Title: Novel Magnetic Resonance Imaging for Diagnosing Traumatic Brachial Plexus Injuries
Funder: Department of Health and Social Care

Abstract: Background: The nerves of the brachial plexus supply the arm with movement and feeling. Brachial plexus injuries (BPI) can result in severe disability needing constant care and medication for intractable pain. In England, 500 adults incur severe nerve injuries following major trauma, costing 0.5million per patient due to lost earnings, treatment/rehabilitation and social care. Early diagnosis of BPI allows early reconstructive surgery, which can restore movement and feeling, enabling independent living. Clinical Problem: Diagnosing a BPI requires extensive exploratory surgery because conventional scans (magnetic resonance imaging, MRI) are not reliable. Our proof-of-concept work has improved the fidelity of conventional MRI scans and generated a novel MRI modality for diagnosing BPI. This novel MRI scan could obviate the need for exploratory surgery, enabling immediate diagnosis and reconstruction. Research questions: In adults with traumatic brachial plexus injuries: What is the diagnostic accuracy of conventional MRI? What is the diagnostic accuracy of our new MRI techniques for diagnosing nerve injury and monitoring nerve regeneration? How does the spinal cord change and cerebral cortex reorganise after injury and treatment? Objectives: The three objectives are: Systematically review the diagnostic accuracy of MRI for adult BPI Conduct a pilot diagnostic accuracy study of our novel MRI scan for adults with traumatic BPI Conduct a hypothesis-generating nested cohort to study a) cerebral sensorimotor plasticity using functional MRI (fMRI), b) whether diffusion MRI can monitor nerve regeneration, and c) how the appearance of the spinal cord changes on MRI, following injury and treatment Methods: The systematic review will follow methods recommended in the Cochrane Handbook for Systematic Reviews of Diagnostic Test Accuracy. The pilot study will recruit 57 adults with BPI who require exploratory surgery and can undergo serial MRI scans. The novel MRI (index test) will be assessed against the reference standard of operative exploration. I will 1) estimate the improvement in diagnostic accuracy offered by the novel MRI scan, and 3) observe changes in the appearance of the brachial plexus, spinal cord and brain following injury and treatment. Timelines for delivery: From October 2018 to September 2021 Anticipated impact and dissemination: The novel MRI scans could revolutionise the management of BPI because exploratory surgery would no longer be required. Further, diagnoses could be made immediately and so reconstruction performed without delay. This would benefit patients by improving physical function and mental health, reduce surgical morbidity and better enable return to normal life. Financial benefits to the NHS could be realised by eliminating the need for exploratory operations and clinic appointments for surveillance. Spinal cord imaging could aid in the identification of those amenable to reconstructive nerve surgery, as we could visualise residual motor nerves in the anterior horn which could be revived. Functional MRI of the brain could help us find those at risk of chronic nerve pain and those who would benefit most from surgery to reanimate the hand: this pilot data will also inform the design of my doctoral research.

Lay abstract: AimsTo investigate new types of magnetic resonance imaging (MRI) scans for diagnosing severe nerve injury in the arm. To understand how the brain and spinal cord respond to severe nerve injury using MRI scans. Why is it important? The nerves which control movement and feeling in the arm can be severely damaged in motorbike crashes, sporting or work-related injuries. Every year 500 adults sustain life-changing major nerve injuries, which might cause 1) disability needing constant care, 2) severe nerve pain and 3) mental illness. Patients describe major nerve injuries as ...life-changing and that the public should be clear on the severity of this problem. In England, major nerve injuries cost 250million every year in hospital treatments, unemployment and social care.Injured nerves can be repaired with surgery. To decide if nerves need repairing, exploratory surgery is needed. Instead, we have developed a new MRI scan which could diagnose nerve injuries, meaning: Exploratory surgery could be avoided Nerve injuries could be diagnosed immediately Reconstructive surgery could be done sooner Our new MRI scan could help patients and save money for the NHS, because: Exploratory operations would not be needed Fewer people would be disabled More people could return to work and support their family Some people with nerve injuries develop lifelong pain - if we could understand how the brain adapts, we could learn how to prevent nerve pain. Also, some people don't recover movement in their hand - if we could understand how the brain reorganises nerves controlling movement, we could predict who would benefit from surgery.Objectives Concerning adults with severe nerve injuries in the arm, my research will: Summarise the accuracy of normal MRI for identifying these injuries; Study the accuracy of our new MRI scan; and Monitor how the brain reorganises and the spinal cord changes after nerve injury, using MRI. How will we recruit participants? I need 57 adults (over 16 years old) with nerve injuries affecting the arm, who require surgery. We will visit patients and/or their family in hospital soon after injury. I will explain the research, provide an information sheet and consent form, and answer questions.What will participants have to do? Participants will have two scans before surgery (to find out the best time to scan), then two after surgery (at 6 and 12 months). These scans will be for research only and will not change treatment.Patient and public involvement Over 2 years, I have received important feedback from patients with nerve injuries and their family. I have met with people individually and as a group. Their input has highlighted the importance of: Personalised communication with patients, as some people cannot answer the telephone, make decisions or remember appointments. Providing travel costs for people taking part in the research. Making the MRI scans comfortable. Patients confirmed that they are happy: With the number of research scans: the more scans the better more information can only be a good thing. Travelling to Leeds from around the region: have you ever been in hospital? it would be [nice] to have a trip out. For family/friends/doctors to give permission for the research on their behalf if they were unconscious: if MRI isn't harmful there's no problem scanning someone [who is] unconscious. Dissemination I plan to share the findings by publishing in journals, and through meetings with surgeons, patient groups and NHS commissioners.Translation to practice In principle, the new MRI scan could be done anywhere in the world, straight away. Beforehand, I need to conduct a larger scale study within the NHS.

Research activity codes: 4.2 EVALUATION OF MARKERS AND TECHNOLOGIES
Health categories: NEUROLOGICAL