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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 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.
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.
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.
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.
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.
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.
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 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.
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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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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