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

Clinical Predictors of C5 Spinal Nerve Viability in Pan-Brachial Plexus Injuries

BACKGROUND

In pan-brachial plexus injury, distinguishing between preganglionic and postganglionic injuries is crucial to reconstructive planning. This study aimed to identify preoperative factors that would accurately predict a reconstructible C5 spinal nerve.

METHODS

Patients with pan-brachial plexus injury from a single institution between 2001 and 2018 were reviewed. Patient demographics, clinical examination, diagnostic imaging, and electrodiagnostic results were recorded. C5 viability was determined based on supraclavicular exploration and intraoperative electrophysiologic testing. Univariate analysis identified significant factors for regression analysis. A multivariable parsimonious model was created using stepwise high-performance logistic regression.

RESULTS

A total of 311 patients (mean age, 29.9 years; 46 women and 265 men; mean Injury Severity Score, 17.2) were included. A total of 134 patients (43%) had a viable C5 nerve, and 50 patients (12%) had a viable C6 nerve. Intact C5 spinal nerve on computed tomographic (CT) myelogram (OR, 5.4), positive Tinel test (OR, 2.6), muscle strength greater than or equal to 4 (according to the modified British Medical Research Council scale) for the rhomboid (OR, 1.3) or greater than or equal to 4 for the serratus anterior (OR, 1.4), and rhomboid needle electromyography (OR, 1.8) were predictive of having a viable C5 spinal nerve. The multivariable parsimonious stepwise model (area under the curve, 0.77) included four factors: positive Tinel test, intact C5 spinal nerve on CT myelogram, hemidiaphragmatic elevation, and midcervical paraspinal fibrillations.

CONCLUSIONS

In this cohort of pan-brachial plexus patients with major polytrauma, there was a 43% incidence of viable C5 spinal nerve. A positive Tinel test (OR, 2.1) and intact C5 spinal nerve on CT myelogram (OR, 4.9) predicted a viable C5 nerve. In contrast, hemidiaphragmatic elevation (OR, 3.1) and midcervical paraspinal fibrillations (OR, 2.92) predicted root avulsion.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Traumatic brachial plexus injury: diagnosis and treatment

PURPOSE OF THE REVIEW

Traumatic brachial plexus injuries (BPI) are devastating life-altering events, with pervasive detrimental effects on a patient's physical, psychosocial, mental, and financial well-being. This review provides an understanding of the clinical evaluation, surgical indications, and available reconstructive options to allow for the best possible functional outcomes for patients with BPI.

RECENT FINDINGS

The successful management of patients with BPI requires a multidisciplinary team approach including peripheral nerve surgeons, neurology, hand therapy, physical therapy, pain management, social work, and mental health. The initial diagnosis includes a detailed history, comprehensive physical examination, and critical review of imaging and electrodiagnostic studies. Surgical reconstruction depends on the timing of presentation and specific injury pattern. A full spectrum of techniques including neurolysis, nerve grafting, nerve transfers, free functional muscle transfers, tendon transfers, and joint arthrodesis are utilized.

SUMMARY

Despite the devastating nature of BPI injuries, comprehensive care within a multidisciplinary team, open and practical discussions with patients about realistic expectations, and thoughtful reconstructive planning can provide patients with meaningful recovery.