Peripheral Nerve-blok Neuromuscular

7/30/2019 Peripheral Nerve-blok Neuromuscular

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PERIPHERAL NERVE


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BRACHIAL PLEXUS LESION

Brachial plexus is a complex structure originatingfrom C5-T1 nerveroots.

Trauma : most common cause of brachialplexopathy.

Closed injuries typically produce injury due totraction on the plexus, such as after a fall.


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ERB PALSY

In injuries that cause head & shoulder to bestretch apart such as in newborn deliveries orfalls on shoulder, result in upper trunkplexopathies with involvement ofC5-C6-C7erb palsy.

Waiters tip deformity :Shoulder : adduction, internal rotation

Elbow : extention, supination

Wrist : flexion


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KLUMPKE PALSY

Injury in which there is forceful upward tractionon arm, result in lower trunk plexopathies affect

C8-T1 fibers

klumpke palsy.

Clinical presentation : hand weakness


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DIAGNOSE

Anamnesa : Trauma ?

Physical Exam. : MMTSensory

Reflexes

Supporting Exam. : NCV / EMG

MRI (tumor ?)


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TREATMENT

Positioning

ROM exercise

Strengthening exercise

Orthoses : shoulder sling, splint

Electro Stimulation : MMT < 3


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CARPAL TUNNEL SYNDROME

Contents of carpal tunnel include :

-Median nerve.

-Flexor pollicis longus-Four tendons each from flexor digitorumsuperficialis & profundus muscles.

Swelling or increased pressure inside carpaltunnel lead to compression ofmedian nerve,producing symptoms of CTS


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Clinical presentation

Paresthesias (numbness, tingling, and burning)involving median nerve distribution (first 3digits).

Deep aching pain in hand & wrist. Pain willradiate info forearm, even rarely to shoulder.

Patient might report subjective swelling of

hand but on inspection, no swelling is usuallyapparent.

Nocturnal worsening of symptoms is common


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Clinical presentation

Flick sign : patient often report awakening withhand paresthesias, which are then relieved by

shaking involved hand.

Advance CTS : sensory symptoms last longer orbecome persistent, & thenar weakness develops.


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CTS is often associated with repetitive hand &wrist movements or the use of vibrating

machine. The great majority of cases are idiopathicin

origin.

Predispose / risk factor :

-DM -RA

-Amyloidosis -Obesity

-Hypothyroidism -Pregnancy


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PHYSICAL EXAMINATION

Abnormality in median sensory testing.

MMT is more advance cases show weakness and

atrophy of Abductor Pollicis Brevis & OpponensPollicis Muscles.

Provocative test : Tinels sign, Phalens sign,Prayer sign

Flick sign

Supporting examination : NCV / EMG


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TREATMENT

ROM exercise


Nocturnal wrist splint : hold the wrist in 0-30 of extension.

USD / Phonoporeses / Laser

Medication : NSAID, Corticosteroidinjection


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POLIOMYELITIS

is a viral infection involving the anterior horncells (LMN), producing weakness in affectedbulbar and/or spinal myotomes.

Clinical presentation :

-Initial symptoms : fever, malaise, headache,

gastrointestinal or upper respiratory tracksymptoms.

-Weakness was typically asymmetric, morecommon in the lower extremities


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Patient with history of polio infection maydevelop fatigue and worsening muscle weakness

severe years or even decades after initialinfection.


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POST POLIO SYNDROME

Criteria for establishing a diagnosis :

Confirmed history of paralitic polio

Partial to fairly complete neurologic & functionalrecovery

Periode of neurologic & functional stability for atleast 15 years.

No other medical explanation for the newhealthproblems


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Onset of 2 or more of following symptoms sinceachieving stability :

-Unaccustomed fatique.-New weakness in muscle previously affectedand/or unaffected

-Muscle and/or joint pain

-Functional loss

-Cold intolerance

-New atrophy


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TREATMENT

ROM exercise


Endurance exercise Orthoses : HKAFO


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BELLS PALSY

idiophatic peripheral fascial nerveparalysis.

Risk factor :

-DM -Hyperacusis

-HT -Lack of lacrimalis

-Pregnancy -Schizophrenia


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TREATMENT

Acute (day of 0-4) :

HEP : warm compress, fascial massage.

HE : sunglasses, Y-plester Day of > 4 :

-SWD / Laser

-ES


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HERNIATED NUCLEUS PULSOSUS

A disk injury in which the nuclear pulposusmigrates through the annular fibers.

A higher prevalence occurs for the lumbarregion at the L4-L5 or L5-S1 followed bythe C5-C6 disc.


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CLASSIFICATION

Buldging disc

Prolapsed disc

Extruded disc

Sequestered disc


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ETIOLOGY

Spontaneous

Lifting activities

Coughting / sneezing

Bending / twisting activity


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CLINICAL PRESENTATION

Acute neck or back discomfort radiatingdown the upper or lower limb

Weakness, numbness, paresthesias or painsecondary to chemical or mechanical stimuli tothe disc or nerve root.

Exacerbation occurs with lumbar motion

(forward flexion, extention), sitting, sneezing,coughing, valsava manuver


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DIAGNOSTIC STUDY

X rays

MRI

Myelography


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TREATMENT

Acute : relative rest

Diathermi : MWD, SWD, USD

Laser TENS

Traction : cervical, lumbal

Orthoses : Lumbar corset HEP : William Flexion Exercise


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LEPROSY (HANSENS DISEASES)

Etiology : Mycobacterium Leprae

Onset : Immune status dependent

Clinical presentation :-Most common world-wide neuropathy

-Sensory abnormality

-Drop hand, drop foot-Fascial palsy


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SIGN OF LEPROSY

A slowly growing patch on the skin that does notitch or hurt

Tingling numbness, or some loss of feeling inthe hand & feet. Or definite loss of feeling inskin patches.

Slight weakness or deformity in hand & feet

Enlargement of certain nerves, with or withoutpain or tenderness.


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DIAGNOSE

Definite loss or change of feeling in skinpatches.

Definite enlargement of nerves. Presence of leprosy bacilli in a skin smear


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TREATMENT

Long term medical treatment : to control the leprosyinfection as early as possible Dapsone, Rifampisin,Clofazimine.

Emergency treatment (when necessary to control) &prevent further damage (from leprosy reaction).

Safety measures, aids, exercise, & education toprevent deformities (sores, burns, injuries, contractures).

Social Rehabilitation. Work with individual, parent,schools, & community to create a better understandingof leprosy, to lessen peoples fear, & to increaseacceptance, so child & adult with leprosy can lead a full,happy, meaningful life


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REHABILITATION OF LEPROSY

ROM exercise

Stretching exercise

Strengthening exercise ES

Orthesa : Knuckle bender, dorsal spring

HEP : Soaking-Oiling-Scrapping HE : sunglasses, glove, shoes/sandal


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THANK YOU

Peripheral Nerve-blok Neuromuscular

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