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Nerve Entrapment Syndromes Workup

  • Author: Amgad Saddik Hanna, MD; Chief Editor: Brian H Kopell, MD  more...
 
Updated: Nov 11, 2015
 

Imaging Studies

Magnetic resonance imaging (MRI) using the short inversion imaging recovery (STIR) technique displays high signal intensity in the affected nerve segment at the site of the compression, probably due to the presence of edema in the myelin sheath and perineurium. Magnetic resonance neurography is evolving as an important tool in sorting out various painful limb syndromes involving the forearm and shoulder. This technique has been incorporated by some groups into the management of patients with routine entrapment syndromes (eg, carpal and cubital tunnel syndrome). For many, MRI and other imaging modalities are used for patients with atypical presentations of common disorders, recurrent symptoms after previous operation, and in those suspected of having rare entrapments. For example, MRI is especially helpful in identifying a mass lesion in patients with a lesion compressing the suprascapular nerve, ulnar nerve at the wrist or PIN.

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Diagnostic Procedures

The diagnosis of most entrapment neuropathies can usually be established on clinical grounds alone. For typical cases of carpal tunnel and ulnar cubital syndromes, electrodiagnostic tests (nerve conduction study and electromyography) are not always necessary. Still, they provide useful information: confirming the clinical diagnosis and localization, grading the lesion, identifying an underlying or superimposed peripheral neuropathy, and distinguishing other entities. Additionally, a baseline electrodiagnostic study may allow comparison to a postoperative study in patients with persistent symptoms.

In more unusual entrapment neuropathies, such as those involving the suprascapular nerve, ulnar nerve at the wrist, or posterior interosseous nerve (PIN), electrodiagnostic tests may be invaluable. For PIN syndrome, electrodiagnostic studies combined with neuromuscular ultrasound can guide accurate electrode localization and provide diagnostic information about lesion location.[16]

Local nerve block with a local anesthetic agent is useful in confirming the diagnosis of certain entrapments, such as meralgia paresthetica.

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Contributor Information and Disclosures
Author

Amgad Saddik Hanna, MD Assistant Professor, Department of Neurosurgery, University of Wisconsin School of Medicine and Public Health

Amgad Saddik Hanna, MD is a member of the following medical societies: American Association of Neurological Surgeons, Central Neuropsychiatric Association, Congress of Neurological Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

James S Harrop, MD Associate Professor, Departments of Neurological and Orthopedic Surgery, Jefferson Medical College of Thomas Jefferson University

James S Harrop, MD is a member of the following medical societies: American Association of Neurological Surgeons, American College of Surgeons, American Spinal Injury Association, North American Spine Society, Congress of Neurological Surgeons, Cervical Spine Research Society

Disclosure: Received consulting fee from Depuy spine for consulting; Received none from Geron for none; Received none from Neural Stem for none; Received ownership interest from Axiomed for none; Received honoraria from Stryker Spine for none.

Robert J Spinner, MD The Burton M Onofrio, MD, Professor of Neurosurgery, Professor of Orthopedics and Anatomy, Mayo Medical School; Co-Director, Brachial Plexus Clinic, Consultant, Department of Neurologic Surgery, Mayo Clinic

Robert J Spinner, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Association for the Advancement of Science, American Association for Hand Surgery, American Association of Neurological Surgeons, American College of Surgeons, American Medical Association, American Orthopaedic Association, American Association of Clinical Anatomists, Congress of Neurological Surgeons, Congress of Neurological Surgeons

Disclosure: Nothing to disclose.

George M Ghobrial, MD Resident Physician, Department of Neurological Surgery, Thomas Jefferson University Hospital

Disclosure: Nothing to disclose.

Tristan B Fried Student Medical Researcher, Thomas Jefferson Hospital; Student Researcher (STAR), Department of Dermatology, Hahnemann University

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Ryszard M Pluta, MD, PhD Associate Professor, Neurosurgical Department Medical Research Center, Polish Academy of Sciences, Poland; Clinical Staff Scientist, Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health (NIH); Fishbein Fellow, JAMA

Ryszard M Pluta, MD, PhD is a member of the following medical societies: Polish Society of Neurosurgeons, Congress of Neurological Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Brian H Kopell, MD Associate Professor, Department of Neurosurgery, Icahn School of Medicine at Mount Sinai

Brian H Kopell, MD is a member of the following medical societies: Alpha Omega Alpha, American Association of Neurological Surgeons, International Parkinson and Movement Disorder Society, Congress of Neurological Surgeons, American Society for Stereotactic and Functional Neurosurgery, North American Neuromodulation Society

Disclosure: Received consulting fee from Medtronic for consulting; Received consulting fee from St Jude Neuromodulation for consulting; Received consulting fee from MRI Interventions for consulting.

Additional Contributors

Michael G Nosko, MD, PhD Associate Professor of Surgery, Chief, Division of Neurosurgery, Medical Director, Neuroscience Unit, Medical Director, Neurosurgical Intensive Care Unit, Director, Neurovascular Surgery, Rutgers Robert Wood Johnson Medical School

Michael G Nosko, MD, PhD is a member of the following medical societies: Academy of Medicine of New Jersey, Congress of Neurological Surgeons, Canadian Neurological Sciences Federation, Alpha Omega Alpha, American Association of Neurological Surgeons, American College of Surgeons, American Heart Association, American Medical Association, New York Academy of Sciences, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Acknowledgements

Dachling Pang, MD, FRCS(C), FACS Professor of Pediatric Neurosurgery, University of California, Davis, School of Medicine; Chief, Regional Center for Pediatric Neurosurgery, Kaiser Permanente Hospitals of Northern California

Dachling Pang, MD, FRCS(C), FACS is a member of the following medical societies: Alpha Omega Alpha, American Association of Neurological Surgeons, American College of Surgeons, Congress of Neurological Surgeons, Ontario Medical Association, and Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Kamran Sahrakar, MD, FACS Clinical Professor, Department of Neurosurgery, University of California at San Francisco

Kamran Sahrakar, MD, FACS is a member of the following medical societies: Alpha Omega Alpha, American Association of Neurological Surgeons, American Medical Association, California Medical Association, Florida Medical Association, and Nevada State Medical Association

Disclosure: Nothing to disclose.

References
  1. Munns JJ, Awan HM. Trends in carpal tunnel surgery: an online survey of members of the American Society for Surgery of the Hand. J Hand Surg Am. 2015 Apr. 40 (4):767-71.e2. [Medline].

  2. Lane LB, Starecki M, Olson A, Kohn N. Carpal tunnel syndrome diagnosis and treatment: a survey of members of the American Society For Surgery of the Hand. J Hand Surg Am. 2014 Nov. 39 (11):2181-87.e4. [Medline].

  3. Clavert P, Thomazeau H. Peri-articular suprascapular neuropathy. Orthop Traumatol Surg Res. 2014 Dec. 100 (8 Suppl):S409-11. [Medline].

  4. Lanz U. Anatomical variations of the median nerve in the carpal tunnel. J Hand Surg Am. 1977 Jan. 2(1):44-53. [Medline].

  5. Ball C, Pearse M, Kennedy D, Hall A, Nanchahal J. Validation of a one-stop carpal tunnel clinic including nerve conduction studies and hand therapy. Ann R Coll Surg Engl. 2011 Nov. 93(8):634-8. [Medline].

  6. Bland JD, Weller P, Rudolfer S. Questionnaire tools for the diagnosis of carpal tunnel syndrome from the patient history. Muscle Nerve. 2011 Nov. 44(5):757-62. [Medline].

  7. Gross MS, Gelberman RH. The anatomy of the distal ulnar tunnel. Clin Orthop Relat Res. 1985 Jun. 238-47. [Medline].

  8. Ruder JR, Wood VE. Ulnar nerve compression at the arch of origin of the adductor pollicis muscle. J Hand Surg Am. 1993 Sep. 18(5):893-5. [Medline].

  9. Fritz RC, Helms CA, Steinbach LS, Genant HK. Suprascapular nerve entrapment: evaluation with MR imaging. Radiology. 1992 Feb. 182(2):437-44. [Medline].

  10. Rengachary SS, Neff JP, Singer PA, Brackett CE. Suprascapular entrapment neuropathy: a clinical, anatomical, and comparative study. Part 1: clinical study. Neurosurgery. 1979 Oct. 5(4):441-6. [Medline].

  11. Bigliani LU, Dalsey RM, McCann PD, April EW. An anatomical study of the suprascapular nerve. Arthroscopy. 1990. 6(4):301-5. [Medline].

  12. Cimino WR. Tarsal tunnel syndrome: review of the literature. Foot Ankle. 1990 Aug. 11(1):47-52. [Medline].

  13. Birch R, Bonney G, Wynn Parry CB. Entrapment neuropathy. Surgical disorders of the peripheral nerves. Churchill Livingstone; 1998. 245-291.

  14. Nord KM, Kapoor P, Fisher J, et al. False positive rate of thoracic outlet syndrome diagnostic maneuvers. Electromyogr Clin Neurophysiol. 2008 Mar. 48(2):67-74. [Medline].

  15. Sanders RJ, Hammond SL, Rao NM. Diagnosis of thoracic outlet syndrome. J Vasc Surg. 2007 Sep. 46(3):601-4. [Medline].

  16. Wininger YD, Buckalew NA, Kaufmann RA, Munin MC. Ultrasound combined with electrodiagnosis improves lesion localization and outcome in posterior interosseous neuropathy. Muscle Nerve. 2015 Jul 22. [Medline].

  17. Dellon AL, Hament W, Gittelshon A. Nonoperative management of cubital tunnel syndrome: an 8-year prospective study. Neurology. 1993 Sep. 43(9):1673-7. [Medline].

  18. Pirela-Cruz MA, Omer GF. Surgical exposure of the peripheral nerves of the upper extremity. Benzel EC, ed. Practical Approaches to Peripheral Nerve Surgery. American Association of Neurological Surgeons; 1992. 139-142.

  19. Palmer DH, Paulson JC, Lane-Larsen CL, Peulen VK, Olson JD. Endoscopic carpal tunnel release: a comparison of two techniques with open release. Arthroscopy. 1993. 9(5):498-508. [Medline].

  20. Bartels RH, Verhagen WI, van der Wilt GJ, Meulstee J, van Rossum LG, Grotenhuis JA. Prospective randomized controlled study comparing simple decompression versus anterior subcutaneous transposition for idiopathic neuropathy of the ulnar nerve at the elbow: Part 1. Neurosurgery. 2005 Mar. 56(3):522-30; discussion 522-30. [Medline].

  21. Biggs M, Curtis JA. Randomized, prospective study comparing ulnar neurolysis in situ with submuscular transposition. Neurosurgery. 2006 Feb. 58(2):296-304; discussion 296-304. [Medline].

  22. Gabel GT, Amadio PC. Reoperation for failed decompression of the ulnar nerve in the region of the elbow. J Bone Joint Surg Am. 1990 Feb. 72(2):213-9. [Medline].

  23. Manske PR, Johnston R, Pruitt DL, Strecker WB. Ulnar nerve decompression at the cubital tunnel. Clin Orthop Relat Res. 1992 Jan. 231-7. [Medline].

  24. Osterman AL, Davis CA. Subcutaneous transposition of the ulnar nerve for treatment of cubital tunnel syndrome. Hand Clin. 1996 May. 12(2):421-33. [Medline].

  25. Learmonth JR. Technique for transplantation of the ulnar nerve. Surg Gynecol Obstet. 1942. 75:792-3.

  26. Cravens G, Kline DG. Posterior interosseous nerve palsies. Neurosurgery. 1990 Sep. 27(3):397-402. [Medline].

  27. McGillicuddy JE, Harrigan MR. Meralgia Paresthetica. Techniques in Neurosurgery. 2000. 6(1):50-56.

  28. de Ruiter GC, Kloet A. Comparison of effectiveness of different surgical treatments for meralgia paresthetica: Results of a prospective observational study and protocol for a randomized controlled trial. Clin Neurol Neurosurg. 2015 Jul. 134:7-11. [Medline].

  29. Humphreys DB, Novak CB, Mackinnon SE. Patient outcome after common peroneal nerve decompression. J Neurosurg. 2007 Aug. 107(2):314-8. [Medline].

  30. Mackinnon SE, Dellon AL. Lower extremity nerves. Kline DG, Hudson AR. Nerve Injuries: Operative Results for Major Nerve Injuries, Entrapments, and Tumors. 1st ed. WB Saunders Co: 1995. 389-394.

  31. Morimoto D, Isu T, Kim K, Sugawara A, Yamazaki K, Chiba Y, et al. Microsurgical Decompression for Peroneal Nerve Entrapment Neuropathy. Neurol Med Chir (Tokyo). 2015. 55 (8):669-73. [Medline].

  32. Yassin M, Garti A, Weissbrot M, Heller E, Robinson D. Treatment of anterior tarsal tunnel syndrome through an endoscopic or open technique. Foot (Edinb). 2015 Sep. 25 (3):148-51. [Medline].

  33. Orlando MS, Likes KC, Mirza S, Cao Y, Cohen A, Lum YW, et al. A decade of excellent outcomes after surgical intervention in 538 patients with thoracic outlet syndrome. J Am Coll Surg. 2015 May. 220 (5):934-9. [Medline].

  34. Kuschner SH, Brien WW, Johnson D, Gellman H. Complications associated with carpal tunnel release. Orthop Rev. 1991 Apr. 20(4):346-52. [Medline].

  35. Filler AG. Piriformis and related entrapment syndromes: diagnosis & management. Neurosurg Clin N Am. 2008 Oct. 19(4):609-22, vii. [Medline].

  36. Tiel RL. Piriformis and related entrapment syndromes: myth & fallacy. Neurosurg Clin N Am. 2008 Oct. 19(4):623-7, vii. [Medline].

  37. Dellon AL. Neurosurgical prevention of ulceration and amputation by decompression of lower extremity peripheral nerves in diabetic neuropathy: update 2006. Acta Neurochir Suppl. 2007. 100:149-51. [Medline].

  38. Elliott R, Burkett B. Massage therapy as an effective treatment for carpel tunnel syndrome. J Bodyw Mov Ther. 12/2012. 17(3):[Medline].

  39. Galardi G, Amadio S, Maderna L, et al. Electrophysiologic studies in tarsal tunnel syndrome. Diagnostic reliability of motor distal latency, mixed nerve and sensory nerve conduction studies. Am J Phys Med Rehabil. 1994 Jun. 73(3):193-8. [Medline].

  40. Kline DG, Hudson AR. Vertebral artery compression. J Neurosurg. 1995 Oct. 83(4):759. [Medline].

  41. Kureshi SA, Friedman AH. Carpal Tunnel Release: Surgical consideration. Techniques in Neurosurgery. 2000. 6(1):5-13.

  42. LeRoux PD, Ensign TD, Burchiel KJ. Surgical decompression without transposition for ulnar neuropathy: factors determining outcome. Neurosurgery. 1990 Nov. 27(5):709-14; discussion 714. [Medline].

  43. Ochoa JL. Genesis of the structural pathology of myelinated fibers in median nerve entrapment. Muscle Nerve. 2012. 46(6):978. [Medline].

  44. [Guideline] Tubbs RS, Mortazavi MM, Farrington WJ, Chern JJ, Shoja MM, Loukas M, et al. Relationships Between the Posterior Interosseous Nerve and the Supinator Muscle: Application to Peripheral Nerve Compression Syndromes and Nerve Transfer Procedures. J Neurol Surg A Cent Eur Neurosurg. May/2013. EPub ahead of print:13. [Medline].

  45. Yalcin E, Unlu E, Akyuz M, Karaahmet OZ. Ultrasound diagnosis of ulnar neuropathy: Comparison of symptomatic and asymptomatic nerve thickness. J Hand Surg Eur Vol. 4/2013. [Medline].

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Chest PA radiograph showing a right cervical rib (arrows), a possible cause of thoracic outlet syndrome.
Ulnar nerve (U) transposition at the elbow. A: The medial intermuscular septum (arrows) is resected to prevent compression of the transposed nerve. Vasoloops are around the ulnar nerve and a vascular pedicle between the nerve and the septum that has been preserved. B: After subcutaneous transposition, the ulnar nerve is observed lax in elbow flexion. The ulnar nerve and its distal branches are surrounded by vasoloops.
Common peroneal nerve decompression at the fibular neck. A: The common peroneal nerve (P) has been identified and mobilized proximal to the fibular tunnel region, fascia (F) covering peroneus longus. B: The common peroneal nerve has been traced through the fibular tunnel. The fascia overlying the peroneus longus muscle has been divided and the muscle (M) has been retracted. The fascial band overlying the nerve is released.
Median nerve (M) after decompression at the wrist; note the congestion from the longstanding compression. The transverse carpal ligament (arrows) has been transected. Fat is observed distally.
 
 
 
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