PLEXOPATHY

Ravanno Fanizza Harahap

Plexopathy
Plexopathy is a disorder affecting a network of
nerves.

The region of nerves it affects are at the

brachial or lumbosacral plexus.

Symptoms include pain, loss of motor control,

and sensory deficits.
Brachial Plexopathy
Brachial Plexus
Brachial
Plexus
 Brachial
Plexopathy

Brachial plexus is network of nerves that supply

sensation and motor function to upper extremity, the
plexus, as it passes from the cervical spine between
the muscles of the neck and beneath the clavicle en
route to the arm, is vulnerable to injury

Formed by ventral primary rami of lowest four cervical

and upper most thoracic nerve (C5-T1)

Causes:

-Injury
-Miscellaneous (Radiation, Tumor)
-Obstetrics
-Iatrogenic (Surgical trauma, Positioning)
-Idiopathic
 Brachial Plexopathy

A brachial plexus injury can be defined by four

elements, which are analogous to the four dimensions
of space: breadth (number of roots involved), length
(level), depth (severity), and time.

The two basic clinical presentations are a partial

lesion (C 5,6 /C 5,6,7) and a complete lesion
(C 5,6,7,8 T1)

The evolution of brachial injuries has three important

milestones. These are at immediate presentation, at
completion of Wallerian degeneration (three weeks),
and at onset of muscle degeneration (six months).
Leffert Classification of Brachial Plexus Injuries

I. Open (usually from stabbing)

II. Closed (usually from motorcycle accident)
II-a: supraclavicular
- preganglionic
• Avulsion of nerve root usually from high speed injury
• No proximal stump, no neuroma formation
• Pseudomeningocele, denervation of neck muscles are common
• Horner’s sign (ptosis, miosis, anhydrosis)
- postganglionic
• Roots remains intact
• Usually from traction injuries
• There are proximal stump & neuroma formation
• Deep dorsal neck muscles are intact & pseudomeningocele will not develop
II-b: infraclavicular
Usually involves branches from trunk
Function is affected based on trunk involvement
upper- biceps, shoulder
middle- wrist, finger extension
lower- wrist, finger flexion
III. Radiation indused
IV. Obstetric
IV-a: Erb’s (Upper root) – waiter’s tip hand
IV-b: Klumke (lower root).
Brachial Plexopathy

Lesi Pre-ganglionik Lesi Post-ganglionik

Brachial Plexopathy -
Injury

Mechanism of traumatic brachial plexopathy at

superior trunks

Mechanism of traumatic brachial plexopathy at

inferior trunks
Brachial Plexopathy - Erb's
Palsy

Stretch injuries of the plexus occur during childbirth

and usually involve the upper plexus C5,C6 (Erb’s
palsy), much less often the lower plexus C8,T1
(Klumpke’s palsy) or the entire plexus.

It can occur if the infant's head and neck are

pulledtoward the side at thesame time as the
shoulders pass throughthe birth canal.

Risk factors:
-Large birth weight
-Maternal diabetes
-Assisted delivery (eg, use of mid/low forceps,
vacuum extraction)
-Forceful downward traction on
the head during delivery
 Brachial Plexopathy - Erb's
Palsy

Signs:

-Loss of sensation in the arm

and paralysis and atrophy of
the deltoid, biceps, andbrachialis muscles.

-The position of the limb,under such conditions, is

characteristic by the arm hangs by the side and is
rotated medially, the forearm is extended and
pronated.

-The arm cannot be raised from the side, all power of

flexion of the elbow is lost, as
is also supination of theforearm.

-The resulting biceps damage is the main cause of

this classic physical position
commonly called "waiter's
tip."
Brachial Plexopathy - Klumpke's Palsy

Injuries of the lower plexus C8,T1 (Klumpke’s palsy)

In Klumpke’s palsy, the muscles of the forearm, wrist

and hand are most affected. It is caused by a birth
injury to the neck and shoulder due to a difficult
vaginal delivery, tumor of the lung or shoulder, or
trauma to the arm and shoulder. The nerves may be
stretched or torn, causing weakness, pain or
numbness.

“claw hand” :
-wrist in extreme extension because of the unopposed
wrist extensors
-hyperextension of MCP due to loss of hand intrinsics
-flexion of IP joints due to loss of hand intrinsics
Brachial Plexopathy - Others

Neuralgic Amyotrophy (NA) : stereotyped clinical

syndrome characterized by the acute onset of pain in
the shoulder and upper arm, followed by weakness,
then atrophy, of variable severity, primarily affecting
upper arm and shoulder muscles

Plexopathy (postradiation or postsurgical) : Radiation

plexopathy may complicate treatment of such tumors
and appears after a delay of months to years. This is
also the time frame in which the radiation therapy may
have kept a tumor at bay. Distinguishing recurrent
tumor from radiation plexopathy is often difficult.

Neoplasm : especially breast and lung, may invade

the plexus.
 Brachial Plexopathy
Finding out the level of injury
Upper Plexus - the shoulder abductors and external
rotators and the forearm supinators are paralysed.
Sensory loss involves the outer aspect of the arm
and forearm.

Lower plexus - Wrist and finger flexors are weak
and the intrinsichand muscles are paralysed.
Sensation is lost in the ulnar forearm and hand.
 -The level of injury is determined by testing
If the entire plexus is damaged, the whole limb is
paralysed and numb.
-The examination of the patient is targeted to
determine the extent of the injury (partial or
complete); the level of the injury (condition of
proximal muscles); the severity of the injury
(avulsion or different grades of rupture); and
the time related changes (reinnervation and
atrophy).
-The extent of injury is most easily determined
by examining sensory dermatomes.
muscles. The signs of avulsion include absent
diaphragmatic function, absent serratus
anterior and rhomboid function, and Horner’s
syndrome.
Brachial Plexopathy

Brachial Plexus Injury - Sensory

Assesment Chart
Brachial Plexopathy

Brachial Plexus Injury - Motor Function

Assesment Chart
Lumbosacral Plexopathy
Lumbar
Plexus
Branches from Lumbar Plexus
Sacral Plexus
Branches of Sacral Plexus
 Lumbosacral
Plexopathy

The lumbosacral plexus represents the nerve supply

to the lower back, pelvis and legs

Lumbosacral plexopathy is an injury to or involvement

of one or more nerves that combine to form or branch
from the lumbosacral plexus. This involvement is
distal to the root level.

Lumbosacral plexopathy has been recognized as a

clinical entity or complication in a variety of surgical
procedures, trauma, diabetic amyotrophy, and
obstetric surgery or delivery and as a clinical finding
or sequel in treatment of pelvic tumors
Lumbosacral
Plexopathy

Acute pain in the lower extremity usually is

the first symptom of lumbar plexopathy,
followed by weakness of the pelvic girdle
leading to limping and refusal to walk.

Muscle atrophy results if symptoms persist

for a long period. Patients may have a
variable sensory loss. Gait abnormalities
and lower extremity edema might be seen,
especially with bilateral lesions.
Seddon and Sunderland Classification of Nerve Injury
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