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Compression Neuropathies
Compression Neuropathies Andrew Martin DO, MBA, CAQSM OMED 2013 Compression Neuropathies • Carpal Tunnel Syndrome • Cubital Tunnel Syndrome • • • • • • • • • 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 Objectives • Upper Extremity Compression Neuropathies • Lower Extremity Compression Neuropathies • Ultrasound and Compression Neuropathies Pathophysiology Pathophysiology Vasa Nervorum Nerve Axons ≠ Action Potentials Pathophysiology Compression Neuropraxia Axonotemisis Seddon Classification of Peripheral Nerve Damage 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 Etiology • • • Posterolateral Disc Herniation Facet Degeneration C7 > C6 > C8 Cervical Radiculopathy Signs and Symptoms • • • Pain, Paresthesia, and Weakness Atrophy Reflex Sympathetic Dystrophy Cervical Radiculopathy Evaluation • • • Sensory, Muscle, and Reflex testing Spurling Test MRI Cervical Radiculopathy Axial View T2 Weighted Spinal Accessory Nerve Compression Etiology Posterior Triangle • • Equipment (backpacks/shoulder pads) Blows to the Shoulder Spinal Accessory Nerve Compression Signs and Symptoms • • • • Shoulder Syndrome Pain over trapezius, heaviness Abnormal Scapular Rotation Adhesive Capsulitis Spinal Accessory Nerve Compression Evaluation • • • Test Trapezius Test Sternocleidomastoid Abnormal Scapular Rotation Suprascapular Nerve Syndrome Etiology • • • • Suprascapular notch Spinoglenoid notch Thickened Transverse Scapular Ligament Extrinsic compression by a spaceoccupying lesion (ganglion cysts or soft tissue tumor) Suprascapular Nerve Syndrome Signs and Symptoms • • Poorly localized pain and discomfort at the back of the shoulder Weakness when raising the arm. 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 Coronal postcontrast T1 image 28-year-old patient High Grade Sarcoma with MRI appearances indicating a right suprascapular nerve entrapment Axillary Nerve Compression Quadrilateral Space Syndrome Etiology • • • • • 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 Axillary Nerve Quadrilateral Space Syndrome Signs and Symptoms • • • 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 Axillary Nerve Compression Quadrilateral 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 Nerve Quadrilateral Space Syndrome Oblique Sagittal T2-fat saturated Oblique Sagittal T1-weighted Severe fatty atrophy of the teres minor muscle Radial Nerve Compression Etiology • • • Spiral Groove of the Humerus Radial Tunnel First Dorsal Wrist Compartment Radial Nerve Compression Spiral Groove Syndrome Etiology • • • Saturday Night Palsy Humerus Fractures Deep puncture wounds Radial Nerve Compression Spiral Groove Syndrome Signs and Symptoms • • • • Triceps Weakness Wrist drop Patient unable to extend wrist or fingers Arm/Forearm/Hand/ Numbness Posterior Interosseous Nerve Compression (Radial Tunnel Syndrome) Etiology • • • • • • 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 Posterior Interosseous Nerve Compression Radial Tunnel Syndrome Signs and Symptoms • • Tenderness more over the Arcade of Frohse • No Sensory Deficits Painless weakness of the wrist and finger extensors 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 Compression Wartenberg's Syndrome Etiology • • Compression of the superficial branch radial nerve (SRN) Compressed by scissoring action of Brachioradialis and Extensor Carpi Radialis Longus Tendons during forearm pronation. Superficial Branch Radial Nerve Compression Wartenberg's Syndrome Signs and Symptoms • • • Ill-defined pain and Paresthesia over dorsoradial hand Aggravation by motions involving repetitive wrist flexion, ulnar deviation and pronation No motor weakness Ulnar Nerve Compression Etiology • • Cubital Tunnel Guyon’s Canal Ulnar Nerve Compression Cubital Tunnel Syndrome Etiology • • • • 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. Ulnar Nerve Compression Cubital Tunnel Syndrome Signs and Symptoms • • Sensory abnormality of the ulnar hand Weakness of the flexor carpi muscle group of the 4th and 5th fingers Ulnar Nerve Compression Cubital 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 Compression Guyon’s Canal Syndrome Etiology • • • • • 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 Level of the Pisiform Space-occupying lesions Trauma Ulnar artery aneurysms. Level of the Hamate Ulnar Nerve Compression Guyon’s Canal Syndrome Signs and Symptoms • • • Motor and sensory findings Depends of position of bifurcation to the superficial (sensory) and deep (motor) branches Types I, II, III Ulnar Nerve Compression Guyon’s Canal Syndrome Axial T1 - weighted Axial T2 fat-saturated 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 Compression Guyon’s Canal Syndrome MR Angiography Using Sensitivity Encoding (SENSE) Median Nerve Compression Etiology • • • Pronator Teres Flexor Digitorum Superficialis Carpal Tunnel Median Nerve Compression Pronator Syndrome Etiology • • • • Between the ulnar and humeral heads of the pronator teres muscle Trauma Congenital abnormalities Pronator teres hypertrophy Median Nerve Compression Pronator Syndrome Signs and Symptoms • Pain and numbness of the volar aspect of the elbow, forearm, and wrist Median Nerve Compression Anterior Interosseous Syndrome Etiology • • • Entrapment of the Anterior Interosseous Nerve in the proximal forearm by the Flexor Digitorum Superficialis Direct nerve trauma Compression from a hematoma or mass Median Nerve Compression Anterior Interosseous Syndrome Signs and Symptoms • • • • Patients may present clinically with pain and muscle weakness in the volar forearm Flexor digitorum profundus Flexor pollicis longus Pronator quadratus Median Nerve Compression Carpal Tunnel Syndrome Etiology • • • • Most common cause of compressive/entrapment neuropathy Repetitive trauma Conditions related to metabolic and hormonal changes Ganglion cysts Median Nerve Compression Carpal Tunnel Syndrome Signs and Symptoms • • Burning wrist pain Paresthesia or numbness in the 1st through 3rd fingers, and the radial aspect of the 4th finger. 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 Etiology • • • • • 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 Sciatic Nerve Compression Signs and Symptoms • • Pain, weakness, parasthesia, or numbness in the leg. Clinical presentations are based upon the level of injury 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. Common Peroneal Nerve Compression Etiology • • • • • 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 Common Peroneal Nerve Compression Signs and Symptoms • • Experience paresthesia and pain at the site of entrapment with foot drop Slapping gait Common Peroneal Nerve Compression MCG Emergency Department Common Peroneal Nerve Compression MCG Emergency Department Common Peroneal Nerve Compression Sagittal T2-weighted fat-saturated Sagittal 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 Compression Tarsal Tunnel Syndrome Etiology • • • • • Formed by the flexor retinaculum medial malleolus and calaneous Posttraumatic fibrosis due to fracture Tenosynovitis / Bursitis Space-occupying lesions Dilated or tortuous veins Tibial Nerve Compression Tarsal Tunnel Syndrome Signs and Symptoms • Burning pain and paresthesia along the plantar foot and toes 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 Compression Morton’s Neuroma Etiology • • • 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 Interdigital Nerve Compression Morton Neuroma Signs and Symptoms • • • Standing on a pebble in your shoe A burning pain in the ball of the foot Paresthesia or numbness in the toes 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 Nerve Carpal Tunnel Hydrodisection of Median Nerve Carpal Tunnel Annual Meeting 2014
