In the emergency department plain radiographs of the cervical spine and shoulder are necessary for skeletal evaluation and the diagnosis of concomitant lesions (scapula, clavicle, humeral head, sternoclavicular joint, first rib, transverse process of C7).
In cases of acute ischemia of the upper limb, an angiography in the emergency department will determine the level of the vascular lesion.
If there is no clinical recovery within a period of 30 days after injury, myelogra-phy, computed tomography (CT) and neurophysiologic investigations should be performed.
• Myelography confirms the existence of root avulsion with pseudo-meningoceles (rupture of the dura sheath and rootlets). Usually pseudomeningoceles are located on the C7, C8 and T1 levels.
• CT is always associated with myelography (CT myelography) and allows visualization of pseudomeningoceles, small defects, irregular roots and interruptions of the rootlets. CT is also useful for the evaluation of the precise aspect of the rootlets at the adjacent level.
• The reliability of CT myelography is approximately 100% and the specificity is 99%.
• A normal CT myelography suggests either a first or second degree lesion (Sunderland's classification) leading to spontaneous recovery or a lesion located on the trunks or further distal, accessible to direct repair or nerve grafting.
• MRI represents the test of the future for the diagnosis of postganglionic lesions as well as peripheral lesions.
• Nowadays, myelography and CT myelography provide information about the proximal lesions of the brachial plexus (root avulsion) but the evaluation of distal injuries relies on clinical examination.
• Neurophysiologic tests are helpful preoperatively in brachial plexus injuries for the decision-making procedure. Electromyography (EMG) is used to record the electrical activity of the motor fibers and also to detect signs of reinnervation. Somatosensory evoked potentials can be used to assess the integrity of sensory conduction from the periphery to the central nervous system. Motor evoked potentials is a promising technique for the assessment of the integrity of the ventral root (motor neuron), but this method is rather uncomfortable for the patient when he is awake. Neurophysi-ologic tests are useful in establishing the level of the lesion in association to the posterior root ganglion: a preganglionic lesion corresponds to an avulsion of the root whereas a postganglionic lesion corresponds to a distal lesion after the posterior root ganglion. Electric tests are also used for the confirmation of conduction of active potentials through a neuroma. However these tests are not yet very reliable and it is necessary to associate CT myelography and MRI imaging to confirm the root lesion.
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