Urazy splotu ramiennego – Patofizjologia i mechanizm

Urazy splotu ramiennego
Patofizjologia i mechanizm

Urazy splotu ramiennego (BPI) obejmują uszkodzenia nerwów od rdzenia kręgowego do kończyny górnej, powstałe głównie na skutek mechanizmów trakcyjnych i bezpośrednich urazów. Lokalizacja uszkodzenia zależy od pozycji kończyny w momencie urazu: przy przywiedzeniu dominują uszkodzenia górnych korzeni (C5-C6), a przy odwiedzeniu nad głową – dolnych (C8-T1). Uszkodzenia dzieli się na przeddzwonowe (avulsja korzeni) i pozadzwonowe, z różnym rokowaniem – avulsje mają najgorsze prognozy i wymagają wczesnej interwencji chirurgicznej. Klasyfikacja stopnia uszkodzenia obejmuje neuropraksję (łagodna, z 90-100% regeneracją w 3-4 miesiące), aksonotmezę (uszkodzenie aksonu i mieliny, regeneracja 4-6 miesięcy) oraz neurotmezę (całkowite przerwanie nerwu z tworzeniem nerwiaka i zwyrodnieniem walleriańskim). Diagnostyka opiera się na mielografii TK, MRI, EMG, NCV oraz potencjałach wywołanych sensorycznych i motorycznych, co pozwala na precyzyjne rozróżnienie uszkodzeń i planowanie leczenia.

Mechanizm powstawania urazów splotu ramiennego

Urazy splotu ramiennego (BPI – Brachial Plexus Injury) to poważne uszkodzenia sieci nerwów przebiegających od rdzenia kręgowego do barku, ramienia i ręki. Powstają wskutek różnych mechanizmów urazowych, które mogą prowadzić do rozciągnięcia, zmiażdżenia lub całkowitego przerwania włókien nerwowych, skutkując zaburzeniami funkcji motorycznych i sensorycznych kończyny górnej.¹²

Podstawowe mechanizmy urazu

Występują dwa główne mechanizmy uszkodzenia splotu ramiennego:¹

Trakcja (pociągnięcie) – najczęstszy mechanizm, prowadzący do rozciągnięcia nerwów splotu ramiennego, co może spowodować różnego stopnia uszkodzenia
Bezpośredni uraz (zmiażdżenie) – powstaje na skutek silnego uderzenia w okolicę nadobojczykową, często związanego ze złamaniem obojczyka

Trakcyjne urazy splotu ramiennego występują najczęściej, gdy głowa i szyja zostają gwałtownie odciągnięte od barku po tej samej stronie. W przypadku urazu górnej części splotu (C5 i C6), zazwyczaj dominuje uszkodzenie, gdy ramię znajduje się przy boku ciała, ponieważ pierwsze żebro działa jak punkt podparcia, kierując siły trakcji preferencyjnie wzdłuż górnej części splotu.¹²

Wzorce uszkodzeń w zależności od pozycji kończyny

Pozycja kończyny górnej w momencie urazu ma kluczowe znaczenie dla lokalizacji i rozległości uszkodzenia:¹

Kończyna przy boku ciała – przy przywiedzionej kończynie największe napięcie i stres mechaniczny oddziałuje na górne korzenie splotu (C5-C6)
Kończyna w odwiedzeniu nad głową – gdy kończyna górna jest uniesiona, a siła trakcyjna działa na ramię lub tułów, znaczne napięcie dotyka dolnych korzeni (C8-T1)

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Kiedy ramię jest gwałtownie i nadmiernie odwiedzione nad głową, typowo uszkadzane są dolne elementy splotu (C8-T1), ponieważ siła jest kierowana wzdłuż C7. Uszkodzenie dolnej części splotu przeważa, gdy ramię jest uniesione, ponieważ wyrostek kruczy działa podobnie jako punkt podparcia. Uszkodzenia dolnego splotu mogą być częstsze również dlatego, że dobrze wykształcone więzadła korzeniowe poprzeczne, które pomagają przeciwdziałać siłom trakcyjnym na poziomie C5, C6 i C7, nie występują w przypadku C8 i T1.¹²

Klasyfikacja uszkodzeń w zależności od lokalizacji

Urazy splotu ramiennego można podzielić ze względu na lokalizację uszkodzenia na:¹²

Uszkodzenia przeddzwonowe (supraganglionic/preganglionic) – dotyczą korzeni nerwowych przed zwojami grzbietowymi, zazwyczaj w postaci wyrwania korzeni z rdzenia kręgowego
Uszkodzenia pozadzwonowe (postganglionic) – występują dystalnie od zwojów rdzeniowych
Uszkodzenia nadobojczykowe – najczęstsza lokalizacja, dotycząca korzeni lub pni nerwowych
Uszkodzenia zaobojczykowe – najrzadziej spotykana lokalizacja, obejmująca podziały splotu
Uszkodzenia podobojczykowe – dotyczące pęczków lub gałęzi końcowych

¹²

Ważne rozróżnienie dotyczy uszkodzeń przeddzwonowych i pozadzwonowych. Uszkodzenia przeddzwonowe odnoszą się do zmian proksymalnych do zwoju grzbietowego, który znajduje się w kanale kręgowym. Mogą być centralne lub bezpośrednie od rdzenia kręgowego lub wewnątrztwardówkowe. Uszkodzenia przeddzwonowe nie powodują zwyrodnienia walleriańskiego ani tworzenia się nerwiaków, ponieważ aksony pozostają w ciągłości z ciałami komórkowymi w zwoju grzbietowym. Uszkodzenia pozadzwonowe definiowane są jako wszelkie zmiany dystalne w stosunku do zwoju rdzeniowego i są fizjologicznie podobne do innych urazów nerwów obwodowych.¹

Patofizjologia urazów splotu ramiennego

Typy uszkodzeń nerwowych

W zależności od stopnia uszkodzenia włókien nerwowych, urazy splotu ramiennego można sklasyfikować jako:¹²

Neuropraksja – najłagodniejsza forma urazu polegająca na rozciągnięciu splotu bez przerwania ciągłości. Uszkodzenie oszczędza akson. Jest to najczęstszy typ urazu splotu ramiennego, z 90-100% odzyskiem funkcji w ciągu 3-4 miesięcy po leczeniu, bez wystąpienia zwyrodnienia walleriańskiego.
Aksonotmeza – uszkodzenie zarówno aksonu, jak i osłonki mielinowej, prowadzące do zwyrodnienia nerwu dystalnie od miejsca urazu. Osłonka epineurium i perineurium często pozostaje nieuszkodzona, a regeneracja, która zwykle nie jest pełna, trwa dłużej (4-6 miesięcy).
Neurotmeza – najcięższy typ urazu związany ze zniszczeniem nerwu i otaczających tkanek, w tym epineurium, perineurium i endoneurium. Uszkodzenie to wiąże się głównie z tworzeniem nerwiaka na skutek trakcji lub laceracji, co prowadzi do zwyrodnienia walleriańskiego.

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Najpoważniejszym rodzajem urazu jest avulsja (wyrwanie), gdzie korzenie nerwowe są wyrwane z rdzenia kręgowego, oraz ruptura (pęknięcie), gdzie nerw jest rozerwany na dwie części.¹ W przypadku avulsji korzeni, które są uszkodzeniami przeddzwonowymi, szansa na spontaniczne zdrowienie jest niska i dlatego wymaga wczesnej interwencji chirurgicznej.¹

Zmiany patofizjologiczne po urazie

Po urazie splotu ramiennego aksony i osłonka mielinowa na końcu dystalnym od miejsca urazu ulegają degeneracji, a następnie rozpadają się na szczątki nerwowe. Komórki Schwanna wytwarzają reakcję autofagii, co ostatecznie prowadzi do zwyrodnienia walleriańskiego na końcu uszkodzonego nerwu.¹

Z czasem następuje proliferacja komórkowa, która zamyka rozdarcie, a w przypadku avulsji tworzy się przepuklina oponowa (oponiowy zbiornik płynu mózgowo-rdzeniowego) – torebkowate rozszerzenie.¹ Obecność przepukliny oponowej 3-4 tygodnie po urazie silnie sugeruje avulsję korzenia.²

Urazy splotu ramiennego mogą również uszkodzić zwój współczulny, prowadząc do zespołu Hornera, który objawia się patognomoniczną triadą: miozą (zwężenie źrenicy), ptozą (opadanie powieki) i anhydrozą (zmniejszone pocenie się).¹²

Mechanizmy centralne i obwodowe w bólu neuropatycznym

Ból po avulsji splotu ramiennego wiąże się zarówno z komponentami obwodowymi, jak i centralnymi; charakteryzuje się jako mieszany (centralny i obwodowy) zespół bólu neuropatycznego.¹

Pomimo obwodowych składników bólu neuropatycznego występującego po avulsji splotu ramiennego, istnieje wiele dowodów potwierdzających rolę mechanizmów związanych z uszkodzeniem centralnym w powstawaniu bólu u tych pacjentów.¹

Centralna sensytyzacja (CS), która jest klasycznym mechanizmem prowadzącym do wzmocnienia i chronifikacji bólu, zwiększa wrażliwość uszkodzonego układu somatosensorycznego i prowadzi do zwiększonego odczuwania bodźców bólowych (hiperalgezja), obniżenia progów (allodynia) i zwiększenia centralnego przetwarzania bodźców obwodowych, prowadzącego do wtórnej hiperalgezji, która typowo wykracza poza obszar odnerwiony.¹

Zmiany te mogą być związane z bezpośrednim uszkodzeniem tkanki rdzenia kręgowego, które występuje po nagłym odłączeniu korzeni rdzeniowych podczas avulsji splotu ramiennego. Utrata neuronów następuje na różnych poziomach, zarówno po tej samej stronie, jak i po stronie przeciwnej do uszkodzenia.¹

Czynniki ryzyka i okoliczności urazów splotu ramiennego

Urazy komunikacyjne i sportowe

Najczęstszymi przyczynami urazów splotu ramiennego u dorosłych są wypadki komunikacyjne, zwłaszcza motocyklowe, oraz upadki z wysokości.¹² Splot ramienny jest zazwyczaj uszkadzany przez mechanizm trakcji lub rozciągania, jak w przypadku, gdy bark i kask motocyklisty są rozdzielane w różnych kierunkach podczas upadku.¹

Wypadki sportowe również stanowią istotną przyczynę urazów splotu ramiennego.¹ W sportach kontaktowych występują trzy główne mechanizmy uszkodzenia splotu ramiennego:

Trakcja (pociągnięcie)
Bezpośredni ucisk splotu w okolicy nadobojczykowej
Ucisk korzeni szyjnych wskutek nadmiernego wyprostu lub zgięcia szyi

Urazy typu „stinger” lub „burner” (przejściowa neuropraksja) są częste wśród sportowców uprawiających sporty kontaktowe, z częstością występowania około 49-65% wśród zawodowych graczy futbolu amerykańskiego, przy czym najczęstszym mechanizmem jest uraz trakcyjny.¹

Urazy porodowe splotu ramiennego

Urazy splotu ramiennego mogą również wystąpić podczas porodu, gdy barki dziecka zostają zaklinowane za kośćmi łonowymi matki. Gdy macica się kurczy, powoduje to nacisk na szyję dziecka, co prowadzi do rozciągnięcia i uszkodzenia splotu ramiennego.¹

Czynniki ryzyka urazów porodowych splotu ramiennego obejmują:¹²

Duży rozmiar płodu
Poród pośladkowy
Przedłużający się lub trudny poród
Poród wspomagany próżniowo lub kleszczami
Ciąża bliźniacza lub wielopłodowa
Historia wcześniejszego porodu skutkującego urazem splotu ramiennego

Tradycyjnie uważano, że przyczyną urazu splotu ramiennego noworodków jest nadmierna trakcja boczna na głowie płodu, typowo występująca przy dystocji barkowej. Jednak urazy te mogą wystąpić nawet przy prawidłowo zastosowanej trakcji osiowej; wystąpienie urazu splotu ramiennego po porodzie nie oznacza automatycznie, że osoba przyjmująca poród zastosowała siłę lub manewry, które spowodowały uszkodzenie nerwu.¹

Inne mechanizmy uszkodzeń

Oprócz urazów trakcyjnych, splot ramienny może ulec uszkodzeniu wskutek:¹²³

Guzów – mogą rosnąć w obrębie splotu ramiennego lub wzdłuż niego, uciskając splot
Procesów zapalnych – jak w zespole Parsonage-Turnera (zapalenie splotu ramiennego), który powoduje zapalenie nerwów splotu ramiennego bez oczywistego urazu barku
Kompresji – w zespole wyjścia z klatki piersiowej (ucisk nerwu między obojczykiem a pierwszym żebrem)
Ran postrzałowych i ran kłutych – zwykle nie powodują ciężkiego uszkodzenia nerwu, a stopień ciężkości zależy od kalibru, prędkości i kąta wejścia pocisku
Zwłóknienia – może wystąpić ucisk splotu ramiennego z powodu zwłóknienia wokół splotu nerwowego po radioterapii

Urazy splotu ramiennego spowodowane ranami postrzałowymi zazwyczaj nie uszkadzają nerwu w znacznym stopniu.¹ Stopień uszkodzenia zależy od kalibru, prędkości i kąta wejścia pocisku.²

Konsekwencje i prognozy urazów splotu ramiennego

Wzorce kliniczne uszkodzeń

Urazy splotu ramiennego mogą powodować różne wzorce deficytów neurologicznych, w zależności od lokalizacji uszkodzenia:¹²

Uszkodzenie górnego splotu (porażenie Erba) – dotyczy korzeni C5-C6 i ewentualnie C7, powoduje utratę funkcji mięśni barku i łokcia
Uszkodzenie dolnego splotu (porażenie Klumpkego) – dotyczy korzeni C8-T1, wpływa na mięśnie przedramienia i dłoni
Całkowite porażenie splotu – obejmuje wszystkie korzenie od C5 do T1, prowadzi do wiotkiej ręki, dotyczy zarówno funkcji motorycznych, jak i sensorycznych

Uszkodzenia górnego splotu są często związane z nadmiernym oddzieleniem głowy od barku, co jest powszechnie spotykane w urazach okołoporodowych, upadkach na bark oraz podczas znieczulenia. Powodują one głównie porażenie mięśni dwugłowego, naramiennego, ramiennego i ramienno-promieniowego, a częściowo także nadgrzebieniowego, podgrzebieniowego i odwracacza.¹

Uszkodzenia dolnego splotu często wynikają z nadmiernego odwiedzenia ramienia, jak w przypadku chwytania czegoś ręką po upadku z wysokości lub czasami w urazach okołoporodowych. Porażają one mięśnie wewnętrzne dłoni (T1) oraz zginacze łokciowe nadgarstka i palców (C8), co prowadzi do deformacji typu „szponiasta dłoń” z powodu niezrównoważonego działania długich zginaczy i prostowników palców.¹

Rokowanie i proces zdrowienia

Rokowanie w urazach splotu ramiennego zależy od kilku czynników:¹²

Uszkodzenia przeddzwonowe (preganglionic) mają gorsze rokowanie
Uszkodzenia pozadzwonowe (postganglionic) mają lepsze rokowanie ze względu na większą zdolność do spontanicznej regeneracji
Avulsja korzeni (uszkodzenia przeddzwonowe) ma najgorsze rokowanie i nie jest naprawialna
Regeneracja zrekonstruowanego splotu może trwać do 3 lat, ponieważ regeneracja nerwów postępuje z prędkością około 1 mm/dzień

Większość łagodnych urazów splotu ramiennego zagoi się sama. Szansa na samoistne wyleczenie łagodnego urazu splotu ramiennego, który prawdopodobnie zagoi się samodzielnie bez interwencji medycznej lub z minimalną interwencją, zależy od rodzaju urazu i liczby uszkodzonych lub uciśniętych nerwów.¹

W przypadku neuropraksji rokowanie jest doskonałe. Samoistne gojenie się avulsji z powodu uszkodzeń korzeni rzadko występuje spontanicznie. W przypadku nerwiaków i rozdarć wymagana jest interwencja. W przypadku zapalenia nerwów (neuritis) konieczne może być podanie antybiotyków lub innych leków w celu leczenia przyczyny zapalenia.¹

Ważne jest, aby pamiętać, że w zależności od ciężkości urazu, nawet operacja może nie być w stanie przywrócić normalnej funkcji ramienia lub ręki.¹ Powrót do zdrowia po urazie splotu ramiennego wymaga czasu, a pacjenci mogą nie odczuwać wyników przez kilka miesięcy.²

Ból neuropatyczny po urazie

Ból, który często występuje po avulsji splotu ramiennego, stanowi dodatkowe obciążenie dla jakości życia pacjentów już upośledzonych przez deficyty motoryczne, sensoryczne i autonomiczne.¹

Dostępne dowody wskazują, że oprócz pierwotnego uszkodzenia korzeni nerwowych, zmiany centralne związane z nagłym odłączeniem korzeni nerwowych od rdzenia kręgowego mogą odgrywać ważną rolę w powstawaniu bólu neuropatycznego u tych pacjentów i mogą częściowo wyjaśniać jego oporność na leczenie.¹

Ból po urazach splotu ramiennego wynika z uszkodzenia rdzenia kręgowego, gdzie korzenie nerwowe zostają wyrwane z rdzenia. Ten ból ma charakter neuropatyczny i może utrzymywać się przez bardzo długi czas. Urazy splotu ramiennego, które występują na poziomie rdzenia kręgowego, często powodują większy ból niż urazy bardziej oddalone od rdzenia kręgowego.¹

Zrozumienie zarówno centralnych, jak i obwodowych mechanizmów przyczyniających się do rozwoju bólu ma ogromne znaczenie dla zaproponowania skuteczniejszych metod leczenia bólu związanego z avulsją splotu ramiennego.¹

Rozpoznanie i leczenie urazów splotu ramiennego

Diagnostyka obrazowa i elektrofizjologiczna

Dokładna diagnoza jest kluczowa dla planowania leczenia. Wykorzystuje się następujące metody diagnostyczne:¹²

Mielografia TK – złoty standard diagnozowania poziomu uszkodzenia korzenia nerwowego; avulsja korzenia szyjnego powoduje zagojenie się osłonki twardej z przepukliną oponową
MRI – może uwidocznić większość splotu ramiennego; zmiany wskazujące na uraz obejmują nerwiaki pourazowe i obrzęk
Elektromiografia (EMG) – pomaga odróżnić uszkodzenia przeddzwonowe od pozadzwonowych
Badanie szybkości przewodzenia nerwowego (NCV) – odróżnia uszkodzenia przeddzwonowe od pozadzwonowych
Potencjały wywołane sensoryczne i motoryczne – bardziej czułe niż EMG i NCV w identyfikacji ciągłości korzeni z rdzeniem kręgowym

Kompatybilność badań obrazowych i testów neurofizjologicznych w ocenie proksymalnej części splotu ramiennego jest niezbędna, szczególnie w przypadku operacji rekonstrukcyjnej.¹

Leczenie operacyjne i nieoperacyjne

Czas operacji w leczeniu urazów splotu ramiennego pozostaje tematem kontrowersyjnym.¹ Pilna eksploracja chirurgiczna splotu jest wskazana, jeśli podejrzewa się avulsję korzenia lub uraz szarpany splotu, lub w przypadkach urazów otwartych, zatrzymanego ciała obcego lub urazu naczyniowego wymagającego naprawy naczynia.¹

Ostre przecięcia splotu ramiennego umożliwiają pierwotną naprawę przeciętych końców w celu optymalizacji regeneracji nerwów. Rokowanie w przypadku urazów splotu ramiennego o niskiej energii jest bardziej korzystne w porównaniu z avulsjami korzeni lub urazami przeddzwonowymi i można je leczyć zachowawczo, aby umożliwić spontaniczną regenerację.¹

Leczenie może być zachowawcze lub operacyjne, w zależności od wieku pacjenta, czasu trwania urazu, stopnia uszkodzenia i zaangażowania korzenia nerwowego:¹

Wczesna interwencja chirurgiczna jest wskazana przy prawie całkowitym uszkodzeniu splotu i przy wysokoenergetycznym mechanizmie urazu
Opóźniona interwencja chirurgiczna jest wskazana przy częściowym uszkodzeniu górnego splotu i niskoenergetycznym mechanizmie

Techniki chirurgiczne obejmują naprawę nerwu, przeszczepy nerwów i neurotyzację (transfery nerwów).¹³

Fizjoterapia i rehabilitacja powinny rozpocząć się prawie natychmiast i muszą być wykonywane kilka razy dziennie. Intensywna fizjoterapia jest jednym z głównych sposobów leczenia.¹

Operację należy rozważyć, jeśli pacjent nadal ma objawy nawet po 3 miesiącach od urazu i nie nastąpiło gojenie. Naprawy nerwów muszą być wykonane w ciągu pierwszych trzech miesięcy od urazu.¹

Metody chirurgiczne

W leczeniu operacyjnym urazów splotu ramiennego stosuje się następujące techniki:¹³²

Neuroliza – procedura chirurgiczna, w której nerw jest wypreparowany i uwolniony od zrostów i narośli, które go ograniczają lub uciskają
Przeszczep nerwu – nerw pobrany z innej lokalizacji przeszczepiany jest w miejsce urazu, aby połączyć przerwany nerw
Transfer nerwów – nerwy z innych części ciała są przenoszone bliżej włókien mięśniowych
Transfer ścięgien i mięśni – funkcjonujące ścięgno jest dołączane do sparaliżowanego ścięgna dotkniętego urazem splotu ramiennego

Mikrochirurgiczne interwencje w leczeniu operacyjnym urazów splotu ramiennego obejmują neurolizę, resekcję nerwiaków z ciągłością z przeszczepami nerwów oraz transfery nerwów.¹

Skuteczność przeszczepów nerwów po urazowym uszkodzeniu splotu ramiennego zmniejsza się wraz z upływem czasu po 8 tygodniach.¹

Najważniejszym czynnikiem determinującym wyniki chirurgiczne jest optymalny czas między urazem a operacją.¹ Mechanizm urazu determinuje odpowiedni czas interwencji chirurgicznej.²

Optymalny czas interwencji chirurgicznej dla urazów splotu ramiennego to 3-6 miesięcy po ostrych urazach, co pozwala na optymalną regenerację i daje czas regenerującym się nerwom na połączenie z sparaliżowanymi mięśniami, zanim rozwinie się gęste bliznowacenie.¹

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#1 Brachial plexus injury – Symptoms and causes – Mayo Clinic
https://www.mayoclinic.org/diseases-conditions/brachial-plexus-injury/symptoms-causes/syc-20350235
The brachial plexus is the group of nerves that sends signals from the spinal cord to the shoulder, arm and hand. A brachial plexus injury happens when these nerves are stretched, squeezed together, or in the most serious cases, ripped apart or torn away from the spinal cord. […] The most serious types of nerve injuries are an avulsion, where the nerve roots are torn away from the spinal cord, and rupture, where the nerve is torn into two pieces. […] Brachial plexus injuries in the upper nerves happen when the shoulder is forced down on one side of the body and the head is pushed to the other side in the opposite direction. The lower nerves are more likely to be injured when the arm is forced above the head. […] Many injuries including those from motor vehicle accidents, motorcycle accidents, falls or bullet wounds can damage the brachial plexus.
#1 Brachial plexus injury – Wikipedia
https://en.wikipedia.org/wiki/Brachial_plexus_injury
The severity of nerve injuries may vary from a mild stretch to the nerve root tearing away from the spinal cord (avulsion). […] The brachial plexus may also be compressed by surrounding damaged structures such as bone fragments or callus from the clavicular fracture, and hematoma or pseudoaneurysm from vascular injury. […] Injury to the brachial plexus can happen in numerous environments. These may include contact sports, motor vehicle accidents, and birth. […] The two mechanisms that can occur are traction and heavy impact. […] Traction, also known as stretch injury, is one of the mechanisms that cause brachial plexus injury. […] Depending on the force, lesions may occur. […] Heavy impact to the shoulder is the second common mechanism to causing injury to the brachial plexus. […] The location of impact also affects the severity of the injury and depending on the location the nerves of the brachial plexus may be ruptured or avulsed.
#1 Mechanisms of brachial plexus lesions – PubMed
https://pubmed.ncbi.nlm.nih.gov/8467591/
The main causes of brachial plexus palsies are traction, due to extreme movements, and heavy impact. In downward traction of the arm and forcible widening of the shoulder-neck angle the lesion will occur in the upper roots and trunk. Forcible upward traction will cause avulsion of T1 and C8. The most violent trauma will result in a lesion at all levels. Rupture of the cords and/or individual infraclavicular nerves will be produced by traction and/or forcible widening of the scapulohumeral angle. Vascular structures are subjected to the same mechanism and injuries of these structures give information about the site and severity of nerve lesions; fractures of the skull, cervical spine, clavicle, first rib or arm yield further data on the mechanism of trauma that has produced the brachial plexus palsy. Heavy impact or crush lesions are caused by direct trauma to the (supra)clavicular region and are nearly always associated with fracture of the clavicle.
#1 Traumatic Brachial Plexus Injuries: Practice Essentials, Anatomy, Pathophysiology
https://emedicine.medscape.com/article/1268993-overview
In traction-type brachial plexus injuries, the head and neck are moved away violently from the ipsilateral shoulder. Upper-plexus injuries (C5 and C6) usually predominate if the arm is at the side because the first rib acts as a fulcrum to direct the traction forces preferentially in line with the upper plexus. […] When the arm is moved violently and abducted overhead, the lower elements (C8-T1) typically are injured because the force is directed in line with C7. A lower-plexus lesion predominates when the arm is raised because the coracoid acts as a fulcrum in a similar fashion. Lower-plexus lesions may be more common, in part because of the well-formed transverse radicular ligaments that help resist traction forces at C5, C6, and C7; C8 and T1 lack these ligaments. […] Traction forces can result in preganglionic or postganglionic injuries. Preganglionic injuries refer to lesions proximal to the dorsal root ganglion, which is in the spinal canal, and the foramen. They may be central or direct from the spinal cord or intradural. Preganglionic lesions do not cause wallerian degeneration or neuroma formation, because the axons remain in continuity with the cell bodies in the dorsal root ganglion. Postganglionic lesions are defined as any lesions distal to the spinal ganglion and are physiologically similar to other peripheral nerve injuries.
#1 Brachial Plexus Injury in Adults
http://thenerve.net/journal/view.php?doi=10.21129/nerve.2017.3.1.1
Brachial plexus injury (BPI) is a severe peripheral nerve injury affecting upper extremities, causing functional damage and physical disability. The most common cause of adult BPI is a traffic accident, and the incidence has steadily increased since the 1980s. BPIs can be divided into three types; preganglionic lesion, postganglionic lesion, and a combination of both. […] The mechanism and classification of injury, clinical manifestations, updated diagnostic studies, and recent treatment strategies would be discussed. […] Root injury is defined as root avulsion from the spinal cord and rupture in the preganglionic root zone or dorsal ganglion at the vertebral foramen. […] The great range of motion of the cervical spine is a distinctive characteristic of the cervical vertebrae. Cervical spinal nerves have a few unique protective mechanisms. […] Closed trauma is the most common cause of adult traumatic BPI. Most common mechanism of closed trauma causing BPI is compression or traction. […] The most commonly injured sites are the roots and trunks in comparison to the rest parts of the brachial plexus. Root avulsions exist in 75% of cases of these supraclavicular injuries. […] The patients position and the location of the upper limb when the injury occurs is the most important point to understand the mechanism of BPI. […] If the upper limb is adducted, the greatest tension and mechanical stress will affect the upper roots. […] When the upper limb is elevated and the traction force affects the arm or the trunk, substantial tension force will affects the lower roots. […] Over time, cellular proliferation occurs and closes the tear, and the meningocele, a pouch like extension, appears.
#1 Brachial Plexopathy: Differential Diagnosis and Treatment | PM&R KnowledgeNow
https://now.aapmr.org/brachial-plexopathy-differential-diagnosis-and-treatment-2/
Brachial plexopathy is an injury of the brachial plexus, that is commonly caused by trauma. […] For purpose of treatment and prognosis, the injury on the plexus is divided into Supraclavicular: most common site, involves the root or trunk level, Retroclavicular: least common site, involves the divisions, Infraclavicular: involves the cords or terminal branches. […] Based on whether the injury is proximal or distal to the dorsal root ganglion (DRG), they are further characterized as preganglionic and postganglionic, respectively. […] Clinically, preganglionic injuries (e.g., root avulsions) can be associated with Horner syndrome (disruption of the autonomic trunk), medial scapular winging (injury to long thoracic and dorsal scapular nerve), and denervation of the cervical paraspinal muscles.
#1 Brachial Plexus Palsy: Pathophysiology, Diagnosis, and Management | Consultant360
https://www.consultant360.com/articles/brachial-plexus-palsy-pathophysiology-diagnosis-and-management
Brachial plexus injuries occur when the infants shoulder becomes lodged behind the mothers pubic bones during delivery. When the uterus contracts it causes pressure on the babys neck, which leads to stretching and injury of the brachial plexus. It is considered a medical emergency and can be fatal. […] Erbs palsy is a brachial plexus birth injury of the superior trunk (C5 through C6), whereas Klumpkes palsy is a birth injury of the posterior or medial cords (C8 through T1). Injuries to the plexus can be divided into 3 types: […] Neuropraxia occurs due to stretching without tearing of the brachial plexus. This injury spares the axon. It is the most common type of brachial plexus injury, with a recovery of 90% to 100% of function within 3 to 4 months after treatment, and occurs without any wallerian degeneration occurring.
#1 Brachial Plexus Injuries – StatPearls – NCBI Bookshelf
https://www.ncbi.nlm.nih.gov/books/NBK482305/
The spinal nerves form when the ventral and dorsal rootlets from the spinal cord converge. The ventral rami of the C5 through T1 spinal nerves form the roots of the brachial plexus. A dorsal root ganglion is a group of neuronal cell bodies that lies proximal to the convergence of the spinal nerves. Injuries that occur proximal to the dorsal root ganglion are appropriately termed preganglionic, while injuries distal to the dorsal root ganglion are termed postganglionic. Distinguishing between preganglionic and postganglionic BPI has substantial implications for treatment and prognosis. The chance of spontaneous recovery after preganglionic injury is low and therefore requires early surgical intervention. Avulsions of the C8 and T1 nerve roots may concomitantly injure the sympathetic ganglion, resulting in Horner syndrome, which presents with the pathognomonic triad of miosis, ptosis, and anhydrosis.[3]
#1 The Role of Functional Electrical Stimulation in Brachial Plexus Injury Repair | IntechOpen
https://www.intechopen.com/chapters/78304
After BPI, the axons and myelin sheath at the distal end of the injury degenerate and then disintegrate into nerve debris, Schwann cells (SCs) produce autophagy reaction, and eventually Wallerian degeneration occurs at the end of the nerve involved. […] The electric field generated by ES can stimulate SCs to crawl, migrate, proliferate and divide, making them further secrete NTFs such as BDNF, NGF and NT 4 / 5. […] The mechanism by which FES exerts the above effects is not clear, but a large number of studies have shown that it is closely related to factors such as promoting the secretion of SCs and NTFs, promoting axon regeneration, increasing blood supply, protecting muscle fibers, and reducing muscle fatigue.
#1 Neuropathic pain after brachial plexus avulsion – central and peripheral mechanisms | BMC Neurology | Full Text
https://bmcneurol.biomedcentral.com/articles/10.1186/s12883-015-0329-x
The pain that commonly occurs after brachial plexus avulsion poses an additional burden on the quality of life of patients already impaired by motor, sensory and autonomic deficits. […] Available evidence indicates that besides primary nerve root injury, central lesions related to the abrupt disconnection of nerve roots from the spinal cord may play an important role in the genesis of neuropathic pain in these patients and may explain in part its refractoriness to treatment. […] The understanding of both central and peripheral mechanisms that contribute to the development of pain is of major importance in order to propose more effective treatments for brachial plexus avulsion-related pain. […] Pain after brachial plexus avulsion involves both peripheral and central components; thereby it is characterized as a mixed (central and peripheral) neuropathic pain syndrome.
#1 Neuropathic pain after brachial plexus avulsion – central and peripheral mechanisms | BMC Neurology | Full Text
https://bmcneurol.biomedcentral.com/articles/10.1186/s12883-015-0329-x
Despite the peripheral contributions to the NeP present after BPA, there is a large body of evidence that also supports the role of central injury-related mechanisms in the genesis of pain in these patients. […] Central sensitization (CS), which is a classical mechanism leading to the amplification and chronification of pain, increases the gain of the injured somatosensory system and leads to increased perception to painful stimulus (hyperalgesia), decrease in thresholds (allodynia) and increase in the central processing of peripheral inputs leading to secondary hyperalgesia, which typically extends beyond the denervated area. […] However, different lines of evidence suggest that BPA leads to central changes that are not frequently seen in other peripheral nerve lesions and are narrowly related to lesions of the central nervous system associated with avulsion.
#1 Neuropathic pain after brachial plexus avulsion – central and peripheral mechanisms | BMC Neurology | Full Text
https://bmcneurol.biomedcentral.com/articles/10.1186/s12883-015-0329-x
These changes may be related to a direct lesion of segmental spinal cord tissue that occurs after the abrupt disconnection of spinal roots during BPA. […] Neuronal loss occurs at various levels, both on the same side and contralateral to the lesion. […] The above data suggest that avulsion leads to molecular, anatomical, biochemical, sensory, and neurophysiological changes that are different from simple rhizotomy, and include central lesions to the spinal cord, at least up to the medial aspect of the LT. […] As we have been discussing, secondary central plastic changes occur after sensory deafferentation to the CNS and phenomena such as central sensitization is widely known to take place and could account for receptive field changes and sensory threshold modifications. […] However, nerve root avulsions still present particularities that include the anatomical disconnection to the sensory ganglia and lesion of spinal cord structures that probably account for its unique clinical presentation.
#1 Brachial Plexus Injuries New York, NY | Nerve Reconstructive Surgery Stamford, CT
http://www.scottwolfemd.com/adult-pediatric-brachial-plexus-injuries-scott-wolfe-md.html
A brachial plexus injury can have a devastating effect on upper limb function. Traumatic brachial plexus injuries, which are most commonly sustained in high speed motor vehicle accidents or sporting events, are characteristically complete, and affect the sensibility and muscle power of the entire extremity. […] The brachial plexus is generally injured by a traction, or stretch mechanism, such as when the shoulder and helmet of a motorcycle driver are forced in divergent directions in a fall. […] The plexus is located immediately above and below the clavicle, or collarbone, and the peripheral nerves begin approximately at the level of the shoulder joint. […] Approximately 15% of brachial plexus injuries have an injury to the blood supply of the arm as well, and emergency surgery may be indicated.
#1 Brachial plexus injury – Wikipedia
https://en.wikipedia.org/wiki/Brachial_plexus_injury
Brachial plexus injuries can occur as a result of shoulder trauma (e.g. dislocation), tumours, or inflammation, or obstetric. […] „The brachial plexus may be injured by falls from a height on to the side of the head and shoulder, whereby the nerves of the plexus are violently stretched. The brachial plexus may also be injured by direct violence or gunshot wounds, by violent traction on the arm, or by efforts at reducing a dislocation of the shoulder joint”. […] Although several mechanisms account for brachial plexus injuries, the most common is nerve compression or stretch. […] Injuries to the brachial plexus result from excessive stretching or tearing of the C5-T1 nerve fibers. […] Traumatic brachial plexus injuries may arise from several causes, including sports, high-velocity motor vehicle accidents, especially in motorcyclists, but also all-terrain-vehicle (ATV) and other accidents.
#1 Brachial plexus injuries in the contact athlete: a narrative review – Windmueller – Annals of Joint
https://aoj.amegroups.org/article/view/9186/html
Brachial plexus injuries (BPIs) are a rare but potentially devastating injury among contact athletes. […] The aim of this review is to discuss this spectrum of injuries in their epidemiology, mechanism in contact sports, diagnosis, and treatment. […] BPIs among contact athletes occur on a spectrum from neuropraxia to neurotmesis. Neuropraxia is very common among contact athletes with approximately a 4965% incidence among career football players with the most common mechanism being a traction injury. […] Injuries may occur anywhere along the brachial plexus, from the cervical nerve root to the terminal branches. In contact sports, there are three suggested primary mechanisms of injury to the brachial plexus. These include traction, direct compression of the plexus at the supraclavicular region, and cervical nerve root compression due to hyperextension or hyperflexion of the neck.
#1 Brachial Plexus Birth Injury | Boston Children’s Hospital
https://www.childrenshospital.org/conditions/brachial-plexus-birth-injury
Brachial plexus birth injury, also known as brachial plexus injury, is an injury to the brachial plexus nerves that occurs in about one to three out of every 1,000 births. […] The nerves of the brachial plexus may be stretched, compressed, or torn in a difficult delivery. The result might be a loss of muscle function, or even paralysis of the upper arm. […] Injuries may affect all or only a part of the brachial plexus: […] Injuries to the upper brachial plexus (C5, C6) affect muscles of the shoulder and elbow. […] Injuries to the lower brachial plexus (C7, C8, and T1) can affect muscles of the forearm and hand. […] The causes of brachial plexus injury may include: […] Large gestational size […] Breech birth […] Prolonged or difficult labor […] Vacuum- or forceps-assisted delivery
#1 Neonatal brachial plexus palsy – UpToDate
https://www.uptodate.com/contents/neonatal-brachial-plexus-palsy/print
However, NBPP can occur even when axial traction is properly applied; the occurrence of NBPP following birth does not automatically indicate that the practitioner applied forces or maneuvers that caused the nerve injury. […] The forces of uterine contraction and maternal pushing alone are probably sufficient to cause excessive traction on the brachial plexus. […] In addition, antepartum factors may predispose to NBPP, including uterine abnormalities such as MÃ¼llerian anomalies and fibroids that can result in fetal malpositioning and compression.
#1 Brachial Plexus Injury BPI Neurosurgery at Emory Brain Health Center
https://www.emoryhealthcare.org/conditions/neurosurgery-conditions/brachial-plexus
Brachial plexus injury (BPI) is a term for a variety of conditions that may impair function of the brachial plexus. […] The degree of functional impairment and potential for recovery depend on the mechanism, type, and complexity of the brachial plexus injury. […] Majority of brachial plexus injuries are caused by trauma, especially auto or motorcycle accidents, sports injuries as well as inflammatory processes (brachial plexitis) and hereditary factors. […] Tumors, compression and irradiation can also affect the brachial plexus.
#1 Brachial Plexus Injuries – OrthoInfo – AAOS
https://orthoinfo.aaos.org/en/diseases–conditions/brachial-plexus-injuries/
Brachial plexus injuries vary greatly in severity, depending upon the type of injury and the amount of force placed on the plexus. The same patient can injure several different nerves of the brachial plexus in varying severity. […] Most traumatic brachial plexus injuries occur when the arm is forcefully pulled or stretched. Many events can cause the injury, including falls, motor vehicle collisions, knife and gunshot wounds, and most commonly, motorcycle collisions. […] Brachial plexus injuries caused by a gunshot wound do not typically damage the nerve severely. […] The severity of injury will depend on the bullet’s caliber, velocity, and angle of entry. […] Lower brachial plexus injuries occur when the arm and shoulder are forced upward, increasing the angle between the arm and the chest.
#1
https://www.orthobullets.com/trauma/1008/brachial-plexus-injuries
Preganglionic injuries involve CNS which does not regenerate little potential recovery of motor function (poor prognosis). […] Postganglionic injuries involve PNS, capable of regeneration (better prognosis). […] Classification based on location: Upper Lesion: Erb’s Palsy (C5,6) results from an excessive displacement of head to opposite side and depression of shoulder on the same side producing traction on plexus. […] Lower Lesion: Klumpke Palsy (C8,T1) usually avulsion injuries caused by excessive abduction. […] Total Palsy (C5-T1) leads to a flaccid arm, involves both motor and sensory. […] Imaging: CT myelography is the gold standard for defining level of nerve root injury; avulsion of cervical root causes dural sheath to heal with meningocele. […] MRI can visualize much of the brachial plexus; findings consistent with injury include traumatic neuromas and edema.
#1 Brachial plexus injuries | PPT
https://www.slideshare.net/slideshow/brachial-plexus-injuries-93887511/93887511
Brachial plexus injuries ANATOMY it is a network of nerves passing through the cervico-axillary canal to reach axilla and innervates brachium (upper arm), antebrachium (forearm) and hand. Brachial plexus is a somatic nerve plexus formed by the union of anterior rami of C5,C6,C7,C8 and T1. The formation of brachial plexus begins just distal to the scalenus muscles. Mechanisms of Injury to the Brachial Plexus A. Traction: direct blow to the shoulder with the neck laterally flexed toward the unaffected shoulder (gymnast falls on beam) B. Direct trauma: direct blow to the supraclavicular fossa over Erbs point C. Compression: Occurs when the neck is flexed laterally toward the patients affected shoulder, compressing / irritating the nerves, resulting in point tenderness over involved vertebrae of affected nerve(s) (Troub, 2001) Mechanisms of Injury to the Brachial Plexus CLASSIFICATION OF BRACHIAL PLEXUS INJURIES: Classification of injuries The various classifications of brachial plexus injury are as follows: 1. Leffert classification of brachial plexus injury 2. Millesi classification of brachial plexus injury 3 . Classification on anatomical location of injury 1. Leffert classification of brachial plexus injury: It is based on mechanism and level of injury and is as follows I Open (usually from stabbing) II Closed (usually from motorcycle accident) IIa Supraclavicular preganglionic: avulsion of nerve roots, usually from high speed injuries no proximal stump, no neuroma formation (neg Tinel’s) pseudomeningocele, denervation of neck muscles are common horner’s sign (ptosis, miosis, anhydrosis) postgangionic: roots remain intact; usually from traction injuries; there are proximal stump and neuroma formation (pos Tinel’s) deep dorsal neck muscles are intact, and pseudomeningoceles will not develop; IIb Infraclavicular Lesion: usually involves branches from the trunks (supraclavicular); function is affected based on trunk involved; III Radiation induced IV Obstetric IVa Erb’s (upper root) IVb Klumpke (lower root) 2. Millesi classification of brachial plexus injury: It is mainly divided into 4 I: supraganglionic/preganglionic. II: infraganglionic/postganglionic III: trunk. IV: cord. 3. Classification on anatomical location of injury: Upper plexus palsy (Erbs palsy in the OBPI cases) involves C5-C6+/- C7roots. Lower plexus palsy (Klumpkes palsy) involves C8-T1 roots (and sometimes also C7) Total plexus lesions involve all nerve roots C5-T1 Mechanisms of Injury to the Brachial Plexus ERB’S PARALYSIS: Site of injury: The region of the upper trunk of the brachial plexus is called Erb’s point. Injury to the upper trunk causes Erb’s Paralysis. Causes of injury: Undue separation of the head from the shoulder, which is commonly encountered in 1)birth injury 2) fall on shoulder, and 3)during anaesthesia Nerve roots involved: Mainly C5 and partly C6. Muscles paralysed: Mainly biceps, deltoid, brachilais and brachioradialis.Partly supraspinatus, infraspinatus and supinator KLUMPKES PALSY Site of injury: Lower trunk of the brachial plexus. Cause of injury: Undue abduction of the arm, as in clutching something with the hand after a fall from a height, or sometimes in birth injury. Nerve roots involved: Mainly T1 and partly C8. Muscles paralysed: Intrinsic muscles of the hand (T1) Ulnar flexors of the wrist and fingers (C8). Deformity: (position of the hand): claw hand due to the unopposed action of the long flexors and extensors of the fingers. in a claw hand there is hyperextension at the metacarpophalangeal joints and flexion at the interphalangeal joints. The pain from brachial plexus injuries results from injury to the spinal cord where the nerve rootlets are avulsed from the cord. This pain is neuropathic in nature. The pain can last for a very long time. Brachial plexus injuries that occur at the level of the spinal cord often produce greater pain than injuries more distant from the spinal cord. In addition, injuries nearer the spinal cord may cause a burning numbness, which is called paresthesias or dysesthesias.
#1 Brachial Plexus Injuries – OrthoInfo – AAOS
https://orthoinfo.aaos.org/en/diseases–conditions/brachial-plexus-injuries/
Pan-plexus palsy may occur if the force of the injury is extreme. In pan-plexus palsy, all levels of the nerves and trunk are damaged. This results in complete paralysis of the arm and hand, which is often referred to as „flail limb.” […] Surgical treatment is typically recommended when the nerves fail to recover on their own or fail to recover enough to restore necessary function to the arm and hand. […] It is important to note that depending on the severity of the injury, even surgery may not be able to return the arm or hand to normal. […] Recovery from a brachial plexus injury takes time, and patients may not experience results for several months.
#1 Brachial Plexus Injury – Everything You Need To Know
https://centenoschultz.com/condition/brachial-plexus-injury/
In neuritis, there is local inflammation of the nerve due to injury or infection that could be viral or bacterial. […] The chances of having a mild brachial plexus injury that’s likely to heal on its own with minimal to no medical intervention depends on the kind of injury and the number of nerves that are compressed or injured. […] If you have had mild neuropraxia, the prognosis is excellent. […] Self-healing of the avulsion due to root injuries rarely occurs spontaneously. […] For neuroma and tears, intervention is required. […] For neuritis, antibiotics or other medication may be needed to treat the cause of the inflammation. […] The goal in brachial plexus injury rehab is to prevent muscle atrophy and secondary deformities, suppression of pain, and the recovery of somato-sensory deficits.
#1 Brachial Plexus Injury Influences Efferent Transmission on More than Just the Symptomatic Side, as Verified with Clinical Neurophysiology Methods Using Magnetic and Electrical Stimulation
https://www.mdpi.com/2227-9059/12/7/1401
Magnetic stimulation is an advantageous addition to the diagnostic standard used in BPI cases. […] The compatibility of imaging studies and neurophysiological tests in evaluating the proximal part of the brachial plexus is essential, especially for reconstructive surgery. […] The above outcomes prove the mixed axonal and demyelination natures of brachial plexus injuries. […] The predominance of C5 and C6 brachial plexus injuries in the cervical root and upper/middle trunk of patients with BPI has been confirmed. […] The abnormalities found in the motor neural transmission on the asymptomatic side of patients following a brachial plexus injury may have important clinical consequences. […] These functional abnormalities have not been detected with standard clinical methods, but there is an opportunity to detect them when using the clinical neurophysiology methods demonstrated in this study. […] The electrical (ENG) and magnetic (MEP) stimuli used for the excitation of the efferent components of the brachial plexus allow for a noninvasive, objective, and repeatable evaluation of the BPI patientâs functional status.
#1 Brachial Plexus Injuries – StatPearls – NCBI Bookshelf
https://www.ncbi.nlm.nih.gov/books/NBK482305/
The surgical timing for the treatment of BPI remains a topic of controversy. Urgent surgical exploration of the plexus is indicated if a root avulsion or laceration injury to the plexus is suspected or in cases of open injury, retained foreign body, or vascular injury requiring vessel repair. Sharp transections of the brachial plexus allow for primary repair of the transected ends to optimize nerve regeneration. Prognosis for low-energy mechanism BPI is more favorable compared to root avulsions or preganglionic injuries and can be treated conservatively to allow for spontaneous recovery.[6] The patient should be closely followed with serial examinations, imaging studies, and electrophysiological testing. Delayed exploration may be indicated at three to six months after injury if the patient fails to regain neurologic function satisfactorily. There are few contraindications to brachial plexus surgery. In general, surgery should be avoided if the patient is not medically or psychologically cleared for surgery or if local wounds or infections obstruct the surgical approach. Adequate surgical exposure may be further obscured by edema and scar tissue in the cervical region. Other contraindications are determined on an individual basis. Chronic injuries to the brachial plexus that are more than 12 months old present a relative contraindication for surgical repair except in children who have greater regenerative potential. Low-demand patients and patients with underlying joint contractures may be poor candidates for surgery due to difficulty in achieving substantial functional improvements. Patients who may be noncompliant or unable to progress through the rigorous physical therapy regimen, which may continue for several years, are likely to have poor outcomes.[6]
#1
https://www.orthobullets.com/trauma/1008/brachial-plexus-injuries
Brachial plexus injuries (BPIs) can involve any degree of injury at any level of the plexus and range from obstetric injuries to traumatic avulsions. […] Diagnosis requires focused physical examination with EMG/NCS and MRI studies used for confirmation as needed. […] Treatment can be conservative versus operative depending on the age of patient, chronicity of injury, degree of injury and nerve root involvement. […] Mechanism: high speed vehicle accidents (mostly motorcycle) predominantly affect upper brachial plexus; with high enough energy all roots can be affected. […] Caudally forced shoulder predominantly affects upper brachial plexus; with high enough energy all roots can be affected. […] Forced arm abduction (as in grabbing onto something while falling) predominantly affects lower roots.
#1
https://www.orthobullets.com/trauma/1008/brachial-plexus-injuries
Electromyography (EMG) can help distinguish preganglionic from postganglionic injuries. […] Nerve conduction velocity (NCV) distinguishes preganglionic from postganglionic. […] Sensory and Motor Evoked Potential is more sensitive than EMG and NCV at identifying continuity of roots with spinal cord. […] Early surgical intervention is indicated for near total plexus involvement and with high mechanism of energy. […] Delayed surgical intervention is indicated for partial upper plexus involvement and low energy mechanism. […] Techniques include nerve repair, nerve grafting, and neurotization. […] Recovery of reconstructed plexus can take up to 3 years; nerve regeneration occurs at speed of 1mm/day. […] Root avulsion (preganglionic injuries) have worst prognosis; not repairable.
#1 Brachial Plexus Injury – Everything You Need To Know
https://centenoschultz.com/condition/brachial-plexus-injury/
Physical therapy and rehab should start almost immediately and must be performed several times a day. Extensive physical therapy is one of the first-line treatments. […] Surgery must be considered if a person is still having symptoms even after 3 months of the injury and there has been no healing. […] Nerve repairs must be done within the first three months of injury. […] Neurolysis is a surgical procedure where the nerve is dissected and is freed up from the adhesions and growths that are restricting or compressing it. […] A nerve graft is when the nerve is taken from another location and transplanted to the site of the injury to connect a torn nerve. […] In a nerve transfer, nerves from other parts of the body are transferred closer to the muscle fiber. […] In a tendon and muscle transfer, a functioning tendon is attached to the paralyzed tendon affected by the brachial plexus injury.
#1
https://journals.lww.com/prsgo/fulltext/2024/08000/current_concepts_in_brachial_plexus_birth.70.aspx
BPBIs are classified by nerve injury severity and anatomical location. The Seddon classification categorizes nerve injury severity into neuropraxia (stretching), axonotmesis (severed axon but intact epineurium), and neurotmesis (complete nerve disruption). […] Surgical intervention is pursued after exhausting nonoperative treatment. Early surgery ( 6 months) is associated with improved outcomes, while delayed surgery ( 18 months) may diminish nerve regeneration potential and result in complications. […] Indications for surgical exploration relies on surgeons expertise and literature-based guidelines. […] Microsurgical interventions for operative treatment of BPBI include neurolysis, neuroma-in-continuity resections with nerve grafting, and nerve transfers. […] Recent studies challenge traditional age cut-offs, indicating potential benefits of nerve transfer beyond the critical window. This underscores the importance of individualized decision-making for optimal outcomes, regardless of age at presentation.
#1 Brachial Plexopathy: Differential Diagnosis and Treatment | PM&R KnowledgeNow
https://now.aapmr.org/brachial-plexopathy-differential-diagnosis-and-treatment-2/
Spontaneous recovery is rare with complete axonal discontinuity, manifested by complete absence of CMAPs, absence of motor unit action potentials (MUAPs) despite good effort, and abnormal spontaneous activity. […] The number of fibrillation potentials and positive sharp waves on electromyography testing does not predict the severity of injury. […] Identification and avoidance of repetitive activities, extreme range of motions and excessive load carriage via shoulder straps that induce pain or weakness is critical. […] The efficacy of nerve grafts after traumatic brachial plexopathy diminishes with time after 8 weeks.
#1 Brachial Plexus Injury in Adults
http://thenerve.net/journal/view.php?doi=10.21129/nerve.2017.3.1.1
Myelography was the traditional mainstay for diagnosis of brachial plexus lesions. […] The diagnostic accuracy is known to be only 37.5%, although accuracy at the level of C8 and T1 was 75%. […] Nowadays, CT myelography is the current gold standard diagnostic method for avulsion injuries. […] The presence of a pseudomeningocele at 3 to 4 weeks after injury highly suggests root avulsion. […] If there is no evidence of spontaneous recovery within 6 months of injury, a reconstructive plan should be formulated. […] The optimal time between injury and surgery is one of the most important factors responsible for the surgical results. […] The mechanism of injury determines the appropriate timing of surgical intervention. […] Operative options used in BPI include nerve grafting, neurotization (nerve transfer), and other brachial plexus reconstructive techniques including the transplantation of various structures. […] Nerve grafting is a procedure which is used to make connectivity of the ruptured nerves in postganglionic injury. […] If the injury is preganglionic, reconstruction using nerve transfers could be helpful. […] Traumatic BPIs in adult arise from various traumatic or non-traumatic mechanisms, and their frequency has been increasing. […] Early recognition of the mechanism and level of the injury is principal in establishing early treatment leads to better outcome.
#1 Brachial Plexus Injuries New York, NY | Nerve Reconstructive Surgery Stamford, CT
http://www.scottwolfemd.com/adult-pediatric-brachial-plexus-injuries-scott-wolfe-md.html
Nerve reconstructive surgery is ideally performed within the first 3-6 months after acute injuries to permit optimal recovery, allowing time for the regenerating nerves to connect with paralyzed muscles before dense scarring develops. […] If there is evidence of complete nerve disruption, surgery can be safely performed as early as 3-6 months of age to repair or graft injured nerves.
#2 Traumatic Brachial Plexus Injuries: Practice Essentials, Anatomy, Pathophysiology
https://emedicine.medscape.com/article/1268993-overview
In traction-type brachial plexus injuries, the head and neck are moved away violently from the ipsilateral shoulder. Upper-plexus injuries (C5 and C6) usually predominate if the arm is at the side because the first rib acts as a fulcrum to direct the traction forces preferentially in line with the upper plexus. […] When the arm is moved violently and abducted overhead, the lower elements (C8-T1) typically are injured because the force is directed in line with C7. A lower-plexus lesion predominates when the arm is raised because the coracoid acts as a fulcrum in a similar fashion. Lower-plexus lesions may be more common, in part because of the well-formed transverse radicular ligaments that help resist traction forces at C5, C6, and C7; C8 and T1 lack these ligaments. […] Traction forces can result in preganglionic or postganglionic injuries. Preganglionic injuries refer to lesions proximal to the dorsal root ganglion, which is in the spinal canal, and the foramen. They may be central or direct from the spinal cord or intradural. Preganglionic lesions do not cause wallerian degeneration or neuroma formation, because the axons remain in continuity with the cell bodies in the dorsal root ganglion. Postganglionic lesions are defined as any lesions distal to the spinal ganglion and are physiologically similar to other peripheral nerve injuries.
#2 Brachial Plexus Injuries – OrthoInfo – AAOS
https://orthoinfo.aaos.org/en/diseases–conditions/brachial-plexus-injuries/
Brachial plexus injuries vary greatly in severity, depending upon the type of injury and the amount of force placed on the plexus. The same patient can injure several different nerves of the brachial plexus in varying severity. […] Most traumatic brachial plexus injuries occur when the arm is forcefully pulled or stretched. Many events can cause the injury, including falls, motor vehicle collisions, knife and gunshot wounds, and most commonly, motorcycle collisions. […] Brachial plexus injuries caused by a gunshot wound do not typically damage the nerve severely. […] The severity of injury will depend on the bullet’s caliber, velocity, and angle of entry. […] Lower brachial plexus injuries occur when the arm and shoulder are forced upward, increasing the angle between the arm and the chest.
#2 Brachial Plexus Injury: What It Is, Symptoms, Treatment & Types
https://my.clevelandclinic.org/health/diseases/22822-brachial-plexus-injury
The main types of brachial plexus injuries include: […] Stretch (neuropraxia): This happens when a brachial plexus nerve mildly stretches, which damages the protective covering of the nerve. […] Rupture: This happens when a more forceful stretch of a brachial plexus nerve causes it to tear partially or fully. […] Avulsion: This is the most severe type of brachial plexus injury. It happens when the nerve root tears away from your spinal cord. […] Brachial plexus injuries often involve multiple nerve roots and there’s usually an absence of neck symptoms, such as neck spasms and pain, unlike with cervical radiculopathy. […] Brachial plexus injuries can occur as a result of: […] Forceful trauma. […] Tumors. […] Inflammation. […] Injuries at birth. […] Damage to the upper part of your brachial plexus often occurs when your shoulder is forced down while your neck is forced up and away from your shoulder.
#2 Brachial Plexus Injury in Adults
http://thenerve.net/journal/view.php?doi=10.21129/nerve.2017.3.1.1
Brachial plexus injury (BPI) is a severe peripheral nerve injury affecting upper extremities, causing functional damage and physical disability. The most common cause of adult BPI is a traffic accident, and the incidence has steadily increased since the 1980s. BPIs can be divided into three types; preganglionic lesion, postganglionic lesion, and a combination of both. […] The mechanism and classification of injury, clinical manifestations, updated diagnostic studies, and recent treatment strategies would be discussed. […] Root injury is defined as root avulsion from the spinal cord and rupture in the preganglionic root zone or dorsal ganglion at the vertebral foramen. […] The great range of motion of the cervical spine is a distinctive characteristic of the cervical vertebrae. Cervical spinal nerves have a few unique protective mechanisms. […] Closed trauma is the most common cause of adult traumatic BPI. Most common mechanism of closed trauma causing BPI is compression or traction. […] The most commonly injured sites are the roots and trunks in comparison to the rest parts of the brachial plexus. Root avulsions exist in 75% of cases of these supraclavicular injuries. […] The patients position and the location of the upper limb when the injury occurs is the most important point to understand the mechanism of BPI. […] If the upper limb is adducted, the greatest tension and mechanical stress will affect the upper roots. […] When the upper limb is elevated and the traction force affects the arm or the trunk, substantial tension force will affects the lower roots. […] Over time, cellular proliferation occurs and closes the tear, and the meningocele, a pouch like extension, appears.
#2 Brachial Plexus Injury – Everything You Need To Know
https://centenoschultz.com/condition/brachial-plexus-injury/
Brachial plexus injuries can vary greatly from mild to severe. […] An injury to this plexus of nerves can affect the movement of the entire arm and forearm. […] Brachial plexus injuries can occur at any level. Based on the location of the injury, brachial plexus injuries are classified into the following categories: […] Brachial plexus injuries can be classified based on their relation to the clavicle into supra clavicular (above the clavicle), retro clavicular (behind the clavicle), or infra clavicular (below the clavicle). […] Brachial plexus injuries often occur when the arm is pulled downwards while the head stretches towards the opposite side. This causes the nerves to stretch and tear, especially in the paper trunk. […] Blunt trauma can often damage multiple nerves since it is usually seen in polytrauma.
#2 Internet Scientific Publications
https://ispub.com/IJHS/1/1/8497
Closed traumatic brachial plexus injury is usually associated with a high energy injury mechanism and is usually caused by traction on the cervical spine, upper limb or both. […] Traction to the upper trunk may produce nerve ruptures which are distal to the dorsal root ganglion and are therefore known as postganglionic injuries. […] The lower trunk is more prone to direct avulsion from the spinal cord and the injury is often proximal to the dorsal root ganglion and therefore is called a preganglionic injury. […] Plexus injuries are anatomically divided into supraclavicular and infraclavicular injuries. […] The majority of plexus injuries in the adult are closed avulsion or traction injuries and they may involve predominantly the upper (70%), lower (20%) or whole (10%) of the plexus.
#2 Brachial Plexus Palsy: Pathophysiology, Diagnosis, and Management | Consultant360
https://www.consultant360.com/articles/brachial-plexus-palsy-pathophysiology-diagnosis-and-management
Axonotmetic in this type of injury, there is damage to both the axon and the myelin sheath leading to nerve degeneration distal to the site of injury. The epineurium and perineurium is often undamaged and recovery, which is usually not complete, takes longer in this type of injury (4 to 6 months). […] Neurometric these injuries are the most severe and are associated with destruction of nerve and surrounding tissue, including the epineurium, perineurium, and endoneurium. The damage with this type of injury is mainly associated with the formation of a neuroma due to traction or laceration. This leads to wallerian degeneration, which is when scar tissue forms distal to the injury site due to the proximal end of the nerve trying to regenerate and approximate itself without supportive tissue. In this type, muscle atrophy starts to develop between 3 and 6 months after injury, and surgery is usually the only treatment option.
#2 Brachial Plexus Injury in Adults
http://thenerve.net/journal/view.php?doi=10.21129/nerve.2017.3.1.1
Myelography was the traditional mainstay for diagnosis of brachial plexus lesions. […] The diagnostic accuracy is known to be only 37.5%, although accuracy at the level of C8 and T1 was 75%. […] Nowadays, CT myelography is the current gold standard diagnostic method for avulsion injuries. […] The presence of a pseudomeningocele at 3 to 4 weeks after injury highly suggests root avulsion. […] If there is no evidence of spontaneous recovery within 6 months of injury, a reconstructive plan should be formulated. […] The optimal time between injury and surgery is one of the most important factors responsible for the surgical results. […] The mechanism of injury determines the appropriate timing of surgical intervention. […] Operative options used in BPI include nerve grafting, neurotization (nerve transfer), and other brachial plexus reconstructive techniques including the transplantation of various structures. […] Nerve grafting is a procedure which is used to make connectivity of the ruptured nerves in postganglionic injury. […] If the injury is preganglionic, reconstruction using nerve transfers could be helpful. […] Traumatic BPIs in adult arise from various traumatic or non-traumatic mechanisms, and their frequency has been increasing. […] Early recognition of the mechanism and level of the injury is principal in establishing early treatment leads to better outcome.
#2 Brachial Plexus Injury in Adults
http://thenerve.net/journal/view.php?doi=10.21129/nerve.2017.3.1.1
BPIs can be divided into three types; preganglionic lesion, postganglionic lesion, and a combination of both. […] Preganglionic injuries involve the nerve roots avulsion, and imply that the rootlets that connect the peripheral nerve to the central nervous system have been disrupted. […] Therefore, the root that is affected cannot be used as a nerve source for reconstruction, and alternative methods of reconstruction are necessary. […] The level of lesion can be analogized by clinical manifestations, such as active and passive movements of the shoulder, upper arm, lower arm and hand and wrist, through a full range of movements. […] An upper brachial plexus lesion (C5, C6) leads to paralysis of the shoulder muscles and biceps. […] Avulsion or damage of the C8 and T1 nerve roots from which the cervical sympathetic chain arises cause Horner syndrome, which is characterized by ptosis, meiosis, anhidrosis of the cheek and enophthalmos.
#2 Brachial Plexus Birth Injury | Boston Children’s Hospital
https://www.childrenshospital.org/conditions/brachial-plexus-birth-injury
Twin or multiple pregnancy […] History of a prior delivery resulting in brachial plexus birth injury. […] Brachial plexus birth injury can be diagnosed by your babys pediatrician upon a thorough medical history and physical examination. […] Most brachial plexus injuries will heal on their own. […] Nerve surgery, also known as microsurgery, repairs or reconstructs the injured nerves and is recommended if recovery is still inadequate 3 to 6 months after birth. […] This surgery generally consists of a combination of nerve grafting and nerve transfer procedures. […] A free muscle transfer is an extensive surgery, typically using leg muscles, which required reconnection of blood vessels and nerves under microscope. […] This depends on the extend of the injury and varies from patient to patient.
#2 Brachial plexus injury: Clinical case, anatomy, symptoms | Kenhub
https://www.kenhub.com/en/library/anatomy/upper-and-lower-brachial-plexus-injury
The brachial plexus is a complex of nerves from C5-T1 that provide motor and sensory innervation to the upper extremity. Injury to the brachial plexus usually results in a pattern of functional deficits that implicates the roots or nerves of the brachial plexus that are compromised. […] Erb, or Erb-Duchenne palsy, is the name given to a typical upper brachial plexus injury involving spinal nerve roots C5 and C6. In contrast, Klumpkes, or Klumpke-Dejerine palsy, affects the lower roots of the brachial plexus (C8, T1). Both these types of lesions usually involve a specific injury mechanism that results in the excessive stretching of either the upper plexus (due to an increase of the angle between the shoulder and head) or the lower plexus (associated with hyper abduction of the arm). […] The generally accepted mechanism of brachial plexus injury in obstetrics is shoulder dystocia. This occurs when, after delivery of the fetal head, the baby’s shoulder becomes wedged behind the pubis. Traction to the neck caused by pull of the obstetrician’s hand or instruments (e.g., forceps) in such cases result in the neck on the side of the trapped shoulder being stretched and this stretch causes a strain on the ipsilateral brachial plexus, resulting in varying degree of injury. The injury most commonly affects the C5 and C6 roots of the brachial plexus, but all roots can be involved.
#2
https://www.orthobullets.com/trauma/1008/brachial-plexus-injuries
Electromyography (EMG) can help distinguish preganglionic from postganglionic injuries. […] Nerve conduction velocity (NCV) distinguishes preganglionic from postganglionic. […] Sensory and Motor Evoked Potential is more sensitive than EMG and NCV at identifying continuity of roots with spinal cord. […] Early surgical intervention is indicated for near total plexus involvement and with high mechanism of energy. […] Delayed surgical intervention is indicated for partial upper plexus involvement and low energy mechanism. […] Techniques include nerve repair, nerve grafting, and neurotization. […] Recovery of reconstructed plexus can take up to 3 years; nerve regeneration occurs at speed of 1mm/day. […] Root avulsion (preganglionic injuries) have worst prognosis; not repairable.
#2 Brachial Plexus Injuries – OrthoInfo – AAOS
https://orthoinfo.aaos.org/en/diseases–conditions/brachial-plexus-injuries/
Pan-plexus palsy may occur if the force of the injury is extreme. In pan-plexus palsy, all levels of the nerves and trunk are damaged. This results in complete paralysis of the arm and hand, which is often referred to as „flail limb.” […] Surgical treatment is typically recommended when the nerves fail to recover on their own or fail to recover enough to restore necessary function to the arm and hand. […] It is important to note that depending on the severity of the injury, even surgery may not be able to return the arm or hand to normal. […] Recovery from a brachial plexus injury takes time, and patients may not experience results for several months.
#2
https://journals.lww.com/prsgo/fulltext/2024/08000/current_concepts_in_brachial_plexus_birth.70.aspx
BPBIs are classified by nerve injury severity and anatomical location. The Seddon classification categorizes nerve injury severity into neuropraxia (stretching), axonotmesis (severed axon but intact epineurium), and neurotmesis (complete nerve disruption). […] Surgical intervention is pursued after exhausting nonoperative treatment. Early surgery ( 6 months) is associated with improved outcomes, while delayed surgery ( 18 months) may diminish nerve regeneration potential and result in complications. […] Indications for surgical exploration relies on surgeons expertise and literature-based guidelines. […] Microsurgical interventions for operative treatment of BPBI include neurolysis, neuroma-in-continuity resections with nerve grafting, and nerve transfers. […] Recent studies challenge traditional age cut-offs, indicating potential benefits of nerve transfer beyond the critical window. This underscores the importance of individualized decision-making for optimal outcomes, regardless of age at presentation.
#3 Brachial Plexus Injury – Everything You Need To Know
https://centenoschultz.com/condition/brachial-plexus-injury/
Medical trauma, such as difficult obstetric deliveries, can stretch the brachial plexus. […] Brachial plexus injuries can occur due to tumor infiltration. […] Brachial plexus compression can also occur due to fibrosis around the nerve plexus after radiotherapy. […] Stretching (Brachial Plexus Neuropraxia): Neuropraxia simply is a stretching of the nerves. It is the mildest form of injury. […] Avulsion is the most severe type of brachial injury. Here, the nerves are cut or torn from the spinal cord. […] Incomplete avulsion, the nerve is damaged but not completely torn, which allows the nerve to slowly heal. […] A rupture is when the nerve is torn but not at the spinal cord level. […] In a neuroma or a benign nerve growth, the nerve gets torn. It does heal, but with scar tissue. This puts pressure on the already-injured nerve and affects the nerve signaling to the muscles.
#3 Brachial Plexus Injury: What It Is, Symptoms, Treatment & Types
https://my.clevelandclinic.org/health/diseases/22822-brachial-plexus-injury
Damage to the lower part of your brachial nerves is more likely to happen when your arm is suddenly forced above your head. […] Tumors can grow in or along your brachial plexus or put pressure on your brachial plexus. […] A rare syndrome called Parsonage-Turner Syndrome (brachial neuritis) causes inflammation of the brachial plexus without any obvious shoulder injury. […] Infants can experience brachial plexus injuries due to compression inside their birth mothers uterus or during a difficult delivery. This injury is called neonatal brachial plexus palsy (NBPP).
#3 Brachial Plexus Injury in Adults
http://thenerve.net/journal/view.php?doi=10.21129/nerve.2017.3.1.1
Myelography was the traditional mainstay for diagnosis of brachial plexus lesions. […] The diagnostic accuracy is known to be only 37.5%, although accuracy at the level of C8 and T1 was 75%. […] Nowadays, CT myelography is the current gold standard diagnostic method for avulsion injuries. […] The presence of a pseudomeningocele at 3 to 4 weeks after injury highly suggests root avulsion. […] If there is no evidence of spontaneous recovery within 6 months of injury, a reconstructive plan should be formulated. […] The optimal time between injury and surgery is one of the most important factors responsible for the surgical results. […] The mechanism of injury determines the appropriate timing of surgical intervention. […] Operative options used in BPI include nerve grafting, neurotization (nerve transfer), and other brachial plexus reconstructive techniques including the transplantation of various structures. […] Nerve grafting is a procedure which is used to make connectivity of the ruptured nerves in postganglionic injury. […] If the injury is preganglionic, reconstruction using nerve transfers could be helpful. […] Traumatic BPIs in adult arise from various traumatic or non-traumatic mechanisms, and their frequency has been increasing. […] Early recognition of the mechanism and level of the injury is principal in establishing early treatment leads to better outcome.