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Common Entrapment Neuropathies Review Article 04/25/2018 on mAXWo3ZnzwrcFjDdvMDuzVysskaX4mZb8eYMgWVSPGPJOZ9l+mqFwgfuplwVY+jMyQlPQmIFeWtrhxj7jpeO+505hdQh14PDzV4LwkY42MCrzQCKIlw0d1O4YvrWMUvvHuYO4RRbviuuWR5DqyTbTk/icsrdbT0HfRYk7+ZAGvALtKGnuDXDohHaxFFu/7KNo26hIfzU/+BCy16w7w1bDw== by https://journals.lww.com/continuum from Downloaded Downloaded Address correspondence to Dr Lisa D. Hobson-Webb, Department of Neurology, from Common Entrapment Duke University Medical https://journals.lww.com/continuum Center, DUMC 3403, Room Neuropathies 1255 EMG Laboratory, Durham, NC 27710, Lisa D. Hobson-Webb, MD; Vern C. Juel, MD, FAAN [email protected]. Relationship Disclosure: Dr Hobson-Webb has served on the editorial board of by mAXWo3ZnzwrcFjDdvMDuzVysskaX4mZb8eYMgWVSPGPJOZ9l+mqFwgfuplwVY+jMyQlPQmIFeWtrhxj7jpeO+505hdQh14PDzV4LwkY42MCrzQCKIlw0d1O4YvrWMUvvHuYO4RRbviuuWR5DqyTbTk/icsrdbT0HfRYk7+ZAGvALtKGnuDXDohHaxFFu/7KNo26hIfzU/+BCy16w7w1bDw== ABSTRACT Clinical Neurophysiology and as an associate editor Purpose of Review: This article addresses relevant peripheral neuroanatomy, for Muscle & Nerve. clinical presentations, and diagnostic findings in common entrapment neuropathies Dr Hobson-Webb involving the median, ulnar, radial, and fibular (peroneal) nerves. receives research/grant support from CSL Behring, Recent Findings: Entrapment neuropathies are a common issue in general neurology the National Institute on practice. Early diagnosis and effective management of entrapment mononeuropathies Aging/Duke University are essential in preserving limb function and maintaining patient quality of life. Median Claude D. Pepper Older Americans Independence neuropathy at the wrist (carpal tunnel syndrome), ulnar neuropathy at the elbow, radial Center, and Sanofi Genzyme. neuropathy at the spiral groove, and fibular neuropathy at the fibular head are among Dr Juel receives research/ the most frequently encountered entrapment mononeuropathies. Electrodiagnostic grant support as site investigator for studies for studies and peripheral nerve ultrasound are employed to help confirm the clinical Alexion Pharmaceuticals, diagnosis of nerve compression or entrapment and to provide precise localization for Inc and the National Institute nerve injury. Peripheral nerve ultrasound demonstrates nerve enlargement at or near of Allergy and Infectious Diseases, Division of sites of compression. Microbiology and Summary: Entrapment neuropathies are commonly encountered in clinical practice. Infectious Diseases. Accurate diagnosis and effective management require knowledge of peripheral Unlabeled Use of neuroanatomy and recognition of key clinical symptoms and findings. Clinical Products/Investigational Use Disclosure: diagnoses may be confirmed by diagnostic testing with electrodiagnostic studies Drs Hobson-Webb and Juel and peripheral nerve ultrasound. report no disclosures. * 2017 American Academy of Neurology. Continuum (Minneap Minn) 2017;23(2):487–511. INTRODUCTION median nerve. Carpal tunnel syn- This article focuses on peripheral drome may be present in up to 42% mononeuropathies, indicating dis- of workers in certain occupations ease or dysfunction in a single periph- (eg, poultry processing) and has an eral nerve. Mononeuropathies may be annual incidence of 193 per 100,000 in caused by focal compression, inflam- all women.1,2 Its prevalence in the mation, nerve tumors, trauma, or United States is estimated at 50 per other etiologies. Compression (or 1000, with a cost of $30,000 per entrapment) is the most common affected individual.3 Morton neuroma, cause. While mononeuropathies may ulnar neuropathy, meralgia paresthetica, also be superimposed upon a back- and radial neuropathy represent ground of polyneuropathy, a survey the other most common peripheral of polyneuropathies is beyond the mononeuropathies.2 scope of this article. Knowing peripheral nerve anatomy Entrapment mononeuropathies and function allows clinical localiza- represent a common reason for visits tion that can be further refined and to primary care and outpatient neu- confirmed with electrodiagnostic stud- on rology practices. The most common of ies and peripheral nerve imaging. In 04/25/2018 these, carpal tunnel syndrome, is patients with mononeuropathy, the related to chronic compression of the etiology, severity, odds of spontaneous Continuum (Minneap Minn) 2017;23(2):487–511 ContinuumJournal.com 487 Copyright © American Academy of Neurology. Unauthorized reproduction of this article is prohibited. Entrapment Neuropathies KEY POINT h Early diagnosis and recovery, and patient preferences MEDIAN NERVE effective management are important factors that guide Median neuropathy at the wrist, spe- of mononeuropathies treatment. Early diagnosis and ef- cifically carpal tunnel syndrome, is the are essential in improving fective management of mononeuro- most common mononeuropathy of patient quality of life and pathies are essential in improving adults. A thorough understanding of reducing costs of care. patient quality of life and reducing the anatomy of the median nerve and costs of care. adjacent structures and of associated This article presents the most com- diagnostic techniques is therefore in- monly encountered entrapment mono- valuable in outpatient neurology. neuropathies, with a focus on relevant anatomy, clinical symptoms, methods Basic Anatomy of diagnosis, and recommended The median nerve forms from the treatment. The pathophysiologic pro- terminal divisions of the medial and cesses related to peripheral nerve lateral cords of the brachial plexus, trauma and compression are not receiving contributions from the C5 to covered in this discussion because T1 nerve roots (Figure 7-1). It courses of space limitations but are compre- medial to the brachial artery throughout hensively reviewed by Stewart.4 the upper arm. In the distal arm, the FIGURE 7-1 Median nerve. The nerve is labeled in bold, and sensory branches are labeled in italics. B 2016 Vern C. Juel. 488 ContinuumJournal.com April 2017 Copyright © American Academy of Neurology. Unauthorized reproduction of this article is prohibited. KEY POINT nerve may pass beneath the ligament In the distal carpal tunnel, the h Patients with carpal of Struthers, which is present in some median nerve divides into the motor tunnel syndrome individuals (1% to 13%) and represents (thenar) branch and sensory branches classically present a rare cause of median nerve entrap- to the digits and palm. The motor with numbness, 5,6 ment. The nerve then passes under branch innervates the abductor tingling, and other the bicipital aponeurosis at the elbow. pollicis brevis, opponens pollicis, and paresthesia affecting Moving distally, the median nerve superficial head of flexor pollicis the first through third then travels between the two heads of brevis.10 An accessory thenar branch digits and the lateral the pronator teres, deep to the hu- may innervate the flexor pollicis brevis aspect of the fourth meral head and superficial to the ul- in nearly half of patients.10 digit. It is not unusual nar head. The nerve then continues Median nerve anatomic variants. for patients to report sensory symptoms distally between the flexor digitorum Martin-Gruber anastomoses are the affecting the entire superficialis and flexor digitorum most common anatomic variants af- hand or radiation from profundus muscles. Approximately fecting the median nerve, with an the hand to the proximal 4 cm distal to the medial epicondyle, estimated prevalence ranging from upper extremity. the anterior interosseus nerve branches 20% to 40%.11,12 Martin-Gruber anas- from the main trunk of the median tomoses typically leave the main me- nerve.5 The anterior interosseus nerve dian nerve or anterior interosseus innervates the flexor pollicis longus, nerve trunk near the elbow and cross flexor digitorum profundus to the over to join the ulnar nerve. There are second and third digits, and prona- four to six types of Martin-Gruber tor quadratus. anastomoses based on the exact anat- Just proximal to the distal wrist omy.12 The main significance of a crease, the palmar cutaneous branch of Martin-Gruber anastomosis is the the median nerve leaves the main nerve confounding effect that it may cause trunk.5 It travels between the palmaris in interpretation of electrodiagnostic longus and flexor carpi radialis tendons studies, as discussed later in this and proceeds outside the carpal tunnel article. Other rare anatomic variants to provide sensation for the thenar of the median nerve include the eminence and proximal lateral palm.7,8 Riche-Cannieu anastomosis (‘‘the all- The median nerve lies superficially ulnar hand’’), Berrettini anastomosis, at the volar distal wrist crease, an and Marinacci anastomosis (the reverse external landmark that roughly ap- Martin-Gruber anastomosis).11 proximates the carpal tunnel inlet. The flexor retinaculum forms the roof Clinical Presentation of the carpal tunnel. Deep to and The most common median mono- surrounding the nerve are the tendons neuropathy results from median nerve of the flexor pollicis longus, flexor compression at the wrist, causing digitorum superficialis, and flexor carpal tunnel syndrome. Patients with digitorum profundus.9 The hook of carpal tunnel syndrome classically the hamate, pyramidal, and pisiform present with numbness, tingling, and bones form the medial (ulnar) border other paresthesia affecting the first of the carpal tunnel, while the scaph- through third fingers and the lateral oid bone, trapezoid bone, and tendon aspect of the fourth finger. It is not of the flexor
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