Scalf et al.

MRI of Patients with Parsonage-Turner Syndrome

M u s c ul o s kel et a l I m ag i n g • C l i n i c a l O b s e r va t i o n s

MRI Findings of 26 Patients with Parsonage-Turner Syndrome
Richard E. Scalf1 Doris E. Wenger1 Matthew A. Frick1 Jayawant N. Mandrekar2 Mark C. Adkins1
Scalf RE, Wenger DE, Frick MA, Mandrekar JN, Adkins MC OBJECTIVE. The objective of our study was to describe the MRI features of patients with Parsonage-Turner syndrome. Familiarity with the MRI features associated with this entity is important because radiologists may be the first to suggest the diagnosis. Twenty-six patients with Parsonage-Turner syndrome were treated at our institution between 1997 and 2005. We retrospectively reviewed the MR images of patients with clinical or electromyographic evidence (or both) of acute brachial neuritis without a definable cause. CONCLUSION. MRI of the brachial plexus and shoulder in patients with Parsonage-Turner syndrome showed intramuscular denervation changes involving one or more muscle groups of the shoulder girdle. The supraspinatus and infraspinatus muscles were the most commonly involved. MRI is sensitive for detecting signal abnormalities in the muscles of the shoulder girdle of patients with Parsonage-Turner syndrome. MRI may be instrumental in accurately diagnosing the syndrome. arsonage-Turner syndrome, also known as “acute idiopathic brachial neuritis,” is a painful nontraumatic disorder involving the shoulder girdle. Patients with Parsonage-Turner syndrome typically present with a sudden onset of shoulder pain or weakness (or both) of the shoulder girdle musculature [1]. Clinically, establishing the diagnosis may be challenging because symptoms are nonspecific and may mimic other shoulder girdle disorders such as labral tear with associated paralabral cyst, rotator cuff tear, impingement, and adhesive capsulitis [1–4]. Evaluation of patients with shoulder pain and weakness typically includes a medical history, physical examination, imaging studies, and possibly electrophysiologic evaluation. MRI is the imaging technique of choice in patients with shoulder pain and weakness and provides the most comprehensive evaluation of the shoulder girdle because of its multiplanar imaging capability and superior soft-tissue contrast. Familiarity with the MRI features of Parsonage-Turner syndrome is critical for radiologists because they may be the first to suggest the diagnosis. In this article, we describe the MRI findings of 26 patients with Parsonage-Turner syndrome. This study and the recently published study by Gaskin and Helms [5] are the largest reported series describing the imaging features of Parsonage-Turner syndrome to date.

P

Materials and Methods
We retrospectively reviewed the records of all the patients from our institution who were examined between 1997 and 2005 and had clinical or electrophysiologic evidence (or both) of acute brachial plexopathy without a definable cause (e.g., appropriate history of trauma or anatomic abnormality). This study was approved by the Mayo Clinic Institutional Review Board and met the criteria established for waiver of informed consent. Patients were identified by searching our database for those who underwent MRI of the brachial plexus or shoulder. The keywords that were used in the search included “Parsonage-Turner,” “acute brachial neuritis,” and “denervation.” Because we searched through an MRI database, patients with the clinical diagnosis of Parsonage-Turner syndrome who did not undergo MRI evaluation were excluded from the study. In addition, after the medical records and MRI examinations were reviewed, patients were excluded if they had a history of trauma, radiation, or neoplasm or if there was MRI evidence of rotator cuff tear, bone or soft-tissue mass, labral tear associated with paralabral cyst, or other conditions that could contribute to muscle weakness. Patients with a clinical diagnosis of Parsonage-Turner syndrome and normal findings after the MRI examination were also excluded because the purpose of our study was to evaluate and report only positive MRI findings of patients with this diagnosis. Twenty-six patients met the inclusion criteria for the study.

Keywords: denervation, idiopathic brachial neuritis, MRI, musculoskeletal imaging, Parsonage-Turner syndrome, shoulder DOI:10.2214/AJR.06.1136 Received August 25, 2006; accepted after revision January 15, 2007.
1Department

of Radiology, Mayo Clinic, 200 First St., SW, Rochester, MN 55905. Address correspondence to D. E. Wenger. of Biostatistics, Mayo Clinic, Rochester, MN.

2Division

WEB This is a Web exclusive article. AJR 2007; 189:W39–W44 0361–803X/07/1891–W39 © American Roentgen Ray Society

AJR:189, July 2007

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matrix. subscapularis. Three or more muscles were affected in 17 patients (65%). oblique sagittal.200/68. Patients (%) es Su bs c Su pr a In fr Te r Pe c as W40 La t is s R AJR:189.200/32. and oblique coronal T1-weighted fast spin-echo images (TR/TE minimum. Each muscle was evaluated for the presence of edema and atrophy (Table 1). FOV.5-T scanner (Signa. and two reviewers had 14 and 10 years of additional experience as musculoskeletal radiologists. on the left side for 12 patients (46%). 4 mm. and oblique sagittal fat-suppressed T2-weighted images (3. weakness. pectoralis. teres minor. infraspinatus. July 2007 . and p values less than 0. the affected side and the dominant handedness of the patient) were assessed using the chi-square test or the Fisher’s exact test as appropriate. Fig. which explains why presenting symptoms mimicked rotator cuff tendon tears or mass in spinoglenoid notch that impinged on suprascapular nerve. One patient presented with pain and numbness and another with weakness and numbness. field of view [FOV]. 130 milliseconds. and oblique sagittal proton density images (3. 4 mm. 2 mm. 90 80 70 60 50 40 30 20 10 0 in or el to id us us is lis ap ul ar sp in at pi na t D to ra M im us ho m bo id s D or si Affected Muscles All MRI examinations were performed using a 1. slice thickness. The most common clinical presentation was pain and weakness (11 patients [42%]). 0. 14 cm. and bilateral for two patients (8%). matrix. Statistical analyses were primarily descriptive. Results We retrospectively identified 26 patients with clinical or electrophysiologic evidence (or both) of Parsonage-Turner syndrome who had positive MRI findings. Muscles were evaluated for evidence of denervation change in the shoulder girdle and chest wall. and continuous variables were summarized using medians and ranges because of skewed distribution. and rhomboids. All patients had clinical findings that were compatible with Parsonage-Turner syndrome. Clinical symptoms were on the right side for 12 patients (46%). or numbness (or a combination of the three). The study patients included 20 males (77%) and six females (23%). The latter two T2weighted imaging sequences in combination were interpreted as the equivalent of T1-weighted images for recognition of fatty infiltration. depending on the clinical suspicion of the cause of the pathologic process. 6 mm. and the second most common was pain alone (six patients [23%]). slice thickness. Nineteen of the 26 patients were evaluated using electromyo- graphy (EMG) and had positive findings for Parsonage-Turner syndrome. 1—Bar graph illustrates spectrum of muscles of shoulder girdle and chest wall that were affected in patients with Parsonage-Turner syndrome and shows percentage of patients with involvement of each muscle. 34 cm. The median age at diagnosis was 45 years (range. intersection gap. Most patients (88%) presented with more than one affected muscle group. or a combination of these findings. muscular atrophy with or without fatty infiltration.5 mm. Associations between categoric variables (e. 256 × 256) and oblique sagittal and oblique coronal T2-weighted fast spin-echo inversion recovery images (TR/TE. slice thickness. 8–77 years). one third showed MR evidence of only intramuscular edema and no evidence of atrophy or fatty infiltration on T1-weighted or non–fat-saturated proton density images (Fig. No statistically significant correlation was identified between the affected side and the dominant handedness of the patient. 6 mm. All brachial plexus images were obtained using a body or torso coil. matrix. Just over one half showed marked diffuse increased T2-weighted signal with atrophy and fatty infiltration on T1-weighted or non–fatsaturated proton density images (Fig. oblique coronal. 0. but each had strong clinical evidence that supported the diagnosis of Parsonage-Turner syndrome and excluded other causes. including the supraspinatus. None of the patients was asymptomatic.5 mm.. Of the patients with a detectable signal abnormality in the supraspinatus and infraspinatus muscles. 3). oblique coronal. Neither intraarticular nor IV gadolinium was used for any of the examinations. Statistical tests were two sided. intersection gap. 400/600. latissimus dorsi.0 SAS. Seven patients did not undergo EMG. Positive MRI findings were defined as features of denervation change that involved muscles of the rotator cuff or shoulder girdle. 1 mm. A small number of patients presented with pain.g. Fatty infiltration was identified on proton density sequences as linear foci of increased intramuscular signal that also showed decreased signal on corresponding fat-saturated T2-weighted or inversion recovery sequences. 256 × 256) were also obtained as a part of the shoulder imaging protocol. weakness. The supraspinatus and infraspinatus muscles were the most commonly affected muscles in our series. including intramuscular edema. FOV. intersection gap. SAS Institute). Clinical symptoms were variable: Most patients presented with isolated pain. 26–30 cm. 14 cm.Scalf et al. two muscles in six patients (23%). intersection gap. Hand dominance was recorded for 20 patients: 17 (85%) were right-handed and three (15%). inversion recovery time. All MRI data were correlated with available initial and follow-up clinical information. Each patient underwent MRI of the brachial plexus or shoulder. FOV. 1). 256 × 192). matrix. Categoric variables were summarized using frequencies and percentages. 2). Axial. 256 × 256). Patients presented with symptoms in various muscles of the shoulder girdle. Muscular atrophy with fatty infiltration was defined as decreased muscle mass and linear foci of increased T1-weighted or proton density intramuscular signal when compared with the relative volume and signal intensity of adjacent normal muscle groups. Each reviewer had completed a 1-year musculoskeletal fellowship. GE Healthcare). and numbness (four patients [15%]) or weakness alone (three patients [12%]). Intramuscular edema was defined as any area of increased intramuscular signal on T2-weighted images. left-handed. 3.550/50. All imaging studies were reviewed by consensus of three musculoskeletal radiologists. Shoulder examinations were performed using a shoulder coil and included axial. deltoid. Brachial plexus examinations included axial.05 were considered statistically significant. All statistical analyses were performed using a commercial software package (version 8. Review of the MRI examinations showed that the supraspinatus and infraspinatus muscles were affected most frequently (Fig. Supraspinatus and infraspinatus muscles were most commonly affected muscle groups. slice thickness. and only one muscle in three patients (12%).

No structural abnormalities were identified that could explain the denervation change.5:1 [3. Although the precise cause of ParsonageTurner syndrome has not been clearly established. We used two imaging protocols in our series because the indications for imaging the brachial plexus or shoulder varied. Males are predominantly affected. (%) of Patients Edema Only 9 (35) 8 (31) 5 (19) 4 (15) 3 (12) 1 (4) 0 (0) 1 (4) Atrophy Only 0 (0) 0 (0) 1 (4) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) Edema and Atrophy 14 (54) 15 (58) 5 (19) 4 (15) 2 (8) 2 (8) 1 (4) 0 (0) Unaffected 3 (12) 3 (12) 15 (58) 18 (69) 21 (81) 23 (88) 25 (96) 25 (96) The MRI findings of two patients with typical imaging features of Parsonage-Turner syndrome are illustrated in Figures 4 and 5. and images were evaluated only for the presence or absence of edema. 9]. but reported ages range from 3 months to 82 years [2. we do not think that it is a significant limitation of the study. Although this difference in protocols resulted in minor differences in sensitivity for the detection of altered intramuscular signal intensity. The overall EMG findings were those of a severe but incomplete left suprascapular neuropathy with evidence of early reinnervation. or labral tear. this did not limit image analysis because fatty infiltration could be assessed accurately by comparing the T2-weighted proton density images without fat saturation with the corresponding T2-weighted fast spinecho images with fat saturation. none of the images showed evidence of a labral tear. 3. viral and autoimmune processes have been proposed [8. and paresthesias [1. Previous reports have shown that the most common EMG abnormalities of Parsonage-Turner syndrome occur in the distribution of the suprascapular nerve. but the disease name was not established until Parsonage and Turner [1] described a series of 136 clinical cases in 1948.64 cases per 100. Examination results were otherwise unremarkable. Our findings correlate with those of other studies that show no evidence of a tendency for the right. MRI of the brachial plexus showed diffuse increased T2-weighted intramuscular signal (Figs. July 2007 W41 . 5A and 5B). Bilateral involvement has been reported for as many as one third of patients [3]. 7]. a branch of the superior trunk of the brachial plexus [10]. 4A and 4B) and atrophy of the supraspinatus and infraspinatus muscles (Fig. paralysis. MRI also provides an advantage for excluding structural abnormalities that may cause similar denervation changes in rotator cuff musculature such as a rotator cuff tear or spinoglenoid and suprascapular notch masses. were most commonly involved. In our series.and T2weighted signal abnormalities. Beghi et al. 4C). The mechanism and time course of MRI signal intensity changes in denervated skeletal muscle are not understood completely [11. Both sequences sensitively detected intramuscular edema. EMG findings were most consistent with severe axillary and suprascapular neuropathies. The FOV was larger for the brachial plexus protocol and includes more muscle groups than the smaller FOV used for the shoulder protocol. The images in Figure 5 were obtained of a 52-year-old man who presented with acute onset of severe left shoulder pain.” “paralytic brachial neuritis. which showed that the supraspinatus and infraspinatus muscles. This correlates with our results. In a clinical study. both of which are innervated by the suprascapular nerve. Discussion Acute brachial neuritis was first reported by Spillane in 1943 [2]. and imaging studies are used to make an accurate diagnosis. In the acute phase of denervation. MRI findings included a broad range of T1. 12]. We therefore had several limitations when comparing patients imaged with the brachial plexus protocol versus those imaged with the shoulder protocol. In addition to excluding more common causes of shoulder pain such as rotator cuff tear. or rotator cuff tear. 4. with male-to-female ratios ranging from 2:1 to 11. 4. MRI of the left shoulder showed diffuse increased T2 signal in the supraspinatus.MRI of Patients with Parsonage-Turner Syndrome TABLE 1: MRI Findings of 26 Patients with Parsonage-Turner Syndrome Affected Muscles Supraspinatus Infraspinatus Deltoid Teres minor Subscapularis Latissimus dorsi Pectoralis Rhomboids No. Treatment is palliative and includes analgesics for pain and physical therapy for weakness. impingement syndrome. His medical history included a presumed viral infection shortly before the onset of shoulder symptoms. [10] examined a series of 99 patients and reported an incidence rate of 1. Intramuscular changes observed in patients with ParsonageTurner syndrome reflect denervation changes and vary with the stage of disease [11. the signal intensity of the muscles may be normal with MRI [11]. Phrenic nerve involvement with diaphragmatic dysfunction has been described [3]. 10]. Most patients with Parsonage-Turner syndrome present with severe onset of nontraumatic shoulder pain with or without associated weakness.or leftside upper extremity or correlation with hand dominance. Other terms used to describe this disease entity include “brachial plexus neuropathy. 6. muscular edema was evaluated using inversion recovery sequences in the brachial plexus protocol and using a T2-weighted fast spin-echo sequence with fat saturation in the shoulder protocol. and deltoid muscles (Figs. although low recurrence rates have been reported [3]. EMG and nerve conduction velocities may show changes of acute denervation in the brachial plexus distribution [10]. but other elements of the upper trunk of the brachial plexus were spared. Medical history and physical examination findings. However. However. 13–15]. paralabral cyst. 2]. 6]. infraspinatus. 6. Most patients present during the third to seventh decade.000 people. the general term “Parsonage-Turner syndrome” is most commonly used. MRI is an important imaging tool for establishing the diagnosis of Parsonage-Turner syndrome. The earliest detectable change AJR:189. The assessment of fatty infiltration of the muscles also varied between the two protocols because T1-weighted images were used in the brachial plexus examination and T2weighted proton density images without fat saturation were used in the shoulder protocol. specifically. EMG tests. Parsonage-Turner syndrome typically has a self-limited course. all were associated with mild fatty atrophy. In addition.” and “acute brachial radiculitis” [3. The images in Figure 4 were obtained of an 18year-old man who presented with shoulder pain and progressive left upper extremity weakness. MRI is sensitive for the detection of signal abnormalities in the shoulder girdle musculature that are related to denervation.

Axial T1-weighted fast spin-echo image shows no detectable atrophy or fatty infiltration of infraspinatus muscle (arrowheads). which may occur without a T1-weighted signal change [11. their study is the largest published series to date. Axial T2-weighted fast spin-echo image with fat saturation of right shoulder shows increased T2 signal (arrowheads) throughout infraspinatus muscle that is compatible with edema. 2—38-year-old man with mild pain and paresthesia along lateral aspect of arm. Coincident with our study. to our knowledge. T1-weighted changes of atrophy without fatty infiltration during followup also were described. A. subscapularis (S). 3—39-year-old man with pain and paresthesias in right shoulder and upper extremity. In the subacute and chronic phases of denervation. infraspinatus. [7] reported increased T2weighted signal in the supraspinatus. 12. Axial T1-weighted fast spin-echo image shows mild atrophy and fatty infiltration of affected muscles: infraspinatus (I). MRI signal change for patients with Parsonage-Turner syndrome has been described in several studies using small patient series. Until recently. and deltoid muscles at initial presentation of three patients with Parsonage- Turner syndrome. Helms et al. linear. MRI intramuscular signal change and clinical symptoms may revert to normal in several months after the chronic phase [11]. subscapularis (S). W42 AJR:189. A B Fig. Atrophic changes in muscle are reflected by decreased muscular mass and increased intramuscular. to our knowledge. A B Fig. and deltoid (D) muscles. 15. B. 16].Scalf et al. T1-weighted signal due to fatty infil- tration. B. A. 15]. and portion of deltoid (D) muscles that is compatible with edema. July 2007 . Axial T2-weighted fast spin-echo image of right shoulder with fat saturation shows increased T2 signal throughout infraspinatus (I). Gaskin and Helms [5] reported the MRI findings of 27 patients with ParsonageTurner syndrome. T2-weighted signal abnormalities persist and muscular atrophy may develop [11. no large studies that reported MRI features of patients with Parsonage-Turner syndrome had been published. in denervated muscles is a diffuse increased T2-weighted signal (due to edema).

In addition. For patients with shoulder pain of an unknown cause. and the low number of follow-up imaging studies available for review. The study was also limited by variations in the anatomic extent of the shoulder girdle musculature included on the examination because the varied symptoms meant that patients were referred for shoulder or brachial plexus examination.MRI of Patients with Parsonage-Turner Syndrome A Fig. lack of information about the timing of MRI features relative to the disease course. An additional limitation was the absence of a definite reference standard for diagnosing ParsonageTurner syndrome that includes evaluation of clinical history. C. Oblique sagittal (A) and axial (B) T2-weighted images with fat saturation show increased T2 signal in supraspinatus (S) and infraspinatus (I) muscles. Familiarity with these MRI features is important for radiologists because they may be the first to suggest the diagnosis. July 2007 W43 . because our study also included patients who were imaged with the large FOV of the brachial plexus protocol. The limitations of the study include the lack of control subjects. The latter findings are likely related to the relative delay between the onset of symptoms and the MRI examination. This patient series presents the MRI features of patients with Parsonage-Turner syndrome. findings at presentation. 4—18-year-old man with shoulder pain and progressive left upper extremity weakness. which include a spectrum of signal abnormalities in various muscle groups of the rotator cuff and shoulder girdle. Others did not return for follow-up evaluation. One patient in our study who initially had edema in the supraspinatus and infraspinatus muscles showed complete resolution of the denervation changes at an 8-month follow-up MRI examination. we noted that other shoulder muscle groups may also have abnormal MRI signal changes. Axial T1-weighted image shows atrophy of infraspinatus muscle (arrowhead). including the latissimus dorsi and rhomboid muscles. B C The MRI findings and anatomic distribution of muscular involvement of patients in our study were similar to those of Gaskin and Helms [5]. were identified more frequently when compared with previous studies. signal intensity changes observed during MRI can be a valuable adjunct to clinical data and electrophysiologic testing for the diagnosis of Parsonage-Turner syndrome. Further studies will need to evaluate MRI features relative to the time course of the disease in patients with Parsonage-Turner syndrome. including evidence of fatty infiltration and decrease in muscle bulk. A and B. MRI findings indicative of muscle atrophy. AJR:189. and physical examination findings. Our study of 26 patients showed that the supraspinatus and infraspinatus muscles were most commonly involved. However. Follow-up MRI examinations were performed infrequently because most patients showed clinical improvement with resolution of symptoms and did not require further imaging.

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