Case XI: Shoulder Weakness 2

(1)

Department of Neurosurgery, University of Wisconsin, Madison, WI, USA

11.1 Case Presentation

A 58-year-old male complains of weakness of the left shoulder. He woke up 4 months ago with some pain in the left shoulder. Then he started noticing weakness mostly in shoulder abduction and external rotation. The pain subsided after a week. There is no history of trauma . He tried PT for a month with no improvement. PSH: right median n decompression at the elbow 23 years ago. FH: lymphoma in a brother, prostate cancer in the maternal grandfather. Socially, he has smoked a pack of cigarettes per month for about 30 years and takes 2–3 alcoholic drinks per day. On examination, left shoulder abduction is 4+ and external rotation 3. The remaining muscle groups are 5/5. Sensation is intact to light touch. Deep tendon reflexes are 2+ and symmetric.

Fig. 11.1

11.2 Questions

1.

What is the diagnosis? What is the cause?
2.

What tests are needed?
3.

What is the plan of treatment?

Answers

1.

Figure 11.1. There is atrophy of supraspinatus and infraspinatus on the left causing prominence of the spine of the scapula. Diagnosis: Left suprascapular neuropathy. The most likely diagnosis is Parsonage-Turner syndrome because of the pain followed by the weakness. This could also be suprascapular n entrapment at the suprascapular notch. Trauma has been ruled out from the history [1].
2.

EMG /NCS Severe left suprascapular neuropathy proximal to the supraspinatus branch (no motor units in left supraspinatus and infraspinatus with positive spontaneous spikes and waves). The absence of involvement of any other nerves makes it less likely Parsonage-Turner syndrome. MRI of the left shoulder (Fig. 11.2) revealed atrophy (T2 hyperintensity) of the supraspinatus (S) and infraspinatus (I). No masses.

Fig. 11.2
3.

Observation. Bring the patient back in 3 months with a repeat EMG /NCS . Continue PT.