902 - Multimodal Management of Persistent Neck Pain and Atypical Brachial Plexus Palsy Following Cervical Fusion: A Case Report

Case Diagnosis: Persistent neck pain with atypical brachial plexus palsy following multilevel cervical fusion.

Case Description:

A 71-year-old male with throat cancer (post resection 2023), type 2 diabetes mellitus, morbid obesity, and obstructive sleep apnea presented six weeks after undergoing C4–C7 laminectomy and C3–T1 posterior fusion for cervical myelopathy. Preoperatively, he reported left upper extremity paresthesias from shoulder to thumb and index finger, consistent with C6 radiculopathy. Postoperatively, he developed severe, burning axial neck pain radiating from C3–T1, accompanied by profound left deltoid weakness (active abduction limited to approximately 20 degrees) with preserved supraspinatus strength. Electromyography revealed denervation changes across multiple upper trunk elements beyond C5, confirming an atypical upper brachial plexopathy rather than a pure radiculopathy or classic C5 palsy.

Discussions: While postoperative C5 palsy is the most frequent complication after cervical decompression, atypical brachial plexopathy sparing the supraspinatus is rare. Careful neurological examination and electromyography are essential to distinguish between radiculopathy, C5 palsy, and plexopathy. The patient’s comorbidities, including diabetes and obesity, likely increased susceptibility to neuropathic injury. Initial conservative therapy with tramadol and stretching was inadequate. A multimodal regimen was initiated with gabapentin titrated for neuropathic pain, naproxen, and tramadol for breakthrough pain. Structured physical therapy emphasized deltoid and rotator cuff strengthening, scapular stabilization, and cervical mobility. Over several months, the patient improved from 2/5 to 4/5 shoulder abduction strength, regained overhead reaching ability, and reported decreased pain, improving independence in daily activities. No further surgical intervention was indicated. This case underscores the importance of multimodal analgesia, opioid-sparing pharmacology, and interdisciplinary rehabilitation in optimizing recovery and minimizing chronic pain after cervical fusion.

Conclusions:

This case broadens the spectrum of recognized cervical fusion complications to include atypical brachial plexus involvement. Early recognition with electrodiagnostic confirmation and comprehensive rehabilitation optimized outcomes, underscoring physiatrists’ essential role in both diagnosis and functional recovery within interdisciplinary spine care.