Segmental neurogenic muscle hypertrophy associated with radiation injury

doi:10.1016/S0303-8467(02)00090-2

Clinical Neurology and Neurosurgery

Volume 105, Issue 1, December 2002, Pages 32-34

https://doi.org/10.1016/S0303-8467(02)00090-2 Get rights and content

Abstract

A 48-year-old man presented with painless left trapezius hypertrophy 20 years after radiotherapy for nasopharyngeal carcinoma. EMG sampling showed myokymic discharges, reduced polyphasic motor unit recruitment and no signs of active denervation. The relationship between radiotherapy, brachial plexopathy and neurogenic muscle hypertrophy is discussed.

Introduction

Segmental neurogenic muscle hypertrophy is an uncommon condition reported in association with a variety of denervating processes [1]. Various pathophysiological mechanisms have been postulated [2]. Focal grouped discharges or myokymia may occur in muscles after radiotherapy for malignancies, likely as a result of radiation-induced plexopathy or neuropathy [3], [4], [5]. For the first time, we describe a case of a 48-year old man showing trapezius muscle hypertrophy after radiotherapy for nasopharyngeal carcinoma. Electromyographic (EMG) sampling revealed continuous elctectromyographical myokymic-like discharges consistent with underlying radiation-induced neurogenic injury.

Section snippets

Case report

A 48-year-old man complained of progressive muscular swelling of the left shoulder region for 1 month associated with twitching for a period of 9 months. He also noticed left shoulder weakness for the same period of time. There was no pain or sensory disturbance. He denied trauma or radicular symptoms in his left arm. There was no history of diabetes mellitus or surgery. There was no significant family history of similar conditions.

He had been diagnosed to have nasopharyngeal carcinoma at age

Discussion

The electrophysiological findings were inkeeping with previous radiation injury involving the left C2, C3, C4, accessory nerve and patchy lesions of nerves supplied by the brachial plexus. The lesion was likely to diffuse, with involvement of upper and lower plexus. This is inkeeping with previous reports on radiation-induced brachial plexopathy [6], [7], [8].

Most cases of neurogenic muscle hypertrophy involve the occurrence of continuous complex repetitive discharges or continuous muscle

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Citation Excerpt :
Pain is reported by at least 15% to 30% of patients after radiation therapy for head and neck cancer.1 Neurologic damage with temporal necrosis, bulbar palsy, cranial nerve paresis, demyelination, and muscle atrophy are also well-known secondary effects of radiation therapy, especially for nasopharyngeal carcinoma.7,8 Our study has shown that in long-term cancer survivors, BT is not useful in the treatment of radiation-induced trismus.
To report the efficacy of botulinum toxin A for radiation-induced pain, trismus, and masticator spasm in head and neck cancer.
This prospective nonrandomized study included patients in complete remission with radiation-induced pain and trismus with or without masticator spasms. Fifty units of Botox (Allergan) or 250 units of Dysport (Ipsen) were injected transcutaneously into the masseter muscles. Jaw opening was measured and patients answered 20 questions about jaw opening, pain, and cramps, before injection at 1 month.
Nineteen patients (7 women, 12 men) were included. Median time after radiation therapy was 5 years (range, 11 months to 22 years). At 1 month, no significant increase in jaw opening was recorded. Improvement was noted in the functional domain (P = 0.004), for pain (P = 0.002) and cramps (P = 0.004), but not in the social (P = 0.83) or emotional (P = 0.43) domains. No side effects occurred.
Botulinum toxin did not improve trismus but significantly improved pain scores and masticator spasms (oromandibular dystonia).
Isolated Spinal Accessory Mononeuropathy Associated With Neurogenic Muscle Hypertrophy: Restricted Neuralgic Amyotrophy or Stretch-Palsy? A Case Report
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Citation Excerpt :
NMH has also been described in 2 patients with chronic motor neuronopathies who had an additional nerve insult (ie, demyelinating neuropathy in Kennedy’s disease,55 radiculopathy in poliomyelitis56). Trapezius NMH has been reported in association with radiation injury,57 surgical injury,58 and whiplash.59 Posttraumatic persistent focal shoulder-elevation dystonia has also been associated with trapezius hypertrophy with or without denervation.60,61
Baker SK. Isolated spinal accessory mononeuropathy associated with neurogenic muscle hypertrophy: restricted neuralgic amyotrophy or stretch-palsy? A case report.
A 55-year-old man developed transient bi-brachial paresthesias followed by severe pain over his left shoulder ridge and periscapular region within 8 hours of rigorous hand-over-hand hoisting of a 33.8-kg (75-lb) object. He experienced weakness in shoulder abduction followed several weeks later by focal hypertrophy of the left trapezius. Electrophysiologic studies showed significant spontaneous motor activity in the form of denervation potentials, fasciculations, and complex repetitive discharges. The 2 major diagnostic considerations were restricted neuralgic amyotrophy versus stretch palsy of the spinal accessory nerve. The clinical similarities and differences between restricted forms of neuralgic amyotrophy and stretch palsies are discussed.
Bilateral neuralgic amyotrophy presenting with left vocal cord and phrenic nerve paralysis
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This article reports the difference between neuralgic amyotrophy and neuropathy caused by chemotherapy and radiation treatment which manifested with severe shoulder pain followed by marked weakness of bilateral upper arms and involvement of cranial nerves. A 62-year-old man presented with acute severe neuropathic pain at the left shoulder, bilateral shoulder weakness, hoarseness of voice from vocal cord palsy, and respiratory insufficiency from left diaphragm palsy, which all occurred sequentially over a 1-month period. The diagnosis of neuralgic amyotrophy was supported and differentiated from tumor-induced and radiation-induced neuropathy by clinical presentation, electrophysiologic and imaging studies. Unlike previous reports of the onset of neuralgic amyotrophy being associated with initiation of radiation treatment in cancer patients, this report demonstrates that neuralgic amyotrophy can occur at any point of the malignant disease process after radiation and chemotherapy.
Muscle hypertrophy with complex repetitive discharges in C-6 radiculopathy
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Objective: To report on a case of post-denervation muscle hypertrophy in an unusual distribution. Case report: A 52-year-old patient with severe flaccid paraparesis after polio developed unilateral C-6 radiculopathy that resolved with conservative treatment. Within 2 years marked hypertrophy, stiffness and pain in the muscles in the affected myotome developed. EMG discovered abundant complex repetitive discharges (CRD) within hypertrophic muscles. On biopsy, true hypertrophy of muscle fibers and some group atrophy was found. Steroid treatment relieved the symptoms and significantly suppressed the CRD. The possible causative role of CRD for hypertrophy in partially denervated muscle is discussed.
Neurogenic muscle hypertrophy: Imaging features in three cases and review of the literature
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Le but de notre étude est de réaliser une analyse de la littérature, concernant des cas suffisamment documentés d’hypertrophie musculaire neurogène pour mieux définir les caractéristiques de cette affection.
Nous avons utilisé les moteurs de recherche PUBMED et SCIENCE DIRECT, pour recenser tous les cas décrits de ce trouble, en utilisant les mots « hypertrophy », « muscle » et « neurogenic ». Nous avons dénombré 48 articles contenant 129 observations. Nous n’avons retenu que 25 cas, en plus de 3 cas personnels récents, répondants à nos critères d’inclusion (atteinte d’un ou plusieurs muscles d’un membre inférieur, réalisation d’au moins un examen d’imagerie (scanner ou IRM) et d’un électromyogramme des membres inférieurs) et d’exclusion (atteinte s’inscrivant dans le cadre de polyneuropathies héréditaires ou acquises).
Les résultats indiquent que l’hypertrophie musculaire neurogène se traduit le plus souvent par un élargissement douloureux d’un mollet chez un patient de sexe masculin de 32 à 60 ans, aux antécédents de lombosciatalgies (les hernies discales et les canaux lombaires étroits représentant 68 % des étiologies), de radiothérapie ou de traumatisme.
La symptomatologie peut conduire à une IRM bien avant l’EMG et il faut savoir évoquer ce diagnostic sur un bilan d’imagerie.
To review the literature on well-documented cases of neurogenic muscle hypertrophy in order to define significant features of this disease.
The PUBMED and SCIENCE DIRECT web-sites were used to conduct an inventory of all reported cases of this disease. We entered the key-words “hypertrophy”, “muscle” and “neurogenic”, and found 48 articles, describing 129 cases. Our criteria of inclusion included hypertrophy of one or several muscles of a lower limb, previous realization of at least one imaging study (CT or MRI) and electromyography of lower limbs; criterion of exclusion was hypertrophy related to hereditary or acquired polyneuropathies. Twenty-five cases were retained for investigation along with 3 recent cases observed in our department.
Results show that neurogenic muscle hypertrophy is usually presents with painful enlargement of a calf in a male, aged 32 to 60 years, with previous history of low back pain and sciatica, 68% of the time due to disk herniation or lumbar stenosis. Other clinical findings may include radiation therapy or trauma.
The symptoms of neurogenic muscle hypertrophy may lead to MRI examination before electromyography. This disease should be included in the differential diagnosis.

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Segmental neurogenic muscle hypertrophy associated with radiation injury

Abstract

Introduction

Section snippets

Case report

Discussion

Electroencephalogr. Clin. Neurophysiol.

Complex repetitive discharges: cause or effect of neurogenic muscle hypertrophy?

Muscle Nerve

Neurogenic muscle hypertrophy

J. Neurol.

Limb myokymia

Muscle Nerve

Distinction between neoplastic and radiation-induced brachial plexopathy, with emphasis on the role of EMG

Neurology

Brachial plexopathy: recurrent cancer or radiation?

Neurology

Radiation-induced brachial plexopathy: clinical and elctectromyographical (EMG) considerations in 13 cases

Electromyogr. Clin. Neurophysiol.