title: Brachial plexus injury mimicking a spinal-cord injury.
abstract: OBJECTIVE
  High-energy impact to the head, neck, and shoulder can result in cervical spine as well as brachial plexus injuries. Because cervical spine injuries are more common, this tends to be the initial focus for management. We present a case in which the initial magnetic resonance imaging (MRI) was somewhat misleading and a detailed neurological exam lead to the correct diagnosis.
  
  
  METHODS
  A 19-year-old man presented to the hospital following a shoulder injury during football practice. The patient immediately complained of significant pain in his neck, shoulder, and right arm and the inability to move his right arm. He was stabilized in the field for a presumed cervical-spine injury and transported to the emergency department.
  
  
  METHODS
  Initial radiographic assessment (C-spine CT, right shoulder x-ray) showed no bony abnormality. MRI of the cervical-spine showed T2 signal change and cord swelling thought to be consistent with a cord contusion. With adequate pain control, a detailed neurological examination was possible and was consistent with an upper brachial plexus avulsion injury that was confirmed by CT myelogram. The patient failed to make significant neurological recovery and he underwent spinal accessory nerve grafting to the suprascapular nerve to restore shoulder abduction and external rotation, while the phrenic nerve was grafted to the musculocutaneous nerve to restore elbow flexion.
  
  
  CONCLUSIONS
  Cervical spinal-cord injuries and brachial plexus injuries can occur by the same high energy mechanisms and can occur simultaneously. As in this case, MRI findings can be misleading and a detailed physical examination is the key to diagnosis. However, this can be difficult in polytrauma patients with upper extremity injuries, head injuries or concomitant spinal-cord injury. Finally, prompt diagnosis and early surgical renerveration have been associated with better long-term recovery with certain types of injury.
authors.affiliation: Department of Neurosurgery, University of Pennsylvania Medical Center, Philadelphia, PA, USA.
authors.forename: Luke J
authors.initials: LJ
authors.lastname: Macyszyn
authors.forename: Ernesto
authors.initials: E
authors.lastname: Gonzalez-Giraldo
authors.forename: Michael
authors.initials: M
authors.lastname: Aversano
authors.forename: Gregory G
authors.initials: GG
authors.lastname: Heuer
authors.forename: Eric L
authors.initials: EL
authors.lastname: Zager
authors.forename: James M
authors.initials: JM
authors.lastname: Schuster