Timing is Everything...

"We will refer the patient for a brachial plexus surgery evaluation, although they will not do surgery until a year after the injury..."

This is a direct quote from the chart of a patient referred to me by a neurologist and an orthopaedic surgeon in another state. To me, this is maddening - absolutely drives me nuts! For that particular patient's injury, waiting more than a year to do the surgery would have left us with minimal chance of success after a nerve reconstruction.

Timing is incredibly important in the treatment of traumatic brachial plexus injuries. I often find myself discussing the importance of timing of treatment with both patients and referring physicians, so I thought this would be a good place to share my thoughts.

After a traumatic nerve injury occurs, the clock starts ticking. When a muscle no longer receives input from a nerve, it can become atrophic - essentially, when it has no signal to perform its function, it withers away. These changes are evident in human muscle at approximately 3 months - sometimes sooner, sometimes later. Somewhere around 12 months, these changes become irreversible, leaving the muscle essentially useless - even if you are able to establish a good nerve signal into the muscle with surgery or spontaneous recovery. At the same time as the muscle withers away, the distal part of the injured nerve (the part of the nerve "downstream" from the injury) also starts to degenerate. This makes it even harder to reconstruct a nerve injury after a long period of time, whether you excise and replace the injured nerve with a nerve graft or bypass the injured nerve with a nerve transfer.

What I wrote above it based on a number of animal studies and laboratory studies of human tissue, but has also been borne out in the clinical experience. While brachial plexus injuries (and this "timing" issue, in particular) are really tough to study with rigorous clinical trials, the collective experience and case series from multiple surgeons reflect that there is a relationship between clinical outcomes and timing of surgery - essentially, the sooner the better.

I prefer to see any patient with a brachial plexus injury or complex peripheral nerve injury as soon after the injury as possible. A pretty good number of these injuries may get better on their own without surgery - with careful watching, repeated examinations, and physical therapy. I would rather have a patient go through that process with me from as close to "day 1" as possible, so that if the recovery is inadequate by 3 months (or 5 months, etc... depending on the specifics of the case), we can be ready to intervene surgically at a time that is optimized for success.

Why I Treat Patients with Brachial Plexus Injuries

When I was recruited to join the faculty of the Peterson Hand Center at Washington University Orthopedics, I was thrilled - and for good reason, as it is one of the premier orthopaedic hand surgery divisions in the world. I immediately told several friends and colleagues from around the country, who shared my excitement, then asked a followup question - what was my area of subspecialty focus? When I would enthusiastically reply "brachial plexus  surgery", I was sometimes greeted by an interesting response - a quizzical look with a subdued shade of pity, paired with "Oooh... Why?"

Although I hardly agree, I can certainly understand why some surgeons do not want to treat patients with brachial plexus injuries - the circumstances are often unfavorable; the surgeries are long, tedious, and can be exhausting; and the outcomes are far from certain. Interestingly, these are some of the same things that I love about treating patients with brachial plexus injuries. From a purely "medical" perspective, I love the challenge of diagnosing the exact injury, figuring out the best treatment plan, seeing the breathtaking anatomy, and performing a surgery that intimidates others. But to be honest, the most rewarding part of it all is when the patient realizes the surgery has worked. After months and sometimes years of being told that they won't be able to use their arm at all, going through a ton of tests and doctors visits, and summoning up the courage to go through a long surgery (sometimes two or more), the patient can feel that things are getting better and that their motion and strength are improving. While this improvement certainly occurs over a long period of time, that initial feeling alone is enough to inspire hope and begin undoing months of pessimism and second guessing. I will never forget the ecstatic impression of my first patient who regained motion in his fingers after a tough nerve injury with a less-than-certain prognosis, and I can guarantee that the feeling never gets old for me. So that look - the initial, unfiltered "wow, that muscle is working!" look - that is why I love treating patients with brachial plexus injuries.