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Nervous System: Peripheral Nerve Entrapments Complex Regional Pain Syndrome

Nervous System: Peripheral Nerve Entrapments Complex Regional Pain Syndrome. PTP 521 Musculoskeletal Diseases and disorders. Peripheral Nerve Dysfunctions. Mechanisms of Injury Transient compression Ischemia Crush Injury Traction Injury Severance of nerve. Basic Nerve Facts.

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Nervous System: Peripheral Nerve Entrapments Complex Regional Pain Syndrome

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  1. Nervous System:Peripheral Nerve EntrapmentsComplex Regional Pain Syndrome PTP 521 Musculoskeletal Diseases and disorders

  2. Peripheral Nerve Dysfunctions • Mechanisms of Injury • Transient compression • Ischemia • Crush Injury • Traction Injury • Severance of nerve

  3. Basic Nerve Facts • Nerve injury • Two classification systems • Seddon • Neuropraxia, axonotomesis, neurotmesis • Based on clinical evaluation and judgment of injury • Preoperative assessment • Sunderland • 1st to 5th degree • Histology • Applicable after nerve exploration

  4. Neuropraxia • Transient compression injury • Minimal structural changes • Axonotmesis • Axon damaged but endoneurial tube is intact • Prognosis depends on regeneration of axon • Neurotmesis • Entire nerve is injured (laceration)

  5. Neurological Dysfunctions: A. UE Entrapment Neuropathies 1. Suprascapular Nerve 2. Median Nerve 3. Ulnar Nerve 4. Radial Nerve

  6. Suprascapular Nerve Entrapment • Suprascapular nerve emerges from trunk of the brachial plexus. Nerve roots are C5, C6 and sometimes C4 • Variable cutaneousinnervation over the proximal lateral 1/3 of the arm • Injuries can occur with: • Trauma • Overuse injuries • Mass lesion • Iatrogenic causes

  7. Traumatic Causes • Scapular fractures • Clavicular fractures • Shoulder dislocations • Penetrating trauma (gunshot wound) • Iatrogenic Causes • Operative procedures

  8. Sites of Entrapment • Suprascapular Notch • Spinoglenoid Notch • Compression between the spine of the scapula and the medial tendinous edge of the infraspinatus and supraspinatus muscles • By a mass such as a ganglion cyst, Ewings sarcoma, • Onset: insidious unless trauma occurs • Risk Factors: age between 20 and 50 • Symptoms: dull, aching pain in the posterior aspect of the shoulder, increases with overhead activities • Signs: atrophy of the infraspinatus, supraspinatus muscles

  9. Imaging studies: • Diagnostic Ultrasound • MRI, T1 or T2 weighted

  10. Median Nerve Entrapments 1. Pronator Syndrome 2. Anterior Interosseous Syndrome 3. Carpal Tunnel Syndrome

  11. Median Nerve a. Pronator Syndrome: nerve passes between the 2 heads of the pronator teres. Compression occurs because of the Lacertus Fibrosis www.aafp.org/.../20000201/691.html?print=yes

  12. High median nerve injury Insidious onset Women 4:1 Repetitive overuse involving pronation and supination

  13. Clinical Manifestations SX: pain • Tenderness • Cramping of the proximal anterior forearm muscles • Sensory changes on palmer surface of digits 2,3,1/2 of 4 Signs: • Pain with resisted pronation • Tenderness to palpation of the pronator teres • Weakness of the FPL, FDP and Pronator Quadratus • + EMG • Weakness of pinch

  14. Provocation Tests Many special tests can assist in diagnosis Lack of sensitivity or specificity on many of the tests 1. Pronator Compression Test • Pressure applied for >30 seconds at edge of PT muscle 2. Resisted Finger Flexion, proximal PIP, 3rd digit • Indicates compression at level of FDS

  15. b. Anterior Interosseous Nerve Syndrome • Kiloh-Nevin Syndrome • Originates in the forearm at the cubital fossa, innervates the FPL, one half of the FDP and pronator quadratus. • Primary site of compression occurs at the point of division from the median nerve, near the tendinous insertion of the pronator teres muscle.

  16. Secondary areas of compression • Accessory bicipital neurosis • Accessory head of FPL (Gantzer muscle) • Palmaris profundus muscle • Flexor carpi radialis muscle

  17. Clinical Manifestations • SX: 8-12 hours deep forearm pain • does not resolve with rest • severe pain in the forearm • no sensory deficits • Signs: + Pinch Test • weakness of FPL, one half of the FDP • three jaw chuck pinch is weak • + EMG

  18. Differentiation: PTS and AIS • Sensory changes Positive: PTS Negative: AIS • Pronator Compression Test Positive: PTS Negative: AIS

  19. c. Carpal Tunnel Syndrome: • Compression of the median nerve at the wrist • Causes: • anything that alters the space in the carpal tunnel including: fractures, overuse, swelling of the tendons or nerve, RA, OA, diabetes, thyroid dysfunctions, pregnancy and menopause, hormonal changes, www.mps1disease.com/patient/about/mps_pt_symp...

  20. Carpal Tunnel Syndrome • Many carpal tunnel syndromes occur as a result of compensations elsewhere in the body. • Must check C spine, shoulder and elbow for joint biomechanics.

  21. Clinical Manifestations SX: • tingling and numbness in the thumb, index and middle fingers • aching in the thumb, wrist and digits of the hand • burning pain at night • clumsiness and weakness of the hand Signs: • decreased sensation to temperature and touch • atrophy of the thenar muscles • Provocation tests • + phalens test • + tinels test at the wrist • + NCS and + EMG

  22. RX: Carpal Tunnel Syndrome 60% respond to conservative treatment, splints with the wrist in 0-20dg of extension Avoid activities that contribute to the problem NSAIDS steroid injections promote tendon gliding after the inflammation has decreased Surgery

  23. Surgical Treatment of Carpal Tunnel Syndrome

  24. Open Carpal Tunnel Surgery

  25. Open Carpal Tunnel Surgery

  26. Open Carpal Tunnel Surgery

  27. Endoscopic Carpal Tunnel Surgery • Shorter Recovery time • Less of an incision for healing and less scar tissue can develop • No difference between the type of surgeries in outcomes

  28. Ulnar Nerve Elbow: a.Cubital Tunnel: around the tunnel, there are three areas that the ulnar nerve can be entrapped. b. Cubital tunnel posterior to the medial epicondyle c. Flexor carpi ulnaris muscle belly Wrist a. Guyon’s canal

  29. Intermuscular septa FCU Cubital Tunnel Guyons Canal

  30. Cubital Tunnel Syndrome • HX: • prolonged flexion of the elbow • common in throwing athletes, manual laborers, and musicians.

  31. Clinical Manifestations • Symptoms • pain in the proximal ulnar aspect of the forearm • tingling in the fifth digit and ulnar half of the fourth digit • clumsiness of the hand • hyperesthesia or numbness • muscle cramping • dull ache after activity or at rest • radiation of pain • Signs: • atrophy of hypothenar eminence and of adductor muscle of thumb • decrease in sensation within ulnar nerve distribution • Sudomotor changes • Provocation Tests • + Tinels at the elbow • + Fromnents signs • + elbow flexion test • + NCS, + EMG

  32. Ulnar Nerve Transposition • RX: surgery, • may transpose the nerve from the groove (anterior transposition) • under the flexor/pronator muscle mass (submuscular transposition) • inside the muscle (intramuscular transposition).

  33. Surgical Procedure

  34. Guyon's Canal Syndrome • Ulnar nerve compression within the canal. • Affects the palmar sensation and motor abilities. • Caused by repeated or chronic trauma to the area, bone or soft tissue injury or ganglia. • SX: decreased palmar sensation, ulnar nerve distribution • Signs: intrinsic muscle weakness, +EMG

  35. Posterior Interosseous Syndrome Superficial Radial Nerve Entrapment

  36. Radial Nerve Posterior interosseous Nerve: radial tunnel, compression neuropathy of the posterior interosseous nerve at the Arcade of Froshe as it enters the proximal border of the supinator muscle

  37. Posterior Interosseous Nerve SX: • aching pain along the extensor surface of the forearm and hand • pain about the elbow • Signs: • no sensory problems • Pain with deep palpation distal to lateral epicondyle • weakness of finger extensors • Provocation Testing • + middle digit Test

  38. Superficial Radial Nerve Entrapment (Wartenberg's syndrome or Cheiralgia paresthetica) Cause: direct trauma to the forearm, blow to the hand, tight cast, tight watchband or bracelet

  39. Superficial Radial Nerve Entrapment SX: • local tenderness at the wrist • pain in the forearm • numbness and parasthesia of the dorsum of the hand Signs: • sensory loss to the radial 2/3 of the dorsum of the hand, dorsal thumb, dorsal aspect of fingers up to ring finger (radial 1/2) from MCP to PIP level.

  40. Sciatic Nerve Entrapments Piriformis Syndrome: Sciatic Nerve Entrapment. Three specific conditions contribute to piriformis syndrome

  41. 1. Myofascial pain referred from trigger points in the piriformis muscle 2. Nerve and vascular entrapment by the piriformis muscle at the greater sciatic foramen 3. Dysfunction of the SI joint

  42. SX: • Buttock pain often radiating down the posterior aspect of the thigh and calf Signs: • Myofascial: weakness on resisted abduction with hip flexed 90 dg, tenderness to palpation decrease of hip IR ROM and pain • Nerve: paresthesias and dysthesias in the nerve distribution, Increase in symptoms in a FABER position, SLR positive SI dysfunction: pelvic torsion noted ** may have one, two or all three co-exist

  43. Maeralgia Paresthetica: Uncommon disorder, seen in obese patients, can be caused by tight underwear, above knee amputees Prevalence: 3/10,000 cases, can occur bilaterally in 20% of population, Males > Females, more common in middle aged adults SX: pain along the course of the nerve, pain along anterolateral aspect of the thigh, hypersensitivity, burning, tingling pain, symptoms relieved by rest Signs: increase in pain with passive extension of the hip, decrease sensation, pain reproduced with pressure on nerve

  44. Tarsal Tunnel Syndrome Most common nerve entrapment syndrome, similar to carpal tunnel in the wrist. • Entrapment of the posterior tibial nerve or one of its branches within the tarsal tunnel.

  45. Clinical Manifestations SX: • Burning dysesthesias or anesthesias in the plantar aspect of the foot • Pain in the plantar aspect of the foot especially at night • Weight bearing increases the symptoms Signs • During gait, will see a rear foot pronation with excessive eversion of the heel during stance phase • Or the heel will remain excessively inverted during the stance phase of gait • Provocative Tests • + tinels at the tarsal tunnel

  46. Morton's Neuroma Risk factors: women between the ages of 25 and 50, typically unilateral SX: • electric shock or burning sensation in the ball of the foot • typically begin near the second toe and spread out toward the others • intermittent pain • increases with weight bearing and at night

  47. Signs: • tender to palpate • compression of metatarsal heads in unison reproduces symptoms RX: surgical

  48. Intercostal Neuralgia (Shingles) Cause: • Infection by Herpes Zoster • Mechanical Nerve Compression by disk protrusion • Osteophyte formation at intervertebral foramen • Neuroma • Fracture • Postherpetic neuralgia (nerve pain that lasts for longer than the 2-4 weeks Incidence: 1-3 cases/1,000 Age, incidence increases to 4-12/1,000 after age 65 Prognosis: heals within 2-4 weeks

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