Abstract
Cross-sectional MRI has modest diagnostic accuracy for diagnosing traumatic brachial plexus root avulsions. Consequently, patients either undergo major exploratory surgery or months of surveillance to determine if and what nerve reconstruction is needed. This study aimed to develop a diffusion tensor imaging (DTI) protocol at 3 Tesla to visualize normal roots and identify traumatic root avulsions of the brachial plexus. Seven healthy adults and 12 adults with known (operatively explored) unilateral traumatic brachial plexus root avulsions were scanned. DTI was acquired using a single-shot echo-planar imaging sequence at 3 Tesla. The brachial plexus was visualized by deterministic tractography. Fractional anisotropy (FA) and mean diffusivity (MD) were calculated for injured and avulsed roots in the lateral recesses of the vertebral foramen. Compared to healthy nerves roots, the FA of avulsed nerve roots was lower (mean difference 0.1 [95% CI 0.07, 0.13]; p < 0.001) and the MD was greater (mean difference 0.32 × 10−3 mm2/s [95% CI 0.11, 0.53]; p < 0.001). Deterministic tractography reconstructed both normal roots and root avulsions of the brachial plexus; the negative-predictive value for at least one root avulsion was 100% (95% CI 78, 100). Therefore, DTI might help visualize both normal and injured roots of the brachial plexus aided by tractography. The precision of this technique and how it relates to neural microstructure will be further investigated in a prospective diagnostic accuracy study of patients with acute brachial plexus injuries.
Highlights
1% of adults involved in major trauma sustain a brachial plexus injury (BPI) [1] which cause disability [2, 3], pain [4], psychological morbidity [5] and impaired quality of life [2, 3].Root avulsions are the most prevalent form of injury in traumatic BPI [6]
Thereafter, we recruited 12 adults with unilateral brachial plexus root avulsions who were surgically explored by a single surgeon between 2009 and 2014; these patients had since been discharged from clinical services
The diagnostic accuracy of deterministic diffusion tensor imaging (DTI) for root avulsions is shown in Table 1, with an overall diagnostic accuracy of 71%
Summary
1% of adults involved in major trauma sustain a brachial plexus injury (BPI) [1] which cause disability [2, 3], pain [4], psychological morbidity [5] and impaired quality of life [2, 3].Root avulsions are the most prevalent form of injury in traumatic BPI [6]. Root avulsions are high-force injuries which affect all neural elements including the anterior horn cells [7], fibers in the transitional zone and free rootlets, all of which precludes re-implantation [8] and mandates reconstruction by nerve transfer. Nerve transfers are cost-effective [9], low morbidity procedures which significantly improve function [10]. Diagnosis is of critical importance because early reconstruction improves outcomes [11, 12] and might mitigate the chronic neuropathic pain [13], which is experienced by 95% of patients with BPIs [4]. Early and accurate diagnosis of root avulsion(s) is of paramount importance
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