Early Management Of Brachial Plexus Injuries
05/31/2013 // Concord, CA, USA // LifeCare123 // Greg Vigna, MD, JD, Joe Motta, JD // (press release)
Life Care Solutions Group Medical Perspective on Brachial Plexus Injuries:
Motor vehicle accidents are the most frequent cause of brachial plexus injuries with .67% of motor vehicle accident victims admitted to acute care hospitals suffering from brachial plexus injuries. These serious injuries from car accidents involve high force and velocity which causes multiple associated injuries including TBI with 72% having some loss of consciousness and 19% of victims in coma, cervical spine fractures in 13%, and shoulder injuries in 20%.
From my experience, says Greg Vigna MD/JD, diagnosis is fairly straightforward in the acutely injured cognitively intact patient. There will usually be markedly asymmetric finding of weakness involving the proximal or distal upper extremity. Diagnosis may be delayed by the presence of associated injuries that cause loss of function of the upper extremity including spinal cord injury, traumatic brain injury, upper extremity fracture dislocations with isolated nerve injury, and rotator cuff tears. It is not unusual to diagnose this problem in an acute inpatient rehabilitation center after a patient with a severe traumatic brain injury recovers from coma to a point where they can participate in a neurologic exam.
Diagnostic test required when a brachial plexus injury is suspected include MRI of the cervical spine and plexus, CT myelogram, neurophysiologic testing including somatosensory evoked potentials and EMG/NC studies, plain films of the cervical spine, clavicle, and shoulder. Early referral to a center of excellence that has the expertise in management of this diagnosis is required is since follow up and continuity of care is helpful for surgeons to monitor for spontaneous recovery and delineate the patients that require surgical exploration, intraoperative nerve testing, and possible surgical repair of the plexus. These surgeons rely on neurophysiologic testing for surgical planning and will often repeat prior EMG/NC and somatosensory evoked potentials with the clinicians who they know provide the quality necessary to plan surgical intervention.
Extensive physical therapy and occupational therapy is necessary both acutely after injury, sub-acutely after injury, and post-operatively. The goals of physical and occupational therapy is to prevent contractures, improve independence with activities of daily living, provide modalities that decrease pain and decrease atrophy such as electrical stimulation and therapeutic ultrasound. Psychological support is necessary both acutely and chronically to help with issues of anxiety, depression, and post-traumatic stress disorder. Neuropsychological support is often necessary to evaluate for cognitive deficits in patients with an associated traumatic brain injury.
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