Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

upper (C5-6) with or without middle (C7) root injury

1st line – supportive care

Back
ACUTE
|
upper (C5-6) with or without middle (C7) root injury
1st line – 

supportive care

Supportive care includes occupational therapy and pain management.

Pain management should involve a multidisciplinary team that includes pain specialists. Neuropathic pain is commonly associated with brachial plexus injury.[33] When usual analgesia is not effective, specific treatments for neuropathic pain, such as gabapentin, carbamazepine, tricyclic antidepressants, topical lidocaine or capsaicin, or opioids (oxycodone) may be used. The anti-inflammatory drug treatment celecoxib has been shown to improve sciatic functional index (SFI) significantly in rats, following sciatic nerve crush injury. Celecoxib may be considered in the treatment of concomitant peripheral nerve injuries, if present.[34]

Avulsion injuries typically involve long-term pain control by pain consultants.

Plus – primary reconstructive surgery

Back
ACUTE
|
upper (C5-6) with or without middle (C7) root injury
|
no recovery by 4 to 6 months after injury
Plus – 

primary reconstructive surgery

Treatment recommended for ALL patients in selected patient group

Most surgeons will evaluate the patient for reconstructive surgery if there is no evidence of motor recovery by 4 to 6 months after injury.[1][32][35][36] This allows time for nerve regeneration down to the paralysed muscles within the critical 1-year time frame.

Nerve transfer techniques are the treatment of choice for microsurgical repair.[1][21][22][23][24] Factors that influence extent of clinical improvement include patient age, mechanism of injury, timing of surgery, and multiple nerve transfers versus single nerve transfers.[22] Nerve transfer requires specialised knowledge and experience, so nerve grafting techniques may be used by non-specialist surgeons.[37]

Plus – glenohumeral fusion

Back
ACUTE
|
upper (C5-6) with or without middle (C7) root injury
|
no shoulder function by 12 months after injury
Plus – 

glenohumeral fusion

Treatment recommended for ALL patients in selected patient group

No shoulder function by 12 months after injury can be due to late referral, or no improvement by 12 months after reconstructive nerve surgery.

Shoulder function is achievable with early nerve reconstructive techniques, but after 6 to 8 months, shoulder fusion is ultimately a better solution than nerve repair.[41]

Plus – nerve transfer + subsequent free muscle transfer

Back
ACUTE
|
upper (C5-6) with or without middle (C7) root injury
|
no arm recovery by 12 months after injury
Plus – 

nerve transfer + subsequent free muscle transfer

Treatment recommended for ALL patients in selected patient group

No arm recovery by 12 months after injury can be due to late referral, or no improvement by 12 months after primary nerve reconstructive surgery.

If the patient has passed the 12-month deadline for primary reconstruction, terminal muscle atrophy is present and provision of a nerve supply cannot result in function.

However, microsurgical techniques can provide both nerve (nerve transfer) and viable new muscle (free muscle transfer) to the limb such that at least functional elbow flexion is achievable.[24][36][38][39] Partial ulnar nerve transfer (PUNT) and intercostal nerve transfer (ICNT) have been shown to be equally effective for reconstructing elbow flexion in patients with upper brachial plexus injuries.[40]

isolated lower root (C8-T1) injury

1st line – nerve transfer + subsequent free muscle transfer

Back
ACUTE
|
isolated lower root (C8-T1) injury
1st line – 

nerve transfer + subsequent free muscle transfer

Due to the time and distance constraints of nerve regeneration, severe injuries to the lower roots usually result in difficult reconstructive situations.

The best solution tends to be a staged combination of nerve transfer to restore innervation, followed several months later by free muscle transfer to replace atrophic muscle for hand function.

Plus – supportive care

Back
ACUTE
|
isolated lower root (C8-T1) injury
Plus – 

supportive care

Treatment recommended for ALL patients in selected patient group

Supportive care includes occupational therapy and pain management.

Pain management should involve a multidisciplinary team that includes pain specialists. Neuropathic pain is commonly associated with brachial plexus injury.[33] When usual analgesia is not effective, specific treatments for neuropathic pain, such as gabapentin, carbamazepine, tricyclic antidepressants, topical lidocaine or capsaicin, or opioids (e.g., oxycodone) may be used. The anti-inflammatory drug treatment celecoxib has been shown to improve sciatic functional index (SFI) significantly in rats, following sciatic nerve crush injury. Celecoxib may be considered in the treatment of concomitant peripheral nerve injuries, if present.[34]

Avulsion injuries typically involve long-term pain control by pain consultants.

total root avulsion (C5-T1) injury

1st line – nerve transfer + subsequent free muscle transfer

Back
ACUTE
|
total root avulsion (C5-T1) injury
1st line – 

nerve transfer + subsequent free muscle transfer

Due to the time and distance constraints of nerve regeneration, severe injuries to the lower roots usually result in difficult reconstructive situations.

The best solution tends to be a staged combination of nerve transfer to restore innervation, followed several months later by free muscle transfer to replace atrophic muscle for hand function. Partial ulnar nerve transfer (PUNT) and intercostal nerve transfer (ICNT) have been shown to be equally effective for reconstructing elbow flexion in patients with upper brachial plexus injuries.[40]

In complete injuries to all 5 roots, there are few ipsilateral sources for nerve restoration, but intercostal nerves can serve as partial donors.[42]

Plus – supportive care

Back
ACUTE
|
total root avulsion (C5-T1) injury
Plus – 

supportive care

Treatment recommended for ALL patients in selected patient group

Supportive care includes occupational therapy and pain management.

Pain management should involve a multidisciplinary team that includes pain specialists. Neuropathic pain is commonly associated with brachial plexus injury.[33] When usual analgesia is not effective, specific treatments for neuropathic pain, such as gabapentin, carbamazepine, tricyclic antidepressants, topical lidocaine or capsaicin, or opioids (e.g., oxycodone) may be used. The anti-inflammatory drug treatment celecoxib has been shown to improve sciatic functional index (SFI) significantly in rats, following sciatic nerve crush injury. Celecoxib may be considered in the treatment of concomitant peripheral nerve injuries, if present.[34]

Avulsion injuries typically involve long-term pain control by pain consultants. In cases of intractable deafferentation pain, common in root avulsion injuries, the surgical dorsal root entry zone (DREZ) lesioning procedure may offer relief of pain.

Plus – glenohumeral fusion

Back
ACUTE
|
total root avulsion (C5-T1) injury
|
loss of shoulder function
Plus – 

glenohumeral fusion

Treatment recommended for ALL patients in selected patient group

Although fusion seems intuitively to prevent movement, in actuality it links the paralysed humerus to the still active scapula, thus allowing arm movement through shrugging and other scapular movements that will still be present.[41]

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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