Hand Peripheral Nerve and Brachial Plexus Surgery

The peripheral nervous system is a network of 43 pairs of motor and sensory nerves that connect the brain and spinal cord (the central nervous system) to the entire human body. These nerves control the functions of sensation, movement, and motor coordination. They are fragile and can be damaged easily. When one of these nerves suffers serious injury or trauma, surgical treatment may be needed.

People with traumatic nerve damage can experience severe, unrelenting pain, burning sensation, tingling, or total loss of sensation or motor function in the part of the body affected by the damaged nerve. Some common causes of peripheral nerve injuries are:

Peripheral Nerve Injury can be classified into 5 categories depending on the severity of the injury.

• First degree – A reversible local conduction block at the site of the injury.
• Second degree – There is a loss of continuity of the axons (the “electrical wires”) within the nerve.

• Third degree – There is damage to the axons and their supporting structures within the nerve.
• Fourth degree – There is damage to the axons and the surrounding tissues sufficient to create scarring that prevents nerve regeneration.
• Fifth degree – These injuries are usually found in lacerations or severe stretch injuries.

Non-Surgical Options

• Acupuncture
• Massage therapy
• Medication
• Orthotics
• Physical therapy and rehabilitation 

Surgical Options

• Neurolysis (release of the nerve from surrounding scarred tissue)
• Nerve decompression (release the nerve from surrounding tight normal tissues)
• Nerve repair
• Nerve grafting (using a segment of another nerve to bridge a gap in a nerve)
• Nerve transfer (using another nerve to restore function)
• Tendon and muscle tranfer (use of another tendon or muscle to restore motor function)

Brachial Plexus Injury

The Brachial Plexus is a network of nerves that conveys movement and sensory signals from the upper spinal cord in the neck down into the arms and hands. Trauma to the neck or shoulder can injure the brachial plexus, causing pain, numbness, weakness, or paralysis in the arms or hands.

Some brachial plexus injuries heal on their own with normal or near-normal function. For more severe injuries, brachial plexus surgery may be the best chance to relieve pain and restore sensation and mobility.

Need for brachial plexus surgery

• People with neck or shoulder trauma
• People with continuing, debilitating pain or loss of function in the arm after a trauma or because of nerve damage during surgery.
• People with scarred nerves that form tumors called neuromas.
• People with nerve tumors of the brachial plexus that were not caused by trauma, such as schwannomas and neurofibromas.

Types of Brachial Plexus Surgery – The goal of brachial plexus surgery is to relieve the pain and restore sensation and motor function to the shoulder, arm, and hand.

Brachial Plexus Nerve Repair

When a nerve is cut or torn, the surgeon may be able to re-connect it by sewing the ends back together. This is performed with the help of a microscope and small, specialized instruments.

Brachial Plexus Decompression and Neurolysis

When a nerve is compressed but otherwise intact, decompression surgery can help relieve the pressure on the nerve and address related symptoms and loss of function. This can be done by removing scar tissue or adhesions (a procedure called neurolysis) from around the injured nerve.

Nerve Grafting Surgery for Brachial Plexus Injuries

When a nerve has been injured or scarred severely, it may no longer be able to carry signals from the brain to the arm and hand, leading to paralysis. In this case, surgeons can remove the damaged nerve segment and replace it with a segment of an expendable sensory nerve from another part of the body, such as the sural nerve in the leg. This procedure helps create a bridge that replaces the injured portion of the nerve and provides a pathway for nerve regeneration.

Brachial Plexus Nerve Transfer Surgery

During a nerve transfer, a nearby functioning nerve that is performing a non-critical function is connected to the injured nerve. This creates a framework for new growth and a pathway for signals. In many cases, a nerve transfer procedure provides the best chance of restoring movement and sensation to the muscles and skin.

Tendon Transfer Surgery for Brachial Plexus Injuries

During a tendon transfer, a functioning and expendable tendon are attached to a tendon that is paralyzed due to brachial plexus injury. After tendon transfer, the functioning tendon will pull on the once paralyzed tendon to restore lost movement in an upper extremity.

Functional Muscle Transplant for Brachial Plexus Injuries

Functional muscle transplant is another option to restore movement when too much time has passed after the brachial plexus injury and when nerve repair, grafting, or transfer is no longer possible. A non-essential muscle, such as the gracilis muscle of the inner thigh, is transplanted to replace a no-nfunctioning muscle in the shoulder, upper arm, or hand.

Recovery After Brachial Plexus Surgery

Recovery after brachial plexus surgery includes healing of the tissues that were operated on and recovery of lost function. While healing of the tissues is relatively quick, function recovery may take months depending on the procedure you had and the extent of the injury.

• After surgery, one may need to use a sling or splint to keep the affected arm.
• For some nerve transfers below the elbow, a splint may be needed for two weeks.
• Nerve repairs, transfers, and grafts above the elbow typically require a sling for only two weeks.
• For tendon transfers and functional muscle transplantation, a sling and/or splint is likely required for one to three months. During this time, you may start physical therapy.
• Physical therapy is critical to help one recover after brachial plexus surgery. The type of therapy, timing, and duration depend on the type of surgery.

After nerve repair, grafting, and transfer, a period of nerve regeneration is required before movement and sensation improved. This can take months to years, depending on the type of surgery performed.