Muscle Nerve –, BRACHIAL PLEXOPATHIES: CLASSIFICATION,. CAUSES, AND CONSEQUENCES. MARK A. FERRANTE. Brachial plexopathies: classification, causes, and consequences. (English) . Cervical rib and median sternotomy-related brachial plexopathies: a reassessment. Items 1 – 20 Brachial Plexopathies, Classification, Causes and Consequences (Muscle and Nerve, ) – Download as PDF File .pdf), Text File .txt) or read.
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Brachial plexopathy is an injury of the brachial plexus, most commonly caused by trauma. Brachial plexus is a peripheral nervous system structure that extends from the cervicothoracic spinal cord to the axilla and provides motor, sensory, and autonomic innervation to the upper extremities.
From proximal to distal, its elements are the following:. Based on whether the injury is proximal or distal to the dorsal root ganglion DRGthey are further characterized as preganglionic and postganglionic, respectively. Clinically, preganglionic injuries eg, root avulsions can be associated with Horner syndrome disruption of the autonomic trunkmedial scapular winging injury to long thoracic and dorsal scapular nerveand denervation of the cervical paraspinal muscles.
Postganglionic injuries typically carry a better prognosis because they often demonstrate greater spontaneous recovery and are more amenable to surgical repair. Demographics for brachial plexus injury depend on the etiology of injury. Traumatic injuries are more common in males aged between 15 and 25 years.
Similar to traumatic spinal cord injury, these injuries are most often associated with motor vehicle and often motorcycle collisions. Commonly affects the infraclavicular plexus.
Primarily plexopatyies iatrogenic complication at delivery, although there is some evidence for congenital brachial plexopathy related to in utero fetal position. Plexopathy results from direct axonal damage, demyelination, and microvascular infarction and more indolently because of compression caused by fibrosis, commonly seen following radiation therapy for breast, lung, lymphoma, and head and neck cancer.
The incidence of radiation-induced plexopathies has decreased with tissue-sparing targeted radiotherapy. Males are approximately two times more commonly affected than females Classically presents with severe upper arm pain, followed by multifocal paresis usually in a different territory as the painpossible bracyial abnormalities, and gradual atrophy of muscles innervated by the affected plexus.
Most affected individuals recover, but some will have persistent pain or weakness, believed to be caused by peripheral myelin brachoal antibodies and complement, often, but not always, associated with recent parvovirus or Bartonella henselae infection, 1,20 immunization, surgery, and childbirth.
Even with severe initial injury, electrodiagnostic evidence of recovery is expected within months with many showing full re-innervation by one year. Rarely, diabetic patients can experience brachial plexopathy as a result of microvasculitis induced ischemic nerve damage, usually seen in conjunction with lumbosacral plexopathy. Paraneoplastic syndrome and NA commonly affect additional peripheral nerves outside the brachial plexus distribution.
Phrenic nerve injury may occur in conjunction with traumatic and non-traumatic plexopathies and may present as hemidiaphragmatic elevation on chest x-ray. Traumatic root avulsions may occur in conjunction with brachial plexus injuries in the context of high-energy stretch.
Lower roots C8-T1 are the most susceptible to avulsion. It is important to differentiate root avulsion from brachial plexus injury for treatment brachixl prognostication as complete root avulsions are incapable of regeneration and are not amenable to surgical repair. Neonatal brachial plexopathy may be associated with glenohumeral joint dysplasia, consqeuences contractures shoulder, elbow, supinationposterior shoulder dislocation, or length discrepancies.
There are no required claswification analyses in the work-up of brachial plexopathy however basic laboratory assessments may be helpful in ruling out alternative bracjial of weakness or in looking for triggers of NA. Evoked potentials are not necessary poexopathies the diagnosis of brachial plexopathy however they may be helpful in ruling out a more central process. Intraoperative neurophysiology may help in diagnosing root avulsions and determining viable donor nerve for surgery in the event of equivocal pre-operative studies.
In general, infraclavicular lesions have better prognosis than supraclavicular lesions and nerve root avulsions consequneces little chance of spontaneous recovery. Axon loss is best determined during nerve conduction studies by decreased amplitude in comparison with the contralateral side if unaffected.
The axonal viability index, the ratio of amplitude of the involved side to the unaffected limb, has been used for electrodiagnostic prognostication in newborns. Spontaneous recovery is rare with complete axonal plexopatuies, manifested by complete absence of CMAPs, absence of motor unit action potentials MUAPs despite good effort, and abnormal spontaneous activity.
The number of fibrillation potentials and positive sharp waves on electromyography testing does not predict the severity of injury. Such abnormal spontaneous activity represents spontaneous depolarization of a muscle fiber in the setting of any kind of denervation.
It may be seen in a primary demyelinating disorder with secondary axonal loss or a primary axonal injury.
Brachial plexopathies: classification, causes, and consequences.
xonsequences Identification and avoidance of repetitive activities, extreme range cassification motions and excessive load carriage via shoulder straps that induce pain or weakness is critical.
No equipment or strengthening has been proven to decrease the risk of brachial plexus injury. A recent publication about patient reported outcomes of health related quality of life after neonatal brachial plexus suggests that physical limitations, followed by social health, and to a lesser degree, emotional health remain significant long-term issues in these patients.
Most stated that their brachial plexus injury had little or no role in their relationships. Return to work RTW: RTW status should be determined only after maximum medical improvement. Functional capacity evaluation can be a useful tool andd determine accurate restrictions and RTW. Rates of employment do seem to be affected by injury.
Of the 24 who were xnd prior to injury, 13 returned to work and 8 within the first year of injury. Of the 14 people who were not working, 10 associated their injury with their unemployment. Of note, these authors found that motor function and functional status did not correlate with employment. The clasification of brachial plexus injury in polytrauma is classificatio poor prognostic significance.
Analysis of outcomes 10 years after trauma reveals that those with brachial plexus injury have lower rates of employment and worse outcome scores. An integrated care team should include a physiatrist, neurologist, neurosurgeon, hand surgeon, occupational therapist, physical therapist, electrodiagnostician, pain specialist, and possibly an oncologist or pediatric neurologist.
Resources, including psychology, vocational rehabilitation, ergonomics, and driver training, can be included as necessary. Counseling regarding etiology, treatment options, prognosis for recovery, and prevention of secondary complications is a critical component of the overall plan of care. Recent evidence indicates that successful surgical management can cause dynamic changes within the brain resting state networks, which includes not only the sensorimotor network but also the higher cognitive networks such as the salience network and default mode network, which indicates brain plasticity and compensatory mechanisms at work Although the standard of care in managing traumatic brachial plexopathies is to delay nerve grafts for 3 to classufication months while monitoring for recovery, there is emerging evidence to suggest that delaying beyond 2 months plxopathies result in poor outcomes.
However, nerve grafts performed at earlier time points may result in unnecessary surgery in individuals who would otherwise demonstrate some degree of spontaneous recovery.
Further research is needed to assist in determining prognosis before 2 months and establishing the most effective timing for surgical intervention.
Differential Diagnosis and Treatment Author s: Definition Brachial plexopathy is an injury of the brachial plexus, most commonly caused by trauma. From proximal to distal, its elements are the following: Long thoracic C and dorsal scapular C5 Trunks: Suprascapular C Lateral cord: Burner or stinger syndrome: It is caused by narrowed thoracic outlet, possibly because of cervical rib likely a fibrous band running from a rudimentary cervical rib to the first thoracic rib or hypertrophied anterior scalene or ischemic injury classificatioj by restricted flow through the subclavian artery.
Brachial plexopathies: classification, causes, and consequences.
C5-T1 with Horner syndrome Klumpke palsy: C8-T1 with Horner syndrome Iatrogenic: While these agents are more commonly associated with length-dependent peripheral polyneuropathies, when used in conjunction with radiation therapy or other drug therapy, they may increase the risk of brachial plexus injury.
History Duration of symptoms Characteristics of pain, sensory changes, weakness, and muscle atrophy Infection, activity, or injury associated with onset Change in symptoms with change in head, neck, or arm position Autonomic symptoms Change in function activities of daily living [ADLs], sports performance, etc Personal or familial history of neoplasm, radiation, chemotherapy, demyelinating disorders, diabetes or previous brachial plexopathy Details of pregnancy and delivery in neonatal beachial Physical examination Standardized neurologic examination Tests of manual muscle cajses, sensation, and reflexes commensurate with the affected portions of the plexus May include Tinel sign over the brachial plexus Vascular: Radial, ulnar, and carotid pulses Allen test: The patient causses takes a deep breath and holds while extending the neck and rotating toward the affected side.
The test is positive when there is a decrease or disappearance of the radial pulse. The patient is asked to open and close their hands repeatedly for 3 minutes. The test plexoapthies considered positive for TOS if it induces progressive pain in neck to shoulder to arm, paresthesias in the forearm or fingers, arm pallor when pleexopathies and hyperemia when lowered vascular TOSor reproduction of the usual symptoms that involve the entire arm.
Functional assessment Assess for specific deficits in the following: LAC, median thumb Middle trunk: LAC, median thumbmedian second digit Posterior cord: Social role and social support system A recent publication about patient reported outcomes of health related quality of life after neonatal brachial plexus suggests that physical limitations, followed by social health, and to a lesser degree, emotional health remain significant long-term issues in these patients.
Available or current treatment guidelines Pain: Timing is a crucial factor in determining the outcome after surgery as the distal nerve and the neuromuscular junction become increasingly incapable of accepting reinnervation by 20—24 months.
In post-ganglionic injury, it is prudent to wait for 3—4 months for spontaneous improvement to occur. The best chance of improvement is in the first 3 months after injury and the next best time window is within the next 3 months. Potential donors for nerve transfers are considered and availability of these checked.
Pre-operative electromyography EMG of muscles innervated by potential donor nerves may be helpful in identifying subclinical injury to these nerves.
Graft length of graft of 6—8 cm is acceptable for obtaining satisfactory results, as results are poorer for more extensive lesions requiring longer graft lengths.
Nerve transfers may borrow from other important nerve such as the phrenic nerve, intercostal nerves, and spinal accessory nerve. In one functional outcomes study, the rate of hemidiaphragm paralysis or elevation Outcomes and rehabilitation after surgery: To date, outcome reporting for brachial plexus surgery has largely centered on motor recovery and typically has not included measures of function or non-musculoskeletal recovery.
Thus, preganglionic total arm brachial plexus injury seems to be the type of injury that may benefit most from earlier nerve reconstruction procedures, especially for hand function reconstruction, which can be obstinate to treatment. There was also a significant correlation between the change in NRS scores and patient satisfaction. Serial casting may initially improve more severe contractures and nighttime splinting may be effective in preventing contracture progression. Gaps in the evidence-based knowledge.
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