INTRODUCTION
Traumatic brachial plexus lesions are the most com- mon form of plexus injuries. This syndrome is fre- quently the result of high-impact trauma following a motorcycle acci- dent or industrial injury.
It can be caused by damage of the cervical vertebrae, the clavicle, and the humerus.

An injury due to trauma of the lumbosacral plexus may also result from a serious accident, but this occurs less frequently.

The lumbosacral plexus can also be involved after a hemorrhage in the pelvic retroperito- neum, or as a result of tumor spread.

brachial plexus injuries can be stratified according to location: preganglionic (ie, nerve root avulsion from the spinal cord), postganglionic, or combination lesions.

Postganglionic lesions can be further classified into nerve disruption and lesions in continuity.

Lesions located between the spinal cord and (proximal) ganglion can result in par- ticularly debilitating pain complaints.

SYMPTOMS
In the presence of a ‘‘preganglionic lesion,’’ the incidence of serious pain increases to approximately 90%.

Patients with root avulsion, severe pain usually occurs immediately following the injury. The initial continuous ‘‘background pain’’ is described as ‘‘burning,’’ ‘‘shooting,’’ or ‘‘stabbing’’ in quality.

Later on it will be paroxysms.

The pain is usually worst in the distal parts of the arm and hand, typically in a nondermatomal distribution.

Injury to upper plexus generally results in extensive loss of function in the proximal part of the arm and shoulder girdle, with motor function in the hand remaining unaltered or partially intact.

By contrast, damage to the lower part of the plexus typically leads to serious loss of hand function, while the sensory losses are less extensive.

Muscle strength can be affected.

Vegetative changes in the arm and hand often arise because of the trauma.

A Horner’s symptom on the affected side is indicative of a plexus lesion in the proximal region of roots C8 to T1.

Combined damage to the plexus and spinal cord may lead to a difficult and time-consuming diagnostic process.

TREATMENT
Extensive physical therapy is a first-line treatment strategy for a traumatic strain or avulsion injury. This is necessary to prevent the development of contractures and secondary pain.
Pharmacological management to control neuropathic pain.
surgical therapies are initiated 3 to 6 months after injury.
Preganglionic injuries are generally not amenable to repair, and may be treated with nerve (eg, intercostal nerves) transfer (sometimes with free muscle transfer) to restore function in denervated muscle(s).

For postganglionic injuries, nerve grafting and nerve repair can improve function in 40% to 75% of patients.
neurostimulation techniques have been reported to have wide-ranging and unpredictable effect.

neurostimulation techniques have been reported to have wide-ranging and unpredictable effect.

Injuries characterized by complete deaffer- entation are unlikely to respond positively to spinal cord stimulation (SCS).

Although there is a zone of spinal hyperactivity in the dorsal part of the spinal cord, which could be amenable to SCS.

motor cortex stimulation (MCS) should have a positive effect on de-afferentation pain.

the DREZ (dorsal root entry zone) procedure, also known as MDT (microsurgical DREZotomy), a 2 mm deep, 35° incision is made ventromedially in the dorsolateral sulcus of the posterior horn. The level(s) at which this intervention takes place depend(s) on the location of the radicular avulsion.

Intrathecal pump with continuous delivery of medication after trial.