This procedure involves stitching the damaged ends of a nerve back together. It is typically performed when the nerve injury is clean and hasn’t been stretched or torn extensively.
Brachial Plexus Surgery
Dr Jacqueline Tan
MBBS (SG) | MRCS (Edin) | MMed (Surgery) | FAMS (Hand Surgery)
Brachial plexus surgery is a specialised surgical procedure aimed at treating injuries to the brachial plexus, a network of nerves that originates in the neck and controls muscle function and sensation in the shoulder, arm, and hand. These injuries can result from trauma, stretching, compression, or, in some cases, birth-related injuries.
The goal of brachial plexus surgery is to restore nerve function, alleviate pain, and improve mobility in the affected limb. Depending on the severity of the injury, surgery may involve repairing, reconstructing, or transferring nerves.
Indications for Brachial Plexus Surgery
Surgical intervention is typically considered when nerve injuries do not heal on their own or when non-surgical treatments fail to restore function.
- Severe Nerve Injuries: Severe injuries can cause a complete or near-complete loss of muscle movement and sensation in the shoulder, arm, or hand. Signs of nerve damage can often be detected through imaging tests like MRI or CT scans, or through special tests that check how well your nerves are working, such as electromyography (EMG).
- Persistent Symptoms: Ongoing symptoms like chronic pain, weakness, or numbness that significantly affect daily activities may require surgery. If symptoms don’t improve within 3–6 months after the injury, surgery may be needed because nerves need timely treatment to heal properly.
- Traumatic Injuries: Serious accidents, such as car crashes, falls, or injuries involving sharp objects, can cause severe damage to the brachial plexus nerves, such as tearing, stretching, or even complete detachment.
- Birth-Related Brachial Plexus Injuries: In babies, conditions like Erb’s palsy caused by birth trauma may need surgical treatment if physical therapy and other non-surgical methods don’t work.
Brachial Plexus Surgical Techniques
Several surgical techniques may be employed, depending on the nature and extent of the injury.
Nerve Repair
Nerve Grafting
In this technique, a healthy nerve from another part of the body, often the sural nerve from the leg, is used to bridge a gap in the damaged nerve. Nerve grafting is commonly used for more severe injuries where the nerve cannot be directly repaired.
Nerve Transfer
A functional nerve is redirected to take over the role of a damaged nerve, helping restore movement or sensation in the affected area. This method is often chosen when the original nerve is too damaged for repair or grafting.
Tendon or Muscle Transfer
For cases involving long-term paralysis, tendons or muscles from other parts of the body are moved to the affected area to help restore function. This approach is often used when nerve recovery is no longer possible.
Preparing for Brachial Plexus Surgery
Preparation involves a comprehensive evaluation by a multidisciplinary team to assess the extent of the injury and determine the best surgical approach.
Pre-Surgical Assessments
Before surgery, several assessments are conducted to evaluate the extent of nerve damage and plan the procedure:
- Imaging Studies: Tests like MRI or CT myelography are used to create detailed images of the brachial plexus and identify areas of damage.
- Electrodiagnostic Tests: These include electromyography (EMG) and nerve conduction studies to check how well the nerves are functioning and pinpoint areas of impairment.
- Physical Examination: The surgeon evaluates muscle strength, range of motion, and sensory deficits to understand the injury’s impact and determine the best approach.
Pre-Operative Instructions
Patients are given specific instructions to prepare for the procedure:
- Fasting: Patients may need to refrain from eating or drinking for several hours before surgery, especially if general anaesthesia will be used.
- Medication Adjustments: Certain medications, such as blood thinners, might need to be paused temporarily to minimise bleeding risks during surgery.
- Lifestyle Modifications: Smoking cessation is strongly encouraged to improve healing and reduce the risk of complications.
Brachial Plexus Surgical Procedure
The specific surgical approach depends on the type and severity of the injury. The procedure typically includes the following steps:
Administering Anaesthesia
Surgery is usually performed under general anaesthesia, ensuring the patient is completely unconscious and pain-free during the procedure.
Accessing the Nerve
An incision is made near the neck, shoulder, or arm to reach the damaged brachial plexus nerves. The exact location of the incision depends on the injury’s location and extent.
Repairing or Reconstructing the Nerve
The surgeon employs techniques such as nerve repair, grafting, or transfer to restore function. In complex cases, multiple techniques may be combined during the same surgery.
Closing the Incision
Once the nerve has been repaired or reconstructed, the incision is closed with sutures, and the area is carefully bandaged to protect the surgical site.
The procedure can take several hours, depending on the complexity of the injury and the techniques used.
Post-Surgical Care and Rehabilitation
Recovery from brachial plexus surgery involves a combination of rest, physical therapy, and close medical supervision to ensure optimal healing and restoration of function.
Immediate Post-Operative Care
Pain management is a key focus in the initial recovery phase, with pain medications and anti-inflammatory drugs often prescribed to reduce discomfort. The affected limb may also be immobilised using a splint or sling to protect the surgical site and support healing.
Rehabilitation
Physical therapy typically begins soon after surgery to prevent stiffness, maintain joint mobility, and encourage the gradual return of movement. Regular follow-up appointments are crucial for monitoring nerve recovery, as nerve regeneration can take several months to years. In addition, occupational therapy helps patients regain fine motor skills and adapt to daily activities, ensuring a smoother return to normal life.
Risks and Complications of Brachial Plexus Surgery
While brachial plexus surgery can provide significant benefits, it does come with potential risks that patients should be aware of:
- Infection: There is a risk of infection at the surgical site, which can usually be managed with antibiotics if detected early.
- Nerve Damage: Surrounding nerves may unintentionally be injured during the procedure, potentially leading to additional symptoms or complications.
- Scarring: Scarring at the incision site is common and may cause stiffness or discomfort in some cases.
Your orthopaedic hand surgeon will thoroughly explain these risks before the procedure, helping you make an informed decision about your care.
Frequently Asked Questions
How long does it take to recover from brachial plexus surgery?
Recovery can vary depending on the severity of the injury and the surgical technique used. Initial recovery may take a few weeks, but nerve regeneration can take several months to years, requiring regular follow-ups and rehabilitation.
Will I regain full function after brachial plexus surgery?
While many patients experience significant improvements, full recovery is not always guaranteed. Outcomes depend on factors such as the type and severity of the injury, the timing of the surgery, and the rehabilitation process.
What are the risks of delaying surgery for a brachial plexus injury?
Delaying surgery may reduce the chances of a successful recovery, as nerve regeneration is time-sensitive. In severe cases, prolonged nerve damage can lead to permanent loss of function.
Dr Jacqueline Tan
MBBS (SG)
MRCS (Edin)
MMed (Surgery)
FAMS (Hand Surgery)
Dr. Jacqueline Tan is a hand surgeon in Singapore with over 18 years of experience in managing hand, wrist, and nerve conditions. Formerly the Head of Department of Hand and Reconstructive Microsurgery at Singapore General Hospital, she has continued to contribute significantly to her profession.
- Director of Micro-Reconstruction Service and the Director of Peripheral Nerve and Paralytic Upper Limb Service
- Upon the completion of her training as a hand surgeon in Singapore, Dr Tan was awarded the prestigious Health Manpower Development Plan scholarship by the Ministry of Health (MOH).
- Completed a one-year advanced fellowship in Taiwan under the tutelage of internationally-acclaimed Hand and Orthopedic Microsurgeon – Professor Yuan-Kun Tu
- Dr Tan’s field of expertise is in early and late brachial plexus reconstruction, peripheral nerve disorders, reconstructive microsurgery of the extremities and wrist disorders.
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