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BRACHIAL PLEXUS
The human nervous system can be divided into the: The brachial plexus is the network of nerves that sends Peripheral nerves can be compared to highly
Centra Nervous system (Brain, spinal cord) signals from the spinal cord to the shoulder, arm and sophisticated cables, that relay information between
Peripheral nervous system hand. It originates from the ventral rami of C5,C6,C7.C8, your brain and the rest of your body.
and T1 spinal nerves (Roots). as they progress they The peripheral nervous system is divided into two main
branch into the cords (medial, posterior, lateral) and parts:
finally form the terminal branches or peripheral nerves. Autonomic nervous system (ANS): Controls
involuntary bodily functions and regulates
glands.
Somatic nervous system (SNS): Controls muscle
movement (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
The constant exchange of information (Telephone calls, doctor's letters) within the team is exceptional Importance. An optimal treatment result can only be achieved if all
members of the therapy team work together seamlessly.
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 Old nerve lesion Brachial Plexsus Lesions
(Carpal Tunnel Syndrome) (long standing nerve palsy)
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
- 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
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.
• Operative treatment
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
If symptoms persist for a longer period of time, surgery is the treatment of choice.
Relief of the carpal canal can be achieved either via a mini-incision or endoscopically.
Adequate postoperative pain therapy must be ensured. Medications (e.g. Arcoxia 90 mg 1-0-0, ...) should be taken already 1 day before surgery. Postoperatively, the hand should be moved
immediately. Physiotherapeutic follow-up should be started early. A large bandage or even immobilization on a splint is not necessary. Suture removal is performed 10 - 14 days after surgery. After
suture removal, scar massage with Vaseline 3-5x/day for 4 - 6 weeks is recommended.
Patients with a desk job are able to work for 1 - 3 days and manual workers for 2 - 3 weeks.
Nocturnal pain should persist immediately after surgery. Pre-existing sensory disturbances disappear - depending on the severity and duration - only after 3 - 12 months.
NOTE: Carpal tunnel release is the second most common hand surgical procedure worldwide
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
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
o post-traumatic lesions of adults
o birth trauma in babies (Obstetrical brachial Plexus
Lesions/OPBL)
chronic damage by compression (thoracic outlet syndrome/TOS)
Radiation-induced brachial plexus neuropathy (RIBPN) (in breast cancer)
Tumor-induced brachial plexus neuropathy (TIBPN) (lung/Pancoast
cancer, breast, ..)
others (inflammation, …….)
Posttraumatic Brachial Plexus Lesion of the Adult
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.
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
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.