Brachial Plexopathy

Brachial Plexopathy Burners/Stingers – 11 Interesting Facts

1. •Burners and stingers are injuries to the brachial plexus resulting from traction, compression, or direct trauma.
2. •The brachial plexus is composed of cervical nerve roots C5 through T1 ( Fig. 111.1A ).Fig 111.1(A) Stingers and burners commonly affect the upper trunk of the brachial plexus creating weakness of the deltoid, biceps, and rotator cuff muscles. (B) The relationship of the brachial plexus to the surrounding anatomic structures including the chest wall.(A, modified from DeLee JC, Drez D Jr, Miller MD, (eds). DeLee & Drez’s Orthopaedic Sports Medicine. Vol. 1, 2nd ed. Philadelphia: WB Saunders, 2003:797; B, modified from Warner CJ, Roddy SP, Darling RC. Upper extremity arterial disease. In Sidawy AN, Perler BA (eds). Rutherford’s Vascular Surgery and Endovascular Therapy , 9th ed. Philadelphia, Elsevier, 2019.)
3. •C5-C6 most commonly affected (see also Fig. 111.1B )
4. •Deltoid, biceps, rotator cuff (supraspinatus, infraspinatus) muscles
5. •Reversible, unilateral upper extremity pain, radiculopathy, and weakness
6. •One of the most common cervical spine injuries in athletes.
7. •Most underreported by the athlete.
8. •Most common in collision and contact sports; as many as 65% of college football players report stingers during their 4-year career
9. •87% of athletes had previous burners or stingers.
10. •Symptoms typically resolve within minutes of the injury.
11. •Limited evidence-based guidelines make return to activity decisions difficult, especially after recurrent episodes.

History

• •Posttraumatic syndrome
  • •Traction: sudden shoulder depression with lateral head deviation, more common in the younger athlete
  • •Compression: extension, ipsilateral compression, rotation to affected side
• •Root injury in narrowed foramen; more common in mature athletes, may be related to congenital spinal stenosis.
  • •Direct trauma: direct blow or compression from shoulder pad and superior medial scapula (Erb point); poorly fitted equipment can play a role.
• •Unilateral burning or tingling sensation in the entire arm
• •Transient inability to actively use the arm (dead arm syndrome)
• •Neurologic symptoms rarely follow a strict dermatomal pattern.
• •If symptoms are bilateral, the concern is for cervical spine injury or transient quadriparesis.

Physical Examination

• •Observation
  • •Splinting of the affected arm Common clinical presentation of an athlete with a stinger that has to support the weight of the arm while leaving the field due to pain or muscle weakness.(From Pritchard JC. Football and other contact sports injuries: diagnosis and treatment. In: Buschbacher RM, Braddom RL, eds.: Sports Medicine and Rehabilitation: A Sport Specific Approach. Philadelphia: Hanley and Belfus; 1994:172.)
  • •Shoulder depression
• •Palpation
  • •Rule out tenderness over the spinous processes and clavicle
  • •May have positive Tinel sign at Erb point
• •Range of motionAlways perform active motion first.
• •Special tests
  • •Spurling test: cervical extension, lateral flexion to the side of the injury, and gentle axial compression reproduce radicular symptoms.Fig 111.3Spurling test is used to recreate foraminal stenosis by ipsilateral extension and rotation.
• •Testing for compression through stenotic foramen
  • •Thorough neurologic examination

Imaging

• •Radiographs
  • •Anteroposterior view: coronal alignment
  • •Lateral view: may have loss of cervical lordosis from spasm
  • •Oblique views: to evaluate cervical foramina
  • •Flexion/extension views: instability, less useful in acute setting
  • •Torg ratio: ratio of sagittal spinal canal width to sagittal vertebral body width; measures degree of congenital spinal stenosis
  • •A ratio of less than 0.8 suggests an increased risk of recurrence
• •Magnetic resonance imaging
  • •To evaluate suspected spinal cord or nerve root injury, herniated cervical disc, foraminal stenosis, canal stenosis, spinal cord edema

Additional Tests

• •Electromyography
• •Not useful in the acute setting
  • •Most useful 2 to 4 weeks after injury if persistent symptoms
  • •After clinical return of normal strength, as many as 80% of patients show electromyographic abnormalities that may persist for more than 5 years.

Differential Diagnosis

• •Cervical spine injury
• •Cervical cord neurapraxia (transient quadriparesis)
• •Clavicle fracture
• •Herniated cervical disc
• •Rotator cuff injury
• •Stress fracture of first rib
• •Thoracic outlet syndrome
• •Parsonage-Turner syndrome

Treatment

• •At diagnosis
  • •If applicable, remove from competition until complete resolution of symptoms and cervical spine injury excluded.
  • •Treatment is largely supportive; a sling may help rest the affected extremity until symptoms improve.
• •Later
  • •Rehabilitation program to restore strength and motion of cervical spine and upper extremity
  • •Athletes should not be allowed to return to competition without a full, pain-free cervical range of motion, negative Spurling test, negative brachial plexus stretch test, and negative axial compression test. This is paramount in preventing more serious spinal cord injury.
  • •The use of neck rolls, a neck-shoulder-cervical orthosis (cowboy collar), and/or pads at the base of the neck in football players can help minimize recurrence.

When to Refer

• •If cervical spine injury is suspected (axial neck pain), immobilization and full radiographic evaluation are warranted.
• •Specialist referral if symptoms last longer than 1 week and there are positive findings suggestive of nerve root injury, bilateral symptoms, or recurrent symptoms.

Prognosis

• •It varies depending on severity.
  • •Grade 1: neurapraxia. All nerve structures remain intact (most common). Complete resolution of symptoms typically occurs in minutes, but may take as long as 6 weeks.
  • •Grade 2: axonotmesis. There are axonal disruption and Wallerian degeneration distal to the injury site. Recovery is complete, but it may take months. An intact epineurium allows axonal regrowth at a rate of approximately 1 mm/day.
  • •Grade 3: neurotmesis. Complete disruption of axons, endoneurium, perineurium, and epineurium. The prognosis varies, with complete loss common.

Troubleshooting

• •Red flags include bilateral symptoms, lower extremity involvement, painful range of motion, axial tenderness, persistent burning, neurologic deficit, and altered consciousness.
• •Immobilize and perform a complete clinical/radiographic evaluation.

Patient Instructions

• •Patients should continue sling use until pain resolves. Monitor for elbow stiffness.
• •Instruct athletes to report all instances of recurrence.
• •Patients may resume activity when full, pain-free range of motion and the return of full upper extremity strength.

Suggested Readings

1. Chao S, Pacella MJ, Torg JS: The pathomechanics, pathophysiology and prevention of cervical spinal cord and brachial plexus injuries in athletics . Sports Med 2010; 40 (1): pp. 59-75.
2. Concannon LG, Harrast MA, Herring SA: Radiating upper limb pain in the contact sports athlete: an update on transient quadriparesis and stingers . Am Coll Sports Med 2012; 11 (1): pp. 28-34.
3. Feinberg JH: Burners and stingers . Phys Med Rehabil Clin N Am 2000; 11: pp. 771-784.
4. Hoppenfeld S: Physical examination of the cervical spine . In Hoppenfeld S (eds): Physical Examination of the Spine and Extremities . 1976. Appleton-Century-Crofts , Norwalk, CT pp. 105-132.
5. Kasow DB, Curl WW: “Stingers” in adolescent athletes . Instr Course Lect 2006; 55: pp. 711-716.
6. Kelley JD: Brachial plexus injuries: evaluating and treating “burners.” . J Musculoskel Med 1997; 14: pp. 70-80.
7. Olson DE, McBroom SA, Nelson BD, et al.: Unilateral cervical nerve injuries: brachial plexopathies . Curr Sports Med Rep 2007; 6: pp. 43-49.
8. Safran MR: Nerve injury about the shoulder. Part 2: long thoracic nerve, spinal accessory nerve, burners/stingers, thoracic outlet syndrome . Am J Sports Med 2004; 32: pp. 1063-1076.
9. Weinberg J, Rokito S, Silber JS: Etiology, treatment, and prevention of athletic “stingers” . Clin Sports Med 2003; 22: pp. 493-500.