Undeveloped semiconic posterosuperior ligament and susceptibility to avulsion of the C-7 spinal nerve in Erb palsy

Abstract

Object In Erb palsy, the C-7 spinal nerve has been found to be more subject to avulsion than the C-5 and C-6 spinal nerves. This study investigated the morphological and biomechanical characteristics of the semiconic posterosuperior ligaments (SPLs) at the C-5, C-6, and C-7 spinal nerves in neonates. Methods Twenty-four brachial plexuses from 12 fresh neonate cadavers were used in this study. In 12 brachial plexuses from 6 cadavers, the following studies were performed with respect to the SPLs at the C-5, C-6, and C-7 spinal nerves: gross observation of morphological and histological characteristics; measurement of length, thickness, and width; and a semiquantitative analysis of collagen. In the other 6 cadavers, biomechanical tension testing was performed bilaterally on the C5–7 SPLs to assess the tensile strength of the ligaments. Results The C5–7 spinal nerves are fixed to the transverse process through the SPL, a structure not observed at the C-8 and T-1 spinal nerves. Except for the width of the SPL insertion on the spinal nerve, which was found to increase gradually from C-5 to C-7, there was no statistically significant difference in the dimensions of the C-5, C-6, and C-7 SPLs. The sectional area percentage of collagen was 51% ± 10% in SPLs for C-5, 51% ± 11% for C-6, and 41% ± 10% for C-7; and this percentage was significantly lower in SPLs for C-7 than for C-5 or C-6 (1-way ANOVA, F = 4.3, p = 0.02; Tukey honestly significant difference test, p = 0.04 and 0.04, respectively). Sharpey fibers were observed at the transverse process origin of the SPL at C-5 and C-6 but not at C-7. Biomechanical tension testing showed that the mean failure load was 6.6 ± 0.9 N for the C-5 SPL, 6.4 ± 1.0 N for the C-6 SPL, and 5.4 ± 0.9 N for the C-7 SPL, and the failure load was significantly lower in SPLs at C-7 than in those at C-5 or C-6 (1-way ANOVA, F = 5.1, p = 0.01; Tukey honestly significant difference, p = 0.01 and 0.048, respectively). Nine of 12 C-7 SPLs failed at their origin from the transverse process, while only 4 of 12 C-5 SPLs and 3 of 12 C-6 SPLs failed at the origin site. Conclusions These findings suggest that the lower density of collagen and absence of Sharpey fibers decrease the biomechanical properties of the C-7 SPL, and this may account for the higher frequency of avulsion of the C-7 spinal nerve (in comparison with the C-5 or C-6 nerve) in Erb palsy.