Management of Adult Brachial Plexus Injuries

Brachial plexus injuries comprise approximately one third of all peripheral nerve injuries, and are seen in just more than 1% of patients presenting to a trauma facility. Younger patients (median age: 34 years) and men are affected more frequently. The most common type of brachial plexus injury is stretch injury (50%). The brachial plexus is broadly subdivided into supraclavicular and infraclavicular portions. The supraclavicular plexus consists of the C5-T1 spinal nerves and the upper, middle, and lower trunks and their branches and divisions, while the infraclavicular plexus refers to the cords and the nerves. Majority (72%) of brachial plexus stretch injuries are supraclavicular, and the most common injury pattern is C5-T1 (57%), or pan-plexus injury. Stretch injury of the brachial plexus is diagnosed clinically and confirmed by electrodiagnostic studies. Imaging studies such as MRI and ultrasound can be used to detect nerve avulsion or disruption. The initial management of stretch injuries is usually conservative. The patient is followed for 3-4 months with periodic clinical and electrodiagnostic examinations. If no improvement is detected, surgery is best performed at 4-5 months post-injury. Surgery usually involves brachial plexus exploration, aided by intraoperative electrophysiology assessment. Depending on the findings, different nerve repair techniques can be used, such as neurolysis, end-to-end repair, graft repair, and neurotization or nerve transfers, with the latter strategy becoming more popular. The outcome after nerve repair surgery varies, depending on the extent and severity of the injury, supra- or infraclavicular plexus involvement, timing of repair, and other factors.