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parsonage_turner_syndrome

Parsonage Turner syndrome

It is named after Maurice Parsonage and John Turner and published in the Lancet in 1948 by Parsonage and Turner 1). The condition, subsequently coined Parsonage-Turner Syndrome, had been previously described in the literature as far back as 1897 with many similar clinical presentations of the syndrome reported prior to the extensive study of the syndrome by Parsonage and Turner.

Parsonage Turner syndrome is also known as acute brachial neuropathy and acute brachial radiculitis.

Other names used are Parsonage–Aldren–Turner syndrome, neuralgic amyotrophy, brachial neuritis, brachial plexus neuropathy, or brachial plexitis.

Epidemiology

Parsonage-Turner Syndrome (PTS) is a rare syndrome with an incidence of 1.64 cases in 100,000 people.

Etiology

The syndrome is idiopathic; although many specific risk factors have been identified (such as; post-operatively, post-infectious, post-traumatic or post-vaccination) the aetiology is still unknown. The condition manifests as a rare set of symptoms most likely resulting from autoimmune inflammation of unknown etiology of the brachial plexus (The brachial plexus is a complex network of nerves through which impulses reach the arms, shoulders and chest.)

This syndrome can begin with severe shoulder or arm pain followed by weakness and numbness.

Those who suffer from Parsonage–Turner experience acute, sudden-onset pain radiating from the shoulder to the upper arm. Affected muscles become weak and atrophied, and in advanced cases, paralyzed. Occasionally, there will be no pain and just paralysis, and sometimes just pain, not ending in paralysis.

Clinical Features

May occur in otherwise normal healthy individuals with sudden, rather abrupt, unilateral shoulder pain that may begin rather insidiously but quickly amplifies in severity and intensity. The acute period of pain is subsequently replaced over a course of a few days to weeks with progressive weakness, reflex changes, and sensory abnormalities in varying presentations that typically involve the shoulder girdle musculature and proximal upper limb muscles. The condition, also known as neuralgic amyotrophy or brachial neuritis, has been reported in numerous clinical situations that involve some sort of antecedent impact on the patient, whether it be surgical, infectious, traumatic, or even therapeutic, such as cases involving vaccinations or antibiotic treatments.

Diagnosis

MRI may assist in diagnosis.

The postsurgical patient who develops PTS poses a specific diagnostic dilemma. In these individuals, the patient has undergone a rather traumatic experience to the body considering perioperative administration of antibiotics, intraoperative anesthesia, operative manipulation of tissue, and various positioning techniques used to facilitate surgical techniques. It is no mystery that, when this cohort of patients develops PTS, it is often attributed to intraoperative positioning or even part of the rehabilitative process manifested as shoulder strain with therapy.

Differential diagnosis

The differential diagnosis in patients presenting with severe, unilateral shoulder pain should also include several similar presenting conditions. Cervical disc herniations or foraminal stenosis causing a cervical radiculopathy or mass lesions compressing the brachial plexus or individual nerves are a few examples. In some of these cases, PTS becomes a diagnosis of exclusion. This is especially true in cases where a magnetic resonance imaging (MRI) of the cervical spine reveals foraminal stenosis or a small cervical intervertebral disk protrusion that does not appear to be clinically significant but still corresponds to the level of involvement.

In these cases, it can be difficult to clearly determine whether the pathology identified on imaging studies is a major contributing factor and whether further treatment options such as epidural injections and/or surgical decompression should be considered. While cervical radiculopathy is probably the most commonly considered clinical diagnosis, conditions such as postherpetic neuralgia, calcific tendonitis, acute subacromial bursitis, and adhesive capsulitis can all present initially and acutely with similar symptoms. Other causes of brachial plexopathies such as thoracic outlet syndrome may present with less acute and severe pain and should also be entertained.

The classic skin lesion associated with shingles will usually be identified in cases of postherpetic neuralgia, making this diagnosis fairly obvious; however, cases of shingles can present without rash, making the diagnosis in these cases more elusive. Patients with cervical radiculopathies will commonly have a positive Spurling test. However, this maneuver is typically negative in patients with PTS. Symptoms that are secondary to calcific tendonitis or an acute subacromial bursitis will be aggravated with shoulder motion, particularly impingement-like maneuvers, and these patients can usually find positions of greater comfort. Cortisone injections (or even a diagnostic lidocaine injection) may help establish a definitive diagnosis and also provide immediate relief.

Prognosis

Despite its wasting and at times long-lasting effects, most cases resolve themselves and recovery is usually good in 18–24 months, depending on how old the person in question is. For instance, a six-year-old could have brachial neuritis for only around 6 months, but a person in their early fifties could have it for over 3 years.

Mixed martial artist Todd Duffee was diagnosed with the condition in early 2013. He returned to professional fighting in December 2014.

1)
PARSONAGE MJ, TURNER JW. Neuralgic amyotrophy; the shoulder-girdle syndrome. Lancet. 1948 Jun 26;1(6513):973-8. PubMed PMID: 18866299
parsonage_turner_syndrome.txt · Last modified: 2016/11/02 08:48 (external edit)