Treatment of Neuropathic Pain in Brachial Plexus Injuries (original) (raw)
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Occurrence and Treatment of Pain After Brachial Plexus Injury
Clinical Orthopaedics and Related Research, 1988
The occurrence of pain was investigated in 118 patients with posttraumatic brachial plexus injuries (BPI). Ninety-five patients were operated upon by the same surgeon. Three to 14 years after BPI and reconstructive surgery, 91% of the patients experienced permanent pain that was severe in 40% and mild in 51% of cases. When early reconstructive surgery was successful, a significant decrease in pain occurred more frequently. For 57% of patients with pain, a plurimodal medical treatment with tricyclic antidepressants, antiepileptic drugs, and behavioral therapy efficiently reduced pain. For the patients with unbearable paroxystic pain, when medical treatment failed, the destruction of deafferented dorsal horns at the level of avulsion (Nashold procedure) could produce pain relief. In all cases psychosocial management produced early rehabilitation.
Journal of Brachial Plexus and Peripheral Nerve Injury
2000
Rationale Carpal tunnel syndrome (CTS) is the most frequently encountered compressive neuropathy of the upper limb. The treatment of CTS ranges from conservative management to carpal tunnel release. Many patients with misconception about the potential morbidity and with the hope of successful conservative treatment delay the surgical release of carpal tunnel. This delay results in reduced recovery of sensory and motor median nerve function. Objective The aim of this study was to evaluate the influence of preoperative duration and severity of symptom on the outcome of carpal tunnel surgery. Method It included 45 cases of CTS, all treated with limited access open carpal tunnel release. The duration of symptoms (i.e., pain, numbness, tingling, waking up at night because of pain/numbness, difficulty in grasping small objects, and their preoperative severity) was noted using Boston CTS questionnaire. To investigate the outcome, patients were divided into three groups based on their duration of symptoms. Result Group1: The severity of symptoms was reduced to normal in a short period of time in patients who presented with duration of symptoms less than 6 months. Group 2: Patients in whom symptoms lasted for 6 to 12 months had reduced or delayed recovery of hand function as compared with first group. Group 3: Patients who had symptoms for more than 12 months had incomplete recovery of grip strength. Return to normal function took the longest time (median: 16 weeks) in this group. Conclusion This study suggests that patients who present late have delayed/incomplete relief of symptoms after carpal tunnel release.
Pain phenomena and sensory recovery following brachial plexus avulsion injury and surgical repairs
The Journal of Hand Surgery: Journal of the British Society for Surgery of the Hand, 2006
Seventy-six patients with severe brachial plexus avulsion injuries were studied using pain questionnaires and quantitative sensory testing. There was significant correlation between pain intensity and the number of roots avulsed prior to surgery (P ¼ 0.0004) and surgical repairs were associated with pain relief. Sensory recovery to thermal stimuli was observed, mainly in the C5 dermatome. Allodynia to mechanical and thermal stimuli was observed in the border zone of affected and unaffected dermatomes in 18% of patients assessed early (o6 months) and 37% patients at later stages. Pain and sensations referred to the original source of afferents occurred at a later stage (46 months) in 12% of patients and were related to nerve regeneration. By contrast, ''wrong-way'' referred sensations (e.g. down the affected arm while shaving or drinking cold fluids) were reported by 44% of patients and often occurred early, suggesting CNS plasticity. Understanding sensory mechanisms will help develop new treatments for severe brachial plexus injuries.
Acta Neurochirurgica, 2011
Background Peripheral nerve lesions usually are associated with neuropathic pain. In the present paper, we describe a simple scale to quantify pain after brachial plexus injuries and apply this scale to a series of patients to determine initial outcomes after reconstructive surgery. Methods Fifty-one patients with traumatic brachial plexus avulsion injuries were treated over the period of one calendar year at one center by the same surgical team. Of these, 28 patients who were available for follow-up reported some degree of neuropathic pain radiating towards the hand or forearm and underwent reconstructive microsurgery and direct pain management, including trunk and nerve neurolysis and repair. A special pain severity rating scale was developed and used to assess patients' pain before and after surgery, over a minimum follow-up of 6 months. An independent researcher, not part of the surgical team, performed all pre- and postoperative evaluations. Findings Of the 28 patients with brachial plexus traction injuries who met eligibility criteria, 93% were male, and most were young (mean age, 27.6 years). The mean preoperative severity of pain using our scale was 30.9 out of a maximum of 37 (±0.76 SD), which fell to a mean of 6.9 (±0.68 SD) 6 months post-procedure. On average, pain declined by 78% across the whole series, a decline that was statistically significant (p Conclusions We have designed and tested a simple and reliable method by which to quantify neuropathic pain after traumatic brachial plexus injuries. Initial surgical treatment of the paralysis—including nerve, trunk and root reconstruction, and neurolysis—comprises an effective means by which to initially treat neuropathic pain. Ablative or neuromodulative procedures, like dorsal root entry zone, should be reserved for refractory cases.
Microsurgery, 2011
After injury of the brachial plexus, sensory disturbance in the affected limb varies according to the extent of root involvement. The goal of this study was to match sensory assessments and pain complaints with findings on CT myelo scans and surgical observations. One hundred fifty patients with supraclavicular stretch injury of the brachial plexus were operated upon within an average of 5.4 months of trauma. Preoperatively, upper limb sensation was evaluated using Semmes-Weinstein monofilaments. Pain complaints were recorded for each patient. With lesions affecting the upper roots of the brachial plexus, hand sensation was largerly preserved. Sensory disturbances were identified over a longitudinal bundle on the lateral arm and forearm. In C8-T1 root injuries, diminished protective sensation was observed on the ulnar aspect of the hand. If the C7 root also was injured, sensation in the long finger was impaired. Eighty-four percent of our 64 patients with total palsy reported pain, versus just 47% of our 72 patients with upper type palsies. This rate dropped to 29% in the 14 patients with a lower-type palsy. C8 and T1, when injured, always were avulsed from the cord; when avulsion of these roots was the only nerve injury, pain was absent. Hand sensation was largely preserved in patients with partial injuries of the brachial plexus, particularly on the radial side. Even when T1 was the only preserved root, hand sensation was mostly spared. This indicates that overlapping of the dermatomal zones seems much more widespread than previously reported.
A Review Article on Injury and Modalities Used for Rehabilisation of Brachial Plexus
Journal of Pharmaceutical Negative Results, 2022
Transcutaneous electrical nerve stimulation (TENS) is not therapeutic cure that works by activating complex neural network and engaging inhibitory descending processes in the central nervous system to diminish hyperalgesia. Neuromuscular electrical stimulation (NMES) have recommended as supplement for other treatments, such as workout, or as a stand-alone treatment to increase muscle power, decrease knee discomfort, and improve function. NMES may be an alternate treatment for people who are unable or unable to engage in full-body exercise to strengthen upper limb muscles. Patients appear to like NMES programmer, which have resulted with advancement in muscle work, physical exercise strength, and wholesomeness. The widespread utilisation of [TENS] Transcutaneous Electrical Nerve Stimulation to alleviate injury is based on pain suppression by extra somatosensory information. High-frequency [50-100 Hz] and of less-intensity 'traditional' TENS, and less-frequency [2-4 Hz] and more-intensity 'acupuncture-like' TENS, both cause analgesia in animal models.
Recent advances in the management of brachial plexus injuries
Indian journal of plastic surgery : official publication of the Association of Plastic Surgeons of India, 2014
Management of brachial plexus injury is a demanding field of hand and upper extremity surgery. With currently available microsurgical techniques, functional gains are rewarding in upper plexus injuries. However, treatment options in the management of flail and anaesthetic limb are still evolving. Last three decades have witnessed significant developments in the management of these injuries, which include a better understanding of the anatomy, advances in the diagnostic modalities, incorporation of intra-operative nerve stimulation techniques, more liberal use of nerve grafts in bridging nerve gaps, and the addition of new nerve transfers, which selectively neurotise the target muscles close to the motor end plates. Newer research works on the use of nerve allografts and immune modulators (FK 506) are under evaluation in further improving the results in nerve reconstruction. Direct reimplantation of avulsed spinal nerve roots into the spinal cord is another area of research in brachi...
Neuropathic pain after brachial plexus avulsion - central and peripheral mechanisms
BMC Neurology, 2015
The pain that commonly occurs after brachial plexus avulsion poses an additional burden on the quality of life of patients already impaired by motor, sensory and autonomic deficits. Evidence-based treatments for the pain associated with brachial plexus avulsion are scarce, thus frequently leaving the condition refractory to treatment with the standard methods used to manage neuropathic pain. Unfortunately, little is known about the pathophysiology of brachial plexus avulsion. Available evidence indicates that besides primary nerve root injury, central lesions related to the abrupt disconnection of nerve roots from the spinal cord may play an important role in the genesis of neuropathic pain in these patients and may explain in part its refractoriness to treatment. Conclusions: The understanding of both central and peripheral mechanisms that contribute to the development of pain is of major importance in order to propose more effective treatments for brachial plexus avulsion-related pain. This review focuses on the current understanding about the occurrence of neuropathic pain in these patients and the role played by peripheral and central mechanisms that provides insights into its treatment. Summary: Pain after brachial plexus avulsion involves both peripheral and central components; thereby it is characterized as a mixed (central and peripheral) neuropathic pain syndrome.
Journal of Clinical Neurology, 2016
Background and PurposezzNeuropathic pain (NeuP) associated with traumatic brachial plexus injury (BPI) can be severe, persistent, and resistant to treatment. Moreover, comorbidity associated with NeuP may worsen the pain and quality of life. This study compared persistent NeuP after BPI between patients with and without co-morbid conditions (psychiatric dysfunction and other painful conditions) and tramadol usage as a second-line agent in combination with an antiepileptic and/or antidepressant during a 2-year follow-up. MethodszzThe medical records of patients diagnosed with BPI referred to a pain center between 2006 and 2010 were reviewed for 2 years retrospectively. Data regarding patient demographics, injury and surgical profiles, characteristics of NeuP and its severity, and treatment received were compared between patients with and without manifesting co-morbid conditions. The NeuP and pain intensity assessments were based on the DN4 questionnaire and a numerical rating scale, respectively. ResultszzOf the 45 patients studied, 24 patients presented with one of the following co-morbid conditions: myofascial pain (21%), psychiatric disorder (17%), phantom limb pain (4%), complex regional pain syndrome (21%), and insomnia (37%). Tramadol was required by 20 patients with co-morbidity and, 9 patients without co-morbidity (p<0.001). The mean pain score after 2 years was higher in patients with co-morbidity than in those without co-morbidity (p<0.05). ConclusionszzPersistent pain following BPI was more common in patients manifesting other painful conditions or psychiatric co-morbidity. A higher proportion of the patients in the comorbid group required tramadol as a second-line of agent for pain relief. Key Wordszz brachial plexus injury, co-morbid, neuropathic pain, pain severity.
A STUDY OF 100 CASES OF BRACHIAL PLEXUS
National Journal of Community Medicine, 2011
Brachial Plexus innervates the upper limb. As it is the point of formation of many nerves, variations are common. The presence of anatomical variations of the peripheral nervous system is often used to explain unexpected clinical signs and symptoms. Therefore, it is of importance to anatomists, radiologists, anesthesiologists and surgeons. The current research work was aimed to study common and anomalous variations of brachial plexsus and communication between its branches. The present study was done on 50 cadavers to study 100 brachial plexuses, 50 each of right and left upper limbs. 10 cases showed absence of musculocutaneous nerve and 8 cases of communication between musculocutaneous and median nerve. 18% of cases showed significant variations which can have bearing on surgical procedures.