Electrodiagnostic approach to the patient with suspected brachial plexopathy

Of the four major PNS plexuses, disorders of the brachial plexus are encountered far more frequently than those of the others. The EDX examination is probably the best procedure available by which to evaluate brachial plexus lesions. It provides localizing, pathologic, pathophysiologic, severity, and prognostic information. By localizing the lesion and identifying the underlying pathophysiology, it often predicts the underlying etiologic process; for example, (1) major T1 APR involvement with true neurogenic thoracic outlet syndrome; (2) C8 APR involvement with postmedian sternotomy brachial plexopathies; (3) supraclavicular demyelinating conduction block with classic postoperative paralysis (often confined to the upper plexus); (4) widespread infraclavicular demyelinating conduction blocks with radiation plexopathy; (5) severe progressive axon loss with neoplastic processes; (6) motor NCS abnormalities exceeding sensory NCS abnormalities for the same peripheral nervous system segment with intraspinal canal lesions (e.g., avulsions); (7) demyelinating conduction block with sparing of the pertinent sensory NCS study with multifocal motor neuropathy; and (8) lack of EDX abnormalities with hysteria, conversion reactions, and malingering, as well as with disputed neurogenic thoracic outlet syndrome. In addition, incorrect clinical considerations may be excluded (e.g., when abnormal SNAPs are identified, an isolated radiculopathy is excluded). Among the various EDX study components, the sensory NCS are the most useful for brachial plexus element localization. One drawback of the sensory NCS for localization occurs in the setting of concomitant carpal tunnel syndrome; the latter negates the utility of the median sensory NCS for brachial plexus localization. The motor NCS and NEE often overcome this drawback and, regardless of sensory NCS findings, are always performed.