Brachial plexus injuries are caused by excessive stretching, tearing, or trauma to a network of nerves from the spinal cord to the shoulder, arm, and hand. Symptoms may include a limp or paralyzed arm, loss of muscle control in the shoulder, arm, hand, or wrist, and lack of feeling or sensation in the arm or hand.
Injuries often occur secondary to motor vehicle accidents, sports injuries or surgeries. Traumatic BPI causes either complete or incomplete damage to the brachial plexus resulting in loss of function and sensation related to level of damage. The recovery from the injury will depend on the severity, level and type of nerve damage. Pain is a very important side effect of the injury and can sometime be very severe and debilitating.
Many brachial plexus injuries happen during birth, if the baby’s shoulders become impacted during the birth process, causing the brachial plexus nerves to stretch or tear. Some brachial plexus injuries may heal with little or no treatment. Many children improve or recover by 3-4 months of age. To expand range of motion and speed rehabilitation, physical and occupational therapies are usually employed.
Treatment is aimed at improving function by repair of nerve, tendon or muscle transfer and pain can be treated successfully by medication or microsurgery on the spinal cord.
Mission and Launch
Mission
Our mission is simply to provide help and support to persons with a BPI, we do not seek to promote any specific form of therapy or treatment protocol, and are not affiliated to any medical or non-medical institution, individual or business. The most useful resources on this site are the injured people themselves and you are encouraged to make contact with others here for one to one support and advice.
You must seek the help of a specialist for detailed information on the type, severity and outcome of the injury. This site only guides you with information that is needed for a common person to know about BPI. There are varying degrees of injury and each individual case varies greatly from any other.
Launch
Kauvery Hospital will support this group for a period of 1 year through technical help, arranging meetings, formation of a support group committee, policy making and advocacy until the group is independently functional. After 1 year the website will be handed over to the support group core committee and Kauvery hospital will only be an advisor at their request.
Kauvery hospital considers this as a CSR activity with no business intention.
About Brachial Plexus Injury
What is the brachial plexus?
The brachial plexus is a network of nerves in the neck and shoulder region (see the diagram below). It is made up from 5 large nerves which come out of the spinal cord between the vertebrae (bones in the neck), pass under the clavicle (collar bone) and into the upper arm. These nerves enable the signals that allow movement and feeling to reach the arm. These nerves are represented in speech and writing by these symbols: C5, C6, C7, C8, T1 (C=cervical, T=thoracic)
What are nerves and the nervous system?
Nerves are cord like structures of tissue formed from a collection of nerve fibers. A single nerve may contain thousands of fibers (a bit like an electrical cable). In the arm, these fibers carry electrical messages both ways between the brain, muscles and tissues. For a muscle to work (contract), a message must travel from the brain, along a nerve that goes directly to the muscle. When nerve fibers are injured, the muscles that the nerve controls may be weakened, even though the injury is not in the muscle itself.
The nervous system integrates all body activities by sensing changes (sensory function), interpreting those (integrative function) and reacting to them (motor function). Sensory neurons carry sensory information into the brain and spinal cord. Motor neurons carry information from the brain and spinal cord into the peripheral nerves. A neuron (or nerve cell) processes and transmits information by electrical or chemical signaling.
What are the Causes of BPI?
Damage to the upper nerves that make up the brachial plexus tends to occur when your shoulder is forced down while your neck stretches up and away from the injured shoulder. The lower nerves are more likely to be injured when your arm is forced above your head. These injuries can occur in several ways, including:
Contact sports:
During football, players can experience stretching to the brachial plexus beyond their limit during collisions with other players.
Difficult births:
New born babies can sustain brachial plexus injuries when there are problems during birth, such as a breech presentation or prolonged labor. If an infant’s shoulders get wedged within the birth canal, there is an increased risk of brachial plexus palsy. Most often, the upper nerves are injured, a condition called Erb’s palsy. Total brachial plexus birth palsy occurs when both the upper and lower nerves are damaged.
Trauma:
Several types of trauma including motor vehicle accidents, motorcycle accidents, falls or bullet wounds can result in brachial plexus injuries.
Inflammation:
Inflammation may cause damage to the brachial plexus. A rare condition known as Parsonage-Turner syndrome (brachial plexitis) causes brachial plexus inflammation with no trauma and results in paralysis of some muscles of the arm.
Tumors:
Noncancerous (benign) or cancerous tumors can grow in the brachial plexus or put pressure on the brachial plexus or spread to the nerves, causing damage to the brachial plexus.
Radiation treatment:
Radiation treatment may cause damage to the brachial plexus.
What happens when there is an injury of the brachial plexus?
Many factors affect how severe the injury to the brachial plexus may be. These depend on:
The number of nerves affected
This varies between patients. Sometimes only one or two nerves are damaged resulting in loss of movement in one area, e.g. shoulder or elbow. In some cases, all the nerves are damaged causing complete loss of movement and feeling in the arm.
How badly the nerves have been damaged
There may be mild stretching or compression of nerves. However, in more severe injuries, nerves may be torn apart by severe stretching. Deep wounds may cut through the nerves.
How do I know how severe the brachial plexus injury is?
We may be able to determine the degree of damage to the nerves by examining you. However, it is quite common for other tests to be done to help tell us where the nerve injury is and how bad it is. These tests may include:
MRI scan
This will provide information about the number of nerves damaged, spinal cord injury and formation of a swelling in the covering of the spinal cord.
Neurophysiology
Recording of the passage of electrical signals along nerves in the limbs using small electrical pulses on your skin. The test may include a recording of the electrical activity of muscles which involve using fine needles. These tests can be used to diagnose a variety of nerve or muscle problems.
Living with Brachial Plexus Injury
A brachial plexus injury can be life changing and you may experience some differences in the following areas of your life:
- General health – Insomnia (sleeplessness), fatigue, loss of appetite, weight loss or gain (this may be related to your medications). These symptoms usually resolve over time.
- Daily living – Difficulty in carrying out everyday activities including your current work, future employment concerns, participation in sports and hobbies, doing housework and child care, shopping etc.
- Psychosocial – Poor concentration, memory and self esteem, lack of self confidence, loss of self control, problems with your libido (sex drive) anxiety, frustration, anger, guilt, focusing on the pain to the exclusion of everything else. You may also experience emotions, thoughts and feelings that are similar to the grieving process.
These may include:
- Anxiety – You may feel anxious when faced with situations that challenge your physical abilities and this may then hinder you from participating in everyday activities especially out of the house amongst company.
- Anger – You may feel angry with yourself and / or you may feel angry with others. This may relate to how your injury was sustained. You may take this anger out on those especially close to you and experience mood swings and temper outbursts.
- Denial – You may feel unable to accept the facts and information of what has really happened. This is a defense mechanism and perfectly natural. Some people can become locked in this stage when dealing with a traumatic change to their life that cannot be ignored.
- Depression – This is a sort of acceptance with emotional attachment. It is natural to feel sadness and regret, fear, uncertainty etc. It shows that you have at least begun to accept the reality of how your injury is impacting on your life.
- Acceptance – This occurs when you realize the full enormity of the circumstances and with it begins the physical and emotional healing processes. Once you enter this stage you will notice a change in your attitude and the real work towards full recovery begins.
It is important for you to seek help with any of these issues that are concerning you or your family. We aim to provide you as much information as we can regarding the treatment.
Disability
Brachial plexus injury is caused by extreme traction exerted on the upper limb causing avulsion of the brachial plexus roots between C5 to T1 either completely or partially in the side of the injury. After injury the affected limb will loose muscle function either completely or partially depending on the severity of the injury. Brachial plexus injury can be classified into three categories: preganglionic lesions, postganglionic lesions, and a combination of the two. A preganglionic lesion involves avulsion of nerve roots from the spinal cord, whereas a postganglionic lesion involves disruption or damage distal to the sensory ganglion. Posts ganglionic injuries are amenable to repair for motor function and pre ganglionic lesions are not amenable to repair hence the functions of some denervated muscles are restored with nerve transfers procedures.
What surgery is available for brachial plexus injuries to improve function?
Surgery may be possible to repair damaged nerves. In order to have a chance of success this surgery must be performed within a few months of the injury.
Nerve Graft
Usually when the nerves are torn, the damaged segment of nerve, either side of the injury, must be removed and repaired using grafts from somewhere else (like the forearm or the lower leg area). The nerve graft acts as a guide through which new nerve fibers can grow and cross the gap caused by the injury. These nerves grow very slowly, recovery time is lengthy and complete recovery may be impossible due to the way that each individual microscopic nerve fibre grows in position.
Nerve Transfer
Undamaged nerves in the area that are doing less valuable jobs can be transferred to other parts of the brachial plexus to try and regain some function within the limb. As the nerves used in this transfer start to recover you will need to work very hard at retraining these nerves to move your arm and initially you may have to do different movements to make your arm work.
Tendon transfers
Each muscle has a starting point (origin) and tapers into a tendon that attaches onto bone (insertion). During surgery the origin is left in place and the tendon attachment/insertion is detached and reattached into a different place.
What other treatment may I have?
Physiotherapy
You can start exercises aimed at preventing joint stiffness. These exercises do not make the nerves heal any faster but keep joints supple and help you look after the arm. You may also get some help and advice with pain management.
You will be given a ‘sling’ to help support your arm and you will be advised on how and when to wear this. The length of time that your arm needs to be immobilized will depend on the severity of your injury and the healing of any other associated injuries e.g. dislocated shoulder or fractures of the arm.
Alternative treatments:
Treatments are aimed at improving the muscle mass and release spasm and stiffness. This can be achieved by medication, TENS machine, nerve stimulations and other alternative treatments like ayurvedic massages etc. These however do not improve function but help nerve recovery and prevent muscle wasting. In most cases time needs to be given to allow natural nerve repair.
Do I need counseling?
Many people are put off counseling because they feel it’s a sign of weakness or that they’ve failed to cope with things on their own. This is far from the truth, as admitting to yourself that you need help is a strength, not a weakness. Your own feelings are what matter right now. You recognize that at this point in your life, you need someone to talk to, to help sort out your thoughts and feelings.
Counseling may help you get back on track if you are experiencing any of these issues:
- Feel very anxious, depressed, sad, tired or angry
- Find it difficult to cope with everyday issues such as work or socializing
- Have problems with sleeping and concentrating
- Have financial, sexual or relationship problems
Pain
Pain is a sensory and emotional experience which can cause serious psychological changes in the person. Pain develops early in 90% of brachial plexus injury cases, and it may be also delayed for 3-4 months. Generally the pain improves by 2-3 years and is usually manageable by the patients. But in 30-40% of patients the pain becomes very severe and unbearable. Pain after injury can be divided into paroxysmal (shock like) pain and continuous (burning) pain. The continuous pain is a chronic burning or stabbing pain that does not ordinarily follow a clear distribution and usually located in the forearm and the hand. The other paroxysmal pain is a sharp electric shock like pain which is crushing, very severe, lasts few minutes and can occur every few minutes and sometimes ‘like putting your hand in a deep frying pan’. Some of the characters of the pain described by the patients are as follows, “ my arm is on fire with continuous electric shocks 24 hours, even a small noise like tapping aggravates pain, I wanted to end my life and attempted suicide several times, I used to have 24hrs pain very slightly reduced with tablets, pain will start from hand all the way up to neck, pain was like pin pricks or someone was stabbing my arm and every time it was different, 22yrs I had pain and even the slightest noise like a baby crying will set it off, I chewed my hand daily for pain relief as it was like on “burning oil”.
What are the different types of pain?
1. Nociceptive pain
This follows an injury to skin, muscles, bones or tendons. It usually settles with healing but can persist and can recur over time.
2. Neuropathic / nerve pain
This is due to damage to the nerves. You may feel some pain that can be different from anything you have felt before. It may vary from mild pins and needles to more severe nerve burning pain or electric shock like shooting pain. Neuropathic pain can be difficult to treat and may respond better to special medicines, which have different actions from normal painkillers. BPI is the worst for of neuropathic pain, which can be very challenging to treat.
How can we assess the pain?
The specialist can assess the pain by asking the following questions, as the treatment will vary according to the type of pain.
1. Location of pain
Is it in a single place or multiple locations on the body? The location and pattern of distribution of the pain can lend clues as to the cause.
2. Nature of pain
Is the pain intermittent, does it come and go depending on something you do like a movement or activity or is it constant and unrelieved?
3. Duration of pain
Is it related to an injury in the acute phase and associated with a normal painful response? Is it chronic – lasting for some months due to an ongoing condition?
4. Intensity of the pain
Often measured on a scale of 1-10 (with 10 being the worst pain).
5. Quality of pain
Is it sharp, does it burn, is it throbbing, does it feel like an electric shock etc?
6. Other factors
Do you have any other symptoms e.g. depression, sleep disturbances, changes in appetite, etc?
What are the treatment methods for pain relief?
The treatment methods for pain relief are surgical methods or non-surgical methods. We will discuss about both methods in detail below.
What non-surgical options are available to treat pain?
Some of the medications used to treat pain are:
Non steroidal anti inflammatory (NSAID’s)
These drugs include Diclofenac, Ibuprofen and others. They work by reducing hormones that cause inflammation and pain in the body and are used to reduce pain, inflammation and stiffness caused by many conditions. Paracetamol can be used with these combinations.
Tramadol
This is effective in the management of moderately severe acute or chronic nociceptive pain. It is often useful when administered with other drugs.
Anti epileptics e.g. gabapentin, pregablain, carbamazepine, lamotrigine, Gabapentin (Neurontin)
This is used to help relieve certain types of nerve pain, but has another use as it can also be prescribed for patients who need help to control seizures (convulsions) or epilepsy. This is usually started at a low dose and gradually increased until a benefit is seen. This drug should not be stopped abruptly. Lyrica (Pregabalin) or Gabapentin are the commonly used drugs.
Anti depressants e.g. amitryptyline, duloxetine
Amitriptyline is in a class of drugs called tricyclic antidepressants. It may be used to treat nerve pain but has another use in patients with symptoms of depression such as feelings of sadness, worthlessness, or guilt; loss of interest in daily activities; changes in appetite; tiredness; sleeping too much or insomnia. It is often given at night and can improve sleeping patterns but may take up to 2 weeks to notice any pain relief.
Topical medicines
E.g. gels, creams, patches
TENS (Transcutaneous Electrical Nerve Stimulation)
This is a small portable electrical device which is designed to help relieve pain. It works by sending a harmless electrical current through pads that are placed on your skin. This is felt as pins and needles and these feelings can help to block pain messages.
When will you say that medical management has failed?
Medical management can fail after sometime when either a single drug or combinations of drugs have been taken up to the maximum acceptable dose for a duration of few months to years or when side effects do not allow you to take the medication that is required. When such a situation arises it is wise to consider surgical options.
When should surgery be considered?
Surgery should be considered only when medical and other treatment methods have failed over a period of 6 months to 2 years and the patient can no longer accept the pain.
What are the surgical options available for pain?
The surgical options available are:
- Nerve block surgeries
- Intrathecal pumps delivering painkillers direct to the area affected
- Ablative (destructive) surgeries, which involve the burning of nerve endings.
What is the DREZ region?
In BPI the nerve can be pulled our or disconnected from the spinal cord. The region where it gets disconnected undergoes scare tissue and become a focus of pain generation. This region is called the “Dorsal Root Entry Zone” (DREZ), which is the first important level of modulation for pain and hence this area can be a target to treat resistant neuropathic pain in avulsion injuries.
How is the outcome of surgery assessed?
The success of surgery can be classified as
“Excellent” – when complete improvement was achieved,
“Good” when relief was 50% or more,
“Mild” when improvement was less than 50%
“Poor” when there was no pain relief or in cases of pain exacerbation.
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Frequently Asked Questions
Following trauma if you have loss of function in one limb or loss of sensation in any part of your limb, we have to have a suspicion of BPI.
If it is mild nerve damage (Neuropraxia), the weakness will improve in a few weeks without any treatment.
If there is more severe nerve damage, then it may be permanent.
Generally no investigation is required in the initial phase unless the trauma is severe and needs immediate attention. The 2 investigations that will help diagnose BPI accurately are-
a) MRI scan of cervical spine and Brachial Plexus
b) Nerve conduction study of the Brachial Plexus
Surgery may be possible to repair damaged nerves. In order to have a chance of success this surgery must be performed within a few months of the injury.
Nerve Graft
Usually when the nerves are torn, the damaged segment of nerve, either side of the injury, must be removed and repaired using grafts from somewhere else (like the forearm or the lower leg area). The nerve graft acts as a guide through which new nerve fibers can grow and cross the gap caused by the injury. These nerves grow very slowly, recovery time is lengthy and complete recovery may be impossible due to the way that each individual microscopic nerve fibre grows in position.
Nerve Transfer
Undamaged nerves in the area that are doing less valuable jobs can be transferred to other parts of the brachial plexus to try and regain some function within the limb. As the nerves used in this transfer start to recover you will need to work very hard at retraining these nerves to move your arm and initially you may have to do different movements to make your arm work.
Tendon transfers
Each muscle has a starting point (origin) and tapers into a tendon that attaches onto bone (insertion). During surgery the origin is left in place and the tendon attachment/insertion is detached and reattached into a different place.
Depending on the severity of lesion, recovery can be expected. If there is permanent weakness, some surgeries as explained in the website can be done to improve disability. Pain can be another limiting factor which can be treated with medicines or surgery. You may require psychological counseling to improve your mental health.
Pain is a sensory and emotional experience which can cause serious psychological changes in the person. Pain develops early in 90% of brachial plexus injury cases, and it may be also delayed for 3-4 months.Generally the pain improves by 2-3 years and is usually manageable by the patients. But in 30-40% of patients the pain becomes very severe and unbearable.
Some of the medications used to treat pain are:
Non steroidalanti inflammatory (NSAID’s)
These drugs include Diclofenac, Ibuprofen and others. They work by reducing hormones that cause inflammation and pain in the body and are used to reduce pain, inflammation and stiffness caused by many conditions. Paracetamol can be used with these combinations.
Tramadol
This is effective in the management of moderately severe acute or chronic nociceptive pain. It is often useful when administered with other drugs.
Anti epileptics e.g. gabapentin, pregablain, carbamazepine, lamotrigine, Gabapentin (Neurontin)
This is used to help relieve certain types of nerve pain, but has another use as it can also be prescribed for patients who need help to control seizures (convulsions) or epilepsy. This is usually started at a low dose and gradually increased until a benefit is seen. This drug should not be stopped abruptly. Lyrica (Pregabalin) or Gabapentin are the commonly used drugs.
Anti depressants e.g. amitryptyline, duloxetine
Amitriptyline is in a class of drugs called tricyclic antidepressants. It may be used to treat nerve pain but has another use in patients with symptoms of depression such as feelings of sadness, worthlessness, or guilt; loss of interest in daily activities; changes in appetite; tiredness; sleeping too much or insomnia. It is often given at night and can improve sleeping patterns but may take up to 2 weeks to notice any pain relief.
Topical medicines
E.g. gels, creams, patches
TENS (Transcutaneous Electrical Nerve Stimulation)
This is a small portable electrical device which is designed to help relieve pain. It works by sending a harmless electrical current through pads that are placed on your skin. This is felt as pins and needles and these feelings can help to block pain messages.
The surgical options available are:
- Nerve block surgeries
- Intrathecal pumps delivering painkillers direct to the area affected
- Ablative (destructive) surgeries, which involve the burning of nerve endings.
Physiotherapy:
You can start exercises aimed at preventing joint stiffness. These exercises do not make the nerves heal any faster but keep joints supple and help you look after the arm. You may also get some help and advice with pain management.
You will be given a ‘sling’ to help support your arm and you will be advised on how and when to wear this. The length of time that your arm needs to be immobilized will depend on the severity of your injury and the healing of any other associated injuries e.g. dislocated shoulder or fractures of the arm.
Alternative treatments:
Treatments are aimed at improving the muscle mass and release spasm and stiffness. This can be achieved by medication, TENS machine, nerve stimulations and other alternative treatments like ayurvedic massages etc. These however do not improve function but help nerve recovery and prevent muscle wasting. In most cases time needs to be given to allow natural nerve repair.
The surgical options available are:
- Nerve block surgeries
- Intrathecal pumps delivering painkillers direct to the area affected
- Ablative (destructive) surgeries, which involve the burning of nerve endings.
DREZ lesion is a neuroabalative procedure which gives 70-90% pain relief following surgery.
Following surgery, the pain relief is usually immediate and can be realized the very next day. Sometimes, it takes about 3-4 weeks before pain relief is achieved.
The chances of being paralyzed after surgery is extremely rare and <1%. There may be very mild temporary weakness due to post operative spinal cord swelling. But this will improve in 2-4 weeks. If you have had any nerve graft procedure, this will not be affected by the surgery.
Neurophysiological monitoring is the method of maping the spinal cord during DREZ operation. This will allow the surgeon to accurately perform the procedure avoiding spinal cord damage and paralysis. There is still a 1 % chance that damage can happen.
The success rate with DREZ operation is about 70-90 % in long term studies. Generally most patients have complete relief of the electric shock like (paroxysmal) pain than the continues burning pain.
Yes, you can lead a complete normal life after the DREZ operation as you do not have to worry about the severe pain. Those who have a good success rate feel that they have a new life with a clear mind. This improves the quality of life both professionally and socially.
