Brachial plexopathy

From WikiCNS

Evaluation and Treatment of Patients with Brachial Plexopathy' '

Pathophys:

Traction

Contusion

Compression

Laceration

Ischemia

Axon loss if sevre or focal demylination

If demyleination then conduction block or slowing

Clinical deficits: muscle paresis or paralysis, sensory loss in all odalities and autonomic distuturbances and pain

Plexus Assessment:

Hx, physical

Tiime and date of onset

Imaging:

Demyelinating injuries from trauma rarely persist more than 6 weeks

After 6 weeks suspect axon loss.

Aneurysm or hematoma cause rapidly progressive plexopathies

Congenital anomalies (cervical rib/ band) and neoplasms cause slowly progressive plexopathies

Serial exams: look for motor recovery. Sensory recovery may be misleading as it can occur without motor recovery

Imaging: XRAYS, CT Myelogram, MRI(most helpful),

Nerve conduction studies (motor and sendory), and Needle electrode examination

Sensory NCS can distinguish between preganglionic and postganglionic injuries

No reliable senory NCS for the lumbar plexsus

SSEP: of limited value in plexsus assessment but helpful intraop

'Brachial Plexopathies'

Brachial Plexsus: 5 roots, three trunks, six divisions, three cords, several terminal nerves

Roots: located between scalene muscles

Trunks: in anterior-inferior portion of the posterior triangle in the neck,

Divisions: between clavicle and first thoracic rib

Cords and terminal nerves: in the axilla

Supraclavicular vs infraclavicular

Supravclavicular: preganglionic vs postganglionic

Upper: C5-6

Middle C7

Lower T1

Types of Brachial Plexsus Lesions:

Acute Trauma: most common, associated injury is common especially bone,

Usually supraclavicular, and usually upper plexsus

Usually: proximal arm weakness, numbness and pain extending to thumb

NCS helpful after seven days

Record exact time of onset

Slowly progressive symoptoms may indicate an expanding hematoma

Examine Serratus anterior, rhomboids, and spinati: weakness indicates root avulsion

Horner’s implies proximal lower plexsus injury

Indicatiosn for Surgery:???

Burner Syndrome

Young males engaged in contact sports

Short lived events prodiced by sudden depression of the shoulder

Transient intense burning and dysesthesia in the upper extremity and generalized weakness

Gunshot wounds

75% infraclavicular

progressive pain: pseudoaneurysm/expanding hematoma: urgent surgery

Stable lesions: follow for 3 months

OR: severe unremitting pain, failure to improve (possible cable grafts)

Lacerations:

Sharp vs dull

Supraclavicular and infraclavicular

Imaging to look for concomitant vascular injury

Sharp laceration: OR within 2 days

Blunt injury: usually delay surgery 3 months

Humeral Head Fractures and Dislocations:

Infraclavicular

Falls and MVAs

Axillary nerve most commonly injurred

Iatrogenic

Obstetrical

Usually supraclavicular

Usually upper plexsus

“Erb’s Palsy” for upper plexsus

Klumpke palsy for lower plexsus

Motor>sensory deficits

Classic Postoperative

Any position but mostly supine

Usually demyelinating conduction block

weakness>>sensory

Post-Median Sternotomy

Most likely cause is fracture of first thoracic rib

Post-disputed N-TOS Surgery