Compression

Neuropathies of the
Upper Limb
Presenter- Dr Zerihun (PSR-3)
Moderator- Dr Hellina (Plastic and Reconstructive Surgeon)
ALERT HOSPITAL
• The blood-nerve barrier (BNB) is a dynamic interface between the
endoneurial microenvironment and surrounding extracellular space or
blood contents, and is localized the innermost layer of multilayered
ensheathing perineurium and endoneurial microvessels
• Bumping the elbow, Crossing legs
• If a nerve is subjected to increased pressure for a relatively short
time, there is a sudden loss of blood flow in the nerve.
• Paresthesia
• Motor fibers - this causes sudden loss of a motor function

• Pain is usually not a component of a chronic nerve compression

syndrome;
• Peripheral nerve to loose its ability to glide in response to movement
of adjacent joints, the nerve may become entrapped
• Controversy-
• Systemic disease that can have an associated peripheral neuropathy, such as diabetes, thyroid
dysfunction, collagen vascular disease, alcoholism, or lead poisoning.
• Symptoms fit with a nerve compression syndrome but whose traditional electrodiagnostic study
findings are interpreted as being "normal.“,
• Double Crush syndrome
• Greater than 20% is placed on the diameter -acute axonal
degeneration
• Gradual period and over a length of the peripheral - After about 2
months of compression -------first pathophysiologic changes become
evident.
• Weakening of the tight junctions of the endothelial cells in the
perineurium, and
• Serum enters the endoneurial space ….. endoneurial edema.--
• Increase in interstitial pressure that decreases blood flow.
• Conscious perception of this phenomenon is a paresthesia.
• Elevated sensory threshold
• Monofilament tests or tests for static two point discrimination with the
Pressure-Specified Sensory Device (PSSD)
• Change in perception of vibratory stimuli applied with a tuning fork or a
vibrometer
• 6 months of this degree of compression-----20%
• thinning of the myelin.
• Increasing loss of myelin,
• Microscopic sections are stained for myelin, there is an apparent loss of the
large myelinated touch fibers.
• Electron microscopy -have not yet begun to degenerate as the now
• Unmyelinated large fibers - weakness in the muscles, increasing numbness in
the cutaneous territory (fingers) supplied by that nerve,
• No atrophy,
• One-point static touch, Two point discrimination
• Electrodiagnostic testing may begin to detect increases in the distal
sensory latency.
• Amplitudes will still be normal
• Time or the degree of compression increases
• Muscle wasting and in the sensory system
• Static two-point discrimination and then for moving two-point discrimination.
• Then one-point static touch – relatively
• Vibrometry
NUMERICAL GRADING SCALE FOR ANY PERIPHERAL NERVE

• Grade Description
• 0 Normal
• 1 Intermittent sensory symptoms
• 2 Increased sensorimotor threshold
• 3 Increased sensorimotor threshold
• 4 Increased sensorimotor threshold
• 5 Persistent sensory symptoms
• 6 Sensorimotor degeneration
• 7 Sensorimotor degeneration
• 8 Sensorimotor degeneration
• 9 Anesthesia
• 10 Muscle atrophy, severe
Double Crush Syndrome
• Upton and McComas19 in 1973
• Suggested that a proximal site of nerve compression might predispose the
peripheral nerve to a second distal site of compression
• Eg- Shoulder strengthening exercises to treat brachial plexus compression
should be combined with splinting for carpal tunnel syndrome or nighttime
splinting of the elbow so that it does not flex beyond 30 degrees.

• Most distal nerve compression should be decompressed first;

• often the site of the more severe compression
• fewest complications
Nerve conduction
studies (NCS) and electromyography
(EMG)
• Painful and expensive
• High false-negative rate,
•
Quantitative sensory testing
• Cooperative and alert
• Subjective
• Most sensitive method to determine whether the innervation of a
piece of skin is abnormal
• QST cannot localize
• Eg- median nerve at the wrist- -the C6 nerve root--opposite cerebral cortex
NCS and EMG
• Identify the source of the nerve problem
• More specific than QST
• Significant demyelination for there to be a decrease in conduction
velocity or distal latency and
• Significant loss of axons before there can be a decrease in amplitude;
TREATMENT OF NERVE COMPRESSION DISORDERS

• On the day after construction of a new fence –Rest

• Carpal tunnel syndrome has severe wasting --Tendon transfer
• Cortisone injections
• Nonoperative management
• Appropriate splinting,
• Modification of activities of daily life
• Control of all medical problems (e.g., diabetes, thyroid dysfunction, collagen
vascular disease, and alcoholism),
• Persistent numbness, muscle wasting, or loss of two-point
discrimination - Surgical decompression
Principles Surgery
• Bloodless,
• Indicating that a pneumatic tourniquet is used whenever possible
• Loupe magnification.
• Experience with the operative microscope.

• Bipolar coagulator should be used.

• Intraoperative electrical stimulation
• Microsurgical instruments
• Neurolysis implies that the nerve itself is surgically separated from
the surrounding (scar) tissues
• Decompression
• External neurolysis vs internal
• Small communicating branch may result in causalgia.
• The next danger from internal neurolysis is damage to the longitudinal,
intrinsic blood supply of the peripheral nerve.
• Internal neurolysis should not be done routinely.
• First week after surgery, 1-week period of rest before collagen
deposition and cross-linking begin
 Median nerve
Initially lateral to
the brachial artery
Superficial layer – pronator
teres, flexor carpi radialis
and palmaris longus.
Intermediate layer -FDS
Deep layer – FPL, pronator
quadratus, and the lateral
half of the FDP
Carpal tunnel syndrome (CTS)
• Refers to the complex of symptoms and signs brought on by
compression of the median nerve as it travels through the carpal
tunnel in the wrist.
• Patients commonly experience pain, paresthesia, and, less
commonly, weakness in the median nerve distribution.
• Most common compressive focal mononeuropathy seen in clinical
practice.
• 4% and 5% worldwide,
• 40 and 60 years

• Variations - bifid median nerve resulting from the high division is

noted in 1% to 3.3%
Motor branch=
Extraligamentous -46%
Subligamentous 31%,
Transligamentous form takes 23%
PCBMN
• Originated from the volar- radial surface of the nerve in 92.6% of
cases,
• Distal wrist crease was 4.5 cm
• Incisions for carpal tunnel release
• 0.4 cm medial to and 1.8 cm lateral to the PL are at risk
• At least 0.5 cm ulnar to the PL.
Risk factors

• Excesses of wrist flexion or extension, monotonous use of the flexor

muscles, and exposure to vibration
• Pressure vary between 2 mmHg and 10 mmHg
• Extrinsic- pregnancy, menopause, obesity, kidney failure,
hypothyroidism, use of oral contraceptives, and congestive heart
failure
• Intrinsic- lumps and tumor-like strains, fractures of the distal radius,
directly or through posttraumatic arthritis
• Neuropathic - include conditions such as diabetes, alcoholism,
vitamin deficiency or toxicity, and exposure to toxins.
Stages
• 1- Wake up from sleep feeling numbness or swelling on the hand,
with no noticeable swelling, spreading to the shoulder, with a tingling
in the hand and fingers
• 2- The occurrence of symptoms, which occur in the day, specific
position for extended periods, clumsiness when using their hands to
grip objects, causing them to fall.
• 3- Atrophy of the thenar eminence
Diagnosis
• Phalen’s maneuver
• Tinel’s sign,
• Manual Carpal compression test

• Monofilament testing, vibration, as well as two-point discrimination

• Katz Hand Diagram sensitivity of a classic or probable diagram ranges

from 64% to 80%, while the specificity ranges from 73% to 90%
Management
• Mild- splinting, corticosteroids, physical therapy, therapeutic
ultrasound,-3 mt – 80 % improve- 80 % recur in 1 yr
• Reversible risk factors, such as pregnancy

• Oral provision of prednisone at a 20 mg daily

• Surgical decompression
• Severe CTS or nerve injury electro-diagnostic
• Symptoms persist
Open approach

• Permits sufficient time for intraoperative exposure to obtain biopsy

samples of synovium if necessary
• Internal neurolysis if necessary
PROXIMAL MEDIAN NERVE COMPRESSION IN THE FOREARM AND
ELBOW REGION
Pronator teres
• 66% arises from unequal two heads:
• The larger humeral head -medial
epicondyle and
• Coronoid process of the ulna

• Absence of the ulnar head is rare

(14%)
• Under the muscle (26%)
• Anterior interosseous nerve (AIN) then
branches from the MN about 5 to 8
cm distal to the medial epicondyle
Struther’s Ligament
• Ligament running from medial
epicondyle to a bony spur on a
distal medial humerus, - in 1-2 %
• High origin of the pronator
teres, which occurs in 17%
 Pronator syndrome Etiology
• Prolonged hammering, ladling food, cleaning dishes, tennis) may
cause PT muscle hypertrophy

• local trauma, compression with Schwanomma,

• Anticoagulation therapy and renal dialysis.
• Tight lacertus fibrosis
Signs
• Aggravated by resisted pronation and flexion,
• Positive Tinel sign over the proximal edge of PT
• Sensory loss is variable,
• involving the palm of the hand or mimic that of carpal tunnel syndrome,
including the thenar eminence, thumb, index, middle, and ring fingers.
• Mild weakness of flexor pollicis longus (FPL) and abductor pollicis
brevis (APB)
• Flexor digitorum profundus (FDP) to digits 2 and 3 and opponens
pollicis (OP)
Ixs
• NCS- seldom show abnormalities
• To rule out other neuropathies
• Electromyography (EMG) abnormalities occur in FPL and FDP to digits
2 and 3, less often in the FDS and APB- 10%

• US- cross-sectional area of MN positively correlates with severity

• 8 weeks of rest, modification of activities that exacerbate the
symptoms, physical and occupational therapy, NSAIDS, and local
injections with corticosteroids
• Surgery if- objective findings in a physical examination of weakness
or motor atrophy, and has abnormal electrodiagnostic studies
• Release of PT muscle as well as all other compressive structures –
ligament of Struthers, lacertus fibrosis, and/or fascia of FDS
• Endoscopic release -
• Does not compromise the nerve's blood supply, reduces scar formation
• recurrence- Open
DDX
• Ligament of Struthers entrapment - paresthesias in the median-
innervated digits is exacerbated by supination of the forearm and
extension of the elbow (versus pronation in PTS

• MN entrapment by hypertrophied lacertus fibrosis - resisted flexion of

the elbow with the forearm in supination

• MN compression by the sublimus bridge of the FDS- resisted flexion

of the PIP joint of the MF while other fingers are held in extension
Carpal Tunnel syndrome(CTS) AIN Syndrome
• Sensation is spared over the • No sensory loss
thenar eminence • Pronation weakness while elbow flexed,
PQ
• Pronation is spared • FPL and FDP to digits 2 and 3 may be
• Nocturnal paresthesia affected
• Surgery – Persistent symptom>12 mts
Pronator syndrome Brachial plexus neuropathy

• Distal motor and sensory

latencies- normal • Sites other than median nerve
territory
• Abnormal at elbow, except when
there is associated CTS
• Surgery- persistent symptoms for
>6 months
Surgery
• Regardless of the clinical presentation,
• Decompress the entire length of the median nerve from the elbow to the
distal forearm, including the lacertus fibrosus, the deep head of the pronator
teres, and the FDS arch

• Taking down of this abnormally positioned head

• If symptoms persist, decompression of the brachial plexus

Ulnar Nerve
• Muscular branch of the ulnar nerve to the forearm muscles arose at
the proximal 1/3 of the forearm
• FCU and medial half of the FDP
Cubital tunnel syndrome
• Paresthesias are often exacerbated by elbow flexion
• Phone use or athletic activities
• Sleep with the elbow in a flexed
• Weak or clumsy hand, weakness affecting the ring or small finger, or
muscle wasting, clawing-----opening jars or holding a pencil
• PE- first dorsal interosseous (FDI), distal interphalangeal (DIP) joint,
FCU, Adductor Pollicis(Froment’s Positive when Thumb IP flexion), 3rd
palmar interosseous(Wartenberg’s sn) and small finger lumbrical
muscles
• Provocative tests- Tinel's sign and elbow flexion test, wrist flexion

• .Ix- Decreased compound muscle action potential (CMAP) of the FDI

muscle could indicate bad prognosis
Management
• Behavior modification, night splints, elbow pads,
• NSAIDs,, and corticosteroid injections- controversial
• 80 % success for mild presentation
• Decompression of the nerve alone, decompression with ulnar nerve
anterior transposition (subcutaneous, submuscular, or intramuscular),
or medial epicondylectomy
• Only the musculofascial lengthening procedure reduced pressure on
the ulnar nerve in all ranges of motion of the elbow
Guyon canal compression Cubital tunnel
• Uncommon • Grip if only severe
• Trauma to the wrist
• Post-traumatic aneurysm of the
ulnar artery
• Sports-related, cycle handle bar
• Extra muscles.
• Normal dorsal cutaneous branch
of the ulnar nerve, Pinch
Radial nerve entrapment in the
forearm
• Pronated position for extended periods, as in typing
• Pinched between the tendons of the brachioradialis and the extensor
carpi radialis longus
• Conservative- Maintain the arms in a supinated position
• Finkelstein sign- Quervain tenosynovitis
• Incision is made over the site of
the Tinel sign in the radial
forearm
PIN compression Radial tunnel syndrome
• All branches of the radial nerve • Will not have the degree of
distal to the branch to the motor weakness that is present
extensor carpi radialis longus with the PIN
• Incision- Muscle-splitting • Resisted MF extension because
incision centered over the radial this activates that fibrous edge
head of ECRB against the radial nerve
• Scarring joining the biceps to the
brachioradialis muscle
Brachial plexus compression
• Cervical rib,
• Bands from C7 to the first rib,
• Anomalous passage for scalene muscles between the plexus,
• Presence of the subclavian artery above the clavicle,
• Accessory muscles
• Fibrous edge of the pleura crossing T1 (Sibson fascia
• Sxs - When the arm is placed overhead
References
• Mathes_ Hand and upper limb 2 nd edition Figure 196-19 Page 966
• Mathes_ Hand and upper limb 2 nd edition Table 196-3
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intraoperative findings: A case report, 2016 Feb 20, PubMed Central
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PubMed Central
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