Brachial plexus injury

The brachial plexus is the network of nerves that sends signals from the spinal cord to the 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 automobile or motorcycle accidents. Severe brachial plexus injuries can leave the arm paralyzed, but surgery may help restore function.

Symptoms

Signs and symptoms of a brachial plexus injury can vary greatly, depending on the severity and location of the 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 the arm
• Numbness and weakness in the arm

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

More-severe injuries

More-severe symptoms result from injuries that seriously hurt or even tear or rupture the nerves. The most serious brachial plexus injury 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 the hand, arm or shoulder
• Complete lack of movement and feeling in the arm, including the 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 health care provider if you have:

• Recurrent burners and stingers
• Weakness in the hand or arm
• Neck pain
• Symptoms in both arms

Causes

Damage to the upper nerves that make up the brachial plexus tends to occur when the shoulder is forced down while the neck stretches up and away from the injured shoulder. The lower nerves are more likely to be injured when the arm is forced above the 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. These may be associated with high birth weight, 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.
• Trauma. Several types of trauma — including motor vehicle accidents, motorcycle accidents, falls or bullet wounds — can result in brachial plexus injuries.
• Tumors and cancer treatments. Radiation treatment to the chest or neck may cause tumors to grow in or along the brachial plexus, or put pressure on the brachial plexus or spread to the nerves. Radiation treatment to the chest may cause damage to the brachial plexus.

Risk factors

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

Complications

Given enough time, many brachial plexus injuries in both children and adults heal with little if any lasting damage. But some injuries can cause temporary or permanent problems, such as:

• Stiff joints. If you experience paralysis of the hand or arm, the joints can stiffen. This can make movement difficult, even if you eventually regain use of the limb. For that reason, your provider is likely to recommend ongoing physical therapy during your recovery.
• Pain. This results from nerve damage and may become chronic.
• Numbness. If you lose feeling in the arm or hand, you run the risk of burning or injuring yourself without knowing it.
• Muscle atrophy. Nerves regrow slowly and can take several years to heal after injury. During that time, lack of use may cause the affected muscles to break down.
• 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 muscle weakness or paralysis.

Prevention

Although damage to the brachial plexus often can't be prevented, you can take steps to reduce the risk of complications once an injury has occurred:

• For yourself. If you temporarily lose the use of the hand or arm, daily range-of-motion exercises and physical therapy can help prevent joint stiffness. Avoid burns or cuts, as you may not feel them if you're experiencing numbness.

  If you're an athlete who has experienced injuries to the brachial plexus area, your provider may suggest you wear specific padding to protect the area during sports.

• For your child. If you're the parent of a child with a brachial plexus palsy, it's important that you exercise your child's joints and functioning muscles every day, beginning when your baby is just a few weeks old. This helps prevent the joints from becoming permanently stiff and keeps your child's working muscles strong and healthy.

Diagnosis

To diagnose your condition, your provider 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:

• X-ray. An X-ray of the shoulder and neck can tell the provider if you have fractures or other associated injuries.
• Electromyography (EMG). During an EMG, your provider inserts a needle electrode through the skin into various muscles. The test evaluates the electrical activity of the 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 they measure the speed of conduction in the 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 a powerful magnetic field and radio waves to produce detailed views of the 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 its reconstruction. 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 the body. CT myelography adds a contrast material, injected during a spinal tap, to produce a detailed picture of the spinal cord and nerve roots during a CT scan. This test is sometimes performed when MRIs don't provide adequate information.

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

Surgery to repair brachial plexus nerves should generally occur within six months after the injury. Surgeries that occur later than that have lower success rates.

Nerve tissue grows slowly, 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 the hand from curling inward.

Types of surgery

• Neurolysis. This procedure consists of freeing up the nerve from scar tissue.
• Nerve graft. In this procedure, the damaged part of the brachial plexus is removed and replaced with sections of nerves taken from other parts of the body. This provides a bridge for new nerve growth over time.
• Nerve transfer. When the nerve root has been torn from the spinal cord, surgeons often take a less important nerve that's still working and connect it to a nerve that's more important but not working. This provides a bypass for new nerve growth.
• Muscle transfer. Muscle transfer is a procedure in which your surgeon removes a less important muscle or tendon from another part of the body, typically the thigh, transfers it to the 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. This pain resolves for most people within three years. If medications can't control the pain, your provider might suggest a surgical procedure to interrupt the pain signals coming from the damaged part of the spinal cord.

Preparing for an appointment

Several tests may be used to help diagnose the type and severity of brachial plexus injuries. When you make your appointment, be sure to ask whether you need to prepare for these tests. For instance, you may need to stop taking certain medications for a few days or avoid using lotions the day of the test.

If possible, take along a family member or friend. Sometimes it can be difficult to absorb all the information you're given during an appointment. Someone who accompanies you may remember something that you forgot or missed.

Other suggestions for getting the most from your appointment include:

• Write down all your symptoms, including how you were injured, how long you've had your symptoms and whether they've gotten worse over time.
• Make a list of all medications, vitamins and supplements that you're taking.
• Don't hesitate to ask questions. Children and adults with brachial plexus injuries have several options for restoring lost function. Be sure to ask your provider about all the possibilities available to you or your child. If you run out of time, ask to speak with a nurse or have your provider call you later.

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