G-25G Clinical Case Slide Presentation Neck and Brachial Plexus
A 17-year-old right-handed male high school football player experienced the immediate onset of right upper extremity (RUE) pain, weakness, and numbness after a tackle. He had tackled the opposing player with his right (R) shoulder resulting in depression of the shoulder and concomitant extension and left side bending of his neck. He stood unassisted after the tackle and walked off the field in visible discomfort cradling his R arm, and was evaluated by the athletic trainer and sideline physician. The player admitted to having had 8–10 stingers in the past, mostly right-sided.
Sideline exam revealed full cervical spine (C-spine) range of motion (ROM) with pain in the upper trapezius at end-range of R side bending, rotation, and with a Spruling's maneuver. There was no tenderness to C-spine bony and paraspinal palpation. Manual muscle testing demonstrated 2/5 R deltoid and biceps, 3/5 wrist extensors, and 4/5 triceps, finger flexors, and finger abductors. The left upper extremity strength was 5/5. Reflexes were not tested at that time. Sensation, gait pattern, balance, cognition, and memory were intact. At ten and twenty-five minutes post-injury examination demonstrated marginal strength improvement in proximal muscles with better strength return distally. He denied pain in the RUE and neck. The remainder of his physical examination was unchanged.
- R brachial plexus injury.
- R cervical polyradiculopathy
- Recurrent RUE stinger/burner
- Parsonage-Turner syndrome
TESTS AND RESULTS
C-spine AP, lateral, flexion/extension views, 3 days post-injury:—Flattening of the cervical lordosis—Otherwise normal. MRI C-spine, 6 days post-injury:—Normal. EMG/NCS, 14 days post-injury:—Increased insertional/spontaneous activity in the R biceps and deltoid—Mild decrease in recruitment in the R extensor carpi radialis—Consistent with R upper trunk, brachial plexopathy.
Right brachial plexus injury in a player with a history of several prior stingers/burners.
TREATMENT AND OUTCOME
- No contact sport and RUE rest for two weeks.
- Rehabilitation- early passive and active-assisted ROM, neck/upper extremity strengthening program, electrical stimulation. Review of tackling technique. Serial follow-up examinations continue to show a progressive, gradual increase of strength in the C5/C6 myotomes.
- Medications- Completed prednisone taper, no other medications prescribed due to absence of pain complaints.
- Bracing- instructed to wear a cowboy collar type device.
- Returned-to-sport after two weeks of rest since strength was returning and C-spine was clear.
- Follow-up electrodiagnostic testing at 4 weeks post-injury.