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.

The Diagnostic Value of CT Myelography, MR Myelography, and Both in Neonatal Brachial Plexus Palsy

“…The findings and predictive values of CT myelography compared with MR myelography were almost the same and were consistent with those previously reported in the literature. 12,[14][15][16]18,19 Other nerve root findings in the absence of pseudomeningocele were also analyzed (absent rootlets, thinned rootlets, and thickened rootlets). These findings did not improve the predictive values for CT, MR imaging, or both CT and MR myelography (Table 4).…”

“…12,[14][15][16][17][18][19] A pseudomeningocele is suggestive of nerve root avulsion, and the additional finding of absent rootlets traversing the pseudomeningocele greatly increases the specificity of this finding. 14 CT myelography requires a lumbar puncture for injection of intrathecal contrast, with attendant risks of infection and seizure.…”

“…Similar to authors of other studies, we report predictive values by using sensitivity, specificity, and predictive values [14][15][16]18,19,[35][36][37] ; and we used clinical examination and/or findings on extradural surgical exploration as our reference standard for the detection of root avulsions. [14][15][16]18,19,35,37,45 Hemilaminectomy and opening of the dura mater would provide a more accurate reference standard and have been used to assess CT, 13,27 MR imaging, 32 and both CT and MR imaging 46 findings in adults.…”

“…[14][15][16]18,19,35,37,45 Hemilaminectomy and opening of the dura mater would provide a more accurate reference standard and have been used to assess CT, 13,27 MR imaging, 32 and both CT and MR imaging 46 findings in adults. However, the procedure involves significant morbidity and is not performed in infants for neonatal brachial plexus palsy reconstruction.…”

Clinical anatomy and clinical significance of the cervical intervertebral foramen: a review

“…Only the fourth, fifth, and sixth cervical spinal nerves have a strong attachment to the vertebral column, and this is to the gutter of the vertebral transverse process [13,46,49].…”