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| COMMENTARY |
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| Year : 2019 | Volume
: 67
| Issue : 7 | Page : 53-54 |
Role of surgery in radiation induced brachial plexus neuropathy
Anil Kumar1, MS Gopalakrishnan2, Manish Beniwal3
1 Department of Neurosurgery, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
2 Department of Neurosurgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
3 Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, India
| Date of Web Publication | 23-Jan-2019 |
Correspondence Address:
Dr. M S Gopalakrishnan
Department of Neurosurgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0028-3886.250717
How to cite this article:
Kumar A, Gopalakrishnan M S, Beniwal M. Role of surgery in radiation induced brachial plexus neuropathy. Neurol India 2019;67, Suppl S1:53-4 |
Radiation-induced brachial plexus neuropathy (RIBPN) is a rare, devastating but a relatively well-described complication that occurs after radiotherapy in the vicinity of the brachial plexus.[1] RIBPN is usually neglected by patients at the early stage, and clinicians should be aware of this complication while following up their patients post-radiotherapy. The incidence of RIBPN is likely to increase over time as recent advancements in the radiation techniques have resulted in longer survival time. Thus, this complication warrants more attention, despite the rarity of reports. The pathogenesis of radiation induced brachial plexopathy remains elusive but is believed to be secondary to the development of organized fibrosis and the entrapment of nerve fibers.[2]
Radiation therapy in the treatment of breast and lung cancer, as well as other neoplasms involving the neck, shoulder, axilla and upper thorax may result in brachial plexopathy. The total tolerance dose of 60Gy has been suggested for the brachial plexus.[3] It has been found that the risk of RIBPN is lesser than 1% when the doses per fraction of radiation ranges between 2.2 and 2.5 Gy, with the total dose ranging between 34 and 40 Gy being administered.[4]
In patients of RIBPN after breast cancer, the lower trunk of the brachial plexus, that is the C-8 or T-1, is commonly involved, and pan-brachial plexus injury may follow in a prolonged clinical course.[5] Clinically, RIBPN begins with unrelieved pain (that is characteristically neuropathic in character) and progressive motor weakness (with resulting fasciculations and amyotrophy). RIBPN ultimately progresses from the onset of hand paralysis to full limb paralysis in a range of 0.2 to 5 years.[5]
The management of radiation-induced brachial plexus neuropathy depends on the grade of severity of injury. In grade 1 and 2 injuries, medical treatment is required which includes non-opioid analgesics, tricyclic antidepressants, benzodiazepines, and anti-epileptics. Physical and occupational therapy may help to maintain function and prevent joint complications. Surgical exploration is justified in the advanced stage (grades 3 and 4) when conservative measures fail and RIBPN has progressed to severe nerve injury and neurovascular involvement.[6] Neurolysis with pedicled omentoplasty has been proposed as a method of operative treatment in radiation-induced brachial plexopathy. It allows neural elements to be released from the fibrotic tissue and fibrosis of the vascular supply to the nerve is prevented.[6] The dorsal root entry zone (DREZ) lesions in the cervical spinal cord provide a safe and effective therapy for the pain associated with RIBPN.[7] Killer et al., reported in their small series that RIBPN, irrespective of the surgery (neurolysis and/or omentum transplant) performed, left two-thirds of the patients with severe or total paresis of the arm. However, the almost complete relief of severe pain in the majority of patients indicates that surgical treatment has a beneficial effect on pain relief.[8]
In this issue, Desai et al., have discussed the pathogenesis of brachial plexus neuropathy after radiotherapy, as well as its natural history, the symptoms of plexopathy and the methods of treatment.[9] The median interval between radiotherapy and the appearance of symptoms was 18.7 months in this series, which is shorter as compared to the previous series and may be due to the fact that the interval becomes shorter when the dose per fraction and/or total dose increases. In their series of 11 patients, the authors report a significant improvement in neurogenic pain in 9 patients, and the motor function failed to improve and deteriorated significantly in 9 patients at a 6-month follow-up period after neurolysis. We also stress that the retrospective nature, relatively small sample size and short follow up duration should be taken into consideration while interpreting results of this study.
Overall, there is no treatment which will reliably reverse or change the natural history of RIBPN; however, neurolysis may delay vascular insufficiency, avoid progression to complete loss of motor function in selected cases, and provide relief of severe pain in the majority of patients.
| » References | |  |
| 1. | Ferrante MA. Brachial plexopathies: Classification, causes, and consequences. Muscle Nerve 2004;30:547-68.  |
| 2. | Pierce SM, Recht A, Lingos TI, Abner A, Vicini F, Silver B, et al. Long-term radiation complications following conservative surgery (CS) and radiation therapy (RT) in patients with early stage breast cancer. Int J Radiat Oncol Biol Phys 1992;23:915-23. |
| 3. | Emami B, Lyman J, Brown A, Coia L, Goitein M, Munzenrider JE, et al. Tolerance of normal tissue to therapeutic irradiation. Int J Radiat Oncol Biol Phys 1991;21:109-22. |
| 4. | Galecki J, Hicer-Grzenkowicz J, Grudzien-Kowalska M, Michalska T, Zalucki W. Radiation-induced brachial plexopathy and hypofractionated regimens in adjuvant irradiation of patients with breast cancer--a review. Acta Oncol 2006;45:280-4. |
| 5. | Fathers E, Thrush D, Huson SM, Norman A. Radiation-induced brachial plexopathy in women treated for carcinoma of the breast. Clin Rehabil 2002;16:160-5. |
| 6. | Gosk J, Rutowski R, Reichert P, Rabczynski J. Radiation-induced brachial plexus neuropathy - aetiopathogenesis, risk factors, differential diagnostics, symptoms and treatment. Folia Neuropathol 2007;45:26-30. |
| 7. | Teixeira MJ, Fonoff ET, Montenegro MC. Dorsal root entry zone lesions for treatment of pain-related to radiation-induced plexopathy. Spine 2007;32:E316-9. |
| 8. | Killer HE, Hess K. Natural history of radiation-induced brachial plexopathy compared with surgically treated patients. J Neurol 1990;237:247-50. |
| 9. | Warade AC, Jha AK, Pattankar S, Desai K. Radiation induced brachial plexus neuropathy. Neurol India; 2019;67:S47-52. |
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