Neural Prolotherapy

REGIONAL ANATOMYUPPER EXTREMITIES

Lee Wolfer, MD, MS

NEUROBIOLOGY AND NEUROKININS

Monoaminergic SystemSerotonergic

NoradrenergicDopaminergic

Cholinergic

Glutamatergic SystemSystem controlling neural plasticity, synaptic sensitisation,

and conscious nociceptive pain through mainly NMDA receptors“20th Century CNS sensitisation”

Peptidergic SystemSystem controlling tissue homeostasis,

neurogenic inflammation peripheral non-synaptic sensitisation

and neuropathic pain

Dermatomal versus Regional painNociceptive painNon-peptidergic

Neuropathic painPeptidergic - Nervi Nervorum

Lee, MK. An evidence based approach to human dermatomes. Clin Anat, 2008

The dermatome is a fundamental concept in human anatomy and of major importance in

clinical practice.

There are significant variations in current dermatome maps in standard anatomy texts.

Our findings demonstrate that current dermatome maps are inaccurate and based on

flawed studies.

THE SENSORY INNERVATION OF THE SHOULDER

• SUPRASCAPULAR NERVE• RADIAL NERVE• AXILLARY

• SUBSCAPULAR NERVE• MUSCULOCUTANEOUS NERVE

• INTERMEDIATE SUPRACLAVICULAR NERVE

Encyclopedia Anatomica 1771Sensocrine nerve anatomy

BRACHIAL PLEXUSKey UE nerves

Ax SLBrC n.Ax SLBrC n.

Rad ILBrC n. Rad ILBrC n.

Rad PBrC n

Rad PABC n.

Musc LAC n.Musc LAC n.

ICBr & MBrC n

MAC

Rad Sup rad & digital brs

Ulnar palmar & DUC

Median palmar & digital brs

SUPRACLAVICULAR FOSSA

Key points:Locate

posteriorintermediate

medial CCIs

Proposed mechanism of ‘whiplash injury’ Neuropraxia/intussusception injury of the

supraclavicular nerves

L Supraclavicular Nerves CCI’s

Posterior

IntermediateMedial

POSTERIOR SUPRACLAVICULAR NERVE

INTERMEDIATE SUPRACLAVICULAR NERVE

Encyclopedia Anatomica 1771Sensocrine nerve anatomy

MEDIAL SUPRACLAVICULAR NERVE“Tietze syndrome” and “Costo-chondritis”

“FROZEN SHOULDER”Suprascapular Nerve Impingement

The suprascapular nerve is derived from the upper trunk of the brachial plexus from the roots of C5 and C6

The nerve supplies the supraspinatus muscle and provides articular branches to the glenohumeral and acromioclavicular joints.

It supplies sensory and sympathetic fibers to two-thirds of the shoulder capsule.

Usually there are no sensory fibers to the skin. The nerve then travels thru spinoglenoid notch under ligament to supply the infraspinatus muscle.

In about 50% of people there is another connective tissue band creating a second fibro-osseous opening for the nerve to traverse.

INFRASCAPULAR NERVE: INJECTION POINTSUNDER SCAPULAR SPINE, DEPTH ½ INCH

CROSSED BODY ADDUCTION TEST STRESSES NERVE IN AXIAL PLANE

“FROZEN SHOULDER”Suprascapular Nerve ImpingementThe suprascapular nerve is derived from the upper trunk of the brachial

plexus from the roots of C5 and C6

Right Supra-scapular Nerve

Impingement (C5,6) This illustration features a

posterior view of the deep muscles of the shoulder. The course of the supra scapular nerve is shown.

A rotator cuff tendon and ‘paralabral spinoglenoid cyst’ has trapped the infra-scapular nerve

Netter: Posterior shoulderQuadrangular space, triangular space & interval

AXILLARYNERVE

Quadrangular space

Teres minorTeres majorLong head,

tricepsHumerus

Superior lateral brachial cut n.

Axillary nerve (C5, C6)Inflammation of the Axillary

nerve trunk can be elicited in abduction and ER causing a

catching pain over the anterior Deltoid

‘Tight’ bands can be palpated in the Deltoid and Teres minor

where the Axillary nerve branches penetrate the

muscle.

Lower Subscapular

nerve CCIto subscapularis

muscle

Triangular interval

Radial nerve “tennis elbow”

CCIs:triangular interval

@ entrance to LIMS

Nerve test: “chicken wings”

Radial nerve

LIMS

Musculocutaneousnerve CCIs

LAC

BRACHIALIS

ARTICULAR BR

CORABRACHIALIS

BICEPS

GREASE: WHY WE THINK DANNY ZUKO HAS GREAT HAIR

OR:HOW TO TEST YOUR MUSCULOSKELETAL NERVE

Posterior shoulder

superiorlateral

brachial nerve

Intercostalis nerves

Nerves of the arm

Medial brachial and antebrachial

nerves“Golfers

elbow” or “Throwers

elbow”

Medial elbow with Bicipital Aponeurosis with risk of CECS

LEFT MEDIAL BRACHIAL AND ANTEBRACHIAL NERVES AND CCIs

ME

MAC ns

Intercostobrachial nMedial brachial cutaneousMAC

Left Lateral elbow (tennis elbow)Anconeus and posterior antebrachial nerves arise from the Radial nerve and the lateral antebrachial

nerve arises from the Musculocutaneous nerve

ANCONEUS

LE

O

LAC

PABCN

Radial, Median and Ulnar palmar nerves of the left wrist

“Carpal tunnel syndrome”, “OA base thumb”

U

M

RR

“De Quervain syndrome”

Musculocutaneous and Radial cutaneous branches

R

POST Br LAC