NERVENERVENERVE NERVE ENTRAPMENT ENTRAPMENT

SYNDROMES [ NES ]SYNDROMES [ NES ]Disorders of peripheral nerve with pain Disorders of peripheral nerve with pain and/or loss of function [ motor and/or and/or loss of function [ motor and/or sensory] due to chronic compressionsensory] due to chronic compressionsensory] due to chronic compression.sensory] due to chronic compression.

e.g., carpal tunnel syndromee.g., carpal tunnel syndrome

IMPORTANT: Memorize IMPORTANT: Memorize completely !!completely !!

Upper limbUpper limbUpper limbUpper limb Nerve place usually referred to Nerve place usually referred to medianmedian

carpal tunnelcarpal tunnel carpal tunnel syndromecarpal tunnel syndromedidi (( i ii i )) i li l ff i ii i medianmedian ((anterior interosseousanterior interosseous) ) proximalproximal forearm forearm anterior interosseous anterior interosseous

MedianMedian pronator terespronator teres pronator teres syndromepronator teres syndrome MedianMedian ligament of Struthersligament of Struthers ligament of Struthersligament of Struthers synsyn UlnarUlnar cubital tunnelcubital tunnel cubital tunnel syndromecubital tunnel syndrome UlnarUlnar Guyon's canalGuyon's canal Guyon's canal syndromeGuyon's canal syndrome radialradial axillaaxilla radial nerve compressionradial nerve compression radialradial spiral groovespiral groove radial nerve compressionradial nerve compression radialradial ((posterior interosseousposterior interosseous)) proximalproximal forearmforearm posterior interosseous nerveposterior interosseous nerve radialradial ((superficialsuperficial radialradial ((posterior interosseousposterior interosseous) ) proximalproximal forearm forearm posterior interosseous nerve posterior interosseous nerve radialradial ((superficial superficial

radialradial) ) distaldistal forearm forearm Wartenberg's SyndromeWartenberg's Syndrome suprascapularsuprascapular suprascapular notchsuprascapular notch etc etc Etc etcEtc etc ETC ETC ETCETC ETC ETC ETC ETC ETC ETC ETC ETC

NESNESNES NES

Def: results from chronic injury to nerve as it travelsDef: results from chronic injury to nerve as it travelsDef: results from chronic injury to nerve as it travels Def: results from chronic injury to nerve as it travels through an osseoligamentous structure, or between through an osseoligamentous structure, or between muscles bundlesmuscles bundles

May have an underlying developmental anomaly or May have an underlying developmental anomaly or variantvariant

Repetitive motion slaps, rubs, compresses the n.Repetitive motion slaps, rubs, compresses the n. Relatively commonRelatively common Often seen in athletes, younger patientsOften seen in athletes, younger patients

Chronic NESChronic NESChronic NESChronic NES

Repetitive injury may lead to edema, ischemia, andRepetitive injury may lead to edema, ischemia, andRepetitive injury may lead to edema, ischemia, and Repetitive injury may lead to edema, ischemia, and finally alteration to the nerve sheath, even finally alteration to the nerve sheath, even demyelinizationdemyelinization

Eventually complete recovery may not be possible, and Eventually complete recovery may not be possible, and there is also the potential for ‘phantom limb’ type there is also the potential for ‘phantom limb’ type symptoms that become centralized in the brain and symptoms that become centralized in the brain and ‘replay’ even after the pathology is fixed.‘replay’ even after the pathology is fixed.

Early recognition and intervention is critical.Early recognition and intervention is critical.

PUDENDAL NERVE PUDENDAL NERVE T TT TENTRAPMENTENTRAPMENT

PN is the main nerve of the perineum;PN is the main nerve of the perineum; PN is the main nerve of the perineum;PN is the main nerve of the perineum; Carries sensation from the external genitalia, Carries sensation from the external genitalia,

skin around the anus scrotum perineumskin around the anus scrotum perineumskin around the anus, scrotum, perineum.skin around the anus, scrotum, perineum. Motor supply to pelvic muscles, external urethral Motor supply to pelvic muscles, external urethral

hi d l hihi d l hisphincter, and ext anal sphinctersphincter, and ext anal sphincter Originates from sacral plexus [occasionally from Originates from sacral plexus [occasionally from

sciatic n. instead ]sciatic n. instead ]

PNE SYMPTOMSPNE SYMPTOMSPNE SYMPTOMSPNE SYMPTOMS

Pain in the lower central pelvis can include anus, Pain in the lower central pelvis can include anus, p ,p ,perineum, scrotum, penis,testicles, vulvaperineum, scrotum, penis,testicles, vulva

Burning pain, sometimes shockBurning pain, sometimes shock--likelike M b il t l bil t lM b il t l bil t l May be unilateral or bilateralMay be unilateral or bilateral Deep ache, ‘severe like toothache’Deep ache, ‘severe like toothache’ Hypersensitivity to touch pressureHypersensitivity to touch pressure Hypersensitivity to touch, pressureHypersensitivity to touch, pressure Often provoked with urination / defecation, Often provoked with urination / defecation,

exacerbated by sittingexacerbated by sitting Often cannot sit; sexual dysfunction commonOften cannot sit; sexual dysfunction common Urinary urgency, dysuria, feeling of ‘always needing to Urinary urgency, dysuria, feeling of ‘always needing to

go’go’gogo

PUDENDAL N.PUDENDAL N.PUDENDAL N.PUDENDAL N.

COURSE:COURSE:

PNPNPNPN

Landmarks:Landmarks: Landmarks:Landmarks:

PUDENDAL NERVE PUDENDAL NERVE T TT TENTRAPMENT [ PNE ]ENTRAPMENT [ PNE ]

PNEPNEPNEPNE

PNEPNEPNEPNE

PNEPNEPNEPNE

"The main daily activities requiring the seated position "The main daily activities requiring the seated position y q g py q g p(work, meals, driving, theaters, etc) are no longer (work, meals, driving, theaters, etc) are no longer available to these patients, whose mental attitude is one available to these patients, whose mental attitude is one of chronic pain sufferers so obsessed with their of chronic pain sufferers so obsessed with their ppmiserable state as to be rapidly regarded by their miserable state as to be rapidly regarded by their doctors as psychiatric cases."doctors as psychiatric cases."

Patients often have to sit on an inflatable ‘donut’ to sitPatients often have to sit on an inflatable ‘donut’ to sit Patients often have to sit on an inflatable donut to sit Patients often have to sit on an inflatable donut to sit at allat all

The variety of symptoms often mean the patient has The variety of symptoms often mean the patient has seen urologist, gynecologist, proctologist, seen urologist, gynecologist, proctologist, gastroenterologists etcgastroenterologists etc

PNEPNEPNEPNE

Often seen in athletes: bicyclists cross countryOften seen in athletes: bicyclists cross country Often seen in athletes: bicyclists, cross country Often seen in athletes: bicyclists, cross country skiers, skaters, dancers, some runners.skiers, skaters, dancers, some runners.

May begin after direct trauma after pelvicMay begin after direct trauma after pelvic May begin after direct trauma, after pelvic May begin after direct trauma, after pelvic surgery, or after child birth.surgery, or after child birth.O h k i i iO h k i i i Or may have no known precipitating eventOr may have no known precipitating event

Early dx and rx offer much better prognosisEarly dx and rx offer much better prognosis

PNEPNEPNEPNE

First line rx ( early cases ): NSAIDs, i.e. ibuprofen; First line rx ( early cases ): NSAIDs, i.e. ibuprofen; ( y ) , p ;( y ) , p ;topical pain relievers [ lidoderm creams, creams with topical pain relievers [ lidoderm creams, creams with capsaicin ]capsaicin ]

d d dd d d Try to identify and avoid acitivity that causes the painTry to identify and avoid acitivity that causes the pain Hot or cold compresses [ can alternate ]Hot or cold compresses [ can alternate ]

K i h di i d i fK i h di i d i f Key is to suspect the diagnosis and sort it out from Key is to suspect the diagnosis and sort it out from other causesother causes

Pain may be provoked by ‘skin rolling’ technique orPain may be provoked by ‘skin rolling’ technique or Pain may be provoked by skin rolling technique or Pain may be provoked by skin rolling technique or direct pressure on ischial tuberositydirect pressure on ischial tuberosity

PNEPNEPNEPNE

Physical rx: some know specialized techniquesPhysical rx: some know specialized techniquesPhysical rx: some know specialized techniquesPhysical rx: some know specialized techniques Lengthen and loosen pelvic floor Lengthen and loosen pelvic floor –– buttocks, thighs, buttocks, thighs,

hips, perineumhips, perineump , pp , p Toe touches, supine leg lifts, side leg raises, range of Toe touches, supine leg lifts, side leg raises, range of

motion ex in swimming poolmotion ex in swimming poolg pg p Next line of approach: meds i.e. elavil, neurontin, Next line of approach: meds i.e. elavil, neurontin,

valproate BUT direct intervention may be bettervalproate BUT direct intervention may be better

PNE injectionsPNE injectionsPNE injectionsPNE injections

The pudendal nerve can be approached very precisely The pudendal nerve can be approached very precisely p pp y p yp pp y p yvia CT scan directionvia CT scan direction

Current national recommendations are for this Current national recommendations are for this b d db d dapproachapproach-- reliable results vs. flouro directed.reliable results vs. flouro directed.

Injx with local anesthestic can confirm the origin of sxInjx with local anesthestic can confirm the origin of sxR l f i j i i blR l f i j i i bl Results of injx in past were variable to poor Results of injx in past were variable to poor -- current current technique better resultstechnique better results

Repeat injx when sx recur often 3 x in 6Repeat injx when sx recur often 3 x in 6--9 months9 months Repeat injx when sx recur, often 3 x in 6Repeat injx when sx recur, often 3 x in 6--9 months9 months

PNE InjectionsPNE InjectionsPNE InjectionsPNE Injections

Injection: using 5” 22 g spinal needle, initial is lidocaine 1%Injection: using 5” 22 g spinal needle, initial is lidocaine 1%-- this will this will i di t l li t / b ti di t l li t / b timmediately replicate/exacerbate sximmediately replicate/exacerbate sx

Additionally, dexamathosone phosphate 4 mg is intermixed with 3 cc 0.5 % Additionally, dexamathosone phosphate 4 mg is intermixed with 3 cc 0.5 % bupivicainebupivicaine

Hyaluronidase 300Hyaluronidase 300--600 units600 units-- hydrolyzes glucosaminic bonds between hydrolyzes glucosaminic bonds between yy y y gy y ghyaluronic acid, a major intercellular substancehyaluronic acid, a major intercellular substance-- this helps remove barriers this helps remove barriers between tissues/cellsbetween tissues/cells-- fluids, including other meds, penetrate betterfluids, including other meds, penetrate better-- helps helps disrupt scarring and reduces density of any new adhesionsdisrupt scarring and reduces density of any new adhesions

Heparin 8000Heparin 8000--10000 units10000 units-- was discovered to inhibit superficial scarwas discovered to inhibit superficial scar Heparin 8000Heparin 8000--10000 units10000 units-- was discovered to inhibit superficial scar was discovered to inhibit superficial scar formation in burn patients following debridements.formation in burn patients following debridements.

BotulinumToxin A [Botox] also can be used if the above fails.BotulinumToxin A [Botox] also can be used if the above fails. Surgery for failed cases: send to the experts such as Dr. Stanley AntolakSurgery for failed cases: send to the experts such as Dr. Stanley Antolak

PNE injxPNE injxPNE injxPNE injx

PIRIFORMIS SYNDROMEPIRIFORMIS SYNDROME[ PS ][ PS ]

Caused by piriformis muscle compressing the sciaticCaused by piriformis muscle compressing the sciaticCaused by piriformis muscle compressing the sciatic Caused by piriformis muscle compressing the sciatic nervenerve–– a true sciatica in that sensea true sciatica in that sense

Piriformis m. is a stabilizer of hip, and lifts and rotates Piriformis m. is a stabilizer of hip, and lifts and rotates p,p,thigh away from bodythigh away from body

Usually pain and tingling in buttocks, often tenderness, Usually pain and tingling in buttocks, often tenderness, y p g gy p g gand subsequently pain extends down the thighand subsequently pain extends down the thigh

Increased by sitting, walking, running, climbing stairs, Increased by sitting, walking, running, climbing stairs, direct compression.direct compression.

PSPSPSPS

PSPSSS

Athletes, runners esp. distance runners, sometimes with Athletes, runners esp. distance runners, sometimes with , p ,, p ,traumatrauma

Can be related to developmental anomaly Can be related to developmental anomaly Si il t b d d b l b diSi il t b d d b l b di Similar symptoms can be produced by lumbar disc Similar symptoms can be produced by lumbar disc

disease, sacroiliac joint disease, and a few others.disease, sacroiliac joint disease, and a few others. May be necessary to image spine and pelvis is dx is not May be necessary to image spine and pelvis is dx is not y y g p py y g p p

clearclear Some articles show many patients with ‘sciatica’ and Some articles show many patients with ‘sciatica’ and

negative lumbar MRI have piriformis synnegative lumbar MRI have piriformis synnegative lumbar MRI have piriformis synnegative lumbar MRI have piriformis syn

PSPSContributing factorsContributing factors

HyperlordosisHyperlordosis HyperlordosisHyperlordosis Muscle anomaliesMuscle anomalies

M l h hM l h h Muscle hypertrophyMuscle hypertrophy Fibrosis due to traumaFibrosis due to trauma Anatomical nerve abnormalitiesAnatomical nerve abnormalities Occasionally due to physical hyperactivity hipOccasionally due to physical hyperactivity hip Occasionally due to physical hyperactivity, hip Occasionally due to physical hyperactivity, hip

replacement surgery, leg length discrepancyreplacement surgery, leg length discrepancy

PSPSPSPS

Accessory fibers and enlargement at origin onAccessory fibers and enlargement at origin on Accessory fibers and enlargement at origin on Accessory fibers and enlargement at origin on rightright

PSPSPSPS

Accessory bundle of piriformis on rightAccessory bundle of piriformis on right Accessory bundle of piriformis on rightAccessory bundle of piriformis on right

PS RX :PS RX :First line First line

Best and safest is care that you provideBest and safest is care that you provide-- Best and safest is care that you provideBest and safest is care that you providemassage, joint manipulation and mobilization, massage, joint manipulation and mobilization, stretching isotonics weight bearingstretching isotonics weight bearingstretching, isotonics, weight bearingstretching, isotonics, weight bearing

Heat therapy, at home, or better with Heat therapy, at home, or better with ultrasonographic rxultrasonographic rxultrasonographic rx.ultrasonographic rx.

Stretching piriformis, external rotators of hip, Stretching piriformis, external rotators of hip, d ddd ddand adductorsand adductors

PS RXPS RXSecond lineSecond line

Refractory cases often benefit from direct interventionRefractory cases often benefit from direct interventionyy Injection performed with 22 g spinal needle with direct Injection performed with 22 g spinal needle with direct

visualization with usvisualization with us Sciatic n identified and the piriformis directly overlying Sciatic n identified and the piriformis directly overlying

is entered with needleis entered with needleI j i h 5 0 5% b i i i i d i h 40I j i h 5 0 5% b i i i i d i h 40 8080 Injx with 5 cc 0.5% bupivicaine mixed with 40Injx with 5 cc 0.5% bupivicaine mixed with 40--80 mg 80 mg triamcinolone, repeat x 2 with recurrencetriamcinolone, repeat x 2 with recurrence

Resistant cases may get good result with same approachResistant cases may get good result with same approach Resistant cases may get good result with same approach Resistant cases may get good result with same approach but with Botoxbut with Botox

US DIRECTED RXUS DIRECTED RXUS DIRECTED RXUS DIRECTED RX

PS INJXPS INJXPS INJXPS INJX

MERALGIA PARESTHETICAMERALGIA PARESTHETICA[ MP ][ MP ]

Entrapment of the lateral femoral cutenousEntrapment of the lateral femoral cutenousEntrapment of the lateral femoral cutenous Entrapment of the lateral femoral cutenous nerve nerve

Occurs between the anterior ‘superior iliac crestOccurs between the anterior ‘superior iliac crestOccurs between the anterior superior iliac crest Occurs between the anterior superior iliac crest and the inguinal ligamentand the inguinal ligament

Tight clothing, obesity, pregnancy, scarring,Tight clothing, obesity, pregnancy, scarring,Tight clothing, obesity, pregnancy, scarring, Tight clothing, obesity, pregnancy, scarring, excessive walking, biking etcexcessive walking, biking etc

Pain may be burning, ‘electric’, stinging, sharpPain may be burning, ‘electric’, stinging, sharpPain may be burning, electric , stinging, sharp Pain may be burning, electric , stinging, sharp ‘shock’ associated with motion‘shock’ associated with motion

If in doubt, EMG is helpfulIf in doubt, EMG is helpfulIf in doubt, EMG is helpfulIf in doubt, EMG is helpful

LFCN compressionLFCN compressionLFCN compressionLFCN compression

PM RXPM RXPM RXPM RX

Chiropractic care with pelvic mobilization,Chiropractic care with pelvic mobilization,Chiropractic care with pelvic mobilization, Chiropractic care with pelvic mobilization, myofascial rx, transverse friction massage, and myofascial rx, transverse friction massage, and stretching may resolve this rapidly in many stretching may resolve this rapidly in many g y p y yg y p y ycases.cases.

Usual recommended medical care starts with Usual recommended medical care starts with “NSAIDS, looser clothing, narcotics if needed, “NSAIDS, looser clothing, narcotics if needed, reduced activity” !!reduced activity” !!

Resistant cases often have excellent response to Resistant cases often have excellent response to injxinjx

MP INJXMP INJXMP INJXMP INJX

Easily done with USEasily done with USEasily done with USEasily done with USIdentify inguinal ligament and the LFCNIdentify inguinal ligament and the LFCNI j 1 l% id i f ll d b 3 0 5%I j 1 l% id i f ll d b 3 0 5%Inject 1cc l% idocaine, followed by 3 cc 0.5% Inject 1cc l% idocaine, followed by 3 cc 0.5%

bupivicaine with 40 mg triamcinolonebupivicaine with 40 mg triamcinolone80% of patients pain free with 1 week, others may 80% of patients pain free with 1 week, others may

require second injx.require second injx.

MP INJXMP INJXMP INJXMP INJX

NES around the kneeNES around the kneeNES around the kneeNES around the knee

Patient with ‘weakness’ and pain in lower legPatient with ‘weakness’ and pain in lower leg Patient with weakness and pain in lower leg Patient with weakness and pain in lower leg and ankle, esp pain in footand ankle, esp pain in foot

Neuro exam suggested problem was commonNeuro exam suggested problem was common Neuro exam suggested problem was common Neuro exam suggested problem was common peroneal nerveperoneal nerveEMG l iEMG l i EMG also suggestiveEMG also suggestive

MRI lower leg orderedMRI lower leg ordered Denervation of medial and lateral heads of Denervation of medial and lateral heads of

gastrocnemiusgastrocnemiusgg

PERONEAL NESPERONEAL NESPERONEAL NESPERONEAL NES

CP NESCP NESCP NESCP NES

COMMON PERONEAL N.COMMON PERONEAL N.COMMON PERONEAL N.COMMON PERONEAL N.

coursecourse coursecourse

CP NESCP NESCP NESCP NES

High signal intensity is seen in acute and subacute High signal intensity is seen in acute and subacute g g yg g ydenervationdenervation

CPN wraps around neck of fibulaCPN wraps around neck of fibula-- a ‘tight ‘ area; a ‘tight ‘ area; bbvulnerable to trauma from fractures, surgery, repetitive vulnerable to trauma from fractures, surgery, repetitive

stress [ athletics], casts, squatting position, chronic stress [ athletics], casts, squatting position, chronic crossing of legs, etccrossing of legs, etccrossing of legs, etccrossing of legs, etc

Developmental variants as wellDevelopmental variants as well Most common mononeuropathy in lower legMost common mononeuropathy in lower legp y gp y g RX correct cause if possible…padding, alter habitsRX correct cause if possible…padding, alter habits

“SPORTS HERNIA”“SPORTS HERNIA”T TT TATHLETIC PUBALGIA [ AP ]ATHLETIC PUBALGIA [ AP ]

‘Sports hernia’ is real misnomer‘Sports hernia’ is real misnomer-- not really a hernia; not really a hernia; pp y ;y ;often seen in athletesoften seen in athletes

Symptoms are in the inguinal/groin area and may Symptoms are in the inguinal/groin area and may mimic hernia mimic hernia

Many patients have had hernia repairs, even for tiny, Many patients have had hernia repairs, even for tiny, inconsequential hernias and still no reliefinconsequential hernias and still no reliefinconsequential hernias, and still no reliefinconsequential hernias, and still no relief

True herniaTrue hernia-- tear in abdominal wall, through which tear in abdominal wall, through which abdominal contents protrudeabdominal contents protrudepp

Pain and tenderness in inguinal area, esp the symphysis Pain and tenderness in inguinal area, esp the symphysis pubispubis

APAPAPAP

It does involve a tear, most commonly of the muscle It does involve a tear, most commonly of the muscle , y, yattachments, specifically an aponeurosisattachments, specifically an aponeurosis

An aponeurosis is a tendonous structure joining An aponeurosis is a tendonous structure joining d b dd b dmuscles and other body parts in a common structuremuscles and other body parts in a common structure--

example plantar fascia of footexample plantar fascia of foot In AP the aponeurosis attached to the symphysis pubisIn AP the aponeurosis attached to the symphysis pubis In AP the aponeurosis attached to the symphysis pubis In AP the aponeurosis attached to the symphysis pubis

is involvedis involved The aponeurosis of the rectus abdominis and the The aponeurosis of the rectus abdominis and the pp

adductor longus of the thigh are the usual culpritsadductor longus of the thigh are the usual culprits

APAPAPAP

RARA--ALAL

APAPAPAP

SAGITALLSAGITALL SAGITALLSAGITALL

Walking running jumping skatingWalking running jumping skating Walking, running, jumping, skating, Walking, running, jumping, skating, falling….there are many movements that stress falling….there are many movements that stress these two muscles simulataneously and causethese two muscles simulataneously and causethese two muscles simulataneously and cause these two muscles simulataneously and cause them to pull against each other at this them to pull against each other at this attachmentattachmentattachment.attachment.

The aponeurosis is strong but contains very little The aponeurosis is strong but contains very little blood supply like many tendons healing is poorblood supply like many tendons healing is poorblood supply, like many tendons, healing is poorblood supply, like many tendons, healing is poor

APAPAPAP

sagittalsagittal sagittalsagittal

APAPAPAP

60 year old male injured from fall on ice60 year old male injured from fall on ice 60 year old male, injured from fall on ice 60 year old male, injured from fall on ice [hockey] several years prior, with re[hockey] several years prior, with re--injuries with injuries with ‘slipping and sliding’ several times; pain greatest‘slipping and sliding’ several times; pain greatestslipping and sliding several times; pain greatest slipping and sliding several times; pain greatest on right on right

Pain too great for exercise now very limitedPain too great for exercise now very limited Pain too great for exercise now, very limited Pain too great for exercise now, very limited activites…. “miserable”activites…. “miserable”H d di dH d di d h l f lh l f l Had many studies and examsHad many studies and exams-- not helpfulnot helpful

He had read about sports hernia and MRIHe had read about sports hernia and MRI

Sagittal leftSagittal leftSagittal leftSagittal left

Sagittal rightSagittal rightSagittal right Sagittal right

axialaxialaxialaxial

axialaxialaxialaxial

APAPAPAP

Like rotator cuff etc. tendons repair poorly on theirLike rotator cuff etc. tendons repair poorly on theirLike rotator cuff etc. tendons repair poorly on their Like rotator cuff etc. tendons repair poorly on their ownown

Initial rx: rest, ice, NSAIDS but if persists needs dx and Initial rx: rest, ice, NSAIDS but if persists needs dx and , , p, , prxrx

Recently open surgery has been offered, and more Recently open surgery has been offered, and more y p g yy p g ypreferable for athletes endoscopic surgerypreferable for athletes endoscopic surgery

Very recently intervention with ultrasound directed Very recently intervention with ultrasound directed injxinjx-- with steroids and anesthetic, now considered best with steroids and anesthetic, now considered best approach before surgery approach before surgery