Parsonage Turner Syndrome

Parsonage Turner Syndrome Overview

Parsonage Turner Syndrome is an inflammatory disorder of the brachial plexus, the nerve supply to the shoulder and arm. This disorder is also called brachial neuritis or brachial plexopathy.

The brachial plexus is the compilation of the five separate nerves roots that exit from the spine in the neck and travel through the front of the chest under the collarbone(clavicle). These nerves supply the shoulder muscles and then descend down into the arm.

Parsonage Turner Syndrome causes inflammation of the brachial plexus. In this disorder, the inflammation is brought on by our own immune system. The immune system wrongly attacks these nerves in a case of mistaken identity.

It is suspected that this nerve injury is brought about by a prior virus illness. Under the effects of a viral infection, our immune system develops antibodies to the virus protein coat. Unfortunately in some viruses, the virus coat has some similar looking proteins to some structural proteins in the body.

In Parsonage Turner Syndrome, the virus proteins are very similar to the components of these brachial plexus nerves. The body then misidentifies the nerve proteins as invading virus proteins and attacks these nerves.

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Parsonage Turner Syndrome Symptoms

Parsonage Turner Syndrome occurs typically with sudden onset pain of the shoulder girdle. One-sided (unilateral) shoulder pain occurs which is sometimes intense over the next couple of days. The pain can last for 1-2 weeks and is typically constant. Pain then leads to progressive weakness and decreased sensation. Atrophy of the muscles will then occur after the onset of weakness.

Weakness generally involves multiple muscles from different nerve roots due to the diffuse nature of this inflammatory attack. Typically, the deltoid muscle is involved (lifts the arm at the shoulder joint) with the biceps also involved (the muscle in the front of the upper arm that lifts the forearm). The rotator cuff is typically involved (the muscles that rotate the arm in and out) and the long thoracic nerve can also be affected (serratus anterior muscle) causing scapular winging. Multiple muscles from other nerves (C7-T1) can also be involved.

Treatment of Parsonage Turner Syndrome

In the early stage of Parsonage Turner Syndrome, the significant pain can be treated with pain medications, muscle relaxants, NSAIDs (non-steroidal anti-inflammatories) and membrane stabilizers (see “medications” on this website-Lyrica and Neurontin). Oral steroids can be effective with an understanding of the potential side effects.

After the initial pain has receded, therapy should be started. Range of motion should be instituted as the muscles are weak and lack of motion could lead to joint contractures.

The recovery of strength and the time to regain strength depends upon the severity of the inflammatory injury to the nerves. See the section on this website under “Nerve Injuries and Recovery”-, the topic “Nerve Damage and Healing” to understand how nerves heal.

Differential Diagnosis/ Radiculopathy

The differential first involves looking for a pinched nerve in the neck (cervical radiculopathy or nerve compression). In cervical nerve compression, the pain, numbness and weakness are only involved with one nerve root (possibly two in uncommon cases). An examination will also note nerve pain radiating into the shoulder with neck extension (bending the head backwards-the Spurling’s test) as the pinched nerve will become more compressed with neck extension.

In Parsonage Turner Syndrome, the muscles that are involved are always in a scattered distribution with no rhyme or reason and are not specific for one spinal nerve. That is, there is no classic pattern of involvement like that of a compressed spinal nerve. Motor strength testing will find multiple nerve involvements. Bending the head backwards should not increase the pain into the arm.

EMG Testing

The EMG test (nerve conduction test) if performed at least three weeks after onset of symptoms will be helpful in differentiating the two disorders. The three week period is necessary to allow changes to the muscles that make the EMG test responsive. If the test is performed before three weeks, it may be negative (won’t show nerve injury).

The reason this test can differentiate the two disorders is anatomy. The spinal nerve is one complete nerve until it splits into two branches right after it exits the foramen (the exit hole in the vertebrae). The two branches become the anterior primary ramus and the posterior primary ramus.

The anterior primary ramus is the much thicker main branch that travels into the shoulder and joins the brachial plexus. This anterior branch is responsible for function of all of the shoulder and arm muscles. The posterior primary ramus is a much smaller branch that is only responsible for the very small muscles of the back of the neck.

Cervical radiculopathy (nerve compression in the neck) injures the nerve before it exits the foramen (the exit hole in the vertebrae). Since the nerve is affected before it splits, both the anterior and posterior primary ramus of the nerve will be injured.

Parsonage Turner Syndrome involves the nerve after it has exited and split into two. This means that in Parsonage Turner Syndrome, the anterior primary ramus is involved but the posterior primary ramus is not involved.

If the EMG test picks up neurogenic changes in the small muscles of the back of the neck, this is a pinched nerve in the neck (cervical radiculopathy). If these small back-of the-neck muscles are normal (not involved), this is most likely Parsonage Turner Syndrome.

Other Differential Diagnoses

Shingles is the reactivation of the chickenpox virus (varicella) that has lain dormant in one nerve root for years. The pain from shingles is very similar to the initial pain of Parsonage Turner Syndrome. Shingles however will develop vesicles (small fluid-filled pimple-like lesions) one to two days after pain onset. Also careful evaluation will reveal that the pain in Shingles is from only one nerve whereas Parsonage Turner Syndrome pain will be from multiple nerves.

Shoulder disorders like subacrominal bursitis; calcific tendonitis and adhesive capsulitis can look like Parsonage Turner Syndrome. Shoulder disorders typically will slowly progress, have previous symptoms displayed or have acute onset from trauma (a fall onto the shoulder or outstretched hand). The above noted shoulder disorders however can have acute onset of symptoms and mimic Parsonage Turner Syndrome. A thorough history and careful physical examination will differentiate these two disorders.

Thoracic outlet syndrome (see website for description) can occasionally mimic Parsonage Turner Syndrome. Thoracic outlet syndrome involves the brachial plexus just like Parsonage Turner Syndrome but in thoracic outlet syndrome , the nerves are pinched but not attacked by the immune system. In thoracic outlet syndrome, if the arm is left at the side of the body, the symptoms will disappear. In Parsonage Turner Syndrome, the symptoms are constant and position of the arm does not affect the pain. Also in thoracic outlet syndrome, muscle weakness is rare where in Parsonage Turner Syndrome weakness is typical.

For additional resources on Parsonage Turner Syndrome, please contact the practice of Dr. Donald Corenman, spine specialist and back doctor offering diagnostic and surgical second opinions to patients in the USA and around the world.

Donald Corenman, MD, DC

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81 reviews

Eric S

Sep 26, 2021

by Eric S on Donald Corenman, MD, DC

Successful pars repair at 46 years old

Back in November of 2018 (at 46 years old) I came from Vancouver BC to have a pars repair done with Dr. Donald Corenman at the Steadman Clinic in Vail Colorado. I'm finally posting this review nearly three years later in late 2021. The reason I waited so long was I wanted to know the final result before I posted my review. Unfortunately in that time Dr. Corenman has retired. Nevertheless, I want to post this review of Dr. Corenman and his staff at the Steadman Clinic in their excellent treatment of my L5 pars interarticularis.

I fractured my pars at age 42 back in 2014 when rolling on the gym floor, and was denied treatment by the Canadian healthcare system, probably due to my age. First my GP told me there was no surgical option for a pars defect, which was quite incorrect! I tried to live with it, but the symptoms worsened (periodic random spine slippage and weeks of resultant pain after just bending over to tie my shoe, so I eventually learned to mostly squat and hardly bend). When I finally consulted with Canadian spine surgeons, I was told they believed my pars defect had been congenital (since birth). This was absurd, considering I had done extreme martial arts (including jiu jitsu) for years prior, as well as 5 years of reinforcing steel full time in my 20s, probably the hardest job on the back you can find. No pars defect like mine would possibly have allowed this--ergo it was impossible that I had had the defect since birth. I did however have an asymptomatic congenital spina bifida occulta that made me more susceptible to a pars fracture. In 2014 in one instant, I went from having the strongest back people I knew said they'd ever seen, to being unable to safely bend over and tie my shoe without a non-negligible risk of my spine slipping randomly (which would lead to weeks of pain after each occurrence). This was due to the unilateral L5 pars defect, otherwise known as spondylolysis. It was when lying in pain on the floor 4 years later after maybe the 6th spine slippage event post injury, that I had had enough, and resolved to have surgery. If Canada's "universal health care" said no, I would make lemonade from lemons, and find the very best surgeon in the world at pars repairs. That was Dr. Donald Corenman. Dr. Corenman back in 2018 ran a website https://neckandback.com/ that dedicated many pages to the science of every aspect of pars repairs, from eligibility (good discs on MRI), to best surgical techniques (minimal open compared to minimally invasive), best imaging to use (i.e., O-Arm with Stealth imaging vs. older fluoroscopy), the ideal amount of BMP to use and why not use too much or too little, and much more, all to do with pars repairs, pages upon pages of his site just on the pars, with scientific references and his own extensive expert opinion. As a health research statistician, I was very impressed with this. It was in stark contrast to the websites of other spine surgeons which barely gave the pars a word or two, focusing almost exclusively on fusions. I had found the best surgeon in the world for pars repairs, and so after Dr. Corenman personally screened my MRI to ensure my discs were healthy, I booked the surgery.

Being 46 years old at the time of surgery in 2018, with a 4-year-old pars fracture from 2014 combined with a congenital SBO meant my pars fragment was somewhat atrophied, but it was "very solid", said Dr. Corenman in the operative report. Nevertheless, it was challenging with two things to fix, the pars and SBO, and OR time was around 4 hours. Recovery over the following months was guided by a very clear "Spine binder" from the Steadman Clinic with strict rules of "no BLT" (no bending, lifting or twisting), and illustrated physiotherapy guidelines. They even warned patients to avoid fish oil supplements, which could excessively dampen inflammation and hence slow bone healing. They answered many questions I had during months of recovery, with responses coming from the very supportive Lori Fugate (then director of Dr. Corenman's practice), and Ehrich Bean (then physician's assistant at the practice), as well as a couple calls with Dr. Corenman himself after two of the CT scans. Ehrich Bean offered great advice for taking the spine binder conservatively due to the nature of pars repairs vs. fusions. The final post-op CT scan I had was a couple weeks ago at 34 months post-op, and Dr. Corenman had retired, but I got a very positive and informative call from Eric Strauch (current PA at the Steadman Clinic under Dr. Corenman's replacement there, and who had also worked with Dr. Corenman previously). The staff at the Steadman Clinic were extremely supportive all the way through the process. I should mention, the local Canadian spine surgeon did offer me very good post-operative support including antibiotics as needed to deal with a mild surface incision-site infection early on, booking numerous x-rays when I felt something was amiss, as well as booking all four of my post-op CT scans. I am very grateful for that support also.

My final result shows plenty of solid bone across the pars and a healed SBO, with my vertebral body now a solid bone ring instead of being broken at two places as it was pre-op. Does my spine hold up in the real world? You bet! I have recently dug and moved several yards of dirt and sand and gravel by myself (shovel and wheelbarrow!) to fix our water main, pulled roots from the yard, moved several "portable" (these are HUGE) air conditioners up several flights of stairs my myself, and lifted weights. I now run 2 miles (3.2 KM) several times weekly with a hard 100 meter dash in the middle. I bend deeply before each run I go on, with no spine slippage. My spine feels amazing. I can bend over to do exercise, or real word tasks, with no risk of spine slippage.

My sincere thanks to God, Dr. Donald Corenman, Lori Fugate, Ehrich Bean, Eric Strauch, and the Steadman Clinic, as well as the Canadian spine surgeon who offered me excellent post-operative care back in Canada. You have all given me a new lease on life.

Sincerely,
Eric S

Robert S

May 11, 2021

by Robert S on Donald Corenman, MD, DC

Back Fusion Surgery

I had my entire lumbar spine fused in November of 2018. I had scoliosis , with pinched nerves that were so painful I could hardly walk - and standing for more than a few minutes was impossible. Even sitting was painful.
The fusion surgery produced immediate relief! And the recovery was much easier than I expected.
To this day I can do all the activities I love from hiking, to standing in a stream fly fishing to riding my bike long distances - or just walking down the street with my wife.
Kudos to Dr. Corenman and his staff, (including the two Erics) for taking such good care of me!

Leslie R

Jul 9, 2020

by Leslie R on Donald Corenman, MD, DC

TLIF

I had my TLIF surgery on 6/24/2020 by Dr. Corenman, I can not say enough good things about the Dr or his staff. I was always treated with respect and explained everything throughly, that made it easy for everyone to understand. I highly recommend Dr. Corenman and the Steadman Clinic.

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