the peripheral nervous system, supplies most of the upper extremity and
shoulder. The high incidence of brachial plexopathies reects its vulnerabil-
ity to trauma and the tendency of disorders involving adjacent structures to
affect it secondarily. The combination of anatomic, pathophysiologic, and
neuromuscular knowledge with detailed clinical and ancillary study evalua-
tions provides diagnostic and prognostic information that is important to
clinical management. Since most brachial plexus disorders do not involve
the entire brachial plexus but, rather, show a regional predilection, a regional
approach to assessment of plexopathies is necessary.
Muscle Nerve 30: 547568, 2004
Department of Neurology, Tulane University Medical Center, New Orleans, Louisiana, USA
The brachial plexus, which supplies most of the clinically (e.g., anconeus), recognize minimally af-
upper extremity and shoulder, is the most complex fected muscles that seem normal clinically, prove
structure in the peripheral nervous system (PNS). Its continuity when visible muscle movement is lacking,
vulnerability to trauma reects its large size, super- recognize remote lesions no longer appreciable clin-
cial location, and position between two highly mo- ically, and estimate lesion severity for current and
bile structures (neck and upper extremity).121,144 future comparative studies.
Also, it may be affected secondarily by pulmonary, By integrating requisite anatomic, pathophysio-
vascular, or skeletal disorders involving neighboring logic, and neuromuscular knowledge with detailed
structures. Hence, most physicians encounter pa- clinical assessment and the results of ancillary stud-
tients with brachial plexopathies. In addition to a ies, the examining physician can make an accurate
comprehensive clinical evaluation, optimal assess- diagnosis and prognosis. The lesion must be local-
ment requires the performance of ancillary studies. ized and characterized. This ability requires an un-
Of these, electrodiagnostic examination is by far the derstanding of the relevant anatomy, as well as a
most helpful. Although an extension of the neuro- familiarity with disorders affecting the brachial
logic examination, it has several advantages over the plexus. This review details a regional approach to
latter, including the ability to localize and character- assessment of the brachial plexus and discusses cer-
ize the lesion, evaluate muscles not easily assessed tain plexopathies, especially those with a regional
proclivity. Pertinent aspects of the anatomy, pathol-
ogy, pathophysiology, electrodiagnosis, and injury
Abbreviations: ADM, abductor digiti minimi; AHC, anterior horn cell; APB, classication of these disorders are reviewed.
abductor pollicis brevis; CMAP, compound muscle action potential; CSF,
cerebrospinal uid; CT, computerized tomography; DRG, dorsal root gan-
glion; DUC, dorsal ulnar cutaneous; EDC, extensor digitorum communis; EIP,
extensor indicis proprius; EPB, extensor pollicis brevis; FDI, rst dorsal in- ANATOMY
terosseous; LABC, lateral antebrachial cutaneous; MABC, medial antebra-
chial cutaneous; MR, magnetic resonance; MUAP, motor unit action poten- The brachial plexus is a triangular-shaped structure
tial; NA, neuralgic amyotrophy; NCS, nerve conduction study; NEE, needle
electrode examination; PNS, peripheral nervous system; SNAP, sensory
that extends from the spinal cord to the axilla. Its
nerve action potential; TOS, thoracic outlet syndrome average extraforaminal length is 15.3 cm.117 It is
Key words: brachial plexus, classic postoperative paralysis, electrodiagnos-
tic evaluation, iatrogenic plexopathy, medial brachial fascial compartment,
composed of connective and neural tissue in a 2 to 1
neoplastic plexopathy, neuralgic amyotrophy, obstetric plexopathy, plexopa- ratio,9,117,154 and contains several elements: (1) ve
thy, Pancoast syndrome, postmedian sternotomy, radiation plexopathy, root
avulsion, rucksack, thoracic outlet syndrome, trauma roots (classically, C5 through T1); (2) three trunks
Correspondence to: M. A. Ferrante, 1720-A Medical Park Drive, Suite 210, (upper, middle, and lower); (3) six divisions (three
Biloxi, MS 39532, USA; e-mail: mferrante@bienvilleortho.com
anterior, three posterior); (4) three cords (lateral,
2004 Wiley Periodicals, Inc.
Published online 27 September 2004 in Wiley InterScience (www.interscience.
posterior, and medial); and (5) several terminal
wiley.com). DOI 10.1002/mus.20131 nerves (Fig. 1). The C6, C7, and C8 roots each
provide about 25% of its nerve bers, and the C5 cles. Preganglionic sympathetic bers leave the spi-
and T1 roots provide the remainder.117 The percent- nal cord and exit the anterior primary rami, via white
age of sensory and motor bers composing each root rami communicantes, to reach the sympathetic gan-
varies. The largest percentage of motor bers is glia. The sympathetic ganglia send postganglionic
found in the C5 and C6 roots; C7 and T1 have the bers, via gray rami communicantes, to the C5
least.46,154 The greatest number of sensory bers is through T1 spinal nerves. Although anatomists de-
found in the C7 root, followed, in descending order, ne the anterior primary rami as the roots of the
by C6, C8, T1, and C5.154 The brachial plexus also brachial plexus, much of the surgical literature de-
carries sympathetic bers. nes them as those PNS elements proximal to the
trunks.144 Because of its clinical utility, the latter
Roots. The dorsal and ventral rootlets exit the spi- approach is used in this article.
nal cord and fuse, forming the dorsal and ventral
roots, respectively. The latter enter the interverte- Trunks. The trunks are located in the posterior
bral foramen and fuse in the distal foramen, just cervical triangle, behind the clavicle and sternoclei-
beyond the dorsal root ganglion (DRG), creating a domastoid. Trunk anomalies are infrequent.75 Typi-
spinal nerve. (The latter are also referred to as cally, the C5 and C6 anterior primary rami unite, the
mixed spinal nerves because they contain both sen- C7 anterior primary ramus continues, and the C8
sory and motor nerve bers.) After exiting the fora- and T1 rami coalesce to become the upper, middle,
men, these nerves give off posteriorly directed and lower trunks, respectively (named for their re-
branches, the posterior primary rami, and continue lationship to each other). The upper trunk gives off
as anterior primary rami (Fig. 2). The anterior pri- the suprascapular nerve and the nerve to the subcla-
mary rami emerge from between the anterior and vius muscle. The lower trunk lies adjacent to the
middle scalene muscles. The long thoracic nerve subclavian artery and the apex of the lung.
(serratus anterior) is derived via branches from the
C5C7 anterior primary rami, the C5 ramus contrib- Divisions. Each trunk divides into anterior and pos-
utes to the phrenic (diaphragm) and dorsal scapular terior divisions, all of which are retroclavicular. The
(levator scapulae; rhomboids) nerves, and the anterior and posterior divisions primarily supply
C5C8 rami supply the scalene and longus colli mus- exor and extensor muscles, respectively. Although
plexus is not subdivided because lesions affecting it ASSESSMENT OF THE BRACHIAL PLEXUS
do not show signicant regional differences in inci- Clinical Assessment. A detailed clinical evaluation
dence, severity, prognosis, or lesion type. is vital for determining lesion localization (especially
FIGURE 3. The relationship between the brachial plexus and its neighboring arteries.
Sensory Fiber Pathways. The lateral antebrachial and DRG (Fig. 4). The sensory bers of the median
cutaneous (LABC) nerve, which exits from the lat- nerve have particularly complicated pathways
eral cord, is the terminal portion of the musculocu- through the brachial plexus. Those innervating the
taneous nerve. Its sensory bers derive from the C6 thumb emanate from the C6 DRG.27 Thus, the me-
DRG.27 Thus, based solely on anatomy, in addition to dian sensory NCS, recording from the thumb, as-
the LABC and musculocutaneous nerves, the LABC sesses the median nerve, lateral cord, upper trunk,
sensory NCS assesses the lateral cord, upper trunk, and the C6 anterior primary ramus, spinal nerve,
and the C6 anterior primary ramus, spinal nerve, and DRG (Fig. 5). Those bers innervating the in-
dex nger derive from the C6 and C7 DRG about
20% and 80% of the time, respectively.27 Hence, the
Table 2. CMAP domains of the brachial plexus elements.* median sensory NCS, recording from the index n-
ger, assesses the median nerve and lateral cord con-
Upper trunk Lateral cord
sistently; the upper trunk and the C6 anterior pri-
Musculocutaneous (biceps) Musculocutaneous (biceps)
Axillary (deltoid) mary ramus, spinal nerve, and DRG in 20% of
Middle trunk Posterior cord instances; and the middle trunk and the C7 anterior
Radial (anconeus) Axillary (deltoid) primary ramus, spinal nerve, and DRG in 80% of
Radial (extensor digitorum instances (Fig. 6). Those bers innervating the mid-
communis)
Radial (extensor indicis
proprius)
Radial (anconeus)
Lower trunk Medial cord
Ulnar (abductor digiti minimi) Ulnar (abductor digiti minimi)
Ulnar (rst dorsal Ulnar (rst dorsal
interosseous) interosseous)
Median (abductor pollicis Median (abductor pollicis
brevis) brevis)
Radial (extensor indicis
proprius)
CMAP, compound muscle action potential. FIGURE 4. Proposed brachial plexus pathway for the sensory
*The recording sites are shown in parentheses. bers assessed by the LABC SNAP.
cial radial; and ulnar, recording from the little motor NCS, recording from extensor digitorum
nger). Whenever a specic region of the brachial communis (EDC) or anconeus, can be added,
plexus requires assessment, additional sensory NCS, though neither assesses solely the middle plexus.
motor NCS, and NEE of muscles belonging to that NEE of selected muscles (Table 4) is useful. Since
particular region are added (see Tables 4 and 5). isolated middle plexopathies are rare,1,27,75 their
Electrodiagnostic Assessment of the Supraclavicular identication should always prompt screening of the
Plexus. Upper plexus. The upper plexus contains adjacent upper and lower plexuses.
nerve bers from C5 and C6. Table 4 details its Lower plexus. The lower plexus (Table 4) con-
electrodiagnostic assessment. Regarding the sensory tains bers from C8 and T1. The ulnar sensory NCS,
NCS, although no studies assess the C5 DRG or its recording from the little nger, assesses the C8 DRG,
postganglionic bers, the other elements of the up- its postganglionic bers, and the lower trunk. The
per plexus are assessable. The median NCS, record- MABC study assesses the corresponding T1 struc-
ing from the thumb, and the LABC NCS both reli- tures. Thus, these two studies are complementary at
ably assess the C6 DRG, its postganglionic bers, and the pre-trunk level. Typically, with lower-trunk le-
the upper trunk. In general, upper plexopathies sions, both are equally affected, whereas their in-
tend to affect these two studies equally. These studies volvement is more discordant with more proximally
may need to be performed contralaterally to identify situated lesions. The DUC sensory NCS typically is
relative abnormalities (i.e., side-to-side differences superuous, since it assesses the same brachial
exceeding 50%). The supercial radial NCS and the plexus elements as the ulnar study.27 The ulnar [re-
median NCS, recording from the index nger, also cording from the abductor digiti minimi (ADM)]
assess these upper-plexus elements, albeit less reli- and median [recording from the abductor pollicis
ably (i.e., in 60% and 20% of instances, respec- brevis (APB)] motor NCS assess the lower plexus, as
tively).27 The musculocutaneous (recording biceps) does the radial motor NCS [recording from the
and axillary (recording deltoid) motor NCS assess all extensor indicis proprius (EIP)]. Although the latter
of the upper-plexus elements. To avoid relative ab- may be spared with partial lower-trunk lesions, its
normalities, these studies are performed bilaterally involvement excludes a medial cord lesion. These
in the presence of upper-plexus SNAP abnormalities three motor NCS assess the pre-trunk level of the
or whenever the recorded CMAP values are near or lower plexus differentiallythe radial NCS assesses
below their lower limit of normal. NEE of the shoul- solely the C8 root; the ulnar, the C8 root predomi-
der girdle, C5,6 radial, C5,6 axillary, and C6 me- nantly; and the median, almost solely the T1
dian innervated muscles is helpful, and evaluation of
levator scapulae, rhomboids, serratus anterior, and
spinati muscles helps to dene the proximal extent
of the lesion.
Middle plexus. The middle plexus (Table 4) con-
tains nerve bers from C7. The sensory nerve bers
subserving the median NCS, recording from the in-
dex and middle ngers, traverse the middle plexus
in approximately 80% and 70% of instances, respec-
tively; whereas those subserving the supercial radial
NCS traverse it in 40% of instances.27 Contralateral FIGURE 10. Proposed brachial plexus pathway for the sensory
studies help identify relative abnormalities. A radial bers assessed by the MABC SNAP.