Case Report

ACUTE SHOULDER PAIN FOLLOWED BY FLACCID PARALYSE OF

SHOULDER (BRACHIAL NEURITIS): A LEARNING FROM A CASE

Julius July1, Eka Julianta Wahjoepramono2

1

Siloam Hospital Lippo Village, Tangerang, Indonesia

Department of Neurosurgery, Faculty of Medicine Pelita Harapan University

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. Its 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

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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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ACUTE SHOULDER PAIN

considerable atrophy and wasting, as well

as a deep dull pain in the affected muscles.
Numbness may occur, depending on the
particular nerves affected, and usually is
found
in
the
nerve
distribution
corresponding to maximal muscle
weakness. However, numbness is rarely a
prominent complaint. Phrenic nerve
involvement occurs in up to 5% of cases
and can result in significant shortness of
breath.9,10,11
Even cranial nerve
involvement ever been reported (IX, X,
XI, XII).12
On physical examination we could find
atrophy of the affected muscles after 2
weeks of weakness. Considerable muscle
pain may be noted on palpation. Passive
and active attempts at shoulder and
scapular movement result in a significant
increase in pain. Movements of the neck
are relatively pain free. Muscle strength in
affected muscles often is very weak.
Reflexes may be reduced or absent.
Sensory loss may be detectable.
DIFFERENTIAL DIAGNOSIS
Acute poliomyelitis, neoplastic brachial
plexopathy, polymyalgia rheumatica,
amyotrophic lateral sclerosis, rotator cuff
disease, cervical disc disease, thoracic
outlet syndrome, mononeuritis multiplex,
anterior interosseous syndrome, pack,
spinal cord tumor, and traumatic
mononeuropathies
INVESTIGATION
Laboratory examination only indicated if
systemic disease is suspected on clinical
grounds. Magnetic resonance imaging
(MRI) should be considered initially to
rule
out
cervical
radiculopathy
(particularly C5/C6). MRI of the brachial
plexus can help to rule out structure
abnormality if clinically indicated.4 A
shoulder radiograph may be indicated to
rule out specific shoulder pathologies. A
chest radiograph is not usually part of the
initial workup; however, it can be useful to

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rule
out
sarcoidosis
or
other
granulomatous disease, as well as
Pancoast tumor.
Needle electromyogram (EMG) shows
denervation (fibrillations, positive sharp
waves, and/or motor unit potential
changes) in affected muscles, usually 2-3
weeks after onset. Lumbar puncture
usually is not indicated.
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.13 Passive ROM (PROM) and active
ROM (AROM) exercises should begin as
soon as the patient's pain has been
adequately controlled. Strengthening of
the rotator cuff muscles and scapular
stabilization may be indicated. Passive
modalities (eg, heat, cold, transcutaneous
electrical nerve stimulation [TENS]) may
be useful as adjunct pain relievers.
Functional conditioning of the upper
extremity may be helpful in patients with
brachial neuritis. Assistive devices and
orthotics may be used, depending on the
particular disabilities present. The
occupational therapist may be involved in
maintaining ROM and strengthening,
particularly if the hand and wrist are
involved.
Treatment is largely symptomatic in
patients with brachial neuritis, and opiate
analgesia often is necessary in the initial
period. Other analgesic could be given
such as acetaminophen alone or in
combination
with
codein.
Immunosuppressive therapy (eg, steroids,
immunoglobulin, and plasma exchange)
has not been shown to be beneficial.
In brachial neuritis, nerve grafting or
tendon transfers may be considered for the
few patients who do not achieve good
recovery by 2 years. Surgery usually is
aimed at improving shoulder abduction.

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MEDICINUS Vol. 3 No. 1 Februari 2009 Mei 2009

sharp and excruciating. The pain starts from
right upper neck and going down to the right

elbow, but mainly on the shoulder.

He went to physician and got pain killer
and was told that he got muscle pain. The
pain stays for about 5 days and totally
gone after a week. The he start to feel that
day by day the right shoulder is getting
weaker, until one day he barely able to
raise his arm. His electromyogram (EMG)
study shows denervation in affected

muscles. Cervical Magnetic Resonance

Imaging (MRI) only shows mild disc
bulge especially to the right side. MRI of
his Brachial plexus also didnt show any
obvious structural abnormality. After 4
weeks, he starts to gain minor power on
his right shoulder, and he definitely sure
that his right shoulder power is improving.
He was sent to physiotherapy and given
some neurotropic vitamins.

Th

Figure 1. The deltoid and parascapular muscles are atrophic (arrow)

LITERATURE REVIEW

Brachial neuritis present in two forms, an

inherited and an idiopathic form. The
idiopathic form is generally accepted as an
immune reaction that the inflammatory
reaction happen against nerve fibers of the
brachial plexus.3,4,5 Axonopathy takes
place and followed by Wallerian
degeneration, although conduction block
has also been described in over 33% of
cases in the series by Lo and Mills.6 The
inherited form is autosomal dominant, it
has been linked to mutations on
chromosome 17q.7

at onset. The pain is constant, even worst

at midnight and causing patient could not
sleep at all. The pain also exacerbated by
movements of the shoulder. Movements of
the neck, coughing, and/or sneezing
usually do not make the pain worse. The
Intense pain can last from only a few
hours to several weeks and many patients
require opiate analgesia. Some low-grade
pain may persist longer; about 20 % could
persist up to a year. As the pain subsides,
the weakness becomes apparent, although
most cases the weakness is maximal at
onset but some can progress to several
weeks. The weakness is usually apparent
within the first 2 weeks of onset.

THE CLINICAL COURSE

The onset of pain is often abrupt and may

associate with prior illness, surgery, 8
immunizations, or even trauma. Up to two
thirds of cases the pain starts at night.
Most of the pain starts at right shoulder,
localized, but it may be bilateral in 1030% of cases. Patient usually describe the
pain as sharp or throbbing in nature, the
intensity is very high (9+/10) and maximal

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A wide variety of muscles could be

affected, particularly those innervated by
the upper trunk. The supraspinatus,
infraspinatus, serratus anterior, and deltoid
muscles are particularly susceptible, but
many different single and multiple
combinations of muscles involvement,
including a pure distal form, have been
reported. The patient may notice

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MEDICINUS Vol. 3 No. 1 Februari 2009 Mei 2009

REFERENCES
1. England JD. The Variations of Neuralgic Amyotrophy. Muscle Nerve.1999; 22(4): 435-6.
2. England JD, Sumner AJ. Neuralgic Amyotrophy: An Increasingly Diverse Entity. Muscle
Nerve.1987; 10(1): 60-8.
3. Suarez GA, Giannini C, Bosch EP, et al. Immune Brachial Plexus Neuropathy: Suggestive
Evidence for an Inflammatory-Immune Pathogenesis. Neurology. 1996; 46(2): 559-61.
4.

Conway RR. Neuralgic Amyotrophy: Uncommon but Not Rare. Mo Med. Mar- 2008;
105(2): 168-9.

5. Sathasivam S, Lecky B, Manohar R, et al. Neuralgic Amyotrophy. J Bone Joint Surg

Br. 2008; 90(5): 550-3.
6. Lo YL, Mills KR. Motor Roots Conduction in Neuralgic Amyotrophy: Evidence of Proximal
Conduction Block. J Neurol Neurosurg Psychiatry. 1999; 66(5): 586-90.

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