What is the management of brachial plexopathy?

Management of Brachial Plexopathy

The management of brachial plexopathy requires specialized imaging with MRI of the brachial plexus as the gold standard diagnostic tool, followed by etiology-specific treatment approaches including conservative management for inflammatory causes and surgical intervention for traumatic or compressive lesions. 1, 2

Diagnostic Evaluation

Initial Imaging

• MRI of the brachial plexus without and with IV contrast is the preferred initial imaging modality due to superior soft-tissue contrast and spatial resolution 1
• For traumatic cases, imaging should be delayed until approximately 1 month after injury to allow for resolution of hemorrhage and edema 2
• MRI protocols should include:
  • Orthogonal views through the oblique planes of the plexus
  • T1-weighted, T2-weighted, fat-saturated T2-weighted sequences
  • Short tau inversion recovery (STIR) sequences
  • Fat-saturated T1-weighted postcontrast sequences 1
• 1.5T MRI may be beneficial when metal is present in the area to reduce artifact 1

Complementary Studies

• Electrodiagnostic studies are essential for confirming plexopathy, defining localization, pathophysiology, chronicity, and severity 3
• CT neck with IV contrast may be appropriate when MRI is contraindicated, offering the next highest level of anatomic visualization 1
• FDG-PET/CT is recommended in cases with known malignancy or post-treatment syndrome 1

Management Based on Etiology

Traumatic Brachial Plexopathy

• Penetrating and open injuries typically require early surgical exploration 2
• Blunt and closed injuries may be managed operatively or non-operatively based on severity 2
• Complete nerve ruptures generally have worse outcomes and often require early operative intervention 2
• For clavicular fracture-related plexopathy, surgical decompression of the brachial plexus is recommended 4

Non-Traumatic Inflammatory Plexopathy

• Parsonage-Turner syndrome (neuralgic amyotrophy) is typically managed conservatively with:
  • Pain management with appropriate analgesics
  • Physical therapy to maintain range of motion
  • Monitoring for recovery 1, 2

Radiation-Induced Brachial Plexopathy (RIBP)

• Limited effective treatments are available for RIBP 5, 6
• Surgical options include:
  • Nerve resection and autografting, which may restore satisfactory elbow flexion in some patients 7
  • Neurolysis with or without omental grafting, which has shown benefit primarily for pain relief rather than functional improvement 5
• Despite surgical intervention, two-thirds of RIBP patients may develop severe or total arm paresis 5

Compressive Plexopathy

• For partial deficits without progression, initial conservative management with close monitoring may be considered 8
• Wrist splinting in a neutral position may be advised to avoid exacerbating compression 8
• Surgical decompression is indicated for progressive neurological deficits or persistent pain 8

Common Pitfalls and Caveats

• Delayed diagnosis is common due to overlapping symptoms with radiculopathy and other neurological conditions 2, 3
• Routine neck, chest, spine, or pelvic MRI protocols are inadequate for proper evaluation of the brachial plexus; specialized brachial plexus protocols are required 1
• For traumatic cases, imaging too early may miss significant findings due to hemorrhage and edema 2
• Surgical outcomes for radiation-induced plexopathy are often disappointing for motor function recovery but may provide significant pain relief 5, 6
• The complex anatomy of the brachial plexus necessitates comprehensive electrodiagnostic testing and an individualized approach to each patient 3