Sudden, Severe Upper Limb Pain and Weakness in a Sleepless Man

Olusegun John Oluwole, MBBS

Disclosures

December 14, 2020

The diagnosis can be easily made on clinical grounds by physicians who are familiar with brachial neuritis. Paradoxically, however, the diagnosis is often delayed by several weeks or even months among physicians who are unaware of this clinical entity.[3] The constellation of sudden-onset intense shoulder pain that lasts weeks and evolves to rapidly progressive shoulder weakness and muscle wasting should always arouse suspicion of brachial neuritis.[8]EMG usually shows evidence of denervation of muscles supplied by the upper part of the brachial plexus, whereas MRI shows T2 hyperintensity within the upper part of the brachial plexus with variable gadolinium enhancement. T2-weighted MRI of the shoulder muscles during the acute phase might show features of neurogenic edema in addition to helping to exclude rotator cuff syndrome.[10]

The clinical management of brachial neuritis is usually divided into two phases. The first phase focuses mainly on pain management and immobilization, and the second phase centers on physiotherapy and rehabilitation.[3,7] During the painful initial phase, treatment with a combination of pain medications is recommended. Oral prednisolone may also be given at this stage, although there is insufficient evidence to support this intervention. Proponents of prednisolone believe it shortens the painful phase and mitigates the overall severity of and disability from the disease.[3] The use of other forms of immunotherapy, such as intravenous immunoglobulin and methylprednisolone, during the early phase of illness has also been reported with varying degrees of success.[7] Once the pain subsides, physical therapy becomes the mainstay of treatment.

About 75% of patients recover completely within 2 years, and about 90% recover fully within 3 years.[8] Patients generally require a great deal of reassurance during the long recovery phase because they are often discouraged by the degree of weakness and the slow pace of recovery. Despite adequate clinical counseling and reassurance, it is not uncommon for patients to visit other physicians in search of alternative diagnoses and treatments. Unfortunately, this leads to endless and fruitless investigations as well as unnecessary interventions.

The patient in this case received oral prednisolone, 60 mg daily, for 2 weeks in addition to a buprenorphine patch, oral duloxetine, and oral gabapentin. After significant pain control was achieved, physical therapy was started and his condition slowly improved over the next several months.

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