Presentation on theme: "The Brachial Plexus – anatomy, lesions and neurophysiology studies"— Presentation transcript:
1The Brachial Plexus – anatomy, lesions and neurophysiology studies Jim Lewis, R.NCS.T., CNCT
2Nerves that originate above or very high in the brachial plexus Spinal Accessory (CN XI)Phrenic (C3-C5)Dorsal Scapular (C5)Suprascapular (C5-C6)Long Thoracic (C5-C7)
3Brachial PlexusThe brachial plexus is an arrangement of nerve fibers (a plexus) running from the spine (vertebrae C5-T1), through the neck, the axilla (armpit region), and into the arm.There are 5 groups of nerve fiber interconnections, roots, trunks, divisions, cords, and branches (or nerves).
4TrunksThe 5 roots of the brachial plexus lie deep to below the sternocleidomastiod muscle.These roots unite to form the trunks.The upper trunk is formed by the C5 and C6 nerve roots.The middle trunk has just one nerve root, C7. The so- called axis of symmetry.The lower trunk is formed by the C8 and T1 roots.
5Divisions The trunks divide into The anterior division and The posterior divisionThese generally indicate if their nerve fibers serve the front (anterior division) or back (posterior division) of the limb.
6CordsThe divisions pass deep to the clavicle and enter the axilla, where they give rise to three large nerve bundlesThe Cordslateral, medial and posteriorAll along the brachial plexus small nerves branch off.
7Branches or NervesThe brachial plexus ends within the axilla where the three cords separate into the 5 important nerves of the upper limb;musculocutaneous,axillary,radial,median andulnar
9The DeMyer Method The 5-3-3-5 method Simple Quick Draw it right in the procedure room while performing the NCSCovers 80% of what we need
105335RootsTrunksCordsBranches/NervesC51. Write 5 – 3 – 3 – 5 across the top of the page and label as shownC62. Write C5 – T1 across theleft side of the pageC7C7 – Middle Trunk – Posterior cord = axis of symmetryC8T13. Draw an arrow head connecting C5 and C6, then do the same for C8 and T1.Draw straight lines from the tip of these two arrowheads and from C7, across the page, as shown
115335RootsTrunksCordsBranches/Nerves4. Label these three trunksUpper, Middle and Lower as shownC5UpperC65. Draw an arrow head connecting the upper and lower trunks to the middle, as shown.MiddleC7C8LowerT1
125335RootsTrunksCordsBranches/NervesC5UpperLateral6. Label these three cords Lateral, Posterior and Medial as shownC6MiddlePosteriorC7C8LowerMedialT17. Draw an arrow head connecting between the posterior and the medial cord (median nerve). Extend the end as shown.
135335RootsTrunksCordsBranches/NervesC5UpperLateralC6MiddlePosteriorC7C8LowerMedial8. Draw a connector (median nerve fibers) from the Middle trunk to the lateral cord, as shownT19. Draw an connector off the posterior cord (axillary nerve) , as shown
145335RootsTrunksCordsBranches/NervesC5UpperLateralMusculocutaneousC6AxillaryRadialMiddlePosteriorC7MedianC8LowerMedialUlnarT110. Label the 5 nerves, as shown
15The Upper Trunk The upper trunk is formed by the C5-C6 nerve roots. The upper trunk divides:The anterior division proceeds to the lateral cordThe posterior division proceeds to the posterior cord
16The Anterior Division of the Upper trunk The anterior division proceeds to the lateral cord and finally, theOuter branch of the median nerveBoth motor and sensory fibers. The motor fibers innervate the pronator teres and flexor carpi radialis (with fibers from C7, middle trunk) while the sensory fibers continue to the lateral portion of the hand, andMusculocutaneous nerveBoth motor and sensory fibers. Motor fibers innervate the biceps, coracobrachialis, and brachialis muscles. The sensory branch, called the lateral antebrachial cutaneous nerve supplies the skin over the lateral aspect of the forearm
17The Posterior Division of the Upper trunk The posterior division proceeds to the posterior cord and branches to the:Axillary nerveBoth motor and sensory fibers. Motor fibers innervate the deltoid muscle while sensory fibers innervate sensation over the deltoid region, andRadial nerveBoth motor and sensory fibers. Motor fibers innervate the brachioradialis and extensor carpi radialis (longus and brevis) with some contributions to the triceps and supinator. Sensory fibers continue to the lateral dorsum of the hand.Also exiting high in the upper trunk is the suprascapular nerveA motor nerve innervating the supraspinatus and infraspinatus muscles in the scapular region.
18The Middle Trunk The middle trunk is formed entirely from the C7 root. Sometimes called the “Axis of Symmetry,” because C7 runs directly into its cord while C5-C6 unites into the upper trunk and C8-T1 unites into the lower trunk.The posterior division goes directly to the posterior cordThe anterior division carrying median sensory fibers proceeds to the lateral cord
19The Posterior Division of the Middle trunk The posterior division goes directly to the posterior cord which,Becomes the axillary nerve (although all fibers supplying the axillary nerve come from the upper trunk),Radial nerve,Motor fibers innervate most of the triceps, and portions of the extensor digitorum communis and extensor indicis proprius as well as the rest of the extensor muscles in the forearm. The muscles in the forearm are innervated after the radial nerve splits and the motor branch becomes the posterior interosseous nerve.Thoracodorsal nerve, innervating a portion of the latissimus dorsi andSubscapular nerve which innervates a portion of the teres major.
20The Anterior Division of the Middle trunk The anterior division proceeds to the lateral cordOuter branch of the median nerveInnervating sensory fibers to the middle finger.In NCS this is a very important point.When evaluating for brachial plexopathies, not recording from the middle finger means you miss middle trunk fibers.Remember the radial SNC is upper trunk.
21The Lower Trunk The lower trunk is formed by the C8-T1 nerve roots. The anterior division continues to the medial cordThe posterior division of the lower trunk proceeds to the posterior cord
22The Anterior Division of the Lower trunk The anterior division continues to the medial cord and finally, theUlnar nerveBoth motor and sensory fibers. The motor fibers innervate the flexor carpi ulnaris in the forearm and the abductor digiti minimi, first dorsal interosseous and the deep head of the flexor pollicis brevis muscles in the hand. Sensory fibers innervate the fourth and fifth digit of the hand.Inner branch of the median nerveMotor fibers to the abductor pollicis brevis, the superficial head of the flexor pollicis brevis and the opponens pollicis
23The Posterior Division of the Lower trunk The posterior division of the lower trunk proceeds to the posterior cordRadial nerveInnervates the additional portions of the radial/posterior interosseous muscles not supplied from C7 and middle trunk
24Medial Antebrachial Cutaneous nerve Additionally, the medial antebrachial cutaneous branches from the medial cord and innervates sensation to the medial forearm.
26Lesions of the Brachial Plexus Injuries and diseases can affect the plexus and cause damage.Upper trunk plexopathies can be caused by a birth trauma, radiation therapy, and neuralgic amyotrophy.Middle trunk plexopathy is rare and usually caused by injury.Lower trunk plexopathy is usually caused by trauma, a Pancoast tumor, Dejerine-Klumpke, CABG (associated with a jugular vein), and metastatic disease.
27Lesions of the Brachial Plexus Traumatic injuries are the most common cause of brachial plexus lesions.automobile,motorcycle,bicycle accidents,penetrating knife, orgunshot wounds.Most Traumatic plexopathies are the result of traction and stretch injuries.Severe traction injuries may result in damage to the roots as well as the plexus.
28Lesions of the Brachial Plexus Root avulsions are when the nerve roots are torn and axons are damaged beyond repair.They often occur in combination with brachial plexus injuries.The most common roots affected in root avulsions are C8/T1.
29Lesions of the Brachial Plexus Nontraumatic plexopathies include neuralgic amyotrophy (sometimes called Parsonage-Turner syndrome or idiopathic brachial plexopathy),hereditary brachial plexopathy,neoplastic or radiation induced brachial plexopathy andneurogenic thoracic outlet syndrome to mention a few.
30Some needle stuff Panplexus: Complete Brachial plexopathy. Muscles Affected:all except theserratus anterior andrhomboidsthese are innervated by nerves (long thoracic and dorsal scapular, respectively) that come directly off the roots, proximal to the plexus.
31Upper trunk plexopathies These are the most common brachial plexopathies.Weakness occurs in nearly all muscles with C5-6 innervation including the deltoid, biceps brachii, brachioradialis, supraspinatus and infraspinatus (the patient has difficulty lifting their arms).Muscles with partial upper trunk contribution such as pronator teres (C6/7) and triceps(C6/7/8) may be affectedSensory loss occurs in the lateral arm, lateral forearm, lateral hand, and thumb.
32DTR’sBiceps and brachioradialis reflex depressedTriceps preserved
33Nerve Conduction Studies Exclude a C5/6 radiculopathy or other mononeuropathiesSensory Nerve ConductionsAbnormalMedian (thumb and index finger), radial and lateral antebrachial cutaneous sensory nerves will show reduced amplitudes particularly when compared to the unaffected arm.NormalThe median (to the middle and ring finger), ulnar and medial antebrachial cutaneous nerves would be normalIf the patient has a C5/6 radiculopathy or a root avulison the sensory nerves would be unaffected
34Nerve Conduction Studies Motor nerve conduction studiesAbnormalMusculocutaneous and axillary motor nerve studies would show decreased CMAP amplitude as compared to the unaffected side.NormalRoutine motor nerve conduction studies of the median and ulnar nerves are not particularly useful in distinguishing upper trunk or C5- 6 radiculopathies, but MNC’s would be absent in avulsion injuries to C5-6.Of note, you could spare the patient the musculocutaneous nerve as you have already performed the LABC sensory, an extension of that nerve.
35Some needle stuffUpper trunk plexopathy: Upper trunk lesion (C5-C6 roots).Muscles Affected:Deltoid,biceps,brachioradialis,supraspinatus, andinfraspinatus .Of note: the lesion could be distal to the suprascapular nerve which would spare the supraspinatus and infraspinatus.Muscles partially affected are thepronator teres (C6-7) andtriceps (C6-C7-C8).
37Middle trunk plexopathies Isolated middle trunk plexopathies are rare.Signs and symptoms resemble those of a C7 radiculopathy.Weakness occurs in the elbow, wrist and finger extensors.Sensory loss occurs in the posterior forearm and the dorsal and palmar aspect of the middle finger.Only triceps DTR abnormal
38Nerve Conduction Studies Sensory nerve conduction studiesAbnormalMedian sensory response to the middle and ring finger will be reduced as compared to the unaffected side.While median sensory fibers to the thumb and index finger transverse the upper trunk the sensory fibers to the middle finger originate in the C7 nerve root and go through the middle trunk and anterior division before joining the rest of the median sensory fibers in the lateral cord.NormalThe remaining sensory nerve conduction studies should be unaffected
39Nerve Conduction Studies Motor nerve conduction studiesAbnormalRadial motor conduction study may show reduced amplitude (has lower trunk innervation as well)NormalThe remaining motor nerves of the upper limb will be sparedIt can be difficult to distinguish a lesion involving the middle trunk from one involving the posterior cord as there are no nerve branches arising directly from the middle trunk.
40Some needle stuffMiddle Trunk Plexopathy: Middle trunk is formed from C7 root.Muscles Affected:Triceps,flexor carpi radialis, andpronator teres muscles.Middle trunk lesions mimic C7 radiculopathies, so needle examination of the cervical paraspinals is necessary.
42Lower trunk plexopathies Lower trunk plexopathies present with symptoms similar to C8-T1 radiculopathies, medial cord plexopathies and even ulnar neuropathies.Weakness is evident in all median and ulnar innervated hand muscles as well as radial innervated distal forearm and wrist muscles.The involvements of radial C8 muscles (lower trunk, posterior cord) help localize the lesion to the lower trunk by excluding the medial cord.Sensory disturbance is seen in the medial aspect of the arm, forearm and hand in a larger distribution than an ulnar neuropathy.No DTR changes
43Nerve Conduction Studies Sensory nerve conduction studiesAbnormalUlnar and medial antebrachial cutaneous nerves reveal reduced amplitudes especially when compared to the unaffected side.NormalMedian sensory nerves remain unaffectedMotor nerve conduction studiesThere would be decreased CMAP amplitude in both ulnar and median motor NCS, although this might be true in severe a severe C8-T1 radiculopathy as well. Distal radial response to the EIP may be decreased (has middle trunk innervation as well).Remaining motor nerves are unaffected.
46Lateral cord plexopathies Weakness of shoulder flexion and abduction, elbow, arm pronation and wrist flexion.Sensory loss can be found in lateral forearm, lateral hand, and first three fingers.Biceps DTR’s are abnormal, triceps and brachioradialis spared
47Nerve Conduction Studies Sensory nerve conduction studiesAbnormalMedian innervated first three digits and the lateral antebrachial cutaneous innervated lateral forearm should show reduced amplitude as compared to the unaffected side.NormalThe radial innervated thumb would be preserved in lateral cord lesions (posterior cord), but would be involved if the lesion were in the upper trunk
48Nerve Conduction Studies Motor nerve conduction studiesAbnormalMusculocutaneous nerve to the biceps would show reduced amplitude as compared to the unaffected side.NormalMedian and ulnar nerves originate from C8-T1, lower trunk and medial cord thus would be unaffected in lateral cord lesions.Study of the axillary nerve should be preserved in lateral cord lesions as it originated in the upper trunk, but transverses the posterior division and continues through the posterior cord.
49Some needle stuffLateral cord Plexopathy: Musculocutaneous nerve and C6-C7 portions of the median nerve.Muscles Affected:Pronator teres,flexor carpi radialis, andbiceps.
51Posterior cord plexopathies Poserior cord plexopathies, like middle trunk plexopathies, are uncommon.The radial, axillary, upper and lower subscapular and thoracodorsal nerves are derived from the posterior cord.Symptoms of posterior cord lesions include weakness of shoulder abduction and adduction, wrist drop and finger drop, and arm extension weakness.Sensory loss is evident in the lateral arm, posterior arm, forearm, and radial dorsal hand.Triceps and brachioradialis reflexes abnormal
52Nerve Conduction Studies Sensory nerve conduction studiesAbnormalThe superficial radial nerve (upper trunk, posterior cord) would show low amplitude especially compared to the unaffected side.NormalThe lateral antebrachial cutaneous (upper trunk, lateral cord), median (upper and middle trunks, lateral cord), ulnar and medial antebrachial cutaneous (lower trunk, medial cord) nerves should be normal.
53Nerve Conduction Studies Motor nerve conduction studiesAbnormalMotor study to the radial innervated extensor indicis proprius would be expected to show reduced amplitude.The axilla to the deltoid, while originating in the upper trunk travels through the posterior cord and should show changes in the affected side.NormalMedian, ulnar and musculocutaneous nerves would be unaffected in posterior cord lesions.
54Some needle stuffPosterior Cord Plexopathy: Radial, axillary, and thoracodorsal nerves are derived from the posterior cord.Muscles affected:latissimus dorsi,deltoid, triceps,brachii, anconeus,brachioradialis, extensor carpi radialis longus,Extensor carpi radialis brevis,Supinator,Extensor digitorum,Extensor digiti minimi,Extensor carpi ulnaris,Abductor pollicis longus,Extensor pollicis brevis,Extensor pollicis longus,Extensor indicis.
56Medial cord plexopathies Findings of medial cord lesions are the same as lower trunk lesions with one notable exception: the radial MNC.Remember, the C8 motor fibers of the radial nerve go thru the lower trunk then the posterior cord while C8 and T1 motor fibers of the median and ulnar nerves also transverse the lower trunk, but these go thru the medial cord.Therefore only median and ulnar innervated muscles will be affected in medial cord lesions.DTR’s are normal
57Nerve Conduction Studies Sensory nerve conduction studiesAbnormalUlnar and medial antebrachial cutaneous nerves, are both C8/T1, lower trunk and medial cord nerves, thus they reveal reduced amplitudes as compared to the unaffected side.NormalMedian sensory nerve, from C6/7, upper and middle trunks and lateral cord, remains normal
58Nerve Conduction Studies Motor nerve conduction studiesAbnormalThere would be decreased CMAP amplitude in both ulnar and median motor NCS, but this could be true in lower trunk and C8/T1 lesions as well.NormalMotor nerve conduction study of the radial nerve (C7/8, lower trunk, posterior cord) to the extensor indicis proprius would be symmetrical, side-to-side.
59Some needle stuffMedial Cord Plexopathy: Direct continuation of the anterior division of the lower trunk.Muscles affected:All ulnar muscles andC8-T1median muscles.
61ConclusionBrachial plexus lesions and injuries can be most challenging.When evaluating brachial plexus injuries, motor amplitudes may not add much to the diagnostic localization. However, sensory studies comparing the affected limb to the contralateral limb are helpful for anatomic localization, especially when determining localization as well as pre- and postganglionic injuries.