Wednesday, February 1, 2017

Nonoperative Treatment of Brachial Plexus Injuries

The last blog post talked about a list of brachial plexus injury topics that patients and their families want more information about... so let's start with talking about nonoperative treatment for brachial plexus injuries. 

One of the most important things to me is seeing patients with suspected brachial plexus injuries relatively soon after their injury, ideally within the first 6 weeks. This lets me establish a relationship with my patients long before we "need" to talk about surgery, since there is often a good chance that the nerve injury will recover without surgery (although lots of time, patience, and therapy is needed to get back to function). 

When I see a patient early on after their injury, we talk about the "basics" - what the brachial plexus is, how the nerves work, how they are usually stretched but can sometimes be pulled out of the spinal cord, and that it takes about 3 months to start to see signs of recovery (not full recovery... but hints that things are going to improve over time). During this initial 3-4 months after their injury, we focus on physical therapy to strengthen the remaining muscles (especially those around the shoulder blade/scapula), stretching to keep the joints supple, getting any nerve-related (neuropathic) pain under control, allowing other injuries (like fractures/broken bones) to mend, and (very importantly) keeping a healthy mind state (since depression and anxiety come up more than we typically expect). 

We usually get a nerve test (EMG) at the 6 week mark and at the 3 month mark, allowing me to compare whether the muscle recovery has progressed over time. Usually at 3 months, we'll see some slight hints of recovery and we can make some decisions about whether to proceed to surgery (if there isn't any recovery) or whether to wait and see what recovers (if there are signs of muscle activity). If we wait and see, we'll get another EMG and I'll examine the patient again in about 6 weeks. If things are moving in the right direction, we'll let the recovery mature and check how things are in another 1-2 months. If there aren't any signs of muscle recovery, we'll discuss surgical options again.

Establishing an early relationship with my nerve injury patients is important to me, since I often end up being the "quarterback" or captain of their care - long after their other injuries have healed, treatment for the nerve injury is front and center. I would rather see patients early on and watch them heal without surgery than meet patients for the first time a little later than I prefer... and have to tell them that they should have surgery.

Just a couple of thoughts for now - I'll follow this up with a brief Q&A with a patient who went through the nonoperative treatment process with me... and is doing incredibly well!