Mononeuropathies: A Practical Approach to Diagnosis and Treatment. Dr. Simran Singh Basi MD, FRCPC, CSCN Diplomate (EMG) February 28, 2018

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1 Mononeuropathies: A Practical Approach to Diagnosis and Treatment Dr. Simran Singh Basi MD, FRCPC, CSCN Diplomate (EMG) February 28, 2018

2 Faculty/Presenter Disclosure Faculty: Dr. Simran Singh Basi Relationships with commercial interests: Grants: Allergan Inc. Consulting Agreement: Allergan Inc.

3 Disclosure of Commercial Support Allergan Inc. (unrestricted educational grant) Allergan Inc. (spasticity consulting agreement) This presentation has not received financial support from Allergan Inc. nor will any of the treatments discussed deal with Allergan Inc. products.

4 Mitigating Potential Bias The information in this presentation is based on recent information that is peer reviewed and all the recommendations involving clinical medicine are based on evidence that is accepted within the profession; and all scientific research referred to, reported or used in the presentation in support or justification of patient care recommendations conforms to the generally accepted standards.

5 Objectives Formulate a differential diagnosis for common mononeuropathies Understand the basics of electrodiagnostic testing Rationalize an approach to treatment

6 Agenda General Approach to Neuromuscular Disorders Median Mononeuropathy Ulnar Mononeuropathy Radial Mononeuropathy Peroneal Mononeuropathy

7 General DDx for Mononeuropathies UMN Brain Spinal Cord LMN Motor or Sensory Neuronopathy Radiculopathy Plexopathy Polyneuropathy Mononeuropathy NMJ Myopathy

8 Electrodiagnostic Testing Nerve Conduction Studies Demyelination Axonopathy Needle Electromyography Muscle pathology patterns Neuropathic NMJ Myopathic

9 Case 1 30 yo M with 3 month history of right hand paresthesias and mild weakness. Works as a mechanic. Difficulty sleeping at night time due to hand symptoms that awaken him from sleep. Otherwise healthy.

10 Entrapment Points: Median Nerve Ligament of Struthers (ligament connecting bone spur to medial epicondyle) Lacertus Fibrosis (Bicipital aponeurosis thickening attaching biceps to radius bone) Sublimis Ridge or Pronator Teres (FDS fascia or two heads of pronator teres) AIN Syndrome Carpal Tunnel

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13 Carpal Tunnel Syndrome Carpal Tunnel Contents: FDS (4 tendons) FDP (4 tendons) FPL Median Nerve Causes of CTS: (if non-dominant hand most involved, likely not idiopathic) Idiopathic (repetitive activity, occupational) (female, dominant hand) Tunnel Volume Changes: Hypothyroid DM2 Renal Failure Mass (Tumor, Hematoma) Pregnancy Bony Changes: Fracture (Colles), OA RA tenosynovitis CHF Amyloidosis

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15 CTS Classification: Mild CTS: Sensory abnormality Moderate CTS: Sensory + Motor abnormality Severe CTS: Sensory + Motor + Muscle Atrophy

16 DDx CTS UMN: CNS lesion (seizure, migraine, TIA/stroke of lateral thalamus + internal capsule) UMN signs LMN C6/C7 Radiculopathy Neck pain, abnormal reflexes (biceps, brachioradialis, triceps) Brachial Plexopathy (Upper/Middle Trunk, Lateral Cord) Widespread Motor and Sensory abnormality Proximal Median Nerve Lesion Palmar Cutaneous Affected Proximal median nerve muscles affected

17 EDx Role in CTS Assess DDx Classify Severity of CTS Mild: sensory nerves only Moderate: motor + sensory nerves Severe: EMG changes in median nerve palm muscles

18 CTS Rx 1. Education: avoid wrist flexion/repetitive activities if possible 2. Modify work environment + proper ergonomics 3. Resting Wrist-Hand Orthosis qhs with 0-5 deg of wrist extension (MILD CTS) 4. Pharmacologic: - NSAIDs, diuretics, thyroid replacement - CSI into carpal tunnel (MODERATE CTS) + still use wrist splint 5. Surgery: Release of transverse carpal ligament (SEVERE CTS or failed non-surgical)

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20 Case 2 40 yo M with 3 month history of right hand weakness and numbness of digits 4&5. Dropping objects due to weakness.

21 Ulnar Nerve Entrapment Points: (from proximal to distal) Arcade of Struthers (fascial band connecting brachialis to triceps) Ulnar Groove proximal to medial epicondyle Cubital Tunnel Syndrome distal to medial epicondyle Guyon s Canal

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Ulnar Neuropathy at the Elbow (UNE) a) Ulnar Groove (located just proximal to medial epicondyle) b) Cubital Tunnel Syndrome (bordered by medial epicondyle, olecranon and overlying FCU aponeurosis) ~

23 Ulnar Neuropathy at the Elbow (UNE) a) Ulnar Groove (located just proximal to medial epicondyle) b) Cubital Tunnel Syndrome (bordered by medial epicondyle, olecranon and overlying FCU aponeurosis) ~ 3 cm distal to medial epicondyle EC1CEF&selectedIndex=1&ccid=N41sHujv&simid= &thid=OIP.M378d6c1ee8ef2b5a7b4e6140d0007 b61o0

24 UNE Causes: Chronic Mechanical Compression Ganglion Tumor Excessive cubital valgus angulation Accessory muscle (anconeous epitrochlearis)

25 DDx in UNE UMN: CNS lesion (seizure, migraine, TIA/stroke of lateral thalamus + internal capsule) UMN signs LMN Motor Neuron No sensory symptoms C8/T1 Radiculopathy Neck pain with radicular features Brachial Plexopathy (Lower Trunk, Medial Cord) Weak Radial Nerve hand muscles Abnormal MABC (medial antebrachial cutaneous nerve) Distal Ulnar Nerve Lesion (ulnar neuropathy at wrist) Normal DUC and PUC

26 EDx Role in UNE Assess DDx Localize entrapment site with inching studies Characterize pathology Demyelinating Axonopathy

27 Next Steps Ultrasound or MRI of elbow to look for causative pathology

28 UNE Rx 1. Education: Ulnar nerve hygiene practices Avoid leaning on elbow Avoid excessive elbow flexion for prolonged period Cubital tunnel splint or pediatric zimmer splint or a towel around elbow qhs 2. Hand-Finger Orthosis if ulnar claw hand develops 3. Surgical Ulnar Nerve Transposition or Nerve Release/Decompression

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30 Case 3 30 yo M with 1 week history of wrist drop. Patient was recently out of the country with his wife for their honeymoon.

31 Radial Nerve Entrapment Sites: (proximal to distal) Crutch Palsy (can also affect axillary and suprascapular nerve) Spiral Groove Radial Tunnel Syndrome (intramuscular septum between Brachialis and BR) NO weakness - just pain PIN lesion/ Arcade of Frohse/ Supinator Syndrome (connective tissue of Supinator) Wartenberg Syndrome (superficial radial nerve palsy)

32 DDx in Wrist Drop UMN: CNS lesion (seizure, migraine, TIA/stroke of lateral thalamus + internal capsule) UMN signs LMN C6/C7 Radiculopathy Neck pain, abnormal Triceps reflex Brachial Plexopathy (Middle Trunk, Posterior Cord) Weak Axillary Nerve muscles Weak Thoracodorsal Nerve muscle (latissimus dorsi) Radial Nerve Lesion Spiral Groove PIN lesion

33 EDx Role in Wrist Drop Assess DDx Localize level of radial nerve lesion Characterize Pathology Demyelinating Axonopathy

34 Radial Nerve Injury at Spiral Groove Caused by: Compression Humerus # Clinical: Weakness and paresthesias in radial nerve below spiral groove (Triceps, Anconeus, Posterior cutaneous nerve of arm OK) Paresthesias in lateral arm, posterior forearm and superficial radial sensory nerve to dorsal lateral hand

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36 Q: How does wrist drop differ if spiral groove lesion vs PIN lesion?

37 A: In PIN lesion, ECRL/ECRB preserved so will get some wrist extension laterally whereas spiral groove lesion has no wrist extension at all.

38 Next Steps U/S or MRI to look for compressive lesion at spiral groove

39 Rx of Radial Neuropathy at Spiral 1. Education Groove 2. Physiotherapy for wrist extensor strengthening 3. Wrist-Hand-Finger Orthosis 4. Pain medication 5. Surgical Intervention

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41 Case 4 40 yo male gardener with 4 weeks history of right foot drop. He is otherwise well. Unremarkable past medical history, no medications, unremarkable family history.

42 DDx Foot Drop UMN: CNS lesion (seizure, migraine, TIA/stroke of lateral thalamus + internal capsule) UMN signs LMN L5 Radiculopathy Back pain, abnormal hamstring reflex Weak foot inversion, weak abductors Lumbosacral Plexopathy Widespread motor and sensory abnormality Sciatic Nerve Weak foot inversion, normal abductors Common Peroneal Nerve Lateral cutaneous nerve of the knee Weak eversion Deep Peroneal Nerve Normal eversion Polyneuropathy ex. CMT Tibialis Anterior Rupture No sensory abnormality

43 Course: Peroneal Nerve Lateral Cutaneous Nerve of Knee (comes from common peroneal before it splits into superficial and deep) provides sensation to lateral knee Superficial Peroneal Branch Deep Peroneal Branch

44 EDx Role in Foot Drop Assess DDx Localize Peroneal Nerve lesion Characterize Pathology Demyelinating Axonal Loss

45 Common Peroneal Neuropathy FIBULAR NECK most common site of nerve injury: Trauma (fibular #) Stretch (forcible ankle inversion) Compression at fibular head: 1. Cast 2. Stockings 3. Improper position during surgery Occupational: 1. Gardening 2. Farmwork (squatting, kneeling) Strawberry Picker s Palsy Entrapment at Fibular Tunnel (between fibula and peroneus longus) Mass Lesion (ganglia, tumors, Baker s Cyst) Miscellaneous (weight loss, habitual leg crossing, DM2)

46 southfloridasportsmedicine.com

47 Next Steps U/S or MRI to look for nerve irritation/mass lesion

48 Common Peroneal Neuropathy Rx 1. Education: avoid leg crossing, repetitive squatting 2. Lateral Knee padding 3. Ankle-Foot-Orthosis (posterior leaf spring) 4. Neuropathic Pain Medication 5. CSI 6. Surgical Intervention

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50 Thank You!

51 References Baima, J and L. Krivickas. Evaluation and treatment of peroneal neuropathy. Curr Rev Musculoskeletal Med Jun; 1(2): Braddam RL. Physical Medicine and Rehabilitation 4 th Edition. Elsevier Saunders p Caliandro, P, La Torre G, Padua R, Giannini F and L. Padua. Treatment of ulnar neuropathy at the elbow (UNE). Cochrane Library. November 15, Cuccurullo SJ. Physical Medicine and Rehabilitation Board Review 3 rd Edition. Demos Medical Publishing p Kothari MJ. Treatment of carpal tunnel syndrome. Lifchez S, Dzwierzynski and J. Sanger. Compression neuropathy of the radial nerve due to ganglion cysts. Hand Jun; 3(2): Preston D and B. Shapiro. Electromyography and Neuromuscular Disorders 3 rd Edition. Elsevier Saunders p Russell SM. Examination of Peripheral Nerve Injuries. Thieme p

Year 2004 Paper one: Questions supplied by Megan

Year 2004 Paper one: Questions supplied by Megan QUESTION 47 A 58yo man is noted to have a right foot drop three days following a right total hip replacement. On examination there is weakness of right ankle dorsiflexion and toe extension (grade 4/5).