Neurovascular Entrapment LM Flashcards
Where segments do the autonomics of the upper limb come from?
T2-6
What segments do the parasympathetics of the upper limb come from?
Gotcha, there are none.
What ganglion do the sympathetics come from?
Stellate.
How important are peripheral cutaneous nerves?
You must know them all grasshopper. I will add them if I get a chance.
Dermatomes, recite them all.
Study more.
What is a mononeuropathy?
Give an example.
pathology affecting a single peripheral nerve; therefore have sensory symptoms in a peripheral cutaneous distribution.
-Ex: Carpal tunnel syndrome
What is a radiculopathy?
Give an example.
pathology affecting the nerve root; therefore have sensory symptoms in a corresponding dermatome.
-Ex: Herniated disc
Why is the difference important?
Therefore à You can more specifically determine where the nerve impingement or lesion is – whether it is a peripheral nerve or a nerve root as well as which nerve/spinal level.
What are the reflex points of C5-7?
Biceps
Bracioradialis
Triceps
What are the parts of the exam of the upper extremity?
Range of motion
Muscle strength
Muscle tone
Sensation (light and sharp)
Proprioception
Deep tendon reflexes (DTR’s)
Radial pulse
Special tests/maneuvers
What are some examples of cervical radiculopathy?
1.Cervical spondylosis – degenerative changes (ex: osteophyte formation) of spine that often causes foraminal narrowing and cervical canal stenosis, which compresses the nerve root.
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1.Disc herniation – the nucleus pulposus prolapses through the annulus of an intervertebral disc and compresses the nerve root.
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1.Infection (ex: Herpes Zoster, Lyme)
Infiltration by tumor (ex: Lymphoma
How will a pt with entrapment present ?
Pain in neck, shoulder, upper thoracics, and/or upper limb
Paresthesia or numbness in upper limb
Weakness of the upper limb
May have precipitating event due to physical exertion or trauma (ex: whiplash)
C5 motor and reflex
Deltoid/biceps
Biceps
C6 motor and reflex?
Biceps/wrist extensors
Brachioradialis
C7 motor and reflex
What is special about C7?
finger extensors
triceps
MOST COMMONLY AFFECTED
Motor and reflex for C8
finger flexors
Zilch
T1 motor
Interossei
Describe the differences between the symptoms of UMN vs LMN?
Upper Motor Neuron (CNS) Lesion
- Spastic
- Increased tone
- Hyperreflexia
Lower Motor Neuron (PNS) Lesion
- Flaccid
- Decreased tone
- Hyporeflexia
- Fasiculation
- Atrophy
Name and describe some special test for cervical radiculopathy?
Spurling Maneuver
Distraction Test
What is thoracic outlet syndrome?
A constellation of signs and symptoms that arise from the compression of the neurovascular bundle.
◦Brachial plexus
◦Subclavian artery
Subclavian vein
What are the 4 causes of thoracic outlet syn?
Cervical rib
Scalene syndrome- tight scalenes
Costocervical syndrome-
3.narrowing of space between 1st rib and clavicle (chronic inflammation, fracture, SD)
Hyperabduction syn-compression by pectoralis minor and coracoid process when arm raised above head
Pt presentation thoracic outlet syn?
Symptoms can be quite variable depending on what structures are affected:
◦Neurogenic – will mimic a cervical radiculopathy of the nerve root spinal level
Lower trunk of brachial plexus (C8-T1)
Upper trunk (C5-C6)
◦Vascular – not as common
Subclavian artery – diffuse numbness, coolness to touch, decreased pulses, exertional fatigue/weakness
Subclavian vein – edema, cyanosis
What are some special test for thoracic outlet syn?
1.Spurling Maneuver/Compression Test – See above (rule out cervical radiculopathy)
2.Hyperabduction Test – Positive if hyperabduction reproduces symptoms
3.Adson’s/Costoclavicular Test – Positive if Radial pulse decreases1.Roo’s Test – Positive if reproduces symptoms or unable to finish due to fatigue
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2.Evaluate scalenes and pectoralis muscles for hypertonicity
3.Evaluate for cervical rib and upper rib SD as well as clavicular SD
What is ulnar nerve entrapment?
Common causes?
Tardy Ulnar Palsy: Entrapment of Ulnar nerve (C8-T1) in Epicodylar groove
Cubital Tunnel Syndrome: Compression of Ulnar nerve (C8-T1) between the two heads of the flexor carpi ulnaris
- Repeated flexion at the elbow
- Trauma or chronic inflammation
- Arthritis
- Osteophytes
Guyon’s canal neuropathy is entrapment of the ulnar nerve between what structures?
Common causes?
palmar carpal ligament anteriorly and flexor retinaculum posteriorly, between the Hamate and Pisiform bones.
- Repeated trauma (common in cyclists)
- Fracture of hook of hamate
What are some symptoms of ulnar nerve entrapment?
- Medial elbow pain that may radiate distally
- Numbness/paresthesia in 4th and 5th digits
- Motor symptoms (less common)
- Claw hand
- Weakness and possible atrophy of intrinsic hand muscles
- Can present as loss of dexterity
•Symptoms may increase with flexion of the elbow
What are some special test for ulnar nerve entrapment?
1.Tinel’s Test – Tap ulnar nerve as it passes through both epicondylar groove and Guyon’s canal. Positive if reproduces symptoms.
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●1.Elbow Flexion Test – Positive if maximal
flexion of elbow for 1min. reproduces symptoms.
- Pressure Test – Apply sustained pressure
over the ulnar nerve as it passes through
epicondylar groove, proximal flexor carpi ulnaris,
and Guyon’s canal. Positive if reproduces symptoms.
What is the most frequent compressive focal mononeuropathy seen in clinical practice?
Carpal tunnel syn.
What is carpal tunnel syn?
Compression of the median nerve (C6-T1) as it travels under the flexor retinaculum/transverse carpal ligament of the wrist.
What are some common causes of Carpal tunnel syn?
Repetitive motions
◦Sustained wrist/palm pressure
◦Prolonged wrist extension and flexion
◦Work with oscillating tools
Trauma
Obesity
Pregnancy
Diabetes
Rheumatoid arthritis
Hypothyroidism
Connective tissue diseases
What will a pt with carpal tunnel present with?
What symptoms are less common?
- Pain in the wrist and hand, can radiate proximally
- Numbness/paresthesia in 1st, 2nd, 3rd, and half of the 4th digits
- Motor symptoms (less common)
- Weakness in abduction and opposition of thumb, decreased grip strength
- Atrophy of thenar eminence
- Can present as loss of dexterity
- Symptoms typically worse at night and may awaken patient from sleep
- Provoked by flexion and extension of the wrist
What are some special test for carpal tunnel syn?
Tinnel’s, Phalen’s, Prayer sign.
How would you confirm a nerve entrapment diagnosis electronically?
Nerve conduction study
Electromyography
What can happen when you let the magic of OMM in your life?
**With experience and well-developed palpation skills, you can even palpate nerves. They feel like al dente spaghetti with a “zing” or vibration.
What is the theory of Double Crush Syndrome?
Because of this what is important when evaluating Nerve entrapment syn?
Theory: If a nerve is compressed at two separate locations along the course of a nerve, even though the degree of each individual compression is insufficient to cause symptoms, the cumulative effect is sufficient enough to cause symptoms.
The initial injury reduces axoplasmic flow and then the second injury further reduces signaling potential below threshold, leading to symptoms.
Check the entire length of the nerve and nerve roots when evaluating for a nerve entrapment syndrome.
If you can list the steps to go through when thinking about an entrapment.
- Is it an upper or lower motor lesion?
- Is it cervical radiculopathy (spinal level) or peripheral compression (peripheral nerve distribution)?
- Which specific spinal level or peripheral nerve is affective?
- Where along the nerve’s course is there a compression/pathology?
