Parsonage-Turner Syndrome affects the nerves controlling the shoulder, arm and hand. “We published data on the first successful surgical treatment in patients who experienced some degree of paralysis due to this mysterious disorder,” said Scott W. Wolfe, MD, director of the Center for Brachial Plexus and Traumatic Nerve Injury at HSS and lead investigator.

Also known as neuralgic amyotrophy, Parsonage-Turner Syndrome most frequently manifests as sudden, severe pain in the shoulder and upper arm, often with no known cause. The intense pain, which usually subsides within a couple of weeks, is followed by progressive weakness. Many patients find they are unable to move their affected shoulder, elbow or hand. The area and degree of paralysis depend on the nerves affected and the muscles they control.

There is no known cure, but doctors generally prescribe pain medication, steroids and physical therapy to help relieve symptoms. Although many patients eventually recover and regain function of their arm, it sometimes takes several years.

For those who do not get better, limited use of their arm or even complete paralysis can be devastating. “Imagine going for months with this condition and not knowing if or when you’re going to get better. Because recovery can take a year or longer, patients have been told to wait, and there’s this feeling of uncertainty,” says O. Kenechi Nwawka, MD, director of the Division of Ultrasound Research at HSS, who performs ultrasound in PTS patients to locate the damaged nerves. “Many patients who come to HSS feel relieved because they have found a group of specialists that really understands their condition.”

Dr. Wolfe and colleagues set out to determine if patients who weren’t improving could be helped by neurolysis, a microsurgical procedure to repair the injured nerve. The doctors hypothesized that successful surgery would allow patients with PTS to regain strength and movement.

To help patients with Parsonage-Turner Syndrome, a multidisciplinary team of specialists is essential. The first step is for a physiatrist to identify which muscles are involved and assess the nerve injury and loss of function. This is achieved through electrodiagnostic testing, which is used again at a later date to look for signs that the nerve is recovering.

It is also critical to pinpoint the exact location of the damaged nerve or nerves with MRI and ultrasound. Hospital for Special Surgery is one of few centers nationwide with the highly specialized team of hand surgeons, physiatrists and radiologists who could pursue such an undertaking.

“Without this team of experts in these varied, but related fields, we could not have made as much progress in a relatively short period of time,” said Dr. Wolfe. “It is not only the members of the team, but the spirit of collaboration among my medical and surgical colleagues at HSS that sets us apart from other institutions.”

The HSS study enrolled 24 patients with PTS, all of whom had suffered paralysis of their arm or hand. A physiatrist performed electromyography (EMG) to measure muscle and nerve function in all the patients.

“EMG testing is first used to confirm and make the definitive diagnosis of PTS,” explained physiatrist Joseph H. Feinberg, MD, medical director of the Center for Brachial Plexus and Traumatic Nerve Injury at HSS. “A damaged nerve will generally start to recover in six to nine months, and additional EMG testing can indicate if there are early signs of nerve regeneration. If the nerve is starting to regenerate, the patient will likely regain muscle strength, so surgery is generally not needed. However, if there is no sign of regeneration within six to nine months of PTS onset, then recovery is less likely, and surgery may be considered.”

Patients in the study met the following criteria: 12 months had passed without improvement since the onset of Parsonage-Turner Syndrome, or there was no evidence of clinical or electrodiagnostic improvement after six months as documented by three successive EMG and clinical exams.

A high-resolution MRI technique known as magnetic resonance neurography (MRN) was performed to zero in on the location of the nerve damage. Previously, radiologists at HSS had documented “hourglass-like” constrictions of the nerve, an anomaly that is unique to patients with PTS. Essentially, a band squeezing the nerve makes it look like an hourglass on the digital image. The MRI, along with high-resolution ultrasound images, is essential in surgical planning.

“Magnetic resonance neurography and ultrasound images give the surgeons a roadmap, a target to treat,” explained Darryl B. Sneag, MD, director, Peripheral Nerve, MRI at HSS. “Instead of having to explore the entire nerve in an arm, the images pinpoint the exact location of the constriction, so the surgeon doesn’t have to spend hours searching for it.”

Hourglass-like constrictions of affected nerves were identified in each study patient, and the images were correlated with EMG findings. Eleven out of the 24 patients opted for neurolysis surgery by Dr. Wolfe and his colleague, Steve K. Lee, MD.

“Once we localized the tiny constrictions in the nerve with imaging, we could confine our surgery to that site, and we could locate the lesion with millimeter precision,” said Dr. Wolfe. “Looking through a microscope with 25X magnification, we then repaired the constricted nerve by releasing the compressive bands around it.”

The mean time from PTS onset to surgery was 12.5 months. At patient follow-up of almost 15 months after the procedure, nine of the 11 patients who had surgery showed clinical improvement, having regained muscle strength and movement. EMG testing revealed significant motor unit recovery from nerve regeneration.

Out of the 13 patients who did not have surgery, only three had recovered strength during follow-up, which took place almost three years after PTS onset.

“Microsurgical neurolysis to repair the hourglass constrictions was associated with dramatic and significantly improved clinical outcomes and nerve regeneration compared to nonsurgical management,” Dr. Wolfe noted. “Therefore, we recommend considering it as a treatment option for patients with chronic Parsonage-Turner Syndrome who have failed to improve with nonoperative treatment.”

“HSS has a long history of highly specialized surgeons whose knowledge and experience have provided the very best orthopedic care,” said Bryan T. Kelly, MD, surgeon-in-chief and medical director of HSS. “The appointments of Drs. Lee and Sink will help us continue to elevate our unique services and continue our exclusive focus on the issues that can be debilitating to a person’s movement and livelihood.”

On November 1, Dr. Lee will succeed Edward A. Athanasian, MD and Dr. Sink will succeed Robert L. Buly, MD, both of whom have helped lead and build their Services over the last nine and four plus years, respectively, and will continue their practices as chiefs emeriti. In the new roles, Drs. Lee and Sink will lead highly-integrated multidisciplinary programs focused on the treatment of simple and complex conditions associated with their areas of expertise.

“We have sustained our leadership position in the industry due to our extraordinary physician leaders who are dedicated to advancing the field,” said Louis A. Shapiro, president and CEO of HSS. “We thank Drs. Athanasian and Buly for their commitment to HSS and look forward to expanding our growth even further with Drs. Lee and Sink at the helm.”

Dr. Lee focuses on hand, wrist, and elbow conditions as well as brachial plexus and peripheral nerve problems. A graduate of Duke University School of Medicine, he joined HSS in 2011. Additionally, Dr. Lee is the Research Director for the HSS Center for Brachial Plexus and Traumatic Nerve Injury.

“Our hands are so critical to our daily lives, yet they can often be taken for granted,” said Dr. Lee. “I look forward to leading our amazing team as we help both children and adults overcome bone and soft-tissue conditions in the hand, wrist, forearm, elbow.”

Dr. Sink specializes in the treatment of hip disorders from newborns into adulthood (40’s) including hip dysplasia. He performs hip preservation procedures such as Periacetabular Osteotomies, Surgical Hip Dislocation and open hip reductions in children. A graduate of Texas Southwestern Medical School, Dr. Sink joined HSS in 2011.

“When people think of hip pain, they often think hip replacement is the only option,” said Dr. Sink. “However, there is a wide array of treatments focused on joint preservation that can help young, active patients restore a high level of function. We have seen that timely intervention for certain hip conditions could slow or even reverse their progression.”

The Hip Preservation Service is a multidisciplinary service with a range of experts in their respective fields who as a team are committed to patient care, education and research regarding improving pain and function in patients with pre-arthritic hip disorders.

HSS has the lowest readmissions rate in Orthopedics in the U.S. In 2018, HSS provided care to 139,000 patients from all 50 states and 80 countries, and performed more than 32,000 surgical procedures.

The research and the copyrighted questionnaire were published in the Journal of Bone & Joint Surgery today.

The brachial plexus is a network of nerves that extends from the spinal cord in the neck, under the collarbone and down the arm. These nerves control the shoulder, arm, elbow, wrist and hand. A brachial plexus injury (BPI) can be life-altering. People often suffer from severe, unrelenting pain and can lose the use of their arm and hand.

"A brachial plexus injury has a profound impact on quality of life," said Carol A. Mancuso, MD, a senior scientist at HSS and lead investigator. "Patients are usually young adults who sustained trauma, such as from a motor vehicle accident or sports injury."

Dr. Mancuso and orthopedic surgeons specializing in complex nerve reconstruction surgery for BPI sought to develop a questionnaire to thoroughly understand the injury’s impact on patients. "The sudden nature of the injury can lead to a realm of psychological challenges, such as emotional distress, loss of independence, and depression, that can overwhelm patients and potentially hamper recovery," said Dr. Mancuso, who specializes in developing surveys and questionnaires at HSS. "Capturing these psychological elements is necessary to thoroughly understand disability and recovery from this complex condition."

"The questionnaire is important because it moves beyond the surgeon’s interpretation of the outcomes of surgery and gets to the heart of patient needs, expectations, and functional satisfaction," said Scott W. Wolfe, MD, director of the Center for Brachial Plexus and Traumatic Nerve Injury at HSS. "It probes the emotional as well as the physical impact of the injury and realizes data that is not identified in any other outcome measure."

Dr. Mancuso developed the questionnaire based on patient input, with preoperative and postoperative versions. Patients with BPI who were undergoing or had already undergone surgical reconstruction were enrolled during routine office visits at HSS.

The study had three phases. Phase 1 included interviews with patients using open-ended questions addressing the impact of BPI and improvement expected before surgery (preoperative patients) or received (postoperative patients). Phase 2 involved assembling a draft questionnaire and administering it twice to establish test-retest reliability. Phase 3 involved selecting final items, developing a scoring system, and assessing validity. Patient scores using the questionnaire were assessed in comparison with scores of the Disabilities of the Arm, Shoulder and Hand (DASH) and RAND-36 measures.

The HSS preoperative and postoperative surveys both include questions rating the severity of BPI symptoms; assess difficulty with activities of daily living, such as getting dressed; address psychological issues, such as depression; and ask how the injury has affected school or work. The preoperative questionnaire also assesses how much improvement patients expect from treatment, while the postoperative version asks how much improvement patients believe they received from surgery or another treatment.

Dr. Mancuso noted that the questionnaire has the potential to improve patient care. "First, it provides a template from which patients can discuss the spectrum of physical and emotional effects of BPI with their surgical team. This, in turn, offers providers the opportunity to comprehensively address patients’ needs directly or through a referral," she said. "Second, the questionnaire fosters discussion of realistic outcome expectations, which are necessary to maintain motivation and ensure long-term participation in rehabilitation. This also enables patients to make appropriate plans for school or work activities."

"We will be able to tell what matters most to patients and then see if we achieved their goals," said Steve K. Lee, MD, director of research, Center for Brachial Plexus and Traumatic Nerve Injury. "Other outcomes measurements were not specific enough to this unique, complex patient population."

Dr. Wolfe noted, "The questionnaire will, without a doubt, improve patient care by aligning surgical and treatment alternatives with patient needs and expectations."

In addition, the survey plays a role in assessing outcomes of highly specialized nerve reconstruction surgery to repair brachial plexus injury, according to Dr. Mancuso. "The questionnaire provides a valid and standardized method for clinicians and researchers to document and compare patient-reported outcomes from specific or novel surgical interventions."

This work was supported by the J.W. Kieckhefer Foundation, the Howard J. Golden Family Research Fund, and a Richard Menschel institutional award.

Institutions that wish to receive a copy of the questionnaire, which is copyrighted, are invited to contact Dr. Mancuso via email: MancusoC@hss.edu.

About the Center for Brachial Plexus and Traumatic Nerve Injury at HSS

The Center for Brachial Plexus and Traumatic Nerve Injury at Hospital for Special Surgery is a national resource for men and women of all ages, providing diagnostic and reconstructive options for patients with injuries to or dysfunction of the peripheral nerve and brachial plexus. Using a multidisciplinary approach, the center utilizes the expertise of a wide range of health care professionals including orthopedic surgeons, physiatrists, neurologists, radiologists, psychiatrists, rheumatologists, pain management specialists, physical therapists and anesthesiologists, so that patients can benefit from a coordinated treatment experience. For more information, visit: http://www.hss.edu/brachialplexuscenter

While historically used to determine SLAC progression, plain radiographic methods are not always sensitive. Researchers from Hospital for Special Surgery assessed the prevalence of radiolunate (RL) ligament wear in SLAC/SNAC patients by comparing operative findings to MRI and plain radiographs to determine diagnostic accuracy.

This retrospective study looked at 41 patients who underwent wrist surgery between 2006 and 2016 and were diagnosed with SLAC or SNAC with preoperative imaging. This ten-year review utilized operative reports as well as radiographs graded by radiologists using the Kelgran Lawrence Joint Grading Scale.

According to operative and MRI findings, the study found that RL wear occurs in late SLAC/SNAC patients. It was determined that plain radiograph findings underestimate the degree of involvement and that MRI has a potentially higher diagnostic accuracy for detection of RL wear. MRI findings had a stronger correlation with operative pathologic findings than radiograph (p = 0.158 vs. p = 0.337).

The study’s results suggest that surgeons should consider taking a high-resolution MRI prior to joint preserving surgery in the wrist. This knowledge can potentially change the surgical management of SLAC/SNAC osteoarthritis.

Abstract Title: Magnetic Resonance Imaging Findings Correlate with Operative Findings in Patients with SLAC/SNAC Osteoarthritis

Authors: Danielle Christine Marshall, BA; Schneider K. Rancy, BA; Alissa J. Burge, MD; Hollis G. Potter, MD; Scott W. Wolfe, MD; Steve K. Lee, MD.

While there are multiple techniques to achieve this, there are no recent studies that analyze which is optimal for patients to regain elbow flexion. Researchers from Hospital for Special Surgery set out to determine the best method to improve elbow flexion strength after BPI.

The study looked at data from 12 patients who underwent a nerve transfer for elbow flexion reconstruction after a BPI. The data was collected between 2005 and 2013 and includes physical examination and electromyographic (EMG) data.  There were no demographic differences between the patients.

The researchers found that the ulnar fascicular nerve transfer to brachialis and median fascicular nerve transfer to biceps brachii motor branch appeared to have more advantages when compared to an ulnar fascicular nerve transfer to biceps brachii and median fascicular nerve transfer to brachialis motor branch. After this method, patients saw a British Medical Research Score (BMRC) grade 4 elbow flexion strength earlier than expected, as well as increased motor unit recruitment of the brachialis muscle EMG. Elbow flexion strength did eventually equalize at 36 months regardless of surgical technique.

With a lack of available literature on this specialized injury, this study provides valuable insight to surgeons who had no prior indication of the most optimal nerve transfer for their patients.

Abstract Title: Elbow Flexion Restoration in Brachial Plexus Injuries: What is the Optimal Nerve Transfer?

Authors: Natalia Fullerton, MD; Eliana Saltzman, MD; Joseph T. Nguyen, MPH; Anum Lalani, MPH; Steve K. Lee, MD; Scott W. Wolfe, MD