The value of preoperative examination and MRI for the diagnosis of graftable roots in total brachial plexus palsy

Echalier, C.; Teboul, F.; Dubois, Elodie; Chevrier, B.; Soumagne, Thibaud; Goubier, J.-N.

doi:10.1016/j.hansur.2019.06.001

Cited by 10 publications

(9 citation statements)

References 19 publications

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“…7,8 Here, in our patients with total paralysis, the rate of C5 root availability was lower (70%). In such patients, Millesi observed a 73% rate of root availability for grafting, 21 whereas corresponding rates were 63% for Echalier et al 13 and just 50% for Addosooki et al 18 We observed C6 root availability for grafting in 35% of our total paralysis group, similar to pre- vious reports of 40% and 44%. 1,7 Echalier et al identified a viable C6 root in only 26% of their patients.…”

Section: Discussionsupporting

confidence: 83%

“…7 Echalier et al estimated a PPV of 100% for the C5 protraction test and 89% for Tinel's sign. 13 Their 94% PPV for MRI was higher than ours, probably because, unlike in our series, all of their MRI studies were performed at a single institution. 13 A positive C6 protraction test predicted a preserved root with 84% accuracy, and this percentage rose to 91% if a positive Tinel's sign was also present and to 93% if congruent MRI findings were added as well.…”

Section: Discussioncontrasting

confidence: 61%

“…13 Their 94% PPV for MRI was higher than ours, probably because, unlike in our series, all of their MRI studies were performed at a single institution. 13 A positive C6 protraction test predicted a preserved root with 84% accuracy, and this percentage rose to 91% if a positive Tinel's sign was also present and to 93% if congruent MRI findings were added as well. Conversely, a negative C6 protraction test was associated with only a 17% rate of C6 root graft eligibility, which fell to 13% and 7% if either Tinel's sign was negative or both Tinel's test and MRI findings were negative too, respectively.…”

Section: Discussioncontrasting

confidence: 61%

“…1,7 Echalier et al identified a viable C6 root in only 26% of their patients. 13 We identified a lower rate (58%) of C5 root graft eligibility in C5-8 root injury patients but a similar rate of 42% for both roots being preserved, as with total paralysis. The major limitation of our study is the absence of any prolonged follow-up of muscle functional recovery, which could have further validated our choice of gold standard.…”

Section: Discussionmentioning

confidence: 81%

“…Intraoperative motor and sensory evoked potentials to rule root avulsion in or out also have not been shown to produce reliable results, leading to poor acceptance among brachial plexus surgeons. 13,18 We chose a pretest probability of 85% for C5 graft eligibility because it is the percentage reported for the largest series published on root preservation. 7,8 Here, in our patients with total paralysis, the rate of C5 root availability was lower (70%).…”

Section: Discussionmentioning

confidence: 99%

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Two clinical tests assessing long thoracic nerve function to determine C5 and C6 root graft eligibility in patients with brachial plexus injury

Bertelli

Gasparelo

Seltser

2022

Journal of Neurosurgery

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OBJECTIVE Identifying roots available for grafting is of paramount importance prior to reconstructing complex injuries involving the brachial plexus. This is traditionally achieved by combining input from both clinical examinations and imaging studies. In this paper, the authors describe and evaluate two new clinical tests to study long thoracic nerve function and, consequently, to predict the status of the C5 and C6 roots after global brachial plexus injuries. METHODS From March 2020 to December 2020, in 41 patients undergoing brachial plexus repair, preoperative clinical assessments were performed using modified C5 and C6 protraction tests, C5 and C6 Tinel’s signs, and MRI findings to predict whether graft-eligible C5 and C6 roots would be identified intraoperatively. Findings from these three assessments were then combined in a logistic regression model to predict graft eligibility, with overall predictive accuracies calculated as areas under receiver operating characteristic curves. RESULTS In the 41 patients, the pretest probability of C5 root availability for grafting was 85% but increased to 92% with a positive C5 protraction test and to 100% when that finding was combined with a positive C5 Tinel’s sign and favorable MRI findings. The pretest probability of C6 root availability was 40%, which increased to 84% after a positive C6 protraction test and to 93% when the protraction test result concurred with Tinel’s test and MRI findings. CONCLUSIONS Combining observations of the protraction tests with Tinel’s sign and MRI findings accurately predicts C5 and C6 root graft eligibility.

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