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Diagnostic accuracy of imaging studies for diagnosing root avulsions in post-traumatic upper brachial plexus traction injuries in adults

  • Original Article - Peripheral Nerves
  • Published:
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Abstract

Background

There is no consensus about which type of imaging study, computed tomography myelography (CTM) or magnetic resonance imaging (MRI), provides better information concerning root avulsion in adult brachial plexus injuries.

Methods

Patients with upper brachial plexus traumatic injuries underwent both CTM and MRI and surgical exploration. The imaging studies were analyzed by two independent radiologists and the data were compared with the intraoperative findings. The statistical analysis was based on dichotomous classification of the nerve roots (normal or altered). The interobserver agreement was assessed using Cohen’s Kappa. The accuracy of CTM and MRI in comparison with the intraoperative findings was evaluated using the same methodology.

Results

Fifty-two adult patients were included. CTM tended to yield slightly higher percentages of alterations than MRI The interobserver agreement was better on CTM than on MRI for all nerve roots: C5, 0.9960 (strong) vs. 0.145 (poor); C6, 0.970 (strong) vs. 0.788 (substantial); C7, 0.969 (strong) vs. 0.848 (strong). The accuracy regarding the intraoperative findings was also higher on CTM (moderate, kappa 0.40–0.59) than on MRI (minimal, kappa 0.20–0.39) for all nerve roots. Accordingly, the overall percentage concordance (both normal or both altered) was superior in the CTM evaluation (approx. 70–75% vs. 60–65%). CTM was superior for both sensitivity and specificity at all nerve roots.

Conclusion

CTM had greater interobserver agreement and higher diagnostic accuracy than MRI in adult patients with root avulsions due to brachial plexus injury.

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Abbreviations

CTM:

Computed tomography myelography

MRI:

Magnetic resonance imaging

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Author information

Authors and Affiliations

  1. Department of Radiology, University of São Paulo Medical School, São Paulo, SP, Brazil

    Marcelo Bordalo-Rodrigues, Ceci O. Kurimori & Ana Carolina R. Carneiro

  2. Peripheral Nerve Surgery Unit, Division of Functional Neurosurgery, Department of Neurosurgery, Institute of Psychiatry, University of São Paulo Medical School, Rua Virgilio de Carvalho Pinto, 381 / apt. 42, São Paulo, SP, 05415-030, Brazil

    Mario G. Siqueira, Roberto S. Martins, Luciano Foroni, Adilson J. M. Oliveira & Davi J. F. Solla

Authors
  1. Marcelo Bordalo-Rodrigues
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  2. Mario G. Siqueira
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  3. Ceci O. Kurimori
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  4. Ana Carolina R. Carneiro
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  5. Roberto S. Martins
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  6. Luciano Foroni
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  7. Adilson J. M. Oliveira
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Correspondence to Mario G. Siqueira.

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The authors declare that they have no conflict of interest.

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All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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Comments

The article by Bordalo-Rodrigues et al. is a prospective study to examine the differences between MRI (with 3D FIESTA) and CT myelography in investigating the existence of nerve root avulsion related to traumatic brachial plexus injury. This is an important topic that needs to be revisited periodically as MRI and CT technology improves. The authors made great effort in study design and presented confirmatory data that, at least at the present time and in their practice settings, CT myelography remains the gold standard in diagnosing nerve root avulsion.

At our institution, we continue to use CT myelography preferentially as part of the diagnostic work-up of patients with severe proximal brachial plexus injuries. Imaging in these patients complements the clinical history, physical examination, and electromyography (EMG) and nerve conduction studies. While preoperative imaging is of great utility, we then correlate the imaging findings with intraoperative electrodiagnostic testing including somatosensory and motor evoked potentials (SSEPs and MEPs) in testing preganglionic injury, and nerve action potentials and EMG in postganglionic injury. At this time where nerve transfers are directing some surgeons away from the supraclavicular brachial plexus, whether for pre or postganglionic injury (particularly in patients with upper pattern lesions), we still routinely explore the plexus, perform intraoperative recordings and hope to find a viable cervical spinal nerve stump for reconstruction of the shoulder (i.e., maintaining spinal accessory nerve and trapezius function for possible secondary reconstruction); we typically perform distal nerve (fascicular) transfer(s) for elbow flexion based on the consistently improved outcomes with this procedure.

Advances in diagnosing nerve root avulsion with MRI are well on their way. Higher resolution with 3T and 7T MRI and newer imaging protocols continue to be developed. Newer steady-state free-precession methods of MRI signal acquisition are being applied to the brachial plexus. These newer technologies are still primarily seen at only tertiary and quaternary care centers, although MR myelography has become more widely available. The future of imaging is bright for further refining the techniques to assess suspected preganglionic injury.

Nikhil Murthy,

Robert J. Spinner,

Rochester, MN, USA

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Bordalo-Rodrigues, M., Siqueira, M.G., Kurimori, C.O. et al. Diagnostic accuracy of imaging studies for diagnosing root avulsions in post-traumatic upper brachial plexus traction injuries in adults. Acta Neurochir 162, 3189–3196 (2020). https://doi.org/10.1007/s00701-020-04465-9

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