Differential Diagnosis between Pre- and Postganglionic Adult Traumatic Brachial Plexus Lesions by Ultrasonography

doi:10.1016/j.ultrasmedbio.2011.04.015

Ultrasound in Medicine & Biology

Volume 37, Issue 8, August 2011, Pages 1196-1203

https://doi.org/10.1016/j.ultrasmedbio.2011.04.015 Get rights and content

Abstract

The goal of this study was to prospectively investigate the feasibility of preoperative ultrasonography evaluation in the differentiation between pre- and postganglionic traumatic brachial plexus lesions. Two expert radiologists employed ultrasonography to observe the morphology of the brachial plexus in 23 patients with suspected traumatic brachial plexus lesions and 40 healthy volunteers. The detection rate was 100% (126/126) for the C5 through C7 nerve roots and upper and middle trunks and three fascicles, 84% (106/126) for the C8 roots and the lower trunks and 64% (81/126) for T1 roots in all subjects. Surgical inspections found 58 lesions in 23 patients (40 preganglionic lesions and 18 postganglionic lesions). Ultrasonography detected most of the brachial plexus lesions (56/58) but misjudged two preganglionic and two postganglionic lesions. The rate of differentiation was 93% (52/56). This study demonstrated that ultrasonography is a useful but experience-dependent supplemental imaging technique for preoperative diagnosis of brachial plexus lesions and differentiation between pre- and postganglionic brachial plexus lesions.

Introduction

The number of adult patients with brachial plexus injuries has increased in China in recent years. Brachial plexus injuries are usually caused by tractions or stretching that separates the arm from the shoulder and can be divided into two major categories: pre- and postganglionic brachial plexus injuries. Preganglionic lesions, or intraspinal nerve root avulsions, represent avulsions of nerve roots from the spinal cord (Fig. 1), which cannot be repaired directly and can only be treated with nerve transfers (neurolization). Postganglionic lesions are reparable and represent lesions distal to the dorsal ganglions (Fig. 1), including lesions of spinal nerves, trunks, fascicles and branches. It is important to distinguish preganglionic brachial plexus lesions from postganglionic lesions because surgical treatment differs and only accurate classification allows proper treatment (Midha, 1997, Penkert et al., 1999, Dubuisson and Kline, 2002, Chuang, 2008, Chuang, 2009). Although MRI (magnetic resonance imaging) or CT (computed tomography) myelography had been used, differentiation between pre- and postganglionic lesions remains critical (Midha, 1997, Penkert et al., 1999, van Es, 2001, Amrami and Port, 2005, van Es et al., 2010). Therapeutic decisions are presently based on a combination of clinical history, physical examination, neurologic tests and imaging tests. With the development of advanced ultrasound techniques, ultrasonography has already been used to determine the site, extent and severity of brachial plexus lesions (Apan et al., 2001, Retzl et al., 2001, Martinoli et al., 2002, Shafighi et al., 2003, Graif et al., 2004, Gruber et al., 2007). This study investigated the feasibility of differentiation between pre- and postganglionic brachial plexus lesions by preoperative ultrasonography.

Section snippets

Patients

Forty (36 males and four females) healthy adult volunteers (21 to 49, 35 ± 6 years) were recruited to assess the feasibility of ultrasonography to depict brachial plexus elements and observe normal brachial plexus ultrasonographic texture. Twenty-three consecutive patients with clinical evidence (including history review, neurologic examination and functional testing) of brachial plexus traumatic injuries participated in this study, including 21 males and two females, with an average age of 36

Ultrasonographic detection rate and normal manifestations of brachial plexus

C5, C6 and C7, the upper and middle trunks, and three fascicles of the brachial plexus and major braches were satisfactorily visualized in all patients and normal control subjects (126/126, 100%). The C8 roots and the lower trunks were satisfactorily visualized in 106 subjects (37/46 in patients and 69/80 in normal control subjects), such that the detection rate was 84%. The T1 roots were satisfactorily visualized in 81 subjects (29/46 in patients and 52/80 in normal control subjects) and the

Discussion

CT myelography and MRI have been proven to be useful in diagnosing brachial plexus injuries. Specifically, intraspinal alterations of root avulsions can be detected by CT myelography and MRI (Miller et al., 1993, Narakas, 1993, Hems et al., 1999, Amrami and Port, 2005, van Ouwerkerk et al., 2005, Yoshikawa et al., 2006, Sureka et al., 2009, van Es et al., 2010). However, insufficient coverage of the entire cervico-thoracic region and high radiation exposure limit the use of CT. MRI is currently

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Will preoperative combined MRI and high-resolution ultrasonography redefine brachial plexus imaging? A comparative study of preoperative MRI versus combined MRI and high-resolution ultrasonography in assessing usable C5, C6 root-stumps for intra-plexal nerve grafting
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To compare the intraoperative findings with the preoperative imaging in detecting usable root stumps using magnetic resonance imaging (MRI) alone versus MRI combined with high-resolution ultrasonography (HRUS) in adults undergoing post-traumatic brachial plexus (BP) surgery. Further, when root stumps were present, the reliability of their measurements using both imaging methods was compared to their intraoperative length.
A consecutive group of adults who were planned for post-traumatic BP surgery between July 2015 and April 2016 were evaluated prospectively. They underwent preoperative MRI and HRUS and the agreement (kappa value) between these imaging methods and their intraoperative findings in categorising roots were then compared. When stumps were present, the reliability of the extraforaminal measurements by each method were compared to their corresponding intraoperative stump length using intraclass correlation coefficients (ICC), and Bland–Altman plots.
Of the initial 60 patients, 48 patients with 82 roots were included in the study. Greater agreement was observed between HRUS and intraoperative findings in categorising BP root stumps (kappa value 0.70, SE 0.07) versus MRI and intraoperative findings (kappa value 0.42, SE 0.07). Similarly, there was a higher correlation between HRUS and intraoperative findings (ICC: 0.94, p<0.001) than that of MRI and intraoperative findings (ICC: 0.53, p<0.001) regarding stump length measurements.
Combining HRUS with MRI in the preoperative imaging of the adult BP injury can better predict the presence of usable nerve root stumps for intra-plexal nerve grafting. HRUS also gave reliable preoperative stump length measurements, and it was determined that a stump should be at least 1.3 cm to be deemed usable for nerve grafting.
Diagnostic Ability of Ultrasonography in Brachial Plexus Root Injury at Different Stages Post-trauma
2022, Ultrasound in Medicine and Biology
Citation Excerpt :
A previous study indicated that the detection of BP nerve roots was 100% for C5–C7, 84% for C8 and 64% for T1 (Chen et al. 2011), which is consistent with our findings that detection rates decrease as nerve depth increases. This is also why some C8 and T1 injuries can be missed with ultrasound because of poor visualization (Haber et al. 2006; Chen et al. 2011; Zhu et al. 2014). Considering the anatomic location, injury type and severity, ultrasound had an overall sensitivity of 87% (95% CI: 78%–94%) for identifying major lesions in a study by Chin et al. (2018) and 67% (95% CI: 64%–91%) in the study by Tagliafico et al. (2013).
Brachial plexus (BP) root injury often results in disability of the upper extremities. Improvements in high-frequency ultrasonography have enabled the visualization of BP nerve roots. This study was aimed at quantifying the diagnostic accuracy of ultrasonography in BP root injury at different stages post-trauma. A consecutive series of 170 patients with BP root injury between 2015 and 2019 were studied retrospectively and divided into three groups on the basis of time between injury and ultrasound examination (≤1 mo, 1–3 mo, >3 mo). Diagnosis of complete BP root injury under ultrasound was determined using a pre-defined criterion, including pseudomeningocele, retraction and rupture. Diagnostic accuracy was calculated based on surgical findings and intra-operative electrophysiological tests. Rates of detection of the cervical (C5–C8) and thoracic (T1) nerve roots under ultrasound were 99.4%, 99.4%, 99.4%, 95.9% and 79.4%, respectively. The sensitivity for complete BP root injury was 0.74, and the specificity was 0.91. No significant differences in sensitivity or specificity were observed across time stages. Ultrasound exhibited substantial consistency with surgical findings (κ = 0.70) for complete BP root injury at any stage post-injury. Ultrasound can be an optional method of diagnosis of complete BP root injury at an early stage post-injury.
A prospective study of high resolution ultrasound in brachial plexopathies – Correlation with electrophysiological measurements
2019, Clinical Neurophysiology
To evaluate the diagnostic role of ultrasound in brachial plexopathies.
We included 59 healthy subjects (HS) and 42 patients consecutively referred with clinical suspicion of brachial plexopathy from October 2015 to May 2016. Patients underwent routine electrodiagnostic testing (EDx) as reference standard and a blinded standardised ultrasound examination of the brachial plexus as index test with cross-sectional area (CSA) as the ultrasound parameter of choice.
Seventeen patients were diagnosed by EDx with brachial plexopathy, ten with mononeuropathies, and ten had normal EDx. Five had a cervical radiculopathy. In 11 (64%) out of the 17 patients with EDx diagnosed plexopathy, we found at least one abnormal level on ultrasound. Six (60%) out of ten normal EDx patients had a normal ultrasound examination at all levels. Ultrasound identified the same abnormal level(s) as EDx in eight (73%) of the 11 patients who had both abnormal EDx and ultrasound results. Mean CSA was higher in the plexopathy group compared to HS at the level of the C6 root (p = .022), the middle trunk (p = .027), and the medial cord (p = .003).
Ultrasound examination showed abnormalities in patients with brachial plexopathies in good agreement with EDx.
Ultrasound may be an important supplement to electrodiagnostics in evaluating brachial plexopathies.
High-resolution ultrasonography for the diagnosis of brachial plexus root lesions
2014, Ultrasound in Medicine and Biology
Citation Excerpt :
The oblique coronal and transverse sections are the ultrasonographic planes most often used to observe the normal anatomy and abnormalities of BP roots (Haber et al. 2006). On these planes, BP roots are displayed in longitudinal views, which delineate the anatomy by showing the root exiting intervertebral foramina and running between the anterior and posterior tubercles of the transverse processes as tubular structures with hyper-echoic walls and thin, linear parallels within the hypo-echoic matrix (Chen et al. 2011). After exiting the intervertebral foramina, nerve roots become smaller.
The aim of this study was to investigate the feasibility of using high-resolution ultrasonography in the diagnosis of brachial plexus (BP) root lesions. A prospective study of ultrasonographic evaluation of BP nerve roots was performed in 37 patients with BP root lesions (29 with root injuries, 8 with tumors). The pre-operative ultrasonographic findings were compared with the surgical and pathohistological findings. All C5–7 roots were detected by ultrasonography in all patients, whereas 92% (68/74) of C8 and 51% (38/74) of T1 nerve roots were visualized. Among 29 patients with BP root avulsion, partial injuries or totally interrupted BP roots were detected in all patients. Cystic masses and neuromas were detected in 16 and 23 patients, respectively. In 8 patients with BP root tumors, 8 hypo-echoic masses were detected inside or partly outside of intervertebral foramina connecting to nerve roots. Surgical exploration revealed that there were 57 BP root avulsions in 29 patients. However, 2 T1 nerve root avulsions had been missed by pre-operative ultrasonography. Pathohistology revealed that all 8 BP root tumors pre-operatively diagnosed by ultrasonography were schwannomas. High-resolution ultrasonography can provide a convenient and accurate imaging modality for quick diagnosis and location of BP root lesions.
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Ultrasound Evaluation of Peripheral Nerves and Focal Neuropathies: Correlation With Electrodiagnosis, Second Edition
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Original ContributionDifferential Diagnosis between Pre- and Postganglionic Adult Traumatic Brachial Plexus Lesions by Ultrasonography

Abstract

Introduction

Section snippets

Patients

Ultrasonographic detection rate and normal manifestations of brachial plexus

Discussion

Hand Clin

Eur J Ultrasound

J Hand Surg Br

Clin Radiol

Eur J Radiol

Brachial plexus reconstruction based on the new definition of level of injury

Injury

Adult brachial plexus reconstruction with the level of injury: Review and personal experience

Plast Reconstr Surg

Sonographic mapping of the normal brachial plexus

AJNR Am J Neuroradiol

Brachial plexus injury: A survey of 100 consecutive cases from a single service

Neurosurgery

Sonographic evaluation of brachial plexus pathology

Eur Radiol

High-resolution ultrasound of the supraclavicular brachial plexus–Can it improve therapeutic decisions in patients with plexus trauma?

Eur Radiol

Sonography of brachial plexus traction injuries

AJR Am J Roentgenol

Ultrasonographic features of brachial plexus traumatic rupture. Case illustration

J Neurosurg

Original Contribution
Differential Diagnosis between Pre- and Postganglionic Adult Traumatic Brachial Plexus Lesions by Ultrasonography