Further Outpatient Care
Continue to monitor the neurologic examination findings and clinical symptomatology. If unexpected changes occur, consider repeating electromyography or MRI.
Reinforce patient education regarding protection and care of the extremity with lymphedema. If lymphedema worsens, consider the aforementioned therapeutic interventions and perform an MRI to rule out metastatic disease.
Inpatient & Outpatient Medications
For pain control, tricyclic antidepressants, anticonvulsants, or serotonin–norepinephrine reuptake inhibitors may be indicated for lancinating/neuropathic-type pain. Traditional analgesics also play a role in the treatment of neuropathic pain.
Transfer
If there is evidence of neoplastic disease, the patient needs to be reevaluated by oncological services.
Deterrence
Use focally directed radiotherapy with doses below 55 Gy. A study by Chen et al indicated that in patients undergoing radiotherapy for head-and-neck cancer, a significant association exists between radiation dosages of more than 70 Gy over more than 10% of the brachial plexus volume and the development of brachial plexopathy symptoms. The study involved 352 disease-free patients who had finished radiotherapy for squamous cell carcinoma of the head and neck a median of 40 months prior to the study. [24]
Complications
Complications may include the following:
-
Lymphangitis
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Cellulitis
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Complex regional pain syndrome, type 2
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Glenohumeral joint subluxation
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Contractures in the involved upper extremity
Prognosis
One third of patients experience significant progression of their radiation-induced plexopathy, whereas the remainder of patients demonstrate gradual progression. Rarely, a mild form of reversible radiation plexopathy may present.
Patient Education
Patients should be educated about the expected progressive course of radiation plexopathy. A home exercise program should be considered to preserve strength and range of motion. Susceptibility to trauma and infection due to altered sensation, edema, and fibrotic tissue should be discussed.
Tables
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 |
