NERVE

ENTRAPMENT
SYNDROMES [ NES ]
Disorders of peripheral nerve with pain
and/or loss of function [ motor and/or
sensory] due to chronic compression.
compression
e.g., carpal tunnel syndrome
 IMPORTANT: Memorize
completely !!
Upper limb
Nerve place usually referred to median
carpal tunnel carpal tunnel syndrome
median
di (anteriori interosseous)
interosseous
i ) proximal
i l forearm
f anterior
i iinterosseous
Median pronator teres pronator teres syndrome
Median ligament of Struthers ligament of Struthers syn
Ulnar cubital tunnel cubital tunnel syndrome
Ulnar Guyon's canal Guyon's canal syndrome
radial axilla radial nerve compression
radial spiral groove radial nerve compression
radial (posterior interosseous)
interosseous) proximal forearm posterior interosseous nerve radial (superficial
radial)) distal forearm
radial Wartenberg's Syndrome
suprascapular suprascapular notch etc
Etc etc
ETC ETC ETC
 NES
Def: results from chronic injury to nerve as it travels
through an osseoligamentous structure, or between
muscles bundles
May have an underlying developmental anomaly or
variant
Repetitive motion slaps, rubs, compresses the n.
Relatively common
Often seen in athletes, younger patients
 Chronic NES
Repetitive injury may lead to edema, ischemia, and
finally alteration to the nerve sheath, even
demyelinization
Eventually complete recovery may not be possible, and
there is also the potential for phantom limb type
symptoms that become centralized in the brain and
replay even after the pathology is fixed.
Early recognition and intervention is critical.
 PUDENDAL NERVE
ENTRAPMENT
T T
PN is the main nerve of the perineum;
Carries sensation from the external genitalia,
skin around the anus
anus, scrotum
scrotum, perineum.
perineum
Motor supply to pelvic muscles, external urethral
sphincter,
hi andd ext anall sphincter
hi
Originates from sacral plexus [occasionally from
sciatic n. instead ]
 PNE SYMPTOMS
Pain in the lower central p
pelvis can include anus,,
perineum, scrotum, penis,testicles, vulva
Burning pain, sometimes shock-
shock-like
May
M b be unilateral
il t l or bil
bilateral
t l
Deep ache, severe like toothache
Hypersensitivity to touch,
touch pressure
Often provoked with urination / defecation,
exacerbated by sitting
Often cannot sit; sexual dysfunction common
Urinary urgency, dysuria, feeling of always needing to
go
go
 PUDENDAL N.
COURSE:
 PN
Landmarks:
 PUDENDAL NERVE
ENTRAPMENT
T T [ PNE ]
PNE
PNE
 PNE
"The main dailyy activities requiring
q g the seated position
p
(work, meals, driving, theaters, etc) are no longer
available to these patients, whose mental attitude is one
of chronic ppain sufferers so obsessed with their
miserable state as to be rapidly regarded by their
doctors as psychiatric cases."
Patients often have to sit on an inflatable donut
donut to sit
at all
The variety of symptoms often mean the patient has
seen urologist, gynecologist, proctologist,
gastroenterologists etc
 PNE
Often seen in athletes: bicyclists,
bicyclists cross country
skiers, skaters, dancers, some runners.
May begin after direct trauma,
trauma after pelvic
surgery, or after child birth.
O may h
Or have no kknown precipitating
i i i event
Early dx and rx offer much better prognosis
 PNE
First line rx ( earlyy cases ):
) NSAIDs,, i.e. ibuprofen;
p ;
topical pain relievers [ lidoderm creams, creams with
capsaicin ]
Try to identify
d and d avoidd acitivity that causes the pain
Hot or cold compresses [ can alternate ]
K is
Key i to suspect the h diagnosis
di i and d sort iit out ffrom
other causes
Pain may be provoked by skin skin rolling
rolling technique or
direct pressure on ischial tuberosity
 PNE
Physical rx: some know specialized techniques
Lengthen and loosen pelvic floor buttocks, thighs,
hips,
p ,pperineum
Toe touches, supine leg lifts, side leg raises, range of
motion ex in swimmingg pool
p
Next line of approach: meds i.e. elavil, neurontin,
valproate BUT direct intervention may be better
 PNE injections
The ppudendal nerve can be approached
pp veryy p
preciselyy
via CT scan direction
Current national recommendations are for this
approach-- reliable
approach b results vs. flouro ddirected.
d
Injx with local anesthestic can confirm the origin of sx
R l off injx
Results i j in
i past were variable
i bl to poor - current
technique better results
Repeat injx when sx recur,
recur often 3 x in 6-6-9 months
 PNE Injections
Injection: using 5 22 g spinal needle, initial is lidocaine 1%-
1%- this will
i
immediately
di t l replicate/exacerbate
li t / b t sx
Additionally, dexamathosone phosphate 4 mg is intermixed with 3 cc 0.5 %
bupivicaine
Hyaluronidase
y 300-600 units-
300- units- hydrolyzes
y y glucosaminic
g bonds between
hyaluronic acid, a major intercellular substance-
substance- this helps remove barriers
between tissues/cells-
tissues/cells- fluids, including other meds, penetrate better-
better- helps
disrupt scarring and reduces density of any new adhesions
Heparin 8000-
8000-10000 units-
units- was discovered to inhibit superficial scar
formation in burn patients following debridements.
BotulinumToxin A [Botox] also can be used if the above fails.
Surgery for failed cases: send to the experts such as Dr. Stanley Antolak
PNE injx
 PIRIFORMIS SYNDROME
[ PS ]
Caused by piriformis muscle compressing the sciatic
nerve
nerve a true sciatica in that sense
Piriformis m. is a stabilizer of hip,
p, and lifts and rotates
thigh away from body
Usuallyy pain
p and tingling
g g in buttocks, often tenderness,
and subsequently pain extends down the thigh
Increased by sitting, walking, running, climbing stairs,
direct compression.
PS
 PS
S
Athletes,, runners esp.
p distance runners,, sometimes with
trauma
Can be related to developmental anomaly
Si il symptoms
Similar t can be
b produced
d d by b lumbar
l b di disc
disease, sacroiliac joint disease, and a few others.
Mayy be necessaryy to imageg spine
p and pelvis
p is dx is not
clear
Some articles show many patients with sciatica and
negative lumbar MRI have piriformis syn
 PS
Contributing factors
Hyperlordosis
Muscle anomalies
Muscle
M l h hypertrophy
h
Fibrosis due to trauma
Anatomical nerve abnormalities
Occasionally due to physical hyperactivity,
hyperactivity hip
replacement surgery, leg length discrepancy
 PS
Accessory fibers and enlargement at origin on
right
 PS
Accessory bundle of piriformis on right
 PS RX :
First line
Best and safest is care that you provide
provide--
massage, joint manipulation and mobilization,
stretching,
stretching isotonics,
isotonics weight bearing
Heat therapy, at home, or better with
ultrasonographic rxrx.
Stretching piriformis, external rotators of hip,
andd adductors
dd
 PS RX
Second line
Refractoryy cases often benefit from direct intervention
Injection performed with 22 g spinal needle with direct
visualization with us
Sciatic n identified and the piriformis directly overlying
is entered with needle
I j with
Injx i h 5 cc 0.5%
0 5% bupivicaine
b i i i mixed i d with
i h 40-
40-80 mg
triamcinolone, repeat x 2 with recurrence
Resistant cases may get good result with same approach
but with Botox
US DIRECTED RX
PS INJX
 MERALGIA PARESTHETICA
[ MP ]
Entrapment of the lateral femoral cutenous
nerve
Occurs between the anterior superior
superior iliac crest
and the inguinal ligament
Tight clothing, obesity, pregnancy, scarring,
excessive walking, biking etc
Pain may be burning, electric,
electric , stinging, sharp
shock associated with motion
If in doubt, EMG is helpful
LFCN compression
 PM RX
Chiropractic care with pelvic mobilization,
myofascial rx, transverse friction massage, and
stretchingg mayy resolve this rapidly
p y in manyy
cases.
Usual recommended medical care starts with
NSAIDS, looser clothing, narcotics if needed,
reduced activity !!
Resistant cases often have excellent response to
injx
 MP INJX
Easily done with US
Identify inguinal ligament and the LFCN
I j 11cc l% idocaine,
Inject id i followed
f ll d by
b 3 cc 0.5%
0 5%
bupivicaine with 40 mg triamcinolone
80% of patients pain free with 1 week, others may
require second injx.
MP INJX
 NES around the knee
Patient with weakness
weakness and pain in lower leg
and ankle, esp pain in foot
Neuro exam suggested problem was common
peroneal nerve
EMG alsol suggestive
i
MRI lower leg ordered
Denervation of medial and lateral heads of
g
gastrocnemius
PERONEAL NES
CP NES
 COMMON PERONEAL N.
course
 CP NES
High
g signal
g intensityy is seen in acute and subacute
denervation
CPN wraps around neck of fibula-fibula- a tight area;
vulnerable
b to trauma from fractures, surgery, repetitive
stress [ athletics], casts, squatting position, chronic
crossing of legs, etc
Developmental variants as well
Most common mononeuropathy p y in lower legg
RX correct cause if possiblepadding, alter habits
 SPORTS HERNIA
ATHLETIC
T T PUBALGIA [ AP ]
Sports
p hernia is real misnomer-
misnomer- not reallyy a hernia;;
often seen in athletes
Symptoms are in the inguinal/groin area and may
mimic hernia
Many patients have had hernia repairs, even for tiny,
inconsequential hernias,
hernias and still no relief
True hernia
hernia-- tear in abdominal wall, through which
abdominal contents protrude
p
Pain and tenderness in inguinal area, esp the symphysis
pubis
 AP
It does involve a tear,, most commonlyy of the muscle
attachments, specifically an aponeurosis
An aponeurosis is a tendonous structure joining
muscles andd other bbodyd parts in a common structure-
structure-
example plantar fascia of foot
In AP the aponeurosis attached to the symphysis pubis
is involved
The aponeurosis
p of the rectus abdominis and the
adductor longus of the thigh are the usual culprits
 AP
RA--AL
RA
 AP
SAGITALL
 Walking running
Walking, running, jumping
jumping, skating
skating,
falling.there are many movements that stress
these two muscles simulataneously and cause
them to pull against each other at this
attachment.
attachment
The aponeurosis is strong but contains very little
blood supply
supply, like many tendons,
tendons healing is poor
 AP
sagittal
 AP
60 year old male
male, injured from fall on ice
[hockey] several years prior, with re-
re-injuries with
slipping
slipping and sliding
sliding several times; pain greatest
on right
Pain too great for exercise now,
now very limited
activites. miserable
H d many studies
Had di and d exams-
exams- not helpful
h l f l
He had read about sports hernia and MRI
Sagittal left
Sagittal right
axial
axial
 AP
Like rotator cuff etc. tendons repair poorly on their
own
Initial rx: rest,, ice,, NSAIDS but if persists
p needs dx and
rx
Recentlyy open
p surgery g y has been offered, and more
preferable for athletes endoscopic surgery
Very recently intervention with ultrasound directed
injx-- with steroids and anesthetic, now considered best
injx
approach before surgery