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.
The pain is often described by the patients as burning, crushing or shooting, can be very severe and be accompanied by agonising spasms. Deafferentation pain is the name given to the type of pain which is caused by a lack of incoming (afferent) input to the nerves of the spinal cord. Conservative measures are most common in treatment and it is useful to involve a pain management team early on in management. Patients can usefully be admitted with this complex pain problem to sort out their medication and adopt a multidisciplinary approach.
Transcutaneous nerve stimulation (TENS) is a popular and sometimes effective physical treatment for pain conditions, sending electrical messages into the spinal cord and affecting pain transmission. Persistence is needed with TENS as it may take time for the effect and the best result to be apparent. Biofeedback, cognitive behavioural therapy, acupuncture, hypnosis and desensitisation have all been tried for this condition, without very good results. Brachial plexus lesions are a complex set of symptoms with physical and psychological problems, best managed by a multidisciplinary team.
An experienced multidisciplinary team is necessary to manage the non-surgical care of these patients, including an occupational therapist, orthotist, physician and physiotherapist. Orthotists provide long term bracing to prevent contractures and to protect healing structures, occupational therapists work at the functional abilities of the person, physiotherapists maintain joint ranges and monitor muscle work and the physician diagnoses and sets the treatment goals. Designated specialist centres are most appropriate for surgical care as only specialists can decide on the relevance of a hugely variable condition and choose from the very large number of operative options.
The outcome of a brachial plexus lesion is extremely variable as the mechanism of injury is so unpredictable and the results uncertain. The type of injury, the patient's age and the surgical treatment all affect the outcome. Muscle transfers, transferring a working muscle to do the work of paralysed ones, can be useful as can sural nerve (a nerve in the leg we can manage without) grafting, with many surgeons settling on surgery between three and six months after injury. Some surgeons have attempted to replace the nerve roots into the spinal cord but the results are not yet predictable, although success would dramatically change attitudes as healing in the central nervous system has not been usefully demonstrated.
Nerve healing after cutting or severe stretching proceeds at an average one millimetre a day, or an inch over a month. The length of time for a nerve to grow down the arm to the hand from the injury site at the neck can be very great, with a risk of the muscle endplates where the nerves connect degenerating before the nerve reaches them. Research into nerve growth factors continues, hoping to improve the speed of nerve recovery after damage and repairs. - 16650
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.
The pain is often described by the patients as burning, crushing or shooting, can be very severe and be accompanied by agonising spasms. Deafferentation pain is the name given to the type of pain which is caused by a lack of incoming (afferent) input to the nerves of the spinal cord. Conservative measures are most common in treatment and it is useful to involve a pain management team early on in management. Patients can usefully be admitted with this complex pain problem to sort out their medication and adopt a multidisciplinary approach.
Transcutaneous nerve stimulation (TENS) is a popular and sometimes effective physical treatment for pain conditions, sending electrical messages into the spinal cord and affecting pain transmission. Persistence is needed with TENS as it may take time for the effect and the best result to be apparent. Biofeedback, cognitive behavioural therapy, acupuncture, hypnosis and desensitisation have all been tried for this condition, without very good results. Brachial plexus lesions are a complex set of symptoms with physical and psychological problems, best managed by a multidisciplinary team.
An experienced multidisciplinary team is necessary to manage the non-surgical care of these patients, including an occupational therapist, orthotist, physician and physiotherapist. Orthotists provide long term bracing to prevent contractures and to protect healing structures, occupational therapists work at the functional abilities of the person, physiotherapists maintain joint ranges and monitor muscle work and the physician diagnoses and sets the treatment goals. Designated specialist centres are most appropriate for surgical care as only specialists can decide on the relevance of a hugely variable condition and choose from the very large number of operative options.
The outcome of a brachial plexus lesion is extremely variable as the mechanism of injury is so unpredictable and the results uncertain. The type of injury, the patient's age and the surgical treatment all affect the outcome. Muscle transfers, transferring a working muscle to do the work of paralysed ones, can be useful as can sural nerve (a nerve in the leg we can manage without) grafting, with many surgeons settling on surgery between three and six months after injury. Some surgeons have attempted to replace the nerve roots into the spinal cord but the results are not yet predictable, although success would dramatically change attitudes as healing in the central nervous system has not been usefully demonstrated.
Nerve healing after cutting or severe stretching proceeds at an average one millimetre a day, or an inch over a month. The length of time for a nerve to grow down the arm to the hand from the injury site at the neck can be very great, with a risk of the muscle endplates where the nerves connect degenerating before the nerve reaches them. Research into nerve growth factors continues, hoping to improve the speed of nerve recovery after damage and repairs. - 16650
About the Author:
Jonathan Blood Smyth is Superintendent of a large team of Physiotherapists at an NHS hospital in Devon. 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 Oxfordshire or elsewhere in the UK.
