Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Traumatic Brachial Plexopathy Workup

  • Author: Vladimir Kaye, MD; Chief Editor: Robert H Meier, III, MD  more...
 
Updated: Aug 27, 2015
 

Laboratory Studies

See the list below:

  • 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. [9, 10]
  • 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. [11]
  • Somatosensory evoked potentials (SSEPs) are also useful to assess proximal lesions, such as root avulsions. [11, 12, 13]
Next

Imaging Studies

Radiography

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.

MRI and CT scanning

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.[14, 15, 16]

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.[17]  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.[18] 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,[13] 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.[17]

The predictive value of MRN in the diagnosis of peripheral nerve trauma has not yet been reliably established.

A retrospective study by Brogan et al found through MRI evaluation that among 280 adults with traumatic brachial plexus injuries, 23 of them (8.2%) had a concomitant full-thickness rotator cuff tear. The investigators therefore proposed that the rotator cuff be imaged in patients with traumatic brachial plexopathy when treatment options are being assessed.[19]

Related Medscape Reference topic:

Brachial Plexus Evaluation with MRI

Previous
Next

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.

Previous
Next

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.

Previous
 
 
Contributor Information and Disclosures
Author

Vladimir Kaye, MD Consulting Staff, Departments of Neurology and Psychiatry, Hoag Hospital

Vladimir Kaye, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, North American Spine Society, American Academy of Anti-Aging Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Murray E Brandstater, MBBS Chairman and Program Director, Professor, Department of Physical Medicine and Rehabilitation, Loma Linda University School of Medicine

Murray E Brandstater, MBBS 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, Royal College of Physicians and Surgeons of the United States

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Aishwarya Patil, MD Physiatrist (Rehabilitation Physician), Vice Chair, Immanuel Rehabilitation Center

Aishwarya Patil, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine, Association of Academic Physiatrists, Association of Physicians of India

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, Association of Academic Physiatrists

Disclosure: Nothing to disclose.

Additional Contributors

Teresa L Massagli, MD Professor of Rehabilitation Medicine, Adjunct Professor of Pediatrics, University of Washington School of Medicine

Teresa L Massagli, MD is a member of the following medical societies: Academy of Spinal Cord Injury Professionals, American Academy of Physical Medicine and Rehabilitation, Association of Academic Physiatrists

Disclosure: Nothing to disclose.

References
  1. Sköld MK, Svensson M, Tsao J, Hultgren T, Landegren T, Carlstedt T, et al. Karolinska institutet 200-year anniversary. Symposium on traumatic injuries in the nervous system: injuries to the spinal cord and peripheral nervous system - injuries and repair, pain problems, lesions to brachial plexus. Front Neurol. 2011. 2:29. [Medline]. [Full Text].

  2. Clancy WG Jr, Brand RL, Bergfield JA. Upper trunk brachial plexus injuries in contact sports. Am J Sports Med. 1977 Sep-Oct. 5(5):209-16. [Medline].

  3. Narakas AO. Traumatic brachial plexus lesions. Dyck PJ, Thomas PK, Lambert EH, et al, eds. Peripheral Neuropathy. Philadelphia, Pa: WB Saunders; 1984. vol 2: 1394.

  4. Crotti FM, Carai A, Carai M, et al. Post-traumatic thoracic outlet syndrome (TOS). Acta Neurochir Suppl. 2005. 92:13-5. [Medline].

  5. Van Alfen N, Malessy MJ. Diagnosis of brachial and lumbosacral plexus lesions. Handb Clin Neurol. 2013. 115:293-310. [Medline].

  6. Kim DH, Murovic JA, Tiel RL, et al. Penetrating injuries due to gunshot wounds involving the brachial plexus. Neurosurg Focus. 2004 May 15. 16(5):E3. [Medline].

  7. Blaauw G, Muhlig RS, Vredeveld JW. Management of brachial plexus injuries. Adv Tech Stand Neurosurg. 2008. 33:201-31. [Medline].

  8. Hentz VR. Is microsurgical treatment of brachial plexus palsy better than conventional treatment?. Hand Clin. 2007 Feb. 23(1):83-9. [Medline].

  9. Mansukhani KA. Electrodiagnosis in traumatic brachial plexus injury. Ann Indian Acad Neurol. 2013 Jan. 16(1):19-25. [Medline]. [Full Text].

  10. Barman A, Chatterjee A, Prakash H, Viswanathan A, Tharion G, Thomas R. Traumatic brachial plexus injury: electrodiagnostic findings from 111 patients in a tertiary care hospital in India. Injury. 2012 Nov. 43(11):1943-8. [Medline].

  11. Aminoff MJ, Olney RK, Parry GJ, et al. Relative utility of different electrophysiologic techniques in the evaluation of brachial plexopathies. Neurology. 1988 Apr. 38(4):546-50. [Medline].

  12. Date ES, Rappaport M, Ortega HR. Dermatomal somatosensory evoked potentials in brachial plexus injuries. Clin Electroencephalogr. 1991 Oct. 22(4):236-49. [Medline].

  13. Insola A, Caliandro P, Pirrone R, et al. Usefulness of a comprehensive neurophysiological assessment for early diagnosis and prognosis of traumatic brachial plexus injuries. Electromyogr Clin Neurophysiol. 2005 Jun. 45(4):209-17. [Medline].

  14. Amrami KK, Port JD. Imaging the brachial plexus. Hand Clin. 2005 Feb. 21(1):25-37. [Medline].

  15. Brunelli GA, Brunelli GR. Preoperative assessment of the adult plexus patient. Microsurgery. 1995. 16(1):17-21. [Medline].

  16. O'Shea K, Feinberg JH, Wolfe SW. Imaging and electrodiagnostic work-up of acute adult brachial plexus injuries. J Hand Surg Eur Vol. 2011 Nov. 36(9):747-59. [Medline].

  17. Chanlalit C, Vipulakorn K, Jiraruttanapochai K, et al. Value of clinical findings, electrodiagnosis and magnetic resonance imaging in the diagnosis of root lesions in traumatic brachial plexus injuries. J Med Assoc Thai. 2005 Jan. 88(1):66-70. [Medline].

  18. West GA, Haynor DR, Goodkin R, et al. Magnetic resonance imaging signal changes in denervated muscles after peripheral nerve injury. Neurosurgery. 1994 Dec. 35(6):1077-85; discussion 1085-6. [Medline].

  19. Brogan DM, Carofino BC, Kircher MF, et al. Prevalence of rotator cuff tears in adults with traumatic brachial plexus injuries. J Bone Joint Surg Am. 2014 Aug 20. 96 (16):e139. [Medline].

  20. Carlstedt TP. Spinal nerve root injuries in brachial plexus lesions: basic science and clinical application of new surgical strategies. A review. Microsurgery. 1995. 16(1):13-6. [Medline].

  21. Krishnan KG, Martin KD, Schackert G. Traumatic lesions of the brachial plexus: an analysis of outcomes in primary brachial plexus reconstruction and secondary functional arm reanimation. Neurosurgery. 2008 Apr. 62(4):873-85; discussion 885-6. [Medline].

  22. Tender GC, Kline DG. The infraclavicular approach to the brachial plexus. Neurosurgery. 2008 Mar. 62(3 Suppl 1):180-4; discussion 184-5. [Medline].

  23. Kachramanoglou C, Li D, Andrews P, East C, Carlstedt T, Raisman G, et al. Novel strategies in brachial plexus repair after traumatic avulsion. Br J Neurosurg. 2011 Feb. 25(1):16-27. [Medline].

  24. Dafydd H, Lin CH. Hand reanimation. Curr Rev Musculoskelet Med. 2014 Mar. 7 (1):76-82. [Medline].

  25. Kim DH, Cho YJ, Tiel RL, et al. Outcomes of surgery in 1019 brachial plexus lesions treated at Louisiana State University Health Sciences Center. J Neurosurg. 2003 May. 98(5):1005-16. [Medline].

  26. Rohde RS, Wolfe SW. Nerve transfers for adult traumatic brachial plexus palsy (brachial plexus nerve transfer). HSS J. 2007 Feb. 3(1):77-82. [Medline]. [Full Text].

  27. Wang SF, Li PC, Xue YH, Yiu HW, Li YC, Wang HH. Contralateral C7 nerve transfer with direct coaptation to restore lower trunk function after traumatic brachial plexus avulsion. J Bone Joint Surg Am. 2013 May 1. 95(9):821-7, S1-2. [Medline].

  28. Sunderland S. Nerves and Nerve Injuries. 2nd ed. London, England: Churchill Livingstone; 1978.

  29. Ali ZS, Heuer GG, Faught RW, et al. Upper brachial plexus injury in adults: comparative effectiveness of different repair techniques. J Neurosurg. 2015 Jan. 122 (1):195-201. [Medline].

  30. Kandenwein JA, Kretschmer T, Engelhardt M, et al. Surgical interventions for traumatic lesions of the brachial plexus: a retrospective study of 134 cases. J Neurosurg. 2005 Oct. 103(4):614-21. [Medline].

  31. Wynn Parry CB. Rehabilitation of patients following traction lesions of the brachial plexus. Clin Plast Surg. 1984 Jan. 11(1):173-9. [Medline].

  32. Grant GA, Goodkin R, Kliot M. Evaluation and surgical management of peripheral nerve problems. Neurosurgery. 1999 Apr. 44(4):825-39; discussion 839-40. [Medline].

  33. Hattori Y, Doi K, Ikeda K, et al. Vascularized ulnar nerve graft for reconstruction of a large defect of the median or radial nerves after severe trauma of the upper extremity. J Hand Surg [Am]. 2005 Sep. 30(5):986-9. [Medline].

  34. Jeon IH, Neumann L, Wallace WA. Scapulothoracic fusion for painful winging of the scapula in nondystrophic patients. J Shoulder Elbow Surg. 2005 Jul-Aug. 14(4):400-6.

  35. Kerr AT. The brachial plexus of nerves in man, the variations in its formation and branches. Am J Anat. 1918. 23:285.

  36. Pitt M, Vredeveld JW. The role of electromyography in the management of the brachial plexus palsy of the newborn. Clin Neurophysiol. 2005 Aug. 116(8):1756-61. [Medline].

  37. Shin AY, Spinner RJ, Steinmann SP, et al. Adult traumatic brachial plexus injuries. J Am Acad Orthop Surg. 2005 Oct. 13(6):382-96. [Medline].

  38. Tagliafico A, Succio G, Serafini G, Martinoli C. Diagnostic accuracy of MRI in adults with suspect brachial plexus lesions: A multicentre retrospective study with surgical findings and clinical follow-up as reference standard. Eur J Radiol. 2011 Nov 7. [Medline].

  39. Trumble TE. Peripheral nerve injury: pathophysiology and repair. Feliciano DV, Moore EE, Mattox KL, eds. Trauma. 4th ed. New York, NY: McGraw-Hill; 2000. 1047-55.

  40. Yilmaz C, Eskandari MM, Colak M. Traumatic musculocutaneous neuropathy: a case report. Arch Orthop Trauma Surg. 2005 Jul. 125(6):414-6. [Medline].

 
Previous
Next
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.