compression neuropathy in the upper limb
TRANSCRIPT
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Compression neuropathy – pathophysiology &treatment
Ian GrantConsultant Plastic Surgeon - Cambridge
17/10/2014
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Compression neuropathy:
Chronic Nerve Compression: acquired neuro-degenerative condition – demyelination
Axon loss – only in later stages of the disease
Pathophysiology – Schwann cellGeneticsHistory of surgical intervention Diagnosis / tests – decision making
chronic nerve compression
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Central nervous system
- not subject to compression or stretch
Peripheral nervous system- vulnerable to compression or stretch
• Chronic nerve compression
SyndromesCarpal tunnel syndromeCubital tunnel syndromeSupraspinatus syndromeAnterior interosseous syndromePosterior interosseous syndromeThoracic outlet syndromeMeralgia parasetheticaTarsal Tunnel syndromePeroneal syndrome
Peripheral entrapment neuropathy
Symptoms - Tingling, numbness, pain, weakness
Pathophysiology - Reduced conductionAbnormal excitability
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RELEASE OF CONSTRICTION – RELIEVES SYMPTOMS
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Photo supplied by: CHOJNOWSKI ADRIAN
OBVIOUS MACROSCOPIC CHANGES IN MEDIAN NERVE AT CONSTRICTION
THENAR MUSCLE WASTING
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Chronicnerve
compression
proximal compressio
n
systemic conditions
genetic predispositi
onHNLPP
Diabetes, AmyloidHypothyroid, Pregnancy , Obesity
1.5 megabase deletion , 17p11.2 – PMP22
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AGE1039 pt’s neurophysiological carpal tunnel syndrome.Nora et al 2004 Mean Age 48
PREVALENCECTS European Prevalence: estimate 2.7-5.8 %
AGE & PREVALENCE OF CARPAL TUNNEL SYNDROME
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>53000 operations for CTS England 2011
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NERVE ANATOMY – THE NERVE CELL
With thanks to Caitlin Monney: illustrator
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Compression neuropathy – crucial event is dymelination - crucial cell – the Swann Cell
Sh3tc2 tuj1
Sh3tc2 tuj1
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sh3tc2sh3tc2
sh3tc2sh3tc2
Caspr
MPZ MPZ
Caspr
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ANATOMY – NERVE FIBRES
With thanks to Caitlin Monney: illustrator
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Denny-Brown, and Bremmer 1944 – rodent sciatic nerve compression
Investigation of compression neuropathy
Oedema – is evident within 4 hours of constriction
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4 hours: 80mmHg
Oedema
Cannulation of the compressed peripheral nerve: confirms increased fluid pressure
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Histologic studies confirm that with prolonged compression (> 4 hours) demeylination occurs
Demyelination
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In vitro studies of Schwann cells, compression results in:
c-Jun, Knox-20
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Neurosci Lett 2009
In vitro immunoflouresence of Schwann cells distraction results in:Characteristic changes in morphology – bands appear
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Compression / stretching
Vascular compromise
oedema
Schwann cell activation
Demyelination / remyelinationThin 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 -
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With thanks to Caitlin Monney: illustrator
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The double crush in nerve entrapment syndromesAdrian 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
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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
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Dilley and Bove 2008
Failure of axoplasmic transport results in accumulation of mechanosensitive components proximal to the blockage
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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
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Treatment : non surgical
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Ramsay Hunt: The thenar and hypothenar types of neural atrophy of theHand 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 nerve,just proximal to the transverse carpal ligament
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Lancet 1946: Spontaneous compression of both median nerve in the carpal tunnel
Russell Brian DM Oxfd, FRCP A Dickson Wright MS Lond., FRCSMarcia Wilkinson BM Oxfd, MRCP
6 cases – middle aged or elderly women
Treated by surgical division of the carpal ligament at the wrist
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Marcia Wilkinson DM Oxfd FRCP 4th February 2013
Arthur Dickson-Wright MS Lond FRCS
Father to the chef:Clarissa Dickson-Wright
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Phalen 1950: Neuropathy of the median nerve due to compressionbeneath 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 ?
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Ulnar nerve compression – cubital tunnel syndrome
Panas, J 1878: Sur une cause peu connue de pralysie du nerf cubitalArchivee 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”
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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 :
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• Mild – intermittent paraesthesia
• Moderate – paraesthesia that interferes with ADL – constant waking
• Severe – constant numbness, wasting, weakness of thumb muscles
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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
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Sensibility testing LIGHT MOVING TOUCHTen-test1 – compare two sides(1.Strauch et al 1997 PRS)
Reliable in unilateral / early disease
2-point discrimination – late disease
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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 value
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• Scar
• Grip
4 weeks 4 months
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Ian GrantConsultant in plastic & reconstructive surgeryCambridge
Addenbrooke’s HospitalThe 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