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Brachial neuritis

Brachial Neuritis

Brachial Neuritis

The Cause and The Cure

Audience: Medical students in pre-medical school

I. Introduction

A. Brachial Neuritis, definition

B. Brachial Plexus, definition

II. Causes

A. Immunizations

B. Surgery

III. Treatments

A. Medications

B. Physical therapy

C. Acupuncture

D. Surgery

IV. Conclusion

Fortunato 1

Brachial Neuritis

Though the cause is unclear, many researchers and physicians agree that

surgical procedures and immunizations are possible causes of brachial neuritis.

Those who are diagnosed with brachial neuritis, depending on the severity of the

disorder will have available different medications and alternative treatments used

to help combat this disorder.

What is brachial neuritis? Brachial neuritis is a condition involving

decreased movement or sensation in the arm and shoulder caused by impaired

function of the brachial plexus, a nerve area that affects the arm followed by

several days of severe pain and discomfort (Health Central 1). The common

diagnosis of patients with acute brachial plexus neuritis is severe,

acute, burning pain in the shoulder and upper arm with no apparent cause. On

occasion, it may awaken the patient from sleep. In the majority of patients, the

pain subsides over the next few days to weeks, resulting in a weakness

in the upper arm--at times to the point of muscle flaccidity. The profile

of initial arm and shoulder pain followed by muscle weakness as the pain subsides

is an important characteristic of acute brachial plexus neuritis (Miller, Pruitt, and

McDonald 3).

The brachial plexus is part of the nervous system that is a channel for the relay of

sensory and motor impulses between the central nervous system on the one hand

and the body surface, skeletal muscles, and internal organs on the other hand, and

is composed of spinal nerves, cranial nerves, and certain parts of the autonomic

nervous system. The brachial plexus nerve pathways are made up of neurons (that

is, nerve cell bodies and their axons and dendrites) as well as the points at which

one neuron communicates with the next (that is, the synapse). The structures

commonly known as nerves (or by such names as roots, rami, trunks, and

branches) are actually composed of orderly arrangements of the axonal and

dendritic processes of many nerve cell bodies (Haines 1). Brachial neuritis occurs

when there is damage to the brachial plexus, the area where the nerve from the

spinal cord splits into the individual arm nerves.

Damage to the brachial plexus is generally related to a direct injury or

trauma to the nerve, stretch type injuries (such as a jerking of the arm), pressure

caused by injuries in the area of the brachial plexus. Causes may be related to

pressure congenital abnormalities tumors, or injury by toxins, chemicals, or drugs

(HealthCentral 2). Some doctors and nurses believe the actual cause of brachial

neuritis, is that while receiving an immunization, or during surgery the brachial

plexus nerve ending has been hit during these procedures (Reneer ).

In the report "Following Routine Childhood Immunization for Diphtheria,

Tetanus, and Pertussis (DTP): Report of Two Cases and Review of the Literature"

by Aline Hamati-Hadad and Gerald Fenichel. This report examined the picture

of this disease in two infants and emphasized the prognosis and its occurrence

after tetanus toxoid immunizations. Brachial neuritis was once known as serum

neuritis due to complications from passive immunization against tetanus, using

horse serum. Incidence reduced since the use of active immunization with tetanus

toxoid. "The Institute of Medicine, in its report on Adverse Events Associated

with Childhood Vaccines, indicated that the evidence favors casual association

between tetanus toxoid administration and the subsequent development of

brachial neuritis". The infants described in this report were healthy and were

of normal health and had received different diphtheria, tetanus, and pertussis

(DTP). This condition is benign with spontaneous resolution, there is the

possibility of recurrence with repeated vaccinations. Completion of the routine

immunization schedule is unlikely in most children (Hamati-Haddad and

Fernichel 3). Though many would disagree to this statement, most in the

healthcare business believe that immunizations are needed and the results far

outweigh the risks (Reneer). Brachial neuritis does not occur spontaneously

during infancy. All affected infants and most adults with brachial neuritis recover

rapidly and completely. Brachial neuritis is a self-limited disease that does not

require treatment. Early use of oral or corticosteroids and the use of physical

therapy has not been shown to alter the course (Hamati-Haddad and Fernichel 3).

While Miller, Pruitt and McDonalds’ study "Acute Brachial Plexus

Neuritis: An Uncommon Cause of shoulder Pain." examined a 66-year-old man

who presented with the complaint of severe, left-sided neck pain that radiated

into the left shoulder, without associated numbness or tingling. The pain had

begun one week earlier. Several weeks before he was examined, he had received

a flu shot. The patient’s symptoms resembled another disorder known as cervical

radiculopathy for which the treatment is significantly different. After several

weeks of from the onset of the symptoms the patient underwent an

electromyogram and nerve conduction studies. The results were consistent with

brachial neuritis. Brachial plexus neuritis has been recognized as a disorder since

the 1940s (Miller, Pruitt, and McDonald). Researchers have thought that viral

infection precipitates brachial neuritis but in 25 percent of these cases, various

infections proceeded the disease (Miller, Pruitt, and McDonald 3). "Up to 15

percent of the cases have been reported to occur following vaccinations" (Miller,

Pruitt, and McDonald 3). Evidence suggests, then that this disease is an

immunologic disease.

Dianna Quan’s report "Neuralgic Amyotropy: Presentation of a Case and a

Review of the Syndrome." Discusses a 36-year-old woman, a patient who had

been in good health prior to 1986 when, a few days after gall bladder surgery, she

noted left arm pain, weakness, and numbness (Quann 1-2). At that time, an MRI

of the cervical spine and electrodiagnostic studies were reportedly consistent with

brachial plexus neuropathy. In October of 1988 the patient was not able to

resume her job as a police officer due to the complications brought on by brachial

neuritis. Her condition remained the same until February 1993 when she hurt her

back after some heavy lifting. She then had surgery to repair a herniated disc.

Ten days after her surgery, she noticed mild tingling sensations in the tip of the

right thumb, which progressed over the next day to include numbness in the entire

thumb. Two days later, there was sharp pain in her right forearm. Abduction of

the shoulder exacerbated the pain. Twenty days after the onset of the latest

symptoms, she had partially improved, after taking the medication naproxen,

twice daily (Quann 2).

Treatment can vary depending on the case and the severity of the

complications. If the injury is minor, recovery may occur in a short time. During

the recovery of nerve function, treatment is aimed at pain control, maintaining

muscle power, and range of motion of the affected arm. Strengthening exercises,

range of motion exercises, and splinting may be helpful. Surgical repair is

considered for severe brachial plexus injuries. Treatment is based largely on the

symptoms, and opiate analgesia often is necessary in the initial period.

Immunosuppressive therapy (e.g., steroids, immunoglobulin, and plasma

exchange) has not been shown to be beneficial (Ashworth 7). The medications

used can very from Acetaminophen (Tylenol, Panadol, Aspirin free Anacin) to

corticosteroids. Over the counter or prescription analgesics may be needed for

pain. Various other medications might be used to reduce stabbing pains that

some patients have experienced, including phenytoin or antidepressants such as

amitriptyline (Healthcentral 3). Acetaminophen is prescribed when the patient is

only feeling minor pain and discomfort. For those patients that fit into this

category need to be advised that there are drug reactions if the patient is taking

some type of barbiturate, taking these medications together may increase the

toxicity of these medications. Patients who suffer from moderate to severe pain,

might be prescribed Hydrocodone or Vicadin. If taking these medications make

sure that it is not in use with such medications as phenothiazines, this will

decrease the pain relieving effects. Other medications for those suffering from

moderate to severe pain are the Oxycodone and Percocet family of drugs. As

with Vicadin and Hydrocodone, phenothiazines can also reduce the pain relieving

effects (Ashworth 8-9). In the case of the 66 year old man he was prescribed

Medrol, hydrocodone and Flexeril. He underwent physical therapy for three

weeks, and his condition slowly improved; however, he still experienced some

mild difficulty with shoulder abduction for several months. Whenever possible

the use of medications should be avoided or minimized to reduce the possibility

of side effects (Healthcentral 4).

For those patients where the pain is so unbearable that medications are not

helping, surgery may be the only recourse. Nerve grafting or tendon transfers may

be considered for the few patients who do not recover after 2 years of treatment.

Surgery generally aimed at improving shoulder abduction (Ashworth 7). Surgery

might be necessary if the disorder is chronic (long term), if symptoms worsen of

if there is difficulty with moving the arms, or if there is evidence that the nerve

has degenerated. Surgical decompression may relieve a trapped nerve, or surgery

may remove lesions that cause pressure on the nerve. Surgery has shown to help

some cases. Consultation with a physician before any surgical procedure is

performed. (Healthcentral 3).

Physical therapy should be focused on the obtaining a full range of

motion in the shoulder and arms. Passive range of motion and active range of

motion exercises should begin as soon as the pain has been controlled adequately, followed by conditioning of the affected areas. Strengthening of the rotator cuff

muscles and shoulder stabilization may be indicated. Passive modalities (e.g.,

heat, cold, and electrical nerve stimulation) may be useful as adjunct pain

relievers (Ashworth 8).

The use of physical therapy exercises to maintain muscle strength may be

appropriate for some patients. Whereas the use of braces, splints, or other

apparatus may maximize the ability to use the arm. Though counseling and

occupational changes, retraining or similar interventions might have to be

considered (Healthcentral 3). Another available form of treatment patients may

want to consider is acupuncture.

Acupuncture has been considered by many to be an alternative method of

healthcare, when other options have been exhausted. A 33-year-old, right-handed

Caucasian male awoke one morning in January, 1994, with a left-sided neck and

shoulder spasm causing severe pain, which was minimally relieved with a muscle

relaxant. The pain radiated from the armpit, near the arm and shoulder joint to the

end of the hand. December, 1992, excision of unstable skin and cross finger flap

reconstruction; left middle and ring fingers were cut off when he fell on a saw

blade. June, 1993, underwent surgery to relieve pressure on the nerves in the left

wrist and the left elbow. Acupuncture was the only method of relief for one

patient for pain in his left upper arm, after being appropriately treated with

medications and physical therapy for one year. Acupuncture treatment was chosen

for relief of all subjective and objective signs of left arm and shoulder girdle

brachial neuritis (Yang and Chang 1).

This patients schedule for this treatment was 27 sessions for three years using 30

gauge 1.5 inch needles for duration of 15 minutes. After the sessions were

completed this patient had immediate relief of the muscle spasm pain and there

was visible relaxation in the muscle themselves. The patients skin color return to

normal and had full range of motion in his left arm. The use of acupuncture as an

alternative therapy was successful in controlling the muscle spasms and pain of

brachial neuritis. The immediate response occurred just five minutes after

treatment sessions began. Acupuncture is an important treatment option for those

with this disorder (Yang and Chang 2-3). With this knowledge, acupuncture may

be subsequently used as alternative therapy for pain relief in similar patients.

While most physicians are used to thinking that every clinical problem has

a diagnosis and every diagnosis has a treatment, this is not the case for the

shoulder. Although most brachial neuritis conditions can be managed well, there

exists a few cases of brachial neuritis that are not amenable to definitive

treatment. In these situations the effectiveness of current treatment methods is

limited. The available resources can be directed to patient education, exercises,

and vocational rehabilitation. However a patient contracts brachial neuritis the

studies have shown that the outcome is generally good. The disease is not

progressive, and muscle strength in most patients begins to improve within the

first month after the onset of the symptoms. Depending on how serious the pain

and the amount of in the arms weakness, are good indicators of recovery in most

patients. The more severe the pain and weakness the longer the recovery time and

the greater chances of residual deficits (Quan 7). Although more is now known

about this condition, the underlying cause and effect continue to

elude physicians and researchers. For this reason, no specific treatment

recommendations can be offered to eliminate the cause. Current therapy is

primarily to treat the symptoms (Quan 7).

"The relationship of brachial neuritis to infections and inoculations

is unclear, but one possible conclusion based on these observations is that there is

an infectious etiology, possibly viral" (Quan 1-10). Though many physicians and

researchers are unclear as to what causes brachial neuritis. They all agree that it

is some type of damage or trauma done to the nerves in the brachial plexus

network. Though treatment is available for the symptoms of brachial neuritis.

Those patients who are diagnosed with brachial neuritis will have available

various forms of treatments such as medications and alternative treatments to

relieve the pain and discomfort brought on by the disorder.

Bibliography:

Works Cited

"Brachial Plexopathy." Health Central. 4. November 11, 2002

Haines, E. Duane. "Human Nervous System."

Britannica Online. 23 Nov. 2002.

Hamati-Haddad, Aline and Gerald M Fenichel. "Brachial Neuritis Following

Routine Childhood Immunization for Diphtheria, Tetanus, and Pertussis

(DTP): Report of Two Cases and Review of the Literature." Pediatrics,

99. 4 91997): 602. Academic Search Premiere. EBSCOhost.

5 Nov. 2002.

Miller, Jimmy D and Stephanie Pruitt, and Thomas McDonald. "Acute Brachial

Plexus Neuritis: An Uncommon Cause of Shoulder Pain". American

Academy of . Family Physician. Nov 2002. Nov 11, 2002

Quan Dianna. "Neuralgic Amyotrophy: Presentation of a Case and a Review of

the Syndrome". P&S Medical Review, Mar 1994: n.p.

Columbia-Presbyterian Medical Center. 11 Nov. 2002.

.

Fortunato 11

Works Cited

Reneer, Linda. Personal Interview. 18 Nov. 2002

Yang, Lynn W and Henry Chang. "Medical Acupuncture".

Medical Acupuncture Journal. 1998. 4.

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