Nerve Entrapment Syndromes

Nerve Entrapment Syndromes

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Entrapment neuropathies are a group of disorders of the peripheral nerves that are characterized by pain and/or loss of function (motor and/or sensory) of the nerves as a result of chronic compression.

The brain and spinal cord receive and send information through muscles and sensory receptors, and the information sent to organs is transmitted through nerves. The nerves travel to the upper and lower extremities and traverse the various joints along their paths. Unfortunately, these nerves can become compressed or entrapped at various regions of the extremities, especially at “tunnel” regions, where they may be predisposed or vulnerable to compression.

Neurosurgeons, among other surgical specialists (eg, orthopedists and plastic surgeones), treat these entrapment neuropathies, which can account for 10-20% of the practice’s cases. The first operations or decompressions for different nerve entrapments were performed more than a century ago, but the disorders were described even earlier by such pioneering physicians as Sir Astley Cooper (1820s) and Sir James Paget (1850s).

Carpal tunnel syndrome (CTS), compression of the median nerve at the wrist, is the most common entrapment neuropathy. Cubital tunnel syndrome is the second most common and is caused by a compression at the elbow. [1] Other rare nerve entrapment syndromes include the suprascapular nerve, which accounts for approximately 0.4% of upper girdle pain symptoms, and meralgia paresthetica, which is a compression of the lateral femoral cutaneous nerve [LFCN] in the groin. [2]

An ulnar nerve transposed at the elbow is shown in the image below.

This article summarizes some basic principles of entrapment neuropathies, and, within each section, the specifics of the most common entrapment syndromes are outlined. Together, this information should provide the reader with a solid basis for further investigation.

Nerve entrapment syndromes result from chronic injury to a nerve as it travels through an osseoligamentous tunnel; the compression is typically between the ligamentous canal and bony surfaces. Other potential anatomical sites for entrapment include the muscular arcade of the supinator (also known as the arcade of Frohse), the posterior interosseous nerve (PIN), and the thoracic outlet for the lower trunk of the brachial plexus. [3]

In cases of nerve entrapment, at least one portion of the compressive surfaces is mobile. This results in either a repetitive “slapping” insult or a “rubbing/sliding” compression against sharp, tight edges, with motion at the adjacent joint that results in a chronic injury. Immobilization of the nerve with a splint or lifestyle adjustments may therefore resolve the symptoms. Entrapment neuropathies can also be caused by systemic disorders, such as rheumatoid arthritis, pregnancy, acromegaly, or hypothyroidism.

Suprascapular nerve entrapment may cause 2% of all cases of chronic shoulder pain. Of the many reported causes of suprascapular nerve entrapment, the most common are para-labral cysts, usually in the spinoglenoid notch, and microtrauma in elite athletes. [4]

Repetitive injury and trauma to a nerve may result in microvascular (ischemic) changes, edema, injury to the outside layers of the nerve (myelin sheath) that aid in the transmission of the nerve’s messages, and structural alterations in membranes at the organelle levels in both the myelin sheath and the nerve axon. Focal segmental demyelination at the area of compression is a common feature of compression syndromes. Complete recovery of function after surgical decompression reflects remyelination of the injured nerve. Incomplete recovery in more chronic and severe cases of entrapment is due to Wallerian degeneration of the axons and permanent fibrotic changes in the neuromuscular junction that may prevent full reinnervation and restoration of function.

See Medical therapy and Intraoperative details.

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

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

Disclosure: Nothing to disclose.

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

Disclosure: Nothing to disclose.

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

Disclosure: Nothing to disclose.

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

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

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Depuy spine consulant, Asterias, Bioventus, Tejin serve on advisory boards<br/>Received research grant from: DOD, PICORI<br/>Received income in an amount equal to or greater than $250 from: Stryker honorarium.

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

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

Disclosure: Nothing to disclose.

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

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

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

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

Disclosure: Nothing to disclose.

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

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

Disclosure: Received consulting fee from Medtronic for consulting; Received consulting fee from Abbott Neuromodulation for consulting.

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

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

Disclosure: Nothing to disclose.

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

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

Disclosure: Nothing to disclose.

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

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

Disclosure: Nothing to disclose.

Nerve Entrapment Syndromes

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