After being diagnosed with a brachial plexus injury, patients, whether they have had surgery or not, are carefully followed with a series of examinations to monitor their progress. Even with the best efforts of the patient, parents, and therapist, progress may stall and plateau. In these cases, secondary surgeries may be needed. Secondary surgeries are usually performed on children who are at least 18 months to two years old. This allows the children to mature and the injury to fully show itself, yet the child is still young enough to benefit from the reconstruction.
After about 18 months without nerve signal, the connection between nerves and muscles (motor end plates) become permanently damaged. At this point, repairing the nerves at the neck is no longer a useful option. If there is some existing level of nerve conduction, secondary surgery may be able to improve conduction. But, muscle groups that have not been receiving signal will have some permanent damage. A variety of surgeries have been developed to, in effect, rearrange the anatomy and bring nerve and muscle to areas where it is lacking.
The most common results of brachial plexus injuries are internal rotation of the arm, difficulty with external rotation and shoulder abduction, some degree of elbow and hand malfunction, and paraesthesias (sensory changes). There are a number of different procedures performed based on the patient’s deficit, including the “mod quad”, tendon transfers, tendon shortening or lengthening, joint capsule tightening, free nerve and muscle flaps, and bony work. Each patient is carefully evaluated with special attention to progress with physical therapy and EMG evaluation and an individualized plan is created. Each specific surgery is further customized for the particular patient’s needs.