Compression Neuropathies Flashcards by M A

There is no single decompression technique at the cubital
tunnel that has been shown to be superior

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Recovery of index and thumb flexion strength is generally
rapid following release ofthe median nerve at the pronator

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Initial symptoms of nerve compression are paresthesia and deep
aches.

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Recovery depends upon

duration and degree of compression and damage, secondary factors
such as hypertension, diabetes, and hypothyroidism, and the presence
of multiple sites ofcompression

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the presenting complain of nerve compression

Numbness

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Sensory loss is measured subjectively or quantitatively

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Abnormal deep tendon
reflexes are signs of nerve root or spinal cord compression

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The roles ofultrasound, MRI, and
MR neurograms in evaluation ofperipheral nerve compression are
controversial

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MRis can show painful conditions that are not apparent on plain
radiographs, such as ligament or cartilage tears, and ganglion cysts
and other soft tissue processes

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patients can have grossly abnormal tests with no symptoms

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Patients should stop taking anticoagulants before surgery

F Patients may often continue taking anticoagulants because expected
blood loss is minimal

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The use of a tourniquet is not necessary for the majority of patients,

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persistence of symptoms for
9 to 12 months is a reasonable indication for surgical

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There is rapid deterioration, a diagnosis of tumor, or penetrating trauma in this case we need to urgent intervention

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Routine postoperative splinting is not indicated,

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CTS is the most commonly recognized compressive neuropathy in
the upper extremity,

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The sensory part of the median nerve
innervates the the thenar eminence.

F innervatesthe volar surfacesofthe thumb, index finger, long finger, and the radial halfofthering finger, but not the thenar eminence

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Most cases ofCTS are presumed to be idiopathic in origin

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Causes of carpal tunnel syndrome

idiopathic
metabolic (obesity, diabetes, pregnancy, hypothyroidism, renal failure, amyloidosis, autoimmune disease)
infectious (leprosy)
mechanical (trauma, large lumbrical muscles, fibrosis of the tenosynovium

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Early symptoms of CTS

Early symptoms of CTS include aching pain in the carpal tunnel area, numbness and/or tingling in the tips of the radial digits,
particularly at night or on waking

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There is no single clinical finding that defines CTS

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Wrist splints decrease tendon excursion and hold the wrist in a position ofdecreased tunnel pressure

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Hand exercise (tendon excursion
under load) tends to aggravate CTS

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stretching exercises
seem to reduce swelling, and thus pain

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Direct intraneural injections can cause severe, irreversible nerve damage

Diuretics and oral steroids are notindicated

The TCL and distal antebrachial fascia of the forearm are divided via a palmar incision

Internal neurolysis is indicated in most cases

F Internal neurolysis is not indicated in most cases

Revision surgery or decompression in the setting of rheumatoid arthritis generally calls for an extended incision crossing the wrist crease

Long-term relief of symptoms is achieved in up to 91% of cases

Surgical complications are pillar pain (aching of the proximal palm), tendon subluxation over the hook of the hamate, and injury to the ulnar nerve and local median nerve branches

Revision carpal tunnel surgery can be performed endoscopically,24 or open with or without hypothenar fat grafting

Pronator syndrome is becoming recognized as being more common than previously thought

In CTS the pain is away from the site of compression

F At the site of compression

compression of the median nerve at the elbow causes pain in the hand or wrist: there is no spontaneous pain in the region of the pronator

Th site of pain in pronator syndrom

Pain is typically in the palm, wrist, and distal forearm and is exacerbated by activities involving sustained forearm pronation.

the presenting symptoms of crapal tunnel is sensory whule in pronater syndrom is motor

The involved mucsle id FPL and FDP of index pronator quadratus (PQ)

Numbness with PMNE is a relatively late symptom and typically occurs at nigh

The thenar area tends to be spares , distinctly different from CTS

F The thenar area tends to be involved, distinctly different from CTS

Thenar muscles maintain normal strength with PMNE

numbness related to PMNE can be provoked by firm palpation of the median nerve just proximal and distal to the elbow crease and with pronation against resistance. Numbness occurring in less than 60 seconds is considered abnormal

Weakness of FDP IF and FPL resolves immediately in the recovery room following surgical release.

The area of possible compression of the median nerve around the elbow.

From proximal to distal, fascia of Struthers, the ligament of Struthers (if present), the deep fascia of the proximal pronator teres muscle, the bicipital aponeurosis, the deep fascia of the ulnar origin of the pronator teres muscle, the deep fascia of the humeral origin of the pronator teres muscle, and the fascia of the arch of the superficial flexors

If wrist pain is the main indication for surgery, release of the bicipital aponeurosis under local anesthesia can be highly effective with a quick recovery

spontaneous AIN palsy, expressed as an acute loss of active flex.ion of the FPL and the FDP IF and paralysis of the PQ

The differential diagnosis od AIN

includes Parsonage-Turner Syndrome and Kiloh-Nevin Syndrome

Cubital tunnel syndrome is the second most commonly recognized compressive neuropathy in the upper extremity

most common sites of compression of the ulnar nerve?

the Arcade of Struthers and intermuscular septum proximal to the elbow, Osborne ligament at the medial epicondyle, and the pronator muscle and flexor fascia distal to the elbow

Risk factors for cubital tunnel syndrome

include male gender, performance of heavy manual labor, and tobacco use

Early symptoms include numbness and tingling along the ulnar aspect of the hand

How you can distinguishes compression of the ulnar nerve in the elbow from the wrist?

An altered sensation of both the dorsal and volar aspects of the ulnar hand occurs with elbow compression At the wrist causes numbness on the volar surface of the hand

compression may be present at both sites

weakness of ulnar-innervated muscles, a positive Froment sign, and loss of ability to concomitantly flex the MCP joints and extend the PIP and DIP joints (the ulnar negative posture)

In the case of Intrinsic muscle atrophy combined with sensory loss without a peripheral explanation what is mean?

an unusual underlying neurologic disorder such as Charcot-Marie-Tooth, or syringomyelia

Loss of muscle strength with a normal sensory exam mean what ?

Is an early sign of amyotrophic lateral sclerosis

Electrodiagnostic tests, ultrasound, and MRI have all been used to isolate the level ofcompression and look for other pathology

for mild disease treatment

Nonoperative management with night splinting, physical therapy, and activity and postural modification is indicated

Surgical treatment incude anterior (subcutaneous) transposition, and intra- or submuscular transposition of ulnar nerve

simple decompression for mild disease

submuscular transposition for severe or recurrent disease

Positive functional and sensory outcomes of cubital tunnel release are high and have been measured at 77% to 86% 1 year after surgery

ulnar nerve passes between the hamate and pisiform dorsal to the palmar carpal ligament and volar to the carpus

studies have shown improvement in ulnar nerve symptoms after median nerve decompression alone

The incision extends from approximately 4 cm proximal to the wrist crease over the flexor carpi ulnaris (FCU) tendon onto the hypothenar eminence.

Radial nerve entrapment with palsy is relatively rare and presents as loss of finger extension

the site of neuropathy is proximal to the posterior interosseous nerve (PIN), lead to loss of finger extension

F loss of wrist extension

The most vulnerable area ofthe radial nerve is in the spiral groove along the lateral aspect of the distal humerus.

Saturday Night Palsy

temporary paralysis ofthe motor aspect of the radial nerve from sustained local pressure on this aspect of the upper arm while sleeping or unconscious due to intoxication and generally resolves completely

Radial tunnel syndrome (RTS), defined as pain without weakness in the dorsal forearm and wrist

Provakting test for radial tunnel syndrom

resisted supination extension of the wrist isolated middle finger extension

41% overlap with lateral epicondylitis,

Electrodiagnostic studies are helpful for evaluating either condition(RTS &epicondylitis)

F Electrodiagnostic studies are not helpful for evaluating either condition

sometimes resolve spontaneously

posterior approach in RTS

an be tedious because of arborization of the motor nerves to the finger extensors

The anterior approach

avoids intramuscular dissection but requires attention to cutaneous nerves and numerous enveloping vessels

Muscular dissection through the extensor carpi radialis brevis may result in a wide scar

The structure that need to release

fascia of the supinator is released over the PIN (the arcade of Frohse), and a transverse tenotomy of the common extensor fascia

The other cause of PIN compression

Parsonage-Turner (neuralgic amyotrophy) and spontaneous hourglass deformity of the nerve

Compression can lead to loss of wrist extension

F Compression can lead to loss of finger extension and radial deviation on extension

Treatment of PIN ?

exploration and release of the arcade of Frohse is indicated ifthere is no recovery after 6 weeks

Wartenberg Syndrome (WS) or cheiralgia paresthetica?

Radial sensory nerve entrapment in the distal forearm

provocation of symptoms

ulnar deviation, wrist flexion, or resisted pronation

The differential diagnosis of distal radial forearm pain

de Quervain tenosynovitis, thumb carpometacarpal osteoarthritis, lateral antebrachial cutaneous neuritis, intersection syndrome, proximal nerve compression

Dorsal-radial wrist/hand pain that responds to a nerve block will reliably respond to surgical decompression

WS vs de Quervain tenosynovitis

WS mimics de Quervain tenosynovitis but does not improve with a steroid injection to the first dorsal extensor compartment

A longitudinal incision is made at the point of maximal tenderness along the radial forearm where the nerve emerges from beneath fascia

the AIN is not a pure motor nerve. The AIN is a motor nerve to the FPL, FDP IF, and PQ, and terminates in a large sensory nerve to the volar wrist bones