Intraoperative electrodiagnosis
Many of the limitations of preoperative electro-diagnosis are overcome by performing similar studies on exposed nerves during brachial plexus reconstruction. In this setting, electrophysiologic studies provide additional information about the number, location, type, and severity of nerve lesions 1,2 . This information can be used to answer important questions left unresolved by preoperative electrodiagnostic studies and to help surgeons make important therapeutic decisions regarding...
Other mechanisms
Though less common than closed injuries, open injuries do occur. If the mechanism results in sharp division eg, by means of a knife , direct repair may be possible. Iatrogenic injuries have been reported from multiple surgical procedures, including mastectomy, first rib resection, and subclavian carotid bypass 19-21 . Emergency exploration for open trauma is usually only warranted in cases of vascular injury or sharp laceration. Lower truck injuries are more likely to have concomitant vascular...
Radiographic evaluation
After a traumatic injury to the neck or shoulder girdle region, radiographic evaluation can give clues to the existence of associated neurologic injury. Standard radiographs should include cervical spine views, shoulder views ante-roposterior, axillary views , and a chest X ray. The cervical spine films should be examined for any associated cervical fractures, which could put the spinal cord at risk. In addition, the existence of transverse process fractures of the cervical vertebrae might...
Preoperative electrodiagnosis
NCSs and needle EMG are the primary studies used to gain information on the location, number, and pathophysiology of lesions affecting the brachial plexus and other peripheral nerves before surgical exploration. NCSs are often accurate enough to localize lesions within several centimeters along the course of a nerve segment. In motor NCSs, a mixed or pure motor nerve is stimulated at several places along the nerve. The summated electrical response of all muscle fibers innervated by the...
Mechanism and pathoanatomy
Most adult brachial plexus pathology is caused by closed trauma. Nerve injury in these cases is from traction and compression, with traction accounting for 95 of injuries 14 . Following a traction injury, the nerves may rupture, be avulsed at the level of the spinal cord, or be significantly stretched but remain intact Fig. 1 . Following are five possible levels where the nerve can be injured Fig. 2 2. The anterior branches of the spinal nerves Root injuries may be further localized with...
Brachial Plexus Injuries in Adults
The loss of upper extremity function following a traumatic brachial plexus injury causes devastating functional deficits that require complex surgical reconstruction. Because of advances and innovations in surgical techniques, it is now possible to reliably restore elbow flexion and shoulder stability, provided intervention is prompt. Recently, innovations have provided additional surgical reconstructive options that can be expected to improve functional outcomes. For example, methods are...
Operative approaches to the brachial plexus
The patient is placed supine, occasionally placed in a modified beach chair position to facilitate a posterior approach to the shoulder or arm. A folded sheet is placed beneath the scapula. The neck is extended gently and turned to the opposite side. A bump is also placed beneath the buttock to externally rotate one leg should a sural nerve graft be desirable . The neck, shoulder, entire limb, chest, and both legs are prepared and draped. The supraclavicular brachial plexus can be approached...
References
1 Jachimowicz J. Les variation du plexus brachial resume . E. Loth, translator. Mem Anat A Univ Varsoviensis l92S 246-82. 2 Kerr A. Brachial plexus of nerves in man. The variations in its formation and branches. Am J Anat 1918 23 28S. 3 Senecail B. Le plexus brachial de l'Homme. In These Reims, vol. 66. 197S. 4 Adolphi H. Uber das Verhalten der zweiten Brustnerven zum plexus brachialis beim Menschen. Anat Anz l898 lS 2S-36. 5 Hirasawa K. Uber den Pelxus Brachialis Mitter-lung die Wurzeln des...
Physical examination
A patient with a brachial plexus injury is often seen in conjunction with significant trauma. This additional trauma can potentially delay diagnosis of any existing nerve injury until the patient is stabilized and resuscitated. A high index of suspicion for a brachial plexus injury should be maintained when examining a patient in the emergency department who has a significant shoulder girdle injury, first rib injuries, or axillary arterial injuries. Often, the patient is obtunded or sedated in...
Traumatic brachial plexopathy
Traumatic brachial plexopathy, which accounts for approximately 50 of cases, can be caused by compression, stretching, or, in its most extreme form, disruption of nerves or avulsion of nerve roots, with or without fractures involving the cervical spine or clavicle 4 . If fracture is suspected, a radiograph clavicle or noncontrast CT with multiplanar reformatting cervical spine should be the initial study 4 . MRI is the study of choice for cases in which fractures of the clavicles or ribs may be...
Imaging the Brachial Plexus
Kimberly K. Amrami, MDa , John D. Port, MD, PhDb aDivision of Body MRI, Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA b Division of Neuroradiology, Department of Radiology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA The brachial plexus is a network of nerves supplying sensory and motor innervation to the upper extremities extending from its origins from the C5 through T1 nerve roots laterally to the axilla. Clinically, evaluating lesions...
of the Brachial Plexus
Alexander Y. Shin, MDa , Robert J. Spinner, MDb aDivision of Hand Surgery, Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN 55905, USA Department of Neurosurgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA Qu'ils n'oublient jamais que sans anatomie il n'y a point de physiologie, point de chirurgie, point de medicine. J. Cruveilhier Traite d'Anatomie Descriptive 1834 The complex anatomy of the brachial plexus is probably one of the most anxiety-provoking subjects of...
Pathoanatomy
The anatomy of the rootlets, roots, and the vertebral foramen contributes to the type of injury avulsion versus rupture that is observed. At every level, each of the roots is formed by the joining of dorsal sensory rootlets and ventral motor rootlets off the spinal cord as they pass through the spinal foramen Fig. 5A . The cell bodies of the sensory nerves lie within ganglia outside the spinal cord ie, the dorsal root ganglia DRG . The rootlets that form the cervical roots are intraspinal and...
General overview of the brachial plexus
The brachial plexus runs within the interscalene triangle formed by the anterior scalene anteriorly, the middle scalene posteriorly, and the superior border of the first rib inferiorly . The brachial plexus is also located within the posterior triangle of the neck formed by the sternocleidomastoid SCM medially, the trapezius laterally, and the clavicle inferiorly . The brachial plexus is the network of nerves that provides sensation and function to the upper extremity. It is formed from the...