In this episode of PodMD, neurosurgeon Dr Jeremy Russell will be discussing the topic of Brachialgia, including what Brachialgia is, treatment and management, when a GP should refer and more.
Please note this is a machine generated transcription and may contain some errors.
*As always, all in this PODMD podcast is intended for health professionals and the comments are of a general nature. Information given is not intended as specific medical advice pertaining to any given patient. If you have a clinical issue with one of your patients please seek appropriate advice from a colleague with expertise in the area.
Today I’d like to welcome to the PodMd studio Neurosurgeon, Dr Jeremy Russell.
Dr Russell’s speciality involves expertise in cerebrovascular surgery, skull base neurosurgery and spinal surgery.
Today, we’ll be discussing the topic of Brachialgia.
*We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD.
If you do have a patient on whom you require specific advice, then please seek advice from a colleague with appropriate expertise in that area.
Jeremy, thanks for talking with us on Pod MD today.
Jeremy: Thank you for having me
The topic of today’s discussion is on upper limb radicular pain or Brachialgia. Jeremy, can you describe for our listeners what brachialgia is?
Jeremy: So today is a variation on our last topic, which was Sciatica, which is essentially pain in the leg. today we’re talking about brachalgia, which has pain in the neck and arm. So again, brachalgia is a lay term. It’s not truly what happens. it’s named after the brachial plexus, which is actually distilled where the compression is, but nonetheless, that’s often what it’s called. similarly it is radicular pain. So, in this case, it’s cervical radicular pain rather than lbar radicular pain. So, it presents as indicated with pain radiating down the arm and more often than not associated with axial neck pain, so pain within the central neck itself. So, most patients, middle-aged or older, but certainly you do see it in younger patients. The youngest person I’ve looked after. I think it was 14 with this.
How would a patient with upper limb radicular pain typically present?
Jeremy: They tend to have had grumbling neck pain on and off for a long period of time. And generally, it starts with neck pain, but then as it gets worse then and radiates down the arm, once more, there are particular dermatitis. So, the brachial plexus is when C5 to T1, you can get pain, however, from the C4. So that would typically typically present to the shoulder tip over the deltoid region, C5 radiates down the outside of your arm to the lateral elbow. And maybe just into the lateral force, C6 six goes to the thb and the pointer finger C7, the middle finger plus or minus either side. So, index or ring thing, C eight goes to the little finger, the pinky and the adjacent finger and the inside of the hand, the hypothenar eminence, and then T1 is in the medial. typically the medial elbow of the medial. and once more, these are fairly consistent, probably 15% of the population would either have what’s called a pre or postfix brachial plexus. So, it can be out by one, but it’s almost never out by more than that. And of course, multiple nerves can be affected. So, it may not be as easy as following that pattern. You need to discern that from the history associated, can the weakness of the arm, and that would follow the pattern of the pain. So C4 has no muscular distribution, so there will be no weakness, C5 and C6 is lifting their shoulder up externally, rotating it and waving. So, it’s, if you are waving goodbye to someone, you can think that C5 C6 is also a wrist extension. That’s actually a very useful one to do, to distinguish between C5 and C6. C7 is finger extension and to a degree grip strength, CIT has more grip strength too. One is abduction adduction of your fingers, and they will also often have a degree of grip, strength issues as well. That’s by far and away, the most common distribution. Most people will give you a very classic description of a shooting. Again, it’s a neuropathic pain shooting, electric sharp stabbing kind of pine, Robin distribution. And often there is associated nbness and tingling
Is any one patient predisposed to brachialgia?
Jeremy: Not necessarily. It really is a degenerative condition. The vast majority of cases, we’re not talking about secondary traa here, et cetera. That’s a very different thing. So, a slow progressive degenerative condition effectively it’s arthritis in the neck. So really, people who are obviously older, but as stated, you can still have younger people, not infrequently. The majority of people I’d see will be 40 and upwards. Aside from that, you can have some congenital abnormalities of your spinal coln with what’s called shortened pedicles and the life, but they’re fairly rare. They’re in the Islander Marieke type population, but for all intents and purposes, it’s really just a degenerative condition that anyone can be affected by
Are there any warning signs a GP or their patient can look out for?
Jeremy: Absolutely. So, in the neck, the main concern is spinal cord compression. So that’s called cervical myelopathy. And that is something that must be asked about because that is by far and away, more concerning and dangerous than nerve compression. So, with myelopathic patients, that’s due to compression of the spinal cord in the neck, rather than a particular exciting nerve in the foramen. They often complain of a very slow, slow progression of difficulty using their hands. So, the questions I would generally ask are, have you noticed any fine motor issues such as writing, putting keys in locks, doing R Barton’s grip strength, et cetera. Another one you can ask is when a patient extends the neck backwards, they can get an electric shock running down their spine. That’s called Lhermitte phenomena and that’s relatively sensitive to survive or myelopathy then as it’s affecting your spinal cord and your neck, obviously that involves your lower limbs as well.
So, I would ask them about their walking or their gait. they tend to have upper motor neuron signs in the legs, so that produces stiffness. So, I ask how their walk-ins being, how they just, they feel like they’re walking as stiff, rubber, nice and fluent. And then similarly, have they had any issues with their bowel and bladder. And again, it’s more urinary retention rather than incontinence, but it can be either. so for anyone with either or either a lbar or neck, I always ask about sphincters’ function and they’re walking. That’s probably the most important one to think of on examination. Then you are looking for signs of upper motor neuron signs. So that would involve brisk reflexes. Whereas with nerve compression alone, you generally have muted reflexes, increased tone, so stiff arms, and you can even look for what’s called a Hoffman sign. So, if you flick their index or middle finger, you’re looking for a reflex flection of the thb and that’s incredibly sensitive.
Then other red flags, again, really infection tends to, and the usual subset of patients. So, diabetics, immunocompromised, people, cancer, et cetera, and more often than not, they, they complain of, again, it’s more of an axial pain. So, it’s really the central pain rather than the shooting pain. That is the predominant concern. Of course, it can involve the existing nerves and you do end up with a radicular or brachialgia feature as well. So as per usual, you’re looking to raise temperature and white cells and CRP, et cetera, et cetera. And then predisposing risk factors. Then finally, the other one per lber is malignancy. And again, at a typical malignancy screen, I won’t go through that. They can complain of, again, more axial pain. It’s often worse at night. It’s sort of a deeper norming achy pain rather than the neuropathic electric shooting pain.
So, anyone with a past history of cancer or cancers go to the bone, but breast lung GI renal melanoma, or pretty common, certainly breast and lung though are the most common and prostate, obviously. if they’ve got a history of any of those things and all of a sudden, they come to you going, Oh, I’ve got this real pain between my shoulder blades in my spine, I’d be scanning them. So, they’re the, the red flags that again, if for no other reason to have at least thought about and excluded, it should run through your mind briefly when presented with a patient such.
What is the treatment/management for upper limb radicular pain?
Jeremy: Sure. So, it’s providing, you’ve excluded any of the nasties. We’ve talked about. It’s the same as for lber, really. So conservative management again, ideally for six or so weeks, and that is in modification of lifestyle or trying to minimize lots of neck movement, et cetera. Talk with them about, you know, more often than we see nowadays people seeing your desk with poor posture or the screen in the wrong position. People will now in, COVID sitting at home and watching TV all the time can precipitate neck issues, very commonly. So those sorts of things are the obvious to begin with then analgesia. So paracetamol short doesn’t work, but you can try it. Antiinflammatories typically I would use ibuprofen Voltaren, something on those lines. Again, it’ll give some relief, but if they’ve got a proper radicular or neuropathic pain, it’s not going to work once more, a neuroleptic agent, I personally prefer amitriptyline or end up starting off at 12 and a half milligrams at night.
What is the likelihood of recurrence of brachialgia?
Jeremy: So, this tends to be like the lbar, but most spinal things tend to be acute on chronic sort of disease. Generally, say to patients that this is going to be a lifelong thing that you need to manage and learn to live with. You’ll have good weeks, months, bad weeks or months, but because it’s a degenerative condition, it doesn’t get better. So, it tends to just get gradually worse and worse, but not always. It doesn’t have to. So certainly, recurrence if someone’s been successfully managed conservatively once or even twice. And then it recurs that is, that is for me something that I would suggest to the patient. Maybe we just need to sort this out once and for all, rather than you coming back, forth, back forth, et cetera, but ultimately, unless there’s any other red flags, again, I refer to this as a lifestyle condition.
You don’t die from it. You don’t lose a limb from it. It just hurts. So if it all adds up and the symptoms fit and the radiology fits and the examination fits there is an 80 or 90% chance that if you offer surgery to them, which is typically in the form of an, either an ACDF form more often now doing artificial disc replacements, they wake up and they’re, pain-free bang immediately. Obviously, there’s risks with those procedures, but they’re pretty, they’re pretty straightforward operations. And I would suggest there is less than a 1% chance of doing anything bad to the patient. So, it really comes down to what concerns the patient more than me or long-term pain, but it’s a fairly straightforward condition disorder and the vast majority of people.
When should a GP refer?
Jeremy: So with any of the red flags, always the concern of myelopathy infection or cancer, or if they’ve got a significant weakness, triceps is one that’s often overlooked because patients don’t use it very much, but if you get them to do a slightly inclined push up on a wall, they will often notice it. But if they’ve got a signal, the main one is anything to do with the hand. So, if they’ve got significant hand weakness, then by all means I’d be referring that patient straight away because of the importance of hand strength on day-to-day function. But if there’s no weakness, et cetera, again, going through the medication trial of the neuroleptic steroid, et cetera, generally, I try and go conservative for at least six weeks, typically three months. And then it comes down to the patient. I sit down and I explained to them what the operation involves the pros and cons, blah, blah, blah.
And if they get to a certain point, it’s them weighing up, what’s worth ongoing medication. And don’t forget that if people are on large doses of certainly, you know, patients come in already on 300, twice a day of Lyrica and they’re walking around like zombies and sure, they’ll say I don’t have any pain, but you know, they can’t walk. They can’t think they can’t work. They can’t interact. It’s not a quality of life. So hence why I refer to it as quality of life surgery. So if you can get them off all that medication, then you know, a risk of less than 1% chance of anything major, probably isn’t looking too bad at that point, but then, the patient has to make the decision. So, I’ll give them all the information I have, pamphlets and everything, and they take it home and read it. And then if they decide that surgery sounds like the better option, then it’s fairly straightforward to sort out from there.
Thank you for your time here today in the PodMD studio. To s up for us, could you please identify the three key take home messages from today’s podcast on brachialgia
Jeremy: With brachialgia or cervical radiculopathy or radicular pain is a neuropathic pain. So, a sharp lancinating electric, light pain, typically going down the arm, depending on what nerve is to what distribution, you always need to consider red flags, which include spinal cord compression, which is cervical myelopathy infection such as discard us or malignancy. And that would mandate an urgent referral. Otherwise, most patients can be managed conservatively for at least six or 12 weeks with a combination of simple energies, such as paracetamol anti-inflammatory. And neuroleptics such as amitriptyline plus or minus a short course of steroids. If that’s not working or they’re escalating, then a referral to a spinal surgeon with an MRI of the cervical spine will be the next step. And then I guess we would determine where it goes from there.
Thanks for your time and the insights you’ve provided.
Jeremy: Thank you for having me