Neurovascular Entrapment LM

Question 1

Where segments do the autonomics of the upper limb come from?

Answer 1

T2-6

Question 2

What segments do the parasympathetics of the upper limb come from?

Answer 2

Gotcha, there are none.

Question 3

What ganglion do the sympathetics come from?

Answer 3

Stellate.

Question 4

How important are peripheral cutaneous nerves?

Answer 4

You must know them all grasshopper. I will add them if I get a chance.

Question 5

Dermatomes, recite them all.

Answer 5

Study more.

Question 6

What is a mononeuropathy?

Give an example.

Answer 6

pathology affecting a single peripheral nerve; therefore have sensory symptoms in a peripheral cutaneous distribution.

-Ex: Carpal tunnel syndrome

Question 7

What is a radiculopathy?

Give an example.

Answer 7

pathology affecting the nerve root; therefore have sensory symptoms in a corresponding dermatome.

-Ex: Herniated disc

Question 8

Why is the difference important?

Answer 8

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.

Question 9

What are the reflex points of C5-7?

Answer 9

Biceps

Bracioradialis

Triceps

Question 10

What are the parts of the exam of the upper extremity?

Answer 10

—Range of motion
—Muscle strength
—Muscle tone
—Sensation (light and sharp)
—Proprioception
—Deep tendon reflexes (DTR’s)
—Radial pulse
—Special tests/maneuvers

Question 11

What are some examples of cervical radiculopathy?

Answer 11

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

Question 12

How will a pt with entrapment present ?

Answer 12

—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)

Question 13

C5 motor and reflex

Answer 13

Deltoid/biceps

Biceps

Question 14

C6 motor and reflex?

Answer 14

Biceps/wrist extensors

Brachioradialis

Question 15

C7 motor and reflex

What is special about C7?

Answer 15

finger extensors

triceps

MOST COMMONLY AFFECTED

Question 16

Motor and reflex for C8

Answer 16

finger flexors

Zilch

Question 17

T1 motor

Answer 17

Interossei

Question 18

Describe the differences between the symptoms of UMN vs LMN?

Answer 18

Upper Motor Neuron (CNS) Lesion

• Spastic
• Increased tone
• Hyperreflexia

Lower Motor Neuron (PNS) Lesion

• Flaccid
• Decreased tone
• Hyporeflexia
• Fasiculation
• Atrophy

Question 19

Name and describe some special test for cervical radiculopathy?

Answer 19

Spurling Maneuver

Distraction Test

Question 20

What is thoracic outlet syndrome?

Answer 20

—A constellation of signs and symptoms that arise from the compression of the neurovascular bundle.
◦Brachial plexus
◦Subclavian artery
Subclavian vein

Question 21

What are the 4 causes of thoracic outlet syn?

Answer 21

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

Question 22

Pt presentation thoracic outlet syn?

Answer 22

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

Question 23

What are some special test for thoracic outlet syn?

Answer 23

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

Question 24

What is ulnar nerve entrapment?

Common causes?

Answer 24

–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

Question 25

Guyon's canal neuropathy is entrapment of the ulnar nerve between what structures? Common causes?

Answer 25

– palmar carpal ligament anteriorly and flexor retinaculum posteriorly, between the Hamate and Pisiform bones. * Repeated trauma (common in cyclists) * Fracture of hook of hamate

Question 26

What are some symptoms of ulnar nerve entrapment?

Answer 26

* 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

Question 27

What are some special test for ulnar nerve entrapment?

Answer 27

1.Tinel’s Test – Tap ulnar nerve as it passes through both epicondylar groove and Guyon’s canal. Positive if reproduces symptoms. ● ● ● ● ● ●1.Elbow Flexion Test – Positive if maximal ## Footnote flexion of elbow for 1min. reproduces symptoms. 3. 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.

Question 28

What is the most frequent compressive focal mononeuropathy seen in clinical practice?

Answer 28

Carpal tunnel syn.

Question 29

What is carpal tunnel syn?

Answer 29

–Compression of the median nerve (C6-T1) as it travels under the flexor retinaculum/transverse carpal ligament of the wrist.

Question 30

What are some common causes of Carpal tunnel syn?

Answer 30

—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

Question 31

What will a pt with carpal tunnel present with? What symptoms are less common?

Answer 31

* 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

Question 32

What are some special test for carpal tunnel syn?

Answer 32

Tinnel's, Phalen's, Prayer sign.

Question 33

How would you confirm a nerve entrapment diagnosis electronically?

Answer 33

Nerve conduction study Electromyography

Question 34

What can happen when you let the magic of OMM in your life?

Answer 34

\*\*With experience and well-developed palpation skills, you can even palpate nerves. They feel like al dente spaghetti with a “zing” or vibration.

Question 35

What is the theory of Double Crush Syndrome? Because of this what is important when evaluating Nerve entrapment syn?

Answer 35

—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.

Question 36

If you can list the steps to go through when thinking about an entrapment.

Answer 36

1. Is it an upper or lower motor lesion? 2. Is it cervical radiculopathy (spinal level) or peripheral compression (peripheral nerve distribution)? 3. Which specific spinal level or peripheral nerve is affective? 4. Where along the nerve’s course is there a compression/pathology?