Plexopathy (plexitis) is a group of diseases based on the lesion of the nerve plexus formed by spinal nerves. Disease is manifested by plexalgia and loss of functions included in the affected plexus of nerve trunks (paresis, muscular hypotension and atrophy, lack of tendon reflexes, trophic and vegetative disorders). Pathology can be diagnosed according to typical neurological symptoms, taking into account anamnesis data, results of electromyography and electroneurography, X-ray, tomographic and ultrasound examinations, consultations of related specialists. Treatment tactics are determined by etiology. Basically, these are conservative methods, the operation is necessary for traumatic and compression plexopathy.
General information
After leaving the spinal column, the spinal nerves are divided into posterior and anterior branches. The latter are grouped and intertwined with their fibers, forming paired nerve plexuses. The cervical plexus is composed of the anterior branches of the roots C1-C4 and is located behind the sternocleidomastoid muscle. In the interstitial space with the transition to the axillary fossa there is a brachial plexus formed by branches C5-Th1.
Spinal nerves of the thoracic level, except for Th1, do not form plexuses. The next nerve plexus is located in the depth of the large lumbar muscle and is called the lumbar. It consists of separate fibers of the anterior branch of the nerve Th12, the anterior branches L1- L3 and partially of the nerve L4. The other part of the fibers of the anterior branch of the spinal nerve L4 together with L5, S1-S4 forms the sacral plexus located in the pelvic cavity. The coccygeal plexus is localized to the side of the sacrum, the sacral muscle is located behind it. The plexus is formed by part of the anterior branches of S5 and two coccygeal nerves.
Causes
A significant place among the factors causing plexopathy belongs to trauma. This can be a strong blow to the plexus area (a bruise of the arm in the shoulder area, a bruise of the lumbar or cervical region, a spinal injury, a fall on the coccyx); a gunshot, cut or stab wound; stretching of the nerve trunks of the plexus with sharp traction for a leg or arm, dislocation of the shoulder or dislocation of the hip, a fracture of the pelvic bones. Posttraumatic plexopathy occurs in the practice of obstetricians-gynecologists and neonatologists, as a consequence of birth trauma (for example, Erb’s palsy). The leading pathogenetic mechanisms in trauma are: damage to the branches of the nerve interweaving with partial or complete rupture of their fibers, compression of the nerve trunks of the plexus by post-traumatic hematoma or edema. The most common is posttraumatic plexopathy of the brachial plexus.
Other causes of plexopathy include: tumors located in the plexus area or lymph nodes enlarged as a result of lymphadenitis, spinal abnormalities, spinal curvature (scoliosis), hypothermia, some infections (herpes zoster, syphilis, influenza, tuberculosis, brucellosis), autoimmune diseases (Guillain-Barre syndrome), metabolic disorders (gout, diabetes mellitus). In some cases, the etiofactors of sacral and coccygeal plexopathy are inflammatory processes (adnexitis, salpingitis, cystitis, prostatitis, etc.) and thrombophlebitis of the pelvic veins. Cervical plexopathy can be caused by an aneurysm of the subclavian artery, an additional cervical rib.
Symptoms
As a rule, plexopathy is one-sided. There are several stages in its course. In the neuralgic stage, plexalgia is the leading symptom — pain that occurs in the nerve plexus and radiates to the periphery along its nerve trunks. Plexalgia often has a spontaneous character, it increases with pressure in the area of the nervous plexus, at night and during movements. Slight sensory disturbances are possible.
The appearance of signs of loss of nerve function of the affected plexus marks the transition of plexopathy to the paralytic stage. There are paresis or paralysis, hypotension and hypotrophy of the muscles innervated by these nerves; there is a loss of the corresponding tendon reflexes. In the areas for the innervation of which the affected plexus is responsible, all types of sensitivity suffer and trophic disorders appear — vasomotor reactions, pasty, hyperhidrosis or anhidrosis, paleness of the skin. Disease can be complete or partial. In the latter case, the symptoms of the paralytic stage manifest themselves more narrowly — only in the areas innervated by the affected part of the plexus.
In the future, plexopathy goes into a recovery stage, which can last up to a year. The degree of recovery of lost nerve functions varies. With incomplete recovery, plexopathy leads to irreversible residual phenomena in the form of persistent flaccid paresis, muscle atrophy, joint contractures.
Cervical form manifests diffuse pains on the antero-lateral surface of the neck, radiating into the ear and occiput. If the nerves of the cervical plexus are irritated, a muscular-dystonic syndrome may develop in the form of spastic torticollis. Possible irritation of the diaphragmatic nerve, accompanied by hiccups. In the paralytic stage, cervical plexopathy is manifested by paresis of the diaphragm, atrophy of the posterior-cervical and subcutaneous muscles.
Shoulder form can be upper, lower and total. Total shoulder plexopathy is characterized by pain in the entire upper limb, bearing separate signs of sympathalgia; sluggish paresis of the arm; atrophy of the muscles of the arm and shoulder girdle; loss of tendon reflexes and signs of vegetative-trophic dysfunction in the tissues of the upper limb. Due to muscle atrophy, a habitual dislocation of the shoulder may occur. At the stage of residual phenomena, contracture of the elbow joint is possible.
Lumbar form is accompanied by plexalgia with pain radiating along the anterior surface of the thigh and into the buttock. The reduction and flexion of the hip, extension in the knee joint is impaired. For this reason, it is difficult for the patient to walk and stand. There is no knee reflex and sensory perception of the gluteal region of the thigh and the medial surface of the lower leg. Atrophic changes are noted in the muscles of the buttocks and the front side of the thigh. Knee joint contracture may develop.
Sacral form is often combined with lumbar plexopathy. For him, pain radiating along the leg in the sacrum area, the presence of trigger points along the gluteal and sciatic nerve trunks, hypesthesia and muscular atrophy along the posterior surface of the thigh, foot and lower leg are typical. plexopathy of the coccygeal plexus is characterized by the absence of an anal reflex, a disorder of defecation, urination and sexual function.
Diagnostics
To establish a preliminary diagnosis of plexopathy, the data of anamnesis and neurological examination allow. The determination of muscle groups with reduced muscle strength, areas of hypesthesia, dropped reflexes provides a basis for diagnosing the level of damage to the peripheral nervous system. Electroneurography and electromyography help the neurologist to clarify the topic of the lesion. In some cases, you may need: consultation of a traumatologist, orthopedist, urologist, gynecologist, oncologist; radiography of the shoulder joint, spine x-ray, radiography of the hip joint, CT of the joint, CT of the spine; Ultrasound of the pelvic organs.
It is necessary to differentiate plexopathy from syringomyelia, polio, sciatica, neuritis, radiculopathy in diseases of the spine (osteochondrosis, herniated disc, spondyloarthrosis), polyneuropathy, joint pathology (arthrosis, arthritis, ligament damage, etc.). Depending on the localization, disease is differentiated from femoral nerve neuropathy, fibular neuropathy, sciatic nerve neuropathies, ulnar and radial neuropathy.
Treatment
In the case of post-traumatic plexopathy, specialists in the field of traumatology and neurology jointly supervise the patient. It is necessary to create peace of the affected area. For this purpose, it is possible to immobilize the limb with a bandage or a splint. With the infectious genesis, appropriate etiotropic therapy is carried out, anti-inflammatory pharmaceuticals (ketorolac, diclofenac, ibuprofen) are used. If disease has a toxic etiology, then detoxification measures are carried out.
Plexopathy of any genesis is an indication for the appointment of neurometabolic treatment (vitamins B6, B1, B12) and therapy aimed at improving metabolic processes in muscle tissue and neuromuscular synapses (ATP, galantamine, neostigmine). The pain syndrome is stopped by taking painkillers and carrying out therapeutic blockades. To improve blood circulation in the plexus tissues and affected muscles, vascular preparations (pentoxifylline, xanthinol nicotinate, nicotinic acid) are recommended for complex treatment.
Among the physiotherapeutic procedures in the therapy, UHF, diadynamic currents, electrophoresis on the corresponding spinal segments, amplipulstherapy, phonophoresis with hydrocortisone on the plexus area, ionophoresis with novocaine are effective. After the relief of acute symptoms, or about 2-3 weeks after the injury, the treatment package includes physical therapy and massage aimed at strengthening muscles and preventing the development of contractures. Acupuncture is used in the initial period of plexitis to relieve pain, then proceed to electroacupuncture. In the recovery period (not earlier than 6 months after the injury), hydrotherapy with radon and hydrogen sulfide baths, mud therapy, ozokeritotherapy are recommended.
Surgical treatment requires post-traumatic form, which is not amenable to conservative therapy, and plexopathy due to compression of the plexus. In the first case, the nerve trunk is plasticized, in the second — removal of hematoma, tumor, etc. compressing factors.
Prognosis and prevention
In the absence of treatment, plexopathy may not have a very favorable prognosis, since the severity of residual phenomena (paresis, contractures) often leads to disability of the patient. In other cases, the prognosis depends on the etiology of plexitis, the age of the patient, the presence of background diseases, and the timeliness of the start of treatment.
To prevent traumatic plexopathy, measures aimed at preventing injuries in adults, children and especially athletes help. The leading role in the prevention of plexitis in newborns is played by proper pregnancy management and an adequate choice of delivery method. Timely treatment of infections can prevent plexopathy of infectious etiology.