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Radiation-Induced Brachial Plexopathy Medication

  • Author: Ryan O Stephenson, DO; Chief Editor: Robert H Meier, III, MD  more...
 
Updated: Mar 10, 2015
 

Medication Summary

The goal of pharmacotherapy is to reduce morbidity and prevent complications.

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Anticonvulsants

Class Summary

Anticonvulsants are used to manage severe muscle spasms and provide sedation in neuralgia.

Gabapentin (Neurontin, Gralise)

 

Gabapentin has anticonvulsant properties and antineuralgic effects; however, the exact mechanism of action is unknown. Gabapentin is structurally related to GABA but does not interact with GABA receptors.

Titration to effect can take place over several days (300 mg on day 1, 300 mg bid on day 2, and 300 mg tid on day 3).

Pregabalin (Lyrica)

 

Pregabalin is a structural derivative of GABA. The mechanism of action is unknown. It binds with high affinity to the alpha2-delta site (a calcium channel subunit). In vitro, it reduces calcium-dependent release of several neurotransmitters, possibly by modulating calcium channel function. It is FDA approved for neuropathic pain associated with diabetic peripheral neuropathy or postherpetic neuralgia and as adjunctive therapy in partial-onset seizures.

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Tricyclic antidepressants

Class Summary

These agents have central and peripheral anticholinergic effects, as well as sedative effects, and block the active reuptake of norepinephrine and serotonin.

Amitriptyline

 

Amitriptyline is indicated as an analgesic for certain types of chronic and neuropathic pain.

Nortriptyline (Pamelor)

 

Nortriptyline has demonstrated effectiveness in the treatment of chronic pain. By inhibiting the reuptake of serotonin and/or norepinephrine by the presynaptic neuronal membrane, it increases synaptic concentration of these neurotransmitters in the CNS.

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Antidepressant, Selective Serotonin/norepinephrine Reuptake Inhibitor (ssnri)

Class Summary

These agents are a complex group of drugs that inhibit serotonin and norepinephrine reuptake. Some drugs in this class are weak inhibitors of dopamine reuptake with sedative effects.

Duloxetine (Cymbalta)

 

Duloxetine is indicated for diabetic peripheral neuropathic pain. It is a potent inhibitor of neuronal serotonin and norepinephrine reuptake.

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Contributor Information and Disclosures
Author

Ryan O Stephenson, DO Assistant Professor, Department of Physical Medicine and Rehabilitation, University of Colorado Health Science Center; Physiatrist, Medical Director of PM&R Inpatient Consultation Service, Medical Director of Polytrauma and Brain Injury, Medical Director of Regional Amputee Center, Department of Physical Medicine and Rehabilitation, Eastern Colorado Veterans Affairs Medical Center

Ryan O Stephenson, DO is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Patrick M Foye, MD Director of Coccyx Pain Center, Professor and Interim Chair of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School; Co-Director of Musculoskeletal Fellowship, Co-Director of Back Pain Clinic, University Hospital

Patrick M Foye, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, International Spine Intervention Society, American Association of Neuromuscular and Electrodiagnostic Medicine, Association of Academic Physiatrists

Disclosure: Nothing to disclose.

Chief Editor

Robert H Meier, III, MD Director, Amputee Services of America; Active Medical Staff, Presbyterian/St Luke’s Hospital, Spalding Rehabilitation Hospital, Select Specialty Hospital; Consulting Staff, Kindred Hospital

Robert H Meier, III, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, Association of Academic Physiatrists

Disclosure: Nothing to disclose.

Additional Contributors

Rajesh R Yadav, MD Associate Professor, Section of Physical Medicine and Rehabilitation, MD Anderson Cancer Center, University of Texas Medical School at Houston

Rajesh R Yadav, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation

Disclosure: Nothing to disclose.

Acknowledgements

Robert J Kaplan, MD Staff Physician, Department of Rehabilitation Medicine, James E Van Zandt VA Medical Center

Robert J Kaplan, MD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation

Disclosure: Nothing to disclose.

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Table. Other Problems to Consider in Radiation-Induced Brachial Plexopathy Diagnosis
Feature Tumor Infiltration Radiation Fibrosis Transient Radiation Injury Acute Ischemic Injury
Incidence of pain 80% 18% 40% Painless
Location of pain Shoulder, upper arm, elbow, fourth and fifth fingers Shoulder, wrist, hand Hand, forearm Hand, forearm
Nature of pain Dull ache in shoulder, lancinating pains in elbow and ulnar aspect of hand; occasional paresthesias and dysesthesias Ache in shoulder; prominent paresthesias in C-5/C-6 distribution of hand and arm Ache in shoulder; prominent paresthesias in C-5/C-6 distribution of hand and arm Paresthesias in C-5/C-6 distribution of hand and arm
Severity Moderate to severe (severe in 98%) Usually mild to moderate



(severe in 20-35%)



Mild Mild
Course Progressive neurologic dysfunction; atrophy and weakness in C-7/T-1 distribution, persistent pain; occasional Horner syndrome Progressive weakness; panplexus or upper plexus distribution; Horner syndrome uncommon Translate weakness with complete resolution Acute nonprogressive weakness and sensory loss
Study findings        
Magnetic resonance imaging High signal intensity on T2-weighted images; may enhance with gadolinium Low signal intensity on T2-weighted images; generally nonenhancing with gadolinium No data Normal
Computed tomography Mass; circumscribed or diffuse tissue infiltration Diffuse tissue infiltration Normal Angiography demonstrates subclavian artery segmental



obstruction



Electromyography Segmental slowing Diffuse myokymia Segmental slowing Segmental slowing
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