Entrapment Neuropathies by Dr. Aryan

Entrapment Neuropathies with basic focus on Carpal Tunnel Syndrome

1. Entrapment neuropathies Presented by : Anish Dhakal 24 th May, 2019 5/23/2019 1

2. Introduction Also known as nerve compression syndrome Compression of peripheral nerve When nerve traverse fibro-osseous tunnel, risk of entrapment and compression Nerve compression impairs epineural blood flow and axonal conduction  giving rise to symptoms

3. Introduction Symptoms Numbness Paraesthesia Muscle weakness Prolonged or severe compression Segmental demyelination Target muscle atrophy Nerve fibrosis

4. Entrapment Neuropathies Median Neuropathy Ulnar Neuropathy Radial Neuropathy Common peroneal Neuropathy Proximal Femoral Neuropathy Lateral Femoral Neuropathy Posterior tibial neuropathy

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6. Carpal Tunnel Syndrome Most common entrapment neuropathy Compression of the median nerve at the wrist Swelling  Compression  Ischemia of nerve More common in women Age group: 40–50 years

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8. Causes Inflammatory causes Rheumatoid arthritis Wrist osteoarthritis Post-traumatic causes Bone thickening after a Colles ' fracture Endocrine causes Diabetes Myxoedema Acromegaly Hypothyroidism Pregnancy Idiopathic commonest cause

9. Clinical Features Pain and paraesthesia in the distribution of median nerve in hand Burning pain, tingling and numbness causing patient to wake up at night Relieving factor: hanging the arm over the side of the bed or shaking the arm

10. sensory loss Median nerve distribution

11. Diagnosis History Motor examination Wasting and weakness of the median- innervated hand muscles (LOAF muscles) L - First and second lumbricals O - Opponens pollicis A - Abductor pollicis brevis F - Flexor pollicis brevis

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13. Special Test Tinel’s nerve percussion test Gentle tapping over the median nerve in the carpal tunnel region  elicits tingling in the nerve distribution Phalen’s wrist flexion test Full flexion of the wrists for up to 60 seconds  induce tingling sensation Electromyography

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15. Phalen’s test 5/23/2019 15

16. Treatment 5/23/2019 16

17. Wrist Splints & Physiotherapy Light splints that prevent wrist flexion  help those with night pain or with pregnancy-related symptoms Most effective when it is applied within three months of the onset of symptoms

18. Oral medication Nonsteroidal anti-inflammatory drugs (NSAIDs) Orally administered corticosteroids Prednisolone 20 mg per day for two weeks followed by 10 mg per day for two weeks

19. F ailure of conservative therapy: Long duration of symptoms (>10 months) Age greater than 50 Constant paresthesias Impaired two-point discrimination (>6 mm) Positive Phalen's sign <30 seconds Prolonged motor and sensory latencies demonstrated by electrodiagnostic testing

20. Treatment Oral glucocorticoid or injections: 10 to 20 mg of lidocaine without epinephrine + 20 to 40 mg of methylprednisolone acetate Surgical: carpel tunnel release

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22. Local Injection Steroid injection into the carpal canal  provides temporary relief Splinting is generally recommended after local corticosteroid injection If the first injection is successful, a repeat injection can be considered after a few months Surgery should be considered if a patient needs more than two injections

23. Surgery Partial or complete surgical division of flexor retinaculum  Carpal tunnel release If symptoms are refractory to conservative measures or if nerve conduction studies show severe entrapment Relieves both compression and resulting symptoms

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25. References Harrison’s Principle of Internal Medicine, 19 th edition Apley’s System of Orthepedics & Fractures, 9 th edition Maheshwari J, Essentials orthopedics, 4 th edition

26. Thank You