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Brachial Plexus Injury
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Houston , TX 77030
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Brachial Plexus Forum

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Resources

  • Before and After TT
  • Bony Improvement - Before and After - Mod-Quad and TT

Nerve Surgery - Primary Surgery

The protocols at The Nath Brachial Plexus Institute are based on our experience with thousands of children with brachial plexus injuries seen in the last 8 years.. Generally, if there is continued significant shoulder and/ or elbow weakness by the age of 4 to 6 months of age, and certainly, if there is significant weakness in the biceps muscle by 6 months of age, we believe that surgical exploration is indicated.

The intraoperative nerve testing then defines the specific procedure used to improve arm function. It is very important to note that in 12 to 18 months following injury, denervated muscles will not accept a new nerve supply, and remain paralyzed or weak permanently. Because nerves only grow back at one inch per month, time is of the essence in managing these and any other nerve injuries. Bone deformity can accompany longstanding paralysis of any limb in growing children.
Brachial plexus anatomy



Click for enlarged view
Specific nerve surgeries that we use are: nerve scar excision (neurolysis), nerve grafting, nerve transfer and neurotization. It is sometimes necessary to perform tendon lengthening procedures in infancy in conjunction with the nerve procedures. These procedures are complex and must be used judiciously in order not to burn bridges for future reconstructive options.

Additionally, wrist, finger and thumb movements are often affected, leading to problems with hand grasp and finger pinch. A series of tendon/ muscle transfers can help to achieve excellent function with these injuries as well.


The basic principle is that some strong muscles and tendons can be re-routed to strengthen weaker functions by sewing the transferred tendons into the paralyzed ones.

Each child of course is very different in terms of type of injury, level of function, age at presentation, and many other elements which are addressed individually; it is often possible that patients require a combination of protocols for optimal recovery, in our experience.

scar removal
Plexus Injury with Neuroma


Plexus after Neuroma Removal


Nerve Grafting of Plexus

If your child has weakness of shoulder, elbow, and/ or hand by the age of 3 to 4 months, we strongly recommend consultation with a surgical specialist with extensive experience in obstetric brachial plexus injury.

If your child has no movement in any part of the arm by 3 months, we strongly recommend surgery at or before 3 months.

We have found this series of steps to offer optimal results. The specifics of application to each child is highly individual, however, and of course other centers may have different management protocols.

EMG's are ideally done at 4 to 6 weeks of age to set a baseline for further evaluation in the future. Similarly, an MRI around that time can be done to determine whether root avulsion (tearing of the roots from the spinal cord) is present, although this test overall is less important than a good EMG examination. The EMG should then be repeated around 3 to 4 months of age to see if improvement has occurred electrically, and to correlate with the physical examination. Generally speaking, if there is not full movement of all elements of the arm (shoulder, elbow, hand) by 3 to 4 months, serious consideration for operative exploration should be initiated. If there is no elbow flexion by 6 months of age, surgery is definitely recommended.


Some modifications to these general rules are:

  • continuing improvement in arm function by 4 to 6 months will delay or contraindicate surgery at that time, but if improvement stops later, surgery might be indicated, as in the next item below;
  • patients who arrive at our clinic well after 9 to 12 months of age with continuing elbow weakness and other deficits will require 2-level reconstruction, at the level of the nerve roots and in the axilla with appropriate nerve transfers and releases;
  • patients who are seen after 2 years of age for the first time are best managed with nerve releases and muscle/ tendon transfers.

Primary Surgery FAQ

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Brachial Plexus Art
  Gallery

A Gallery of images
showing the human side
of the injury, and
giving sense of hope
for the future.

 

Association of BPI Therapists

The Association of
Brachial Plexus Therapists
would like to provide
a means for therapists..
- Read More

 

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