Brachial neuritis ,Parsonage turner - Everything You Need To Know - Dr. Nabil Ebraheim

Dr. Ebraheim’s educational animated video describes the Acute Brachial Neuritis.
This is a very important topic for the clinical practice and it may also appear on examinations.
Brachial neuritis is also referred to as:
• Neuralgic Amyotrophy (NA).
• Parsonage – Turner Syndrome.
It is a condition of severe shoulder pain that usually radiates down the arm and up the neck and scapula, the pain is sudden, severe and may last weeks.
This pain may wake people up from sleep, it usually happens by itself without a history of trauma.
It can occur more in males and can affect any age.
The position of comfort is the shoulder adducted with the elbow flexed, and it’s called the Adduction/ Flexion sign of Acute Brachial Neuritis.
Neck movement and Valsalva’s maneuver do not increase the pain; the pain will increase by moving the arm.
Although the pain is severe and sudden, lasting at least a few weeks, the condition is usually under diagnosed or not diagnosed at all, or there is a delay in the diagnosis.
Weakness may be absent in the acute phase, however as the pain resolve, weakness of certain muscles will remain.
The degree of weakness correlates with the severity of the initial pain.
The Muscles that are commonly involved are:
- Supraspinatus muscle, Infraspinatus muscle: the external rotators, with the suprascapular nerve is the most commonly involved.
- Deltoid muscle, which is the abductor of the shoulder, innervated by the axillary nerve.
The condition may occur bilaterally.
It may occur subclinically (only seen on IMG).
Muscle weakness may continue for a long period of time.
Sensory changes are variable:
- If there is no sensory loss, this is a classic finding that confirm the diagnosis.
- There is decreased sensation in a lot of cases.
- The lateral antibrachial cutaneous nerve is usually involved.
- The motor changes predominate over the sensory changes.
- It can involve the brachial plexus from C5-T1 with variable degree of weakness.
- It can affect more than one nerve branch with certain patterns of involvement can be seen on MRI.
- It is a benign, self limiting problem with 90% of patients returning to near normal condition in about 3 years.
- Only about 1/3 of patients will recover at about 1 year.
The Etiology is unknown; it may be any of the following:
• Viral
• Shoulder trauma or overuse
• Autoimmune disease
• Stress
• Immunization
• Genetic: there is a genetic form, which is rare, its autosomal dominant.
Imaging:
- Hyperintense muscles involved in the sagittal plane (supraspinatus, infraspinatus, deltoid)
- In advanced cases, the muscles will either be atrophied or have fatty infiltration.
EMG and Nerve Studies:
- Helpful for the diagnosis and the prognosis.
- In the first 4 weeks there will be acute denervation in the roots and the peripheral nerves.
- EMG may be abnormal for up to 7 years after the diagnosis.
Differential Diagnosis:
- Rule out other conditions, such as radiculopathy from a herniated disc.
- This can be excludes by imaging the cervical spine.
- Adhesive capsulitis or frozen shoulder.
- Lyme disease.
The 2 particular conditions that are very interesting with acute brachial neuritis (caused by the Brachial neuritis):
1- Bilateral Interosseous nerve palsy: which is caused by viral brachial neuritis (published data), patient will lose the ability to do the O.K. sign, usually the motor loss follows intense shoulder pain, usually resolves with time especially if that lesion occurred due to neuritis.
2- Winging of the Scapula:
- If you have a case of winging of the scapula: Serratus anterior muscle involvement may cause dull aches and pain.
- But if you have winging of the scapula and the patient has: Acute, sudden severe pain then think of acute brachial neuritis that involves the C7 nerve roots.
- C7 nerve root gives the long thoracic nerve which innervates the serratus anterior muscle.
- This means that if the patient has:
Severe shoulder pain + Winging of the scapula: then you have to rule out Brachial Neuritis.
Treatment:
• Rest
• Observation
• Steroid injection
• Avoid using a sling as it will cause flexion and internal rotation contracture of the shoulder, and will cause also stiff elbow.
Usually you will expect recovery for these patients.

Become a friend on facebook:
  / drebraheim  

Follow me on twitter:
https://twitter.com/#!/DrEbraheim_UTMC

Donate to the University of Toledo Foundation Department of Orthopaedic Surgery Endowed Chair Fund:
https://www.utfoundation.org/foundati...