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Entrapment Neuropathy

Neuropathies Entrapment

Entrapment neuropathy is a rather common type of nerve injury in which mechanical factors lead to compression of the nerve and subsequent appearance of pain, paresthesias, and associated muscle abnormalities. Virtually any peripheral nerve can be affected, and the diagnosis should be suspected in all patients who report typical symptoms that suggest a neuronal origin. Imaging studies, in addition to clinical criteria, are used to make the diagnosis.


Presentation

Entrapment neuropathy is a term describing a type of neuropathy that is rather commonly encountered in clinical practice (carpal tunnel syndrome is one of the examples) and results from either compression, traction or structural impairment of the nerve [1] [2] [3]. As the nerve becomes compressed or "entrapped" in tissues after trauma or some other form of injury, the blood supply to the nerve is diminished, eventually causing edema, ischemia, necrosis and death of neuronal tissue if the structural deformity is not repaired promptly [4] [5]. During this process, typical symptoms of neuronal injury arise, such as pain, paresthesia, and numbness [1]. Depending on the affected nerve, both sensory and motor deficits can be observed. For example, deltoid weakness indicates axillary nerve entrapment; restriction of wrist flexion is present in the setting of median nerve compression, whereas loss of sensation in the dorsal proximal areas of the index finger, middle finger and the thumb suggests radial nerve entrapment [1] [2]. It must be noted that several nerves could be entrapped at more than one anatomical location, which is why recognizing associated signs and symptoms is pivotal for identifying the affected nerve [1] [2] [6]. The appearance of symptoms can be abrupt or slowly progressive [1].

Hemophilia A
  • […] dislocation) Post traumatic arthritis (osteophytes) Aberrant muscles (lumbricals, palmaris longus, palmaris profundus) Local tumours (neuroma, lipoma, ganglion, cysts, multiple myeloma) Persistent medial artery Hyrertrophic synovium Hematoma (hemophilia[slideshare.net]
Limb Pain
  • Página 212 - Jensen TS, Krebs B, Nielsen J, Rasmussen P: Immediate and longterm phantom limb pain in amputees — incidence, clinical characteristics and relationship to pre-amputation limb pain. Pain 21:267278, 1985. ‎[books.google.es]
Paresthesia
  • When evaluating patients with unilateral leg pain and paresthesias, one should consider the possibility of entrapment of peripheral nerve. Electrodiagnostic studies are helpful in establishing the diagnosis.[ncbi.nlm.nih.gov]
  • We report an extremely rare case of proximal entrapment neuropathy of the median nerve above the elbow in a 44-year-old man who presented with paresthesia with median nerve distribution.[ncbi.nlm.nih.gov]
  • This 53-year-old man had a 10-year history of paresthesia and pain in the right anterolateral thigh exacerbated by prolonged standing and walking. His symptoms improved completely but transiently by LFCN block. The diagnosis was LFCN entrapment.[ncbi.nlm.nih.gov]
  • All patients complained of pain or paresthesia of the lateral aspect of affected lower thigh and instep; all manifested a Tinel-like sign at the entrapment point.[ncbi.nlm.nih.gov]
  • This peripheral neuropathy is characterized by distal lower extremity paresthesias, dysesthesias, and/or weakness. Paresthesias occur most commonly in the feet and toes in a symmetric pattern and progress proximally.[spineuniverse.com]
Foot Drop
  • Foot drop is often caused by an entrapment below and behind the knee before the nerve splits into these two branches, but I knew this was not the cause.[tonymorris.github.io]
  • Four patients had classical rheumatoid arthritis, while foot-drop developed in one man after trauma to the knee. In all five patients, a painful palpable enlargement in the popliteal area became most symptomatic with the[jamanetwork.com]
  • Motor nerve injury would then cause two particular symptoms of weakness, foot drop and inversion sprain. Foot drop occurs when walking. The foot will slap on the ground when the heel strikes the surface.[neckandback.com]
  • Weakness usually starts in a distribution of a single peripheral nerve with unilateral wrist drop, foot drop, or grip weakness. 1–3,15 It can differentially involve branches of a peripheral nerve; a common clinical finding noted in some patients is the[touchneurology.com]
  • It needs to be distinguished from an L5 radiculopathy (foot drop) when tripping and fractures occur, especially in older people.[care.diabetesjournals.org]

Workup

A delayed diagnosis of entrapment neuropathy and nerve compression may lead to irreversible neuronal injury and cause a significant impairment in daily life, thus early recognition of this clinical entity is of absolute necessity [3] [6]. One of the first steps toward the diagnosis is a detailed patient history that will determine the duration of symptoms and their severity, followed by a thorough physical examination, perhaps the pivotal part of the diagnostic workup [1] [6]. Depending on the cause and location of symptoms, a complete motor evaluation of muscle groups and the sensorium in the areas where the patient reports pain, paresthesias, or numbness, is the mainstay in revealing which nerve is injured [1] [6]. A presumptive diagnosis might be made solely on clinical findings, but imaging and electrophysiologic studies are highly useful in confirming entrapment neuropathy. Plain radiography, although important in delineating skeletal injuries as potential causes, is of no use in assessing nervous tissues [1]. For this reason, ultrasonography (US) and magnetic resonance imaging (MRI) are recommended but are not equally effective for all anatomical sites [1] [2] [6] [7]. A hypoechogenic appearance of the nerve, as well as edema, thickening, and fatty atrophy of the muscles supplied by the injured nerve, are frequent findings on US, whereas swelling and hyperintensity are seen on MRI studies [1] [4] [7]. Conversely, electromyography (EMG) and nerve conduction studies are often used in the setting of peripheral nerve injury and provide important clues in discerning between peripheral and central nerve injuries [1] [6].

Treatment

  • The objective of this study was to present the long-term surgical outcomes of operative treatment for superior cluneal nerve (SCN) entrapment neuropathy (SCNEN) and to analyze the causes of poor results and further treatment required.[ncbi.nlm.nih.gov]
  • Both methods are currently mainstays of surgical treatment.[ncbi.nlm.nih.gov]
  • Below, we describe the decision making process for the diagnosis and treatment of his pudendal neuropathy.[ncbi.nlm.nih.gov]
  • In the very elderly, their general condition and poor compliance with drug regimens can render the treatment of low back pain (LBP) difficult.[ncbi.nlm.nih.gov]
  • The SF-36 mental health score before treatment was lower in the study group than in the hernia group.[ncbi.nlm.nih.gov]

Prognosis

  • Whether or not it is appropriate to offer surgery in any particular case depends on the severity of the symptoms, the risks of the proposed operation, and the prognosis if untreated.[en.wikipedia.org]
  • However, the little research that has been done to determine the prognosis for individuals who have undergone surgery has focused on the patency rate of the arteries after surgery and the presence or absence of complications.[ncbi.nlm.nih.gov]
  • The overall prognosis is good, with almost 75% of patients experiencing complete recovery within 2 years. However, the period of time for complete recovery is variable, ranging from 6 months to 5 years.[musculoskeletalkey.com]
  • Prognosis Diagnostic delay is common; untreated ACNES can lead to functional disability and reduced quality of life resulting in high medical health care costs, highlighting the importance of the awareness of ACNES among medical professionals.[orpha.net]
  • Treatment and prognosis Acute limb-threatening thrombosis requires urgent bypass surgery. Intermittent occlusion can usually be cured with the release of the popliteal artery alone or with saphenous vein bypass 2 .[radiopaedia.org]

Etiology

  • In this study, the etiologic factors leading to this clinical entity were evaluated and also the clinical and imaging findings were examined. The study was conducted in 3 groups.[ncbi.nlm.nih.gov]
  • Lastly, the etiological structure may be the descriptor, such as pronator teres syndrome.[mhmedical.com]
  • Further, this is an extremely painful and distressing condition resulting in symptoms that can be very distracting from the actual etiology. I am not a medical expert, just an independent thinker who owns too many medical text books.[tonymorris.github.io]
  • Etiology:  Ganglion cyst  Proliferative synovitis (rheumatoid arthritis) • Electro diagnostic testing may localize the site of compression. • Initially : observation & non operative treatment. • Operative methods: exploration & appropriate division[slideshare.net]
  • -numerous etiologies, metabolic, endocrinologic, chemical, pharmacologic, or rheumatologic -- Nerve dysfunction.[quizlet.com]

Epidemiology

  • Epidemiology of Entrapment Neuropathy or Nerve Compression Syndrome Carpal tunnel syndrome is the most common form of entrapment neuropathy. Lifetime risk is approximately 10% and annual risk is 0.1%.[epainassist.com]
  • Popliteal artery ICD-10 codes A- initial encounter D- subsequent encounter S- sequela Popliteal Artery Entrapment Syndrome ICD-9 904.4 Injury to blood vessels of lower extremity; popliteal blood vessels Popliteal Artery Entrapment Syndrome Etiology / Epidemiology[eorif.com]
  • Summary Epidemiology Around 20% of patients with chronic abdominal pain have abdominal wall pain, which is often caused by ACNES. The prevalence in patients alleged to have functional abdominal pain is estimated to be 3-4%.[orpha.net]
  • EPIDEMIOLOGY The estimated incidence of abdominal wall pain is 1 in 1800 individuals [ 8 ].[uptodate.com]
Sex distribution
Age distribution

Pathophysiology

  • Therefore, cumulatively, only 69 of our 12,736 cases of CTS and UN-E satisfied the pathophysiologic and one of the anatomic requirements of the DCH.[n.neurology.org]
  • Subscribe on iTunes Session 36 – Moving Beyond ‘Trapped Nerves’ – Entrapment Neuropathy with Annina Schmid Annina Schmid is a Physiotherapist and associate professor whose research focusses on advancing our understanding of the pathophysiology of entrapment[chewshealth.co.uk]
  • The pathophysiological changes following nerve compression 8 – 21 are dependent on the degree, rate, and duration of compression.[clinicalgate.com]
  • Pathophysiology of chronic groin pain in the athlete.” Int J Sports Med 1.1 (2000). (link) Anagnostopoulou, Sofia, et al.[blog.tmorris.net]
  • Pathophysiology of Entrapment Neuropathy or Nerve Compression Syndrome Repetitive trauma and injury to a nerve may result in microvascular changes, leading to edema and injury to the myelin sheath or the outside layers of the nerve that aid in the transmission[epainassist.com]

Prevention

  • A thorough understanding of the anatomy of these nerves can prevent stapling in the areas of danger and thus greatly reduce the incidence of this complication.[ncbi.nlm.nih.gov]
  • For prevention of recurrence, as many SCN branches as possible should be decompressed in the operation field during the first operation. 4.[ncbi.nlm.nih.gov]
  • Prevention Changing physical activities can often help reduce the injury, when nerve entrapment injuries are caught early.[minneapolisclinic.com]
  • -*No deep closure prevents hematoma & scarring -Postop compression dressing and immobilization for 2-3 weeks NWB- keep the edema , pressure down -Start WB and ROM exercises to limit adhesions -Better results found in patients with the removal of space[quizlet.com]

References

Article

  1. Neal S, Fields KB. Peripheral nerve entrapment and injury in the upper extremity. Am Fam Physician. 2010;81(2):147-155.
  2. Miller TT, Reinus WR. Nerve entrapment syndromes of the elbow, forearm, and wrist. AJR Am J Roentgenol. 2010;195(3):585-594.
  3. Choi S-J, Ahn JH, Ryu DS, et al. Ultrasonography for nerve compression syndromes of the upper extremity. Ultrasonography. 2015;34(4):275-291.
  4. Deniel A, Causeret A, Moser T, Rolland Y, Dréano T, Guillin R. Entrapment and traumatic neuropathies of the elbow and hand: An imaging approach. Diagn Interv Imaging. 2015;96(12):1261-1278.
  5. Kobayashi S, Meir A, Baba H, Uchida K, Hayakawa K. Imaging of intraneural edema by using gadolinium-enhanced MR imaging: experimental compression injury. AJNR Am J Neuroradiol. 2005;26(4):973-980.
  6. Fox IK, Mackinnon SE. Adult Peripheral Nerve Disorders—Nerve Entrapment, Repair, Transfer and Brachial Plexus Disorders. Plast Reconstr Surg. 2011;127(5):10.1097/PRS.0b013e31820cf556.
  7. Lawande AD, Warrier SS, Joshi MS. Role of ultrasound in evaluation of peripheral nerves. Indian J Radiol Imaging. 2014;24(3):254-258.

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Last updated: 2017-08-09 14:15