Transcript بسم الله الرحمن الرحیم Entrapment Neuropathies

‫بسم اهلل الرحمن‬
‫الرحیم‬
Entrapment
Neuropathies
 Carpal tunnel syndrome (CTS)
 Ulnar neropathy at the elbow
 Thoracic outlet syndrome (TOS)
 Meralgia paresthetica
 Tarsal tunnel syndrome (TTS)
 Morton’s neuroma
 Patterns of weakness and sensory
loss can identify which nerves are
injured and localize the site of
injury.
 Provocative maneuvers, which
briefly increase pressure at a site of
compression, aid diagnosis by recreating or exacerbating symptoms.
 Electrodiagnostic testing (EDX) should be performed to
confirm the diagnosis
 Magnetic resonance imaging (MRI) or ultrasonagraphy
should be performed to identify the source of compression
 Diagnosis of one entrapment neuropathy does not exclude
another.
 such as carpal tunnel syndrome and cervical radiculopathy.
This phenomenon is called a “double crush.” Symptoms and
signs can overlap.
 EDX can also provide prognostic information.
 EDX often differentiate myelin dysfunction
from axon damage.
 When a compressive lesion causes only focal
demyelination, the injury is called
neurapraxic, and carries a better prognosis
for quick and complete recovery.
 Axon loss ,recovery will be slower and
perhaps incomplete.
CARPAL TUNNEL
SYNDROME
CTS is the most common and
most studied entrapment
neuropathy.
PATHOLOGY

The median nerve can be compressed as it passes through
the carpal tunnel. The tunnel is at the base of the hand.
 The carpal, or wrist bones, form the floor of the tunnel and
the flexor retinaculum forms the roof. Nine flexor tendons
also pass through the tunnel.
 Due
to this crowded arrangement, tenosynovial
proliferation, fluid collection, or arthritic deformity can lead
to carpal tunnel syndrome.
 Epineural ischemia(impede flow to arteries)
 Intraneural edema(venous stasis)
SYMPTOMS
•
Numbness on the palmar surface of the thumb and index, middle, and
half of the ring finger
 Patients are often not aware of the true distribution of numbness and
may report that all five fingers are involved.
 The pain can be both distal and proximal to the site of compression.
Patients can report pain in the hand, wrist, elbow, and shoulder. Carpal
tunnel syndrome should be considered in any obscure complaint of pain
in the arm.
 symptoms at night/Driving
 “flick sign”(needing to shake hand)
 Patients usually do not complain of weakness. They may report dropping
things or having difficulty with certain motor activities like doing up
buttons or opening a jar.
PHYSICAL FINDINGS
 The median nerve after it exits the carpal tunnel supplies
sensation to the palmar surface of the thumb and index,
middle, and half the ring finger. It also supplies the dorsal
tips of these same fingers.
 The palmar branch of the median nerve, which supplies
sensation to the proximal portion
 The palm and thenar eminence, does
not go through the carpal tunnel, and is
therefore spared in carpal tunnel
syndrome.
 Phalen’s maneuver
 Tinel’s sign
ELECTRODIAGNOSIS
 sensitivity as high as 95%. The hallmark
of electrodiagnosis is a delay in the
distal latency of median nerve
conduction.
 Rule out cervical RAD/ TOS/ diff PNP
TREATMENT
 splinting to maintain the wrist in a
neutral position
 Anti-inflammatory
 Surgical decompression
RISK FACTORS
 computer use
 flexion and extension at the wrist
 obesity, arthritis, diabetes, and
hypothyroidism
 shape of the wrist
ULNAR NEUROPATHY
AT THE ELBOW
 Ulnar nerve entrapment at the
elbow is the second most
common neuropathy in the
upper extremity.
 Entrapment can occur either at
the ulnar groove or at the cubital
tunnel.
PATHOLOGY
 The ulnar nerve is particularly vulnerable to
compression or stretch as it crosses the elbow and
passes through the cubital tunnel.
 The ulnar groove is formed by the medial
epicondyle and the olecranon process.
 The nerve is also vulnerable to impingement if there
is a bony deformity or scar formation. Patients with
a remote history of supracondylar fracture can
develop such a bony deformity and nerve
impringement in what has been called “tardy ulnar
palsy.”
SYMPTOMS
 Intermittent numbness and tingling in the
distribution of the ulnar nerve is usually the first
symptom of ulnar palsy.
 Patients can wake up with elbow pain radiating into
the fifth digit.
 There can be cramping and aching in the
hypothenar eminence.
 Symptoms can be exacerbated by flexion of the
elbow.
 Patients may complain about a generalized loss of
strength in the hand or loss of dexterity.
PHYSICAL FINDINGS
 The ulnar nerve supplies sensory fibers to the fifth finger,
both palmar and dorsal surfaces, and usually
 in some individuals the ulnar nerve may supply the whole
ring finger and even part of the long finger.
 weaken grasp and pinch strength( froment sign)
 Difficulty addacting the fifth digit(wartenberg sign)
 Clawing of digits 4&5 and finger abduction weakness
(Benediction Posture)
 Weakness of ulnar flexor digitorum
 Atrophy of the hypothenar eminence and the first dorsal
interosseous can often be seen.
 tenderness with palpation and Flexion of the elbow
ELECTRODIAGNOSIS
 EDX testing is necessary to confirm a diagnosis and
to exclude other causes including brachial
plexopathy, cervical radiculopathy, and an ulnar
entrapment at the wrist.
 NCS will usually show slowing across the elbow and
sometimes a drop in response amplitude across the
elbow.
 Inching techniques can sometimes localize the site
of compression to the ulnar groove or the cubital
tunnel.
TREATMENT
 Mild cases of ulnar palsy at the elbow can be
successfully treated with an elbow pad to reduce
trauma to the nerve or by avoiding prolonged
flexion at the elbow.
 More severe cases may require surgery. The precise
site of entrapment will determine the surgical
procedure, which can include transposition of the
nerve, decompression at the aponeurosis, or even
medial epicondylectomy.
RISK FACTORS
 Resting a bent elbow on a hard surface is a behavior that can
provoke ulnar palsy. For example, truck drivers can develop a
left ulnar palsy from resting their elbow on the window of
the truck while driving.
 Direct trauma including elbow fractures can cause acute
ulnar nerve injury.
 Delayed or tardy ulnar palsies can result from bony
deformities that develop after trauma or fracture.
THORACIC OUTLET SYNDROMES
(TOS)
 There are many structures that can compress or impinge the
brachial plexus as it enters the arm.
 Vascular structures can also be compressed in the same way.
 Various positions of the shoulder can also compromise both
vascular and neural structures in the thoracic outlet.
PATHOLOGY
 A cervical rib is the most discussed source of compromise in
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
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
TOS, but easily identified by x-ray
An anomalous fibrous band from the transverse process of
the last cervical vertebra to the first rib is a common cause of
impingement.
by the scalenes, subclavius, and pectoralis minor muscles
have all been reported.
Hyperextension injuries of the neck can lead to intrascalene
muscle hemorrhage and swelling with resultant scar
formation in the muscle or around the brachial plexus.
Most commonly in neurogenic TOS the lower trunk of the
brachial plexus is most involved.
Vascular syndromes usually involve compromise of the
axillary and subclavian vessels/Flow studies
SYMPTOMS
 The symptoms of TOS depend on whether they are primarily
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
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arterial, venous, or neurologic and can vary with shoulder
position.
In the arterial form, symptoms are ischemic in nature and
include pain, paresthesia, coldness, and color change.
Venous symptoms can include swelling, and cyanosis, as well
as pain and paresthesia.
Neurogenic symptom -numbness of the medial forearm and
ulnar side of the hand. aching pain, poorly localized in the
arm and anterior chest.
clumsiness or weakness in the hand and fingers. Atrophy of
both the thenar and hypothenar eminences can be seen.
 Elicit symptoms with Anterior flexion and Abduction and
supination of the arm
PHYSICAL FINDINGS
 the lower trunk of the brachial plexus-sensory deficits on the
ulnar
 weakness and atrophy of the thenar eminence
 syndrome progresses, sensory loss can involve all five fingers.
 True neurogenic TOS initially causes weakness of median
innervated hand muscles and later ulnar innervated muscles.
 Atrophy of both thenar and hypothenar eminences can occur
 Provocative tests
Adson’s maneuver involves extending the arm at shoulder
height to the side and supinating the hand .loss of radial pulse,
and an increase in sensory symptoms.
The Elvey maneuver stresses the brachial plexus by again
extending the arm to the side and then tilting the head to the
opposite side
ELECTRODIAGNOSIS
 Reduction in the amplitude of the medial
antebrachial cutaneous sensory response.
 Later ulnar sensory responses in the hand will be
diminished.
 Late responses such as F-waves will become
prolonged and conductions across the plexus will be
slowed as plexopathy progresses.
 Needle examination may elicit denervation changes
in both median and ulnar innervated hand muscles
in advanced cases.
TREATMENT
 Correction of shoulder posture
 Exercises that strengthen the rhomboid and trapezius muscles
 Clavicle straps
 Surgery-The most common surgical procedures are resection of cervical
rib and fibrous band, and calenectomies. Both procedures carry
significant morbidity.
 The injection of botulinum toxin into the scalene muscles subclavius,
pectoralis minor, trapezius, and levator scapula also have been injected
with good results in some patients. Potential complications of botulinum
toxin injections in this area include dysphagia, dysphonia, and muscle
weakness.
MERALGIA
PARESTHETICA
 Entrapment of the lateral
femoral cutaneous nerve of
the thigh has been well
described for over 100 years.
PATHOLOGY
 The lateral femoral cutaneous nerve of the thigh
(L2&L3)arises from upper lumbar roots, travels through
the pelvis, and exits into the leg at the upper lateral end of
the inguinal ligament.
 The nerve is usually trapped as it passes under or through
the inguinal ligament.
 Blunt trauma to this area can cause damage to the nerve.
More chronic episodic external compression from tightfitting clothes, a holster, or tool belt can provoke meralgia.
 increased intra-abdominal ressure from weight gain or
pregnancy. Mass lesions, including lipomas and fibroids,
have been reported in some cases.
SYMPTOMS
 unpleasant sensations and numbness in the
lateral thigh.
 Light touch in the area can be unpleasant.
PHYSICAL FINDINGS
 The lateral femoral cutaneous nerve is a
purely sensory nerve that supplies just the
lateral thigh.
ELECTRODIAGNOSIS
 difficult to elicit sensory responses from
the lateral femoral cutaneous nerve in
normal individuals.
TREATMENT
 Pain control with medication is the
standard treatment. Reduction of risk
factors
 Nerve blocks
 Surgical intervention
RISK FACTORS
 Obesity
 Pregnancy
 Diabetes
 tight-fitting clothes
 Pelvic osteotomy
 stabilization devices during spine surgery
TARSAL TUNNEL
SYNDROME
 posterior tibial nerve at the
medial ankle
PATHOLOGY
 The tarsal tunnel is formed by the ankle bones and
the flexor retinaculum.
 Through the tunnel passes the posterior tibial
nerve, tendons of the foot and toe flexors, and the
posterior tibial artery.
 Increased pressure in the tunnel brings on the
syndrome. This can occur from an ankle fracture or
sprain, arthritic changes, tenosynovitis, or fluid
collection. Mass lesions in the tarsal tunnel like
ganglion cysts or convoluted blood vessels,
SYMPTOMS
 foot pain
 Burning
 Painful numbness
 Walking and standing can exacerbate symptoms
PHYSICAL FINDINGS
 Intrinsic foot muscles primarily toe flexors and
abductors, can be affected but clinical testing of
these muscles can be difficult.
 Pressure
 Painful
 Eversion and dorsiflexion can also provoke
symptoms
ELECTRODIAGNOSIS
 motor and sensory slowing through the tarsal
tunnel.
 Needle examination of intrinsic foot muscles can be
misleading
TREATMENT
 Anti-inflammatory medication
 Surgical decompression is highly effective
RISK FACTORS
 Ankle trauma
 Rheumatoid arthritis
 diabetes mellitus both increase the risk for tarsal
tunnel syndrome
INTERDIGITAL NEUROPATHY
(MORTON’S NEUROMA)
 Pressure on an interdigital nerve in one of the
intermetatarsal spaces can cause pain and
numbness in the distal foot and toes.
PATHOLOGY
 The interdigital nerves are distal branches of the
lateral and medial plantars.
 actual scar
 Neuroma
 This most commonly occurs between the third and
fourth metatarsal heads but can involve other
interdigital nerves.
SYMPTOMS
 burning pain in the ball of the foot that radiates to
one or two toes.
 The corresponding toes may feel numb. Pain will be
worse with weight bearing.
PHYSICAL FINDINGS
 Pain can be elicited by pushing on the ball of the
foot over the affected interdigital nerve.
 A neuroma can often be visualized with MRI or
ultrasound.
ELECTRODIAGNOSIS
 Difficult and often unreliable. Both orthodromic
and antidromic sensory or mixed nerve studies
using both surface electrodes and near-needle
electrodes have been described, but none are
routinely performed.
 excluding other neuropathologies that also manifest
with foot pain and numbness, in particular TTS,
lumbosacral radiculopathy, and generalized PNP.
TREATMENT
 physical therapy, orthotics, and avoiding offending
footwear are often successful.
 Interdigital anesthetic nerve blocks, often with
corticosteroids, have been effective in some
patients.
 A variety of surgical interventions have been used,
all with some success.
RISK FACTORS
 Activities that increase trauma to the foot can all
increase one’s risk for interdigital neuropathy.
 Ill-fitting shoes, especially high heels, also
predispose one to develop Morton’s neuroma.
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