Helping Hands

A wrenching, high-speed tumble off a motorcycle; an unexpected fall; a car crash; the wedging of a shoulder in the birth canal—accidents like these can happen at random, yet can take a terrible, lifelong toll.

Not infrequently, such traumas cause injuries to the network of nerves in the neck that send signals down the arm—a complex known as the brachial plexus. The damage disrupts critical communication between the spinal cord and the affected limb, potentially causing pain, impairment, decreased sensation, or even the loss of use of a shoulder, arm, elbow, or hand.

When these injuries happen, time is of the essence. Nerves have a limited ability to regenerate, and muscles will stop working over time if they don’t receive signals sparking them to action. That means there’s a ticking clock on efforts to fix the problem—as little as three to six months before the effects of the injury become irrevocable.

While prompt treatment is crucial, the complicated, specialized care that offers the best outcomes for brachial plexus injuries isn’t available everywhere. Too often, patients have to go to large and distant cities for state-of-the-art care—a practice untenable for many without the time, money, or transportation to travel.

Fortunately, these obstacles are no longer a problem for patients in southwestern Virginia. In 2017, several factors aligned, including the fortuitous recruitment of the right personnel and the vision of Carilion Clinic leaders, resulting in the foundation of the Brachial Plexus Clinic at Carilion’s Institute for Orthopaedics and Neurosciences.

“Our region sees a number of these traumatic injuries,” says Peter Apel, M.D., Ph.D., an orthopaedic surgeon at the clinic and an assistant professor of orthopaedic surgery at the Virginia Tech Carilion School of Medicine. “We established the Brachial Plexus Clinic to be a home for these patients, where they could get appropriate, timely, and, quite frankly, life-changing care.”

Tackling a “Whole-Life Problem”

The brachial plexus is crucial for both sensory and motor function of the arm. Damage to the network, inflicted when the nerves are overstretched, compressed, or torn, can have a range of consequences.

People who sustain such injuries can have trouble lifting a shoulder or bending an elbow, or even using the hand on their injured side. They might not be able to pick things up or bring a fork to their mouth. Putting on a shirt, reaching for a door handle, or scratching an itch can be a challenge.

Patients with brachial plexus injuries might even have what’s known as a flail arm—one that’s weak, senseless, essentially “dead weight.” The effects can severely limit an individual’s ability to work and necessitate support from family or friends. “A brachial plexus injury isn’t just a nerve problem,” Dr. Apel says. “It’s a whole-life problem.”

How patients are affected can depend on the severity and location of the injury itself—which and how many of the brachial plexus nerves are damaged, and where in the neck the injury occurs.

“Every patient is different,” says Cesar Bravo, M.D., an orthopaedic surgeon at the Brachial Plexus Clinic and a faculty member of the Virginia Tech Carilion School of Medicine. “Some injuries are more complex and some might present in a delayed fashion. Those differences change what we are able to do for treatment.”

Making the diagnosis—and developing and executing the right treatment plan—requires the input of specialists in many disciplines. Electromyography and nerve-conduction studies are needed to figure out which nerves and muscles are working or impaired. Physical and occupational therapy sessions are key to improving movement and mobility, as well as tracking progress in recovery of day-to-day function. In some cases, surgery is required to repair, reconstruct, or transfer nerves or tendons. Amid all this, patients need help with daily life issues such as addressing work situations, acquiring specialized equipment, and coordinating rides.

The entire process requires a dedicated crew and a multidisciplinary approach—a mindset that has been baked into the Brachial Plexus Clinic from the start. Modeled after some of the large centers in which Drs. Apel and Bravo conducted their medical training, treatment at the clinic relies on multispecialty involvement at every step. Patients make a single appointment to see their surgeons and therapists, the nerve specialists who conduct diagnostic tests, a social worker, and the nurse who coordinates their care.

 “It’s literally a team approach,” says Dr. Apel. “It’s not like a typical doctor’s visit. The entire medical team meets with the patient and family in a big room. Ideas are discussed. We encourage everyone, whether it’s the therapist, nurse, patient, or family members, to speak up. We talk through the injury, the situation, the plan—everything—because they affect everybody.”

The clinic runs monthly, and visits usually take an hour. “These aren’t rushed doctor’s appointments,” says Dr. Apel. “We’re dealing with life-changing injuries for these patients, and we take all the time needed to understand how patients are being affected and where they are in their recovery.”

The clinic’s dedicated physical and occupational therapists, who have expertise helping patients recover from brachial plexus injuries, are a critical part of the team.Patients work with these therapists exclusively throughout their time with the clinic.

“At each visit, we see how the patient is progressing,” Dr. Bravo says. “We assess how they’re working back into their professional and social life. Together we’re able to see where the patient has recovered—and what functions they’re not going to recover. That’s how we develop the treatment plan.”

If needed, that plan can involve surgery. But even in the operating room, brachial plexus injuries demand an especially team-minded approach. The operations for these injuries are delicate procedures that take several hours. Two surgeons with the highly specialized training are needed.

Dr. Bravo and Dr. Apel set aside one day a month to make sure they’re available to perform these time-sensitive procedures together.

Operating Shoulder to Shoulder

Several hours into such complicated surgeries, fatigue is bound to set in for the surgeons. The procedure can get frustrating. Maneuvering a tiny nerve fiber through a larger web of nerves, under a microscope, can be exhausting. Doing it when you know that the surgery is potentially life-changing—that the use of the patient’s arm hangs in the balance—adds to the stress.

It’s times like these that a surgeon truly appreciates the team approach. It helps to have a second surgeon there—a co-pilot on the journey—not just to help work through technical challenges, but also to provide emotional support.

“He knows my right hand and I know his left hand,” Dr. Bravo says. “Over the years we’ve gotten to know what the other is thinking. These are fairly extensive surgeries, so you need a partner you can trust, who has the right capabilities, so together you can provide patients with the best care.”

It’s also reassuring to know that the clinic’s team of experts have helped identify the exact problem, the nerve or nerves involved, and the proper procedure to ensure the best possible outcome.

Surgical options include nerve repair, reconstruction, and transfer. Repair entails a reconnection of fibers. Reconstruction involves removing injured or scarred tissue in the damaged nerve and replacing it with a graft. And, when a damaged nerve can’t be repaired, nerve transfer allows it to be replaced with a live functioning one nearby.

“In a nerve transfer, we’re basically taking a functioning nerve, rerouting it, and hooking it up to a nerve that’s not functioning. That provides that muscle, and by extension that extremity, with the connection it needs to work,” Dr. Bravo says. “It’s like taking from Peter to pay Paul. We’re redirecting the nerve and rewiring that person’s anatomy.”

The surgeons say finding that donor nerve—one that works yet isn’t essential to existing function—is particularly challenging. Then comes the chore of extracting it from surrounding tissue, an exercise akin to pulling a single thread from a rich fabric without damaging it. Then, finally, comes sitting down at the microscope and sewing the reworked or rewired nerve fibers together with sutures smaller than a human hair.

The operations can run eight hours, but the grind is worth it for the patients and families—and their doctors.

“We may not always get full return of function, but every bit can mean a great deal,” says Dr. Bravo. “It’s amazing to see how life-altering this type of procedure can be.”

Thinking Local

“What sometimes happens to patients in areas where this type of specialized care isn’t available is they get lost in the shuffle,” Dr. Apel says. “They’re seen somewhere where the condition goes unrecognized. They’re sent for tests or follow-up appointments they don’t need. Time slips by and they lose their opportunity for recovery. We created the clinic to have a means for capturing these patients and getting them prompt care so we can maximize their outcomes.”

To that end, the team has educated others in the Carilion system about brachial plexus injuries—to identify them early and refer them to the clinic. A gradual increase in patients year over year suggests their education efforts are working.

“With the help of clinicians throughout Carilion, we’re able to catch patients who weren’t being treated in a timely fashion,” says Dr. Bravo, who credits his early training at Mayo Clinic with helping to inspire the formation and multidisciplinary approach of the Brachial Plexus Clinic.

“My exposure to these techniques early in my training opened my eyes to the need for this type of medical access for patients with these types of injuries,” he says, noting that such specialization has too often been limited only to major health care hubs.

Dr. Apel agrees. “Our team is really proud,” he says, “that we’re providing what is, by all measures, world-class care for our patients here in little old Roanoke.”

Story by Veronica Meade-Kelly