Iatrogenic Brachial Plexopathy With Lateral Cord Transection

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Iatrogenic Brachial Plexopathy With Lateral Cord Transection

Authors, Editors, Case Information Author: Milan Oxspring, MD Affiliation: Mayo Clinic, Department of Physical Medicine and Rehabilitation Co Author(s): James B. Meiling, DO Senior Editor: Wesley Troyer, DO Clinical Vignette: A 61-year-old right-handed female developed immediate postoperative right upper extremity weakness, numbness, and severe pain following a right reverse shoulder arthroplasty which was complicated by axillary vein thrombosis and postoperative hematoma. Exam was notable for diffuse upper extremity weakness, though most prominent with elbow flexion, wrist flexion, and finger flexion. There were absent deep tendon reflexes of the biceps brachii and brachioradialis. Type of Probe Used: 4-18 MHz linear-array ultrasound transducer Unlabeled Long Axis View of the Brachial Plexus Lateral Cord Unlabeled long axis view of the lateral cord of the right brachial plexus in the infraclavicular view. Labeled Long Axis View of the Brachial Plexus Lateral Cord Labeled long axis view of the lateral cord of the right brachial plexus lying deep to the pectoralis major and minor muscles in the infraclavicular view. The lateral cord (dashed line) is seen to approach distal to proximal but abruptly ends (arrow) as the cord becomes focally hypoechoic and disorganized, indicating complete lateral cord transection (neural discontinuity or neurotmesis). Unlabeled Short Axis View of the Brachial Plexus Lateral Cord Unlabeled short axis view of the lateral cord of the right brachial plexus in the infraclavicular view. Labeled Short Axis View of the Brachial Plexus Lateral Cord Labeled short axis view of the lateral cord of the right brachial plexus in the infraclavicular window. At this site there is focal enlargement of the lateral cord (dashed line, cross-sectional area 26.85 mm2), just distal to the cord transection (not visualized in this image). In this view, the lateral cord lies deep to both the pectoralis major and minor muscles, lateral to the axillary artery (asterisk). The posterior cord is seen deep to the axillary artery, marked by arrowheads. Interpretation Image Interpretation: Focal area of neural tissue disruption within the distal portion of the lateral cord of the right brachial plexus, just proximal to its bifurcation into the musculocutaneous and median nerves. This region demonstrated loss of organized fascicular pattern without doppler hyperemia, consistent with traumatic neural injury. The lateral cord abruptly ends as the cord becomes focally hypoechoic and disorganized, indicating complete lateral cord transection (neural discontinuity or neurotmesis). The terminal nerves in the axilla (median, ulnar, radial, musculocutaneous) and the supraclavicular roots, trunks, and divisions appear normal without enlargement, torsion, entwinement, or hourglass constrictions. Teaching Pearl: Ultrasound evaluation of the brachial plexus can be performed from supraclavicular, infraclavicular, and axillary windows, each showing different portions of the plexus. The infraclavicular view is especially useful for the cords, where focal loss of fascicular architecture, discontinuity, neuroma, hematoma, or scarring can localize injury. Ultrasound can give an anatomic explanation for postoperative or iatrogenic plexopathy that complements electrodiagnostic testing. Localizing the lesion to the lateral cord near its terminal branches can help guide prognosis, further imaging, and surgical referral decisions. References: 1. Baute V, Strakowski JA, Reynolds JW, et al. Neuromuscular ultrasound of the brachial plexus: a standardized approach. Muscle Nerve. 2018;58(5):618-624. doi:10.1002/mus.26144 2. Koneru S, Nguyen VT, Hacquebord JH, Adler RS. Brachial plexus nerve injuries and disorders: MR imaging-ultrasound correlation. Magn Reson Imaging Clin N Am. 2023;31(2):255-267. doi:10.1016/j.mric.2023.01.006 3. Rocks MC, Comunale V, Sanchez-Navarro GE, Nicholas RS, Hacquebord JH, Adler RS. Diagnostic capability of ultrasonography in evaluating peripheral nerve injuries of the brachial plexus. Hand (N Y). 2025;20(8):1252-1258. doi:10.1177/15589447241277844
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Authors, Editors, Case Information

Unlabeled Long Axis View of the Brachial Plexus Lateral Cord

Labeled Long Axis View of the Brachial Plexus Lateral Cord

Unlabeled Short Axis View of the Brachial Plexus Lateral Cord

Labeled Short Axis View of the Brachial Plexus Lateral Cord

Interpretation

UPCOMING EVENTS

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