Hospital for Special Surgery (HSS) orthopedic surgeons successfully performed microsurgery to repair damaged nerves and restore muscle strength and movement to patients with paralysis due to Parsonage-Turner syndrome (PTS). This is according to a study published online in the Journal of Hand before going to press.
Parsonage-Turner syndrome affects the nerves that control the shoulder, arm, and hand. “We have published data on the first successful surgical treatment in patients who have experienced some level of paralysis as a result of this mysterious disorder,” said Dr. Scott Wolfe, Director of the Center for Brachial Plexus and Traumatic Nerve Injury at HSS and lead investigator.
Parsonage-Turner syndrome, also known as neuralgic amyotrophy, most commonly manifests as sudden, severe pain in the shoulder and upper arm, often for no known cause. The intense pain, which usually subsides within a few weeks, is followed by progressive weakness. Many patients find that they cannot move their affected shoulder, elbow, or hand. The area and degree of paralysis will depend on the nerves affected and the muscles that control them.
There is no known cure, but doctors generally prescribe pain relievers, steroids, and physical therapy to relieve symptoms. Although many patients eventually recover and regain the function of their arm, it sometimes takes several years.
For those who are not getting better, limited use of their arm or even complete paralysis can be devastating. “Imagine going with this disease for months and not knowing if or when you will get better. Since recovery can take a year or more, patients have been told to wait and there is this feeling of insecurity “says O. Kenechi Nwawka, MD, director of the Department of Ultrasound Research at HSS, who performs ultrasounds on PTS patients to locate the damaged nerves. “Many patients who come to HSS feel relieved because they have found a group of specialists who really understand their condition.”
Dr. Wolfe and colleagues wanted to find out if patients who didn’t get better could be helped by neurolysis, a microsurgical procedure used to repair the injured nerve. Doctors hypothesized that successful surgery would allow patients with PTS to regain strength and movement.
To help patients with Parsonage-Turner syndrome, a multidisciplinary team of specialists is essential. The first step is to have a physical practitioner identify which muscles are affected and assess the nerve injury and loss of function. This is achieved through electrodiagnostic tests, which are used again at a later date to look for signs that the nerve is recovering.
It is also important to determine the exact location of the damaged nerve or nerves using MRIs and ultrasound. The Specialty Surgery Hospital is one of the few centers in the country with a highly specialized team of hand surgeons, physiologists, and radiologists who could pursue such an endeavor.
“Without this team of experts in these diverse but related areas, we would not have been able to make so much progress in a relatively short period of time,” said Dr. Wolfe. “It’s not just the members of the team, but also the spirit of collaboration between my medical and surgical colleagues at HSS that sets us apart from other institutions.”
The HSS study enrolled 24 patients with PTS, all of whom had arm or hand paralysis. A physiater performed electromyography (EMG) to measure muscle and nerve function in all patients.
“EMG tests are first used to confirm and establish the final diagnosis of PTS,” explained physiologist Dr. Joseph Feinberg, Medical Director of the Center for Brachial Plexus and Traumatic Nerve Injury at the HSS. “A damaged nerve will generally begin to recover in six to nine months, and additional EMG testing may show if there are any early signs of nerve regeneration. If the nerve begins to regenerate, the patient will likely regain muscle strength, so that one Operation generally done. ” not mandatory. However, if there are no signs of recovery within six to nine months of PTS onset, recovery is less likely and surgery may be considered. “
The patients in the study met the following criteria: 12 months had passed since the onset of Parsonage-Turner syndrome without improvement, or there was no evidence of clinical or electrodiagnostic improvement after six months, as documented by three consecutive EMG and clinical exams .
A high-resolution MRI technique known as magnetic resonance neurography (MRN) was performed to zero the location of the nerve damage. Previously, radiologists at the HSS had documented “hourglass-like” narrowing of the nerve, an anomaly that only occurs in patients with PTS. Essentially, a band pinching the nerve makes it look like an hourglass on the digital image. MRI, along with high-resolution ultrasound images, is crucial for surgical planning.
“Magnetic resonance neurography and ultrasound images give surgeons a roadmap to a goal to treat,” explained Dr. Darryl Sneag, Director, Peripheral Nerves, MRI at HSS. “Instead of having to examine the entire nerve in one arm, the images show the exact location of the constriction so the surgeon doesn’t have to spend hours looking for it.”
In each study patient, hourglass-like narrowing of the affected nerves was found and the images correlated with the EMG findings. Eleven of the 24 patients opted for neurolysis surgery by Dr. Wolfe and colleague Steve Lee, MD.
“Once we had imaging localized the tiny constrictions in the nerve, we were able to limit our surgery to that area and pinpoint the lesion with millimeter precision,” said Dr. Wolfe. “Using a 25x microscope, we then repaired the constricted nerve by loosening the pressure bands around it.”
The mean time from onset of PTS to surgery was 12.5 months. When the patients were followed up almost 15 months after the procedure, nine of the eleven operated patients showed clinical improvement after regaining muscle strength and movement. EMG testing showed significant motor unit recovery after nerve regeneration.
Of the 13 patients who did not undergo surgery, only three had regained their strength during the follow-up visit, which occurred almost three years after the onset of PTS.
“Microsurgical neurolysis to repair the hourglass constrictions has been associated with dramatic and significantly improved clinical outcomes and nerve regeneration compared to non-surgical management,” noted Dr. Wolfe. “Therefore, we recommend considering it as a treatment option for patients with chronic Parsonage-Turner syndrome who have not gotten better with non-surgical treatment.”
The study uses a novel MRI technique to find a biomarker for Parsonage-Turner syndrome
Karthik R. Krishnan et al., Results of Microneurolysis of Hourglass Constrictions in Chronic Neuralgic Amyotrophy, The Journal of Hand Surgery (2020). DOI: 10.1016 / j.jhsa.2020.07.015 Provided by the hospital for special surgery
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