24-34: Brachial & Lumbar Plexus Lesions

1. BRACHIAL PLEXUS NEUROPATHY

Brachial plexus neuropathy may be idiopathic, sometimes occurring in relationship to a number of different nonspecific illnesses or factors. In other instances, brachial plexus lesions follow trauma or result from congenital anomalies, neoplastic involvement, or injury by various physical agents. In rare instances, the disorder occurs on a familial basis.

Idiopathic brachial plexus neuropathy (neuralgic amyotrophy) characteristically begins with severe pain about the shoulder, followed within a few days by weakness, reflex changes, and sensory disturbances involving especially the C5 and C6 segments but affecting any nerve in the brachial plexus. Symptoms and signs are usually unilateral but may be bilateral. Wasting of affected muscles is sometimes profound. The disorder relates to disturbed function of cervical roots or part of the brachial plexus, but its precise cause is unknown. Recovery occurs over the ensuing months but may be incomplete. Treatment is purely symptomatic, although emerging evidence suggests that microsurgical neurolysis of hourglass-like constrictions on affected nerves identified by magnetic resonance neurography or high-resolution ultrasound improves outcome in patients who have not recovered after several months of conservative management.

2. CERVICAL RIB SYNDROME

Compression of the C8 and T1 roots or the lower trunk of the brachial plexus by a cervical rib or band arising from the seventh cervical vertebra leads to weakness and wasting of intrinsic hand muscles, especially those in the thenar eminence, accompanied by pain and numbness in the medial two fingers and the ulnar border of the hand and forearm. Electromyography, nerve conduction studies, and somatosensory evoked potential studies may help confirm the diagnosis. MRI may be especially helpful in revealing the underlying compressive structure. Plain radiographs or CT scanning sometimes shows the cervical rib or a large transverse process of the seventh cervical vertebra, but normal findings do not exclude the possibility of a cervical band. Treatment of the disorder is by surgical excision of the rib or band.

3. LUMBOSACRAL PLEXUS LESIONS

A lumbosacral plexus lesion may develop in association with diseases such as diabetes, cancer, or bleeding disorders or in relation to injury. It occasionally occurs as an isolated phenomenon similar to idiopathic brachial plexopathy (nondiabetic lumbosacral radiculoplexus neuropathy), and pain and weakness then tend to be more conspicuous than sensory symptoms. The distribution of symptoms and signs depends on the level and pattern of neurologic involvement.