Magnetic resonance imaging for detecting root avulsions in brachial plexus birth injuries

Abstract

Introduction:

We assessed the diagnostic accuracy of 3T magnetic resonance imaging in comparison with surgical exploration for detecting root avulsion in brachial plexus birth injuries.

Methods:

This retrospective cohort study describes a consecutive series of 18 infants with brachial plexus birth injuries born between January 2019 and May 2024 who had a surgical exploration of the plexus preceded by magnetic resonance imaging under the same general anaesthetic.

Results:

The overall diagnostic accuracy of magnetic resonance imaging for detecting root avulsion(s) of C5–T1 was 68%, with 67% sensitivity and 92% specificity. It has a ‘good’ diagnostic accuracy for detection of root avulsion, although only a ‘sufficient’ sensitivity.

Conclusion:

Although useful, magnetic resonance imaging in its current form cannot be solely relied upon for clinical decision-making in brachial plexus birth injuries.

Level of evidence:

Keywords

Brachial plexus birth injury Erb’s palsy magnetic resonance imaging surgery

Introduction

Brachial plexus birth injury (BPBI) is defined as flaccid paralysis of the upper limb at birth, resulting from excessive traction applied to the neck during delivery (Andersen et al., 2006). BPBI affects an estimated 0.4–1 children per 1000 births (DeFrancesco et al., 2019; Evans-Jones et al., 2003; Mollberg et al., 2023) and is often associated with risk factors such as maternal diabetes, shoulder dystocia and instrumented births using forceps or ventouse (Lombard et al., 2020). Although all spinal nerve roots of the brachial plexus from C5 to T1 can be damaged, the most frequently involved are C5 and C6, known as Erb’s palsy (Gilbert and Whitaker, 1991). Although spontaneous recovery can occur within the first 3 months of life, up to 30% of cases have incomplete recovery, leading to joint deformity, permanent loss of function and psychological morbidity (Terzis and Kokkalis, 2009). The functional outcome of BPBI depends on the severity of the nerve damage, with neuropraxia (nerve stretching) being associated with the best prognosis, whereas nerve rupture and root avulsion result in permanent injury requiring nerve reconstruction (Kirjavainen et al., 2007).

The challenge in managing BPBI lies in accurately determining the extent of injury and predicting long-term outcomes. Although scoring systems such as the Active Movement Scale (Curtis et al., 2002) can aid in assessment, surgical exploration of the brachial plexus remains the diagnostic ‘gold (reference) standard’. Imaging methods have evolved to support clinical decision-making in BPBI, with magnetic resonance imaging (MRI) increasingly favoured over computed tomography myelography owing to the absence of ionizing radiation and intrathecal contrast agents (Grahn et al., 2019). Its advantages include enhanced soft tissue visualization, multiplanar reconstructions and opportunities for quantitative imaging (Gad et al., 2020).

Magnetic resonance imaging is typically done under general anaesthesia in infants with persistent upper limb functional limitations. The diagnostic accuracy of MRI in detecting nerve root avulsion and differentiating between pre-ganglionic and post-ganglionic injuries is crucial since these require different surgical approaches and have different prognoses. Pre-ganglionic injuries have the worst prognosis (Dolan et al., 2012), whereas post-ganglionic injuries can achieve better functional recovery if nerve continuity is restored (Dubuisson and Kline, 2002). The presence of nerve abnormalities such as scarring, neuroma or rupture can also be detected by MRI (Brooks et al., 2025). However, the variable sensitivity (60–75%) and specificity (89–100%) of MRI for detecting nerve injuries limits its reliability to fully inform clinical decisions (Gad et al., 2020; Gunes et al., 2018; Medina et al., 2006).

Surgical exploration is indicated if there is no significant improvement in biceps or deltoid function by 3 months of age or if the child has a low prognostic clinical score such as the Toronto test score (Curtis et al., 2002; Smith et al., 2004). During surgery, nerve disruption can be treated by transfers or grafts, with nerve transfers used for pre-ganglionic injuries (root avulsions) and nerve grafts for post-ganglionic injuries (Terzis and Papakonstantinou, 2004). Early reconstructive surgery has been associated with better functional outcomes (Terzis and Kokkalis, 2009). Despite being the reference standard for detecting root avulsions and other nerve abnormalities, surgical exploration carries risks, including bleeding, infection, accidental extubation, postoperative fluid overload and phrenic nerve injury (Grossman et al., 2018).

The aim of this study was to assess the diagnostic accuracy of MRI for BPBI, to define its clinical role and identify areas for development. The primary objective was to determine the diagnostic accuracy of 3T MRI (index test) in comparison with surgical exploration of the brachial plexus (reference standard) for detecting root avulsion in infants with BPBI under 1 year old. The secondary objectives were: to determine the diagnostic accuracy of the finding of pseudomeningocele in comparison with surgical exploration of the brachial plexus for detecting root avulsion in infants under 1 year with BPBI; to determine the diagnostic accuracy of 3T MRI (index test) in comparison with surgical exploration of the brachial plexus for detecting any root abnormality in infants under 1 year old with BPBI; and to determine whether age at MRI is associated with agreement between MRI and surgical exploration for root avulsion.

Methods

Design

This was a retrospective cohort study of consecutive patients at a specialist centre for the management of paediatric and adult brachial plexus pathology. The study has been reported in accordance with STARD guidance (Cohen et al., 2016). Ethical approval for this study was waived by our institutional review board and was given approval as a clinical audit, reference SE0254. Therefore, informed consent was not obtained as the data gathered have been approved as part of routine data collection.

Eligible patients were infants under 1 year old with brachial plexus birth injury born between 1 January 2019 and 1 May 2024 who had undergone surgical exploration of the brachial plexus and had a preoperative MRI. Patients were identified from radiology electronic records.

Before MRI patients may have had radiography of the clavicle and humerus to examine for fractures. Apart from clinical examination there were no other tests of the brachial plexus. Clinical examination included calculation of the Toronto test score at 3 months of age (Michelow et al., 1994).

Index test

The index test was MRI of the brachial plexus. Magnetic resonance imaging was done under general anaesthetic on a GE Signa Architect 3T (GE Healthcare, Illinois, USA) scanner using the protocol described in Table 1. Scans were carried out immediately before surgery and the results of the surgery (reference standard) were not known at the time of scan reporting. All scans were reported by one of two experienced musculoskeletal radiologists (JK and one other) with access to clinical records. The original radiology reports were used for this study. Root avulsion was defined as lack of continuity or absence of the nerve root between the spinal cord and exit foramen. Pseudomeningocele was defined as an increase in volume of the space containing the nerve root and cerebrospinal fluid within the foramen, plus an abnormal contour of the dura within the spinal canal. Nerve root abnormalities included root avulsion and pseudomeningocele, nerve root neuroma and thickening or thinning of the nerve root. Examples of imaging are shown in Figure 1.

Table 1.

Magnetic resonance imaging sequence parameters for brachial plexus birth injury.

Sequence	FOV (mm)	Slice thickness (mm)	TR (ms)	TE (ms)	Frequency resolution (voxels)	Phase resolution (voxels)
Sagittal T2 fast recovery fast spin echo (FRFSE)	200	3	3000	102	352	320
Sagittal T1 fluid attenuated inversion recovery	200	3	2100	24	320	320
Coronal T2 fast spin echo short tau inversion recovery (STIR)	190	3	8038	50	320	320
Coronal T2 flex	200	3	5442	68	320	320
Axial T2 FRFSE	160	3	4082	102	288	256
Axial T1	160	3	655	Minimum (9-27)	224	224
Coronal T2 fast imaging employing steady-state acquisition	180	0.6	6.5	Minimum (2.5-22)	320	320
Coronal 3D T2 STIR	360	0.6	3000	110	288	288
Coronal 3D T2	240	0.4	2500	90	288	288

FOV: field of view; TR: repetition time; TE: time to echo.

Figure 1.

Example images from magnetic resonance imaging (MRI) of infant brachial plexus, all shown in Coronal T2 fast imaging employing steady-state acquisition sequence. (a) No root avulsions seen on MRI or at surgery; true negative. (b) Avulsions with absent pre-ganglionic roots at left C7 and C8 which were confirmed operatively; true positive. (c) Pseudomeningocele at C8 in same patient as in image (b). A pseudomeningocele was also seen at C7 (not shown in this image). (d) Avulsion at left C6 root shown by root thickening (no pseudomeningocele). Finding confirmed at surgery; true positive. This is a subtle sign with the root appearing thicker with less clear-cut edges than a typical root. (e) Reported as no convincing root avulsion. At operation an avulsion was found at right C6; false negative. (f) Reported as left C6 avulsion owing to root thickening. No avulsion was found at surgical exploration; false positive.

Reference standard

Operative exploration was the reference standard for diagnosing root avulsion of the brachial plexus. Avulsion was defined as being present using a combination of the following: lack of nerve roots in the foramina; relaxation, attenuation and displacement of the scarred proximal nerve trunks or dorsal root ganglion; no identifiable nerve fascicles on exploration of the nerve root; empty proximal nerve sheaths; and the absence of any muscle activity on electrical stimulation of the nerve. Nerve root abnormality was defined as the presence of avulsion, or of nerve rupture, neuroma, scarred or stretched nerve.

Indications

The indications for surgical exploration were a Toronto test score <3.5 or a score >3.5 but with poor biceps recovery at 3 months of age and no or poor further recovery after monthly review. When children were operated on at older ages (10–11 months) this was because of a late referral to our centre. There is variation in the timing of MRI and surgery in this cohort because during the period of the study the availability and use of MRI changed, including the addition of an MRI scanner to the operating theatre suite. The results of the MRI were not used to decide whether or not to proceed to surgery, as it had already been decided that surgery was necessary.

Analysis of data

There were no missing data. Data are presented descriptively as numbers for categorical data or median and interquartile range for continuous data. Fisher’s exact test was used to analyse the association of sex and injury side with the presence of avulsion. The Wilcoxon rank-sum was used to determine the association of Toronto test score, age at MRI and age at surgery with the presence of avulsion. Sensitivity, specificity, positive predictive values and negative predictive values were calculated on per root, per total roots and per plexus bases. Exact binomial 95% confidence intervals were obtained for the per total roots analyses. Spearman’s rho was used to assess the correlation between age at MRI and the agreement between index and reference tests. The result from the Spearman’s rho analysis was bootstrapped to obtain the 95% confidence interval. The agreement between avulsion counts on MRI and at surgery was presented as Cohen’s kappa (perfect agreement k = 1; no agreement k = 0). The Wilcoxon rank-sum test was used to examine the association between age at MRI and presence of pseudomeningocele. Diagnostic accuracy was defined as: (true positive + true negative)/total.

Results

Eighteen potential participants were identified and included in this study. The median birth weight of the participants was 4.0 kg (IQR: 3.7 to 4.2). Twelve participants had shoulder dystocia, six underwent instrumented delivery and the bilateral case was a breech presentation. Two cases had Horner’s syndrome. Patients with root avulsion at surgery had a lower Toronto test score compared with those without, but this difference was not significant. Magnetic resonance imaging and surgery were both carried out at a slightly younger age in patients found to have root avulsions, but this difference was not significant (Table 2). The youngest age an MRI was conducted was at 9.4 weeks.

Table 2.

Patient demographics with comparison between cases with root avulsion at surgical exploration and those without.

Patient demographics	Patients with no root avulsions (n = 7)	Patients with any root avulsion (n = 11)	p-Value*
Sex
Male	2	5
Female	5	6	0.63
Side of injury
Right	4	7
Left	3	3
Bilateral	–	1	0.78
Median Toronto score (IQR)	5.2 (4.2–7.3)	3.9 (0–4.5)	0.07
Median age at MRI in weeks (IQR)	28 (17–49)	19 (15–22)	0.08
Median age at operative exploration in weeks (IQR)	28 (17–49)	19 (14–22)	0.22

Comparison between ‘Patients with no root avulsions’ and ‘Patients with any root avulsion’.

The Toronto score was calculated at age 3 months and is not available for all patients as some cases were referred from out of area at a later age.

Table S1 (available online) shows the per patient and per root agreement between MRI and surgical exploration for root avulsion. Table 3 presents a per root comparison of root avulsion between MRI and surgery. Using a per plexus analysis, the diagnostic accuracy of MRI to detect root avulsion in comparison with surgical exploration was 68%, which means that the injury was incorrectly classified in nearly a third of cases. On a per root analysis MRI had a good negative predictive value of 91%. However, this was only 57% with a per plexus analysis, meaning that four out of 10 patients with root avulsion would be missed on MRI.

Table 3.

Diagnostic accuracy of MRI in comparison with surgical exploration for root avulsion in infants with brachial plexus birth injury.

Location of suspected avulsion on MRI	Avulsion found at operative exploration		Sensitivity (%)	Specificity (%)	Positive predictive value (%)	Negative predictive value (%)
Location of suspected avulsion on MRI	Yes	No	Sensitivity (%)	Specificity (%)	Positive predictive value (%)	Negative predictive value (%)
At least one avulsion (per plexus analysis)
Yes	9	3
No	3	4	75	57	75	57
C5 root
Yes	4	2
No	3	10	57	83	67	77
C6 root
Yes	6	4
No	3	6	67	60	60	67
C7 root
Yes	2	0
No	1	16	67	100	100	94
C8 root
Yes	1	0
No	0	18	100	100	100	100
T1 root
Yes	1	0
No	0	18	100	100	100	100
Cumulative (per root) suspicion of root avulsion for C5-T1
Yes	14	6
No	7	68	67(95% CI: 57 to 76)	92(95% CI: 86 to 97)	70(95% CI: 61 to 79)	9195% CI: 84 to 97)

Table 4 describes the diagnostic accuracy of pseudomeningoceles as a surrogate marker of root avulsion. Using a per plexus analysis the overall diagnostic accuracy was 79%. Pseudomeningocele was highly specific for root avulsion at 100%, indicating that pseudomeningoceles were associated with avulsions.

Table 4.

Diagnostic accuracy of presence of pseudomeningoceles on MRI in comparison with surgical exploration for detecting root avulsions in infants with brachial plexus birth injury.

Location of pseudo-meningocele on MRI	Avulsion found at operative exploration		Sensitivity (%)	Specificity (%)	Positive predictive value (%)	Negative predictive value (%)
Location of pseudo-meningocele on MRI	Yes	No	Sensitivity (%)	Specificity (%)	Positive predictive value (%)	Negative predictive value (%)
At least one pseudomeningocele
Yes	8	0
No	4	7	67	100	100	63
C5 root
Yes	3	0
No	4	12	43	100	100	75
C6 root
Yes	4	0
No	5	10	44	100	100	67
C7 root
Yes	2	0
No	1	16	67	100	100	94
C8 root
Yes	1	0
No	0	18	100	100	100	100
T1 root
Yes	1	0
No	0	18	100	100	100	100
Cumulative (per root) presence of pseudomeningocele for C5-T1
Yes	11	0
No	10	74	52(95% CI: 42 to 62)	100(95% CI: 100 to 100)	100(95% CI: 100 to100)	88(95% CI: 82 to 94)

We explored the use of MRI to detect any nerve root abnormalities in comparison with surgery (Table S2, available online). Magnetic resonance imaging had a poor negative predictive value for detecting any nerve root abnormalities. The overall diagnostic accuracy was 68% on a per plexus analysis and 80% on a per root analysis.

A younger age at MRI scanning was associated with better agreement between the finding of avulsions at MRI and surgery (Spearman’s rho, −0.62; 95% CI: −0.98 to −0.26; p = 0.008). On a per root analysis, the agreement between MRI and surgery for avulsions was 86% (k = 0.6; p < 0.001). There was no association between age at MRI and the presence of pseudomeningocele.

One patient initially underwent MRI as a ‘feed and wrap’ scan when awake. However, the images were degraded by motion artefact, so the scan was repeated under general anaesthesia. Only the results from the scan done under general anaesthesia have been included in this study. There were no other adverse events from MRI scanning. For the surgical exploration (with or without reconstruction of the brachial plexus) no patients had a reported adverse event within 30 days of operation.

Discussion

The primary objective of this study was to determine the diagnostic accuracy of MRI in detecting root avulsions in infants with brachial plexus birth injury and to compare these findings with surgical exploration.

The results showed that MRI has a moderate diagnostic accuracy in detecting root avulsion when compared with surgical exploration on a per root analysis. This group was already clinically highly selected for surgery, so a high accuracy of MRI is required. However, MRI has limited sensitivity, particularly in the roots most frequently injured (C5 and C6). The overall per plexus sensitivity of MRI for detection of root avulsion was 75%, meaning that in one quarter of infants diagnosed with root avulsion, the roots were in fact in continuity. Equally, the specificity per plexus was 57%, which means that in over 40% of infants determined to have no root avulsion, there was an avulsion present. This indicates that currently MRI does not have sufficient accuracy to allow informed decisions about operative planning to be made.

The sensitivity and specificity of MRI varied across different nerve roots. The specificity of MRI was generally high, particularly for the C8 and T1 roots. However, the sensitivity was lower for the upper nerve roots associated with Erb’s palsy (C5 and C6). This may be related to the frequency of root avulsions, which were much more common in the upper roots. However, this variability is in keeping with previous studies (Gad et al., 2020; Grahn et al., 2019; Gunes et al., 2018) and underlines the problem of using MRI as a stand-alone diagnostic tool for certain nerve root levels.

We studied the usefulness of pseudomeningocele as a surrogate marker for root avulsion. It had a high specificity of 100% across all nerve roots, indicating that its presence is a strong predictor of root avulsion. However, the sensitivity was lower, particularly for the C5 and C6 roots. This suggests that although pseudomeningocele is a reliable marker when present, its absence does not reliably exclude root avulsion.

There was an association between younger age at MRI and increased diagnostic agreement between MRI and surgical exploration. The youngest patient in the series was 9.4 weeks old at the time of MRI. This highlights that imaging patients with BPBI at a young age is feasible and may have better accuracy than imaging at older ages. Imaging at an older age may also reduce frequency of finding of pseudomeningocele owing to resorption of the cerebrospinal fluid (Solomon et al., 2013), although this was not identified in our study. There is a potential bias in those cases referred early in that those with more severe injuries had lower Toronto test scores and the decision to operate would have been made at a single review at 3 months. However, some babies were referred later (>13 weeks) so the decision to operate was based on poor recovery. We cannot assume that these were more, or less, severe lesions as we do not have the clinical assessment at 3 months of age.

Given the moderate diagnostic accuracy of MRI, it is crucial to combine MRI findings with clinical examination and other diagnostic methods to ensure accurate diagnosis and appropriate management. Currently MRI is useful in supporting clinical findings and for complex surgical planning, for example whether to use nerve grafts or transfers. Better imaging protocols and advanced MRI techniques (Vargas et al., 2018), such as enhanced field strength (Menon et al., 2021), reduced slice thickness (Davidson et al., 2023) and diffusion tensor imaging (Wade et al., 2025) may offer improved diagnostic accuracy. Biomarkers of nerve injury and recovery should be the focus of future research. Even for the most experienced surgeon interpretation of the nerve injury in BPBI can be difficult. Patients clinically selected for surgical exploration of the brachial plexus will continue to undergo a preoperative MRI.

This study has some limitations. The sample size was small, which may limit the generalizability of the findings. The study was retrospective, although the cases were consecutive which minimizes selection bias. There was a relatively broad age range so correlations with age will need to be validated in a larger cohort. Variations can arise in diagnostic accuracy owing to the subjective nature of image interpretation. An experienced radiologist is necessary to review the images and this may limit the reproducibility of our results in units without this expertise.

In conclusion, MRI has moderate diagnostic accuracy in detecting root avulsion in infants with BPBI, with good specificity but variable sensitivity in different nerve roots.

Supplemental Material

sj-docx-1-jhs-10.1177_17531934251406957 – Supplemental material for Magnetic resonance imaging for detecting root avulsions in brachial plexus birth injuries

Supplemental material, sj-docx-1-jhs-10.1177_17531934251406957 for Magnetic resonance imaging for detecting root avulsions in brachial plexus birth injuries by Claire M Hardie, Chiraag Karia, Ryckie G Wade, Jeannette K Kraft, Rob Bains and Grainne Bourke in Journal of Hand Surgery (European Volume)

Footnotes

Acknowledgements

We gratefully acknowledge the support of George Wormald in obtaining the MRI sequence parameters.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Ryckie Wade is an Academic Clinical Lecturer funded by the National Institute for Health Research (NIHR, CL-2021-02-002). The views expressed are those of the author(s) and not necessarily those of the UK’s National Health Service, NIHR or Department of Health.

Ethical approval and informed consent statements

Ethical approval for this study was waived by Leeds Teaching Hospitals Trust institutional review board and was given approval as a clinical audit, reference SE0254. Therefore, informed consent from subjects was not obtained as the data gathered have been approved as part of routine data collection.

Trial registration

not applicable as not clinical trial.

Guarantor

Not applicable.

ORCID iDs

Claire M Hardie

Chiraag Karia

Ryckie G Wade

Data availability statement

All data used within this study is contained within the article and supplemental files. If images are required these will need to be requested owing to patient confidentiality.

Supplementary material

Supplemental material for this article is available online.

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Supplementary Material

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