Atypical cervical radiculopathy presenting with brachioradial pruritus: illustrative cases

BACKGROUND

Brachioradial pruritus (BRP) is a rare form of chronic dysesthesia characterized by persistent itching, burning, or tingling commonly involving the dorsolateral upper extremities. Although the exact pathophysiology remains unclear, the condition may be a manifestation of atypical cervical radiculopathy.

OBSERVATIONS

The authors describe two patients with BRP, a 44-year-old female and a 51-year-old male, both of whom benefited from surgical intervention for atypical cervical radiculopathy, while also highlighting their presentation, diagnostic testing, treatment, and outcomes.

LESSONS

The cases demonstrate the potential relationship between cervical spondylosis and BRP while examining the role of surgical intervention as a treatment option.

Management of Brachioradial Pruritus With Cervical Epidural Steroid Injection: A Case Report

Brachioradial pruritus (BRP) is a neuropathic dysesthesia described as itching over the dorsolateral forearm. The etiology of BRP has not been fully identified but is hypothesized to be multifactorial, including sun exposure and cervical spine disease. Management of BRP is challenging, and conservative measures often fail to provide notable improvement. We present a case of a 71-year-old woman with BRP refractory to topical and oral treatment, with radiographic evidence of cervical spinal canal and neuroforaminal stenosis. Two rounds of cervical epidural steroid injections (CESI) were performed at the C6-C7 epidural space resulting in a marked improvement of symptoms. With this case report, we would like to add to the current scientific knowledge of BRP management and the potential utilization of CESIs to provide symptomatic relief to patients suffering from refractory pruritus.

Scratching increases epidermal neuronal branching and alters psychophysical testing responses in atopic dermatitis and brachioradial pruritus

Background

Chronic scratching imposes a major stress on the skin and can lead to itch intensity worsening, and consequently, patients may enter an itch-scratch cycle. This repetitive mechanical stress can result in lichenification, worsening of epidermal barrier function, and enhanced cutaneous inflammation. Furthermore, a reduction of intraepidermal nerve fibers was previously described in lichenification.

Aim

The aim of this study was to investigate the influence of chronic scratching on the epidermal neuroanatomy and on sensory changes, in particular the prevalence of hyperknesis and alloknesis in patients after mechanical, chemical, and electrical stimuli.

Methods

Analyses were performed on pruritic lichenified (chronically scratched), pruritic non-lichenified (not chronically scratched), and non-pruritic non-lesional (unaffected) skin areas of patients with inflammatory pruritus, i.e., atopic dermatitis (n = 35), and neuropathic pruritus, i.e., brachioradial pruritus (n = 34) vs. healthy matched controls (n = 64). Our fine-grained spatial skin characterization enabled specifically studying the differential effects of chronic scratching in inflammatory and neuropathic itch.

Results

Analysis of intraepidermal nerve fiber density showed rarefaction of fibers in all three skin areas of patients compared with healthy controls in both diagnoses. Even more, the two pruritic areas had significantly less nerve fibers than the unaffected skin, whereas electrically induced itch was massively increased. Epidermal branching of the remaining nerve fibers in lichenified/chronically scratched skin was increased, particularly in patients with brachioradial pruritus, which may contribute to the pronounced local neuronal sensitivity. Hyperknesis and alloknesis were found to increase independently of lichenification.

Conclusion

Our results indicate that chronic scratching may not affect intraepidermal nerve fiber density but leads to a stronger branching pattern of intraepidermal nerve fibers, which may contribute to local hypersensitivity. The increased sensitivity in the pruritic areas suggests mechanisms of peripheral sensitization, whereas the increased sensation of electrically and chemically induced itch in unaffected skin indicates central sensitization for itch.

Treatment Refractory Brachioradial Pruritus Treated with Topical Amitriptyline and Ketamine

Brachioradial pruritus is an uncommon chronic neurocutaneous condition that often presents as extreme itching, burning or tingling on the dorsolateral aspect of the arm. The lack of primary skin lesions in brachioradial pruritus in addition to its poorly established pathophysiology can often lead to both diagnostic and therapeutic challenges for many physicians. Here, we present a case of brachioradial pruritus and the unique combination of topical amitriptyline and ketamine as an effective therapy, including a brief review of the literature on similar such cases.

Intractable pruritus after traumatic spinal cord injury

BACKGROUND

This report describes a young woman with incomplete traumatic cervical spinal cord injury and intractable pruritus involving her dorsal forearm.

METHOD

Case report.

FINDINGS

Anatomic distribution of the pruritus corresponded to the dermatomal distribution of her level of spinal cord injury and vertebral fusion. Symptoms were attributed to the spinal cord injury and possible cervical root injury. Pruritus was refractory to all treatments, including topical lidocaine, gabapentin, transcutaneous electrical nerve stimulation, intravenous Bier block, stellate ganglion block, and acupuncture.

CONCLUSIONS

Further understanding of neuropathic pruritus is needed. Diagnostic workup of intractable pruritus should include advanced imaging to detect ongoing nerve root compression. If diagnostic studies suggest radiculopathy, epidural steroid injection should be considered. Because the autonomic nervous system may be involved in complex chronic pain or pruritic syndromes, sympatholysis via such techniques as stellate ganglion block might be effective.