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Spatial mapping of the brachial plexus using three-dimensional ultrasound

Cambridge University Departments of ¹ Radiology and ² Anaesthesia, Addenbrookes Hospital NHS Trust, Hills Road, Cambridge CB2 2QQ and ³ Cambridge University Department of Engineering, Trumpington Street, Cambridge CB2 1PZ, UK

View larger version (37K): [in a new window]   Figure 1. The whole data set is illustrated. The position of the transducer at the beginning and end of the sweep is demonstrated on the left and right, respectively.

View larger version (34K): [in a new window]   Figure 2. (a) The whole data set from the extraforaminal to the costo-clavicular section of a right brachial plexus. (b) An individual B-scan from the data set from the interscalene triangle and illustrates the vertical alignment of the plexus trunks at this stage. The individual components of the plexus on this single image have been manually segmented (dotted lines). (c) A series of representative outlines of the brachial plexus, from the whole data set.

View larger version (95K): [in a new window]   Figure 3. The first rib, subclavian artery and components of the brachial plexus have been manually segmented. Arrowheads indicate a nerve containing fibrillar structures occasionally seen within the brachial plexus at this level.

View larger version (112K): [in a new window]   Figure 4. (a) A multiplanar reconstruction (MPR), reconstructed from a data set from a left brachial plexus along the longitudinal plane of the plexus. The image quality improves by correcting for operator-induced misregistration (b). (c,d,e) The original B-scans from the data set of the trunk, divisions and cord level, respectively. A hyper-reflective sheath clearly outlines the brachial plexus trunks and divisions (c,d).

View larger version (53K): [in a new window]   Figure 5. Examples of surface rendered 3D reconstructions of the brachial plexus in relation to segments of the carotid and subclavian artery and the first rib. A right brachial plexus viewed from (a) a lateral and (b) an anteroposterior perspective, respectively.

View larger version (45K): [in a new window]   Figure 6. Surface rendered reconstructions of a right and left brachial plexus from the same individual viewed laterally (a, b) and from above (c, d). This individual demonstrates clumped right sided divisions, white arrows (a, c), and flatter left sided divisions, arrowheads.

View larger version (60K): [in a new window]   Figure 7. Original B-scans illustrating the different alignment of the divisions over the first rib within a single individual. The anteroposterior width of the plexus at this level measures 10 mm on the right and 15 mm on the left.

View larger version (129K): [in a new window]   Figure 8. The course of the C5 nerve root (dashed line) appears to run anterior to scalenus anterior (SA) (a, b) rather than between scalenus anterior and medius (SM). It runs over the lateral border of scalenus anterior before reuniting with the remaining nerve roots, C6 and C7 (c, d). The course of the C6 and C7 nerve roots (dotted line) runs between scalenus anterior and medius (c, d).

View larger version (65K): [in a new window]   Figure 9. (a) The plexus has formed divisions whilst still apparently within the scalene muscles. (b) The divisions first appear once the plexus has emerged from between the scalene muscles.

View larger version (95K): [in a new window]   Figure 10. In the majority of volunteers, an artery was seen crossing the brachial plexus in an anteroposterior direction within the supraclavicular fossa. This artery is most likely either the superficial cervical or suprascapular branch of the subclavian artery.

View larger version (26K): [in a new window]   Figure 11. The brachial plexus may be divided into roots, trunks, divisions and cords. The upper trunk is formed from the union of the roots C5 and C6, the middle trunk is a continuation of C7 root and the lower trunk is formed by the union of C8 and T1 roots. Each trunk divides into anterior and posterior divisions. The lateral cord is formed by the union of the anterior divisions of the upper and middle trunks. The medial cord is formed by the anterior divisions of the lower trunk. The posterior cord is formed by the union of the posterior divisions of all the trunks.