Saturday, October 11, 2008
Sensory nerve injuries after uterosacral lig suspension
Flynn MK et al. AJOG 2006;195: 1869-72. The procedure is done to suspend the prolapsed vaginal apex. 7 of 182 women reviewed developed buttock/posterior thigh pain to the popliteal fossa. 3 women had removal of the suture within 2 days resulting in immediate improvement of the pain and the other 4 were treated conservatively with gradual resolution of the pain. In some of the women, pelvic exam showed exacerbation of the pain pulling on the suture. This is the posterior femoral cutaneous nerve that arises from S2-3 roots.
Sunday, September 7, 2008
Ulnar neuropathy pearls
Most distal muscle of ulnar nerve is adductor pollicis reached at the first free web space between the thumb and forefinger. It adducts the thumb. Unlike abductor digiti minimi itmay be involved in lesions of Guyon's canal. Like ADM its involved in other ulnar entrapments (cubital tunnel, tardy ulnar palsy, cervical rib).
Klumpke's paralysis (avulsion of C8 T1 roots) will involve these plus abductor pollicis brevis (APB median C8 T1).
The FDI may occassionally get innervation from the median nerve / musculocutaneous nerve
Tuesday, August 19, 2008
Thoracic Outlet Syndromes
True TOS is a clear syndrome with weakness and sensory loss in the arm and hand usually caused by a fibrous band over which the lower trunk of the brachial plexus is stretched and angulated. It may coexist with a small rudimentary cervical rib.
Arterial TOS involves ischemia or even emboli in fingers and hands from a cervical rib causing stenosis and poststenotic dilatation of the subclavian artery. This type is more common in athletes.
Venous TOS is an acute or chronic syndrome with swelling of the arm due to stenosis or thrombotic occlusion of the subclavian vein.
Disputed (or nonspecific nonneurologic) TOS are chronic aching and pains or paresthesias in arms and shoulders with no findings. This is a large group, but neurologic signs are "either nonexistent or meager."
Posttraumatic TOS asociated with clavicular fracture and associated brachial plexopathy see separate article.
Clinical presentations
True TOS young to middle aged women develop paresthesias , pain and weakness on the ulnar border of the hand, rarely much pain, and no vascular symptoms. Per Thomas Swift they may have hand,arm, shoulder and neck pain. They have low set shoulders, long graceful "swan" necks and horizontal or downsloping clavicles. Muscle wasting resembles CTS with wasted APB but usually some ulnar innervated muscles waste as well. Sensory loss does not split the fourth digit. There is often weakness of the forearm flexors. The differential is median and ulnar neuropathy, lower trunk plexus lesion, radiculopathy. CT and MRI usually miss the fibrous band but may show other causes of plexus lesion. Plain films show characteristic bony abnormality most of the time. Treatment is supraclavicular exploration with division of the band.
Notes-- Adson;s test is valueless, because 11-80 % healthy controls obliterate radial pulse by holding hand above head. Other similarly useless tests are photoplethysmographic studies of blood flow in the fingers following Adson's test, the elevated arms stress test (east) with the arm abducted to 90 degrees, the elbow flexed and braced, the fist opened and closed for several minutes. Bruits are of no significance in the subclavian fossa. Arteriography and dopplers are useless. In contrast, there may be a Tinel's in the fourth and fifth fingers tapping the brachial plexus, and symptoms may be exacerbated pulling arm down to ground and relieved by pushing up (again from Swift). Patients are better when lying down (contrast to CTS) and by using armrests.
Plain films may show upper 3-4 thoracic vertebrae due to shoulders. OBLIQUE CERVICAL SPINE FILMS WILL SHOW CERVICAL RIBS IF THEY ARE PRESENT! Symptoms are usually unilateral but cervical rib may be bilateral, usually C 7 also occassionally C 6. The cervical rib has a one percent prevalence, again not all symptomatic. The fibrous band extending off the rib technically compresses the C8 and T1 roots.
The best treatment of nonspecific neurologic TOS may involve posture correction, stretching and strengthening exercises (of rhomboids, levator and trapezius, the shoulder elevators), and an orthosis designed to elevate the shoulder. Operate if a band is present it will help.
The association of TOS in musicians is debated by Stewart
Arterial TOS involves ischemia or even emboli in fingers and hands from a cervical rib causing stenosis and poststenotic dilatation of the subclavian artery. This type is more common in athletes.
Venous TOS is an acute or chronic syndrome with swelling of the arm due to stenosis or thrombotic occlusion of the subclavian vein.
Disputed (or nonspecific nonneurologic) TOS are chronic aching and pains or paresthesias in arms and shoulders with no findings. This is a large group, but neurologic signs are "either nonexistent or meager."
Posttraumatic TOS asociated with clavicular fracture and associated brachial plexopathy see separate article.
Clinical presentations
True TOS young to middle aged women develop paresthesias , pain and weakness on the ulnar border of the hand, rarely much pain, and no vascular symptoms. Per Thomas Swift they may have hand,arm, shoulder and neck pain. They have low set shoulders, long graceful "swan" necks and horizontal or downsloping clavicles. Muscle wasting resembles CTS with wasted APB but usually some ulnar innervated muscles waste as well. Sensory loss does not split the fourth digit. There is often weakness of the forearm flexors. The differential is median and ulnar neuropathy, lower trunk plexus lesion, radiculopathy. CT and MRI usually miss the fibrous band but may show other causes of plexus lesion. Plain films show characteristic bony abnormality most of the time. Treatment is supraclavicular exploration with division of the band.
Notes-- Adson;s test is valueless, because 11-80 % healthy controls obliterate radial pulse by holding hand above head. Other similarly useless tests are photoplethysmographic studies of blood flow in the fingers following Adson's test, the elevated arms stress test (east) with the arm abducted to 90 degrees, the elbow flexed and braced, the fist opened and closed for several minutes. Bruits are of no significance in the subclavian fossa. Arteriography and dopplers are useless. In contrast, there may be a Tinel's in the fourth and fifth fingers tapping the brachial plexus, and symptoms may be exacerbated pulling arm down to ground and relieved by pushing up (again from Swift). Patients are better when lying down (contrast to CTS) and by using armrests.
Plain films may show upper 3-4 thoracic vertebrae due to shoulders. OBLIQUE CERVICAL SPINE FILMS WILL SHOW CERVICAL RIBS IF THEY ARE PRESENT! Symptoms are usually unilateral but cervical rib may be bilateral, usually C 7 also occassionally C 6. The cervical rib has a one percent prevalence, again not all symptomatic. The fibrous band extending off the rib technically compresses the C8 and T1 roots.
The best treatment of nonspecific neurologic TOS may involve posture correction, stretching and strengthening exercises (of rhomboids, levator and trapezius, the shoulder elevators), and an orthosis designed to elevate the shoulder. Operate if a band is present it will help.
The association of TOS in musicians is debated by Stewart
Brachial plexitis causes and differential and foils
Avulsions occur with traction injuries and may be overlooked in patients with multi-trauma.
Clavicle fractures can injure the plexus through bone fragments or hematomas, scar tissue (in a healed fracture) or development of a subclavian pseudoaneurysm.
Stingers and burners (See separate post http://emgnotes.blogspot.com/2007/04/traunmatic-neuropathy-stingers.html ). Compression of the upper brachial plexus may occur between the shoulder pad and upper medial scapula and may be prevented with an orthosis (Markey et al, 1993, Am J Sports Med). Lesion can also be in the ventral rami, cord, roots or cervical cord but in professional players is more likely to be spinal stenosis .
Intraoperative plexopathy of brachial plexus can be due to hyperabduction of the relaxed arm, plexitis (autoimmune) following surgery, during median sternotomy such as CABG (5-7 % of time) which can mimic an ulnar neuropathy, with variable locale and severity. It can occur with traction on the plexus during wide sternotomy, during jugular cannulation, and is tenfold higher when the internal mammary artery is used for bypass grafting. Forceful traction can also fracture the first rib that then can cause plexopathy. Upper trunk damage can occur if the patient is held head down and the arm is abducted simultaneously.
Acute compression occurs with coma, or carrying heavy backpacks causing a bilateral syndrome especially affecting serratia anterior.
Hematomas during axillary angiograms can cause blood leak at edge of pectoralis muscle and recovery IF blood is removed rapidly. False aneurysms can occur years after trauma to plexus, median or radial nerve.
Newborns do not have a falling incidence of brachial plexus injury (0.05-0.3 % births) with Erb's being most common (weak shoulder abduction and elbow flexion), Klumpke's less common.
Malignant plexopathy is most often due to cancer of lung, breast, or lymphoma, rarely early except in the Pancoast tumor syndrome. It usually presents with shoulder pain radiating down the arm (medial most often) followed by paresthesias and weakness. The differential includes radiation plexopathy, intraoperative plexus trauma, and unrelated brachial plexitis.
Pancoast syndrome due to tumor at apex of the lung causes pain down inner arm with two thirds developing Horner's syndrome, and one third, weakness and sensory changes in lower trunk distribution.
Primary tumors of brachial plexus include neurofibromas (often/usually plexiform) with pain, supraclavicular mass, and mild neurologic deficit. Schwannomas with "dumbbell" lesions and sensory symptoms withouu deficit. Intraneural perineurioma (or localized hypertrophic neuropathy) presents with slowly progressive upper limb deficits. Malignant nerve tumors are rare.
Radiation plexitis can occur within 26 years of radiation of the plexus and presents with sensory and motor signs and swelling. Horner's occurs less frequently than in malignant plexitis but it can happen. Radiation is commonly, but not universally thought to be more likely to affect the upper trunk. It may be relentlessly progressive and lead to a useless arm. Occassionally it may stop or respond to PT or OT.
Radiation can also cause malignant nerve sheath tumors with painful enlarging mass and dysfunction. Ischemic plexitis can occur due to radiation induced segmental occlusion of the subclavian artery.
Thoracic outlet syndromes are discussed in another post.
Parsonage-Turner syndrome causes pain then weakness. It may mimic a shoulder joint lesion.
Hereditary neuropathy with liability to pressure palsies (HNPP) often affects the brachial plexus.
Patients with plexitis due to diabates have a subacute onset and good recovery. Plexitis in heroin addicted patients has less severe pain, and involvement of the lower part of the plexus.
Clavicle fractures can injure the plexus through bone fragments or hematomas, scar tissue (in a healed fracture) or development of a subclavian pseudoaneurysm.
Stingers and burners (See separate post http://emgnotes.blogspot.com/2007/04/traunmatic-neuropathy-stingers.html ). Compression of the upper brachial plexus may occur between the shoulder pad and upper medial scapula and may be prevented with an orthosis (Markey et al, 1993, Am J Sports Med). Lesion can also be in the ventral rami, cord, roots or cervical cord but in professional players is more likely to be spinal stenosis .
Intraoperative plexopathy of brachial plexus can be due to hyperabduction of the relaxed arm, plexitis (autoimmune) following surgery, during median sternotomy such as CABG (5-7 % of time) which can mimic an ulnar neuropathy, with variable locale and severity. It can occur with traction on the plexus during wide sternotomy, during jugular cannulation, and is tenfold higher when the internal mammary artery is used for bypass grafting. Forceful traction can also fracture the first rib that then can cause plexopathy. Upper trunk damage can occur if the patient is held head down and the arm is abducted simultaneously.
Acute compression occurs with coma, or carrying heavy backpacks causing a bilateral syndrome especially affecting serratia anterior.
Hematomas during axillary angiograms can cause blood leak at edge of pectoralis muscle and recovery IF blood is removed rapidly. False aneurysms can occur years after trauma to plexus, median or radial nerve.
Newborns do not have a falling incidence of brachial plexus injury (0.05-0.3 % births) with Erb's being most common (weak shoulder abduction and elbow flexion), Klumpke's less common.
Malignant plexopathy is most often due to cancer of lung, breast, or lymphoma, rarely early except in the Pancoast tumor syndrome. It usually presents with shoulder pain radiating down the arm (medial most often) followed by paresthesias and weakness. The differential includes radiation plexopathy, intraoperative plexus trauma, and unrelated brachial plexitis.
Pancoast syndrome due to tumor at apex of the lung causes pain down inner arm with two thirds developing Horner's syndrome, and one third, weakness and sensory changes in lower trunk distribution.
Primary tumors of brachial plexus include neurofibromas (often/usually plexiform) with pain, supraclavicular mass, and mild neurologic deficit. Schwannomas with "dumbbell" lesions and sensory symptoms withouu deficit. Intraneural perineurioma (or localized hypertrophic neuropathy) presents with slowly progressive upper limb deficits. Malignant nerve tumors are rare.
Radiation plexitis can occur within 26 years of radiation of the plexus and presents with sensory and motor signs and swelling. Horner's occurs less frequently than in malignant plexitis but it can happen. Radiation is commonly, but not universally thought to be more likely to affect the upper trunk. It may be relentlessly progressive and lead to a useless arm. Occassionally it may stop or respond to PT or OT.
Radiation can also cause malignant nerve sheath tumors with painful enlarging mass and dysfunction. Ischemic plexitis can occur due to radiation induced segmental occlusion of the subclavian artery.
Thoracic outlet syndromes are discussed in another post.
Parsonage-Turner syndrome causes pain then weakness. It may mimic a shoulder joint lesion.
Hereditary neuropathy with liability to pressure palsies (HNPP) often affects the brachial plexus.
Patients with plexitis due to diabates have a subacute onset and good recovery. Plexitis in heroin addicted patients has less severe pain, and involvement of the lower part of the plexus.
Thursday, July 17, 2008
Differential C8-T1 radiculopathy
C8-T1 root lesion--
C8
Finger extensors, finger flexors, wrist flexors, hand intrinsics
T1
Hand intrinsics
Pancoast-- C8-T1 plus Horner's
Lateral cord-- muscles to forearm and sensation in distribution of median nerve
Medial cord-- all median and ulnar intrinsic muscles weak
Thoracic outlet syndrome- neurogenic, vascular, combined or traumatic. Vascular, that presents with pain, pallor and coolness is uncommon. TOS affects C8,T1 and lower trunk.
Compression may occur from a cervical (C7) rib (seen in 10%), an enlarged C7 transverse process (incomplete rib), a fibrous band (most common) from C7 TP to the clavicle, or fibrotic scalene mucles. The clinical presentation is
mild aching pain of ulnar forearm/hand (66%) without neck pain. Weakness occurs in all hand muscles (ulnar and median – thenar, hypothenar, and interossei). Ulnar (not median) numbness occurs. Hand weakness/clumsiness is prominent. Atrophy (“guttering”) of the lateral thenar eminence (APB) is characteristic. Thenar, hypothenar, and interossei atrophy – Gilliat-Sumner hand. TOS is bilateral in 50%, but less affected side is usually subclinical . No reliable provocative test exists, but 90° abduction + external rotation has best predictive value. Patients may have Tinel’s sign over supraclavicular fossa. Adsons test: turn head back & to affected side & lose radial pulse (for vascular variant) but this sign has been considered mythological (ie rarely present) by some authors.
EMG/NCV: Low APB (median) amplitudes (ulnar amplitudes are normal or slightly low). Low ulnar sensory potentials with normal median sensory potentials. Some say unreliable.
Chest or (oblique) c-spine Xrays or CT to look for C7 TP, cervical rib, etc. Treatment is ???
surgical. Medical treatment, physical therapy is not indicated for true TOS (per Kline)
§ Anterior supraclavicular approach: favored. Incision usually supraclavicular, parallel to clavicle.
§ Posterior subscapular approach: used for morbidly obesity, large cervical ribs, previous anterior surgery. See N10/04.
§ Transaxillary cervical rib resection: favored by vascular surgeons, orthopedists. Per Kline has higher complication rate, less success
Parsonage Turner-- pain then weakness, 90 % recovery within 3 years, affects males predominantly (4:1).
Ulnar neuropathy (see separate entry)
C8
Finger extensors, finger flexors, wrist flexors, hand intrinsics
T1
Hand intrinsics
Pancoast-- C8-T1 plus Horner's
Lateral cord-- muscles to forearm and sensation in distribution of median nerve
Medial cord-- all median and ulnar intrinsic muscles weak
Thoracic outlet syndrome- neurogenic, vascular, combined or traumatic. Vascular, that presents with pain, pallor and coolness is uncommon. TOS affects C8,T1 and lower trunk.
Compression may occur from a cervical (C7) rib (seen in 10%), an enlarged C7 transverse process (incomplete rib), a fibrous band (most common) from C7 TP to the clavicle, or fibrotic scalene mucles. The clinical presentation is
mild aching pain of ulnar forearm/hand (66%) without neck pain. Weakness occurs in all hand muscles (ulnar and median – thenar, hypothenar, and interossei). Ulnar (not median) numbness occurs. Hand weakness/clumsiness is prominent. Atrophy (“guttering”) of the lateral thenar eminence (APB) is characteristic. Thenar, hypothenar, and interossei atrophy – Gilliat-Sumner hand. TOS is bilateral in 50%, but less affected side is usually subclinical . No reliable provocative test exists, but 90° abduction + external rotation has best predictive value. Patients may have Tinel’s sign over supraclavicular fossa. Adsons test: turn head back & to affected side & lose radial pulse (for vascular variant) but this sign has been considered mythological (ie rarely present) by some authors.
EMG/NCV: Low APB (median) amplitudes (ulnar amplitudes are normal or slightly low). Low ulnar sensory potentials with normal median sensory potentials. Some say unreliable.
Chest or (oblique) c-spine Xrays or CT to look for C7 TP, cervical rib, etc. Treatment is ???
surgical. Medical treatment, physical therapy is not indicated for true TOS (per Kline)
§ Anterior supraclavicular approach: favored. Incision usually supraclavicular, parallel to clavicle.
§ Posterior subscapular approach: used for morbidly obesity, large cervical ribs, previous anterior surgery. See N10/04.
§ Transaxillary cervical rib resection: favored by vascular surgeons, orthopedists. Per Kline has higher complication rate, less success
Parsonage Turner-- pain then weakness, 90 % recovery within 3 years, affects males predominantly (4:1).
Ulnar neuropathy (see separate entry)
Prognosis of nerve injuries
Nerve injury
Most injuries recover spontaneously but there is a difference by location. 40 % of C5-6 injuries, 18 % of C5-7 injuries and 5 % of C5-T1 injuries (flail arm) recover. Injuries that are progressive , eg. hematoma, compartment syndrome, and pseudoaneurysm need immediate attention and often surgery. Progression of Tinel's sign can be used to follow recovery.
Repair of lacerations should be done acutely for sharp injuries (first three days) but after several weeks for a blunt injury to allow definition of injury. Penetrating injuries can be explored early, gunshot wounds if contiguous after 3 months, or EMG or SEP every three months.
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