DR. MANOJ R. KANDOIM.S.,D.N.B.,D’ORTH,F.C.P.S.,F.I.C.S.,F.R.S.M.,M.N.O.F.FELLOW: UNIVARSITY OF WASHINGTON MILANO UNIVARSITY HISSINGPARK CLINIC,AUGSBERG,GERMANY HARBORVIEW MEDICAL CENTRE,SEATTLE,U.S.A POLICLINICO MULTIMEDICA,MILAN,ITALY AITS – IRCAD, TAIWAN,R.O.CHINA INOR FELLOW,BRITISH ORTHOPEDIC SOCIETY INTERNATIONAL COLLEGE OF SURGEONS,CHICAGO IRCAD ,STRAUBERG, FRANCE AMC,AMSTERDAM,NETHERLAND
What is a peripheral neuropathy? Peripheral neuropathy is disorder of nerve(s) apart from the brain and spinal cord. Patients with peripheral neuropathy may have tingling, numbness, unusual sensations, weakness, or burning pain.
What causes a peripheral neuropathy? Diabetes Mellitus Shingles (post herpetic neuralgia) Vitamin deficiency, particularly B12 and folate Alcohol Autoimmune diseases, including lupus, rheumatoid arthritis or Guillain-Barre syndrome AIDS, whether from the disease or its treatment, syphilis, and kidney failure Inherited disorders, such as amyloid polyneuropathy or Charcot-Marie-Tooth disease Exposure to toxins, such as heavy metals, gold compounds, lead, arsenic, mercury, and organophosphate pesticides Cancer therapy drugs such as vincristine (Oncovin, Vincasar), and other medications [for example antibiotics such as metronidazole (Flagyl), and isoniazid (Nydrazid, Laniazid)] While diabetes and post herpetic neura
Symptoms The symptoms depend on which type of nerve is affected. The three main types of nerves are: Nerves that carry sensations (sensory) Nerves that control muscles (motor) Nerves that carry information to organs and glands (autonomic)
SENSATION CHANGES Burning sensations Changes in sensation Inability to determine joint position, which causes lack of coordination Nerve pain Tingling or numbness
MOVEMENT DIFFICULTIES Difficulty breathing or swallowing Difficulty or inability to move a part of the body (paralysis) Falling (from legs buckling or tripping over toes) Lack of dexterity (such as being unable to button a shirt) Lack of muscle control Loss of muscle tissue (muscle atrophy) Muscle twitching or cramping
AUTONOMIC SYMPTOMS Abdominal bloating Blurred vision Constipation Decreased sweating Diarrhea Dizziness that occurs when standing up or fainting due to a drop in blood pressure Feeling full after eating a small amount (early satiety) Heat intolerance with exertion Incomplete bladder emptying Male impotence Nausea or vomiting after meals Urinary hesitancy (taking a long time to start urinating) Urinary incontinence Weight loss without trying
Signs and tests Tests that find and help classify neuropathy may include: Electromyogram (EMG) -- a recording of electrical activity in muscles) Nerve conduction velocity tests (NCV) -- a recording of the speed at which signals travel along nerves Nerve biopsy -- taking a small sample of a nerve to look at under a microscope
Treatment Addressing the cause (such as diabetes or excess alcohol use) Controlling symptoms Helping the patient gain maximum independence and self-care ability Replacing any vitamin or other deficiencies in the diet Stopping injury to the nerve (for example, in cases of neuropathy due to compression such as carpal tunnel syndrome)
Complications Deformity Loss of tissue mass Poor healing Scarring Tissue erosions Decreased self-esteem Difficulty breathing Difficulty swallowing Irregular heart rhythms (arrhythmias) Need for amputation Partial or complete loss of movement or control of movement Partial or complete loss of sensation Relationship problems related to impotence
Entrapment neuropathies Entrapment neuropathies are a group of disorders of the peripheral nerves that are characterized by pain and/or loss of function (motor and/or sensory) of the nerves as a result of chronic compression
Common entrappment syndromes Carpal tunnel syndrome (CTS), compression of the median nerve at the wrist, is the most common entrapment neuropathy. Cubital tunnel syndrome is caused by a compression at the elbow. suprascapular nerve compression, which accounts for approximately 0.4% of upper girdle pain symptoms, and meralgia paresthetica, a compression of the lateral femoral cutaneous nerve [LFCN] in the groin
CARPAL TUNNEL SYNDROME Median nerve compression at the wrist is at the transverse carpal ligament (TCL), which attaches to and arches between the pisiform and hamate on the ulnar side and the scaphoid and trapezium on the radial side
CARPAL TUNNEL SYNDROME Dull, aching pain at the wrist that may extend up the forearm to the elbow. Often, associated with distressing paresthesias in the thumb and index finger, particularly upon awakening. Typically, patients rub their wrists or shake their hands to try to "get the blood back into their wrists.“ The pain is typically worse at night and disturbs their sleep
RESULTS OF SURGERY SATISFYING SYMPTOMS TEND TO COMPLETELY RESOLVE
CUBITAL TUNNEL SYNDROME The ulnar nerve travels on the medial side of the brachial artery in the upper arm, pierces the medial intermuscular septum at mid arm, and continues toward the elbow on the medial head of the triceps. At the elbow, it passes through the cubital tunnel, a groove between the medial humeral epicondyle and the olecranon. The nerve travels beneath the aponeurotic arcade between the 2 heads of the flexor carpi ulnaris and down the forearm between the deep and superficial finger flexors.
5 potential areas of ulnar nerveentrapment : The arcade of Struthers stretches from the medial head of the triceps to insert into the medial intermuscular septum. It is located approximately 6-8 cm above the medial epicondyle. It can be a factor in ulnar nerve compression after ulnar nerve transposition. The medial intermuscular septum presents a sharp edge that can indent the nerve, particularly after anterior transposition, in which the nerve may be kinked. The cubital tunnel is floored by the medial collateral ligament of the elbow and roofed by the arcuate ligament (cubital tunnel retinaculum) that stretches between the medial humeral epicondyle and the medial aspect of the olecranon. The arching band of aponeurosis between the 2 heads of the flexor carpi ulnaris (so-called Osborne band) may compress the nerve, especially during repetitive contraction of the muscle. The aponeurotic covering between the flexors digitorum profundus and superficialis is occasionally a site of compression.
CLINICAL PRESENTATIONS Pain typically presents as a deep ache around the elbow region Pain is exacerbated when the medial elbow is impacted Intermittent paresthesias and numbness in the ring and little fingers Hand weakness, especially with gripping objects
CLINICAL SIGNS Sensation over the palmar portion of the fifth digit and the ulnar half of the fourth digit specifically is decreased to the following stimuli: Pinprick Light touch Two-point discrimination Sensory loss can also be detected along the dorso-ulnar aspect of the hand (due to involvement of the dorsal cutaneous branch of the ulnar nerve which arises proximal to the wrist). Late symptoms include dense numbness and profound weakness and atrophy of the intrinsic hand muscles. An ulnar claw hand may be present with extension of the little and ring fingers. Extension at the metacarpophalangeal joints and flexion at the intraphalangeal joints is caused by the loss of lumbricals 3 and 4. Provocative tests: A gentle tapping of the nerve at and around the cubital tunnel elicits distressing electrical shock, tingling, or both down into the ulnar fingers (percussion test).
FROMENT SIGN Weakness of finger abductors and adductors (interossei) and adductor of the thumb (adductor pollicis) may be detected whereas thumb abduction is normal
Ulnar nerve compression at the wrist(Guyon canal) At the wrist, the ulnar nerve runs above the flexor retinaculum lateral to the flexor carpi ulnaris tendon and medial to the ulnar artery. At the proximal carpal bones, it dips between the pisiform and the hook of the hamate at the entrance to the Guyon canal, roofed over by an extension of the TCL between these 2 bones
Clinical presentation young man with painless atrophy of the hypothenar muscles and interossei with sparing of the thenar group. Sensory loss and pain involving the ulnar 1.5 digits may be present.
SIGNS A positive Phalen test and percussion tenderness over the course of the ulnar nerve at the wrist may be present.
posterior interosseous nerve syndromeRelevant anatomy At mid arm, the radial nerve descends behind the humerus, deep to the long head of the triceps, and then spirals around the humerus in between the medial and lateral heads of the triceps in the spiral groove. Approximately 5- 10 cm above the lateral humeral epicondyle, the nerve pierces the lateral intermuscular septum to gain the anterior compartment of the arm. Here, it immediately enters the deep, muscular groove bordered medially by the biceps and brachialis and laterally by the brachioradialis, the extensor carpi radialis longus (ECRL), and the extensor carpi radialis brevis (ECRB). The nerve then courses immediately in front of the radiocapitellar joint capsule, where it divides into the (motor) deep branch of the radial nerve and the sensory superficial radial nerve (SRN).
causes PIN compression is most commonly associated with tendinous hypertrophy of the arcade of Frohse and fibrous thickening of the radiocapitellar joint capsule. Vascular compression by the leash of Henry has been reported. Lesions, such as lipoma, synovial cyst, rheumatoid synovitis, and a vascular aneurysm, have been found in some cases.
clinical picture Fatigue during finger extension and elbow supination. The extension in the metacarpophalangeal joints is weakened,. in the early stage of entrapment, the hand exhibits a characteristic pattern upon finger extension, in which the middle 2 fingers fail to extend, while the index and little fingers can be extended ("sign of horns"). Progression of paralysis eventually causes weakness in all of the finger extensors and in thumb abduction. No sensory symptoms are present.
Suprascapular nerve entrapmentRelevant anatomy The suprascapular nerve arises from the lateral aspect of the upper trunk of the brachial plexus, runs across the posterior triangle of the neck together with the suprascapular artery and the omohyoid muscle, dips under the trapezius, and then passes through the suprascapular notch at the superior border of the scapula. As the nerve enters the supraspinous fossa, it supplies the supraspinatus muscle, then curls tightly around the base of the spine of the scapula, enters the infraspinous fossa, and supplies the infraspinatus
cause A stout, strong suprascapular ligament closes over the free upper margins of the suprascapular notch. Suprascapular nerve entrapment is caused by this ligament, often in conjunction with a tight, bony notch.
Pain symptoms Pain with insidious onset Deep, dull aching pain in the posterior part of the shoulder and upper periscapular region Noncircumscribed pain No neck or radicular symptoms Shoulder weakness
Signs Weakness is confined to the supraspinatus, which initiates shoulder abduction and/or the infraspinatus, which externally rotates the arm. Atrophy can manifest as hollowing of the infraspinous fossa and prominence of the scapular spine. Supraspinatus atrophy may not be obvious because of the overlying trapezius. Deep pressure over the midpoint of the superior scapular border may produce discomfort.
Lateral femoral cutaneous nervecompression(meralgia paresthetica) This purely sensory nerve is formed just deep to the lateral border of the psoas muscle, then descends in the pelvis over the iliacus muscle deep to the iliacus fascia. Just medial to the ASIS, the nerve exits the pelvis by passing through the deep and superficial bands of the inguinal ligament as they attach to the ASIS. The nerve is almost horizontal while still within the pelvis before it traverses the inguinal ligament, but then it takes a vertical course out to the surface of the thigh.
etiology A protruding, pendulous abdomen, as seen in obesity and pregnancy, compresses the inguinal ligament downward and onto the nerve, causing it to be kinked. This angulation of the nerve is further exaggerated with extension of the thigh and relaxed with flexion.
symptoms The main symptoms are an uncomfortable numbness, tingling, and painful hypersensitivity in the distribution of the LFCN, usually in the anterolateral thigh down to the upper patella region.
Common peroneal nerve entrapmentIt is 1 of the 2 terminal divisions of the sciatic nerve. It winds around the lateral aspect of the neck of fibula deep to the peroneus longus (fibular tunnel), where it divides into superficial peroneal, deep peroneal, and articular branches. Entrapment occurs where the nerve is in close relationship to the neck of fibula.
ETIOLOGY Trauma or injury to the knee Fracture of the fibula (a bone of the lower leg) Use of a tight plaster cast (or other long-term constriction) of the lower leg Habitual leg crossing Regularly wearing high boots Pressure to the knee from positions during deep sleep or coma Injury during knee surgery
Clinical presentation Pain radiating from the knee region to the dorsal aspect of the foot Sensory loss on the dorsum of the foot Foot drop (loss of dorsiflexion of the foot) and loss of extension of toes, and eversion of ankle (This is differentiated from an L5 radiculopathy, in which posterior tibialis function (inversion in plantar flexion) is affected.)
Drawing of the dorsal aspect of the foot illustrates the territories of the deep peroneal nerve (DPN), lateral plantar nerve (LPN), medial plantar nerve (MPN), sural nerve (SN), and superficial peroneal nerve (SPN
Deep peroneal nerve compressionsyndrome most common site of compression is at the top of the foot where a small tendon compresses the deep peroneal nerve against the underlying bone
ETIOLOGY a crush injury to the foot wearing tight shoes or tightly laced boots, a broken foot bone, or foot surgery
SYMPTOMS Symptoms here are only sensory, and may feel like a knife sticking in the top of the foot, and pain between the first and second toes
Sup per. Nerve compression syndrome It travels in the lateral compartment and supplies the peroneus longus and brevis muscles. In most individuals, the superficial peroneal nerve pierces the deep fascia and emerges into the subcutaneous fat at approximately the level of the middle and lower third of the leg and at an average of about 10-15 cm above the tip of the lateral malleolus
Etiology Local trauma or compression Repeated ankle sprains prolonged kneeling and squatting any procedure about the anterior ankle, including use of the anterolateral ankle arthroscopy portal
Clinical numbness or paresthesia in the distribution of the nerve have pain about the lateral leg vague pain over the dorsum of the foot symptoms increase with activity, such as running, walking, or squatting
treatment injection of steroids plus lidocaine near the site of involvement in the lower leg can reduce symptoms and serve as a diagnostic tool in confirming the zone of nerve compression release of the superficial peroneal nerve at the lateral leg for surgical decompression with partial or full fasciotomy
Sural nerve compression Sural nerve is a purely sensory nerve Sural nerve arises from the branches of common peroneal and tibial nerve the nerve passes from proximal calf to the ankle posterior to the lateral malleolus Sural nerve supplies skin of the lateral calf and feet
ETIOLOGY Sural nerve can be affected by compression from tight socks, Bakers cyst or laceration
SYMPTOMS Patient complains of abnormal sensation over the lateral calf and foot
Tarsal tunnel syndrome Compression of the tibial nerve behind the medial malleolus, or tarsal tunnel syndrome (TTS),
Tarsal tunnel syndrome The roof of the tunnel is formed by the flexor retinaculum stretched between the medial malleolus and the calcaneus. The tarsal bones are the floor. Numerous fibrous septae between the roof and the floor subdivide the tunnel into separate compartments at various points. The contents of the tarsal tunnel at its proximal end are, from front to back, as follows: The tibialis posterior tendon The flexor digitorum longus tendon The posterior tibial artery and vein The tibial nerve The flexor hallucis longus tendon
The tibial nerve has 3 terminal branches. It bifurcates into the medial and lateral plantar nerves within 1 cm of the malleolar-calcaneal axis in 90% of cases; in the other 10% of cases, the medial and plantar nerves are 2-3 cm proximal to the malleolus. The calcaneal branch usually comes off the lateral plantar fascicles, but around 30% leave the main nerve trunk just proximal to the tunnel. Distally, the medial and lateral plantar nerves travel in separate fascial compartments. The medial branch supplies the intrinsic flexors of the great toe, the first lumbrical, and the sensation over the medial plantar surface of the foot inclusive of at least the first 3 toes. The lateral branch supplies all of the interossei and the lateral 3 lumbricals, as well as sensation over the lateral plantar surface of the foot. The calcaneal branch, which traverses its own tunnel, provides sensation to the heel.
Drawing illustrates the PTN trifurcation. ADQM = abductor digiti quinti muscle, AHM = abductor hallucis muscle
Drawing of the plantar aspect of the foot illustrates the territories of the lateral calcaneal nerve (LCN), lateral plantar nerve (LPN), medial calcaneal nerve (MCN), medial plantar nerve (MPN), and sural nerve (SN)
Clinical presentation Early symptoms are burning, tingling, and dysesthetic pain over the plantar surface of the footIn advanced cases, theintrinsic flexors of the great toeare weak and atrophied,producing hollowing of theinstep. The lateral toes mayalso show clawing due toparalysis of the intrinsic toeflexors