The most difficult injuries to manage are those caused by severe stretch or traction as there is no obvious guide to what has occurred inside. Doing surgery early might interfere with normal recovery while leaving surgery for too long can allow important parts of the nervous system to degenerate without connections. Nerve avulsion can be surgically approached after three to six weeks or if natural recovery does not occur as expected then surgery can be approached at 3 to 6 months. If the nerve has been cut then repair can be attempted, whilst if it has been avulsed then grafting can be performed. To speed up recovery a nerve transfer may be used.
A very difficult part of brachial plexus lesions is the unexpected pain which can develop with time. Even though the nerves have been pulled out from the spinal cord connections, a chronic pain problem can develop in the area the nerves supply normally, which is the arm. As the nerves transmitting impulses to and from the spinal cord have been severed by being forcibly disconnected, the spinal cord nerves which normally receive their inputs are deprived of this. These nerves change and start transmitting signals spontaneously, generating an abnormal pain problem which can be unpleasant and persistent.
The pain is often described by the patients as burning, crushing or shooting, can be very severe and be accompanied by agonising spasms. Deafferentation pain is the name given to the type of pain which is caused by a lack of incoming (afferent) input to the nerves of the spinal cord. Conservative measures are most common in treatment and it is useful to involve a pain management team early on in management. Patients can usefully be admitted with this complex pain problem to sort out their medication and adopt a multidisciplinary approach.
TENS, transcutaneous nerve stimulation, is a physical modality for pain control which sends signals into the spinal cord to affect the pain gating system and may be useful in some cases. It can take a long time for an effect to be forthcoming and for the best outcome to be clear. There are a list of other treatments for brachial plexus lesions, none of them with much demonstrable success, including CBT (cognitive behavioural therapy), biofeedback, acupuncture, desensitisation and hypnosis. Due to the varied nature of the presenting symptoms a multidisciplinary team is vital to manage the patient over time.
An experienced multidisciplinary team is necessary to manage the non-surgical care of these patients, including an occupational therapist, orthotist, physician and physiotherapist. Orthotists provide long term bracing to prevent contractures and to protect healing structures, occupational therapists work at the functional abilities of the person, physiotherapists maintain joint ranges and monitor muscle work and the physician diagnoses and sets the treatment goals. Designated specialist centres are most appropriate for surgical care as only specialists can decide on the relevance of a hugely variable condition and choose from the very large number of operative options.
The outcome of a brachial plexus lesion is extremely variable as the mechanism of injury is so unpredictable and the results uncertain. The type of injury, the patient's age and the surgical treatment all affect the outcome. Muscle transfers, transferring a working muscle to do the work of paralysed ones, can be useful as can sural nerve (a nerve in the leg we can manage without) grafting, with many surgeons settling on surgery between three and six months after injury. Some surgeons have attempted to replace the nerve roots into the spinal cord but the results are not yet predictable, although success would dramatically change attitudes as healing in the central nervous system has not been usefully demonstrated.
Nerves heal at an average speed of about an inch a month, or one millimetre a day, which means that if the nerve injury is a long way from the muscle it needs to supply it will take a very long time to get there. The connecting endplates on the muscles may degenerate before the nerves have a chance to grow down to them. Nerve growth factors are the subject of much research to increase the rate of recovery of nerve repairs and grafting.
Autor: Jonathan Blood-Smyth
Jonathan Blood Smyth is a Superintendent of Physiotherapy at an NHS hospital in the South-West of the UK. He specialises in orthopaedic conditions and looking after joint replacements as well as managing chronic pain. Visit the website he edits if you are looking for physiotherapists in Dorset.
Added: January 26, 2009
Source: http://ezinearticles.com/
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