Brachial Plexus Injuries are caused by excessive stretching, tearing, or trauma to a network of nerves from the spinal cord to the shoulder, arm, and hand. Injuries often occur secondary to motor vehicle accidents, sports injuries or surgeries. Traumatic BPI causes either complete or incomplete damage to the brachial plexus resulting in loss of function and sensation related to level of damage. The recovery from the injury will depend on the severity, level and type of nerve damage. Pain is a very important side effect of the injury and can sometime be very severe and debilitating.
Nerves are cord like structures of tissue formed from a collection of nerve fibers. A single nerve may contain thousands of fibers (a bit like an electrical cable). In the arm, these fibers carry electrical messages both ways between the brain, muscles and tissues. For a muscle to work (contract), a message must travel from the brain, along a nerve that goes directly to the muscle. When nerve fibers are injured, the muscles that the nerve controls may be weakened, even though the injury is not in the muscle itself.
The nervous system integrates all body activities by sensing changes (sensory function), interpreting those (integrative function) and reacting to them (motor function). Sensory neurons carry sensory information into the brain and spinal cord. Motor neurons carry information from the brain and spinal cord into the peripheral nerves. A neuron (or nerve cell) processes and transmits information by electrical or chemical signalling.
The brachial plexus is a network of nerves in the neck and shoulder region (see the video above). It is made up from 5 large nerves which come out of the spinal cord between the vertebrae (bones in the neck), pass under the clavicle (collar bone) and into the upper arm. These nerves enable the signals that allow movement and feeling to reach the arm. These nerves are represented in speech and writing by these symbols: C5, C6, C7, C8, T1 (C=cervical, T=thoracic)
Pain is a sensory and emotional experience which can cause serious psychological changes in the person. Pain develops early in 90% of brachial plexus injury cases, and it may be also delayed for 3-4 months. Generally the pain improves by 2-3 years and is usually manageable by the patients. But in 30-40% of patients the pain becomes very severe and unbearable. Pain after injury can be divided into paroxysmal (shock like) pain and continuous (burning) pain. The continuous pain is a chronic burning or stabbing pain that does not ordinarily follow a clear distribution and usually located in the forearm and the hand. The other paroxysmal pain is a sharp electric shock like pain which is crushing, very severe, lasts few minutes and can occur every few minutes and sometimes ‘like putting your hand in a deep frying pan’. Some of the characters of the pain described by the patients are as follows, “ my arm is on fire with continuous electric shocks 24 hours, even a small noise like tapping aggravates pain, I wanted to end my life and attempted suicide several times, I used to have 24hrs pain very slightly reduced with tablets, pain will start from hand all the way up to neck, pain was like pin pricks or someone was stabbing my arm and every time it was different, 22yrs I had pain and even the slightest noise like a baby crying will set it off, I chewed my hand daily for pain relief as it was like on “burning oil”.
Medical management can fail after sometime when either a single drug or combinations of drugs have been taken up to the maximum acceptable dose for a duration of few months to years or when side effects do not allow you to take the medication that is required. When such a situation arises it is wise to consider surgical options.
Surgery should be considered only when medical and other treatment methods have failed over a period of 6 months to 2 years and the patient can no longer accept the pain.
In BPI the nerve can be pulled our or disconnected from the spinal cord. The region where it gets disconnected undergoes scar tissue transformation and become a focus of pain generation. This region is called the “Dorsal Root Entry Zone” (DREZ), which is the first important level of modulation for pain and hence this area can be a target to treat resistant neuropathic pain in avulsion injuries.
The dorsal root entry zone (DREZ) lesioning procedure is a treatment for severe pain caused by nerves that have been torn away (avulsed) from the spinal cord. The procedure itself involves a neurosurgeon entering the spinal cord and causing multiple lesions in that damaged areas of pain generation from the spinal cord. Dr G Balamurali is among the very few Surgeons in the Country who has vast experience in performing this procedure under neuromonitoring. We have a 80% success rate.
The surgery is explained in the video below and also visit our website www.bpisupportgroup.com
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