Entrapment neuropathy

Surat Tanprawate, MD, FRCP(T)

Northern Neuroscience Center
Chiangmai University
 Concept
• All of confusing problem co
me form plexus
• Entrapment level: root, ple
xus, nerve
• Concept to be remembered
: muscle
– Same nerve: different root
– Same root: different nerve
• Step to remember
– Muscle: nerve innervation
– Muscle: root innervation
• Step approach
1. Clarify symptom: where’s
drop?
2. What’s muscle affected?
3. What’s nerve and root in
nervated that muscle?
4. Test key muscle: muscle i
nnervated by :
same nerve, different roo
t : sa
me root, different nerve
 Median n.
Musculocutaneous n.
Ulnar n.

5 6 7 8 T1

5 6 7 8

Axillary n. Radial n.
 Proximal forearm
• Musculocutaneous nerv • Axillary nerve
e – Pass under axillar
– Muscle: Bicep m. – Supply: deltoid m.
– Cutaneous: lateral cutan
eous of forearm
 Radial nerve
• Radial n: Tricep
– Run around radial groov
e
• Form: Brachioradialis
– Posterior interosseous n.
– Superficial radial n. Extensor
• Special test Carpi
– Out stretch arm test
Extensor
Digitorum
Pollicis
Indices
 Median nerve
Flexor carpi
• Median n:
radialis
– Run median of arm
• Form:
Flexor digitorum
• Median n. superficialis
• Anterior interosseous n.
• Special test Flexor digitorum LOAF
– Finger pinch or O.K. test: งอ profundus 1,2
distal ไม่ได ้
– Benediction’s sign
– Tinel’s and Phalen’s test for Flexor Pollicis
CTS longus
Pronator
quadratus
 Median nerve syndrome
• Carpal tunnel syndrome
 Pronator teres syndrome
• Signs:
 Ulnar nerve
Flexor carpi
• Ulnar n:
ulnaris
– Run ulnar of arm
• Most intrinsic hand exce
Flexor digitorum
pt LOAF profundus 3,4
• Special test
– Open your hand:
• Ulnar claw hand Intrinsic hand
– Prayer test muscle except
LOAF
 Ulnar n syndrome
• Cubital tunnel syndrome
• wrist
 Entrapment of upper extremities
• Clinical approach
– Proximal arm weakness
– Wrist drop
– Hand atrophy
 Proximal arm weakness
• Proximal arm muscle: ke • Pattern involved
y muscle – Deltoid alone
– Deltoid:C5,6- axillary n. • axillary n. lesion
– Bicep: C5, 6- musculocut – Deltoid, bicep, brachiora
aneous n. dialis involved(spare tric
– Tricep: C7,8- radial n. ep)
• C5,6 root
– Brachioradialis: C5, 6- ra
– Involve alls muscle
dial n.
• Brachial plexus
• Cord
 Wrist drop
• Wrist drop
– Extexsor carpi radialis lo
ngus(C5, C6 and radial n
erve)
– Extensor carpi ulnarlis( C
7, C8 and posterior inter
osseous branch of radial
nerve)
 Key muscle: nerve, root
• Key muscle: radial distri • Key muscle: C5,6
bution – Deltoid: axiallary n
– Radial n: tricep, brachior – Bicep: musculocutaneou
adialis s n.
– P.I.N: extensor digitorum – Tricep: radial n.(C6,7,8)
, extensor carpi ulnaris – FCR: median n.(C6,7)
 • Generalized weakness: esp.
weakness of deltoid, tricep,
wrist ext, finger ext.
– UMN: corticospinal tract lesio
n

Interprete

• Selected weakness
– C7,C8 root or plexus
– Radial nerve lesion
– Posterior interosseous n
erve lesion
Out stretch arm test
 Tricep Brachioradiali Wrist Finger Finger
s extension extension flexion

PIN lesion Normal Normal Normal Weak Normal

(finger drop (radial
with radial diviation)
deviation)
C7,8 or Weak Normal Radial Weak Weak
brachial diviation
plexus lesion
Radial nerve Normal Weak Weak Weak Normal
lesion(radial
groove)
(wrist drop)
C5,6 or Mild Weak Weak Normal Normal
Brachial Weak
plexus
Hand atrophy(wast hand)
Muscle of hand

Median
Ulnar nerve
nerve

LOAF Others than

LOAF

ADM and 1
APB
DI
 Hand atrophy
• Muscle of hand
– LOAF(median n.), other t
han LOAF(ulnar n.)
– Key muscle: 3 muscle
• APB(for LOAF), ADM and
1 DI(for other than LOAF)
• Root innervation
– APB: C8 T1
– 1DI: C8, T1
– ADM: C8, T1
• Pattern of weakness
– Only APB: median n. lesi
on-test other flexor m. gr
oup
– Only ADM and 1DI: ulnar
n. lesion
– Weak all 3 muscle: many
causes
 Weak all 3 key muscle
• 3 muscle plus finger extensor, tricep, finger flexor
– C7,8,T1 root
• Fail arm+ all sensation
– Brachial plexus
• Fail arm and cape distribution sensory loss
– Spinal cord
• Generalized
– MND
– Polyneuropathy
 C8 radiculopathy Brachial Brachial plexus, Ulnar neuropathy
plexus,lower medial cord
trunk

Wrist flexion Weak Weak Weak Weak

Finger flexion Normal Weak Weak Normal

Thumb flexion, Normal Weak Weak Normal

opposision
Interossei Yes Yes Yes Yes(esp. atrophy of
weakness, atrophy 1 dorsal interossei

Senseory loss Same as Similar to medial Same as Ulnar aspect of

ulnar+ulnar aspect cord ulnar+palmar hand, 5 digit and
of forearm aspect of hand and half of 4
digit1-4

Tricep reflex Partial No Partial No

Hand shape Either Simian hand Simian hand Claw hand

Horner syndrome Can occur Can occur Never Never

Causes Compression by Traumatic injury at Traumatic, tumor, Compression, ulnar

cervical disc birth neuritis groove
 Lower extremities
• Lumbosacral plexus
• Proximal
– Anterior: obturator n., femoral n.
– Posterior: gluteal n., sciatic n(hamstring m.)
• Distal
– Anterior: peroneal nerve(deep VS superficial)
– Posterior: tibial nerve
Entrapment neuropathy of lower extremiti
es
Obturator n.
Femoral n.

L1 L2 L3 L4 L5 S1 S2

Femoral nerve
- Iliopsoas(L1,2,3)
- Quadricep(L2,3,4)
Obturator nerve
- Adductor group(L2,3,4)
 Entrapment neuropathy of lower extremiti
es
Glureal n. Gluteal n.
Superior gluteal n
Inferior gluteal n

L1 L2 L3 L4 L5 S1 S2
Tibial n.
TP. m.(L4,5)
Deep peroneal n.
Gastroc m(S1,2)
TA. M(L4,5)
Sciatic n.
EHL m.(L5, S1)
 Proximal weakness of legs
• Key muscle • Weak
– Iliopsoas m: L1, 2- femor • Iliopsoas+quadricep
al n. – Femoral n. lesion
– Quadricep m: L2,3- femo
• Iliopsoas+quadricep+ hi
ral n.
– Adductor m: L3,4- obtur
p adduction
ator n. – L2,3, 4 lesion
– Hamstring m: L5, S1,2- sc
iatic n.
– Gluteus maximus m: L5,
S1,2- inferior gluteal n
 Foot drop
• Due to weakness of tibialis anterior
• Key muscle
– Tibialis anterior m: L4,5-DPN
– EHL: L5, S1- DPN
– Peroneus m: L5, S1- SPN
– Tibialis posterior m: L4,5 - tibial n.
– Gastrocnemius m: S1,2 - tibial n.
 Pattern of foot drop
• weakness of • Alls movement of foot
• Dorsiflex+eversion+EHL – Peripheral neuropathy
– Common peroneal n. lesi – Sciatic n. lesion
on – Plexus lesion
• Dorsiflex+inversion+ hip – Cauda equina lesion
abduction – Anterior horn cell diseas
– L4, 5 root or plexus lesio e
n
 Differential diagnosis of foot drop
L5 radiculopathy Lumbar Sciatic Peroneal
plexopathy neuropathy neuropathy

Ankle inversion W W N or mildly weak N

Toe flexion W W N or mildly weak N

Plantar flexion N N N or mildly weak N

Ankle jerk N N or depress N or depress N

Sensory loss Big toe L5 dermatome Entire lateral leg Distal 2/3 of
and dorsum of lateral leg,
foot dorsum of foot
Pain Rare, deep pain Radicular pain Can be severe Radicular pain

Causes Disc herniation Prolong labor, Hip surgery Compression

pelvic fracture
Good luck