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Detection Avulsion

Patients

Brachial
Andrew
Alain

of Nerve Rootlet on CT Myelography in with Birth Palsy and Plexus Injury AfterTrauma
Recent advances require The purpose
myelography plexus injuries fr

T.Walker1

OBJECTIVE.
brachial postganglionic high-resolution patients with

in neurosurgical of this study
revealing before

tteatment

of traumatic nerve
nerve

and

birth-related avulsion

John C. Chaloupka1’2
C. J. de Lotbiniere3

plexus

injuries
lesions. CT brachial

differentiation

of preganglionic was to evaluate
cervicothoracic

rotlet
rootlet

from
in

the efficacy

of thin-section
avulsion

Scott
Richard
E.

W. Wolfe4
Goldman5

Leon Kier1
CT

MATERIALS
birth-related myelography brachial

AND befbre rootlet
Results

METHODS. injury surgical exploration

surgery. We evaluated plain and repair.

eight film

patients

with
and

psttraumatic
high-resolution

or

plexus

on cervical

myelography
and and

CT myelograms

were
deformity

retrospectively
of the

evaluated
arachnoid

for nerve
space.

avulsion. traumatic pseudonieningocele. were correlated with surgical exploration
(95C% ) of 76 imaged cervicothoracic

subsoma-

intraoperative

tosensory evoked potentials. RESULTS. Seventy-two shown on CT myelography.
2 1 levels. at

levels disruption.

were

adequately was shown at

Nerve

rootlet

avulsion.

or preganglionic

Associated
potentials

pseudomeningocele. levels.
showed complete

or deformity Surgical
preganglionic

of’ the suharachnoid and intraoperative ro()tlet avulsion myelography
was found

space. at 22 levels.
CT

was

seen

I 2 (57k

) of the 2 1 avulsion avulsions levels,
avulsions

exploration nerve revealed

somatosensory One of
myelogram.

evoked

the complete 98%
None

revealed

by surgery correctly nerve
CT correctly

was not included on CT avulsion
on the with

on the patients

Of the 2 1 imaged specificity).
ofthe partial

20 were partial
was

(9Y%
at three

sensitivity.
other levels.

At surgery.

rootlet
identified myelography

CT myelograms.
thin contiguous with CT prognosis brachial myelographv and surgical axial sections plexus in birth these is

CONCLUSION. sensitive for revealing
palsies and allows brachial a more

High-resolution

complete
plexus complete

nerve
injuries injury

rootlet
after evaluation

avulsion

in patients

trauma.

Preoperative for accurate

patients

planning.

Received March 5, 1996; accepted May 16,1996.
t

after revision of Diagnostic Ra-

Section

of Neuroradiology,

Department

R
related
ferentiation glionic

ecent

advances made

in microneurosurexploration and

treated birthperineural maintained
if the nerve

by
scar

microsurgical
tissue if nerve

neurolysi
continuity

s

of
is

diology, Yale University School of Medicine, 333 Cedar St.. New Haven, CT 06510. Address correspondence to A. T. Walker. 2The Interventional Neuroradiology Service, Departments of Diagnostic Radiology and Surgery (Neurosurgery), Yale University School of Medicine, New Haven, CT 06510. 3Section of Neurosurgery, Department of Surgery, Yale University School of Medicine, New Haven, CT 06510. 4Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, CT 06510.

gery have repair of brachial
plexus

traumatic injuries planning

and possible requires from

or by interpo)sition
is

nerve

grafting

I Idii-

completely
and CT

transected
myelography examinations
plexus

( I -31.
have of
tnjuries.

3j. Adequate
lesions.

surgical
Avulsion

Myelography been
choice

of preganglionic

postganor dorsal

the
for

neuroradiologic
evaluating brachial

of ventral

nerve rootlets preganglionic

from the spinal cord nerve root injury nerve
treatment

results
with

in
no

MR in

imaging evaluating
been

has also been shown to be useful brachial plexus injuries 4-61. of nerve root avulsion
based space on showing

potential
cases. zation. distal

for

regeneration.
consists

In

these of the

The diagnosis
erally

has gen-

5Section of Neuroradiology, Department of Radiology. Hartford Hospital, 180 Seymour St., Hartford, CT 06106.
AJR 1996:167:1283-1287 0361-803X196/1675-1283

surgical

of neurotiplexus
cervical Postganmay

or rnicrosurgical portions
transfer

reinnervation the brachial
accessory.

suharachnoid Although
nerve a significant

defrmity of the or a pseudoiieningocele.
exists between

of
ftotii

by

a strong

association

nerve

spinal nerves plexus

root avulsion
percentage of pseudomeni

and pseudomeningoceles. of avulsions
ngocele. and

plexus.
glionic

or intercostal
brachial

[ l-3J.
lesions

show
pseudo-

no

© American Roentgen Ray Society

he

evidence

AJR:167, November

1996

1283

accurate integrity Although fulness cally deterniination of spinal nerve root at each level fioiii C5 to T I a recent report film documented the use- A level neither normal space. on left (open arrow). Axial CT myelogram at level of C5 vertebral body shows normal right Cl nerve rootlets exiting and entering cervical cord (arrowl. surgical inadequately the were avulsion However. uous spinal neural ventral cord foranien fragments rootlets or exit ). at the General WI. sac (closedarrow). left pseudomeningocele brachial plexopathy . with 2). Our objective was to evalu- intraoperative potentials injury rootlet rootlet additional nerve Results Seventy-two cothoracic levels preganglionic (95Y were at 22 levels. Axial CT myelogram at level of C6-C7 neural foramina shows normal right Cl nerve rootlets exiting thecal . tncorrectlv scanner Mtlwaukee. retrospectively rootlet tags of rootlet Because therapeutic fling and of the vider options. In two the shown by the presence somatosensory of the 22 of diminished evoked surgically but proven mainavul- tai ned Twenty potentials. November 1996 . deformity 0) traunuttic who was exatiutier nerve Radiologic findings evoked ltd pseudotiieningocele.Walker et al. Nerve disruption.-Left C7 nerve rootlet avulsion and associated in 10-month-old boy with after traumatic delivery. and the second at a level inadequately evaluated because of an artifact. B. one at a level not at 2 1 levels by the lack and dorsal rootlet entry (Table were I of contigthe the and sustained tiyelography accidents. After fluoroscopic and plain film evaluation. nerve rootlets exploration tosensory series. tnyelography surwere the old) plexits quately TI nerve bilaterally rootlets were of madebeam because incotiiplete with CT repair. seen in our significant deformity was arachnoid instance cal of space was of plain evaluating myelography nerve in specifirootlets with intraoperative pseudomeningocele seen and evoked nerve with root nerve nerve three the cervical 171. Partial at continuity in birth palsy and CT lateral myelography brachial in eight plexus plexus injury after trauma. 1. to reptissue deforseen at or 17-91. A. using the standard. The C4 ver- Complete Partial Normal avulsion avulsion 1 0 0 0 1 2 0 3 1 50 CT scans were intttated two tn the earliest examtnattons Fig. Note that left C7 nerve rootlets are not seen. Myelogratiis evaluated and CT for space mvelograms nerve by the resent avulsion small scar. and Methods tiutle patients or ( 8 nionths patients to 67 years brachial before injuries and Cervical New birth. . levels residual and were thought or was I ). patients underwent CT scanning. NY: 10-14 ml in adults and 3-4 ml in infants). Surgisomashowed adequate cervical nyelography is often dilticult to perlorni in acutely injured individuals and small infants. . two of some patients rootlet Materials Eight with injury and gical other contrast cotiiplete were high-resolution exploration in was related was the CT scan was initiated below the origins of the C5 nerve roots. nieningoccles avulsion can occur withoitt nerve r(x)t in the were sertes. Contiguous axial images were obtained froni C3 to T2 at I rntii intervals and at 2to with 3-miii I -turn slice thickness with in infants 3-mm sltce or - uous intermittently If1Surgica1 and CT Myelographic Correlation CT Myelographic Findings intervals thickness in adults. two not cottkl rootlets and know detect withtn findings surgtcal and netifindshown subarachcorrelated soma- fibrotic mity at nine gocele I 2 of the Pseudomeningocele subarachnoid levels space (Fig. consistentwith Note pseudomeningocele No left C7 nerve rootlets are avulsion. The two avulsions not detected occurred at levels not adequately evaluated on the CT myelograms. None of the three partial preganglionic injuries were correctly identified on CT a water-soluble Small noncontigseen at agent (Oninipaque York. appropriate the suharaclitioid deetied of the levels or prognosis roradtologtsts Ings. shown with In cervion uni- consistent (Table diagnosed visual I ). high-resolution hone reconstruction algorithm a 9f()() Electric tebral Surgical Findings on Complete Avulsion 20 Partial Avulsion 0 Inadequate Evaluation 1 Level Not Included 1 Normal 0 or HiSpeed Medtcal body level Advantage Systems. 1284 AJR:167. Nycomed.0 :. seen. tosensorv potentials. between zone included on a scan. detail. subNo intact wheti eral tioid the contralat- no evidence of pseudomeninof the (Fig. vehicle to traumatic with I 80: performed cervical Seven myelography hardening avulsion. diagnosed and streak or preganglionic artifact. rootlet was evaluated and motor sions were correctly identified at CT myelography. deterniination of range o1 available surgical planrequire avulsion. avulsion avulsion levels rootlets was by and ate the efficacy of thin-section high-resolution CT niyelography for detecting cervicothoracic brachial nerve rootlet avulsion ) of 76 imaged adequately patients injury.

lesions Surgical rootlets from treatment post- ganglionic preganglionic tion by nerve consists of spinal of neurotizaaccessory. plexus injury posttraumatic (7. Excluding the one proven avulsion that was not included on the patient’s CT myelogram. The fifth and sixth cervical nerve rootsjoin to form the elbow zation to the paralyzed transfer is used pseudomeningocele Other in 20% studies and have without rootlet avulsion superior continues or upper as the trunk. B. to or intercostal plexus. nerve of the nerve injury. Axial CT myelogram at level of C6 vertebral body shows absence of right Cl nerve rootlets entering and exiting cervical cord. level was 3). roots and the eighth intermedius or middle cervical and first thoracic plete avulsion of nerve rootlets possibility of nerve regeneration ganglionic lesions may be confers I l-3J. and narrowing residual of spinal canal limit examination. 3. Axial CT myelograms they are difficult to differentiate of left C7 nerve rootlets. 1). and The poste- tally by microsurgical and adhesions removal of perineural if’ nerve interpreted one inadequately surgically trunks nor further divisions. documented nerve posttraumatic surgical pregangli- have palsy and planning onic lesions requires differentiating tance sion of of showing in birth cervical rootlet avulbrachial ficity rootlet for the avulsion detection of complete on CT myelography. divide forming anterior the lateral. result of these Traction in brachial levels. was join to fbrm the inferior into or lower trunk. without deformity of subarachnoid space or pseudomeningocele. Note normal left Cl rootlets. ventral rootlets exiting cord (arrow but normal in B). One avulsion level (Fig. which may represent because of streak artifact. myelography (Table as a complete (Fig. restore try to nerves This some limb. The length AJR:167. November 1996 1285 . interjxsition evaluated. scartissue continuity (neurolysis) or by as normal and one medial. we found a 95% sensitivity and 98% speci- and sion ries posterior forces at any may cords. Note normal left Cl root sleeve (arrow in C). Axial CT myelogram at level of C6 vertebral right Cl rootlets are seen (arrow).CT Fig. because to distal transfer level Neuroticomof ficient for diagnosing In the 21 instances seen in our series. compres- is maintained. cal and first thoracic spinal nerves. but at level of C6-C7 neural foramina show minimal linear density. B and C. The demonstration of a pseudomeningocele is not suf’nerve of nerve nine (4Y4 rootlet rootlet ) had avulsion. avulsion transfer Discussion The tral rami brachial plexus is formed through by the yencervi- cervical portions of the fifth the eighth plexus. ated reported of the brachial flexion by nerve no associspace or is performed deformity nerve of the subarachnoid . 4). Fig. 81. Closed arrow = left Cl rootlet. Axial CT myelogram at level of C6-C7 neural foramna shows absence of right Cl rootlets and normal right Cl root sleeve (open arrow).-Surgically motor vehicle proven accident partial avulsion of left Cl nerve rootlets interpreted body shows absence as complete avulsion on CT myelogram Streak artifact in 67-year-old man with left brachial plexopathy after A.-Avulsion pseudomeningocele Myelography of Nerve Rootlet Avulsion of right Cl nerve in 23-year-old rootlets without man with right bra- chial plexopathy after motorcycle accident A. and Adequate nerve plexus Prior grafting transection reports at levels I of complete the brachial impor- plexus inju- 1-31. no Post- pseudomeningocele mal 44c/ deformity of cases of the subarachnoid only minispace in of time treated segmen- 16-91. The seventh root trunk. 2.

Three-millimeter axial CT myelogram at level of C6 vertebral body shows some of dura near left Cl nerve root sleeve origin may mimic exiting ventral rootlets may have been useful in limiting partial volume averaging and possibly shows normal detecting Even ographic difficulty film myelbecause nerve of root- left C7 nerve (arrow). found rootlet ngocele within no [71. C. lets in infants. or immobility of the patient. B. MR imaging sensitive showing has as nerve recently plain rootlet been f’ilm avulsion shown myelography to be as in in the upper cervical son of was spine 161. 4.-Right Cl and C8 nerve rootlet avulsion in 27-year-old man with right brachial plexopathy after motorcycle accident. evaluation 5).Walker et al. One-millimeter images to in visualizing asymmetry of left Cl rootlets suggest partial avulsion. A. we are found 8 that to a significant in evaluate number patients nerve stiiall of cervical madeat under all rootlets infants obliquely shoulders sides In ries. A. B. to evaluate rootlets in which were the at each the plain suboptimal the small it is curstatus level. avulsion myelograms in the CT and prevent axial evaluation contributing of alignment image. no compariMR imaging to CT myelography made. but nerve rootlets are not well seen. 5). markedly limited by patient immobility caused by multiple acute fractures. acute multisystem trauma (Fig. of all Fig. these the in However. Both occurred instances at TI of madebecause of mine formation difference whether occurs. poor contrast opacification of the cervical subarachnoid space. brachial cervicothoracic of the plexus between patients imaged weeks of injury. in delayed the without incidence pseudomeningocele we of pseudomeni acutely. on a single any all imaged a mean of especially after injury. 1286 AJR:167. 5. in 21Infolding MR technical unable plexus in cases images developments. general anesthesia and in patients with Fig. Study was November 1996 . improve with evaluation of the C5 and C6 nerve because visualization of the lower was ratios limited and by loss decreased of imaging soft-tissue may signal-to-noise Although further rently brachial proven partial avulsion of left Cl nerve rootlets interpreted as normal on CT myelogram rootlets. and those 4-5 months quate levels. and the study was limited to rootlets rootlets contrast. Anteroposterior view from cervical myelogram shows small pseudomeningoceles at C6-C7 and Cl-Ti on right )arrows). CT myelography show ventral and dorsal rootlets was able to or levels exiting of the required for pseudomeningocele develop- A recent report of has emphasized myelographic the rootlets entering evaluated quate beam the the spinal cord at 95% ment is unknown. Axial CT myelogram at level of C6-C7 neural foramina left Cl root sleeve. and no patient in our series was examined at two different times to deter- i mportance meticulous (Fig. Axial CT myelogram at level of C6-C7 neural foramina shows avulsion of right Cl rootlets with pseudomeningocele arrow) and normal left Cl rootlets. and streak We now scanner artifact position to caused patients offset by the two injunerve However. nerve evaluation in patients suspected of the with avulsion individual brachial plexus nerve injury and have hardening shoulders. Coronal reconstruction of CT myelogram shows avulsion of right Cl and C8 nerve rootlets with associated pseudomeningoceles arrows). However.-Surgically year-old man with left brachial plexopathy after motorcycle accident.

In: ed. Kimori K. Sutton D. In two of our early was initiated below the origin rootlets. Detection tion algorithm is used to improve visualization of the individual nerve rootlets. Vielvoye H. Samardzic transfer Neurnsurg 1991:1285-1301 M. J rootlet origins from C5 to TI must be many recovery. Nerve of myelogsomatoscnsory palsies injuries. rootlet to the brachial 9. We recommend axial images in adults MR imaging. Ne. Itoh K. In summary. for brachial evaluating plexus mm contiguous and a 3over- 1993:189:481-484 avulsions 6. References 1. the scan of the CS nerve as high as C3 detection Lippincott. Taylor plexus and may necesis rootlets CT axial see- a more careful surgical exploration and somatosensory evoked potentials for complete analysis of brachial plexus injuries. 2. myelography 1ev- of upper brachial 1993:79:197-203 MJ. Millesi tive 10. Hoffmann in cervical Radial in bni- 1%6:39:362-37l Neuroradiological avulsion. in traumatic l9:l9-B:55-59 N. Radiolog’ 1991:178:841-845 8. cases. Bligh AS. electrophysiological. et al. after (abstr). Shenaq Ct 3. included. thickness interval. rsxt management for regeneration the potential to predict repair. Incomplete els limits sitate unable [7. evaluation presurgical extensive of all contributing planning surgical that CT exploration. MR imaging avulsion ML. in adults: operainvestigations CFE. Mitomo CT M.shimoto T. we found myelography helpful when plexus mm lapping slice 4.- evaluated.. Boop FA. of birth-related AJNR 1989: brachial Despite reports lOlsuppll:S98 CM. Brachial plexus Gelberman injury RH. of T2 is required contributions to include nerve 17:913-922 instances although in our series correctly one occurred at a level Partial is difficult avulsion because dilemma. In adults. or if the imaging physical examidata. quately much less promising. was three fled. Popovich FC. and We posttraumatic found a 95% brachial sensitivity A high-resolution reconstruc- value of MRI (BrJ hrchial plexus and 98% specificity for complete nerve rootlet avulsion with a positive predictive value of 95% and a negative predictive value of 98%. Operative rol Neurosurg 1993:95lsuppll:S36-S38 AJR:167. Clinical.. in with traumatic Radiology to delineate we have with be highly to individual nerve found high-resolution thin contiguous useful in high-resolution CT evaluating brachial the use of 1in infants with a 2-mm 5. avulsion with J HandSurg 7. myelographic spinal EMG root studies avulsions: of 9 patients discrepancies Muscle Nerve and cervical between 1994: with of partial avulsion with none injury of the identimadeis also and a the C3 vertebral body and x-ray findings.CT Myelography of Nerve Rootlet Avulsion Philadelphia: V. Grujicic in brachial Lee which is typically may be aided myelography ume by correlation with plain film or by decreasing partial-volat susin our need for D. Glasier plexopathy evaluation myelography tions nerve birth rootlet injuries. Trojaborg W. Ha. Helmer plexus Griebel infants E. but their presence series underscores the continued 1992:76: 19 1-197 R. Imaging to the superior all plexus. Preoperative CT myelography allows more complete injury evaluation for accurate prognosis and surgical planning. artifact with 1-mm axial images picious levels. lkuta Y. Miller Brachial delivery: SF. Watanabe The diagnostic plexus root raphy M. cases The show no significant of partial functional avulsions iieri’e repair and reconstruction. Antunovic plexus S. BrJ GJ. Ochi M. correction J Neurosurg al. 10]. Hirabuki comparison and of birth palsy: myelography findings do not correlate with nation or electromyelographic from aspect evoked potential. November 1996 1287 . Myelography chial plexus injury. repeat imaging at selected levels with 1-mm contiguous axial images may be of further help if subtle injury is suspected. Neurosurgical birth injuries. traction because of the oblique downward course of the nerve rootlets in the subarachnoid space. Cli. Laurent JP. Davies ER. injuty. Nerve injuries.