300 - Rehabilitation and Pain Management of Brachial Plexus Injury after Gunshot Wound

Thursday, February 22, 2024

5:00 PM – 6:30 PM EDT

Presenting Author(s)

GA

Gary B. Allen, MD

Resident Physician
Vanderbilt University Medical Center
Nashville, Tennessee, United States

Co-Author(s)

VC

Valentine Chukwuma, MD

Resident Physician
Vanderbilt University Medical Center
Antioch, Tennessee, United States
JM

Jed Maslow, MD, MSCI

Assistant Professor
Vanderbilt University Medical Center
Nashville, Tennessee, United States
William M. Jones, MD

Assistant Professor
Vanderbilt University PM&R
Nashville, Tennessee, United States

Case Diagnosis: Brachial Plexus Injury after Gunshot Wound

Case Description: A 32-year-old right-hand-dominant male with history of sickle cell anemia treated with methadone and oxycodone, sustained gunshot wound (GSW) to the right axilla resulting in right upper extremity hemorrhage and flaccidity. A brachial plexus injury (BPI) was suspected given his initial presentation of diffuse right arm weakness, numbness, and paresthesias. Three months post-injury, he reports improved right shoulder and biceps strength. He still has a severe right wrist drop, difficulty with right hand function, and diffuse right arm neuropathic pain. Electrodiagnostic evaluation demonstrated a right BPI affecting the upper, middle, and lower trunks with evidence of early reinnervation in upper trunk innervated muscles (deltoid, biceps, and infraspinatus). Given the electrodiagnostic results, hand surgery decided to continue conservative management. The patient noted little pain relief with gabapentin and nortriptyline. Pain management plans to place a 60-day peripheral nerve stimulator (PNS) trial for pain control and to avoid additional opiate use.

Discussions: GSWs are a devastating cause of BPIs. Clinical features of BPI include muscle weakness, altered sensation, and neuropathic pain in the affected arm. Electrodiagnostic studies are integral to the diagnosis of BPIs and can be repeated to monitor recovery and aid in planning before surgical intervention. A multispecialty, multidisciplinary approach, including physiatry, is important to address this complex injury. Common rehabilitation approaches after BPIs include kinesiology, electrothermal and phototherapy, manual therapy, and sensory re-education strategies, though only low-level evidence exists. Surgical treatment options to improve function in severe injuries include nerve graft, nerve transfer, and free-functioning muscle transfer. One study and case reports have demonstrated the successful use of PNS to treat neuropathic pain after BPI with results lasting up to one year post-treatment.

Conclusions: Brachial plexopathy requires a multidisciplinary treatment approach. PNS may be considered to reduce opiate usage in BPI pain management.