Brachial plexus injury

Definition

Brachial plexus injury is a lesion of the brachial nerve plexus manifested by pain syndrome combined with motor, sensory, and autonomic dysfunction of the upper limb and shoulder girdle. The clinical picture varies depending on the level of the plexus lesion and its genesis. Diagnosis is carried out by a neurologist in conjunction with other specialists; it may require electroneurography, ultrasound, radiography, CT, or MRI of the shoulder joint and the plexus area, the study of blood chemistry, and the level of C-reactive protein. It is possible to cure brachial plexitis and fully restore the function of the plexus only within the first year, provided that the cause of the disease is eliminated, adequate and comprehensive therapy and rehabilitation.

General information

The brachial plexus is formed by branches of the lower cervical spinal nerves C5-C8 and the first thoracic root Th1. The nerves emanating from the brachial plexus innervate the skin and muscles of the shoulder girdle and the entire upper limb. Clinical neurology distinguishes between a total lesion of the plexus – Kerer’s palsy, a lesion of only its upper part (C5-C8) – proximal Duchenne-Erb’s palsy, and a lesion of only its lower part (C8-Th1) – distal Dejerine-Klumpke palsy.

Depending on the etiology, brachial plexitis is classified as posttraumatic, infectious, toxic, compression-ischemic, dysmetabolic, or autoimmune. Among plexitis of other localizations (cervical plexitis, lumbosacral plexitis), brachial plexitis is the most common. The disease’s widespread and polyetiologic nature determines its relevance for neurologists and specialists in traumatology and orthopedics, obstetrics and gynecology, rheumatology, and toxicology.

Reasons

Trauma is the most common cause of brachial plexitis. Damage to the plexus is possible with clavicle fracture, dislocation of the shoulder (including habitual dislocation), ligament sprain or tendon damage of the shoulder joint, shoulder contusion, stabbing, stabbing or gunshot wounds in the area of the brachial plexus. Often, brachial plexitis occurs against the background of chronic microtraumatization of the plexus, for example, when working with vibrating tools or using crutches. In obstetric practice, Duchenne-Herb obstetric palsy, which is a consequence of birth trauma, is well known.

The second place by prevalence is occupied by brachial plexitis of compression-ischemic genesis, which occurs when the plexus fibers are compressed. This can occur when the arm is in an uncomfortable position for a long time (during sound sleep, in bedridden patients) when the plexus is compressed by a subclavian artery aneurysm, tumor, posttraumatic hematoma, enlarged lymph nodes, an extra cervical rib, and Pancoast cancer.

Shoulder plexitis of infectious etiology is possible against the background of tuberculosis, brucellosis, herpetic infection, cytomegaly, syphilis after influenza, and sore throat. Dysmetabolic brachial plexitis may occur with diabetes mellitus, dysproteinemia, gout, etc., and metabolic diseases. Iatrogenic damage to the brachial plexus during various surgical interventions in the area of its location is not excluded.

Symptoms

Shoulder plexitis is manifested by a pain syndrome—plexalgia—that is shooting, aching, drilling, and breaking. Pain is localized in the clavicle and shoulder and extends to the entire upper extremity. Increased pain sensations are observed at night, provoked by shoulder joint and arm movements. Then, muscle weakness in the upper limb joins and progresses to plexalgia.

Duchenne-Erb paralysis is characterized by hypotonia and decreased strength in the proximal arm muscles, resulting in difficulty in shoulder joint movements, arm extension and elevation (especially when it is necessary to hold a weight), and arm flexion in the elbow joint. In contrast, Dejerine-Klumpke paralysis is accompanied by weakness of the muscles of the distal parts of the upper extremity, which is clinically manifested by difficulty in performing hand movements or holding various objects in it. As a result, the patient cannot hold a cup, use cutlery, fasten buttons, open a door with a key, etc.

Motor disorders are accompanied by a decrease or loss of ulnar and carporadial reflexes. Sensory disturbances in the form of hypoesthesia affect the lateral edge of the shoulder and forearm in proximal paralysis and the inner region of the shoulder, forearm, and hand in distal paralysis. When sympathetic fibers in the lower part of the brachial plexus are affected, one manifestation of Dejerine-Klumpke palsy may be Gorner’s syndrome (ptosis, pupil dilation, and enophthalmos).

In addition to motor and sensory disorders, brachial plexitis is accompanied by trophic disorders that develop due to dysfunction of peripheral autonomic fibers. The upper extremity is swollen and marbling, there is increased sweating or anhidrosis, excessive skin thinning and dryness, and increased nail brittleness. The skin of the affected limb is easily traumatized, and wounds do not heal for a long time.

Often, partial brachial plexus involvement is present with either proximal Duchenne-Herb or distal Dejerine-Klumpkepalsy. More rarely, total brachial plexitis, including the clinic of both paralyses, is present. In exceptional cases, plexitis is bilateral, which is more typical for infectious, dysmetabolic, or toxic genesis lesions.

Diagnosis

A neurologist can diagnose brachial plexus injury based on history, complaints, and examination results, confirmed by electroneurographic examination and, in its absence – electromyography. It is essential to distinguish plexitis from brachial plexus neuralgia. The latter, as a rule, manifests after hypothermia, plexalgia, and paresthesias, not accompanied by motor disorders. In addition, brachial plexitis should be differentiated from polyneuropathy, mononeuropathies of the nerves of the arm (neuropathy of the median nerve, neuropathy of the ulnar nerve, and neuropathy of the radial nerve), pathology of the shoulder joint (arthritis, bursitis, arthrosis), radiculitis.

For differential diagnosis and establishment of the etiology of plexitis, if necessary, consultation with a traumatologist,orthopedist, rheumatologist, oncologist, infectious disease specialist; ultrasound of the shoulder joint, radiography or CT scan of the shoulder joint, MRI of the brachial plexus, lung radiography, blood sugar level, blood chemistry, and C-reactive protein examinations.

Treatment

Differential therapy is determined by the genesis of plexitis. When indicated, antibiotic therapy, antiviral treatment, immobilization of the injured shoulder joint, removal of hematoma or tumor, detoxification, and correction of metabolic disorders are used. In some cases (more often in obstetric paralysis), a joint decision with a neurosurgeon on the feasibility of surgical intervention—repair of the nerve trunks of the plexus—is required.

The general treatment direction is vasoactive and metabolic therapy, which provides improved nutrition and, thus, the fastest recovery of nerve fibers. Patients with brachial plexitis receive pentoxifylline, complex preparations of B vitamins, nicotinic acid, and ATP. Some physical procedures—electrophoresis, mud treatment, heat procedures, and massage—are also aimed at improving the tropism of the affected plexus.

Symptomatic therapy, including the management of plexalgia, is of great importance. Patients are prescribed NSAIDs, therapeutic blocks with novocaine, and reflex therapy. To support muscles, improve blood circulation, and prevent contractures of the joints of the affected arm, a special complex of physiotherapy and massage of the upper limb are recommended. 

All these treatment options are available in more than 940 hospitals worldwide (https://doctor.global/results/diseases/brachial-plexus-injury). For example, Brachial plexus surgery can be done in 31 clinics across Turkey for an approximate price of $5.8 K (https://doctor.global/results/asia/turkey/all-cities/all-specializations/procedures/brachial-plexus-surgery). 

Prognosis and prevention

Timely initiation of treatment, successful elimination of the causative trigger (hematoma, tumors, trauma, infection, etc.), and adequate rehabilitation therapy usually contribute to the full recovery of nerve function in the affected plexus. With a delayed start of therapy and the inability to eliminate the influence of the causative factor, brachial plexitis does not have a very favorable prognosis in terms of recovery. Over time, irreversible changes occur in the muscles and tissues caused by insufficient innervation; muscle atrophy and joint contractures are formed. Since the leading hand is most often affected, the patient loses their professional capabilities and the ability to perform self-care.

Measures that can prevent brachial plexitis include prevention of traumatism, adequate choice of the method of delivery and professional management of labor, compliance with surgical techniques, timely treatment of injuries, infectious and autoimmune diseases, and correction of dysmetabolic disorders. Increasing nerve tissue resistance to various unfavorable influences helps observe a normal regimen, revitalizing physical activity, and proper nutrition.