Magnetic resonance imaging for detecting root avulsions in traumatic adult brachial plexus injuries: protocol for a systematic review of diagnostic accuracy

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Abstract

Background

Adult brachial plexus injuries (BPI) are becoming more common. The reconstruction and prognosis of pre-ganglionic injuries (root avulsions) are different to other types of BPI injury. Preoperative magnetic resonance imaging (MRI) is being used to identify root avulsions, but the evidence from studies of its diagnostic accuracy are conflicting. Therefore, a systematic review is needed to address uncertainty about the accuracy of MRI and to guide future research.

Methods

We will conduct a systematic search of electronic databases alongside reference tracking. We will include studies of adults with traumatic BPI which report the accuracy of preoperative MRI (index test) against surgical exploration of the roots of the brachial plexus (reference standard) for detecting either of the two target conditions (any root avulsion or any pseudomeningocoele as a surrogate marker of root avulsion). We will exclude case reports, articles considering bilateral injuries and studies where the number of true positives, false positives, false negatives and true negatives cannot be derived. The methodological quality of the included studies will be assessed using a tailored version of the QUADAS-2 tool. Where possible, a bivariate model will be used for meta-analysis to obtain summary sensitivities and specificities for both target conditions. We will investigate heterogeneity in the performance of MRI according to field strength and the risk of bias if data permits.

Discussion

This review will summarise the current diagnostic accuracy of MRI for adult BPI, identify shortcomings and gaps in the literature and so help to guide future research.

Systematic review registration

PROSPERO CRD42016049702.

Electronic supplementary material

The online version of this article (10.1186/s13643-018-0737-2) contains supplementary material, which is available to authorized users.

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Most cited references 40

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Epidemiology of brachial plexus injuries in a multitrauma population.

R Midha (1997)

The purpose was to identify the prevalence, causative factors, injury types, and associated injury patterns in multitrauma patients who sustained brachial plexus injuries. A retrospective review of a prospectively collected and computerized database and a chart review were performed. Brachial plexus injuries were identified in 54 of 4538 (1.2%) patients presenting to a regional trauma facility. Young male patients predominated. Motor vehicle accidents were the most frequent cause overall, but only 0.67% of such accidents resulted in plexus injuries. Conversely, 4.2% of motorcycle accident victims and 4.8% of snowmobile accident victims suffered brachial plexus injuries. Injuries were supraclavicular for 62% of patients and infraclavicular for 38%. Supraclavicular injuries were more likely to be severe (Sunderland Grade 3 or 4), compared with infraclavicular injuries, which were neurapraxic in 50% of cases (P < 0.01). The former therefore required surgical exploration and reconstruction more often (52 versus 17%; P < 0.05). Associated injuries included closed head injuries with loss of consciousness in 72% of patients (coma in 19%), cervical spine fractures in 13%, and clavicle, scapular, or humeral fractures and shoulder dislocations or sprains in 15 to 22%. Rib fractures were observed in 41% and were complicated by internal thoracic injuries in a similar percentage of cases. The injury severity score ranged from 5 to 59, with a mean of 24, and two patients died. Brachial plexus injuries afflict slightly more than 1% of multitrauma victims. Motorcycle and snowmobile accidents carry especially high risks, with the incidence of injury approaching 5%. Head injuries, thoracic injuries, and fractures and dislocations affecting the shoulder girdle and cervical spine are particularly common associated injuries. Supraclavicular injuries are more common, are of more severe grade, more often require surgery, and are associated with worse prognosis, compared with infraclavicular injuries.

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Brachial plexus injury: a survey of 100 consecutive cases from a single service.

Annie S Dubuisson, David G Kline (2002)

We analyzed the epidemiology, preoperative management, operative findings, operative treatment, and postoperative results in a group of 99 patients who sustained 100 injuries to the brachial plexus. The charts of 100 consecutive surgical patients with brachial plexus injuries were reviewed. The patient group comprised 80 males and 19 females ranging from 5 to 70 years of age. One male patient had bilateral brachial plexus palsy. Causes of injury were largely sudden displacement of head, neck, and shoulder and included 27 motorcycle accidents. There were 23 open wounds, including 8 gunshot wounds, 6 other penetrating wounds, and 9 wounds caused by operative or iatrogenic trauma. Loss was exhibited at C5-C6 in 19 patients, at C5-C7 in 15 patients, and at C5-T1 in 39 patients, and 8 patients had another spinal root pattern of injury. Nineteen patients had injury at the cord or the cord to nerve level. Associated major trauma was present in 59 patients. Emergency surgery for vessel or nerve repair was necessary in 18 patients. Myelography (n = 57) or magnetic resonance imaging (n = 7) revealed at least one root abnormality in 52 patients. The median interval from trauma to operation was 7 months. Operative exposures used included anterior supraclavicular, infraclavicular, combined supra- and infraclavicular, or a posterior approach in 5, 14, 77, and 4 patients, respectively. The surgical procedures performed included neurolysis alone in 12 patients and nerve grafting, end-to-end anastomosis, and/or neurotization in 81, 5, and 47 patients, respectively. Postoperative follow-up of at least 36 months was conducted in 78% of the patients. Grade 3 recovery according to Louisiana State University Medical Center criteria means contraction of proximal muscles against some resistance and of distal muscles against at least gravity. Among the 18 patients with open wounds, 14 (78%) recovered to a Grade 3 or better level, as did 35 (58%) of 60 patients with stretch injuries. In all cases of C5-C6 stretch injuries repaired by nerve grafting (n = 10), the patients recovered useful arm function. Brachial plexus injury represents a severe, difficult-to-handle traumatic event. The incidence of such injuries and the indications for surgery have increased during recent years. Graft repair and neurotization procedures play an important role in the treatment of patients with such injuries.

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Neuropathic pain after brachial plexus avulsion - central and peripheral mechanisms

Manoel Teixeira, Matheus Gomes da S da Paz, Mauro Tupiniquim Bina … (2015)

Review The pain that commonly occurs after brachial plexus avulsion poses an additional burden on the quality of life of patients already impaired by motor, sensory and autonomic deficits. Evidence-based treatments for the pain associated with brachial plexus avulsion are scarce, thus frequently leaving the condition refractory to treatment with the standard methods used to manage neuropathic pain. Unfortunately, little is known about the pathophysiology of brachial plexus avulsion. Available evidence indicates that besides primary nerve root injury, central lesions related to the abrupt disconnection of nerve roots from the spinal cord may play an important role in the genesis of neuropathic pain in these patients and may explain in part its refractoriness to treatment. Conclusions The understanding of both central and peripheral mechanisms that contribute to the development of pain is of major importance in order to propose more effective treatments for brachial plexus avulsion-related pain. This review focuses on the current understanding about the occurrence of neuropathic pain in these patients and the role played by peripheral and central mechanisms that provides insights into its treatment. Summary Pain after brachial plexus avulsion involves both peripheral and central components; thereby it is characterized as a mixed (central and peripheral) neuropathic pain syndrome.

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Author and article information

Contributors

Ryckie G. Wade: ryckiewade@gmail.com

Yemisi Takwoingi: y.takwoingi@bham.ac.uk

Justin C. R. Wormald: justin.wormald@ndorms.ox.ac.uk

John P. Ridgway: john.ridgway1@nhs.net

Steven Tanner: steventanner@nhs.net

James J. Rankine: james.rankine@nhs.net

Grainne Bourke: grainnebourke@nhs.net

Journal

Journal ID (nlm-ta): Syst Rev

Journal ID (iso-abbrev): Syst Rev

Title: Systematic Reviews

Publisher: BioMed Central (London )

ISSN (Electronic): 2046-4053

Publication date (Electronic): 19 May 2018

Publication date PMC-release: 19 May 2018

Publication date Collection: 2018

Volume: 7

Electronic Location Identifier: 76

Affiliations

[1 ]ISNI 0000 0000 9965 1030, GRID grid.415967.8, Department of Plastic and Reconstructive Surgery, , Leeds Teaching Hospitals Trust, ; Leeds, UK

[2 ]ISNI 0000 0004 1936 8403, GRID grid.9909.9, Faculty of Medicine and Health Sciences, , University of Leeds, ; Leeds, UK

[3 ]ISNI 0000 0004 1936 7486, GRID grid.6572.6, Institute of Applied Health Research, , University of Birmingham, ; Birmingham, UK

[4 ]ISNI 0000 0000 9947 0731, GRID grid.413032.7, Department of Plastic and Reconstructive Surgery, , Stoke Mandeville Hospital, Buckinghamshire Healthcare NHS Trust, ; Aylesbury, UK

[5 ]ISNI 0000 0004 1936 8948, GRID grid.4991.5, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), , University of Oxford, ; Oxford, UK

[6 ]ISNI 0000 0000 9965 1030, GRID grid.415967.8, Department of Radiology, , Leeds Teaching Hospitals Trust, ; Leeds, UK

[7 ]ISNI 0000 0004 0426 1312, GRID grid.413818.7, Leeds Biomedical Research Centre, , Chapel Allerton Hospital, ; Leeds, UK

Article

Publisher ID: 737

DOI: 10.1186/s13643-018-0737-2

PMC ID: 5960500

PubMed ID: 29778092

SO-VID: 0d03613c-1b9c-4d3a-862f-f4cd36b4c6f0

License:

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

History

Date received : 27 June 2017

Date accepted : 1 May 2018

Custom metadata

ScienceOpen disciplines: Public health

Keywords: review,diagnostic test accuracy,root avulsion,pre-ganglionic,brachial plexus,magnetic resonance imaging,sensitivity,specificity

Data availability:

ScienceOpen disciplines: Public health

Keywords: review, diagnostic test accuracy, root avulsion, pre-ganglionic, brachial plexus, magnetic resonance imaging, sensitivity, specificity

Magnetic resonance imaging for detecting root avulsions in traumatic adult brachial plexus injuries: protocol for a systematic review of diagnostic accuracy

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Abstract

Background

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Discussion

Systematic review registration

Electronic supplementary material

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Karger: Neurology and Neuroscience

Most cited references 40

Epidemiology of brachial plexus injuries in a multitrauma population.

Brachial plexus injury: a survey of 100 consecutive cases from a single service.

Neuropathic pain after brachial plexus avulsion - central and peripheral mechanisms

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