Brachial Plexus Injuries


Article Author:
T. David Luo


Article Editor:
Zhongyu Li


Editors In Chief:
Shivajee Nallamothu
Matthew Varacallo
Joshua Tuck


Managing Editors:
Avais Raja
Orawan Chaigasame
Khalid Alsayouri
Kyle Blair
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beenish Sohail
Hajira Basit
Phillip Hynes
Sandeep Sekhon


Updated:
11/11/2019 10:34:17 AM

Introduction

The earliest written description of a brachial plexus injury (BPI) is attributed to Homer circa 800 BC in his depiction of a battle during which Hector struck Teucer over the clavicle with a rock, rendering him incapable of wielding his bow in The Iliad.[1] In the simplest terms, the brachial plexus can be thought of as 5 nerve roots (C5 through T1), which originate in the posterior triangle of the neck and extend into the axilla and terminate in five nerves: musculocutaneous, axillary, radial, median, and ulnar. The plexus occasionally receives contributions from the C4 and T2 nerve roots.[2] The levels of the brachial plexus are arranged as roots, trunks, divisions, cords, and branches from proximal to distal, with the roots and trunks more commonly injured than the divisions, cords, and branches.

Etiology

Obstetric injury; severe trauma caused by falls, direct, blunt blows, or high-speed motor vehicle collisions; penetrating injury; forceful traction injury; and compression injury can all result in damage to the brachial plexus. Upper trunk traction injuries occur when the head and neck are violently pulled caudally from the shoulder and torso. Similarly, lower trunk traction injuries occur when the arm is violently abducted above the head.[3] In the polytrauma patient, injuries to the brachial plexus are rare, but concomitant blunt trauma to the head, torso, extremities, and major blood vessels often takes precedence for treatment and further obscures the clinical picture.[4]

Epidemiology

BPI is most common in younger males between the ages of 15 and 25.[3] In Naraka’s analysis of BPI in over 1000 patients,[5] he described the law of 7 seventies:

Approximately 70% of traumatic BPIs result from traffic accidents, of which 70% involve motorcycles or bicycles; of these patients, approximately 70% sustain multiple injuries; 70% of patients sustain a lesion of the supraclavicular plexus, of which 70% will have one or several avulsion of the plexus roots; 70% of these patients will also sustain root avulsions of the lower plexus; 70% of patients with root avulsions of the lower plexus will experience chronic pain.

Ballistic trauma is the second most common mechanism of injury to the brachial plexus and typically produces neuropraxia.[6] Injuries to the brachial plexus cause substantial debility and long-lasting difficulties in activities of daily living. The burden to the patient and their caregivers can come from psychosocial and socioeconomic reasons.

Pathophysiology

The spinal nerves form when the ventral and dorsal rootlets from the spinal cord converge. The ventral rami of the C5 through T1 spinal nerves form the roots of the brachial plexus. A dorsal root ganglion is a group of neuronal cell bodies that lies proximal to the convergence of the spinal nerves. Injuries that occur proximal to the dorsal root ganglion are appropriately termed “preganglionic,” while injuries distal to the dorsal root ganglion are termed “postganglionic.” Distinguishing between preganglionic and postganglionic BPI has substantial implications for treatment and prognosis. The chance of spontaneous recovery after preganglionic injury is low and therefore requires early surgical intervention. Avulsions of the C8 and T1 nerve roots may concomitantly injure the sympathetic ganglion, resulting in Horner syndrome, which presents with the pathognomonic triad of miosis, ptosis, and anhydrosis.[3]

History and Physical

Obtaining a thorough history in a patient with possible BPI is necessary to identify the injury mechanism, associated fractures, and other concomitant trauma to the neck, shoulder, and chest cage. Careful inspection of the patient can provide important clues to the extent of the injury. Considerable bruising and swelling may indicate deep trauma with possible vascular injury, which can be confirmed by evaluating the radial, ulnar, and brachial pulses. A detailed neurologic examination is warranted to ascertain the location of the lesion. Paralysis of the paraspinal muscles may indicate injury at the cervical level of the foramen. Firing of the latissimus dorsi muscle (innervated by the thoracodorsal nerve, a branch of the posterior cord) and pectoralis major muscle (sternal and clavicular heads innervated by the medial and lateral pectoralis nerves, respectively from the medial and lateral cords) should be evaluated to determine whether the lesion is proximal or distal to the cord level.[3]

Evaluation

Plain radiographs must be evaluated for fractures of the cervical spine, transverse processes, clavicle, first rib, and scapula. Findings on initial examination are supplemented with advanced imaging and electrophysiological evaluation to determine the prognosis of neurologic recovery further. MRI and CT myelogram allow for identification of pseudomeningocele associated with root avulsions.[7] Hematoma at the site of the injury may distort the imaging; therefore, CT myelogram should not be performed earlier than 3 to 4 weeks from initial injury to allow for resorption. MRI of the cervical spine is less invasive than CT myelogram and also can provide information regarding inflammation and edema.[7]

Recording of sensory nerve action potential (SNAP) in response to distal stimulation of the peripheral nerves helps to differentiate pre- and postganglionic lesions. If the patient exhibits a loss of sensation in a specific dermatomal distribution, a preserved SNAP is indicative of preganglionic injury due to the intact sensory cell bodies in the dorsal root ganglion.[8] Electromyography can also be utilized to differentiate pre- and postganglionic lesions by needle stimulation of proximal muscles innervated by nerves that branch off at the root level of the brachial plexus (paraspinal, rhomboid, and serratus anterior muscles).[3] The dorsal scapular nerve (C5) innervates the rhomboids. The long thoracic nerve (C5 through C7) innervates the serratus anterior muscle, and injury leads to medial scapular winging. The C5 contribution of the phrenic nerve may be injured with root avulsions, resulting in elevation of the ipsilateral hemidiaphragm on chest x-ray.

Treatment / Management

The surgical timing for the treatment of BPI remains a topic of controversy. Urgent surgical exploration of the plexus is indicated if a root avulsion or laceration injury to the plexus is suspected or in cases of open injury, retained foreign body, or vascular injury requiring vessel repair. Sharp transections of the brachial plexus allow for primary repair of the transected ends to optimize nerve regeneration. Prognosis for low-energy mechanism BPI is more favorable compared to root avulsions or preganglionic injuries and can be treated conservatively to allow for spontaneous recovery.[6] The patient should be closely followed with serial examinations, imaging studies, and electrophysiological testing. Delayed exploration may be indicated at three to six months after injury if the patient fails to regain neurologic function satisfactorily. There are few contraindications to brachial plexus surgery. In general, surgery should be avoided if the patient is not medically or psychologically cleared for surgery or if local wounds or infections obstruct the surgical approach. Adequate surgical exposure may be further obscured by edema and scar tissue in the cervical region. Other contraindications are determined on an individual basis. Chronic injuries to the brachial plexus that are more than 12 months old present a relative contraindication for surgical repair except in children who have greater regenerative potential. Low-demand patients and patients with underlying joint contractures may be poor candidates for surgery due to difficulty in achieving substantial functional improvements. Patients who may be noncompliant or unable to progress through the rigorous physical therapy regimen, which may continue for several years, are likely to have poor outcomes.[6]

Pearls and Other Issues

  • The brachial plexus originates from the ventral rami of spinal nerves C5, C6, C7, C8, and T1 but may occasionally receive contributions from C4 and T2.

  • Root avulsions may present with rhomboid/paraspinal muscle paralysis, medial scapular winging, Horner syndrome, and hemidiaphragm paralysis.

  • Evaluation of latissimus dorsi and pectoralis major motor function helps to localize the lesion as supraclavicular or infraclavicular (proximal or distal to the cord level).

Enhancing Healthcare Team Outcomes

The diagnosis and management of BPI is extremely complicated and controversial. The injury is best managed by an interprofessional team that includes a neurologist, neurosurgeon, hand surgeon, physical therapist, internist, nurse practitioner and the primary care provider. After a diagnosis of BPI is made, the surgical timing for the treatment of BPI remains a topic of controversy.

There are few contraindications to brachial plexus surgery. In general, surgery should be avoided if the patient is not medically or psychologically cleared for surgery or if local wounds or infections obstruct the surgical approach. Adequate surgical exposure may be further obscured by edema and scar tissue in the cervical region. Other contraindications are determined on an individual basis. Chronic injuries to the brachial plexus that are more than 12 months old present a relative contraindication for surgical repair except in children who have greater regenerative potential.

Low-demand patients and patients with underlying joint contractures may be poor candidates for surgery due to difficulty in achieving substantial functional improvements. Patients who may be noncompliant or unable to progress through the rigorous physical therapy regimen, which may continue for several years, are likely to have poor outcomes.[6][9][10][11] Most patients do have residual neurological deficits and the quality of life is poor.[6]


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Brachial Plexus Injuries - Questions

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Which anatomical structure does not play a role in brachial plexus injury?

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A lesion of the upper trunk of the brachial plexus will present with which of the following?



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A patient is unable to abduct her left arm after an accident. This indicates damage to which of the following parts of the brachial plexus?



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Which of the following would result from an injury to the upper trunk of brachial plexus?



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After getting tackled at the shoulder level during a game, a 17-year-old high school football player reports a burning sensation down his arm with subsequent numbness and weakness. Which of the following statements about "burners" is not correct?



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Following a leg injury, a professional football player used axillary crutches for several weeks. He then complains that abduction at his shoulder joint above 15 degrees has become difficult. What is most likely injured?



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A 17-year-old female presents with right, anterior upper arm flaccidity and atrophy. She also demonstrates weakness when flexing her elbow. Where is a lesion most likely located?

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Which of the following statements about the types of brachial plexus injuries is true?



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A 21-year-old male complains of persistent right upper extremity weakness after sustaining a motorcycle crash two weeks ago. Electromyography (EMG) shows normal activity of his paraspinal and rhomboid muscles. The patient's injury is likely associated with which of the following?



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An 18-year-old was the victim of a stab the left neck and complains of weakness in the left upper extremity. Initial evaluation demonstrated drooping left eyelid and left pupil constriction. Which of the following is likely associated with this injury pattern?



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A 36-year-old male falls from a tree while building a tree house for his son. He can grab hold of the branch with one arm as he falls. What is the most likely finding on physical exam?

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A 24-year-old professional football player was tackled to the ground during a game. During the tackle, his right arm was pulled caudally as he landed on the side of his head/neck. He experienced immediate right arm weakness and walked off the field, holding his arm in an adducted and internally rotated position. What other associated injuries is he most likely to demonstrate?



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Brachial Plexus Injuries - References

References

Brachial plexus surgery. An historical perspective., Robotti E,Longhi P,Verna G,Bocchiotti G,, Hand clinics, 1995 Nov     [PubMed]
Brachial plexus anatomy., Leinberry CF,Wehbé MA,, Hand clinics, 2004 Feb     [PubMed]
Adult traumatic brachial plexus injuries., Shin AY,Spinner RJ,Steinmann SP,Bishop AT,, The Journal of the American Academy of Orthopaedic Surgeons, 2005 Oct     [PubMed]
Brachial plexus injury in adults: Diagnosis and surgical treatment strategies., Thatte MR,Babhulkar S,Hiremath A,, Annals of Indian Academy of Neurology, 2013 Jan     [PubMed]
The treatment of brachial plexus injuries., Narakas AO,, International orthopaedics, 1985     [PubMed]
Indications for peripheral nerve and brachial plexus surgery., Dubuisson A,Kline DG,, Neurologic clinics, 1992 Nov     [PubMed]
Cervical nerve root avulsion in brachial plexus injuries: magnetic resonance imaging classification and comparison with myelography and computerized tomography myelography., Doi K,Otsuka K,Okamoto Y,Fujii H,Hattori Y,Baliarsing AS,, Journal of neurosurgery, 2002 Apr     [PubMed]
Diagnosis of brachial plexus traction lesions by sensory nerve action potentials and somatosensory evoked potentials., Jones SJ,Parry CB,Landi A,, Injury, 1981 Mar     [PubMed]
Midha R,Grochmal J, Surgery for nerve injury: current and future perspectives. Journal of neurosurgery. 2019 Mar 1;     [PubMed]
Allemann F,Heining S,Zelle B,Probst C,Pape HC, Risk factors for complications and adverse outcomes in polytrauma patients with associated upper extremity injuries. Patient safety in surgery. 2019;     [PubMed]
Yau CWH,Pizzo E,Prajapati C,Draycott T,Lenguerrand E, Obstetric brachial plexus injuries (OBPIs): health-related quality of life in affected adults and parents. Health and quality of life outcomes. 2018 Nov 15;     [PubMed]

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