Brachial plexus injury (BPI) represents a severe and debilitating peripheral nerve injury often affecting young adult population carrying significant economic and social burden. The prevalence of BPI among multitrauma victims is 1.2%, and the primary cause of injury is high-energy accidents, mostly motorcycle and snowmobile accidents with an incidence approaching 5%. ¹ Typically, men are more affected than women because of the association with violent trauma and contact sport leading to other related injuries, such as head and cervical spine injuries, which may delay diagnosis and management of the BPI. It is important to recognize, diagnose, and manage these patients in a timely manner to allow best chance of recovery. In this chapter, we briefly describe the approach to patients with BPI with emphasis on appropriate surgical management and outcomes.

Appreciating the structures of the brachial plexus, starting with the cervical spinal cord, nerve roots, trunks, divisions, cords, and terminal branches, together with the corresponding muscles and skin innervation, is paramount for clinical evaluation of these patients and directly relates to the surgical management.

66.2 Patient Selection

Classification of BPI can be according to the extent of neural involvement: complete (flail arm) or incomplete, where only some elements of the brachial plexus are involved. Further classification refers to the level of injury, which includes avulsion injury (preganglionic), supraclavicular injury (upper, middle, or lower trunk) and infraclavicular injury (cords or terminal branches). Obtaining a thorough history with regard to the mechanism of injury and detailed physical examination with grading (motor and sensory) of each level assist with classification and localization of the injury.

In a large series by Kim et al, the outcome of 1,019 patients treated surgically for brachial plexus lesions during a 30-year period were analyzed. ² This study is a landmark in the field of brachial plexus surgery; the authors analyze the extensive experience of a single surgeon in one institute. In this series, 698 brachial plexus lesions were related to trauma. The most common mechanism of traumatic injury was stretch/contusion (including avulsion injury) accounting for 509 (73%) of BPI, most of which were supraclavicular (72%). Other BPI included those from 118 gunshot wounds (17%) and 71 from lacerations (10%).

High-energy injury, as in motor vehicle accident, results in higher risk of root avulsion, which can be further suspected and confirmed based on characteristic clinical and laboratory findings ( ▶ Table 66.1). Preganglionic disruption should be recognized early for better prognostication and management of these injuries because we do not expect any spontaneous recovery and return of function of the avulsed level. Surgical treatment for avulsion injuries and many of the extensive proximal injuries mainly consist of nerve transfers and possibly later muscle or tendon transfers, depending on the function of adjacent levels and timing for surgical intervention ^{3,​ 4} ( ▶ Fig. 66.1).

Expected recovery is dependent on the type of injury and the extent of involvement of brachial plexus elements ( ▶ Table 66.2). A complete BPI (flail arm) with evidence of C5–T1 involvement carries a poor prognosis with a low chance of recovery. Treatment of these patients includes exploration of the spinal nerve roots to evaluate whether grafting could be done from C5 or others ² because the possibility and results with extraplexal donors for nerve transfers are quite limited. Generally, a graft repair is combined with nerve transfers using extraplexal donors or free muscle grafts, although functional recovery of the arm and hand is usually limited. Supraclavicular BPI involving only C5 and C6 nerve roots carry relatively favorable outcome after reconstruction (graft repair with or without nerve transfer). Infraclavicular BPI is less frequent than supraclavicular injury and often is associated with other upper extremity injuries (e.g., vascular injury, shoulder dislocation or fracture, humeral fracture). These infraclavicular injuries, particularly for lateral and posterior cords and their terminal nerve, are amenable to good outcomes with graft repairs. ²

Classification and accurate localization of BPI are important for prognostication, estimating expected functional recovery, and tailoring the most appropriate intervention. Other neurologic insults should be noted, such as traumatic brain injury or spinal cord injury, which may influence the current neurologic status and also recovery potential. It is important that the patient and supporting family understand the goals of surgery and have reasonable expectations. For example, normal function of the affected arm and, respectively, the hand is not expected in cases of severe injury. As mentioned, the level of the injury plays an important role. In general, as the injury is more proximal, the recovery is often restricted. Timing of the surgical intervention is scheduled usually within 3 to 6 months after the injury to allow for spontaneous recovery. An exception is in cases of sharp, clean transection of the brachial plexus elements. In these rare cases, primary repair should be performed as soon as possible but not longer than 3 days thereafter. The potential to restore function from nerve repairs 12 months or longer after the injury is limited and should be avoided. If a patient seeks treatment more than 1 year after the injury, salvage procedures such as free muscle or tendon transfers may be indicated ( ▶ Fig. 66.1).

66.3 Preoperative Preparation

After BPI, the patient should be clinically evaluated, and unless operation is performed within 72 hours (e.g., in rare case of sharp, clean laceration), imaging and electrophysiology studies should be obtained. Magnetic resonance imaging of the cervical spine and brachial plexus should be ordered to evaluate for possible avulsion injury ( ▶ Table 66.1, ▶ Fig. 66.2).

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