Surg Radiol Anat (2010) 32:891–894
DOI 10.1007/s00276-010-0683-8
ANATOMIC VARIATIONS
Anatomical variation in formation of brachial plexus
and its branching
Anjali Aggarwal • Nidhi Puri • Aditya K. Aggarwal
K. Harjeet • Daisy Sahni
Received: 7 March 2010 / Accepted: 17 May 2010 / Published online: 3 June 2010
Ó Springer-Verlag 2010
Abstract Variant brachial plexus formation with two
trunks and two cords is uncommon and has clinical
implications as it may result in failure of regional brachial
or axillary block. During routine anatomical dissection,
unilateral variation in the formation of brachial plexus
accompanied by unusual positional relationship with axil-
lary artery was discovered in the left upper extremity of a
52-year-old Indian male cadaver. Brachial plexus showed
two trunks formed by ventral rami of C5, C6 and C7, C8,
T1 spinal nerves, respectively, which first split and then
reunited in an unusual manner to form two cords: posterior
and lateral instead of three. Medial cord was absent. The
branching pattern of the brachial plexus also showed
important variations. Second part of axillary artery was
found lying inferomedial to brachial plexus instead of
passing between medial and lateral cords. Transverse cer-
vical artery was found to be coursing between two trunks
instead of passing superficial to brachial plexus. Median
nerve was observed to be formed from a single root, instead
Electronic supplementary material The online version of this
article (doi:10.1007/s00276-010-0683-8) contains supplementary
material, which is available to authorized users.
A. Aggarwal
K. Harjeet
D. Sahni
Department of Anatomy, Post Graduate Institute of Medical
Education and Research, Chandigarh 160012, India
A. K. Aggarwal
Department of Orthopaedic Surgery, Post Graduate Institute of
Medical Education and Research, Chandigarh 160012, India
N. Puri
Department of Anatomy, MMIMSR, Mullana, India
A. Aggarwal (&)
# 123-C Type V, Sector 24-A, Chandigarh 160023, India
e-mail: anjli_doc@yahoo.com; agg_adityadoc@yahoo.co.in
•
of usual two roots. Embryologically, this rare variation
may be due to the development of axillary artery from
ninth segmental artery instead of usual seventh cervical
intersegmental artery. Such rare variation is clinically
important as this knowledge may help the anesthesiologists
and the surgeons to avoid any inadvertent damage to nerves
and axillary artery during blocks and surgical interventions.
Keywords Brachial plexus
Variation
Median nerve

Axillary artery
Introduction
Complex nature of the brachial plexus and its intimate
relationship with axillary artery has always been an area of
interest not only for the anatomists but also for the clini-
cians as well. Normally, ventral rami of C5 and C6 spinal
nerves unite to form upper trunk, C8 and T1 ventral rami
unite to form lower trunk and C7 continues as middle trunk
of brachial plexus. Anterior and posterior divisions of the
trunks unite in a systematic manner to form three cords, i.e.
lateral, medial and posterior cords, named according to
their position relative to second part of axillary artery [13].
Variations in the formation of trunk, cords and their sub-
sequent branches have been well documented in literature
[4, 9]. However, variation in the brachial plexus at all
levels right from the formation of trunks to the origin of
terminal branches along with its aberrant relationship with
axillary artery stem is very rare.
Purpose of the present case report was to highlight the
rare variant formation of brachial plexus, its variant rela-
tionship with axillary artery and its relevance in clinical
situations especially during the surgical interventions.
Embryological basis of this variation is also suggested.
123
892
Case report
The brachial plexus with variations in its formation and its
relationship with the axillary artery was found in the left
upper extremity of a 52-year-old embalmed male cadaver
during routine dissection for undergraduate teaching
(Figs. 1, 2). In right upper extremity, brachial plexus and
axillary artery showed normal anatomy.
Ventral rami of C5 and C6 spinal nerves united to
constitute upper trunk (UT), which bifurcated unequally
into a thicker posterior (PD) and a thinner anterior divi-
sions (AD). Posterior division gave off the suprascapular
nerve. Ventral rami of C7, C8 and T1 spinal nerves unified
into a single common flat lower trunk (LT) which was
almost double the thickness of upper trunk. Lower trunk
was divided into two sub-trunks; for the purpose of
description we named them as LT1 and LT2, respectively.
Both sub-trunks namely, LT1 and LT2 divided into an
anterior and a posterior division (AD and PD). Anterior
division of upper trunk while descending anterior to pos-
terior division of LT2 was joined on its deeper aspect by
anterior division of LT2 and subsequently by anterior
division of LT1 to constitute a unified cord named as lateral
cord (LC). Posterior divisions of upper trunk, LT1 and LT2
merged together to form the posterior cord (PC). Posterior
cord was placed in a posterolateral plane relative to the
lateral cord.
Medial and lateral pectoral nerves emanated from
anterior aspect of the lateral cord. After giving rise to the
medial cutaneous nerve of arm from its medial aspect,
lateral cord divided into four terminal branches namely:
musculocutaneous nerve from the lateral aspect, ulnar
nerve and medial cutaneous nerve of forearm from the
medial aspect and median nerve lying in intermediate
Fig. 1 Dissection of the left side of neck and axilla. Axn axillary
nerve, Ax.art axillary artery, LC lateral cord, LT lower trunk, LT1
lower subtrunk1, LT2 lower subtrunk2, Lsn lower subscapular nerve,
Mcn musculocutaneous nerve, Mcna medial cutaneous nerve of arm,
Mcnf medial cutaneous nerve of forearm, Mn median nerve, PC
posterior cord, Rn radial nerve, Sn suprascapular nerve, S.art
suprascapular artery, Tdn thoracodorsal nerve, Tr.cer.art transverse
cervical artery, Un ulnar nerve, Usn upper subscapular nerve, UT
upper trunk
123
Surg Radiol Anat (2010) 32:891–894
position. Median nerve was formed from a single root
originating from the lateral cord. Posterior cord terminated
into radial and axillary nerves. Thoracodorsal nerve ema-
nated from the radial nerve. Lower subscapular nerve arose
from the thoracodorsal nerve, whereas axillary nerve gave
off upper subscapular nerve.
Second part of axillary artery was found lying infero-
medial to the cords of brachial plexus and further distally it
was seen coursing laterally after passing deep to the ter-
minal branches of lateral cord. In posterior triangle,
transverse cervical artery after arising from the subclavian
artery passed laterally lying superficial to the unified lower
trunk. Further, it plunged into the gap between two trunks
and then coursed laterally lying deep to the upper trunk.
Suprascapular artery traversed laterally superficial to LT1
and LT2 and deep to anterior division of the upper trunk
and further laterally superficial to posterior division of
upper trunk. Branches of axillary artery did not demon-
strate any variation from the standard described anatomy.
Axillary vein was placed medial to axillary artery.
Discussion
In this case report, variation in the formation of brachial
plexus was observed right from the level of trunk. It was
marked by the formation of two trunks instead of three. We
report a union of ventral roots of C7, C8 and T1 spinal
nerves to form lower trunk with absent middle trunk. Such
uncommon variation has also been reported by Matejeik
[5] (3 cases) and Yang [14] (1 case). Fusion of fibers of C7
spinal nerves into upper trunk has more commonly been
reported than that into lower trunk [8, 10, 12]. Uysal [12]
reported absent lower trunk in 9% and absent upper trunk
in 1% cases. In our case the lower trunk was formed by
fusion of middle and lower trunks. Subdivision of lower
trunk into two sub-trunks and their further bifurcation into
anterior and posterior divisions was another unusual feature
of the present study which has not been reported in liter-
ature so far. In this case report, three anterior divisions
merged into a single cord instead of forming lateral and
medial cords. Only a few studies have reported fusion of
lateral and medial cords in the literature [4, 9, 13]. Kerr [4]
found three cases in which lateral and medial cords fused
into a single cord placed anterior to the axillary artery.
Fused cord and posterior cord were found anterior and
posterior to the artery, respectively, whereas in our case
fused and posterior cords were found lateral and postero-
lateral to the artery, respectively. Yang et al. [14] reported
formation of brachial plexus from two trunks and two cords
in one case but subdivision of fused lower trunk was not
observed. In the study by Pandey et al. [9], medial and
lateral cords were united by a communicating branch rather
Surg Radiol Anat (2010) 32:891–894
Fig. 2 Schematic diagram of
left brachial plexus. For
abbreviations see Fig. 1
than proper fusion as seen in the present study. Complete
fusion as seen in our case was reported by Yang et al. [14].
The three cords of brachial plexus have received their
names according to their relationship with the second part
of axillary artery [3, 13]. Only two cords were noticed in
this case report namely, posterior and lateral cords. Medial
cord was absent.
Suprascapular nerve in our case was found to be arising
from posterior division of upper trunk. A few studies have
also reported variant origin of suprascapular nerve from
posterior division of upper trunk instead of upper trunk [1,
2].
In this case report, lateral cord was found to be termi-
nating into musculocutaneous, median and ulnar nerves
representing terminal branches of lateral and medial cords.
Normally axillary artery is clasped on its medial and lateral
aspects by medial and lateral roots of the median nerve,
respectively. In present study, the axillary arterial stem
failed to pass through the brachial plexus. Thus, the char-
acteristic loop of median nerve which is formed by bran-
ches from lateral and medial cords was not seen as it arose
from the single cord. Instead, it was formed from a single
root which might be attributed to union of two cords. Such
feature of single root median nerve has also been reported
in the literature [14]. In this case report, posterior cord gave
rise to two terminal branches namely, radial and axillary
nerves. Thoracodorsal nerve arose from radial nerve. Upper
subscapular nerve originated from the axillary nerve,
whereas lower subscapular nerve arose from thoracodorsal
nerve. A few studies have reported the origin of upper and
lower subscapular nerves from axillary nerve [2, 4, 11].
Kerr [4] has described the origin of thoracodorsal nerve
from the radial nerve.
Miller [6] and Müller [7] explained relationship between
axillary artery and brachial plexus as a combination of
893
embryological and evolutionary process. Müller [7]
hypothesized that axillary artery was formed by anasto-
mosis of local vessels and alteration in the level of pene-
tration of brachial plexus by the artery might depend upon
its embryological origin from the intersegmental artery.
Usually axillary artery is considered to be the continuation
of seventh intersegmental branch of dorsal aorta which
penetrates the plexus between middle and lower trunks.
Sometimes the axillary artery is derived from 6th, 8th or
9th intersegmental branch of dorsal aorta, thus resulting in
the altered relationship of axillary artery and brachial
plexus [3, 6]. In this case report, arterial stem lays caudal to
the brachial plexus. Such caudal positioning of arterial
stem in relation to brachial plexus has been reported in a
few studies [6, 14]. Probable source of origin of axillary
artery in the present study was from 9th segmental artery
and a part of the seventh persisted as a branch of it and
gave rise to transverse cervical artery which thus traversed
through the gap between two trunks. This assumption is
based on the hypothesis described by Miller [6]. In his
study, main stem of the axillary artery was arising from 9th
segmental artery in one case. Remnant of seventh seg-
mental artery branched off from it which passed through
the median loop and developed into deep brachial and
humeral circumflex arteries. Generally, the transverse cer-
vical artery, a branch of subclavian artery passes laterally
superficial to the brachial plexus. In our case, it was found
coursing between upper and lower trunks. Until now there
is no experimentally proved explanation of exact origin of
arterial stem. This variant passage of transverse cervical
artery between upper and lower trunk has not been reported
in the literature so far.
Thus, the knowledge of relationship of the brachial
plexus with the axillary artery is paramount to ensure safe
and successful regional anesthesia of upper extremity.
123
894
Variant formation of brachial plexus with superficial
position of axillary artery may lead to injury during surgery
in upper axilla. Hence, such variations are of clinical
importance to the anesthesiologists and the surgeons.
Supra- or infraclavicular brachial plexus block may inad-
vertently damage the artery.
Acknowledgments The authors wish to thank Mr. Vijay Bakshi
senior artist of Department of Anatomy for drawing the illustration.
References
1. Aggarwal A, Harjeet K, Sahni D, Aggarwal A (2009) Bilateral
multiple complex variations in the formation and branching
pattern of brachial plexus. Surg Radiol Anat 31:723–731
2. Fazan VPS, AdS Amadeu, Caleffi AL, Filho OAR (2003) Bra-
chial plexus variations in its formation and main branches. Acta
Cir Bras 18(Suppl 5):14–18
3. Hollinshead WH (1982) The back and limbs. In: Anatomy for
surgeons, vol 3, 3rd edn. Harper & Row, Philadelphia, pp 220–
236
4. Kerr AT (1918) The brachial plexus of nerves in man, the vari-
ations in it formation and branches. Am J Anat 23:285–395
5. Matejeik V (2003) Anatomical variation in the brachial plexus
trunks and nerve roots. Rozhl Chir 82:450–459
123
Surg Radiol Anat (2010) 32:891–894
6. Miller RA (1939) Observation upon the arrangement of the
axillary artery and brachial plexus. Am J Anat 64:143–163
7. Müller E (1903) Beiträge zur Morphologie des Gefässsystems. I.
Die Armarterien des Menschen. Anat Heft 1 Abt Bd S 22:376–
576
8. Nayak S, Somayaji N, Vollala VR, Raghunathan D, Rodrigues V,
Samuel VP, Alathady-Malloor P (2005) A rare variation in the
formation of the upper trunk of the brachial plexus: a case report.
Neuroanatomy 4:37–38
9. Pandey SK, Shukla VK (2007) Anatomical variations of brachial
plexus and the median nerve. Clin Anat 20:150–156
10. Prakash, Prabhu LV, Kumar J, Singh G (2006) Brachial plexus
with two trunks and double axillary veins: applied importance
and clinical implications. Firat Tip Dergisi 11:210–212
11. Tubbs RS, Loukas M, Shahid K, Judge T, Puinyard J, Shoja MM,
Slappey JB, McEvoy WC, Oakes WJ (2007) Anatomy and
quantitation of the subscapular nerves. Clin Anat 20:656–659
12. Uysal II, Seker M, Karabulut AK, Buyukmumcu M, Ziylan T
(2003) Brachial plexus variations in human fetuses. Neurosurgery
53:676–684
13. Williams PL, Bannister LH, Berry MM, Collins P, Dyson M,
Dussek JE, Ferguson MWJ (1995) Nervous system. In: Gray’s
anatomy, 38th edn. Churchill Livingstone, New York, pp 1266–
1272
14. Yang HE, Gil YC, Lee HY (2009) Intersegmental origin of the
axillary artery and accompanying variation in the brachial plexus.
Clin Anat 22:586–594