**3. Future treatment possibilities**

(first do no harm) [44]. Any measure or technical improvement aiming to decrease the chance of these unwanted iatrogenic injuries will always be most welcomed. Knowledge, awareness,

The age of the patient, the mechanism of injury (blunt or penetrating), the location (proximal or distal in the upper limb), and the extent of the lesion will influence the type and timing of the treatment algorithm as well as the final result [46, 47]. When all brachial plexus roots are affected, particularly if avulsed, there will be very limited treatment options, and the end results will be a severe upper limb disability with a very limited chance of a useful functional

Particularly, it is important to find out if the lesion is pre- or postganglionic as the first one has no chance of spontaneous recovery [51]. Magnetic resonance imaging has proven very useful in this respect [52]. Waiting for spontaneous recovery will entail an inexcusable waste of time that will lead to an unsatisfactory recovery [50, 53]. Thus, once the diagnosis of the nerve root avulsion is confirmed, the repair will have to be done as soon as the patient is able to tolerate the surgical procedure needed to be done [54, 55]. The "urgent" repair, a few days after injury, has been reported by some in cases of confirmed avulsion and in clean nerve

The treatment strategy is based on the mechanism of injury [54], the findings of the physical and neurological examinations [57], and the results of the complementary diagnostic tests (electrodiagnostic studies [58], magnetic resonance imaging [59], and ultrasonography [60]). This last one is relatively inexpensive and can be made available to places with very limited resources [61]. It can also been used intraoperatively to see the anatomy of the damaged nerves, helping to decide if the lesioned nerve segment has to be removed and the gap grafted or a neurolysis will solve the problem [62]. The evolution of their results overtime is particularly useful to locate the lesion(s), assess its severity, and control the response to the treatments (physiotherapy, observation, surgical repair, electrostimulation, etc.) [63]. Computerized myelo-tomography was used in the past to diagnose the nerve root avulsions,

Spontaneous recovery can be expected in most brachial plexus injuries [67], particularly in the case of obstetric patients [68]. Among them the rate of spontaneous recovery is particularly high (66–92%) [69]. Physical therapy is essential to correct muscle contractures and avoid neglect of the damaged limb while waiting for spontaneous recovery [69]. In the case of inad-

Progressive improvement of the surgical techniques with direct nerve repair, nerve grafting, and particularly with nerve transfers has greatly improved the results in the brachial plexus injuries [47, 70–72]. Direct repair, when at all possible, is still the first choice, provided that there is no tension in the suture line [73]. Nerve grafts are required to cover the gaps, but the results are often not as good as expected [74, 75]. Meanwhile, the nerve transfers have expanded our treatment capabilities with excellent results [72, 76]. They are particularly

but nowadays it has been replaced by magnetic resonance imaging [59, 64–66].

equate recovery, on-time surgical treatment might be indicated [3, 68].

and training of all hospital personnel must be a priority in our daily basis [45].

**2. Treatment modalities**

4 Treatment of Brachial Plexus Injuries

recovery [48–50].

sections (i.e., glass) [56].

Currently, there is an intense research on pharmacological agents that accelerate the axonal regeneration, shortening the time needed to achieve the reinnervation [90, 91]. Other areas of research are the use of stem cells and growth factors as well as the search for artificial conduits that could substitute the autologous nerve grafts [90, 92]. The most serious injuries, the nerve root avulsions, are still awaiting an effective solution. Reimplantation has been attempted but the results are dismal [50].

Treatment of a complete brachial plexus avulsion with its resultant flail arm poses still a serious challenge [49]. Even with contralateral C7 nerve root transfer, only some primitive movements are regained with limited use in the daily life [93]. Some have recommended upper limb amputation in these unfortunate cases [94].

Tetraplegic [88] and stroke [95] patient treatments are an area of expansion, aiming to recover some functions in the upper limbs that can improve their quality of life [88, 96]. The rationale behind is to use nerve transfers to recover specific functions (like finger movement) in areas of irreversible spinal cord or motor strip damage [76, 97].

Some technical refinements have been described attempting to reduce the chance of iatrogenic injury in cases of anesthetic brachial plexus block [98, 99]. The use of ultrasonography can be of invaluable help [100]. Some recommendations on patient positioning have also been forwarded [44]. The long-term commitment of every hospital employee is essential to minimize these unwanted mishaps.
