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Peripheral nerves & Brachial Plexus
The human nervous system can be divided into the:
Centra Nervous system (Brain, spinal cord)
Peripheral nervous system
Brachial plexus is the network of nerves that sends signals from the spinal cord to the shoulder, arm and hand. It originates from the ventral rami of C5,C6,C7.C8, and T1 spinal nerves (Roots). as they progress they branch into the cords (medial, posterior, lateral) and finally form the terminal branches or peripheral nerves.
Peripheral nerves can be compared to highly sophisticated cables, that relay information between your brain and the rest of your body.
The peripheral nervous system is divided into two main parts:
Autonomic nervous system (ANS): Controlsinvoluntary bodily functions and regulates glands.
Somatic nervous system (SNS): Controls musclemovement (motor function) and relays information from ears, eyes and skin (sensory function) to the central nervous system.
What are the reasons for peripheral Nerve Injuries
Peripheral nerves can be damaged in several ways:
- Injury by cut, crush or acute and chronic (Carpal Tunnel syndrome) compression
Infection (leprosity/Hanson`s disease, …) - Metabolic Disorders: Diabetes, mucopolysaccharoid, …)
- Medical conditions: Pregnancy, Renal failure (dialysis patients), …)
- autoimmune Diseases (Guillain-Barre syndrome, Lupus, Rheumatoid arthritis and Sjogren's syndrome, ….)
- Intoxications, ……
Symptomes of peripheral nerve lesions
Peripheral nerves may have motor, sensory and autonimic functions, which may be impaired to different degrees.
Motor function
Damage to these nerves is typically associated with
– muscle weaknes (palsy)
– muscle cramps
– uncontrollable muscle twitching
Sensory function
Damage to sensory nerves is typically associated with:
– altered touch
– alterted temperature
– pain
Autonomous function
Damage to autonomic nerves can be associated with activities that are not controlled consciously, such as
breathing, the heart, thyroid function, and digestion, which can result in secondary complications secondary to:
– excessive sweating
– changes in blood pressure
– inability to tolerate heat
– gastrointestinal symptoms
Multidisciplinary Patient Care
Only through an intensive interdisciplinary Cooperation can achieve an optimal therapy result be reached. Therapy team members are :
Hand Surgery (often in conjunction with the neuropathologist)
- Physiotherapy
- Neurology
- Radiology
- Anesthesia & Pain Clinic (deafferentation pain, causalgia, …)
- Internal Medicine (Diabetes, Dialysis, ….)
- Social services/employment office/professional association (professional rehabilitation or reintegration)
- Orthopedic technician (sleeve and splint apparatus)
- Mental support
- Patient support groups
The constant exchange of information (Telephone calls, medical reports) within the team is exceptional Importance. An optimal treatment result can only be achieved if all members of the therapy team work together seamlessly.
Integrated Treatment Concept according to BERGER
Prof. Dr. Robert Hierner is a reference in the field of interdisciplinary and multi-professional treatment of peripheral nerve lesions.
For the treatment of lesions of peripheral nerves, the so-called “integrative therapy concept according to BERGER” is used. It comprises:
- Primary nerve reconstruction (primary nerve suture/coaptation, nerve transplantation, ….)
- Secondary muscle replacement surgeries (Tendon transfer, free functional muscle transplantation, …)
- (tertiary) adjuvant interventions
The duration of therapy depends on the type of lesion from 2 – 6 weeks up to 3 – 5 years. During this period is a physiotherapeutic Basic therapy – in different form and
intensity – is Indispensable requirement
Acute Nerve Injury
Chronic Nerve Compression (Carpal Tunnel Syndrome)
Old nerve lesion (long standing nerve palsy)
Brachial Plexsus Lesions
Acute Nerve Injury
Acute nerve injuries can leed to 2 situations:
- Lesion with continuity loss
- Lesion-in-continuity
Peripheral nerve reconstruction with the aim of improving motor skills should be carried out no later than 12
(large distance, i.e. proximal lesion) or a maximum of 18 months (small distance, distal lesion), as the endorgan muscle will undergo irreversible degenerative changes with muscle denervation. If improvement in (protective) sensitivity is to be achieved, an nerval reconstruction can still be carried out after
24 – 36 months.
- Lesion with continuity loss
– In cases with clear cut and no nerve tissue loss, microsurgical tension-free nerve suture (nerve
coaptation) is performed.
– In cases with loss of nerve tissue, reconstruction of the nerve gap can be performed using
several techniques, such as nerve tubes or nerve grafts taken from the patient (autologous)
Postoperatively the coaptation must be protected for 10- 14 days by immobilization. Heavy work and impact action can be resumed after 6 weeks. The higher the nerve lesion, the longer regeneration time (1mm a day). At the hand level, nerve regeneration needs 6 – 12 months
- Lesion-in-continuity
In cases of preserves continuity, standardized clinical and neurophysiological examinations are
mandatory, for at least 3 – 6 months. Depending on the quality of nerve regeneration, different forms of nerve reconstruction as necessary
Chronic Nerve Compression
(Carpal Tunnel Syndrome)
What causes carpal tunnel syndrome?
Nerve compression syndrome – also known as nerve entrappment syndrome – is a
chronic nerve lesion. It occurs where peripheral nerves pass through anatomical
narrows bounded by rigid structures. Factors such as metabolic disorders (diabetes,
pregnancy, mucopolysacharoidosis, …) or toxic factors (dialysis, …) favor the
occurrence of compression syndromes. In case of arthritic changes at the cervical spine
with beginning nerve root compression (radicular compression) the peripheral
compression syndrome can be inhanced (“double crush syndrome”)
Carpal Tunnel Syndrome, which is the entrapment syndrome of the median nerve at the wrist level – is the most common chronic compression syndrome in humans. Nearly, 50% of all humans will experience more or less carpal tunnel syndrome during aging.
Other frequent chronic nerve compression syndromes in the arm are:
- Carpal tunnel syndrome
- Sulcus ulnar nerve syndrome
- Posterior interosseous nerve syndrome
- Thoracic outlet syndrome (TOS)
What are the Symptomes of Carpal Tunnel Syndrome?
The resulting functional disorder depends on the extent and duration of the constriction. It can
range from slight discomfort (“hands go to sleep”) to a minor motor weakness (increasing
clumsiness) to complete (senso-motor) paralysis. Nocturnal pain is also typical, waking the
patient up and causing him to shake his/her hands or let him/her hang down from the bed
How can you treat carpal tunnel syndrome?
Nerve lesions of any kind need a full neurological work-up. For the treatment of carpal tunnel syndrome we are using the "Integrative Therapy ” Concept according to BERGER”. The goal of treatment is to relieve the pain and restore normal sensibility and grip function, by:
- Prevention and Awareness
- Conservative (non-operative) treatment
- Operative treatment
Basic Nerve Care
The best therapy for age-related carpal tunnel is to avoid it (wear and tear due to repetive motions, excessive strain, lack of exercise, poor diet, …).
Vitamin B complex is a necessary component for the development of peripheral nerves. Deficiency leads tothe increased susceptibility of nerves to
chronic pressure.
Non-operative (conservative) Treatment
Non-surgical treatments can be used successfully, especially when symptoms first manifest:
- Night splinting
- Cortisone injection
- Physiotherapy
- Anti-inflammatory treatment
- Correction of water balance
Operative Treatment
With the help of numerous conservative and minimally invasive treatment methods, a significant reduction in age-related skin changes in the hand area can be achieved without surgery. The different methods have different main treatment goals.
The various techniques can be used alone or in combination with other conservative, minimally invasive and surgical treatment methods.
Old nerve lesion
(long standing nerve palsy)
Complete nerve lesions lead to irreversible changes at the muscles (motor function) after 12 to 18 months and nerve receptors (sensory function) after 24 – 36\ months. Beyond this timeframe, there is no useful function results to be expected from nerve repair/reconstruction. For these cases secondary reconstructive methods are used.
- Secondary muscle function reconstruction
- Secondary sensory function reconstruction
- Secondary muscle function reconstruction (muscle replacement surgery)
Muscle functions can be restored by motor replacement surgery which are indicated to replace a lost motor function or augment a partially recovered motor function. These replacement surgeries are an essential part of the integrative Concept for rehabilitation after peripheral nerve injuries.
With normal innervated muscle-tendon units postoperative immobilization with a splint in the position relieving the tendon sutures for 4-6 weeks. Intensive physiotherapy is necessary to train the new motor function. In motor replacement surgery after lesions of the Plexus brachialis has proven the ” 6+6 rule”. an Immobilization phase of 6 weeks is followed by a phase of progressive load build-up of also 6 weeks.
- Secondary sensory function reconstruction (nerve replacement surgery)
When touching or grasping objects, important non-visual information about the environment can be realised, which is particularly clear in the case of blind persons. The ulnar side of the fingertips of the index and middle fingers and the radial side of the ring and little fingers are of lesser significance for tactile realisation . The contra-lateral side of each fingertip is described as dominant on account of its gnostic significance. The sensitivity in the area of the ulnar thumb tip and the radial index fingertip is essential for the point and key grips. According to their functional value, the hierarchy of the fingertip areas can be given as:
– the ulnar hemipulp DI
– the radial hemipulp DII
– the radial hemipulp DIII
– the ulnar hemipulp DV
– the radial hemipulp DIV
– The quality and quantity of this non-visual information are dependent on the possibility of information from the hand, especially in the area of the fingertips, its transmission by the peripheral nervous system and its processing in the central nervous system.
Brachial Plexus Lesion
Acquired brachial plexus lesions may be caused by
- acute trauma
- post-traumatic lesions of adults
- birth trauma in babies (Obstetrical brachial Plexus
Lesions/OPBL) - chronic damage by compression (thoracic outlet syndrome/TOS)
- Radiation-induced brachial plexus neuropathy (RIBPN) (in breastcancer)
- Tumor-induced brachial plexus neuropathy (TIBPN) (lung/Pancoast cancer, breast, ..)
- others (inflammation, …….)
Posttraumatic Brachial Plexus Lesion of the Adult
In adults, post-traumatic injuries to the Brachial plexus most commonly caused by traction, compression, or a combination of both. Most cases involve motorcycle accidents.
Brachial Plexus lesions require a multidisciplinary team approach using a common diagnostic and documentation.
We use a standardized diagnostic procedure to record the damage as precisely as possible. In the case of post-traumatic lesions of the brachial plexus in the context of polytrauma, the standardized diagnostic procedure mentioned above must be integrated into a comprehensive diagnostic and therapeutic scheme for polytrauma. The primary therapy (conservative vs. operative) is determined based on the results of repeated clinical and instrumental examination. Based on the examination results, 3–6 months after the trauma, patients can be filtered out with a high degree of probability who have to reckon with serious defect healing after conservative therapy.
For the treatment of Brachial Plexus lesions we are using the integrated treatment concept according to BERGER, which in addition to the primary nerve reconstruction uses secondary muscle replacement surgeries and (tertiary) adjuvant interventions. The duration of therapy is independent from the chosen primary therapy (conservative vs. operative) about 3-5 years. Adequate Pain management and intensive physiotherapy is during the entire duration of therapy – in different form, intensity and objective – are integral parts of the therapy. Reconstruction of basic functons depends on the severity of lesion.
- Obstetrical Brachial Plexus Lesions/OPBL
A birth traumatic lesion of the brachial plexus occurs in 0.5–3 from 1,000 births. "Risk factors" for OPBL
are:
- child's birth weight > 4,000 g (NOTE: Diabetes mellitus of the mother)
- anatomical variants in the area of the woman's birth canal
- breech position (usually with a small birth weight of the child)
- emergency situation during the advanced birth with threat for child and/or mother (NOTE: OPBL can
also occur with C-section)
Brachial Plexus lesions require a multidisciplinary team approach using a common diagnostic and documentation. We use a standardized diagnostic procedure to record the damage as precisely as possible. The primary therapy (conservative vs. operative) is determined based on the results of repeated clinical and instrumental examination. Based on the examination results, 3–6 months after the trauma, patients can be filtered out with a high degree of probability who have to reckon with serious defect healing
after conservative therapy. For the treatment of Brachial Plexus lesions we are using the integrated treatment concept according to BERGER, which in addition to the primary nerve reconstruction uses secondary muscle replacement surgeries and (tertiary) adjuvant interventions. The duration of therapy is independent from the chosen primary therapy (conservative vs. operative) about 3-5 years. Tthe earlier the secondary corrective operations are performed, the greater the natural potential for correction through growth. Adequate Pain management and intensive physiotherapy is during the entire duration of therapy – in different form, intensity and objective – are integral parts of the therapy. Reconstruction of basic functions depends on the severity of lesion. The shoulder function is the quality indication of treatment.
Chronic damage by compression Thoracic outlet syndrome/TOS (Chronic damage by compression)
Thoracic Outlet Syndrome (TOS) is a poorly defined complex of complaints caused by compression of the so-called neurovascular bundles, i.e. of the brachial plexus and/or the Arteria and vena subclavia in the area of the upper thoracic aperture.
During the course of the neurovascular bundle from the neck to the upper extremity, there are various possibilities of a static and/or dynamic entrapment possibilities
- Supraclavicular compresssion
- pleural ligaments
- scalenus muscle aberrations
- cervical rib/ligament
- Retroclavicular compression
- Backpack palsy
- Infraclavicular compression
- clavipectoral region
- retropectoral region
- infrapectoral region
- Affected are predominantly 20 to 50 year old, skinny patients. The peak age is between 30 and 40 years with a clear preference for the female gender.
The most common causes of TOS are:
* Anatomical malformations (see above)
* Trauma in the shoulder and neck area (slingshot, impact and strain trauma)-
* Postural abnormalities: Limp posture phenotype with drooping forward shoulders. It is characteristic that the complaints in the 3rd decade of life,
i.e. H. at the time of physiological lowering of the shoulder girdle.
Diagnostic and Treatment of TOS requires a multidisciplinary team approach using a common diagnostic and documentation.
There is a classical patient history: The patients initially mostly report symptoms of irritation in shape of paresthesia or pain predominantly in the Th1 dermatome,
later also C8. Overhead work or carrying heavy loads on the hanging arm, the symptoms can trigger or increase. Paresis occurs in later stages. Various provocation
tests, e.g. the ADSON test, the traction test or the ROOS test, have been described for the TOS.
The Choice of treatment mainly depends on the type of symptoms:
if neurological symptoms are present, physiotherapy should be done over 6 – 12 weeks, aiming to strengthen the shoulder girdle muscles. If the symptom
increase or persist, surgical decompression of the brachial plexus is indicated
if vascular symptoms are present the indication for surgical therapy is made at an early stage
Radiation-induced brachial plexus neuropathy (RIBPN)
Radiation-induced brachial plexus neuropathy (RIBPN) is a rare and delayed non traumatic injury to the brachial plexus, which occurs following radiation therapy to the chest wall, neck, and/or axilla in previously treated patients with cancer. The incidence of RIBPN is more common in patients treated for carcinoma of the breast and Hodgkin lymphoma. With the improvement in radiation techniques, the incidence of injury to the brachial plexus following radiotherapy has dramatically reduced. The currently reported incidence is 1.2% in women irradiated for breast cancer.
The progression of symptoms is gradual in about two-thirds of cases; the patients may initially present with paresthesia followed by pain, and later progress to motor weakness in the affected limb.
Most Patient are treated conservatively.
Surgical intervention consists of removing scar tissue and replace it by well vascularized tissue. Aim of surgery is to
reduce/relief chronic pain, not to improve motor or sensory function.
Tumor-induced brachial plexus neuropathy (TIBPN)
The brachial plexus can be involved in a primary /very rare) or secondary (lung/Pancoast Tumor, breast cancer, ..) tumor process.
The clinical presentation of brachial plexus tumors in patients is often variable but can include a painless palpable mass, local or radiating pain, motor loss, sensory loss, paresthesias, and dyspnea. Treatment of the brachial plexus involvement must be integrated in a multidisciplinary, multimodale tumor treatment, set by a tumor board.
