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Compression Neuropathies
Andrew Martin DO, MBA, CAQSMOMED 2013
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Compression Neuropathies
• Spinal Accessory Nerve
• Upper/Lower Trunk Plexopathy
• Long Thoracic Nerve
• Axillary Nerve
• Suprascapular Nerve
• Musculocutaneous Nerve
• Guyon Canal Syndrome
• Cubital Tunnel Syndrome
• Ulnar Nerve Interdigital Neuroma
• Tibial Nerve
• Plantar Nerve
• Common Peroneal Nerve
• Superficial Peroneal Nerve
• Deep Peroneal Nerve
• Medial Calcaneal Nerve
• Sural Nerve
• Saphenous Nerve
• Obturator Nerve
• Interdigital
• Lat. Femoral Cutaneous Nerve
• Medial Hallucal Nerve
• Carpal Tunnel Syndrome• Cubital Tunnel Syndrome
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Objectives
• Upper Extremity Compression Neuropathies
• Lower Extremity Compression Neuropathies
• Ultrasound and Compression Neuropathies
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Pathophysiology
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Pathophysiology
Vasa Nervorum
Nerve Axons ≠ Action Potentials
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Pathophysiology
Seddon Classification of Peripheral Nerve Damage
NeuropraxiaCompression Axonotemisis Neurotemsis
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Treatments
• Surgery
• Physical Therapy
• OMM
• Injections
• Bracing
• NSAIDS, Muscle Relaxers, Oral Steroids, Narcotics, Antidepressants
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Entrapments of the Upper Extremity
• Cervical Radiculopathy
• Spinal Accessory Nerve Compression
• Suprascapular Nerve Syndrome
• Quadrilateral Space Syndrome
• Radial Nerve Compression
• Ulnar Nerve Compression
• Median Nerve Compression
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Cervical Radiculopathy
• Posterolateral Disc Herniation
• Facet Degeneration
• C7 > C6 > C8
Etiology
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Cervical Radiculopathy
• Pain, Paresthesia, and Weakness
• Atrophy
• Reflex Sympathetic Dystrophy
Signs and Symptoms
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Cervical Radiculopathy
• Sensory, Muscle, and Reflex testing
• Spurling Test
• MRI
Evaluation
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Cervical Radiculopathy
Axial View T2 Weighted
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Spinal Accessory Nerve Compression
Posterior Triangle
• Equipment (backpacks/shoulder pads)
• Blows to the Shoulder
Etiology
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Spinal Accessory Nerve Compression
• Shoulder Syndrome
• Pain over trapezius, heaviness
• Abnormal Scapular Rotation
• Adhesive Capsulitis
Signs and Symptoms
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Spinal Accessory Nerve Compression
• Test Trapezius
• Test Sternocleidomastoid
• Abnormal Scapular Rotation
Evaluation
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Suprascapular Nerve Syndrome
• Suprascapular notch
• Spinoglenoid notch
• Thickened Transverse Scapular Ligament
• Extrinsic compression by a space-occupying lesion (ganglion cysts or soft tissue tumor)
Etiology
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Suprascapular Nerve Syndrome
• Poorly localized pain and discomfort at the back of the shoulder
• Weakness when raising the arm.
Signs and Symptoms
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Suprascapular Nerve Syndrome
Sagittal oblique T2 fat-saturated Sagittal oblique T1 weighted
42 yo swimmer with clinical and EMG evidence of right supraspinatus and infraspinatus muscle denervation at the suprascapular notch. Mild muscle atrophy with fatty infiltration.
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Suprascapular Nerve Syndrome
Axial T2 fat-saturated image
28-year-old patient High Grade Sarcoma withMRI appearances indicating a right suprascapular nerve entrapment
Coronal postcontrast T1 image
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Axillary Nerve CompressionQuadrilateral Space Syndrome
• Axillary Nerve enters the quadrilateral space w/ circumflex artery
• Supplies the teres minor and deltoid muscles and the overlying skin of the shoulder
• Compression from abduction and external rotation of the shoulder joint
• Hypertrophy of the adjacent musculature
• Space-occupying lesions
Etiology
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Axillary NerveQuadrilateral Space Syndrome
• Poorly localized shoulder pain and paresthesias in the affected arm in a nondermatomal distribution.
• Weakness/Atrophy of the Deltoid and Teres Minor
• Confused with rotator cuff pathology or other shoulder joint-related abnormalities
Signs and Symptoms
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Axillary Nerve CompressionQuadrilateral Space Syndrome
Oblique Coronal T2-fat saturated
26 year old Baseball Pitcher presented with Right Shoulder pain. Had clinical and EMG evidence of quadrilateral space syndrome.
Severe fatty atrophy of the teres minor muscle
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Axillary NerveQuadrilateral Space Syndrome
Oblique Sagittal T2-fat saturated Oblique Sagittal T1-weighted
Severe fatty atrophy of the teres minor muscle
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Radial Nerve Compression
• Spiral Groove of the Humerus
• Radial Tunnel
• First Dorsal Wrist Compartment
Etiology
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Radial Nerve CompressionSpiral Groove Syndrome
• Saturday Night Palsy
• Humerus Fractures
• Deep puncture wounds
Etiology
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Radial Nerve CompressionSpiral Groove Syndrome
• Triceps Weakness
• Wrist drop
• Patient unable to extend wrist or fingers
• Arm/Forearm/Hand/ Numbness
Signs and Symptoms
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Posterior Interosseous Nerve Compression(Radial Tunnel Syndrome)
• Formed by the superficial layer of the Supinator Muscle (arcade of Frohse)
• Radiocapitellar joint ganglions
• Synovitis
• Congenital tightness of Arcade of Frohse
• Prominent radial recurrent artery (RRA)
• Radial Head Dislocations
Etiology
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• Tenderness more over the Arcade of Frohse
• Painless weakness of the wrist and finger extensors
• No Sensory Deficits
Signs and Symptoms
Posterior Interosseous Nerve CompressionRadial Tunnel Syndrome
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Posterior Interosseous Nerve Entrapment
Axial T2 fat-saturated Axial T1-weighted
An 18-year-old Tennis Player with clinical and EMG evidence of PIN entrapment. Level of right distal humerus show thickening and high T2 signal of the radial nerve.
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Posterior Interosseous Nerve Entrapment
Axial T2 fat-saturated
An 18-year-old Tennis Player with clinical and EMG evidence of PIN entrapment. Supinator muscle edema
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Superficial Branch Radial Nerve CompressionWartenberg's Syndrome
• Compression of the superficial branch radial nerve (SRN)
• Compressed by scissoring action of Brachioradialis and Extensor Carpi Radialis Longus Tendons during forearm pronation.
Etiology
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Superficial Branch Radial Nerve CompressionWartenberg's Syndrome
• Ill-defined pain and Paresthesia over dorsoradial hand
• Aggravation by motions involving repetitive wrist flexion, ulnar deviation and pronation
• No motor weakness
Signs and Symptoms
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Ulnar Nerve Compression
• Cubital Tunnel
• Guyon’s Canal
Etiology
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Ulnar Nerve CompressionCubital Tunnel Syndrome
• Cubital Tunnel is formed by the Arcuate Ligament
• Caused by abnormal fascial bands, subluxation, or dislocation of the ulnar nerve over the medial epicondyle
• Trauma
• Direct compression by soft tissue masses.
Etiology
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Ulnar Nerve CompressionCubital Tunnel Syndrome
• Sensory abnormality of the ulnar hand
• Weakness of the flexor carpi muscle group of the 4th and 5th fingers
Signs and Symptoms
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Ulnar Nerve CompressionCubital Tunnel Syndrome
Axial T2 fat-saturated (Normal-Distal) Axial T2 fat-saturated (Abnormal-Cubital Tunnel)
A 17-year-old Baseball Pitcher with right cubital tunnel syndrome.
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Ulnar Nerve CompressionGuyon’s Canal Syndrome
• Formed by the flexor retinaculum and the palmar carpal ligament
• Ulnar nerve divides into the superficial sensory and deep motor branches at the level of the hamate
• Space-occupying lesions
• Trauma
• Ulnar artery aneurysms.
Etiology
Level of the Pisiform
Level of the Hamate
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Ulnar Nerve CompressionGuyon’s Canal Syndrome
• Motor and sensory findings
• Depends of position of bifurcation to the superficial (sensory) and deep (motor) branches
• Types I, II, III
Signs and Symptoms
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Ulnar Nerve CompressionGuyon’s Canal Syndrome
Axial T2 fat-saturatedAxial T1 - weighted
A 57-year-old Cyclist with clinical evidence of right ulnar nerve compression at wrist. Crowded Guyon’s Canal compressed by a tortuous ulnar artery.
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Ulnar Nerve CompressionGuyon’s Canal Syndrome
MR Angiography Using Sensitivity Encoding (SENSE)
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Median Nerve Compression
• Pronator Teres
• Flexor Digitorum Superficialis
• Carpal Tunnel
Etiology
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Median Nerve CompressionPronator Syndrome
• Between the ulnar and humeral heads of the pronator teres muscle
• Trauma
• Congenital abnormalities
• Pronator teres hypertrophy
Etiology
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Median Nerve CompressionPronator Syndrome
• Pain and numbness of the volar aspect of the elbow, forearm, and wrist
Signs and Symptoms
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Median Nerve CompressionAnterior Interosseous Syndrome
• Entrapment of the Anterior Interosseous Nerve in the proximal forearm by the Flexor Digitorum Superficialis
• Direct nerve trauma
• Compression from a hematoma or mass
Etiology
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Median Nerve CompressionAnterior Interosseous Syndrome
• Patients may present clinically with pain and muscle weakness in the volar forearm
• Flexor digitorum profundus
• Flexor pollicis longus
• Pronator quadratus
Signs and Symptoms
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Median Nerve CompressionCarpal Tunnel Syndrome
• Most common cause of compressive/entrapment neuropathy
• Repetitive trauma
• Conditions related to metabolic and hormonal changes
• Ganglion cysts
Etiology
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Median Nerve CompressionCarpal Tunnel Syndrome
• Burning wrist pain
• Paresthesia or numbness in the 1st through 3rd fingers, and the radial aspect of the 4th finger.
Signs and Symptoms
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Carpal Tunnel Syndrome
Axial T1 - weighted Axial T2 fat-saturated
48-year-old patient with surgically proven right carpal tunnel syndrome. There is thickening and increased signal intensity of the median nerve.
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Carpal Tunnel Syndrome
Axial T1 - weighted Axial T2 fat-saturated
Bowing of the flexor retinaculum with a flattened median nerve at the level of hamate.
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Entrapments of the Lower Extremity
• Sciatic Nerve
• Common Peroneal Nerve
• Tibial Nerve
• Interdigital Nerve
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Sciatic Nerve Compression
• Occurs in the hip region and less commonly in the thigh
• Fibrous or Muscular Type entrapment
• Vascular compression
• Scarring related to trauma or radiation
• Tumors
Etiology
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Sciatic Nerve Compression
• Pain, weakness, parasthesia, or numbness in the leg.
• Clinical presentations are based upon the level of injury
Signs and Symptoms
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Sciatic Nerve Compression
Axial T1 - weighted Sagittal T2-weighted fat-saturated
54 year old patient after a water skiing injury which resulted in an extensive tear of the left hamstring at the muscle origin with sciatic nerve scarring.
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Sciatic Nerve Compression
Axial T2-weighted fat-saturated Sagittal T1-weighted postcontrast
Surgically proven neurofibroma of the left sciatic nerve in a 33-year-old patient.
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• Level of fibular head due to its superficial location, or as it travels deep to the origin of the peroneus longus
• Idiopathic mononeuritis
• Space-occupying lesions including (intraneural ganglion cyst)
• Traumatic injury
• Tumors
Etiology
Common Peroneal Nerve Compression
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• Experience paresthesia and pain at the site of entrapment with foot drop
• Slapping gait
Signs and Symptoms
Common Peroneal Nerve Compression
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Common Peroneal Nerve Compression
MCG Emergency Department
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Common Peroneal Nerve Compression
MCG Emergency Department
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Common Peroneal Nerve Compression
Sagittal T2-weighted fat-saturatedSagittal T2-weighted fat-saturated
44-year-old patient with a 6-month history of right foot drop, Intraneural ganglion cyst multilobulated structure compressing the adjacent common peroneal nerve.
Patchy high signal in tibialis anterior and extensor digitorum longus muscles
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Tibial Nerve CompressionTarsal Tunnel Syndrome
• Formed by the flexor retinaculum medial malleolus and calaneous
• Posttraumatic fibrosis due to fracture
• Tenosynovitis / Bursitis
• Space-occupying lesions
• Dilated or tortuous veins
Etiology
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Tibial Nerve CompressionTarsal Tunnel Syndrome
• Burning pain and paresthesia along the plantar foot and toes
Signs and Symptoms
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Tarsal Tunnel Syndrome
Axial T1-weighted Axial T2-weighted fat-saturated
Tarsal tunnel syndrome caused by a ganglion cyst in a 32-year-old patient. Multilobulated cystic structure within the right tarsal tunnel, adjacent tibial nerve.
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Interdigital Nerve CompressionMorton’s Neuroma
• Most frequently occurs in the second and third intermetatarsal spaces
• Repetitive mechanical stress with subsequent perineural fibrosis
• Compression of the nerve by an inflamed intermetatarsal bursa
Etiology
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Interdigital Nerve CompressionMorton Neuroma
• Standing on a pebble in your shoe
• A burning pain in the ball of the foot
• Paresthesia or numbness in the toes
Signs and Symptoms
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Morton Neuroma
Coronal T1-weighted Coronal T2-weighted with fat saturation
Morton neuroma in a 38-year-old patient. Tear-drop-shaped soft tissue mass in the third intermetatarsal space. A small amount of fluid is noted within the
intermetatarsal bursa dorsal to the neuroma.
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Ultrasound Carpal Tunnel Syndrome
Short Axis (cross sectional area) Long Axis
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Hydrodisection of Median NerveCarpal Tunnel
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Hydrodisection of Median NerveCarpal Tunnel
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Annual Meeting 2014