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Dermatomes and Myotomes: What Are They And How Do They Work?

Dermatomes and Myotomes: What Are They And How Do They Work?

The spinal cord and brain make up the central nervous system while the spinal nerves that branch to the spinal cord and cranial nerves that branch to the brain makes up the peripheral nervous system.

There are thirty-one sets of nerves that extend out of the spinal cord and are connected to it by the nerve root. Each nerve branches out about a half inch from the spinal cord before dividing into smaller branches. The dorsal rami are on the posterior side of the branch while the larger ventral rami are on the anterior side.

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The dorsal rami provide nerve function for the skin of the trunk and posterior muscles. The ventral rami from T1 to T12 provide nerve function to the skin of the trunk as well as the lateral and anterior muscles. The anterior divisions that remain for plexuses, networks that provide nerve function to the body. Each plexus has specific areas on the body for skin sensitivity as well as certain muscles. Their point where they exit the spine determines how they are numbered. The four primary plexuses are:

  • Cervical plexus, C1 � C4, innervates the diaphragm, shoulder, and neck
  • Brachial plexus, C5 � T1, innervates the upper limbs
  • Lumbar plexus, T12/L1 � L4, innervates the thigh
  • Sacral plexus, L4 � S4, innervates the leg and foot.

These spinal nerves have two sets of fibers: motor and sensory. Motor fibers facilitate movement and provide nerve function to the muscles. Sensory fibers facilitate sensitivities to touch, temperature and other stimuli. They provide nerve function to the skin.

dermatomes myotomes injury medical chiropractic clinic el paso, tx.

What are Myotomes and Dermatomes?

A group of muscles that are innervated by the motor fibers that stem from a specific nerve root is called a myotome. An area of the skin that is innervated by the sensory fibers that stem from a specific nerve root is called a dermatome. These patterns of myotome and dermatome are almost always identical from person to person. There are occasionally variances, but that is rare.

This consistency allows doctors to treat nerve pain in patients. If a specific area is hurting, they know that it is attributed to a certain myotome or dermatome, whichever the case may be, and its corresponding nerve root. Problems with nerve damage are often the result of stretching the nerve or compressing it.

When the nerves are injured in specific areas like the lumbosacral or brachial plexus, it presents as sensory and motor deficits in the limbs that correspond to them. Myotomes and dermatomes are used to assess the extent of the damage.

How are Myotomes and Dermatomes used to Assess Nerve Damage?

dermatomes myotomes injury medical chiropractic clinic el paso, tx.

When a doctor tests for nerve root damage in a patient, he or she will often test the myotomes or dermatomes for the nerves assigned to that location. A dermatome is examined for abnormal sensation, such as hypersensitivity or lack of sensitivity.

This is done by using stimulus inducing tools such as a pen, paper clip, pinwheel, fingernails, cotton ball, or pads of the fingers. The patient is instructed to provide feedback regarding their response. Some of the abnormal sensation responses include:

  • Hypoesthesia (decreased sensation).
  • Hyperesthesia (excessive sensation).
  • Anesthesia (loss of sensation).
  • Paresthesia (numbness, tingling, burning sensation).

A myotome is tested for nerve damage in the muscles which presents as muscle weakness. This grading scale, which assigns a rating to the degree of muscle weakness, is often used:

  • 5 � Normal � Complete range of motion against gravity with full resistance
  • 4 � Good � Complete range of motion against gravity with some resistance
  • 3 � Fair � Complete range of motion against gravity with no resistance, active ROM
  • 2 � Poor � Complete range of motion with some assistance and gravity eliminated
  • 1 � Trace � Evidence of slight muscular contraction, no joint motion evident
  • 0 � Zero � No evidence of muscle contraction
thoracic spine chiropractic treatment el paso tx.

During a typical chiropractic exam, your chiropractor will assess both dermatomes and myotomes for potential neurological problems. This gives them additional insight on how to treat your condition, whether it’s related to a subluxation of vertebral bodies or other, other disease processes.

Back Pain Chiropractic Treatment | El Paso, Tx

Origin Of Head Pain | El Paso, TX.

Origin Of Head Pain | El Paso, TX.

Origin: The most common cause of�migraines/headaches�can relate to neck complications. From spending excessive time looking down at a laptop, desktop, iPad, and even from constant texting, an incorrect posture for extended periods of time can begin to place pressure on the neck and upper back leading to problems that can cause headaches. The majority of these type of headaches occurs as a result of tightness between the shoulder blades, which in turn causes the muscles on the top of the shoulders to also tighten and radiate pain into the head.

Origin Of Head Pain

  • Arises from pain sensitive structures in the head
  • Small diameter fibers (pain/temp) innervate
  • Meninges
  • Blood vessels
  • Extracranial structures
  • TMJ
  • Eyes
  • Sinuses
  • Neck muscles and ligaments
  • Dental structures
  • The brain has no pain receptors

Spinal Trigeminal Nucleus

  • Trigeminal nerve
  • Facial nerve
  • Glossopharyngeal nerve
  • Vagus nerve
  • C2 nerve (Greater occipital nerve)

Occipital Nerves

origin headache el paso tx.http://dailymedfact.com/neck-anatomy-the-suboccipital-triangle/

Sensitization Of Nociceptors

  • Results in allodynia and hyperalgesia

origin headache el paso tx.http://slideplayer.com/9003592/27/images/4/Mechanisms+associated+with+peripheral+sensitization+ to+pain.jpg

Headache Types

Sinister:
  • Meningeal irritation
  • Intracranial mass lesions
  • Vascular headaches
  • Cervical fracture or malformation
  • Metabolic
  • Glaucoma
Benign:
  • Migraine
  • Cluster headaches
  • Neuralgias
  • Tension headache
  • Secondary headaches
  • Post-traumatic/post-concussion
  • “Analgesic rebound” headache�
  • Psychiatric

HA Due To Extracranial Lesions

  • Sinuses (infection, tumor)
  • Cervical spine disease
  • Dental problems
  • Temporomandibular joint
  • Ear infections, etc.
  • Eye (glaucoma, uveitis)
  • Extracranial arteries
  • Nerve lesions

HA Red Flags

Screen for red flags and consider dangerous HA types if present

Systemic symptoms:
  • Weight loss
  • Pain wakes them from sleep
  • Fever
Neurologic symptoms or abnormal signs:
  • Sudden or explosive onset
  • New or Worsening HA type especially in older patients
  • HA pain that is always in the same location
Previous headache history
  • Is this the first HA you�ve ever had?
    Is this the worst HA you�ve ever had?
Secondary risk factors:
  • History of cancer, immunocompromised, etc.

Dangerous/Sinister Headaches

Meningeal irritation
  • Subarachnoid hemorrhage
  • Meningitis and meningoencephalitis
Intracranial mass lesions
  • Neoplasms
  • Intracerebral hemorrhage
  • Subdural or epidural hemorrhage
  • Abscess
  • Acute hydrocephalus
Vascular headaches
  • Temporal arteritis
  • Hypertensive encephalopathy (e.g., malignant hypertension, pheochromocytoma)
  • Arteriovenous malformations and expanding aneurysms
  • Lupus cerebritis
  • Venous sinus thrombosis
Cervical fracture or malformation
  • Fracture or dislocation
  • Occipital neuralgia
  • Vertebral artery dissection
  • Chiari malformation
Metabolic
  • Hypoglycemia
  • Hypercapnea
  • Carbon monoxide
  • Anoxia
  • Anemia
  • Vitamin A toxicity
Glaucoma

Subarachnoid Hemorrhage

  • Usually due to ruptured aneurysm
  • Sudden onset of severe pain
  • Often vomiting
  • Patient appears ill
  • Often nuchal rigidity
  • Refer for CT and possibly lumbar puncture

Meningitis

  • Patient appears ill
  • Fever
  • Nuchal rigidity (except in elderly and young children)
  • Refer for lumbar puncture – diagnostic

Neoplasms

  • Unlikely cause of HA in average patient population
  • Mild and nonspecific head pain
  • Worse in the morning
  • May be elicited by vigorous head shaking
  • If focal symptoms, seizures, focal neurologic signs, or evidence of increased intracranial pressure are present rule our neoplasm

Subdural Or Epidural Hemorrhage

  • Due to hypertension, trauma or defects in coagulation
  • Most often occurs in the context of acute head trauma
  • Onset of symptoms may be weeks or months after an injury
  • Differentiate from the common post-concussion headache
  • Post-Concussive HA may persist for weeks or months after an injury and be accompanied by dizziness or vertigo and mild mental changes, which will all subside

Increase Intracranial Pressure

  • Papilledema
  • May cause visual changes

origin headache el paso tx.

https://openi.nlm.nih.gov/detailedresult.php?img=2859586_AIAN-13-37- g001&query=papilledema&it=xg&req=4&npos=2

origin headache el paso tx.

Temporal (Giant-Cell) Arteritis

  • >50 years old
  • Polymyalgia rheumatic
  • Malaise
  • Proximal joint pains
  • Myalgia
  • Nonspecific headaches
  • Exquisite tenderness and/or swelling over the temporal or occipital arteries
  • Evidence of arterial insufficiency in the distribution of branches of the cranial vessels
  • High ESR

Cervical Region HA

  • Neck trauma or with symptoms or signs of cervical root or cord compression
  • Order MR or CT cord compression due to fracture or dislocation
  • Cervical instability
  • Order cervical spine x-rays lateral flexion and extension views

Ruling Out Dangerous HA

  • Rule our history of serious head or neck injury, seizures or focal neurologic symptoms, and infections that may predispose to meningitis or brain abscess
  • Check for fever
  • Measure blood pressure (concern if diastolic >120)
  • Ophthalmoscopic exam
  • Check neck for rigidity
  • Auscultate for cranial bruits.
  • Complete neurologic examination
  • If needed order complete blood cell count, ESR, cranial or cervical imaging

Episodic Or Chronic?

<15 days per month = Episodic

>15 days per month = Chronic

Migraine HA

Generally due to dilation or distension of cerebral vasculature

Serotonin In Migraine

  • AKA 5-hydroxytryptamine (5-HT)
  • Serotonin becomes depleted in migraine episodes
  • IV 5-HT can stop or reduce severity

Migraine With Aura

History of at least 2 attacks fulfilling the following criteria

One of the following fully reversible aura symptoms:
  • Visual
  • Somatic sensory
  • Speech or language difficulty
  • Motor
  • Brain stem
2 of the following 4 characteristics:
  • 1 aura symptom spreads gradually over ?5 min, and/or 2 symptoms occur in succession
  • Each individual aura symptom lasts 5-60 min
  • 1 aura symptom is unilateral
  • Aura accompanied or followed in <60 min by headache
  • Not better accounted for by another ICHD-3 diagnosis, and TIA excluded

Migraine Without Aura

History of at least 5 attacks fulfilling the following criteria:
  • Headache attacks lasting 4-72 h (untreated or unsuccessfully treated)
  • Unilateral pain
  • Pulsing/pounding quality
  • Moderate to severe pain intensity
  • Aggravation by or causing avoidance of routine physical activity
  • During headache nausea and/or sensitivity to light and sound
  • Not better accounted for by another ICHD-3 diagnosis

Cluster Headache

  • Severe unilateral orbital, supraorbital and/or temporal pain
  • �Like an ice pick stabbing me the eye�
  • Pain lasts 15-180 minutes
At least one of the following on the side of headache:
  • Conjunctival injection
  • Facial sweating
  • Lacrimation
  • Miosis
  • Nasal congestion
  • Ptosis
  • Rhinorrhea
  • Eyelid edema
  • History of similar headaches in the past

Tension Headache

Headache pain accompanied by two of the following:
  • Pressing/tightening (non-pulsing) quality
  • �Feels like a band around my head�
  • Bilateral location
  • Not aggravated by routine physical activity
Headache should be lacking:
  • Nausea or vomiting
  • Photophobia and phonophobia (one or the other may be present)
  • History of similar headaches in the past

Rebound Headache

  • Headache occurring on ?15 days a month in a patient with a pre-existing headache disorder
  • Regular overuse for >3 months of one or more drugs that can be taken for acute and/or symptomatic treatment of headache
  • Due to medication overuse/withdrawal
  • Not better accounted for by another ICHD-3 diagnosis

Sources

Alexander G. Reeves, A. & Swenson, R. Disorders of the Nervous System. Dartmouth, 2004.

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Brainstem And The Rule Of 4 | El Paso, TX.

Brainstem And The Rule Of 4 | El Paso, TX.

The rule of 4 of the brainstem: a simplified method for understanding brainstem anatomy and brainstem vascular
syndromes for the non-neurologist.

The Rule Of 4 & The Brainstem

The rule of 4 is a simple method developed to help �students of neurology� to remember the anatomy of the brainstem and thus the features of the various brainstem vascular syndromes. As medical students, we are taught detailed anatomy of the brainstem containing a bewildering number of structures with curious names such as superior colliculi, inferior olives, various cranial nerve nuclei and the median longitudinal fasciculus. In reality when we do a neurological examination we test for only a few of these structures. The rule of 4 recognizes this and only describes the parts of the brainstem that we actually examine when doing a neurological examination. The blood supply of the brainstem is such that there are paramedian branches and long circumferential branches (the anterior inferior cerebellar artery (AICA), the posterior inferior cerebellar artery (PICA) and the superior cerebellar artery (SCA). Occlusion of the paramedian branches results in medial (or paramedian) brainstem syndromes and occlusion of the circumferential branches results in lateral brainstem syndromes. Occasionally lateral brainstem syndromes are seen in unilateral vertebral occlusion. This paper describes a simple technique to aid in the understanding of brainstem vascular syndromes.

Any attempt to over simplify things runs the risk of upsetting those who like detail and I apologize in advance to the anatomists among us, but for more than 15 years this simple concept has helped numerous students and residents understand, often for the first time, brainstem anatomy and the associated clinical syndromes that result.

In The Rule Of 4 There Are 4 Rules:
  1. There are 4 structures in the �midline� beginning with M.
  2. There are 4 structures to the side beginning with S.
  3. There are 4 cranial nerves in the medulla, 4 in the pons and 4 above the pons (2 in the midbrain).
  4. The 4 motor nuclei that are in the midline are those that divide equally into 12 except for 1 and 2, that is 3, 4, 6 and 12 (5, 7, 9 and 11 are in the lateral brainstem).

If you can remember these rules and know how to examine the nervous system, in particular the cranial nerves, then you will be able to diagnose brainstem vascular syndromes with ease.

brainstem el paso tx.

Figure 1 shows a cross-section of the brainstem, in this case at the level of the medulla, but the concept of 4 lateral and 4 medial structures also applies to the pons, only the 4 medial structures relate to midbrain vascular syndromes.

brainstem el paso tx.

The 4 Medial Structures & The Associated Deficit Are:
  1. The Motor pathway (or corticospinal tract): contra lateral weakness of the arm and leg.
  2. The Medial Lemniscus: contra lateral loss of vibration and proprioception in the arm and leg.
  3. The Medial longitudinal fasciculus: ipsilateral inter- nuclear ophthalmoplegia (failure of adduction of the ipsilateral eye towards the nose and nystagmus in the opposite eye as it looks laterally).
  4. The Motor nucleus and nerve: ipsilateral loss of the cranial nerve that is affected (3, 4, 6 or 12).
The 4 Lateral Structures & The Associated Deficit Are:
  1. The Spinocerebellar pathways: ipsilateral ataxia of the arm and leg.
  2. The Spinothalamic pathway: contra lateral alteration of pain and temperature affecting the arm, leg and rarely the trunk.
  3. The Sensory nucleus of the 5th: ipsilateral alteration of pain and temperature on the face in the distribution of the 5th cranial nerve (this nucleus is a long vertical structure that extends in the lateral aspect of the pons down into the medulla).
  4. The Sympathetic pathway: ipsilateral Horner�s syndrome, that is partial ptosis and a small pupil (miosis)

These pathways pass through the entire length of the brainstem and can be likened to �meridians of longitude� whereas the various cranial nerves can be regarded as �parallels of latitude�. If you establish where the meridians of longitude and parallels of latitude intersect then you have established the site of the lesion.

Figure 2 shows the ventral aspect of the brainstem.

brainstem el paso tx.

The 4 Cranial Nerves In The Medulla Are:

9 Glossopharyngeal: ipsilateral loss of pharyngeal sensation.
10 Vagus: ipsilateral palatal weakness.
11 Spinal accessory: ipsilateral weakness of the trapezius and sternocleidomastoid muscles.
12 Hypoglossal: ipsilateral weakness of the tongue.

The 12th cranial nerve is the motor nerve in the midline of the medulla. Although the 9th, 10th and 11th cranial nerves have motor components, they do not divide evenly into 12 (using our rule) and are thus not the medial motor nerves.

The 4 Cranial Nerves In The Pons Are:

5 Trigeminal: ipsilateral alteration of pain, temperature and light touch on the face back as far as the anterior two-thirds of the scalp and sparing the angle of the jaw.
6 Abducent: ipsilateral weakness of abduction (lateral movement) of the eye.
7 Facial: ipsilateral facial weakness.
8 Auditory: ipsilateral deafness.

The 6th cranial nerve is the motor nerve in the pons.

The 7th is a motor nerve but it also carries pathways of taste, and using the rule of 4 it does not divide equally in to 12 and thus it is not a motor nerve that is in the midline. The vestibular portion of the 8th nerve is not included in order to keep the concept simple and to avoid confusion. Nausea and vomiting and vertigo are often more common with involvement of the vestibular connections in the lateral medulla.

The 4 Cranial Nerves Above The Pons Are:

4 Olfactory: not in midbrain.
5 Optic: not in midbrain.
6 Oculomotor: impaired adduction, supraduction and infraduction of the ipsilateral eye with or without a dilated pupil. The eye is turned out and slightly down.
7 Trochlear: eye unable to look down when the eye is looking in towards the nose.

The 3rd and 4th cranial nerves are the motor nerves in the midbrain.

Thus a medial brainstem syndrome will consist of the 4 M�s and the relevant motor cranial nerve, and a lateral brainstem syndrome will consist of the 4 S�s and either the 9�11th cranial nerve if in the medulla, or the 5th, 7th and 8th cranial nerve if in the pons.

MEDIAL (PARAMEDIAN) BRAINSTEM SYNDROMES

Let us assume that the patient you are examining has a brainstem stroke. If you find upper motor neurone signs in the arm and the leg on one side then you know the patient has a medial brainstem syndrome because the motor pathways is paramedian and crosses at the level of the foramen magnum (decussation of the pyramids). The involvement of the motor pathway is the �meridian of longitude�. So far the lesion could be anywhere in the medial aspect of the brainstem, although if the face is also affected it has to be above the mid pons, the level where the 7th nerve nucleus is.

The motor cranial nerve �the parallels of latitude� indicates whether the lesion is in the medulla (12th), pons (6th) or midbrain (3rd). Remember the cranial nerve palsy will be ipsilateral to the side of the lesion and the hemiparesis will be contralateral. If the medial lemniscus is also affected then you will find a contra lateral loss of vibration and proprioception in the arm and leg (the same side affected by the hemiparesis) as the posterior columns also cross at or just above the level of the foramen magnum. The median longitudinal fasciculus (MLF) is usually not affected when there is a hemiparesis as the MLF is further back in the brainstem.

The MLF can be affected in isolation �a lacunar infarct� and this results in an ipsilateral internuclear ophthalmoplegia, with failure of adduction (movement towards the nose) of the ipsilateral eye and leading eye nystagmus on looking laterally to the opposite side of the lesion in the contra lateral eye. If the patient had involvement of the left MLF then, on being asked to look to the left, the eye movements would be normal, but on looking to the right the left eye would not go past the midline, while there would be nystagmus in the right eye as it looked to the right.

Figure 3 shows the clinical features of the medial brainstem syndromes.

brainstem el paso tx.LATERAL BRAINSTEM SYNDROMES

Once again we are assuming that the patient you are seeing has a brainstem problem, most likely a vascular lesion. The 4 S�s or �meridians of longitude� will indicate that you are dealing with a lateral brainstem problem and the cranial nerves or �parallels of latitude� will indicate whether the problem is in the lateral medulla or lateral pons.

A lateral brainstem infarct will result in ipsilateral ataxia of the arm and leg as a result of involvement of the Spinocerebellar pathways, contralateral alteration of pain and temperature sensation as a result of involvement of the Spinothalamic pathway, ipsilateral loss of pain and temperature sensation affecting the face within the distribution of the Sensory nucleus of the trigeminal nerve (light touch may also be affected with involvement of the spinothalamic pathway and/or sensory nucleus of the trigeminal nerve). An ipsilateral Horner�s syndrome with partial ptosis and a small pupil (miosis) is because of involvement of the Sympathetic pathway. The power tone and the reflexes should all be normal. So far all we have done is localize the problem to the lateral aspect of the brainstem; by adding the relevant 3 cranial nerves in the medulla or the pons we can localize the lesion to this region of the brain.

brainstem el paso tx.The lower 4 cranial nerves are in the medulla and the 12th nerve is in the midline so that 9th, 10th and 11th nerves will be in the lateral aspect of the medulla. When these are affected, the result is dysarthria and dysphagia with an ipsilateral impairment of the gag reflex and the palate will pull up to the opposite side; occasionally there may be weakness of the ipsilateral trapezius and/or sternocleidomastoid muscle. This is the lateral medullary syndrome usually resulting from occlusion of the ipsilateral vertebral or posterior inferior cerebellar arteries.

The 4 cranial nerves in the pons are: 5th, 6th, 7th and 8th. The 6th nerve is the motor nerve in the midline, the 5th, 7th and 8th are in the lateral aspect of the pons, and when these are affected there will be ipsilateral facial weakness, weakness of the ipsilateral masseter and pterygoid muscles (muscles that open and close the mouth) and occasionally ipsilateral deafness. A tumour such as an acoustic neuroma in the cerebello-pontine angle will result in ipsilateral deafness, facial weakness and impairment of facial sensation; there may also be ipsilateral limb ataxia if it compresses the ipsilateral cerebellum or brainstem. The sympathetic pathway is usually too deep to be affected.

If there are signs of both a lateral and a medial (paramedian) brainstem syndrome, then one needs to consider a basilar artery problem, possibly an occlusion.

In summary, if one can remember that there are 4 pathways in the midline commencing with the letter M, 4 pathways in the lateral aspect of the brainstem commencing with the letter S, the lower 4 cranial nerves are in the medulla, the middle 4 cranial nerves in the pons and the first 4 cranial nerves above the pons with the 3rd and 4th in the midbrain, and that the 4 motor nerves that are in the midline are the 4 that divide evenly into 12 except for 1 and 2, that is 3, 4, 6 and 12, then it will be possible to diagnose brainstem vascular syndromes with pinpoint accuracy.

P. GATES

The Geelong Hospital, Barwon Health, Geelong, Victoria, Australia

REFERENCES

1 Chapter 7. Neurology. In: Williams PL, Warwick R, Dyson M, Bannister LH, eds. Gray�s Anatomy, 37th edn. Edinburgh: Churchill Livingstone; 1989; 860�1243.

Cranial Nerves: Introduction | El Paso, TX.

Cranial Nerves: Introduction | El Paso, TX.

Human Cranial nerves are a set of 12 paired nerves that come directly from the brain. The first two (olfactory and optic) come from the cerebrum, with the remaining ten come from the brain stem. The names of the these nerves relate to what function they perform and are also numerically identified in roman numerals (I-XII).�The�nerves serve in functions of smell, sight, eye movement, and feeling in the face. These�nerves also control balance, hearing, and swallowing.

Cranial Nerves: Review

  • CN I � Olfactory
  • CN II � Optic
  • CN III � Oculomotor
  • CN IV � Trochlear
  • CN V � Trigeminal
  • CN VI � Abducens
  • CN VII � Facial
  • CN VIII � Vestibulocochlear
  • CN IX � Glossopharyngeal
  • CN X � Vagus
  • CN XI � Accessory
  • CN XII – Hypoglossal

Location Of Nerves

cranial el paso tx.

http://www.strokeeducation.info/images/cranial%20nerves%20chart.jpg

 

cranial el paso tx.

https://upload.wikimedia.org/wikipedia/commons/thumb/8/84/Brain_human_normal_inferior_view_ with_labels_en.svg/424px-Brain_human_normal_inferior_view_with_labels_en.svg.png

cranial el paso tx.

https://diagramchartspedia.com/cranial-nerve-face-diagram/cranial-nerve-face-diagram-a- synopsis-of-cranial-nerves-of-the-brainstem-clinical-gate/

CN I � Olfactory

cranial el paso tx.CN I Clinically

  • Lesions resulting in anosmia (loss of the sense of smell) can be caused by:
  • Trauma to the head, especially patient�s hitting the back of their head
  • Frontal lobe masses/tumors/SOL
  • Remember that loss of the sense of smell is one of the first symptoms seen in Alzheimer’s and early dementia patients

Testing CN I

  • Have the patient close their eyes and cover one nostril at a time
  • Have them breathe out through their nose, THEN place the scent under the nostril while they breathe in.
  • Ask them �do you smell anything?�
  • This tests if the nerve is functioning
  • If they say yes, ask them to identify it
  • This tests if the processing pathway (temporal lobe) is functional

Cranial Nerve II � Optic

cranial el paso tx.Cranial Nerve II Clinically

Lesions to this nerve can be the result of:

  • CNS disease (such as MS)
  • CNS tumors and SOL
  • Most problems with the visual system arise from direct trauma, metabolic or vascular diseases
  • FOV lost in the periphery can mean SOL affecting the optic chiasm such as a pituitary tumor

Testing Cranial Nerve CN II

  • cranial el paso tx.

    https://upload.wikimedia.org/wikipedia/commons/9/9f/Snellen_chart.svg

    Can the patient see?

  • If patient has vision in each eye, nerve is functional
  • Visual acuity testing
  • Snellen chart (one eye at a time, then two eyes together)
  • Distance vision
  • Rosenbaum chart (one eye at a time, then two eyes together)
  • Near vision

 

 

 

 

 

Associated Testing For Visual System

  • Ophthalmoscopic/Funduscopic exam
  • Assessment of A/V ratio and vein/artery health
  • Assessment of cup to disc ratio
  • Field of vision testing
  • Intraoccular pressure testing
  • Iris shadow test

Cranial Nerve III � Oculomotor

cranial el paso tx.Cranial Nerve III Clinically

  • Diplopia
  • Lateral strabismus (unopposed lateral rectus m.)
  • Head rotation (yaw) away from the side of the lesion
  • Dilated Pupil (unopposed dilator pupillae m.)
  • Ptosis of the eyelid (loss of function of levator palpebrae superioris m.)
  • Lesions to this nerve can be the result of:
  • Inflammatory diseases
  • Syphilitic and tuberculous meningitis
  • Aneurysms of the posterior cerebral or superior cerebellar aa.
  • SOL in the cavernous sinus or displacing the cerebral peduncle to the opposite side

Testing Cranial Nerve CN II & III

  • Pupillary reflex testing
  • Move the light in front of the pupil from the lateral side and hold 6 seconds
  • Watch for direct (ispilateral eye) and consensual (contralateral eye) pupillary constriction

cranial el paso tx.Testing Cranial Nerve CN II & III

cranial el paso tx.

https://commons.wikimedia.org/wiki/File:1509_Pupillary_Reflex_Pathways.jpg

Cranial Nerve IV � Trochlear

cranial el paso tx.Cranial Nerve IV Clinically

  • Patient has diplopia & difficulty in downward gaze
  • Often complain of difficulty walking down stairs, tripping,falling
  • Extortion of the affected eye (unopposed inferior oblique m.)
  • Head tilt (roll) to the unaffected side
  • Lesions to this nerve can be the result of:
  • Inflammatory diseases
  • Aneurysms of the posterior cerebral or superior cerebellar aa.
  • SOL in the cavernous sinus or superior orbital fissure
  • Surgical damage during mesencephalon procedures

Head Tilt In Superior Oblique Palsy (CN IV Failure)

cranial el paso tx.

Pauwels, Linda Wilson, et al. Cranial Nerves: Anatomy and Clinical Comments. Decker, 1988.

Cranial Nerve VI � Abducens

cranial el paso tx.Cranial Nerve VI Clinically

cranial el paso tx.

  • Diplopia
  • Medial strabismus (unopposed medial rectus m.)
  • Head rotation (yaw) toward the side of the lesion
  • Lesions to this nerve can be the result of:
  • Aneurysms of the posterior inferior cerebellar or basilar aa.
  • SOL in the cavernous sinus or 4th ventricle (such as a cerebellar tumor)
  • Fractures of the posterior cranial fossa
  • Increased intracranial pressure

Testing Cranial Nerve CN III, IV & VI

  • H-Pattern testing
  • Have the patient follow an object no larger than 2 inches
  • Patient�s can have focus difficulty if the item is too large
  • It�s also important not to hold the object too close to the patient.
  • Convergence and accommodation
  • Bring object close to the bridge of the patient�s nose and back out. Perform at least 2 times.
  • Look for pupillary constriction response as well as convergence of the eyes

Cranial Nerve V � Trigeminal

cranial el paso tx.Cranial Nerve V Clinically

  • Decreased bite strength on the ipsilateral side of lesion
  • Loss of sensation in V1, V2 and/or V3 distribution
  • Loss of corneal reflex
  • Lesions to this nerve can be the result of:
  • Aneurysms or SOL affecting the pons
  • Specifically tumors at the cerebellopontine angle
  • Skull fractures
  • Facial bones
  • Damage to foramen ovale
  • Tic doloureux (Trigeminal neuralgia)
  • Sharp pain in V1-V3 distributions
  • Tx with analgesic, anti-inflammatory, contralateral stimulation

Testing Cranial Nerve CN V

  • V1 � V3 pain & light touch testing
  • Testing is best done toward the more medial or proximal areas of the face, where V1, V2 &V3 are better delineated
  • Blink/Corneal reflex testing
  • Puff of air or small tissue tap from the lateral side of the eye on the cornea, if normal, the patient blinks
  • CN V provides the sensory (afferent) arc of this reflex
  • Bite strength
  • Have patient bite down on tongue depressor & try to remove
  • Jaw jerk/Masseter Reflex
  • With patient�s mouth slightly open place thumb on patient�s chin and tap your own thumb with a reflex hammer
  • Strong closure of the mouth indicates UMN lesion
  • CN V provides both the motor and sensory of this reflex

cranial el paso tx.

https://upload.wikimedia.org/wikipedia/commons/a/ab/Trigeminal_Nerve.png

Cranial Nerve VII � Facial

cranial el paso tx.Cranial Nerve VII Clinically

  • As with all nerves, symptoms describe the location of the lesion
  • Lesion in the lingual nerve will result in loss of taste, general sensation in tongue & salivary secretion
  • Lesion proximal to the branching of the chorda tympani such as in the facial canal will result in the same symptoms without the loss of general sensation of the tongue (because V3 has not yet joined the CN VII)
  • Corticobulbar innervation is asymmetric to the upper and lower parts of the Facial Motor Nucleus
  • If there is an UMN lesion (lesion to the corticobulbar fibers) the patient will have paralysis of the muscles of facial expression in the contralateral lower quadrant
  • If there is a LMN lesion (lesion to the facial nerve itself) the patient will have paralysis of the muscles of facial expression in the ipsilateral half of the face
  • Bell�s Palsy

Testing Cranial Nerve CN VII

  • Ask the patient to mimic you or follow instructions to make certain facial expressions
  • Be sure to assess all four quadrants of the face
  • Raise eyebrows
  • Puff cheeks
  • Smile
  • Close eyes tightly
  • Check for strength of the buccinator muscle against resistance
  • Ask patient to hold air in their cheeks as you press gently from the outside
  • Patient should be able to hold air in against resistance

Cranial Nerve VIII – Vestibulocochlear

cranial el paso tx.Cranial Nerve VIII Clinically

  • Changes in hearing alone are most often due to
  • Infections (otitis media)
  • Skull fracture
  • The most common lesion to this nerve is caused by an acoustic neuroma
  • This affects CN VII and CNVIII (cochlear AND vestibular divisions) due to proximity in the internal auditory meatus
  • Symptoms include nausea, vomiting, dizziness, hearing loss, tinnitus, and bell�s palsy etc.

Testing Cranial Nerve CN VIII

  • Otoscopic Exam
  • Scratch Test
  • Can the patient hear equally on both sides?
  • Weber Test
  • Tests for lateralization
  • 256 Hz tuning fork placed on top of the patient�s head in the center, is it louder on one side than the other?
  • Rinne Test
  • Compares air conduction to bone conduction
  • Normally, air conduction should last 1.5-2 as long as bone conduction

Testing Cranial Nerve CN VIII

https://informatics.med.nyu.edu/modules/pub/neurosurgery/cranials.html

Cranial Nerve IX � Glossopharyngeal

cranial el paso tx.Cranial Nerve IX Clinically

  • This nerve is rarely damaged alone, due to it�s proximity to CN X & XI
  • Look for signs of CN X & XI damage as well if CN IX involvement is suspected

Cranial Nerve X � Vagus

cranial el paso tx.Cranial Nerve X Clinically

  • Patient may have dysarthria (difficulty speaking clearly) and dysphagia (difficulty swallowing)
  • May present as food/liquid coming out their nose or frequent choking or coughing
  • Hyperactivity of the visceral motor component can cause hypersecretion of gastric acid leading to ulcers
  • Hyper-stimulation of the general sensory component can cause coughing, fainting, vomiting and reflex visceral motor activity
  • The visceral sensory component of this nerve only provides general feelings of un-wellness, but visceral pain is carried on the sympathetic nerves

Testing Cranial Nerve IX & X

cranial el paso tx.

https://d1yboe6750e2cu.cloudfront.net/i/172ce0f0215312cee9dec6211a2441606df26c97

  • Gag reflex
  • CN IX provides the afferent (sensory) arc
  • CN X provides the efferent (motor) arc
  • ~20% of patients have a minimal or absent gag reflex
  • Swallowing, gargling, etc.
  • Requires CN X function
  • Palatal elevation
  • Requires CN X function
  • Is it symmetrical?
  • Palate elevates and uvula deviates contralateral to damaged side
  • Auscultation of the heart
  • R CN X innervates SA node (more rate regulation) and L CN X the AV node (more rhythm regulation)

 

Cranial Nerve XI � Accessory

cranial el paso tx.Cranial Nerve XI Clinically

  • Lesions may result from radical surgeries in the neck region, such as removal of laryngeal carcinomas

Testing Cranial Nerve XI

  • Strength test SCM m.
  • Patient will have difficulty turning head against resistance toward the side opposite of the lesion
  • Strength test trapezius m.
  • Patient will have difficulty with shoulder elevation on the side of the lesion

Cranial Nerve XII � Hypoglossal

cranial el paso tx.Cranial Nerve XII Clinically

cranial el paso tx.

https://openi.nlm.nih.gov/imgs/512/71/4221398/PMC4221398_arm-38-689-g001.png

  • On tongue protrusion, the tongue deviates toward the side of the inactive genioglossus m.
  • This could be contralateral to a corticobulbar (UMN) lesion OR ipsilateral to a hypoglossal n. (LMN) lesion

 

 

 

 

 

 

Testing Cranial Nerve XII

  • Ask patient to stick out their tongue Look for deviation as in above slide
  • Have patient place tongue inside cheek and apply light resistance, one side at a time
  • Patient should be able to resist moving the tongue with pressure

Clinical Examination – CN’s I – VI (Lower CN’s)

Clinical Examination – CN’s VII – XII

Sources

Blumenfeld, Hal. Neuroanatomy through Clinical Cases. Sinauer, 2002.
Pauwels, Linda Wilson, et al. Cranial Nerves: Anatomy and Clinical Comments. Decker, 1988.

Neuropathy Presentation | El Paso, TX. | Part II

Neuropathy Presentation | El Paso, TX. | Part II

Neuropathy Presentation II:�El Paso, TX. Chiropractor, Dr. Alexander Jimenez�continues the overview with neuropathy part II. Continued are the most common neuropathies to be seen in practice. Because the human body is composed of many different kinds of nerves which perform different functions, nerve damage is classified into several types. Neuropathy can also be classified according to the location of the nerves being affected and according to the disease causing it. For instance, neuropathy caused by diabetes is called diabetic neuropathy. Furthermore, depending on which nerves are affected will depend on the symptoms that will manifest. The complications which follow neuropathy depends on the type of nerves that are damaged. According to Dr. Jimenez, different neuropathies can cause numbness and/or 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 bladder control function.

Sciatic Nerve Entrapment

  • Piriformis Syndrome
  • Peroneal Nerve Entrapment
  • Tarsal Tunnel Syndrome

neuropathy presentation el paso tx.

Sciatic N. Piriformis Syndrome

neuropathy presentation el paso tx.Causes

  • Anatomic variation
  • Piriformis overuse/tension

Exam

  • Positive Lase?gue test possible
  • Doctor extends patient�s leg passively, while patient is lying supine positive test if maneuver is limited by pain
  • Tenderness and palpable tension in piriformis muscle which elicits symptoms

Sciatic N. Peroneal Nerve Entrapment

  • Peroneal or Fibular branch of Sciatic nerve entrapped at the fibular head
  • Tinel�s sign may be present at fibular head/neck
  • Usually affects common peroneal nerve, therefore motor and sensory symptoms can be seen
  • Weakness of ankle dorsiflexion and eversion (tibialis anterior m.)
  • Sensory disruption on the dorsum of the foot and lateral aspect of the calf

Sciatic N. Tarsal Tunnel Syndrome

  • Tibial nerve impinged in the tarsal tunnel
  • Sensory changes in the sole of the foot
  • Tinel�s sign may be present with percussion posterior to the medial malleolus

neuropathy presentation el paso tx.Radiculopathy

  • A mononeuropathy � located in one specific area
  • Neuropathy involving spinal nerve roots
  • Presents as changes in sensory and/or motor function affecting a single or a few nerve root level(s)
  • Most commonly seen radiculopathies include:
  • Sciatica
  • Cervical radiculopathy

Common Causes Of Radiculopathy

  • Disc herniation
  • Osteophytes
  • Spinal Stenosis
  • Trauma
  • Diabetes
  • Epidural abscess or metastasis
  • Nerve sheath tumors (schwannomas and neurofibromas)
  • Guillain-Barre? syndrome
  • Herpes Zoster (shingles)
  • Lyme disease
  • Cytomegalovirus
  • Myxedema/Thyroid disorder
  • Idiopathic neuritis

Narrowing Down Common Causes Of Radiculopathy

  • Disc Herniation

  • Most commonly affected nerve roots are C6, C7, L5 & S1
  • Spinal Stenosis

  • Lumbar stenosis may produce neurogenic claudication
  • Pain & weakness with ambulation
  • Cervical stenosis may present with mixed picture of radiculopathy and myelopathy due to long tract involvement
  • Trauma

  • May cause compression, trauma or avulsion of the nerve roots
  • Diabetes

  • More likely to cause a polyneuropathy, but mononeuropathy is possible
  • Herpes Zoster (Shingles)

  • Most often on the trunk, accompanied by vesicular lesions in a single dermatome
  • If pain persits past vesicular regression = post-herpetic neuralgia

Patient History Of Radiculopathy

  • The patient will often complain of burning pain or tingling that radiates or shoots down an affected area in a dermatomal pattern.
  • Sometimes patient will complain of motor weakness, however if onset is recent, there is often no motor involvement

Exam Of Radiculopathy

  • Most often hypoesthesia in the affected dermatome level
  • Best to evaluate for pain, as light touch can be difficult for these patient�s to distinguish
  • Fasciculations and/or atrophy may be seen if radiculopathy is chronic, due to lower motor neuron being impinged
  • Motor weakness may be seen in muscles innervated by the same root level

Orthopedic tests:

  • Straight-leg raise test (SLR)
  • Pain between 10-60 degrees likely indicates nerve root compression
  • Well-leg raise/Crossed straight-leg raise test (WLR)
  • If positive, 90% specificity for L/S nerve root compression
  • Valsalva Maneuver
  • Positive if increase in radicular symptoms
  • Spinal Percussion
  • Pain may indicate metastatic disease, abscess or osteomyelitis

Examinations: Merck Manual Professional

How To Test Reflexes

How To Do A Sensory Exam

How To Do A Motor Examination

Dermatomes

neuropathy presentation el paso tx.Testing Cervical Nerve Roots

neuropathy presentation el paso tx.Testing Lumbosacral Nerve Roots

neuropathy presentation el paso tx.

Specific Radiculopathy Patterns

  • T1 radiculopathy can cause Horner�s syndrome
  • This is due to affect on cervical sympathetic ganglia
  • Ptosis, miosis, anhidrosis
  • Below L1, radiculopathies can cause Cauda Equina syndrome
  • Saddle anesthesia (sensory loss in S2-S5 distribution)
  • Urinary retention or overflow incontinence
  • Constipation, decreased rectal tone or fecal incontinence
  • Loss of erectile function
  • Must be referred for emergency care immediately to prevent permanent dysfunction

Other Patterns Of Neuropathy

  • Cape/Shawl distribution of symptoms
  • Intramedullary lesion
  • Syringomyelia
  • Intramedullary tumor
  • Central cord damage
  • Stocking and Glove Distribution of Symptoms
  • Diabetes mellitus
  • B12 deficiency
  • Alcoholism/hepatitis
  • HIV
  • Thyroid dysfunction/myxedema

Cape/Shawl Pattern

  • Intramedullary lesion such as tumor, syringomyelia or hyperextension injury in patient with C/S spondylosis

neuropathy presentation el paso tx.

  • Loss of pain and temp sensation in C/T dermatomes because of arrangement of lateral spinothalamic tract

neuropathy presentation el paso tx.Stocking & Glove Pattern

neuropathy presentation el paso tx.

  • Symmetrical polyneuropathy
  • Feet/legs usually affected first, followed by hands/arms
  • Vibration sensation in the smallest toes is usually the first thing lost and neuropathy progresses across foot to great toe and then upward through the ankle and leg, then hands, arms and finally trunk if sever
  • Most likely cause of this distribution is diabetes mellitus, but other possible causes include B12 deficiency, alcoholism, HIV, chemotherapy treatment, thyroid dysfunction and multiple other causes

Diabetic Neuropathy

  • Diabetic neuropathy often presents as a polyneuropathy but can also present as a mononeuropathy, usually with acute onset
  • Most common in CN III, femoral and sciatic nerves

Demyelinating Neuropathies

  • Acute inflammatory demyelinating polyneuropathy (Guillain-Barre? syndrome)
  • Chronic inflammatory demyelinating polyneuropathy

Guillain-Barre? Syndrome (AIDP)

  • Onset 1-2 weeks post viral infection
  • Progressive weakness
  • Loss of DTRs/areflexia
  • Paresthesia in hands and feet
  • More motor involvement than sensory
  • Potential autonomic fiber involvement
  • Elevated CSF protein
  • EMG/NCV studies indicate demyelination
  • May require treatment with plasmapheresis or IV Ig therapy

Chronic Inflammatory Demyelinating Polyneuropathy

  • Appears similar to AIDP but does not follow infection
  • Symptoms must be present for at least 8 weeks for this diagnosis to be considered
  • Anti-inflammatory treatments may help

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.

Neuropathy Presentation | El Paso, TX. | Part I

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

neuropathy presentation el paso tx.

*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

neuropathy presentation el paso tx.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

neuropathy presentation el paso tx.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

neuropathy presentation el paso tx.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

neuropathy presentation el paso tx.

  • 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

neuropathy presentation el paso tx.

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

neuropathy presentation el paso tx.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

neuropathy presentation el paso tx.

Etiology

  • Compression of the median nerve at the wrist

Causes

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

 

 

Orthopedic Tests

neuropathy presentation el paso tx.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

neuropathy presentation el paso tx.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

neuropathy presentation el paso tx.

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

neuropathy presentation el paso tx.

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

neuropathy presentation el paso tx.

  • 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.