Case Report

ACUTE SHOULDER PAIN FOLLOWED BY FLACCID PARALYSE OF SHOULDER (BRACHIAL NEURITIS): A LEARNING FROM A CASE

Julius July1, Eka Julianta Wahjoepramono2
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Siloam Hospital Lippo Village, Tangerang, Indonesia Department of Neurosurgery, Faculty of Medicine Pelita Harapan University

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ABSTRACT Brachial neuritis is a rare syndrome affecting mainly the lower motor neurons of the brachial plexus and/or individual nerves or nerve branches. We present a case of 66 years old male with acute onset of right shoulder pain for several days, and then followed by flaccid paralysis of his right shoulder and parascapular muscles. It’s a quite typical scenario of brachial neuritis. It is prognosis is quite promising, not as bad as motor neuron disease nor other autoimmune entities. This article report one case of brachial neuritis with literature review. Key words: brachial neuritis - shoulder pain - flaccid paralysis ABSTRAK Neuritis brachial merupakan suatu sindroma yang sangat jarangyang terutama mengenai lower motor neuron plexus brachialis dan/atau saraf-saraf tunggal atau cabang-cabang saraf. Kami melaporkan sebuah laporan kasus dari seorang laki-laki berusia 66 tahun yang menderita nyeri akut di bahu kanan selama beberapa hari, yang kemudian diikuti dengan dengan lumpuh layuh pada bahu kanan dan otot parascapulanya. Hal ini merupakan gambaran kasus neuritis brachial yang sangat khas. Prognosis penyakit ini sangat baik, tidak seperti penyakit pada motor neuron ataupun karena autoimun. Laporan kasus ini dilengkapi pula dengan suatu tinjuan pustaka. Kata kunci: neuritis brachial – nyeri bahu – lumpuh layuh

INTRODUCTION Brachial neuritis is a rare syndrome affecting mainly the lower motor neurons of the brachial plexus and/or individual nerves or nerve branches. There is no clear explanation about its etiology. It is usually characterized by acute onset of excruciating shoulder pain ------------------------------------------------------Julius July ( ) Departemen of Neurosurgery, Faculty of Medicine Universitas Pelita Harapan Jl. Boulevard Jend.Sudirman, Lippo Karawaci, Tangerang, Indonesia. Tel: +62-21-54210130; Fax: +62-21-54210133; e-mail: juliusjuly@yahoo.com

unilaterally, and then several days later it is followed by flaccid paralysis of shoulder and parascapular muscles. Brachial neuritis can vary greatly in presentation and nerve involvement.1, 2 Brachial neuritis is not a fatal condition, although the phrenic nerve may be involved. CASE REPORT We present a case of 66 years old male with flaccid paralysis of his right shoulder. The deltoid and parascapular muscle are atrophic (pic.1-5) About 8 weeks prior, he suffered right shoulder pain, acute onset, and its pain is

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cervical disc disease. numbness is rarely a prominent complaint.4 A shoulder radiograph may be indicated to rule out specific shoulder pathologies. Considerable muscle pain may be noted on palpation. neoplastic brachial plexopathy. usually 2-3 weeks after onset. The occupational therapist may be involved in maintaining ROM and strengthening. steroids. immunoglobulin. Assistive devices and orthotics may be used. In brachial neuritis. Sensory loss may be detectable. and opiate analgesia often is necessary in the initial period. Surgery usually is aimed at improving shoulder abduction. as well as Pancoast tumor. particularly if the hand and wrist are involved. Movements of the neck are relatively pain free. Immunosuppressive therapy (eg. Strengthening of the rotator cuff muscles and scapular stabilization may be indicated. and/or motor unit potential changes) in affected muscles. it can be useful to rule out sarcoidosis or other granulomatous disease. A chest radiograph is not usually part of the initial workup. nerve grafting or tendon transfers may be considered for the few patients who do not achieve good recovery by 2 years. anterior interosseous syndrome. however. XI. depending on the particular nerves affected. Passive modalities (eg. MRI of the brachial plexus can help to rule out structure abnormality if clinically indicated. XII). Magnetic resonance imaging (MRI) should be considered initially to rule out cervical radiculopathy (particularly C5/C6). Needle electromyogram (EMG) shows denervation (fibrillations. Functional conditioning of the upper extremity may be helpful in patients with brachial neuritis. rotator cuff disease. spinal cord tumor. Phrenic nerve involvement occurs in up to 5% of cases and can result in significant shortness of breath. X. cold.9.ACUTE SHOULDER PAIN considerable atrophy and wasting.10. Numbness may occur. transcutaneous electrical nerve stimulation [TENS]) may be useful as adjunct pain relievers. depending on the particular disabilities present. DIFFERENTIAL DIAGNOSIS Acute poliomyelitis. heat. positive sharp waves. Reflexes may be reduced or absent. Lumbar puncture usually is not indicated. polymyalgia rheumatica. as well as a deep dull pain in the affected muscles. TREATMENT Physical therapy for patients with brachial neuritis should be focused on the maintenance of full range of motion (ROM) in the shoulder and other affected joints. 16 UNIVERSITAS PELITA HARAPAN . amyotrophic lateral sclerosis. Muscle strength in affected muscles often is very weak. and plasma exchange) has not been shown to be beneficial. Passive and active attempts at shoulder and scapular movement result in a significant increase in pain. Other analgesic could be given such as acetaminophen alone or in combination with codein. mononeuritis multiplex. and traumatic mononeuropathies INVESTIGATION Laboratory examination only indicated if systemic disease is suspected on clinical grounds. However.13 Passive ROM (PROM) and active ROM (AROM) exercises should begin as soon as the patient's pain has been adequately controlled. thoracic outlet syndrome. and usually is found in the nerve distribution corresponding to maximal muscle weakness. Treatment is largely symptomatic in patients with brachial neuritis.12 On physical examination we could find atrophy of the affected muscles after 2 weeks of weakness.11 Even cranial nerve involvement ever been reported (IX. pack.

until one day he barely able to raise his arm. After 4 weeks. even worst at midnight and causing patient could not sleep at all. Some low-grade pain may persist longer. and he definitely sure that his right shoulder power is improving. about 20 % could persist up to a year. localized.7 THE CLINICAL COURSE at onset. including a pure distal form. The deltoid and parascapular muscles are atrophic (arrow) LITERATURE REVIEW Brachial neuritis present in two forms. Movements of the neck. particularly those innervated by the upper trunk. but it may be bilateral in 1030% of cases. although conduction block has also been described in over 33% of cases in the series by Lo and Mills. 8 immunizations. The pain is constant. have been reported. Patient usually describe the pain as sharp or throbbing in nature. the weakness becomes apparent. The pain also exacerbated by movements of the shoulder. the intensity is very high (9+/10) and maximal UNIVERSITAS PELITA HARAPAN 15 . His electromyogram (EMG) study shows denervation in affected muscles. but many different single and multiple combinations of muscles involvement.MEDICINUS · Vol.5 Axonopathy takes place and followed by Wallerian degeneration.6 The inherited form is autosomal dominant. The Intense pain can last from only a few hours to several weeks and many patients require opiate analgesia. and/or sneezing usually do not make the pain worse. or even trauma. Most of the pain starts at right shoulder. He was sent to physiotherapy and given some neurotropic vitamins. MRI of his Brachial plexus also didn’t show any obvious structural abnormality. →→→ Th Figure 1. As the pain subsides. The idiopathic form is generally accepted as an immune reaction that the inflammatory reaction happen against nerve fibers of the brachial plexus. surgery. The he start to feel that day by day the right shoulder is getting weaker. A wide variety of muscles could be affected. serratus anterior. it has been linked to mutations on chromosome 17q. infraspinatus. He went to physician and got pain killer and was told that he got muscle pain. The supraspinatus. The weakness is usually apparent within the first 2 weeks of onset. 3 No.3. Cervical Magnetic Resonance Imaging (MRI) only shows mild disc bulge especially to the right side. The pain stays for about 5 days and totally gone after a week. but mainly on the shoulder. The patient may notice The onset of pain is often abrupt and may associate with prior illness. although most cases the weakness is maximal at onset but some can progress to several weeks.4. coughing. an inherited and an idiopathic form. and deltoid muscles are particularly susceptible. The pain starts from right upper neck and going down to the right elbow. 1 Februari 2009 – Mei 2009 sharp and excruciating. he starts to gain minor power on his right shoulder. Up to two thirds of cases the pain starts at night.

Motor Roots Conduction in Neuralgic Amyotrophy: Evidence of Proximal Conduction Block. Suarez GA. The Variations of Neuralgic Amyotrophy. 2. et al. Sumner AJ. Muscle Nerve. Sathasivam S. Manohar R. England JD. England JD. et al. UNIVERSITAS PELITA HARAPAN 17 . Bosch EP.2008. Neurology. 46(2): 559-61. J Neurol Neurosurg Psychiatry. Neuralgic Amyotrophy.1999. Giannini C. 1996. Immune Brachial Plexus Neuropathy: Suggestive Evidence for an Inflammatory-Immune Pathogenesis.1987. 1999. J Bone Joint Surg Br. 90(5): 550-3. 10(1): 60-8. 3 No. 3. 6. 2008. Mills KR. 105(2): 168-9. Lo YL. 1 Februari 2009 – Mei 2009 REFERENCES 1. 5. Mo Med. Neuralgic Amyotrophy: An Increasingly Diverse Entity. Mar. Conway RR. 4. Muscle Nerve. Lecky B. 66(5): 586-90.MEDICINUS · Vol. 22(4): 435-6. Neuralgic Amyotrophy: Uncommon but Not Rare.