Head and Neck Imaging

Brachial plexus

1. Anatomy

Neural plexus originating from the fifth cervical to the first thoracic spinal nerve, forming trunks, divisions, cords and finally nerves innervating the shoulder girdle and upper limb; it passes behind the subclavian artery between the anterior and middle scalene muscle, and into the axillary region above the axillary artery. Also, see brachial plexus.

2. Pathology

Traumatic pathology of the brachial plexus

  • direct injury of the brachial plexus usually occurs by direct peripheral traction (due to violent and extreme movement of the cervical spine, violent displacement of the shoulder girdle relative to the trunk or shoulder girdle relative to the arm). The plexus may suffer elongation, finally leading to avulsion at its weakest place, which is the junction of the nerve roots and the spinal cord. As a result of tearing of the dura (and sometimes also the arachnoid), accompanying the spinal nerves in the neuroforamina, nerve root avulsion commonly becomes radiologically visible as post-traumatic meningoceles or pseudomeningoceles (Fig.1).

  • indirect traumatic injury of the brachial plexus, when it is compressed or irritated by a soft tissue haematoma or hypertrophic callus originating from a clavicular fracture.

    Nontraumatic pathology of the brachial plexus

  • primary tumour: schwannoma head and neck (Fig.2)

  • superior sulcus neoplasm: malignant neoplasm originating from the apical lung; it often invades the superior thoracic wall and may grow into the brachial plexus (see Pancoasts neoplasm). Other neoplasms possibly invading the brachial plexus are local extensions or recurrences of breast cancer, soft tissue sarcomas and lymphoma.

  • brachial neuritis: possibly related to an infection or an autoimmune condition. See also Parsonage Turner syndrome

  • brachial plexopathy after irradiation. It is most often seen in patients treated for breast cancer. It is clinically and also radiologically difficult to differentiate from recurrent tumour. The presence of a mass lesion in or near the brachial plexus indicates tumour recurrence in most cases (Fig.3) (Fig.4).

  • thoracic outlet syndrome

    RH

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    Fig.1

    Left-sided post-traumatic upper limb paralysis. Maximum intensity projection of coronal thin sliced T2-weighted MR-images shows post-traumatic meningoceles (arrowheads) and pseudomeningoceles (arrows) in the lower cervical and upper thoracic region; this finding strongly suggests avulsion of several brachial plexus nerve roots.
    Brachial plexus, Fig.1
    Brachial plexus, Fig.2
    Brachial plexus, Fig.3 (a)
    Brachial plexus, Fig.3 (b)
    Brachial plexus, Fig.4 (a)
    Brachial plexus, Fig.4 (b)