What is the initial approach to treating brachial plexopathy?

Initial Approach to Treating Brachial Plexopathy

MRI of the brachial plexus is the gold standard initial diagnostic approach for brachial plexopathy, as it provides superior soft-tissue contrast and spatial resolution necessary for proper treatment planning. 1, 2

Diagnostic Evaluation

• MRI of the brachial plexus should include orthogonal views through the oblique planes of the plexus, with T1-weighted, T2-weighted, fat-saturated T2-weighted or short tau inversion recovery sequences, and may include fat-saturated T1-weighted postcontrast sequences 1
• For traumatic brachial plexopathy, imaging should be delayed until approximately 1 month after injury to allow for resolution of hemorrhage and edema, and for pseudomeningocele formation 1, 2
• Electrodiagnostic studies should complement imaging to determine the pathophysiology, chronicity, severity, and prognosis 3
• CT with IV contrast can be considered when MRI is contraindicated, as it offers the next highest level of anatomic visualization 1

Treatment Based on Etiology

Traumatic Brachial Plexopathy

• Penetrating and open injuries often require early surgical exploration 1, 2
• Blunt and closed injuries may be managed operatively or non-operatively depending on severity 1
• Complete nerve ruptures generally require early operative management due to worse prognosis 1, 2
• Determining whether injury is preganglionic (intraspinal nerve roots) or postganglionic (plexus lateral to dorsal root ganglion) is crucial as treatment approaches differ 1

Non-traumatic Brachial Plexopathy

• For inflammatory causes like Parsonage-Turner syndrome (brachial neuritis), treatment typically includes:

  • Pain management with analgesics and anti-inflammatory medications 2
  • Physical therapy to maintain range of motion and prevent contractures 3

• For neoplastic involvement:

  • Treatment depends on tumor type and extent of involvement 1
  • MRI with and without contrast is essential to characterize the extent of malignant involvement 1
  • FDG-PET/CT can help differentiate radiation plexopathy from neoplastic plexopathy in post-treatment settings 1

• For iatrogenic causes (e.g., positioning during surgery):

  • Typically managed conservatively with physical therapy and pain management 4
  • Most cases resolve spontaneously, though recovery may take up to 7 months 4

Common Pitfalls and Caveats

• Brachial plexopathy symptoms may overlap with radiculopathy, making clinical localization difficult 2, 5
• CT cervical spine alone is inadequate for evaluation as it cannot visualize preganglionic nerve roots and does not fully evaluate the postganglionic brachial plexus 1
• Routine neck, chest, spine, or pelvic MRI sequences are insufficient; dedicated brachial plexus protocols are required 1
• Imaging at 1.5T may be beneficial to reduce artifact if metal is present in the area of clinical concern 1
• Delayed diagnosis is common when improper imaging techniques are used - 35% of non-traumatic cases have had incomplete or inappropriate CT examinations leading to significant diagnostic delays 5

Monitoring and Follow-up

• Serial clinical examinations and electrodiagnostic studies help monitor recovery 3
• Early rehabilitation intervention is crucial to prevent complications such as muscle atrophy and joint contracture 6
• Follow-up imaging may be necessary to assess treatment response, particularly in neoplastic cases 1