Complete BPI

Brachial plexus injuries are closely associated with the brachial plexus, a network of nerves in the neck and shoulder region. Typically, complete brachial plexus injuries result from accidents where the arm is forcefully stretched or injured. These injuries involve the complete severance of nerve roots C5, C6, C7, C8, and T1 in the neck, leading to weakness, numbness, or loss of motion in the affected shoulder, arm, forearm, and hand.

Complete brachial plexus injuries leave the limb entirely incapacitated. Individuals with such injuries cannot move, lift their affected shoulder, elbow, or wrist, and they lose all hand movements and the ability to grasp objects or sense anything in the affected limb. This injury is more commonly observed in men aged 15-25 years. Notably, upper brachial plexus nerves (C5, C6) are more prone to stretching or rupturing, while lower brachial plexus nerves (C8, T1) tend to avulse or detach from the spinal cord.

In the immediate aftermath of an accident, it is crucial to conduct a thorough examination of the patient to rule out fractures at the injury site or injuries to other body parts, such as the head, spinal cord, or chest. Assessing the patient’s level of consciousness and their ability or inability to lift the limb after the accident can provide valuable insights for later management. Addressing any limb fractures takes precedence before planning any surgery for Brachial Plexus Injuries. For more information on the causes, investigations, and the role and timing of surgery, please refer to our Brachial Plexus injuries page.

The timing of surgical intervention is critical in cases of complete injuries. The adage “sooner the treatment, better the outcome” holds true for brachial plexus injuries. Surgery involves exploring, repairing, and transferring nerves. In cases of sharp open injuries, immediate surgery is performed. In contrast, blunt closed injuries, which are more common, are observed for the first 2-3 months. This period allows for spontaneous recovery, if present. If no recovery is observed after three months post-accident, nerve repair or transfer surgery is conducted as soon as possible.

For injuries occurring within 9 months to 1 year, surgery is still a viable option, although the chances of recovery are somewhat diminished compared to surgeries performed within 3 months. However, after 1 year post-accident, attempts at nerve transfer surgery have shown very limited success due to insufficient time for nerve regeneration. In such cases, specific targeted muscle and tendon transfers are preferred over nerve transfer surgery.

During surgery for complete brachial plexus injuries, the focus is on restoring several essential movements, including shoulder abduction, elbow flexion, wrist extension, and some sensory recovery in the hand.

It’s important to note that a single surgery cannot fully restore all upper limb movements due to the limited availability of donor nerves. Achieving comprehensive recovery typically necessitates multiple staged surgical procedures to regain and target different hand movements.

• The optimal timing for this procedure is within 3-5 months of the injury to reactivate paralyzed muscles effectively, leading to a strength level of grade 4.
• This surgery is conducted under General Anesthesia, with patients admitted a day before the procedure. Prior to surgery, routine blood investigations are performed, a pre-anesthetic check-up is conducted, and an informed written consent form is signed.
• In many cases, nerves are harvested from the leg to repair complete brachial plexus injuries. This procedure does not create any deficit in the leg, except for mild sensory abnormalities in the outer aspect of the ankle region, which tend to subside over time.
• Nerve repair is employed in cases of nerve ruptures. The brachial plexus is explored to identify ruptured nerves, remove scarred nerve segments, and perform nerve repair. In upper brachial plexus ruptures, nerve repair is feasible, as the lower trunks are avulsed from the spinal cord, making nerve repairs impossible.
• The procedure typically involves an incision in the neck region above the clavicle. Muscles are dissected, and nerves are explored. Neuroma is excised from the upper brachial plexus, and nerve repair is accomplished using nerve grafts from various parts of the body. Additionally, the spinal accessory nerve is transferred to the suprascapular nerve to restore the initiation of shoulder abduction movement, a vital transfer in all Brachial Plexus Injuries.
• Nerve transfer is a surgical option that intentionally divides an actively functioning nerve (with minimal donor-related complications) and transfers it to a more crucial yet irreparable paralytic nerve of the brachial plexus.
• Intra-plexus nerve transfer is typically applied in cases of nerve avulsion from the spinal cord, where at least one spinal nerve has experienced rupture but is still suitable for transfer. These transfers are not returned to their original pathway but redirected to more critical nerves. The choice of intra plexus nerve transfer is personalized, depending on intraoperative findings, the surgeon’s approach, and the patient’s specific condition and requirements.
• Extra Plexus nerve transfer entails transferring a neighboring nerve (either from the same or opposite side of the neck) to the avulsed brachial plexus, facilitating the negotiation of a paralytic nerve. Commonly used donor nerves are primarily aimed at motor re-innervation, including the phrenic nerve, spinal accessory nerve (accessed via an anterior neck approach), deep motor branches of the cervical plexus (cervical motor branches; CMBs), hypoglossal nerve (XII), contralateral C7 (CC7) spinal nerve, and intercostal nerves. Extra Plexus sensory nerve transfer, such as supraclavicular sensory nerves to the median nerve transfer, is occasionally employed to restore sensation to the paralytic hand.

a) Nerve Repair

b) Nerve Transfer

1. Intraplexus (Within the Brachial Plexus) Nerve Transfer

1. Extra Plexus (Outside the Brachial Plexus) Nerve Transfer

1. Brachial plexus neurotization procedures are lengthy surgeries, typically lasting a minimum of 6 to 8 hours.
2. After surgery, patients usually spend 2 days in the hospital before being discharged.
3. Non-dissolvable sutures are removed after 14 days.
4. Subsequently, regular monthly follow-up examinations are mandatory to assess the progress of nerve repair and nerve regeneration.

The outcomes of nerve repair surgery for complete injuries are frequently incomplete and can vary significantly. These outcomes hinge on various factors such as age, weight, co-existing medical conditions, and the time elapsed since the accident.

The best possible result that patients can achieve, with dedicated effort and physiotherapy, in the case of complete brachial plexus injury includes the ability to:

These improvements enable individuals to use their paralyzed hand as a supportive hand. It’s important to understand that nerve regeneration occurs gradually, at an approximate rate of 1 mm per day. Recovering from a brachial plexus injury is a time-intensive process, with patients often not experiencing significant results for several months, even after a successful surgery.

1. Abduct (lift the arm away from the body) the arm up to 90 degrees.
2. Flex the elbow (bend the elbow towards the body).
3. Achieve a mild grip in the hand (sufficient for holding objects).
4. Attain mild to moderate sensory recovery in the hand to prevent injuries or burns.

Following surgery for brachial plexus injuries, patients are advised to undergo regular physiotherapy and Transcutaneous Electric Nerve Stimulation (TENS) therapy. Maintaining a positive mindset and having the support of family, friends, and healthcare professionals are essential components of recovery and rehabilitation.

Complete recovery after surgery for brachial plexus injuries can be unpredictable. Even in the best medical centers globally, success rates hover around 50% to 60%. In cases of incomplete recovery or when specific functions need to be regained in the arm, patients may require additional surgeries in the future.

If more than one year has passed since the accident, it is advisable to consider muscle or tendon transfers for Complete Brachial Plexus Injuries (C5678T1) . This approach helps optimize functional restoration when the window for nerve repair or transfer has closed.

1. Less Than 1 Year of Injury – Partial Brachial Plexus Injury (C56 or C567)
2. More than 1 Year of Injury – Partial Brachial Plexus Injury (C56 or C567)