L11 UE Neuro Flashcards
Myelinated nerves are more sensitive to
stretch
compression
Patient History w/ neuropathic pain
burning, searing pain
hypo/hyperesthesia, allodynia
qualities are unique
symptoms make move
Peripheral Neuropathies can be caused by
Systemic Disease–> MS, Diabetes
Vitamin B and E deficiencies
Medications–> chemo, statins
alcohol
toxins
infection
congenital
trauma
entrapment
Peripheral neuropathy
damage or disease affecting nerves outside the CNS
Polyneuropathies
often bilateral, symmetrical
more likely to be systemic
Radiculopathies
one or two spinal nerve roots
usually unilateral
sensory, motor, and reflex changes
Mononeuropathies
one single peripheral nerve gets trapped somewhere along its course
site of S/S depends on the nerve
source of S/S is entrapment
Onset is often slow, mild and chronic S/S
Entrapment Neuropathies RF
ischemia
firbosis
demyelination
axon degeneration
neuroinflammation
altered axonal transport
CNS issues
NERVE ROOT vs Peripheral Nerve
Pain and/or sensory changes
often reflex changes
positive cervical clearning and scan provocation
Nerve Root vs PERIPHERAL NERVE
pain and or sensory cnages are often in smaller patches
no reflex changes (musculotaneous is the exception)
negative cervical clearing and scan exam
Double crush syndrome
compression at one site makes it more sensitive to compression at another due to impaired axoplasmic flow
usually caused by failed surgeries, peripheral and central nerve root issue
Prevalence of Neuropathies
Carpal tunnel is most common in general pop and workforce
Most people experience cervical radiculopathy at C7
RF for Neuropathies
-physical factors; increased BMI
-systemic disease; DM, smoking
-occupational factors; vibration, manual labor
-psychosocial
-genetic predispositions
Cervical Radiculopathy
Nerve root comes out lateral, exits at one segment below
can be compression or inflammation of nerve or both that is causing S/S
Brachial plexopathy
multilevel
doesn’t match peripheral or spinal distribution
circumferential rather than dermatomal
Peripheral Mononeuropanty
matches a peripheral distribution, from level of entrapment distally
doesn’t match spinal distribution
What happens when nerve is injured?
changes to intracellular signaling transduction, molecular biologic mechanisms, neurotrophic factors and myelin sheath
microcirculation changes
inflammatory response
lymphatic system changes
scar tissue formation
Axillary Innervation
Muscles: deltoid, teres minor
Cutaneous: upper arm, deltoid
entrapment: quadrangular space
Spinal Accessory Innervation
Muscles: Traps, Levator scap, SCM, middle scalene
No cutaenous innervation
Suprascapular Innervation
Muscle: supraspinatus, infraspinatus
No cutaneous innervation
Long Thoracic Innervation
Muscle: serratus anterior
No cutaneous innervation
Entrapment: between clavicle and 1st rib, superifical along outer SA
Musculotaneous Innervation
Muscles: biceps and brachialis
Cutaneous: skin of lateral and post forearm
Entrapment: coracobrachialis, retractors
Axillary Injury
MOI: crutch use, throwers, shoulder dislocation
S/S: weakness, atrophy in deltoid/teres minor
Need to differentiate with c5 radiculopathy
Spinal Accessory Injury
MOI: direct trauma to traps, GH dislocation, cervical node biopsy
DDX: c4 radic
Suprascapular Nerve Injury
DDX: RCT, C5 radiculopathy
MOI: direct trauma to spine of scap, repeptive overhead loading
Long Thoracic Injury
MOI: improper crutch use, direct blow to side, inferior directed blow to shoulder, OH lifting
S/S: decreased abduction and elevation MMT, scapular winging
Musculotaneous Injury
MOI: shoulder surgery, repetitive flexion and elbow flexion with pronation, rowers
S/S: biceps weakness, absent DTR, lateral forearm parethesia, typically non-painful
Median Innervation
Muscles: pronators, flexors of wrist and fingers, thumbs
Cutaneous: palm of hand 1-3 fingers, dorsum, tops of fingers 2-3
Entrapment: ligament of struthers, bicipital aponeourosis, pronator teres, FDS, carpal tunnel
Median Nerve: Lacertus Fibrosus/Ligament of Struthers
S/S: pain and paresthesias in median, deep pain at ligament, pain increases at night
Exam findings: weakness in all median muscles, decreased thumb opp, benedictions hand, positive distal tinel’s, elbow flexion and supination cause S/S
Pronator Teres Syndrome
MOI: repetitve pronation activity
S/S: pain/paresthesias in hand/fingers
Clinical findings: weakness in all median muscles except pronator teres and ECRB. Positive proximal tinels, sensory loss in median n, resisted pronation w/elbow extended causes S/S
Anterior Interosseous Syndrome
S/S: difficulty writing or making a fist. dull pain in proximal 1/3 of forearm
Clinical findings: weakness in FDP, FPL, pronator quad. + OK sign, no sensory loss, direct pressure at FDS arch causes pain
Carpal Tunnel Syndrome
S/S: pain or paresthesias in fingers, not palm, pain/cramp worse at night, difficulty with grasp/pinch
Clinical findings: + flicks, + tinels, + phalen’s, sensation at thumb is intact but atrophy of muscles
Ulnar innervation
muscles: flexors, pinky, interossei, adductor
Cutaneous: ulnar hand, 5th ray, half of 4th finger
Cubital Tunnel Syndrome
MOI: rests elbows on desk or prolonged elbow flexion, baseball/javelin/boxing
S/S: pain in forarm and tingling in medial fingers
Clinical findings: atrophy of hand intrinsics, + compression, + froment, + claw
entrapment of ulnar nerve at elbow
Tunnel of Guyon Syndrome
MOI: drills, jackhammers, cycling
S/S: worse at night, pain in palmar lateral hand, worse at night, wrist extension aggravates
Clinical findings: + tinel’s at hamate, +phalens, -palmar creases with resisted 5th finger abd, abd/add of pinky are normal
entrapment of ulnar nerve at wrist
Radial innervation
muscles: triceps, anconeus, ECRL, supinator, extensors of forearm and fingers
Cutaneous: post lateral upper arm and elbow, post forearm, radial side of hand, dorsum of hand (not DIPS)
Spiral Groove Compression
MOI: Ill fitting crutches, recent humeral fx, saturday night palsy, alcohol consumption
Clinical findings: weakness/pain in radial nerve distribution, wrist drop
Posterior Interosseous syndrome
MOI: repetitive pronation, forearm extension, and wrist flexion
S/S: deep pain in post forearm, difficulty making fist
Clinical findings: pain on compression distal to lateral humeral epicondyle, weakness of finger and wrist extensors (except ECRL), + wrist drop, no sensory deficits
DDX: lateral epicondylitis
Interventions
postural, ergonomic mods
tissue protection
patient ed
scar, soft tissue, jt mobs
strengthening
spinal traction
neural mobs
taping/splinting
Refer patient back to MD
if there is brachial plxeopathy, peripheral polyneuropathies
Red flags
B UE symptoms
distal to proximal progression
significant atrophy
constitiutional symptoms
exam doesn’t match history
no change with interventions
