Jonathan Isaacs, M.D.
Director, Upper Extremity and Peripheral Nerve Center
Chief, Division of Hand Surgery
Department of Orthopaedic Surgery
Virginia Commonwealth University
Justin Brown, M.D.
Director of Neurosurgery Peripheral Nerve Program and Co-Director of the Center for Neurophysiology and Restorative Neurology
Associate Professor, Neurosurgery
University of California, San Diego Health System
Zhongyu John Li, M.D., Ph.D.
Department of Orthopaedic Surgery
Wake Forest Baptist Medical Center
Winston-Salem, North Carolina
Glenn Gaston, M.D.
Chief of Hand Surgery
Orthocarolina Hand Fellowship Director
Carolinas Medical Center
Charlotte, North Carolina
Allan Belzberg, M.D., FRCSC
Director of the Peripheral Nerve Center
Associate Professor of Neurological Surgery
Johns Hopkins Medicine
GP is a 56 yo RHD male initially presenting 5 weeks post injury, complaining of severe pain and loss of function in his left upper extremity. A 1-2 ton piece of metal fell on him at work (he worked as a foreman at a petroleum company) (worker’s compensation injury). Initial injuries included right ankle fracture, multiple left rib fractures, C7 left transverse process fracture, and left clavicle fracture all treated prior to presentation in our clinic.
Past medical history remarkable for heart disease (s/p six vessel bypass), high blood pressure, and diabetes.
Medications included hydrochlorothiazide, amlodipine, amiodarone, metformin, and neurontin. He is unable to tolerate any narcotic medication (an observation tested and proven accurate multiple times during our interaction with him).
Pertinent physical findings: mild distress, obese, + Horner’s syndrome, shoulder appears slightly subluxed; no obvious atrophy; moderate hand and shoulder stiffness, 5/5 trapezial, 3/5 elbow flexion, 1/5 deltoid, 4/5 rhomboids; o/w 0/5 throughout. Decreased sensation along lateral aspect of brachium and reports some sensation along radial aspect of forearm (and medial aspect of proximal brachium);
Radiographs (Fig 1): midshaft clavicle fracture healed with callus, bayonetting, and 1cm shortening; Glenohumoral joint subluxed 50%; MRI of plexus does not reveal any discrete structures
Initial impression: significant brachial plexus injury with possible lower root avulsion but some retained upper plexus elements in an obese male with substantial co-morbidities
Initial plan: therapy to improve shoulder and hand stiffness; MRI of c-spine to evaluate for root avulsion; new EMG/NCS of upper extremity
-will maximize Neurontin dosing at 900mg TID and add Tramadol
JB: Given the Horner’s and C7 TP fracture, very high likelihood that he has suffered avulsions. If the MRI does not clearly define what is and is not avulsed, I like to use the old fashioned CT myelogram. It is still usually better than some of the best MRI sequences.
8 weeks post injury:
Pain becoming more of complaint (described as burning, tingling, radiating into fingers).
NCS: no conduction in ulna nerve
MRI- done in open MRI (worker’s compensation insisted on setting up study) - poor quality
Impression: no conduction in ulna nerve suggests that roots not avulsed (if roots avulsed, the cell bodies of sensory nerves in lower plexus would still be in continuity—only separated from spinal cord; though the person would be insensate, the NCS would demonstrate functioning nerve tissue)
Plan: need MRI of adequate quality; will repeat but start planning surgical exploration at 3-4 months post injury
JB: I would trust the imaging over the NCS. There can certainly be injury to the roots in the post-ganglionic region of the nerve root even if it is avulsed. I think preserved NCS are sensitive, but not specific. Get that myelogram and operate earlier if the avulsion is present
3 mos post injury:
-regaining some weak elbow extension; still struggling with pain
- New MRI suggesting C7-T1 avulsion (Fig 2)
PE: shoulder, hand, and wrist getting stiffer (70 degrees of shoulder abduction and fingers passively only 3 cm from palm); atrophy now noted diffusely in hand
5/5 trapezial, 5/5 rhomboids, 5/5 serratus anterior, 4-/5 shoulder abduction, 4-/5 external rotation, 5-/5 internal rotation, 1/5 brachiothoracic pinch (cannot tell which muscle contracting), 5-/5 elbow flexion, 1/5 elbow extension, 5-/5 supination; 0/5 pronation, wrist and finger motion
sensation only in lateral aspect of brachium and forearm
no obvious Tinel’s
Impression: preservation of upper plexus with probably lower trunk avulsion; triceps may be coming from upper plexus; some potential for pec recovery; has potential of median nerve sensory recovery; overall poor prognosis for other spontaneous recovery Plan: will explore to confirm avulsion injury of C7 primarily (will look at lower plexus though even rupture at this level with poor prognosis); will consider spinal accessory to radial nerve branch to triceps; if able to restore elbow control, would consider fusing wrist for assist hand; intercostals not considered an option due to severe left chest trauma and patients habitus (obese) and significant co-morbidities
JB: I would skip plexus exploration. Likelihood of getting regeneration to the forearm from grafting at the plexus is not great, and sounds like we have good evidence that things are avulsed. We don’t want to downgrade what is preserved. I would be inclined to assess with EMG what the innervation is like to the remaining muscles. Poorly innervated muscle groups (few large MUPs) are not good donors for nerve transfers, but can be okay for tendon transfers
Surgery (4 mos post injury)
C7, C8, T1 avulsion confirmed; Triceps contracted and Brachioradialis contracted with stimulation; Spinal Accessory Nerve transferred to long head of triceps with 30cm sural nerve graft (hoping to allow continued recovery of part of triceps vs potential innervation from transfer);
May be able to use Brachioradialis for transfer to wrist extensor down the road (though would work better if elbow extension restored)
JB: If long head of triceps contracted, would skip the transfer. If it clearly has no MUPs, would be more inclined to use intercostals to neurotize it and avoid the long graft. I like the brachioradialis plan. I would be inclined to use additional transfers at this stage, or shortly hereafter. Inventory potential donors (brachialis, supinator)
5 mos post injury
Triceps improved to 2-3/5; may have trace wrist extension; pain much worse
-will add Elavil and TENS unit (still can’t tolerate narcotics)
6mos post injury
Pain getting worse; now w/ periscapular and trapezial spasms
Respond temporarily to injections (lidocaine); will try lododerm patches and continue therapy
JB: Have therapy assess his shoulder and scapular dynamics. Does he need bracing. Is he on Neurontin/lyrica? Is pain management involved??
6 and 7 mos post injury:
pain still the main issue; wrist extension 3/5
Plan: continue current treatment for pain despite suboptimal response; suggest that we consider distal nerve transfers using branches either from BR or supinator to AIN or wrist flexor (wrist extension recovering)
Must get worker’s comp approval for change in plan (which we get at 9 mos post injury; we consider this at the edge of window of opportunity so continue back to OR)
JB: BR likely a poor axon donor. Would not use this for a nerve transfer, but preserve this for tendon transfer at a later date when it reaches its full strength. Supinator is a great thought, but again would check it with EMG to assess its innervation. I would skip wrist flexor as a target. If you would like to maintain wrist movement and avoid a fusion, extension is your priority.
Surgery (10mos post injury)
Transferred two branches of supinator: to AIN and branch to FCR; BR branch considered too proximal considering time since injury but supinator branches only a few inches from targets)
JB: See above. Supinator is a great thought for donor, but I would be very selective with targets as it is not strong even in a healthy patient.
12 mos post injury:
no change in exam (maintains supination strength); pain predominates discussions; now with severe insomnia
Plan: has not tolerated Elavil; will try over the counter sleep aids
JB: Time for a trial of spinal cord stimulation.
14 mos post injury
no change in exam; switched to Lyrica with slight improvement in pain though prolonged course clearly taking toll; patient reports marriage falling apart, breaks down into tears during interview;
Plan- referral for consideration of spinal stimulator
15 mos post injury
1/5 FCR contraction; wrist extension seems improved to about 3-4/5; no other significant change; pain is all he wants to talk about
What to do now?
At this point, close to 18 mos post injury, patient has functional elbow flexion and shoulder abduction, weak elbow extension and wrist extension, still with insensate hand, but with severe debilitating pain; when we discuss further options (like a special brace to allow return to fishing which he had been passionate about), he reports that he can’t even ride in a car to get to the river; he is clearly depressed and in constant and consuming pain; our interventions to date have made no difference in his function and may have made him worse (Brachioradialis no longer contracting since our exploration of that nerve though we did not take it; Trapezial spasms may be a result of weakening after harvest of spinal accessory though we took distal to initial muscle innervation).
Fig 1. Radiograph showing left shoulder with early subluxation
Fig 2. MRI showing avulsed left nerve root.
JB: I thought we had no wrist extension. This is great news! Regarding pain, he may need referral to a center that is good with the DREZ, but again an assessment of the scapular kinematics and what is the course of his pain would be a priority. We should work hard on the wrist extension and treat the hand like a tetraplegic. Consider a thumb CMC fusion, House intrinsic balance for MP flexion and IP extension at D2-4. Then you could think about using brachialis to power FDPs as described by Bertelli versus just driving passive grasp from his wrist extension.
ZL: Lower brachial plexus injury remains a major challenge to nerve surgeons. This patient poses even more problem for his neuropathic pain management with his intolerance to narcotics and his worker comp status. A multi- disciplinary pain management approach is necessary for this type of patients. Early therapy emphasizes pain modalities, joint range of motion maintenance and strengthening. Oral medications include a combination of tricyclics, anticonvulsants, lyrica and NSAID. Counseling with a psychologist is also beneficial and is an important part of the management as patients are often depressed.
Although this patient’s clinical presentations clearly consist with a lower brachial plexus avulsion injury, we would also wait for about 3-6 months to observe the recovery of the upper plexus and its innervated muscles before proceeding for surgery. We need to know which nerves/muscles could be considered as a potential donor for transfer. The majority of lower plexus injury patients will recover some wrist extension. Pronator teres (C6, 7) and supinator (C5, 6) are usually functioning. We prefer distal nerve transfers without a proximal exploration for this type of injury since the results of proximal lower brachial plexus reconstruction are universally poor. Our current transfer strategy includes - pronator teres branch to the anterior interosseous nerve (AIN) for thumb/finger flexion and the supinator branch to the posterior interosseous branch (PIN) for thumb/ finger extension. The brachialis branch to AIN transfer as describe by Gu, et al. would be considered if the pronator branch is not suitable as in this patient. This patient is only 6 months out from his distal nerve transfer. It is too early to determine whether the transfer is a success. Based on our experience and as reported by Dong et al and Bertelli et al., 9-12 months is the typical time to see some early signs of muscle function recovery after transfer.
GG: The authors have made a valiant effort for a difficult problem. Those who care for brachial plexus patients regularly all go through the same frustrations and failures that the authors present. I think this case really highlights an under-reported and under-discussed problem: the emotional and psychological impact of this injury. While most studies focus on range of motion and strength, there is no question the psychological toll on the patient drives outcomes as much as any intervention we perform.
To that end, all of our patients are referred to a clinical psychologist at the time of presentation and pain specialists if there is any excessive pain. Treating these patients certainly involves treating the entire patient (physical and emotional well being).
As for a treatment plan at this time, once the psychological and pain control issues have been maximally improved I would consider the following algorithmic approach:
In an adult case with middle and lower trunk avulsion injury, I have not been impressed with regaining function from nerve transfers over the natural history. We have used brachialis to AIN with minimal success and this has not been a transfer that has provided good “functional” recovery. In this case, I would wonder if secondary surgery with tendon transfer will afford the best outcome. I will defer to our hand surgeons.
There is some discussion about the NCV not indicating avulsion. This is not correct. When there is an absent motor and a normal SNAP then there is preganglionic lesion. When the SNAP and motor are absent, this does not rule out an avulsion as there is often a stretch injury distal to the DRG in addition to the avulsion. In the latter situation, as in this case, one must pay more attention to the imaging. In this case the avulsion injury was clear and perhaps surgical intervention could have been performed earlier. The transfer of spinal accessory to a distal target such as the triceps (in this case) or biceps, in our hands, has not been useful unless performed early in the process.
Pain is the predominant debilitating factor. It has not been clearly described to allow a determination if the pain is due to the avulsion, musculoskeletal issues or neurotic pain from partial nerve injury. I will assume this to be avulsion related pain with crushing pain in the hand. This pain, when severe, is often refractory to medications. Dorsal column stimulation is unlikely to work as in avulsion there is no dorsal column to stimulate. Deep brain stimulation and frontal cortical stimulation are options with moderate results. DREZ lesioning is an option for the patient and even with the comorbidities, the benefits will greatly outweigh the risks. This will likely bring the pain under control and allow for better rehabilitation, in a truly holistic manner. It is one of my favorite surgical procedures in terms of impact on quality of life.
Again, thank you for presenting this case and I look forward to reading how various people would manage it. There is certainly more than one way to repair a plexus.