ppt

1. ENTRAPMENT NEUROPATHIES
PRESENTER
Dr. NAGARJUN M N
CHAIR PERSON
PROF. B INDIRA DEVI

2. DEFINITION
Entrapment neuropathy is defined as “Pressure or pressure
induced injury to a segment of a peripheral nerve secondary
to anatomical or pathologic structures”

3. TYPES
UPPER LIMB
• Carpal tunnel syndrome
• Cubital tunnel syndrome
• Supraspinatus syndrome
• Anterior interosseous syndrome
• Posterior interosseous syndrome
LOWER LIMB
• Meralgia paresthetica
• Tarsal tunnel syndrome
• Piriformis syndrome
• Peroneal tunnel syndrome
Controversial entrapment neuropathies like
• Radial tunnel syndrome
• Tarsal tunnel syndrome
• Piriformis syndromes.

4. ANATOMY

5. In general all entrapments
have any one of the
following basic structure –
1.Fibro-osseous tunnels like
• Carpal tunnel(median
nerve)
• Tarsal tunnel(posterior
tibial nerve)
• Suprascapular tunnel
(suprascapular nerve)

6. 2.Fibrotendinous arcade at the
origin of certain muscle-
• Supinator(arcade of Frohse)
• Flexor carpi ulnaris (cubital
tunnel)
• Flexor digitorum sublimis
(sublimis bridge)
• Common peroneal nerve
entrapment
• Anterior and posterior
interosseous nerve entrapments
• Piriformis syndrome

7. 3.Abnormal bands causing
compression-
• Thoracic outlet syndrome
• Meralgia paresthetica

8. CARPAL TUNNEL
• Earliest description of CTS was given by Sir James Paget in
1854
• Fibro-osseous passageway in the anterior aspect of the wrist
formed by the carpal bones and flexor retinaculum.
• Floor volar radiocarpal ligament .
• Roof Transverse Carpal Ligament(TCL), attaches
medially to the pisiform and hook of the hamate and laterally
to the scaphoid tuberosity and crest of the trapezium.
• The TCL is approximately 3 to 4 cm in width and 2.5 to 3.5 mm
in thickness and is 4 to 6 cm in length

9. • Contents
1.The median nerve and its vascular bundle,
2.Tendons- flexor digitorum superficialis
(FDS), profundus (FDP) and flexor pollicis longus

10. ULNAR NERVE ENTRAPMENT
• Henry Earle in 1816 was the first to report surgical treatment for
ulnar nerve compression at elbow. In 1956, Feindel and Stratford
proposed the designation “cubital tunnel” to describe the site of UN
compression at the elbow.
• Most common site of entrapment between the
medial epicondyle and olecranon within the cubital tunnel
• Roof cubital tunnel retinaculum or arcuate ligament
of Osborne which extends from tip of the olecranon to the medial
epicondyle.
• Fibers oriented in transverse fashion and become taut with elbow
flexion.
• Floor capsule of the elbow joint and medial collateral
ligament.
• Walls medial epicondyle and olecranon.

11. DIFFERENT SITES OF ULNAR NERVE
ENTRAPMENT IN ELBOW

12. POSTERIOR INTEROSSEOUS NERVE
ENTRAPMENT
• Terminal branch of radial nerve arising in front of the lateral
epicondyle of elbow.
• Supplies extensor carpi radialis brevis and supinator and enters
arcade of Frohse which is the usual site of entrapment.
• Arcade is a tough fibrotendinous ring like structure at the origin of
supinator muscle.
• Arcade is absent in full term fetuses and seen in 30% adults
indicating that “the arcade is probably formed in the most proximal
part of the superficial head of the supinator in response to
repeated rotary movement of the forearm”
• It passes in the dorsal aspect of forearm and supplies most of the
extensors of hand and wrist.
• No cutaneous branches

13. POSTERIOR INTEROSSEOUS NERVE
ENTRAPMENT

14. ANTERIOR INTEROSSEUS
SYNDROME
• principally a motor nerve
• branch of median nerve in proximal
forearm arising variably between the
2 heads of pronator teres, descends
vertically in front of interosseous
membrane between flexor digitorum
profundus and flexor pollicis
longus, supplies these 2 muscles and
terminates by supplying the pronator
quadratus.
• The nerve can get entrapped due to
fractures, penetrating
wounds, constricting bands mostly
near its origin.
• In majority the cause is not found

15. ANATOMY
RADIAL TUNNEL
• Radial tunnel is the space SYNDROME
surrounding the distal radial
nerve and proximal PIN from
humeroradial joint to within
the supinator muscle.
The tunnel is 5 cm long, is anterior to
proximal radius.
The floor is formed by capsule of
radial capitulum. The brachioradialis,
ECRL and ECRB form lateral wall and
biceps and brachialis form the medial
wall.

16. SUPRASCAPULAR ENTRAPMENT
• Suprascapular nerve is a mixed nerve arising from superior
trunk of brachial plexus.
• Supplies supraspinatus, infraspinatus and sensory supply to
capsule of shoulder joint.
• Runs through posterior triangle of neck, parallel to inferior
belly of digastric under trapezius, through suprascapular
notch, below suprascapular ligament and into suspinous
fossa. From there loops around the lateral angle of spine and
enters deep surface of infraspinatus to supply it.
• The nerve commonly gets trapped in the suprascapular
notch, rarely in spinoglenoid notch

17. SUPRASCAPULAR ENTRAPMENT

18. THORACIC OUTLET SYNDROME
• Galen first described the presence of a cervical rib in 150 AD
• The thoracic outlet refers to the communication of the thoracic
cavity with the root of the neck.
• There are three sites within the thoracic outlet where
neurovascular compression may occur:
• The interscalene triangle
• The costoclavicular space
• The subpectoral tunnel.
The most important passageway clinically is interscalene triangle,
bordered by anterior scalene muscle anteriorly, middle scalene muscle
posteriorly and medial surface of the first rib inferiorly.
Contains trunks of the brachial plexus and subclavian artery

19. THORACIC OUTLET SYNDROME

20. TARSAL TUNNEL SYNDROME
• The TT is a continuation of the deep posterior compartment
of the calf into the posteromedial aspect of the ankle and the
medial plantar aspect of the foot.
• The TT is made up of two main compartments:
• An upper (tibiotalar) and a lower (talocalcaneal)
compartment.
• Floor of the upper compartment posterior aspect of
the tibia and the talus
• The posterior tibial neurovascular bundle runs through this
space with the tendons of the Tibialis Posterior, Flexor
Digitorum Longus and Flexor Hallucis Longus. The lower
compartment of the TT contains the abductor hallucis muscle.

21. • The tibial nerve passes
within the upper
compartment of the TT
posterior to the tendons of
the TP and FDL and the
posterior tibial artery and
vein.
• The medial and inferior
calcaneal nerves may arise
proximal to, within or distal
to the TT. 1. TIBIALIS POSTERIOR TENDON
• The roof is formed by a 2. FDL TENDON
3. TIBIAL NERVE
deep aponeurosis.
4. FLEXOR RETINACULUM
5. MEDIAL PLANTAR NERVE
6. LATERAL PLANTAR NERVE

22. PIRIFORMIS SYNDROME
• Piriformis originates from the anterior
surface of the sacrum and the superior margin
of the greater sciatic notch. It also has
attachment to the capsule of the sacro-iliac
joint and also the sacrotuberous ligament.
• Exits pelvis through greater sciatic notch, fibres inserted into the
superior aspect of the greater trochanter of the femur
• The sciatic nerve passes deep to piriformis in most cases
(approximately 85% of people) but can pierce the piriformis
itself, predisposing to piriformis syndrome and subsequent sciatica.
• Even if the sciatic nerve runs deep to piriformis, spasm in this
muscle put direct pressure on the nerve, causing the resultant pain
and discomfort.

23. COMMON PERONEAL NERVE
ENTRAPMENT
• The common peroneal nerve after emerging out of the
popliteal fossa courses around the fibular neck and passes
through the fibro-osseous opening in the superficial head
of the peroneus longus muscle at its origin which forms a
sharp crescentric arch
• This opening can be quite tough, and can result in the
nerve angulating through it at an acute angle
• Fibrous connective tissue secures the nerve to this proximal
portion of the fibula, potentially compromising the nerve
• This opening in peroneus longus is called fibular tunnel
where the common peroneal nerve gets entrapped
commonly

24. COMMON PERONEAL NERVE

25. PATHOLOGY
• The effect of nerve compression is mediated by ischemia and
edema.
1. Disruption of blood nerve barrier
2.Dysfunction of intraneural circulation reversible
3.Segmental demyelination
4.Edema
1.Epineural fibrosis irreversible
2.Thickening of nerve
3.Myelin sheath damage
4.Axonal disruption

26. PREDISPOSING FACTORS
Congenital narrowing of osseous canal
through which the nerve traverses like increased
carrying angle malunited epiphysis
Thickening of overlying retinaculum due to
systemic diseases like hypothyroidism,
occupation related like carpenters and musicians
having thickened flexor retinaculum in the wrist

27. CAUSES
1.Normal anatomy with abnormal contents
• Tumors- intraneural neuroma, lipoma, Ganglion,
schwannoma, hemangioma, neurofibroma, desmoid tumors,
angiomas, fibrolipomatosis, hamartomas, vascular
abnormalities.
Exostosis, chondromatosis, Baker cysts- more commonly seen
around the knee in relation to the compression of the common
peroneal nerve
• Congenital- Persistent median artery as in carpal tunnel
• Rudimentary cervical rib in TOS
• Anamolous fibrous bands

28. CAUSES
2.Abnormal anatomy of the normal contents
• Inflammation or edema of surrounding
structures
• Accessory or hypertrophic muscles
• Varicosities
• Tenosynovitis
• Prominent C7 transverse process in TOS
• Reflex spasm of the muscle like piriformis in
piriformis syndrome
• Abnormal course of the nerve through the
muscle or its tendon –sciatic nerve through the
piriformis
• Altered biomechanics resulting from limb
length discrepancy leading to stretching and
shortening of the muscle like piriformis
• Malunited fractures like fibular neck

29. Common Conditions Associated with
Carpal Tunnel Syndrome
Metabolic/endocrine: Anatomic:
• Diabetes mellitus • Persistent median artery
• Pregnancy • Anomalous tendons or muscles
• Hypothyroidism • Congenital stenosis of the carpal tunnel
• Acromegaly • Fracture and/or dislocation at the wrist
• Renal failure Infectious:
• Pyridoxine (vitamin B6) deficiency • Septic arthritis
Autoimmune/inflammatory: • Lyme disease
• Rheumatoid arthritis • Tuberculosis
• Amyloidosis • Histoplasmosis
• Sarcoidosis Neoplasm:
• Tenosynovitis • Nerve sheath tumor
• Ganglion cyst

30. CLINICAL PRESENTATION

31. Age and gender vary-
• Carpal tunnel- Middle aged female
• Thoracic outlet syndrome- young, thin female with a long
neck and drooping shoulders
• Meralgia Paresthetica- middle aged over-weight men
• Athletes in general predisposed to cubital tunnel syndrome,
thoracic outlet syndrome, piriformis syndrome
Occupation : carpentry, painting, and musicians are more
susceptible for Ulnar nerve compression
Military personal wearing heavy belts -meralgia paresthetica
Postural variation -Symptom aggravated by standing and walking
and relieved by rest in meralgia paresthetica

32. COMPLAINTS
• Pain, numbness are the early symptoms.
• weakness, wasting, deformity are the late symptoms.
Certain syndromes have specific symptoms like
• nocturnal increase in pain with disturbed sleep - Carpal tunnel
syndrome and Tarsal tunnel syndrome
• Vasomotor disturbances such as changes in skin color and
temperature - thoracic outlet syndrome
• Motor weakness may precede sensory disturbances because
of the predominance of motor fibers within the Ulnar nerve
as in Cubital tunnel
• Frequent dropping of objects - Ulnar nerve involvement

33. SIGNS
• Sensory loss in the distribution of the nerve
• Wasting of the muscles supplied by the nerve
• Deformities of the hand/leg due to selective involvement of the
muscles like clawed hand in ulnar involvement, foot drop in
common peroneal involvement
• Trophic ulcers in the distribution of the nerve in long standing
sensory nerve involvement
• Flick sign- To relieve the symptoms, patients often “flick” their
wrist as if shaking down a thermometer in Carpal tunnel
syndrome

34. TINELS SIGN
Tapping of the nerve at the site of involvement
produces paresthesia all along the distribution of
the nerve

35. PHALENS MANEUVER
It reproduces the symptoms in Carpal
tunnel syndrome

36. ROOS TEST
Elevated arm stress test to induce reproduction of the
neurological symptoms in Thoracic Outlet Syndrome

37. WRIGHT TEST
Progressive shoulder abduction to reproduce the
symptoms in Thoracic Outlet Syndrome

38. ADSON TEST
Full neck extension and head rotation toward the side
being examined, during deep inhalation, to detect a
reduction in radial pulse amplitude in thoracic outlet
syndrome

39. WARTENBERG SIGN
In ulnar nerve compression the third volar interosseous
muscle is weak and allows the extensor digiti minimi to abduct
the fifth finger during extension causing finger catching while
placing the affected hand in pocket.

40. DIFFERENTIAL DIAGNOSIS OF CUBITAL
TUNNEL SYNDROME
Differential Diagnosis of Cubital Tunnel Syndrome
• Spinal cord Cervical spondylotic myelopathy
Cervical syrinx
Cervical spinal cord tumor
• Nerve root Motoneuron disease(Amyotrophic lateral
sclerosis (ALS)-initial stages )
C8 or T1 radiculopathy
• Peripheral nerve Brachial plexopathy (lower trunk or
medial cord)
• Ulnar nerve Nerve sheath tumor
Ulnar nerve compression at the arcade of
Struthers.
Ulnar nerve entrapment at Guyon's canal
• Other Peripheral neuropathy
Thoracic outlet syndrome

41. Differential Diagnoses for Neurogenic
Thoracic Outlet Syndrome
Spinal Cervical disk disease or foraminal stenosis
Cervical spinal cord tumor
Cervical syrinx
Peripheral nerve Brachial plexitis
Median nerve entrapment neuropathy
Ulnar nerve entrapment neuropathy
Nerve sheath tumor
Orthopedic Shoulder abnormalities (rotator cuff injury)
Other Complex regional pain syndrome
Fibromyalgia
Apical lung lesion (Pancoast's tumor)

42. INVESTIGATIONS
X-rays - To see for any fractures, osteophyte formation,
hypertrophic changes, cervical rib
Ultrasound - to see for abnormal contents like tumors, cysts,
varicosities, edema of the surrounding structures.
• Refinements of the techniques has allowed direct
visualization of neural structures and associated sites of
constriction or compression.
• Entrapped peripheral nerves appear swollen, hypo echoic or
flattened.
• Is found useful and highly sensitive is CTS, UN entrapment,
suprascapular, axillary and radial neuropathies

43. ELECTROPHYSIOLOGY
• Electrophysiology is an important investigation
• EMG and NCSs use different means of measuring action
potentials of nerve axons or muscle fibers
• SNAP(Sensory nerve action potentials ) and CMAP(Compound
Muscle Action Potential) are recorded on both the limbs for
comparison and in different nerves of same limb to rule out
symmetric involvement.
• These recordings should be done across the suspected area of
the lesion
• Recording should be done by inching technique.
• In entrapments generally the latency is increased, conduction
velocity is reduced and amplitude is reduced in later stages.

44. CARPAL TUNNEL SYNDROME
• Important objective information to support the diagnosis of CTS.
• Palmar sensory latency - most sensitive test .
• Distal motor latency may be normal in 25% of patients.
• Sensory nerve action potentials (SNAPs) are either unrecordable or of low
amplitude at the wrist.
• Helpful in grading the severity of CTS.
In mild CTS,
SNAP or mixed nerve action potential (NAP)- prolonged
SNAP amplitude- below the lower limit of normal.
In moderate CTS,
findings of mild CTS plus prolongation of median motor distal latency
In severe CTS,
median motor and sensory distal latencies-prolonged, absent SNAPs
or mixed NAPs or absent or reduced thenar compound motor action
potentials or both.
• Fibrillations, reduced recruitment, and changes in motor unit potential are
often seen in severe cases.

45. CUBITAL TUNNEL SYNDROME
• Prolonged motor and sensory latency across the
elbow but normal latency in the distal part of the
forearm.
• Motor conduction velocities of less than 50 m/sec
across the elbow also suggest entrapment at the
elbow.
• Electromyography of ulnar-innervated muscles
may show reduced voluntary motor
units, fibrillations, increased insertional
activity, and other electro physiologic signs of
denervation

46. POSTERIOR INTEROSSEOUS NERVE
ENTRAPMENT
• Needle electromyographic examination-
denervation potentials in innervated muscles and
absence of same in muscles directly innervated
by radial nerve localises lesion to PIN.
• Further absence in extensor carpi radialis brevis
and supinator localises to arcade of Frohse.
• Nerve conduction velocity studies show slowing
across entrapment site.

47. THORACIC OUTLET SYNDROME
• In true neurogenic TOS,EMG shows reduced motor units under voluntary
control in hand muscles.
• Needle examination of cervical paraspinal muscles –normal
• Maximal motor conduction velocity may be slowed in the median nerve
but normal in the ulnar nerve, and distal motor latencies for both nerves
are normal.
• Compound motor action potentials(CMAP) over thenar muscles are
reduced in situations of marked axonal loss, whereas those over the
hypothenar muscles are generally normal.
• Sensory nerve action potentials(SNAP) recorded at the median nerve in
the wrist have normal amplitude and latency, but they are often small or
absent from the ulnar nerve after stimulation of the fifth finger.
• In disputed neurogenic TOS, electrophysiologic studies are normal.
• Nerve conduction velocities(NCV) for the medial antebrachial cutaneous
nerve abnormal in patients with neurogenic TOS in the absence of other
electrophysiologic findings

48. TARSAL TUNNEL SYNDROME
• Tibial motor nerve conduction-prolonged, distal onset latency
when recorded over the abductor hallucis and abductor digit
minimi.
• Mixed nerve conduction studies of the medial and lateral
plantar nerves- prolonged peak latency or slowed velocity
• Sensory nerve conduction of the two nerves may be slowed
or absent across the tarsal tunnel.

49. MAGNETIC RESONANCE IMAGING
• Greater sensitivity in the detection of peripheral nerve
inflammation.
• MRI techniques useful in patients with normal electrophysiological
studies or in those with an underlying systemic neuropathy altering
the electrophysiological results.
• A normal nerve appears isointense to muscle in all sequences
• Nerve thickening or nerve enlargement on MRI signifies
inflammation.
• Nerve may be enlarged proximally to the point of constriction
• Increased signal intensity within inflamed peripheral nerves seen on
short tau inversion recovery (STIR) images or fat-suppressed T2-
weighted spin echo images.
• Muscles that are innervated by the distal portion of the entrapped
nerves appear bright on T2 and STIR thus confirming the identity of
the nerve.

50. Axial STIR image through the distal forearm of a patient who has
surgically confirmed AIN syndrome. In the T1-weighted image (A),
atrophy of the PQ (arrows) is seen. In the STIR image (B),
increased signal within the PQ is visible, but there is also
increased signal without atrophy in FDP1 and FDP2 (arrows).

51. MRI
• May suggest adhesion of nerve to surrounding tissue.
• Magnetic resonance neurography is useful in demonstrating
nerve position in relation to an adjacent joint placed in
varying degrees of flexion.
• After denervation MRI changes in denerved muscle precedes
the EMG change.
• Inflammatory conditions of the nerves also enhance on T2 but
the enhancement is more diffuse.
• Inflammatory conditions, tumors and traumatic neuromas
enhance with current contrast but entrapped nerves do not
enhance.
• Also useful in the detection of mass lesions

52. NEWER TECHNIQUES IN MRI
• DTI(diffusion Tensor Imaging ) is used to track the nerves, can
be used for viewing changes at the microscopic structure of
the nerve at and proximal to the entrapment which are not
seen on T2 or STIR
• 3D pulse sequences-high quality image reformatting in all
planes. It has been applied to brachial plexus and sciatic
nerves and has shown promise for being able to show
longitudinal images of nerves over long segments thus
identifying areas of focal narrowing or extrinsic compression

53. (A) T1-weighted image of excised human median nerve, obtained on
a 3-T magnetic resonance microscopy system.
(B) Light microscopy of the same nerve. These are not seen in
normal imaging techniques.

54. NEWER TECHNIQUES IN MRI
• Newer agents like Gadoflurine –M (not yet available for
human use) and Vasovist having longer clearance values from
blood due to tight protein binding are seen to produce
enhancement in demyelinating and degenerating peripheral
nerves which otherwise fail to enhance on conventional
contrast agents may become useful in entrapments also.
• Magic angle effect-Water containing longitudinally arranged
proteins as in nerves and collagen when makes an angle of
55⁰ with main magnetic field it appears more bright on T2 and
STIR

55. CAN MRI REPLACE
ELECTROPHYSIOLOGY?
• In syndromes where the nerves are deep and recording is not
practical MRI definitely is the preferred technique
• IN CTS where both can be employed, many RCTs have been
done to look for the sensitivity and specificity of the results of
each of these 2 modalities. In CTS it can be concluded that
MRI has some what inferior accuracy to nerve conduction
studies but is preferred by patients as it is non invasive, fast
and also contributes additional information.
• In ulnar nerve entrapment at elbow MRI has a sensitivity of
(>95%) as compared to nerve conduction studies (60-70%).
Bland JD. Carpal tunnel syndrome. Curr Opin Neurol 2005;18:581–5. Vucic S,
Cordato DJ, et al.
Utility of magnetic resonance imaging in diagnosing ulnar neuropathy at the
elbow. Clin Neurophysiol 2006;117:590–5

56. • In piriformis syndrome MRI has shown 93% specificity for two
findings namely T2 hyperintense signal of the sciatic nerve in
the sciatic notch and piriformis asymmetry
• In peroneal nerve entrapment, MRI is useful in distinguishing
this condition from L5 root involvement by demonstrating the
additional involvement of Tibialis posterior and popliteus in L5
root involvement apart from involvement of TA,ED,PL in both
cases. MRI can demonstrate causes like ganglionic cysts and
origin of these cysts(joint vs. nerve)

57. TREATMENT

58. NON-SURGICAL
GENERAL
• Splints, physical therapy, ultrasound therapy, ice and heat
therapy, diuretics, nonsteroidal anti-inflammatory drugs
(NSAIDs)
• Corticosteroids (either oral or direct )
• Avoid positions that trigger pain
• Lifestyle modification: avoidance of activities that exacerbate
or provoke symptoms
• Correcting poor posture
• Nerve blocks
• Muscle denervation through targeted injection of botulinum
toxin
• Psychological counseling

59. SPECIFIC
• Resting the affected shoulder as in suprascapular entrapment
• Weight reduction in obese people in meralgia paresthetica
• Physiotherapy-example, Piriformis stretching exercises
• Sports massage techniques

60. WRIST SPLINTS

61. LOCAL STEROID INJECTION

62. LOCAL STEROID INJECTION
• The benefit of steroid treatment is transient.
• About 50% of the nerves become worse within 6 months
and 90% within 18 months.
• Only a small percentage (8%) of the nerves remain
improved at the 2-years follow-up.
Paolo Girlanda et al. Local steroid treatment in idiopathic carpal tunnel syndrome short- and long-
term efficacy:Journal of Neurology Volume 240, Number 3, 187-190

63. SURGICAL TREATMENT
• Release of the constriction is the main surgical treatment.
• The timing of surgery, type and extent of surgery is much
debated aspect.
Patients with motor deficits invariably require surgical
decompression at the earliest, if any improvement is expected.
This is undebatable.
Dilemma regarding timing and decision for surgery is present in
following group of patients
1. Patients with only pain
2. Pain without motor symptoms with normal
electrophysiology
3. Controversial syndromes

64. SURGICAL OPTIONS FOR CTS
METHODS
• OPEN REDUCTION
Goal is complete excision of flexor retinaculum.
A 3- to 4-cm straight or slightly curvilinear incision, starting
at distal wrist crease and ending at a point intercepting an
imaginary line (Kaplan's) drawn from the distal border of
the extended thumb to the pisiform prominence, in line
with the long axis of the radial side of the ring finger.
TCL divided at midpoint, once median nerve visualized, TCL
incised both proximally and distally. The distal TCL incised
till deep palmar fat pad is visualized

65. In mini open approach, 1.5-3 cm incision is given.
ENDOSCOPIC TECHNIQUES-
Uniportal technique
1.Okutsu technique
2.Agee technique.
Biportal technique
1.Chow technique
2.Brown technique

66. OPEN vs. ENDOSCOPIC SURGERY IN
CTS
• Cochrane collaboration did a systemic review of 33 studies looking
at return to work or normal daily activity, complications. They found
transient nerve dysfunction was more in endoscopic ones
compared to open ones, the latter had more wound complications.
They concluded that no strong evidence to suggest replacement of
standard OCTR with ECTR.
• In 2004,Thoma and colleagues performed meta-analysis and found
no statistically significant difference in pain or return to work.
• Atroshi and colleagues published a RCT. Primary outcome was
severity of postoperative incisional or palmar pain and secondary
outcomes were length of work absence ,severity of CTS symptoms
and functional status at intervals up to 1 year. In the end they
questioned the cost-effectiveness of endoscopy as there was no
difference in the outcome
Eichhorn J, Dietrich K. Open versus endoscopic carpal tunnel release. Results of a prospective study. Chir
Praxis. 2003;61:279

67. ULNAR NERVE ENTRAPMENT
Types
1. Simple decompression (with or without medial
epicondylectomy)
2. Anterior subcutaneous transposition
3. Intramuscular transposition
4. Submuscular transposition
Simple or in situ decompression- of the UN, which involves
unroofing of the cubital tunnel, is the easiest and most
commonly used option.
Once decompression is completed, the elbow is flexed and
extended to look for nerve subluxation and stretch.

68. Anterior subcutaneous or sub muscular transposition
• Complete external neurolysis of the Ulnar nerve(UN) must be performed.
• Articular branches and small vessels tethering the UN need to be divided.
• A distal segment of the medial intermuscular septum must be excised to
prevent tethering or compression of the transposed UN
• In anterior subcutaneous transposition, the nerve is brought anterior to
the medial epicondyle, and a fascial sling is created to hold the nerve in
place
• In the case of submuscular transposition, the origin of the flexor-
pronator mass is isolated and divided in a step-cut or Z-plasty
configuration, with a proximal cuff of muscle and fascia left intact.
• Arm is placed in a sling for approximately 3 weeks

69. • Recently, endoscope has been used to decompress the UN at
the elbow. Through a 2 to 3 cm incision over the course of the
UN at the elbow, it is possible to decompress up to 10 cm
proximal and 10 cm distal to the medial epicondyle

70. INSITU DECOMPRESSION vs.
TRANSPOSITION IN ULNAR ENTRAPMENT
• In 2007, Zlowodzki and coauthors published a meta-analysis of four
randomized controlled trials that comparing in situ decompression
and anterior transposition
• A total of 261 patients with an average follow-up of 21 months
were included in this study. The results of this analysis found no
significant difference in clinical outcome or postoperative nerve
conduction velocity between in situ decompression, subcutaneous
transposition, and sub muscular transposition
• In initial cases at the end of insitu decompression with flexion and
extension of the elbow if there is no tension in the nerve, there is
no need for transposition
• Transposition is often procedure of choice in recurrent cases or in
patients with significant ulnar nerve subluxation
Zlowodzki M, Chan S, Bhandari M, et al. Anterior transposition compared with simple
decompression for treatment of cubital tunnel syndrome. A metaanalysis of randomized,
controlled trials. J Bone Joint Surg Am. 2007;89:2591

71. SUPRASCAPULAR ENTRAPMENT
• Sectioning of the suprascapular ligament is treatment of
choice in people not improving with conservative treatment
• Posterior approach is generally used
• Anterior supraclavicular approach has not gained popularity
• Sequence of recovery is pain relief followed by gain of motor
strength, atrophy if at all reverses at the end
• Arthroscopic and endoscopic methods have been developed
and recent RCTs favor endoscopy as it is associated with less
complications
Tubbs RS, Loukas M, Shoja MM, et al. Endoscopically assisted decompression of the
suprascapular nerve in the supraspinous fossa: a cadaveric feasibility study. Laboratory
investigation. J Neurosurg 2007;107:1164–7.

72. ANTERIOR INTEROSSEUS SYNDROME
• Conservative management for 8-12 weeks as most cases
recover spontaneously
• SURGICAL TREATMENT-explore the nerve and divide the
constricting band which is commonly found near the origin of
the nerve.

73. POSTERIOR INTEROSSEUS SYNDROME
• Conservative treatment for 4-8 weeks
• Refractory cases, surgery is considered which
involves exploration and dividing of arcade of
Fosche and any other constricting bands.

74. TARSAL TUNNEL SYNDROME
• Open exploration of the TT is the preferred surgical
technique
• Success rates for surgical decompression of the TT have
been reported to be between 44% and 93%,Success
defined as resolution or improvement of symptoms, no
requirement for pain medications, and the ability to return
to work.
• The deep fascia over the neurovascular bundle is divided
proximal to the Tarsal tunnel(TT), and division is continued
distally upto flexor retinaculum..
• The medial and lateral plantar nerves are followed into
their separate tunnels. Both tunnels are released by
dividing the fascial origin of the abductor hallucis brevis,
which forms their roof.
• Complete external neurolysis is usually performed

75. MERALGIA PARESTHETICA
• Surgical management has 2 options-
Decompression of the nerve
Sectioning of the nerve
• A horizontal or curvilinear vertical incision medial
to ASIS is used to locate the nerve.
• All possible constricting bands to be divided and
free space should be made around the nerve.
• Some advocate transposing the nerve medially
for a straighter course.

76. THORACIC OUTLET SYNDROME
TYPES
1. Anterior supraclavicular approach-most commonly
used.Wider exposure of the supraclavicular plexus and
the middle two thirds of the first rib, where most
potential anomalous fibrous bands are attached.
2. Transaxillary approach with first rib resection-
Advantage is, it allows easy and almost complete access
to the first rib, unhindered by adjacent neurovascular
structures
3. Posterior subscapular approach-excellent exposure of
the C8 and T1 spinal nerves and the lower trunk of the
brachial plexus. Useful in patients who have previously
undergone anterior approaches or received radiation
therapy to the area.

77. COMMON PERONEAL NERVE
ENTRAPMENT
• Surgical decompression of the nerve
• Excision of the offending lesion
E.g., intra neural or extra neural tumors or masses.
• Open decompression is recommended between third
and fourth months if symptoms persist or recovery is
incomplete, even if the patient has only sensory
symptoms that have been substantiated by electro
physiologic studies.
• Surgery involves exposure of the nerve, decompression
by releasing the tendinous arch and other bands if
present and reconstruction in severely damaged cases.

78. CONTROVERSIAL SYNDROMES

79. RADIAL TUNNEL SYNDROME
CONTRAVERSIES
• There is considerable doubts as to whether this clinical entity
or anatomical tunnel exists
• It is differentiated from PIN syndrome(which involves loss of
motor function ) by presence of pain and tenderness over
proximal radial forearm without weakness. Recent studies
have shown that patients diagnosed clinically and electro
physiologically as Radial tunnel syndrome had MRI T2 and
STIR hyper intense signal changes in the muscles innervated
by PIN, indicating its involvement
• ENMG is usually normal
• The duration of recommended conservative management in
cases with or without weakness has wide variation among
different studies. There is no study comparing non surgical
treatment with the surgery treatment.
• Effectiveness of the surgical decompression of the PIN was
found to be in the range of 67% to 95% in different studies.

80. PIRIFORMIS SYNDROME
CONTRAVERSIES/CONFUSIONS
• Gluteal trauma with hematoma, injection palsy, compression, hip
arthroplasty, hip fracture, or endometrial Implant can cause proximal sciatic
nerve compression near to piriformis and hence need to be differentiated
before labelling proximal sciatic nerve compression as piriformis syndrome
• How much a small structure like piriformis muscle can compress the sciatic
nerve is very doubtful.
• SPASM-Abnormal leg movement(external rotation ) is never described, So is
spasm isometric ? Nerve compression?
• The PS is the only entrapment neuropathy attributable to a muscle.
• Pace test –sciatic pain with abduction of the hip against resistance. Freiburg
test- pain with forced internal rotation, stretching the muscle. Diametrically
opposite tests causing same compression?
• Freiburg test should decompress the nerve by stretching the
muscle, removing the pressure and improving the symptoms.

81. THORACIC OUTLET SYNDROME
CONTROVERSIES
• The most common variety is the disputed neurogenic one making upto 97% of TOS
• The diagnostic tests are exceptionally sensitive and have poor specificity.
• The provocative tests have been found to be abnormal in control groups to the
extent of 2/3rd in RCTs
• In proximal entrapments the role of electrophysiology is limited as distal recording
will be normal and localisation is difficult(even in true thoracic syndromes).
• The diagnosis of disputed TOS is by clinical signs and symptoms as elctrophysiology
doesn’t show any abnormality.
• On MRI nerve compression has been found in only few about 7% of symptomatic
patients.
• Patients with disputed type undergoing surgery can develop objective deficits which
were absent before.
Roos DB. Thoracic outlet syndrome is underdiagnosed.Muscle Nerve 1999;22:126–9 [discussion 136–7]

82. OUTCOME OF SURGICAL TREATMENT
Outcome is good in well recognized and common entrapments
like Carpal tunnel syndrome:
• Open method-improvement in pain-87%,paresthesias-92%
• Endoscopy- upto 82% patients had complete resolution of
symptoms (Hankins et al)
• In controversial syndromes like Thoracic outlet syndrome-
Resolution of pain or paresthesias, or both is seen in 50% to
60% of patients and a partial response in another 20% to 30%.
• Hankins CL, Brown MG, Lopez RA, et al. A 12-year experience using the Brown two-portal
endoscopic procedure of transverse carpal ligament release in 14,722 patients: defining a
new paradigm in the treatment of carpal tunnel syndrome. Plast Reconstr Surg.
2007;120:1911.
• Maxey TS, Reece TB, Ellman PI, et al. Safety and efficacy of the supraclavicular approach to
thoracic outlet decompression. Ann Thorac Surg. 2003;76:396.

83. COMPLICATIONS
Complications are few:
General
Scarring, operative site pain and pain with movement, injury to cutaneous nerves
and paresthesia, injury to adjacent neurovascular structures, neuroma formation
• Approach related deficits like weakness due to muscle dissection, fascial cutting
• Requirement for re-exploration
Specific complications
Chylothorax, pneumothorax, phrenic nerve injury,supraclavicular numbness in
Thoracic outlet syndrome surgeries
• Hernia formation due to inguinal ligament cutting in treatment of meralgia
paresthetica
• Carpal tunnel release surgeries-Incomplete sectioning of the TCL is the most
common complication . Injury to the palmar cutaneous branch (PCB) of the
median nerve is the second most common complication. Severance of the thenar
motor branch (TMB) of the median nerve

84. NIMHANS EXPERIENCE

85. SURGICAL OUTCOME OF ULNAR NERVE
LESIONS AT ELBOW.
• Patients with ulnar nerve injuries who underwent
secondary nerve repair had improvement in 64.7%
cases.
• Best results when done within 6 months of trauma.
Dr.Gopalakrishnan MS,Dissertation for
MCh in neurosurgery,NIMHANS 2005.

86. AN ASSESSMENT OF REGENERATION
IN RAT SCIATIC NERVE
• Uptake of pretreated (cold preserved)
allografts better with primary suturing.
Dr.Shaji KR ,Dissertation for MCh in
Neurosurgery, NIMHANS 2000.

87. PERIPHERAL NERVE REGENERATION ACROSS
COLD PRESERVED NERVE ALLOGRAFTS IN
RATS .
• Cold preservation reduces host immune response to allograft.
• Co-relation noted between functional, electrophysiological
and histological outcome in rats.
• Laminin has an important role in nerve regeneration
Dr.Dhananjay I Bhat, Dissertation for MCh in Neurosurgery,
NIMHANS 2003.

88. BRACHIAL PLEXUS INJURIES -OUTCOME
FOLLOWING NEUROTIZATION
• Intercostal nerve neurotization for Brachial plexus
(avulsions) is a viable option.
• Results with Axillary nerve neurotization better than
musculocutaneous nerve.
• Good functional outcome if done within 6 months of
denervation (Early diagnosis important)
Dr.Aliasgar Moiyadi, Dissertation for
MCh Neurosurgery,NIMHANS 2005.
J Neurosurg 107:308-313, 2007

89. TO SUMMARISE
• Entrapment neuropathies are far more common than thought
to be
• These syndromes are under-diagnosed
• With advances in investigations like MRI more cases can be
diagnosed and less controversies in decision regarding
management
• Conservative management initially
• Surgery for appropiate patients
• Response to surgery is good overall
• Most of these entrapments can be relieved under local
anasthesia on daycare bases with good results
• Complications can be reduced by better anatomical
knowledge

90. THANKYOU