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Introduction:
Brachial plexus injuries are devastating injuries and the pre-operative diagnosis can be difficult despite the aid of current imaging techniques and nerve physiologic studies. It is at times particularly difficult to distinguish between preganglionic and postganlionic injuries based on the pre-operative assessment. The hypothesis of this study is that the accuracy of pre-operative diagnosis of traumatic brachial plexus injury is good when compared to the findings at the time of brachial plexus exploration.

Methods:
At one institution, 31 consecutive trauma patients had brachial plexus surgery from 2005-2012. Pre-operative assessment tools include history and physical examination, nerve physiologic studies according to the same protocol, chest radiographs, pulmonary function testing as well as MR imaging and CT/myelogram imaging techniques. Of these, 23 underwent complete brachial plexus exploration and were included in the study. The average patient age was 35 years. The most common mechanism of injury was a motor cycle accident, followed by motor vehicle accident, assault, fall and gunshot wound. Eighteen of the patients had advanced imaging studies while 5 patients had no advanced imaging. The intra-operative diagnosis was then compared to the pre-operative diagnosis and judged as having either good or poor correlation.

Results:
In 16/23 (or 69.6%) patients there was good correlation between pre-operative and intra-operative diagnosis. Six of the 7 (or 85%) patients having pre-op diagnoses with poor correlation to intra-op diagnosis were in patients with at least one nerve root avulsion injury. Fifteen of the 16 patients (or 93.8%) with good correlation with intra-operative diagnosis were in patients who had post-ganglionic nerve root injuries only. All 15 patients with post-ganglionic nerve root injuries in this study had good correlation with intra-operative diagnosis. One observation of the authors was that pre-operative testing can on occasion yield conflicting data making the pre-operative diagnosis difficult. One limitation of the study was that all patients did not have identical pre-operative imaging studies, although nerve physiologic testing and physical examination were performed in identical manner.

Discussion and Conclusion:
The accuracy of pre-operative diagnosis following pre-operative assessment of brachial plexus injury is good in the majority of patients. The pre-operative diagnosis may be less accurate when nerve root avulsion injuries are present. We recommend that when nerve root avulsion injuries are believed to be present based on pre-operative testing and examination, the surgeon should be prepared for several different operative procedures with the final decision made based on intra-operative findings.