Cervical Plexus

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Infantile Brachial Plexus Injury

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Description
The cervical plexus consists of deep and superficial branches.The
superficial branches provide sensation to the skin and the deep branches
are mostly motor in nature. The communication of the anterior divisions of
the upper four cervical nerves (C1-C4) forms the cervical plexus. [1]

Location/Path
It lies under the sternocleidomastoid (SCM) muscle, opposite the upper
four cervical vertebrae. It rests upon the levator anguli scapulae and
scalenus medius muscles, and emerges from the posterior border of the
SCM.[1]

Branches and Supplied Structures

 [2]

Its branches consist of a superficial and deep set. The superficial branches
are the great auricular nerve, lesser occipital nerve, transverse cervical,
suprasternal, and supraclavicular nerves. The deep branches are the
phrenic, communicantes cervicalis, communicating, and muscular. [1]

 Ansa Cervicalis (C1-3) [3]

o Superior (C1-2) & inferior (C2-3) roots form loop
o Sensory: None
o Motor: Omohyoid, sternohyoid, sternothyroid

 Lesser Occipital Nerve (C2-3) [3]

o Arises from the posterior border of SCM
o Sensory: Superior region behind auricle
o Motor: None
[4]

 Great Auricular Nerve (C2-3) [3]

o Exits inferior to lesser occipital nerve, ascends on SCM
o Sensory: Over parotid gland and behind ear
o Motor: None

 Transverse Cervical Nerve (C2-3) [3]

o Exits inferior to greater auricular nerve, than to anterior neck
o Sensory: Anterior triangle of the neck
o Motor: None

 Supraclavicular (C2-3) [3]

o Splits into 3 branches: anterior, middle, posterior
o Sensory: Over clavicle, outer trapezius and deltoid
o Motor: None

 Phrenic Nerve (C3-5) [3]

o On anterior scalene, into thorax between subclavian artery and
vein
o Sensory: Pericardium and mediastinal pleura
o Motor: Diaphragm

Diagram
Related articles
Brachial Plexus - Physiopedia Introduction The brachial plexus passes from the neck
to the axilla and supplies the upper limb. It is formed from the ventral rami of the 5th
to 8th cervical nerves and the ascending part of the ventral ramus of the 1st thoracic
nerve. Branches from the 4th cervical and the 2nd thoracic ventral ramus may
contribute. [1] Compression of the medial, lateral and posterior cords of the brachial
plexus can occur between the first rib and clavicle (known as thoracic outlet) and
below pectoralis minor [1] The right brachial plexus with its short branches, viewed
from in front. Function[edit | edit source] The brachial plexus is responsible for
cutaneous and muscular innervation of the entire upper limb, with two exceptions:
the trapezius muscle innervated by the spinal accessory nerve (CN XI) and an area of
skin near the axilla innervated by the intercostobrachial nerve.[2] Description[edit |
edit source] Path[edit | edit source] The brachial plexus is divided into 5 anatomical
sections: Roots, Trunks, Divisions, Cords, and Branches. There are five "terminal"
branches and numerous other "pre-terminal" or "collateral" branches that leave the
plexus at various points along its length. [3][4] The five Roots are the five anterior
rami of the lower four cervical and first thoracic nerve roots (C5-C8, T1) after they
have given off their segmental supply to the muscles of the neck. These Roots merge
to form three Trunks: [3][4] Upper Trunk (C5-C6) Middle Trunk (C7) Lower Trunk
(C8, T1) Each Trunk then splits into anterior and posterior divisions, to form six
Divisions. The anterior/posterior divisions innervate flexor groups versus extensor
groups: [3][4] anterior divisions of the upper, middle, and lower trunks posterior
divisions of the upper, middle, and lower trunks These six Divisions will regroup to
become the three Cords. The Cords are named by their position to the axillary artery.
[3] [4] The Posterior Cord is formed from the three posterior divisions of the trunks
(C5-C8, T1) The Lateral Cord is the anterior divisions from the upper and middle
trunks (C5-C7) The Medial Cord is simply a continuation of the anterior division of
the lower trunk (C8, T1) Anatomical illustration of the brachial plexus with areas of
roots, trunks, divisions, and cords marked. Specific Branches[edit | edit source] The
branches are listed below. They mostly branch from the cords, but some originate
from earlier structures. From Nerve Roots Muscles Cutaneous roots Dorsal scapular
nerve C4, C5 Rhomboid muscles and Levator scapulae - roots Long thoracic nerve
C5, C6, C7 Serratus anterior - upper trunk Nerve to the subclavius C5, C6 Subclavius
muscle - upper trunk Suprascapular nerve C5, C6 Supraspinatus and Infraspinatus -
lateral cord Lateral pectoral nerve C5, C6, C7 Pectoralis major and Pectoralis minor
(by communicating with the Medial pectoral nerve) - lateral cord Musculocutaneous
nerve C5, C6, C7 Coracobrachialis, Brachialis and Biceps Brachii becomes the
Lateral cutaneous nerve of the forearm lateral cord lateral root of the Median nerve
C6, C7 fibres to the median nerve - posterior cord Upper subscapular nerve C5, C6
Subscapularis (upper part) - posterior cord Thoracodorsal nerve (middle subscapular
nerve) C6, C7, C8 Latissimus dorsi - posterior cord Lower subscapular nerve C5, C6
subscapularis (lower part ) and Teres major - posterior cord Axillary nerve C5, C6
anterior branch: deltoid and a small area of overlying skin posterior branch: Teres
minor and deltoid muscles posterior branch becomes Upper lateral cutaneous nerve
of the arm posterior cord Radial nerve C5, C6, C7, C8, T1 Triceps brachii, Supinator,
Anconeus, the extensor muscles of the Forearm, and Brachioradialis skin of the
posterior arm as the Posterior cutaneous nerve of the arm medial cord Medial
pectoral nerve C8, T1 Pectoralis major and Pectoralis minor - medial cord medial root
of the Median nerve C8, T1 fibres to the median nerve portions of hand not served by
ulnar or radial medial cord Medial cutaneous nerve of the arm C8, T1 - front and
medial skin of the Arm medial cord Medial cutaneous nerve of the forearm C8, T1 -
medial skin of the forearm medial cord Ulnar nerve C8, T1 Flexor carpi ulnaris, the
medial two bellies of Flexor digitorum profundus, the intrinsic hand muscles except
the Thenar muscles and the two most lateral lumbricals the skin of the medial side of
the hand and medial one and a half fingers on the palmar side and medial two and a
half fingers on the dorsal side Specific branches can be visualised on the diagram
below: Injuries[edit | edit source] Injury to the brachial plexus can be very
problematic because the nerves branching off of the plexus provide innervation to
the upper extremity. Clinical signs and symptoms vary with which area of the plexus
is involved, and generally result in paralysis or anesthesia.[3] Symptoms can range
from transient nerve dysfunction to complete upper extremity weakness. These
injuries can be a challenge to diagnose due to the anatomical variant sof the brachial
plexus. [5] Mechanism of Injury[edit | edit source] The main causes of brachial plexus
palsies are traction, due to extreme movements, and heavy impact. [5] Brachial
plexus injury can occur in a variety of ways and can occur as a result of shoulder
trauma, tumours, or inflammation. The rare Parsonage-Turner Syndromecauses
brachial plexus inflammation without obvious injury, but with nevertheless disabling
symptoms. But in general, brachial plexus lesions can be classified as either
traumatic or obstetric. Obstetric injuries may occur from a mechanical injury
involving shoulder dystocia during a difficult childbirth. During birth, excessive
stretching of the neck or pulling the upper extremity can result in an upper brachial
plexus injury or inferior trunk, respectively. The incidence of brachial plexus injury is
approximately 1 in 1,000 live births.[6] Traumatic injury may arise from penetrating
or sports-related injuries, falls, work-related injuries, radiation therapy and
iatrogenic causes (i.e. first rib resection, shoulder surgery, brachial plexus block).
However, the most common mechanism of injury is a traction injury due to the
forceful separation of the neck from the shoulder. Common associated injuries can
include fractures of the proximal humerus, clavicle, scapula, cervical spine and upper
limb vascular injuries. [5] Management of these injuries may complicate the picture
when diagnosing brachial plexus injury but can also guide in determining the
mechanism of injury. [7] Classification of Injury[edit | edit source] There are many
classification systems for brachial plexus injuries, they can be divided into three
types: An upper brachial plexus lesion, which occurs from excessive lateral neck
flexion away from the shoulder. Most commonly, forceps delivery or falling on the
neck at an angle causes upper plexus lesions leading to Erb's Palsy. This type of
injury produces a very characteristic sign called Waiter's tip deformity due to loss of
the lateral rotators of the shoulder, arm flexors, and hand extensor muscles. Less
frequently, the whole brachial plexus lesion occurs. Most infrequently, sudden
upward pulling on an abducted arm (as when someone breaks a fall by grasping a
tree branch) produces a lower brachial plexus lesion, in which the eighth cervical
(C8) and first thoracic (T1) nerves are injured either before or after they have joined
to form the lower trunk. The subsequent paralysis affects the intrinsic muscles of the
hand and the flexors of the wrist and fingers. This results in a form of paralysis
known as Klumpke Paralysis. However, a commonly used system is Leffert's
classification system which is based on etiology and level of injury: I Open (usually
from stabbing) II Closed (usually from a motorcycle accident) IIa Supraclavicular
(preganglionic or postganglionic) IIb Infraclavicular IIc Combined III Radiation-
induced IV Obstetric IVa Erb's (upper root) IVb Klumpke (lower root) IVc Mixed
Check here on the Brachial Plexus Injury page for a further division of Leffert
Classification System Another system used is the Millesi Classification System. The
third classification, Classification on Anatomical Location of Injury, is further
described on the Brachial Plexus Injury page. Signs and Symptoms[edit | edit source]
Nerve damage causes a multifaceted clinical picture consisting of sensorimotor
disturbances (pain, muscle atrophy, muscle weakness, secondary deformities) as well
as the reorganisation of the Central Nervous System that may be associated with
upper limb underuse.[8] Pain is most common, in particular, those affecting the
preganglionic fibres[9]. Often described as crushing with intermittent severe attacks
shooting down the arm. Paralysis and anaesthesia in the affected extremity. Bizarre
sensations, hyperalgesia, dysesthesia, and allodynia. Myoclonic jerks in the affected
extremity. Ipsilateral Horner's Syndrome with T1 injury. Investigations[edit | edit
source] The following are ways to assess the involvement of the brachial plexus and
surrounding structures: [4] X-ray of the shoulder area and cervical spine to
determine if any boney abnormalities are causing the lesion. MRI will help to
visualise causative pathology such as tumors, neuritis, radiation injury. EMG and
NCS help to confirm a diagnosis, localise the lesion and determine the degree of
axonal loss. These tests are the most useful tests to determine localisation of the
plexopathy, especially, the sensory nerve conduction studies (SCSs) because sensory
nerve action potential amplitude will decrease in plexopathies due to Wallerian
degeneration of the postganglionic sensory fibers[10]. Histamine test to differentiate
between pre and postganglionic lesion[9]. Management[edit | edit source] Brachial
plexus injury may result in severe and chronic impairments in both adults and
children, thus requiring early and long-term treatment. [8] Medical Management[edit
| edit source] The main aspect of medical management is pain control. Often treated
in a similar way to neuropathic pain with NSAIDs, tricyclic antidepressants,
anticonvulsants, and oral or transdermal opioids.[11] Psychological Management[edit
| edit source] Psychological problems and a lack of cooperation by the patient may
limit rehabilitation effects and increase disability.[8] Physiotherapy Management[edit
| edit source] See the Brachial Plexus Injury page for Physiotherapy Management
The aim is to maintain the range of motion of the extremity, to strengthen the
remaining functional muscles, to protect the denervated dermatomes, and to manage
pain.[11] Pain control - acupuncture, TENS Maintaining ROM - passive movements,
exercise therapy, splinting, positioning[11] Strengthen affected muscles -
biofeedback, exercise therapy Managing chronic oedema - compression garments,
advice, massage therapy Intervention Management[edit | edit source] Continuous
brachial plexus block Transcutaneous nerve stimulation Dorsal route entry zone
(DREZ) ablation or implantable dorsal route stimulators. Surgical techniques include
neurolysis, nerve grafting, and nerve transfer. Intercostal nerves are commonly used
to reinnervate muscles after a brachial plexus injury with avulsion of spinal nerve
roots.[11][12] Brachial Plexus Block[edit | edit source] A brachial plexus block allows
a surgeon to operate on an upper extremity without the use of a general anesthetic,
when combined with a tourniquet.[13] The location of the injection is between the
posterior border of the sternocleidomastoid and the clavicle. The axillary sheath
surrounds the axillary vein, axillary artery, and the three cords of the brachial
plexus. When the injection takes effect, the muscles and skin innervated by the cords
found in the sheath are anesthetized. [13] Read more here [14] Other
Information[edit | edit source] Some mnemonics for remembering the branches:
Posterior Cord Branches STAR - subscapular (upper and lower), thoracodorsal,
axillary, radial ULTRA - upper subscapular, lower subscapular, thoracodorsal, radial,
axillary Lateral Cord Branches LLM "Lucy Loves Me" - the lateral pectoral, lateral
root of the median nerve, musculocutaneous Medial Cord Branches MMMUM "Most
Medical Men Use Morphine" - medial pectoral, medial cutaneous nerve of arm,
medial cutaneous nerve of forearm, ulnar, the medial root of the median nerve
Resources[edit | edit source] Journal of Brachial Plexus and Peripheral Nerve Injury
Presentations[edit | edit source] Learn the Brachial Plexus in Five Minutes or Less
This is a great little presentation to teach you the brachial plexus through simplified
drawing. Have a go! Brachial Plexus Block and Translational Manipulation for
Adhesive Capsulitis Created by Tom Denninger & Ben Hando as part of the Evidence
in Motion, OMPT Fellowship, 2011 View the presentation Case Studies[edit | edit
source] Dahlin LB, Blackman C, Duppe H, Saito H, Chemnitz A, Abul-Kasim K, Maly
P. Compression of the lower trunk of the brachial plexus by a cervical rib in two
adolescent girls: case reports and surgical treatment. J Brachial Plex Peripher Nerve
Inj. 2009;4(14).] - FREE FULL TEXT Saliba S, Saliba EN, Pugh KF, Chhabra A,
Diduch D. Rehabilitation considerations of a brachial plexus injury with complete
avulsion of C5 and C6 nerve roots in a college football player: A Case Study. Sports
Health. 2009:1(5): 370-375. - FREE FULL TEXT Lumbar Plexus -
PhysiopediaIntroduction The lumbar plexus (LS) is a complex neural network formed
by the lower thoracic and lumbar ventral nerve roots. They are formed where T12 to
L5 exit the spinal cord via intervertebral foramina. The supply motor and sensory
innervation to the lower limb and pelvic girdle[1]. The nerves arising from the
lumbar plexus are important for functioning of the lower extremity function and
movement allowing knee extension, hip flexion and adduction of the thigh[2]. Origin
and Location[edit | edit source] The origin of the lumbar plexus is within the psoas
major muscle, anterior to the lumbar transverse processes. The dorsolumbar nerve,
which joins the anterior ramus of spinal nerve L1, contributes to the creation of the
lumbar plexus via the anterior ramus of spinal nerve T12. The iliohypogastric and
ilioinguinal nerves are derived from a single trunk formed by these roots (T12, L1).
The anterior rami of L1 and L2 each have a branch that merge to form the
genitofemoral nerve. Nerves[edit | edit source] The lumbar plexus allows nerves to
combine at different levels to create multiple functioning nerves that serve to
innervate various structures. The nerves that arise from the lumbar plexus are listed
below, from superior to inferior. The iliohypogastric nerve is created from spinal
levels T12 and L1. Sensory input: lateral gluteal area. Motor innervation: internal
oblique muscle and transverse abdominis. The ilioinguinal nerve derives from a
branch of the L1 spinal nerve. Sensory input: anterior superior and medial parts of
the thigh; males, the distal portions of the nerve become the anterior scrotal nerve
that inputs sensory fibers to the root of the penis and the superior part of the
scrotum; females, the distal portions of the nerve are the anterior labial nerves that
help to provide sensory inputs to the skin covering the mons pubis and the labia
majora. The genitofemoral nerves arise from the superior aspects of L1 and L2
spinal nerves. The nerve divides into the genital and the femoral branch. Sensory
input (genital branch): Skin of the scrotum in men and the mons pubis and labia
majora in women Sensory input (femoral branch): innervation to the anterior and
superior area of the thigh Motor innervation (genital branch): Cremaster muscle in
men The lateral femoral cutaneous nerve comes from the L2 and L3 spinal nerves.
Sensory input: It's only function is to supply sensory innervation to most of the
lateral portion of the thigh. The obturator nerve arises from L2, L3, and L4 spinal
nerves. Motor innervation: Primary motor supply to the medial (hip adductors)
muscle compartment of the thigh. [2]. The femoral nerve ranks as the largest nerve
that arises from the lumbar plexus. It is created from lumbar spinal nerves L2, L3,
and L4. It leaves the plexus and enters the femoral triangle, passing just lateral to
the femoral artery. Sensory input: anterior compartment of the thigh. A portion of
the cutaneous branch becomes the saphenous nerve - this provides sensory
innervation to the skin over the patella, and portions of the medial and anterior
aspects of the distal lower extremity. Motor innervation: There are four major
branches: muscular (motor), cutaneous, articular, and vascular. They innervate the
muscles rectus femoris, sartorius, and articularis genu. Its principal function is to
supply motor and sensory innervation to the anterior compartment of the thigh. To
remember the major branches of the lumbar plexus why not use this useful
Pneumonic? Interested In Getting Lunch On Friday Iliohypogastric Ilioinguinal
Genitofemoral Lateral femoral cutaneous Obturator Femoral Physiotherapy
Implications[edit | edit source] Damage to the lumbar plexus or nerves proximal and
distal to it can result in several pathologies. LS plexopathy can be challenging to
diagnose and manage. Ther usual symptoms include low back and/or leg pain, with
possible motor weakness, other sensory symptoms of numbness, paresthesia, and/or
sphincter dysfunction. LS plexopathy has multiple potential etiologies for example
diabetes mellitus, traumatic injury, and neoplasms. LS plexopathy can be
debilitating, severely affecting a patient's quality of life.[3] Other causes that
physiotherapists' are likly to see include: Lumbar disc herniation can cause occlusion
of the intervertebral foramen, compressing lumbar spinal nerves near their entry to
the lumbar plexus. This syndrome can cause paresthesia and weakening in the
lumbar plexus nerves' innervated locations. The lateral femoral cutaneous nerve,
which is a branch of the lumbar plexus, can cause a common and serious nerve
compression condition. This is known as meralgia paresthetica, and is caused by the
nerve becoming trapped as it passes beneath or through the inguinal ligament. In
order to accurately determine the cause of patients' pain or dysfunction, first it is
important to determine which level is affected. This will assist in choosing the right
interventions which will lead to better outcomes .Functional Anatomy of the
Cervical Spine - Physiopedia Introduction The cervical spine supports the weight of
the head and enables head and neck movement.[1] [2] Intervertebral discs maintain
the spaces between the vertebrae. These discs act like shock absorbers throughout
the spinal column to cushion the bones as the body moves. Ligaments hold the
vertebrae in place, and tendons attach the muscles to the spinal column. The cervical
spine is subjected to a range of extrinsic factors such as repetitive movements,
whole-body vibrations and static load.[3] Cervical spine Key Terms[edit | edit source]
Axes: lines around which an object rotates. The rotation axis is a line that passes
through the centre of mass. There are three axes of rotation: sagittal passing from
posterior to anterior, frontal passing from left to right, and vertical passing from
inferior to superior. The rotation axes of the foot joints are perpendicular to the
cardinal planes. Therefore, motion at these joints results in rotations within three
planes. Example: supination involves inversion, internal rotation, and plantarflexion.
Bursae: reduce friction between the moving parts of the body joints. A bursa is a
fluid-filled sac. There are four types of bursae: adventitious, subcutaneous, synovial,
and sub-muscular. Capsule: one of the characteristics of the synovial joints. It is a
fibrous connective tissue which forms a band that seals the joint space, provides
passive and active stability and may even form articular surfaces for the joint. The
capsular pattern is "the proportional motion restriction in range of motion during
passive exercises due to tightness of the joint capsule." Closed pack position: the
position with the most congruency of the joint surfaces. In this position, joint stability
increases. For example, the closed pack position for the interphalangeal joints is full
extension. Degrees of freedom: the direction of joint movement or rotation; there is a
maximum of six degrees of freedom, including three translations and three rotations.
Ligament: fibrous connective tissue that holds the bones together. Open (loose) pack
position: position with the least joint congruency where joint stability is reduced.
Planes of movement: describe how the body moves. Up and down movements
(flexion/extension) occur in the sagittal plane. Sideway movements
(abduction/adduction) occur in the frontal plane. The transverse plane movements
are rotational (internal and external rotation). Cervical Spine Structure[edit | edit
source] Cervical Vertebrae[edit | edit source] There are seven cervical vertebrae,
which are known as C1-C7. Their role is to support the head and neck and to promote
head movement. The cervical spine is only exposed to small weight-bearing loads.
Therefore, the cervical vertebral bodies do not need to be large and "an increased
range of motion takes priority over vertebral size and rigidity".[2] However, because
of this increased range of motion at the cervical spine, there is a heightened injury
risk for the spinal cord and the associated neurovascular structures.[2] The cervical
vertebral bodies (C3-C6) have unique characteristics:[2][4] vertebral bodies are
smaller compared to the rest of the spine vertebral foramen is triangular spinous
process is bifid (i..e. it splits into two distally) there are openings in the transverse
processes which allow passage for the vertebral artery, vein, and sympathetic nerves
The Atlas (C1), Axis (C2) and C7 have further distinguishing features: Atlas (C1) has
no vertebral body or spinous process instead, it has lateral masses for articulation
with the occiput of the head and the second cervical vertebra (the Axis) Atlas - C1
Axis (C2) has a bony projection from the anterior portion called the dens, or the
odontoid process, which articulates with the atlas it is the primary weight-bearing
bone of upper cervical region Axis - C2 C7 singular spinous process larger spinous
process spinous process is not bifid C3-C6 **In supine, it may be difficult to palpate
the spinous process of C3-C6 in individuals with normal cervical lordosis.
Intervertebral Discs (IVD)[edit | edit source] The intervertebral discs make up 25% of
the height of the entire spine. However, in the cervical region, they make up 40% of
the height. This increased height relative to vertebral body height provides a mobility
advantage.[5] The nucleus pulposus of the cervical discs is gelatinous in children and
young people. However, it dries out by the age of 30 years and becomes a firm,
fibrocartilaginous plate.[6] Intervertebral disc The following are characteristics of
the cervical spine intervertebral discs: thicker anteriorly than posteriorly concave
superior surface convex inferior surface movement limited by the uncinate process
anteroposterior translation does occur ** Due to the location of the uncinate process,
posterolateral disc herniations are less frequent. Cervical Lordosis[edit | edit source]
Typically, the cervical spine has a lordotic curvature. A lordotic posture can resist
large compressive loads. It also helps to decrease stress on vertebral end plates.
Compressive loads are distributed differently in the cervical spine than in the
thoracic and lumbar spine. In the cervical spine, the anterior column absorbs 36% of
the load, and the posterior facet (zygapophyseal) joints absorb 64%.[7] Kinematics
and Joints of the Cervical Spine[edit | edit source] Range of Motion in Cervical Spine
The cervical spine is the most mobile part of the vertebral column. Flexion range of
motion is usually around 40 degrees, and extension is around 50 degrees. The largest
contributors to flexion/extension are: C4/C5 and C5/C6 in sitting C6/C7 in supine
C7/T1 contributes the least to flexion/extension. Lateral flexion range of motion is
normally close to 30 degrees. C3/C4 and C6/C7 allow for the most movement in this
plane of motion. Cervical rotation range of motion is usually close to 70 degrees.
Flexibility in this plane is mainly achieved through the C1/C2 segment.[8] Joints of
the Cervical Spine[5][9] Joint Location/Articulations Function
Orientation/Composition Intervertebral Disc Joint Between the vertebral bodies Bear
weight Facilitate motion Absorb shock Facet (Zygapophyseal) Joints Formed by
articulations between the superior and inferior articular processes of adjacent
vertebrae Guide motion at the segmental level Determine the direction of motion
Upper cervical spine = horizontal Lower cervical spine = more vertical
Uncovertebral Joint Between the five lower cervical vertebral bodies Anteromedially
to the nerve root Posteromedially to the vertebral artery Control movement Limit
lateral flexion Atlanto-Axial Joint Between the atlas and axis Two lateral: interior
facets of the lateral masses of C1 and superior facets of C2 One medial: between the
dens of C2 and the articular facet of C1 Cervical rotation (60% of cervical rotation
occurs at this joint) Lateral: plane-type synovial joint Medial: pivot-type synovial joint
Atlanto-Occipital Joint Between the spine and cranium Between the superior facets of
the lateral masses of the atlas and the occipital condyles Flexion and extension of the
head on the neck Lateral flexion Condyloid-type synovial joint Spinal Ligaments[edit |
edit source] Ligaments present throughout the entire vertebral column: Anterior
longitudinal ligament: anterior surface of the vertebral bodies; limits extension of the
spine Posterior longitudinal ligament: posterior surface of the vertebral bodies; limits
flexion of the spine Ligamentum flavum: connects the laminae of each vertebrae;
series of short ligaments Intertransverse ligament: a series of short ligaments that
connect the laminae of each vertebrae; preserves upright posture and prevents
hyperflexion of the spine[10] Ligaments Unique to the Cervical Spine Ligament
Origin Insertion Role/Function Nuchal ligament Occiput Tips of the spinous process
from C1-C7 Limits hyperflexion Transverse ligament Attaches to lateral masses of
atlas Anchors dens in place Apical ligament Dens of the axis Foramen magnum
Connects the dens of the axis to the foramen magnum Stabilises the skull on the
spine Alar ligament Dens of the axis Occiput Connects the dens of the axis to the
occiput Limits atlanto-axial rotation Cruciform or cruciate ligament 1. Superior
longitudinal band 2. Inferior longitudinal band 3. Transverse band Superior:
transverse band Inferior: transverse band Transverse: dens of the axis Superior:
foramen magnum Inferior: second vertebral body Transverse: between the lateral
masses of the atlas Holds dens in place ** ligaments in spinal column Muscles of the
Cervical Spine[edit | edit source] The muscles of the cervical spine can be divided by
location or by function. Anterior vertebral muscles Anterior (Prevertebral) Vertebral
Muscles[edit | edit source] Rectus capitis anterior Rectus capitis lateralis Longus
capitis Longus colli/ Longus cervicis (3 portions: superior oblique, inferior oblique,
vertical) These muscles are also known as the deep cervical (neck) flexors. Lateral
Vertebral Muscles[edit | edit source] Scalenes anterior middle posterior minimus (not
always present) Lateral view of cervical muscles Posterior Vertebral Muscles[edit |
edit source] These can be further divided into intrinsic and extrinsic muscles.
Extrinsic muscles[edit | edit source] Trapezius Levator scapulae Intrinsic
muscles[edit | edit source] Posterior muscles of the cervical spine Superficial
muscles : splenius capitis splenius cervicis Deep muscles: suboccipital group rectus
capitis posterior major rectus capitis posterior minor obliquus capitis inferior
obliquus capitis superior transversospinalis muscles semispinalis capitis semispinalis
cervicis rotatores cervicis multifidus (these are also known as deep neck extensors)
interspinales and intertransversarii Movement[edit | edit source] Motion Flexion
Extension Lateral Flexion Rotation Muscles Longus colli Sternocleidomastoid Scalene
anterior Longus capitis Rectus capitis anterior (head only) Iliocostal cervicis Splenius
cervicis Splenius capitis Trapezius Erector spinae Rectus capitis posterior, major and
minor (head only) Sternocleidomastoid Longissimus capitis Spinalis capitis Scalene
anterior, medius and posterior Sternocleidomastoid Splenius capitis Trapezius
Erector spinae Rectus capitis lateralis (head only) Spinalis capitis Semispinalis
cervicis Multifidus Scalene anterior Splenius cervicis and capitis
Sternocleidomastoid Inferior oblique (head only) Rectus captitis posterior major
(head only) Longissius capitis Spinalis capitis [11] The following tables identify the
origin, insertion, innervation and action of key cervical muscles. Muscles with
multiple functions are repeated in the relevant tables. Cervical Spine Flexors[edit |
edit source] Muscle Origin Insertion Innervation Action Rectus capitis anterior
Lateral mass and transverse process of atlas (C1) Basilar part of occipital bone
Anterior rami of 1st and 2nd cervical spinal nerves (C1, C2) Flexion of the head at
the atlanto-occipital joint Longus colli Transverse processes of C3-C5 and the
vertebral bodies of C5-T3 Anterior tubercle of C1, the vertebral bodies of C2-C4, and
the transverse processes of C5 and C6. Anterior rami of the 2nd to 6th cervical spinal
nerves (C2-C6) Unilateral contraction: neck lateral flexion (ipsilateral), neck rotation
(contralateral) Bilateral contraction: neck flexion Longus capitis Transverse
processes of C3-C6 Occipital bone Anterior rami of 1st to 3rd cervical spinal nerves
(C1-C3) Unilateral contraction: rotation of the head (ipsilateral) Bilateral contraction:
flexion of the head and neck Anterior scalene Transverse processes of C3-C6 First rib
Anterior rami of 4th to 6th cervical spinal nerves (C4-C6) Unilateral contraction:
neck lateral flexion (ipsilateral), neck rotation (contralateral), elevation of the first
rib Bilateral contraction: neck flexion Accessory muscle of respiration
Sternocleidomastoid Manubrium and the medial portion of the clavicle Mastoid
process of the temporal bone Accessory nerve (CN XI), branches of cervical plexus
(C2-C3) Unilateral contraction: ipsilateral lateral flexion, elevation of the chin,
contralateral rotation of head Bilateral contraction: flexes the neck, extension of the
upper vertebral joints, extension of the neck and head, elevation of the head,
elevation of the sternum and clavicle, expansion of the thoracic cavity Rectus capitis
lateralis Transverse process of atlas (C1) Jugular process of occipital bone Anterior
rami of 1st and 2nd cervical spinal nerves (C1-C2) Lateral flexion of the head
(ipsilateral) Neck flexion Stabilisation of the atlanto-occipital joint Cervical Spine
Extensors[edit | edit source] Muscle Origin Insertion Innervation Action Obliquus
capitis superior Transverse process of the atlas Occipital bone Suboccipital nerve
(posterior ramus of 1st cervical spinal nerve (C1)) Bilateral contraction: head
extension Unilateral contraction: rotation of head to the ipsilateral side Stabilises the
atlanto-occipital joint during head movements Obliquus capitis inferior Spinous
process of the axis Tansverse process of atlas Suboccipital nerve (posterior ramus of
1st cervical spinal nerve (C1)) Bilateral contraction: head extension Unilateral
contraction: rotation of head to the ipsilateral side Stabilises the atlanto-axial joint
Rectus capitis posterior major Spinous process of C2 Occipital bone Suboccipital
nerve (posterior ramus of 1st cervical spinal nerve (C1)) Unilateral contraction: head
rotation (ipsilateral) Bilateral contraction: head extension Rectus capitis posterior
minor Posterior tubercle of the atlas Occipital bone Suboccipital nerve (posterior
ramus of 1st cervical spinal nerve (C1)) Head extension Iliocostal cervicis Ribs 3-6
Transverse process of C4-C6 Dorsal rami of the upper thoracic and lower cervical
spinal nerves Laterally flexes and extends the lower cervical region Trapezius
Occipital bone, nuchal ligament and spinous process C7-T12 Lateral third of the
clavicle, acromian and spine of the scapula Spinal root of accessory nerve (CN XI)
(motor) Cervical nerves (C3 and C4) (pain and proprioception) Supports the spinal
column to remain erect Neck extension when scapulae are fixed Ipsilateral lateral
flexion of neck Splenius cervicis Spinous process of T3-T6 Transverse process of C1-
C3 Dorsal rami of cervical spinal nerves (C5-C8) Acting bilaterally: extend the neck
Acting unilaterally: lateral flexion and rotation of the head and neck to the ipsilateral
side Splenius capitis Spinous process of C7-T3 and nuchal ligament Occipital bone
Posterior rami of the 2nd and 3rd cervical spinal nerves Acting bilaterally: extension
of the head and neck Acting unilaterally: lateral flexion and rotation of the head and
neck to the ipsilateral side Spinalis capitis Spinous process of C7 and T1 Occipital
bone Dorsal rami of spinal nerves Acting bilaterally: extension of the neck Acting
unilaterally: ipsilateral lateral flexion and rotation of the neck Longissimus capitis
Transverse process of upper 4 thoracic vertebrae and articular process lower three
cervical vertebrae Mastoid process Posterior/dorsal rami of spinal nerves Acting
bilaterally: extension of neck Acting unilaterally: ipsilateral lateral flexion and
rotation of the neck ** The transversospinal muscles (rotatores, multifidus,
semispinalis) are the deep muscle of the spine. They attach between the transverse
and spinous process of the vertebrae. They stabilise and extend the spine. The
rotatores also provide rotation. Cervical Spine Lateral Flexors[edit | edit source]
Muscle Origin Insertion Innervation Action Splenius cervicis Spinous process of T3-
T6 Transverse process C1-C3 Dorsal rami of cervical spinal nerves (C5-C8) Acting
unilaterally: lateral flexion and rotation of the head and neck to the ipsilateral side
Acting bilaterally: extend the neck Splenius capitis Spinous process of C7-T3 and
nuchal ligament Occipital bone Posterior rami of the 2nd and 3rd cervical spinal
nerves Acting unilaterally: lateral flexion of the head and neck and rotation of the
head to the ipsilateral side Acting bilaterally: extension of the head and cervical
spine Sternocleidomastoid Manubrium and the medial portion of the clavicle Mastoid
process of the temporal bone Accessory nerve (CN XI), branches of cervical plexus
(C2-C3) Unilateral contraction: ipsilateral lateral flexion, elevation of the chin,
contralateral rotation of head Bilateral contraction: flexes the neck, extension of the
upper vertebral joints, extension of the neck and head, elevation of the head,
elevation of the sternum and clavicle, expansion of the thoracic cavity Anterior
scalene Transverse processes of C3-C6 First rib Anterior rami of 4th to 6th cervical
spinal nerves (C4-C6) Unilateral contraction: neck lateral flexion (ipsilateral), neck
rotation (contralateral), elevation of the first rib Bilateral contraction: neck flexion
Accessory muscle of respiration Middle scalene Posterior tubercles of the transverse
processes of C1-C7 Scalene tubercle of the first rib Anterior rami of C3-C8 Elevation
of the first rib Ipsilateral contraction causes ipsilateral lateral flexion of the neck
Respiration Posterior scalene Posterior tubercles of the transverse processes of C4-
C6 2nd rib Anterior rami of C6-C8 Elevation of the second rib Ipsilateral lateral
flexion of the neck Respiration Trapezius Occipital bone, nuchal ligament and
spinous process C7-T12 Lateral third of the clavicle, the acromian and the spine of s
scapula Spinal root of accessory nerve (CN XI) (motor) Cervical nerves (C3 and C4)
(pain and proprioception) Supports the spinal column to remain erect Neck extension
when scapulae are fixed Ipsilateral lateral flexion of the neck Rectus capitis lateralis
Superior surface of the transverse process of atlas Inferior surface of the jugular
process of the occipital bone Anterior rami of C1-C2 spinal nerves Lateral flexion of
the head (ipsilateral) Deep neck flexion Stabilisation of the atlanto-occipital joint
Spinalis capitis Spinous process of C7 and T1 Occipital bone Dorsal rami of spinal
nerves Acting bilaterally: extension of the neck Acting unilaterally: ipsilateral lateral
flexion and rotation of the neck Longissimus capitis Transverse process of upper 4
thoracic vertebrae and articular process lower three cervical vertebrae Mastoid
process Posterior/dorsal rami of spinal nerves Acting bilaterally: extension of the
neck Acting unilaterally: ipsilateral lateral flexion and rotation of the neck Cervical
Spine Rotators[edit | edit source] Muscle Origin Insertion Innervation Action Rectus
capitis posterior major Spinous process of C2 Occipital bone Suboccipital nerve
(posterior ramus of 1st cervical spinal nerve (C1)) Unilateral contraction: head
rotation (ipsilateral) Bilateral contraction: head extension Rectus capitis posterior
major Spinous process of C2 Occipital bone Suboccipital nerve (posterior ramus of
1st cervical spinal nerve (C1)) Unilateral contraction: head rotation (ipsilateral)
Bilateral contraction: head extension Sternocleidomastoid Manubrium and the medial
portion of the clavicle Mastoid process of the temporal bone Accessory nerve (CN
XI), branches of cervical plexus (C2-C3) Unilateral contraction: ipsilateral lateral
flexion, elevation of the chin, contralateral rotation of head Bilateral contraction:
flexion of the neck, extension of the upper vertebral joints, extension of the neck and
head, elevation of the head, elevation of the sternum and clavicle, expansion of
thoracic cavity Splenius capitis Spinous process ofC7-T3 and nuchal ligament
Occipital bone Posterior rami of the 2nd and 3rd cervical spinal nerves Acting
unilaterally: lateral flexion of the head and neck and rotation of the head to the
ipsilateral side Splenius cervicis Spinous process T3-T6 Transverse process C1-C3
Dorsal rami of cervical spinal nerves (C5-C8) Acting unilaterally: lateral flexion and
rotation of the head and neck to the ipsilateral side Spinalis capitis Spinous process
of C7 and T1 Occipital bone Dorsal rami of spinal nerves Acting bilaterally: extension
of the neck Acting unilaterally: ipsilateral lateral flexion and rotation of the neck
Longissimus capitis Transverse process of upper 4 thoracic vertebrae and articular
process lower three cervical vertebrae Mastoid process Posterior/dorsal rami of
spinal nerves Acting bilaterally: extension of the neck Acting unilaterally: ipsilateral
lateral flexion and rotation of the neck Innervation of the Cervical Spine[edit | edit
source] Nerves originating from the cervical plexus innervate the muscles of the
neck. Each nerve root in the cervical spine exits above its corresponding nerve root.
There are eight pairs of cervical nerves despite there being seven cervical vertebrae.
The C8 nerve root exits below the seventh cervical vertebra. The accessory nerve,
which is cranial nerve XI innervates sternocleidomastoid and trapezius.[2] Nerve
Motor Sensory C1 Flexion of the head and neck Rectus capitus anterior and lateralis,
longus capitis C2 Flexion of the head and neck Rectus capitus anterior and lateralis,
longus capitus, prevertebral muscles and sternocleidomastoid Lateral occiput and
submandibular area C3 Head and neck flexion and rotation Longus capitus, longus
colli, prevertebral muscles and sternocleidomastoid, diaphragm, levator scapulae,
trapezius and scalenus medius Lateral occiput and lateral neck, overlapping C2 C4
Head and neck flexion and rotation Longus capitus, longus colli, levator scapulae,
scaleni, trapezius, diaphragm Lower lateral neck and medial shoulder area C5
Deltoid, biceps, bicep tendon reflex Clavicle level and lateral arm C6 Biceps, wrist
extensors (brachioradialis tendon reflex) Lateral forearm, thumb, index and half of
2nd finger C7 Wrist flexors, triceps (triceps tendon reflex) Second finger C8 Finger
flexors, interossei Medial forearm, ring and little finger T1 Interossei Medial arm
Vascular Supply of the Cervical Spine[edit | edit source] Vertebral arteries, veins and
nerves pass through the transverse foramina of the cervical vertebrae except for in
C7, where the vertebral artery passes around the vertebra instead of through the
transverse foramen.[4] The neural components sit posterior to the vertebral artery.
[12] The cervical spine vascular supply is primarily provided by the vertebral arteries
on each side of the spine. These arteries arise from the subclavian arteries, which
originate directly from the arch of the aorta on the right and the brachiocephalic
trunk on the left. ** The common carotid artery bifurcates into the internal and
external carotid arteries at the C3 segmental level. Only the external carotid artery
provides any blood supply to the neck. Clinical Relevance[edit | edit source] Atlanto-
axial instability (AAI) can have serious neurological consequences: conditions with
the potential for AAI include: rheumatoid arthritis Down syndrome: laxity in the
transverse ligament is present in 14-22% of individuals with Down syndrome. A tight
sternocleidomastoid muscle can cause torticollis. Disc herniation: disc herniations in
the cervical spine are a lot less common than in the lumbar spine typical locations:
C5-C6 C6-C7 Because the prevertebral cervical muscles stabilise the neck,
dysfunction in these muscles can cause cervicogenic pain Trigger points that develop
in the suboccipital muscles can refer pain to the head, causing cervicogenic
headaches[10] Resources[edit | edit source] Functional Anatomy of the Thoracic
Spine and Rib Cage Functional Anatomy of the Lumbar Spine and Abdominal Wall
Cervical Deep Neck Extensors Cervical Deep Neck Flexors Sacral Plexus -
PhysiopediaDescription Sacral Plexus The sacral plexus is situated on the
posterolateral wall of the pelvic cavity, lying anterior to the Piriformis. The sacral
contributions pass out of the anterior sacral foramina and course laterally &
inferiorly on the pelvic wall. A majority of the nerves originating from the sacral
plexus pass through the greater sciatic foramen - inferior to the piriformis muscle -
and enter the gluteal region of the lower limb. The remaining follow various courses
or do not leave the pelvic cavity.[1] Root[edit | edit source] The sacral plexus is
formed by the anterior rami of S1 to S4 as well as the lumbosacral trunk (anterior
ramus of L4 & L5). The lumbosacral trunk courses vertically into the pelvic cavity
from the abdomen and pass immediately anterior to the sacroiliac joint.
Branches[edit | edit source] The sacral plexus provides motor and sensory
innervation through the following nerves: Sciatic Nerve (L4 - S3) Pudendal Nerve
(ventral divisions of S2 - S4) Superior Gluteal Nerve (dorsal divisions of L4 - S1)
Inferior Gluteal Nerve (dorsal divisions of L5 - S2) Nerve to Obturator Internus
(ventral divisions of L5 - S2) Nerve to Quadratus Femoris Posterior Femoral
Cutaneous Nerve Perforating Cutaneous Nerve Nerve to Piriformis Obturator Nerve
(L2 - L4) Clinical relevance[edit | edit source] Lesions of the sacral plexus can be
caused by pelvic fractures, hip surgery, malignant infiltration, local radiotherapy,
and the use of orthopaedic traction tables. These lesions are usually unilateral and
do not result in significant sexual dysfunction unless the sensory symptoms become
disruptive.[2] Cancers can invade the sacral plexus causing pain radiating pain
syndromes similar to sciatic nerve lesions.[3] Numbness in the perianal region as
well as involvement of sympathetic fibers causing "hot and dry foot" [4] can be found.
The sacral plexus can be entrapped by the fetal head at the pelvic brim during the
final trimester of pregnancy or labour. The clinical syndrome will resemble an L5
radiculopathy and symptoms will usually resolve completely on its own 4 - 6 months
post-birth. [5] Assessment[edit | edit source] Sensory testing has moderate sensitivity
in the detection of lumbo-sacral radiculopathy prior knowledge of MRI results is a
source of bias in sensory testing In clinical practice, diagnosis of lumbo-sacral
radiculopathy should always be reached through the combined use of sensory, motor,
and deep tendon reflex tests - not through single test results.[6] Treatment[edit | edit
source] Physiotherapy [7] - patients with severe neuropathic incontinence should
first undergo intensive conservative management including physiotherapy/pelvic
floor retraining (biofeedback) before surgical treatment is considered. Sacral Nerve
Stimulation [8] - there is good emerging evidence for treatment of patients with end-
stage faecal incontinence Resources[edit | edit source] [9] Brachial Plexus Injury -
PhysiopediaIntroduction Brachial Plexus (BP) injuries range in severity and cause.
The effects may be mild or severe. Unfortunately traumatic incidences of BP injuries
are on the rise, often leading to severe social and financial hardships, and greatly
affecting quality of life (QOL). This page outlines the main issues arising from BP
injuries and the rationale behind their management.[1] Historical note : Homer
(approx. 800 BC) depicted a battle in The Illiad which involved Hector striking
Teucer over the clavicle with a rock and preventing him from wielding his bow.[2]
Function[edit | edit source] Brachial plexus is the network of nerves which runs
through the cervical spine, neck, axilla and then into arm or it is a network of nerves
passing through the cervico axillary canal to reach the axilla, and innervates the
brachium (upper arm), antebrachium (forearm) and the hand. It is a somatic nerve
plexus formed by intercommunications among the ventral rami (roots) of the lower 4
cervical nerves (C5-C8) and the first thoracic nerve (T1). The brachial plexus is
responsible for cutaneous and muscular innervation of the entire upper limb, with
two exceptions: the trapezius muscle innervated by the spinal accessory nerve (CN
XI) and an area of skin near the axilla innervated by the intercostobrachial nerve.
Clinical Anatomy[edit | edit source] The plexus consists of roots, trunks, divisions,
cords and branches. Roots[edit | edit source] These consist of the anterior primary
rami of spinal nerves C5 - C8 and T1 with contributions from the anterior primary
rami of C4 and T2. The origin of the plexus may shift one segment either upward or
downward resulting in a pre-fixed plexus or post-fixed plexus respectively. In a
prefixed plexus, the contribution by C4 is large, and in that form T2 is often absent.
In a post-fixed plexus, the contribution by T1 is large, T2 is always present, C4 is
absent, and C5 is reduced in size.[3] The roots join to form trunks as follows:
Trunks[edit | edit source] Upper trunk is formed by C5 & C6 Middle trunk is formed
by C7 Lower trunk is formed by C8 & T1 Divisions (of the trunk)[edit | edit source]
Each trunk divides into ventral and dorsal divisions (which ultimately supply the
anterior and posterior aspects of the limb). These divisions join to form cords. Cords
(it forms 3 cords)[edit | edit source] The Posterior Cord is formed from the three
posterior divisions of the trunks (C5-C8,T1) The Lateral Cord is the anterior divisions
from the upper and middle trunks (C5-C7) The Medial Cord is simply a continuation
of the anterior division of the lower trunk (C8,T1) Branches[edit | edit source] The
specific branches of each cord can be seen on this page Mechanism of injury[edit |
edit source] Injury to brachial plexus can occur in many ways. These include, contact
sports, motor vehicle accidents, or during birth. Grossly, it can be divided into:
Traumatic, e.g motor vehicle accident, contact sports Non traumatic, e.g. obstetric
palsy and Parsonage-Turner Syndrome The network of nerves is fragile and can be
damaged by stretching, pressure, or cutting. Stretching can occur when the head and
neck are forced away from the shoulder, which could happen in a fall from a
motorcycle. If severe enough, the nerves can actually avulse, or tear out of their
roots in the neck. Pressure could occur from crushing of the brachial plexus between
the collarbone and first rib, or swelling in this area from injured muscles or other
structures [4]. The former examples of events are caused by one of two mechanisms
that remain constant during the injury. [5] The two mechanisms that can occur are
'traction' and 'heavy impact' [6]. These two methods disturb the nerves of the
brachial plexus and cause the injury [7]. Traction: Traction, also known as stretch
injury, is a mechanism that causes brachial plexus injury. The nerves of the brachial
plexus are damaged due to the forced pull by the widening of the shoulder and neck.
Traction occurs from severe movement and causes a pull or tension among the
nerves. There are two types of traction: downward traction, and upward traction. In
downward traction there is tension of the arm which forces the angle of the neck and
shoulder to become broader. This tension is forced and can cause lesions of the
upper roots and trunk of the nerves of the brachial plexus. Upward traction also
results in the broadening of the angle between the arm and chest as occurs when the
arm and shoulder are forced upward, with the nerves of T1 and C8 are torn away.[8]
[9] Impact: Heavy impact to the shoulder is the second common mechanism for
brachial plexus injury. Depending on the severity of the impact, lesions can occur at
all nerves in the brachial plexus. The location of impact also affects the severity of
the injury, and depending on the location the nerves of the brachial plexus may be
ruptured or avulsed. Some forms of impact that cause injury to the brachial plexus
are shoulder dislocation, clavicle fractures, hyperextension of the arm, and
sometimes delivery at birth. [10] During the delivery of a baby, the shoulder of the
baby may graze against the pelvic bone of the mother. During this process, the
brachial plexus can experience damage which results in injury. This is very low
compared to the other identified brachial plexus injuries.[11] Classification of
injuries[edit | edit source] There are three types of classification systems for brachial
plexus injuries, with many classification systems. The various classifications of
brachial plexus injury are as follows: Leffert Classification System[edit | edit source]
Leffert Classification System (based on etiology and level of injury): I Open (usually
from stabbing) II Closed (usually from motorcycle accident) IIa Supraclavicular
Preganglionic: avulsion of nerve roots, usually from high speed injuries with other
injuries and LOC no proximal stump, no neuroma formation (neg Tinel's)
pseudomeningocele, denervation of neck muscles are common Horner's sign (ptosis,
miosis, anhydrosis) Postgangionic: roots remain intact; usually from traction injuries;
there are proximal stump and neuroma formation (pos Tinel's) deep dorsal neck
muscles are intact, and pseudomeningoceles will not develop; Infraclavicular lesion:
usually involves branches from the trunks (supraclavicular); function is affected
based on trunk involved III Radiation induced IV Obstetric IVa Erb's (upper root) -
waiter's tip hand; IVb Klumpke (lower root) Millesi Classification System[edit | edit
source] Millesi Classification System: [12] I: supraganglionic/preganglionic II:
infraganglionic/postganglionic III: trunk IV: cord. Classification on anatomical
location of injury Classification on Anatomical Location of Injury[edit | edit source]
Upper plexus palsy (Erb’s palsy in the OBPI cases) involves C5-C6+/-C7 roots[13][14]
Lower plexus palsy (Klumpke’s palsy) involves C8-T1 roots (and sometimes also C7)
Total plexus lesions involve all nerve roots C5-T1 Some authors have included a
fourth type, an intermediate type that primarily involves the C7 root.[15][16]
Injuries[edit | edit source] [17] Injuries to roots, trunks, and cords of the brachial
plexus produce characteristic defects which are as follows: [3] Erb's Paralysis[edit |
edit source] Site of Injury[edit | edit source] The region of the upper trunk of the
brachial plexus is called Erb's point. Six nerves meet here. Injury to the upper trunk
causes Erb's Paralysis. Causes of Injury[edit | edit source] Undue separation of the
head from the shoulder, which is commonly encountered in Birth injury Fall on
shoulder During anaesthesia Nerve Roots Involved[edit | edit source] Mainly C5
Partly C6 Muscles Paralysed[edit | edit source] Mainly: biceps, deltoid, brachialis,
and brachioradialis. Partly: supraspinatus, infraspinatus, and supinator
Deformity[edit | edit source] Arm: Hangs by the side, adducted and medially rotated
Forearm: Extended and pronated The deformity is known as "Policeman's tip hand"
or "Porter's tip hand" Disability[edit | edit source] Abduction and lateral rotation of
the arm. Flexion and supination of forearm. Biceps and supinator jerks are lost.
Sensations are lost over a small area over the lower part of the deltoid. Klumpke's
Paralysis[edit | edit source] Site of Injury[edit | edit source] Injury to the Lower trunk
of the brachial plexus is called Klumpke Paralysis. Cause of Injury[edit | edit source]
Undue abduction of the arm, as in clutching a tree branch with the hand during a fall
from a height, or sometimes in a birth injury. Nerve Roots Involved[edit | edit source]
Mainly T1 Partly C8 Muscles Paralysed[edit | edit source] Intrinsic muscles of the
hand (T1) Ulnar flexors of the wrist and fingers (C8). Deformity[edit | edit source]
Claw hand (position of the hand) due to the unopposed action of the long flexors and
extensors of the fingers. In a claw hand there is hyperextension at the
metacarpophalangeal joints and flexion at the interphalangeal joints. Disability[edit |
edit source] Claw hand Cutaneous anaesthesia and analgesia in a narrow zone along
the ulnar border of the forearm and hand. Horner's syndrome: ptosis, miosis,
anhydrosis, enophthalmos, and loss of ciliospinal reflex - may be associated. This is
because of injury to sympathetic fibres to the head and neck that leave the spinal
cord through nerve T1. Vasomotor changes: The skin areas with sensory loss is
warmer due to arteriolar dilation. It is also drier due to the absence of sweating as
there is loss of sympathetic activity. Tropic changes: Long standing case of paralysis
leads to dry and scaly skin. The nails crack easily with atrophy of the pulp of fingers.
Injury to Lateral Cord[edit | edit source] Cause[edit | edit source] Dislocation of
humerus associated with others. Nerve Involved[edit | edit source]
Musculocutaneous, lateral root of median nerve. Muscles Paralysed[edit | edit
source] Biceps Coracobrachialis All muscles supplied by the median nerve, except
those of hand. Deformity and Disability[edit | edit source] Midprone forearm Loss of
flexion of forearm Loss of flexion of the wrist Sensory loss on the radial side of the
forearm Vasomotor and trophic changes. Injury to Medial Cord[edit | edit source]
Cause[edit | edit source] Subcoracoid dislocation of humerus. Nerves Involved[edit |
edit source] Ulnar, Medial root of median nerve. Muscles Paralysed[edit | edit
source] Muscles supplied by ulnar nerve Five muscles of the hand supplied by the
median nerve. Deformity and Disability[edit | edit source] Claw hand Sensory loss on
the ulnar side of the forearm and hand Vasomotor and tropic changes as a bone
Physiotherapy Treatment[edit | edit source] Physiotherapy treatment for Brachial
Plexus Injury varies significantly according to the type and severity of the injury. In
mild cases physiotherapy and rehabilitation will assist recovery, while in more severe
cases surgery and bracing may be needed.[18] The goal always stays constant, to
return to previous level of function and preventing potential disability. Physiotherapy
Treatment Aims[edit | edit source] Development of strength, flexibility, stamina, and
co-ordination Maintaining ROM via passive movements, exercise therapy, splinting
and positioning, and protection of denervated dermatomes.[19] Functional training
and adoption adaptive devices if needed.[20] Pain control via acupuncture and TENS
Managing chronic oedema via education, compression garments, and massage
therapy.[19] A systematic review indicated that physiotherapy interventions like
constraint-induced movement therapy, kinesiotaping, electrotherapy, virtual reality
simulation, and use of splints or orthotics have positive outcomes for the affected
upper limb functionality in obstetric brachial palsy from 0 to 10 years.[21] The video
clips below highlight the scope of treatment that may be undertaken for the various
respective injuries: The following video shows treatment for an infant with brachial
plexus injury. [22] [23] [24] [25] [26] The following video shows treatment methods
that may be employed after a Vespa scooter accident. [27] This video shows
treatment that may occur following a simple over stretching of the brachial plexus.
[28] This video demonstrates that BP neuromobility stretching could be used in the
rehabilitation of sporting BP injuries. Neuromobilty places an important role in
eliminating pain and restoring function. [29] Physiotherapy Following Surgery for
Brachial Plexus Injury[edit | edit source] Surgery is an option for severe brachial
plexus injuries, and to be viable should occur within certain timeframes. Surgery
aims to regain function by surgical repair. This can take the form of nerve grafts,
nerve transfers, or both, and possible musculoskeletal reconstruction.[20]
Physiotherapists are crucial in the rehabilitative phase post-surgery in the restoring
of function via strength, co-ordination, flexibility, ROM, power, and use of splinting if
needed. The client needs to be aware that the rehabilitation duration will be for some
year(s), and not weeks.[20] The video clips below are examples of use of allografts
and autografts. These complex procedures will need intensive physiotherapy after to
restore the arm to the most optical outcome. [30] [31] Medical Management -
Implications for Physiotherapy[edit | edit source] Pain management is often a major
issue. Significant pain occurs with root avulsions, causing neuropathic pain. Severe
pain will also exhaust the client, and if not treated appropriately will hinder
physiotherapy rehabilitation. This is when drugs, such as NSAIDs and opioid drugs,
should be used during the first stages (but not with neuropathic chronic pain).
Neuropathic pain requires careful use of anti-epileptic drugs (gabapentin and
carbamazepine) or antidepressants such as amitriptyline. However, less than a third
of clients report significant pain relief with this approach.[1] Physiotherapy may offer
an additional source of pain relief with use of TENS, biofeedback, acupuncture, and
pain neuroscience education (PNE). [1] Dorsal Root Entry Zone (DREZ) operation is
an option for persistent pain. The operation aims to destroy the nerve signal
transmission from the secondary central sensory centrally. Spinal Cord Stimulator
(SCS) used to mask pain signals before they reach the brain, similar to TENS, but
involves a small device and wires being inserted under the skin.[32] Cervical SCS
can be an effective form of treatment for patients with neuropathic pain from a
brachial plexus avulsion[33]. Psychological Management[edit | edit source]
Psychological problems and a lack of cooperation by the patient may limit
rehabilitation effects and increase disability.[8] Funny Fact........What are armies for?
To hang your handy's from! see also Nerve Injury Rehabilitation Physiotherapy

References
1. ↑ Jump up to:1.0 1.1 1.2 Jarvis, Rajan, R. S., & Roberts, A. (2022). The cervical
plexus. BJA Education, 23(2), 46–51.
https://doi.org/10.1016/j.bjae.2022.11.008 Last assessed: 15/12/2024
2. ↑ fatcat2983472. Cervical Plexus Drawing SO GOOD!!!. Available
from: http://www.youtube.com/watch?v=Oj9J9b8FIIg [last accessed
12/02/16]
3. ↑ Jump up to:3.0 3.1 3.2 3.3 3.4 3.5 Thompson JC (2010). Netter's Concise Orthopaedic
Anatomy (2nd ed). Philadelphia, PA: Saunders Elsevier.
4. ↑ Kiara Rivera. Cervical Plexus Drawing and Spinal Segments - EASY.
Available from: http://www.youtube.com/watch?v=-Nz8-bnZGBI [last
accessed 12/02/16]