Neuralgic amyotrophy - Beyond the plexus: A case of surgical treatment of bilateral distal peripheral nerve involvement in neuralgic amyotrophy/Parsonage-Turner Syndrome.

Introduction: Neuralgic amyotrophy (NA), traditionally considered a self-limiting inflammatory plexopathy, is increasingly recognised as a disorder in which focal structural nerve lesions - most notably hourglass-like constrictions (HGC) - play a critical role. This paradigm shift has reinforced the relevance of peripheral nerve surgery for selected patients who fail to recover spontaneously.

Research question: We report a surgically treated case of bilateral involvement of the deep branch of the radial nerve (DBRN) within a clinical context of NA. Emerging evidence supporting the operative management of focal constrictions underscoring how timely surgical referral can influence outcome is reviewed.

Methods: The case is described according to CARE guidelines. A focused PubMed review was performed to identify literature on NA, distal nerve involvement, HGC detection, and surgical treatment.

Results: A 55-year-old patient presented with acute bilateral shoulder pain followed by progressive bilateral wrist and finger drop. HRUS and MRN demonstrated bilateral HGCs. Conservative treatment, including corticosteroids and intravenous immunoglobulins, failed to achieve recovery. Surgical neurolysis at 7 and 10 months revealed severe focal constrictions. Postoperatively, the patient demonstrated marked functional improvement, achieving MRC 4/5 strength in wrist and finger extension bilaterally.

Discussion and conclusion: This case highlights the expanding role of peripheral nerve surgery in NA. Distal structural lesions can be reliably identified with modern imaging, and surgical decompression or neurolysis may meaningfully improve outcomes when spontaneous recovery is absent. Multidisciplinary pathways involving peripheral nerve surgeons are essential to optimize diagnosis and treatment.