Teaching Video NeuroImages: Hourglass-like fascicular constriction in Parsonage-Turner syndrome

Summary

  • 43yo F
  • c/c
    • pain in Lt U/E
    • after hysterectomy
  • Ex
    • EMG
      • acute denervation
      • volitiona; motor activity (–)
  • Dx
    • PTS (Parsonage-Turner synd)

Background

Terminology

Original

P01

A 43-year-old woman presented with intense pain in the left upper arm, a plegic flexor pollicis longus, and flexor digitorum profundus of the 2nd digit without sensory symptoms occurring 8 days after a hysterectomy. Needle myography showed acute denervation and absent volitional motor activity of affected muscles. The patient was diagnosed with Parsonage-Turner syndrome (PTS) (figures 1 and 2, video 1).

Figure 1

Figure.1

Ultrasound, intraoperative photograph, and histopathology (A) Longitudinal ultrasound section of an anterior interosseous nerve fascicle in the median nerve at elbow level, hourglass-like, torsional constriction (distal constriction; proximal constriction not shown).
(B) Intraoperative confirmation of 2 constrictions (thick arrows) with slight torsion at internal neurolysis; fascicular grafting followed.
(C) Histology of resected fascicle with subtotal loss of vital nerve tissue within the constriction; note the torsional appearance.

Figure 2

Figure.2

Video still Preoperative dynamic ultrasound of the median nerve (filled arrows) in cross-sectional view with inhomogeneous fascicular diameters, from distal to proximal. Thin arrows: prominent fascicle with constrictions and swellings at the level of (A) the distal constriction, (B) between constrictions, (C) the proximal constriction, and (D) the adjacent, proximal, “ballooned” swelling.

Video 1

Video

Preoperative dynamic US of the median nerve in cross-section from distal to proximal, see video stills (A–D).

P02

PTS or neuralgic amyotrophy presents with subacute intense extremity pain, followed by patchy axonal lesions of upper extremity or plexus nerves. The combination of long thoracic and anterior interosseous nerve affections is almost pathognomonic. Recently, hourglass-like fascicular constrictions and torsions have been observed in the clinical context of neuralgic amyotrophy.1,2

References

  1. Aranyi Z, Csillik A, Devay K, et al. Ultrasound identification of nerve pathology in neuralgic amyotrophy: enlargement, constriction, fascicular entwinement and torsion. Muscle Nerve 2015;52:503–511.Google Scholar
  2. Pan YW, Wang S, Zhen D, et al. Hourglasslike constrictions of peripheral nerve in the upper extremity: a clinical review and pathological study. Neurosurgery 2014;74:10–22.