Compression neuropathy in the upper limb
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Compression neuropathy: pathophysiology, history, diagnosis, and treatment (including the management of carpal tunnel syndrome, and cubital tunnel syndrome).
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Compression neuropathy in the upper limb
- 1. Compression neuropathy – pathophysiology & treatment Ian Grant Consultant Plastic Surgeon - Cambridge 17/10/2014
- 2. Compression neuropathy: Chronic Nerve Compression: acquired neuro-degenerative condition – demyelination Axon loss – only in later stages of the disease Pathophysiology – Schwann cell Genetics History of surgical intervention Diagnosis / tests – decision making chronic nerve compression
- 3. Central nervous system - not subject to compression or stretch Peripheral nervous system - vulnerable to compression or stretch • Chronic nerve compression Syndromes Carpal tunnel syndrome Cubital tunnel syndrome Supraspinatus syndrome Anterior interosseous syndrome Posterior interosseous syndrome Thoracic outlet syndrome Meralgia parasethetica Tarsal Tunnel syndrome Peroneal syndrome Peripheral entrapment neuropathy Symptoms - Tingling, numbness, pain, Pathophysiology - Reduced conduction Abnormal excitability
- 4. RELEASE OF CONSTRICTION – RELIEVES SYMPTOMS
- 5. Photo supplied by: CHOJNOWSKI ADRIAN OBVIOUS MACROSCOPIC CHANGES IN MEDIAN NERVE AT CONSTRICTION THENAR MUSCLE WASTING
- 6. Chronic nerve compression proximal compression systemic conditions genetic predispositio n HNLPP Diabetes, Amyloid Hypothyroid, Pregnancy , Obesity 1.5 megabase deletion , 17p11.2 – PMP22
- 7. AGE 1039 pt’s neurophysiological carpal tunnel syndrome. Nora et al 2004 Mean Age 48 PREVALENCE CTS European Prevalence: estimate 2.7-5.8 % AGE & PREVALENCE OF CARPAL TUNNEL SYNDROM
- 8. >53000 operations for CTS England 2011
- 9. NERVE ANATOMY – THE NERVE CELL With thanks to Caitlin Monney: illustrator
- 10. Compression neuropathy – crucial event is dymelination - crucial cell – the Swann Cell Sh3tc2 tuj1 Sh3tc2 tuj1
- 12. ANATOMY – NERVE FIBRES With thanks to Caitlin Monney: illustrator
- 13. Denny-Brown, and Bremmer 1944 – rodent sciatic nerve compression Investigation of compression neuropathy Oedema – is evident within 4 hours of constriction
- 14. 4 hours: 80mmHg Oedema Cannulation of the compressed peripheral nerve: confirms increased fluid pressure
- 15. Histologic studies confirm that with prolonged compression (> 4 hours) demeylination occurs Demyelination
- 16. In vitro studies of Schwann cells, compression results in: c-Jun, Knox-20
- 17. Neurosci Lett 2009 In vitro immunoflouresence of Schwann cells distraction results in: Characteristic changes in morphology – bands appear
- 18. Compression / stretching Vascular compromise oedema Schwann cell activation Demyelination / remyelination Thin myelin Axon loss, Intraneural fibrosis / degeneration Axoplasmic transport interrupted Intraneural fibosis: reduced extensibility increased ion channels along axon: Abnormal Impulse Generating Sites Matrix-metalloproteinases (MMPs) 2 and 9 hypoxia-inducible factor 1α (HIF1α), catalase, superoxide dismutase (SOD) Summary of sequence of changes -
- 19. With thanks to Caitlin Monney: illustrator
- 20. The double crush in nerve entrapment syndromes Adrian Upton, Alan McComas, Lancet 1973 • 115 patients with entrapment • 70% had cervical lesion A sick nerve or proximal compression: predisposes to entrapment neuropathy at a peripheral site This is explained through interruption of axoplasmic transport
- 21. Nerve pain: mechanically sensitive as consequence of compression or entrapment • Ectopic electrogenesis • Nervi-nervorum on outside of nerve – increased sensitivity to stretch STRAIN Connective tissue thickening Restricted neural mobility
- 22. Dilley and Bove 2008 Failure of axoplasmic transport results in accumulation of mechanosensitive components proximal to the blockage
- 23. Oedema Demyelination / remyelination Diffuse Demyelination, structural irreversible changes / established pain and weakness Duration and magnitude of compression symptoms Irretrievable Loss of function Window of treatment
- 24. Treatment : non surgical
- 25. Ramsay Hunt: The thenar and hypothenar types of neural atrophy of the Hand American Journal of Medical Sciences 1911 Gessler:Die motorische Endplatte und ihre Bedeutung für die peripherische Lähmung, Habitations Schrift, München, 1885 Treatment: Surgery for CTS Marie and Foix 1913: Atrophie isolé de l’éminence thénar d’origine néevritique. Rôle du ligament annulaire antérieur du carpe dans la patholgénie de la lésion. Rev Neurol., 26: 647-649, 1913 Severe bilateral atrophy of the thenar muscles, at autopsy a neuroma of the median nerv just proximal to the transverse carpal ligament
- 26. Lancet 1946: Spontaneous compression of both median nerve in the carpal tunnel Russell Brian DM Oxfd, FRCP A Dickson Wright MS Lond., FRCS Marcia Wilkinson BM Oxfd, MRCP 6 cases – middle aged or elderly women Treated by surgical division of the carpal ligament at the wrist
- 27. Marcia Wilkinson DM Oxfd FRCP 4th February 2013 Arthur Dickson-Wright MS Lond FRCS Father to the chef: Clarissa Dickson-Wright
- 28. Phalen 1950: Neuropathy of the median nerve due to compression beneath the transverse carpal ligament 4 cases = three of which were treated by surgical division of the transverse carpal Ligament, with excellent results Linked disease to occupation ?
- 29. Ulnar nerve compression – cubital tunnel syndrome Panas, J 1878: Sur une cause peu connue de pralysie du nerf cubital Archivee Générales de Médecine, 2 (VII Serie) Repeated trauma – hyperaemia – oedema, - infiltration of fibrous tissue Geoffrey Osbourne 1957: “tardy ulnar neuritis” – band of fibrous tissue bridging the two heads of flexor carpi ulnaris – Sir W.R Gowers 1866 – Manual of diseases of the nervous system Alan Apley remarked : that he had “difficulty accepting this analogy, - pain was a prominent factor in carpal tunnel syndrome”
- 31. The patient has severe neurological symptoms at presentation for example altered sensation, muscle wasting or weakness of thenar abduction. OR The patient has moderate symptoms has not responded to a minimum of 3 months of conservative management, including local corticosteroid injections and a compliant trial of nocturnal neutral wrist splints. Surgery funded if :
- 32. • Mild – intermittent paraesthesia • Moderate – paraesthesia that interferes with ADL – constant waking • Severe – constant numbness, wasting, weakness of thumb muscles
- 33. Clinical tests – questionable value CTS • Tinel’s • Phalen’s • Reverse Phalen’s • Carpal compression Cubital tunnel syndrome • Elbow flexion • Froment’s Catch me if you can 2002
- 34. Sensibility testing LIGHT MOVING TOUCH Ten-test1 – compare two sides(1.Strauch et al 1997 PRS) Reliable in unilateral / early disease 2-point discrimination – late disease
- 35. Neurophysiological tests Images: Dr Andrew Michell, Consultant Neurophysiologist • Scored questionnaire • 80-85% sensitivity, 90% positive predictive value • Nerve Conduction studies • 92-96% sensitive, 92- 94% positive predictive
- 37. • Scar • Grip 4 weeks 4 months
- 38. Ian Grant Consultant in plastic & reconstructive surgery Cambridge Addenbrooke’s Hospital The Spire Lea Hospital Hand surgery: including children’s hands & peripheral nerve surgery With thanks to Caitlin Monney, Dr Rhys Russel, Mr Adrain Choznowski, Mr Harry Belcher, Dr Andrew Michell