Combined injuries of the brachial plexus and spinal cord

Can Magnetic Resonance Imaging Reveal Lower Motor Neuron Damage after Traumatic Spinal Cord Injury? A Scoping Review

Restoring muscle function to patients with spinal cord injuries (SCIs) will invariably require a functioning lower motor neuron (LMN). As techniques such as nerve transfer surgery emerge, characterizing the extent of LMN damage associated with SCIs becomes clinically important. Current methods of LMN diagnosis have inherent limitations that could potentially be overcome by the development of magnetic resonance imaging (MRI) biomarkers: specific features on MRI that are indicative of LMN integrity. To identify research on MRI biomarkers of LMN damage in the acute phase after SCI, we searched PubMed, EMBASE, MEDLINE, and the Cochrane Central Register of Controlled Trials for articles published from inception to April 27, 2021. Overall, 2 of 58 unique articles screened met our inclusion criteria, both of which were small studies. We therefore identify MRI biomarkers of LMN damage overlying SCI as a notable gap in the literature. Because of the lack of existing literature on this specific problem, we further our discussion by examining concepts explored in research characterizing MRI biomarkers of spinal cord and neuronal damage in different contexts that may provide value in future work to identify a biomarker for LMN damage in SCI. We conclude that MRI biomarkers of LMN damage in SCI is an underexplored, but promising, area of research as emerging, function-restoring therapies requiring this information continue to advance.

MR neurography of the brachial plexus in adult and pediatric age groups: evolution, recent advances, and future directions

Introduction: MR neurography (MRN) of the brachial plexus has emerged in recent years as a safe and accurate modality for the identification of brachial plexopathies in pediatric and adult populations. While clinical differentiation of brachial plexopathy from cervical spine-related radiculopathy or nerve injury has long relied upon nonspecific physical exam and electrodiagnostic testing modalities, MRN now permits detailed interrogation of peripheral nerve anatomy and pathology, as well as assessment of surrounding soft tissues and musculature, thereby facilitating accurate diagnosis. The reader will learn about the current state of brachial plexus MRN, including recent advances and future directions, and gain knowledge about the adult and pediatric brachial plexopathies that can be characterized using these techniques.Areas Covered: The review details recent developments in brachial plexus MRN, including increasing availability of 3.0-T MR scanners at both private and academic diagnostic imaging centers, as well as the advent of multiple new vascular and fat signal suppression techniques. A literature search of PubMed and SCOPUS was used as the principal source of information gathered for this review.Expert Opinion: Refinement of fat-suppression, 3D techniques and diffusion MR imaging modalities has improved the accuracy of MRN, rendering it as a useful adjunct to clinical findings during the evaluation of suspected brachial plexus lesions.

Epidemiology, etiology, and types of severe adult brachial plexus injuries requiring surgical repair: systematic review and meta-analysis

The literature describing epidemiology, etiology, and types of serious brachial plexus injuries (BPIs) is sparse. The aim of this review was to investigate the epidemiological and etiopathogenetical data of serious BPIs undergoing surgical reconstruction. A systematic search was conducted from January 1985 to December 2017. All studies that reported data about prevalence of specific types and causes of BPIs in adults treated surgically were included and cumulatively analyzed. Ten studies including 3032 patients were identified. The pooled prevalence of closed BPIs was 93% (95% CI: 87-97%), lacerations accounted for 3% (95% CI: 1-6%), and gunshot wounds (GSWs) for 3% (95% CI: 0-7%). The prevalence of male patients was 93% (95% CI: 90-96%) and female cases 7% (95% CI: 4-10%). The most common cause of closed BPI was motorcycle accidents with 67% (95% CI: 49-82%) prevalence followed by car crashes with 14% (95% CI: 8-20%). Other causes were rare. Ninety percent (95% CI: 78-98%) of patients suffered from a supraclavicular or combined supra-/infraclavicular trauma, while 10% (95% CI: 2-22%) from isolated infraclavicular injury. The prevalence of complete lesions was 53% (95% CI: 47-58%) followed by upper plexus lesion with 39% (95% CI: 31-48%) and lower plexus injury with 6% (95% CI: 1-12%). This meta-analysis demonstrates that the typical patient suffering from severe BPI is a male after motorcycle accident with closed supraclavicular injury causing complete or slightly less commonly upper plexus palsy. Lacerations and GSWs of brachial plexus are rare.

Two Cases of Traumatic Brachial Plexus Injury With Complete Spinal Cord Injury

BACKGROUND

Traumatic brachial plexus injury (BPI) in patients with complete spinal cord injury (SCI) such as paraplegia or tetraplegia is a very rare and debilitating combined injury that can occur in high-energy traumas. Management of a BPI should be aimed at regaining strength for self-transfers and activities of daily living to restore independence. However, brachial plexus reconstruction (BPR) in this unique patient population requires considerable planning due to the combined elements of upper and lower motor neuron injuries.

METHODS

We present 2 cases of traumatic complete SCI with concomitant BPI with mean follow-up of 42 months after BPR. The first patient had a left C5-7 BPI with a T2 complete SCI. The second patient sustained a left C5-8 BPI with complete SCI at C8.

RESULTS

The first patient underwent BPR including free functioning muscle, intra- and extraplexal nerve transfers, and tendon transfers resulting in active elbow flexion and active elbow, finger, and thumb extension, but no recovery of shoulder function. While the second patient underwent extra-plexal nerve transfer to restore elbow flexion yet did not recover any function in the left upper extreimty.

CONCLUSIONS

Because extensive upper and lower motor neuron injuries are present in these combined injuries, treatment strategies are limited. Expectations should be tempered in these patients as traditional methods to reconstruct the brachial plexus may result in less than ideal functional outcomes due to the associated upper motor neuron injury.

Delayed diagnosis of traumatic gunshot wound Brown-Sequard-plus syndrome due to associated brachial plexopathy

Introduction

Brown-Séquard Syndrome (BSS) is one of the rarest incomplete spinal cord syndromes. The combination of injuries to peripheral nerves and the central nervous system result in an array of symptoms that can result in overlapping clinical presentations and delayed diagnosis. Early detection of spinal cord injury in patients with peripheral nerve injury has been observed to have a positive effect on outcomes.

Case presentation

This report discusses the case of a 29-year-old male patient with Brown-Sequard-Plus Syndrome (BSPS) and Brachial Plexopathy (BP) secondary to gunshot wound in the left inferior neck. The patient was found initially with left hemibody weakness. A chest CT Scan demonstrated a fracture of the left T2 transverse process. Imaging studies of the spinal cord were not performed in the acute setting. Evaluation in an outpatient setting 3 weeks later showed significant left upper extremity weakness with improvement of left lower extremity strength. Also present were loss of pain and temperature sensation on the right side below the T2 dermatome level. A cervico-thoracic MRI was requested and revealed a T2 level spinal cord contusion. Electrodiagnostic studies confirmed a lower trunk left BP.

Discussion

The patient was diagnosed with BSPS and associated left lower trunk BP. To our knowledge, this is the first reported case of a concomitant BSPS and BP secondary to a gunshot wound. Delayed diagnosis of BSPS may occur in a trauma setting underlying the importance of a detailed history and physical examination for favorable outcomes.

Brachial plexus injuries

Brachial Plexus Injuries result from a variety of causative mechanisms. They often present in a polytraumatic setting, and as such there is often a delay in their diagnosis and treatment. An understanding of the anatomy of the Brachial Plexus, and associated clinical pictures associated with injury, allows for early diagnosis and treatment. This review will consider the specific features of Brachial Plexus injuries relating to incidence, anatomy, mechanisms of injury, clinical presentation, and diagnostic evaluation.

Prognosis for patients with traumatic cervical spinal cord injury combined with cervical radiculopathy

OBJECTIVE

To delineate cervical radiculopathy that is found in combination with traumatic cervical spinal cord injury (SCI) and to determine whether attendant cervical radiculopathy affects the prognosis and functional outcome for SCI patients.

METHODS

A total of 66 patients diagnosed with traumatic cervical SCI were selected for neurological assessment (using the International Standards for the Neurological Classification of Spinal Cord Injury [ISNCSCI]) and functional evaluation (based on the Korean version Modified Barthel Index [K-MBI] and Functional Independence Measure [FIM]) at admission and upon discharge. All of the subjects received a preliminary electrophysiological assessment, according to which they were divided into two groups as follows: those with cervical radiculopathy (the SCI/Rad group) and those without (the SCI group).

RESULTS

A total of 32 patients with cervical SCI (48.5%) had cervical radiculopathy. The initial ISNCSCI scores for sensory and motor, K-MBI, and total FIM did not significantly differ between the SCI group and the SCI/Rad group. However, at discharge, the ISNCSCI scores for motor, K-MBI, and FIM of the SCI/Rad group showed less improvement (5.44±8.08, 15.19±19.39 and 10.84±11.49, respectively) than those of the SCI group (10.76±9.86, 24.79±19.65 and 17.76±15.84, respectively) (p<0.05). In the SCI/Rad group, the number of involved levels of cervical radiculopathy was negatively correlated with the initial and follow-up motors score by ISNCSCI.

CONCLUSION

Cervical radiculopathy is not rare in patients with traumatic cervical SCI, and it can impede neurological and functional improvement. Therefore, detection of combined cervical radiculopathy by electrophysiological assessment is essential for accurate prognosis of cervical SCI patients in the rehabilitation unit.

Concomitant traumatic spinal cord and brachial plexus injuries in adult patients

BACKGROUND

Combined injuries to the spinal cord and brachial plexus present challenges in the detection of both injuries as well as to subsequent treatment. The purpose of this study is to describe the epidemiology and clinical factors of concomitant spinal cord injuries in patients with a known brachial plexus injury.

METHODS

A retrospective review was performed on all patients who were evaluated for a brachial plexus injury in a tertiary, multidisciplinary brachial plexus clinic from January 2000 to December 2008. Patients with clinical and/or imaging findings for a coexistent spinal cord injury were identified and underwent further analysis.

RESULTS

A total of 255 adult patients were evaluated for a traumatic traction injury to the brachial plexus. We identified thirty-one patients with a combined brachial plexus and spinal cord injury, for a prevalence of 12.2%. A preganglionic brachial plexus injury had been sustained in all cases. The combined injury group had a statistically greater likelihood of having a supraclavicular vascular injury (odds ratio [OR] = 22.5; 95% confidence interval [CI] = 1.9, 271.9) and a cervical spine fracture (OR = 3.44; 95% CI = 1.6, 7.5). These patients were also more likely to exhibit a Horner sign (OR = 3.2; 95% CI = 1.5, 7.2) and phrenic nerve dysfunction (OR = 2.5; 95% CI = 1.0, 5.8) compared with the group with only a brachial plexus injury.

CONCLUSION

Heightened awareness for a combined spinal cord and brachial plexus injury and the presence of various associated clinical and imaging findings may aid in the early recognition of these relatively uncommon injuries.

22. Traumatic plexus lesion

Pain, motor, and sensory deficits characterize patients with a traumatic lesion of the brachial plexus. Frequently, more severe injuries co-exist that require immediate surgical attention. Early rehabilitation and physical therapy are the cornerstones of treatment. Pharmacological management can be difficult. Surgical reconstruction is frequently advised when nerves are disrupted. The results, mostly from small historical reports, vary greatly. Neurostimulation may have an additional beneficial effect, especially if the pathophysiology of nociception and neuropathic pain becomes evident in these complex patients.

SPINAL CORD HERNIATION INTO ASSOCIATED PSEUDOMENINGOCELE AFTER BRACHIAL PLEXUS AVULSION INJURY

OBJECTIVE

Posttraumatic spinal cord herniation is a rare condition. We describe a case of spinal cord herniation into an associated pseudomeningocele after a brachial plexus avulsion injury.

CLINICAL PRESENTATION

A 33-year-old man began to develop progressive Horner's syndrome 14 years after a brachial plexus avulsion injury. At a clinical presentation 17 years after that injury, sensory disturbance and a unilateral pyramidal sign were also evident. In addition to myelography and computed tomographic myelography findings, coronal magnetic resonance imaging scans clearly demonstrated herniation of the spinal cord into a large pseudomeningocele inside the C7–T1 intervertebral foramen. Another pseudomeningocele inside the T1–T2 intervertebral foramen was also noted.

INTERVENTION

The patient underwent a C6–T2 laminectomy, during which the spinal cord was found to be herniated through a dural defect into a pseudomeningocele at the C8 root level, and a second dural defect was also shown, with an arachnoid outpouching that included an avulsed T1 root. The spinal cord herniation was reduced and the dural defects were repaired. After surgery, the patient showed no significant neurological changes, and his condition stabilized.

CONCLUSION

Brachial plexus root avulsions may result in the formation of pseudomeningoceles and can lead to spinal cord herniation. Coronal magnetic resonance imaging is useful to demonstrate spinal cord herniation as well as pseudomeningoceles. Surgical treatment is recommended for such cases with progressive symptoms to prevent further deterioration.