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Title: Nerve Transfer Boosts Recovery After Brachial Plexus Injury

Body text: When evaluating a patient with a brachial plexus injury, it is important to determine whether recovery might occur with time, or whether surgery will be required to restore movement to the arm. Because these injuries are relatively rare, though, most centers have little experience with them. By contrast, brachial plexus injuries are a mainstay of the practice of <a href="https://advances.massgeneral.org/contributors/contributor.aspx?id=1114">Justin M. Brown, MD</a>, Director of the Mass General Paralysis Center. Working with a multidisciplinary team, Dr. Brown has been able to restore function even in arms that completely lacked movement. <h2>Nerve Transfer: Pioneering a New Approach</h2> Dr. Brown has devoted his career to developing new surgical procedures for brachial plexus injuries, most notably the nerve transfer. “When part of the arm is paralyzed, we are able to splice the remaining nerves to recover muscle function,” Dr. Brown explains. For example, if the patient has a healthy hand, but no movement in the biceps and shoulder, Dr. Brown can “rewire” from a portion of the median and ulnar nerves into the musculocutaneous nerve to produce strong elbow flexion. And then he could use branches from the triceps to restore the deltoid, and splice the spinal accessory nerve to the rotator cuff to allow external rotation and abduction of the shoulder. <h2>Timely Referral Is Key</h2> “Unlike spinal cord injuries, where you can do things long after the accident, for brachial plexus injuries it’s important that the patient come in as soon as possible,” Dr. Brown emphasizes. “The longer they wait, the fewer options we have available to restore their function.” Mild brachial plexus injuries, those associated with paresthesia in the arm and sometimes weakness of the shoulder, often heal on their own. But complete numbness and paralysis in the arm and/or hand signifies very severe damage. It is important to determine right away whether surgery will be needed to restore movement. <h2>The Importance of a Multidisciplinary Team</h2> Dr. Brown urges colleagues to refer patients with brachial plexus injuries to a center of excellence that takes a team approach. The procedures involved in restoring movement to paralyzed limbs requires expertise and collaboration from a variety of fields, and “most centers don’t have all of those at their disposal,” Dr. Brown says. At Mass General, these specialists cooperate with each other closely. <a href="https://www.massgeneral.org/doctors/doctor.aspx?id=17975">Martin P. Torriani, MD</a>, of the <a href="https://www.massgeneral.org/Imaging/">Department of Radiology</a>, has developed MRI techniques that capture the fine detail needed by neurosurgeons. Dr. Brown works regularly with a neurologist, <a href="https://www.massgeneral.org/doctors/doctor.aspx?id=19918">Reiner See, MD</a>, who specializes in gathering electromyography data to predict the extent of a patient’s recovery. Dr. Brown also collaborates with <a href="https://www.massgeneral.org/doctors/doctor.aspx?id=19573">Kyle R. Eberlin, MD</a>, and <a href="https://www.massgeneral.org/doctors/doctor.aspx?id=17405">Jonathan M. Winograd, MD</a>, of the <a href="https://www.massgeneral.org/plasticsurgery/">Division of Plastic and Reconstructive Surgery</a>, as well as two hand surgeons in the <a href="https://www.massgeneral.org/ortho/">Department of Orthopaedic Surgery</a>, <a href="https://advances.massgeneral.org/contributors/contributor.aspx?id=1129">Neal Chen, MD</a>, and <a href="https://advances.massgeneral.org/contributors/contributor.aspx?id=1132">Chaityana Mudgal, MD</a>, to choose the best reconstructive strategy for any given patient. “Making a limb move again often involves fairly innovative strategies,” Dr. Brown says. “We may have to use plastic surgery to find a muscle from the leg that can be used in the arm that can restore movement we weren’t able to achieve with the primary nerve repair.” <h2>Support for Rehabilitation</h2> Dr. Brown tells patients that nerve transfer is analogous to planting a garden. The “wires” within the nerves must grow back down to the muscle, which must begin to activate and then be strengthened. Recovery generally takes between three months and two years, depending on the complexity of the case. Beginning immediately after surgery, Dr. Brown says, he and his team make sure that patients maintain passive range of motion of the arm and strengthen the nerves. They start working with therapists as soon as they begin to regain motion, to learn how to move and strengthen the muscle. He sees patients for at least three years postoperatively, and adjusts treatment if another procedure might improve their function even more. “The difficulty with brachial plexus injuries across the country is that there are many surgeons who are willing to try surgery,” concludes Dr. Brown. “But because they rarely see these injuries, many patients have poor results. It’s important for patients to come to a place that has real comfort with all of the different reconstructive options.”

Publish date: 06/07/2018

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Brachial plexus injuries need to be assessed as quickly as possible after injury to give surgeons more options in restoring function
Restoring severe brachial plexus injuries often requires a team of doctors and surgeons from a variety of fields including neurosurgery, orthopedics, plastic surgery and more
Dr. Brown has devoted his career to pioneering new approaches for brachial plexus injuries, most notably the nerve transfer

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