Brachial Plexus Involvement Research Articles

Enigmatic osteomyelitis and bilateral upper limb palsy in a neonate

This report describes a male infant who developed right upper limb palsy 5 days after birth and contralateral paralysis at 14 days. Abnormal in utero posture of the right arm had resulted in a difficult cephalic delivery. Right shoulder osteomyelitis was diagnosed at age 16 days from clinical, hematologic, and radiologic findings. Antibiotics were administered, followed by complete resolution of the symptoms in 2 weeks. Electromyographic and nerve conduction studies demonstrated direct involvement of the right brachial plexus, secondary to the osteomyelitis, explaining the unilateral onset and the persistent neurogenic pattern involving the muscles innervated by the right posterior branch to the brachial plexus. However, somatosensory evoked potentials indicated damage to the cervical spinal cord likely related to the birth trauma, which in all likelihood was the cause of the left limb palsy and contributed to the right limb picture.

Dyspnea as the Predominant Manifestation of Bilateral Phrenic Neuropathy

Phrenic neuropathy associated with brachial neuritis has been well described; however, bilateral phrenic neuropathy with minimal or no involvement of the brachial plexus has not. We review the clinical features, as well as the results of radiographic studies, pulmonary function tests, and electrodiagnostic studies, of 3 patients in whom dyspnea was the presenting manifestation of bilateral phrenic neuropathy. All 3 patients had acute-onset dyspnea, which led to consideration of a pulmonary or cardiac etiology. Phrenic nerve conduction studies showed bilateral axonal degeneration of the phrenic nerves. Diaphragmatic paralysis should be considered in the differential diagnosis of acute-onset dyspnea. Dyspnea increases typically when the patient lies down, and paradoxical respiration may be present. Neck, shoulder, or upper limb pain may occur at onset. Inspiratory pressures may be reduced, but a comparison of the forced vital capacity when the patient is standing and supine is more specific for diaphragmatic weakness. Phrenic nerve conduction studies and diaphragmatic electromyography may provide evidence of bilateral involvement. Subclinical evidence of brachial plexus involvement may be present. The prognosis for patients with bilateral phrenic neuropathy may be more favorable than reported previously.

Posterior shoulder dislocation in infants with neonatal brachial plexus palsy.

Glenoid dysplasia and posterior shoulder subluxation with resultant shoulder stiffness is a well-recognized complication in infants with neonatal brachial plexus palsy. It is generally considered to be the result of a slowly progressive glenohumeral deformation secondary to muscle imbalance, physeal trauma, or both. Recent publications about infantile posterior shoulder dislocation have suggested that the onset of dysplasia occurs at an earlier age than has been previously recognized. The prevalence of early dislocation in infants with this disorder has not been previously reported, to our knowledge. We studied 134 consecutive infants with neonatal brachial plexus palsy who were seen at our institution over a period of two years. All infants were examined at monthly intervals to assess neurological recovery and the status of the upper extremity until recovery occurred or a treatment plan was established. The type of brachial plexus involvement was classified. Specific clinical signs associated with subluxation and dislocation were recorded. These included asymmetry of skin folds of the axilla or the proximal aspect of the arm, apparent shortening of the humeral segment, a palpable asymmetric fullness in the posterior region of the shoulder, or a palpable click during shoulder manipulation. The infants who were identified as having these clinical signs were evaluated with ultrasonographic imaging studies. Eleven (8%) of the 134 infants had a posterior shoulder dislocation. The mean age at the time of diagnosis was six months (range, three to ten months). There was no correlation between the occurrence of dislocation and the type of initial neurological deficit. A rapid loss of passive external rotation between monthly examinations indicated a posterior shoulder dislocation. Posterior shoulder dislocation can occur earlier (before the age of one year) and more rapidly in infants with neonatal brachial plexus palsy than has been appreciated previously. As with developmental dysplasia of the hip, a high index of suspicion, recognition of clinical signs, and the use of ultrasonography will allow the diagnosis to be established. Following early diagnosis, attention should be focused on improving the stability and congruency of the shoulder joint.

The role of imaging in screening, diagnosis and staging of Non-Small Cell Lung Cancer (NSCLC)

Imaging plays a vital role in the management of NSCLC including diagnosis, staging and follow up. Computerised tomography (CT) is of value not only in the diagnosis of lung cancer, but also for screening and guiding intervention. CT and magnetic resonance imaging (MRI) are used in staging and provide anatomical information but have well known limitations in differentiating reactive from malignant nodes, fibrosis from active disease and in defining the extent of invasion. MRI, with its superior soft tissue contrast provides optimal information on brachial plexus and central nervous system involvement. Functional imaging using 2-18 fluoro-deoxyglucose positron emission tomography (FDG-PET) is increasingly being used to provide unique information and when combined with anatomic imaging will provide better staging information for both local disease and the extent of metastases. FDG-PET or 99mTc-depreotide may help in deciding which lesions need further investigation and the most appropriate lesion to biopsy. Multidetector CT is being used to detect lung cancer at an early stage when it is potentially curable by surgery although many problems exist, particularly the high false positive rates requiring further investigation, which will have implications on cost effectiveness for lung cancer screening programs.

Advances in radiological staging of non-small cell lung cancer (NSCLC)

Imaging plays a vital role in the management of non-small cell lung cancer including diagnosis, staging and follow-up. CT and magnetic resonance imaging (MRI) are used in staging and provide anatomical information but have well known limitations in differentiating reactive from malignant nodes, and fibrosis from active disease and in defining the extent of invasion. MRI with its superior soft tissue contrast provides optimal information on brachial plexus and central nervous system involvement. Functional imaging using 2-18 fluoro-deoxyglucose positron emission tomography is increasingly being used to provide unique information and when combined with anatomic imaging will provide better staging information for both local disease and the extent of metastases.

Poster 168: Ludwig’s angina complicated by nerve injury: a case report.

Setting: Inpatient rehabilitation unit of a tertiary care hospital. Patient: A 21-year-old white man. Case Description: The patient developed Ludwig’s angina after a tooth extraction for an abscess, which was complicated by mediastinitis, pericarditis, pericardial effusion, empyema, multiple pneumonias, respiratory failure leading to tracheostomy and mechanical ventilation, profound weight loss, bilateral hypoglossal nerve injury, and left brachial plexus involvement resulting in upper-extremity weakness. Assessment/Results: The patient had multiple admissions to the department of medicine, medical intensive care, and rehabilitation unit. The medical course was complicated by mediastinitis and pericardial effusion requiring pericardial window, empyema leading to thoracostomy, respiratory failure requiring emergency tracheostomy and ventilatory support, and malnutrition requiring percutaneous endoscopic gastrostomy placement. During his hospital stay, tongue and left upper-extremity weakness was noticed. Electrodiagnostic studies revealed extensive spontaneous potentials and no active motor units in the tongue, the left biceps, deltoid, supraspinatus, and brachioradialis muscles. Discussion: The patient was an active young man with no comorbid conditions. The sublingual and submandibular spaces were infected by direct extension, causing the Ludwig’s angina. In adults, 52% of cases of Ludwig’s angina are caused by dental caries and have a mortality rate of 5% to 10%. Submandibular and sublingual spaces freely communicate and, with involvement of deep cervical fascia, infection may spread rapidly with grave consequences. Extension along the carotid sheath or the retropharyngeal space can cause the mediastinitis. In this patient, nerve injury to both the hypoglossal nerve and the brachial plexus complicated his physical condition and rehabilitation. Conclusions: This case demonstrates the potentially catastrophic complications of odontogenic infections. Prompt diagnosis and early definitive care can minimize the morbidity and mortality of these serious infections.The rehabilitation can be prolonged and requires thorough attention to complications.

Surgical treatment of superior sulcus tumors with spinal and brachial plexus involvement.

Non-small cell lung carcinomas with spinal and brachial plexus involvement have traditionally been considered to be Stage IIIb lesions and therefore unresectable. Advances in spinal surgery, the application of magnetic resonance (MR) imaging, and improvements in neoadjuvant therapy require a reassessment of the potential for complete resection. The authors conducted a retrospective review of all procedures involving the resection of superior sulcus tumors with spinal or brachial plexus involvement performed between 1985 and 1999. Assessment or resectability and operative planning were based on an MR imaging classification scheme in which the extent of spinal involvement was considered. Class A tumors involved the periosteum of the vertebral body (VB) (16 patients); Class B, distal neural foramen without epidural compression (eight patients); Class C, proximal neural foramen with epidural compression (four patients); and Class D, bone involvement (VB or posterior elements) with or without epidural involvement (14 patients). Brachial plexus involvement was present in 21 patients, including 17 with T-1 nerve root only and four with C-8 or lower-trunk infiltration. Complete tumor resection was achieved in 27 patients and incomplete resection in 15. Complications occurred in 14 patients, two of which were related to instrumentation failures. The overall median survival was 1.44 years. The median survival for the complete and incomplete resection groups were 2.84 and 0.79 years, respectively (p = 0.0001). There was no statistical difference in survival among classification groups. Complete tumor resection of superior sulcus tumors is possible in selected patients in whom involvement of the spinal column and/or brachial plexus is present. Preoperative MR imaging is essential for evaluation of the spine and surgical planning. Survival and cure are dependent on complete resection, regardless of the extent of spinal involvement.

The involvement of the brachial plexus in cardiac surgery with median sternotomy for the revascularization of the myocardium: clinical evaluation

To evaluate the involvement of brachial plexus in cardiac surgery with median sternotomy for the revascularization of the myocardium 113 patients (87 men and 26 women) were clinically examined in the preoperative and between the fifth and eight post-operative days. The internal thoracic artery was used in 65 of the 113 patients. The electroneuromyography was not effected in any of the patients. A lesion of the brachial plexus was found in three patients though the internal thoracic artery was used in only one patient. We believe that factors such as posture of the patient, hypothermia, thoracic braces and use of the internal thoracic artery are relevant in the lesions. Hence one must be attentive to all the factors mentioned above so as to avoid or minimize the lesions.

A case of referred pain evoked by remote light touch after partial nerve injury

An unusual case of referred pain is presented in which a 63-year-old man, who suffered a severe injury to his right hand and arm during young adulthood, describes the later development of dysesthesia and shooting pain in his arm subsequent to stimulation of the ipsilateral scalp, the temporal and infrazygomatic region of the face, and the back. Referred sensations of this type are usually reported following amputation of an arm. Clinical examination of the sensory and motor function of the arm and hand revealed partial damage to the radial, ulnar and median nerves as well as possible brachial plexus involvement. Interestingly, pain could be evoked by repeated light touches applied to the remote trigger areas suggesting the involvement of a `wind-up'-like process.

Use of positron emission tomography in evaluation of brachial plexopathy in breast cancer patients

18-Fluoro-2-deoxyglucose (FDG) positron emission tomography (PET) has previously been used successfully to image primary and metastatic breast cancer. In this pilot study, 19 breast cancer patients with symptoms/signs referrable to the brachial plexus were evaluated with 18FDG-PET. In 11 cases computerized tomography (CT) scanning was also performed. Of the 19 patients referred for PET study, 14 had abnormal uptake of 18FDG in the region of the symptomatic plexus. Four patients had normal PET studies and one had increased FDG uptake in the chest wall that accounted for her axillary pain. CT scans were performed in 9 of the 14 patients who had positive brachial plexus PET studies; six of these were either normal or showed no clear evidence of recurrent disease, while three CTs demonstrated clear brachial plexus involvement. Of two of the four patients with normal PET studies, one has had complete resolution of symptoms untreated while the other was found to have cervical disc herniation on magnetic resonance imaging (MRI) scan. The remaining two patients almost certainly had radiation-induced plexopathy and had normal CT, MRI and PET study. These data suggest that 18FDG-PET scanning is a useful tool in evaluation of patients with suspected metastatic plexopathy, particularly if other imaging studies are normal. It may also be useful in distinguishing between radiation-induced and metastatic plexopathy. © 1999 Cancer Research Campaign

Late treatment of brachial plexus palsy secondary to birth injuries: rotational osteotomy of the proximal part of the humerus.

We retrospectively reviewed the results of rotational osteotomy that had been performed distal to the surgical neck of the humerus in twenty-two patients who had sustained an injury of the brachial plexus at birth. Eighteen patients had a lesion of the superior trunk of the brachial plexus (the fifth and sixth cervical nerve roots), and four had involvement of the entire brachial plexus. The patients ranged in age from four to seventeen years old (average age, ten years and three months old) at the time of the operation. The average duration of follow-up was fourteen years (range, two to thirty-one years). Preoperatively, the patients had been unable to perform self-care activities, such as grooming, feeding, and washing themselves, because of limited active external rotation or fixed internal rotation of the shoulder. All patients had decreased strength of the lateral rotator and abductor muscles and normal strength of the subscapularis and pectoralis major muscles. Radiographs showed some flattening of the humeral head, and four patients had posterior subluxation of the humeral head. A lateral rotational osteotomy of the proximal part of the humerus was performed between the insertions of the subscapularis and pectoralis major muscles. The site of the osteotomy was stabilized with catgut sutures in the periosteum in ten patients and with one or two staples in twelve. The extremity was immobilized in a plaster shoulder-spica cast for six weeks. At the latest follow-up evaluation, the average increase in active abduction was 27 degrees (range, 0 to 60 degrees) and the average increase in the arc of rotation was 25 degrees (range, 5 to 85 degrees). Supination of the forearm also had increased commensurate with the increase in external rotation. The appearance of the extremity had improved as well.

Idiopathic Brachial Plexitis After Total Shoulder Replacement with Interscalene Brachial Plexus Block

Idiopathic Brachial Plexitis After Total Shoulder Replacement with Interscalene Brachial Plexus Block

Avulsão do plexo braquial em cães - 3: eletroneuroestimulação dos nervos radial, mediano, ulnar e musculocutâneo

O objetivo deste trabalho foi relacionar os aspectos clínicos, neurológicos e histopatológicos (descritos nas partes l e 2 deste trabalho) com os resultados obtidos após estimulação elétrica dos nervos radiai, mediano, ulnar e musculocutâneo. Realizou-se a estimulação elétrica destes nervos durante o ato cirúrgico no qual foram coletados os fascículos para histopatolo gia. Os nervos radial, mediano e ulnar de todos os cães submetidos à eletroneuroestimulação apresentaram evidências de degenera- ção. enquanto que o nervo musculocutâneo apresentava função próxima do normal em 25% dos casos. A associação dos resultados do exame neurológico, da histologia e da eletroneuroestimulação sugeriu envolvimento quase que total das raízes do plexo braquial, enfatizando a necessidade de continuidade de pesquisas na área, visando principalmente a recuperação das raízes nervosas envolvidas.

Clavicle Fracture and Brachial Plexus Palsy in the Newborn: Risk Factors and Outcome

We undertook this study in aprimary care setting of a developing country, in apopulation with high parity and a high incidence ofdiabetes in pregnancy, aiming to determine the incidenceof these injuries in infants born in our hospital, to identifypossible risk factors in our population and to determine theprognosis for full recovery of affected babies.

Chronic inflammatory demyelinating polyradiculoneuropathy

We present three patients with atypical chronic inflammatory demyelinating polyradiculoneuropathy and discuss the management of patients who appear treatment resistant or present with unusual manifestations. The clinical features of the patients included massive nerve root hypertrophy causing myelopathy and movement-provoked paresthesia, pupillary dysfunction, visual loss due to increased intracranial pressure, and focal brachial plexus involvement. Each patient ultimately required prolonged courses of immune modulating therapy before benefit was attained, illustrating the importance of intensive and prolonged treatment combined with objective assessment of response to therapy.

4: Brachial plexopathy in breast carcinoma—an unsolved problem

Brachial plexus involvement from carcinoma of the breast produces a severe disability which presents difficulties in diagnosis and treatment. Five patients who suffered this complication are described and the problems they present are discussed.

Noninvasive Discrimination of Brachial Plexus Involvement In Upper Limb Pain

The ability of Elvey's "brachial plexus tension test" to identify pain referred from the cervical region was investigated in 50 patients with unilateral shoulder and upper arm pain: 25 reported symptoms commencing after open heart surgery, indicating a high probability of referred pain due to that procedure; 25 were athletes with injuries from throwing movements, a cause appearing much less likely to cause referred pain. Twenty-five asymptomatic subjects with no history of spinal or limb pain also were tested. Cervical and upper limb maneuvers of the test were assessed goniometrically. The cardiac group showed significantly greater test results than those of the other groups, suggesting that the test is able to discriminate referred and local sources of upper limb pain.

The Spectrum of Neurofibromatosis: Neurologic Manifestations with Malignant Transformation

Neurofibromatosis is an uncommon cause of tetraplegia. Spinal cord compression in association with brachial plexus involvement is rare. A case of neurofibromatosis with malignant transformation illustrates the neurologic features associated with this condition. Malignant transformation of a neurofibroma should always be considered in patients with recurrent lesions or progressive neurologic dysfunction.

Evaluation of Neoplastic Involvement of Brachial and Lumbosacral Plexus

Traditionally, the regions of brachial and lumbosacral plexi have been difficult to evaluate, both by physical examination and conventional radiography. Presenting symptoms of plexus involvement may include pain, paresthesia, focal weakness, sensory deficits, and muscle atrophy. The symptomatology as well as electrodiagnostic studies are nonspecific and many conditions, such as mechanical compromise of the pathway by a benign process, inflammation, and infiltration by a neoplasm originating or metastatic to the region of plexi share similar features and cannot be differentiated. A general term "brachial or lumbosacral plexopathy" is universally used, to describe a variety of clinical syndromes, including tumor infiltration, neuritis, postsurgical, and postradiation changes as well as idiopathic conditions. Significant progress in detection and assessment of the extent of plexus disease has been made after introduction of computed tomography (CT). Further anatomical detail and tissue characteristics have been provided by magnetic resonance imaging (MRI). However, in spite of valuable contribution from both imaging methods, the plexi frequently present a challenging problem for a clinician as well as for a radiologist.

MRI of the brachial plexus: A review of 51 cases

We present a magnetic resonance imaging (MRI) study in 51 patients where the brachial plexus was evaluated. Using a 1.5 T clinical imaging system, we obtained T1-weighted sequences, and double-echo (intermediate-and T2-weighted) spin-echo images. The coronal plane was imaged in all examinations and was supplemented by images in the sagittal and/or axial planes. Twenty cases had proven pathological brachial plexus involvement, whereas, in 31 cases, no brachial plexus involvement was present. In 4 cases, the MRI findings were not in agreement with the final diagnosis found in the charts.