Post on 02-May-2019
Compression Neuropathies
Andrew Martin DO, MBA, CAQSMOMED 2013
Compression Neuropathies
• Spinal Accessory Nerve
• Upper/Lower Trunk Plexopathy
• Long Thoracic Nerve
• Axillary Nerve
• Suprascapular Nerve
• Musculocutaneous Nerve
• Guyon Canal Syndrome
• Cubital Tunnel Syndrome
• Ulnar Nerve Interdigital Neuroma
• Tibial Nerve
• Plantar Nerve
• Common Peroneal Nerve
• Superficial Peroneal Nerve
• Deep Peroneal Nerve
• Medial Calcaneal Nerve
• Sural Nerve
• Saphenous Nerve
• Obturator Nerve
• Interdigital
• Lat. Femoral Cutaneous Nerve
• Medial Hallucal Nerve
• Carpal Tunnel Syndrome• Cubital Tunnel Syndrome
Objectives
• Upper Extremity Compression Neuropathies
• Lower Extremity Compression Neuropathies
• Ultrasound and Compression Neuropathies
Pathophysiology
Pathophysiology
Vasa Nervorum
Nerve Axons ≠ Action Potentials
Pathophysiology
Seddon Classification of Peripheral Nerve Damage
NeuropraxiaCompression Axonotemisis Neurotemsis
Treatments
• Surgery
• Physical Therapy
• OMM
• Injections
• Bracing
• NSAIDS, Muscle Relaxers, Oral Steroids, Narcotics, Antidepressants
Entrapments of the Upper Extremity
• Cervical Radiculopathy
• Spinal Accessory Nerve Compression
• Suprascapular Nerve Syndrome
• Quadrilateral Space Syndrome
• Radial Nerve Compression
• Ulnar Nerve Compression
• Median Nerve Compression
Cervical Radiculopathy
• Posterolateral Disc Herniation
• Facet Degeneration
• C7 > C6 > C8
Etiology
Cervical Radiculopathy
• Pain, Paresthesia, and Weakness
• Atrophy
• Reflex Sympathetic Dystrophy
Signs and Symptoms
Cervical Radiculopathy
• Sensory, Muscle, and Reflex testing
• Spurling Test
• MRI
Evaluation
Cervical Radiculopathy
Axial View T2 Weighted
Spinal Accessory Nerve Compression
Posterior Triangle
• Equipment (backpacks/shoulder pads)
• Blows to the Shoulder
Etiology
Spinal Accessory Nerve Compression
• Shoulder Syndrome
• Pain over trapezius, heaviness
• Abnormal Scapular Rotation
• Adhesive Capsulitis
Signs and Symptoms
Spinal Accessory Nerve Compression
• Test Trapezius
• Test Sternocleidomastoid
• Abnormal Scapular Rotation
Evaluation
Suprascapular Nerve Syndrome
• Suprascapular notch
• Spinoglenoid notch
• Thickened Transverse Scapular Ligament
• Extrinsic compression by a space-occupying lesion (ganglion cysts or soft tissue tumor)
Etiology
Suprascapular Nerve Syndrome
• Poorly localized pain and discomfort at the back of the shoulder
• Weakness when raising the arm.
Signs and Symptoms
Suprascapular Nerve Syndrome
Sagittal oblique T2 fat-saturated Sagittal oblique T1 weighted
42 yo swimmer with clinical and EMG evidence of right supraspinatus and infraspinatus muscle denervation at the suprascapular notch. Mild muscle atrophy with fatty infiltration.
Suprascapular Nerve Syndrome
Axial T2 fat-saturated image
28-year-old patient High Grade Sarcoma withMRI appearances indicating a right suprascapular nerve entrapment
Coronal postcontrast T1 image
Axillary Nerve CompressionQuadrilateral Space Syndrome
• Axillary Nerve enters the quadrilateral space w/ circumflex artery
• Supplies the teres minor and deltoid muscles and the overlying skin of the shoulder
• Compression from abduction and external rotation of the shoulder joint
• Hypertrophy of the adjacent musculature
• Space-occupying lesions
Etiology
Axillary NerveQuadrilateral Space Syndrome
• Poorly localized shoulder pain and paresthesias in the affected arm in a nondermatomal distribution.
• Weakness/Atrophy of the Deltoid and Teres Minor
• Confused with rotator cuff pathology or other shoulder joint-related abnormalities
Signs and Symptoms
Axillary Nerve CompressionQuadrilateral Space Syndrome
Oblique Coronal T2-fat saturated
26 year old Baseball Pitcher presented with Right Shoulder pain. Had clinical and EMG evidence of quadrilateral space syndrome.
Severe fatty atrophy of the teres minor muscle
Axillary NerveQuadrilateral Space Syndrome
Oblique Sagittal T2-fat saturated Oblique Sagittal T1-weighted
Severe fatty atrophy of the teres minor muscle
Radial Nerve Compression
• Spiral Groove of the Humerus
• Radial Tunnel
• First Dorsal Wrist Compartment
Etiology
Radial Nerve CompressionSpiral Groove Syndrome
• Saturday Night Palsy
• Humerus Fractures
• Deep puncture wounds
Etiology
Radial Nerve CompressionSpiral Groove Syndrome
• Triceps Weakness
• Wrist drop
• Patient unable to extend wrist or fingers
• Arm/Forearm/Hand/ Numbness
Signs and Symptoms
Posterior Interosseous Nerve Compression(Radial Tunnel Syndrome)
• Formed by the superficial layer of the Supinator Muscle (arcade of Frohse)
• Radiocapitellar joint ganglions
• Synovitis
• Congenital tightness of Arcade of Frohse
• Prominent radial recurrent artery (RRA)
• Radial Head Dislocations
Etiology
• Tenderness more over the Arcade of Frohse
• Painless weakness of the wrist and finger extensors
• No Sensory Deficits
Signs and Symptoms
Posterior Interosseous Nerve CompressionRadial Tunnel Syndrome
Posterior Interosseous Nerve Entrapment
Axial T2 fat-saturated Axial T1-weighted
An 18-year-old Tennis Player with clinical and EMG evidence of PIN entrapment. Level of right distal humerus show thickening and high T2 signal of the radial nerve.
Posterior Interosseous Nerve Entrapment
Axial T2 fat-saturated
An 18-year-old Tennis Player with clinical and EMG evidence of PIN entrapment. Supinator muscle edema
Superficial Branch Radial Nerve CompressionWartenberg's Syndrome
• Compression of the superficial branch radial nerve (SRN)
• Compressed by scissoring action of Brachioradialis and Extensor Carpi Radialis Longus Tendons during forearm pronation.
Etiology
Superficial Branch Radial Nerve CompressionWartenberg's Syndrome
• Ill-defined pain and Paresthesia over dorsoradial hand
• Aggravation by motions involving repetitive wrist flexion, ulnar deviation and pronation
• No motor weakness
Signs and Symptoms
Ulnar Nerve Compression
• Cubital Tunnel
• Guyon’s Canal
Etiology
Ulnar Nerve CompressionCubital Tunnel Syndrome
• Cubital Tunnel is formed by the Arcuate Ligament
• Caused by abnormal fascial bands, subluxation, or dislocation of the ulnar nerve over the medial epicondyle
• Trauma
• Direct compression by soft tissue masses.
Etiology
Ulnar Nerve CompressionCubital Tunnel Syndrome
• Sensory abnormality of the ulnar hand
• Weakness of the flexor carpi muscle group of the 4th and 5th fingers
Signs and Symptoms
Ulnar Nerve CompressionCubital Tunnel Syndrome
Axial T2 fat-saturated (Normal-Distal) Axial T2 fat-saturated (Abnormal-Cubital Tunnel)
A 17-year-old Baseball Pitcher with right cubital tunnel syndrome.
Ulnar Nerve CompressionGuyon’s Canal Syndrome
• Formed by the flexor retinaculum and the palmar carpal ligament
• Ulnar nerve divides into the superficial sensory and deep motor branches at the level of the hamate
• Space-occupying lesions
• Trauma
• Ulnar artery aneurysms.
Etiology
Level of the Pisiform
Level of the Hamate
Ulnar Nerve CompressionGuyon’s Canal Syndrome
• Motor and sensory findings
• Depends of position of bifurcation to the superficial (sensory) and deep (motor) branches
• Types I, II, III
Signs and Symptoms
Ulnar Nerve CompressionGuyon’s Canal Syndrome
Axial T2 fat-saturatedAxial T1 - weighted
A 57-year-old Cyclist with clinical evidence of right ulnar nerve compression at wrist. Crowded Guyon’s Canal compressed by a tortuous ulnar artery.
Ulnar Nerve CompressionGuyon’s Canal Syndrome
MR Angiography Using Sensitivity Encoding (SENSE)
Median Nerve Compression
• Pronator Teres
• Flexor Digitorum Superficialis
• Carpal Tunnel
Etiology
Median Nerve CompressionPronator Syndrome
• Between the ulnar and humeral heads of the pronator teres muscle
• Trauma
• Congenital abnormalities
• Pronator teres hypertrophy
Etiology
Median Nerve CompressionPronator Syndrome
• Pain and numbness of the volar aspect of the elbow, forearm, and wrist
Signs and Symptoms
Median Nerve CompressionAnterior Interosseous Syndrome
• Entrapment of the Anterior Interosseous Nerve in the proximal forearm by the Flexor Digitorum Superficialis
• Direct nerve trauma
• Compression from a hematoma or mass
Etiology
Median Nerve CompressionAnterior Interosseous Syndrome
• Patients may present clinically with pain and muscle weakness in the volar forearm
• Flexor digitorum profundus
• Flexor pollicis longus
• Pronator quadratus
Signs and Symptoms
Median Nerve CompressionCarpal Tunnel Syndrome
• Most common cause of compressive/entrapment neuropathy
• Repetitive trauma
• Conditions related to metabolic and hormonal changes
• Ganglion cysts
Etiology
Median Nerve CompressionCarpal Tunnel Syndrome
• Burning wrist pain
• Paresthesia or numbness in the 1st through 3rd fingers, and the radial aspect of the 4th finger.
Signs and Symptoms
Carpal Tunnel Syndrome
Axial T1 - weighted Axial T2 fat-saturated
48-year-old patient with surgically proven right carpal tunnel syndrome. There is thickening and increased signal intensity of the median nerve.
Carpal Tunnel Syndrome
Axial T1 - weighted Axial T2 fat-saturated
Bowing of the flexor retinaculum with a flattened median nerve at the level of hamate.
Entrapments of the Lower Extremity
• Sciatic Nerve
• Common Peroneal Nerve
• Tibial Nerve
• Interdigital Nerve
Sciatic Nerve Compression
• Occurs in the hip region and less commonly in the thigh
• Fibrous or Muscular Type entrapment
• Vascular compression
• Scarring related to trauma or radiation
• Tumors
Etiology
Sciatic Nerve Compression
• Pain, weakness, parasthesia, or numbness in the leg.
• Clinical presentations are based upon the level of injury
Signs and Symptoms
Sciatic Nerve Compression
Axial T1 - weighted Sagittal T2-weighted fat-saturated
54 year old patient after a water skiing injury which resulted in an extensive tear of the left hamstring at the muscle origin with sciatic nerve scarring.
Sciatic Nerve Compression
Axial T2-weighted fat-saturated Sagittal T1-weighted postcontrast
Surgically proven neurofibroma of the left sciatic nerve in a 33-year-old patient.
• Level of fibular head due to its superficial location, or as it travels deep to the origin of the peroneus longus
• Idiopathic mononeuritis
• Space-occupying lesions including (intraneural ganglion cyst)
• Traumatic injury
• Tumors
Etiology
Common Peroneal Nerve Compression
• Experience paresthesia and pain at the site of entrapment with foot drop
• Slapping gait
Signs and Symptoms
Common Peroneal Nerve Compression
Common Peroneal Nerve Compression
MCG Emergency Department
Common Peroneal Nerve Compression
MCG Emergency Department
Common Peroneal Nerve Compression
Sagittal T2-weighted fat-saturatedSagittal T2-weighted fat-saturated
44-year-old patient with a 6-month history of right foot drop, Intraneural ganglion cyst multilobulated structure compressing the adjacent common peroneal nerve.
Patchy high signal in tibialis anterior and extensor digitorum longus muscles
Tibial Nerve CompressionTarsal Tunnel Syndrome
• Formed by the flexor retinaculum medial malleolus and calaneous
• Posttraumatic fibrosis due to fracture
• Tenosynovitis / Bursitis
• Space-occupying lesions
• Dilated or tortuous veins
Etiology
Tibial Nerve CompressionTarsal Tunnel Syndrome
• Burning pain and paresthesia along the plantar foot and toes
Signs and Symptoms
Tarsal Tunnel Syndrome
Axial T1-weighted Axial T2-weighted fat-saturated
Tarsal tunnel syndrome caused by a ganglion cyst in a 32-year-old patient. Multilobulated cystic structure within the right tarsal tunnel, adjacent tibial nerve.
Interdigital Nerve CompressionMorton’s Neuroma
• Most frequently occurs in the second and third intermetatarsal spaces
• Repetitive mechanical stress with subsequent perineural fibrosis
• Compression of the nerve by an inflamed intermetatarsal bursa
Etiology
Interdigital Nerve CompressionMorton Neuroma
• Standing on a pebble in your shoe
• A burning pain in the ball of the foot
• Paresthesia or numbness in the toes
Signs and Symptoms
Morton Neuroma
Coronal T1-weighted Coronal T2-weighted with fat saturation
Morton neuroma in a 38-year-old patient. Tear-drop-shaped soft tissue mass in the third intermetatarsal space. A small amount of fluid is noted within the
intermetatarsal bursa dorsal to the neuroma.
Ultrasound Carpal Tunnel Syndrome
Short Axis (cross sectional area) Long Axis
Hydrodisection of Median NerveCarpal Tunnel
Hydrodisection of Median NerveCarpal Tunnel
Annual Meeting 2014