MR Imaging Brachial Plexus Abbot

VOL 18, 2004 MRI OF INFANTS WITH OBSTETRICAL BRACHIAL INJURIES 1
MRI IMAGING OF THE BRACHIAL PLEXUS IN CHILDREN WITH BRACHIAL

PLEXUS INJURIES
Rick Abbott
INN, Beth Israel Medical Center
INTRODUCTION
Increasing over the past decade pediatric neurosur-

geons are being asked to evaluate infants who have sus-
tained an injury to their brachial. This injury occurs to 0.3
to 3.6 infants for every 1,000 live births1-6. While most such
injuries spontaneously resolve with minimal functional
disabilities, about 10% will have a signicant impairment
in function due to an incomplete recovery.
This is predicted when an infant does not regained
antigravity strength in the shoulder musculature and upper
arm exors. In particular, concern is raised when the infant
cannot lift their hand to their mouth by 5 months of age.
These are markers which have been used to select infants
for surgical exploration of the plexus.
DIAGNOSIS
Naturally, diagnostic studies should be done prior to

surgery. In addition to electromyography and nerve con-
duction studies (EMG/NCS), imaging studies are desirable.
A decade ago CT myelography was the imaging study of
choice. (Fig 1A and 1B)3.
It was felt that this test was superior to MRI in demons-
trating avulsed nerve roots and pseudomeningoceles. As
the resolution of MRI has improved this can no longer
be claimed. We recently reviewed our experience with
the imaging of 15 infants referred to us for treatment
of their obstetrical brachial plexus injury7. We were able
to visualize evidence of either scar tissue or a reparative
neuroma within the plexus in 14 of 15 patients. 11 of 15
had a shoulder subluxation including the one infant who
had an otherwise normal scan of the plexus. Only 7 had
a pseudomeningocele, the marker of injury to the plexus
used when analyzing a CT myelogram and in every one
of these cases we were able to see on the MRI either scar
tissue or a reparative neuroma involving the plexus.
DISCUSSION Fig. 1. A. Black arrow points to pseudomeningocele seen as out-

pocketing of cerebrospinal uid column visualized with standard
myelogram. B. CAT scan myelogram with arrow showing out-ppoc-
Correspondencia: 170 East End Ave., New York, NY 10128, USA keting of dye column due to a pseudomeningocele.
2 R. ABBOTT REV. ARGENT. NEUROC.
Doi et al compared their success rate in identifying injury

to the brachial plexus when using CT myelography vs. MRI.
They found a success rate of 97% using overlapping or fast
spin-echo MR imaging (paralleling our experience), while
myelography had a success rate of 100%8. They could nd
no statistically signicant dierence using the two techni-
ques.
In another report of using fast spin-echo MRI to analyze
three infants with obstetrical brachial plexus injuries there
was success in visualizing pseudomeningoceles, leading to
a diagnosis of nerve root avulsion1. These studies reect an
early experience in interpreting MR imagery of obstetrical
brachial plexus injury, focusing on whether or not there is Fig. 2. Arrow points to a pseudomeningocele which appears as
an out-pocketing of the cerebrospinal uid column.
evidence of nerve root avulsion. As experience is gained,
analysis of the images will move out into the plexus seeking
to describe injuries to the plexus as opposed to the roots
supplying it. This will be a powerful tool for the surgeon
when discussing expectations of outcome with the infants
parents.
To obtain good resolution we require that all infants
have their scan performed while under a general anesthesia.
Scans should be done on a high strength, closed magnet (1.5
tesla). We have found T1 axial and coronal images and T2
axial, coronal and sagittal to be the most useful in analyzing
the plexus. The scan should include the spinal canal looking
for pseudomeningoceles, the plexus looking for evidence of
scarring or a reparative neuroma and the shoulder looking
for evidence of subluxation. In infants both shoulders can
be imaged on axial exam to allow for comparison.
When analyzing MRIs of the brachial plexus attention is
rst focused on the spines foramina looking for evidence Fig. 3. Arrow points to plexus elements invested in scar tissue
of a nerve root avulsion. It will show as a lateral expansion as they exit from between the scalene muscles (the spherical
structures just medial with dark gray appearance. Note to relative
of the CSF column projecting out into the foramen of the
rectangular shape to the plexus elements in distinction to the
involved nerve root (Fig. 2). Next the scalene muscles are globular enlargement seen with large reparative neuromas.
located and the plexus elements inspected as they bisect
these muscle to then run along their lateral border. Subtle
scarring (Fig. 3) can easily be dierentiated from a large
reparative neuroma (Fig. 4). Unfortunately, there is a large
gray zone in imaging injured plexuses that encompasses
the majority of cases of scarring and reparative neuroma
making dierentiating the two impossible at present.
What may become possible as our experience increases
is the ability to identify preoperatively which cases will
require neuroma resection and grafting. This would be
useful both for counseling parents and speeding the time
to the operating room. Finally, the shoulder is inspected
for evidence of subluxation. This is useful in preparing the
parents for the likelihood of future surgeries which will be
needed.
CONCLUSION Fig. 4. The arrow points to a large, globular neuromajust lateral

to scalene muscle which are two spherical structures with darker
Increasingly we are nding the MRI an indispensable tool rim.
VOL 18, 2004 MRI OF INFANTS WITH OBSTETRICAL BRACHIAL INJURIES 3
in assessing injuries to the brachial plexus. It has completely Childs Nerv Syst
replaced CT myelography for evaluating infants with injuries 8. Doi K, Otsuka K, Okamoto Y, et al. Cervical nerve root
to their brachial plexuses and as our knowledge increases avulsion in brachial plexus injuries: magnetic resonance
imaging classication and comparison with myelography
it is providing us with more and more information.
and computerized tomography myelography. J Neurosurg
2002; 96: 277-84
References
1. Francel PC, Koby M, Park TS, et al. Fast spin-echo magnetic

resonance imaging for radiological assessment of neonatal
brachial plexus injury. J Neurosurg 1995; 83: 461-6
2. Laurent JP, Lee R, Shenaq S, et al. Neurosurgical correction
of upper brachial plexus birth injuries. J Neurosurg 1993;
79: 197-203
3. Laurent JP, Lee RT. Birth-related upper brachial plexus injuries
in infants: operative and nonoperative approaches. J Child
Neurol 1994; 9: 111-7
4. Laurent J. 2001. Brachial plexus injury. In Pediatric Neuro-
surgery. Surgery of the Developing Nervous System, ed. M
DG, . Philadelphia: WB Saunders, 2001, pp. 953-60
5. Piatt JH, Jr. 1991. Neurosurgical management of birth injuries
of the brachial plexus. Neurosurg Clin N Am 1991; 2: 175-
85
6. Sjoberg I, Erichs K, Bjerre I. Cause and eect of obstetric
(neonatal) brachial plexus palsy. Acta Paediatr Scand 1988;
77: 357-64
7. Abbott R, Abbott M, Alzate J, Lefton D. In Press. Magnetic
resonance imaging of obstetrical brachial plexus injuries.

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VOL 18, 2004 MRI OF INFANTS WITH OBSTETRICAL BRACHIAL INJURIES 1

MRI IMAGING OF THE BRACHIAL PLEXUS IN CHILDREN WITH BRACHIAL

INN, Beth Israel Medical Center

Increasing over the past decade pediatric neurosur-

Naturally, diagnostic studies should be done prior to

DISCUSSION Fig. 1. A. Black arrow points to pseudomeningocele seen as out-

Doi et al compared their success rate in identifying injury

CONCLUSION Fig. 4. The arrow points to a large, globular neuromajust lateral

1. Francel PC, Koby M, Park TS, et al. Fast spin-echo magnetic

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