Brachial plexus injury

The brachial plexus is the network of nerves that sends signals from your spine to your shoulder, arm and hand. A brachial plexus injury occurs when these nerves are stretched, compressed, or in the most serious cases, ripped apart or torn away from the spinal cord.

Minor brachial plexus injuries, known as stingers or burners, are common in contact sports, such as football. Babies sometimes sustain brachial plexus injuries during birth. Other conditions, such as inflammation or tumors, may affect the brachial plexus.

The most severe brachial plexus injuries usually result from auto or motorcycle accidents. Severe brachial plexus injuries can leave your arm paralyzed, with a loss of function and sensation. Surgical procedures such as nerve grafts, nerve transfers or muscle transfers can help restore function.

Symptoms and causes

Symptoms

Signs and symptoms of a brachial plexus injury can vary greatly, depending on the severity and location of your injury. Usually only one arm is affected.

Less severe injuries

Minor damage often occurs during contact sports, such as football or wrestling, when the brachial plexus nerves get stretched or compressed. These are called stingers or burners, and can produce the following symptoms:

• A feeling like an electric shock or a burning sensation shooting down your arm
• Numbness and weakness in your arm

These symptoms usually last only a few seconds or minutes, but in some people may linger for days or longer.

More-severe injuries

More-severe symptoms result from injuries that seriously injure or even tear or rupture the nerves. The most serious brachial plexus injury (avulsion) occurs when the nerve root is torn from the spinal cord.

Signs and symptoms of more-severe injuries can include:

• Weakness or inability to use certain muscles in your hand, arm or shoulder
• Complete lack of movement and feeling in your arm, including your shoulder and hand
• Severe pain

When to see a doctor

Brachial plexus injuries can cause permanent weakness or disability. Even if yours seems minor, you may need medical care. See your doctor if you have:

• Recurrent burners and stingers
• Weakness in your hand or arm
• Weakness in any part of the arm following trauma
• Complete paralysis of the upper extremity following trauma
• Neck pain
• Symptoms in both arms
• Symptoms in upper and lower limbs

It’s important to be evaluated and treated within six to seven months after the injury. Delays in treatment may compromise outcomes of nerve surgeries.

Causes

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. Many football players experience burners or stingers, which can occur when the nerves in the brachial plexus get stretched beyond their limit during collisions with other players.
• Difficult births. Newborns 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 a 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.

Risk factors

Participating in contact sports, particularly football and wrestling, or being involved in high-speed accidents increases your risk of brachial plexus injury.

Complications

Given enough time, many brachial plexus injuries in both children and adults heal with no lasting damage. But some injuries can cause temporary or permanent problems:

• Stiff joints. If you experience paralysis of your hand or arm, your joints can stiffen, making movement difficult, even if you regain use of your limb. For that reason, your doctor is likely to recommend ongoing physical therapy during your recovery.
• Pain. This results from nerve damage and may become chronic.
• Loss of feeling. If you lose feeling in your arm or hand, you run the risk of burning or injuring yourself without knowing it.
• Muscle atrophy. Slow-growing nerves can take several years to heal after injury. During that time, lack of use may cause the affected muscles to break down (degenerate).
• Permanent disability. How well you recover from a serious brachial plexus injury depends on a number of factors, including your age and the type, location and severity of the injury. Even with surgery, some people experience permanent disability, ranging from weakness in the hand, shoulder or arm to paralysis.

Diagnosis

To diagnose your condition, your doctor will review your symptoms and conduct a physical examination.

To help diagnose the extent and severity of a brachial plexus injury, you may have one or more of the following tests:

• Electromyography (EMG). During an EMG, your doctor inserts a needle electrode through your skin into various muscles. The test evaluates the electrical activity of your muscles when they contract and when they’re at rest. You may feel a little pain when the electrodes are inserted, but most people can complete the test without much discomfort.
• Nerve conduction studies. These tests are usually performed as part of the EMG, and measure the speed of conduction in your nerve when a small current passes through the nerve. This provides information about how well the nerve is functioning.
• Magnetic resonance imaging (MRI). This test uses powerful magnets and radio waves to produce detailed views of your body in multiple planes. It often can show the extent of the damage caused by a brachial plexus injury and can help assess the status of arteries that are important for the limb or for reconstruction of it. New methods of high-resolution MRI, known as magnetic resonance neurography, may be used.
• Computerized tomography (CT) myelography. Computerized tomography uses a series of X-rays to obtain cross-sectional images of your body. CT myelography adds a contrast material, injected during a spinal tap, to produce a detailed picture of your spinal cord and nerve roots during a CT scan. This test is sometimes performed when MRIs don’t provide adequate information.
• Angiogram. If your doctor suspects that the blood vessels feeding your arm might be injured, he or she might suggest an angiogram — an imaging test where contrast material is injected into an artery or vein to check the condition of your blood vessels. This information is important in planning your surgical procedure.

Treatment

Treatment depends on several factors including the severity of the injury, the type of injury, the length of time since the injury and other existing conditions.

Nerves that have only been stretched may recover without further treatment.

Your doctor may recommend physical therapy to keep your joints and muscles working properly, maintain the range of motion, and prevent stiff joints.

The healing process sometimes forms scar tissue that must be removed surgically to improve the nerve’s function. Surgical repair is often required for nerves that have significant surrounding scar tissue or that have been cut or torn.

Surgery to repair brachial plexus nerves should generally occur within six to seven months after the injury. If nerve surgery occurs more than six to seven months after the injury, the muscles may not recover their function.

Types of surgery

• Nerve graft. In this procedure, the damaged part of the brachial plexus is removed and replaced with sections of nerves harvested from other parts of your body. This helps restore your arm’s function.
• Nerve transfer. When the nerve root has been torn from the spinal cord, surgeons often take a less important nerve that’s still attached to the spinal cord and connect it to the nerve that’s no longer attached to the spinal cord.

  In some cases, surgeons may perform this technique at a level close to the targeted muscle in an effort to speed up recovery rather than doing a repair (nerve graft) farther from the muscle. Sometimes doctors may perform a combination of nerve graft and nerve transfer.

  Nerve tissue grows slowly, about an inch (2.5 centimeters) a month, so it can take several years to know the full benefit of surgery. During the recovery period, you must keep your joints flexible with a program of exercises. Splints may be used to keep your hand from curling inward.

• Muscle transfer. Muscle transfer is a procedure in which your surgeon removes a less important muscle or tendon from another part of your body, typically the thigh, transfers it to your arm, and reconnects the nerves and blood vessels supplying the muscle.

Pain control

Pain from the most severe types of brachial plexus injuries has been described as a debilitating, severe crushing sensation or a constant burning. Narcotic medications are often used initially, but may be changed as your recovery progresses to optimize pain relief.

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