Working Diagnosis:
C5 traumatic injury

Treatment:
Recommended to stop contact football and to avoid the chiropractor. He was allowed to continue cardiovascular exercise along with gentle upper body strength training.

Outcome:
Patient improved gradually and had complete resolution of symptoms after 3 months of conservative management with watchful waiting and slow progression of activities. He returned to full strength with no further atrophy or any deficits noted on exam and so was cleared to return to collision sports.

Author's Comments:
Consistent with the motor deficits in this patient, C5 contributes to the axillary, musculocutaneous, and suprascapular nerves. As his symptoms were more persistent than what would be expected with a typical "burner," the injury was likely present from the initial hit and exacerbated by the second. Interestingly, his head was rotated towards the side of the injury both times, implying a compression force rather than the typical traction mechanism of injury.

Spontaneous recovery can be seen in 3-4 months in as high as 40% of patients when the injury is limited to C5-C6.(1-2) However, operative management is indicated if symptoms are more persistent, with the best outcomes when performed less than 6 months after injury.(3)

Editor's Comments:
Trauma is the most common cause of brachial plexopathy in all ages. The anatomy of the brachial plexus can have variability but most commonly the upper trunk is formed by the C5 and C6 nerve roots. Transient brachial plexopathy or burners are typically the result of a traction or compression injury to this area during contact sports. Younger patients are thought to have a traction injury to the plexus more often while in adults compression to the nerve root in the neural foramen is more common. Symptoms include unilateral burning, numbness, or weakness of the entire arm. These symptoms are typically transient and resolve within minutes but can persist depending on the grade of nerve injury. Neuropraxia (grade I) involves the disruption of nerve function from demyelination with remyelination typically within three weeks. Axonotmesis (grade II) occurs when actual axonal damage and Wallerian degeneration result from trauma. Nerve function can return anywhere from three weeks to one year. Neurotmesis (grade III) is considered if there is permanent nerve damage which fortunately is rare in sports.

References:
1. Kim DH, Cho YJ, Tiel RL, Kline DG: Outcomes of surgery in 1019 brachial plexus lesions treated at Louisiana State University Health Sciences Center. J Neurosurg 98:1005–1016, 2003.
2. Kline DG: Timing for brachial plexus injury: a personal experience. Neurosurg Clin N Am 20:24–26, v, 2009.
3. Martin E, Senders JT, DiRisio AC, Smith TR, Broekman MLD. Timing of surgery in traumatic brachial plexus injury: a systematic review. J Neurosurg. 2018 May 1:1-13. doi: 10.3171/2018.1.JNS172068. Epub ahead of print. PMID: 29999446.

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