Brachial plexus injuries can occur from various causes like trauma, tumors, or obstetrical injuries. Electrodiagnostic evaluation is important for localization. Needle EMG can show abnormal spontaneous activity and decreased recruitment in a pattern corresponding to the plexus anatomy. Nerve conduction studies focus on amplitude changes, with lower amplitudes localizing to more proximal sites. Together, EMG and NCS provide information to distinguish preganglionic from postganglionic injuries and localize the level of involvement.
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Electrodiagnostic Evaluation of Brachial Plexus Injuries
Brachial plexus injuries can occur from various causes like trauma, tumors, or obstetrical injuries. Electrodiagnostic evaluation is important for localization. Needle EMG can show abnormal spontaneous activity and decreased recruitment in a pattern corresponding to the plexus anatomy. Nerve conduction studies focus on amplitude changes, with lower amplitudes localizing to more proximal sites. Together, EMG and NCS provide information to distinguish preganglionic from postganglionic injuries and localize the level of involvement.
Brachial plexus injuries can occur from various causes like trauma, tumors, or obstetrical injuries. Electrodiagnostic evaluation is important for localization. Needle EMG can show abnormal spontaneous activity and decreased recruitment in a pattern corresponding to the plexus anatomy. Nerve conduction studies focus on amplitude changes, with lower amplitudes localizing to more proximal sites. Together, EMG and NCS provide information to distinguish preganglionic from postganglionic injuries and localize the level of involvement.
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Electrodiagnostic Evaluation of Brachial Plexus Injuries
Brachial plexus injuries can occur from various causes like trauma, tumors, or obstetrical injuries. Electrodiagnostic evaluation is important for localization. Needle EMG can show abnormal spontaneous activity and decreased recruitment in a pattern corresponding to the plexus anatomy. Nerve conduction studies focus on amplitude changes, with lower amplitudes localizing to more proximal sites. Together, EMG and NCS provide information to distinguish preganglionic from postganglionic injuries and localize the level of involvement.
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Electrodiagnostic Evaluation of Brachial Plexus Injuries
William McKinley MD Associate Professor PM&R Virginia Commonwealth University
Incidence 10% of all peripheral nervous system injuries 14% of UE neurological injuries Bimodal distribution:
Obstetrical: male = female, R > L Ages 20-30, males (MVA, violence)
BP lesion localization Know clinical ANATOMY!!!
Root/trunk/division/cord/branch (RTDCB) Motor/sensory innervation NCS & needle EMG Consider less common motor/sensory NCS
Comprehensive Edx eval
BP Anatomy Anterior (ventral) rami C5-T1 R/T/D/C/B (5-3-6-3-5) Palindrome BP extends from vert column to axilla clavicle separates R/T from C/B
less common (radial, MC, Axillary, SS) proximal NCS (C5-6, Erbs point) (technically possible, difficult, uncomfortable)
Needle EMG (recruitment, abnl spont pots) Late-responses (H-reflex, F wave)- may be abnormal but ? less useful
Motor/Sensory NCS Distal latency & NCV are not helpful Amplitude is key parameter
remains NL(on distal stim) if no axonal loss (cond block, demyelination) or with preganglionic BPI (SNAP NL) look for decreased side-side > 50% motor day 4-7 (NMJ fragmentation) sensory day 8-10
Localizing NCS involement
Terminal branches of Brachial Plexus
Median, Ulnar, Radial, Axillary, MC sensory & motor
travel to and from the CNS thru the various roots, trunks, divisions & cords in a fairly consistent pattern
Sensory NCS Localization
Nerve Musculocut. Median (1) Median (2-3) Radial Ulnar Cord Lateral Lateral Lateral Posterior Medial Trunk Upper Upper Middle Upper Lower
Motor NCS Localization
Nerve Musculocutan Axillary Suprascapular Radial Median Ulnar
Cord lateral posterior --posterior medial medial
Trunk upper upper upper middle low lower
Needle EMG Abnormal spontaneous potentials
positive sharp waves, fibrillations 7-10 days (paraspinal), 2-4 weeks (distal ms) Important: follow pattern of BP innervation
Paraspinal Ms WNL! (distal to Post rami) Decreased recruitment (voluntary MUAP)
Adjunctive tests Xrays (C-spine, clavicle, humerus, 1st rib) Myelography - w/i 2-3 weeks, nerve root avulsion forms diverticulum c/w SA space MRI (>CT)
Somatosensory Evoked Potential (SSEP)
Supraclav. Fossa / Erbs pt. (N9) / cervical spine (N13) / contra somatosensory cortex (N19) sensory fibers / post column / thalamus Considerations (less than ideal agreement)
To evaluate pre vs post ganglionic lesion 1% SQ histamine normally leads to a vasodilation, wheal & flare due to reflex between DRG & cutaneous receptors
Triple response in light of clinical picture c/w BPI = lesion proximal to DRG (ie: preganglionic root avulsion & poor prognosis) Loss of flare = postganglionic (better prognosis)
Case Study Hx: MVC Clinical exam: Prox UE wk (Sh Fl/Abd, EF), numbness lateral arm/forearm/hand What NCS & needle exam abnormalities will assist in localizing the site of injury?
