Neuropathy Presentation | El Paso, TX. | Part I

Neuropathy Presentation: El Paso, TX. Chiropractor, Dr. Alexander Jimenez presents an overview of neuropathy. These are the most common neuropathies to be seen in practice. Neuropathy is a medical term used to characterize damage or injury to the nerves, which refers to the peripheral nerves as opposed to the central nervous system. The complications which follow neuropathy depends largely on the type of nerves that are affected. According to Dr. Alex Jimenez, different neuropathies can cause numbness and tingling sensations, increased pain or the loss of ability to feel pain, muscle weakness along with twitching and cramps, even dizziness and/or loss of control over bladder function.

Neuropathy

Three primary classifications based on location of symptoms:

• Mononeuropathy (focal)
• Mononeuropathy multiplex (multifocal)
• Polyneuropathy (generalized)
• Can involve CNS and/or PNS
• Can affect large and/or small diameter fibers
• Can affect both sensory and motor fibers
• Sometimes one more than the other, but often both
• May be permanent or reversible

*https://neupsykey.com/muscle-weakness-cramps-and-stiffness/

Assessment Of Neuropathy

Sensory Exam:

• Determine What Sensory Modalities Are Involved

• If sensory disruption is limited to certain modalities, it implies CNS is involved
• If all sensation is affected in the area, implies PNS is involved

• Determine Pattern Of Symptoms

• Mononeuropathy (focal)?
• Mononeuropathy multiplex (multifocal)?
• Polyneuropathy (generalized)?

• Motor Exam

• Determine if there is change to muscle strength
• Determine if there is a change in muscle tone
• Determine which muscles are affected
• Determine if there has been a change in reflexes
• This information can help determine the level(s) of involvement

• Check For Autonomic Signs

• Auscultate heart
• Palpate palms
• Auscultate abdomen
• Assess autonomic history
• For example, is patient complaining about sweating more on one side than another? Complaining of stress levels?
• Suggest ANS involvement

Exams: Merck Manual Professional Version

How To Test Reflexes

How To Do The Sensory Exam

How To Do The Motor Examination

Classification Of Nerve Injuries Resulting In Neuropathy

• Neurapraxia – This is a transient episode of motor paralysis with little or no sensory or autonomic dysfunction; no disruption of the nerve or its sheath occurs; with removal of the compressing force, recovery should be complete
• Axonotmesis – This is a more severe nerve injury, in which the axon is disrupted but the Schwann sheath is maintained; motor, sensory, and autonomic paralysis results; recovery can occur if the compressing force is removed in a timely fashion and if the axon regenerates
• Neurotmesis – This is the most serious injury, in which both the nerve and its sheath are disrupted; although recovery may occur, it is always incomplete, secondary to loss of nerve continuity

Brachial Plexopathies

• Erb’s Palsy
• Klumke’s Palsy

Erb’s Palsy

• AKA Erb–Duchenne palsy or Waiter’s tip palsy
• Most common mechanism of injury in adults is a patient who fall forward while holding onto something behind them
• Can also happen to an infant during childbirth ? Results from damage to C5-6 nerve roots in the brachial plexus
• Dermatomal distribution of sensory disruption
• Weakness or paralysis in deltoid, biceps, and brachialis muscles resulting in “waiter’s tip” position

Klumke’s Palsy

• AKA Dejerine–Klumpke palsy
• Happens to infants during childbirth if arm is pulled overhead
• Can also happen to adults with overhead traction injuries
• Results from damage to C8-T1 nerve roots in the brachial plexus
• Dermatomal distribution of sensory disruption
• Weakness or paralysis in wrist flexors and pronators as well as muscles of the hand
• May produce Horner’s syndrome due to T1 involvement
• Results in a “claw hand” appearance
• Forearm supinated with wrist hyperextended, with finger flexion

Entrapment Neuropathies

• Thoracic Outlet Syndromes
• Median Nerve Entrapment
• Pronator Teres syndrome
• Carpal Tunnel syndrome
• Ulnar Nerve Entrapment
• Cubital Tunnel syndrome
• Tunnel of Guyon syndrome
• Radial Nerve Entrapment
• Spiral Groove Entrapment
• Supinator Syndrome
• Posterior Interosseous Syndrome (Radial Tunnel Syndrome)
• Sciatic Nerve Entrapment
• Piriformis syndrome
• Fibular head entrapment
• Tarsal tunnel syndrome

Thoracic Outlet Syndromes

• Neurogenic thoracic outlet syndrome

• Compression of the brachial plexus

• Vascular thoracic outlet syndrome

• Veins (venous thoracic outlet syndrome) or arteries (arterial thoracic outlet syndrome) are compressed

• Nonspecific-type thoracic outlet syndrome

• Worsens with activity
• Idiopathic

Causes

• Cervical rib
• Subclavius muscle tension
• Postural – excessive thoracic kyphosis
• Trauma
• Repetitive activity
• Obesity
• Pregnancy

Tests

• Adsons test
• Allen maneuver
• Costoclavicular maneuver
• Halstead maneuver
• Reverse bakody maneuver
• Roos test
• Shoulder compression test
• Wright test

Median Nerve Entrapment

• Sensory disruption in the lateral portion (3.5 fingers) of the palmar aspect of the hand, and dorsal finger tips of the same fingers
• Motor fibers affected in forearm if applicable, muscles of the thenar eminence
• Abductor pollicis brevis
• Opponens pollicis
• Flexor pollicis brevis

Median N. Pronator Teres Syndrome

Etiology

• Compression of the median nerve at the elbow

Causes

• Repetitive movement
• Pronator teres muscle inflammation
• Thickened bicipital aponeurosis

Findings

• Tenderness with palpation of the pronator teres muscle
• Pain with resisted pronation of the arm
• Flexor pollicus longus and flexor digitorum profundus involvement
• Otherwise may appear similar to carpal tunnel syndrome in symptoms, but without positive wrist orthopedics

Median N. Carpal Tunnel Syndrome

Etiology

• Compression of the median nerve at the wrist

Causes

• Repetitive motions
• Hypothyroidism
• Obesity
• Rheumatoid Arthritis
• Diabetes
• Pregnancy

Orthopedic Tests

Tinel’s Sign

• Positive if tapping over the median nerve reproduces/exacerbates symptoms

Phalen’s Maneuver/Prayer Sign

• Hands together with wrists flexed
• Repeat in reverse with wrists extended
• Hold each for at least 60 seconds
• Positive if tests reproduce/exacerbate symptoms

Wringing Test

• Wringing a towel produces paresthesia

Ulnar Nerve Entrapment

• Sensory disruption in the medial two digits of the palmar & dorsal aspects of the hand
• Motor fibers affected in hand, all fingers besides the thumb weakened general hand weakness

Ulnar N. Cubital Tunnel Syndrome

Etiology

• Compression of the ulnar nerve at the elbow

Causes

• Repetitive motions
• Hypothyroidism
• Obesity
• Diabetes
• Trauma to the cubital tunnel
• Prolonged sitting with pressure on bent elbow

Ulnar N. Tunnel Of Guyon Syndrome

Etiology

• Compression of the ulnar nerve at the wrist

Causes

Repetitive motions

• Long term crutch use
• Break of the hamate
• Ganglion cyst
• Hypothyroidism
• Obesity
• RheumatoidArthritis
• Diabetes

Orthopedic Tests

Tinel’s Sign

• Present if test over the ulnar nerve at the wrist elicits symptoms

Wartenberg Sign

• 5th digit abducts when patient performs hard grip strength test or attempts to squeeze fingers together
• Reduced two-point discrimination in the hand

Radial Nerve Entrapment

• Sensory disruption in the lateral 3.5 digits of the dorsal aspect of the hand
• Motor fibers affected in posterior arm and extensor compartment of the forearm
• Wrist drop may be seen

Spiral Groove Entrapment

• All radial nerve innervated muscles below entrapment are affected
• “Saturday night palsy” (from sleeping on own arm)
• Brachioradialis & triceps reflexes both diminished

Supinator Syndrome

• Compression at the arcade of Frohse
• No change in reflexes

Posterior Interosseous Syndrome (Radial Tunnel Syndrome)

• No change in reflexes

By Rachel Klein, ND, DC, DACNB

National University of Health Sciences Master of Science (MS) – Advanced Clinical Practice (ACP) MS ACP 551: Clinical Neurology © 2018

Sources

Blumenfeld, Hal. Neuroanatomy through Clinical Cases. Sinauer, 2002.

Evans, Ronald C. Illustrated Orthopedic Physical Assessment. Mosby/Elsevier, 2009.

“Radial Nerve Entrapment: Background, Anatomy, Pathophysiology.” Medscape, 25 Oct. 2017, emedicine.medscape.com/article/1244110- overview#a8.