Upper Extremity Neuropathy: CTS and Beyond
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1 Upper Extremity Neuropathy: CTS and Beyond Steven A. Day, MD Providence Neurological Specialties
2 Median Neuropathy
3 Carpal Tunnel Syndrome
4 CTS Median nerve entrapment at the wrist The most common focal neuropathy F:M 3:1 Peak age: >70 y/o: F=M
5 CTS: Hx Insidious onset/slowly progressive Tingling Pain Numbness Swollen
6 CTS: Hx Provocation of sx Sleep due to wrist flexion Hand use Dominant > non-dominant hand Distribution Digits 1-4 Note: Many c/o whole hand or arm involvement
7 Median Nerve sensory impairment: CTS Aids to the examination of the peripheral nervous system, 4th edition 2000
8 CTS: Pathophysiology Increased pressure within carpal tunnel leading to a progression of: hypoperfusion ischemia demyelination axon loss
9 CTS: Risk Factors 1 Reduced Tunnel space Wrist structure: shallow, narrow wrists RA: synovial thickening and osteophytes OA: osteophytes Ganglia Trauma: fracture, hematoma Diabetes: Microangiopathic ischemia Hypothyroidism: myxedema
10 CTS: Risk Factors 2 Pregnancy: esp 3 rd trimester (edema) Hemodialysis: beta-2-microglobulin Obesity Metabolic syndrome
11 CTS: Risk Factors 3 Activities: Manual labor Hand held vibratory tools Other work or recreational activities with repeated flexion/extension esp with gripping Sports (wt lifting, football, golf) Chronic wheelchair use
12 CTS: Risk Factors 4 Note: the balance of evidence does not support keyboarding/computer work as a significant risk factor
13 CTS: Exam Inspection Thenar eminence atrophy Sensory Light touch: cotton or your fingers Pin prick at volar vs dorsal surfaces of fingers and palm Motor Abductor pollicis brevis Palm flat; thumb abducted at 90 degrees
14 CTS: Exam Provocative maneuvers Tinel s sign: paresthesias with percussion over nerve at wrist Phalen s or Reverse Phalen s Tests Carpal compression test: pressure over the tunnel with both thumbs
15 CTS: EMG/NCS Sensitivity: > 85% Specificity: > 95% Purpose Confirm dx Determine severity for treatment planning including pre-surgical prognosis Limitation Only abnormal when there has been nerve damage Patient discomfort
16 CTS EMG will be normal in a patient with episodic hypoperfusion who has not progressed to ischemia/demyelination/axon loss
17 CTS: Treatment Treat underlying medical condition Avoidance of precipitating activities Wrist splints Nocturnal only vs day/night NSAIDs: brief benefit Oral steroids x 1 month: temporary benefit Gabapentin OT
18 CTS Treatment: Steroid Injections Effective in reducing symptoms Temporary benefit Role: Delay surgery Non surgical candidates
19 CTS Treatment: Surgical Decompression 1 Open Endoscopic Reduced post op pain? More rapid recovery Equally effective 75% success (range 27%-100%)
20 CTS Treatment: Surgical Decompression 2 Surgical failures : Wrong diagnosis Normal EMG/NCS Incomplete release End-stage CTS: no salvageable nerve Coexistent systemic illness (diabetes, RA)
21 Proximal Median Neuropathies
22 Proximal Median Neuropathy More likely to be acute: Often a hx of specific trauma or compression Broader distribution of weakness Forearm pronation Wrist and finger flexion Orator s hand Circle sign Sensory: lateral fingers and palm
23 Median Nerve sensory impairment: arm lesion Aids to the examination of the peripheral nervous system, 4th edition 2000
24 Median: Axillary and Upper Arm Crutch compression Anterior shoulder dislocation Humerus fracture Stab wounds Hematoma Dialysis fistulas Sleep palsy
25 Median: Elbow/Forearm Elbow fracture, dislocation, and reduction Supracondylar Spur and Ligament Trauma Iatrogenic: Brachial artery catheterization Venipuncture Pronator Teres hypertrophy/overuse Fractures of radius or ulna
26 Focal Peripheral Neuropathies, 4 th Ed Supracondylar anatomy
27 Ulnar Neuropathy
28 Ulnar Neuropathy at the Elbow (UNE)
29 Ulnar Neuropathy at Elbow Nerve compression or injury at medial epicondyle or just distal in the cubital tunnel M:F approx 2:1
30 Ulnar groove and cubital tunnel Focal Peripheral Neuropathies, 4 th Ed. 2010
31 UNE: Etiology 1 Bony Deformity RA, OA Congenitial: valgus deformity or shallow groove Old fracture Trauma Fracture Dislocation Soft tissue injury
32 UNE: Etiology 2 External pressure: Single or multiple episodes Leaning on elbow at desk or driving Perioperative Critical illness/icu/prolonged hospitalization Repetitive or prolonged elbow flexion Causes compression in cubital tunnel Sleep: can mimic CTS hx Nerve prolapse over medial epicondyle
33 UNE: Etiology 3 Compression in cubital tunnel (FCU aponeurosis fibrosis) Others Diabetes mellitus Synovial cysts (in RA) Tumor/mass Fibrous band Leprosy Idiopathic
34 UNE: Hx Sensory sx in ulnar hand/fingers Caveat: Pain often more diffuse/non localized Aching at elbow Sensory sx wake from sleep or worse with arm use Hand/grip weakness
35 UNE: Sensory Exam Modalities Pinprick Light touch with examiner s fingers or cotton Distribution Anatomically medial hand Digit 5 Digit 4: medial aspect No sensory loss proximal to the wrist crease
36 UNE: Sensory Exam Tinel s sign: paresthesias in medial hand with tapping of ulnar nerve at the elbow Not sensitive Not specific Useful if negative on asymptomatic side
37 Ulnar neuropathy at elbow sensory distribution Aids to the examination of the peripheral nervous system, 4 th edition 2000
38 UNE: Motor Exam Inspect hand intrinsic muscles First dorsal interosseus (FDI) Abductor digiti minimi (ADM) Compare to median innervated APB Focused Strength exam Hand intrinsic muscles (ulnar vs median) Wrist flexor with medial deviation (ulnar FCU) Compare to wrist and/or finger extensors (Radial n) Triceps (Radial n)
39 Ulnar intrinsic muscle atrophy Focal Peripheral Neuropathies, 4 th Ed. 2010
40 UNE: Other Evaluate for ulnar nerve prolapse Palpate nerve in the condylar groove with arm straight Slowly flex elbow while palpating and note any shifting of the nerve over the medial epicondyle
41 UNE: EMG/NCS Goals: Confirm ulnar neuropathy Exclude radiculopathy Localize lesion Determine severity Sensitivity: 37-86% Specificity: > 95%
42 UNE: MRI Eval for osteophytes, lipomas, ganglia Increased T2 signal in ulnar nerve Enlargement of ulnar nerve
43 UNE: Management Natural history: Imperfect data Reports that 30-90% have improvement or complete recovery with non-surgical management In general surgical intervention is less successful than in CTS
44 UNE: Non-surgical Patient education Ergonomics Goals Avoid pressure on elbow Avoid prolonged elbow flexion
45 UNE: Non-surgical Ulnar nerve elbow pad Soft sports elbow pad Orthotics company OT fabricated Day use: padding over ulnar groove Night use depends on sleep position Padding over ulnar groove padding reversed to prevent elbow flexion
46 Ulnar nerve elbow pad 1 Focal Peripheral Neuropathies, 4 th Ed. 2010
47 Ulnar nerve elbow pad 2 Focal Peripheral Neuropathies, 4 th Ed. 2010
48 UNE: Non-surgical OT if hand weakness No clear utility of steroid injections Non-surgical mgt first Follow closely every 1-2 months MRI if decline Surgical exploration if significant progression
49 UNE: Surgical 1. Cubital tunnel decompression Slitting the flexor carpi ulnaris aponeurosis Choice for idiopathic 2. Anterior transposition Nerve relocated to anterior elbow surface For nerve prolapse 3. Medial epicondylectomy Removal of the bony prominence over which the nerve stretches with elbow flexion For nerve prolapse 4. Other: remove mass or bony abnormality
50 Ulnar Neuropathy: Axilla and Upper Arm
51 Ulnar Neuropathy: Proximal Uncommon External compression Crutches Sleep/intoxication/coma Anterior shoulder dislocation Humerus fracture Other trauma Dialysis fistula: ischemia
52 Ulnar Neuropathy at the wrist and hand
53 Ulnar neuropathy: wrist/hand Less common than CTS or UNE Sx Sensory at digit 5 and ulnar portion digit 4 Weakness of ulnar intrinsic hand muscles Majority caused by external pressure in palm Cyclists Hand tools Other: ganglia, synovial cysts (RA), lipoma
54 Ulnar neuropathy: wrist/hand Diagnostics EMG/NCS Localize lesion severity X Ray: arthritis or old fracture MRI: ganglia, lipomas U/S: ganglia, lipomas
55 Ulnar neuropathy: wrist/hand Management Avoid ongoing compression Surgical decompression of mass lesions
56 Radial Neuropathy
57 Radial Neuropathy Less common than either median or ulnar neuropathies No overuse syndrome No entrapment sites or tunnels Symptoms dependent on location of injury, typically traumatic or compressive
58 Radial nerve function Elbow extension Elbow flexion Wrist & digit extension Thumb abduction Sensation at dorsal arm/forearm/hand
59 Radial neuropathy: Axilla Etiology typically compressive/traumatic Crutch Intoxication/sedation/sleep Proximal humerus fracture Shoulder dislocation
60 Radial neuropathy: upper arm Humerus fracture Blunt trauma Compression: Intoxication/sedation/sleep Triceps spared Wrist & Finger drop Tourniquet
61 Radial neuropathy: elbow Affects the terminal branch of radial nerve: Posterior Interosseous Nerve Finger drop without wrist drop Trauma Radius head dislocation Radius fracture and fixation Mid-forearm radius or ulna fractures Soft tissue mass RA synovial cyst hypertrophy
62 Superficial Radial neuropathy Sensation to dorsolateral hand Compression Handcuffs Casts Watchband/bracelets Iatrogenic Surgical Venipuncture
63 Radial Neuropathy: Work up EMG/NCS Confirm vs C7 radiculopathy Lesion location Severity/prognosis X rays: Fractures/dislocations MRI: mass lesions
64 Radial Neuropathy: Mgt And Prognosis Sleep/Saturday night palsies Typically resolve in 6-8 weeks If axon loss: months to a year Prognosis: 90% full recovery Fractures/dislocations Prognosis overall 70-88% recovery rate If no evidence of recovery by 2-3 months (clinically/emg): surgical exploration
65 Distal Radial Neuropathy: Mgt And Prognosis Posterior Interosseous Neuropathy Traumatic: If no evidence of recovery by 2-3 months (clinically/emg): surgical exploration Spontaneous: EMG/NCS & MRI Superficial Radial Neuropathies Avoid compression (watches/bracelets) Laceration: surgical repair
66 Radial Neuropathy: Mgt Occupational Therapy Dorsal wrist cock-up with dynamic finger extension
67 EMG/NCS Why? Confirm clinical dx Assess severity Prognosis What? Nerve conduction testing Needle electrode exam
68 The Netter Collection of Medical Illustrations, Volume 1, Nervous System, 2002
69 EMG/NCS: key Operator dependent Study is customized to the diagnostic question Timing affects diagnostic sensitivity Immediate: not useful 3 weeks for axon loss to show (4-6 ideal) Uncomfortable Requires patient cooperation
70 EMG/NCS: limitations Intolerant patient Non-cooperative patient Obese Elderly Chronic lesions can reduce sensitivity for a new condition
71 EMG/NCS: How to order Be specific about the diagnostic question and limb to be studied (if localized) Yes Bilateral CTS Left arm: radiculopathy vs neuropathy Right leg radiculopathy Polyneuropathy No CTS 4 limbs: pain
72 EMG vs Neurology Consult Consult If results will likely trigger a consult Non-diabetic polyneuropathy Myopathy ALS EMG Comfortable managing the dx Pre-surgical cases
73 EMG/NCS: How to order Providence System For now Referral for EMG: limb/indication Don t put in an order too Coming soon! (they promise) New Epic order No referral needed Independent/Non-Providence Referral for EMG: limb/indication
74 EMG/NCS: Where to order PBSI Neurology St Vincent Providence Portland Vancouver: Esther Short Milwaukie Bridgeport Newberg PBSI Physiatry St Vincent Providence Portland
75
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