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Spinal Nerves: Plexus I01:22

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Nerve plexuses are networks of interlacing nerves that serve as communication hubs to distribute and organize nerve action across various body regions. The nerve plexuses are organized into the cervical plexus located in the neck region, brachial plexus in the shoulder area, lumbar plexus found in the lower back, sacral plexus situated in the pelvis, and coccygeal plexus located in the coccygeal region.
The Cervical Plexus
The cervical plexus, formed by the anterior rami of the first four...
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Clinical Classification Versus MRI Patterns of Injury in Brachial Plexus Birth Injury.

Caroline H Hu1, Ann E Van Heest2, Michelle A James3

  • 1Department of Orthopedic Surgery, Boston Children's Hospital, Boston, MA; Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA; Department of Orthopedic Surgery, University of Minnesota, Minneapolis, MN; Department of Orthopedic Surgery, Gillette Children's Specialty Healthcare, St. Paul, MN.

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Summary

The Narakas classification for brachial plexus birth injury (BPBI) may not accurately reflect nerve root damage. MRI revealed more extensive injuries than clinically expected in many infants with BPBI.

Keywords:
Brachial plexus birth injuryMRINarakas classificationheatmaps

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Area of Science:

  • Pediatric Neurology
  • Musculoskeletal Imaging
  • Birth Trauma Research

Background:

  • Brachial plexus birth injury (BPBI) is a significant concern in neonatology.
  • The Narakas classification is a widely used system to categorize BPBI based on clinical motor weakness patterns.
  • The correlation between clinical presentation and underlying nerve root pathology in BPBI remains incompletely understood.

Purpose of the Study:

  • To compare the distribution of nerve root injuries identified on magnetic resonance imaging (MRI) with the clinical Narakas classification in infants with BPBI.
  • To evaluate the accuracy of the Narakas classification in reflecting the true extent of nerve root involvement.

Main Methods:

  • Prospective enrollment of infants with BPBI across three children's hospitals.
  • Clinical assessment to determine Narakas group and MRI of the brachial plexus prior to 16 weeks of age.
  • Neuroradiologists assessed nerve root injury severity (intact, rupture, avulsion) on MRI and compared findings with the clinical Narakas classification.

Main Results:

  • Sixty-eight infants with BPBI underwent MRI, revealing 19 distinct nerve injury patterns.
  • MRI findings frequently did not align with the expected nerve root involvement based on the Narakas classification.
  • Narakas 1 and 2 classifications showed more extensive injuries on MRI than anticipated, with significant involvement of additional nerve roots (C7, C8, T1) in Narakas 1, and only 26% of Narakas 2 patients having C5-C7 injury exclusively.
  • Higher Narakas grades correlated with an increased number of affected nerve roots and avulsions, with C6 and C8 being the most commonly injured and avulsed, respectively.

Conclusions:

  • The pathoanatomy of BPBI is more complex than suggested by the Narakas classification.
  • Clinical assessment via the Narakas classification may underestimate the extent of nerve root injury in infants with BPBI.
  • MRI provides a more detailed understanding of brachial plexus injury, highlighting discrepancies with clinical grading systems.