DOCSLIB.ORG

Neurosurgery 1992-98 June 1994, Volume 34, Number 6 1087

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Neurosurgery 1992-98 June 1994, Volume 34, Number 6 1087 Neurosurgery 1992-98 improvement. June 1994, Volume 34, Number 6 At our initial examination, abnormal findings were 1087 Windmill Pitcher's Radial Neuropathy isolated to the right radial nerve distribution. Strength Case Report in the right triceps was 4-/5, the brachioradialis and supinator were 0/5, and the wrist and finger extensors AUTHOR(S): Sinson, Grant, M.D.; 1/5. The left arm had normal strength throughout. The Zager, Eric L., M.D.; Kline, David G., M.D. right triceps and brachioradialis reflexes were absent. Sensation over the dorsal aspect of the patient's distal Division of Neurosurgery, Hospital of the University forearm and thumb was decreased. The remainder of of Pennsylvania (GS, ELZ), Philadelphia, the examination's findings were normal and Tinel's Pennsylvania; Department of Neurosurgery, sign did not occur over the brachial plexus or the Louisiana State University Medical Center (DGK), course of the radial nerve. A second EMG showed New Orleans, Louisiana fibrillations and positive sharp waves in the extensor Downloaded from https://academic.oup.com/neurosurgery/article/34/6/1087/2757659 by guest on 27 September 2021 digitorum and brachioradialis, with only occasional Neurosurgery 34; 1087-1089, 1994 fibrillations in the triceps. The deltoid was normal. A magnetic resonance imaging scan of the brachial ABSTRACT: THE AUTHORS PRESENT two cases plexus showed no mass lesion or anatomic anomaly. of severe radial nerve injury with different sites of Approximately 11 months after the injury, the right pathology but a similar mechanism: the "windmill" brachial plexus was explored via the infraclavicular pitching motion of competitive softball. Both patients approach. At operation, the posterior cord and radial required surgical intervention with neurolysis, and nerve were found to be severely scarred. A fusiform both improved postoperatively. The literature on neuroma in continuity measuring 16 cm in length and related radial nerve injuries is briefly reviewed and approximately three to four times the diameter of a pathophysiological mechanisms are discussed. normal posterior cord was found (Fig. 1). The axillary nerve was also involved, but not as severely. KEY WORDS: Athletic injuries; Brachial plexus; The lateral and medial cords as well as the axillary Nerve compression syndromes; Radial nerve injury; artery appeared normal. Radial nerve surgery Intraoperative electrophysiological recording was performed. A nerve action potential could not be The radial nerve is not infrequently injured during recorded from the posterior cord to the radial nerve, athletic or other strenuous activities. Midshaft and this was undoubtedly related to the severe fractures of the humerus and compression at the scarring. An extensive external and internal fibrous arcade of Frohse are commonly recognized neurolysis of the posterior cord and radial nerve was mechanisms of radial nerve injury. More recently, then completed under magnification. After cases of radial nerve entrapment by the fibrous arch neurolysis, stimulation of the posterior cord and at the lateral head of the triceps have been radial nerve did elicit triceps contraction. The documented (3-7,10). We present two cases of radial dissection was stopped at this point. nerve injury with different sites of pathology but a Initially after surgery, the patient had 1/5 triceps similar mechanism: the "windmill" pitching motion strength. By 21 months postoperatively, she has of competitive softball. recovered 4+/5 triceps function. She as yet has no distal function clinically, but there is now EMG CASE REPORTS evidence of reinnervation of the brachioradialis and Patient 1 extensor digitorum. This healthy 16-year-old, right-handed girl was referred to the Hospital of the University of Patient 2 Pennsylvania with a 10-month history of weakness in This 53-year-old, right-handed man came to the the right arm and hand. Her deficits were first noted Louisiana State University Medical Center with an 8- while she was learning the windmill pitching motion month history of progressive weakness in his right in her high-school softball team. The weakness in the arm. He had been a pitcher in a fast-pitch softball right arm was predated by 2 weeks of soreness in the league for many years. He did not recall any incident posterior aspect of her shoulder associated with of injury to the shoulder or arm, and there were no pitching. Her weakness then progressed over the complicating medical conditions. Physical course of the next month as she continued to pitch. examination revealed no tenderness or Tinel's sign She found that she could not release the ball at the along the course of the radial nerve. The right triceps end of the pitching motion. There was also transient was moderately weak (3/5), the brachioradialis weakness in the right shoulder. Neurological severely weak (1/5), and there was no contraction of examination and an electromyogram (EMG) the supinator, wrist, or finger extensors (0/5). The documented severe radial nerve palsy involving the triceps reflex was reduced and the brachioradialis triceps and all distal muscles innervated by the radial reflex absent. There were no sensory deficits. The left nerve. Apparently, her original deltoid weakness had arm had normal strength and reflexes throughout. The only been transient, since at the initial and all findings of the remainder of the examination were subsequent physical examinations she had normal normal. An EMG demonstrated partial denervation of deltoid strength. She was managed conservatively at the triceps and changes indicating severe denervation another institution for 10 months but experienced no in all distal muscles innervated by the radial nerve. Redistribution of this article permitted only in accordance with the publisher's copyright provisions. The radial nerve was surgically exposed on both branches to the triceps and proximal to the posterior the medial and lateral sides of the arm. An area of cutaneous branch. In dissecting the posterior thinning and discoloration was noted in the nerve just compartment of the arm, the radial nerve is found proximal to and within the region of the spiral groove coursing along the spiral groove of the posterior of the humerus. A nerve action potential was humerus and then deep to the lateral head of the transmitted across this narrow segment, but had a low triceps. These investigators found a fibrous arch of amplitude and conducted at only 32 m per second. As tendon giving rise to muscle fibers of the triceps in a result, a simple neurolysis was performed. "almost every case" (p 504). Indeed, in an unspecified After follow-up of 3.5 years, recovery has occurred number of dissections, some fibers originated below but has been incomplete. The triceps improved this arch and arose from the more distal humerus, significantly (4/5); the brachioradialis has 4/5 which they termed the "accessory origin of the lateral strength, the extensor carpi radialis 3/5, the extensor head" (p 503). The radial nerve courses between this carpi ulnaris 2/5, and finger extension 1/5. A tendon fibrous arch and the humerus and then, quite Downloaded from https://academic.oup.com/neurosurgery/article/34/6/1087/2757659 by guest on 27 September 2021 transfer to improve finger extension has been offered distinctly, through the opening in the lateral but was refused by the patient. He is able to continue intermuscular septum to enter the anterior his sales work satisfactorily but no longer plays compartment of the arm. Lotem et al. (3) also noted softball. that while there was no obvious compression of the radial nerve at this location, there was considerable DISCUSSION variability in how tight the fibrous arch was in These cases demonstrate two different sites of relation to the radial nerve (Fig. 2). radial nerve injury with the same unusual mechanism. Much earlier, Wilson (11) had speculated that some The windmill pitching technique used in fast-pitch patients may have an anatomic predisposition to softball places the shoulder through its full range of radial nerve injury. Lotem et al. (3) proposed motion. The initial movements fully abduct the compression by the fibrous arch of the lateral head of shoulder with the arm held above the head. As the the triceps as the source of this predisposition, arm is brought downward from behind, it undergoes particularly in muscular individuals. Since then, there rapid acceleration that results in forced elbow have been several descriptions of cases of radial extension and forearm supination along with shoulder nerve injuries occurring at the same portion of the rotation. How this complex motion can result in nerve but unrelated to previous muscular activity (4, isolated injury of the posterior cord and radial nerve 7). All of these injuries have been attributed to is not entirely clear. compression by the lateral head of the triceps. There are several reports of radial nerve injury due Operative exploration in these cases revealed either a to strenuous muscle activity (1,3-12). These have fibrous (4,7) or a muscular (5,6) arch of the lateral head similarities to our second patient. In 1892, Gowers of the triceps as the point of radial nerve compression (1) described three cases of radial nerve injury that (Fig. 2). Alternatively, Prochaska et al. (8) attributed occurred "... once during the act of pulling on a tight the nerve injury to an anomalous fibrous band from pair of boots, once from throwing a stone with the long head of the triceps. energy, and once from grasping a lamp-post to avoid A compressive mechanism alone cannot explain a fall during a severe attack of giddiness." Wilson the injury described in our first patient, however. (11) referred to radial nerve injury subsequent to Nerve traction can be related to arm traction, nerve sudden elbow extension, and Woltman et al. (12) diameter, and nerve length. Nerve traction varies described a radial nerve injury resulting from directly with arm traction (2).
Load more

Recommended publications
  • Anatomical, Clinical, and Electrodiagnostic Features of Radial Neuropathies
    Anatomical, Clinical, and Electrodiagnostic Features of Radial Neuropathies a, b Leo H. Wang, MD, PhD *, Michael D. Weiss, MD KEYWORDS Radial Posterior interosseous Neuropathy Electrodiagnostic study KEY POINTS The radial nerve subserves the extensor compartment of the arm. Radial nerve lesions are common because of the length and winding course of the nerve. The radial nerve is in direct contact with bone at the midpoint and distal third of the humerus, and therefore most vulnerable to compression or contusion from fractures. Electrodiagnostic studies are useful to localize and characterize the injury as axonal or demyelinating. Radial neuropathies at the midhumeral shaft tend to have good prognosis. INTRODUCTION The radial nerve is the principal nerve in the upper extremity that subserves the extensor compartments of the arm. It has a long and winding course rendering it vulnerable to injury. Radial neuropathies are commonly a consequence of acute trau- matic injury and only rarely caused by entrapment in the absence of such an injury. This article reviews the anatomy of the radial nerve, common sites of injury and their presentation, and the electrodiagnostic approach to localizing the lesion. ANATOMY OF THE RADIAL NERVE Course of the Radial Nerve The radial nerve subserves the extensors of the arms and fingers and the sensory nerves of the extensor surface of the arm.1–3 Because it serves the sensory and motor Disclosures: Dr Wang has no relevant disclosures. Dr Weiss is a consultant for CSL-Behring and a speaker for Grifols Inc. and Walgreens. He has research support from the Northeast ALS Consortium and ALS Therapy Alliance.
    [Show full text]
  • The Usefulness of Proximal Radial Motor Conduction in Acute Compressive Radial Neuropathy
    JCN Open Access ORIGINAL ARTICLE pISSN 1738-6586 / eISSN 2005-5013 / J Clin Neurol 2015;11(2):178-182 / http://dx.doi.org/10.3988/jcn.2015.11.2.178 The Usefulness of Proximal Radial Motor Conduction in Acute Compressive Radial Neuropathy Kun Hyun Kima b Background and PurposezzThe objective of this study was to determine diagnostic and Kee-Duk Park a prognostic values of proximal radial motor conduction in acute compressive radial neuropathy. Pil-Wook Chung a MethodszzThirty-nine consecutive cases of acute compressive radial neuropathy with radial Heui-Soo Moon conduction studies–including stimulation at Erb’s point–performed within 14 days from a Yong Bum Kim clinical onset were reviewed. The radial conduction data of 39 control subjects were used as a Won Tae Yoon reference data. b Hyung Jun Park ResultszzThirty-one men and eight women (age, 45.2±12.7 years, mean±SD) were enrolled. Bum Chun Suha All 33 patients in whom clinical follow-up data were available experienced complete recov- ery, with a recovery time of 46.8±34.3 days. Partial conduction block was found frequently a Department of Neurology, Kangbuk Samsung Hospital, (17 patients) on radial conduction studies. The decrease in the compound muscle action po- Sungkyunkwan University tential area between the arm and Erb’s point was an independent predictor for recovery time. School of Medicine, Seoul, Korea zzProximal radial motor conduction appears to be a useful method for the early b Conclusions Department of Neurology, detection and prediction of prognosis of acute compressive radial neuropathy. Mokdong Hospital, Ewha Womans University Key Wordszz radial neuropathy, nerve conduction study, conduction block, diagnosis, School of Medicine, Seoul, Korea prognosis.
    [Show full text]
  • Perioperative Upper Extremity Peripheral Nerve Injury and Patient Positioning: What Anesthesiologists Need to Know
    Anaesthesia & Critical Care Medicine Journal ISSN: 2577-4301 Perioperative Upper Extremity Peripheral Nerve Injury and Patient Positioning: What Anesthesiologists Need to Know Kamel I* and Huck E Review Article Lewis Katz School of Medicine at Temple University, USA Volume 4 Issue 3 Received Date: June 20, 2019 *Corresponding author: Ihab Kamel, Lewis Katz School of Medicine at Temple Published Date: August 01, 2019 University, MEHP 3401 N. Broad street, 3rd floor outpatient building ( Zone-B), DOI: 10.23880/accmj-16000155 Philadelphia, United States, Tel: 2158066599; Email: [email protected] Abstract Peripheral nerve injury is a rare but significant perioperative complication. Despite a variety of investigations that include observational, experimental, human cadaveric and animal studies, we have an incomplete understanding of the etiology of PPNI and the means to prevent it. In this article we reviewed current knowledge pertinent to perioperative upper extremity peripheral nerve injury and optimal intraoperative patient positioning. Keywords: Nerve Fibers; Proprioception; Perineurium; Epineurium; Endoneurium; Neurapraxia; Ulnar Neuropathy Abbreviations: PPNI: Perioperative Peripheral Nerve 2018.The most common perioperative peripheral nerve Injury; MAP: Mean Arterial Pressure; ASA CCP: American injuries involve the upper extremity with ulnar Society of Anesthesiology Closed Claims Project; SSEP: neuropathy and brachial plexus injury being the most Somato Sensory Evoked Potentials frequent [3,4]. In this article we review upper extremity PPNI with regards to anatomy and physiology, Introduction mechanisms of injury, risk factors, and prevention of upper extremity PPNI. Perioperative peripheral nerve injury (PPNI) is a rare complication with a reported incidence of 0.03-0.1% [1,2]. Anatomy and Physiology of Peripheral PPNI is a significant source of patient disability and is the Nerves second most common cause of anesthesia malpractice claims [3,4].
    [Show full text]
  • 069-Workshop-Food Allergy
    WORKSHOP Practical Pointers For Your Practice Short Snappers in Neurology: Clinical Strategies and Problems Alan E. Goodridge , MD, FRCPC Presented at Memorial University’s Wednesday at Noon Ask the Consultant Seminar, January 17, 2007. Scenario 1 The approach to the neurological hen faced with a examination Wneurological The neurological exam can be daunting, but strate - problem, it is helpful, gies can be developed to target the key aspects of the during the history, to n neurological exam to answer the clinical questions make ©a judgment utio raised by the history. When faced with a neurologi - ht rib ig ist ad, cal problem, it is helpful, during the history, to mayke rregarding Dwhetwhnelor the p ial n do a judgment regarding whether the probleom is more rc rs ca use C proeblemuseis monoarl e likely likely to be of peripheral or central nervous system mm rised pers o utho y for (CNS) origin. r C ed. Ato bceopof peripheral or o hibit ingle When there are localizianglseymptomprs,osuch ats a s S use prin CNS origin. acute presentatiofnoofra hemirpisleegdia, the ceanntrdal origin t utho view of theNprooblem wUilnl abe obvioluasy. ,With clinical prob - This approach contrasts with problems that, disp lems where there are usually no localizing symp - based on the history, suggest a peripheral nervous toms, such as a headache or a seizure, the clinical system origin. For example, when the symptoms are exam is primarily directed towards the question of a localized to one limb ( i.e., with pain and numbness possible problem of central origin. in one arm).
    [Show full text]
  • Posterior Interosseous Neuropathy Supinator Syndrome Vs Fascicular Radial Neuropathy
    Posterior interosseous neuropathy Supinator syndrome vs fascicular radial neuropathy Philipp Bäumer, MD ABSTRACT Henrich Kele, MD Objective: To investigate the spatial pattern of lesion dispersion in posterior interosseous neurop- Annie Xia, BSc athy syndrome (PINS) by high-resolution magnetic resonance neurography. Markus Weiler, MD Methods: This prospective study was approved by the local ethics committee and written Daniel Schwarz, MD informed consent was obtained from all patients. In 19 patients with PINS and 20 healthy con- Martin Bendszus, MD trols, a standardized magnetic resonance neurography protocol at 3-tesla was performed with Mirko Pham, MD coverage of the upper arm and elbow (T2-weighted fat-saturated: echo time/repetition time 52/7,020 milliseconds, in-plane resolution 0.27 3 0.27 mm2). Lesion classification of the radial nerve trunk and its deep branch (which becomes the posterior interosseous nerve) was performed Correspondence to Dr. Bäumer: by visual rating and additional quantitative analysis of normalized T2 signal of radial nerve voxels. [email protected] Results: Of 19 patients with PINS, only 3 (16%) had a focal neuropathy at the entry of the radial nerve deep branch into the supinator muscle at elbow/forearm level. The other 16 (84%) had proximal radial nerve lesions at the upper arm level with a predominant lesion focus 8.3 6 4.6 cm proximal to the humeroradial joint. Most of these lesions (75%) followed a specific somato- topic pattern, involving only those fascicles that would form the posterior interosseous nerve more distally. Conclusions: PINS is not necessarily caused by focal compression at the supinator muscle but is instead frequently a consequence of partial fascicular lesions of the radial nerve trunk at the upper arm level.
    [Show full text]
  • Musculoskeletal Disorders and Treatment
    ISSN: 2572-3243 Terlemez et al. J Musculoskelet Disord Treat 2018, 4:045 DOI: 10.23937/2572-3243.1510045 Volume 4 | Issue 1 Journal of Open Access Musculoskeletal Disorders and Treatment ShorT CommEnTarY Diagnostic Ultrasound for Traumatic Radial Nerve Injury: A Visual Vignette Rana Terlemez*, Selda Çiftçi, Tülay Erçalık, Jülide Öncü, Figen Yilmaz and Banu Kuran Department of Physical Medicine and Rehabilitation, Şişli Hamidiye Etfal Training and Research Hospital, Turkey *Corresponding author: Rana Terlemez, MD, Department of Physical Medicine and Rehabilitation, Şişli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey, Tel: +90-5355544638, E-mail: Check for [email protected] updates A 35-year-old man had fallen down from the first lumbrical muscle grades were about 1/5. We also ob- floor and admitted emergency department with pain, served a sensory deficit in the radial nerve dermatome. swelling and deformity on the right elbow. The radio- In ultrasonographic examination, we observed thicken- graph showed fracture of the right supracondylar hu- ing in the nerve, increased hypoechogenicity and loss merus. After surgical exploration and internal fixations, of neuronal fascicle distinction at the distal part of the the patient referred to our clinic as elbow contracture elbow. No power Doppler signal was observed as a sign with traumatic median and ulnar nerve injury. The sur- of neovascularization (Figure 1). Electrodiagnostic stud- geon noted that radial nerve was seen as intact. In phys- ies also showed severe axonal injury to the radial nerve. ical examination strength of extensor carpi radialis, ex- Motor study of the radial nerve showed decrease in the tensor digitorum communis, extensor carpi ulnaris and compound muscle action potential (CMAP).
    [Show full text]
  • Peripheral Nerve Disorders
    CLINICAL GUIDELINES PND Imaging Policy Version 1.0 Effective February 14, 2020 eviCore healthcare Clinical Decision Support Tool Diagnostic Strategies: This tool addresses common symptoms and symptom complexes. Imaging requests for individuals with atypical symptoms or clinical presentations that are not specifically addressed will require physician review. Consultation with the referring physician, specialist and/or individual’s Primary Care Physician (PCP) may provide additional insight. CPT® (Current Procedural Terminology) is a registered trademark of the American Medical Association (AMA). CPT® five digit codes, nomenclature and other data are copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in the CPT® book. AMA does not directly or indirectly practice medicine or dispense medical services. AMA assumes no liability for the data contained herein or not contained herein. © 2019 eviCore healthcare. All rights reserved. PND Imaging Guidelines V1.0 Peripheral Nerve Disorders (PND) Imaging Guidelines Abbreviations for Peripheral Nerve Disorders Imaging Guidelines 3 PN-1: General Guidelines 4 PN-2: Focal Neuropathy 5 PN-3: Polyneuropathy 7 PN-4: Brachial Plexus 8 PN-5: Lumbar and Lumbosacral Plexus 9 PN-6: Muscle Disorders 10 PN-7: Magnetic Resonance Neurography (MRN) 13 PN-8: Amyotrophic Lateral Sclerosis (ALS) 14 PN-9: Peripheral Nerve Sheath Tumors (PNST) 15 PN-10: Nuclear Imaging 16 ______________________________________________________________________________________________________
    [Show full text]
  • Neuroanatomy for Nerve Conduction Studies
    Neuroanatomy for Nerve Conduction Studies Kimberley Butler, R.NCS.T, CNIM, R. EP T. Jerry Morris, BS, MS, R.NCS.T. Kevin R. Scott, MD, MA Zach Simmons, MD AANEM 57th Annual Meeting Québec City, Québec, Canada Copyright © October 2010 American Association of Neuromuscular & Electrodiagnostic Medicine 2621 Superior Drive NW Rochester, MN 55901 Printed by Johnson Printing Company, Inc. AANEM Course Neuroanatomy for Nerve Conduction Studies iii Neuroanatomy for Nerve Conduction Studies Contents CME Information iv Faculty v The Spinal Accessory Nerve and the Less Commonly Studied Nerves of the Limbs 1 Zachary Simmons, MD Ulnar and Radial Nerves 13 Kevin R. Scott, MD The Tibial and the Common Peroneal Nerves 21 Kimberley B. Butler, R.NCS.T., R. EP T., CNIM Median Nerves and Nerves of the Face 27 Jerry Morris, MS, R.NCS.T. iv Course Description This course is designed to provide an introduction to anatomy of the major nerves used for nerve conduction studies, with emphasis on the surface land- marks used for the performance of such studies. Location and pathophysiology of common lesions of these nerves are reviewed, and electrodiagnostic methods for localization are discussed. This course is designed to be useful for technologists, but also useful and informative for physicians who perform their own nerve conduction studies, or who supervise technologists in the performance of such studies and who perform needle EMG examinations.. Intended Audience This course is intended for Neurologists, Physiatrists, and others who practice neuromuscular, musculoskeletal, and electrodiagnostic medicine with the intent to improve the quality of medical care to patients with muscle and nerve disorders.
    [Show full text]
  • Distinguishing Radiculopathies from Mononeuropathies
    CURRICULUM, INSTRUCTION, AND PEDAGOGY published: 13 July 2016 doi: 10.3389/fneur.2016.00111 Distinguishing Radiculopathies from mononeuropathies Jennifer Robblee and Hans Katzberg* Division of Neurology, University Health Network (UHN), University of Toronto, Toronto, ON, Canada Identifying “where is the lesion” is particularly important in the approach to the patient with focal dysfunction where a peripheral localization is suspected. This article outlines a methodical approach to the neuromuscular patient in distinguishing focal neuropathies versus radiculopathies, both of which are common presentations to the neurology clinic. This approach begins with evaluation of the sensory examination to determine whether there are irritative or negative sensory signs in a peripheral nerve or dermatomal distri- bution. This is followed by evaluation of deep tendon reflexes to evaluate if differential hyporeflexia can assist in the two localizations. Finally, identification of weak muscle groups unique to a nerve or myotomal pattern in the proximal and distal extremities can most reliably assist in a precise localization. The article concludes with an application of the described method to the common scenario of distinguishing radial neuropathy versus C7 radiculopathy in the setting of a wrist drop and provides additional examples for self-evaluation and reference. Edited by: Keywords: radiculopathy, focal neuropathy, mononeuropathy, neuromuscular, nerve root Adolfo Ramirez-Zamora, Albany Medical College, USA Reviewed by: INTRODUCTION Ignacio Jose Previgliano, Maimonides University Although nerve conduction studies (NCS) and electromyography (EMG) are standard tests in the School of Medicine, Argentina evaluation of focal peripheral neuropathies (1), newer techniques, including peripheral nerve ultra- Robert Jerome Frysztak, sound and MRI neurography, have started to gain acceptance (2).
    [Show full text]
  • Challenges in Entrapments & Axonal Vs. Demyelinating Neuropathies
    Challenges in Entrapments & Axonal vs. Demyelinating Neuropathies Mazen M. Dimachkie, M.D. Professor of Neurology Executive Vice Chairman Vice Chairman for Research Programs Director of Neuromuscular Division University of Kansas Medical Center Kansas City, Kansas Dr. Dimachkie is on the speaker’s bureau or is a consultant for Baxalta, Catalyst, CSL Behring, Mallinckrodt, Novartis and NuFactor. He has received grants from Alexion, Biomarin, Catalyst, CSL-Behring, FDA/OPD, GSK, MDA, NIH, Novartis, Orphazyme and TMA. Case 1 A 39 year old woman presents with 3 years h/o right medial proximal forearm pain exacerbated with activity Examination: Normal strength, sensory and reflexes Tenderness in the right medial forearm Tinel sign over right medial forearm Supination causes pain radiation to thumb What pattern? NP3 Case 1 Which nerve is involved? A. Median at the wrist / Carpal tunnel Sd B. Median at the forearm C. Median at the brachial plexus D. Ulnar at the elbow E. Radial at the spiral groove Median Neuropathy at the Wrist aka Carpal Tunnel Syndrome The most common entrapment neuropathy Lifetime prevalence is 10%, 50% bilateral It is a clinical syndrome & mostly sensory Occasionally loss of dexterity due to weak opponens pollicis & APB Signs: Flick, Tinel & Phalen Mendell, Kissel, Cornblath,Diagnosis & Management of Peripheral Nerve Disorders, 2001 Anterior Interosseous Syndrome Weak FPL, pronator quadratus & long flexor of index & middle fingers Pinch sign or OK sign, no sensory loss Pain is exacerbated by resisted proximal interphalangeal flexion of the middle finger DDX: ‘Forme fruste’ of neuralgic amyotrophy; MMN; mass lesion Dimachkie MM. Median neuropathies other than carpal tunnel syndrome.
    [Show full text]
  • The Nerve.2020.6(2):83-85 the Nerve CASE REPORT
    eISSN2465-891X The Nerve.2020.6(2):83-85 The Nerve https://doi.org/10.21129/nerve.2020.6.2.83 CASE REPORT www.thenerve.net Surgical Treatment of Compressive Radial Neuropathy Presenting with Motor Weakness and Pain: A Case Report Gwangyoon Choi, Jinseo Yang, Yongjun Cho, Hyukjai Choi, Jinpyeong Jeon, Sukhyung Kang Department of Neurosurgery, Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Chuncheon, Republic of Korea Corresponding author: Jinseo Yang Compressive radial neuropathy, a type of nerve entrapment, can cause pain, extensor weak- Department of Neurosurgery, Chuncheon ness, and sensory change. Usually, clinicians draw a distinction between posterior intero- Sacred Heart Hospital, Hallym University posterior interosseous nerve (PIN) syndrome in which weak extensor function is the main College of Medicine, 77, Sakju-ro, Chuncheon 24253, Republic of Korea symptom, and radial tunnel syndrome (RTS), which causes pain but not motor weakness. Tel: +82-33-240-5171 Here, we present a case of a 55-year-old patient who experienced pain and tenderness in Fax: +82-70-5096-8691 his right forearm, followed by extensor weakness, leading to finger and wrist drop. After E-mail: [email protected] undergoing surgical intervention, the patient showed improvement in both pain and motor weakness. This report indicates that clinical diagnosis should focus on clinical presentation before distinguishment as PIN syndrome or RTS. We suggest surgical Received: May 18, 2020 intervention as an effective treatment for entrapment symptoms. Revised: June 8, 2020 Accepted: June 29, 2020 Key Words: Muscle weakness; Pain; Radial neuropathy INTRODUCTION CASE REPORT Compressive radial neuropathy, a type of nerve entrapment, A 58-year-old male patient was referred to us by a local can cause pain, extensor weakness, and sensory change5).
    [Show full text]
  • Traumatic Injury to Peripheral Nerves
    AAEM MINIMONOGRAPH 28 ABSTRACT: This article reviews the epidemiology and classification of traumatic peripheral nerve injuries, the effects of these injuries on nerve and muscle, and how electrodiagnosis is used to help classify the injury. Mecha- nisms of recovery are also reviewed. Motor and sensory nerve conduction studies, needle electromyography, and other electrophysiological methods are particularly useful for localizing peripheral nerve injuries, detecting and quantifying the degree of axon loss, and contributing toward treatment de- cisions as well as prognostication. © 2000 American Association of Electrodiagnostic Medicine. Published by John Wiley & Sons, Inc. Muscle Nerve 23: 863–873, 2000 TRAUMATIC INJURY TO PERIPHERAL NERVES LAWRENCE R. ROBINSON, MD Department of Rehabilitation Medicine, University of Washington, Seattle, Washington 98195 USA EPIDEMIOLOGY OF PERIPHERAL NERVE TRAUMA company central nervous system trauma, not only Traumatic injury to peripheral nerves results in con- compounding the disability, but making recognition siderable disability across the world. In peacetime, of the peripheral nerve lesion problematic. Of pa- peripheral nerve injuries commonly result from tients with peripheral nerve injuries, about 60% have 30 trauma due to motor vehicle accidents and less com- a traumatic brain injury. Conversely, of those with monly from penetrating trauma, falls, and industrial traumatic brain injury admitted to rehabilitation accidents. Of all patients admitted to Level I trauma units, 10 to 34% have associated peripheral nerve 7,14,39 centers, it is estimated that roughly 2 to 3% have injuries. It is often easy to miss peripheral nerve peripheral nerve injuries.30,36 If plexus and root in- injuries in the setting of central nervous system juries are also included, the incidence is about 5%.30 trauma.
    [Show full text]