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Han Y, An M, Zilundu PLM, Zhuang Z, Chen J, Jiang Z, Gu L, Yang J, Wang D, Xu D, Zhou LH. Anatomical variations of the brachial plexus in adult cadavers: A descriptive study and clinical significance. Microsurgery 2024; 44:e31182. [PMID: 38798147 DOI: 10.1002/micr.31182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 02/24/2024] [Accepted: 04/18/2024] [Indexed: 05/29/2024]
Abstract
BACKGROUND Brachial plexus injury is recognized as one of the most severe clinical challenges due to the complex anatomical configuration of the brachial plexus and its propensity for variation, which complicates safe clinical interventions. This study aimed to ascertain the prevalence and characterize the types of brachial plexus variations, and to elucidate their clinical implications. MATERIALS AND METHODS We conducted meticulous dissections of 60 formalin-fixed cadavers' upper arm, axilla and lower neck to reveal and assess the roots, trunks, divisions, cords, and branches of the brachial plexus. The pattern of branching was noted by groups of dissecting medical students and confirmed by the senior anatomists. The variations discovered were record and photographed using a digital camera for further analysis. RESULTS Variations in the brachial plexus were identified in 40 of the 60 cadavers, yielding a prevalence rate of 66.7%. These variations were classified into root anomalies (2.1%), trunk anomalies (8.5%), division anomalies (2.1%), and cord anomalies (4.3%). Notably, anomalies in communicating branches were observed in 39 cadavers (83.0%): 14 with bilateral anomalies, 14 with anomalies on the left side, and 11 on the right side. These communicating branches formed connections between the roots and other segments, including trunks, cords, and terminal nerves, and involved the median, musculocutaneous, and ulnar nerves. CONCLUSION The frequency and diversity of brachial plexus variations, particularly in communicating branches, are significant in cadavers. It is imperative that these variations are carefully considered during the diagnostic process, treatment planning, and prior to procedures such as supraclavicular brachial plexus blocks and nerve transfers, to mitigate the risk of iatrogenic complications.
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Affiliation(s)
- Yueyin Han
- Department of Anatomy, Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Mingjie An
- Department of Anatomy, Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Prince L M Zilundu
- Basic Medical and Dental Sciences Department Center of Medical and Bio-allied Health Sciences Research, Ajman University, Ajman, United Arab Emirates
| | - Zhuokai Zhuang
- Department of Anatomy, Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Junyu Chen
- Department of Anatomy, Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Zhen Jiang
- Department of Anatomy, Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Liqiang Gu
- Department of Microsurgery and Orthopedic Trauma, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Jiantao Yang
- Department of Microsurgery and Orthopedic Trauma, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Dong Wang
- Department of Orthopedics, The Seventh Affiliated Hospital of Sun Yat-sen University, Shenzhen, China
| | - Dazheng Xu
- Department of Anatomy, Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, People's Republic of China
| | - Li-Hua Zhou
- Department of Anatomy, Zhongshan School of Medicine, Sun Yat-sen University, Guangzhou, People's Republic of China
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Patel NT, Smith HF. Clinically Relevant Anatomical Variations in the Brachial Plexus. Diagnostics (Basel) 2023; 13:diagnostics13050830. [PMID: 36899974 PMCID: PMC10001373 DOI: 10.3390/diagnostics13050830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 02/16/2023] [Accepted: 02/19/2023] [Indexed: 02/24/2023] Open
Abstract
Anatomical variation in the brachial plexus may result in a variety of clinically relevant patterns, including various neuralgias of the upper extremity and differing nerve territories. Some conditions can be debilitating in symptomatic patients, resulting in paresthesia, anesthesia, or weakness of the upper extremity. Others may simply result in cutaneous nerve territories that deviate from a traditional dermatome map. This study evaluated the frequency and anatomical presentations of a large number of clinically relevant brachial plexus nerve variations in a sample of human body donors. We identified a high frequency of various branching variants, of which clinicians, especially surgeons, should be aware. The medial pectoral nerves in 30% of the sample were found to originate from either the lateral cord, or both the medial and lateral cords of the brachial plexus rather than exclusively from the medial cord. The dual cord innervation pattern greatly increases the number of spinal cord levels traditionally believed to innervate the pectoralis minor muscle. The thoracodorsal nerve arose as a branch of the axillary nerve 17% of the time. The musculocutaneous nerve sent branches to the median nerve in 5% of specimens. The medial antebrachial cutaneous nerve shared a common trunk with the medial brachial cutaneous nerve in 5% of individuals and derived from the ulnar nerve in 3% of specimens.
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Affiliation(s)
- Niki T. Patel
- Arizona College of Osteopathic Medicine, Midwestern University, Glendale, AZ 85308, USA
| | - Heather F. Smith
- Arizona College of Osteopathic Medicine, Midwestern University, Glendale, AZ 85308, USA
- Department of Anatomy, College of Graduate Studies, Midwestern University, Glendale, AZ 85308, USA
- School of Human Evolution and Social Change, Arizona State University, Tempe, AZ 85287, USA
- Correspondence: ; Tel.: +1-623-572-3726
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Benes M, Kachlik D, Belbl M, Havlikova S, Kunc V, Whitley A, Kaiser R, Kunc V. A meta-analysis on the anatomical variability of the brachial plexus: Part III - Branching of the infraclavicular part. Ann Anat 2022; 244:151976. [PMID: 35787441 DOI: 10.1016/j.aanat.2022.151976] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 05/21/2022] [Accepted: 06/12/2022] [Indexed: 11/17/2022]
Abstract
INTRODUCTION The anatomy of the brachial plexus has been a subject of interest to many researchers over time resulting in an inconsistent amount of data. Previously, our team had published two evidence-based studies on the anatomical variations involving the brachial plexus, therefore the aim of this study was to analyze the findings regarding the infraclavicular part of the brachial plexus with the use of meta-analytic techniques to complete the comprehensive series. MATERIAL AND METHODS Major scientific databases were extensively searched to compile anatomical studies investigating the morphology of the infraclavicular part of the brachial plexus. Extracted data were classified based on our proposed classification system and subsequently analyzed with the use of random effects meta-analysis to state the pooled prevalence estimates of the distinct variation patterns. RESULTS A total of 75 studies (4772 upper limbs) were selected for the meta-analysis. The branches of the lateral cord, including the lateral pectoral nerve and musculocutaneous nerve, resembled their usual origin in 76.8% (95% CI 50-96%) and 98.8% (95% CI 98-100%), respectively. The medial pectoral nerve, medial brachial cutaneous nerves, medial antebrachial cutaneous nerve and ulnar nerve emerging from the medial cord were observed originating from their usual origins in 90.9% (95% CI 68-100%), 90.7% (95% CI 73-100%), 87.9% (95% CI 67-99%) and 97.7% (95% CI 94-100%), respectively. Lastly, nerves branching from the posterior cord, including the superior and inferior subscapular nerves, thoracodorsal nerve, axillary nerve and radial nerve, originated as per textbook description in 90.7% (95% CI 80-98%), 76.1% (95% CI 61-89%), 90.1% (95% CI 84-95%), 79.8% (95% CI 68-90%) and 99.0% (95% CI 96-100%), respectively. Moreover, the usual origin of the median nerve from the lateral and medial cord via the corresponding roots was encountered in 89.7% (95% CI 84-95%) of cases. CONCLUSIONS The nerves originating from the infraclavicular part of the brachial plexus exhibit a wide spectrum of possible origins. However, the usual patterns were significantly the most common types present in more than three quarters of cases. Especially clinicians might profit from the enhanced understanding of the brachial plexus anatomy presented herein, since we offer a strong guide for handling the anatomically challenging pathologies in this specific area.
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Affiliation(s)
- Michal Benes
- Department of Anatomy, Second Faculty of Medicine, Charles University, Plzenska 130/221, 150 06 Prague 5, Czech Republic
| | - David Kachlik
- Department of Anatomy, Second Faculty of Medicine, Charles University, Plzenska 130/221, 150 06 Prague 5, Czech Republic; Department of Health Care Studies, College of Polytechnics, Tolsteho 16, 586 01 Jihlava, Czech Republic
| | - Miroslav Belbl
- Department of Anatomy, Second Faculty of Medicine, Charles University, Plzenska 130/221, 150 06 Prague 5, Czech Republic
| | - Sarlota Havlikova
- Department of Anatomy, Second Faculty of Medicine, Charles University, Plzenska 130/221, 150 06 Prague 5, Czech Republic
| | - Vladimir Kunc
- Department of Computer Science, Czech Technical University, Karlovo namesti 13, 121 35 Prague 2, Czech Republic
| | - Adam Whitley
- Department of Anatomy, Second Faculty of Medicine, Charles University, Plzenska 130/221, 150 06 Prague 5, Czech Republic; Department of Surgery, University Hospital Kralovske Vinohrady, Third Faculty of Medicine, Charles University, Srobarova 50, 100 34 Prague 10, Czech Republic
| | - Radek Kaiser
- Department of Neurosurgery and Neurooncology, Military University Hospital, First Faculty of Medicine, Charles University, U vojenske nemocnice 1200, 169 02 Prague 6, Czech Republic
| | - Vojtech Kunc
- Department of Anatomy, Second Faculty of Medicine, Charles University, Plzenska 130/221, 150 06 Prague 5, Czech Republic; Clinic of Trauma Surgery, Masaryk Hospital, Socialni pece 3316/12A, 400 11 Usti nad Labem, Czech Republic.
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Benes M, Kachlik D, Belbl M, Kunc V, Havlikova S, Whitley A, Kunc V. A meta-analysis on the anatomical variability of the brachial plexus: Part I - Roots, trunks, divisions and cords. Ann Anat 2021; 238:151751. [PMID: 33940116 DOI: 10.1016/j.aanat.2021.151751] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 04/15/2021] [Accepted: 04/15/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The brachial plexus is a complex anatomical structure that gives rise to all the nerves of the upper limb. Its variability is frequently observed and represents a challenge for interventions in the lower neck and axilla. The aim of this study was to present a comprehensive and evidence-based review with meta-analytic techniques on the variability of roots, trunks, divisions and cords of the brachial plexus. MATERIALS AND METHODS Major medical databases were searched to identify all anatomical studies investigating the variability in the formation of the brachial plexus. Data extracted consisted of demographic information, morphometric parameters, the arrangement of the brachial plexus at the level of the roots, trunks, divisions and cords and the relationship of the brachial plexus to the axillary artery and scalene muscles. The different configurations of the brachial plexus were put into a new classification, and the pooled prevalence of each case was calculated using a random effects model. A sub-analysis on age and geographical location was also performed. RESULTS A total of 40 studies (3055 upper limbs) were included in the meta-analysis. The regular arrangement of roots forming trunks was identified in 84% (95% CI 79-89%) of cases. The overall prevalence of the prefixed and postfixed brachial plexus was 11% (95% CI 6-17%) and 1% (95% CI 0-1%), respectively and in less than 0.1% of cases the brachial plexus received a branch from both C4 and T2. For divisions forming cords, the regular arrangement was observed in 96% (95% CI 93-98%) of cases. Additional communicating branches between the components of the brachial plexus appeared in 5% (95% CI 3-7%) of cases. The relationship of the brachial plexus to the axillary artery and scalene muscles was considered regular in 96% (95% CI 89-100%) and 86% (95% CI 66-98%) of cases, respectively. Analysis of the morphometric parameters revealed the proportional consistency between the components forming the plexus during aging. CONCLUSIONS Knowledge of anatomical variations of the brachial plexus is important for examinations and interventions in the lower neck and axilla. The variability was observed especially in the roots forming trunks, while divisions forming cords showed quite stable appearance. The results of this evidence-based review and meta-analysis can be applied in many different medical disciplines.
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Affiliation(s)
- Michal Benes
- Department of Anatomy, Second Faculty of Medicine, Charles University, V Úvalu 84, 150 06 Prague 5, Czech Republic
| | - David Kachlik
- Department of Anatomy, Second Faculty of Medicine, Charles University, V Úvalu 84, 150 06 Prague 5, Czech Republic; Department of Health Care Studies, College of Polytechnics, Tolsteho 16, 586 01 Jihlava, Czech Republic.
| | - Miroslav Belbl
- Department of Anatomy, Second Faculty of Medicine, Charles University, V Úvalu 84, 150 06 Prague 5, Czech Republic
| | - Vladimir Kunc
- Department of Computer Science, Czech Technical University, Karlovo namesti 13, 121 35 Prague 2, Czech Republic
| | - Sarlota Havlikova
- Department of Anatomy, Second Faculty of Medicine, Charles University, V Úvalu 84, 150 06 Prague 5, Czech Republic
| | - Adam Whitley
- Department of Anatomy, Second Faculty of Medicine, Charles University, V Úvalu 84, 150 06 Prague 5, Czech Republic; Department of Surgery, University Hospital Kralovske Vinohrady, Third Faculty of Medicine, Charles University, Srobarova 50, 100 34 Prague 10, Czech Republic
| | - Vojtech Kunc
- Department of Anatomy, Second Faculty of Medicine, Charles University, V Úvalu 84, 150 06 Prague 5, Czech Republic; Clinic of Trauma Surgery, Masaryk Hospital, Socialni pece 3316/12A, 400 11 Usti nad Labem, Czech Republic
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Carroll MA, Blandino J, Flynn A, Laughran R, Pennella S. Neurovascular axillary variations: superficial brachial artery and single-corded brachial plexus. Anat Sci Int 2020; 96:161-167. [PMID: 32785843 DOI: 10.1007/s12565-020-00563-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 08/08/2020] [Indexed: 10/23/2022]
Abstract
Variants of the axillary artery and brachial plexus were found bilaterally in the axilla of an 86-year-old Asian female. On the left, the cadaver donor had a high bifurcation of the second part of the axillary artery, creating a superficial brachial artery. Meanwhile, the right axilla presented with root, trunk, and cord variations in the formation of the brachial plexus, the most interesting feature being a single, unified cord. Presented in this case report are the structural relationships of the variants with considerations regarding anatomy, embryology, prevalence, and clinical importance.
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Affiliation(s)
- Melissa A Carroll
- Division of Healthcare Professions, Doctor of Physical Therapy Program, DeSales University, 2755 Station Avenue, Center Valley, PA, 18034-9568, USA.
| | - Jennifer Blandino
- Division of Healthcare Professions, Doctor of Physical Therapy Program, DeSales University, 2755 Station Avenue, Center Valley, PA, 18034-9568, USA
| | - Alex Flynn
- Division of Healthcare Professions, Doctor of Physical Therapy Program, DeSales University, 2755 Station Avenue, Center Valley, PA, 18034-9568, USA
| | - Ryan Laughran
- Division of Healthcare Professions, Doctor of Physical Therapy Program, DeSales University, 2755 Station Avenue, Center Valley, PA, 18034-9568, USA
| | - Shannon Pennella
- Division of Healthcare Professions, Doctor of Physical Therapy Program, DeSales University, 2755 Station Avenue, Center Valley, PA, 18034-9568, USA
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Acer N, Turgut M. Evaluation of Brachial Plexus Using Combined Stereological Techniques of Diffusion Tensor Imaging and Fiber Tracking. J Brachial Plex Peripher Nerve Inj 2019; 14:e16-e23. [PMID: 31198435 PMCID: PMC6561765 DOI: 10.1055/s-0039-1687913] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 02/18/2019] [Indexed: 02/03/2023] Open
Abstract
Background Brachial plexus (BP) is composed of intercommunications among the ventral roots of the nerves C5, C6, C7, C8, and T1 in the neck. The in vivo and in vitro evaluation of axons of the peripheral nervous system is performed using different techniques. Recently, many studies describing the application of fiber tractography and stereological axon number estimation to peripheral nerves have been published. Methods Various quantitative parameters of nerve fibers, including axon number, density, axonal area, and myelin thickness, can be estimated using stereological techniques. In vivo three-dimensional reconstruction of axons of BP can be visualized using a combined technique of diffusion tensor imaging (DTI) and fiber tracking with the potential to evaluate nerve fiber content. Conclusion It is concluded that terminal branches of BP can be successfully visualized using DTI, which is a highly reproducible method for the evaluation of BP as it shows anatomical and functional features of neural structures. We believe that quantitative morphological findings obtained from BP will be useful for new experimental, developmental, and pathological studies in the future.
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Affiliation(s)
- Niyazi Acer
- Department of Anatomy, Erciyes University School of Medicine, Kayseri, Turkey
| | - Mehmet Turgut
- Department of Neurosurgery, Adnan Menderes University School of Medicine, Aydın, Turkey
- Department of Histology and Embryology, Adnan Menderes University Health Sciences Institute, Aydın, Turkey
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Keet K, Louw G. Superficial location of the brachial plexus and axillary artery in relation to pectoralis minor: a case report. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2018. [DOI: 10.1080/22201181.2018.1489463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- K Keet
- Division of Clinical Anatomy and Biological Anthropology, Department of Human Biology, University of Cape Town, Cape Town, South Africa
| | - G Louw
- Division of Clinical Anatomy and Biological Anthropology, Department of Human Biology, University of Cape Town, Cape Town, South Africa
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Connections between radial and ulnar nerve at high humeral level in cadavers: incidence, topography, and literature review. Surg Radiol Anat 2017; 40:313-322. [PMID: 29124342 DOI: 10.1007/s00276-017-1939-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 10/27/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE Although communications between branches and cords of the brachial plexus have been extensively published, there is a scarcity of reports concerning radial and ulnar nerve (RN-UN) communication in the arm. The current study aims to demonstrate the incidence, topography, and length of communicating branches between RN and UN. Any additional coexisted variations were also recorded. MATERIALS AND METHODS Two hundred and sixty-six upper limbs collected from one hundred and thirty-three (81 males and 52 females) Greek cadavers were dissected. RESULTS Three out of one hundred and thirty-three cadavers, accounting for an incidence of up to 2.3%, were found to have an atypical communicating branch originating at a high humeral level from RN towards UN. In two cadavers, communicating branches were detected on the left side and in one cadaver bilaterally. CONCLUSIONS The study of atypical communications between RN and UN attracts great attention for its clinical importance, mainly in cases of peripheral neuropathies with diagnostic dilemma or upper limb nerve injury producing an otherwise unexpected symptomatology due to the aberrant nerve supply. Familiarity with these variations is crucial in avoiding misdiagnosis and preserving valuable communicating branches, thus achieving an uneventful outcome in cases of upper limb nerve injury repair.
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