eMedicine Specialties > Physical Medicine and Rehabilitation > Plexopathy

Traumatic Brachial Plexopathy: Differential Diagnoses & Workup

Author: Vladimir Kaye, MD, Consulting Staff, Departments of Neurology and Psychiatry, Hoag Hospital
Coauthor(s): Murray E Brandstater, MBBS, PhD, Chairman and Program Director, Professor, Department of Physical Medicine and Rehabilitation, Loma Linda University School of Medicine
Contributor Information and Disclosures

Updated: Sep 25, 2008

Differential Diagnoses

Cervical Radiculopathy
Spinal Stenosis
Guillain-Barre Syndrome
Syringomyelia
Multiple Sclerosis
Thoracic Outlet Syndrome
Neoplastic Brachial Plexopathy
Traumatic Brain Injury: Definition, Epidemiology, Pathophysiology
Spinal Cord Injury: Definition, Epidemiology, Pathophysiology

Other Problems to Be Considered

Traumatic root avulsion
Anterior horn cell disorders
Cerebrovascular accident (CVA)
Peripheral neuropathy
Entrapment syndromes of the upper extremity
Iatrogenic injury - Injection and/or block, thoracotomy, tourniquet paralysis
Sports injury - Stingers, burners
Psychogenic paralysis
Intraspinal and brachial plexus neoplasm
Myopathy
Neurodegenerative process
Toxic process - Exposure to heavy metals, synthetic hydrocarbons, alcohol
Infiltrative process
Vasculitic process - Polyarteritis nodosa (PAN), systemic lupus erythematosus (SLE), diabetes
Hemorrhagic process in the spinal cord or nerve sheath
Immunogenic process -Human immunodeficiency virus (HIV) infection, transverse myelitis
Shoulder and scapulothoracic dislocation, fracture, tendinitis, or capsulitis

Workup

Laboratory Studies

  • Electrodiagnosis has become a mainstay in the diagnostic evaluation of brachial plexopathies. Electrodiagnostic tests provide physiologic data about the continuity of pathways and of lesion type and severity. Serial testing is helpful to determine prognosis.
  • While positive waves and fibrillations (which indicate axonal injury) do not appear for several weeks after injury, sensory nerve action potentials (SNAPs) can be useful within days of injury to distinguish a presynaptic lesion from a postsynaptic lesion. With postsynaptic lesions, SNAPs are absent, whereas they are present with presynaptic ganglionic lesions.7
  • Somatosensory evoked potentials (SSEPs) are also useful to assess proximal lesions, such as root avulsions.7,8,9

Imaging Studies

  • Many peripheral nerve injuries can be associated with other soft-tissue or bone injuries that can be detected at radiography.
    • Radiographs of the injury site help to identify fractures or foreign bodies. For example, fractures of the cervical spine are frequently associated with brachial plexus injuries.
    • In cases of phrenic nerve paralysis, chest radiographs demonstrate unilateral elevation of the diaphragm.
    • Midhumeral fractures are associated with radial nerve injuries, and midforearm fractures of the ulna or radius are associated with median or ulnar nerve injuries, respectively.
    • To rule out bony and ligamentous injuries, all patients with axillary nerve injury should initially undergo radiography of the shoulder and cervical spine.
  • The resolution of the fine anatomic detail of soft tissue is better with magnetic resonance imaging (MRI) than with computed tomography (CT) scanning.
    • Conventional MRI is used to visualize normal and abnormal peripheral nerve structures.10
    • Moreover, in a study by West and colleagues, MRI depicted signal intensity changes in denervated muscle as early as 4 days after clinical symptoms developed.11 With short-tau inversion recovery (STIR) techniques, signal intensity changes in the thenar muscles were demonstrated on MRI scans of 100% of the patients with clinically advanced carpal tunnel syndrome.
    • With neurapraxic nerve injuries,9 the signal intensity in the innervated muscles remains normal on STIR or T2-weighted images. Therefore, after a peripheral nerve injury, early MRI of the muscle can be useful in distinguishing a neurapraxic injury from more severe axonotmesis or neurotmesis.
  • Because CT scanning and traditional MRI techniques have inherent limitations in their resolution and distinction of peripheral nerves from the surrounding structures, magnetic resonance neurography (MRN) has been developed.
    • MRN can depict normal and abnormal peripheral nerves in various regions of the body.
    • The injured peripheral nerve can be assessed by orienting the images along the course of the damaged nerve. For example, the loss of signal intensity on T2-weighted images indicates damage to the myelin sheath.
    • In addition, loss of water content in denervated nerves of the deep muscles can be assessed with MRN when needle electromyography (EMG) is difficult to perform.10
    • The predictive value of MRN in the diagnosis of peripheral nerve trauma has not yet been reliably established.
  • CT scanning can be used in the investigation of occult fractures that are not depicted on plain radiographs.
  • With myelography, CT scanning can be used to demonstrate root avulsion.12,13

Related eMedicine topic:
Brachial Plexus, MRI

Other Tests

Clinical threshold testing can be used to evaluate sensory function in peripheral nerves. These tests can be used to determine the level of stimulus necessary to elicit a response.

Semmes-Weinstein monofilaments are fine filaments that exert a discrete amount of pressure on the fingertips. They are used to perform threshold testing. Vibratory senses can be assessed by means of clinical threshold testing with low (30 Hz) to high (256 Hz) frequencies.

Histologic Findings

At light microscopy, nerves injured with epineurectomy or a crush mechanism have widespread fiber degeneration and myelin debris in the subperineurial region. The centrofascicular areas are relatively preserved compared with the subperineurial regions. The central vessels are preserved mostly within the centrofascicular area of the injured nerve. The thickness of myelin in the axons is decreased after injury, and the internodal length becomes more variable compared with its length before injury. A loss of cross-sectional area without a loss in the muscle fiber count begins within 1 week of denervation.

More on Traumatic Brachial Plexopathy

Overview: Traumatic Brachial Plexopathy
Differential Diagnoses & Workup: Traumatic Brachial Plexopathy
Treatment & Medication: Traumatic Brachial Plexopathy
Follow-up: Traumatic Brachial Plexopathy
References
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References

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Further Reading

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Keywords

traumatic brachial plexopathy, brachial plexus, brachial, plexopathy, peripheral neuropathy, peripheral nerve injury, thoracic outlet syndrome, brachial plexus injury, brachial plexus injuries, traumatic brachial plexus injury, brachial plexus neuropathy, brachial plexus lesion, stinger injury, stingers, burner injury

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Contributor Information and Disclosures

Author

Vladimir Kaye, MD, Consulting Staff, Departments of Neurology and Psychiatry, Hoag Hospital
Disclosure: Nothing to disclose.

Coauthor(s)

Murray E Brandstater, MBBS, PhD, Chairman and Program Director, Professor, Department of Physical Medicine and Rehabilitation, Loma Linda University School of Medicine
Murray E Brandstater, MBBS, PhD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, American Congress of Rehabilitation Medicine, American Medical Association, Association for Academic Psychiatry, California Society of Physical Medicine and Rehabilitation, Canadian Association of Physical Medicine and Rehabilitation, Canadian Medical Association, Canadian Society of Clinical Neurophysiologists, Catholic Medical Association, National Stroke Association, Ontario Medical Association, Royal College of Physicians and Surgeons of Canada, and Royal College of Physicians and Surgeons of the United States
Disclosure: Nothing to disclose.

Medical Editor

Teresa L Massagli, MD, Residency Director, Professor, Department of Rehabilitation Medicine and Pediatrics, University of Washington School of Medicine
Teresa L Massagli, MD is a member of the following medical societies: American Academy of Pediatrics, American Academy of Physical Medicine and Rehabilitation, and Association of Academic Physiatrists
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Kat Kolaski, MD, Assistant Professor, Departments of Orthopedic Surgery and Pediatrics, Wake Forest University School of Medicine
Kat Kolaski, MD is a member of the following medical societies: American Academy for Cerebral Palsy and Developmental Medicine and American Academy of Physical Medicine and Rehabilitation
Disclosure: Nothing to disclose.

CME Editor

Kelly L Allen, MD, Regional Medical Director, IMX-Medical Management Services
Disclosure: Nothing to disclose.

Chief Editor

Robert H Meier III, MD, Director, Amputee Services of America; Active Medical Staff, Presbyterian/St Luke's Hospital, Spalding Rehabilitation Hospital, Select Specialty Hospital; Consulting Staff, Kindred Hospital
Robert H Meier III, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation and Association of Academic Physiatrists
Disclosure: Nothing to disclose.

 
 
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