Attending Physician St. Charles Hospital/CHSLI Port Jefferson, New York, United States
Case Diagnosis: Pre- and postganglionic brachial plexus injury
Case Description: 31-year-old male presented one month after a motorcycle accident with right upper extremity flaccidity and numbness. CT imaging revealed a healing C7 spinous process, right transverse process fractures and dissected right vertebral artery. MRI showed cord compression at C3-C4, a pseudomeningocele at C6-C7 suggesting an avulsion of the C7 nerve root (preganglionic injury). Brachial plexus MRI, revealed a discontinuity of the trunks and divisions with thickening of the lateral, posterior and medial cords (postganglionic injury). Patient presented with an atrophic right shoulder most notably infraspinatus, and deltoid with winging of the right scapula. There was no sensation in the right upper extremity, except for dull sensation over the medial forearm and fingers. Patient underwent one month of acute rehabilitation and minimally recovered wrist and finger flexion with trace intrinsic function.
Discussions: Imaging confirmed pre- and postganglionic brachial plexus injuries. Supraclavicular (preganglionic) injuries are most common and arise mainly by a caudal force on the shoulder affecting the upper brachial plexus are associated with root avulsion, carrying a poor prognosis as they are unrepairable. Infraclavicular plexus injuries (postganglionic) injuries have a better prognosis as they may resolve through (axonotmesis) or with surgical repair. As in this patient, proximal plexus injuries are associated with transverse process fractures, as the C4-C7 nerve roots are tethered to the cervical transverse process. Fractures at these levels have strong evidence of preganglionic root injuries. Goals of rehabilitation were to improve and stabilize bicep and shoulder function while reducing neuropathic pain.
Conclusions: Pre- and postganglionic brachial plexus injuries are devastating injuries portending serious lifestyle changes. Newer surgical techniques using nerve transfers in addition to nerve grafting have shown promising results in promoting upper extremity function. Providing a patient with proper rehabilitation and surgical repair strategy is integral in improving their function and prognosis.