Indications for peripheral nerve and brachial plexus surgery

Management of peripheral nerve injuries differs depending on the mechanism of injury. 1. If a nerve has been sharply and completely transected, it should be acutely repaired, especially if proximally located. 2. If a nerve has been bluntly divided and the stumps are found to be bruised, they should be tacked to adjacent planes. A secondary repair at 2 to 4 weeks is then recommended. 3. With closed injury in which the nerve is most likely still in continuity, the patient should be followed clinically and electrically for 2 to 5 months, depending on the nerve involved and the mechanism of injury. If there is no reversal of the proximal portion of the neurologic deficit by that time, surgical exploration should be done. Use of intraoperative NAP testing is important in this large category of injuries. 4. Injection and electrical injuries to a nerve are two special categories of lesions in continuity and require a highly specialized and individualized treatment dependent on the degree of deficit and severity of pain. 5. Pain unresponsive to medical treatment may also be an indication for surgery on a peripheral nerve, especially if the injured nerve needs to be repaired because of persistent neurologic loss. 6. Management of brachial plexus injuries is somewhat different. Function of each element of the plexus has to be analyzed separately. Several clinical, electrical, and radiologic findings may provide important information about how proximal the lesion is. 7. Missile wounds usually leave the nerve in continuity. Initial management is surgically conservative. Nonetheless, many of these lesions will subsequently require resection based on NAP recordings. 8. Management of obstetric brachial plexus palsy is controversial. We recommend initial conservative management, with observation much longer (9 to 12 months) than for other stretch injuries occurring in adults. With this approach, some but not many of such injuries will still need repair.