Radiological and Electrophysiological Detection of Nerve Roots Avulsion in Patients with Birth-Related Brachial Plexus Paralysis

ABSTRACT

The differential diagnosis between preganglionic and postganglionic lesions of the brachial plexus at the level of individual roots is critical. Preoperative neuroradiologic and electrophysiological studies are considered useful in detecting of root avulsions of the brachial plexus. In this study, the predictive value of plain cervical myelography, following computed tomography myelography (CTM) and preoperative electrodiagnostic evaluation, in detecting nerve root avulsions in cases of obstetrical brachial plexus paralysis was determined. The charts of 321 patients who had sustained brachial plexus paralysis and were operated on in our center from 1982 to 2003 were reviewed and analyzed. This study includes 70 cases of obstetrical brachial plexus palsy. Preoperative cervical myelography and CTM, as well as electrophysiological studies, were compared with final intraoperative diagnosis. A total of 420 spinal nerves were examined in 70 patients. Fifty-two patients (74.3%) had avulsion injury of brachial plexus. Intraoperatively, 135 roots (32.1%) were found to be avulsed. Accuracy, sensitivity, and specificity of preoperative plain myelography were 85.3%, 71.0%, and 92.3%; of CTM they were 89.4%, 83.2%, and 92.1%, respectively; and of electrodiagnostic studies they were 76.2%, 39.5%, and 93.2%, respectively. CTM and plain myelography were significantly more accurate and sensitive than electrophysiological studies (p < 0.05). There was no statistically significant difference in accuracy and sensitivity between plain myelography and CTM.

KEYWORDS

Brachial plexus - spinal nerve avulsion - myelography - electrophysiological studies

REFERENCES

• 1 Terzis J K, Papakonstantinou K S. Management of obstetrical brachial plexus palsy.  Hand Clin. 1999;  15 717-736
• 2 Shenaq S N, Berzin E, Lee R, Laurent J P, Nath R, Nelson M R. Brachial plexus birth injuries and current management.  Clin Plast Surg. 1998;  25 527-536
• 3 Marcus J R, Clarke H M. Management of obstetrical brachial plexus palsy: evaluation, prognosis, and primary surgical treatment.  Clin Plast Surg. 2003;  30 289-306
• 4 Gilbert A, Tassin J L. Obstetrical palsy: a clinical, pathologic and surgical review. In: Terzis JK Microreconstruction of the nerve injuries Philadelphia; WB Saunders 1987
• 5 Gilbert A. Obstetrical paralysis: indications and strategy. In: Gilbert A Brachial Plexus Injuries London; Martin Dunitz 2001: 205-210
• 6 Smith S J. The role of neurophysiological investigation in traumatic brachial plexus lesions in adults and children.  J Hand Surg [Br]. 1996;  21 145-147
• 7 Sunderland S. Meningeal-neural relations in the intervertebral foramen.  J Neurosurg. 1974;  40 756-763
• 8 Frykholm R. Lower cervical nerve roots and their investment.  Acta Chir Scand. 1951;  101 457-471
• 9 Frykholm R. The mechanism of cervical radicular lesions resulting from friction or forceful traction.  Acta Chir Scand. 1951;  102 93-98
• 10 Nathan H, Feuerstein M. Angulated course of spinal nerve roots.  J Neurosurg. 1970;  32 349-352
• 11 Reid J D. Ascending nerve roots.  J Neurol Neurosurg Psychiatry. 1960;  23 148-155
• 12 Reid J D. Effect of flexion extension movements of the head and spine upon the spinal cord and nerve roots.  J Neurol Neurosurg Psychiatry. 1960;  23 214-221
• 13 Jennett R J, Tarby T J, Kreinick C J. Brachial plexus palsy: an old problem revisited.  Am J Obstet Gynecol. 1992;  166 1673-1676
• 14 Ubachs J MH, Slooff A CJ. Obstetrical paralysis: aetiology. In: Gilbert A Brachial Plexus Injuries. London; Martin Dunitz 2001: 151-157
• 15 Sunderland S. Mechanism of cervical nerve root avulsion in injuries of the neck and shoulder.  J Neurosurg. 1974;  41 705-714
• 16 Roaf M. Lateral flexion injuries of the cervical spine.  J Bone Joint Surg [Br]. 1963;  45 36-38
• 17 Murphey F, Hartung W, Kirklin J W. Myelographic demonstration of avulsing injury of the brachial plexus.  AJR Am J Roentgenol. 1947;  58 102-105
• 18 Jeager R, Whiteley W H. Avulsion of the brachial plexus.  JAMA. 1953;  153 633-635
• 19 Taylor P E. Traumatic intradural avulsion of the nerve roots of the brachial plexus.  Brain. 1962;  85 579-602
• 20 Heon M. Myelogram: a questionable aid in diagnosis and prognosis of brachial plexus components in traction injuries.  Conn Med. 1965;  29 260-262
• 21 Davies E R, Sutton D, Bligh A S. Myelography in brachial plexus injury.  Br J Radiol. 1966;  39 362-371
• 22 Yeoman P M. Cervical myelography in traction injuries of the brachial plexus.  J Bone Joint Surg Br. 1968;  50B 253-260
• 23 Kewalramani L, Taylor R. Brachial plexus root avulsion: role of myelography.  J Trauma. 1975;  15 603-608
• 24 Cobby M J, Leslie I J, Watt I. Cervical myelography of nerve root avulsion injuries using water-soluble contrast media.  Br J Radiol. 1988;  61 673-678
• 25 Marshall R W, De Silva R D. Computerized axial tomography in traction injuries of the brachial plexus.  J Bone Joint Surg Br. 1986;  68 734-738
• 26 Bonney G, Gilliatt R W. Sensory nerve conduction after traction lesion of the brachial plexus.  Proc R Soc Med. 1958;  51 365-367
• 27 Nagano A, Ochiai N, Sugioka H, Hara T, Tsuyama N. Usefulness of myelography in brachial plexus injuries.  J Hand Surg [Br]. 1989;  14 59-64
• 28 Tarlov I M. Myelography to help localize traction lesions of the brachial plexus.  Am J Surg. 1954;  88 266-271
• 29 White J C, Hanelin J. Myelographic signs of brachial plexus avulsion.  J Bone Joint Surg [Am]. 1954;  36 113-118
• 30 Rayle A A, Gay B B, Meadows J L. Myelogram in avulsion of the brachial plexus.  Radiology. 1955;  65 65-71
• 31 Robles J. Brachial plexus avulsion.  J Neurosurg. 1968;  28 434-438
• 32 Hashimoto T, Mitomo M, Hirabuki N et al.. Nerve root avulsion of birth palsy: comparison of myelography with CT myelography and somatosensory evoked potential.  Radiology. 1991;  178 841-845
• 33 Terzis J K, Liberson W T, Levine R. Obstetrical brachial plexus palsy.  Hand Clin. 1986;  2 773-786
• 34 Slooff A CJ, Versteege C WM, Blaauw G, van Ouwerkerk W JR. Radiological and related investigations. In: Gilbert A Brachial Plexus Injuries London; Martin Dunitz 2001: 31-37
• 35 Chow B C, Blaser S, Clarke H M. Predictive value of computed tomographic myelography in obstetrical brachial plexus palsy.  Plast Reconstr Surg. 2000;  106 971-977
• 36 Walker A T, Chaloupka J C, de Lotbiniere A C, Wolfe S W, Goldman R, Kier E L. Detection of nerve rootlet avulsion on CT myelography in patients with birth palsy and brachial plexus injury after trauma.  AJR Am J Roentgenol. 1996;  167(5) 1283-1287
• 37 Carvalho G A, Nikkhah G, Matthies C et al.. Diagnosis of root avulsions in traumatic brachial plexus injuries: Value of computerized tomography myelography and magnetic resonance imaging.  J Neurosurg. 1997;  86 69-76
• 38 Doi K, Otsuka K, Okamoto Y, Fujii H, Hattori Y, Baliarsing A S. Cervical nerve root avulsion in brachial plexus injuries: magnetic resonance imaging classification and comparison with myelography and computerized tomography myelography.  J Neurosurg Spine. 2002;  96 277-284
• 39 Liberson W T, Terzis J K. Some novel techniques of clinical electrophysiology applied to the management of brachial plexus palsy.  Electromyogr Clin Neurophysiol. 1987;  27 371-383
• 40 Vredeveld J W. Clinical neurophysiological investigations. In: Gilbert A Brachial Plexus Injuries. London; Martin Dunitz 2001: 39-44
• 41 Deletis V, Morota N, Abbot I R. Electrodiagnosis in the management of brachial plexus.  Hand Clin. 1995;  11 555-561
• 42 Trojaborg W. Clinical, electrophysiological, and myelographic studies of 9 patients with cervical spinal root avulsions: discrepancies between EMG and X-ray findings.  Muscle Nerve. 1994;  17 913-922
• 43 Vredevelt J, Blaauw G, Slooff B, Rozeman S. The findings in pediatric obstetric brachial palsy differ from those in older patient: suggested explanation.  Dev Med Child Neurol. 2000;  42 158-161
• 44 Foerster O. The dermatomes in man.  Brain. 1933;  56 1-39
• 45 Keegan J J, Garrett F D. The segmental distribution of the cutaneous nerves in the limbs of the man.  Anat Rec. 1948;  102 409-437
• 46 Bonney G. The value of axon responses in determining the site of lesion in traction injuries of the brachial plexus.  Brain. 1954;  77 588-609
• 47 Bonney G. Prognosis in traction lesion of the brachial plexus.  J Bone Joint Surg Br. 1959;  41 4-35
• 48 Dykes R W, Terzis J K. Spinal nerve distributions in the upper limb: the organization of the dermatome and afferent myotome.  Philos Trans R Soc Lond B Biol Sci. 1981;  293 509-554
• 49 Parry G J. Electrodiagnostic studies in the evaluation of peripheral nerve and brachial plexus injuries.  Neurol Clin. 1992;  10 921-934
• 50 Aminoff M J, Olney R K, Parry G J et al.. Relative utility of different electrophysiologic techniques in the evaluation of brachial plexopathies.  Neurology. 1988;  38 546-550