What is Brachial Neuritis (neuralgic amyotrophy, Parsonage-Turner syndrome)?
Brachial neuritis, which is sometimes referred to as neuralgic amyotrophy or Parsonage-Turner syndrome, is a condition that affects your peripheral nerves, which are the nerves outside your brain and spinal cord. We don’t know much about this condition yet, and it often gets overlooked or incorrectly diagnosed. Initially, it was believed that brachial neuritis was caused by inflammation. However, today, the cause still remains unclear. Researchers do suggest that our immune system, physical injury, and certain genetic factors could play a role in developing the condition.
The main symptoms of brachial neuritis are sudden and intense shoulder pain, either on one or both sides, eventually leading to muscle weakness. In some people, there may be a loss or change in sensation. Usually, these symptoms can extend to the neck, arms, and forearms and could last anywhere from a few days to about a month on average.
Identifying brachial neuritis can be tricky for doctors. This is due to the varied symptoms, different ways it can present itself, and because changes related to the disease that can confirm it only become apparent on testing after some time. Doctors need to be well-versed in the progression of brachial neuritis symptoms and how it differs from other similar conditions. Incorrect diagnosis could lead to unwanted surgeries and added complications. Diagnosis is usually based on clinical symptoms but often confirmed using nerve conduction studies, needle electromyography (EMG – a test to evaluate the health of muscles and the nerves that control them), lab tests, and imaging.
Doctors usually approach treatment in two phases: acute (immediate treatment) and chronic (long-term management). The type of treatment provided often depends on how the symptoms progress. Most common management options include supportive measures like pain relief, physical therapy, corticosteroids (a class of drug that can reduce inflammation), and intravenous immunoglobulin (a treatment involving a mixture of antibodies given through the vein). In certain cases, surgical procedures such as neurolysis (surgery to break down nerve tissue) might be considered. By improving recognition of brachial neuritis, making the right diagnostic choices, managing the condition effectively, and encouraging team-based care, we can ensure better outcomes for patients with this disorder.
What Causes Brachial Neuritis (neuralgic amyotrophy, Parsonage-Turner syndrome)?
Brachial neuritis, a disorder affecting nerve function, doesn’t have a known exact cause. However, experts think immune-related conditions could be the main driving factor. There may also be specific elements that make some people more susceptible to this disorder, although we don’t yet know what these are. Other influential factors connected with brachial neuralgia could be mechanical, like physical injury, or genetic.
Studies have found that over half of people diagnosed with brachial neuritis had a condition that affected their immune system. These include infections such as hepatitis E, coxsackie viruses, Covid-19, Escherichia coli, Staphylococcus aureus, and Aspergillus, as well as surgery, connective tissue disorders, lupus, temporal arteritis, immunizations, pregnancy, and radiation therapy. Notably, hepatitis E virus is one of the most common infections linked to this disorder.
Mechanical stress or physical damage to the nerves also seems to contribute to brachial neuritis. For example, intense exercise involving the upper body, shoulder injuries, and heavy physical labor have been identified in some patients. Moreover, it’s been observed that having a family member with the disorder could increase the chances of developing it, suggesting a genetic component. This inherited version is often referred to as hereditary neuralgic amyotrophy (HNA). More than half of the people with HNA have been found to have changes in the SEPT9 gene, but it’s still unclear why this is related to the condition.
Risk Factors and Frequency for Brachial Neuritis (neuralgic amyotrophy, Parsonage-Turner syndrome)
Brachial neuritis frequently affects men around the age of 40, though it can affect both men and women of any age. Interestingly, in cases related to HNA, people are typically affected at a younger average age of 20. Brachial neuritis is quite prevalent, occurring in 1 out of every 1,000 people. Some research even suggests that this condition is even more common among newborns and teenagers. It’s important to know that about 1 in 4 people might experience a recurrence of brachial neuritis within 5 to 10 years after the initial symptoms. However, for those with HNA, the chance of a recurrence is even higher, with it happening in about 3 out of 4 people.
- Brachial neuritis often impacts middle-aged men, with the average age of onset being 40.
- Both men and women of any age can get it.
- In cases associated with HNA, the average age of onset is 20.
- Brachial neuritis is quite common, occurring in 1 out of every 1000 people.
- The occurrence rate is possibly higher in newborns and teenagers.
- Approximately 25% of people may experience a recurrence within 5 to 10 years of the onset.
- For those with HNA, the recurrence rate is much higher, at 75%.
Signs and Symptoms of Brachial Neuritis (neuralgic amyotrophy, Parsonage-Turner syndrome)
Brachial neuritis is a condition that often varies in its symptoms and presentation because it can affect many nerves in different places to different extents. The symptoms you might experience depend on the phase of the condition you’re in – there are acute (short-term) and chronic (long-term) phases. Brachial neuritis has a wide range of possible effects.
The majority of people with this condition initially experience intense sharp or throbbing shoulder pain and muscle weakness, with the symptoms taking a few days to a few weeks to develop. Some common areas where the pain is felt include the shoulder, shoulder blade, upper side of the chest, and the inside of the elbow, and it can often spread to the neck and the outer side of the forearm. This is due to the involvement of a number of different nerves. It’s common for the pain to be more severe at night, and people often find that changing their position doesn’t help to relieve it.
After roughly four weeks, the intense pain generally starts to lessen. However, 10% of brachial neuritis patients experience pain for more than eight weeks. The longer the pain lasts, the longer it tends to take for the symptoms to get better. After the pain subsides, people develop weakness in the shoulder and arm. Sometimes, the forearm and hands can be affected too but that’s less common. Some people experience sensory problems, and in cases where the phrenic nerve is affected, there could be issues with diaphragm function, causing problems with breathing and severe fatigue. As the condition moves into the chronic phase, ongoing pain, sensory problems, and musculoskeletal issues may continue. Some patients also experience muscle wasting, although muscle function generally begins to improve slowly after 6 to 18 months.
During a medical examination, several tests are done to assess the condition. The movement of your shoulder blade and the strength of your shoulder will be evaluated. One sign of brachial neuritis is that muscles controlled by the same peripheral nerve will be affected. In the later stages of the disease, lower motor neuron signs can present, which includes decreased muscle tone, reduced reflexes, muscle wasting, and twitching. After the acute pain has resolved, you might show signs of decreased shoulder abduction and external rotation. Other signs may manifest depending on the specific nerves involved. Many patients also notice changes in sensation, often involving pins and needles and a reduced sensitivity to pain or changes in temperature.
Testing for Brachial Neuritis (neuralgic amyotrophy, Parsonage-Turner syndrome)
Because medical professionals often mistake brachial neuritis for other similar conditions like rotator cuff tendonitis, nerve entrapment, or cervical cord compression, it’s very important to spot the particular symptoms of brachial neuritis. It’s also crucial to use specific medical tests that can confirm the diagnosis. Accurately diagnosing brachial neuritis is important to ensure you don’t receive treatments that you actually don’t need. While brachial neuritis is usually diagnosed based on your symptoms and clinical examination, additional medical studies can provide extra evidence and rule out other similar conditions.
Nerve conduction and electromyography studies are two such tests that are helpful in confirming a diagnosis of brachial neuritis, especially if your symptoms aren’t typical. These studies measure the electrical activity in your nerves and muscles. However, these tests may not initially show abnormalities if you have brachial neuritis. On average, nerve conduction studies can take about a week to show abnormal findings, while electromyography can take about 4 weeks. Certain features that show up on these tests, like reduced amplitudes of action potentials or an inability to localize specific nerve branches, may suggest brachial neuritis in about 30% to 45% of patients. These tests can also help doctors to exclude certain other conditions that damage the protective covering of the nerves.
Magnetic resonance imaging (MRI) scans of the shoulder and spine using a special dye known as gadolinium can also be used to assess brachial neuritis. On these scans, the affected nerves can show up as brightly lit signals, which is indicative of inflammation, or show “hourglass” constrictions. MRI scans without the dye are used to check for abnormalities in the structure of your spine or shoulders, but they typically show the bundle of nerves in the shoulder (brachial plexus) as being normal. Recent studies have shown that ultrasound scans of the affected nerves can also reveal signs of brachial neuritis, including abnormal enlargement, constriction, or tangling of the nerves.
Lab tests such as complete blood count and erythrocyte sedimentation rate, which measures inflammation in your body, typically appear normal in patients with brachial neuritis. These tests are mainly used to rule out other conditions. Similarly, analysis of the fluid that bathes your brain and spinal cord (cerebrospinal fluid) is typically normal in brachial neuritis, but in some patients, it might show a mild increase in the number of white blood cells. Further tests might be needed to check for specific infections like Epstein-Barr virus, varicella-zoster (the virus that causes chickenpox and shingles), dengue, and hepatitis E.
Treatment Options for Brachial Neuritis (neuralgic amyotrophy, Parsonage-Turner syndrome)
Brachial neuritis is a condition that often gets better on its own. However, a variety of treatments may be used to reduce discomfort and improve eventual outcomes. The treatments are separated into those used in the initial, acute phase of the illness, and those for the later, chronic phase, and might differ based on the progression of symptoms.
Common treatments include supportive care, physical therapy, medication to reduce inflammation (corticosteroids), and medication to boost the immune system (intravenous immunoglobulin). But, it’s important to note that the proof of the effectiveness of these treatments is still questionable due to these treatments primarily being based off of individual case studies.
Medications, like opioids and corticosteroids, are commonly used in the acute or initial phase to help manage the condition’s symptoms. But, the value of these medications in the long-term or chronic phase is still debated. Generally, combining medicinal treatments with other forms of treatments could help manage symptoms more effectively. In some cases, surgical procedures may be considered.
In the acute phase, managing severe pain is critical. Pain medications like opioids and anti-inflammatory drugs are often used. Certain other pain medications are usually not as effective during this phase because they are slow-acting. Intense pain from brachial neuritis is typically short-lived and begins to improve after about 8 weeks, at which point these pain medications may be reduced. Additionally, corticosteroids and intravenous immunoglobulin can lead to faster resolution of the acute pain if they are used early in the treatment process.
To avoid worsening symptoms, immobilizing the affected area can be beneficial to manage severe pain during the acute phase until the pain begins to lessen.
Moving into the chronic phase, once the pain is managed, physical therapy and occupational therapy become very important. Therapies that involve range of motion, strengthening exercises and stretching exercises are crucial. Physical therapy mainly helps in improving movement, while occupational therapy teaches patients how to adapt so that they can perform self-care activities, household chores, and athletic exercises. Strengthening exercises might not be recommended for entirely damaged muscles. If these muscles continue to be in a damaged state for more than 4 months, use of electrical stimulation is debatable.
Surgery is generally considered if symptoms don’t improve after 3 months of conservative therapies. Procedures like neurolysis or nerve transfer could be conducted to help patients with persistent symptoms. About 90% patients experience symptom improvement after neurolysis. Medical experts may use the extent of nerve constriction to advise if neurolysis or nerve grafting ought to be performed. If nerve constriction is less than 75%, intrafascicular neurolysis is suggested, but if constriction is ≥75%, nerve grafting could be an option. Experts also suggest nerve or tendon transfers if neurolysis is not a suitable choice.
What else can Brachial Neuritis (neuralgic amyotrophy, Parsonage-Turner syndrome) be?
Brachial neuritis, also known as brachial plexopathy, can be easily mixed up with several other conditions due to the similarity in symptoms. It’s important to rule out the following potential conditions:
- Cervical root lesion
- Mononeuritis multiplex
- Multifocal motor neuropathy
- Tumors of the brachial plexus
- Transverse myelitis
- Amyotrophic lateral sclerosis
- Shingles (Herpes Zoster)
- Frozen shoulder (Adhesive capsulitis)
- Acute calcific tendinitis
- Superior sulcus tumor (Pancoast tumor)
- Complex regional pain syndrome
- Heart attack (Myocardial infarction)
- Pulmonary embolism
- Rotator cuff tear
- Entrapment neuropathy
Remember, if you’re feeling unwell and have any symptoms, you should seek medical help immediately.
What to expect with Brachial Neuritis (neuralgic amyotrophy, Parsonage-Turner syndrome)
The recovery prospects for patients with brachial neuritis, a nerve condition, largely rely on the extent of nerve damage and the ability to revive nerve function. Research indicates that within 2 to 3 years, most patients regain a significant amount of their nerve function. Still, over 70% of patients continue to experience some level of weakness or other lingering symptoms.
Many patients continue to struggle with persistent symptoms during the initial six months, making returning to work quite challenging. After three years, however, a small percentage (7.7%) of patients experience a complete recovery. Still, 26.7% could not return to their jobs.
Further research suggests that timely and adequate treatment can improve a patient’s prospects. Interestingly, children tend to bounce back better than adults, probably due to a greater capacity for nerve flexibility in children.
Some medical tests can help doctors predict a patient’s recovery prospects. One such test, an EMG, measures the electrical activity of muscles. If this test shows a reduced level of bursts of muscle activity by more than 70%, it suggests only partial revival of nerve function, implying a poorer outcome.
Other studies show that specific diagnostic ultrasound results, such as noticeable bottlenecks and interwoven nerve fibers, indicate severe nerve damage and predict a poorer outcome.
Possible Complications When Diagnosed with Brachial Neuritis (neuralgic amyotrophy, Parsonage-Turner syndrome)
While most people do recover to some extent from brachial neuritis, complications do occur. These can stem from the muscle wasting and weakness brought on by the condition, leading to an unstable joint in the shoulder, wrist, or hand. These instabilities can also heighten the likelihood of the joint partially dislocating or “catching” incorrectly during movement. “Frozen shoulder,” or adhesive capsulitis, may also develop, causing pain and hindering the range of motion in the shoulder. Any remaining pain or weakness can make everyday tasks such as reaching, lifting, or repetitive movements using the shoulder and arm, challenging. It’s also important to note that people who have had brachial neuritis before are more prone to complications.
Common Complications:
- Joint Instability in Shoulder, Wrist, or Hand
- Increased Risk of Partial Dislocation or Incorrect Catching of Joint
- “Frozen Shoulder” or Adhesive Capsulitis
- Persistent Pain and Weakness
- Difficulty with Everyday Tasks
- Higher Risk of Complications for Recurrent Brachial Neuritis Patients
Preventing Brachial Neuritis (neuralgic amyotrophy, Parsonage-Turner syndrome)
Many people start to feel better a few months after starting treatment, but for some, symptoms can last much longer. That’s why doctors spend time teaching patients how to handle lingering pain, tiredness, and weakness. For instance, they often recommend strategies like changes in daily routines to minimize discomfort.
Physical therapy, an exercise program designed by a healthcare professional, often plays a key role in recovery. It can help improve strength and joint movement. Doing regular exercise, eating a healthy diet, and avoiding unhealthy habits, such as smoking and drinking alcohol, can also aid in managing this condition.
Brachial neuritis, a condition involving nerve inflammation typically in the shoulder area, can often cause feelings of anxiety and emotional stress. Doctors usually suggest relaxation techniques and advice on reducing stress in your daily environment to help manage these mental health impacts.
