1. Traumatic brachial plexus injury, is it serious?
What is traumatic brachial plexus nerve injury?
Dr. Wang Shufeng: Before talking about traumatic brachial plexus injury, we need to understand the anatomical structure of the brachial plexus nerve. The brachial plexus consists of the anterior branches of the cervical 5-8 nerves (i.e., cervical 5, 6, 7, and 8 nerves) and the anterior branch of the thoracic 1 nerve. The brachial plexus nerves emanate from the spinal cord in the cervical spinal canal and pass through the cervical clavicle up to the axilla. After repeated branching and convergence, these nerves eventually emit five large nerves in the axilla: median nerve, ulnar nerve, radial nerve, musculocutaneous nerve, and axillary nerve.
When a traffic accident, such as a common motorcycle accident, or a heavy object or machine strangulation, causes injury to any part of the brachial plexus nerve during its journey from the spinal cord to the axilla, resulting in upper extremity dysfunction, it is called a brachial plexus injury. It is worth noting that sometimes, after an accident, the injured person does not have skin laceration of the affected limb, and no fracture occurs, but the injured person’s affected limb just can’t move, then it is necessary to consider the brachial plexus injury.
How to determine the severity of traumatic brachial plexus injury?
Dr. Wang Shufeng: When the nerve is stretched, if the nerve is not broken and only temporarily loses its function, the degree of injury is relatively mild; when the stretched violence is large enough, although the appearance of the affected limb is not abnormal, several nerves may have been broken, or even worse, all five nerves of the brachial plexus are pulled out from the spinal cord, just like the wind pulling out the tree by its roots. Injury, the injury is often more serious.
2, how to diagnose the brachial plexus injury?
For patients with minor injuries, do they need treatment? How to treat?
Dr. Wang: For patients with mild injuries, oral medication, electrical stimulation and rehabilitation are usually required within 3 months of injury, and temporary loss of function may be slowly restored.
What are the symptoms of nerve avulsion or rupture?
Dr. Shufeng Wang: Brachial plexus avulsion is a more serious nerve injury, especially total brachial plexus root avulsion. In addition, when the doctor examines the patient, he or she can find that one eye is large and one eye is small, and the pupil on the affected side becomes smaller and half of the face does not sweat. This symptom becomes Hornersyndrome, which is a sign of avulsion of the lower brachial plexus (C8,T1) nerve.
When two to three nerves in the upper brachial plexus are injured (C5-C7), dysfunction occurs in the shoulder and elbow joints. If all 5 nerves are injured, whether each nerve is experiencing an avulsion injury, rupture or temporary dysfunction is determined by ancillary testing.
In the past, doctors could only rely on electromyography alone, but with the development of imaging, 95% of patients with nerve injuries can now quickly determine whether the nerve is broken or uprooted or just stretched a little by CT or MRI, which is much more advanced than in the past.
Can a nerve avulsion injury recover on its own? How is it treated?
Dr. Shu-Feng Wang: Since a brachial plexus avulsion injury is a more serious nerve injury, especially a total brachial plexus nerve root avulsion injury, the nerve root is pulled out and it is impossible to recover, so the only treatment is early surgery.
3, nerve displacement, repair of brachial plexus avulsion injury What is nerve displacement? How does it treat the brachial plexus nerve avulsion injury?
Dr. Wang Shufeng: A tree can still sprout if its trunk is broken, but there are still roots under the ground; if it is uprooted, the tree is dead and no longer sprouts. Similarly, if a nerve is broken, the broken nerve can be bridged and connected; but if a nerve is torn and uprooted, the nerve needs to be moved from somewhere else to remedy the situation. This is called nerve displacement.
Does nerve displacement have any effect on the normal nerve?
Dr. Shu-Feng Wang: When a nerve is displaced, the area where the nerve was displaced (the area where the power nerve was removed) will lose function. However, if this loss of function has a relatively small effect on the displaced area, and the nerve is repaired by repairing the brachial plexus nerve, then it is more cost effective and worthwhile to perform the procedure.
It is important to note that not any part of the body can undergo nerve displacement. There are currently four main nerves that can be moved: the paracentral nerve, the intercostal nerve, the phrenic nerve, and the cervical 7 nerve on the healthy side.
4.Whole brachial plexus nerve injury, how is it treated?
What is the treatment for a patient with an avulsion injury of the brachial plexus nerve who wants to make the paralyzed hand hold something?
Dr. Wang Shufeng: When avulsion injury occurs in the upper two to three of the five nerves of the brachial plexus, it can cause the shoulder to be unable to lift and the elbow to be unable to move. After nerve displacement surgery, 80% of these patients can lift their arms and curl up their elbows, and generally have no problem in taking care of themselves.
The difficulty all over the world is that all five nerves of the brachial plexus are avulsed, i.e., total brachial plexus avulsion injury. At this time, the patient’s entire upper limb is completely paralyzed. If you want such a patient to be able to live a self-care life and actively hold things with the paralyzed hand, you need to restore at least five major functions: first, to lift the shoulder up; second, to curl up the elbow; third, to extend the arm; fourth, to grasp things with the hand; fifth, to open the hand.
Among these five functions, the most difficult one is the ability to grasp things with the hand and the ability to open the hand. In particular, hand grasping is a worldwide problem, and the current solution is to repair it by transposition of the cervical 7 nerve on the healthy side. However, the healthy cervical 7 nerve, although powerful, is on the opposite side of the affected brachial plexus nerve and is relatively far from the injury test. Previously, when performing a healthy cervical 7 nerve transposition, it was done by circling around the neck to reach the injury. Now we have improved this by taking a “shortcut” from inside the neck, i.e., directly through the neck to the affected area. After guiding the cervical 7 nerve on the healthy side to the affected side, we connect it directly to the brachial plexus nerve on the affected side, which controls the function of the hand, so that the patient’s hand can achieve practical results.
Currently, this “shortcut” improvement has resulted in a significant increase in finger flexion strength, with up to 64% of patients achieving grade IV strength, improving the patient’s hand grip.
As for the hand opening function, we have now designed a new protocol. Since the nerves that can be transposed are relatively thin, like matchsticks or toothpicks, and the nerves that need to be repaired, such as the radial nerve, are very thick, the final result will be affected by the mismatch between the thickness of the two when transposition is performed. We now do a selective innervation, which means that we find a small bundle of nerves in the large bundle of injury that specifically controls the straightening and opening of the hand, and target the “relief” of this bundle. The posterior limb of the lower trunk of the brachial plexus is one such bundle, as thick as a matchstick, which controls the straightening of the hand, and we have connected the phrenic nerve directly to it, and 40% of the patients have been able to open their hands.
5.What are patients’ concerns about nerve displacement, is it done at one time or does it need to be done in many times?
Dr. Wang Shufeng: The total brachial plexus injury requires three nerve grafts to restore five major functions. In addition to the cervical 7 nerve shift on the healthy side to restore hand grasp and elbow flexion, the paramedian and phrenic nerves also need to be transposed to restore other functions. In the past, treatment of total brachial plexus nerve injury required three to four surgeries, but now three nerve grafts can be done in one surgery, and the number and cost of surgeries are significantly reduced.
How long does the whole surgery take to treat a total brachial plexus injury?
Dr. Wang Shufeng: It takes about 8 hours to perform three nerve grafts in one surgery, sometimes it takes even 10 hours for complicated conditions.
6.When is the best time to operate for brachial plexus nerve injury?
For brachial plexus nerve avulsion injury, when is the best time to treat it?
Dr. Wang Shufeng: In the past, we relied on time to diagnose the severity of brachial plexus nerve injury, and patients with mild injury recovered within 3 months. Therefore, in the past, patients may have had to wait several months before going for treatment. However, there are now many tests available, such as MRI and CTM imaging, which can determine whether a nerve has been ruptured or avulsed and how many have been broken at the first examination. There is no need to wait any longer at this point. The reason is that when a nerve is ruptured or torn, no amount of waiting is going to restore it, and at this point, if the body can tolerate the surgery, the sooner it can be repaired, the better. Only if the nerve is not ruptured is it necessary to wait three months for it to recover on its own.
Can I still have surgery if I miss the best time?
Dr. Shu-Feng Wang: Generally, for patients who have nerve displacement surgery, it is best to have the brachial plexus nerve injury for no more than 1 year, and the earlier the surgery is done, the better the results. When the injury is more than 1 year old, the muscle has already atrophied and the surgery is often ineffective. If the muscle has already atrophied, the light bulb will not light up even if there is electricity. At this point the patient needs to have more complex surgery to rebuild the function of the muscle, such as a muscle graft. But even then, only partial function can be restored, and the number of surgeries will increase.
7.After nerve transposition surgery, how to do rehabilitation?
What kind of rehabilitation is needed after surgery?
Dr. Wang Shufeng: After the nerve displacement surgery, you usually need to wear a brace for 4-6 weeks. Then, under the guidance of the doctor, passive functional training of the upper limbs, such as external rotation and abduction of the shoulder joint, flexion and extension of the elbow joint, and passive movement of the metacarpophalangeal joint of the hand, etc. The main purpose is to keep these joints from becoming damaged. The main purpose is to keep these joints from stiffening, because if the joints are stiff, they cannot show function even if the muscles are restored.
Also, after nerve transfer surgery, if the nerves are to grow fast, they need to be trained in an appropriate way. For example, after nerve transfer with phrenic nerve, you need to practice inhalation frequently; after nerve transfer with healthy cervical 7 nerve, the healthy upper limb needs to do more fist clenching and inversion activities.
8.After nerve transfer, can the arm recover to the same extent as a normal person?
To what extent can the arm recover after surgery? Can it move like a normal arm?
Dr. Wang Shufeng: The degree of arm recovery after surgery depends on the specific situation. When two of the brachial plexus nerves are injured, such as the cervical 5 and 6 nerves or the cervical 5, 6 and 7 nerves, only the shoulder and elbow joints are dysfunctional.
As for the total brachial plexus nerve injury, after we started a new surgical method in 2006, the whole recovery period for these patients is 3 years after the surgery, in which the movement of shoulder lifting and elbow flexion starts to recover about 8 to 10 months after the surgery, and the hand movement starts only 1 year after the surgery. After all five major functions have been restored, i.e., 3 years after surgery, the patient will need a second surgery for functional reconstruction. After that, patients are basically able to live on their own and do some simple activities, but moving as a normal arm is impossible. It is worth noting that our study of 500 patients with total brachial plexus injury found that about 35% of the patients were eventually able to resume doing simple activities, and as for heavy work, it was difficult for these patients to engage in it again.
9.What should I do if I have pain after nerve displacement surgery?
Some patients reported pain in the arm or fingers after surgery, is it because the surgery was not done properly?
Dr. Wang Shufeng: After total brachial plexus nerve avulsion surgery, with the passage of time, some patients begin to experience mild or severe pain, and for some more severe pain, sometimes it makes patients feel worse than death. Most importantly, this pain stays with the patient for the rest of his or her life.
This pain is difficult to control, and the best way to do so at this time is to distract the patient from the pain. This pain, although intense, is not always present, but occurs intermittently, rather briefly, for about a few dozen seconds at a time. When the pain occurs, immediate distraction can control the pain better. As for medication, since the pain will be accompanied by a lifetime, that means if medication is administered, it will also need to be taken for life.
When the pain is so severe that the patient cannot tolerate it, surgical treatment, such as destruction of the posterior spinal root entry zone (DREZ), is available. This surgery is effective, but there are some risks, and some patients may walk shakily as if they were drunk after the surgery. Therefore, patients are advised to try to treat by distraction or oral painkillers, and this surgery is not recommended as a last resort.
10.What is the approximate cost of nerve displacement surgery for the consultation guide to see Prof. Wang Shufeng?
Dr. Wang Shufeng: The cost of nerve transfer surgery for patients with total brachial plexus injury is about 50,000 RMB. For a brachial plexus injury where only the shoulder and elbow are dysfunctional, the cost of surgery is about 30,000 RMB.
What kind of information do I need to bring with me when I inquire about the possibility of surgery for brachial plexus injury?
Dr. Wang Shufeng: We can bring the films and reports of electromyography and MRI, as well as the information of the original surgery, so that we can make a comprehensive analysis.
How long does it take to schedule a bed for surgery?
Dr. Wang Shufeng: Since the treatment of total brachial plexus injury is complicated, only one patient can be operated on a day, so the patient may have to wait 2 to 3 weeks before surgery. However, if the brachial plexus injury is only dysfunctional in the shoulder and elbow, you can wait about 1 week for surgery.
Dr. Wang Shufeng’s clinic hours: Wednesday, all day.