Description

A 66-year-old man was brought to the hospital after an episode of binge drinking, in which he was found in an unusual position (both arms trapped between the toilet and the sink). During extraction, his son used different manoeuvres, including traction, abduction and flexion of the arms. Muscle strength was reduced, and sensitivity and myotatic reflexes were altered in the upper limbs (table 1).

The lower limb examination was normal. Although cervical MRI showed only moderate degenerative disease (figure 1A), the clinical manifestations were attributed to spinal shock/acute traumatic central cord syndrome. No improvement was observed after 2 weeks, raising suspicions of bilateral brachial plexopathy (BBP), shown in the plexus MRI (figure 1B,C). The presence 4 weeks later on electrodiagnostic testing (in different nerves or muscles) of fibrillation; positive sharp waves; decrease/absent compound muscle action potential amplitude; decrease/absent sensory nerve action potential; and nerve conduction blocks, confirmed the diagnosis. Partial recovery occurred with intensive rehabilitation (table 1). BBP is extremely rare in adults. The main causes are postoperative paralysis, and severe traumatic accidents.1 ,2 In our case, the history, the bilateralism and the absence of symptoms such as pain, paresthesias, made these diagnosis very unlikely. In an appropriate context, brachial plexus MRI is sensitive, and highly specific for the diagnosis of traumatic brachial lesions.1 ,2 However, electromyography remains as the diagnostic gold standard.1 Restoring of strength through collateral reinnervation over time is a possibility. Surgical intervention depends on the lesion severity and degree of recovery during the first 6 months.3

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Figure 1

(A) Cervical MRI showing moderate degenerative changes, moulding of the subarachnoid space at C5–C6 and C6–C7 (arrows), without any sign of spinal cord lesion; (B) Short tau inversion recovery imaging showing bilateral hyperintense, enlarged trunks (arrows) compatible with postganglionic brachial plexus lesion (axonotmesis or neurotmesis); (C) Amplified image of plexus injury (right side).