Traumatic Brachial Plexopathy Research Articles

A pentavalent approach for the evaluation of traumatic brachial plexopathy on MRI: correlation of macropattern and micropattern.

Macropattern analysis of traumatic brachial plexopathy (TBP) by Magnetic Resonance Imaging (MRI) encompasses localization of injured segments and determination of the severity of injury. The micropattern analysis implies the correlation of the MRI features of TBP with Sunderland's grading of the nerve injury, thereby guiding the management protocol. This review article presents a simplified novel pentavalent approach for the radiological anatomy of brachial plexus, MRI acquisition protocol for the evaluation of brachial plexus, cardinal imaging signs of TBP, and their correlation with Sunderland's microanatomical grading.

A Decade of Imaging Patients with Traumatic Brachial Plexopathy: What have We Learned?

Aim  In this paper, the authors share their experience of imaging patients with traumatic brachial plexopathy by magnetic resonance neurography (MRN) spanning over a period of nearly 10 years. Setting and Design  This was a single-institution, prospective, observational study conducted between August 2012 and March 2022. Materials and Methods  Children and adults presenting to the plastic surgery outpatient department with features of traumatic brachial plexopathy were included in the study. The MRN study was performed in a 1.5T scanner (Magnetom Essenza, Siemens, Erlangen, Germany). The area scanned extended from C3 level to T3 level. Statistical Analysis Descriptive statistics (percentages, mean, median, and mode). Results  A total of 134 patients ( n  = 134) were included in the study. The age of our patients ranged from 6 months to 65 years. The mean age was 24.95 ± 12.10 years, with a median of 23 years. All patients had unilateral injury, and the right side was more commonly involved. Road traffic accident was the most common mode of injury, and blunt crush-avulsion was the most common mechanism of injury. Involvement of shoulder, elbow, and hand together (panplexopathy) was the most common clinical presentation. Conclusion  This study of patients with traumatic brachial plexopathy imaged by MRN, spanning nearly a decade, has led to several interesting observations. The majority of these injuries occur in young men from urban areas who usually present with panplexopathy. The most common mode of injury is road traffic accident, and blunt crush-avulsion is the most common mechanism of injury.

Magnetic Resonance Imaging in Traumatic Brachial Plexopathy: A Guiding Light for Surgeons

Background: The brachial plexus is a group of major neural structures providing sensory and motor innervations to the upper limb. The brachial plexus originates from four cervical (C5-C8) and the first thoracic root (T1). Objectives: The aim of the current study was to evaluate the role of MRI in the diagnosis and localization of traumatic brachial plexopathies and co-relate MRI findings with intraoperative findings wherever possible. Methods: A total of 40 patients with traumatic brachial plexitis underwent a dedicated MRI at our institution. Clinical and electrodiagnostic tests were done in all patients. The findings of MR imaging were correlated with surgical findings as concordant (CR), partially concordant (PC), or nonconcordant (NC). Patients who were not operated were followed over a period of six months to one year. Results: Road traffic accidents (n=32) were the most common cause of brachial plexopathy in our study. Clinical evaluation revealed sensory symptoms in 28 (70 %), motor symptoms in 25 (63%), and autonomic manifestation in 2 (5%) patients. The electrodiagnostic tests were abnormal in 30 (75%) of our patients. MRI findings included pre-ganglionic injury (n=5, 12.5%), post-ganglionic injury (n=17 42.5%), mixed injury (n=9 22.5%) and normal in 9 (22.5%) patients. MRI findings were perfectly concordant with surgical findings in 23(66%), partially concordant in 8(23%), and nonconcordant in 4(11%) patients. MRI has a sensitivity of 87.88%, specificity of 100%, and accuracy of 89.47% for traumatic brachial plexopathy evaluation. Conclusion: MRI is an essential component of traumatic brachial plexopathy evaluation. MR imaging, although not absolutely perfect, helps in the localization of injury in traumatic plexopathies (pre vs. post-ganglionic), thereby acting as a guiding light for surgical management. Normal MRI in traumatic brachial plexopathy is an enigma, and management in these patients should be based on clinical and electrodiagnostic tests.

Localization of Brachial Plexopathies Using a Novel Diagnostic Program.

Background: Assessing the extent and specific location of brachial plexus injuries can be difficult given the variety of mechanisms of injury and anatomic complexity of the plexus. We developed a program to accurately assess the location of a patient's neurologic injury based on electromyographic data. Purpose: We sought to test our hypothesis that the location of traumatic brachial plexopathies could be accurately assessed with a novel program that processed electromyogram (EMG) and mechanism of injury data. Methods: This retrospective diagnostic cohort study was carried out with a novel diagnostic algorithm developed with the Python programming language. The program accepts user input of muscles demonstrating decreased motor unit recruitment, positive sharp waves, or fibrillation potentials. The testing data set was derived from a registry of brachial plexus injuries treated at our center. The primary outcome was the percent concordance of the algorithm's diagnosis with the surgical diagnosis. Results: Ninety-five cases met the inclusion criteria. Median time from injury onset to EMG examination was 4 months; median time from EMG examination to surgery was 1.2 months. The program diagnosis matched the surgical diagnosis in 92 out of 95 (97%) of cases, including cases with multilevel injuries and additional peripheral nerve injuries. Conclusion: This program accurately localized brachial plexopathies in nearly all cases, including those involving polytrauma or complex patterns of injury. This algorithm may be valuable as an aid to complete electrodiagnostic examinations, a diagnostic adjunct when planning treatment of severe plexus palsies, or an educational tool.

Nerves transfers for functional hand recovery in traumatic lower brachial plexopathy.

Background: Distal nerve transfers are an innovative modality for the treatment of C8-T1 brachial plexus lesions. The purpose of this case series is to report the authors’ results with hand restoration function by nerve transfer in patients with lower brachial plexus injury.Methods: Three consecutive nerve transfers were performed in a series of 11 patients to restore hand function after injury to the lower brachial plexus: brachialis motor branch to anterior interosseous nerve (AIN) and supinator branch to the posterior interosseous nerve (PIN) in a first surgical procedure, and AIN to pronator quadratus branch of ulnar nerve between 4 and 6 months later.Results: In all, 11 male patients underwent 33 surgical procedures. Time between brachial plexus injury and surgery was a mean of 11 months (range 4–13 months). Postoperative follow-up ranged from 12 to 24 months. We observed recovery of M3 or better finger flexion strength (AIN) and wrist extension (PIN) in 8 of the 11 surgically treated upper limbs. These patients recovered full thumb and finger extension between 6 and 12 months of surgery, without significant loss of donor function.Conclusion: Nerve transfers represent a way of restoring volitional control of upper extremity function in patients with C8-T1 brachial plexus injury.

Traumatic Brachial Plexopathy in Athletes: Current Concepts for Diagnosis and Management of Stingers.

Traumatic upper trunk brachial plexopathy, also known as a stinger or burner, is the most common upper extremity neurologic injury among athletes and most commonly involves the upper trunk. Recent studies have shown the incidence of both acute and recurrent injuries to be higher in patients with certain anatomic changes in the cervical spine. In addition, despite modern awareness, tackling techniques, and protective equipment, some think the incidence to be slowly on the rise in contact athletes. The severity of neurologic injury varies widely but usually does not result in significant loss of playing time or permanent neurologic deficits if appropriate management is undertaken. Timely diagnosis allows implementation of means to minimize the risk of recurrent injury. It is important for treating physicians to understand the pathogenesis, evaluation, and acute and long-term management of stingers to improve recovery and minimize chronic sequela.

Traumatic brachial plexopathy in a patient with off‐state Parkinson disease

AbstractThe patient was a 67‐year‐old woman who had an advanced Parkinson disease. She developed flaccid monoplegia with areflexia in the right upper limb after a fall during off‐state. Neurophysiological examinations revealed a neurapraxia in the proximal segment of the peripheral nerves. MRI showed high signal intensity in the right supraclavicular area including the brachial plexus and peripheral tissue on short TI inversion recovery images, which supported the diagnosis of the crush injury. The diagnosis of the traumatic brachial plexopathy was made. By the combination of neurophysiological examination and MRI, more elaborate diagnosis of the traumatic nerve injuries can be made.

Magnetic Resonance Morphometry of Neuroplastic Changes in the Brain during Conservative Treatment of Traumatic Brachial Plexopathy

Objectives. To identify neuroplastic changes in brain structures in the treatment of traumatic axonotomy of the brachial plexus using MR morphometry data. Materials and methods. MR morphometry of the gray and white matter of the brain was studied in 62 patients with traumatic axonopathy of the brachial plexus. Results. Correlational relationships were identified between the thickness of the sensorimotor cortex and the morphometric parameters (volume, diffuseness, fractional anisotropy) of subcortical formations (the corticospinal tracts, the forceps minor (frontal) of the corpus callosum) of the brain with the severity of neurological impairments and the dynamics of neurological deficit depending on therapeutic strategy. Conclusions. The data obtained here expand current concepts of the central mechanisms of post-traumatic axon regeneration in a model of traumatic brachial plexopathy and identify the patterns of neuroplastic processes in the CNS and the neuromodulatory effect of Neuromidin and Noofen. Use of individual morphometric parameters as markers for reactive neuroplastic processes in the CNS is suggested.

Free functioning gracilis transfer for reanimation of elbow and hand in total traumatic brachial plexopathy in children.

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MR neurography in traumatic, non-obstetric paediatric brachial plexopathy.

Many studies have elaborated on the role of magnetic resonance neurography (MRN) in evaluating traumatic brachial plexopathies. Most of these deal with MR findings in adult traumatic plexopathies or children with obstetric brachial plexus palsy (OBPP). Hence, the authors felt the need for this particular study, which focuses on MRN findings in children with non-obstetric traumatic brachial plexus palsy, to find out the distribution and severity of injuries in these patients. This was a single-institution, prospective study conducted between April 2015 and June 2016. All children presenting to the hospital with features of brachial plexopathy and a history of non-obstetric trauma were included in the study. At MRN, we looked for signs of injury at three levels: roots, trunks and cords. Signs of injury were found at the level of the roots in 22 patients (88%), at the level of the trunks in 20 patients (80%) and at the level of the cords in 22 patients (88%). This study, conducted on children suffering from non-obstetric, traumatic brachial plexopathy returned some interesting conclusions including that when the paediatric plexus is injured, the injury is severe and multi-level, with a very high incidence of root injuries. • Brachial plexus injury in paediatric age group is a devastating injury. • The most common cause of this is trauma sustained during birth. • Other causes include road traffic accidents and blunt injury. • MR neurography has revolutionised the diagnosis of brachial plexopathy.

[MRI morphometry of neuroplastic changes in the brain after conservative treatment of traumatic brachial plexopathy].

To identify neuroplastic changes in the brain structures during treatment of traumatic axonotomy of the brachial plexus (the pathology of peripheral nervous system). MRI morphometry of white and grey matter was studied in 62 patients with traumatic axonotomy of the brachial plexus. There were correlations between the thickness of sensorimotor cortex, morphometric parameters (volume, diffusion, fractional anisotropy) of subcortical formations (corticospinal tracts, the forceps minor), severity of neurological deficit and dynamics of clinical course depending on the therapeutic strategy. The results expand the current view on central mechanisms of posttraumatic axon regeneration on the model of traumatic brachial plexopathy and establish a neuromodulative effect of neuromidin and noofen. Some morphometric parameters may be used as the markers of reactive neuroplastic processes in the central nervous system.

Magnetic resonance imaging of traumatic and non-traumatic brachial plexopathies.

Adult-onset brachial plexopathy can be classified into traumatic and non-traumatic aetiologies. Traumatic brachial plexopathies can affect the pre- or postganglionic segments of the plexus. Non-traumatic brachial plexopathies may be due to neoplasia, radiotherapy, thoracic outlet syndrome and idiopathic neuralgic amyotrophy. Conventional magnetic resonance imaging (MRI) is useful to localise the area of injury or disease, and identify the likely cause. This review discusses some of the common causes of adult-onset brachial plexopathy and their imaging features on MRI. We also present a series of cases to illustrate some of these causes and their MRI findings.

Electromyographic Findings in Gracilis Muscle Grafts Used to Augment Elbow Flexion in Traumatic Brachial Plexopathy.

Gracilis muscle graft transplantation is one of the last resort surgical options to restore elbow flexion in patients with chronic traumatic upper-trunk brachial plexopathies. We retrospectively identified 34 patients who underwent surgeries between 1997 and 2014, and had postoperative follow-up for at least 12 months. Demographic, clinical, and electromyographic preoperative and postoperative data were analyzed. The median age of injury was 30 years old. Most subjects had a complete loss of elbow flexion preoperatively (n = 28, 82.4%). Median time from injury to surgery was 20 months (range = 3-226 months). It did not correlate with the time to reinnervation on EMG (r = 0.35, 95% CI = 0.007-0.62) or with the time improvement in muscle strength (r = 0.35, 95% CI = 0.007-0.62). The mean postoperative follow-up interval was 22.35 months. During that period, 32 of 34 (94%) patients achieved reinnervation. Median times from surgery to graft innervation and to any improvement in elbow flexor muscle power were the same (8.5 months) with overlapping time to event curves. Despite the long-standing and complete loss of elbow flexion in most of our patients, gracilis transfer surgeries have helped most of them to achieve reinnervation and start to regain function. Electromyography is a helpful tool, which along with the clinical examination, can predict postoperative improvement.

Newer MR Imaging Techniques in Traumatic Brachial Plexopathies

Newer MR Imaging Techniques in Traumatic Brachial Plexopathies

Diagnosis of nerve root avulsion injuries in adults with traumatic brachial plexopathies: MRI compared with CT myelography

Background: Computed tomography myelography (CTM) has been broadly adopted as the ‘gold standard’ imaging technique in the diagnosis of nerve root avulsion injuries in traumatic brachial plexopathies. CTM has the distinct advantage of better spatial resolution than magnetic resonance imaging (MRI); however, this technique is invasive and can result in significant patient discomfort. MRI, therefore, seems relatively more advantageous as it is less invasive (requires no lumbar puncture), lacks radiation exposure, has no adverse reactions related to intrathecal contrast agents and confers excellent soft-tissue contrast. Objectives: To compare the sensitivity and specificity of MRI with CTM in the diagnosis of preganglionic nerve root avulsion injuries in adults with traumatic brachial plexopathies at the Inkosi Albert Luthuli Central Hospital.Method: A retrospective comparative analysis was performed on 16 adult patients with traumatic preganglionic brachial plexopathies who underwent both MRI and CTM at Inkosi Albert Luthuli Central Hospital. Radiologists experienced in both CTM and MRI interpreted the data and a comparison was made using CTM as the gold standard. Results: The sensitivity and specificity for MRI detecting preganglionic nerve root avulsion injuries and pseudomeningoceles was 82% and 100% respectively. The interobserver agreement between CTM and MRI for the detection of preganglionic nerve root avulsion injuries was 81.25% (Kappa = 0.77) and 87.5% (Kappa = 0.84) for the detection of pseudomeningoceles. Conclusion: MRI was as sensitive as CTM at detecting preganglionic nerve root avulsion injuries and pseudomeningoceles of spinal nerve roots C7–T1 of the brachial plexus. Some mild discrepancies existed at the C5 and C6 nerve root levels. Owing to the invasiveness of the procedure and resultant patient discomfort, CTM should be reserved for complicated cases or for patients with contraindications to MRI.

MR neurography in traumatic brachial plexopathy

ObjectivesImaging of the brachial plexus has come a long way and has progressed from plain radiography to CT and CT myelography to MRI. Evolution of MR imaging sequences has enabled good visualization of the small components of the plexus. The purpose of our study was to correlate the results of MR neurography (MRN) in patients with traumatic brachial plexopathy with their operative findings. We wanted to determine the usefulness of MRN and how it influenced surgical planning and outcome. MethodsTwenty patients with features of traumatic brachial plexopathy who were referred to the MRI section of the Department of Radiology between September 2012 and January 2014 and subsequently underwent exploration were included in the study. MR neurography and operative findings were recorded at three levels of the brachial plexus—roots, trunks and cords. ResultsFindings at the level of roots and trunks were noted in 14 patients each and at the level of the cords in 16 patients. 10 patients had involvement at all levels. Axillary nerve involvement as a solitary finding was noted in two patients. These patients were subsequently operated and their studies were assigned a score based on the feedback from the operating surgeons. The MRN study was scored as three (good), two (average) or one (poor) depending on whether the MR findings correlated with operative findings at all three levels, any two levels or at any one level, respectively. ConclusionsMR neurography is an extremely useful modality to image the traumatized brachial plexus. It influences both surgical planning and outcome/prognosis.

Traumatic brachial plexopathies – Analysis of postsurgical functional and psychosocial outcome

IntroductionBrachial plexus injuries (BPI) not only affect motor but also psychosocial aspects of patients' lives. Aims and objectivesTo evaluate results of surgery in terms of motor, functional and psychosocial recovery; and to evaluate the surgical outcome in relation to location of injury, time since injury and type of surgical procedure. MethodsA total of 36 patients with traumatic BPI operated between Jan and Sept 2011 were prospectively analysed. Parameters analysed included demographic profile and complete injury details. Patients were evaluated in pre-op and post op (6, 9 months and then 6 monthly). Primary outcome measure was motor outcome. Secondary outcome measures included functional outcome as assessed by SF-36 score, DASH questionnaire, PVAS and psychosocial outcome assessment performed by DAQ and LH score. ResultsMean interval between injury and surgery was 8 months (range 3–20 months). There were 15 partial and 21 panplexal injuries. Mean follow up was 13.5 months (range 9–18 months). Good motor recovery rate was 71% in partial and 23% in pan BPI. Neurotisation yielded the best motor outcome (53% patients). There was no statistical difference between motor recovery, timing of surgery and type of neurotisation. There was statistically significant improvement in all the functional outcome scores and mean PVAS score after surgery (p < 0.05). ConclusionsSurgery offers a significant relief of neuropathic pain and improves the emotional well-being of the patient and should be offered to all, irrespective of delay in presentation.

Therapeutic effects of peripheral magnetic stimulation on traumatic brachial plexopathy: Clinical and neurophysiological study

To evaluate the therapeutic effects of peripheral repetitive magnetic stimulation (rMS) on recovery of traumatic brachial plexopathy. Thirty-four patients with traumatic brachial plexopathy were studied. Strength of different muscles of upper limbs was evaluated neurologically. Nerve conduction studies (NCS), upper limb F-waves and visual analogue scales (VAS) for shoulder pain were obtained for all patients. These were randomly assigned into two groups with a ratio of 2:1; each patient received conventional physical therapy modalities and active exercises as well as real or sham rMS applied over the superior trapezius muscle of the affected limb daily for 10 sessions. Patients were reassessed with the same parameters after the 5th and the 10th session, and 1 month after rMS treatment. No significant between-group differences were recorded at baseline assessment. Significant improvement was observed (time X groups) after real rMS in comparison to the sham group (P=0.0001 for muscle strength and 0.01 for VAS of shoulder pain). These improvements were still present at 1 month after the end of treatment. In accordance with the clinical improvement, a significant improvement was recorded in the neurophysiological parameters in the real vs the sham group. We demonstrate that peripheral rMS for 10 sessions may have positive therapeutic effects on motor recovery and pain relief in patients with traumatic brachial plexopathy. Therefore, it is a useful adjuvant in the therapy of these patients.

Imaging and electrodiagnostic work-up of acute adult brachial plexus injuries

Imaging and electrodiagnostic studies form an essential part of the evaluation of the patient with traumatic brachial plexopathy, enabling clarification of surgical options, prognostication of outcome and formulation of postoperative management. The primary objective of imaging is to identify pre-ganglionic injury indicative of nerve root avulsion. The presence of one or more nerve root avulsion injuries is a critical factor in surgical decision-making and the prognosis of surgical reconstruction. CT myelography is the current imaging modality of choice for this purpose. Initial electrodiagnostic (EDX) testing is ideally performed no sooner than 4 weeks following injury unless otherwise clinically indicated. Follow-up testing can be helpful at approximately 6 week intervals. The sensory nerve amplitudes are the most important component of nerve conduction testing in distinguishing between pre- and post-ganglionic injuries. Electromyographic studies will also assist in the determination of a pre- from post-ganglionic injury, the level of plexus involvement and identify potential donor nerves that may be suitable for use as transfers.

Imaging in clinical medicine: traumatic pseudomeningocoele

An 18-year-old male was involved in a road traffic accident that led to a fracture of the left clavicle. He was put in a brace. Over a month, the patient noted tingling, numbness, and difficulty in moving his left upper limb. Clinical examination showed severe motor weakness in the left upper limb. A traumatic brachial plexopathy was suspected. Nerve conduction studies and electromyography showed a complete brachial plexopathy affecting C5-D1 fibers with complete axon degeneration. A cervical magnetic resonance imaging (MRI) showed paraspinal cystic lesions at the level of C7-D1 and D1-D2 neural foramen consistent with traumatic pseudomeningocoeles. No spinal cord injury was found. (Published: 26 April 2011) Citation: Libyan J Med 2011, 6 : 6307 - DOI: 10.3402/ljm.v6i0.6307