Tomado de: Electrodiagnosis in Diseases of Nerve and Muscle: Principles and Practice, 3ra. ed., Jun Kimura.

Oxford University Press, Oxford, 2001. Chapter 26 P.712

Mononeuropathies Syndromes,

And

Entrapment

4 Radial Nerve Proximal and Distal Sites of Compression Nerve injury at the axilla from an incorrectly used crutch results in weakness of all the radialinnervated muscles and in loss of the triceps stretch reflex. Fractures of the head of the radius injure the nerve more distally. External trauma at the spiral groove commonly injures the nerve with or without a concomitant supracondylar fracture of the humerus.94, 144, 315 539 , A local compression at this level also results from improper use of walkers and wheelchairs.22, 48 The lateral head of the triceps muscle may entrap the radial nerve following continuous repetitive arm exercise,498 in association with focal myositis14 or 344 spontaneously. An individual, often intoxicated, may compress the nerve by falling asleep while leaning against a hard surface or with an arm draped over a bench as in the socalled Saturday night palsy. The lesion here usually spares the triceps but involves all the remaining long extensor muscles of the hand, wrist, and fingers as well as the brachioradialis. A radial nerve injury spares the extension at the interphalangeal joints subserved by the medianand ulnar-innervated lumbricalis. The sensory losses vary but most often affect the dorsum of the hand and first two digits. Rarely, children also suffer from traumatic or atraumaticmononeuropathy involving the proximal or distal main radial nerve or the posterior interosseous nerve.132 In newborn infants, the umbilical cord may play a role in the entrapment.434 Compression of the recurrent epicondylar branch causes pain at the elbow, usually with simultaneous entrapment of the deep branch of the radial nerve. This syndrome, one of the

many entities commonly known as tennis elbow, results from repeated indirect trauma by forceful supination as the predisposing factor. Pain and tenderness localized to the lateral aspect of the elbow resemble the symptoms of lateral epicondylitis, another condition referred to by some as tennis elbow. In the entrapment syndrome; however, additional dysfunctions indicate the involvement of the radial nerve. Subluxation of the head of the radius may produce a radial nerve palsy. Focal damage at this level also results from crush or twisting injury to the wrist or forearm or from repetitive pronation and supination at work.105 Superficial radial neuropathy may develop after wearing a tight watchband.415 Handcuff-related compression injuries often involve the sensory fibers of the radial nerve with or without concomitant involvement of the median or ulnar nerves at the wrist.115, 290, 317, 497 Nerve conduction studies should include comparison with the ipsilateral lateral antebrachial cutaneous nerve and with the contralateral superficial radial nerve.482 Surgical maneuver for trigger release may cause iatrogenic laceration of the radial digital nerve of the thumb.64 Conduction studies after a fracture of the humerus may reveal slowing across the compression site at the spiral groove or the absence of both motor and sensory potentials. The size of the muscle or antidromic sensory potential elicited by distal stimulation differentiates between neurapraxia and axonotmesis. Most cases have prominent conduction block and a varying degree of axon loss.48, 535Electromyographic exploration helps demonstrate the type and location of injury (see Figs. 1414 and 1417).515 Pressure neuropathy of the radial nerve usually resolves in 68 weeks, but recovery takes considerably longer after loss of a substantial number of axons. Posterior Interosseous Nerve Syndrome The posterior interosseous nerve, the terminal motor branch of the radial nerve in the forearm, penetrates the supinator muscle in its entrance to the forearm.406 The compression syndrome here may develop spontaneously or following closed injuries to the elbow.221 Other conditions

occasionally associated with this syndrome include rheumatoid arthritis with synovitis,327 congenital hemihypertrophy of the arm,120 therapeutic excision of the radial head for certain fractures,90lipoma, chondroma,134 and ganglion cysts arising from the proximal radicular joint320 and Charcot-Marie-Tooth disease type 1 (CMT1).65Violin players may develop transient symptoms as the result of prolonged pronation of the forearm.305 The entrapment usually involves the nerve at the arcade of Frohse between the two heads of the supinator152, 361, 430 The patient complains of pain over the lateral aspect of the elbow but no sensory loss. A lesion at this level causes weakness in the extensors of the wrist and digits with a notable sparing of the supinator, which usually receives innervation proximal to the site of compression. The radial nerve proper supplies the extensor carpi radialislongus and brevis. Normal contraction of these muscles coupled with the weakness of the extensor carpi ulnaris results in the characteristic radial deviation of the wrist on attempted dorsiflexion. Constriction at the distal portion of the supinator muscle may result in selective injury of one of the terminal branches, causing isolated paralysis of the abductor of the thumb and extensors of the thumb and index.200 Conversely, a compressive lesion may predominantly involve the extensor digitorumcommunis, partially or entirely sparing the extensor indices proprius and, to a lesser degree, the extensor digitiminimi. In this case, selective finger drop of the third and fourth digits with the intact digits on both ends results in the so-called longhorn sign. Operative neurolysis usually, but not always, results in good recovery from posterior interosseous nerve palsy.562 In addition to electromyographic abnormalities of the affected muscles, conduction studies may reveal mild slowing across the entrapment, especially if tested with the arm supinated against resistance.429 The differential diagnosis includes rupture of the extensor tendons, especially if paralysis affects only the last three digits, with preservation of the first two. In this case, weak muscles show no evidence of denervation, and passive palmar flexion of the

wrist induces no extension metacarpophalangeal joints.

of

the

5. Median Nerve The median nerve traverses three common sites of constriction along its course. At the elbow, entrapment may occur between the two heads of the pronator teres or more distally with selective involvement of the anterior interosseous branch. Carpal tunnel syndrome results from compression at the distal edge of the transverse carpal ligament or less commonly within the intermetacarpal tunnel. Pronator Teres Syndrome and Proximal Sites of Compression In 83 percent of dissections, the median nerve pierces the two heads of the pronator teres before passing under it. The pronator teres syndrome develops at this point with trauma, fracture, muscle hypertrophy, persistent median artery,218 or an anomalous fibrous band connecting the pronator teres to the tendinous arch of the flexor digitorumsublimis. The clinical features include pain and tenderness over the pronator teres, weakness of the flexor pollicis and abductor pollicisbrevis, and preservation of forearm pronation. Hypoesthesia over the thenar eminence helps differentiate this entity from carpal tunnel syndrome, which spares the sensory branch passing superficially to the flexor retinaculum. The conduction studies may reveal mild slowing in the proximal forearm in conjunction with a normal distal latency.340 Test maneuvers such as elbow flexion, forearm pronation, and finger flexion generally fail to enhance conduction abnormalities across the entrapment site.343 Injection of corticosteroids into the pronator teres may relieve the pain to aid in diagnosis, but definitive treatment requires a surgical decompression.256 A similar but distinct entrapment may develop as the median nerve traverses the ligament of Struthers, a fibrous band attached to an anomalous spur on the anteromedial aspect of the lower humerus.33 This ligament may compress the median nerve together with the brachial artery above the elbow, proximal to the innervation to the pronator teres. Compression of the brachial artery with full extension of the

forearm obliterates the radial pulse. Similar proximal median neuropathies may result from entrapment by an enlarged communication vein42 or an accessory bicipital aponeurosis,485 often involving the pronator teres and flexor carpi radialis in addition to the more distal muscles. Incremental short segmental stimulation near the proximal portion of the aponeurosis localizes the precise site of compression.359 Weakness and electromyographic abnormalities of the pronator teres and flexor carpi radialis serve to differentiate these conditions from the classic pronator teres syndrome, which usually spares the proximal muscles.8, 181, 503 Anterior Interosseous Nerve Syndrome Anterior interosseous nerve syndrome, also called the syndrome of Kiloh and Nevin,234 results from selective injury of the anterior interosseous nerve that branches off the median nerve just distal to the pronator passage, unilaterally or bilaterally.349, 543 The palsy occurs either spontaneously or as a complication of an injury such as a forearm fracture.158 Unlike the pronator syndrome, examination reveals no distinct sensory abnormalities despite the common presenting symptoms of pain in the forearm or elbow. Pure motor weakness typically involves pronator quadrates, flexor pollicislongus and the radial half of the flexor digitorum profundus,19 sparing the more proximal pronator teres. Asked to make an OK sign (or money sign in Japan) with the first two digits, the patient will form a triangle instead of a circlethe so-called pinch sign. Spontaneous recovery takes place from 6 weeks to 18 months. Neuralgic amyotrophy caused by lesions in the brachial plexus (see Chapter 243) may manifest as an anterior interosseous nerve palsy421 presumably because the responsible lesion selectively involves the nerve bundle already grouped to form the terminal nerve branch at this level.451 Similarly, the syndrome may appear acutely in a patient with hereditary neuropathy with liability to pressure palsies.136 A partial median nerve lesion at an antecubital level can also involve the bundle destined to form the anterior interosseous nerve544 or, even more selectively,

only the branches innervating the flexor pollicis longus.87 The anterior interosseous nerve syndrome may develop bilaterally as an idiopathic case99 or in association with cytomegalovirus infection.124 Ordinary nerve conduction studies of the median nerve reveal no abnormalities. Stimulation of the anterior interosseous nerve at the elbow may demonstrate a delayed latency of the compound muscle action potential recorded from the pronator quadratus.349 Comparison of the median motor latency to the pronatusquadratus and abductor pollicisbrevis may prove useful.432Electromyographic explorations show the evidence of selective denervation in the flexor pollicislongus, flexor digitorumprofundus I and II, and pronator quadratus. Although the current recommendation for the treatment of spontaneous anterior interosseous nerve paralysis centers on surgical decompression, some of theses lesions may represent a form of neuritis. In one series, most patients treated by observation had signs of recovery in 6 months and full recovery within 1 year.333 Carpal Tunnel Syndrome Of all the entrapment neuropathies, carpal tunnel syndrome is by far the most prevalent, showing the lifetime risk of approximately 10 percent.207 The median nerve passes, with nine extrinsic digital flexors, through the tunnel bound by the carpal bones and transverse ligament, which is attached to the scaphoid, trapezoid, and hamate. Anatomically the carpal tunnel narrows in cross section at 2.02.5 cm distal to the entrance, rigidly bound on three sides by bony structures and roofed by a thickened transverse carpal ligament. An abnormally high intracarpal tunnel pressure also peaks at this level in patients with carpal tunnel syndrome.299 Pathologic studies show that a striking reduction in myelinated fiber size takes place under the carpal ligament at this point.510 Interestingly, even in normal subjects the slowest nerve conduction occurs 24 cm distal to the origin of the ligament.241 This finding suggests a mild compression of the median nerve at this particular level in some clinically

asymptomatic hands. In fact, a histologic study357 revealed focal abnormalities at this site in 5 of 12 median nerves at routine autopsy despite the absence of any symptoms suggestive of the carpal tunnel syndrome in life.163 Certain anatomical peculiarities may predispose some individuals to the entrapment neuropathy. These include limited longitudinal sliding of the median nerve under the ligament,525 a smaller cross-sectional area of the tunnel,36 greater anteroposterior diameter of the wrist,175 obesity,353, 540 and small hand.345 Any expanding lesion in the closed space of the carpal tunnel enhances compression. Wrist flexion and extension also substantially alter the cross-sectional areas of the carpal tunnel as estimated by magnetic resonance imaging477 and the intracarpal tunnel pressure as measured by a catheter.506 A measurement of cross-sectional areas of the carpal tunnel by computerized axial tomography, however, paradoxically revealed a significantly larger area in carpal tunnel patients than in controls.555 A statistical analysis based on median and ulnar nerve comparisons of motor and sensory latencies may provide a useful risk prediction for the diagnosis of carpal tunnel syndrome.130 Carpal tunnel syndrome affects women more than men, most commonly in the fifth or sixth decade491 showing a greater prevalence in older populations.354, 355 Age-related changes of median nerve conduction, however, also develop naturally, not necessarily leading to symptoms of compression. 199, 353 The symptoms usually involve the dominant hand352 or are contralateral to amputation418 and show a higher incidence in those who use their hands occupationally43, 403 or for arnbulation with a cane, crutch, or wheelchair.518541 Symptoms may appear during pregnancy and resolve after delivery. The rare syndrome seen during the early ages108 causes a characteristic feature of short-lasting but severe attacks of pain.,444 In contrast to the sporadic incidence in most adult cases,192 rare familial occurrence prevails in children,40, 176, 285, 412 sometimes with anomalous thickening of the transverse carpal ligament.326 Other associated abnormalities include insensitivity to pain in the mutilated hand.23, 505

The syndrome also accompanies a variety of polyneuropathies and systemic illnesses.10, 188 Hereditary neuropathy with liability to pressure palsies should rank high in the differential diagnosis of familial carpal tunnel syndrome.524, 565 Patients with familial amyloidosis have a high incidence of carpal tunnel syndrome.268, 346 , 431 Certain secondary amyloidoses, especially those associated with multiple myeloma, may also give rise to neuropathy. Of the endocrine disorders, acromegaly231367 occurs most often, one study reporting 35 of 100 patients with evidence of the entrapment neuropathy.367 Carpal tunnel syndrome occurs in a high proportion of patients with rheumatoid arthritis,143 often as the initial manifestation of the tenosynovitis affecting the wrist flexor. Patients with rheumatoid arthritis may also develop thenar atrophy from disuse, cervical spine disease, or compression of the ulnar nerve at the elbow. Other conditions associated with a high incidence of carpal tunnel syndrome include eosinophilic fascitis,215 myxedema,450 lupus erythematosus,469 hyperparathyroidism,427 toxic shock syndrome,443 Lyme borreliosis,187 long-term renal hemodialysis,161fibrolipomatous hamartoma,325 torsion dystonia,118 and other conditions associated with prolonged wrist and finger hyperflexion.111 Symptoms may develop with extra tunnel pressure by an anomalous artery546 or sudden growth of ganglion cysts.230 A nonspecific tenosynovitis also gives rise to symptoms similar to those of idiopathic carpal tunnel syndrome.229 Patients often have other evidence of degenerative arthritis such as trigger fingers, bursitis, tendinitis, and tennis elbow. In addition, traumatic conditions may result in acute compression of the median nerve at the wrist. These include Colles' fracture291 isolated fracture of capitatum452 or hamate,309 acute soft tissue swelling after crushing injury of the hand, and acute intraneural hemorrhage.195 Most of these cases require emergency decompression of the median nerve. The lateral border of the flexor digitorumsuperficialis muscle may compress the median nerve against the forearm fascia and other flexor tendons. This rare entity causes symptoms similar to those of carpal tunnel syndrome, with

additional findings of local tenderness and firmness in the forearm.154456 Differential diagnoses also include high median nerve compression at the elbow, a C6 radiculopathy, and traumatic injury at the wrist, including a handcuff neuropathy.290 Carpal tunnel syndrome may accompany degenerative cervical spine diseases. This combination, called the double-crush syndrome,523 probably represents a chance occurrence of two very common entities.75, 422 Nonetheless, an awareness of this possibility underscores the need of adequate electrophysiologic assessments because the presence of one condition does not preclude the other. Some series67, 458 but not others52, 192 report a high incidence of electrophysiologic evidence for median and ulnar nerve lesions at the wrist. In typical cases of idiopathic carpal tunnel syndrome, paresthesias in the hand frequently awaken patients at night. The pain often extends to the elbow and not uncommonly to the shoulder, mimicking the clinical features of cervical spine disease or high median nerve compression.78The differential diagnosis rests in part on the symptoms of proximal lesions that are exacerbated with manipulation of the neck or shoulder girdle and subside with the arm at rest. In contrast, moving the hand often alleviates the pain in carpal tunnel syndrome. Compression can affect the peripheral autonomic fibers, causing defective vasomotor reflex. Thus, Raynaud's phenomenon may develop, especially in patients with systemic diseases such as rheumatoid arthritis. Sensory changes vary a great deal in early stages.490Hypesthesia involves the first three digits and the radial half of the fourth digit or, not uncommonly, only the second or third digit. Patients may indeed complain of a sensory loss outside the median nerve distribution. In one large series, 83 percent of 384 patients had a sensory disturbance mostly consisting of hypesthesia often confined to the tip of the third digit.397 Typically, the sensory changes spare the skin of the thenar eminence innervated by the palmer cutaneous branch that arises approximately 3 cm proximal to the carpal tunnel. Occasional patients, however, also have thenar numbness with the additional entrapment of this branch by

the fascia of flexor digitorum superficialis.468 Examination of the fourth digit usually reveals characteristic sensory splitting into median and ulnar halves, a pattern rarely seen in radiculopathies. Because of early detection, patients now seldomly develop major wasting of thenarmuscles, once considered a distinctive feature of the syndrome. Nonetheless, a comparison between the affected hand and the normal side often reveals a slight weakness. To test the abductor pollicisbrevis in relative isolation, the patient presses the thumb upward perpendicular to the plane of the palm. For the assessment of the opponens, the patient presses the tip of the thumb against the tip of the little finger. The two heads of the flexor pollicisbrevis receive mixed median and ulnar innervation with considerable variation. Passive flexion or hyperextension of the affected hand at the wrist for more than 1 minute may worsen the symptoms,396whereas a gentle squeeze of the hand may ease the pain.307 Hyperextension of the index finger may exacerbate the symptom with volar forearm pain.269 Percussion of the median nerve at the wrist causes paresthesia of the digits, although it has no localizing value in the carpal tunnel syndrome.322, 494 In fact, electrophysiologic data show the focal abnormality about 23 cm distal to the traditional percussion site on the volar aspect of the wrist.241 The phenomenon originally described by Tinel513 relates to tapping the proximal stump of an injured nerve to elicit a paresthesia as an indication for axonal regeneration and not for entrapment neuropathy.484 Symptoms of carpal tunnel syndrome worsen during ischemia of the arm. The factors that determine the degree of such susceptibility include the severity of pain and paresthesia but not the extent of muscle wasting or duration of symptoms.149 These findings suggest rapidly reversible changes in the nerve fibers associated with ischemic attacks. Sharply focal structural changes seen in entrapment neuropathy, however, indicate that mechanical factors must play an important role in the pathogenesis.150, 371 Simpson's original contribution475 on carpal tunnel syndrome, demonstrating focal slowing at the wrist, paved the way for clinical

conduction studies of this entity. Since then a number of investigators have published extensive studies51, 164, 166, 207, 219, 274, 323, 396, 509 Early work yielded a higher sensitivity of sensory conduction testing than studies of the motor axons.52323509 In our series,241however, the sensory and motor axons showed a comparable incidence of abnormalities. In addition, we often encountered selective involvement of motor fibers, with normal sensory conductions or vice versa. Antidromic or orthodromic sensory conduction studies find more abnormalities when tested in all the median nerve innervated digits.461 In one series,302 digit 3 proved the most sensitive, whereas in other studies digit 1259 and digit 4507 provided a better yield than the others. Wrist flexion may delay motor or sensory conduction across the wrist,310, 455 but not to the extent of any diagnostic value.123 Nerve conduction measures generally show a good relationship to the clinical symptom 561 severity. Electrophysiologic procedures have, however, become so sensitive that they cannot only confirm the clinical diagnosis in most patients but also detect an incidental finding in some asymptomatic subjects.419 A sensible interpretation of the test results in the context of patients' symptoms and clinical findings avoids unnecessary or premature surgical intervention.1 Diagnostic studies should establish selective conduction abnormalities involving the wrist-topalm segment of the median nerve for sensory or motor fibers.49, 52, 97, 109, 240, 241, 288, 384, 391, 435 489 , In our series,241 palmar stimulationelucidated sensoryor motor conductionabnormalities in allbut 13 (8%) of 172 clinicallyaffectedhands. Without palmar stimulation, anadditional 32 (19%) handswouldhaveescapeddetection. Recording of the orthodromic sensoryaction potentialal sorevealed more abnormalities with the addition of palmar stimulation.103, 334Palmar stimulation is a simple means to differentiate compression by the transverse carpal ligament from diseases of the most terminal segment, as might be expected in a distal neuropathy. In advanced stages, however, the axons may degenerate distal to the entrapment. Conversely, retrograde changes may also occur in the forearm as a

result of a severe compression at the wrist.16, 495 519 , The loss of fast-conducting fibers also leads to slowed conduction velocity proximal to the site of the lesion if recorded from digits.145Mixed nerve conduction study in the forearm measures the segment of interest per se,392, 495 although a possible cutaneous palmar branch bypassing the carpal ligament confuses the issue.190 With serial stimulation from the midpalm to the distal forearm in 1 cm increments, sensory axons normally show a latency change of 0.16 0.21 ms/cm (see Fig. 67A, B). In about one half of the affected nerves, there is an abrupt latency increase across a 1 cm segment, most commonly 24 cm distal to the origin of the transverse carpal ligament.241, 351, 354, 355 In these hands, the focal latency change across the affected 1 cm segment averages more than four times that of the adjoining distal or proximal 1 cm segments (see Fig. 67C, D). In the remaining hands, conduction delay affected more than one 1 cm segment across the carpal tunnel but was usually maximal at the site described above. Segmental studies of the motor axons in short increments are technically more demanding because of the recurrent course of the thenar nerve that varies anatomically from one subject to another.214, 241, 545 Digital stimulation allows simultaneous multichannel recordings of the orthodromic sensory potential across the carpal tunnel for segmental latency studies.201, 242 The inability to compare the amplitudes and waveform of the responses recorded from different sites limits the clinical value of orthodromic incremental studies (see Chapter 76). A number of other variations may improve the sensitivity of the motor and sensory conduction studies. The difference between the right and left sides, although useful with unilateral lesions, provides limited help in assessing a bilateral compression. With palmar stimulation, the simultaneous recording from the digit and the median nerve trunk at the wrist has the advantage of instantaneously assessing the latencies over the two segments.301 Recording from two different sites, however, precludes an accurate amplitude comparison between the antidromic sensory potential and mixed nerve potential. Other measures include the relative

latency change of the median sensory latency to radial, ulnar, or palmar cutaneous sensory latency for the same nerve length63, 69, 390, 521 and between median and ulnar motor latencies by lumbrical and interossei or thenar eminence recording.407, 408, 446, 517, 531 An interesting approach along the same line takes advantage of simultaneous stimulation of two nerves, for example, median and ulnar for recording of sensory potentials from the fourth digit or median and radial for recording sensory potentials from the first digit.73, 213, 384, 522 Recording from the fourth digit also allows comparison of median and ulnar nerve potentials elicited by palmar and wrist stimulation. The affected median nerve typically shows a distally elicited synchronized response and a proximally evoked temporally dispersed delayed potential, in sharp contrast to the nearly identical ulnar responses regardless of stimulus sites (see Chapter 62). These studies generally fail to serve as a useful test in patients with polyneuropathy.83 Two motor conduction measures compare the terminal latency of the distal segment to the conduction time in the proximal segment adjusted to the same distance (see Chapter 5 4). Of these, the residual latency increases,260 and the terminal latency index decreases below the normal range244, 463, 474 in patients with carpal tunnel syndrome. Even with complete denervation of the thenar muscles, the first and second lumbricals may maintain part of their innervation presumably because of a deeper location of their motor funiculi.106, 142 Recognition of lumbrical sparing thus helps establish the diagnosis especially in advanced cases with severe loss of axons supplying thenar muscles.296 Conversely, lumbrical muscles may show a prolonged latency despite an otherwise normal motor study.142 In advanced cases, electromyographic studies show fibrillation potentials and positive sharp waves in the median innervated intrinsic hand muscles. Needle studies, though not necessary in typical cases of the carpal tunnel syndrome may aid in excluding other diagnostic possibilities.86, 170 Other techniques of theoretical interest include quantitative studies of sensory thresholds178, 324 and strength-duration testing.335 Quantitative

somatosensory thermotesting may demonstrate impairment of thin nerve fiber function,276 but the ulnar-innervated digit 5 may also show abnormal findings.171 Some advocate the use of portable nerve conduction testing for screening, but its inability to measure the amplitude and waveforms poses a major limitation.488 Nonoperative measures sometimes suffice as the initial treatment212 although some 553 recommend early surgery. Conservative therapy consists of patient education, wrist splinting, B vitamins, nonsteroidal antiinflammatory medication, steroid injections, oral administration of steroid, and job change or modification.72, 194 Splinting works best if applied within 3 months of symptom onset.264 Local steroid injections for symptomatic relief help confirm the diagnosis and treat the disorder. In one series, treatment with a single dose of 40 mg triamcinolone acetonide resulted in complete remission in 35 percent of patients and partial relief in 58 percent.160 An inadvertent injection into the nerve can result in permanent damage.293 Two practices can help avoid this complication: placing the needle carefully midway between the palmarislongus tendon and the flexor carpi ulnaris tendon at the proximal edge of the transverse carpal ligament in a line with the superficial tendon of the ring finger146 and discontinuing injection and redirecting the needle if the patient experiences paresthesia of any kind. Some advocate noninvasive laser neurolysis as an alternative therapy, although its role in management awaits further study.538 If conservative therapy fails, division of the transverse carpal ligament is usually the standard operative procedure for unilateral and occasionally for bilateral release at one operation.385 Carpal tunnel decompression also benefits patients with advanced thenar atrophy and sensory deficits139, 362 and those with under-lying peripheral neuropathy.339 Although surgery is usually successful, 730 percent of patients will have either residual or recurring symptoms.93, 381 Endoscopic release may shorten the convalescence time for return to work7 provided the intraoperative safety and outcomes equal those of surgery.45

Digital Nerve Entrapment The interdigital nerves supply the skin of the index and middle fingers and half of the ring finger as extensions of the median sensory fibers. Sensory symptoms may result from compression of these small sensory branches against the edge of the deep transverse metacarpal ligament. Entrapment is associated with trauma, tumor, phalangeal fracture or inflammation of the metacarpophalangeal joint or tendon.256 Patients complain of pain in one or two digits exacerbated by lateral hyperextension of the affected digits and tenderness and dysesthesia over the palmar surfaces between the metacarpals. Local infiltration of a steroid may relieve the symptoms and assist in diagnosis.348 Abnormal median sensory potentials may result from unsuspected digital nerve lesions.208 6 Ulnar Nerve Tardy Ulnar

Palsy

and

Cubital

Tunnel

Syndrome The ulnar nerve enters the flexor carpi ulnaris between the humeral and ulnar heads of the muscle. After an intramuscular course of several centimeters, the nerve exits the flexor carpi ulnaris to lie between this muscle and the flexor digitorum profundus.59 Ulnar neuropathy commonly results from a focal entrapment in the retroepicondylar groove or at the humeroulnaraponeurotic arcade joining the two heads of the flexor carpi ulnaris.58 In one study of 130 cadavers, the humeroulnar arcade lay from 320 mm distal to the medial epicondyle, the intramuscular course ranged from 1870 mm through the flexor carpi ulnaris, and the nerve exited the tunnel 2869 mm distal to the medial epicondyle.58 Ulnar neuropathy at the elbow results from widely varying causes.329 These include repeated trauma at the retrocondylar groove, pressure from immobilization of the upper limb during surgery,536 entrapment by the accessory anconeusepitrochlearis muscle,316 spontaneous intraneural hemorrhage,405 and a gouty tophus.9, 533Originally, tardy ulnar palsy implied antecedent traumatic joint deformity or recurrent

subluxation. Many clinicians, however, now use the term for entrapment of the ulnar nerve at the elbow, even without a history of trauma. The compressive lesion at this site can affect different fascicles, involving the terminal digital nerves and the fibers to the hand muscles much more frequently than those to the forearm muscles.492 Classic clinical symptoms also appear with a more proximal involvement at Erb's point225, 261 or at the level of the upper arm after injections into the middle deltoid.157 Ulnar nerve palsy at the elbow may also constitute part of diffuse neuropathy or develop concomitantly with lower cervical spine disease involving C8 and T1 roots or with the thoracic outlet syndrome.347 In one study, ulnar sensory and motor nerve fibers showed similar conduction changes across the elbow in motor neuron disease. This finding casts doubt on double crush syndrome, which postulates the greater susceptibility of the proximalty affected axons to a distal entrapment.75 Some reports emphasize the cubital tunnel syndrome as the most common discrete entity.129, 328, 329 In this condition, nerve entrapment accompanies neither a joint deformity nor a history of major trauma. 128 A number of factors give rise to entrapment of the nerve under the aponeurosis connecting the two heads of the flexor carpi ulnaris.330, 502 Here, the nerve has the largest diameter,71 may show palpable swelling in the ulnar groove, and appears hyperemic at surgery. Frequent hand use in the elbow flexed position narrows the cubital tunnel and exacerbates the symptoms.328 In one study,357 routine autopsy revealed focal pathologic changes at the aponeurosis in 5 of 12 presumably normal nerves. The appearance of bilateral ulnar neuropathy in a large number of patients suggests a congenital predisposition to this syndrome.191, 328, 329 In fact, the asymptomatic contralateral nerve may show some involvement histologically in some cases of idiopathic ulnar neuropathy.356 The earliest clinical features include impairment of sensation over the fifth digit and the ulnar half of the fourth digit. Weakness and wasting predominate in the first dorsal interosseous and other ulnarinnervated intrinsic hand muscles, such as the third and fourth lumbricals, giving

rise to the partial claw hands, and the third volar interosseous, causing an inability to adduct the fifth digit, or the Wartenberg sign. Electromyography further defines the site of involvement by demonstrating the distribution of denervation. Typically, the cubital tunnel syndrome affects the ulnar half of the flexor digitorumprofundus, which receives the nerve supply distal to the aponeurosis, sparing the flexor carpi ulnaris supplied by a proximal branch. This distinction, however, does not necessarily hold as commonly believed, reflecting variable innervation patterns.57 Nerve conduction and electromyographic studies help localize the site of major pathology in these patients.249, 417Some have localized slowing of motor or sensory conduction velocity across the elbow compared with the more proximal or distal segments.475 Tests conducted with the elbow flexed rather than extended generally yield a more reliable result.257 Test accuracy is improved by maintaining the identical limb position during recording and measuring the surface distance. Waveform changes provide a more sensitive measure than the generally accepted criteria for slowing of conduction exceeding 10 m/s.373 The segment distal to the presumed compression may show mild slowing165 associated with a reduction in amplitude of the compound muscle action potential elicited by distal stimulation. This finding usually indicates axonal degeneration, although on rare occasion it may result from a quickly reversible change in nerve membrane excitability.321 Recording from the flexor carpi ulnaris supplements the conduction study in severe cases showing atrophy of the intrinsic hand muscles.520 Recording a normal or nearly normal compound muscle action potential from a clinically weak muscle with distal stimulation indicates the presence of conduction block at a proximal site of compression. A drop in motor amplitude greater than 25 percent across the elbow usually localizes the lesion in this segment.399 Stimulating the nerve at multiple sites across the cubital tunnel identifies the precise site of the lesion.60, 220, 328 A nonlinear change in amplitude or latency or both serves as the most sensitive measure of a focal abnormality (see

Chapter 75).243 Intraoperative studies pinpoint the site of entrapment for optimal surgical therapy, showing a major conduction block at the point of exit from the cubital tunnel in some cases. Some electromyographers advocate near nerve recording for better localization.372 A strict nonoperative regimen should constitute the initial management of the cubital tunnel syndrome.104 Surgical treatment consists of transposition,193 simple decompression,287, 331, or interfascicular neurolysis.358 Patients may have some functional recovery if operated on early.273 Once a moderate degree of motor deficit has developed, symptoms persist after operative intervention in 30 percent or more of patients.129 In selected cases, anterior transposition of the nerve results in good clinical and electrophysiologic improvement148, 253, 409 even as a reoperation for failed decompression.153 Compression at Guyon's Canal The ulnar nerve enters the hand through Guyon's canal at the wrist.113 Nerve injury at this level, seen less commonly than at the elbow, has clinical features similar to those of tardy ulnar palsy. Sensory deficit, if present, characteristically spares the dorsum of the hand innervated by the dorsal cutaneous branch, which arises proximal to the wrist. In Guyon's canal syndrome,464 the responsible lesion may involve both deep and superficial branches of the ulnar nerve (type 1) or only the deep branch, thus producing the palmarisbrevis sign or sparing of this muscle innervated by the superficial branch (type 2).202, 402 In either case, the other ulnar-innervated intrinsic hand muscles show weakness and atrophy as well as electromyographic evidence of denervation, whereas the flexor carpi ulnaris and flexor digitorumprofundus III and IV function normally. The reverse, however, does not necessarily hold because a proximal lesion can selectively damage the bundle of axons destined for the more distal muscles. In fact, ulnar nerve lesions at any level tend to affect the first dorsal interosseous muscle most consistently. Predominant involvement of the superficial branch results in selective paralysis of the palmarisbrevis and loss of sensation in the fifth digit and ulnar half of the fourth digit (type 3).

Entrapment in Guyon's canal most commonly results from a ganglion.380 Less frequent causes include trauma, rheumatoid arthritis, tortuous arteries,459 calcium deposits in Guyon's canal in scleroderma,512 an accessory palmaris muscle that arises from the base of the fifth metacarpal,420 and pisiform-hamate coalition.30 Ganglions and fractures usually cause combined motor and sensory deficits or isolated motor weakness, whereas synovitis may cause isolated sensory loss.267 The presence of a Martin-Gruber anastomosis may confuse the issue with an unusual presentation.251 Handcuff neuropathy, which usually involves the superficial radial nerve, may also affect the ulnar nerve selectively or concomitantly.449, 457 Ulnar nerve compression in the distal forearm may result from the enlarged normally tendinous portion of the flexor carpi ulnaris.56 A segment of the nerve may anomalously penetrate this tendon.569 Surgical decompression generally improves the 224 383 symptoms. , In types 1 and 2, motor conduction studies reveal reduced amplitude and increased digital latency of the abductor digiti quinti and first dorsal interosseous responses showing asymmetry between the affected and normal sides.380 Other useful techniques include short incremental stimulation across the wrist383 and comparison between ulnar and median motor latency by lumbrical and interossei recording.258, 465 Eliciting a normal sensory potential from the proximally branching dorsal ulnar cutaneous nerve usually localizes the lesion at the wrist,209, 235 although a lesion at the elbow could possibly spare this branch in partial involvement.527 Reduced or absent ulnar sensory action potentials of the fourth and fifth digits indicate involvement of the superficial branch. The mixed nerve action potential between the wrist and elbow remains normal. Recording from the fourth digit provides a sensitive measure of comparison between median and ulnar nerve sensory amplitude and latency (see Chapters 62 and this chapter, part 5). Involvement of the Palmar Branch Further distally, the deep motor branch may sustain external trauma or compression by a

ganglion arising from the carpal articulations168, 499 or by the arch of origin of the adductor pollicis muscles439 or tumor.413 Using the heel of the hand against a crutch causes repeated injuries to this branch as does an attempt to shut or raise a window by striking the bottom edge with the palm. Compression of the ulnar nerve at the palm has also followed prolonged bicycle riding.127, 189 Other entities reported include video-game palsy,147 and pizza cutter's palsy.437 Damage distal to the origin of the superficial branch gives rise to no sensory abnormality clinically or electrophysiologically. In cyclist's palsy, however, a severe lesion may also affect the sensory fibers supplying the skin of the fourth and fifth digits.364 A palmar lesion usually spares the more proximal motor fibers supplying the hypothenar muscles. Thus, conduction studies reveal no abnormalities between the elbow and wrist and a normal distal latency from the wrist to the abductor digitiminimi. The compound action potential recorded from the first dorsal interosseous, however, may show a prolonged latency and reduced amplitude compared with the unaffected side. Segmental stimulation of the motor branch in the palm can establish precise localization of the lesion along the course of the nerve (see Chapter 62). Electromyography shows selective abnormalities of the ulnar-innervated intrinsic hand muscles except for the abductor digitiminimi. These findings indicate slowing or block of nerve conduction distal to the origin of the hypothenar branch.39, 126