Peripheral nerve injury in the upper extremity is common and can result from repetitive strain, direct trauma, or compression. The most common site of injury is the carpal tunnel. A thorough history and physical exam is important to determine the location and nature of symptoms in order to establish a differential diagnosis. While imaging and electrodiagnostic testing may be warranted for persistent or worsening symptoms, most nerve injuries are initially treated conservatively with splinting, injections, or activity modification. Recovery depends on the severity of injury, with mild injuries having better prognosis.
This document summarizes research on recovery of motor function after stroke and spinal cord injury. It discusses evidence that motor function can improve through recovery of marginally functional neurons or relearning via neuroplasticity. Studies in rats and primates found improved motor skills after stroke when rehabilitation was paired with low-frequency stimulation of the injured cortex. A clinical trial also found improvements in hand function in stroke patients receiving motor cortex stimulation during rehabilitation. The document also reviews research attempting to promote regeneration in severed spinal cords by rerouting peripheral nerves, with initial positive results seen in human patients with traumatic paraplegia.
The temporal branch of the facial nerve is a commonly injured nerve during facial trauma due to its superficial course over the zygomatic arch, and is a commonly damaged nerve during facial surgery.1 We report a case of trauma to the left temporal fossa, and subsequent unilateral forehead paralysis. Early exploration revealed external suture compression as the origin of his paralysis. Removal of the suture led to complete resolution of the neurological deficit. The differential diagnosis did not include the possibility of the compression of the nerve by a suture, however the decision for early exploration led to a full recovery.
This document discusses the anatomy and classification of peripheral nerve injuries. It begins by describing the cellular components of nerves, types of nerve fibers, and classifications of nerve injuries including Seddon's and Sunderland's. It then discusses signs and symptoms of nerve injuries, common sites of injury, Wallerian degeneration, nerve regeneration, and various surgical and non-surgical treatment options including neurolysis, nerve grafting, and nerve repair. Classification of injuries is based on damage to nerve components and ability for spontaneous recovery. Surgical treatment depends on the degree and severity of injury.
This document provides information on various interventional pain management procedures including:
1) Lumbar interlaminar epidural steroid injections can help manage lumbar radicular symptoms by injecting medication into the posterior epidural space.
2) Transforaminal epidural steroid injections target the affected nerve root by injecting medication along the nerve root in the anterior epidural space.
3) Peridural adhesiolysis uses catheterization and injectate to break up epidural scarring which can cause pain after back surgery.
4) Potential complications of interventional procedures include infection, bleeding, neurological injury, adverse drug reactions, and allergic reactions. Precautions and management of side effects are also
The document summarizes interventional pain management techniques for treating chronic pain, including low back pain. It discusses procedures like medial branch blocks, radiofrequency ablation, epidural steroid injections, vertebroplasty, and spinal cord stimulation. It also notes that the author's experience with these techniques has found 50% pain relief in 50% of patients for durations ranging from 3 weeks to 14 months.
Traumatic brain injury and stabilisation of long bone fracturesAhmed Azmy
This document discusses the debate around the timing and type of stabilization of long bone fractures in patients with severe traumatic brain injury. While early definitive fracture stabilization may help reduce pain and complications, it also risks exacerbating brain injury through potential secondary insults like fat embolism, hypotension, and hypoxia during surgery. Alternatively, delaying fracture fixation avoids these risks but allows pain and complications from the fractures. Overall, the recommendation is to stabilize fractures only once physiological stability is achieved, in order to prioritize optimal oxygenation and regulation of cerebral blood flow over definitive fracture care.
This document summarizes research on recovery of motor function after stroke and spinal cord injury. It discusses evidence that motor function can improve through recovery of marginally functional neurons or relearning via neuroplasticity. Studies in rats and primates found improved motor skills after stroke when rehabilitation was paired with low-frequency stimulation of the injured cortex. A clinical trial also found improvements in hand function in stroke patients receiving motor cortex stimulation during rehabilitation. The document also reviews research attempting to promote regeneration in severed spinal cords by rerouting peripheral nerves, with initial positive results seen in human patients with traumatic paraplegia.
The temporal branch of the facial nerve is a commonly injured nerve during facial trauma due to its superficial course over the zygomatic arch, and is a commonly damaged nerve during facial surgery.1 We report a case of trauma to the left temporal fossa, and subsequent unilateral forehead paralysis. Early exploration revealed external suture compression as the origin of his paralysis. Removal of the suture led to complete resolution of the neurological deficit. The differential diagnosis did not include the possibility of the compression of the nerve by a suture, however the decision for early exploration led to a full recovery.
This document discusses the anatomy and classification of peripheral nerve injuries. It begins by describing the cellular components of nerves, types of nerve fibers, and classifications of nerve injuries including Seddon's and Sunderland's. It then discusses signs and symptoms of nerve injuries, common sites of injury, Wallerian degeneration, nerve regeneration, and various surgical and non-surgical treatment options including neurolysis, nerve grafting, and nerve repair. Classification of injuries is based on damage to nerve components and ability for spontaneous recovery. Surgical treatment depends on the degree and severity of injury.
This document provides information on various interventional pain management procedures including:
1) Lumbar interlaminar epidural steroid injections can help manage lumbar radicular symptoms by injecting medication into the posterior epidural space.
2) Transforaminal epidural steroid injections target the affected nerve root by injecting medication along the nerve root in the anterior epidural space.
3) Peridural adhesiolysis uses catheterization and injectate to break up epidural scarring which can cause pain after back surgery.
4) Potential complications of interventional procedures include infection, bleeding, neurological injury, adverse drug reactions, and allergic reactions. Precautions and management of side effects are also
The document summarizes interventional pain management techniques for treating chronic pain, including low back pain. It discusses procedures like medial branch blocks, radiofrequency ablation, epidural steroid injections, vertebroplasty, and spinal cord stimulation. It also notes that the author's experience with these techniques has found 50% pain relief in 50% of patients for durations ranging from 3 weeks to 14 months.
Traumatic brain injury and stabilisation of long bone fracturesAhmed Azmy
This document discusses the debate around the timing and type of stabilization of long bone fractures in patients with severe traumatic brain injury. While early definitive fracture stabilization may help reduce pain and complications, it also risks exacerbating brain injury through potential secondary insults like fat embolism, hypotension, and hypoxia during surgery. Alternatively, delaying fracture fixation avoids these risks but allows pain and complications from the fractures. Overall, the recommendation is to stabilize fractures only once physiological stability is achieved, in order to prioritize optimal oxygenation and regulation of cerebral blood flow over definitive fracture care.
1) Entrapment neuropathies occur when nerves are injured by chronic compression, angulations, or stretching forces, causing mechanical damage. Carpal tunnel syndrome is an example where the median nerve is compressed as it passes through the wrist.
2) Clinical features of entrapment neuropathies include pain, numbness, tingling, burning, and weakness in the affected area. Electrodiagnostic tests like nerve conduction studies and electromyography are important diagnostically.
3) Treatment involves conservative measures like splinting, steroid injections, and physical therapy. Surgery is considered if conservative treatment fails or for severe cases. Proper identification of the site of nerve entrapment is key to determining appropriate treatment
1. Percutaneous spinal interventions involve minimally invasive procedures using needles and fluoroscopy to inject medications into the spine to treat chronic pain.
2. Common spinal interventions include caudal epidural injections in the lower back, transforaminal epidural injections to access specific spinal nerves, and radiofrequency ablation to disrupt nerve conduction.
3. Spinal interventions are generally low-risk outpatient procedures that provide pain relief and can avoid the need for surgery in many chronic pain cases.
This document discusses failed back syndrome, specifically defining it as any condition where there is failure to improve satisfactorily following back surgery. It then classifies failures into those with no immediate improvement and temporary relief but recurrence of pain within weeks, months, or years. Causes of failures include wrong diagnosis, technical errors during surgery, infection, arachnoiditis, and recurrent stenosis. The document also discusses juxtafacet cysts near facet joints.
This document provides information on carpal tunnel syndrome (CTS), including its anatomy, etiology, diagnosis, and treatment options. Some key points:
- CTS is caused by compression of the median nerve as it passes through the carpal tunnel in the wrist. Symptoms include pain, numbness, and tingling in the hand.
- Diagnosis is primarily clinical through tests like Tinel's sign and Phalen's maneuver. Electrodiagnostic tests like nerve conduction studies can help assess severity.
- Conservative treatments include splinting, injections, and exercises. Surgery (open or endoscopic release) is recommended if conservative options fail.
- The goals of any surgical technique are to completely
Carpal tunnel syndrome is caused by compression of the median nerve in the carpal tunnel of the wrist. It affects up to 10% of the general population and is characterized by motor, sensory, vasomotor and trophic symptoms in the hand. Conservative treatments include splinting, anti-inflammatory medications, injections, and vitamin B6, while surgical treatment involves releasing the transverse carpal ligament to decompress the median nerve. Diagnosis is based on symptoms, physical exam findings like a positive Phalen's or Tinel's sign, and electrodiagnostic testing to measure nerve conduction velocities.
Ultrasound guided pulsed radiofrequency treatment of the pudendal nerve in ch...Jason Attaman
This case report summarizes the effectiveness of ultrasound-guided pulsed radiofrequency treatment of the pudendal nerve in three patients with chronic pelvic pain. The three patients, two males with interstitial cystitis and one female with pudendal neuralgia, underwent ultrasound-guided pudendal nerve blocks followed by pulsed radiofrequency treatment of the pudendal nerve. All three patients experienced reduced pain scores and decreased analgesic use following the treatment. No complications occurred. The report concludes pulsed radiofrequency treatment of the pudendal nerve under ultrasound guidance provides adequate analgesia for chronic pelvic pain.
Systemic inflamatory rheumatoid arthritis & non inflamatory osteoarthritisaditya romadhon
Rheumatoid arthritis (RA) is a systemic autoimmune disease characterized by chronic inflammation of multiple joints. Genetic and environmental factors contribute to disease development. RA is associated with elevated inflammatory markers like ESR and CRP. Early diagnosis and treatment with DMARDs can reduce joint damage. Osteoarthritis (OA) is the most common form of arthritis. It is a degenerative joint disease characterized by cartilage breakdown in the joints. Risk factors include age, obesity, trauma, and genetic predisposition. OA shows asymmetric joint involvement and symptoms are typically worse in the evening. Treatment focuses on weight loss, braces, and conservative measures to reduce joint stress.
This document discusses the choice of anaesthetic for primary total hip replacement surgery and whether general anaesthesia or regional anaesthesia provides the best perioperative outcomes. It defines general anaesthesia and regional anaesthesia. Regional anaesthesia options for hip replacement include spinal, epidural, and peripheral nerve blocks. Meta-analyses have found regional anaesthesia may reduce the risk of deep vein thrombosis, pulmonary embolism, and blood transfusion requirements compared to general anaesthesia. Regional anaesthesia also provides better immediate postoperative analgesia. However, the choice of anaesthetic depends on each patient's individual factors, medical history, and comorbidities.
Accidental sundural injection case reportRitoban C
The document describes a case report of accidental subdural injection during attempted epidural anesthesia for labor pain relief. Key details include:
- A 32-year-old woman received an epidural catheter that produced an unusually high sensory block level without significant motor weakness or hypotension.
- Imaging with contrast dye injection through the catheter later revealed the dye had spread exclusively in the cephalad direction within the subdural space, confirming an accidental subdural placement of the catheter.
- Subdural injections can occur due to anatomical variations that allow local anesthetic to spread within the narrow potential space between the dura and arachnoid membranes, producing an unpredictable sensory block. Proper diagnosis and treatment
Management of the patient with suspected perioperative nerve injuryEdward R. Mariano, MD
At the conclusion of the activity participants should be able to: discuss potential risks for perioperative nerve injury; estimate occurrence rates of various regional anesthesia complications; evaluate the patient with suspected nerve injury and recommend appropriate testing.
ANESTHETIC CONSIDERATIONS FOR STEREOTACTIC ELECTROENCEPHALOGRAPHY (SEEG) IMP...Anurag Tewari MD
The refractory seizures have significant impact on the quality of life and increase long term neurologic and non-neurologic complications. Implantation of Stereotactic Electroencephalography (SEEG) leads is one of the newer surgical techniques intended to localize seizure foci with higher accuracy than the conventional methods. Most of the commonly utilized anesthetic agents depress EEG waveforms affecting intra operative monitoring during these surgeries. Hence, the anesthetic goals include a stable induction and maintenance with agents which have minimal effect on EEG. This article discusses the peri-operative considerations of multiple anti-epileptic medications, recent advances in anesthetic management, and important post-operative concerns.
Keywords: Anesthesia, epilepsy surgery, intra-operative EEG, intra operative monitoring, refractory seizures, SEEG, seizure foci, stereotactic electroencephalography
The document discusses various spine injection procedures and techniques. It provides details on trigger point injections, lumbar epidural steroid injections (ESIs), transforaminal ESIs, cervical ESIs, medial branch blocks, radiofrequency ablation (RFA) of medial branches, and sacroiliac (SI) joint injections. The risks of these procedures include infection, bleeding, dural puncture, nerve injury, and steroid side effects. Proper positioning, needle placement using fluoroscopy, and injection of local anesthetic with or without steroid are emphasized.
Pulsed radiofrequency ablation of pudendal nerve for treatment of a case of r...Jason Attaman
This case report describes a 51-year-old woman suffering from chronic pelvic pain due to pudendal neuralgia. Various medication trials provided only limited pain relief. Diagnostic pudendal nerve blocks and MR neurography imaging revealed pudendal neuropathy as the cause. The patient underwent pulsed radiofrequency ablation of the pudendal nerve, resulting in over 6 weeks of significant pain relief. This report adds to evidence that PRF ablation and MR neurography can effectively treat and diagnose pudendal neuralgia.
Relief of urinary urgency, hesitancy, and male pelvic pain with pulsed radiof...Jason Attaman
This document summarizes a case report of a 86-year-old man who underwent pulsed radiofrequency ablation (RFA) of the pudendal nerve to treat urinary urgency, hesitancy, and pelvic pain. The patient had a 30-year history of urinary symptoms and had tried various medications and procedures without success. After undergoing pulsed RFA of the pudendal nerve, the patient reported marked improvement in his pelvic pain and a significant reduction in his urinary symptoms. The summary concludes that pudendal nerve block with pulsed RFA may be an effective treatment for pelvic pain and urinary symptoms.
Central post-stroke pain (CPSP) is a chronic neuropathic pain syndrome that can develop after a stroke and affect the body areas corresponding to the damaged brain region. CPSP is characterized by burning, aching pain and abnormal skin sensations and occurs in 1-12% of stroke patients. The pathophysiology likely involves changes in thalamic and cortical processing of sensory information after damage to brain areas involved in temperature and pain signaling. Treatment involves medications like antidepressants and anticonvulsants, as well as neurostimulation therapies for refractory cases, with varying success rates.
This document discusses neurological complications that can arise from regional anesthesia used in obstetrics. It outlines two case reports of patients experiencing numbness after epidurals for labor and delivery, with one case likely due to positioning during prolonged labor. It then discusses obstetric and anesthesia-related causes of neurological deficits. Obstetric causes include compression injuries from prolonged labor or forceps delivery. Proper diagnosis requires a thorough history, physical exam, and potential imaging or laboratory tests. Neurological complications from regional anesthesia are very rare but careful technique aims to minimize risk.
This document discusses neuromuscular problems that can occur in the ICU. It notes that ICU admissions related to neuromuscular disorders are generally due to respiratory muscle weakness and swallowing difficulties. It also describes how motor weakness in ICU patients can be caused by a pre-existing condition, a new condition, or critical illness complications. The document provides guidance on evaluating and identifying the severity and cause of neuromuscular weakness in ICU patients in order to provide appropriate treatment.
This document discusses complications that can arise from regional anesthesia. It covers nerve injuries, infections, systemic toxicity from local anesthetics, and issues related to anticoagulation. Specific complications covered include nerve injuries from peripheral nerve blocks, infections from continuous perineural catheters, cardiac and neurological toxicity from local anesthetics, and challenges with anticoagulated patients. Prevention strategies and management approaches are provided.
This document provides an overview of nerve compression syndromes, including their pathophysiology, clinical presentation, assessment, and management. It discusses how nerve compression can lead to neuropathic pain through mechanisms like ischemia, inflammation, and central nervous system changes. Common compression neuropathies like carpal tunnel syndrome and sciatica are mentioned. The document emphasizes that entrapment neuropathies have complex presentations that do not always clearly fit the grading criteria for neuropathic pain. A thorough clinical assessment including history, exam, and provocation tests is important for diagnosis.
1) Entrapment neuropathies occur when nerves are injured by chronic compression, angulations, or stretching forces, causing mechanical damage. Carpal tunnel syndrome is an example where the median nerve is compressed as it passes through the wrist.
2) Clinical features of entrapment neuropathies include pain, numbness, tingling, burning, and weakness in the affected area. Electrodiagnostic tests like nerve conduction studies and electromyography are important diagnostically.
3) Treatment involves conservative measures like splinting, steroid injections, and physical therapy. Surgery is considered if conservative treatment fails or for severe cases. Proper identification of the site of nerve entrapment is key to determining appropriate treatment
1. Percutaneous spinal interventions involve minimally invasive procedures using needles and fluoroscopy to inject medications into the spine to treat chronic pain.
2. Common spinal interventions include caudal epidural injections in the lower back, transforaminal epidural injections to access specific spinal nerves, and radiofrequency ablation to disrupt nerve conduction.
3. Spinal interventions are generally low-risk outpatient procedures that provide pain relief and can avoid the need for surgery in many chronic pain cases.
This document discusses failed back syndrome, specifically defining it as any condition where there is failure to improve satisfactorily following back surgery. It then classifies failures into those with no immediate improvement and temporary relief but recurrence of pain within weeks, months, or years. Causes of failures include wrong diagnosis, technical errors during surgery, infection, arachnoiditis, and recurrent stenosis. The document also discusses juxtafacet cysts near facet joints.
This document provides information on carpal tunnel syndrome (CTS), including its anatomy, etiology, diagnosis, and treatment options. Some key points:
- CTS is caused by compression of the median nerve as it passes through the carpal tunnel in the wrist. Symptoms include pain, numbness, and tingling in the hand.
- Diagnosis is primarily clinical through tests like Tinel's sign and Phalen's maneuver. Electrodiagnostic tests like nerve conduction studies can help assess severity.
- Conservative treatments include splinting, injections, and exercises. Surgery (open or endoscopic release) is recommended if conservative options fail.
- The goals of any surgical technique are to completely
Carpal tunnel syndrome is caused by compression of the median nerve in the carpal tunnel of the wrist. It affects up to 10% of the general population and is characterized by motor, sensory, vasomotor and trophic symptoms in the hand. Conservative treatments include splinting, anti-inflammatory medications, injections, and vitamin B6, while surgical treatment involves releasing the transverse carpal ligament to decompress the median nerve. Diagnosis is based on symptoms, physical exam findings like a positive Phalen's or Tinel's sign, and electrodiagnostic testing to measure nerve conduction velocities.
Ultrasound guided pulsed radiofrequency treatment of the pudendal nerve in ch...Jason Attaman
This case report summarizes the effectiveness of ultrasound-guided pulsed radiofrequency treatment of the pudendal nerve in three patients with chronic pelvic pain. The three patients, two males with interstitial cystitis and one female with pudendal neuralgia, underwent ultrasound-guided pudendal nerve blocks followed by pulsed radiofrequency treatment of the pudendal nerve. All three patients experienced reduced pain scores and decreased analgesic use following the treatment. No complications occurred. The report concludes pulsed radiofrequency treatment of the pudendal nerve under ultrasound guidance provides adequate analgesia for chronic pelvic pain.
Systemic inflamatory rheumatoid arthritis & non inflamatory osteoarthritisaditya romadhon
Rheumatoid arthritis (RA) is a systemic autoimmune disease characterized by chronic inflammation of multiple joints. Genetic and environmental factors contribute to disease development. RA is associated with elevated inflammatory markers like ESR and CRP. Early diagnosis and treatment with DMARDs can reduce joint damage. Osteoarthritis (OA) is the most common form of arthritis. It is a degenerative joint disease characterized by cartilage breakdown in the joints. Risk factors include age, obesity, trauma, and genetic predisposition. OA shows asymmetric joint involvement and symptoms are typically worse in the evening. Treatment focuses on weight loss, braces, and conservative measures to reduce joint stress.
This document discusses the choice of anaesthetic for primary total hip replacement surgery and whether general anaesthesia or regional anaesthesia provides the best perioperative outcomes. It defines general anaesthesia and regional anaesthesia. Regional anaesthesia options for hip replacement include spinal, epidural, and peripheral nerve blocks. Meta-analyses have found regional anaesthesia may reduce the risk of deep vein thrombosis, pulmonary embolism, and blood transfusion requirements compared to general anaesthesia. Regional anaesthesia also provides better immediate postoperative analgesia. However, the choice of anaesthetic depends on each patient's individual factors, medical history, and comorbidities.
Accidental sundural injection case reportRitoban C
The document describes a case report of accidental subdural injection during attempted epidural anesthesia for labor pain relief. Key details include:
- A 32-year-old woman received an epidural catheter that produced an unusually high sensory block level without significant motor weakness or hypotension.
- Imaging with contrast dye injection through the catheter later revealed the dye had spread exclusively in the cephalad direction within the subdural space, confirming an accidental subdural placement of the catheter.
- Subdural injections can occur due to anatomical variations that allow local anesthetic to spread within the narrow potential space between the dura and arachnoid membranes, producing an unpredictable sensory block. Proper diagnosis and treatment
Management of the patient with suspected perioperative nerve injuryEdward R. Mariano, MD
At the conclusion of the activity participants should be able to: discuss potential risks for perioperative nerve injury; estimate occurrence rates of various regional anesthesia complications; evaluate the patient with suspected nerve injury and recommend appropriate testing.
ANESTHETIC CONSIDERATIONS FOR STEREOTACTIC ELECTROENCEPHALOGRAPHY (SEEG) IMP...Anurag Tewari MD
The refractory seizures have significant impact on the quality of life and increase long term neurologic and non-neurologic complications. Implantation of Stereotactic Electroencephalography (SEEG) leads is one of the newer surgical techniques intended to localize seizure foci with higher accuracy than the conventional methods. Most of the commonly utilized anesthetic agents depress EEG waveforms affecting intra operative monitoring during these surgeries. Hence, the anesthetic goals include a stable induction and maintenance with agents which have minimal effect on EEG. This article discusses the peri-operative considerations of multiple anti-epileptic medications, recent advances in anesthetic management, and important post-operative concerns.
Keywords: Anesthesia, epilepsy surgery, intra-operative EEG, intra operative monitoring, refractory seizures, SEEG, seizure foci, stereotactic electroencephalography
The document discusses various spine injection procedures and techniques. It provides details on trigger point injections, lumbar epidural steroid injections (ESIs), transforaminal ESIs, cervical ESIs, medial branch blocks, radiofrequency ablation (RFA) of medial branches, and sacroiliac (SI) joint injections. The risks of these procedures include infection, bleeding, dural puncture, nerve injury, and steroid side effects. Proper positioning, needle placement using fluoroscopy, and injection of local anesthetic with or without steroid are emphasized.
Pulsed radiofrequency ablation of pudendal nerve for treatment of a case of r...Jason Attaman
This case report describes a 51-year-old woman suffering from chronic pelvic pain due to pudendal neuralgia. Various medication trials provided only limited pain relief. Diagnostic pudendal nerve blocks and MR neurography imaging revealed pudendal neuropathy as the cause. The patient underwent pulsed radiofrequency ablation of the pudendal nerve, resulting in over 6 weeks of significant pain relief. This report adds to evidence that PRF ablation and MR neurography can effectively treat and diagnose pudendal neuralgia.
Relief of urinary urgency, hesitancy, and male pelvic pain with pulsed radiof...Jason Attaman
This document summarizes a case report of a 86-year-old man who underwent pulsed radiofrequency ablation (RFA) of the pudendal nerve to treat urinary urgency, hesitancy, and pelvic pain. The patient had a 30-year history of urinary symptoms and had tried various medications and procedures without success. After undergoing pulsed RFA of the pudendal nerve, the patient reported marked improvement in his pelvic pain and a significant reduction in his urinary symptoms. The summary concludes that pudendal nerve block with pulsed RFA may be an effective treatment for pelvic pain and urinary symptoms.
Central post-stroke pain (CPSP) is a chronic neuropathic pain syndrome that can develop after a stroke and affect the body areas corresponding to the damaged brain region. CPSP is characterized by burning, aching pain and abnormal skin sensations and occurs in 1-12% of stroke patients. The pathophysiology likely involves changes in thalamic and cortical processing of sensory information after damage to brain areas involved in temperature and pain signaling. Treatment involves medications like antidepressants and anticonvulsants, as well as neurostimulation therapies for refractory cases, with varying success rates.
This document discusses neurological complications that can arise from regional anesthesia used in obstetrics. It outlines two case reports of patients experiencing numbness after epidurals for labor and delivery, with one case likely due to positioning during prolonged labor. It then discusses obstetric and anesthesia-related causes of neurological deficits. Obstetric causes include compression injuries from prolonged labor or forceps delivery. Proper diagnosis requires a thorough history, physical exam, and potential imaging or laboratory tests. Neurological complications from regional anesthesia are very rare but careful technique aims to minimize risk.
This document discusses neuromuscular problems that can occur in the ICU. It notes that ICU admissions related to neuromuscular disorders are generally due to respiratory muscle weakness and swallowing difficulties. It also describes how motor weakness in ICU patients can be caused by a pre-existing condition, a new condition, or critical illness complications. The document provides guidance on evaluating and identifying the severity and cause of neuromuscular weakness in ICU patients in order to provide appropriate treatment.
This document discusses complications that can arise from regional anesthesia. It covers nerve injuries, infections, systemic toxicity from local anesthetics, and issues related to anticoagulation. Specific complications covered include nerve injuries from peripheral nerve blocks, infections from continuous perineural catheters, cardiac and neurological toxicity from local anesthetics, and challenges with anticoagulated patients. Prevention strategies and management approaches are provided.
This document provides an overview of nerve compression syndromes, including their pathophysiology, clinical presentation, assessment, and management. It discusses how nerve compression can lead to neuropathic pain through mechanisms like ischemia, inflammation, and central nervous system changes. Common compression neuropathies like carpal tunnel syndrome and sciatica are mentioned. The document emphasizes that entrapment neuropathies have complex presentations that do not always clearly fit the grading criteria for neuropathic pain. A thorough clinical assessment including history, exam, and provocation tests is important for diagnosis.
This document discusses brachial plexus disorders including their anatomy, causes, clinical presentation, diagnostic approach, management, and specific conditions like idiopathic brachial plexitis and injuries. Key points covered include the brachial plexus anatomy and branches, common causes of brachial plexus disorders like injury and idiopathic plexitis, clinical features of shoulder pain and weakness, and electrodiagnostic and imaging studies used in evaluation and diagnosis. Management depends on the underlying cause but may include corticosteroids, physiotherapy, and conservative treatment.
Approach to radial nerve injury case report and journal discussionAnmol Mittal
Radial nerve injury is one of the most dreaded consequences of humerus fractures. Hence the approach to any case with potential of this sequalae needs to be approached in a calculated manner as explained in this case discussion and review of two recent jounral articles
Broad frame work of management in peripheral nerveVenkat Jampana
This document outlines the management of peripheral nerve injuries. It discusses the initial assessment and treatment, as well as factors that influence recovery prognosis. Open injuries may be explored early, while closed injuries are monitored for signs of regeneration before potential surgery. Surgical techniques like nerve grafting and tendon transfers are described. Motor, sensory, reflex, autonomic, and trophic complications of peripheral nerve injuries are also summarized.
This document discusses classifications of spine fractures. It defines clinical instability as loss of ability to maintain vertebral relationships without damage to the spinal cord or nerves or development of pain or deformity. It reviews classification systems including Denis, AO, and TLICS. TLICS is based on fracture morphology, integrity of the posterior ligamentous complex, and neurological status. Each category is scored to determine treatment, with the highest score determining approach. PLC disruption generally requires posterior surgery, while incomplete neurological injuries and anterior compression require anterior procedures. Qualifiers like comorbidities can also influence treatment.
This document discusses the history and techniques of peripheral nerve repair. It notes that peripheral nerves have the ability to regenerate after injury, unlike the central nervous system. The key points covered include:
- The timeline of discoveries and advances in peripheral nerve repair from the 17th century to present day.
- The anatomy of peripheral nerves and the different layers (epineurium, perineurium, endoneurium)
- Grading systems for peripheral nerve injuries.
- Pre-operative evaluation techniques like nerve conduction studies and EMG.
- Surgical techniques for different types of injuries like transection, avulsion or neuroma in continuity.
- Microsurgical techniques like
The document discusses neurodynamics and summarizes key points in 3 sentences:
Neurodynamics examines the nervous system as a continuum that can withstand tension or sliding longitudinally and transversely. Proper sequencing and structural differentiation of movements is important for neurodynamic testing to isolate neural responses from musculoskeletal influences. Abnormal neurogenic responses on testing can be overt, reproducing symptoms, or covert, evoking different symptoms, and determining the relevance of the response guides clinical decisions.
Electromyography (EMG) and nerve conduction studies (NCS) provide physiological information about nerves and muscles. They are important diagnostic tools but only provide one piece of the puzzle, and must be interpreted along with other clinical information. EMG and NCS can help establish diagnoses, determine appropriate treatment, and provide prognostic information. They are generally safe when performed by a skilled clinician but have small risks like infection, bleeding, or tissue injury that should be weighed against the potential benefits for any given patient.
The document discusses neuropathic pain, specifically trigeminal neuralgia. It defines trigeminal neuralgia as paroxysmal attacks of intense, sharp, superficial pain affecting one or more divisions of the trigeminal nerve. The pain is often triggered by innocuous stimuli like tooth brushing or talking. Trigeminal neuralgia is mostly idiopathic, but can occasionally be caused by underlying conditions like multiple sclerosis or tumors. The most widely accepted theory is that trigeminal neuralgia is caused by vascular compression of the trigeminal nerve root, which results in demyelination and hyperexcitability of nerve fibers.
Neuropatías focales y por atrapamientos .pdfAngelOvalle13
This document discusses electrodiagnosis of common mononeuropathies, focusing on median neuropathy at the wrist (carpal tunnel syndrome). Standard electrodiagnostic techniques are recommended for initial assessment, including nerve conduction studies and needle electromyography. Nerve conduction studies are useful to confirm injury, localize sites of injury, and assess severity and recovery. For carpal tunnel syndrome specifically, electrodiagnostic studies can confirm median nerve involvement at the wrist and exclude other conditions. Both routine and advanced nerve conduction studies are described.
This document discusses somatosensory evoked potentials (SEPs), which are electrical signals generated in the nervous system in response to sensory stimuli. SEPs reflect the activation of neural structures along somatosensory pathways. They are recorded using electrodes on the scalp and spine in response to electrical stimulation of peripheral nerves. SEP waves are labeled according to their polarity and latency. Clinical uses of SEPs include evaluating peripheral nerves and central somatosensory pathways, localizing lesions, and monitoring patients in intensive care and during surgery. Abnormal SEPs can indicate disorders of the peripheral or central nervous system.
This document provides an overview of common nerve entrapments around the shoulder, including the axillary nerve, suprascapular nerve, long thoracic nerve, spinal accessory nerve, and dorsal scapular nerve. It discusses the anatomy and pathways of each nerve, potential causes of entrapment including repetitive microtrauma and compression, characteristic clinical presentations such as localized pain and muscle weakness, diagnostic techniques including electromyography and magnetic resonance imaging, and potential treatment approaches including injections and surgical decompression.
Monitorização em cirurgia de cabeca e pescocoLeonardo Rangel
Neuromonitorização em Cirurgia de Cabeça e Pescoço discusses nerve monitoring in head and neck surgery. The main points are:
1) The primary morbidity of head and neck surgeries are nerve injuries that cause sequelae. Different types of nerve lesions are discussed ranging from neurapraxia to neurotmesis.
2) Various nerves in the head and neck region are described such as the facial, hypoglossal, accessory, and marginal nerves. The most common causes of injury to these nerves are discussed.
3) Techniques for nerve monitoring are outlined including anatomy, physiology, types of lesions, and types of monitoring used to help reduce nerve injuries during
1. This document discusses principles of peripheral nerve repair, including making an accurate diagnosis, determining the injury mechanism, timing of repair, adequate debridement of nerve stumps, use of microsurgery, and postoperative management.
2. Specific techniques are presented, such as cable grafts to bridge nerve gaps and nerve transfers to restore shoulder function. Complications from various injuries like gunshot wounds and traumatic false aneurysms compressing nerves are also reviewed.
3. Hereditary conditions like Hereditary Neuropathy with Liability to Pressure Palsies that increase susceptibility to nerve injuries are mentioned.
Role of magnetic resonance Imaging in acute spinal trauma hazem youssef
1. Magnetic resonance imaging (MRI) plays an important role in evaluating acute spinal trauma by detecting injuries that may be missed on other imaging studies like CT scans or x-rays.
2. MRI is better than other imaging modalities at identifying ligamentous injuries, disc herniations, epidural hematomas, and spinal cord injuries which are important to evaluate spinal stability and guide management.
3. The typical MRI protocol for acute spinal trauma includes sagittal and axial T1-weighted, T2-weighted, STIR, and T2* gradient echo sequences to fully characterize bone fractures, disc abnormalities, cord injuries, ligamentous injuries, and hemorrhage.
This document provides an overview of nerve injury, including the mechanism, structure, classification, physiological changes, diagnosis, and treatment. It begins with the mechanism of nerve injury such as trauma, ischemia, or toxins. It then describes the structure of a nerve including the epineurium, fascicles, perineurium, endoneurium, myelin sheath, and axon. Common classification systems for nerve injury including Seddon's and Sunderland's are presented. The physiological changes after injury like Wallerian degeneration and regeneration are discussed. Methods for diagnosing a nerve injury through history, physical exam including the Tinel sign, and neurological tests are covered.
This document discusses complications that can occur with regional anesthesia techniques. It begins by outlining general principles for safe regional anesthesia including thorough patient assessment, skilled monitoring during the procedure, and having necessary equipment and assistance available. It then discusses specific complications that can occur with local anesthetics including allergic reactions, systemic toxicity, and cardiac issues. Potential complications of peripheral nerve blocks are reviewed such as direct needle trauma, pneumothorax, and vascular or spinal cord injury. The toxic effects of local anesthetics on nerves and surrounding tissues like myotoxicity and phrenic nerve paresis are also covered. Finally, complications associated with neuroaxial blocks like direct needle trauma, ischemic injuries, and management of neurologic injuries are summarized.
Neurospinal monitoring techniques have been used since the 1970s to provide surgeons with information about the integrity of the spinal cord and nerves during complex spine surgeries. The most common monitoring methods are somatosensory evoked potentials (SSEP), which evaluate dorsal column pathways, and motor evoked potentials (MEP), which assess the corticospinal tract. Together these help detect mechanical or ischemic injuries to the spinal cord. A 1995 study found SSEP monitoring to have a 92% sensitivity and 98.9% specificity in detecting new postoperative neurological deficits in over 51,000 spine surgeries.
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Adhd Medication Shortage Uk - trinexpharmacy.comreignlana06
The UK is currently facing a Adhd Medication Shortage Uk, which has left many patients and their families grappling with uncertainty and frustration. ADHD, or Attention Deficit Hyperactivity Disorder, is a chronic condition that requires consistent medication to manage effectively. This shortage has highlighted the critical role these medications play in the daily lives of those affected by ADHD. Contact : +1 (747) 209 – 3649 E-mail : sales@trinexpharmacy.com
ABDOMINAL TRAUMA in pediatrics part one.drhasanrajab
Abdominal trauma in pediatrics refers to injuries or damage to the abdominal organs in children. It can occur due to various causes such as falls, motor vehicle accidents, sports-related injuries, and physical abuse. Children are more vulnerable to abdominal trauma due to their unique anatomical and physiological characteristics. Signs and symptoms include abdominal pain, tenderness, distension, vomiting, and signs of shock. Diagnosis involves physical examination, imaging studies, and laboratory tests. Management depends on the severity and may involve conservative treatment or surgical intervention. Prevention is crucial in reducing the incidence of abdominal trauma in children.
Does Over-Masturbation Contribute to Chronic Prostatitis.pptxwalterHu5
In some case, your chronic prostatitis may be related to over-masturbation. Generally, natural medicine Diuretic and Anti-inflammatory Pill can help mee get a cure.
Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
Rasamanikya is a excellent preparation in the field of Rasashastra, it is used in various Kushtha Roga, Shwasa, Vicharchika, Bhagandara, Vatarakta, and Phiranga Roga. In this article Preparation& Comparative analytical profile for both Formulationon i.e Rasamanikya prepared by Kushmanda swarasa & Churnodhaka Shodita Haratala. The study aims to provide insights into the comparative efficacy and analytical aspects of these formulations for enhanced therapeutic outcomes.
2. Nerve Injury
148 American Family Physician www.aafp.org/afp Volume 81, Number 2 ◆
January 15, 2010
should be determined. Table 1 outlines the differential
diagnosis of upper extremity nerve injury by symptom
and area of the body.5,6
Initial physical examination of a patient with an upper
extremity injury includes looking for the presence of a
radial pulse, and sensation and movement in the digits.
If there is no obvious neurovascular compromise, the
remainder of the examination is based on the patient’s
history. The examination should follow the classic pat-
tern of inspection, palpation, joint range of motion,
muscle strength testing, and sensory and neurologic
examination. It is helpful to understand the nerves com-
monly involved, their function, and the corresponding
areas of the body at risk of compression or entrapment.
Figures 1 and 2 show typical distributions of nerves in the
upper extremity.7
Common Nerve Injuries and Entrapment
Syndromes of the Upper Extremity
Tables 2 through 4 outline the evaluation process and
differential diagnosis of nerve injuries to the upper
extremity.5,6
SHOULDER AND ARM
Axillary Nerve: Quadrilateral Space Syndrome. The axil-
lary nerve is vulnerable to trauma as it passes through
the quadrilateral space. Injury can occur from shoul-
der dislocation; upward pressure (e.g., from improper
crutch use); repetitive overload activities (e.g., pitching a
ball, swimming); and arthroscopy or rotator cuff repair.
The typical symptom is arm fatigue with overhead activ-
ity or throwing. There may be associated paresthesias of
the lateral and posterior upper arm. Examination reveals
weak lateral abduction and external rotation of the arm.
Brachial Plexus Nerve: Stinger. A brachial plexus injury
(i.e., stinger) is common in persons who play football,
but it also occurs with other collision sports. The classic
presentation is acute onset of paresthesias in the upper
arm. A key characteristic is a circumferential rather than
dermatomal pattern of paresthesias. Symptoms typically
last seconds to minutes. Motor symptoms may be pres-
ent initially or develop later.
A brachial plexus injury must be differentiated from
a cervical spine injury. The initial examination should
focus on the neck, with palpation of the cervical verte-
brae to detect point tenderness and evaluation of neck
SORT: KEY RECOMMENDATIONS FOR PRACTICE
Clinical recommendation
Evidence
rating References
Patients with a brachial plexus nerve injury (i.e., stinger) should undergo periodic reexamination for two
weeks after the injury. Continued or new symptoms should be evaluated using neuroimaging and
electrodiagnostics because a more severe nerve injury is likely.
C 8-10
For patients with a carpal tunnel syndrome diagnosis based on typical history and physical examination
findings, electrodiagnostic testing does not usually change the diagnosis.
C 24, 25
Symptom relief from splinting, corticosteroid injections, and other conservative modalities for carpal tunnel
syndrome have similar outcomes. Surgical intervention has been shown to have better outcomes than splinting.
B 25, 29, 48
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-
oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.
org/afpsort.xml.
Table 1. Symptoms of Upper Extremity
Nerve Injuries
Anatomic area Symptom
Nerve injuries
to consider
Shoulder Pain or numbness Axillary
Brachial plexus
Weakness Axillary
Brachial plexus
Long thoracic
Spinal accessory
Suprascapular
Forearm Pain or numbness Pronator
Radial tunnel
Weakness Posterior interosseous
Hand Pain or numbness Radial at wrist
Ulnar at wrist or elbow
Weakness Median at wrist
Ulnar at elbow
Information from references 5 and 6.
3. January 15, 2010 ◆
Volume 81, Number 2 www.aafp.org/afp American Family Physician 149
Supraclavicular nerve
Axillary nerve
Radial nerve
Terminal part of
muscolocutaneous nerve
Ulnar nerve Ulnar nerve
Median nervePosterior Anterior
Radial nerve
Upper Limb Cutaneous Innervation
Figure 1. Posterior and anterior views of upper limb cutaneous
innervation.
Information from reference 7.
Nerve Injury
range of motion. Any indication of a cervi-
cal spine injury mandates further emergent
neurologic and radiologic evaluation. Point
tenderness of the cervical vertebrae or pain
with neck movement is a red flag for a cer-
vical spine injury, in which case the patient
should be immobilized. Bilateral symptoms
or those involving upper and lower extremi-
ties are less likely to be from a brachial
plexus injury.
If motor symptoms occur, the upper
extremity muscle group exhibiting weak-
ness correlates with the part of the brachial
plexus that has been injured. Because motor
symptoms may occur hours to days after the
injury, repeated neurologic examinations are
necessary—the patient should be reevaluated
after 24 hours and then at least every few days
for two weeks. If new symptoms or signifi-
cant worsening of existing symptoms occurs,
neuroimaging, electrodiagnostics, or surgical
referral should be considered.8
Patients who
have multiple occurrences of stingers should
also have a more thorough workup, because
they may have an underlying neck pathology
that predisposes them to this injury.9,10
Occurrence during participation in a
sporting event raises the issue of return
to play. If all symptoms resolve within
15 minutes and there is no concern for cervi-
cal spine injury, the player may return to the
same event with at least one repeat examina-
tion during that event.11
Long Thoracic Nerve. Injury to the long
thoracic nerve occurs acutely from a blow to
the shoulder, or with activities that involve
chronic repetitive traction on the nerve (e.g.,
tennis, swimming, baseball). Presenting
symptoms include diffuse shoulder or neck
pain that worsens with overhead activities.
Examination reveals scapular winging and
weakness with forward elevation of the arm.
Spinal Accessory Nerve. Injury to the spi-
nal accessory nerve can occur with trapezius
trauma or shoulder dislocation. Radical neck
dissection, carotid endarterectomy, and cer-
vical node biopsy are iatrogenic sources of
injury. Patients usually present with general-
ized shoulder pain and weakness. Examina-
tion of the shoulders reveals asymmetry. The
affected side appears to sag and the patient is
Figure 2. Posterior and anterior views of upper limb dermatomes.
Information from reference 7.
C3
C4
C5
C6
C7
C8
T1
C6
C8
C7Posterior
C3
C5
C4
C6
T1
C8
Anterior
Upper Limb Dermatomes
ILLUSTRATIONBYReneeCannonILLUSTRATIONBYReneeCannon
4. Nerve Injury
150 American Family Physician www.aafp.org/afp Volume 81, Number 2 ◆
January 15, 2010
unable to shrug the shoulder toward the ear. Associated
weakness of forward arm elevation above the horizon-
tal plane is common. With chronic injury, the trapezius
may atrophy.
Suprascapular Nerve. Injury to the suprascapular
nerve is associated with repetitive overhead loading. The
suprascapular nerve serves the supraspinatus and infra-
spinatus muscles. The infraspinatus may be the only
muscle affected, depending on the site of injury. Loss of
infraspinatus function presents as weak external rota-
tion of the arm. Supraspinatus involvement additionally
presents with weak arm elevation, which is most pro-
nounced in the range of 90 to 180 degrees. Suprascapular
nerve injury can result from other shoulder pathologies,
specifically a glenoid labrum tear. Cyst formation at the
suprascapular notch from a labral tear is not uncom-
mon. The cyst compresses the suprascapular nerve,
affecting the supraspinatus and infraspinatus muscles.12
Suprascapular nerve injury and rotator cuff tear both
lead to supraspinatus and infraspinatus weakness.
Differentiating the two injuries may require magnetic
resonance imaging (MRI).
FOREARM AND ELBOW
Median Nerve at the Elbow: Pronator Syndrome. The
pronator teres muscle in the forearm can compress the
median nerve, which may cause symptoms that mimic
carpal tunnel syndrome. Symptoms are discomfort and
aching in the forearm with activities requiring repeti-
tive pronation of the forearm, especially with the elbow
extended. Paresthesias in the thumb and first two digits
may be present. Forearm sensation is normal, and sensa-
tion of the digits may also be normal. In pronator syn-
drome, there is sensory loss over the thenar eminence,
which is not a finding of carpal tunnel syndrome. Results
of the Tinel sign and Phalen maneuver at the wrist should
be negative in patients with pronator syndrome.13
Radial Nerve at the Elbow: Radial Tunnel and Pos-
terior Interosseous Nerve Syndromes. The radial nerve
divides into a superficial branch (sensory only) and a
Table 2. Shoulder and Arm Examination: Abnormalities That May Indicate Nerve Injury
Component
of evaluation Evaluation area Diagnoses to consider
Inspection Clavicle symmetry and integrity
Humeral head position
Muscle deformity or atrophy
Shoulder symmetry
Skin ecchymoses or swelling
Dislocation or fracture
Shoulder dislocation; look for radial nerve injury
Muscle tear or chronic nerve injury
Sagging shoulder suggests spinal accessory nerve injury
Localized injury
Palpation Acromioclavicular and sternoclavicular joints
Clavicle, scapular spine
Muscle tenderness, integrity, or deformity
Dislocation
Fracture
Contusion or muscle tear
Range of motion* Forward flexion 180 degrees; extension
45 degrees; lateral abduction 180 degrees;
adduction 45 degrees; internal rotation
55 degrees; external rotation 40 degrees
If active range of motion is normal, no need to test passive range
of motion; if active range of motion is abnormal and passive
range of motion is normal, consider muscle or nerve injury;
abnormal passive range of motion indicates joint pathology
Muscle strength Adduction
Extension
External rotation
Forward flexion
Internal rotation
Lateral abduction
Shoulder protraction (reaching); possibly
winged scapula
Shoulder shrug
Weakness in many movements of the
shoulder or upper arm
Pectoralis and latissimus muscles
Posterior deltoid muscle, axillary nerve
Infraspinatus muscle, suprascapular nerve; teres minor muscle,
axillary nerve
Anterior deltoid muscle, axillary nerve
Subscapular muscle and nerve
Middle deltoid muscle, axillary nerve; supraspinatus muscle,
suprascapular nerve
Serratus anterior muscle, long thoracic nerve
Trapezius muscle, spinal accessory nerve
Brachial plexus nerve injury
Sensory/neurologic Circumferential anesthesia or paresthesia
Dermatomal anesthesia or paresthesia
Brachial plexus nerve injury
Individual nerve root injury
*—Measured in degrees from neutral position. Compare with contralateral side.
Information from references 5 and 6.
5. Nerve Injury
January 15, 2010 ◆
Volume 81, Number 2 www.aafp.org/afp American Family Physician 151
deep branch (posterior interosseous nerve) at the lateral
elbow. Forearm pain that is exacerbated by repetitive
forearm pronation is the presenting symptom of radial
tunnel syndrome, which involves injury to the superficial
branch of the radial nerve. Symptoms of radial tunnel
syndrome are almost identical to those of tennis elbow
(i.e., lateral epicondylitis), and distinguishing the two
can be difficult because physical examination maneu-
vers that aggravate radial tunnel syndrome may also be
positive in patients with tennis elbow (e.g., supination
against resistance with the elbow and wrist extended, and
resisted extension of the middle finger).14
A differentiat-
ing factor is the point of maximal tenderness. In radial
tunnel syndrome, this point is over the anterior radial
neck; in tennis elbow, it is at the origin of the extensor
carpi radialis brevis muscle.
The presence of any motor symptoms is more likely
related to injury of the posterior interosseus nerve,
which supplies the extensor muscles of the hand. Gener-
alized hand weakness is the presenting symptom of pos-
terior interosseus nerve syndrome. Examination reveals
weakness of digit and wrist extension, although this is
usually more prominent in the digits than in the wrist.
Ulnar Nerve at the Elbow: Cubital Tunnel Syndrome.
The ulnar nerve at the elbow is very superficial and at
risk of injury from acute contusion or chronic compres-
sion. Compression can be from an external or internal
source. As the elbow flexes, the cubital tunnel volume
decreases, causing internal compression. Cubital tunnel
syndrome may cause paresthesias of the fourth and fifth
digits. There may be elbow pain radiating to the hand,
and symptoms may be worse with prolonged or repetitive
elbow flexion. Paresthesias precede clinical examination
findings of sensory loss. Weakness may occur, but is a late
symptom. When present, motor findings are weak digit
abduction, weak thumb abduction, and weak thumb-
index finger pinch. Power grip is ultimately affected.
HAND AND WRIST
Median Nerve at the Wrist: Carpal Tunnel Syndrome. Car-
pal tunnel syndrome is the most common nerve entrap-
ment injury.15
Early symptoms are paresthesias of the
Table 3. Elbow and Forearm Examination: Abnormalities That May Indicate Nerve Injury
Component
of evaluation Evaluation area Diagnoses to consider
Inspection Carrying angle in full extension (men: 5 degrees,
women: 15 degrees); compare with contralateral side
Diffuse elbow joint swelling; joint held in flexion
Swelling over olecranon
Biceps muscle and tendon tenderness or deformity
Cubital fossa tenderness or swelling
Epicondyles or distal humerus
Radial head
Ulnar nerve in sulcus: tender or thickened area over
nerve
Wrist extensor tenderness
Wrist flexor or pronator muscle group tenderness
Decreased angle suggests supracondylar fracture;
increased angle suggests lateral epicondylar fracture;
consider possible ulnar nerve injury
Interarticular joint pathology
Olecranon bursitis
Palpation Ruptured distal biceps muscle or tendon
Joint capsule strain or hyperextension injury; look for
median and musculocutaneous nerve injury
Fracture
Fracture or dislocation; consider radial nerve injury
Ulnar nerve injury or entrapment
Radial tunnel syndrome or lateral epicondylitis (tennis elbow)
Pronator syndrome or golfer’s elbow
Range of motion* Flexion 135 degrees; extension 0 to 5 degrees;
supination 90 degrees; pronation 90 degrees
If active range of motion is normal, no need to test passive
range of motion; if active range of motion is abnormal
and passive range of motion is normal, consider muscle
or nerve injury; abnormal passive range of motion
indicates joint pathology
Muscle strength Extension
Flexion
Pronation
Supination
Triceps muscle, radial nerve
Brachioradialis muscle, musculocutaneous nerve
Pronators, acute nerve irritation of branch median nerve
Biceps muscle, musculocutaneous nerve
Sensory/neurologic Biceps DTR
Brachioradialis DTR
Triceps DTR
Musculocutaneous nerve C5
Radial nerve C6
Radial nerve C7
DTR = deep tendon reflex.
*—Measured in degrees from neutral position. Compare with contralateral side.
Information from references 5 and 6.
6. Nerve Injury
152 American Family Physician www.aafp.org/afp Volume 81, Number 2 ◆
January 15, 2010
thumb,indexdigit,andlongdigit.Somepatientsalsohave
forearm pain. The most helpful physical examination
findings are hypalgesia (positive likelihood ratio of 3.1)
and abnormality in a Katz hand diagram.16
Although
commonly used in patients with carpal tunnel syndrome,
Tinel sign and Phalen maneuver are less accurate.16
The
sensory examination is normal initially, although late
findings include sensory loss in the median nerve dis-
tribution, weak thumb abduction, and thenar atrophy.
Electrodiagnostic testing can be useful and quantitates
severity of entrapment, although false negatives and false
positives may occur.16,17
Radial Nerve at the Wrist: Handcuff Neuropathy. The
superficial branch of the radial nerve crosses the volar
wrist on top of the flexor retinaculum of the carpal tun-
nel. It is vulnerable to compression by anything wound
tightly around the wrist. Historically, this is an area eas-
ily injured by tight handcuffs, thus the name “handcuff
neuropathy.” The injury leads to numbness on the back
of the hand, mostly on the radial side. Examination may
reveal decreased sensation to soft touch and pinprick
over the dorsoradial hand, dorsal thumb, and index
digit. Motor function is typically intact.
Ulnar Nerve at the Wrist: Cyclist’s Palsy. Injury of the
ulnar nerve at the wrist is common in cyclists because
the ulnar nerve gets compressed against the handlebar
during cycling, resulting in “cyclist’s palsy.” This type
of nerve injury occurs with other activities involving
prolonged pressure on the volar wrist (e.g., jackhammer
use). Symptoms are paresthesias in the fourth and fifth
digits. Digit weakness is uncommon because the motor
portion of the nerve at the wrist is less superficial. Unless
the activity is prolonged or chronic, results of the sen-
sory examination are normal and numbness will resolve
within a few hours after stopping the activity.
Diagnostic Testing
IMAGING
Plain radiography is primarily useful for identifying
other diagnoses, such as fracture or cervical spondylo-
arthropathy. MRI is rarely needed for initial evaluation
of a typical nerve injury, although it may be helpful for
specific nerves (Table 5).18
Chronic nerve injury can lead to denervation changes
in muscle. These changes may be visible on MRI as
abnormal signal patterns. A normal MRI finding does
not rule out nerve injury. Newer techniques, such as
gadofluorine M–enhanced MRI, may ultimately be able
to assess nerve regeneration.19
Ultrasonography is a less
expensive modality to define anatomic entrapment, but
its use is limited by lack of standardization of technique
and interpretation.20
ELECTRODIAGNOSTIC TESTING
Electrodiagnostic testing consists of nerve conduction
studies and electromyography (EMG). Nerve conduction
studies assess the integrity of sensory and motor nerves.
Areas of nerve injury or demyelination appear as slowing
of conduction velocity along the nerve segment in ques-
tion. EMG records the electrical activity of a muscle from
Table 4. Hand and Wrist Examination: Abnormalities That May Indicate Nerve Injury
Component
of evaluation Evaluation area Diagnoses to consider
Inspection Bilateral symmetry of knuckles in clenched fist
Dorsal or volar wrist mass
Skin ecchymoses or swelling
Symmetric bulk of thenar and hypothenar eminences
Asymmetry suggests metacarpal fracture
Ganglion cyst
Localized injury
Thenar atrophy suggests chronic median nerve injury;
hypothenar atrophy suggests chronic ulnar nerve injury
Palpation Anatomical snuff-box tenderness
Carpal tunnel (Tinel sign)
Guyon canal (depression between hamate hook and
pisiform), asymmetric or excessive tenderness
Scaphoid bone fracture
Median nerve injury
Ulnar nerve injury
Range of motion Symmetric flexion and extension of all digits Inability to flex or extend individual digit suggests tendon
injury or fracture
Muscle strength Active wrist extension
Active wrist flexion
Digit adduction or abduction
Pincer mechanism thumb and index digit
Radial nerve injury
Ulnar and/or median nerve injury
Ulnar nerve injury
Ulnar nerve injury
Sensory/neurologic Phalen maneuver at wrist
Sensation lateral hand
Sensation of web space between thumb and index digit
Median nerve injury
Ulnar nerve injury
Radial nerve injury
Information from references 5 and 6.
7. Nerve Injury
January 15, 2010 ◆
Volume 81, Number 2 www.aafp.org/afp American Family Physician 153
a needle placed into the muscle, looking for signs of dener-
vation.21,22
The combination of nerve conduction studies
and EMG can help distinguish peripheral from central
nerveinjuries.Electrodiagnostictestingiscommonlyused
to evaluate for carpal tunnel syndrome and cubital tunnel
syndrome. Nerve conduction studies have been shown
to confirm carpal tunnel syndrome with a sensitivity of
85 percent and a specificity of 95 percent.23
Nerve conduc-
tionstudiesalsomayhelpconfirmthediagnosisinpatients
who have a history or physical examination findings that
are atypical of carpal tunnel syndrome. For most patients
who have a typical presentation, nerve conduction studies
do not change the diagnosis or management.24,25
Treatment
The initial management of most nerve injuries is nonsur-
gical. The main components of treatment are relative rest
and protection of the injured area. Anti-inflammatory
medications are often added, although it is unknown if
they aid healing. Mobility of associated joints should be
maintained at full range of motion, and effort should be
made to increase the strength of any supporting or acces-
sory muscles. Specifics of conservative therapy and indi-
cations for surgical referral are shown in Table 6.13,15,25-46
Systematic reviews of carpal tunnel syndrome have
found short-term benefit from local corticosteroid injec-
tion, splinting, oral corticosteroids, ultrasound, yoga,
and carpal bone mobilization.29
Symptom relief from
local injection has not been shown to last longer than one
month, and there is no demonstrated benefit from a sec-
ondinjection.30
Clinicaloutcomefromlocalcorticosteroid
injection is similar to that from splinting combined with
anti-inflammatory medication.29
Vitamin B6
, ergonomic
keyboards, diuretics, and nonsteroidal anti-inflammatory
drugs have not been shown to be beneficial.29,30
Patient
characteristics that predict a poor response to nonsurgical
therapy include age older than 50 years, symptom dura-
tion longer than 10 months, history of trigger digit, con-
stant paresthesias, and Phalen maneuver that is positive in
less than 30 seconds.47
Surgical treatment likely has better
outcomes than splinting, but it is unclear if surgical treat-
ment is better than corticosteroid injection.48
The authors thank Martha Delaney, MA, for her assistance in the prepara-
tion of the manuscript.
The Authors
SARA L. NEAL, MD, MA, ABFP, CAQ Sports Medicine, is an assistant profes-
sor at Moses Cone Health System in Greensboro, N.C., and is assistant pro-
gram director for the Moses Cone Primary Care Sports Medicine Fellowship.
KARL B. FIELDS, MD, ABFP, CAQ Sports Medicine, is a professor of family
medicine in and associate chairman of the Department of Family Medicine
at the University of North Carolina School of Medicine, Chapel Hill. He is
also program director for the Moses Cone Primary Care Sports Medicine
Fellowship.
Table 5. MRI Evaluation of Specific Nerves of the Upper Extremity
Nerve MRI usefulness Comments
Suprascapular nerve
at scapula
Often useful Useful for evaluation of suspected ganglion cyst; oblique coronal view
for suprascapular notch, axial view for spinoglenoid notch; also
evaluates for rotator cuff pathology
Axillary nerve in
shoulder
Useful if diagnosis unclear or recovery
not following expected clinical course
Useful for evaluation of suspected paralabral cyst or labral pathology;
oblique sagittal view of shoulder shows nerve at inferior rim of
the glenoid; MRI less useful for evaluation of quadrilateral space
because it is a dynamic entity
Median nerve at wrist Useful if diagnosis unclear or recovery
not following expected clinical course
Axial images of carpal tunnel evaluates for hypertrophy of synovium,
space-occupying lesions (ganglion cyst)
Radial nerve at elbow Useful if diagnosis unclear or recovery
not following expected clinical course
Axial images at elbow show mass effect from enlarged bicipitoradial
bursa, hypertrophy of extensor carpi radialis brevis muscle, or
vascular pathology
Ulnar nerve at elbow Useful if diagnosis unclear or recovery
not following expected clinical course
Axial images can evaluate the cubital tunnel for nerve subluxation,
arcuate ligament pathology; may need views of elbow in flexion
and extension if subluxation suspected
Long thoracic nerve Occasionally useful Imaging of nerve itself not usually useful, but can sometimes show
denervation changes of supraspinatus and infraspinatus muscles
MRI = magnetic resonance imaging.
Information from reference 18.
8. Nerve Injury
154 American Family Physician www.aafp.org/afp Volume 81, Number 2 ◆
January 15, 2010
Table 6. Treatment of Specific Upper Extremity Nerve Entrapment Injuries
Nerve injury
type Conservative therapy
Therapy duration
and considerations Indications for surgery
Axillary 26-28
Shoulder range-of-motion exercises, including
posterior capsule stretching; avoid heavy lifting
For injuries associated with specific activity,
assess shoulder biomechanics for that activity
Consider baseline nerve
conduction studies at
one month, repeat at
three months
Conservative therapy for
three to six months
Rare
Carpal
tunnel15,25,29,30
Activity modification, splints worn at night
Consider one steroid injection
Oral steroids, yoga, ultrasound, and carpal bone
mobilization have short-term benefit
Consider nerve
conduction studies if
no improvement within
four to six weeks
Common
Consider surgery if nerve conduction
studies show severe injury, thenar
atrophy, motor weakness
Cubital tunnel31-33
Pad external elbow against external
compression; decrease repetitive elbow flexion
Extension splint (70 degrees) worn at night
Conservative therapy only
for sensory symptoms
Occasional
Consider surgery for motor
weakness that is moderate or that
does not respond to conservative
therapy after three months
Poor surgical outcome for
established intrinsic muscle atrophy
Interosseous
nerve
syndrome34,35
Cock-up splint to assist weakened wrist muscles
Avoid provocative activities
Consider elbow immobilization
Three to six months Consider surgery sooner if late
presentation with severe weakness
or atrophy, progressive weakness
Long
thoracic36,37
Shoulder range-of-motion exercises to prevent
contracture
Strengthen trapezius, rhomboids, and levator
scapula (remaining scapular stabilizers)
Nine to 12 months is
average recovery time;
consider conservative
treatment for up to
24 months
Rare
Pronator13,38,39
Activity modification; consider single steroid
injection
Splinting with elbow at 90 degrees can be used,
with monitoring for loss of range of motion
at elbow
Three to six months Occasional
Radial
tunnel38,40,41
Physical therapy for extensor-supinator muscle
group
Consider single corticosteroid injection
Three months of physical
therapy before
consideration of surgery
(unless intractable pain)
Consider surgical decompression
for intractable pain, although
no available evidence from
randomized controlled trials
Radial wrist39,42
Eliminate external compression
May consider single cortisone injection
Three months Rare
Suprascapular43-45
Physical therapy to maintain full shoulder range
of motion and strengthen other shoulder
(compensatory) muscles
Avoid heavy lifting and repetitive overhead
activities
Early magnetic resonance
imaging (at one month)
to rule out anatomic
lesion (i.e., ganglion cyst)
Conservative treatment
for six to 12 months if
no anatomic lesion
Rare unless labral ganglion cyst
present
Presence of cyst indicates early
consideration for surgery
Ulnar wrist39,46
Pad volar wrist area; activity modification
Splint wrist in neutral position
Six months Rare
Information from references 13, 15, and 25 through 46.
9. Nerve Injury
January 15, 2010 ◆
Volume 81, Number 2 www.aafp.org/afp American Family Physician 155
Address correspondence to Sara L. Neal, MD, MA, Moses Cone Health
System, 1125 N. Church St., Greensboro, NC 27401 (e-mail: sara.neal@
mosescone.com). Reprints are not available from the authors.
Author disclosure: Nothing to disclose.
REFERENCES
1. Atroshi I, Gummesson C, Johnsson R, Ornstein E, Ranstam J, Rosén I.
Prevalence of carpal tunnel syndrome in a general population. JAMA.
1999;282(2):153-158.
2. Hallet M. Peripheral nerve injury. In: Jordan BD, Tsairis P, Warren RF, eds.
Sports Neurology. 2nd ed. Philadelphia, Pa.: Lippincott-Raven Publish-
ers; 1998:241-253.
3. Townsend CM, Sabiston DC. Sabiston Textbook of Surgery: The Biologi-
cal Basis of Modern Surgical Practice. 18th ed. Philadelphia, Pa.: Saun-
ders; 2007:2172.
4. Gupta R, Rummler L, Steward O. Understanding the biology of com-
pressive neuropathies. Clin Orthop Relat Res. 2005;(436):251-260.
5. Miller MD. Review of Orthopaedics. Philadelphia, Pa.: Saunders; 2004.
6. Snell RS. Clinical Anatomy for Medical Students. 4th ed. Boston, Mass.:
Little, Brown; 1992.
7. Netter FH, Colacino S. Atlas of Human Anatomy. Summit, N.J.: CIBA-
GEIGY Corp; 1989.
8. Safran MR. Nerve injury about the shoulder in athletes, part 2: long
thoracic nerve, spinal accessory nerve, burners/stingers, thoracic outlet
syndrome. Am J Sports Med. 2004;32(4):1063-1076.
9. Dimberg EL, Burns TM. Management of common neurologic conditions
in sports. Clin Sports Med. 2005;24(3):637-662, ix.
10. Levitz CL, Reilly PJ, Torg JS. The pathomechanics of chronic, recurrent
cervical nerve root neurapraxia. The chronic burner syndrome. Am J
Sports Med. 1997;25(1):73-76.
11. Cantu RC. Stingers, transient quadriplegia, and cervical spinal stenosis:
return to play criteria. Med Sci Sports Exerc. 1997;29(7 suppl):S233-235.
12. Safran MR. Nerve injury about the shoulder in athletes, part 1: suprascap-
ular nerve and axillary nerve. Am J Sports Med. 2004;32(3):803-819.
13. Rehak DC. Pronator syndrome. Clin Sports Med. 2001;20(3):531-540.
14. Lubahn JD, Cermak MB. Uncommon nerve compression syndromes of
the upper extremity. J Am Acad Orthop Surg. 1998;6(6):378-386.
15. Cranford CS, Ho JY, Kalainov DM, Hartigan BJ. Carpal tunnel syndrome.
J Am Acad Orthop Surg. 2007;15(9):537-548.
16. D’Arcy CA, McGee S. The rational clinical examination. Does this patient
have carpal tunnel syndrome? [published correction appears in JAMA.
2000;284(11):1384]. JAMA. 2000;283(23):3110-3117.
17. Longstaff L, Milner RH, O’Sullivan S, Fawcett P. Carpal tunnel syndrome:
the correlation between outcome, symptoms and nerve conduction
study findings. J Hand Surg Br. 2001;26(5):475-480.
18. Stoller DW. Magnetic Resonance Imaging in Orthopaedics and Sports
Medicine. 3rd ed. Philadelphia, Pa.: Lippincott Williams Wilkins; 2007.
19. Bendszus M, Wessig C, Schütz A, et al. Assessment of nerve degenera-
tion by gadofluorine M-enhanced magnetic resonance imaging. Ann
Neurol. 2005;57(3):388-395.
20. Martinoli C, Tagliafico A, Bianchi S, et al. Peripheral nerve abnormalities,
ultrasound clinics. Musculoskeletal Ultrasound. 2007;2(4):655-667.
21. Aminoff MJ. Electrophysiologic testing for the diagnosis of peripheral
nerve injuries. Anesthesiology. 2004;100(5):1298-1303.
22. Barboi AC, Barkhaus PE. Electrodiagnostic testing in neuromuscular dis-
orders. Neurol Clin. 2004;22(3):619-641, vi.
23. Jablecki CK, Andary MT, Floeter MK, et al. Practice parameter: Elec-
trodiagnostic studies in carpal tunnel syndrome. Report of the Ameri-
can Association of Electrodiagnostic Medicine, American Academy of
Neurology, and the American Academy of Physical Medicine and Reha-
bilitation. Neurology. 2002;58(11):1589-1592.
24. Graham B. The value added by electrodiagnostic testing in the diag-
nosis of carpal tunnel syndrome. J Bone Joint Surg Am. 2008;90(12):
2587-2593.
25. Finsen V, Russwurm H. Neurophysiology not required before surgery for
typical carpal tunnel syndrome. J Hand Surg Br. 2001;26(1):61-64.
26. Steinmann SP, Moran EA. Axillary nerve injury: diagnosis and treatment.
J Am Acad Orthop Surg. 2001;9(5):328-335.
27. Hoskins WT, Pollard HP, McDonald AJ. Quadrilateral space syndrome:
a case study and review of the literature. Br J Sports Med. 2005;39(2):e9.
28. Perlmutter GS. Axillary nerve injury. Clin Orthop Relat Res. 1999;(368):
28-36.
29. O’Connor D, Marshall S, Massy-Westropp N. Non-surgical treatment
(other than steroid injection) for carpal tunnel syndrome. Cochrane
Database Syst Rev. 2003;(1):CD003219.
30. Marshall SC, Tardif G, Ashworth NL. Local corticosteroid injection
for carpal tunnel syndrome. Cochrane Database Syst Rev. 2007;(2):
CD001554.
31. Elhassan B, Steinmann SP. Entrapment neuropathy of the ulnar nerve.
J Am Acad Orthop Surg. 2007;15(11):672-681.
32. Szabo RM, Kwak C. Natural history and conservative management of
cubital tunnel syndrome. Hand Clin. 2007;23(3):311-318, v-vi.
33. Bradshaw DY, Shefner JM. Ulnar neuropathy at the elbow. Neurol Clin.
1999;17(3):447-461, v-vi.
34. Tsai P, Steinberg DR. Median and radial nerve compression about the
elbow. J Bone Joint Surg Am. 2008;90(2):420-428.
35. Toussaint CP, Zager EL. What’s new in common upper extremity entrap-
ment neuropathies. Neurosurg Clin N Am. 2008;19(4):573-581, vi.
36. Gentchos EJ. Isolated peripheral nerve lesions of the brachial plexus
affecting the shoulder joint. UPOJ. 1999;12:40-44.
37. Wiater JM, Flatow EL. Long thoracic nerve injury. Clin Orthop Relat Res.
1999;(368):17-27.
38. Huisstede B, Miedema HS, van Opstal T, de Ronde MT, Verhaar JA, Koes
BW. Interventions for treating the radial tunnel syndrome: a systematic
review of observational studies. J Hand Surg Am. 2008;33(1):72-78.
39. Lanzetta M, Foucher G. Entrapment of the superficial branch of the
radial nerve (Wartenberg’s syndrome). A report of 52 cases. Int Orthop.
1993;17(6):342-345.
40. Elbow and forearm. In: DeLee J, Drez D, Miller MD, eds. DeLee Drez’s
Orthopaedic Sports Medicine: Principles and Practice. 2nd ed. Philadel-
phia, Pa.: Saunders; 2003:1328-1329.
41. Henry M, Stutz C. A unified approach to radial tunnel syndrome and
lateral tendinosis. Tech Hand Up Extrem Surg. 2006;10(4):200-205.
42. Levine BP, Jones JA, Burton RI. Nerve entrapments of the upper extrem-
ity: a surgical perspective. Neurol Clin. 1999;17(3):549-565, vii.
43. Romeo AA, Rotenberg DD, Bach BR Jr. Suprascapular neuropathy. J Am
Acad Orthop Surg. 1999;7(6):358-367.
44. Martin SD, Warren RF, Martin TL, Kennedy K, O’Brien SJ, Wickiewicz TL.
Suprascapular neuropathy. Results of non-operative treatment. J Bone
Joint Surg Am. 1997;79(8):1159-1165.
45. Cummins CA, Messer TM, Nuber GW. Suprascapular nerve entrapment.
J Bone Joint Surg Am. 2000;82(3):415-424.
46. Szabo RM, Steinberg DR. Nerve entrapment syndromes in the wrist.
J Am Acad Orthop Surg. 1994;2(2):115-123.
47. KaplanSJ,GlickelSZ,EatonRG.Predictivefactorsinthenon-surgicaltreat-
ment of carpal tunnel syndrome. J Hand Surg Br. 1990;15(1):106-108.
48. Verdugo RJ, Salinas RA, Castillo JL, Cea JG. Surgical versus non-
surgical treatment for carpal tunnel syndrome. Cochrane Database Syst
Rev. 2008;(4):CD001552.