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14 UNIVERSITAS PELITA HARAPAN

Case Report

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

Julius July1, Eka Julianta Wahjoepramono21Siloam Hospital Lippo Village, Tangerang, Indonesia

2Department of Neurosurgery, Faculty of Medicine Pelita Harapan University

ABSTRACTBrachial neuritis is a rare syndrome affecting mainly the lower motor neurons of the brachialplexus and/or individual nerves or nerve branches. We present a case of 66 years old malewith acute onset of right shoulder pain for several days, and then followed by flaccidparalysis of his right shoulder and parascapular muscles. Its a quite typical scenario ofbrachial 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 literaturereview.

Key words: brachial neuritis - shoulder pain - flaccid paralysis

ABSTRAKNeuritis brachial merupakan suatu sindroma yang sangat jarangyang terutama mengenailower motor neuron plexus brachialis dan/atau saraf-saraf tunggal atau cabang-cabangsaraf. Kami melaporkansebuah laporan kasus dari seorang laki-laki berusia 66 tahun yangmenderita nyeri akut di bahu kanan selama beberapa hari, yang kemudian diikuti dengandengan lumpuh layuh pada bahu kanan dan otot parascapulanya. Hal ini merupakangambaran kasus neuritis brachial yang sangat khas. Prognosis penyakit ini sangat baik, tidakseperti 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 affectingmainly the lower motor neurons of thebrachial plexus and/or individual nerves ornerve branches. There is no clear explanationabout its etiology. It is usually characterizedby 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 isfollowed by flaccid paralysis of shoulder andparascapular muscles. Brachial neuritis canvary greatly in presentation and nerveinvolvement.1, 2Brachial neuritis is not a fatalcondition, although the phrenic nerve may beinvolved.

CASE REPORT

We present a case of 66 years old male withflaccid paralysis of his right shoulder. Thedeltoid and parascapular muscle are atrophic(pic.1-5) About 8 weeks prior, he sufferedright shoulder pain, acute onset, and its pain is

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ACUTE SHOULDER PAIN

16 UNIVERSITAS PELITA HARAPAN

considerable atrophy and wasting, as wellas a deep dull pain in the affected muscles.Numbness may occur, depending on theparticular nerves affected, and usually isfound in the nerve distributioncorresponding to maximal muscleweakness. However, numbness is rarely a

prominent complaint. Phrenic nerveinvolvement occurs in up to 5% of casesand can result in significant shortness ofbreath.9,10,11 Even cranial nerveinvolvement ever been reported (IX, X,XI, XII).

12

On physical examination we could findatrophy of the affected muscles after 2weeks of weakness. Considerable musclepain may be noted on palpation. Passiveand active attempts at shoulder andscapular movement result in a significant

increase in pain. Movements of the neckare relatively pain free. Muscle strength inaffected muscles often is very weak.Reflexes may be reduced or absent.Sensory loss may be detectable.

DIFFERENTIAL DIAGNOSIS

Acute poliomyelitis, neoplastic brachialplexopathy, polymyalgia rheumatica,amyotrophic lateral sclerosis, rotator cuffdisease, cervical disc disease, thoracicoutlet syndrome, mononeuritis multiplex,

anterior interosseous syndrome, pack,spinal cord tumor, and traumaticmononeuropathies

INVESTIGATION

Laboratory examination only indicated ifsystemic disease is suspected on clinicalgrounds. Magnetic resonance imaging(MRI) should be considered initially torule out cervical radiculopathy(particularly C5/C6). MRI of the brachialplexus can help to rule out structureabnormality if clinically indicated.4 Ashoulder radiograph may be indicated torule out specific shoulder pathologies. Achest radiograph is not usually part of theinitial workup; however, it can be useful to

rule out sarcoidosis or othergranulomatous disease, as well asPancoast tumor.Needle electromyogram (EMG) showsdenervation (fibrillations, positive sharpwaves, and/or motor unit potentialchanges) in affected muscles, usually 2-3

weeks after onset. Lumbar punctureusually is not indicated.

TREATMENT

Physical therapy for patients with brachialneuritis should be focused on themaintenance of full range of motion(ROM) in the shoulder and other affectedjoints.

13Passive ROM (PROM) and active

ROM (AROM) exercises should begin assoon as the patient's pain has beenadequately controlled. Strengthening of

the rotator cuff muscles and scapularstabilization may be indicated. Passivemodalities (eg, heat, cold, transcutaneouselectrical nerve stimulation [TENS]) maybe useful as adjunct pain relievers.

Functional conditioning of the upperextremity may be helpful in patients withbrachial neuritis. Assistive devices andorthotics may be used, depending on theparticular disabilities present. Theoccupational therapist may be involved inmaintaining ROM and strengthening,

particularly if the hand and wrist areinvolved.

Treatment is largely symptomatic inpatients with brachial neuritis, and opiateanalgesia often is necessary in the initialperiod. Other analgesic could be givensuch as acetaminophen alone or incombination with codein.Immunosuppressive therapy (eg, steroids,immunoglobulin, and plasma exchange)has not been shown to be beneficial.

In brachial neuritis, nerve grafting ortendon transfers may be considered for thefew patients who do not achieve goodrecovery by 2 years. Surgery usually isaimed at improving shoulder abduction.

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MEDICINUS Vol. 3 No. 1 Februari 2009 Mei 2009

UNIVERSITAS PELITA HARAPAN 15

sharp and excruciating. The pain starts fromright upper neck andgoing down to the rightelbow, but mainly on the shoulder.He went to physician and got pain killerand was told that he got muscle pain. Thepain stays for about 5 days and totallygone after a week. The he start to feel that

day by day the right shoulder is gettingweaker, until one day he barely able toraise his arm. His electromyogram (EMG)study shows denervation in affected

muscles. Cervical Magnetic ResonanceImaging (MRI) only shows mild discbulge especially to the right side. MRI ofhis Brachial plexus also didnt show anyobvious structural abnormality. After 4weeks, he starts to gain minor power onhis right shoulder, and he definitely sure

that his right shoulder power is improving.He was sent to physiotherapy and givensome neurotropic vitamins.

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

LITERATURE REVIEW

Brachial neuritis present in two forms, aninherited and an idiopathic form. Theidiopathic form is generally accepted as animmune reaction that the inflammatoryreaction happen against nerve fibers of thebrachial plexus.3,4,5 Axonopathy takesplace and followed by Walleriandegeneration, although conduction blockhas also been described in over 33% ofcases in the series by Lo and Mills.

6The

inherited form is autosomal dominant, ithas been linked to mutations onchromosome 17q.7

THE CLINICAL COURSE

The onset of pain is often abrupt and mayassociate with prior illness, surgery, 8immunizations, or even trauma. Up to twothirds of cases the pain starts at night.Most of the pain starts at right shoulder,localized, but it may be bilateral in 10-30% of cases. Patient usually describe thepain as sharp or throbbing in nature, theintensity is very high (9+/10) and maximal

at onset. The pain is constant, even worstat midnight and causing patient could notsleep at all. The pain also exacerbated bymovements of the shoulder. Movements ofthe neck, coughing, and/or sneezingusually do not make the pain worse. TheIntense pain can last from only a fewhours to several weeks and many patientsrequire opiate analgesia. Some low-gradepain may persist longer; about 20 % couldpersist up to a year. As the pain subsides,the weakness becomes apparent, althoughmost cases the weakness is maximal atonset but some can progress to severalweeks. The weakness is usually apparentwithin the first 2 weeks of onset.

A wide variety of muscles could be

affected, particularly those innervated bythe upper trunk. The supraspinatus,infraspinatus, serratus anterior, and deltoidmuscles are particularly susceptible, butmany different single and multiplecombinations of muscles involvement,including a pure distal form, have beenreported. The patient may notice

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