient has recovered from the other injuries, patient is examined thoroughly for all the movements at all his joints of the paralysed arm. Hand function is completely normal in patients with partial brachial plexus injuries of C5,6 nerve roots. If C7 nerve root is also injured, then patient might not be able to extend his elbow, wrist and fingers but finger flexion will be possible.

Patient will be advised for regular physiotherapy and, explained to examine himself as per the features described below and follow up is done every month. If no recovery is perceived, patient will undergo few diagnostic investigations. Chest radiographs, Magnetic Resonance Neurography of Brachial Plexus, Pulmonary function tests (PFT), Electromyelography (EMG) and Nerve Conduction Studies (NCSs) are done to confirm the diagnosis, localize and characterize the nerve lesion.

Surgical Procedure of Nerve Repair/Transfer for Complete BPI

The surgery is done under General Anaesthesia and patient is admitted a day before surgery in the hospital. Routine blood investigations are done, Pre-anaesthetic checkup is done, and Informed written consent form is signed before surgery. In many of the cases, nerve is also harvested from the leg for repair of partial brachial plexus injuries. It does not create any deficit in the leg apart from mild sensory abnormality in the outer aspect of the ankle region which subsides overtime.

The procedure is best done within a golden time period, within 3-5 months of the injury, to reactivate the paralyzed muscle(s) early, effectively, and successfully to muscle strength to grade 4 power.

Nerve repair

Nerve repair is done in cases of rupture of nerves. Brachial plexus is explored, ruptured nerves are identified, scarred portion of the nerves are removed and nerve repair is done by taking nerve graft from different parts of the body. Usually, Nerve repair is possible in upper brachial plexus rupture as the lower trunks are avulsed from the spinal cord making nerve repairs impossible. Incision is given in the neck region above the level of clavicle. Muscles are dissected and the nerves are explored. Neuroma Is excised andnerves are repairedby taking nerve graft from the legif the proximal nerve roots are healthy.

Additionally spinal accessory nerve is transferred to the supra scapular nerve torestore initiation of the shoulder abduction movement. This is a very vital transfer done in all Brachial Plexus Injuries.

Nerve Transfer

Nerve transfer is a surgical option that intentionally divides a physiologically active nerve (with low donor morbidity) and transfers it to a distal more important but irreparable paralytic nerve of the brachial plexus.

• Oberlin I & IImethod
  The most commonly used nerve transfer technique for elbow flexion in upper arm type BPI is the Oberlin I transfer. Incision is given on inside of the arm and nerves are explored. One or two nerve fascicles are transferred from the ulnar nerve and directly coapted (joined) to the motor branch of the biceps muscle of the musculocutaneous nerve(MCN). In Oberlin II transfer, one nerve fascicleis transferredfrom the median nerve and directly coapted (joined) to the motor branch of the brachialis muscle.The addition of the Median nerve coaptation has markedly increased the success rate of elbow flexion without sacrificing the donor nerve (MN and UN) function in hands. These transfers restore elbow flexion following loss of the C5,6 nerve roots.
• Mackinnon's method
  The most commonly used nerve transfer technique for shoulder abduction in upper arm type BPIis Susan McKinnon method.Incision is giving on backside of the arm and nerves are explored underneath the triceps and deltoid muscle. Nerve fascicles from median branch of the nerve of tricepsare transferred and directly coapted to the anterior and posterior divisions of the axillary nerve. This can restore the shoulder movements without sacrificing the function of triceps nerve.

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