As part of a world-renowned academic medical center, the Mass General Paralysis Center offers the most innovative technology and surgical approaches to patients suffering from nerve conditions worldwide.
Brachial Plexus Injuries
The brachial plexus is a complex network of nerves that extends from the spinal cord within the neck through the axilla (armpit) and supplies nerves to the chest, shoulder and arm. In general, brachial plexus injuries are caused by trauma that affects the region of the neck and shoulder. This trauma can result from motorcycle or auto accidents, falls, lacerations or other injuries or medical conditions.
Partial injuries most commonly occur in the upper part of the brachial plexus and result in paralysis of shoulder and elbow function. The arm is left hanging at the side, but hand function is usually preserved.
Previously, these injuries had a poor prognosis and required extensive grafting procedures. Surgeons now use nerve transfers, a procedure where a less essential nerve or nerve section is "transferred," to restore function in a more crucial nerve to treat patients with these injuries. This new strategy restores useful function in a fraction of the time that was required for recovery from the grafting procedures.
However, it’s important that patients see a surgeon relatively soon after the accident or injury. Surgeons generally prefer to schedule operations within three to four months after the injury but can operate earlier if an avulsion (a condition in which a nerve is pulled out of the spinal cord) is found on MRI or myelogram. Patients should avoid waiting for more than a year to undergo an operation to treat any nerve or brachial plexus injury.
Surgical Options for Complete Injuries
When the brachial plexus is completely injured, patients have no function at all in their extremity. They generally can neither feel nor move their arm.
With these injuries, it is important to determine which nerves are scarred or torn versus those that are avulsed (pulled out of the spinal cord). If nerves are avulsed, the surgeon can operate earlier instead of giving time for recovery, knowing that these injuries will not recover on their own. Special studies can be used to determine whether nerves are avulsed and grafts can be used with nerves that are scarred or torn.
Reconstructive surgery for complete brachial plexus injuries generally consists of a combination of nerve grafting and nerve transfer procedures. The treatment for each patient will be determined according to his or her individual condition.
Patients can undergo surgery within three to four months after the injury. In order to provide for the best recovery, it is often important that the patient receive physical therapy before the surgery to keep the joints mobile and to learn to recruit the nerves that will be transferred and, after the surgery, to learn to use the muscles that are now run by different nerves.
Cervical Spinal Cord Injuries, Resulting in Guadriplegia
Cervical level spinal cord injury can significantly affect hand function. Depending on the level and type of injury, surgery to improve hand and arm function may be an option. Surgical treatment may include nerve transfers or other procedures.
This nerve transfer surgery can only benefit patients with spinal cord injury. The goal of the procedure is to restore hand function with the ability to pinch the thumb and index finger.
Foot drop is the paralysis of the muscles below the knee that lift the front part of the foot, resulting in a foot that "hangs" at the ankle.
A person who has foot drop may have difficulty walking and might need to wear a brace on the leg. Possible causes of foot drop include lumbar disc herniation (damage to a nerve root in the lumbar spine), damage to the peroneal nerve (usually near the knee) or damage to the nerve bundles in the lumbosacral plexus. A foot drop can begin after an injury to the back or leg, an operation on the knee or even such benign activities as squatting for prolonged periods of time or crossing the legs.
When the weakness is due to compression of the peroneal nerve, a simple operation can be performed to improve the situation. The peroneal nerve runs around the neck of bone on the outside of the leg (fibula) just below the knee. It then runs under a muscle that frequently has a tight fascial edge (the peroneus longus). At the point where the nerve runs under this muscle, this tight spot can be released and pressure eliminated. Many times, this is all that is required to restore function to the foot.
If weakness is due to nerve root compression within the lumbar spine, often an operation can be performed to open the space where the nerve leaves the spine (the spinal foramen) by either removing a herniated disk (microdiscectomy), opening this foramen (foraminotomy), or in more complex cases, a combination of these procedures with or without a fusion, where the bones are fixed together to avoid problematic movement.
At times, these procedures will not be sufficient to restore the function of the foot. In such cases, nerve transfers can sometimes be used. This procedure involves taking "donor" nerves with less important roles - or branches of a nerve that perform redundant functions to other nerves - and "transferring" them to restore function in a more crucial nerve that has been severely damaged.
A nerve transfer for correcting a foot drop may involve taking branches of the tibial nerve, which supplies muscles that push the foot down, and plugging those in (transferring them) to nerves that supply muscles involved in pulling the foot up. Either the branches of the tibial nerve that innervate the muscles that flex the toes or those that contribute to flexing the calf muscles may be used as donor nerves.
After this procedure, patients will still be able to activate their donor muscles, meaning they will still be able to push the foot down. However, as they regain function from the nerve transfer, they also will be trained to use these muscles to pull the foot up. The brain then learns this trick, and the patient is able to pull the foot up simply by thinking about pulling the foot up. This can be a difficult transfer to learn and may require much therapy. Training the mind to conceptualize how to use the transferred nerve to pull the foot up may take longer to learn when the transfer involves a nerve that originally performed the opposite function. A physical therapist helps patients learn this technique.
Recovery of function after nerve transfer is a long process. Patients generally see small signs of recovery three to six months after the operation, but in most cases, return of movement takes six to 12 months.
Parsonage-Turner Syndrome, also known as brachial neuritis or neuralgic amyotrophy, is a peripheral nerve disorder that causes severe pain, usually involving the shoulder and arm. This pain is followed by weakness, usually occurring between a few days and two weeks. The most common muscles involved are the shoulder and biceps muscles, but any nerve in the arm or even the leg can be involved. In rare instances, this weakness can progress to complete paralysis of the involved muscles.
Parsonage-Turner Syndrome may develop after a viral illness, mild trauma, physical exertion or even surgery, but often the cause is not obvious. The most common theory as to its cause is that of a viral-induced, immune-mediated process.
The vast majority of patients with Parsonage-Turner Syndrome recover without any treatment as the strength returns and pain resolves. These patients are managed with physical therapy and pain control and followed with serial electrodiagnostic evaluations. Patients are generally given six to nine months before surgery is considered. In a patient who is experiencing some recovery, this may consist of releasing entrapment sites that are impeding recovery.
In those demonstrating minimal or no evidence of recovery, the surgical treatment consists of nerve transfers to restore function to muscle groups that have been paralyzed by the syndrome.
Hemiplegia and Spasticity
Spasticity is a movement disorder that can occur from any upper motor neuron injury. Spasticity is one of the common complications of a stroke or brain injury. It is also common following a spinal cord injury, multiple sclerosis, cerebral palsy and any other disorder that affects the central nervous system. Often, spasticity develops months or even a year after the injury — and often may become more noticeable during recovery.
Spasticity occurs when the neurons in the brain that control movement are injured. The signals traveling along the axons between the brain and muscle fibers are unbalanced. This results in hyperexcitable stretch reflexes, increased muscle tone, and sudden jerky or involuntary movements that can’t be controlled. When spasticity is severe, contractures (fixed limitations of range of motion) may develop.
What Is Spasticity?
Spasticity can cause a muscle to become rigid. Patients with hemiparesis often will have a clenched hand, the wrist is flexed, the elbow is flexed and the shoulder is turned inward. They have difficulty opening the hand, extending the wrist and extending the elbow in accomplishing tasks with that hand.
So in one sense, the muscles all work in that they all contract, but they don’t actually work, in that they don’t do, what the patient is trying to make the muscle do.
Muscle stiffness, tightness, rigidity, and inflexibility are often evident as spasticity. After such an injury, the arms, the legs or even the face can become weak or paralyzed. When this is from a stroke, it typically affects one side of the body. Brain injury is usually worse on one side, but can affect both sides to some degree. Spinal cord injury will typically involve both sides below the level of the injury.
When these injuries occur, a patient cannot control muscle movement well. Often weak muscles become “stuck” in a rigid or tight position and cannot comfortably relax when you want them to.
Sometimes, with milder spasticity, you might be able to move your muscles, but they may resist your movements instead of moving smoothly. Moving requires significant effort. Some people with spasticity notice that the arm or leg may fall into an unusual or twisted position while at rest, and it might be difficult to straighten this out. Stretching the limb and using braces to restore a more normal limb posture are usually an important part of therapy to control this spasticity. Medications may help as well.
What Causes Spasticity?
After a stroke, the nervous system attempts to “rewire” and repair itself to compensate for the lost motor control. In many cases, the nervous system is unable to restore normal control to all the muscles. Some muscles do not respond at all, while others are significantly overactive, resulting in dysfunctional postures of the shoulder, arm and hand, and often leg and foot as well. These dysfunctional muscles at times hide muscles that may actually have good control. The blocked messages between the brain and the muscles cause arm and leg muscles to cramp or spasm (spasticity) and not respond to your attempts to move as they should. Spasticity limits your coordination and muscle movement, making daily activities such as taking a shower, eating and dressing more difficult.
Spasticity can cause long periods of strong contractions in major muscle groups, which can even be quite painful. These spasms can produce:
- A tight fist
- Bent elbow
- Arm pressed against the chest
- Stiff knee
- inverted ankle and curled toes
If left untreated, spasticity can lead to shortened tendons and limbs that can no longer be straightened out. This can also lead to skin breakdown and pressure sores and will dramatically impair your potential to recover useful function in that limb. Contracture causes the muscles in the hand and wrist to tighten and shrink, which can lead to deformity of the joints and progressive loss of function over time.
Spasticity is a challenging problem, but there are solutions and ways to effectively control it or eliminate it entirely.
After an injury like this takes place, initially, the patient will have no movement, and then slowly some muscle tone returns and spasticity develops over the next few weeks to months. The first type of management for a patient like this is to undergo appropriate physical therapy.
The patient needs to stretch their muscles. They need to try to learn how to use the limb and they can make a lot of recovery in the first year. By the end of that year, from twelve months to sometimes 18 months, we typically hit a plateau, where the patient has gained as much recovery of function as they’re going to. Physical therapy, bracing and what we call conservative measures don’t go on to gain much additional function, after that time.
Time To See A Paralysis Specialist
At this point, we recommend seeing a Paralysis Specialist at the Paralysis Center, who will diagnose your condition, and discuss and select treatment techniques that could offer you the best chance of recovery.
Diagnosis & Treatment
A year of rehabilitation is usually the first course of treatment before surgery or other treatments are considered.
Treatment techniques our team use to restore function include:
- Botox injections
- Partial cutting of an overactive nerve (selective peripheral neurotomy)
- Transfer of nerves to exchange spastic function for good control in important muscle groups (nerve transfer)
- Lengthening or cutting of tendons that are shortened and immobile
- Rerouting of tendons to balance forces across a joint (tendon transfer)
- Spinal cord stimulation is finding its place as an emerging treatment to reduce spasticity and improve function in patients with UMN injuries
The Mass General Paralysis Center is comprised of doctors from a variety of specialties to ensure the best possible care for our patients. Learn more in these research investigator and physician profiles.