(Kiosk 3) Bilateral Upper Extremity Paresthesia in Severe Burn Patient: A Case Report

Case Diagnosis: 45-year-old male with 70% Total Body Surface Area 2nd and 3rd degree burns.

Case Description or Program Description: The patient was admitted to inpatient rehabilitation after polytrauma, extensive burn injuries, and multiple debridement and graft surgeries. He was noted to have soft tissue restrictions in bilateral axillae (right greater than left), left hip, knees, elbows, and hands. Joint x-rays were taken showing no evidence of mature heterotopic ossification. For post-surgical pain he was prescribed scheduled morphine and as needed oxycodone. For neuropathic pain, he was initially prescribed gabapentin, but replaced with pregabalin with improved efficacy. On day 36 of admission, bilateral forearm paresthesias were noted, suspected to be related to either cervical nerve root compression, brachial plexopathy, or peripheral nerve compression at a different location. The painful paresthesias were provoked with shoulder abduction and external rotation, with noted anterior glenohumeral laxity. These maneuvers result in anterior subluxation of the humeral head, suggesting transient musculocutaneous or radial nerve compression provoking the paresthesias. CT cervical spine showed mild degenerative changes, but not at concordinant levels. MRI cervical spine noted similar degenerative changes, but no neuroforaminal stenoses or cord signal changes.

Setting: Inpatient Rehab Hospital.

Assessment/Results: During the sixth week of rehabilitation course, he began experiencing intermittent, painful paresthesias across lateral arm and forearm provoked by shoulder abduction and external rotation. Imaging ruled out cervical and nerve root compression. Electrodiagnostic testing was deferred due to upper limb edema and reduced skin integrity. Therapy treatments aimed at improving scapular mobility, rotator cuff strengthening, and improving cervicothoracic posture were implemented. In conjunction with scheduled anti-inflammatories and pregabalin, these paresthesias resolved over several weeks. The scheduled anti-inflammatories were stopped due to provocation of limb edema.

Discussion (relevance): This case demonstrates the potential for multiple sites of nerve injury in burn and polytrauma patients, making neurologic localization and advanced imaging helpful in diagnosis. In patients with burn injuries, peripheral edema and skin integrity make electrodiagnostics and sensory testing challenging.

Conclusions: Patients with axillary contractures experiencing transient forearm neuropathies elicited with dynamic movement should be evaluated with cervical spine MRI first to rule out urgent causes, and afterwards assessed for possible brachial plexopathy or other peripheral nerve entrapments.