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Nerve Compression Syndromes. Gavin O’Mahony, MD. Objectives. To understand the cause and natural history of NCSs To understand the diagnosis and work up of NCSs To review operative and non-operative treatment modalities. Pathophysiology of Chronic Nerve Compression.

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nerve compression syndromes

Nerve Compression Syndromes

Gavin O’Mahony, MD

objectives
Objectives
  • To understand the cause and natural history of NCSs
  • To understand the diagnosis and work up of NCSs
  • To review operative and non-operative treatment modalities
pathophysiology of chronic nerve compression
Pathophysiology of Chronic Nerve Compression
  • Compression causes ischemic neuropathy
  • Continuum of neural changes depend on the force and duration of compression
slide4

Neural changes do not occur uniformly across the nerve

  • Vary depending on the distribution of compressive forces
  • Superficial fascicles undergo changes sooner
  • Result in varying patient symptoms within a single nerve distribution
  • Example: Early Carpal tunnel
  • Superficial fascicles to the long and ring fingers
  • More central fascicles to the thumb and radial side of
  • The index finger
systemic conditions and personal factors
Systemic Conditions and Personal Factors
  • Diabetes Mellitus
  • Hypothyroidism
  • Excessive alcohol use
  • Obesity
  • Tobacco use
  • Occupational Factors
  • Certain postures and positions may contribute to nerve compression
  • Positions of moderate flexion and extension increase pressure in the carpal tunnel
  • Elbow flexion increases pressure in cubital tunnel
  • Relationship accepted by workers compensation agencies
median nerve
Median nerve
  • Carpal Tunnel Syndrome
  • Pronator Syndrome
  • Anterior Interosseous Syndrome
carpal tunnel syndrome
Carpal Tunnel Syndrome
  • Compression of the Median n. at the wrist
  • Most common nerve compression in UE
  • Paresthesia, numbness or bothin the median nerve distribution
slide10

Aching in the thenar eminence

  • Weakness of APB and OP (Palmar abduction)
  • Clinical diagnosisbased on a combination of
  • Symptoms and characteristic physical findings
provocative tests
Provocative tests
  • Phalen’s test
slide14

Electrodiagnostic studies can be useful to confirm diagnosis in equivocal cases

  • NCS can also stage the degree of nerve degeneration
  • Limitations of NCS – it evaluates only large myelinated fibers
  • Includes motor axons and sensory axons relaying vibration and light touch
  • Does not include smaller axons conveying pain or temperature sensation
  • Does not detect dynamic changes in blood flow that produce intermittent alterations.
  • Dependent on expertise of the examiner
non operative treatment
Non-Operative treatment
  • Wrist splinting
  • Most prefabricated splints position the wrist in 30 degrees of extension
  • This increased carpal canal pressure
  • Wrist splints are most effective in neutral position – this makes it difficult to perform normal daily activity
  • Most providers recommend splinting only at night in neutral position
non operative treatment1
Non-Operative Treatment

Corticosteroid injections – temporary relief is an excellent prognostic factor for successful carpal tunnel surgery

Not indicated routinely – temporary relief with finite risk of nerve injury

Nerve gliding exercises - avoidance of surgery in up to 80% of patients with mild or moderate compression

Anaerobic exercise program – has been shown in one study to produce improvement in median nerve function

operative treatment
Operative treatment
  • Transverse carpal ligament release
  • Classic (standard) approach
  • Two-portal Endoscopic Technique
  • Single Portal Endoscopic Technique
  • Mini-open approach
pronator syndrome
Pronator Syndrome
  • Compression of the Median n. in the forearm
  • Between the 2 heads of the Pronator Teres
  • Much less common than CTS
  • Linked to repetitive upper extremity activity
slide19

Aching pain in the proximal volar forearm

  • Paresthesias radiating into the thumb, IF, MF and radial ½ of the RF
  • Similar to CTS
  • Palmar Cutaneous br. arises 4 cm above the wrist
  • Decreased sensation over the thenar eminence suggests a more proximal lesion
  • Provocative tests for CTS negative
provocative tests1
Provocative tests
  • Resisted forearm pronation
  • Resisted elbow flexion with forearm supinated
  • Resisted flexion of the MF FDS
  • Pressure over the leading edge of the pronator teres with the forearm in maximum supination and the wrist in neutral produces paresthesias in the median sensory distribution.
  • NCS usually negative – useful to exclude other sites of compression
treatment
Treatment
  • Surgery usually not necessary
  • Activity modification, rest
  • NSAIDS, Corticosteroids
  • Conservative management effective in 50-70%
  • Surgery if space-occupying lesion or if several-month course of nonsurgical treatment fails.
  • Surgery success rate 90%
slide22

X-ray of the distal humerus may show a supracondylar process

  • Compression by anomalous ligament of Struthers
anterior interosseous nerve syndrome
Anterior Interosseous Nerve Syndrome
  • Weakness or motor loss of:
  • Flexor Pollicis Longus
  • FDP to the IF (and occasionally the MF)
  • Pronator Quadratus
slide24

Weakness or motor loss usually occur spontaneously

  • Patient may describe clumsiness with fine motor skills such as writing and pinching.
  • AIN does not innervate the skin – no sensory loss
  • Pain may be present in the forearm along the course of the nerve
slide25

Electrodiagnostic studies are an important part of the workup

  • Can rule out more proximal lesions and distinguish AIN Syndrome from flexor tendon rupture
  • Nonsurgical treatment
  • Rest, splinting and observation for several months
  • Most improve without surgical intervention
  • Surgical decompression for patients who fail a several-month course of nonsurgical treatment
operative treatment1
Operative treatment
  • Decompression of the median nerve in the forearm is the same for pronator syndrome and compression of the AIN
  • All potential compressive sites are released
ulnar nerve
Ulnar Nerve
  • Cubital Tunnel Syndrome
  • Guyon’s Canal
cubital tunnel syndrome
Cubital Tunnel Syndrome
  • Second most common compression syndrome
  • Also a clinical diagnosis
  • Electrodiagnostic testing frequently negative – good for staging
  • Numbness in the ring and small finger
  • Aching in the medial aspect of the elbow and forearm
slide30

Tinel’s sign positive at or proximal to Cubital Tunnel

  • Elbow flexion test
  • Elbow flexion combined with digital pressure
non operative treatment2
Non-Operative treatment
  • Avoid positioning that combines elbow flexion with pressure over the ulnar nerve
  • Driving, phoning, during sleep
  • Nerve gliding exercises
  • Static night splinting in extension
  • Rigid splints often ineffective due to discomfort and noncompliance
  • 24 hour use of soft elbow pads to protect the ulnar nerve from direct compression
slide36

Mild Cuts can often be managed successfully with 2-4 months of non-operative treatment

  • If this is unsuccessful or if severe on presentation surgery is usually required
  • In Situ Decompression
  • Anterior Subcutaneous transposition
  • Anterior Subfascial/Submuscular transposition
  • Medial epicondylectomy
  • Outcomes tend to be less predictable than for Carpal tunnel
  • 75% with unilateral decompression report improvement
  • 68% with bilateral decompression report improvement
slide38

Nerve can be compressed:

  • Proximal to it’s bifurcation - motor and sensory deficits
  • Along the course of the deep motor branch – motor deficits only
  • Along superficial sensory branch – sensory deficits only
slide39

Often caused by space occupying lesion in the canal

  • Ganglions, thrombosis, pseudoaneurysms
  • Hamate hook nonunion
  • Anomalous muscles
  • Pre op imaging studies and electrodiagnostic studies are helpful
  • Non-operative treatment is recommended with acute cases of localized closed trauma
  • Wrist splint in neutral
radial nerve
Radial Nerve
  • SRN compression
  • PIN Syndrome
  • Radial Tunnel Syndrome
posterior i nterosseous nerve syndrome
Posterior Interosseous Nerve Syndrome
  • Muscles innervated by PIN are affected:
  • ECRB, Supinator, ECU, EDC, EDQ, EIP, APL, EPL, EPB
  • May occur after trauma or may have insidious onset
slide42

Present with dropped fingers and thumb

  • Even with complete PIN palsy function of the ECRL (wrist extension) is preserved
  • Partial lesions are more common
  • MRI may reveal a mass causing the compression – Lipoma, ganglia
  • Nerve conduction studies can be useful – EMG detects motor dysfunction
  • Therapeutic approach identical to RTS – same nerve affected
radial tunnel syndrome
Radial Tunnel Syndrome
  • Symptoms of pain and weakness after activities of forceful elbow extension and forearm pronation
  • Pain typically localizes to the lateral aspect of the forearm
  • Weakness is often secondary to the pain
  • May occur simultaneously with lateral epicondylitis
  • The tendinous origin of the ECRB can be involved in both conditions
slide44

Radial tunnel begins anterior to the radiocapitellar joint

  • Approximately 5cm in length
  • Formed laterally by the ECRL and BR
  • Medially by the biceps tendon and brachialis
  • Posteriorly by the radiocapitellar joint capsule
  • The BR passes over the nerve in a lateral to anterior

direction to form the roof

  • Ends at the arcade of Frohse
slide45

Clinical diagnosis

  • Most patients have normal NCS
  • Few objective tests to confirm the presence of RTS
  • Pain relief after administration of Lidocaine/corticosteroid adjacent to the PIN at the level of the proximal radius is useful in diagnosis
treatment1
Treatment
  • Nonsurgical management of both PIN syndrome and RTS is recommended initially
  • Rest, activity modification, splinting, stretching, anti-inflammatories
  • Nerve gliding exercises may be useful
  • In patients with concomitant lateral epicondylitis, tennis elbow straps are not recommended because of the increased pressure on the radial nerve
  • Surgical decompression after trial of

non-operative management

controversy
Controversy
  • Generally described as a nerve compression and entrapment syndrome
  • Dispute over etiology
  • Prominent focal tenderness
  • Normal neurologic function
  • No confirmatory electrodiagnostic evidence
  • Symptoms do not occur in the distribution of the affected nerve
superficial radial nerve compression aka wartenberg s syndrome
Superficial Radial Nerve Compressionaka Wartenberg’s Syndrome
  • Paresthesia, pain or numbness in the radial sensory nerve distribution
slide49

Symptoms are reproduced by forearm pronation and ulnar wrist deviation

  • Tinel sign over the radial sensory nerve at the point where it exits the deep fascia in the forearm
  • Nerve conduction studies rarely useful
t reatment
Treatment
  • Modify activities to maintain a more supinated position wherever possible
  • Avoidance of excessive pronosupination
  • Local corticosteroid injection at the entrapment site between tendons of BR and ECRB are often successful.
  • Splinting not usually recommended
  • SRN decompression if non-operative treatment unsuccessful