P-NE021. Spinal cord injury versus brachial plexus injury: The importance of nerve conduction studies (NCS) in major trauma patients

Abstract

Introduction . High impact injuries to the neck, shoulder and upper arm can lead to both cervical cord or brachial plexus injuries, which at times prove to be a diagnostic dilemma should imaging be inconclusive. We present a case of a trauma patient, with indeterminate scans. A 20 year-old motorcyclist, with no significant past medical history, presented after colliding with a cyclist and shoulder pain was complained on scene. Trauma series imaging (CT head, spine, thorax, abdomen and pelvis) noted intact clavicles, scapulae, sternum and proximal humerus with no fracture identified. He had a small pneumothorax and lung contusion. Clinically, the patient had significant pain across the whole right upper limb, power 0/5 on muscle power assessment (MRC) scale on shoulder abduction, elbow flexion and extension, and wrist flexion and extension. The presentation was in keeping with a brachial plexus injury. Results . Cervical spine and brachial plexus MRI noted not only cervical cord oedema and haemorrhage, but also noted possible preganglionic type of root avulsion injury. There was also no gross discontinuity of the brachial plexus and was inconclusive. The right hemidiaphragm was also elevated in chest x-ray which was suggestive of phrenic nerve injury. Nerve conduction studies performed confirmed severe right pan-plexopathy, with all sensory and motor response on the right upper limb attenuated or absent. The neuropathic pain was managed with gabapentin, amitriptyline and opiates which controlled the pain. He was referred to the plastic surgeons for considerations of nerve reconstruction surgery. Conclusion . Although brachial plexus MRI is deemed to be the gold standard for assessing brachial plexus injuries, its role maybe limited in cases where images are inconclusive and proves a diagnostic dilemma to distinguish between spinal cord and brachial plexus injury. Clinical examination together with nerve conduction studies plays a salient role in diagnosing for appropriate management.