MRI evaluation of nerve root avulsion in neonatal brachial plexus palsy: understanding the presence of isolated dorsal/ventral rootlet disruption

2021 ◽  
pp. 1-5
Author(s):  
Brandon W. Smith ◽  
Kate W. C. Chang ◽  
Hemant A. Parmar ◽  
Mohannad Ibrahim ◽  
Lynda J. S. Yang
Keyword(s):  
Spinal Cord ◽  
Brachial Plexus ◽  
Nerve Root ◽  
Brachial Plexus Palsy ◽  
Potential Donor ◽  
Neonatal Brachial Plexus Palsy ◽  
High Resolution Mri ◽  
Nerve Root Avulsion ◽  
Definition Of

OBJECTIVE The evaluation, treatment, and prognosis of neonatal brachial plexus palsy (NBPP) continues to have many areas of debate, including the use of ancillary testing. Given the continued improvement in imaging, it is important to revisit its utility. Nerve root avulsions have historically been identified by the presence of pseudomeningoceles or visible ruptures. This “all-or-none” definition of nerve root avulsions has many implications for the understanding and management of NBPP, especially as characterization of the proximal nerve root as a potential donor remains critical. This study examined the ability of high-resolution MRI to more specifically define the anatomy of nerve root avulsions by individually examining the ventral and dorsal rootlets as they exit the spinal cord. METHODS This is a retrospective review of patients who had undergone brachial plexus protocol MRI for clinical evaluation of NBPP at a single institution. Each MR image was independently reviewed by a board-certified neuroradiologist, who was blinded to both established diagnosis/surgical findings and laterality. Each dorsal and ventral nerve rootlet bilaterally from C5 to T1 was evaluated from the spinal cord to its exit in the neuroforamen. Each rootlet was classified as avulsed, intact, or undeterminable. RESULTS Sixty infants underwent brachial plexus protocol MRI from 2010 to 2018. All infants were included in this study. Six hundred individual rootlets were analyzed. There were 49 avulsed nerve rootlets in this cohort. Twenty-nine (59%) combined dorsal/ventral avulsions involved both the ventral and dorsal rootlets, and 20 (41%) were either isolated ventral or isolated dorsal rootlet avulsions. Of the isolated avulsion injuries, 13 (65%) were dorsal only, meaning that the motor rootlets were intact. CONCLUSIONS A closer look at nerve root avulsions with MRI demonstrates a significant prevalence (approximately 41%) of isolated dorsal or ventral nerve rootlet disruptions. This finding implies that nerve roots previously labeled as “avulsed” but with only isolated dorsal (sensory) rootlet avulsion can yet provide donor fascicles in reconstruction strategies. A majority (99%) of the rootlets can be clearly visualized with MRI. These findings may significantly impact the clinical understanding of neonatal brachial plexus injury and its treatment.

Utility of electrodiagnostic testing and computed tomography myelography in the preoperative evaluation of neonatal brachial plexus palsy

2012 ◽  
Vol 9 (3) ◽  
pp. 283-289 ◽  
Author(s):  
Kelly L. VanderHave ◽  
Karen Bovid ◽  
Hilary Alpert ◽  
Kate Wan-Chu Chang ◽  
Douglas J. Quint ◽  
...  
Keyword(s):  
Brachial Plexus ◽  
Nerve Root ◽  
Comprehensive Evaluation ◽  
Nerve Repair ◽  
Perinatal Care ◽  
Preoperative Evaluation ◽  
Inclusion Criteria ◽  
Brachial Plexus Palsy ◽  
Early Management ◽  
Neonatal Brachial Plexus Palsy

Object The rate of neonatal brachial plexus palsy (NBPP) remains 0.4%–4% despite improvements in perinatal care. Among affected children, the extent of brachial plexus palsy differs greatly, as does the prognosis. Controversial elements in management include indications and timing of nerve repair as well as type of reconstruction in patients in whom function will ultimately not be recovered without surgical intervention. Differentiating preganglionic (avulsion) from postganglionic (rupture) lesions is critical because preganglionic lesions cannot spontaneously recover motor function. Distinguishing between these lesions at initial presentation based on clinical examination alone can be difficult in infants. The purpose of the present study was to determine the sensitivity of preoperative electrodiagnostic studies (EDSs) and CT myelography (CTM) in determining the presence of nerve root rupture and avulsions in infants with NBPP. Methods After receiving institutional review board approval, the authors conducted a retrospective review of patients referred to the Neonatal Brachial Plexus Program between 2007 and 2010. Inclusion criteria included children who underwent brachial plexus exploration following preoperative EDSs and CTM. The CTM scans were interpreted by a staff neuroradiologist, EDSs were conducted by a single physiatrist, and intraoperative findings were recorded by the operating neurosurgeon. The findings from the preoperative EDSs and CTM were then compared with intraoperative findings. The sensitivities and 95% confidence intervals were determined to evaluate performance accuracy of each preoperative measure. Results Twenty-one patients (8 male amd 13 female) met inclusion criteria for this study. The sensitivity of EDSs and CTM for detecting a postganglionic rupture was 92.8% (CI 0.841–0.969) and 58.3% (CI 0.420–0.729), respectively. The sensitivity for EDSs and CTM for preganglionic nerve root avulsion was 27.8% (CI 0.125–0.509) and 72.2% (CI 0.491–0.875), respectively. In cases in which both CTM and EDSs gave concordant results, the sensitivity for both modalities combined was 50.0% (CI 0.237–0.763) for avulsion and 80.8% (CI 0.621–0.915) for rupture. Overall, EDSs were most useful in identifying ruptures, particularly in the upper plexus, whereas CTM was most sensitive in identifying avulsions in the lower plexus. Conclusions Knowledge of the spinal nerve integrity is critical for early management of patients with NBPP. Surgical management, in the form of nerve repair/reconstruction, and optimal prognostication of NBPP depend on the accurate diagnosis of the level and type of lesion. Both EDSs and CTM scans must always be interpreted in the context of a comprehensive evaluation of the patient. They provide supplemental information (in addition to the physical examination) for early detection of nerve root rupture and avulsion injuries, aiding surgical decision making and preoperative planning for NBPP. Continued advances in imaging, EDSs, and microsurgical nerve repair techniques will allow surgeons to achieve greater success for functional recovery in management of NBPP.

scholarly journals Nerve transfer in brachial plexus traction injuries

1992 ◽  
Vol 76 (2) ◽  
pp. 191-197 ◽  
Author(s):  
Miroslav Samardzic ◽  
Danica Grujicic ◽  
Vaso Antunovic
Keyword(s):  
Brachial Plexus ◽  
Nerve Root ◽  
Nerve Transfer ◽  
Spinal Nerve ◽  
Spinal Nerve Root ◽  
Root Avulsion ◽  
Brachial Plexus Palsy ◽  
Content Type ◽  
Spinal Accessory ◽  
Nerve Root Avulsion

✓ Brachial plexus palsy due to traction injury, especially spinal nerve-root avulsion, represents a severe handicap for the patient. Despite recent progress in diagnosis and microsurgical repair, the prognosis in such cases remains unfavorable. Nerve transfer is the only possibility for repair in cases of spinal nerve-root avulsion. This technique was analyzed in 37 patients with 64 reinnervation procedures of the musculocutaneous and/or axillary nerve using upper intercostal, spinal accessory, and regional nerves as donors. The most favorable results, with an 83.8% overall rate of useful functional recovery, were obtained in patients with upper brachial plexus palsy in which regional donor nerves, such as the medial pectoral, thoracodorsal, long thoracic, and subscapular nerves, had been used. The overall rates of recovery for the spinal accessory and upper intercostal nerves were 64.3% and 55.5%, respectively, which are significantly lower. The authors evaluate the results of nerve transfer and analyze different donor nerves as factors influencing the prognosis of surgical repair.

The Diagnostic Value of MRI in Traumatic Brachial Plexus Injury

1994 ◽  
Vol 19 (1) ◽  
pp. 55-59 ◽  
Author(s):  
M. OCHI ◽  
Y. IKUTA ◽  
M. WATANABE ◽  
K. KIMOR ◽  
K. ITOH
Keyword(s):  
Brachial Plexus ◽  
Nerve Root ◽  
Brachial Plexus Injury ◽  
Diagnostic Value ◽  
Resonance Imaging ◽  
Nerve Roots ◽  
Surgical Exploration ◽  
Nerve Root Avulsion ◽  
Magnetic Resonance Imaging Mri ◽  
The Individual

Findings in 34 patients with traumatic brachial plexus injury documented by surgical exploration and intra-operative somatosensory-evoked potentials were correlated with findings on myelography and magnetic resonance imaging (MRI) to determine whether MRI can identify nerve root avulsion. The coronal and sagittal planes were not able to demonstrate avulsion of the individual nerve roots. The axial and axial oblique planes did provide useful information to determine which nerve root was avulsed in the upper plexus, although it was difficult to clearly delineate the lower cervical rootlets. The accuracy of MRI was 73% for C5 and 64% for C6 and that of myelograpby 63% for C5 and 64% for C6. Thus, the diagnostic accuracy of MRI for upper nerve roots was slightly superior to myelography. Although its primary diagnostic value is limited to the upper nerve roots whose avulsion is relatively difficult to diagnose by myelography, MRI can provide useful guidance in the waiting period prior to surgical exploration after brachial plexus injury.

scholarly journals Peripartum and neonatal factors associated with the persistence of neonatal brachial plexus palsy at 1 year: a review of 382 cases

2016 ◽  
Vol 17 (5) ◽  
pp. 618-624 ◽  
Author(s):  
Thomas J. Wilson ◽  
Kate W. C. Chang ◽  
Suneet P. Chauhan ◽  
Lynda J. S. Yang
Keyword(s):  
Brachial Plexus ◽  
Prediction Algorithm ◽  
University Of Michigan ◽  
Brachial Plexus Palsy ◽  
Factors Associated ◽  
Neonatal Brachial Plexus Palsy ◽  
Active Range Of Motion ◽  
Wide Range ◽  
Nerve Surgery ◽  
The University

OBJECTIVE Neonatal brachial plexus palsy (NBPP) occurs due to the stretching of the nerves of the brachial plexus before, during, or after delivery. NBPP can resolve spontaneously or become persistent. To determine if nerve surgery is indicated, predicting recovery is necessary but difficult. Historical attempts explored the association of recovery with only clinical and electrodiagnostic examinations. However, no data exist regarding the neonatal and peripartum factors associated with NBPP persistence. METHODS This retrospective cohort study involved all NBPP patients at the University of Michigan between 2005 and 2015. Peripartum and neonatal factors were assessed for their association with persistent NBPP at 1 year, as defined as the presence of musculoskeletal contractures or an active range of motion that deviated from normal by > 10° (shoulder, elbow, hand, and finger ranges of motion were recorded). Standard statistical methods were used. RESULTS Of 382 children with NBPP, 85% had persistent NBPP at 1 year. A wide range of neonatal and peripartum factors was explored. We found that cephalic presentation, induction or augmentation of labor, birth weight > 9 lbs, and the presence of Horner syndrome all significantly increased the odds of persistence at 1 year, while cesarean delivery and Narakas Grade I to II injury significantly reduced the odds of persistence. CONCLUSIONS Peripartum/neonatal factors were identified that significantly altered the odds of having persistent NBPP at 1 year. Combining these peripartum/neonatal factors with previously published clinical examination findings associated with persistence should allow the development of a prediction algorithm. The implementation of this algorithm may allow the earlier recognition of those cases likely to persist and thus enable earlier intervention, which may improve surgical outcomes.

scholarly journals Medical Decision-Making among Adolescents with Neonatal Brachial Plexus Palsy and Their Families

2013 ◽  
Vol 131 (6) ◽  
pp. 880e-887e ◽  
Author(s):  
Lee Squitieri ◽  
Bradley P. Larson ◽  
Kate W.-C. Chang ◽  
Lynda J.-S. Yang ◽  
Kevin C. Chung
Keyword(s):  
Decision Making ◽  
Brachial Plexus ◽  
Medical Decision Making ◽  
Medical Decision ◽  
Brachial Plexus Palsy ◽  
Neonatal Brachial Plexus Palsy

scholarly journals Upper thoracic spinal cord herniation after traumatic nerve root avulsion

2004 ◽  
Vol 16 (5) ◽  
pp. 306-309
Author(s):  
Victor R. DaSilva ◽  
Mubarak Al-Gahtany ◽  
Rajiv Midha ◽  
Dipanka Sarma ◽  
Perry Cooper
Keyword(s):  
Spinal Cord ◽  
Nerve Root ◽  
Signs And Symptoms ◽  
Root Avulsion ◽  
Thoracic Spinal Cord ◽  
First Case ◽  
Thoracic Spinal ◽  
Spinal Cord Herniation ◽  
Nerve Root Avulsion ◽  
Upper Thoracic

✓ Transdural herniation of the spinal cord, a rare but well-documented entity, has been reported sporadically for more than 25 years as a possible cause for various neurological signs and symptoms ranging from isolated sensory or motor findings to myelopathy and Brown–Séquard syndrome. The authors report, to the best of their knowledge, the first case of upper thoracic spinal cord herniation occurring after traumatic nerve root avulsion.

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