NERVE ENTRAPMENT SYNDROMES.ppt cubital tunnel cubital tunnel syndrome Ulnar Guyon's canal Guyon's...
Transcript of NERVE ENTRAPMENT SYNDROMES.ppt cubital tunnel cubital tunnel syndrome Ulnar Guyon's canal Guyon's...
NERVENERVENERVE NERVE ENTRAPMENT ENTRAPMENT
SYNDROMES [ NES ]SYNDROMES [ NES ]Disorders of peripheral nerve with pain Disorders of peripheral nerve with pain and/or loss of function [ motor and/or and/or loss of function [ motor and/or sensory] due to chronic compressionsensory] due to chronic compressionsensory] due to chronic compression.sensory] due to chronic compression.
e.g., carpal tunnel syndromee.g., carpal tunnel syndrome
IMPORTANT: Memorize IMPORTANT: Memorize completely !!completely !!
Upper limbUpper limbUpper limbUpper limb Nerve place usually referred to Nerve place usually referred to medianmedian
carpal tunnelcarpal tunnel carpal tunnel syndromecarpal tunnel syndromedidi (( i ii i )) i li l ff i ii i medianmedian ((anterior interosseousanterior interosseous) ) proximalproximal forearm forearm anterior interosseous anterior interosseous
MedianMedian pronator terespronator teres pronator teres syndromepronator teres syndrome MedianMedian ligament of Struthersligament of Struthers ligament of Struthersligament of Struthers synsyn UlnarUlnar cubital tunnelcubital tunnel cubital tunnel syndromecubital tunnel syndrome UlnarUlnar Guyon's canalGuyon's canal Guyon's canal syndromeGuyon's canal syndrome radialradial axillaaxilla radial nerve compressionradial nerve compression radialradial spiral groovespiral groove radial nerve compressionradial nerve compression radialradial ((posterior interosseousposterior interosseous)) proximalproximal forearmforearm posterior interosseous nerveposterior interosseous nerve radialradial ((superficialsuperficial radialradial ((posterior interosseousposterior interosseous) ) proximalproximal forearm forearm posterior interosseous nerve posterior interosseous nerve radialradial ((superficial superficial
radialradial) ) distaldistal forearm forearm Wartenberg's SyndromeWartenberg's Syndrome suprascapularsuprascapular suprascapular notchsuprascapular notch etc etc Etc etcEtc etc ETC ETC ETCETC ETC ETC ETC ETC ETC ETC ETC ETC
NESNESNES NES
Def: results from chronic injury to nerve as it travelsDef: results from chronic injury to nerve as it travelsDef: results from chronic injury to nerve as it travels Def: results from chronic injury to nerve as it travels through an osseoligamentous structure, or between through an osseoligamentous structure, or between muscles bundlesmuscles bundles
May have an underlying developmental anomaly or May have an underlying developmental anomaly or variantvariant
Repetitive motion slaps, rubs, compresses the n.Repetitive motion slaps, rubs, compresses the n. Relatively commonRelatively common Often seen in athletes, younger patientsOften seen in athletes, younger patients
Chronic NESChronic NESChronic NESChronic NES
Repetitive injury may lead to edema, ischemia, andRepetitive injury may lead to edema, ischemia, andRepetitive injury may lead to edema, ischemia, and Repetitive injury may lead to edema, ischemia, and finally alteration to the nerve sheath, even finally alteration to the nerve sheath, even demyelinizationdemyelinization
Eventually complete recovery may not be possible, and Eventually complete recovery may not be possible, and there is also the potential for ‘phantom limb’ type there is also the potential for ‘phantom limb’ type symptoms that become centralized in the brain and symptoms that become centralized in the brain and ‘replay’ even after the pathology is fixed.‘replay’ even after the pathology is fixed.
Early recognition and intervention is critical.Early recognition and intervention is critical.
PUDENDAL NERVE PUDENDAL NERVE T TT TENTRAPMENTENTRAPMENT
PN is the main nerve of the perineum;PN is the main nerve of the perineum; PN is the main nerve of the perineum;PN is the main nerve of the perineum; Carries sensation from the external genitalia, Carries sensation from the external genitalia,
skin around the anus scrotum perineumskin around the anus scrotum perineumskin around the anus, scrotum, perineum.skin around the anus, scrotum, perineum. Motor supply to pelvic muscles, external urethral Motor supply to pelvic muscles, external urethral
hi d l hihi d l hisphincter, and ext anal sphinctersphincter, and ext anal sphincter Originates from sacral plexus [occasionally from Originates from sacral plexus [occasionally from
sciatic n. instead ]sciatic n. instead ]
PNE SYMPTOMSPNE SYMPTOMSPNE SYMPTOMSPNE SYMPTOMS
Pain in the lower central pelvis can include anus, Pain in the lower central pelvis can include anus, p ,p ,perineum, scrotum, penis,testicles, vulvaperineum, scrotum, penis,testicles, vulva
Burning pain, sometimes shockBurning pain, sometimes shock--likelike M b il t l bil t lM b il t l bil t l May be unilateral or bilateralMay be unilateral or bilateral Deep ache, ‘severe like toothache’Deep ache, ‘severe like toothache’ Hypersensitivity to touch pressureHypersensitivity to touch pressure Hypersensitivity to touch, pressureHypersensitivity to touch, pressure Often provoked with urination / defecation, Often provoked with urination / defecation,
exacerbated by sittingexacerbated by sitting Often cannot sit; sexual dysfunction commonOften cannot sit; sexual dysfunction common Urinary urgency, dysuria, feeling of ‘always needing to Urinary urgency, dysuria, feeling of ‘always needing to
go’go’gogo
PUDENDAL N.PUDENDAL N.PUDENDAL N.PUDENDAL N.
COURSE:COURSE:
PNPNPNPN
Landmarks:Landmarks: Landmarks:Landmarks:
PUDENDAL NERVE PUDENDAL NERVE T TT TENTRAPMENT [ PNE ]ENTRAPMENT [ PNE ]
PNEPNEPNEPNE
PNEPNEPNEPNE
PNEPNEPNEPNE
"The main daily activities requiring the seated position "The main daily activities requiring the seated position y q g py q g p(work, meals, driving, theaters, etc) are no longer (work, meals, driving, theaters, etc) are no longer available to these patients, whose mental attitude is one available to these patients, whose mental attitude is one of chronic pain sufferers so obsessed with their of chronic pain sufferers so obsessed with their ppmiserable state as to be rapidly regarded by their miserable state as to be rapidly regarded by their doctors as psychiatric cases."doctors as psychiatric cases."
Patients often have to sit on an inflatable ‘donut’ to sitPatients often have to sit on an inflatable ‘donut’ to sit Patients often have to sit on an inflatable donut to sit Patients often have to sit on an inflatable donut to sit at allat all
The variety of symptoms often mean the patient has The variety of symptoms often mean the patient has seen urologist, gynecologist, proctologist, seen urologist, gynecologist, proctologist, gastroenterologists etcgastroenterologists etc
PNEPNEPNEPNE
Often seen in athletes: bicyclists cross countryOften seen in athletes: bicyclists cross country Often seen in athletes: bicyclists, cross country Often seen in athletes: bicyclists, cross country skiers, skaters, dancers, some runners.skiers, skaters, dancers, some runners.
May begin after direct trauma after pelvicMay begin after direct trauma after pelvic May begin after direct trauma, after pelvic May begin after direct trauma, after pelvic surgery, or after child birth.surgery, or after child birth.O h k i i iO h k i i i Or may have no known precipitating eventOr may have no known precipitating event
Early dx and rx offer much better prognosisEarly dx and rx offer much better prognosis
PNEPNEPNEPNE
First line rx ( early cases ): NSAIDs, i.e. ibuprofen; First line rx ( early cases ): NSAIDs, i.e. ibuprofen; ( y ) , p ;( y ) , p ;topical pain relievers [ lidoderm creams, creams with topical pain relievers [ lidoderm creams, creams with capsaicin ]capsaicin ]
d d dd d d Try to identify and avoid acitivity that causes the painTry to identify and avoid acitivity that causes the pain Hot or cold compresses [ can alternate ]Hot or cold compresses [ can alternate ]
K i h di i d i fK i h di i d i f Key is to suspect the diagnosis and sort it out from Key is to suspect the diagnosis and sort it out from other causesother causes
Pain may be provoked by ‘skin rolling’ technique orPain may be provoked by ‘skin rolling’ technique or Pain may be provoked by skin rolling technique or Pain may be provoked by skin rolling technique or direct pressure on ischial tuberositydirect pressure on ischial tuberosity
PNEPNEPNEPNE
Physical rx: some know specialized techniquesPhysical rx: some know specialized techniquesPhysical rx: some know specialized techniquesPhysical rx: some know specialized techniques Lengthen and loosen pelvic floor Lengthen and loosen pelvic floor –– buttocks, thighs, buttocks, thighs,
hips, perineumhips, perineump , pp , p Toe touches, supine leg lifts, side leg raises, range of Toe touches, supine leg lifts, side leg raises, range of
motion ex in swimming poolmotion ex in swimming poolg pg p Next line of approach: meds i.e. elavil, neurontin, Next line of approach: meds i.e. elavil, neurontin,
valproate BUT direct intervention may be bettervalproate BUT direct intervention may be better
PNE injectionsPNE injectionsPNE injectionsPNE injections
The pudendal nerve can be approached very precisely The pudendal nerve can be approached very precisely p pp y p yp pp y p yvia CT scan directionvia CT scan direction
Current national recommendations are for this Current national recommendations are for this b d db d dapproachapproach-- reliable results vs. flouro directed.reliable results vs. flouro directed.
Injx with local anesthestic can confirm the origin of sxInjx with local anesthestic can confirm the origin of sxR l f i j i i blR l f i j i i bl Results of injx in past were variable to poor Results of injx in past were variable to poor -- current current technique better resultstechnique better results
Repeat injx when sx recur often 3 x in 6Repeat injx when sx recur often 3 x in 6--9 months9 months Repeat injx when sx recur, often 3 x in 6Repeat injx when sx recur, often 3 x in 6--9 months9 months
PNE InjectionsPNE InjectionsPNE InjectionsPNE Injections
Injection: using 5” 22 g spinal needle, initial is lidocaine 1%Injection: using 5” 22 g spinal needle, initial is lidocaine 1%-- this will this will i di t l li t / b ti di t l li t / b timmediately replicate/exacerbate sximmediately replicate/exacerbate sx
Additionally, dexamathosone phosphate 4 mg is intermixed with 3 cc 0.5 % Additionally, dexamathosone phosphate 4 mg is intermixed with 3 cc 0.5 % bupivicainebupivicaine
Hyaluronidase 300Hyaluronidase 300--600 units600 units-- hydrolyzes glucosaminic bonds between hydrolyzes glucosaminic bonds between yy y y gy y ghyaluronic acid, a major intercellular substancehyaluronic acid, a major intercellular substance-- this helps remove barriers this helps remove barriers between tissues/cellsbetween tissues/cells-- fluids, including other meds, penetrate betterfluids, including other meds, penetrate better-- helps helps disrupt scarring and reduces density of any new adhesionsdisrupt scarring and reduces density of any new adhesions
Heparin 8000Heparin 8000--10000 units10000 units-- was discovered to inhibit superficial scarwas discovered to inhibit superficial scar Heparin 8000Heparin 8000--10000 units10000 units-- was discovered to inhibit superficial scar was discovered to inhibit superficial scar formation in burn patients following debridements.formation in burn patients following debridements.
BotulinumToxin A [Botox] also can be used if the above fails.BotulinumToxin A [Botox] also can be used if the above fails. Surgery for failed cases: send to the experts such as Dr. Stanley AntolakSurgery for failed cases: send to the experts such as Dr. Stanley Antolak
PNE injxPNE injxPNE injxPNE injx
PIRIFORMIS SYNDROMEPIRIFORMIS SYNDROME[ PS ][ PS ]
Caused by piriformis muscle compressing the sciaticCaused by piriformis muscle compressing the sciaticCaused by piriformis muscle compressing the sciatic Caused by piriformis muscle compressing the sciatic nervenerve–– a true sciatica in that sensea true sciatica in that sense
Piriformis m. is a stabilizer of hip, and lifts and rotates Piriformis m. is a stabilizer of hip, and lifts and rotates p,p,thigh away from bodythigh away from body
Usually pain and tingling in buttocks, often tenderness, Usually pain and tingling in buttocks, often tenderness, y p g gy p g gand subsequently pain extends down the thighand subsequently pain extends down the thigh
Increased by sitting, walking, running, climbing stairs, Increased by sitting, walking, running, climbing stairs, direct compression.direct compression.
PSPSPSPS
PSPSSS
Athletes, runners esp. distance runners, sometimes with Athletes, runners esp. distance runners, sometimes with , p ,, p ,traumatrauma
Can be related to developmental anomaly Can be related to developmental anomaly Si il t b d d b l b diSi il t b d d b l b di Similar symptoms can be produced by lumbar disc Similar symptoms can be produced by lumbar disc
disease, sacroiliac joint disease, and a few others.disease, sacroiliac joint disease, and a few others. May be necessary to image spine and pelvis is dx is not May be necessary to image spine and pelvis is dx is not y y g p py y g p p
clearclear Some articles show many patients with ‘sciatica’ and Some articles show many patients with ‘sciatica’ and
negative lumbar MRI have piriformis synnegative lumbar MRI have piriformis synnegative lumbar MRI have piriformis synnegative lumbar MRI have piriformis syn
PSPSContributing factorsContributing factors
HyperlordosisHyperlordosis HyperlordosisHyperlordosis Muscle anomaliesMuscle anomalies
M l h hM l h h Muscle hypertrophyMuscle hypertrophy Fibrosis due to traumaFibrosis due to trauma Anatomical nerve abnormalitiesAnatomical nerve abnormalities Occasionally due to physical hyperactivity hipOccasionally due to physical hyperactivity hip Occasionally due to physical hyperactivity, hip Occasionally due to physical hyperactivity, hip
replacement surgery, leg length discrepancyreplacement surgery, leg length discrepancy
PSPSPSPS
Accessory fibers and enlargement at origin onAccessory fibers and enlargement at origin on Accessory fibers and enlargement at origin on Accessory fibers and enlargement at origin on rightright
PSPSPSPS
Accessory bundle of piriformis on rightAccessory bundle of piriformis on right Accessory bundle of piriformis on rightAccessory bundle of piriformis on right
PS RX :PS RX :First line First line
Best and safest is care that you provideBest and safest is care that you provide-- Best and safest is care that you provideBest and safest is care that you providemassage, joint manipulation and mobilization, massage, joint manipulation and mobilization, stretching isotonics weight bearingstretching isotonics weight bearingstretching, isotonics, weight bearingstretching, isotonics, weight bearing
Heat therapy, at home, or better with Heat therapy, at home, or better with ultrasonographic rxultrasonographic rxultrasonographic rx.ultrasonographic rx.
Stretching piriformis, external rotators of hip, Stretching piriformis, external rotators of hip, d ddd ddand adductorsand adductors
PS RXPS RXSecond lineSecond line
Refractory cases often benefit from direct interventionRefractory cases often benefit from direct interventionyy Injection performed with 22 g spinal needle with direct Injection performed with 22 g spinal needle with direct
visualization with usvisualization with us Sciatic n identified and the piriformis directly overlying Sciatic n identified and the piriformis directly overlying
is entered with needleis entered with needleI j i h 5 0 5% b i i i i d i h 40I j i h 5 0 5% b i i i i d i h 40 8080 Injx with 5 cc 0.5% bupivicaine mixed with 40Injx with 5 cc 0.5% bupivicaine mixed with 40--80 mg 80 mg triamcinolone, repeat x 2 with recurrencetriamcinolone, repeat x 2 with recurrence
Resistant cases may get good result with same approachResistant cases may get good result with same approach Resistant cases may get good result with same approach Resistant cases may get good result with same approach but with Botoxbut with Botox
US DIRECTED RXUS DIRECTED RXUS DIRECTED RXUS DIRECTED RX
PS INJXPS INJXPS INJXPS INJX
MERALGIA PARESTHETICAMERALGIA PARESTHETICA[ MP ][ MP ]
Entrapment of the lateral femoral cutenousEntrapment of the lateral femoral cutenousEntrapment of the lateral femoral cutenous Entrapment of the lateral femoral cutenous nerve nerve
Occurs between the anterior ‘superior iliac crestOccurs between the anterior ‘superior iliac crestOccurs between the anterior superior iliac crest Occurs between the anterior superior iliac crest and the inguinal ligamentand the inguinal ligament
Tight clothing, obesity, pregnancy, scarring,Tight clothing, obesity, pregnancy, scarring,Tight clothing, obesity, pregnancy, scarring, Tight clothing, obesity, pregnancy, scarring, excessive walking, biking etcexcessive walking, biking etc
Pain may be burning, ‘electric’, stinging, sharpPain may be burning, ‘electric’, stinging, sharpPain may be burning, electric , stinging, sharp Pain may be burning, electric , stinging, sharp ‘shock’ associated with motion‘shock’ associated with motion
If in doubt, EMG is helpfulIf in doubt, EMG is helpfulIf in doubt, EMG is helpfulIf in doubt, EMG is helpful
LFCN compressionLFCN compressionLFCN compressionLFCN compression
PM RXPM RXPM RXPM RX
Chiropractic care with pelvic mobilization,Chiropractic care with pelvic mobilization,Chiropractic care with pelvic mobilization, Chiropractic care with pelvic mobilization, myofascial rx, transverse friction massage, and myofascial rx, transverse friction massage, and stretching may resolve this rapidly in many stretching may resolve this rapidly in many g y p y yg y p y ycases.cases.
Usual recommended medical care starts with Usual recommended medical care starts with “NSAIDS, looser clothing, narcotics if needed, “NSAIDS, looser clothing, narcotics if needed, reduced activity” !!reduced activity” !!
Resistant cases often have excellent response to Resistant cases often have excellent response to injxinjx
MP INJXMP INJXMP INJXMP INJX
Easily done with USEasily done with USEasily done with USEasily done with USIdentify inguinal ligament and the LFCNIdentify inguinal ligament and the LFCNI j 1 l% id i f ll d b 3 0 5%I j 1 l% id i f ll d b 3 0 5%Inject 1cc l% idocaine, followed by 3 cc 0.5% Inject 1cc l% idocaine, followed by 3 cc 0.5%
bupivicaine with 40 mg triamcinolonebupivicaine with 40 mg triamcinolone80% of patients pain free with 1 week, others may 80% of patients pain free with 1 week, others may
require second injx.require second injx.
MP INJXMP INJXMP INJXMP INJX
NES around the kneeNES around the kneeNES around the kneeNES around the knee
Patient with ‘weakness’ and pain in lower legPatient with ‘weakness’ and pain in lower leg Patient with weakness and pain in lower leg Patient with weakness and pain in lower leg and ankle, esp pain in footand ankle, esp pain in foot
Neuro exam suggested problem was commonNeuro exam suggested problem was common Neuro exam suggested problem was common Neuro exam suggested problem was common peroneal nerveperoneal nerveEMG l iEMG l i EMG also suggestiveEMG also suggestive
MRI lower leg orderedMRI lower leg ordered Denervation of medial and lateral heads of Denervation of medial and lateral heads of
gastrocnemiusgastrocnemiusgg
PERONEAL NESPERONEAL NESPERONEAL NESPERONEAL NES
CP NESCP NESCP NESCP NES
COMMON PERONEAL N.COMMON PERONEAL N.COMMON PERONEAL N.COMMON PERONEAL N.
coursecourse coursecourse
CP NESCP NESCP NESCP NES
High signal intensity is seen in acute and subacute High signal intensity is seen in acute and subacute g g yg g ydenervationdenervation
CPN wraps around neck of fibulaCPN wraps around neck of fibula-- a ‘tight ‘ area; a ‘tight ‘ area; bbvulnerable to trauma from fractures, surgery, repetitive vulnerable to trauma from fractures, surgery, repetitive
stress [ athletics], casts, squatting position, chronic stress [ athletics], casts, squatting position, chronic crossing of legs, etccrossing of legs, etccrossing of legs, etccrossing of legs, etc
Developmental variants as wellDevelopmental variants as well Most common mononeuropathy in lower legMost common mononeuropathy in lower legp y gp y g RX correct cause if possible…padding, alter habitsRX correct cause if possible…padding, alter habits
“SPORTS HERNIA”“SPORTS HERNIA”T TT TATHLETIC PUBALGIA [ AP ]ATHLETIC PUBALGIA [ AP ]
‘Sports hernia’ is real misnomer‘Sports hernia’ is real misnomer-- not really a hernia; not really a hernia; pp y ;y ;often seen in athletesoften seen in athletes
Symptoms are in the inguinal/groin area and may Symptoms are in the inguinal/groin area and may mimic hernia mimic hernia
Many patients have had hernia repairs, even for tiny, Many patients have had hernia repairs, even for tiny, inconsequential hernias and still no reliefinconsequential hernias and still no reliefinconsequential hernias, and still no reliefinconsequential hernias, and still no relief
True herniaTrue hernia-- tear in abdominal wall, through which tear in abdominal wall, through which abdominal contents protrudeabdominal contents protrudepp
Pain and tenderness in inguinal area, esp the symphysis Pain and tenderness in inguinal area, esp the symphysis pubispubis
APAPAPAP
It does involve a tear, most commonly of the muscle It does involve a tear, most commonly of the muscle , y, yattachments, specifically an aponeurosisattachments, specifically an aponeurosis
An aponeurosis is a tendonous structure joining An aponeurosis is a tendonous structure joining d b dd b dmuscles and other body parts in a common structuremuscles and other body parts in a common structure--
example plantar fascia of footexample plantar fascia of foot In AP the aponeurosis attached to the symphysis pubisIn AP the aponeurosis attached to the symphysis pubis In AP the aponeurosis attached to the symphysis pubis In AP the aponeurosis attached to the symphysis pubis
is involvedis involved The aponeurosis of the rectus abdominis and the The aponeurosis of the rectus abdominis and the pp
adductor longus of the thigh are the usual culpritsadductor longus of the thigh are the usual culprits
APAPAPAP
RARA--ALAL
APAPAPAP
SAGITALLSAGITALL SAGITALLSAGITALL
Walking running jumping skatingWalking running jumping skating Walking, running, jumping, skating, Walking, running, jumping, skating, falling….there are many movements that stress falling….there are many movements that stress these two muscles simulataneously and causethese two muscles simulataneously and causethese two muscles simulataneously and cause these two muscles simulataneously and cause them to pull against each other at this them to pull against each other at this attachmentattachmentattachment.attachment.
The aponeurosis is strong but contains very little The aponeurosis is strong but contains very little blood supply like many tendons healing is poorblood supply like many tendons healing is poorblood supply, like many tendons, healing is poorblood supply, like many tendons, healing is poor
APAPAPAP
sagittalsagittal sagittalsagittal
APAPAPAP
60 year old male injured from fall on ice60 year old male injured from fall on ice 60 year old male, injured from fall on ice 60 year old male, injured from fall on ice [hockey] several years prior, with re[hockey] several years prior, with re--injuries with injuries with ‘slipping and sliding’ several times; pain greatest‘slipping and sliding’ several times; pain greatestslipping and sliding several times; pain greatest slipping and sliding several times; pain greatest on right on right
Pain too great for exercise now very limitedPain too great for exercise now very limited Pain too great for exercise now, very limited Pain too great for exercise now, very limited activites…. “miserable”activites…. “miserable”H d di dH d di d h l f lh l f l Had many studies and examsHad many studies and exams-- not helpfulnot helpful
He had read about sports hernia and MRIHe had read about sports hernia and MRI
Sagittal leftSagittal leftSagittal leftSagittal left
Sagittal rightSagittal rightSagittal right Sagittal right
axialaxialaxialaxial
axialaxialaxialaxial
APAPAPAP
Like rotator cuff etc. tendons repair poorly on theirLike rotator cuff etc. tendons repair poorly on theirLike rotator cuff etc. tendons repair poorly on their Like rotator cuff etc. tendons repair poorly on their ownown
Initial rx: rest, ice, NSAIDS but if persists needs dx and Initial rx: rest, ice, NSAIDS but if persists needs dx and , , p, , prxrx
Recently open surgery has been offered, and more Recently open surgery has been offered, and more y p g yy p g ypreferable for athletes endoscopic surgerypreferable for athletes endoscopic surgery
Very recently intervention with ultrasound directed Very recently intervention with ultrasound directed injxinjx-- with steroids and anesthetic, now considered best with steroids and anesthetic, now considered best approach before surgery approach before surgery