Brachioradial Pruritus – Neuropathic itch

Ross Hauser, MD., Danielle R. Steilen-Matias, PA-C

Among the many symptoms we see in our patients are problems of skin rashes and itching. The problems of itching can in itself be challenging. Is it a problem of the skin and skin rashes or is it a problem of neurology and a symptom more on its own? If you are reading this article the most important thing to you is that there is an answer to stop the itching no matter what is causing it.

In this article, we are going to present information on a very interesting case of “itching” in a patient that we treated. It was an uncontrolled itching from an unknown source. We found the source. It was coming from the patient’s neck and her cervical spine instability.

This is a Hauser Neck Center at Caring Medical case study. The patient herself speaks in the video. Below are explanatory notes of points made during the video.

A miserable, itchy patient.

Danielle R. Steilen-Matias, PA-C: Attending clinician.

When this patient came in she was miserable. Itching up and down her arms. She was not sleeping and had tried many treatments and remedies to get rid of the itching.
Initially, she thought the itching was from too much sun.
We spoke about a condition of bilateral (both arms) upper arm itching called brachial radial pruritus that can be traced to the cervical spine nerve roots.

Too much sun? Cervical spine and neck instability? Both?

Many people contact us after years of topical steroid cream, high doses of gabapentin, muscle relaxants, cortisone injection, among other treatments. They have complaints of insomnia, stress, anxiety, irritability, and depression.

When people have itching of unknown origins they will typically be sent off to the dermatologist. This probably happened to you. The initial treatments offered were probably more potent or heavy-duty prescription ointments and creams than those you had already bought over the counter or on the internet. When these treatments are not working or have been eliminated from being useful for you, the next step is of course to dig deeper and look for other things.

If you are often out in the sun, the sun becomes an easy culprit. As you will see in our patient story, she was told by her dermatologist to avoid the sun, after two months of sun avoidance and no relief our patient decided that the sun was not the problem.

A paper in the Journal of the American Academy of Dermatology (1) found that the itching described as brachioradial pruritus, could be from the sun, it could be from neck instability causing compression in the cervical root nerves among many causes. People could also be at greater risk if they had neck instability and problems in the cervical spine and spent a lot of time in the sun.

So it could be from too much sun, cervical spine and neck instability, and both. Here is what the research says:

“There has been controversy regarding the cause of brachioradial pruritus: is it caused by nerve compression in the cervical spine or is it caused by prolonged exposure to sunlight?…. The temporal course (the time of year you get it, spring compared to fall for instance) of the brachioradial pruritus and the histological changes in the skin similar to those caused by ultraviolet light, indicate that sunlight is an eliciting (can cause the itching) factor and that cervical spine disease can be a predisposing (puts you at higher risk) factor.”

Exacerbated by exposure to bright sunlight or ultraviolet radiation (UVR), and is associated with degenerative changes in the cervical spine.

As I state throughout this article, cases of Brachioradial pruritus are thought to be rare and when a case is considered strange and rare enough it is published in a medical journal. We are finding these cases to be more common in our patient population and these people’s stories well match the examples from independent clinics published in the medical literature. That being a terrible itch with no diagnosis and no effective treatment.

This is a case history presented by doctors at the Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care, and Pain Medicine, Harvard Medical School. It was published in the medical journal Case Reports in Women’s Health. (2)

Diagnosis is difficult and is usually delayed for two-three years.

“Brachioradial pruritus is a specific subtype of neuropathic pruritus that commonly presents in women. This condition is a type of neurological itch that mostly involves the dorsal forearm. It is more common in fair-skinned females, is exacerbated by exposure to bright sunlight or ultraviolet radiation (UVR), and is associated with degenerative changes in the cervical spine. Diagnosis is difficult, and is usually delayed for two-three years.”

A patient who suffered brachioradial pruritus for many years and was misdiagnosed by multiple specialists

“(In this case history the doctors describe) a patient who suffered brachioradial pruritus for many years and was misdiagnosed by multiple specialists until she presented to our pain clinic. The patient had undergone invasive diagnostic testing by previous specialists but this had not led to a diagnosis. After a thorough history and exam, the diagnosis of brachioradial pruritus was considered and the patient was treated with anticonvulsant medications, as these have been shown to be effective in this condition. This case is of interest to all physicians treating female patients as consideration of this diagnosis can avoid unnecessary invasive diagnostic testing.”

What the doctors at Harvard Medical School describe is what we see in many people that come to our center. Difficult to understand problem. A difficult-to-understand problem is a difficult-to-treat problem. People lived with it. For some of our patients with cervical instability, that in the past they could get an itching rash when exposed to too much sun was an understood consequence of being outside. The idea that it was coming from a neck problem, may not be as well understood.

Digital Motion X-Ray (DMX) demonstrates cervical spine instability.

From those of you reading this article and researching your itching problem the idea that your problem is coming from the neck or nerves may not be a new one as you may have symptoms of neck pain and instability and itching is one skin manifestation of many you may suffer from. Please see our article: Skin Pain, Hot, and Cold Skin: Are fixing upper cervical neck instability problems the missing treatment?

The images of the patient’s neck will be explained below. Based on these images we could then suggest beyond a reasonable doubt that the patient’s itching was related to her cervical spine instability.

So now let’s explain:

What is a DMX digital motion x-ray?
What does the image below mean?
How does this address the problem of itching?

If you are watching along with the video we are at 1:40:

To confirm our suspicions that brachial radial pruritus, the severe itching in both her arms was coming from nerve compression in the cervical spine we ordered a digital motion x-ray of her neck.
A digital motion x-ray is an x-ray movie that allows us to see cervical segment instability or cervical ligament laxity in the neck that could cause or allow pinched, herniated, compressed nerves to occur. These nerves of course run through the cervical spine.
The image above on the left is an image of the patient leaning forward, head down. The image to the right is the patient with her head back, chin in the air.

What do the red lines mean?

The red lines should be reflected as a continuous line. The continuous nature would show us that the cervical vertebrae are lined up in their proper alignment, the neck is stable. That is not the case however in this patient. What we see is this.
- Left side image: with the patient looking down we see that the line displaces at C3/C4. The vertebrae are in motion or they are hypermobile, not where they are supposed to be. This is cervical instability and vertebrae in motion can press on the cervical nerve roots that pass between them and go down your arm. The condition also exists at C4/C5 and C5/C6.
- Right side image: with the patient looking up we see that the line displaces at C4/C5. The value of the DMX motion picture x-ray is that we can see that on certain movements the patient’s symptoms can worsen or can be lessened.

Irritating Itching, pruritis from spinal instability

A patient had a horrific itching in the arms. She went to doctors and nobody seemed to be able to help her.
Later it was revealed that the patient had dizziness, clicking, and grinding in her neck and she had cervical spine instability. Among her may symptoms her cervical spine instability was causing the itching. After treatment, we were able to resolve her itching issues. That was about ten years ago.

Itching and nerve irritation

Itching can be from any type of nerve irritation. You may have been given a diagnosis of pruritus. If you have sciatic-like problems you may have been diagnosed with lumbar radicular pruritus. In other words, the sciatic nerve is getting irritated and causing itching in the leg or in the arm. This is a diagnosis of brachial radial pruritus or brachial pruritus and if it involves the neck is often called cervical pruritus.

One side of the body itching

In other patients, we see one side of the body itching. This is an indication that the problem is coming from the neck. In people like this, we examine them with a Digital Motion X-Ray (DMX) to determine the amount of cervical spine instability and if this is indeed a factor in their unexplainable and difficult-to-treat itch sensation. If the itch is on the left side of the body DMX will typically reveal cervical spine instability on that side of the body. We typically focus, based on decades of experience in treating these chronic neck cases on the C1-C2 when there are symptoms of pruritus although cervical spine instability at multiple regions can cause many conditions including symptoms.

In the video above the title refers to the strange sensations that a patient may experience with cervical spine instability that cause compression on their nerves and spinal column. One of the reasons we call these symptoms strange is that many of the people we see have been looking for and chasing a viable treatment for problems that are neurologic-like in nature. We see many people with these challenges.

Multiple inconclusive diagnostic evaluations (dermatology, rheumatology, neurology, and psychiatry) and unsatisfactory multimodal conservative treatment attempts.

The concept of itching skin or Brachioradial Pruritis is still considered somewhat of a medical ailment in the medical community. Here is a case history reported by the Department of Orthopaedic Surgery, Hospital for Special Surgery, and published in the Journal of the American Academy of Orthopaedic Surgeons (3). This is what the attending physicians wrote:

“Brachioradial pruritus is a rare condition characterized by chronic localized itching of the dorsolateral (back and to the side) upper extremities. Although the exact pathophysiology is still unknown, cervical nerve compression is thought to be a cause.

(This case history presents) the case of a 56-year-old man with a 6-year history of disabling chronic bilateral upper extremity pruritus and pain as well as concurrent neck pain. The patient presented to our office after multiple inconclusive diagnostic evaluations (dermatology, rheumatology, neurology, and psychiatry) and unsatisfactory multimodal conservative treatment attempts.

His symptoms markedly impeded his ability to get restful sleep. Imaging of the cervical spine revealed multilevel cervical spondylosis, spinal stenosis with cord compression, and multilevel foraminal stenosis. The patient underwent successful multilevel anterior cervical decompression and fusion and was instantly symptom-free. The present case highlights that patients complaining of itching of the dorsolateral forearms of seemingly unknown etiology should undergo a workup of the cervical spine. If conservative treatment fails, surgical decompression may be considered in select patients.”

As you read in this case the patient’s itching was resolved by a cervical fusion surgery. Many people have very successful spinal fusions that helped resolve their symptoms. These are typically the people we do not see at our center. We see the people for whom cervical fusion is not considered a good risk, have had failed cervical fusion, or want to explore every option before having the surgery.

A patient story: I have been suffering from stinging, itching, pain in both arms. No one could help me and on my own I found the diagnosis of Brachioradial Pruritis. I usually suffer from this burning itch pain equally in both arms but recently one of my arm became so bad I now have bruises from holding and squeezing my arm to try to relieve the pain.

I have been on Neurontin for years and have the neck traction at home to help relieve the symptoms. I am sleep deprived from it and now it is affecting my daily life.

Here is a case where these pinched nerves, can cause a neuropathic itch

Research note: Neuropathic itch can be caused by many diseases in addition to cervical spine instability. As mentioned above, if you are reading this article and you have suffered from this challenge, it would probably be safe to say that you have been to a dermatologist and followed the path that your blood work and other testing took you until you received some type of treatment or treatments and that has not worked that well for you.

Let’s look at a 2011 and a 2020 study and we can see that the understanding of Neuropathic itch remains a challenge.

You may hear yourself being described in this research.

“Many physicians including neurologists are unaware that neurological problems alone can cause chronic itch.”

In 2011 Anne Louise Oaklander, MD, Ph.D. of the departments of Neurology and Pathology, Massachusetts General Hospital, Harvard Medical School wrote in the journal Seminars in Cutaneous Medicine and Surgery: (4)

“Many physicians including neurologists are unaware that neurological problems alone can cause chronic itch. Neuropathic itch and pain are signaling abnormalities – the source of the problem is not where the symptoms are felt. Like neuropathic pain, the neuropathic itch is still poorly understood despite fundamental advances in understanding the mechanisms of itch in the normal nervous system.

Considered physiologically, the neuropathic itch is a pathological form of itch where the stimulus-response curve that governs normal sensation has become distorted and the itch sensation is out of proportion or even completely independent of any pruritogenic stimuli (something that would normally cause an itch.) In other words, the itch can be of unknown origin.

Like an electrical problem in the wiring harness of an automobile, the actual location and cause of neuropathic itch can be extremely difficult to pin down, but effective treatment may require anatomical and etiological identification of the neurological problem and institution of disease-modifying treatment. In some cases, this may be neurosurgical. (Some type of surgery to the nerves).

Neuropathic itch does not often respond to antihistamines, topical steroids, or other medications effective for the conventional itch. Furthermore, like other neurological symptoms, the itch can signal a potentially serious neurological problem that might need treatment. Most neurology textbooks and training do not discuss the localization and etiology of errant itch, so not all neurological consultations will be insightful. A dermatologist should first examine the patient to exclude conventional causes of itch before requesting neurological consultation.”

Now to 2020

A September 2020 French study (5) showed the confusion in identifying neurological itch and the confusion of treatment which is often ineffective.

Chronic pruritus can occur in the absence of skin diseases and may be secondary to various causes. In this study, patients who sought dermatological treatment were studied.
- The study had 197 patients with chronic pruritus without skin disease.
- The average age of the patient was about 67. Almost an even split between men and women.
The main causes identified were psychogenic pruritus (41.1% of patients). The disease was coming from emotional or psychological distress.
Neuropathic (36.5%),
Endocrine (12.2%),
Haematological (9.6%) (Blood type cancers)
and iatrogenic reaction to some type of medical treatment (7.1%) causes.
The cause was unknown in 20.8% of patients.
The total percent is more than 100 because some patients had several etiologies.
Concerning symptomatic treatments, emollients (creams and ointments) were prescribed for 40.6% of patients and topical steroids for 20.3%.
Among systemic treatments, gabapentinoids (33%), antidepressants (27.4%), and antihistamines (25.3%) were prescribed. The efficacy of these treatments was rarely complete. (Did not work that well).

The itch is coming from a syrinx

When we see patients with problems of cervical spine instability, Chiari malformation, and syrinx, these patients come in with more symptoms than they can even list. One problem they may have is the itch.

A case report comes from the Michael E. DeBakey VA Medical Center and the McGovern Medical School at The University of Texas Health Science Center at Houston. It was published in the PM & R: The Journal of Injury, Function, and Rehabilitation. (6)

“This case describes a 56-year-old man with known thoracic spinal cord injury undergoing evaluation for a pruritic rash on the dorsolateral aspect of his forearms with no upper extremity neuromuscular symptoms. Common diagnoses were considered and treated with little success. The diagnosis of brachioradial pruritus was made, and evaluation for possible causes revealed a large cervicothoracic syrinx. To our knowledge, brachioradial pruritus has not been described previously as the presenting sign of post-traumatic syringomyelia.”

As stated numerous times in this article, when doctors come upon a case that is strange, rare, even unexplainable, they publish a case history to tell other doctors about what they found.

Is the itching coming from nerve compression in the neck? What are we seeing in this image?

Looking for a narrowing of the nerve space

If you have cervical spine problems and itching is just one manifestation of your symptoms, you do not need a lengthy explanation of what cervical foraminal stenosis is. If your doctors are starting to explore a cervical spine connection to a vast array of neurological type symptoms that you are suffering from and this is “new territory,” in your medical journal, here is a brief explanation. Cervical foraminal stenosis is the narrowing of the openings between the bones of the cervical vertebrae. The tunnel that your nerves move through is getting narrower. As these tunnels close in the nerves can be compressed and nerve message traffic comes to a standstill. If your nerves are not able to transmit correct messages you get neuralgic symptoms including skin problems and uncontrollable itching.

The tunnels that we are talking about are called foramen, the closing of the tunnels either through boney buildup on the tunnel walls or the compression of the walls is called a stenosis.

At 2:45 of the video. We had our clue that this is where the itching was coming from.

We did a view of the neural foramina to see if she had any narrowing of the neural foramina.

What we were looking for is where the nerve roots exit the spinal column if there was:
- Nerve compression on certain movements.
- The existence of a cervical neural foraminal stenosis.
- In general, nerve compression could lead to pain, numbness, and itching. We want to note here that this patient did not have neck pain or numbness that extended into the arms. This is not typical of the patients we see.
- But we did see that as she moved her neck, the foramen openings at C4/C5 and C5/C6 were narrowing and pinching on the nerves. We had our clue that this is where the itching was coming from. Nerves at C4/C5 and C5/C6.

What did we do about it?

This patient received Prolotherapy treatments. After the first treatment, she was able to sleep. After the second treatment, the itching went away. Disclaimer: These results may not be typical. The treatments may not help some people. Cervical spine instability may not be the cause of your itching.

Caring Medical has published dozens of papers on Prolotherapy injections as a treatment in difficult-to-treat musculoskeletal disorders. Prolotherapy is an injection technique utilizing simple sugar or dextrose. Our research documents our experience with our patients. The treatment is explained further below, but first the patient’s story.

Before we get to the patient’s story, please be aware that her story is an individual experience reflecting on her experience with our treatments. Results may vary among different individuals. Not everyone will have the same level of success.

The patient’s story begins at 4:20 of the video

I have been having severe itching in my forearms for at least a month-and-a-half. Then it progressed to my upper arms and it started to be accompanied by nerve-ending pain and burning. If I scratched my skin, it made it much worse, severely worse.

I had researched a lot and found that I thought it might be what they called Brachioradial Pruritis which could come from your neck.

I like to work out and be active so I didn’t feel like I was having neck issues or that I was doing things to irritate my nerves.

I had had Prolotherapy treatments in the past with Ross Hauser, MD, and now with his physician assistant Danielle R. Steilen-Matias, PA-C. The treatments helped my with wrist and hip pain. So when I began to suspect my neck was a problem I thought of Prolotherapy. But first, I went to a neurologist. They agreed with me that we should look at my neck and get an EMG and some imaging studies. I had a slight bulging of the discs. The intimal treatment reaction to these findings was to increase my medications to try to help me sleep at night. That did not help. The only thing that did help was ice packs. But I knew I could not spend the rest of my life sleeping with ice packs. The doctors I was seeing could not help me. They told me to come back in six months so that they could monitor the progression or regression of symptoms. I told these doctors that this plan was not helping me, I have two six-year-olds who need me and I have to function.

After the first Prolotherapy treatment I had maybe two bouts of itching within two weeks but it wasn’t anything as severe as I’ve had before. After the second treatment, I had zero symptoms. I can sleep every night I’m not taking one thing for the pain.

The treatment of cervical spine instability at the Hauser Neck Center – Research on cervical instability and Prolotherapy

In the above article, we suggest that many of the problems related to among other symptoms, itching, skin sensations, burning nerve pain. can be treated by addressing cervical spine instability in the neck. There are many ways to treat this problem. Our preferred choice is regenerative medicine injections that begin with Prolotherapy.

In 2015, our research team at Caring Medical published findings in the European Journal of Preventive Medicine investigating the role of Prolotherapy in the reduction of pain and symptoms associated with increased cervical intervertebral motion, structural deformity, and irritation of nerve roots. Irritation of nerve roots causes many of the symptoms and challenges our patients face.

Prolotherapy addresses cervical spine instability by addressing problems with the structures that hold the neck in its rightful place. The cervical spine ligaments. Ligaments are bands of connective tissue that hold C1 to C2 and C2 to C3 and C3 to C4, etc. In the images above in the patient’s DMX, we saw that the vertebrae were not being held in their proper place. This is where we directed the Prolotherapy injections as demonstrated in the above video.

In our research study, twenty-one study participants were selected from patients seen for the primary complaint of neck pain. Following a series of Prolotherapy injections, patient-reported assessments were measured using questionnaire data, including range of motion (ROM), crunching, stiffness, pain level, numbness, and exercise ability, between 1 and 39 months post-treatment (average = 24 months).

Ninety-five percent of patients reported that Prolotherapy met their expectations in regards to pain relief and functionality. Significant reductions in pain at rest, during normal activity, and during exercise were reported.
Eighty-six percent of patients reported overall sustained improvement, while 33 percent reported complete functional recovery.
Thirty-one percent of patients reported complete relief of all recorded symptoms. No adverse events were reported.

We concluded that statistically significant reductions in pain and functionality, indicating the safety and viability of Prolotherapy for cervical spine instability. (6)

In 2014, we published a comprehensive review of the problems related to weakened damaged cervical neck ligaments in The Open Orthopaedics Journal. (7) We are honored that this research has been used in at least 6 other medical research papers by different authors exploring our treatments and findings and cited, according to Google Scholar, in more than 40 articles.

This is what we wrote in this paper: “To date, there is no consensus on the diagnosis of cervical spine instability or on traditional treatments that relieve chronic neck instability issues like those mentioned above. In such cases, patients often seek out alternative treatments for pain and symptom relief. Prolotherapy is one such treatment that is intended for acute and chronic musculoskeletal injuries, including those causing chronic neck pain related to underlying joint instability and ligament laxity. While these symptom classifications should be obvious signs of a patient in distress, the cause of the problems are not so obvious. Further and unfortunately, there is often no correlation between the hypermobility or subluxation of the vertebrae, clinical signs or symptoms, or neurological signs (such as excessive sweating or inability to sweat and temperature dysregulation or other skin sensations mentioned in this article) or symptoms.”

What we demonstrated in this study is that the cervical neck ligaments are the main stabilizing structures of the cervical facet joints in the cervical spine and have been implicated as a major source of chronic neck pain and in the case of many of the symptoms we mentioned above.

Summary and contact us. Can we help you? How do I know if I’m a good candidate?

We hope you found this article informative and it helped answer many of the questions you may have surrounding Brachioradial Pruritus – Neuropathic itch. Just like you, we want to make sure you are a good fit for our clinic prior to accepting your case. While our mission is to help as many people with chronic pain as we can, sadly, we cannot accept all cases. We have a multi-step process so our team can really get to know you and your case to ensure that it sounds like you are a good fit for the unique testing and treatments that we offer here.

Please visit the Hauser Neck Center Patient Candidate Form

References:

1 Wallengren J, Sundler F. Brachioradial pruritus is associated with a reduction in cutaneous innervation that normalizes during symptom-free remissions. Journal of the American Academy of Dermatology. 2005 Jan 1;52(1):142-5. [Google Scholar]
2 Berger AA, Urits I, Orhurhu V, Viswanath O, Hasoon J. Brachioradial pruritus in a 52-year-old woman: A case report. Case reports in women’s health. 2019 Oct 1;24:e00157.
3 Salzmann SN, Okano I, Shue J, Hughes AP. Disabling Pruritus in a Patient With Cervical Stenosis. JAAOS Global Research & Reviews. 2020 Mar;4(3). [Google Scholar]
4 Oaklander AL. Neuropathic itch. InSeminars in cutaneous medicine and surgery 2011 Jun (Vol. 30, No. 2, p. 87). NIH Public Access. [Google Scholar]
5 Robert M, Misery L, Brenaut E. Chronic Pruritus in the Absence of Skin Disease: A Retrospective Study of 197 French Inpatients. Acta Dermato-venereologica. 2020 Sep 14. [Google Scholar]
6 Skelton F, Frontera JE. Brachioradial pruritus as a harbinger of syrinx in chronic spinal cord injury: a case report. PM&R. 2017 Mar 1;9(3):311-3.
7 Hauser RA, Steilen D, Sprague IS. Cervical Instability as a Cause of Barré-Liéou Syndrome and Definitive Treatment with Prolotherapy: A Case Series. European Journal of Preventive Medicine. 2015;3(5):155-66. [Google Scholar]
8 Steilen D, Hauser R, Woldin B, Sawyer S. Chronic neck pain: making the connection between capsular ligament laxity and cervical instability. The open orthopaedics journal. 2014;8:326. [Google Scholar]

4629