Understanding Brachial Plexus Neuropathy: An Overview of Parsonage-Turner Syndrome

Imagine a busy highway with cars zipping by, taking people to their destinations. Our bodies have something similar called the brachial plexus, which is like a major “nerve highway.” Located near our neck and shoulder, it carries important messages between our brain and our arms. Thanks to this system, we can do things like pick up a cup, wave to our friends, or even play an instrument.

But what happens if there’s a “roadblock” on this nerve highway? In medical terms, we often refer to such disturbances as “neuropathy.” Think of neuropathy as a situation where the messages along these nerve pathways get mixed up, delayed, or blocked entirely. This can lead to feelings of pain, weakness, or even a strange tingling sensation in our arms or hands.

Now, there’s a specific condition that acts like a sudden, unexpected roadblock on our brachial plexus. It’s called Parsonage-Turner Syndrome (PTS). Some people might also hear it referred to as Brachial Plexus Neuropathy or even Neuralgic Amyotrophy. This condition can start with a sharp pain in the shoulder, almost like a sudden cramp, and then lead to challenges with moving the arm. While it might sound a bit technical, our goal is to help everyone understand it better, whether you’re hearing about it for the first time or seeking deeper knowledge.

Anatomy and Physiology of the Brachial Plexus

The brachial plexus is an intricate web of neural structures, extending from the lower cervical to the upper thoracic spinal cord, specifically from the anterior rami of the C5 to T1 nerve roots. This nexus serves as the primary neurological conduit to the upper extremity, proving its mettle in both motor and sensory capacities.

Components and Structure:

The brachial plexus can be conceptualized in a structured manner, with roots leading to trunks, which further divide into divisions, and subsequently form cords that give rise to the terminal branches.

• Roots: The origin points from the anterior rami of spinal nerves C5 to T1.
• Trunks: These are formed by the confluence of roots – Upper (C5 and C6), Middle (C7), and Lower (C8 and T1).
• Divisions: Each trunk then divides into anterior and posterior divisions, delineated based on their destined muscle group.
• Cords: Named according to their spatial relation to the axillary artery, we identify the lateral, medial, and posterior cords.
• Terminal Branches: The culmination of this complex pathway results in the five primary peripheral nerves of the upper extremity: the axillary, radial, median, ulnar, and musculocutaneous nerves.

Nerves and Their Respective Functions:

Each terminal nerve emanating from the brachial plexus has its unique role:

• Axillary: Governs the deltoid and teres minor muscles, and sensory information from the skin over a portion of the deltoid.
• Radial: Innervates the posterior compartment of the arm and forearm, playing a significant role in wrist and finger extension.
• Median: Vital for most flexors in the forearm and intrinsic muscles of the lateral half of the hand.
• Ulnar: Supplies the medial hand and a few forearm muscles, notably the intrinsic muscles of the medial half of the hand.
• Musculocutaneous: Predominantly feeds the anterior compartment of the arm, including the biceps brachii.

Importance of the Brachial Plexus in Daily Activities and Movements:

The brachial plexus, in its entirety, ensures that the upper limb is not just a passive appendage but a dynamic structure capable of fine precision and strength. From intricate tasks such as writing or performing surgical procedures to gross movements like lifting or throwing, the integration of motor and sensory feedback through the brachial plexus is indispensable. Any injury or dysfunction at various levels of this neural network can manifest in diverse clinical ways, underscoring its paramount importance in both health and pathology.

This version provides a deep dive into the anatomy and physiology, suitable for individuals with a foundational knowledge in medicine.

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Brachial Plexus Neuropathy: The Basics

Definition and Key Characteristics:

Picture the brachial plexus as the main highway for nerves between our neck and arm. Now, Brachial Plexus Neuropathy is like a major traffic jam or roadblock on this highway. When this happens, the signals or messages that usually travel smoothly get disrupted. This means our arm might not move as it should, or it might feel strange sensations.

Causes and Risk Factors:

You might wonder, “What’s causing this traffic jam?” Well, there are several reasons:

• Injury: Think of this as a crash on our nerve highway. A hard hit or accident can hurt these nerves.
• Medical Procedures: Imagine roadwork or construction that accidentally damages part of the road. Similarly, surgeries or treatments near the neck or chest can sometimes disturb the brachial plexus.
• Inflammation: This is like the body mistakenly putting up a roadblock. Occasionally, our body’s defense system gets confused and sees these nerves as a threat, causing swelling.
• Other Factors: Things like tumors can be compared to big trucks parked on our nerve highway, pressing against it. Some infections might also cause disruptions.

Some people might be more likely to face these disruptions. For example, someone who plays rough sports or has had operations near the chest or neck might have a slightly higher chance of this issue.

Symptoms and Their Progression:

How do we know there’s a traffic jam? The signs can vary:

• Initial Onset: It might start with a sudden, sharp pain in the shoulder or arm, like a horn blaring unexpectedly.
• Muscle Weakness: Over time, it might feel like the arm is getting tired easily, making it harder to carry things or even just move around.
• Tingling or Numbness: Some people describe it as the feeling you get when your foot falls asleep.
• Progression: The good news is, like most traffic jams, it doesn’t last forever. With some patience and the right help, the symptoms often start to get better, though how long it takes can vary.

Delving into Parsonage-Turner Syndrome (PTS)

Historical Background: Who were Parsonage and Turner?

Our journey begins by stepping back in time. Imagine a world where medicine was just beginning to understand the intricate web of nerves in our body. In this backdrop, two dedicated doctors, Maurice Parsonage and John Aldren Turner, were like detective partners, piecing together a mysterious ailment in the 1940s. Their collaboration led to a significant discovery, and as a nod to their hard work, the syndrome was named after them – Parsonage-Turner Syndrome or, more simply, PTS.

PTS as a Subset of Brachial Plexus Neuropathy:

Remember our earlier analogy of the brachial plexus being like a major highway for nerve signals? Well, think of PTS as a specific type of roadblock on this highway. While brachial plexus neuropathy covers a range of disruptions on this road, PTS is one unique and particular kind. It’s caused when the body’s defense system, in a mix-up, attacks this nerve highway.

Clinical Features Distinguishing PTS from Other Neuropathies:

So, how do we spot this particular roadblock amidst all others? Here are some signs that make PTS stand out:

• Sudden Onset: PTS is like a storm that hits without warning. Patients often feel a sharp, sudden pain in their shoulder or arm, catching them off guard.
• Widespread Impact: While other roadblocks might affect just a section of the highway, PTS can affect a broader range, leading to muscle weakness or wasting in different parts of the arm.
• Recovery Curve: Like a storm that clears up gradually, PTS symptoms tend to improve over time. Many patients regain most, if not all, of their strength and sensation over months to years, but the journey can be different for everyone.
• No Clear External Cause: Often, there’s no injury or surgery that triggers PTS. It’s like a roadblock that appears without any clear reason for being there.

Etiology and Pathophysiology of PTS

Theories on the Origin:

Have you ever tried to trace back why something happened? Doctors and scientists do that with health conditions. For Parsonage-Turner Syndrome (PTS), there are a few “suspected culprits” they consider:

• Viral Infections: Some researchers believe certain viral infections may be linked to the onset of PTS. For instance, patients have reported symptoms after illnesses caused by Epstein-Barr virus, cytomegalovirus, or HIV. The mechanism isn’t entirely clear, but it’s theorized that viruses could directly damage the nerve or indirectly trigger an immune response against it (1).
• Immunological Causes: PTS might be an autoimmune disorder, where the body’s immune system mistakenly attacks its own nerves. This theory is supported by the finding of inflammatory cells in nerve biopsies of PTS patients (2).
• Family History: Just as we inherit eye color or height from our parents, some people might have genes making them more likely to get PTS (3). It’s a bit like having a family recipe, but not a good one

Physical and Biochemical Changes in the Affected Nerves:

Imagine the nerves as electric cables. Now, when PTS strikes, it’s like those cables getting frayed or even cut:

• Inflammation: It’s as if there’s a small “fire” or “inflammation” in the nerve area, with our body’s defense cells crowding around, causing damage.
• Demyelination: The protective sheath around nerves, called myelin, can get damaged in PTS. Without this protection, nerve impulses can slow down or become irregular (4).
• Axonal Damage: In more severe cases, it’s not just the protective coat but the core wire (or axon) inside that gets damaged.
• Chemical Changes: Picture this as the electric cable losing its power supply or balance, affecting how well it works.

Factors Contributing to Persistence or Recurrence of Symptoms:

Why do some people take longer to recover, while others might face a return of symptoms?

• Initial Severity: If the initial “fire” or damage is extensive, it’s like a road that’s taken a harder hit; it’ll take longer to repair.
• Incomplete Healing: Sometimes, even after the “fire” is out, the protective coat around our nerve doesn’t fully rebuild, much like a road that’s been patched up but still has potholes.
• Re-ignition: Some triggers, like a new virus, can reignite the body’s mistaken attack on the nerves.
• Lasting Changes: Over time, chronic “fires” can change the landscape of our nerve “roads,” making it harder for them to function as they used to.

Read More: Why Do Some Lung Cancer Patients Experience Shoulder Pain

Diagnosis of Parsonage-Turner Syndrome

Clinical Examination and Patient History:

When a doctor is trying to find out what’s wrong, they often start like detectives, gathering clues and piecing the puzzle together.

• History Taking: Doctors will chat with you about the pain you’ve felt, especially if it’s sharp and sudden in your shoulder or arm. They’ll also ask if you’ve recently been sick, had a vaccination, undergone surgery, or had any injuries. All these bits of information can hint towards Parsonage-Turner Syndrome (5).
• Physical Check: Just like checking a car’s engine when it’s acting up, doctors will examine your muscles and reflexes, especially around the shoulders and upper arms, to see how they’re working.

Diagnostic Tools:

Just like mechanics use tools to inspect cars more deeply, doctors have their tools to look closer into our bodies:

• Electromyography (EMG): This is like a “phone tap” for your muscles. EMG listens to the electric signals in your muscles to see if they’re working right. It helps doctors know if the nerves controlling the muscles are damaged (4).
• Nerve Conduction Studies (NCS): This test is like checking the speed of your internet connection but for your nerves. It measures how fast and well your nerves are sending signals.
• Magnetic Resonance Imaging (MRI): Think of this as a super-powered camera that takes pictures of the insides of your body. For Parsonage-Turner Syndrome, it can show if there’s swelling or any unusual changes in the nerves near your shoulders. While not diagnostic by itself, in PTS, it may show high-intensity signals in the affected muscles, indicative of denervation (6).

Differential Diagnosis: Ruling Out Other Conditions:

Sometimes, symptoms can trick doctors because they look like other illnesses or conditions. So, they play a game of “What’s not it?” to narrow down the possibilities:

• Traumatic Brachial Plexopathy: If someone has hurt their arm or shoulder, their symptoms might seem like Parsonage-Turner Syndrome, but it’s due to the injury.
• Cervical Radiculopathy: This is a fancy term for nerve pain because of issues in the neck, often due to things like slipped discs.
• Thoracic Outlet Syndrome (TOS): Another condition affecting the same nerve area, but this one might also make your hand swell or change color.
• Neoplasms or Tumors: Sometimes, growths in the body can press on nerves and cause pain or weakness. Special scans can help doctors see if this is the cause.

Read More: Is Your Shoulder Pain Related to Ankylosing Spondylitis?

Treatment Methods for Parsonage-Turner Syndrome (PTS)

Conservative Management:

• Physical Therapy: Just like athletes need coaches to guide their training, some patients benefit from physical therapists who show them special exercises. These exercises help maintain movement, reduce stiffness, and strengthen muscles, ensuring that the arm or shoulder remains as functional as possible (7).
• Pain Management: For some people, PTS can be painful. To help manage this, doctors might recommend treatments that use tiny electrical pulses (TENS) or even sound waves (therapeutic ultrasound) to ease the pain. It’s also about learning how to do everyday tasks in ways that don’t make the pain worse.

Medications:

• Anti-inflammatories: These are drugs that help reduce swelling and pain. They’re the same kind of meds you might take for a headache or a sore back. However, they’re not candy, so it’s essential to use them as the doctor recommends.
• Corticosteroids: Think of these as super-powered anti-inflammatories. They can be powerful in reducing swelling, especially if the body’s immune system is causing the problem (8). They might come as pills or even as an IV drip.
• Other Drug Classes: Some medicines weren’t initially designed for pain but can help with nerve pain. For example, some meds initially made for epilepsy can assist here. If those don’t work, doctors might try medications often given for depression because they can also help with nerve pain.

Surgical Interventions:

1. When to Consider Surgery: Surgery is like the “big guns” of treatment. Doctors consider it if other treatments aren’t helping or if something specific inside the body is causing the problem, like a growth pressing on a nerve.
2. Nerve Decompression or Neurolysis: If something is squeezing the nerve – like how a kinked hose can’t let water flow – surgeons might step in to release that pressure. It’s like unkinking the hose.
3. Nerve Transfers: If a nerve isn’t healing or working, surgeons might borrow a nearby working nerve to help out. It’s like redirecting traffic if a main road is closed.
4. Tendon Transfers: If the muscles aren’t responding because of the nerve problem, a surgeon might move a working tendon to the place of one that’s not working. Think of it like using a spare part to fix a broken machine.

Staying Well in the Long Run and Avoiding a Comeback of PTS:

• Regular Check-ups: Even if you’re feeling better, it’s good to visit the doctor now and then. They can spot early signs if the problem might be returning.
• Smart Choices: Learning about things that might bring back the pain or weakness can help in avoiding them. For example, repetitive tasks or certain activities might be triggers.
• Medications and Therapies: In some cases, doctors might suggest taking specific meds that can prevent the problem from returning.
• Keep Moving: Continuing with exercises or therapy can keep muscles strong and joints moving smoothly. This not only helps with PTS but also ensures overall good health.

Conclusion

Just like finding a small leak in a boat before it gets bigger, spotting PTS early can make a huge difference. The sooner it’s identified, the better the chances are to manage it and possibly even speed up recovery. So, listening to our bodies and seeking help when something feels off is vital.

Managing PTS isn’t a one-size-fits-all. It might need exercises, medications, therapies, or even surgeries. But the main idea is to ensure that the person affected gets a plan tailored just for them. That’s why having a team of doctors, therapists, and even counselors can make the journey smoother.

There’s a lot we know about PTS, but there’s also more to discover. Continued research is like a beacon of hope. It promises better ways to diagnose, treat, and maybe one day, even prevent the condition. Supporting and understanding this research can pave the way for brighter futures for those affected.

FAQ’s

1. What is Brachial Plexus Neuropathy?

Answer: Brachial Plexus Neuropathy refers to a condition where the brachial plexus, a network of nerves near the neck that control the arm muscles, gets injured or inflamed. This can result in muscle weakness, numbness, and pain in the arm and shoulder.

2. What is Parsonage-Turner Syndrome (PTS)?

Answer: Parsonage-Turner Syndrome, also known as neuralgic amyotrophy, is a rare type of Brachial Plexus Neuropathy. It causes sudden-onset shoulder pain followed by severe muscle weakness. The exact cause of PTS is unknown, but it’s believed to be related to autoimmune reactions.

3. How is Brachial Plexus Neuropathy different from Parsonage-Turner Syndrome?

Answer: While both refer to conditions affecting the brachial plexus, Parsonage-Turner Syndrome is a specific subtype of Brachial Plexus Neuropathy. PTS is characterized by its sudden onset and is believed to have an autoimmune component.

4. What causes Parsonage-Turner Syndrome?

Answer: The exact cause of PTS is not fully understood. However, it is often linked to factors such as viral infections, surgery, immunizations, stress, or autoimmune reactions.

5. How is Parsonage-Turner Syndrome diagnosed?

Answer: The diagnosis of PTS typically involves a clinical examination, patient history, and diagnostic tools like Electromyography (EMG), nerve conduction studies, and MRI to rule out other conditions with similar symptoms.

6. What are the symptoms of Brachial Plexus Neuropathy?

Answer: Symptoms include sharp, burning, or shooting pain in the shoulder or arm, muscle weakness, numbness, tingling, and difficulty moving or lifting the arm.

7. Are there any treatments available for Parsonage-Turner Syndrome?

Answer: Treatment options include pain management using medications, physical therapy, and in severe cases, surgical interventions. Early diagnosis and treatment are crucial for better outcomes.

8. How common is Parsonage-Turner Syndrome?

Answer: Parsonage-Turner Syndrome is a rare condition, affecting only about 1 to 3 people per 100,000 annually.

9. Can PTS lead to permanent damage?

Answer: In most cases, individuals with PTS experience a full recovery. However, recovery can be slow, sometimes taking up to a few years. A small percentage of people might have lasting weakness or other symptoms.

10. Are there any known risk factors for Brachial Plexus Neuropathy or PTS?

Answer: While the exact causes are not clear, trauma, surgeries near the shoulder or neck area, certain infections, and autoimmune reactions are considered potential risk factors.

References

1. Tsairis, P., Dyck, P.J. and Mulder, D.W., 1972. Natural history of brachial plexus neuropathy: report on 99 patients. Archives of neurology, 27(2), pp.109-117. https://jamanetwork.com/journals/jamaneurology/article-abstract/571532

2. Suarez, G.A., Giannini, C., Bosch, E.P., Barohn, R.J., Wodak, J., Ebeling, P., Anderson, R., McKeever, P.E., Bromberg, M.B. and Dyck, P.J., 1996. Immune brachial plexus neuropathy: suggestive evidence for an inflammatory-immune pathogenesis. Neurology, 46(2), pp.559-561. https://n.neurology.org/content/46/2/559.short

3. Beghi, E., Kurland, L.T., Mulder, D.W. and Nicolosi, A., 1985. Brachial plexus neuropathy in the population of Rochester, Minnesota, 1970–1981. Annals of Neurology: Official Journal of the American Neurological Association and the Child Neurology Society, 18(3), pp.320-323. https://onlinelibrary.wiley.com/doi/abs/10.1002/ana.410180308

4. Feinberg, J.H. and Radecki, J., 2010. Parsonage-turner syndrome. HSS Journal®, 6(2), pp.199-205. https://journals.sagepub.com/doi/abs/10.1007/s11420-010-9176-x

5. Van Alfen, N., 2011. Clinical and pathophysiological concepts of neuralgic amyotrophy. Nature Reviews Neurology, 7(6), pp.315-322. https://www.nature.com/articles/nrneurol.2011.62

6. Gaskin, C.M. and Helms, C.A., 2006. Parsonage-Turner syndrome: MR imaging findings and clinical information of 27 patients. Radiology, 240(2), pp.501-507. https://pubs.rsna.org/doi/abs/10.1148/radiol.2402050405

7. Van Alfen, N. and Van Engelen, B.G., 2006. The clinical spectrum of neuralgic amyotrophy in 246 cases. Brain, 129(2), pp.438-450. https://academic.oup.com/brain/article-abstract/129/2/438/292269

8. Van Eijk, J.J., Groothuis, J.T. and Van Alfen, N., 2016. Neuralgic amyotrophy: an update on diagnosis, pathophysiology, and treatment. Muscle & nerve, 53(3), pp.337-350. https://onlinelibrary.wiley.com/doi/abs/10.1002/mus.25008

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Dr. M Shahadat Hossain

Physiotherapy Specialist at ASPC Manipulation Therapy Centre

BSPT (DU), MSc PT(DU), PhD-fellow (JU), Dip. in-Manipulation Therapy (Certified ETOMG-Belgium), McKenzie (A&B), Mulligan and dry Needling (India) Faculty Member of Bangladesh Health profession Institute (CRP), Savar.
Assistant professor, Dhaka College of Physiotherapy
Chief Consultant(Ex): Popular Medical college Hospital, Dhanmondi- 2.
Chairman and Chief Consultant: ASPC Manipulation Therapy Centre, Nurjahan Road, Mohammadpur.
Founder and conceptual inventor: Structural Diagnosis and Management (SDM) concept.
Secretary: Centre for the Rehabilitation of Autism and Person with Disabilities (CARD).
Secretary-General: Bangladesh Physiotherapy Association (BPA).
Phone +88 01712-867364
Email aspc.dhaka@gmail.com
Website https://aspc.com.bd

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