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The Texas Brachial Plexus Institute, located in the heart of The Texas Medical Center in Houston, is a multidisciplinary team of physicians and support staff, consisting of reconstructive peripheral nerve surgeons, neuroelectrophysiologists, physiotherapists, orthopedic hand and shoulder specialists, physical and occupational therapists, and nurses who are dedicated to the treatment and research of brachial plexus injury. All of us have been involved with the care of brachial plexus patients, starting with the clinic when it was at Texas Children's Hospital, and have worked with each other for many years. Our staff and physicians have the experience to answer your questions and concerns, and help you with all you necessary arrangements.

Our mission at Texas BPI is to help children and adults with brachial plexus injuries world wide, with innovative treatments based in research and experience.

Drs. Armenta and Berzin are certified by the American Board of Plastic Surgery, and both have completed a microsurgery and peripheral nerve surgery fellowship at Baylor College of Medicine in Houston with Dr. Saleh M. Shenaq, a recognized leader in the field of brachial plexus surgery. In their residency and practice, they have treated thousands of patients with brachial plexus injuries and have written numerous articles, presented world wide, and have created innovative techniques in the treatment of brachial plexus injury. It was Dr Shenaq's final request before his passing that they continue his clinic and his work with children and adults who have this devastating injury.

Lisa Thompson has a wealth of experience working with brachial plexus families. For 12 years she was the brachial plexus surgery coordinator for the Brachial Plexus Team at Texas Childrens Hospital working very closely with Lisa Davis, RN. In 2007, Mrs. Thompson joined the practice of Dr. Berzin and Dr. Armenta to continue the legacy of the work of the late Dr. Saleh Shenaq. Lisa is an invaluable source of information for families that are planning their trip here to Houston to visit our team. She schedules all appointments, surgeries and works closely with families and their insurance companies to make this process as easy and uncomplicated as possible. "The day to day contact I have with brachial plexus patients, both children and adults is a very rewarding part of my job and I am so pleased to be working with the "team" once again!

Services( characters out of 5000)

Initial Repairs
Initial treatment options for patients include physical therapy where stretching and other activities begin to stimulate function. Daily passive range of motion exercises are done to all joints of the shoulder, elbow, wrist and hand. Therapists offer a wide range of treatments and also serve to objectively evaluate recovery. These treatments are continued from the time of injury to three months of age. By three months, patients are examined to see if functional milestones have been met. We agree with most experts in the field that if a child has no biceps function by three months then a primary surgical exploration is needed.

The surgical approach of the brachial plexus is performed through an "L" shaped incision along the posterior border of the sternocleidomastoid muscle with a lateral extension superior to the clavicle. In rare circumstances, an infraclavicular extension is made for more severe injuries. Meticulous care is taken during the operation as there usually is a significant amount of scarring from the initial injury. The brachial plexus is identified and tagged, and neuromas are examined to plan for appropriate reconstruction. A neuroelectrophysiologist then performs nerve conduction test and somatic evoked potentials to determine the severity of nerve injury and the conduction through the neuroma.

The final reconstructive plan is then made in conjunction with the family taking into consideration all physical findings and functional abilities.

Type of Primary Reconstruction SurgeryPrimary Exploration
If the amount of signal transmitted through the nerve injury is 50% amplitude or above, a neurolysis is performed to the roots, neuroma, and branches. This is a removal of the scar tissue that encases the nerves and slows conduction. Bypass grafts are used side to side from the nerve roots to the respective branches in an attempt to increase nerve regeneration. The sural nerve from the patient's leg is used as a nerve graft, or nerve allografts (donor nerves) are used in our studies.

If there is less than 50% conduction through the neuroma, the neuroma is excised (removed) and the nerve roots and branches are examined. The nerve roots and branches are cut back until healthy nerve tissue is reached. Again, the sural nerves are used and additional allografts are used as nerve grafts. When nerve roots are found to be avulsed, the remaining available roots are used to graft to the necessary branches.

Patients are then placed in protective splints for two weeks and then start aggressive physical therapy. Therapy is vital to every patient and in our experience we have seen the best results in patients whose families are most involved with therapy and its implementation both at home and with a licensed therapist. These patients are seen routinely and functional milestones are assessed throughout childhood.

In our center, we have found that implementing this surgical plan early is critical to recovering the most functionality. Delaying surgery past this date will only result in decreased capability later. However, we have seen and performed surgery on patients past this three-month time frame that have gained function despite the delay in treatment. The most important factor in these patients is to determine who will need surgery and to perform that surgery as early as possible. The earlier surgery is done when indicated the better functional recovery is obtained. There have been reports of patients as old as two years of age undergoing a primary repair with improvement.

“Mod Quad” and Other Secondary Surgeries

Secondary SplintA common secondary brachial plexus surgery coined the "mod quad" consists of a series of procedures in one surgery aimed to improve shoulder abduction, external rotation, and elbow and hand function. The outpatient operation involves an incision in the armpit, neurolysis (removal of scar tissue surrounding nerves) to improve conduction of damaged nerves, moving the latissimus muscle (and sometimes the teres major muscle) insertion from being an internal rotator to becoming an external rotator, releasing or weakening tight muscles that cause internal rotation, and intraoperative nerve stimulation to check viability and conduction of other nerves. Patients are placed in a splint for two weeks and then aggressive physical therapy is started. Depending on the severity of injury, other procedures can be added, such as nerve grafts, in preparation for future procedures.

As the patient grows, functional deficits become more apparent or problematic. Again, with careful examination and EMG evaluation, the overall rate of progress is accessed in order to decide if surgery is the right option. If surgery is needed, these issues are dealt with by a series of surgeries that in essence follow the Robin Hood principle-take from the rich and give to the poor. Muscles and tendons are rerouted to provide additional strength in areas of weak function.

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