Syndrome of defeat of the brachial plexus

Along with the selective lesion of individual nerves, departing. From the brachial plexus, it is often observed violations of the function of all or part of this plexus.

In accordance with the anatomical structure, the following symptom-complex of lesions of primary and secondary bundles of the brachial plexus are distinguished. When the pathological process in the supraclavicular region affects the primary bundles.

The syndrome of the lesion of the upper primary beam (CV - CVI) is observed in the pathological focus after passage between the stair muscles, especially at the fixation site to the fascia of the subclavian muscle. Projected this place is located 2 - 3 cm above the clavicle, about a finger width posteriorly from the sternocleidomastoid muscle (supraclavicular point of Erb). At the same time, the axillary nerve, the long nerve of the thorax, the anterior thoracic nerves, the subscapular nerve, the back nerve of the scapula, the cutaneous-muscular and part of the radial nerve are simultaneously affected.

The upper limb hangs like a whip in such cases, the patient can not actively lift it upwards, bend it in the elbow joint, take it off and turn it outward, and supine. The function of the humerus and supinator is broken (innervated by CV - CVI, the fibers go into the radial nerve). All movements of the hand and fingers are saved.

Sensitivity is broken along the outer side of the shoulder and forearm along the peripheral type. Pressing in the supraclavicular point of Erba is painful.

After 2-3 weeks from the onset of paralysis, the atrophy of the deltoid, supra- and subacute muscles develops, as well as the shoulder flexors of the shoulder. Deep reflexes disappear from the biceps arm and carporadial muscles.

The defeat of the upper primary plexus of the brachial plexus is called Duchenne-Erb's paralysis. This type of paralysis occurs in cases of trauma (falling on the upper limb, stretched forward, with a long throwing of the hands behind the head during surgery, wearing a backpack, etc.), in newborns with pathological births using methods for delivery, after various infections, allergic reactions to introduction of rabies and other serums.

One of the clinical variants of ischemic involvement of the upper trunk of the brachial plexus and its branches is the neuralgic amyotrophy of the shoulder belt (the Persononeja-Turner syndrome): first there is an increasing pain in the region of the shoulder, shoulder and shoulder blade, and after a few days the intensity of pain subsides, but deep paralysis of the proximal departments of the hand. After 2 weeks, distinct atrophies of the anterior dentate, deltoid, paraloplegic muscles, partially - biceps and triceps muscles of the shoulder are revealed. The strength of the muscles of the hand does not change. Moderate or mild hypesis in the shoulder and shoulder area (CV - CVI).

The syndrome of the defeat of the primary primary bundle of the brachial plexus (CVII) is characterized by difficulty (or impossibility) of extension of the shoulder, hand and fingers. However, the triceps brachii muscle, extensor of the thumb and the long distal muscle of the thumb are not completely paralyzed, since they are suitable for fibers not only from the segment of the CVII of the spinal cord, but also from the segments CV and СVI. The function of the brachial muscle, innervated by CV and CVI, is preserved. This is an important feature in the differentiation of the lesion of the radial nerve and the roots of the brachial plexus. With the isolated lesion of the spinal root or primary bundle of the brachial plexus, along with the disorder of the radial nerve function, the function of the lateral root of the median nerve is also impaired. Therefore, the bending and deflection of the hand in the radial direction, the pronation of the forearm and the opposition of the thumb will be upset.

Sensitive disorders are limited to a narrow band of hypoesthesia on the back surface of the forearm and the outer surface of the rear of the hand. Reflexes disappear from the triceps muscles of the shoulder and metacarpal.

The syndrome of the primary plexus of the brachial plexus (CVII-TI) is manifested by Dejerine-Clumpke paralysis. The function of the elbow, skin internal nerves of the shoulder and forearm, part of the median nerve (medial spine) is turned off, which is accompanied by paralysis of the hand.

Unlike the combined defeat of the median and ulnar nerves, the function of the muscles innervated by the lateral spine of the median nerve is preserved.

Extension and retraction of the thumb due to the paresis of the short extensor of the big toe and the muscle draining the thumb, innervated by the radial nerve, are impossible or difficult, since these muscles receive fibers from the neurons located in the segments of the CIII and TI. The function of the basic muscles, supplied with the radial nerve, while maintaining the syndrome.

Sensitivity on the upper limb is impaired on the inner side of the shoulder, forearm and hand along the root type.

The pain is simultaneously disturbed by the function of the connective branches that go to the stellate node, then Claude Bernard-Horner's syndrome develops (ptosis, miosis, enophthalmus, scleral vessel enlargement). When these sympathetic fibers are irritated, the clinical picture is different - the pupil and eyelid enlargement, exophthalmos (Purfur du Petit's syndrome).

With the development of the process in the subclavian area, the following syndromes of lesion of secondary bundles of the brachial plexus can be formed.

The syndrome of the defeat of the lateral bundle of the brachial plexus is characterized by a violation of the function of the cutaneous-muscular nerve and the upper leg of the median nerve.

The syndrome of the defeat of the posterior fascicle of the brachial plexus is manifested by the disabling of the function of the radial and axillary nerves.

The syndrome of damage to the medial bundle of the brachial plexus is expressed by a violation of the function of the ulnar nerve, the inner leg of the median nerve, the medial cutaneous nerve of the shoulder and the medial cutaneous nerve of the forearm.

With the defeat of the entire brachial plexus (total defeat), the function of all muscles of the upper extremity belt is disrupted. In this case, only the possibility of "shrugging" can be preserved due to the function of the trapezius muscle innervated by the additional nerve, the posterior branches of the cervical and thoracic spinal nerves. The brachial plexus is affected by gunshot wounds of the supra-and subclavian areas, with a fracture of the clavicle, I rib, with a dislocation of the humerus, compression of the aneurysm of the subclavian artery, an additional cervical rib, tumor, etc. Sometimes the plexus is affected by its overextension with strongly retracted back upper limb, by laying it by the head, by cutting the turning of the head in the opposite direction, with birth trauma in newborns. Less often it happens with infections, intoxications, allergic reactions of the body. Most often the brachial plexus is affected by spasticity of the anterior and middle stair muscles due to the irrational reflex manifestations of cervical osteochondrosis - the syndrome of the anterior staircase (Nuffziger syndrome).

The clinical picture is dominated by complaints of a feeling of heaviness and pain in the neck, deltoid region, shoulder and along the ulnar edge of the forearm, hand. The pain can be mild, aching or extremely harsh, up to the sensation of a "detached" arm. Usually, at first the pain appears at night, but it also occurs in the daytime. It increases with a deep breath, turning the head to a healthy side, with sharp movements of the upper limb, especially when it is retracted (when shaving, writing, drawing), with vibration (working with tools). Sometimes the pain spreads to the armpit and thorax (with left-sided pain, there is often a suspicion of coronary artery disease).

There are paresthesias (tingling and numbness) along the ulnar edge of the hand and forearm, gipalgesia in this zone. The weakness of the upper limb is determined, especially in the distal sections, hypotension and hypotrophy of the muscles of the hypotenar, in part and tenar. Possible swelling and swelling in the supraclavicular area, sometimes in the form of a tumor (pseudotumor Kovtunovich) due to lymphostasis. Painful palpation of anterior staircase. Frequent vegetative-vascular disorders on the upper limb, with oscillography, the amplitude of arterial oscillations decreases, pallor or zannoticity, pastosity of the tissues, a decrease in cutaneous temperature, fragility of the nails, osteoporosis of the hand bones, etc. Are observed. Arterial pressure on the upper limb can change under the influence of the strain of the anterior staircase muscle (with the head leaning to the healthy side).

There are several test-samples for revealing this phenomenon: Eaton's test (turn of the head of the examinee towards the sick arm and simultaneous deep inspiration lead to a decrease in blood pressure on this arm, the pulse on the radial artery becomes softer); the Odeon-Coffey test (decrease in the height of the pulse wave and the appearance of a crawling sensation in the upper limbs with a deep inhalation of the subject in the sitting position with the palms on his knees and with a slightly straightened head); Tanozzi test (the subject lies on his back, his head passively deviates somewhat and turns in the direction opposite to the upper limb, on which the pulse is determined, with a positive sample it decreases); Edson's test (the decrease or even disappearance of the pulse wave and lowering of arterial pressure occurs in the subject with deep inspiration, lifting the chin and turning the head towards the limb on which the pulse is determined).

Skalenus syndrome often develops in people who have weight on their shoulders (including backpacks, military equipment), as well as with direct injury to the muscles, with osteochondrosis and deforming spondyloarthrosis of the cervical spine, tumors of the spine and spinal cord, with tuberculosis of the apex of the lung, with irritation of the diaphragmatic nerve due to pathology of internal organs. The hereditary-constitutional features of both the muscles themselves and the skeleton have undoubted significance.

Differential diagnosis of the scalenus syndrome has to be carried out with many other painful conditions, which are also accompanied by compression of m and ischemia of the nerve formation of the brachial plexus or by the irritation of the upper limb belt receptors. Diagnosis of the syndrome of the additional cervical rib helps radiography of the cervical spine.

Excessive rotation of the shoulder and the removal of it from the outside (for example, in a wrestling match) can lead to compression of the subclavian vein between the clavicle and the front staircase.

Active reduction of stair muscles (tilting and turning of the head) leads to a decrease in the pulse wave on the radial artery

The same compression of the vein is possible between the I rib and the tendon of the subclavian muscle. This may damage the inner shell of the vessel with a subsequent vein thrombosis. Develops perivascular fibrosis. All this is the essence of the Paget-Shreter syndrome. The clinical picture is characterized by edema and cyanosis of the upper limb, pain in it, especially after sudden movements. Venous hypertension is accompanied by spasm of arterial vessels of the upper limb. Often, the scalenus syndrome must be differentiated from the syndrome of small pectoralis muscle

The syndrome of the small pectoral muscle develops when the neurovascular bundle is compressed in the armpit region due to a pathologically altered small pectoral muscle due to neuroosteophybrosis in cervical osteochondrosis. In the literature, it is also referred to as hyperactivity syndrome Wright-Mendlovich.

The small pectoral muscle starts from the II-V ribs and rises obliquely outward and upward, attaching a short tendon to the coracoid scapula of the scapula. With a strong arm lead with a turn outward (hyperabduction) and when the upper limb is lifted high up the neuromuscular bundle is pressed tightly to the tensioned pectoral muscle and bends over it over the attachment site to the coracoid process. With frequent repetition of such movements, performed with stress, the small pectoral muscle is stretched, injured, sclerosed and can squeeze the trunks of the brachial plexus and subclavian artery.

The clinical picture is characterized by pain in the chest with irradiation in the shoulder, forearm and hand, sometimes in the scapula, paresthesia in the IV - V fingers of the hand.

Diagnostic value has the following method: the arm is withdrawn and placed behind the head, after 30-40 s there is pain in the chest and shoulder area, paresthesia on the palmar surface of the hand, blanching and puffiness of the fingers, weakening of pulsation on the radial artery. Differential diagnosis should also be carried out with the brachycephalic syndrome of Steinbroke and brachialgia in diseases of the shoulder joint.

Steinbroke's syndrome. Or "shoulder-brush" syndrome, is characterized by excruciating burning pains in the shoulder and hand, reflex contracture of the shoulder and wrist muscles with pronounced vegetative-trophic disorders, especially in the hand. The skin on the brush is edematic, smooth, shiny, sometimes there is erythema in the palm of your hand or cyanosis of the hand and fingers. With the passage of time, muscle atrophies, flexural contracture of the fingers, osteoporosis of the hand (atrophy of Zudeck) join and partial ankylosis of the shoulder joint is formed. Steinbroke's syndrome is caused by neurodystrophic disorders in cervical osteochondrosis, myocardial infarction, ischemia of trophic zones of the spinal cord, as well as trauma to the upper limb and shoulder girdle.

When brachialgia due to arthrosis or arthritis of the shoulder joint and surrounding tissues (periarthrosis), symptoms of loss of function of sensory and motor fibers are not detected. Hypotrophy of the shoulder muscle is possible due to prolonged shaking of the upper limb. The main diagnostic criteria are limitations of mobility in the shoulder joint, both with active and passive movements, with x-ray findings of the joint.

Most often the syndrome of the anterior staircase muscle has to be differentiated from the spondylogic lesions of the lower cervical roots. The complexity of the problem lies in the fact that both the Scalenus syndrome and cervical radiculitis most often have a spondylogenic conditioning. Stair muscles are innervated by fibers of CIII - СVII of spinal nerves and when osteochondrosis of almost all cervical intervertebral discs is included early in the irrotative-reflex disorders proceeding with pain and spasticity of these muscles. The spastic front staircase is stretched when the head turns to the opposite (healthy) side. In this situation, the compression of the subclavian artery between this muscle and the 1st rib increases, which is accompanied by the resumption or sharpening of the corresponding clinical manifestations. Turning the head toward the affected muscle does not cause these symptoms. If the turn of the head (with or without load on it) causes paresthesia and pain in the dermatome CVI-CVII, the decisive role of the staircase muscle is excluded. In such cases, paresthesia and pain can be explained by the compression of the spinal nerves CVI and CVII near the intervertebral foramen. Important is the test with the introduction of a solution of novocaine (10-15 ml) in the front staircase. With scalenus syndrome, pain and paresthesia disappear after 2 to 5 minutes after blockade, strength in the upper limbs increases, skin temperature rises. With the root syndrome, clinical phenomena after such a blockade persist.

The trunk of the brachial plexus can be squeezed not only by the front stair and small chest, but sometimes by the scapular-hyoid muscle. The tendon jumper and lateral head in the subclavian area are located above the stair muscles. In such patients, pain in the shoulder and neck region occurs when the upper limb is withdrawn back, and the head - in the opposite direction. The pain and paresthesia increase with pressure on the area of the hypertrophied lateral abdomen of the scapular-hyoid muscle, which corresponds to the zone of the middle and front stair muscles.