Compression neuropathy: pathophysiology, history, diagnosis, and treatment (including the management of carpal tunnel syndrome, and cubital tunnel syndrome).
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
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
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
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
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”
30.
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
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