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Brachial Plexopathy

Naden, Catherine M. MD

Current Sports Medicine Reports: May/June 2017 - Volume 16 - Issue 3 - p 121
doi: 10.1249/JSR.0000000000000351
CAQ Review

Address for correspondence: Catherine M. Naden, MD, Boston University, The Ryan Center for Sports Medicine, 915 Commonwealth Avenue, Boston, MA, 02215; E-mail: catherine.mygatt@gmail.com. Column Editor: John R. Hatzenbuehler, MD; E-mail: jhatz@intermed.com.

Brachial plexopathy is a nerve injury that can cause sensory and/or motor deficits in the ipsilateral upper extremity. The brachial plexus arises from C5-T1 and can be divided into roots from each spinal level, which merge into the upper, middle, and lower trunks, then anterior and posterior divisions, followed by lateral, medial, and posterior cords, and finally the individual nerve branches of the upper extremity.

Brachial plexopathies have a variety of etiologies. The athletics-associated “burner” or “stinger” is either a traction injury or compressive trauma. It is commonly seen in football after a forceful blow depressing the shoulder while the athlete’s neck is rotated and side-bent to the contralateral side. Brachial plexopathies in the general population also may result from compression due to thoracic outlet syndrome, intraoperative positioning, or primary or metastatic malignancy (commonly lung and breast cancers). Additionally, inflammatory processes such as postviral Parsonage-Turner syndrome and idiopathic brachial neuritis, or radiation therapy can trigger symptoms. The incidence of football associated traumatic brachial plexopathies has been reported as 2.04/10,000 athlete exposures in a study of NCAA football players between 2009 and 2014. This is lower than what has previously been reported or suspected, which is attributed to the theory that stingers are underreported (1). Parsonage-Turner syndrome occurs at a rate of 1 per 1000 (4). The other etiologies are rare and outside the scope of this topic.

Approximately 50% of football players will experience a stinger during their career. The common presentation is acute onset of a circumferential, rather than dermatomal, paresthesia that lasts seconds to minutes. Given the dynamics of the shoulder, this more commonly affects the upper and middle trunks, arising from C5–C7. Alternatively, an athlete who falls from a height catching himself on an abducted and externally rotated arm, such as a climbing accident, is likely to injure the lower trunk, arising from C8-T1. A lower trunk injury also may result in Horner syndrome due to the proximity of the sympathetic ganglion. Other traumatic causes of brachial plexopathy include birth-related trauma as well as trauma from blunt force or penetrating wounds.

Evaluation of any brachial plexopathy starts with a thorough history and physical examination, with attention paid to nature of onset, predominance of motor or sensory impairment, and distribution of symptoms. Bilateral symptoms or those involving upper and lower extremities make brachial plexopathy unlikely. Plain radiography is primarily useful to rule out cervical spine injury, mechanical causes of symptoms such as a cervical rib, or local malignancy. Magnetic resonance imaging is indicated only in cases of recurrent stingers or brachial plexopathies that pose a diagnostic quandary. Magnetic resonance imaging of the cervical spine can identify stenosis, disc herniation and masses, whereas a focal brachial plexus magnetic resonance imaging may reveal focal thickening in inflammatory or postradiation etiologies, direct nerve injury or compression in traumatic cases, and muscle atrophy reflecting denervation, which can further localize the lesion (3). For symptoms lasting longer than 3 weeks, nerve conduction studies and electromyography may help localize the lesion or further elucidate the etiology.

Management is initially nonsurgical in most cases, involving rest, protection, and therapy to address symptoms and maintain function of the affected muscle groups. Anti-inflammatories and corticosteroids are commonly used, although their efficacy has not been clearly documented (2). Early surgical intervention is indicated in cases of mass effect by traumatic hematomas or malignant etiologies. Otherwise, surgical intervention is reserved for cases resistant to conservative management, particularly when impairment is severe.

The author declares no conflict of interest and does not have any financial disclosures.

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References

1. Green J, Zuckerman SL, Dalton SL, et al. A 6-year surveillance study of “stingers” in NCAA American Football. Res. Sports Med. 2017; 25:26–36.
2. Neal S, Fields KB. Peripheral nerve entrapment and injury in the upper extremity. Am. Fam. Physician. 2010; 81:147–55.
3. Tharin BD, Kini JA, York GE, Ritter JL. Brachial plexopathy: a review of traumatic and nontraumatic causes. AJR Am. J. Roentgenol. 2014; 202:W67–75.
4. van Alfen N, van Eijk JJ, Ennik T, et al. Incidence of neuralgic amyotrophy (Parsonage Turner syndrome) in a primary care setting—a prospective cohort study. PLoS One. 2015; 10:e0128361.
Copyright © 2017 by the American College of Sports Medicine.