Initial treatment options for patients include physical therapy where stretching and other activities begin to stimulate function. Daily passive range of motion exercises are done to all joints of the shoulder, elbow, wrist and hand. Therapists offer a wide range of treatments and also serve to objectively evaluate recovery. These treatments are continued from the time of injury to three months of age. By three months, patients are examined to see if functional milestones have been met. We agree with most experts in the field that if a child has no biceps function by three months then a primary surgical exploration is needed.
The surgical approach of the brachial plexus is performed through an “L” shaped incision along the posterior border of the sternocleidomastoid muscle with a lateral extension superior to the clavicle. In rare circumstances, an infraclavicular extension is made for more severe injuries. Meticulous care is taken during the operation as there usually is a significant amount of scarring from the initial injury. The brachial plexus is identified and tagged, and neuromas are examined to plan for appropriate reconstruction. A neuroelectrophysiologist then performs nerve conduction test and somatic evoked potentials to determine the severity of nerve injury and the conduction through the neuroma.
The final reconstructive plan is then made in conjunction with the family taking into consideration all physical findings and functional abilities.
Type of Primary Reconstruction Surgery
If the amount of signal transmitted through the nerve injury is 50% amplitude or above, a neurolysis is performed to the roots, neuroma, and branches. This is a removal of the scar tissue that encases the nerves and slows conduction. Bypass grafts are used side to side from the nerve roots to the respective branches in an attempt to increase nerve regeneration. The sural nerve from the patient’s leg is used as a nerve graft.
If there is less than 50% conduction through the neuroma, the neuroma is excised (removed) and the nerve roots and branches are examined. The nerve roots and branches are cut back until healthy nerve tissue is reached. Again, the sural nerves are used as nerve grafts. When nerve roots are found to be avulsed, the remaining available roots are used to graft to the necessary branches.
Patients are then placed in protective splints for two weeks and then start aggressive physical therapy. Therapy is vital to every patient and in our experience we have seen the best results in patients whose families are most involved with therapy and its implementation both at home and with a licensed therapist. These patients are seen routinely and functional milestones are assessed throughout childhood.
In our center, we have found that implementing this surgical plan early is critical to recovering the most functionality. Delaying surgery past this date will only result in decreased capability later. However, we have seen and performed surgery on patients past this three-month time frame that have gained function despite the delay in treatment. The most important factor in these patients is to determine who will need surgery and to perform that surgery as early as possible. The earlier surgery is done when indicated the better functional recovery is obtained. There have been reports of patients as old as two years of age undergoing a primary repair with improvement.