What is the treatment for chronic brachial plexopathy?

Treatment for Chronic Brachial Plexopathy

The treatment of chronic brachial plexopathy is primarily etiology-driven and symptom-focused, with MRI of the brachial plexus (with or without IV contrast) as the essential first step to identify the underlying cause and guide management. 1

Initial Diagnostic Workup

Obtain dedicated MRI of the brachial plexus as the gold standard imaging modality, not routine neck, chest, or spine MRI protocols which are inadequate for proper plexus evaluation. 1, 2

• The MRI protocol must include orthogonal views through the oblique planes of the plexus with T1-weighted, T2-weighted, fat-saturated T2 or STIR sequences, and fat-saturated T1 postcontrast sequences. 1, 2
• MRI without IV contrast (rated 7/9) or MRI with and without IV contrast (rated 9/9) are both appropriate initial imaging options for chronic nontraumatic brachial plexopathy. 1
• If MRI is contraindicated due to implanted devices, CT neck with IV contrast is the next best alternative. 1

Etiology-Specific Treatment Approaches

Inflammatory/Immune-Mediated Plexopathy (Parsonage-Turner Syndrome)

Conservative management with physical therapy is the primary treatment for neuralgic amyotrophy/brachial neuritis. 2, 3

• Physical therapy should focus on maintaining range of motion during the recovery phase. 2, 3
• Anti-inflammatory medications may provide symptomatic benefit. 3
• Most patients experience spontaneous recovery over months, though complete resolution may take 1-2 years. 2

Neoplastic Plexopathy

Treatment must be directed at the underlying malignancy with consideration of FDG-PET/CT to evaluate tumor extent. 1, 3

• MRI with and without IV contrast improves delineation of tumor margins compared to non-contrast imaging alone. 1
• Surgical decompression may be indicated for compressive masses. 1
• Intrinsic nerve sheath tumors (neurofibromas, schwannomas) may require surgical excision. 1

Radiation-Induced Plexopathy

Symptomatic management is the mainstay as radiation damage is often permanent. 3, 4

• Medical management includes anticonvulsants, tricyclic antidepressants, and selective serotonin-norepinephrine reuptake inhibitors for neuropathic pain. 4
• Physical therapy to maintain function and range of motion. 4
• Pulsed radiofrequency ablation may be considered as an alternative interventional treatment modality for refractory pain. 4
• FDG-PET/CT can help differentiate radiation plexitis from tumor recurrence in patients with new symptoms after regional radiation therapy. 1

Traumatic/Compressive Plexopathy

Surgical decompression is recommended when compression of the brachial plexus is identified, particularly in cases of clavicle nonunion or thoracic outlet syndrome. 5

• Penetrating and open injuries often require early surgical exploration. 2
• Complete nerve ruptures generally have worse outcomes and often require early operative management. 2
• A multidisciplinary approach minimizes complications associated with surgical management. 5

Refractory Pain Management

Neuromodulation Options

For intractable severe pain refractory to conservative treatments, neuromodulation should be considered. 6

• Spinal cord stimulation (SCS) can provide initial pain relief, reducing pain from NRS 10/10 to NRS 4-5/10. 6
• Combined SCS and peripheral nerve stimulation (PNS) is recommended when SCS alone becomes inadequate, as it stimulates the target nerve both directly and indirectly. 6
• PNS electrode placement on the affected nerve (e.g., radial nerve) can be performed under ultrasound guidance. 6
• This combined approach can eliminate background pain and reduce analgesic requirements. 6

Common Pitfalls to Avoid

Do not order routine neck, chest, spine, or pelvic MRI protocols when evaluating brachial plexopathy—these are inadequate and specialized brachial plexus protocols are required. 2, 3

• Ensure the imaging order specifically requests "MRI brachial plexus" with dedicated plexus sequences. 1
• Consider 1.5T MRI when metal is present in the area to reduce artifact. 1, 2
• Do not confuse plexopathy with radiculopathy—symptoms may overlap but localization differs. 2
• Electrodiagnostic studies (NCS and EMG) should complement imaging to confirm diagnosis and assess severity. 3, 7