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Neurology of the Upper Limb

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Neurology of the Upper Limb Neurology of the Upper limb Donald Sammut Hand Surgeon Kings Upper Limb Anatomy plus lecture notes The$Neck$ The$Nerve$roots$which$supply$the$Upper$Limb$are$C5$to$T1$ Pre<fixed$(C4$to$C8)$and$Post<fixed$(C6$to$T2)$plexus$not$uncommon.$ Also$common$contributions$from$C4$and$from$T2$in$a$normally$rooted$plexus.$ $ The$anterior$nerve$roots$emerge$between$the$vertebrae$and$immediately$pass$ $through$the$first$area$of$possible$compression:$ The$root$nerve$canal$is$bounded$$ Anteriorly$by$the$posterior$margin$of$the$intervertebral$disc$and$$ Posteriorly,$by$the$facet$joint$between$vertebrae.$ $ Pathology$of$the$disc,$or$joint,$or$both,$can$narrow$this$channel$and$compress$ $the$nerve$root$ The$roots$emerge$from$the$cervical$spine$into$the$plane$between$$ Scalenius$Anterior$and$Scalenius$Medius.$$ $ Scalenius*Anterior:** Origin:$Anterior$tubercles$of$Cervical$vertebae$C3$to$6$(C6$tubercle$is$the$Carotid$tubercle)$ Insertion:$The$scalene$tubercle$on$inner$border/upper$surface$1st$rib$ $ Scalenius*Medius:* Origin:$Posterior$tubercles$of$all$cervical$vertebrae$ Insertion:$Quadrangular$area$between$the$neck$and$subclavian$groove$1st$rib$ $ Exiting$from$the$Scalenes,$the$trunks$lie$in$the$posterior$triangle$of$the$neck.$ The$posterior$triangle$is$bounded$anteriorly$by$SternoCleidoMastoid$and$$ posteriorly$by$the$Trapezius.$ The$inferior$border$is$the$clavicle$.$ The$apex$of$the$triangle$superiorly$is$at$the$back$of$the$skull$on$the$superior$nuchal$line$ $ $ The$Posterior$Triangle$ SternoCleidoMastoid$ Trapezius$ Scalenius$Medius$ Scalenius$Anterior$ The$general$route$of$travel$of$the$Brachial$$Plexus$:$ $ $Exit$from$the$root$canals$$ $–$travel$through$plane$between$Scalenius$Anterior$and$Scalenius$Medius$ $–$In$posterior$triangle$covered$by$investing$layer$of$deep$Cervical$fascia$$ $–$over$first$rib$in$company$of$Subclavian$artery$ $–$enclosed$in$axillary$sheath$ $ $–$into$apex$of$axilla$$ $–through$axilla$and$ending$in$5$main$terminal$branches$ The$Brachial$Plexus$is$formed$from$the$anterior$rami$of$C5,6,7,8,T1$after$they$$ have$supplied$prevertebral$and$scalene$muscles$.$ $ The$various$parts$of$the$Brachial$Plexus$$and$their$location:$ $ ROOTS:$ $ $$Between$the$scalenes$ TRUNKS:$ $ $In$the$Posterior$Triangle$ DIVISIONS: $ $Behind$the$clavicle$ CORDS: $ $$In$the$axilla$ $ (Thus$the$roots$and$Trunks$are$Supra<clavicular$while$the$Divisions$and$cords$are$Infra<Clavicular).$ $ The$Plexus$exists$as$a$system$of$delivering$fibres$from$more$than$one$root$into$a$$ specific$end$nerve.$ $ $ $ THE$BRACHIAL$PLEXUS$ Dorsal$Scapular$Nerve$(nerve$to$Rhomboids)$ Suprascapular$Nerve$ N.$To$$ Subclavius$ Lateral$Pectoral$Nerve$ MUSCULOCUTANEOUS$ AXILLARY$ Long$Thoracic$Nerve$ RADIAL$ (Nerve$to$Serratus$Anterior)$ MEDIAN$ $Nerve$ Upper$Subscapular$Nerve$ Thoracodorsal ULNAR$ Lower$Subscapular$Nerve$ ROOTS$ TRUNKS$ DIVISIONS$ CORDS$ TERMINAL$$ BRANCHES$ IN$SCALENES$ POSTERIOR$$ TRIANGLE$ BEHIND$CLAVICLE$ IN$AXILLA$ There$are$5$main$Terminal$Branches$of$the$Brachial$Plexus:$ $ FROM$THE$POSTERIOR$CORD:$ $ $THE$RADIAL$NERVE$ $$$$$THE$AXILLARY$NERVE$ $ FROM$THE$LATERAL$AND$MEDIAL$CORDS: $THE$MUSCULOCUTANEOUS$NERVE$ $$$$$THE$MEDIAN$NERVE$ $$$$$THE$ULNAR$NERVE$ $ $ $ $ $ 5$MAIN$TERMINAL$BRANCHES$ MUSCULO$ CUTANEOUS$ AXILLARY$ MEDIAN$ RADIAL$ ULNAR$ C5$ C6$$$C6$ USUAL$ROOTS$ C7$$$C7$ $ C8$$$C8$ $$$$POST<FIXED$ T1$$$$T1$ $$$$$$$$$T2$ $ $ $ $ The$scalenes$are$Prevertebral$muscles$which$have$migrated$anteriorly$along$the$1st$rib.$ Like$other$prevertebral$muscles$they$are$invested$in$Pre<Vertebral$fascia.$$ $ This$fascia$is$prolonged$over$the$Brachial$plexus$as$it$exits$between$the$two$scalenes$and$forms$$ the$Axillary$sheath.$$ Since$the$Subclavian$artery$passes$posterior$to$the$Scalenius$anterior,$it$comes$to$lie$within$the$$ sheath$along$with$the$nerve.$$ The$axillary$sheath$thus$contains$the$subclavian$artery$and$the$tightly$bunched$up$terminal$$ branches$$of$the$plexus$–$an$important$anatomical$feature$relevant$t$o$the$administration$of$ axillary$nerve$blocks.$ $ $ $ BACHIAL$PLEXUS$BLOCKS$ $ Nerve$blocks$involve$the$infiltration$of$the$space$around$a$nerve$with$local$anaesthetic.$ The$axillary$sheath$forms$a$convenient$discrete$compartment$which$retains$anaesthetic$ $around$the$nerves.$ The$subclavian$artery$pulsations$are$palpable$and$present$a$convenient$means$of$locating,$$ by$palpation,$the$nerves.$ $ Blocking$of$the$Brachial$plexus$can$be$performed$at$many$levels:$ Inter$Scalene$ Supra$Clavicular$ Infra$Clavicular$ Axillary$ $ The$commonest,$and$safest,$method$of$locating$the$Brachial$plexus$is$by$the$use$of$an$$ Ultrasound$Probe.$This$demonstrates$the$nerve$and$artery$and$also$the$needle$tip$as$it$is$$ advanced.$ $$ Accurate$Placement$is$crucial:$ The$infiltration$must$NOT$be$into$the$nerve$substance$–$this$causes$direct$nerve$damage.$ The$anaesthetic$must$NOT$be$inserted$intravascularly$–$The$agent$works$by$blocking$electrical$ conduction.$$ It$will$do$so$equally$effectively$with$nerve$conduction$and$with$the$conduction$of$Cardiac$Muscle$$ fibres.$ Major$Intravascular$injection$of$local$anaesthetic$agent$will$cause$a$bradycaria$(slowing$of$heart$rhythm)$ and$may$even$cause$total$block$i.e.$it$will$stop$the$heart.$ $ $ $ THE$AXILLARY$$ SHEATH$ Interscalene$Block$ Supraclavicular$Block$ Infraclavicular$Block$ Axillary$Block$ The$exit$of$the$nerve$roots$and$the$course$of$the$Brachial$plexus$through$the$neck$$ make$it$vulnerable$to$various$points$of$compression$ $ 1. Common,$high,$$insertion$of$Scalenius$Anterior$and$Scalenius$Medius.$ $ This$causes$the$lower$parts$of$the$Brachial$plexus$to$kink$over$the$(usually$sharp)$common$$ Muscle.$Compression$at$this$point$will$mainly$affect$C8/T1.$ $ 2.$The$presence$of$an$anomalous$Cervical$Rib$or$Cervical$band,$will$also$cause$the$$ lower$reaches$of$the$brachial$Plexus$to$kink$over$the$raised$exit$point$from$the$neck.$ $ The$presence$of$a$cervical$rib$is$associated$with$a$post<fixed$Brachial$plexus$ $(i.e.$a$Plexus$formed$from$the$roots$of$C6$–$T2)$ $ C6$ C7$ C8$ T1$ T2$ 3.$SIBSON’S$FASCIA$or$$THE$SUPRAPLEURAL$MEMBRANE,$is$a$tough$fibrous$‘lid’$$ to$the$thoracic$cavity,$covering$the$apex$of$the$lung.$ $It$is$formed$by$the$Scalenius$Minimus,$which$arises$$ from$the$transverse$process$of$the$C7$vertebra.$The$Membrane$is$to$be$considered$$ the$flattened$out$tendon$of$this$small$muscle.$ The$Suprapleural$membrane$is$attached$to$the$inner$border$of$the$first$rib$and$is$deficient$$ posteriorly$where$the$root$of$T1$crosses$the$neck$of$the$rib$to$join$the$Brachial$Plexus.$$ It$is$also$deficient$medially,$where$it$blends$with$the$lung$pleura.$ $ The$Membrane$is$tensed$during$respiration$in$order$to$prevent$the$lung$apex$bulging$ $into$the$lower$neck$during$strong$or$forced$inspiration.$ $ Hypertrophy$of$the$muscle$and$thickening$of$the$membrane$posterior$edge,$can$$ cause$compression$and$kinking$of$the$T1$contribution$ $ Scalenius$Minimus$ Sibson’s Suprapleural Membrane Francis(Sibson;(Physician,(St(Mary’s(,(London(181491876( 4.$A$tumour$in$the$apex$of$the$lung$can$infiltrate$all$structures$here$and$cause$compression$$ or$direct$infiltration$of$the$lower$parts$of$the$Brachial$Plexus$($Thoracic$Outlet$Syndrome).$$ $ Typically,$an$early$sign$is$Horner’s$Syndrome$(compression$of$the$sympathetic$ganglion$ $at$this$level)$and$can$present$with$Superior$Vena$Cava$obstruction$ $ PANCOAST’S$$ TUMOUR$ A$DERMATOME$is$an$area$of$skin$supplied$by$a$single$spinal$nerve.$ $ It$is$useful$to$know$the$general$distribution$of$dermatomes$(and$segmental$levels)$of$the$ Upper$limb.$ $ The$general$pattern$is$that$of$the$‘apex’$of$the$limb,$the$hand,$being$supplied$by$C6,7,8$ $ Above$this,$along$the$pre<axial$border$of$the$limb,$are$the$upper$parts$of$the$Plexus:$C5,6,7$ Below$this,$along$the$post$axial$border$of$the$limb,$are$the$lower$parts$of$the$Plexus:$C7$to$T2$ $ $ This$general$pattern$is$consistent$and$reliable,$but$the$specific$areas$supplied$are$very$variable$$ (i.e.$there$are$no$reliable$and$consistent$boundaries)$ C3,4$ DERMATOMES$ C5,6$ $ $ $ $ T2$ C5,6$ $ $ FOREARM$ $ RADIAL:$$ $$$$$$$$C5,6$ MEDIAL$CUTANEOUS:$C8,TI$ C5,6$ $ $ C8,T1$ $ $ C7,8$ $ HAND$ $ MEDIAN:$$ $$$$$C6,7,8$ C8,T1$ ULNAR:$ $ $$$$$C8,$T1$ C6,7,8$ MYOTOMES$ $ The$same$segmental$innervation$applies$to$the$muscles.$$ A$MYOTOME$is$a$group$of$muscles$innervated$by$a$single$spinal$nerve.$ In$clinical$practice,$it$is$best$to$remember$actions$and$their$innervation,$rather$than$$ single$groups$and$these$may$involve$more$than$one$root$ $ $ SHOULDER:$ $ $Abduct$and$laterally$Rotate:$ $C5$ $$$Adduct$and$medially$Rotate:$ $C6,7,8$ $ $ ELBOW: $ $$Flex:$ $ $$C5,6$ $$$Extend:$ $ $$C7,8$ $ $ FOREARM: $ $$Pronate: $ $$C7,8$ $$$Supinate $ $$:C6$ $ $ WRIST: $ $$Flex: $ $$C6,7$ $$$Extend: $ $$C6,7 $$$ $ $ LONG$TENDONS $ $Flex: $ $$C7,8$ Fingers$and$Thumb $ $Extend: $ $$C7,8 $$$$ $ $$$$ HAND$INTRINSICS $ $All $ $$T1$ $ $ $ It$is$useful$to$remember$the$main$nerve$to$each$functional$compartment:$ Thus:$ $ In$the$arm:$ Flexor$Compartment:$MUSCULOCUTANEOUS$NERVE$ Extensor$Compartment:$RADIAL$NERVE$ $ In$the$forearm:$ Flexor$compartment:$MEDIAN$(and(some(by(Ulnar*)( Extensor$Compartment:$POSTERIOR$INTEROSSEOUS$NERVE$ $ In$the$hand: $$$$$$$$ULNAR$(and(some(by(Median*)( ( *(See(below $$ $ $ $ FLEX.$ARM:$ MUSCULOCUTANEOUS$ EXT.$ARM:$ RADIAL$ EXT.$FOREARM$ FLEX.$FOREARM:$ POST.$INTEROSS$ MEDIAN$(+(Ulnar)( HAND:$ ULNAR$ (+Median)( The$Musculo$cutaneous$Nerve$ $ Nerve$of$the$Flexor$Compartment$of$the$arm$ MUSCULO$ CUTANEOUS$ The$MusculoCutaneous$nerve$leaves$the$lateral$cord$of$the$Brachial$Plexus$in$the$axilla.$ $ It$exits$between$the$two$heads$of$Coracobrachialis,$supplying$both.$ It$travels$in$the$plane$between$Biceps$Brachii$and$Brachialis,$supplying$both$segmentally$
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