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Home , Suprascapular nerve, Suprascapular notch, Teres minor muscle

Compression Neuropathies

Andrew Martin DO, MBA, CAQSM OMED 2013 Compression Neuropathies

Carpal Tunnel Syndrome • Tibial • • Plantar Nerve Syndrome • • Common Peroneal Nerve • Spinal Accessory Nerve • Superficial Peroneal Nerve • Upper/Lower Trunk Plexopathy • Deep Peroneal Nerve • • Medial Calcaneal Nerve • • Sural Nerve • • Saphenous Nerve • • Obturator Nerve • Guyon Canal Syndrome • Interdigital • Cubital Tunnel Syndrome • Lat. Femoral Cutaneous Nerve • Interdigital Neuroma • 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 Neurotemsis

Seddon Classification of Peripheral Nerve Damage Treatments

• Surgery • Physical Therapy • OMM • Injections • Bracing • NSAIDS, Muscle Relaxers, Oral Steroids, Narcotics, Antidepressants Entrapments of the Upper Extremity

• Cervical Radiculopathy • • Spinal Accessory Compression Nerve Compression • Ulnar Nerve • Suprascapular Nerve Compression Syndrome • • Quadrilateral Space Compression Syndrome 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/ pads) • Blows to the Shoulder Spinal Accessory Nerve Compression

Signs and Symptoms

• Shoulder Syndrome • Pain over , heaviness • Abnormal Scapular Rotation • Adhesive Capsulitis Spinal Accessory Nerve Compression

Evaluation

• Test Trapezius • Test Sternocleidomastoid • Abnormal Scapular Rotation Suprascapular Nerve Syndrome

Etiology

• • Spinoglenoid notch • Thickened Transverse Scapular • Extrinsic compression by a space- occupying 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 . Suprascapular Nerve Syndrome

Sagittal oblique T2 fat-saturated Sagittal oblique T1 weighted

42 yo swimmer with clinical and EMG evidence of right supraspinatus and 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 • Supplies the teres minor and deltoid muscles and the overlying skin of the shoulder • Compression from abduction and external rotation of the • 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 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 • 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

• Weakness • • Patient unable to extend wrist or fingers • Arm/// 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 • Painless weakness of the wrist and finger extensors • No Sensory Deficits 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 Superficial Branch Radial Nerve Compression Wartenberg's Syndrome

Etiology

• Compression of the superficial branch radial nerve (SRN) • Compressed by scissoring action of 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 Level of the Pisiform sensory and deep motor branches at the level of the hamate • 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 • 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