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Peripheral Nerves
 

Peripheral Nerve Conditions

What are the Peripheral Nerves?

The peripheral nerves relay information from your central nervous system (brain and spinal cord) to muscles and other organs and from your skin, joints, and other organs back to your brain. Peripheral neuropathy occurs when these nerves fail to function properly, resulting in pain, loss of sensation, or inability to control muscles.

Mr. D'Urso treats various conditions that affect the peripheral nervous system. Click on the links below to learn more about these specific conditions.

Carpal Tunnel Syndrome

What is Carpal Tunnel Syndrome?Carpal Tunnel

Carpal tunnel syndrome is a common problem that affects the use of your hand. It most often occurs when the median nerve in the wrist becomes inflamed after being aggravated by repetitive movements such as typing on a computer keyboard or playing the piano. The condition may cause progressive narrowing or compression (squeezing) of the median nerve. The "carpal tunnel" is formed by the bones, tendons and ligaments that surround the median nerve. Since the median nerve supplies sensation to the thumb, index and middle finger, and part of the ring finger, and provides motion to the muscles of the thumb and hand, patients will often notice numbness and weakness in these areas. Finger numbness or wrist pain may be most significant during the night, when it can actually awaken a patient from sleep. During the day, it may occur during any activities that involve bending of the wrist. Symptoms can include hand and wrist pain, a burning sensation in the middle and index fingers, thumb and finger numbness, or an electric-like shock through the wrist and hand.

Common Causes of Carpal Tunnel SyndromeCarpal Tunnel

Diseases or conditions that may predispose the development of carpal tunnel syndrome include pregnancy, diabetes, menopause, broken or dislocated bones in the wrist, and obesity. Additional causes include repetitive and forceful grasping with the hands, bending of the wrist, and arthritis. Any repetitive motions that cause significant swelling, thickening or irritation of membranes around the tendons in the carpal tunnel can result in pressure on the median nerve, disrupting transmission of sensations from the hand up to the arm and to the central nervous system.

Diagnosing Carpal Tunnel Syndrome

It is important to seek medical assistance when you first notice persistent symptoms. Do not wait for the pain to become intolerable. Before your doctor can recommend a course of treatment, he or she will perform a thorough evaluation of your condition, including a medical history, physical examination and diagnostic tests. Your doctor will document your symptoms and ask about the extent to which these symptoms affect your daily living. The physical examination will include an assessment of sensation, strength and reflexes in your hand. If conservative treatment such as medication or physical therapy does not provide sufficient relief, your doctor may perform diagnostic studies to determine if surgery is an effective option. These diagnostic studies may include:

  • X-ray: An x-ray will show the bones of the wrist and determine if any abnormalities may be contributing to carpal tunnel syndrome or another disorder.
  • Electromyogram and Nerve Conduction Studies (EMG/NCS): These tests primarily study how the nerves and muscles are working together. They measure the electrical impulse along nerve roots, peripheral nerves and muscle tissue.

Conservative (Non-surgical) TreatmentCarpal Tunnel

The main objective of conservative treatment is to reduce or eliminate repetitive injury to the median nerve. In some cases, carpal tunnel syndrome can be treated by immobilising the wrist in a splint to minimise or stop pressure on the nerves. If that does not work, patients are sometimes prescribed anti-inflammatory medications or cortisone injections in the wrist to reduce swelling. Also, hand and wrist exercises may be recommended both during and after work hours. Treatment for carpal tunnel syndrome may include rest, the use of a wrist splint during sleep, or physical therapy. Conservative treatment methods may continue for up to six or eight weeks.

When Surgery is Necessary

If patients experience severe pain that cannot be relieved through rest, rehabilitation or non-surgical treatment, there are several surgical procedures that can be performed to relieve pressure on the median nerve. Neurosurgeons are uniquely qualified to perform these operations, as they are trained to treat disorders affecting the entire nervous system. The most common procedure is called a carpal tunnel release, which can be performed using an open incision or with endoscopic techniques. The open incision procedure or carpal tunnel release, involves the doctor opening the wrist and cutting the ligament at the bottom of the wrist to relieve pressure. The endoscopic carpal tunnel release procedure involves making a smaller incision and using a miniaturised camera to assist the neurosurgeon in viewing the carpal tunnel. The possibility of nerve injury is slightly higher with the endoscopic surgery, but the patient's recovery and return to work timeframe is quicker. It is important to discuss in detail these two types of surgery with the particular surgeon you have chosen to perform your surgery. However, only a low percentage of patients require surgery. Factors leading to surgery include the presence of persistent neurological symptoms and lack of response to conservative treatment. Recurrence of symptoms after surgery for carpal tunnel syndrome is rare, occurring in less than five percent of patients.

Recovery After Surgery

Approximately one percent of individuals with carpal tunnel syndrome can develop permanent injury. The majority recover completely. They avoid reinjury by changing the way they perform repetitive movements, the frequency with which they perform the movements, and the amount of time they rest between periods when they must perform the movements. After surgery, a bulky dressing will be applied to the hand. You should leave this secured in place until your first office visit following surgery. You may need bandages on one or both wrists depending on your surgery. If this is the case, you may require extra assistance at home completing everyday activities. Your sutures can be removed approximately 10-14 days after surgery. Make sure to avoid repetitive use of the hand for four weeks after surgery and avoid getting the stitches wet. You will notice that the pain and numbness begins to improve after surgery, but you may have tenderness in the area of the incision for several months.

Neurosurgeon's Role in Treating Carpal Tunnel Syndrome

Neurosurgeons are medical specialists trained to help patients suffering from carpal tunnel syndrome as well as a host of other illnesses, ranging from neck and back pain to epilepsy and Parkinson's disease. Neurosurgeons provide operative and nonoperative care (prevention, diagnosis, evaluation, treatment, critical care and rehabilitation) of neurological disorders. They undergo six to eight years of specialised training following medical school, one of the largest training periods of any medical specialty. A neurosurgeon's primary role in treatment of carpal tunnel syndrome is diagnosis, interpretation of test results, and when necessary, surgery. However, there may be other medical professionals involved in the treatment process, including physical therapists and other specialists.

Click here to download an Information sheet on Carpal Tunnel Surgery

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Cubital Tunnel Syndrome

Cubital tunnel syndrome is a condition that involves the ulna nerve as it crosses the elbow. The ulna nerve provides sensation to the ring and little fingers as well as making some of the muscles in the hand work. When it is damaged, numbness and tingling occurs in the fingers. It can feel as if it involves the whole hand, although it is only two fingers. The hand may also feel weak or clumsy. Sometimes the inside of the elbow will be painful.Cubital Tunnel

The ulna nerve sits in a groove (cubital tunnel) towards the back and inside of the elbow. Normally it is protected. However, it can be bumped which results in the "hitting the funny bone" sensation. Long term damage to the nerve can come from repeated bending of the elbow (such as operating levers or lifting), leaning on it (such as reading or driving) or a direct blow. The diagnosis of cubital tunnel syndrome begins by asking specific questions as to which fingers feel different, if the hand is weak and where any pain is located. The physical examination involves tapping on nerves to determine where they are irritated. It is important to determine that other causes of "pinched nerves" are not present such as diabetes or kidney disease. The ulna nerve can also be trapped in other areas such as the neck. Sometimes electrical diagnostic tests such as EMGs or nerve conduction studies are needed. These tests measure the speed of the nerve and how quickly information travels down the nerve. An area where the nerve is pinched will slow the speed. Treatment usually starts with resting of the elbow. Keeping the elbow straight, especially at night reduces the amount of "stretch" on the nerve. An elbow pad rotated into the bend of the elbow can stop the elbow from fully bending. Activities that put stress on the cubital tunnel should not be done. Sometimes anti-inflammatory medicines are helpful. Surgery may be needed if symptoms do not go away. This consists of "decompression", which removes the roof or one wall of the tunnel to decrease the pressure on the nerve, or "transposition" which moves the ulna nerve out of the cubital tunnel to another place. After surgery, most patients must wear a splint and rest the arm. Therapy after surgery may be used to help you get motion and strength back. While treatment can help symptoms of cubital tunnel syndrome, not all patients recover completely after surgery. If your symptoms are not severe or present for a shorter time, you have a better chance of a complete recovery. Sometimes the changes you make at work and in leisure activity will have to be permanent for you to stay free of symptoms.

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Meralgia Parasthetica

Background: A painful mononeuropathy of the lateral femoral cutaneous nerve (LFCN), meralgia paresthetica is commonly due to focal entrapment of this nerve as it passes through the inguinal ligament. Rarely, it has other etiologies such as direct trauma, stretch injury, or ischemia. It typically occurs in isolation. The clinical history and examination is usually sufficient for making the diagnosis. However, the diagnosis can be confirmed by nerve conduction studies. Treatment is usually supportive. The LFCN is responsible for the sensation of the anterolateral thigh. It is a purely sensory nerve and has no motor component.

Pathophysiology: Reviewing the anatomy of the LFCN is essential for understanding the mechanism of its injury. The LFCN originates directly from the lumbar plexus and has root innervation from L2-3. The nerve runs through the pelvis along the lateral border of the psoas muscle to the lateral part of the inguinal ligament. Here, it passes to the thigh through a tunnel formed by the lateral attachment of the inguinal ligament and the anterior superior iliac spine. This is the most common site of entrapment.

Frequency: The exact frequency of meralgia paresthetica is unknown, but the condition is not rare.

Race: No racial predilection is known.

Sex: No gender proclivity is known.

Age: Lateral femoral cutaneous neuropathies have been reported in all age groups.

History: When the LFCN is entrapped, paresthesias and numbness of the upper lateral thigh area are the presenting symptoms. The paresthesias may be quite painful. Symptoms are typically unilateral. Walking or standing may aggravate the symptoms; sitting tends to relieve them.

Physical: Examination reveals numbness of the anterolateral thigh in all or part of the area involved with the paresthesias. Occasionally, patients are hyperesthetic in this area. Tapping over the upper and lateral aspects of the inguinal ligament or extending the thigh posteriorly, which stretches the nerve, may reproduce or worsen the paresthesias. Motor strength in the involved leg should be normal.

Causes: Pregnancy, tight clothing, and obesity predispose to compression of the nerve at the inguinal ligament. Lying in the fetal position for prolonged periods also has been implicated. Meralgia paresthetica is more common in diabetics than in the general population. Although rare, impingement of the LFCN by masses (eg, neoplasms, contained iliopsoas hemorrhages) in the retroperitoneal space before it reaches the inguinal ligament can cause the same symptoms.

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