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A Basic Approach to Common Upper Extremity Mononeuropathies and Brachial Plexopathies

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A Basic Approach to Common Upper Extremity Mononeuropathies and Brachial Plexopathies A Basic Approach to Common Upper Extremity Mononeuropathies and Brachial Plexopathies Paul E. Barkhaus, MD Aiesha Ahmed, MD Kerry H. Levin, MD Zachary Simmons, MD AANEM 60th Annual Meeting San Antonio, Texas Copyright © October 2013 American Association of Neuromuscular & Electrodiagnostic Medicine 2621 Superior Drive NW Rochester, MN 55901 Printed by Johnson Printing Company, Inc. 11 Please be aware that some of the medical devices or pharmaceuticals discussed in this handout may not be cleared by the FDA or cleared by the FDA for WKHVSHFL¿FXVHGHVFULEHGE\WKHDXWKRUVDQGDUH³RIIODEHO´ LHXVHQRWGHVFULEHGRQWKHSURGXFW¶VODEHO ³2IIODEHO´GHYLFHVRUSKDUPDFHXWLFDOVPD\EH XVHGLILQWKHMXGJPHQWRIWKHWUHDWLQJSK\VLFLDQVXFKXVHLVPHGLFDOO\LQGLFDWHGWRWUHDWDSDWLHQW¶VFRQGLWLRQ,QIRUPDWLRQUHJDUGLQJWKH)'$FOHDUDQFH VWDWXVRIDSDUWLFXODUGHYLFHRUSKDUPDFHXWLFDOPD\EHREWDLQHGE\UHDGLQJWKHSURGXFW¶VSDFNDJHODEHOLQJE\FRQWDFWLQJDVDOHVUHSUHVHQWDWLYHRUOHJDO FRXQVHORIWKHPDQXIDFWXUHURIWKHGHYLFHRUSKDUPDFHXWLFDORUE\FRQWDFWLQJWKH)'$DW 22 A Basic Approach to Common Upper Extremity Mononeuropathies and Brachial Plexopathies Table of Contents 3URJUDP&RPPLWWHH &RXUVH2EMHFWLYHV Faculty 5 The Median Nerve: A Schematic Approach With Clinical Neurophsyiological Pitfalls and Myths 7 Paul E. Barkhaus, MD Ulnar Nerve 17 Aiesha Ahmed, MD The Radial Nerve 23 Kerry H. Levin, MD Brachial Plexopathies: The Basics 27 Zachary Simmons, MD CME Questions 33 1RRQHLQYROYHGLQWKHSODQQLQJRIWKLV&0(DFWLYLW\KDGDQ\UHOHYDQW¿QDQFLDOUHODWLRQVKLSVWRGLVFORVH Authors/faculty have nothing to disclose Chair: Zachary Simmons, MD 7KHLGHDVDQGRSLQLRQVH[SUHVVHGLQWKLVSXEOLFDWLRQDUHVROHO\WKRVHRIWKHVSHFL¿FDXWKRUV DQGGRQRWQHFHVVDULO\UHSUHVHQWWKRVHRIWKH$$1(0 33 Objectives Objectives - Participants will acquire skills to (1) Identify and distinguish the anatomical and clinical features of upper extremity mononeuropathies and brachial plexopathies, (2) design and perform EDX studies for assessment of median, ulnar, and radial neuropathies and brachial plexopathies, and FRUUHFWO\LQWHUSUHWWKH(';¿QGLQJVZKHQVWXG\LQJPHGLDQXOQDUDQGUDGLDOQHXURSDWKLHVDQGEUDFKLDOSOH[RSDWKLHV Target Audience: Neurologists, physical medicine and rehabilitation and other physicians interested in neuromuscular and electrodiagnostic medicine Health care professionals involved in the diagnosis and management of patients with neuromuscular diseases Researchers who are actively involved in the neuromuscular and/or electrodiagnostic research Accreditation Statement - The AANEM is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing PHGLFDOHGXFDWLRQ &0( IRUSK\VLFLDQV CME Credit - 7KH$$1(0GHVLJQDWHVWKLVOLYHDFWLYLW\IRUDPD[LPXPRISXWLQAMA PRA Category 1 Credits™,ISXUFKDVHGWKH$$1(0 GHVLJQDWHVWKLVHQGXULQJPDWHULDOIRUDPD[LPXPRIAMA PRA Category 1 Credits™7KLVHGXFDWLRQDOHYHQWLVDSSURYHGDVDQ$FFUHGLWHG*URXS /HDUQLQJ$FWLYLW\XQGHU6HFWLRQRIWKH)UDPHZRUNRI&RQWLQXLQJ3URIHVVLRQDO'HYHORSPHQW &3' RSWLRQVIRUWKH0DLQWHQDQFHRI&HUWL¿FDWLRQ 3URJUDPRIWKH5R\DO&ROOHJHRI3K\VLFLDQVDQG6XUJHRQVRI&DQDGD3K\VLFLDQVVKRXOGFODLPRQWKHFUHGLWFRPPHQVXUDWHZLWKWKHH[WHQWRIWKHLU SDUWLFLSDWLRQLQWKHDFWLYLW\&0(IRUWKLVFRXUVHLVDYDLODEOH± CEUs Credit -7KH$$1(0KDVGHVLJQDWHGWKLVOLYHDFWLYLW\IRUDPD[LPXPRI$$1(0&(8¶V,ISXUFKDVHGWKH$$1(0GHVLJQDWHVWKLV HQGXULQJPDWHULDOIRUDPD[LPXPRI&(8¶V 2012-2013 Program Committee Vincent Tranchitella, MD, Chair Robert W. Irwin, MD David B. Shuster, MD York, PA Miami, FL Dayton, OH Thomas Bohr, MD, FRCPC Shawn Jorgensen, MD Zachary Simmons, MD Loma Linda, CA Queensbury, NY Hershey, PA Jasvinder P. Chawla, MBBS, MD, MBA A. Atruro Leis, MD Jeffrey A. Strommen, MD Atlanta, GA Jackson, MS Rochester, MN Maxim Moradian, MD T. Darrell Thomas, MD New Orleans, LA Knoxville, TN 2012-2013 AANEM President Peter A. Grant, MD Medford, OR A Basic Approach to Common Upper Extremity Mononeuropathies and Brachial Plexopathies Faculty Paul E. Barkhaus, MD Kerry H. Levin, MD Professor of Neurology and Physical Medicine & Chairman, Department of Neurology Rehabilitation, Medical College of Wisconsin Director, Neuromuscular Center 0LOZDXNHH:, Cleveland Clinic Cleveland, OH 'U %DUNKDXV UHFHLYHG KLV PHGLFDO GHJUHH IURP :D\QH 6WDWH 8QLYHUVLW\LQ'HWURLW0,+HFRPSOHWHGHOHFWURP\RJUDSK\ (0* 'U /HYLQ UHFHLYHG KLV PHGLFDO GHJUHH IURP -RKQV +RSNLQV IHOORZVKLSVDWWKH8QLYHUVLW\RI0LQQHVRWDDQG'XNH8QLYHUVLW\ 8QLYHUVLW\ 6FKRRO RI 0HGLFLQH +H FRPSOHWHG KLV QHXURORJ\ as well as a fellowship in clinical neuromuscular diseases at the UHVLGHQF\ DW 8QLYHUVLW\ RI &KLFDJR +RVSLWDOV DQG DQ 8QLYHUVLW\RI$UL]RQD+HLVDSURIHVVRURIQHXURORJ\DQGSK\VLFDO HOHFWURP\RJUDSK\ (0* IHOORZVKLSDW0D\R&OLQLFLQ5RFKHVWHU PHGLFLQH UHKDELOLWDWLRQDWWKH0HGLFDO&ROOHJHRI:LVFRQVLQ 01+HLVFXUUHQWO\WKHFKDLUPDQRIWKH'HSDUWPHQWRI1HXURORJ\ He is also head of the Neuromuscular Disease and Autonomic DQGWKHGLUHFWRURIWKH1HXURPXVFXODU&HQWHUDW&OHYHODQG&OLQLF Section in the Department of Neurology and director of the ALS +HDOVRVHUYHVDVWKHQHXURORJ\GLUHFWRUIRUWKH$PHULFDQ%RDUG 3URJUDP +H KDV QXPHURXV SXEOLFDWLRQV RQ TXDQWLWDWLYH (0* RI3V\FKLDWU\DQG1HXURORJ\ motor nerve conductions, motor unit estimation as well as multi- PHGLDHGXFDWLRQDOPDWHULDOV Zachary Simmons, MD Professor of Neurology Aiesha Ahmed, MD Director, Neuromuscular Program and EMG Laboratory Program Director, Clinical Neurophysiology and Pennsylvania State University Hershey Medical Center Neuromuscular Medicine Fellowships Hershey, PA Assistant Professor of Neurology Pennsylvania State University Hershey Medical Center 'U 6LPPRQV UHFHLYHG KLV PHGLFDO GHJUHH IURP WKH 8QLYHUVLW\ Hershey, PA RI )ORULGD DQG WKHQ WUDLQHG LQ QHXURORJ\ DW WKH 8QLYHUVLW\ RI Iowa and in neuromuscular diseases and electromyography at the 'U$KPHG UHFHLYHG KHU PHGLFDO GHJUHH IURP %DTXDL 0HGLFDO 8QLYHUVLW\RI0LFKLJDQ+HQRZVHUYHVDVSURIHVVRURIQHXURORJ\ College in Karachi, Pakistan, and an internship in internal DW3HQQV\OYDQLD6WDWH8QLYHUVLW\+HUVKH\0HGLFDO&HQWHUZKHUH PHGLFLQHDW6W-RVHSK+RVSLWDOLQ&KLFDJR6KHFRPSOHWHGKHU KHLVWKHGLUHFWRURIWKH1HXURPXVFXODU3URJUDPDQGWKH(0* QHXURORJ\UHVLGHQF\IURPWKH8QLYHUVLW\RI,OOLQRLVDW&KLFDJR /DERUDWRU\+HIRXQGHGDQGGLUHFWVWKH+HUVKH\0HGLFDO&HQWHU and a clinical neurophysiology fellowship and neuromuscular $/6 &OLQLF $FWLYH UHVHDUFK SURJUDPV XQGHU KLV VXSHUYLVLRQ PHGLFLQH IHOORZVKLS ERWK IURP 3HQQ 6WDWH 8QLYHUVLW\ 'U include studies of quality of life, the development of evidence- Ahmed is the program director of Clinical Neurophysiology and based practice protocols, the use of brain-computer interfaces, Neuromuscular medicine fellowships and an assistant professor DQGJHQRPLFVRI$/6'U6LPPRQVKDVVHUYHGRQWKH$PHULFDQ RIQHXURORJ\DW3HQQV\OYDQLD6WDWH8QLYHUVLW\+HUVKH\0HGLFDO Association of Neuromuscular and Electrodiagnostic Medicine &HQWHU6KHLVFHUWL¿HGE\WKH$PHULFDQ%RDUGRI3V\FKLDWU\DQG 7UDLQLQJ 3URJUDP :RUNVKRS DQG 3URJUDP &RPPLWWHHV KDV 1HXURORJ\ $PHULFDQ %RDUG RI &OLQLFDO 1HXURSK\VLRORJ\ DQG EHHQFKDLURIWKH$PHULFDQ%RDUGRI(OHFWURGLDJQRVWLF0HGLFLQH $PHULFDQ ERDUG RI 1HXURPXVFXODU 0HGLFLQH 6KH LV FXUUHQWO\ $%(0 0DLQWHQDQFHRI&HUWL¿FDWLRQ&RPPLWWHH+HLVFXUUHQWO\ D *0( FRPPLWWHH PHPEHU IRU $PHULFDQ $VVRFLDWLRQ RI co-chair of the Program Committee and serves on the AANEM 1HXURPXVFXODUDQG(OHFWURGLDJQRVWLF0HGLFLQH %RDUGRI'LUHFWRUV'U6LPPRQVLVDQ$%(0'LSORPDWH 55 66 A BASIC APPROACH TO COMMON UPPER EXTREMITY MONONEUROPATHIES AND BRACHIAL PLEXOPATHIES The Median Nerve: A Schematic Approach With Clinical Neurophysiologic Pitfalls and Myths Paul E. Barkhaus, MD Professor of Neurology and Physical Medicine & Rehabilitation, Medical College of Wisconsin 0LOZDXNHH:, INTRODUCTION A traditional choice for discussing the median nerve (MN) is the Forearm FRQYHQWLRQDO³URRWWR¿QJHUQDLO´DQDWRPLFFRXUVHRIWKH01ZLWK The MN descends through the forearm, deep and adherent to the D OLWWOH HVRWHULFD WKURZQ LQ IRU JRRG PHDVXUH +HUH D GLIIHUHQW ÀH[RU GLJLWRUXP VXSHU¿FLDOLV$ERXW FP SUR[LPDO WR WKH ÀH[RU DSSURDFK LV WDNHQ JLYHQ WKH OLPLWHG WLPH IRU WKLV SUHVHQWDWLRQ UHWLQDFXOXPLWHPHUJHVIURPEHKLQGWKHODWHUDOHGJHRIWKH)'67KXV %HJLQQLQJZLWKWKHWUDGLWLRQDODQDWRP\SURSHUKRPDJHLVSDLG LWEHFRPHVPRUHVXSHU¿FLDOMXVWSUR[LPDOWRWKHZULVWO\LQJEHWZHHQ WR WKH PDQ\ SRWHQWLDO DQDWRPLF YDULDQWV 7KLV LV IROORZHG E\ WKHWHQGRQVRIWKHÀH[RUFDUSLUDGLDOLV )&5 DQG)'6:KHQSUHVHQW sections on functional anatomy, focal lesions, and MN mimic LWPD\EHFRYHUHGE\WKHWHQGRQRIWKHSDOPDULVORQJXV V\QGURPHV7KHODVWVHFWLRQVRQHOHFWURGLDJQRVLVFRYHUWKHPRWRU and sensory study of the MN with emphasis on electrodiagnostic The branches of the MN in the forearm include an articular ('; SLWIDOOV DQG P\WKV 0DQ\ RI WKH ODWWHU DSSO\ WR FOLQLFDO EUDQFK LHHOERZDQGSUR[LPDOUDGLRXOQDUMRLQWV DQGPXVFXODU QHXURSK\VLRORJ\LQJHQHUDOEXWLQWKLVDXWKRU¶VRSLQLRQWKH\DUH EUDQFKHV WR WKH IRUHDUP ÀH[RUV SURQDWRU WHUHV )&5 SDOPDULV SDUWLFXODUO\LPSRUWDQWLQVWXG\LQJWKH017KHXOWLPDWHJRDOLV ORQJXVDQG)'6 7KHEUDQFK HV WRWKHSURQDWRUWHUHVPD\DULVH IRUWKHUHDGHUWREHDEOHWRXWLOL]HWKHVHSUDFWLFDOWHDFKLQJSRLQWV MXVW DERYH DW RU LPPHGLDWHO\ EHORZ WKH PHGLDO HSLFRQG\OH WREHQH¿WWKHLUSDWLHQWV The muscular branches to the FCR are almost always distal to the medial epicondyle and may occur as separate branches or ANATOMY EUDQFKHVLQFRPPRQZLWKWKRVHVXSSO\LQJWKH)'6$QH[FHSWLRQ LVWKHEUDQFKRIWKH)'6WKDWVXSSOLHVWKHLQGH[¿QJHU7KLVEUDQFK The typical course of the MN is described below, followed by a DULVHVGLVWDOO\LQWKHPLGGOHRIWKHIRUHDUP EULHIGHVFULSWLRQRIDQDWRPLFYDULDQWV+HUHHPSKDVLVLVRQWKH PXVFXODUDQGFXWDQHRXVEUDQFKHV 7KHDQWHULRULQWHURVVHRXVQHUYH $,1 LVDGLVWLQFWPDMRUEUDQFK RIWKH01WKDWDULVHVIURPWKHSRVWHULRUVXUIDFHRIWKH01MXVW Origin and Upper Arm GLVWDO WR WKH VSHFL¿F PXVFOH EUDQFKHV PHQWLRQHG DERYH ZKHUH 7KH¿EHUVRIWKH01RULJLQDWHIURPIRXUPDLQURRWV&DQG
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