brachial plexus injuries

[bedrock]

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I've been seeing more and more patients with brachial plexus injuries, mostly work comp, and the patient was lifting a patient who then fell, or someone had arm pulled suddenly at work etc.
I'm referring to brachial plexus patients with >90% or more of their strength, so not surgical. Most of them just have pain some at rest, generally worse at extremes of ROM.

Other than EMG/neuropathic meds/PT is there anything else you all do for these patients?

Unfortunately WC in my state has decided to stop covering SCS, so not an option.

 

[Baron S]

Not much. EMG just helps localize the lesion and give you an idea on prognosis and timeframe, which you can likely ascertain with H&P. Treatment is exactly as you said. Vitamin C for CRPS prevention?

I'm sure some folks have done PNS with varying results but I'm sure if SCS isn't covered, it won't either.

Edit: I suppose if they have CRPS symptoms can try SGB

 

[MitchLevi]

Med recommendation is SCS IMO. I would make that recommendation and tell the pt all I can do is antineuropathics.

 

[painfree23]

Scs over pns?

 

[SSdoc33]

Just PT, time, and neuropathics.

Unless it is a severe lesion, strength will come back

 

[Orin]

We have been doing PNS or pumps when SCS isn't feasible or helpful.

It's a easy thing to drop SPR/Sprint or Bioventus/Stimrouter leads there. You can use any but 3 of the 4 can easily do motor programs for some possible FES help but not necessary in your population with 90% strength.

 

[Baron S]

We have been doing PNS or pumps when SCS isn't feasible or helpful.

It's a easy thing to drop SPR/Sprint or Bioventus/Stimrouter leads there. You can use any but 3 of the 4 can easily do motor programs for some possible FES help but not necessary in your population with 90% strength.

Where are you putting the pump and what are you putting in it?

 

[Orin]

The pump goes in the abdominal wall. I'm starting most on Ziconotide @ 1-3 mcg/d.

Still, I put the catheter tip ~C3-5 for the brachial plexus as I would have to swap to drugs with less spread if the conotoxin fails.

 

[Ducttape]

med management.

severe disease (such as avulsion due to GSW) have referred for DREZ lesioning.

have done interscalene blocks with steroids. has helped.

 

[bedrock]

med management.

severe disease (such as avulsion due to GSW) have referred for DREZ lesioning.

have done interscalene blocks with steroids. has helped.

I like the interscalene blocks.

I have tried something new recently. I was never taught this, but decided to give it a try on these WC cases. I've started doing unilateral C4-C5, C5-C6, C6-C7 facet injections, but I do the facet injections the way I do them for MVA patients, so while I inject the joint, I also inject half the medication on the joint capsule and ligaments.

Definitely doesn't work for everyone, but I have seen 40-50% of these mild-moderate brachial plexus patients achieve 50-60% sustained relief of their neuropathic arm pain. I expect there is a contributing component from cervical spasm, but I never achieved this level of results after cervical TPI.

 

[drmamba]

How much steroids/volume are you all injecting in these interscalenes?

 

[Ducttape]

10 mg of dexamethasone and 1 ml 0.25% bupivacaine. ultrasound guided.

 

[JBM16BYU]

Sorry to resurrect a 2-year-old thread, but are there any updates for brachial plexus pain management, from an interventional standpoint? I've had patients who have not had benefit from neuropathic medications, not interested in opioid medications, who wonder if there is some interventional procedure that has helped. From my understanding (I'm not a pain medicine physician), sometimes SCS or PNS are tried, correct? Have you all found anything else helpful?