Idiopathic brachial neuritis (IBN) is a well-recognized clinical syndrome

characterized by brachial pain followed by a patchy amyotrophy of

muscles in the shoulder girdle and arm innervated by individual
branches of the brachial plexus. Postsurgical IBN has not been widely
recognized since Parsonage and Turner's original description in which
10% of patients had antecedent surgery. We present 6 patients who
1-13 days postoperatively developed signs and symptoms which met
the clinical and electrophysiologic criteria for IBN. Postsurgical neural-
gic amyotrophy is an under-recognized clinical entity which in most
cases is ascribed to brachial plexus stretch injuries occurring during
anesthesia. Early recognition of this condition may prevent unneces-
sary surgical exploration and allow for a more accurate prediction of
functional recovery. 0 1994 John Wiley & Sons, Inc.
Key words: brachial plexus neuralgic amyotrophy brachial neuritis
brachial plexus trauma
MUSCLE & NERVE 17520-324 1994

POSTSURGICAL IDIOPATHIC
BRACHIAL NEURITIS
RICHARD 1. MALAMUT, MD, WILSON MARQUES, MD, JOHN D. ENGLAND, MD,
and AUSTIN J. SUMNER, MD

Idiopathic brachial neuritis ( I B N ) is a well- MATERIALS AND METHODS

recognized clinical syndrome characterized by bra-
chial pain followed by a patchy amyotrophy of
muscles in the shoulder girdle and arm innervated
by individual branches of the brachial plexus. 12215,21
The annual incidence of IBN has been reported to
be 1.64 cases per 100,000 population.' Although
the axillary, suprascapular, and long thoracic
nerves are commonly affected, the disorder may
involve a variety of nerves in the upper extremity.5
This multifocal pattern of denervation is best dem-
onstrated by electrodiagnostic studies. The overall
prognosis is excellent with more than 80% of pa-
tients attaining full functional recovery within 2
years of onset and more than 90% by the end of 3
years.I4 We now present 6 patients (Table 1) ex-
amined in the past year who 1-13 days postoper-
atively developed signs and symptoms which met
the clinical and electrophysiologic criteria for idio-
pathic brachial neuritis.
From the Department of Neurology, Louisiana State University School of
Medicine, New Orleans, Louisiana (Drs Malarnut, Marques, and Sumner).
and the University of Colorado Health Science Center, Denver, Colorado
(Dr. England)
Presented in part at the AAEM meeting, Chicago, September, 1990
Address reprint requests to Dr. Malamut, Crozer-Chester Medical Center,
Chester, PA 19013
Accepted for publication October 1. 1993
CCC 0148-639x1941030320-05
0 1994 John Wiley & Sons, Inc.
All patients presented to either the LSU Medical
Center Out-Patient Department or the University
of Colorado Health Science Center during a 24-
month period of time. A detailed history and neu-
rologic examination was performed on all patients.
An electrophysiologic evaluation was performed at
the time of presentation using a Teca TD-20 or
Teca Mystro electromyography (TECA Corp.,
Pleasantville, NY).
Median and ulnar sensory potentials were re-
corded orthodromically at the wrist. Radial sensol y
potentials were recorded antidromically at the
wrist. Motor nerve conduction studies were per-
formed by conventional methods using percutane-
ous nerve trunk stimulation at the wrist and elbow.
Electromyography was performed with disposable
concentric needle electrodes (Type DMC 37 Med-
elec, TECA Corp.). Chronic partial denervation
was defined as the presence of high amplitude,
long duration polyphasic motor unit potentials fir-
ing at increased rates with an incomplete interfer-
ence pattern.
Where possible, patients were reevaluated both
clinically and electrophysiologically at a later date.
CASE HISTORY #l
J.H. is a 32-year-old woman who underwent a ton-
sillectomy and adenoidectomy under general anes-
thesia. She was well that evening but awoke the

320 Postsurgical IBN MUSCLE & NERVE March 1994

 ~

Table 1. Summary of case histories.

Onset/
Case Surgical duration Onset of Site of
no. Agelsex procedure of pain* weakness* Evolution nerve lesions
1 321F Tonsilectomy 1 day13 weeks 3 days Improved power at R. long thoracic
1 month
2 271M Appendectomy lrnrned 12 weeks 7 days Normal at 1 year R long thoracic
R suprascapular
3 431F Left first rib Imrned.13 weeks 1 day Improved power at L post inteross
resection 6 months L suprascapular
L lower trunk
4 491F Vaginal 4 days (left), 16 3 weeks (bilat.) Improved power at L long thoracic
hysterectomy days (right)l>l 1 year R long thoracic
(epidural) month R suprascapular
5 611M Coronary artery 8 days (left), 13 8 days (left), 13 Unchanged at 1 L long thoracic
bypass days (right)l>l days (right) year L suprascapular
month L lower trunk
L thoracodorsal
R long thoracic
R suprascapular
R lower trunk
6 291M Knee arthrotomy 2 days13 weeks 3 weeks Improved power at L ant inteross
1 year L post inteross

*PostoDefafive time

following morning with an intense, deep burning
pain in the medial wall of her right axilla and the
inner border of her right upper arm. This pain
persisted for 3 weeks and then began to slowly re-
solve. Within a few days after the onset of the pain,
she became aware of right arm weakness.
Neurologic examination was normal with the
exception of right scapular winging secondary to
weakness of serratus anterior muscle.
On EMG, moderate amounts of fibrillations
and positive waves were recorded from the right
serratus anterior muscle. No volitional MUPs were
activated in this muscle. The right upper trapezius,
supraspinatus, infraspinatus, deltoid, biceps, tri-
ceps, and FDIO muscles were normal.
CASE HISTORY #2
G.A. is a 28-year-old man who underwent an ap-
pendectomy under general anesthesia. Immedi-
ately postoperative, he noted a deep, aching pain
in his right shoulder and scapula. This pain per-
sisted for 2 weeks and then began to slowly resolve.
Within a week of the onset of pain, he began to
note both weakness while raising his arm and wing-
ing of the right scapula. By the time of his first
neurologic evaluation 4 months later, he believed
that his power hand improved. At a follow-up visit
1 year later, he claimed that his strength had al-
most returned to normal.
Initial neurologic examination revealed atro-
phy of the right infraspinatus more than su-
praspinatus. Winging of the right scapula second-
ary to weakness of the serratus anterior muscle was
noted. Power was 315 in right infraspinatus, 415 in
right supraspinatus, 5-15 in right deltoid, and
normal throughout the rest of the right upper ex-
tremity. Deep tendon reflexes and sensory exami-
nation were normal.
Nerve conduction studies of the right median
and ulnar nerves were normal. Moderate amounts
of spontaneous activity were recorded from the
right infraspinatus, supraspinatus, and serratus
anterior muscles. None was seen in deltoid. No vol-
untary units could be activated in the serratus an-
terior and infraspinatus. Moderate amounts of
chronic partial denervation were seen in the del-
toid and supraspinatus muscles with a few very low
amplitude, long duration, polyphasic MUPs re-
corded from the latter muscle.
CASE HISTORY #3
L.D. is a 43-year-old woman who underwent a left
carpal tunnel release and left first rib resection un-
der general anesthesia. Immediately postopera-

Postsurgical IBN MUSCLE & NERVE March 1994 321

tively, she noted the onset of a severe pain in her
left shoulder and posterior forearm which lasted 3
weeks and then slowly resolved. Within 24 h, she
was unable to extend her elbow, wrist, and fingers.
She had somewhat less weakness of shoulder ab-
duction and external rotation, as well as hand mus-
cles. She had noted gradual improvement of elbow
extension by the time of her initial neurologic eval-
uation 6 months later.
Neurologic examination revealed 0-115 weak-
ness of finger extension; normal power of wrist
extension but with radial deviation; 415 weakness
of infraspinatus, supraspinatus, and hand intrinsic
muscles; and normal power of deltoid, biceps, tri-
ceps, brachioradialis, and finger flexors. Deep ten-
don reflexes were normal.
Needle examination of the left arm revealed
profuse spontaneous activity in the extensor digi-
torum communis (EDC) and extensor carpi ulnaris
(ECU) muscles. No voluntary MUPs were recorded
from ECU and only two large amplitude polypha-
sic MUPs were recruited in EDC. Moderate
amounts of chronic partial denervation were seen
in infraspinatus and supraspinatus. Mild chronic
partial denervation was recorded from extensor
carpi radialis longus (ECRL), triceps, first dorsal
interosseous (FDIO), and abductor pollicis brevis
(APB) muscles. Deltoid, biceps, and rhomboid
muscles were normal.
CASE HISTORY #4
M.F. is a 49-year-old woman who underwent ab-
dominal hysterectomy under epidural anesthesia
for uterine fibroids. Four days postoperatively, she
noted the onset of a severe, aching pain in her left
shoulder which was followed 2-3 weeks later by
the onset of a similar pain in her right shoulder. A
few days after this, she began to note right-sided
greater than left-sided weakness of the shoulder
girdle muscles with scapular winging. Over the
1-year period between her surgery and neurologic
evaluation, she noted a marked improvement in
both her pain and weakness. She denied sensory
complaints.
Neurologic examination revealed bilateral,
right greater than left, scapular winging secondary
to weakness of the serratus anterior muscle. The
right supraspinatus and infraspinatus were 4f5 in
power. All other muscles in the arms were normal.
Sensory examination and deep tendon reflexes
were normal.
On EMG, no spontaneous activity was seen.
Moderate amounts of chronic partial denervation
were recorded from the right serratus anterior and
322 Postsurgical IBN
infraspinatus muscles. The right upper trapezius,
deltoid, rhomboids, biceps, and triceps muscles
were normal.
CASE HISTORY #5
W.R. is a 61-year-old man who underwent coro-
nary artery bypass surgery under general anesthe-
sia via a median sternotomy approach. He had no
neurologic complaints until the eighth postopera-
tive day when he noted left shoulder aching and
difficulty raising his left arm. Five days later, he
noted less severe pain and weakness about the
right shoulder girdle. At initial neurologic evalua-
tion 14 months after surgery, he reported n o
change in his weakness but the shoulder pain was
gone. He denied any sensory symptoms. He did
admit to an upper respiratory infection 10 days
prior to his surgery.
Neurologic examination revealed left worse
than right wasting of the infraspinatus and su-
praspinatus muscles. Scapular winging due to
weakness of the serratus anterior muscles was seen
bilaterally but was again more prominent on the
left. There also appeared to be some left latissimus
dorsi atrophy. He had 415 weakness of bilateral
infraspinatus, bilateral supraspinatus, and left la-
tissimus dorsi muscles. All other muscles of the
arms were of normal bulk and power. The deep
tendon reflexes and sensory examination were
normal.
Nerve conduction studies of the bilateral me-
dian, ulnar, and radial nerves were normal.
No spontaneous activity was recorded in either
arm o r shoulder girdle. Moderate amounts of
chronic partial denervation were recorded from
bilateral supraspinatus, infraspinatus, serratus an-
terior, and left latissimus dorsi muscles. Less
marked changes were seen in bilateral FDIO, APB,
and EDC muscles. Bilateral deltoid, biceps, triceps,
pronator teres, and cervical paraspinous muscles
were normal.
CASE HISTORY #6
M.D. is a 29-year-old man who underwent recon-
structive surgery of his left knee under general
anesthesia. Two days postoperatively, he noted a
bilateral, symmetric deep aching pain of his shoul-
ders, which within a few days began to involve his
left antecubital area. T h e pain persisted for 3
weeks and began to abate. At the same time, he
began to notice “stiffness” in raising his left arm
and a definite weakness in hand muscles, particu-
larly in thumb flexion. He presented for neuro-
MUSCLE & NERVE March 1994
logic evaluation 5 weeks after the onset of his
symptoms.
Neurologic evaluation of the left arm revealed
normal bulk and tone. Power testing showed 015
power in flexor pollicis longus (FPL) muscle. He
had 415 power in the EDC, APB, opponens pollicis,
and the median-innervated flexor digitorum pro-
fundus (FDP) muscle. Normal power was found in
all other muscles of the left arm and shoulder gir-
dle. Deep tendon reflexes in the arms were normal
and symmetric. Sensory examination revealed a
subjective decrease in sensation over the medial
forearm and thenar eminence. The right arm was
normal.
Nerve conduction studies of the left median,
ulnar, and radial nerves were normal. Median and
ulnar nerve F-wave latencies were normal. The
flexor pollicis longus muscle was completely dener-
vated with profuse spontaneous activity and no
voluntary units. The pronator teres, flexor digito-
rum sublimis (FDS), abductor pollicis brevis, and
extensor indicus proprius (EIP) muscles all showed
mild amounts of spontaneous activity and a re-
duced interference pattern composed of normal
appearing motor unit potentials firing at fast rates.
The extensor digitorum communis muscle dis-
played a similar pattern with muscle activation.
The deltoid, biceps, triceps, brachioradialis, ECRL,
FDIO, supraspinatus, and infraspinatus muscles
were all normal.
Follow-up evaluation 4 months later revealed
complete resolution of forearm pain with weakness
now seen only in the flexor pollicis longus. This
muscle continued to show no voluntary motor unit
potentials on EMG. The pronator teres, flexor dig-
itorum sublimis, extensor digitorum communis,
and abductor pollicis brevis now showed no spon-
taneous activity and well-compensated chronic
partial denervation.
DISCUSSION
The pathogenesis of IBN is currently unknown.
Cases have occurred following imrnuni~ation,'~ re-
mote trauma," antecedent viral infection," and
antitoxin injection, most commonly tetanus." IBN
has been seen during pregnancy or within the
postpartum period. l 3 A heredofamilial form of
IBN has been r e p ~ r t e d Most
. ~ cases occur, how-
ever, without an evident predisposing cause.
Postsurgical IBN has not been widely rec-
ognized since Parsonage and Turner's classic de-
scriptions in 1948 and 195712,'7in which 201218
patients (9%) had antecedent surgery. I n the
280 cases reported subsequently by various au-
Postsurgical IBN
thors, only 6 (2%)had undergone a recent opera-
tion.2-6,8-12,14,16-19 we have reported 6 additional
cases who had the onset of their symptoms of IBN
soon after a surgical procedure. None of our cases
had other risk factors for IBN. No patient had
clinical or electrophysiologic evidence of other dis-
eases such as polyneuropathy, radiculopathy, vas-
culitis, or other systemic diseases.
In the setting of an operative procedure, a def-
inite diagnosis of IBN is often questioned. Postop-
erative weakness of the arms is often ascribed to
compressive mononeuropathies, cervical radicul-
opathies, or brachial plexus stretch injuries occur-
ring during general anesthesia as a result of pa-
tient positioning. Five of our patients had general
anesthesia, but the delayed onset of the presenting
symptom, pain, and the multifocal pattern of
nerve involvement demonstrated by EMG made
these conditions unlikely. Though not a multifocal
injury, isolated involvement of the long thoracic
nerve (case 1) was the most common lesion de-
scribed in IBN by T u r n e r and Parsonage in
1957.17A compressive lesion was excluded by the
delayed onset of pain and weakness. Direct injury
to the brachial plexus during first rib resection for
thoracic outlet syndrome (case 3 ) was excluded as
the sole cause by electrophysiologic studies which
showed predominant involvement of the supra-
scapular and posterior interosseous nerves in ad-
dition to the more mild lower trunk lesion. The
possibility of bilateral stretch injuries was unlikely
in case 4 where the patient did not have general
anesthesia. Bilateral lower trunk brachial plexus
injury during cardiac surgery due to sternal retrac-
tion is a well-recognized complication, but is an
unlikely explanation for the clinical picture seen in
case 5. This patient had the postoperative onset of
pain and weakness after 8 days on the left and
after 13 days on the right rather than the expected
immediate and more symmetric onset of symp-
toms. This patient's EMG demonstrated multiple
nerve branch involvement bilaterally. We believe
that all of our patients met the clinical and electro-
physiologic criteria for IBN.
The explanation for the apparent inciting in-
fluence of surgery in the production of IBN is
speculative. Autoimmune neuropathies such as the
Guillain-Barre syndrome have been reported
postoperatively.' This is a more generalized demy-
elinative condition whereas IBN is more focal and
causes primary axonal degeneration. T h e stress of
surgery may activate an unidentified virus lying
dormant in nerve roots." No serologic or viral
study has supported this hypothesis. Additionally,
MUSCLE & NERVE March 1994 323
sometimes IBN affects individual peripheral nerve
branches rather than main nerve trunks or roots as
would be expected from a viral activation.!’ Finally,
the multifocal electrophysiologic abnormalities
and the delayed onset of symptoms postoperatively
make a compressive or stretch injury unlikely.
We conclude that IBN which is brought on by a
surgical procedure is an underrecognized clinical
entity. We have encountered as many cases in the
past 2 years as have been reported in the past 30
years. It is likely that many cases are ascribed to
brachial plexus stretch injuries occurring during
general anesthesia. Other cases may have deficits
so mild as to escape detection during routine post-
operative care. Surgeons and anesthesiologists
should be made more aware of this clinical entity.
Early diagnosis may prevent unnecessary surgical
exploration and allow for a more accurate predic-
tion of functional recovery.
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MUSCLE & NERVE March 1994