The electrodiagnostic natural history of parsonage-turner syndrome

Hourglass-like constrictions on MRI are common in electromyography-confirmed cases of neuralgic amyotrophy (Parsonage-Turner syndrome): A tertiary referral center experience

INTRODUCTION/AIMS

Hourglass-like constrictions (HGCs) of involved nerves in neuralgic amyotrophy (NA) (Parsonage-Turner syndrome) have been increasingly recognized with magnetic resonance neurography (MRN). This study sought to determine the sensitivity of HGCs, detected by MRN, among electromyography (EMG)-confirmed NA cases.

METHODS

This study retrospectively reviewed records of patients with the clinical diagnosis of NA, and with EMG confirmation, who underwent 3-Tesla MRN within 90 days of EMG at a single tertiary referral center between 2011 and 2021. "Severe NA" positive cases were defined by a clinical diagnosis and specific EMG criteria: fibrillation potentials or positive sharp waves, along with motor unit recruitment (MUR) grades of "discrete" or "none." On MRN, one or more HGCs, defined as focally decreased nerve caliber or diffusely beaded appearance, was considered "imaging-positive." Post hoc inter-rater reliability for HGCs was measured by comparing the original MRN report against subsequent blinded interpretation by a second radiologist.

RESULTS

A total of 123 NA patients with 3-Tesla MRN performed within 90 days of EMG were identified. HGCs were observed in 90.2% of all NA patients. In "severe NA" cases, based on the above EMG criteria, HGC detection resulted in a sensitivity of 91.9%. Nerve-by-nerve analysis (183 nerve-muscle pairs, nerves assessed by MRN, muscles assessed by EMG) showed a sensitivity of 91.0%. The second radiologist largely agreed with the original HGC evaluation, (94.3% by subjects, 91.8% by nerves), with no significant difference between evaluations (subjects: χ2 = 2.27, P = .132, nerves: χ2 = 0.98, P = .323).

DISCUSSION

MRN detection of HGCs is common in NA.

MR Neurography and Quantitative Muscle MRI of Parsonage Turner Syndrome Involving the Long Thoracic Nerve

BACKGROUND

Parsonage-Turner syndrome (PTS) is characterized by severe, acute upper extremity pain and subsequent paresis and most commonly involves the long thoracic nerve (LTN). While MR neurography (MRN) can detect LTN hourglass-like constrictions (HGCs), quantitative muscle MRI (qMRI) can quantify serratus anterior muscle (SAM) neurogenic changes.

PURPOSE/HYPOTHESIS

1) To characterize qMRI findings in LTN-involved PTS. 2) To investigate associations between qMRI and clinical assessments of HGCs/electromyography (EMG).

STUDY TYPE

Prospective.

POPULATION

30 PTS subjects (25 M/5 F, mean/range age = 39/15-67 years) with LTN involvement who underwent bilateral chest wall qMRI and unilateral brachial plexus MRN.

FIELD STRENGTH/SEQUENCES

3.0 Tesla/multiecho spin-echo T2-mapping, diffusion-weighted echo-planar-imaging, multiecho gradient echo.

ASSESSMENT

qMRI was performed to obtain T2, muscle diameter fat fraction (FF), and cross-sectional area of the SAM. Clinical reports of MRN and EMG were obtained; from MRN, the number of HGCs; from EMG, SAM measurements of motor unit recruitment levels, fibrillations, and positive sharp waves. qMRI/MRN were performed within 90 days of EMG. EMG was performed on average 185 days from symptom onset (all ≥2 weeks from symptom onset) and 5 days preceding MRI.

STATISTICAL TESTS

Paired t-tests were used to compare qMRI measures in the affected SAM versus the contralateral, unaffected side (P < 0.05 deemed statistically significant). Kendall's tau was used to determine associations between qMRI against HGCs and EMG.

RESULTS

Relative to the unaffected SAM, the affected SAM had increased T2 (50.42 ± 6.62 vs. 39.09 ± 4.23 msec) and FF (8.45 ± 9.69 vs. 4.03% ± 1.97%), and decreased muscle diameter (74.26 ± 21.54 vs. 88.73 ± 17.61 μm) and cross-sectional area (9.21 ± 3.75 vs. 16.77 ± 6.40 mm2). There were weak to negligible associations (tau = -0.229 to <0.001, P = 0.054-1.00) between individual qMRI biomarkers and clinical assessments of HGCs and EMG.

DATA CONCLUSION

qMRI changes in the SAM were observed in subjects with PTS involving the LTN.

LEVEL OF EVIDENCE

2 TECHNICAL EFFICACY: Stage 1.

Clinical Outcomes of Upper Extremity Nerve Transfers in Neuralgic Amyotrophy

SUMMARY

Neuralgic amyotrophy (NA) is a disease affecting peripheral nerves. Treatment has historically been conservative, as the natural course of the disease was thought to be self-limiting. Recent work has demonstrated that as many as two-thirds of people with NA have persistent pain, fatigue, or weakness. At the authors' center, supercharged end-to-side (SETS) nerve transfers are commonly performed in patients with NA to optimize motor recovery while allowing for native axonal regrowth. The authors describe the technique and clinical outcomes of patients with NA affecting the anterior interosseous nerve (AIN) who were treated with SETS nerve transfer from extensor carpi radialis brevis to AIN. Ten patients (90% male; mean age, 51.3 ± 9.7 years) underwent extensor carpi radialis brevis-to-AIN transfer at a mean period of 6.4 ± 1.4 months after onset of symptoms. Mean postoperative follow-up duration was 14.8 ± 3.2 months. Before surgery, all patients demonstrated clinically significant weakness in the flexor pollicis longus (FPL), flexor digitorum profundus muscle to the index finger (FDP2), or both. FPL strength improved from a median Medical Research Council (MRC) grade of 1.5 to 4 ( P = 0.011) and FDP2 strength improved from a median MRC grade of 1 to 5 ( P = 0.016). A postoperative MRC grade of 4 or greater was achieved in nine of 10 (90%) FPL and 10 of 10 (100%) FDP muscles. This is the first report of SETS nerve transfer for the treatment of NA. The outcomes of this work suggest that SETS nerve transfers may be an option to optimize motor outcomes in patients with NA.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

[Diagnostics and treatment of hourglass-like nerve constrictions and torsions in neuralgic amyotrophy]

Neuralgic amyotrophy is a disease of the peripheral nervous system characterized by severe neuropathic pain followed by peripheral paralysis. A distinction is made between a hereditary and an idiopathic form, which is assumed to have an autoimmunological origin. Conservative medicinal treatment mainly consists of nonsteroidal anti-inflammatory drugs (NSAID), opioids and glucocorticoids; however, despite treatment, symptoms in the form of pain or paralysis persist in over 50% of cases. Inflammation can lead to strictures and torsions of peripheral nerves, which can be visualized by imaging using nerve sonography or magnetic resonance (MR) neurography and confirmed intraoperatively during surgical exploration. Based on the currently available data, patients with strictures and torsions of peripheral nerves can benefit from neurosurgical treatment.

Parsonage-Turner Syndrome With an Uncommon Trigger: A Case Study and Literature Review

Patients with Parsonage-Turner syndrome (PTS) are often misdiagnosed due to overlapping symptoms with other conditions and coinciding procedures. Because it is most commonly seen following viral infection, it is often not considered in other cases. We present a rare case in which a 79-year-old female, with no significant past medical history, was diagnosed with PTS two months after a biopsy of the right levator scapulae muscle. Forty-eight hours after the procedure, she developed sudden-onset pain and weakness in the right scapulae and neck, followed by worsened weakness. This case report highlights the importance of considering PTS before proceeding with treatment. Patients with suspected PTS should undergo electromyography (EMG) to confirm diagnosis and monitor disease progression and resolution.

Congenital, Acquired, and Trauma-Related Risk Factors for Thoracic Outlet Syndrome-Review of the Literature

Thoracic outlet syndrome is a group of disorders that affect the upper extremity and neck, resulting in compression of the neurovascular bundle that exits the thoracic outlet. Depending on the type of compressed structure, the arterial, venous, and neurogenic forms of TOS are distinguished. In some populations, e.g., in certain groups of athletes, some sources report incidence rates as high as about 80 cases per 1000 people, while in the general population, it is equal to 2-4 per 1000. Although the pathogenesis of this condition appears relatively simple, there are a very large number of overlapping risk factors that drive such a high incidence in certain risk groups. Undoubtedly, a thorough knowledge of them and their etiology is essential to estimate the risk of TOS or make a quick and accurate diagnosis.

Anterior interosseous nerve syndrome following infection with COVID-19: a case report

BACKGROUND

Various neurological manifestations associated with coronavirus disease 2019 have been increasingly reported. Herein, we report a rare case of anterior interosseous nerve syndrome, which occurred 5 days after the onset of coronavirus disease 2019.

CASE PRESENTATION

A 62-year-old Asian woman with a history of coronavirus disease 2019 who developed a complete motor deficit in the left flexor pollicis longus and pronator quadratus without sensory deficits. The symptoms appeared as a sudden onset fatigue and severe pain of the left arm, 5 days after the onset of coronavirus disease 2019. She noticed paralysis of the left thumb at 2 weeks after the onset of coronavirus disease 2019. Electromyography assessment of the anterior interosseous nerve-dominated muscles revealed neurogenic changes such as positive sharp wave and fibrillation in flexor pollicis longus and pronator quadratus, confirming the diagnosis of anterior interosseous nerve syndrome. There were no other diseases that could have resulted in peripheral nerve palsy. We performed a functional reconstruction surgery of the thumb by tendon transfer from the extensor carpi radialis longus to the flexor pollicis longus. The patient reported a good patient-reported outcome (2.27 points in QuickDASH Disability/Symptom scoring and 5 points in Hand20 scoring) at final follow-up (1 year after the surgery).

CONCLUSION

This case highlights the need for vigilance regarding the possible development of anterior interosseous nerve syndrome in patients with coronavirus disease 2019. Tendon transfer from extensor carpi radialis longus to flexor pollicis longus can provide good functional recovery for unrecovered motor paralysis after anterior interosseous nerve syndrome.

Autoimmune polyneuropathies

The autoimmune peripheral neuropathies with prominent motor manifestations are a diverse collection of unusual peripheral neuropathies that are appreciated in vast clinical settings. This chapter highlights the most common immune-mediated, motor predominant neuropathies excluding acute, and chronic inflammatory demyelinating polyradiculoneuropathy (AIDP and CIDP, respectively). Other acquired demyelinating neuropathies such as distal CIDP and multifocal motor neuropathy will be covered. Additionally, the radiculoplexus neuropathies, resulting from microvasculitis-induced injury to nerve roots, plexuses, and nerves, including diabetic and nondiabetic lumbosacral radiculoplexus neuropathy and neuralgic amyotrophy (i.e., Parsonage-Turner syndrome), will be included. Finally, the motor predominant peripheral neuropathies encountered in association with rheumatological disease, particularly Sjögren's syndrome and rheumatoid arthritis, are covered. Early recognition of these distinct motor predominant autoimmune neuropathies and initiation of immunomodulatory and immunosuppressant treatment likely result in improved outcomes.

Anterior Interosseous Nerve Syndrome

Anterior interosseous nerve syndrome (AINS) is a rare form of peripheral neuropathy which involves disruption of the anterior interosseous nerve. The pathophysiology of AINS remains unclear. AINS typically initially presents with forearm pain and may gradually progress to palsy of the deep muscles of the anterior forearm. Diagnosis of AINS requires thorough patient history and physical exam. EMG is the preferred diagnostic study and classically reveals abnormal activity and prolonged latency periods within the evoked action potentials of the FPL and PQ. Due to the self-limiting nature of AINS, there is general agreement that conservative and symptomatic management should be explored for up to 6 months as first line therapy, which usually includes analgesics and nonsteroidal anti-inflammatory drugs, contracture prevention, hand therapy, and hand splinting. Surgical options such as internal neurolysis and minimally invasive endoscopic decompression may be explored if functional recovery from conservative management is limited.

Parsonage-Turner syndrome following COVID-19 vaccination and review of the literature

Background

Parsonage-Turner syndrome (PTS) is a rare brachial plexopathy characterized by self-limiting shoulder girdle and upper arm pain followed by the upper extremity weakness and sensory changes. While the etiology is not well-understood, the most common cause of PTS is thought to be postviral. There are at least nine reports, to the best of our knowledge, of PTS associated with COVID-19 infection and nine reports associated with COVID-19 vaccination.

Case Description

Here, we present a case of PTS after COVID-19 vaccination in a 64-year-old male and a review of the current literature.

Conclusion

PTS can occur post-COVID-19 vaccination and should be on the differential diagnosis when patient continues to experience shoulder pain and develops weakness or sensory changes in the extremity.

Revision Reverse Total Shoulder Arthroplasty With Pectoralis Major Transfer for Anterior Deltoid Deficiency: A Case Report

CASE

A 70-year-old male patient presented with anterior deltoid weakness from Parsonage-Turner neuropathy status post failed nerve transfer and a failed total shoulder arthroplasty with pseudoparalysis. The patient underwent revision to a reverse total shoulder arthroplasty with concomitant pectoralis major transfer to substitute for the anterior deltoid. An excellent functional result was attained as early as 6 weeks after surgery.

CONCLUSION

Pectoralis major transfer can be an effective treatment option for isolated anterior deltoid insufficiency, even in the setting of a reverse total shoulder arthroplasty.

Parsonage–Turner recurrent acute idiopatic neuralgic amyotrophy case. Case report

Recurrent ParsonageTurner syndrome is a hereditary form of a syndrome from neuralgic amyotrophic group, with a characteristic clinical picture in the form of severe pain syndrome with remission and subsequent development of upper shoulder girdle atrophy, proceeding with the accumulation of neurological deficit. Despite the characteristic clinical picture, the syndrome requires a differential diagnosis with a number of conditions, in which electroneuromyography helps along with other techniques. Wherein neuropathic sings of the upper extremity nerves are usually detected, and the long thoracic and suprascapular nerves are most often affected, at that more often by axonopathic type. Electromyography reveals denervation sings in the upper brachial muscles. This article describes ParsonageTurner recurrent acute neuralgic amyotrophy case, discusses the issues of the clinical picture, diagnosis and treatment of this disease.

Electrodiagnostic Assessment of Plexopathies

Disorders of the brachial and lumbosacral plexus are complex and may occur as a consequence of trauma, compression, inflammatory disorders, malignant infiltration, or delayed effects of radiation therapy. An understanding of plexus anatomy and surrounding structures will allow the electromyographer to facilitate an efficient and comprehensive assessment of the plexus. A careful and thorough electrodiagnostic assessment allows for localization within the plexus and may provide important information about underlying pathology and prognosis.

Anterior Interosseous Nerve Syndrome Reconsidered: A Critical Analysis Review

Anterior interosseous nerve syndrome (AINS) represents a form of neuralgic amyotrophy (Parsonage-Turner syndrome). AINS does not originate from external compression of the AIN in the forearm. Fascicular constrictions (FCs) of the median nerve are identified within the anterior interosseous fascicular group at or above the medial epicondyle. Spontaneous recovery is not ensured, leaving up to 30% of patients with permanent weakness or palsy. Fascicular microneurolysis of the median nerve, performed at or above the elbow, is a treatment option for patients who do not recover spontaneously.

Development of Parsonage-Turner Syndrome After Interscalene Brachial Plexus Block Including 10-Year Follow-up: A Case Report

CASE

A 22-year-old female patient demonstrated physical examination findings of Parsonage-Turner syndrome (PTS) 5 days after left shoulder arthroscopic surgery with interscalene brachial plexus block. The diagnosis was confirmed with electrodiagnostic testing 2 weeks after surgery. Symptoms resolved spontaneously within 2 years with full return-to-preinjury sport and job activity. These outcomes were maintained at the 10-year follow-up.

CONCLUSIONS

PTS should be considered in the differential diagnoses for any postsurgical neurological variations after upper extremity surgery under regional anesthesia.

Outcomes of Microneurolysis of Hourglass Constrictions in Chronic Neuralgic Amyotrophy

PURPOSE

Wide variability in the recovery of patients affected by neuralgic amyotrophy (NA) is recognized, with up to 30% experiencing residual motor deficits. Using magnetic resonance imaging and ultrasound (US), we identified hourglass constrictions (HGCs) in all affected nerves of patients with chronic motor paralysis from NA. We hypothesized that chronic NA patients undergoing microsurgical epineurolysis and perineurolysis of constrictions would experience greater recovery compared with patients managed nonsurgically.

METHODS

We treated 24 patients with chronic motor palsy from NA and HGCs identified on magnetic resonance imaging and US either with microsurgical epineurolysis and perineurolysis of HGCs (11 of 24) or nonsurgically (13 of 24). Muscle strength (both groups) and electrodiagnostic testing (EDX) (operative group) was performed before and after surgery. Preoperative EDX confirmed muscle denervation in the distribution of affected nerve(s). All patients met criteria for microneurolysis: 12 months without improvement since onset or failure of clinical and EDX improvement after 6 months documented by 3 successive examinations, each at least 6 weeks apart.

RESULTS

Mean time from onset to surgery was 12.5 ± 4.0 months. Average time to most recent post-onset follow-up occurred at 27.3 months (range, 18-42 months; 15 nerves). Average time to latest follow-up among nonsurgical patients was 33.6 months (range, 18-108 months; 16 nerves). Constrictions involved individual fascicular groups (FCs) of the median nerve and the suprascapular, axillary and radial nerves proper (HGCs). Nine of 11 operative patients experienced clinical recovery compared with 3 of 13 nonsurgical patients. EMG revealed significant motor unit recovery from axonal regeneration in the operative group.

CONCLUSIONS

Microsurgical epineurolysis and perineurolysis of FCs and HGCs was associated with significantly improved clinical and nerve regeneration at an average follow-up of 14.8 months compared with nonsurgical management. We recommend microneurolysis of HGCs and FCs as a treatment option for patients with chronic NA who have failed to improve with nonsurgical treatment.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Brachial and lumbosacral plexopathies: A review

Diseases of the brachial and lumbosacral plexus are uncommon and complex. The diagnosis of plexopathies is often challenging for the clinician, both in terms of localizing a patient's symptoms to the plexus as well as determining the etiology. The non-specific clinical features and similar presentations to other root, nerve, and non-neurologic disorders emphasize the importance of a high clinical index of suspicion for a plexopathy and comprehensive clinical evaluation. Various diagnostic tests, including electrodiagnostic (EDX) studies, neuroimaging (including ultrasound, MRI, or PET), serologic studies, and genetic testing, may be used to confirm a plexopathy and assist in identifying the underlying etiology. EDX testing plays an important role in confirming a plexopathy defining the localization, pathophysiology, chronicity, severity, and prognosis. Given the complexity of the plexus anatomy, multiple common and uncommon NCS and an extensive needle examination is often required, and a comprehensive, individualized approach to each patient is necessary. Treatment of plexopathies often focuses on symptomatic management although, depending on the etiology, specific targeted treatments may improve outcome. This article reviews the clinical features, EDX approaches, and evaluation and treatment of brachial and lumbosacral plexopathies.

Arm Numbness at 45 Degrees Abduction: A Case Report of Thoracic Outlet Syndrome After Brachial Neuritis

Objective

To describe a case of nerve kinking correlating with surgical findings in neurogenic thoracic outlet syndrome in a patient with history of brachial neuritis. Thoracic outlet syndrome and brachial neuritis are briefly reviewed.

Case report

A 32-year-old woman with a history of bilateral brachial neuritis presented with paraesthesias in her hand when abducting her shoulder to 45° or higher. A kink in the superior trunk of the brachial plexus, as well as asymmetrically narrowed costoclavicular space, was found on magnetic resonance imaging with the shoulder abducted. Conservative measures failed, leading to partial anterior scalenectomy and neurolysis, which led to improvement in her symptoms.

Conclusion

Anatomical variations in combination with biomechanical changes after brachial neuritis can be associated with neurogenic thoracic outlet syndrome.

Development of Parsonage-Turner Syndrome After Heat Stroke in Firefighters: A Report of 2 Cases

CASE

Two firefighters developed Parsonage-Turner syndrome (PTS) shortly after sustaining episodes of heat stroke. Patient 1 was a 40-year-old man who presented with shoulder pain and supraspinatus and infraspinatus weakness. Patient 2 was a 35-year-old man who presented with shoulder pain and absent external rotation strength. Both had electrodiagnostic testing and magnetic resonance imaging findings consistent with PTS. Both demonstrated partial but incomplete recovery at 1- and 2.5-year follow-ups, respectively.

CONCLUSIONS

PTS should remain on the differential diagnosis for any patient presenting with sudden onset shoulder pain and neurological deficits after an episode of heat-related illness.

Clinico-diagnostic features of neuralgic amyotrophy in childhood

Neuralgic amyotrophy (NA), even known as Personage-Turner's syndrome (PTS), is a neurologic condition, affecting the lower motor neurons of brachial plexus and/or individual nerves or nerve branches, characterized by pain, muscle weakness/atrophy, and sensory symptoms. NA has an acute/subacute onset, after an infection or vaccination; it is more common in male and is rare in the pediatric population. The etiology remains uncertain, being considered heterogeneous and multifactorial. A severe acute neurologic pain around the shoulder girdle is the classic presenting symptom at onset. As the pain subsides, weakness and paresis develop. NA is usually unilateral, but sometimes, a subclinical contralateral limb involvement could be present and bilateral affection has been described. The diagnosis is clinical, through a comprehensive history and neurological examination. However, electrophysiological testing and imaging are critical, because there is no diagnostic test for PTS and it remains a diagnosis of exclusion. Upper brachial plexus peripheral involvement with weakness of periscapular and perihumeral muscles is the classic presentation, associated with electrophysiological evidence of denervation in the affected muscles. Imaging, laboratory, and genetic testing can be useful for the differential diagnosis. NA is in most cases a self-limiting condition, and it is characterized by good recovery. Treatment of NA usually involves a combination of corticosteroids, analgesics, immobilization, and physical therapy, even if limited data are available in children. Physiotherapy is required to maintain muscle strength.

"Isolated" Suprascapular Neuropathy: Compression, Traction, or Inflammation?

BACKGROUND

Several hypotheses have been proposed for the pathophysiology of suprascapular nerve (SSN) palsy, including compression, traction, and nerve inflammation.

OBJECTIVE

To provide insight into the pathophysiology of isolated nontraumatic SSN palsy by performing critical reinterpretations of electrodiagnostic (EDX) studies and magnetic resonance (MR) images of patients with such diagnosis.

METHODS

We retrospectively reviewed all patients referred to our institution for the past 20 yr with a diagnosis of nontraumatic isolated suprascapular neuropathy who had an upper extremity EDX study and a shoulder or brachial plexus MR scan. Patient charts were reviewed to analyze their initial clinical examination, and their original EDX study and MR images were reinterpreted by an experienced neurologist and a musculoskeletal radiologist, respectively, both blinded from the authors' hypothesis and from each other's findings.

RESULTS

Fifty-nine patients were included. Fifty of them (85%) presented with at least 1 finding that was inconsistent with an isolated SSN palsy. Forty patients (68%) had signs on physical examination beyond the SSN distribution. Thirty-one patients (53%) had abnormalities on their EDX studies not related to the SSN. Twenty-two patients (37%) had denervation atrophy in other muscles than the spinati, or neural hyperintensity in other nerves than the SSN on their MR scans, without any evidence of SSN extrinsic compression.

CONCLUSION

The great majority of patients with presumed isolated SSN palsy had clinical, electrophysiological, and/or imaging evidence of a more diffuse pattern of neuromuscular involvement. These data strongly support an inflammatory pathophysiology in many cases of "isolated" SSN palsy.

Parsonage-Turner Syndrome as a Rare Extrahepatic Complication of Hepatitis E Infection

Parsonage-Turner syndrome, also known as neuralgic amyotrophy, is a rare disorder characterized by painful clinical manifestations mainly involving the upper limbs. This syndrome seems to be triggered, among other factors, by some viral infections, although its pathophysiology remains unclear. Moreover, it has rarely been related to hepatitis E virus infection. We report the case of a 33-year-old man who was diagnosed with Parsonage-Turner syndrome following acute hepatitis E infection.

LEARNING POINTS

Parsonage-Turner syndrome is a painful and disabling condition.Hepatitis E infection can lead to extra-hepatic manifestations such as neurological complications.The association of Parsonage-Turner syndrome with hepatitis E infection is rare but some cases have been reported previously in the literature.

A CARE-compliant article: a case report of idiopathic brachial neuritis treated with ultrasound-guided electroacupuncture

RATIONALE

Electroacupuncture is commonly used for treating nerve injury. However, studies published in recent years have not described an appropriate method for accurately identifying the location and depth of injured nerves beneath the acupoints.

PATIENT CONCERNS

A 26-year-old male patient had left shoulder pain and weakness after tetanus, diphtheria, and pertussis vaccination and was diagnosed with idiopathic brachial neuritis 24 months before this study. The patient had undergone prednisone and ibuprofen treatment in another hospital, but the therapeutic effect was poor and limited.

DIAGNOSES

The nerve conduction studies showed decreased amplitude over the left supraspinatus and deltoid muscles. Electromyography showed increased giant waves and polyphasic waves with reduced recruitments in the left deltoid muscle and increased giant waves with reduced recruitment in the left supraspinatus muscle. The condition was diagnosed with idiopathic brachial neuritis.

INTERVENTIONS

Ultrasound was used to identify the location and depth of axillary and suprascapular nerves, and direct electroacupuncture was conducted at the quadrangular space and suprascapular notch to stimulate the nerves. Other needles were placed according to deltoid and supraspinatus muscles origins and insertions. The procedure was conducted once a week, and rehabilitation activities were conducted daily.

OUTCOMES

The patient experienced significant improvements of left shoulder pain and muscle weakness after ultrasound-guided electroacupuncture treatment. The total shoulder pain and disability index score declined from 49.23% to 11.54%. The scores of both pain and disability domains improved and maintained stable declining after the intervention. The disability of the arm, shoulder; and hand scores declined from 60 to 23.3. According to amplitude data from nerve conduction studies, the injured axillary nerve showed remarkable improvement in the third month. Muscle strength improved to the normal state. The patient was generally satisfied with the ultrasound-guided electroacupuncture treatment.

LESSON

Ultrasound-guided electroacupuncture was based on anatomical correlations between nerves and muscles and on electrical stimulation theories. The results suggest that this intervention might be an alternative therapy for idiopathic brachial neuritis. Furthermore, in this study, it had minimal adverse effects. This therapy is demonstrated to be effective in future controlled studies.

Electrodiagnostic evidence of suprascapular nerve recovery after decompression

INTRODUCTION

The purpose of this study was to determine whether surgical arthroscopic decompression or ultrasound-guided aspiration of a paralabral cyst would result in suprascapular nerve recovery from axonal regeneration based on electrodiagnostic testing.

METHODS

Nine patients with preoperative electromyography (EMG) evidence of suprascapular neuropathy due to paralabral cysts at the suprascapular or spinoglenoid notch were prospectively studied. Eight patients underwent arthroscopic surgical decompression, and 1 patient underwent ultrasound-guided aspiration. Postoperative EMG was performed in all patients to evaluate nerve regeneration.

RESULTS

Three (33%) patients had cysts at the suprascapular notch, whereas 6 (67%) patients had cysts at the spinoglenoid notch. All patients showed complete electrophysiological recovery after decompression.

DISCUSSION

Decompression of paralabral cysts at the suprascapular or spinoglenoid notch resulted in postoperative EMG evidence of nerve recovery. Long-term studies with a greater number of patients are required to elucidate time to recovery. Muscle Nerve 59:247-249, 2019.