Brachial Plexus Burner

Aka: Brachial Plexus Burner, Brachial Plexus Stinger, Stinger, Burner

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II. Epidemiology

  1. Occurs in Contact Sports (esp. football, wrestling)
  2. Most common c-spine related injury in football
    1. Incidence as high as 65% per football player (and 50% of other collision athletes)

III. Mechanism

  1. Transient Neuropraxia of nerve roots or Brachial Plexus
    1. Cervical nerves pinched by extension-compression
    2. Brachial Plexus stretched during block or tackle
    3. Most commonly affected at C5 and C6
  2. Older athletes
    1. Disc disease or other pathology in 94% of cases

IV. Symptoms

  1. Sharp, burning pain or parestheias in Shoulder region
    1. Radiation into arm and hand
    2. Follows circumferential pattern of Paresthesias
      1. Does not follow Dermatomal Distribution
  2. Typically unilateral
    1. Consider Cervical Cord Neuropraxia if bilateral
  3. Symptoms last seconds to minutes
    1. Patient regains strength and range of motion after resolution
  4. Motor weakness may occur at time of injury or develop hours to days later
  5. NO Cervical Spine findings on exam (e.g. midline Cervical Spine tenderness, reduced neck range of motion)

V. Exam

  1. Neurologic Exam
  2. Cervical Spine Exam
  3. Shoulder Exam
  4. Hand Neurovascular Exam

VI. Differential Diagnosis

  1. Cervical Cord Neuropraxia
  2. Cervical Spine Injury
  3. Thoracic Outlet Syndrome

VII. Red flags

  1. Consult Neurosurgery for red flag findings
  2. Findings suggestive of serious Cervical Spine Injury
    1. Persistent symptoms (especially >24 hours)
      1. Burners usually resolve in minutes
    2. Bilateral symptoms
    3. Upper and lower extremities involved
    4. C-Spine range of motion diminished or spinal process tenderness

VIII. Evaluation: Serial examinations

  1. Baseline
  2. Repeat in 24 hours and then every few days for first 2 weeks

IX. Diagnostics

  1. Indications
    1. New or significant worsening symptoms
    2. Recurrent Stingers
  2. Studies
    1. Nerve Conduction Studies and EMG
    2. MRI C-Spine
    3. Consider neurosurgery Consultation

X. Management: Sideline

  1. Indications to return to play after brief event
    1. All symptoms resolve within 5 minutes
    2. Normal Neurologic Exam (see Hand Neurovascular Exam)
    3. Normal and symmetric radial pulses
    4. No findings of Cervical Spine Injury
      1. No midline Cervical Spine tenderness
      2. Full Cervical Spine range of motion
  2. Return to play requires at least one repeat examination during event
  3. Cantu (1997) Med Sci Sports Exerc 29(7 Suppl): S233-5 [PubMed]

XI. Management: General

  1. No Contact Sports until symptoms resolve
  2. Evaluate for associated head and neck injury
    1. See Cervical Spine Injury
    2. See Concussion in Sports
    3. Assess for Brachial Plexus Injury
  3. Symptom duration determines return to play
    1. Symptoms that resolve in minutes may return to play
      1. See return to play indications above
    2. Symptoms persist in 5-10% of cases
      1. Full evaluation needed if symptoms last >24 hours
  4. Return to play indications
    1. Symptoms resolved AND
    2. No pain with Cervical Spine range of motion or midline tenderness AND
    3. Normal radial pulses AND
    4. Normal Neurologic Exam
      1. Normal strength exam
      2. Normal Sensory Exam
  5. Recurrent symptom evaluation
    1. Assess for Cervical Spinal Stenosis

XII. Course

  1. Pain and Paresthesia resolves quickly, seconds-minutes
  2. Weakness typically resolves within 24 hours, but may persist for days up to 6 weeks
  3. Persistent weakness or sensory changes beyond 2 weeks
    1. Suggests Brachial Plexus Injury

XIII. Prevention

  1. Isotonic Exercises for neck and Shoulder
  2. Preventive equipment
    1. Neck roll
    2. "Cowboy" collar

XIV. References

  1. Kalsi, Kaufman and Hudson (2018) Crit Dec Emerg Med 32(10): 3-10
  2. Page (2004) South Med J 97:766-9 [PubMed]
  3. Nissen (1996) Physician Sportsmed 24:57-64 [PubMed]
  4. Usman (2022) Am Fam Physician 106(5): 543-8 [PubMed]

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