What is the treatment for Burners (Brachial Plexus) syndrome?

Treatment of Burners (Brachial Plexus) Syndrome

Burners syndrome should be managed with immediate rest from activity, followed by high-dose pulsed corticosteroids for initial pain control, combined with NSAIDs or acetaminophen, and early physical therapy focusing on restoring scapular mechanics and preventing contractures, while avoiding opioids entirely. 1

Acute Phase Management (First 24-72 Hours)

Pain Control

• Initiate high-dose pulsed corticosteroids immediately for initial pain control, as this is the only intervention shown to assist with the severe neuropathic pain characteristic of brachial plexus neuritis 1
• Start oral NSAIDs or topical NSAIDs as first-line analgesics, maximizing these before considering other options 2
• Add acetaminophen 650 mg every 4-6 hours (maximum 4g/day) as an adjunct to NSAIDs if needed 2
• Apply heat therapy to the affected shoulder and upper arm region 2

Activity Modification

• Immediate cessation of athletic activity or the triggering event is essential, as continued stress on the inflamed brachial plexus will worsen outcomes 1
• The severe shoulder and arm pain typically begins suddenly and is followed by paralysis and weakness within hours to days 3

Subacute Phase (Days to Weeks)

Continued Pain Management

• Do not use opioids or tramadol for burners syndrome, as nonopioid therapies are equally effective with lower risk, and the condition responds better to time and non-narcotic pain medications 1, 2
• Continue NSAIDs and acetaminophen as needed for ongoing neuropathic pain 2
• Note that weakness and subsequent pain after the acute phase are not clearly responsive to steroids and instead benefit from time, physical therapy, and non-narcotic pain medications 1

Physical Therapy Initiation

• Begin physical therapy early, focusing on:
  • Restoring functional scapular mechanics 1
  • Energy conservation techniques 1
  • Contracture prevention 1
  • Pain management strategies 1

Chronic Phase (Months)

Rehabilitation Focus

• Continue intensive physical therapy as the primary intervention, since most patients make dramatic functional recovery with time 1
• Monitor for muscle atrophy and weakness patterns, which can persist for months but usually resolve eventually 3
• Lifetime residual pain and weakness are rare with appropriate management 1

Interventional Considerations

When Conservative Management Fails

• Peripheral nerve blocks are indicated only if:
  • Pain persists beyond 6-8 weeks despite maximal conservative management 4
  • The patient has failed to achieve adequate analgesia without intolerable side effects 5
  • Nerve blocks should be performed with ultrasound guidance to minimize complications 4

Surgical Intervention Timing

• Consider tendon transfers only when recovery does not occur after 18 months of conservative management 1
• Early neurolysis and nerve grafts remain controversial and should not be performed routinely 1

Critical Pitfalls to Avoid

• Never prescribe opioids for burners syndrome, as they increase risk of long-term opioid use (adjusted OR 2.08-6.14) without improving outcomes compared to NSAIDs 2
• Do not continue steroids beyond the acute phase, as they do not improve weakness or long-term pain outcomes 1
• Do not delay physical therapy, as early rehabilitation focusing on scapular mechanics is critical for functional recovery 1
• Do not rush to surgery, as most patients recover dramatically with conservative management and time 1

Recurrent Episodes

• For patients with hereditary brachial plexus neuropathy (HBPN) who experience recurrent attacks, prophylactic steroids or intravenous immunoglobulin may reduce surgical- or childbirth-induced attacks 1
• Recurrent attacks are common in HBPN, requiring ongoing monitoring 1