AANEM Connect

Hi all,

I have had two cases recently which I would love the group's thoughts on. Both patient's had an atraumatic onset of severe pain through the shoulder/scapular/lateral arm region. This involved some sensory symptoms and weakness. The pain was so severe to keep them awake for a few days. They both then developed significant atrophy through C5 myotomes in the coming months with scapula winging. 

I saw them month approx 5 months post event. The NCS demonstrated recordable lateral cutaneous nerve responses, both within allowable symemtry of the contralateral side. The remainder of the NCS were normal (sensory/motor studies of median, ulnar, radial, antebrachial bilaterally). 

The EMG demonstrated involvement of seemingly fairly isolated C5 muscles (Rhomboids, supraspin, infraspin, deltoid, biceps with sparing of brachioradialis, triceps, EDC, FDI, serratus anterior) with both spontaneous neurogenic changes and neurogenic units with reduced recruitment. 

The MRI Cx spines for these patients demonstrated a mild, and a moderate (respectively) C5 formainal stenosis without nerve impingement. 

The MRI plexus was normal (but this was a delayed scan post my assessment, so approx 5-6 months post event)

My questions for the group

1) Historically, involvement of Rhomboids was used to demonstrate pre-plexus localisation. There have been a number of case reports in recent times, with people documenting involvement in later diagnosed plexopathies. How many people would still use Rhomboid involvement as evidence of pre-plexus localisation? 

2) Severe onset, atraumatic pain keeping patients awake with then progressive atrophy is not restricted to Brachial Plexopathies, but would make one think this, rather than a Radiculoapthy. These two patients have a very C5 isolated picture, Rhomboid involvement, seemingly spared peripheral nerves (including LABC), with mild and moderate formainal stenosis. Acknolwedging that you would be trusting my  ncs skills/report, who would lean towards a radiculopathy and who towards a C5/very early upper plexoapthy. 

Thank you all