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Timing of Investigations

Time 0

  • CXR ( Inspiration & Expiration)
  • X-Ray Cervical Spine
  • Other related X- Rays

Time 6 weeks

  • EMG/NCS
  • MRI (may be done earlier also)

Imaging of Brachial Plexus

The chest X-ray should include inspiration and expiration views to exclude diaphragmatic palsy.

Cervical spine X-rays are evaluated for any fracture of the transverse process, spinous process, or vertebrae body.

MRI is the gold standard technique to make the radiological diagnosis of the Brachial Plexus Injury.

The latest advance in MRI technique is the three-dimensional (3D) fast imaging employing steady-state acquisition (FIESTA).

Initial Assessment

The patient with a brachial plexus injury frequently presents to the emergency department with multi-system trauma.

The ABCs of trauma remain the first priority, and life-threatening injuries should be ruled out.

The brachial plexus palsy is usually first noticed by the conscious patient, and therefore diagnosis is often delayed if sedation or anesthesia has

been administered.

Pain control is a significant issue for many of these patients. A detailed evaluation should include the nature and severity of pain and the

response to commonly prescribed medications.

Electrical

Clinical

History

Radiological

MRI cervical spine myelogram of the same patient. If a pseudomeningocele (*) is present, there is a greater likelihood of a nerve root avulsion.

More than 90% of these injuries occur following traffic accidents with a very large percentage being motorcycle accidents. 90% of these patients belong to the age group 15-40 years.

Patient history should include mechanism of injury, conscious level at the time of trauma, associated injury (such as head injury, fracture, open wound, chest injury, vascular injury), kinds of previous surgical intervention (such as chest intubation,

cervical spine surgery), and characteristics of pain.

Shoulder dislocation or Glenoid fracture - level 4 injury

Cervical spine injury - level 1 root injury

Artery rupture imply the site of nerve injury e.g. Arm traction by rolling machine or conveyor belt often causes an open wound in the axilla, extensive ecchymosis around the shoulder and chest and level 4 BPI

Segmental thrombosis of the subclavian artery is usually associated with C8–T1 root injury.

History of rib fracture and chest intubation may preclude intercostal nerve transfer

Extreme causalgia is often seen in cases of root avulsion in lower-root (C8–T1) avulsion

(A) Right C5–T1 avulsion cysts on the ventral view using magnetic resonance imaging (MRI) three-dimensional (3D) fast imaging employing steady-state

acquisition (FIESTA) technique; (B) dorsal view, using MRI 3D FIESTA and curve planar reformat techniques

The arrows on the opposite side of the avulsion (*) show the normal dorsal and ventral rootlet outline of the uninjured side. Notice how these outlines are missing on the injured side.

Mechanism of Injury

Electrodiagnostic Studies for Brachial Plexus

Electrodiagnostic studies, mainly consisting of nerve conduction studies (NCSs) and needle electromyography (EMG), are used to localize the lesion and to assess its severity. For the NCS, only amplitudes of the sensory nerve action potentials (SNAPs) and compound muscle action potentials (CMAPs)are of value. Both SNAP and CMAP amplitudes provide a good indication of the degree of axon loss, or in contrast, the number of survival axons capable of conducting impulses. Sensory NCSs assess the function of the postganglionic portion of the sensory pathway. Therefore, abnormally low SNAP amplitudes indicate a ganglionic or postganglionic lesion. Conversely, SNAP amplitude remains normal in a pure preganglionic lesion such as root avulsion. A combination of unelicitable CMAPs with abnormal low SNAP amplitudes suggests a combined preganglionic and postganglionic lesion. Presence of denervation potentials (i.e., fibrillation potentials and positive sharp waves) is the most sensitive indicator of motor axon loss.

Diagnosing

Brachial Plexus Injury

With abduction and traction, as in a hanging injury, the lower elements of the plexus (C8, T1) can be injured.

Upper brachial plexus injuries occur when the head and neck are violently moved away from the ipsilateral shoulder. The shoulder is forced downward whereas the head is forced to the opposite side.

Dr. Anubhav Gupta

Pre Ganglionic vs Post Ganglionic

Symptoms

BPI may result in some of the following symptoms:

Pain

Loss of sensation

Muscle weakness

Paralysis of some or all of the muscles of the shoulder and upper limb

Some patients may experience avulsion pain (a burning, crushing type of pain) in the distribution of the injured nerves.

Horner's Sign, Winging of Scapula, Muscular atrophy of Parascapular Muscles and Causalgia indicate Pre Ganglionic injury

Tinel's sign in the Supraclavicular region, sweating in the palm, amd minimum movements of joints are suggestive of Post Ganglionic injury

Clinical Examination

A detailed examination of the brachial plexus and its terminal branches can be performed in a few minutes on an awake and cooperative patient.

Active and passive range of motion should be recorded. Reflexes should be assessed. The physician should ensure that there is no evidence of concomitant spinal cord injury by examining for lower limb strength, sensory levels, increased reflexes, or pathologic reflexes. Percussing the nerve is especially helpful. Acutely, pain over a nerve suggests a rupture. An avulsion may be present when there is no percussion tenderness over the brachial plexus.

A vascular examination should also be performed. This examination should include feeling distal pulses, feeling for thrills, or listening for bruits. It is possible to rupture the axillary artery ina significant brachial plexus injury.

Motor Examination

Muscle by Muscle examination from distal to proximal using British MRC Scale

Diaphragm Palsy implies C4 & C5 injury

Serratus Anterior : winging of Scapula is suggestive of C7 injury, commonly involving the C5 & C6 roots

A functional Clavicular portion of the Pectoralis Major Muscle may imply an Infraclavicular ( Level 4) Injury

Obstetric Brachial Plexus Injury

Obstetric brachial plexus palsy (OBPP) is an obstetric trauma: risk factors include overweight babies (>4000 grams) in cephalic presentation, underweight babies (<2500 grams) in breech presentation, or fetal distress(such as septicemia) with loss of protective muscular tone during cesarean section

Newborns are difficult to examine thoroughly. A precise muscle or sensory examination of an infant is impossible.

Evaluation should include parents’ observation at home,especially during bathing or dressing.

Neurodiagnostic studies are not performed routinely. EMG in OBPP is usually positive and too optimistic, and may not be accurate enough to predict useful function.

Improving techniques of MRI are now useful to evaluate level 1 and 2 lesions as in adult BPI, and are becoming our routine investigation for preoperative imaging

Mechanism of Injury

Sensory Examination

Sensibility tests include pain and temperature appreciation, static and moving two-point

discrimination, constant touch, and vibration.

Pinprick test from areas of normal to abnormal sensation to map out the area of sensory disturbance is sufficient for most

brachial plexus-injured patients

Sequential Clinical examinations are essential to understand the recovery of the plexus and to arrive at an operative plan.

Obstetric Brachial Plexus Palsy

Horner’s syndrome

Horner’s syndrome (miosis, ptosis, enophthalmos, and anhidrosis)

is a sign of sympathetic nervous system disturbance.

It indirectly implies avulsion of the T1 and C8 roots because the

sympathetic fibers from the T1–2 sympathetic ganglia are

quite close to the preganglionic fibers of T1 and C8

A 4-year-old girl shows

Klumpke’s palsy of her right upper limb.

(A) A 2-month-old infant showed improving shoulder abduction of his right upper limb; (B) a 3-month-old infant shows improving elbow flexion of her right

upper limb. Both were cases of Erb’s palsy without primary nerve surgery.

Tinel's sign

Clinical Examination of OBPI

The Hoffman-Tinel sign helps in determining the location of a neuroma and tracking the regeneration of the injured nerves. Palpation and Percussion at the route of different nerves along their course may induce an electric sensation( like pins and needles) running down the shoulder or the hand( positive Tinels's sign)

If the Tinel's sign remains fixed on serial observation it means retardation of progression.

If Tinel's sign progresses from proximal to distal then nerve regeneration is taking place.

If Tinel's is weak or absent in the neck region it ususally means total root avulsion

The infant is placed in the lateral decubitus position with the normal side down. The examiner then tickles the baby (tickling test), or covers the infant’s face with a towel (towel test) and uses this to evaluate dynamic movements of the infant’s shoulder, elbow, and hand

An ipsilateral clavicle fracture is usually a good prognostic sign

due to traction force divergence. However, a contralateral

clavicle fracture is usually a bad prognostic sign, as this indicates

a high-energy traction force.uscle strength score (movement with weight

An M2 muscle strength score (movement with weight

eliminated) in a newborn infant is sufficient to predict a good

result when the infant grows.

(A) Tickling test; and (B) towel test to examine infant obstetric brachial plexus palsy.

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