MRI Findings of 26 Patients with Parsonage-Turner Syndrome

Scalf et al. Musculoskeletal Imaging • Clinical Observations
MRI of Patients with
Parsonage-Turner
Syndrome

Downloaded from www.ajronline.org by 50.116.19.84 on 08/02/16 from IP address 50.116.19.84. Copyright ARRS. For personal use only; all rights reserved MRI Findings of 26 Patients with
Parsonage-Turner Syndrome

Richard E. Scalf1 OBJECTIVE. The objective of our study was to describe the MRI features of patients with
Doris E. Wenger1 Parsonage-Turner syndrome. Familiarity with the MRI features associated with this entity is im-
Matthew A. Frick1 portant because radiologists may be the first to suggest the diagnosis. Twenty-six patients with
Jayawant N. Mandrekar2 Parsonage-Turner syndrome were treated at our institution between 1997 and 2005. We retrospec-
Mark C. Adkins1 tively reviewed the MR images of patients with clinical or electromyographic evidence (or both)
of acute brachial neuritis without a definable cause.
Scalf RE, Wenger DE, Frick MA, Mandrekar
JN, Adkins MC CONCLUSION. MRI of the brachial plexus and shoulder in patients with Parsonage-Turner
syndrome showed intramuscular denervation changes involving one or more muscle groups of the
shoulder girdle. The supraspinatus and infraspinatus muscles were the most commonly involved.
MRI is sensitive for detecting signal abnormalities in the muscles of the shoulder girdle of patients
with Parsonage-Turner syndrome. MRI may be instrumental in accurately diagnosing the syndrome.

P arsonage-Turner syndrome, also Materials and Methods
known as “acute idiopathic brachial
neuritis,” is a painful nontraumatic We retrospectively reviewed the records of all
the patients from our institution who were exam-
disorder involving the shoulder gir- ined between 1997 and 2005 and had clinical or
electrophysiologic evidence (or both) of acute bra-
dle. Patients with Parsonage-Turner syndrome chial plexopathy without a definable cause (e.g.,
appropriate history of trauma or anatomic abnor-
typically present with a sudden onset of shoul- mality). This study was approved by the Mayo
Clinic Institutional Review Board and met the cri-
der pain or weakness (or both) of the shoulder teria established for waiver of informed consent.

girdle musculature [1]. Clinically, establishing Patients were identified by searching our data-
base for those who underwent MRI of the brachial
the diagnosis may be challenging because plexus or shoulder. The keywords that were used
in the search included “Parsonage-Turner,” “acute
symptoms are nonspecific and may mimic other brachial neuritis,” and “denervation.” Because we
searched through an MRI database, patients with
shoulder girdle disorders such as labral tear with the clinical diagnosis of Parsonage-Turner syn-
drome who did not undergo MRI evaluation were
associated paralabral cyst, rotator cuff tear, im- excluded from the study. In addition, after the
medical records and MRI examinations were re-
pingement, and adhesive capsulitis [1–4]. Eval- viewed, patients were excluded if they had a his-
tory of trauma, radiation, or neoplasm or if there
uation of patients with shoulder pain and weak- was MRI evidence of rotator cuff tear, bone or
soft-tissue mass, labral tear associated with paral-
Keywords: denervation, idiopathic brachial neuritis, MRI, ness typically includes a medical history, abral cyst, or other conditions that could contrib-
musculoskeletal imaging, Parsonage-Turner syndrome, ute to muscle weakness. Patients with a clinical di-
shoulder physical examination, imaging studies, and pos- agnosis of Parsonage-Turner syndrome and
normal findings after the MRI examination were
DOI:10.2214/AJR.06.1136 sibly electrophysiologic evaluation. also excluded because the purpose of our study
was to evaluate and report only positive MRI find-
Received August 25, 2006; accepted after revision MRI is the imaging technique of choice in ings of patients with this diagnosis. Twenty-six
January 15, 2007. patients met the inclusion criteria for the study.
patients with shoulder pain and weakness and
1Department of Radiology, Mayo Clinic, 200 First St., SW,
Rochester, MN 55905. Address correspondence to provides the most comprehensive evaluation
D. E. Wenger.
of the shoulder girdle because of its multipla-
2Division of Biostatistics, Mayo Clinic, Rochester, MN.
nar imaging capability and superior soft-tis-
WEB
This is a Web exclusive article. sue contrast. Familiarity with the MRI fea-

AJR 2007; 189:W39–W44 tures of Parsonage-Turner syndrome is
0361–803X/07/1891–W39
© American Roentgen Ray Society critical for radiologists because they may be

the first to suggest the diagnosis. In this arti-

cle, we describe the MRI findings of 26 pa-

tients with Parsonage-Turner syndrome. This

study and the recently published study by

Gaskin and Helms [5] are the largest reported

series describing the imaging features of Par-

sonage-Turner syndrome to date.

AJR:189, July 2007 W39

Scalf et al.

Downloaded from www.ajronline.org by 50.116.19.84 on 08/02/16 from IP address 50.116.19.84. Copyright ARRS. For personal use only; all rights reserved Fig. 1—Bar graph Patients (%) 90 graphy (EMG) and had positive findings for
illustrates spectrum of 80 Parsonage-Turner syndrome. Seven patients
muscles of shoulder 70 did not undergo EMG, but each had strong
girdle and chest wall that 60 clinical evidence that supported the diagnosis
were affected in patients 50 of Parsonage-Turner syndrome and excluded
with Parsonage-Turner 40 other causes.
syndrome and shows 30
percentage of patients 20 The study patients included 20 males (77%)
with involvement of each 10 and six females (23%). The median age at diag-
muscle. Supraspinatus nosis was 45 years (range, 8–77 years). No sta-
and infraspinatus 0 tistically significant correlation was identified
muscles were most between the affected side and the dominant
commonly affected SSIuunfpTbrresaarcsseaspppiiunnMliaaattnruiuosssr handedness of the patient. Hand dominance
muscle groups, which LatissiRhPmeoucstmDeoblDrtooiaolridisissd was recorded for 20 patients: 17 (85%) were
explains why presenting right-handed and three (15%), left-handed.
symptoms mimicked Clinical symptoms were on the right side for 12
rotator cuff tendon tears patients (46%), on the left side for 12 patients
or mass in spinoglenoid (46%), and bilateral for two patients (8%).
notch that impinged on
suprascapular nerve. Clinical symptoms were variable: Most pa-
tients presented with isolated pain, weakness,
All MRI examinations were performed using a Affected Muscles or numbness (or a combination of the three).
1.5-T scanner (Signa, GE Healthcare). Each patient The most common clinical presentation was
underwent MRI of the brachial plexus or shoulder, of increased intramuscular signal on T2-weighted pain and weakness (11 patients [42%]), and the
depending on the clinical suspicion of the cause of images. Muscular atrophy with fatty infiltration second most common was pain alone (six pa-
the pathologic process. Brachial plexus examina- was defined as decreased muscle mass and linear tients [23%]). A small number of patients pre-
tions included axial, oblique sagittal, and oblique foci of increased T1-weighted or proton density in- sented with pain, weakness, and numbness
coronal T1-weighted fast spin-echo images (TR/TE tramuscular signal when compared with the relative (four patients [15%]) or weakness alone (three
minimum, 400/600; field of view [FOV], 34 cm; volume and signal intensity of adjacent normal patients [12%]). One patient presented with
slice thickness, 6 mm; intersection gap, 1 mm; ma- muscle groups. Fatty infiltration was identified on pain and numbness and another with weakness
trix, 256 × 256) and oblique sagittal and oblique proton density sequences as linear foci of increased and numbness. None of the patients was asymp-
coronal T2-weighted fast spin-echo inversion re- intramuscular signal that also showed decreased tomatic. Patients presented with symptoms in
covery images (TR/TE, 3,200/68; inversion recov- signal on corresponding fat-saturated T2-weighted various muscles of the shoulder girdle, includ-
ery time, 130 milliseconds; FOV, 26–30 cm; slice or inversion recovery sequences. The latter two T2- ing the supraspinatus, infraspinatus, deltoid,
thickness, 6 mm; intersection gap, 2 mm; matrix, weighted imaging sequences in combination were teres minor, subscapularis, latissimus dorsi,
256 × 192). All brachial plexus images were ob- interpreted as the equivalent of T1-weighted im- pectoralis, and rhomboids.
tained using a body or torso coil. ages for recognition of fatty infiltration. All MRI
data were correlated with available initial and fol- Review of the MRI examinations showed
Shoulder examinations were performed using a low-up clinical information. that the supraspinatus and infraspinatus mus-
shoulder coil and included axial, oblique coronal, cles were affected most frequently (Fig. 1).
and oblique sagittal proton density images Statistical analyses were primarily descriptive. Most patients (88%) presented with more
(3,200/32; FOV, 14 cm; slice thickness, 4 mm; in- Categoric variables were summarized using fre- than one affected muscle group. Three or
tersection gap, 0.5 mm; matrix, 256 × 256). Axial, quencies and percentages, and continuous variables more muscles were affected in 17 patients
oblique coronal, and oblique sagittal fat-suppressed were summarized using medians and ranges be- (65%), two muscles in six patients (23%), and
T2-weighted images (3,550/50; FOV, 14 cm; slice cause of skewed distribution. Associations between only one muscle in three patients (12%).
thickness, 4 mm; intersection gap, 0.5 mm; matrix, categoric variables (e.g., the affected side and the
256 × 256) were also obtained as a part of the shoul- dominant handedness of the patient) were assessed Muscles were evaluated for evidence of den-
der imaging protocol. Neither intraarticular nor IV using the chi-square test or the Fisher’s exact test as ervation change in the shoulder girdle and chest
gadolinium was used for any of the examinations. appropriate. Statistical tests were two sided, and p wall. Each muscle was evaluated for the pres-
values less than 0.05 were considered statistically ence of edema and atrophy (Table 1). The su-
All imaging studies were reviewed by consensus significant. All statistical analyses were performed praspinatus and infraspinatus muscles were the
of three musculoskeletal radiologists. Each re- using a commercial software package (version 8.0 most commonly affected muscles in our series.
viewer had completed a 1-year musculoskeletal fel- SAS, SAS Institute). Of the patients with a detectable signal abnor-
lowship, and two reviewers had 14 and 10 years of mality in the supraspinatus and infraspinatus
additional experience as musculoskeletal radiolo- Results muscles, one third showed MR evidence of only
gists. Positive MRI findings were defined as fea- We retrospectively identified 26 patients intramuscular edema and no evidence of atro-
tures of denervation change that involved muscles phy or fatty infiltration on T1-weighted or
of the rotator cuff or shoulder girdle, including in- with clinical or electrophysiologic evidence non–fat-saturated proton density images
tramuscular edema, muscular atrophy with or with- (or both) of Parsonage-Turner syndrome who (Fig. 2). Just over one half showed marked dif-
out fatty infiltration, or a combination of these find- had positive MRI findings. All patients had fuse increased T2-weighted signal with atrophy
ings. Intramuscular edema was defined as any area clinical findings that were compatible with and fatty infiltration on T1-weighted or non–fat-
Parsonage-Turner syndrome. Nineteen of the saturated proton density images (Fig. 3).
26 patients were evaluated using electromyo-

W40 AJR:189, July 2007

MRI of Patients with Parsonage-Turner Syndrome

TABLE 1: MRI Findings of 26 Patients with Parsonage-Turner Syndrome MRI is an important imaging tool for estab-
lishing the diagnosis of Parsonage-Turner syn-
Affected Edema Only No. (%) of Patients Unaffected drome. In addition to excluding more common
Muscles Atrophy Only Edema and Atrophy causes of shoulder pain such as rotator cuff
tear, impingement syndrome, or labral tear,
Supraspinatus 9 (35) 0 (0) 14 (54) 3 (12) MRI is sensitive for the detection of signal ab-
normalities in the shoulder girdle musculature
Infraspinatus 8 (31) 0 (0) 15 (58) 3 (12) that are related to denervation. MRI also pro-
vides an advantage for excluding structural ab-
Downloaded from www.ajronline.org by 50.116.19.84 on 08/02/16 from IP address 50.116.19.84. Copyright ARRS. For personal use only; all rights reserved Deltoid 5 (19) 1 (4) 5 (19) 15 (58) normalities that may cause similar denervation
changes in rotator cuff musculature such as a
Teres minor 4 (15) 0 (0) 4 (15) 18 (69) rotator cuff tear or spinoglenoid and supras-
capular notch masses. In our series, MRI find-
Subscapularis 3 (12) 0 (0) 2 (8) 21 (81) ings included a broad range of T1- and T2-
weighted signal abnormalities. Intramuscular
Latissimus dorsi 1 (4) 0 (0) 2 (8) 23 (88) changes observed in patients with Parsonage-
Turner syndrome reflect denervation changes
Pectoralis 0 (0) 0 (0) 1 (4) 25 (96) and vary with the stage of disease [11, 12].

Rhomboids 1 (4) 0 (0) 0 (0) 25 (96) We used two imaging protocols in our se-
ries because the indications for imaging the
The MRI findings of two patients with typi- Although the precise cause of Parsonage- brachial plexus or shoulder varied. We there-
cal imaging features of Parsonage-Turner syn- Turner syndrome has not been clearly estab- fore had several limitations when comparing
drome are illustrated in Figures 4 and 5. The lished, viral and autoimmune processes have patients imaged with the brachial plexus pro-
images in Figure 4 were obtained of an 18- been proposed [8, 9]. Most patients present tocol versus those imaged with the shoulder
year-old man who presented with shoulder pain during the third to seventh decade, but re- protocol. The FOV was larger for the brachial
and progressive left upper extremity weakness. ported ages range from 3 months to 82 years plexus protocol and includes more muscle
The overall EMG findings were those of a se- [2, 3, 6, 10]. In a clinical study, Beghi et al. groups than the smaller FOV used for the
vere but incomplete left suprascapular neurop- [10] examined a series of 99 patients and re- shoulder protocol. In addition, muscular
athy with evidence of early reinnervation. MRI ported an incidence rate of 1.64 cases per edema was evaluated using inversion recov-
of the brachial plexus showed diffuse increased 100,000 people. Males are predominantly af- ery sequences in the brachial plexus protocol
T2-weighted intramuscular signal (Figs. 4A fected, with male-to-female ratios ranging and using a T2-weighted fast spin-echo se-
and 4B) and atrophy of the supraspinatus and from 2:1 to 11.5:1 [3, 4, 6]. Our findings cor- quence with fat saturation in the shoulder pro-
infraspinatus muscles (Fig. 4C). Examination relate with those of other studies that show no tocol. Although this difference in protocols
results were otherwise unremarkable; specifi- evidence of a tendency for the right- or left- resulted in minor differences in sensitivity for
cally, none of the images showed evidence of a side upper extremity or correlation with hand the detection of altered intramuscular signal
labral tear, paralabral cyst, or rotator cuff tear. dominance. Bilateral involvement has been intensity, we do not think that it is a signifi-
reported for as many as one third of patients cant limitation of the study. Both sequences
The images in Figure 5 were obtained of a [3]. Phrenic nerve involvement with dia- sensitively detected intramuscular edema,
52-year-old man who presented with acute phragmatic dysfunction has been described and images were evaluated only for the pres-
onset of severe left shoulder pain. His medical [3]. Treatment is palliative and includes anal- ence or absence of edema.
history included a presumed viral infection gesics for pain and physical therapy for weak-
shortly before the onset of shoulder symp- ness. Parsonage-Turner syndrome typically The assessment of fatty infiltration of the
toms. EMG findings were most consistent has a self-limited course, although low recur- muscles also varied between the two proto-
with severe axillary and suprascapular neuro- rence rates have been reported [3]. cols because T1-weighted images were used
pathies, but other elements of the upper trunk in the brachial plexus examination and T2-
of the brachial plexus were spared. MRI of the Most patients with Parsonage-Turner syn- weighted proton density images without fat
left shoulder showed diffuse increased T2 sig- drome present with severe onset of nontrau- saturation were used in the shoulder protocol.
nal in the supraspinatus, infraspinatus, and matic shoulder pain with or without associ- However, this did not limit image analysis be-
deltoid muscles (Figs. 5A and 5B); all were ated weakness, paralysis, and paresthesias [1, cause fatty infiltration could be assessed ac-
associated with mild fatty atrophy. No struc- 2]. Medical history and physical examination curately by comparing the T2-weighted pro-
tural abnormalities were identified that could findings, EMG tests, and imaging studies are ton density images without fat saturation with
explain the denervation change. used to make an accurate diagnosis. EMG and the corresponding T2-weighted fast spin-
nerve conduction velocities may show echo images with fat saturation.
Discussion changes of acute denervation in the brachial
Acute brachial neuritis was first reported plexus distribution [10]. Previous reports The mechanism and time course of MRI
have shown that the most common EMG ab- signal intensity changes in denervated skele-
by Spillane in 1943 [2], but the disease name normalities of Parsonage-Turner syndrome tal muscle are not understood completely [11,
was not established until Parsonage and occur in the distribution of the suprascapular 13–15]. In the acute phase of denervation, the
Turner [1] described a series of 136 clinical nerve, a branch of the superior trunk of the signal intensity of the muscles may be normal
cases in 1948. Other terms used to describe brachial plexus [10]. This correlates with our with MRI [11]. The earliest detectable change
this disease entity include “brachial plexus results, which showed that the supraspinatus
neuropathy,” “paralytic brachial neuritis,” and and infraspinatus muscles, both of which are
“acute brachial radiculitis” [3, 4, 6, 7]. How- innervated by the suprascapular nerve, were
ever, the general term “Parsonage-Turner most commonly involved.
syndrome” is most commonly used.

AJR:189, July 2007 W41

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AB

Fig. 2—38-year-old man with mild pain and paresthesia along lateral aspect of arm.
A, Axial T2-weighted fast spin-echo image with fat saturation of right shoulder shows increased T2 signal (arrowheads) throughout infraspinatus muscle that is compatible
with edema.
B, Axial T1-weighted fast spin-echo image shows no detectable atrophy or fatty infiltration of infraspinatus muscle (arrowheads).

AB

Fig. 3—39-year-old man with pain and paresthesias in right shoulder and upper extremity.
A, Axial T2-weighted fast spin-echo image of right shoulder with fat saturation shows increased T2 signal throughout infraspinatus (I), subscapularis (S), and portion of deltoid
(D) muscles that is compatible with edema.
B, Axial T1-weighted fast spin-echo image shows mild atrophy and fatty infiltration of affected muscles: infraspinatus (I), subscapularis (S), and deltoid (D) muscles.

in denervated muscles is a diffuse increased tration. MRI intramuscular signal change and Turner syndrome. T1-weighted changes of at-
T2-weighted signal (due to edema), which clinical symptoms may revert to normal in rophy without fatty infiltration during follow-
may occur without a T1-weighted signal several months after the chronic phase [11]. up also were described. Until recently, no large
change [11, 15, 16]. In the subacute and studies that reported MRI features of patients
chronic phases of denervation, T2-weighted MRI signal change for patients with Parson- with Parsonage-Turner syndrome had been
signal abnormalities persist and muscular at- age-Turner syndrome has been described in published, to our knowledge. Coincident with
rophy may develop [11, 12, 15]. Atrophic several studies using small patient series. our study, Gaskin and Helms [5] reported the
changes in muscle are reflected by decreased Helms et al. [7] reported increased T2- MRI findings of 27 patients with Parsonage-
muscular mass and increased intramuscular, weighted signal in the supraspinatus, in- Turner syndrome; to our knowledge, their
linear, T1-weighted signal due to fatty infil- fraspinatus, and deltoid muscles at initial pre- study is the largest published series to date.
sentation of three patients with Parsonage-

W42 AJR:189, July 2007

MRI of Patients with Parsonage-Turner Syndrome

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Fig. 4—18-year-old man with shoulder pain and progressive left upper extremity
weakness.
A and B, Oblique sagittal (A) and axial (B) T2-weighted images with fat saturation
show increased T2 signal in supraspinatus (S) and infraspinatus (I) muscles.
C, Axial T1-weighted image shows atrophy of infraspinatus muscle (arrowhead).

C

The MRI findings and anatomic distribu- tures relative to the time course of the disease follow-up MRI examination. Others did not
tion of muscular involvement of patients in in patients with Parsonage-Turner syndrome. return for follow-up evaluation. An additional
our study were similar to those of Gaskin and limitation was the absence of a definite refer-
Helms [5]. Our study of 26 patients showed The limitations of the study include the lack ence standard for diagnosing Parsonage-
that the supraspinatus and infraspinatus mus- of control subjects, lack of information about Turner syndrome that includes evaluation of
cles were most commonly involved. How- the timing of MRI features relative to the dis- clinical history, findings at presentation, and
ever, because our study also included patients ease course, and the low number of follow-up physical examination findings.
who were imaged with the large FOV of the imaging studies available for review. The study
brachial plexus protocol, we noted that other was also limited by variations in the anatomic For patients with shoulder pain of an un-
shoulder muscle groups may also have abnor- extent of the shoulder girdle musculature in- known cause, signal intensity changes ob-
mal MRI signal changes, including the latis- cluded on the examination because the varied served during MRI can be a valuable adjunct
simus dorsi and rhomboid muscles. In addi- symptoms meant that patients were referred to clinical data and electrophysiologic testing
tion, MRI findings indicative of muscle for shoulder or brachial plexus examination. for the diagnosis of Parsonage-Turner syn-
atrophy, including evidence of fatty infiltra- drome. This patient series presents the MRI
tion and decrease in muscle bulk, were iden- Follow-up MRI examinations were per- features of patients with Parsonage-Turner
tified more frequently when compared with formed infrequently because most patients syndrome, which include a spectrum of signal
previous studies. The latter findings are likely showed clinical improvement with resolution abnormalities in various muscle groups of the
related to the relative delay between the onset of symptoms and did not require further im- rotator cuff and shoulder girdle. Familiarity
of symptoms and the MRI examination. Fur- aging. One patient in our study who initially with these MRI features is important for radi-
ther studies will need to evaluate MRI fea- had edema in the supraspinatus and in- ologists because they may be the first to sug-
fraspinatus muscles showed complete resolu- gest the diagnosis.
tion of the denervation changes at an 8-month

AJR:189, July 2007 W43

Scalf et al.

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Fig. 5—52-year-old man with acute onset of severe left shoulder pain.
A and B, Oblique coronal (A) and oblique sagittal (B) T2-weighted images with fat saturation show increased T2 signal in supraspinatus (S), infraspinatus (I in B), and deltoid
(D) muscles.

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W44 AJR:189, July 2007