Parsonage-Turner Syndrome Revisited

Posted by Daniel Rubio, Drexel University College of Medicine Class of 2014

Parsonage-Turner Syndrome (PTS) is an inflammatory disorder that affects the brachial plexus an important network of nerves which lies deep in the armpit (axilla) giving off nerve brachnes including the axillary, radial, musculocutaneous, ulnar and median nerves which supply power to the shoulder and entire upper extremity.

What does PTS look like?

Unlike other brachial plexopathies, PTS begins spontaneously, without any prior injury to the arm, neck, or axilla.  The classical presentation is severe pain followed by patchy weakness in the shoulder, biceps, and the muscles controlling the thumb and first two fingers (index and middle).  It may also present with a finding known as winged scapula: the shoulder blade sticks out more from the back especially when pushing yourself off a wall.  Weakness may be so severe that the muscles may actually shrink (atrophy).  Pain may be found in the shoulder and along the outside of the upper arm and the thumb-side (lateral) of the forearm and hand.  Pain symptoms usually occur before the weakness and may last up to 4 weeks.  Patients may experience alteration in sensations in the upper extremity, specifically increased sensitivity to touch and temperature and/or tingling.  Symptoms may affect one or both sides, but they usually are asymmetric if they both sides.

 

What causes PTS?

Approximately 50% of patients describe some type of stressful event or illness prior to the onset of symptoms: infection, exercise, surgery, pregnancy, or vaccination.

Diagnosing PTS

Your neurologist can make the diagnosis based on signs and symptoms (especially if you do the above dance); however, sometimes further testing is required to ensure accurate diagnosis.  Suspicion of PTS should occur based upon pattern of initial sudden and severe pain followed by weakness in the upper extremity and slow recovery.  The neurologist may use nerve conduction studies and needle electromyography to document denervation to support clinical suspicion.  Blood tests and imaging rarely help make the diagnosis of PTS.

Help doctor! Fix me?

There is currently no specific treatment for PTS and management usually involves symptom relief.  Pain relief with short course of narcotics may be necessary.  A short course of steroids may be given, which may or may not help relieve symptoms or hasten recovery.  Physical therapy may be prescribed to maintain range of motion and decrease risk of atrophy.  Despite the above measures, there is no treatment to quicken recovery.

When will I be cured?

Recovery of symptoms begins 1-3 months following onset of symptoms; however, maximal recovery may take up to 1-3 years and some patients may be left with residual symptoms.

Acute Back Pain, What Not To Do!

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70-80% adults have experienced acute back pain, almost 30% seek medical attention, and this problem is one of the commonest reasons for a doctors’ office visit.

Most cases are caused by sprains or tears in one of the numerous muscles or ligaments in the back triggered by twisting or lifting something heavy.

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These “soft tissue” injuries will usually improve on their own within a few weeks with anti-inflammatory medications and physical therapy.

However a recent study showed that more and more such patients are getting unnecessary imaging studies right away leading to surgeries and other invasive procedures that they don’t need.

Possible reasons cited for the necessary procedures include patient expectations and financial incentives for doctors.

flag_status_redDoctors shouldn’t immediately order an MRI or CT scan to determine the cause of back pain if a patient doesn’t have any red flags such as tingling in the legs — a sign of a nerve problem such as spinal stenosis — or a previous history of cancer.

Otherwise, imaging studies ordered for nonspecific back pain may reveal incidental disk problems, the result of aging, and not the cause of the symptoms.

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This will then often lead to unnecessary and unproven interventional pain management procedures.

Most back pain patients simply need to be told that their pain will improve with antiinflammatory medications, physical therapy, massage therapy, and/or supervised exercise programs.

However, in the words of Dr. John Mafi, one of the study’s authors, “it takes longer to sit and reassure patients that their pain will likely resolve on its own than it does to order an MRI.”

Prescription Pain Meds, Sometimes A Necessary Evil

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NPR recently aired an interview between NY Times reporter Barry Meier and Fresh Air’s Terry Gross regarding prescription pain medicine abuse and his new ebook – “A World of Hurt: Fixing Pain Medicine’s Biggest Mistake”.

Mr Meier suggested that physicians should be treating the actual cause of pain rather than just prescribing pain medications, that patients can reduce chronic pain by exercise, and questioned the role of drugs like Oxycontin for treating chronic pain.

In fact this is just one of many recent backlashes against doctors for prescribing narcotic medications. Doctors who prescribe narcotic pain medications now face multiple telephone calls from individual and insurance company pharmacists urging them to taper narcotic medications or try something else.

It is true that there has been a marked increase in the use of prescription narcotic medications for chronic non-cancer pain over the last 2 yrs, and this has led to many cases of prescription medication abuse, including unintentional overdose deaths:

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Source: Stanos, Phys Sportsmed. 2012 Nov;40(4):12-20.

There have certainly been many instances of rogue physicians writing narcotic prescriptions for cash during walk-in visits in so-called pain pill mills.

Critics of prescription narcotics have cited a concern about the lack of rigorous scientific outcome data showing any long term benefit from the use of narcotics for non-cancer related chronic pain.

Obviously, physicians should be encouraged to investigate the cause of chronic pain and look into treatments other than chronic pain medications.   There are now many “pain management physicians” who will only treat back pain patients with interventional procedures and won’t prescribe narcotics.  However, there iis little to no data demonstrating any long term outcome benefit from epidural injections for back pain.  Furthermore, each of these procedures cost health care carriers up to a thousand of dollars.  There can be no doubt that there are unethical physicians seeking insurance reimbursed for unnecessary procedures, just as their are unethical physicians writing narcotic prescriptions for cash.

There are studies that show chronic pain is under-treated in the community leading to poor quality of life, disability, and healthcare over-utilization.

It is clear that there are many patients currently being treated by ethical physicians for chronic pain with long-acting narcotic medications, and we need to be more careful that increased regulation does not deprive these legitimate pain patients of a necessary evil.  There are many anecdotal examples of physicians who won’t prescribe narcotics or take on new patients who are already taking these medications for fear of state medical board scrutinization or action.

Clearly, we need some kind of a compromise here:

Yes, physicians should investigate the cause of pain, and if possible treat that underlying problem rather than just prescribing pain medications.

Nevertheless, it is not good medicine to let patients suffer needlessly while this is being accomplished.

Physicians need to know it’s OK to prescribe pain meds as long as they take steps to be sure they are doing their best to only prescribe narcotics to legitimate patients without causing drug addiction and overdose:

Ten steps of universal precautions in pain medicine management, from Brennan J: Multidiscip Healthc. 2013 Jul 23;6:265-80.

The media and regulatory authorities needs to do a better job distinguishing appropriate from inappropriate prescription narcotic use.

One wonders if reporters who write about prescription drug abuse have ever been unfortunate enough to experience severe pain themselves and then encountered physicians too afraid to prescribe pain medications?

Osteoporosis from epidural steroid injections

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Epidural steroid injections are often offered to patients as a conservative treatment for back or leg pain from herniated discs.

We have already highlighted the lack of outcome studies to support this intervention in an earlier post on radiculopathy.

Data from a new study now indicates that epidural steroids may actually be harmful, and increase the risk of osteoporosis with spinal compression fractures.

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Intrathecal baclofen for spasticity in non-ambulatory patients

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We have already made several posts about intrathecal baclofen for reducing spasticity and improving function in ambulatory patients:

However, intrathecal baclofen can also be used in patients with spasticity who are non-ambulatory or bedbound:

Normalizing muscle tone may not improve function, but it alleviates pain, allows for better positioning and hygiene, and improves quality of life.

Click here to find out more about our spasticity center.

A less invasive surgical treatment for spinal stenosis?

…..The jury is still out!….

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First, the problem:

Lumbar spinal stenosis is an abnormal narrowing (stenosis) of the spinal canal that can lead to compression of the cauda equina, resulting in pain, numbness, and weakness in the legs.

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Affected patients complain of back pain, leg pain and weakness, worse with prolonged standing and walking, better with sitting or flexing the spin forward (such as pushing a supermarket trolley).

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Next, the solution(s):

This stenosis (or narrowing) is caused by degenerative bone spurs, disc disease and ligamental hypetrophy.  While many patients try conservative measures including physical therapy and epidural injections, spinal stenosis is a mechanical problem, and usually necessitates a mechanical (surgical) solution to alleviate symptoms.  Consider the analogy of a blocked sewer pipe – you can try pouring chemicals down the sink, but ultimately you know you are going to need to call a plumber  (Rota-Rooter)!

blocked pipe

Traditional surgical management calls for a lumbar laminectomy to decompress the spinal canal and alleviate symptoms.

In some cases,  laminectomy can leave the spine unstable necessitating a spinal fusion using bone garft, rods and screws (“hardware”) done at the same time, and this major surgery can lead to an extended recovery period of months to a year.

Implantation of a interspinous spacer has been proposed as a less-invasive alternative surgical option than spinal fusion:

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Which is better?

A recent study compared the outcomes of these techniques in 99,000 Medicare patients who underwent surgery for spinal stenosis from 2006 to 2009.

6,000 patients who underwent implantation of new interspinous spacers were compared with 76,000 who underwent laminectomy, and 17,000 patients who underwent laminectomy with spinal fusion.

The results showed that patients treated with spacers had the lowest rate of major medical complications: 1.2%, compared to 1.8%with laminectomy and 3.3% with spinal fusion. Patients receiving spacers also spent less time in the hospital: average 1.4 days versus 2.7 days in the decompression group.

However, patients receiving spacers had the highest rate of revision surgery – about 17% of patients receiving spacers needed a second operation on the lumbar spine, compared to only 8.5%  in the laminectomy group and about 10% in the fusion group.

Patients receiving spacers tended to be older and to have other medical problems. With adjustment for these and other factors, patients in the spacer group were more than twice as likely to require repeat surgery.

Hospital payments for spacer surgery were greater for decompression alone, but less than for fusion procedures

Other than the need for repeat surgery (presumably because initial surgery was ineffective), the study did not look at pain control or functional outcome between the groups.  More data is needed.

Nevertheless, so far it looks as if the higher cost and higher re-operation rate with spacers may argue in favor of conventional decompression surgery, except in higher risk older patients with medical problems.

Back pain? Could it be coming from inside your head?

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Most people agree that emotional stress or psychological factors can make any pain, including back pain pain worse.

However, the concept of “stress-related” or psychosomatic back pain, which is primarily caused by psychological and emotional factors, is usually harder to grasp.

It is important to make affected patients understand that even though psychological factors may be causing the physical symptoms, the symptoms are not imaginary

Instead, the unresolved emotional tension is pushed out of awareness into the unconscious mind, which then causes changes in the body’s nervous system, leading to muscle tension, spasm and the back pain experienced by the patient.  This chronic pain can lead to insomnia, fatigue, disability and then depression in a viscous feedback cycle:

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This syndrome can be hard to recognize for 2 reasons:

First, the pain may actually start with an identifiable incident that caused lower back sprain or strain, but then continue as the result of emotional factors long after any physical  injury should have  healed.

disc bulge

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Second, MR imaging studies are so sensitive, that when used inappropriately they may demonstrate incidental “findings” such as a “disc bulge” or “degenerative disc disease”, and the pain becomes attributed to this even when stress is the actual culprit.

The end result is that the affected patient gets sent for endless cycles of physical therapy, then epidural injections and even surgery.  Despite these measures, many patients continue in chronic pain.

If the back pain can be correctly identified as stress related in the first place, then the patient can be encouraged to “think psychological, not physical”,  and get some psychotherapy to address the unconscious issues.

Obviously, this approach is very different than the way most physicians manage patients with back pain.

Perhaps it’s time for a game change?

Click here to find out more.

2012-13 Neurology Student Research Presented at Drexel University College of Medicine

Monmouth neurology students presenting their posters during medical student research day at Drexel University College of Medicine in Philadelphia on March 20, 2013:

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1: Addressing blood glucose control in diabetic peripheral neuropathy:  A missed opportunity for neurologists?

Darsi Pitchon and Seun Ku Kim

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Key points:

Most neurology visits for diabetic neuropathy did not include counseling about blood glucose levels, unless they were with a neuromuscular fellowship trained sub specialist.   Because neuropathy can be the presenting and/or predominant problem in diabetes, some of these patients may be primarily followed by their neurologist, so this is a missed treatment opportunity.

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2.  Acute myelopathy with normal CSF and imaging:

Denis Chang

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Chang

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Key Points:

Spinal cord infarction from fibrocartilaginous embolism can present with acute quadriparesis in young patients with normal CSF and MRI scans.  If this diagnosis is suspected, a follow-up MRI 2-3 days can be quite helpful.  This is not an inflammatory process, and will not improve with steroids or other immunosupressive medications, which can hurt more than they help.

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3. The benefits of an on-line neurology clinical course for 4th year clerkship students

Ilya Grinberg

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Key points:

The on-line video course used by the Monmouth neurology clerkship led to improved test scores on an on-line clinical test compared to students who did their clerkship at other sites.  The on-line clinical test is a low cost but effective method of evaluating students’ clinical skills in neurology over multiple clerkship sites.

Making Sure Pedicle Screws are Correctly Placed During Spine Surgery

spinal hardware

 During a spinal fusion, two or more vertebra are fused together in orrder to eliminate abnormal motion caused by degenerative conditions.

A spinal fusion may require stabilization of the lumbar spine using artificial devices (known as “instrumentation”) including wires, rods, plates and vertebral cages.

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This instrumentation is usually fixed to the vertebral body with a pedicle screw, as can be seen in the adjacent lateral radiograph.

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The pedicle screw is inserted through the bony lumbar pedicle, into the anterior vertebral body.

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These screws are inserted blindly from the back, similar to nailing the back panel on a book case, and just like with the book case, it’s easy to get off track:

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Remember the last time you put a book case together – you nailed the back panel onto the frame (or where you thought the wood frame was), then flipped the whole thing over and found that many nails had missed.

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Obviously, a misplaced screw can end up inside the spinal canal, where it could injure the adjacent nerve roots, a potential cause of post operative deficit:

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Various degrees of misplaced pedicle screws, and then (right) a pathologic specimen showing a pedicle wall that has been perforated by a pedicle screw

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bad screw

As many as 70% of patients undergoing spinal fusion with instrumentation may have a misplaced screw, although most are just misplaced by a millimeter or two, and only 5-10% of those misplaced screws are cause for concern.

However, the incidence of an actual new neurologic deficits from a misplaced screw is much lower, estimated at less than 2 per 1000 screws in a recent study.

Nevertheless, this is still cause for concern, because it may be difficult to detect a misplaced screw during surgery.   Pedicle screw placement may be checked by:  Direct inspection and palpation, Fluoroscopy, Electrical testing, Computerized navigation or the Pediguard system.

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laminectomy

If the surgery involves a laminectomy, then the spinal canal will be open, and the surgeon will either see the misplaced screw, or feel it when they swipe a finger along the medial pedicle wall.

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However, in most cases, there is no laminectomy required, and doing so would prolong surgery time unnecessarily, so misplaced screws can go unrecognized.

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intraop fluoro

Intraoperative fluoroscopy (live X-rays taken during the operation) can detect most pedicle wall perforations and misplaced screws, but is only about 75% accurate because of limited available two dimensional viewing planes.  Furthermore, excessive use can expose the patient to excessive radiation.

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Real time electrophysiologic testing has been used in the operating room to confirm correct placement of pedicle holes and screws during surgery.

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The premise here is that a pedicle screw or hole that is correctly placed within the wall of the bony pedicle (b, above), will be separated from the adjacent nerve root by a layer of cortical bone which has a high impedance (resistance) to the passage of electrical current.

However, a pedicle hole or screw that has perforated the medial bony wall of the pedicle (a, above), will lie directly adjacent to the nerve root without that intervening layer of cortical bone.

Hence electrical stimulation of that perforated hole or screw (a) is more likely to activate the adjacent nerve root and evoke a recordable muscle twitch in the innervated muscle (a) at a lower stimulus intensity (threshold)  than in case of the correctly placed hole or screw (b).

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This electrical threshold testing has become very popular, but requires the presence of specialized equipment and personal in the operating room.

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New “O-arm” technology allows computed tomographic images to be fused with a computerized navigation system, allowing 3 dimensional visualization of pedicle screw tracks as they are inserted in the operating room:

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However, this technology is expensive, and may not be widely available.

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And finally, the Pediguard, a simple, cheaper and widely available technique that uses a disposable hand held drill that emits a signal based on the thickness of surrounding bone, and can be used by any surgeon in any operating room to ensure correct placement of pedicle screws in real time without the need for extra specialized equipment or personnel.

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