Shoulder / Arm

Cervical Plexus Neuralgia

Definition

Traumatic cervical lesions caused by overstretching the plexus with possible avulsion of the nerve roots. As a consequence, patients suffer neurological deficits and/or pain in the area of the peripheral nerve of the plexus.

Aetiology

The most frequent causes are high-energy trauma, together with sports injuries, penetrating trauma, and surgery that result in damage to the plexus. In particular injuries causing damage between the spinal cord and spinal ganglion (proximal) lead to severe pain.

Signs and symptoms

Apart from severe neurological deficits, neuropathic pain of the arm (deafferentiation pain) is the main complaint in 30-90% of patients with a plexus lesion.

In the case of preganglion lesions (avulsion of the nerve root near the spinal cord), the chance of severe neuropathic pain rises to 90%. In this group of patients, pain occurs after a pain-free interval.

The initially continuous 'background pain' with its burning or stabbing character, is later reinforced by the addition of spontaneous pain attacks.

These pain attacks are mainly located in the distal part of the arm, hand and fingers. No clear radicular pain pattern is usually seen.

Frequently, due to trauma, vegetative changes occur in the arm and hand. When Horner's syndrome is seen on the affected side, the plexus lesion is located proximally to level C8-Th1.

Combined damage of the spinal cord and plexus make the diagnosis of a plexus lesion very difficult, and therefore, it is frequently delayed.

Diagnostics

Physical Examination

Neurological examination focuses on sensory and motor deficits, which are dependent on whether upper (C5, C6 en C7) or lower (C8 en Th1) plexus damage is involved.

In upper plexus lesions, motor deficit of the abduction of the upper arm, internal rotation of the arm, and pronation of the hand will mainly be found.

In lower plexus lesions, the finger flexors and small muscles of the hand are predominantly affected and atrophic.

If there is no history of trauma, differential diagnostically amyotrophic shoulder neuralgia must be considered.

Additional Somatic Diagnostics

  • Additional examinations when serious trauma is seen on standard X-rays, and CT and MRI scans.
  • CT myelography for nerve root avulsion.
  • Neurophysiological evaluation (EMG and SSEP) to localise the course of the disease, and neurosurgical intervention.
  • RAND-36 (quality of life)
  • VAS Pain (maximal, minimal, actual, average/week)
  • PCS (catastrophising)
  • HADS (fear and depression)

Additional Psycho-cognitive Diagnostics

Multidisciplinary Treatment

Whether or not somatic treatment is indicated is based on the pain diagnosis.  Based on the findings of the pain questionnaires, additional diagnostics and/or multidisciplinary treatment consisting of various non-somatic treatments may be necessary.

Non-somatic Treatment

Somatic Treatment

Pharmacological treatment:

  • Tricyclic antidepressants
  • Anticonvulsives: carbamazepine, oxcarbazepine, gabapentine en pregabaline.

Other Treatments

Interventional Pain Treatment

Invasive Treatment

  • Neurosurgical plexus reconstruction