Peripheral Neuroanatomy and Focal Neuropathies ‘cal neuropathies may result from compres- sion, entrapment, ischemia, stretch, direct srauma such as lacerations and missile ‘wounds, involvement in fractures or dislocations, and other processes. While carpal tunnel syndrome (CTS), ulnar neuropathy atthe elbow (UNE), pero- real neuropathy atthe knee, retcohumeral radial neu~ ropathy, and facial neuropathy constitute the majority of focal neuropathies, virtually any nerve in the body can be compressed or entrapped. This chapter reviews the anatomy of the peripheral nervous system and some of the more common focal neuropathies. PERIPHERAL NEUROANATOMY Cervical Plexus “The cervical plexus is formed by the anterior primary rami of CI-C4. These divide into anterior and pos terior branches oF divisions that unite to form three anastomotic loops. The cervical plexus is situated in the lateral neck, adjacent to che upper four cervieal vertebrae deep’ to the sernoceidomastoid muse cle. The phrenic nerve isthe most important nerve derived from the cervical plexus; it arises fom C3, (C4, and sometimes C5 and innervatesthe diaphragm Other motor branches innervate the paravertebral muscles, scalenus medius, and levator seapulae; join ‘with CN IX to supply portions of the experi muse cle; or connect with CN XII (Figure 20.2) The most notable cutaneous nerves are che lesser occipital (pric marly C2) and the gree auricular. Postganglionie sympatheric nerve fiber that originate i the superior cervical ganglion also traverse the cervical plexi Damage co the cervical plexus may occur from surgical wsuma (eg, radial neck disecions of carotid endarterectomy) or penetrating injuries. Nonpenetrating violent trauma occurs from motor vehicle especially mocoreycle, accidents. Other pro- cesses that may damage the cervical plexus include invasion by neoplasm, usually metastases or Iympho- mas and squamous cell carcinomas of the head and neck and iatrogenic causes, for example, radiation therapy or intraoperative posicioning, The most seri- ‘ous manifestation of cervical plexopathics is involve- ment of the phrenic nerve (see below). Brachial Plexus “The brachial plexus (BP) arises from the ancer primary rami of C51 (Figure 46.1). The post primary rami leave che spinal nerves just after they ‘exit co innervate the paraspinal muscles. Assessment of the paraspinal muscles by needle elecuromyogra- phy is essential in localizing a disease process to the brachial or lumbosacral plexus (LSP) and excluding radiculopathy. The phrenic, long thoracic, and dorsal scapular nerves come off a too level and this Feaure ‘an sometimes help in localization of plexus lesions. “The plexus is made up of uppes, middle, and lower twunks; anterior and posterior divisions: medial lat- cra, and posterior cords; and terminal branches. The C5 and C6 roots join to form the upper trunk. The suprascapular nerve co the supraspinatus and infaspi- zatus comes off the upper trunk, making the spinati the most proximal muscles innervated by the plexus propet. The C7 anterior primary ramus continues as the middle trunk, ‘The C8 and TI rami combine to form the lower unk. The trunks are named for their telationship to one another, “The three crunks slope laterally and then split {nto anterior and posterior divisions, from which the three conds are derived. The lower trunk is adjacentDorsal scapular nerve, Suprascapular ne Meciat pectoral nerve Lateral pectorai nore, Medial cord Posterior cows, Lateral cord, Medial nerve Median nerve SECTION || THE AUTONOMIC AND PERIPHERAL NERVOUS SYSTEMS “Long theracie nerve Upper subscapular nerve Lower sunscapular nerve Medial cutaneous nerve of arm Uipar cerve * wtusculocutaneous nerve FIGURE 46.1 frat plows showings varios const tuars anther ainsi to struct al, ana shale to the apex of the lung. The cords of the BP are named for their anatomical relationship lary arcery. All the posterior divisions come together +0 form the posterior cord, which les posterior to the artery Iv is smaller than the other cords and contains lisde if any contribution from TI. It divides into ‘ovo major terminal branches: the radial and axillary nerves. The anterior divisions form the medial and lateral cords, The anterior divisions of the upper and middle erunk combine to form the lateral cord, which lies lateral to the artery and terminates in two major branches: the musculocutancous nerve and the lat- ‘ral head of the median nerve. The lateral head of the median carries all median sensory functions and th to the axle pec hast res and flexor motor innervation to the pronsto carpi radials, The anterior division oft continues as the medial cord, which lies medial tothe artery, and also terminates in two major branches: the ‘medial head of the median nerve and the ulnar nerve, The medial head of th her median motor functions but has no cutancous sensory component. After giving off the medial head to the median nerve, the medial cord continues asthe ulnar nerve. As a generalization, the posterior cord supplies the extensor muscles, and che lateral and ‘medial cords the flexor muscles. TThe roots and trunks ofthe plexus lie in the pos: terior triangle of the neck, in the angle between the lower rank c median nerve cartes al oftheCHAPTER 46 | PERIPHERAL NEUROANATOMY AND FOCAL NEUROPATHIES clavicle and the posteroinferior border of the sterno- cleidomastoids the cards lc in che axilla: the divisions span the gap and lie approximately beneath the medial ‘wocthirds of the clavicle, between the clavicle and the firs ib, The cords are che longest component of the plexus. In che lower axilla, che BP divides into its terminal branches. The plexus is sometimes divided into a supraclavicular portion (roots and trunks) and an infraclavicular portion (divisions, cords, and ter- ‘minal branches). In other schemes, the divisions are ssid to joint the supra- and infrachvicular portions of che plexus. The BP is also broadly divided into the upper plexus (upper trunk and lateral cord) and lower plexus (lower erunk and medial cord). Some patho- logic processes have a predilection for different parts of the plexus. Trauma is particularly likely to affect the upper plexus (e4, Erbs palsy); lower plexopa- thies are often nontraumatic (eg, Pancoast tumor or thoracic oudet syndrome). The terminal branches of the BP may he divided into « supraclavicular and an infraclvicular group. The clinically important supraclavicular nerves are the phrenic, long thoracic, suprascapular, and dorsal scapular. The other eermi- nal branches are infaclavicular, The BP can be involved in a plethora of dis- ease processes. The most common and clinically imporcant of these include neuralgie amyotrophy (NA, acute brachial plexopathy, brachial plexits, Parsonage-Turner syndrome); trauma, such as with missile and stab wounds oF motor vehicle (specially motorcycle) accidents; neoplasms; postradiation + obstetrical palsies; postsurgical plexopa- finger” or “burner” phenomenon that fre- quently affects football players, which i likely a mild form of plexus injury; and thoracic outlet syndrome. NA (brachial plexts, acute BP neuropathy) is a fairly stereotyped clinical syndrome characterized by the acute onset of pain in the shoulder and upper arm, followed by weakness, then atrophy, of variable sever- ity, primarily affecting upper arm and shoulder mus- cles. The BP can sustain injury in a number of ways missile and stab wounds, motor vehicle (especially motorcycle) accidents, football, and iatrogenically Seretch injuries of the plexus occur during childbieth and usualy involve the upper plexus (Erb's palsy), much less often the lower plexus (Klumpke's palsy) or the entire plexus. Neoplasms, especially breast and lung, may invade the plexus, Radiation plexopa- thy may complicate treatment of such tumors and appears after a delay of months to years. This is also the time frame in which the radiation therapy may have kept « tumor at bay. Distinguishing recurrent ‘tumor from radiation plexopathy is often dificult ‘Other etiologies of brachial plexopathy include ‘external compression (eg, backpack or rucksack palsy), compression from an internal process (eg, encroachment on the lower BP from a Pancoast ‘tumor or involvement in systemic processes such as systemic lupus erythematosus (SLE) or arcoid, or iat- rogenic plexopathy during cardiac surgery. The plexus may rarely be involved in a number of ot tions, including lupus, lymphoma, Ehlers-Danlos syndrome, and infectious or parainfectious disorders Some ofthese processes are by nature progressive. With pressure injuries, the same gencral rules apply as for other nerves. Mild lesions produce pri- marily demyelination and can cause severe clinical deficits but have an excellent prognosis. With plex- ‘opzthies, there may be the additional complication of disease progression, Many of the condi affect the plexi are not static, Pancoast tumors con- tinue to grow, radiation damage tends to progress, and systemic diseases suck as SLE continue their activity, All these mechanisms of injury make the pathophysiology of plesopathies complex and « clinical evaluation challenging. condi- sas that The Phrenic Nerve TThe phrenic nerve arises from the phrenic nucleus at C3-C5; it also carries some sensory filaments from the diaphragm, pericardium, and pleura. The fibers of the phrenic nerve arise from root level, Unilateral diphrag- matic paralysis is frequently asymptomatic, except for orthopnea and exertional dyspnea, With bilateral paralysis, chere is dyspnea on the slightest exertion, a scaphoid abdomen that does not protrude on expira- tion, absence of Litters sign, increased excursion of the costal margins, retraction ofthe epigastrium on inspi- ration, overactivity of the accessory respiratory muscles, and diffculy in coughing, sneccing, or making quick forceful inspiratory movements such as snifing, The nerve may be involved in NA, damaged by surgical procedures on the neck or chest, or com- pressed in the mediastinum by enlarged nodes, aneu- rysms, or neoplasms. The segmental supply to the diaphragm is frequently compromised in upper spi- ral cord injuries and determines whether the quadri- plegic patient will or 4 ventilator, Involvement of phrenic motor neurons is common in amyotrophic lateral sclerosis. Other ‘causes of phrenic neuropathy include diabetes ‘tus, mediastinal irradiation, sarcoidosis, suberculosis, ll not be able to live withoutLyme disease, and acute and chronic inflammatory demyelinating polyneuropathics. Idiopathic bilateral phrenie neuropathies causing diaphragmatic paralysis may occur. The Long Thoracic Nerve This nerve is derived from the C5-C7 roots and sup- plies the reatus anterior muscle, Paralysis of che ser 1 muscle causes winging of the scapula (Figure 27.8). The long thoracic nerve (ETN) may be injured by pressure fom carrying heavy objects or packs on the shoulder (backpack or rucksack palsy ‘or by penetrating wounds. Ie may be involved in NA, sometimes in isolation, Iarogenie LIN palsy may follow anesthesia or local invasive procedures om the anterolateral aspect ofthe thorax. Paralysis may also ‘occur with myopathic processes such a FSH dystro- phy and che scapuloperoneal syndeomes. The Dorsal Scapular Nerve The dorsal scapular nerve arises directly from the C5 nerve root to innervate the thomboid muscles ‘Weakness causes lateral displacement of the vertebral border of the scapula and lateral displacement of the inferior angle. Atrophy may be obscured by the over- Iying trapezius. Isolated lesions have been reported in bodybuilders. tis occasionally of importance, espe- cially leczromyographically, in distinguishing between 5 radiculopathy and upper trunk brachial plexopathy. The Suprascapular Nerve This nerve is derived from C5-C6 and arises from the upper trunk. Ie runs posteriorly through the supras- capular notch, beneath the suprascapular ligament, to innervate the supraspinatus musc the glenoid process of the spine of the scapula in the spinoglenoid notch to reach the infraspinous fossa and innervate the infraspinatus. The nerve may be ‘entrapped at the suprascapular notch, causing pain and weakness of both supraspinatus and infraspina- tus, or at the spinoglenoid notch, causing weakness of only the infraspins vulnerability a lesion at the suprascapular notch may also involve only the infraspinatus branch. A com- mon cause of suprascapular neuropathy is NA. TThe most common causes of suprascapular neu- ropathy are occupational overuse, sports-related injury, direct trauma, and ganglion eysts. Suprascapular neu- ropathy may occur after scapular fracture or by direct pressure (mobile telephone user’ shoulder droop). Repetitive motion injuries in sports that particuas is. Because of selective fascicular SECTION || THE AUTONOMIC AND PERIPHERAL NERVOUS SYSTEMS involve strenuous overhead activity pose a particular hazard. The prevalence of infaspinatus muscle at phy in the hitting shoulders of professional beach vol- leyball players is 30%. The Axillary Nerve TThe axillary (circumflex) nerve isa terminal branch of che posterior cord of the BP derived from C5-Cé, It accompanies the posterior humeral circumflex antery through the quadrangular space and then divides into anterior and posterior branches. The anterior branch supplies the anterior part of the del- toid muscle; the posterior branch supplies the poste- sot part of the deltoid and the teres minor muscles and sends sensory ewvigs co a small cizcular area of skin over the deltoid muscle just above the deltoid attachment. Axillary nerve lesions are usually due to trauma ot NA. The nerve may be injured by frac- ture or dislocation of the humeral head, penetrating wounds, misplaced therapeutic injections, arthros- copy, oF direct blows to the shoulder. It is also prone to injury by overhead activity in sports, especially volleyball, tennis, and baseball. There is weakness and wasting of the deltoid, often profound, and a small patch of sensory loss over the shoulder. Isolated lesions of the anterior branch may spare sensation. Conversely, isolated involvement of the sensory branch has been reported after shoulder arthroscopy. Preservation of dorsal scapular and suprascapalar rnceve function helps distinguish axillary neuropathy from C5 radiculopathy and upper trunk plexopathy, but the evaluation of suprascapular nerve function must usually be made electromyographically, as both the deltoid and supraspinatus are shoulder abduc- tors, and both the teres minor and ingraspinatus are external rotators The Musculocutaneous Nerve This nerve is derived from C5-C7 and is a terminal branch of the lateral cord, Ie passes into the upper arm in the groove between the deltoid and pectoral mus- cles, sends a branch to the coracobrachialis muscle, then traverses @ foramen in the muscle, after which i descends and innervates the biceps and most of the borachilis. At the elbow, it pierces the deep fascia just lateral to the biceps tendon and continues as the lat- cral antebrachial cutancous nerve (lateral cutancous nerve of che forearm) to supply sensation tothe lateral aspect of the forearm from the elbow eminence. The musculocutaneous may be injured by overly vigorous elbow flexion (weight lifter’ palsy, the thenar‘CHAPTER 46 | PERIPHERAL NEUROANATOMY AND FOCAL NEUROPATHIES FIGURE 46.2 Muscvoevianeus newopaty after performing oe ‘ered ul-ype Natta senha atopy and smear en the Csibuion te el acetal ctnoais ne Figure 46.2). There is weakness of elbow fein with the forearm supinated and marked weakness of supi- sation. The semipronated forcarm can sil be flexed by the brachioraialis. There isa relatively small area of scasory loss on the lateral surface of the forcarm. ‘The biceps reflex is diminished or absent. Preservation of acllary, dorsal seapular, and supracapular nerve functions differentiate musculocutancous palsy from an upper trunk lesion and C5 radiculopathy, and preservation of forearm pronation and lateral hand sensation, median nerve functions, distinguishes from a lateral cord lesion and Cé radiculopathy. The Median Nerve ‘The median nerve has two componcnss lateral divi sion and a medial division, The lateral cord ofthe BP divides into owo terminal branches: One becomes the musculocutancous nerve, and the other hecomes the lateral division of dhe median nerve. The medial cord of the BP also divides into two terminal branches: One forms the medial division of the median nerve, and the other continucs as the ulnar nerve. The redial and lateral divisions of the median nerve jin to form single trunk, which passes through che ‘upper arm without branching down to the region of the elbow (Figure 46.3). “There the branches begin to separate, Innervating ‘segs are given off fom the lateral head to che proma- tor tere and Bexor carpi radials muscles. The main trunk passes through the wo heads ofthe pronator tercs muscle and beneath an aponcurosis connecting the two heads ofthe flexor digitorum supericilis (che sublimis bridge). Just disal to the pronator teres, che nerve gives off che anterior interosscous nerve (AIN), which runs along the interosicous membrane and innervates the median head (lateral portion) of the flexor digitorum profundus (FDP), the flexor poli- cis longus, and the pronator quadratus. The AIN has no cutancous sensory component, The main trunk of the median nerve continues down the forearm, giv- ing off muscular branches to the palmaris longus and flexor digitorum superficial ‘The median nerve crosses from the distal Fore- farm to the hand through the carpal tunnel. The ‘walls and loor ofthe tunnel are formed by the earpal bones and the roof by the transverse caxpal ligament (ICL). The TCL evolves from the antebrachial fascia at about the level of the wrist crease and extends 4 t0 {6 em into the palm. The passageway is narrowest 2.0 to 2.5 em distal to its origin, which corresponds to the usual site of median nerve compression in CTS (Figure 46.4). Lying with the median nerve in the canal are the cight deep and superficial finger flexor tendons and the tendon of the flexor pollicis longus surrounded by a complex synovial sheath, ‘The palmar cutaneous branch of the median nerve leaves the main trunk 5 to 8 em proximal to the wrist crease, It travels through ies own separate passageway in the TCL and provides sensation to the chenar eminence; it does not traverse the carpal tunnel. Loss of sensation over the thenar eminence is not part of CTS and suggests lesion proximal ro the wrist, After exiting the arpal tunnel, the median nerve gives off its reeurtentthenar mo:or branch, which curves backward and radially co innervate the median thenar muscles (abductor pollicis brevis ‘opponens pollicis, nd lateral head ofthe Alexor pol leis brevis). The nerve ends by giving off terminal motor branches to innervate the fist and sscond lumbricals and then dividing into common digital sensory branches that carry sensory fibers from the palmar susfices ofthe thumb, index and middle fin- ger, palmar aspect ofthe radial half ofthe ving finger, and the dorsal spect ofthe middle and distal phalan- ses of the index and middle Singers and radial half of the ing Sager. The fngce flexor reflex is medisted in part by the median nerve. The pronatorseflex, prone tion of the forearm after tapping. in the region ofthe radial styloid on che volar surface of the forcarm, is also median innervated Carpal Tunnel Syndrome Entrapment of the median nerve beneath the TCL is ‘often brought on oF exacerbated by excessive hand vwrislfinger movements; the combination of repeti- tive Binger flexion with wrist motion seems to be theFEB] secon | ie autonomic ano renpiera nenvous srsrens FIGURE 46.3 Common sta fe ir to he median nee and the dtibton of sear ls witha proxial median noe lesion in carpal ture syne CTS session oer th thre riranco ssa. most hazardous ergonomic stress. Both vocational and in the general population. CTS can rarely result from recreational activites can incite or aggravate the con- mas lesions narrowing the passageway (for example, dision, Although keyboarding is often blamed, the ganglion, osteophyte, lipoma, aneurysm, anomalous frequency of CTS in computer users is similar to that muscle). Numerous systemic conditions predispose to‘CHAPTER 46 | PERIPHERAL NEUROANATOMY AND FOCAL NEUROPATHIES Median newe~. ‘Transverse catpal Tigamont™._ ‘Thumb muscles Uthenar)~ CTS, including cheumatoid archi, diabetes mellitus, chronic renal insufficiency and hemodialysis, hypothy- roids, amyloidosis, myeloma, acromegaly, and preg- nancy, Constriction within the carpal tunnel is often due to nonspecific enosynovits ofthe Hexor tendons. A congenitally narrow canal may predispose some patients CTS produces a characteristic clinical picture of hhand pain, numbness, and paresthesss, all usually more severe at night, Patients often claim relief by shaking or flicking (see below) the hand. The reason for the nocturnal exacerbation of symptoms remains obscure, but the diagnosis should remain suspect in the absence of this feature, Proximal upper-extremity pain, usually in the forearm but sometimes as far as the shoulder, is lex gypical but not uncommon, ‘Many patients complain of “whole hand” numbness, and rarely, for unclear reasons, a patient with CTS ‘may present with ulnar or even radial distribution paresthesias. Ina survey of 100 patients with elecro- diagnostically confirmed CTS and no other pathol- ‘ogy, symptoms were most commonly reported in both median and ulnar digits, followed by median digits only and a glove distribution. Unusual sensory pattems were reported by some patients. In another study, over 50% of patients with exclusive CTS had tingling or numbness involving the whole hand, ulnar or radial nerve distributions, Some patients reported symptoms proximal o the wrist, Muscles of tite tinger (rypotnenan) FIGURE 46.4 The restonsip of te motan nono to the ‘ranvrse capl iganent and he st of compressinin CIS. Compression Findings on examination vary with the severity of the condition, Patients with mild CTS may have a normal physical exam or trivial sensory loss over the Fingertips. The earliest sensory loss seems to occur over the volar tip of the middle finger. Patients with more advanced disease have more easily demonstrable sen- sory loss and frequently have weakness of the thenar muscles, The opponens pollicis is occasionally, and the abductor pollicis brevis rarely, innervated by the ulnar nerve and may be spared in some paticnts. The lumbrical muscles are usually spared. Although there may be sensory complaints in unusual distributions, sensory signs do not extend beyond the median nerve tervitory, recalling of course that there may be varia- tionsin the territory of cutaneous nerves (Figure 36.5) Patients with severe involvement demonstrate thenar weakness and atrophy and dense sensory los. ‘Tinel’ sign is paresthesias produced by percussion lover a peripheral nerve that may indicate focal nerve pathology. Elicting a Tinels sign can be useful, but many normal patients “Tinel” over all their nerves; only the presence of a disproporionaely active ‘Tinel’ sign over the clinically suspect nerve has any localizing value. Phalen’s (wrist flexion) testis numb- ness or paresthesia in the median distribution pro- duced by forceful Hexion of the wrist for 1 minute ‘The reverse Phalen’s (prayer) cest isthe same but with the wrist hyperextended. In the carpal compressionmaneuver, the examiner applies firm thumb pressure ‘over the median nerve atthe wrist crease, seeking to reproduce CTS symptoms, These provocative tests have proven disappointing, with high proportions of false positives and false negatives, The “fick” sign, in ‘which the patients flick the wrist to demonstrate what they do to “restore the circulation” at night is more useful but still imperfect. The rare “reverse Tinel’s sign” with paresthesias radiating retrograde up the forearm may be more specific for CTS, The tourni quet test (cuff compression test) seeks reproduction ‘of pain and paresthesias with compression above systolic pressure. The elevated arm sttess test (Roos test) has been touted as useful in both thoracic outlet, syndrome and CTS but has a high incidence of false positives in both. The most common differential diagnostic exer: cise is between CTS and cervical radiculopathy, most often C5, Neck and shoulder pain, weakness in 6 innervated muscles, reflex changes, sensory loss restricted to the thumb, the absence of nocturnal par cesthesias, and reproduction of the patesthesias with root compression maneuvers all Favor cetvieal radie: ulopathy. Other conditions occasionally meriting consideration include proximal median neuropathy, neurogenic thoracie outlet syndrome, and upper bra chial plexopathy. Various musculoskeletal conditions, SECTION || THE AUTONOMIC AND PERIPHERAL NERVOUS SYSTEMS especially de Quervain’s tendonitis, can cause hand and wrist pain suggestive of CTS, Proximal Median Neuropathy TThe proximal median nerve is well protected by soft tissues and, accordingly, is injured less frequently than cither the radial or the ulnar nerve, Ie may be involved in dislocations of the shoulder, inju- ries of the elbow joint, fractures of the humerus ot radius, penctrating wounds, or compression injuries Proximal median neuropathy may be a complica. tion of shune placement for hemodialysis. A triad neuropathy is involvement of median, ulnar, and radial nerves, usually from 2 lesion in the axilla, for ‘example, crutch palsy, or ofthe BP distal branches. A complete proximal median nerve lesion causes paral- ysis of flexion of the wrist and radial fingers pronation, and thumb abduction, opposition, and fexion. Finger flexion at the metacarpophalangeal (MCP) joints may be partially preserved because of preserved interosscous function, Loss of ability to ex the distal phalanx ofthe index finger, without a bone or tendon lesion to account for it, is pathognomonic. The thumb lies adducted and extended; it cannot bbe opposed to the tip of the litle finger or abducted at right angles to the palm (palmar abduction), and the terminal phalanx cannot be flexed (Figure 46.5). Many ofthe lost movements, except for flexion of the distal phalans of the index finger and mov the thumb, can be substituted for by ul muscles, There is no substitution for palmar abduc- tion, and comparison of this movement on the ovo sides is an important est of median nerve function, Thenat atrophy with the thumb rotated and resting in adduction produces the simian (ape) hand deform- ity (monkey paw"). Loss of finger flexion when attempting to make a fise produces a posture resem- bling the hand used by clergy in making a benedic- tion, a term best avoided (see below). The sensory changes involve the radial side of the palm, including the chenar region (palmar cuta- ancous distribution), the index and middle fingers, and the radial half of the ring finger. They are less complete on the dorsum of the hand chan on the palmar surface, and usually involve only the distal {or middle and distal) phalanges of the index and ‘middle fingers, and somesimes part of the thumb and radial half ofthe ring finger (Figure 36.4). T no significant reflex changes. Median nerve paaly- sis i often accompanied by vasomotor and trophic hanges and by intractable, burning pain (causalgia, ents of innervated‘CHAPTER 46 | PERIPHERAL NEUROANATOMY AND FOCAL NEUROPATHIES reflex sympathetic dystrophy, complex regional pain syndrome) especially ifthe lesion is incomplete. The skin may be flushed, cyanotic, and either wet oF dey: the nails are britde or striated, and there may be changes in haie growth ‘The median nerve may rarely he entrapped by the ligament of Struthers, an anomalous Sbrous band running from distal humeral supracondylae spur to the medal epicondyle (ME) Inthe pronacor teres syndrome, the median nerve is entrapped a che point where ie pases through the two heads of the pronator tres it may affect the main trunk, caus ing both motor and sensory dysfunction (Seyfrah’ syndrome); more often, only the AIN is involved (iloh-Nevin syndrome). Hyperrophy of the pt nator tees as been implicated. There i often pain in the proximal forcazm, and there may be tender ness and/or a Tinels sgn over the pronator muscle, Depending on the individal anatomy and the ort gin of the branch to che pronator teres, the promi: tor teres may oF may not be involved in a pronator syndrome, The pronator quadratus is involved with ither proximal median neuropathy or the AIN syn- drome; distinguishing berwecn pronator seres and pronator quadritas requires careful elbow postion- dng (sce Chapter 27) ‘Complete AIN paralysis causes inability to lx the disal phalanx of either the thumb or index Singer ‘The patient cannot make a circle by touching the ip of the chum tothe tip ofthe index finger, making a triangle instead by touching the finger pade (pinch sign, oF OK sig [the patient is unable to make the OK sign widh the involved hand) Figure 46.6) ‘There afe no cutaneous sensory changes in AIN paly, bur there may be pain carried by afferent bers innervating joints, AIN palsy often occurs as an iso- lated manifestation of NA. Other etiologies include strenuous exertion, especially when involving flexion and pronation of the forearm, trauma, for exemple, fracture, venipuncture, penetrating injury, and intra- ‘operative positioning, In the pseudo-AIN syndrome, the lesion predominantly involves AIN fascicles in the main trunk of the median nerve. There may be median distribution sensory changes, The usual etiol- ogy is a supracondylar fracture. Median neuropathy proximal to the carpal tunnel may occur in wheel= chair athletes. The Ulnar Nerve ‘The ulnar nerve arises as a continuation of the medial cord of the BP. As it exits from the thorax, ie passes through the axilla and into che upper arm lying medial to the brachial artery in a common neurovascular sheath with the median nerve and che medial brachial and antcbrachial cutancous nerves. ‘At about the level ofthe insertion of the coracobra- chialis, che ulnar leaves the common neurovascular bundle and pierces the medial intermuscular septum to gain the posterior compartment of the arm, The nerve then descends toward the elbow in a groove alongside the medial head of the triceps. The point of the ulnar nerve’s penetration of the medial inter- muscular sepeum and the nearby deep fascia bind- ing the nerve in the triceps groove are sometimes referred co as the arcade of Struthers, a potential ‘entrapment site (not to be confused with the liga- ment of Struthers). Whether the arcade of Struthers actually exists remains a point of disagreement, After piercing the medial intermuscular sepeum, the nerve slants distally and medially, and chen traverses the FIGURE 46.6 Arttritrsseous nop th paints unable flex tb tal pana te hun or io nga ands thus unable to make ne “OK sign” A. Patent ne le, ental on teri noted ses te patents ratEE] secrion | Tae autonomic ano PERIPHERAL NERVOUS SYSTEMS retrocpicondylar (ulnar) groove between the ME and ‘olecranon process (OP). It then passes beneath the humeroulnar aponeurotic arcade (HUA), a dense aponeurosis joining the humeral and ulnar heads of origin of the lexor carpi ulnaris (FCU) musee, which typically lies 1.0 t0 2.5 em distal toa line con- necting the ME and the OF After passing under the HUA, the nerve runs through the belly of the FCU, then exits through the deep flexor-pronator aponeurosis lining the deep surface of the muscle 4.0 to 6.0 em beyond the ME, and then runs distally toward the wrist. ‘The alnar palmar cutaneous branch arises in the mid to distal forearm and pursues a separate course to the hand. It ‘enters the hand superficial to Guyon's canal and sup- plies sensation to the skin of the hypothenar region. TThe large dorsal ulnar cutaneous (DUC leaves the main trunk 5 to 10 em proximal to the wrist to wind posteriorly and emerge on the dorsal surface of the wrist to provide sensation to the dor- sal ulnar aspect of the hand, as well as che small and ring fingers. The ulnar nerve enters the hand through Guyon's canal. The'lCL, which forms the roof of che carpal tunnel, dips downward as ic spans medially and forms the floor of Guyon’s canal. The pisoham- ate ligamens, which runs from the pisiform bone to the hook of the hamate, forms the distal pare of che oor of the canal, The volar carpal ligament, a thin ment that is basically a continuation of deep forearm fascia arches over and ‘of Guyonis canal along with the thin palmaris brevis muscle, ‘The hook of the hamate forms the lateral, and the pisiform bone and FCU tendon the medial, boundaries. ‘As it emerges from beneath the volar carpal liga- meng, the ulnar gives a branch to the palmaris bre- vis and then branches into the superficial terminal sensory division and the deep palmar deep branch exits Guyon’s canal, passes through the pisohamate hiatus, and then arches laterally beneath the flexor tendons, innervating the interossei and breaking up inco terminal branches on reaching the adductor pollicis and first dorsal interosseous. The deep head of the flexor pollicis brevis is usually sup- plied by a shore ewig from the terminal branch to the adductor pollicis branch rms the roof vision. The Ulnar Neuropathy at the Elbow UNE is most often due to compression in the etro- epicondylar groove but may be due to entrapment beneath the HUA, other entrapment sites are rare. UNE was originally deseribed inpatients with elbow deformities due to remore fracture andlor dislocation. The UNE occurred because of chronic compression and stretch and typically followed the injury by months or years (cardy ulnar palsy). Gradually, the term tardy ulnar palsy became a generic for any UNE, even without a history of evidence of elbow joint pathology. Compression at the HUA was actually recognized in the 1920s by Buzzard and Sargent, but it was not until the land- ‘mark Canadian papers of the 1950s that it became widely known. Fiendel and Stratford proposed the term cubital tunnel syndrome (cabit is Latin for elbow) to refer to compression by the HUA. The title of their paper is telling: “The role of the eubi- tal cunnel in tardy ulnar palsy.” Gradually, cubital tunnel syndrome has replaced tardy ulnar palsy as a generic referring to any UNE. The term is thus used very inconsistently, and has outlived its useful ness, but is very entrenched, Although rare cases of UNE are caused by ganglia, tumors, Rbrous bands, or accessory muscles, most are caused by external compression, repeated srauma ot repetitive elhow flexion. Chronic minor trauma and compression, including leaning on che elbow, can result in U at the groove. It can al nts who suf fer compression during anesthesia oF coma In the majority of patients with UNE, the intial symptoms are intermittent numbness and tingling in the ulnar nerve distribution, often associated with elbow flexion. Occasionally, the inital problems may be motor dysfunction, such as a feeling of weakness of grasp and pinch, ora loss of dexcericy. Patients may not see a physician until che initially small degrees of. intrinsic muscle atrophy become difficult co overlook. A history of elbow fracture or dislocation, seute blunt trauma, chronic occupational trauma, or arthritis ‘may be imporcant. When there is no relevant his- tory, entrapment at the HUA should be considered, An early motor sympeom sometimes noted is loss of control ofthe small finger, which may cause the fin- get to get caught when the patient is trying to place the hand in a pocket, and examination may show an abducted posture of the small finger (Wartenberg's sign), both due to weakness of the third palmar inter- osseous muscle, Examination usually discloses weakness of ulnar innervated hand intrinsic. Not all intrinsics are necessarily involved to an equal degree; dorsal interosseous is the most commonly affected, firstCHAPTER 46 | PERIPHERAL NEUROANATOMY AND FOCALNEUROPATHIES — ETE] ‘Weakness of the adductor pollicis interferes with thumb adduction; impaired adduction is often tested by trying to elicit Froment’ sign. The patient is asked to hold a piece of paper between palm and thumb, and the examiner attempss to withdraw it With weak thumb adduction, the patiene will sub- stitute the flexor pollicis longus and flex the IP joint of the thumb, Wealeness of the FCU andlor the FDP to the ring and small fingers reliably point to an clbow lesion. However, the wlnar forearm muscles are frequently spared in UNE, cal, or even electromyographic, abnormality in these muscles in no way exchudes a lesion at the elbow Non-ulnar innervated hand and forearm muscles should be systematically assessed in suspected ulnar neuropathy. Weakness of non-ulnar muscles is the asa clue to disease involving che lower BP or C8 root. In the elbow flexion test, the elbow is held fully Rexed and pressure applied just distal to the alnar groove to elicit paresthesias. A variant is to hhold the elbow flexed and the wrist flexed in ulnar deviation, The lumbricals flee the MCP joints and extend the interphalangeal (IP) joints. The lum- brricals for the ring and small fingers are normally supplied by the ulnar nerve and those for the index and middle fingers by the median. In ulnar lesions, anopposed extensor tone at the fourth and Sfth MCP joints and unopposed flexor tone at the IP joints produce the ulnar griffe or claw deformity (Figure 46.7). Clawing varies, depending upon the amount of muscle weakness, the laxity of the 10 the lack of clini- MCP joints, and the level of the lesion. A “low” (distal) ulnar lesion with preserved function of the FDP induces more clawing than a “high” (proxi- mal) ulnar lesion, where the accompanying FDP weakness creates less of the unopposed flexor pull deforming the ring and small fingers. ‘The term benediction hand (hand of the papal benediction, papal band) is sometimes used to refer o an ulnar iriffe with che hand at rest and sometimes to a high median neuropathy when the patient is attempting to make a fist. The hand posture is somewhat simi- lar in that the ring and small fingers are Alexed and the index and middle fingers are not. Usage favors median neuropathy in the neurology literature and alnar neuropathy in the nonneurology literature. TThere is conjecture that a medieval pope had chis hand deformity, and his successor learned it as the proper hand position for blessing the masses, pass- ing it down as tradition, FIGURE 46.7 Motor ad sony charges in 2 lesion of he ur neve A. View oan of thhans Parapet. Obi view Ulnar sensory loss is usually easiest to establish ‘over the distal ewo phalanges ofthe little finger, as this autonomous zone of the ulnar nerve. Sensory abnormality is more often observed for tactile as‘opposed to pinprick and thermal sensations; ‘wo- poine discrimination and abilgy to feel eextures and lighe touch may constitute the most revealing tests (On the volar finger surface, the median and ulnar distributions usually splie the ring finger, and such splitting furly reliably excludes plexopathy and radic- ulopathy. However, in about 2096 of cases, the ulnar nerve supplies the entire ring and ulnar half of the middle finger or only the small fnger. The DUC sup- plies the dorsal skin over the ffth and the ulnar half ‘of che fourth metacarpal, and the same area of the fourth and fifth digits. The palmar cutancous branch supplies the hypothenar eminence. There are many variations ofthis sensory distribution, The cutaneous field of the ulnar nerve does not extend more than 4 few centimeters proximal to che wrist crease. The medial antebrachial cutancous nerve (medial cutane- ‘ous nerve of the forearm) arises as a separate branch from the BP and travels with the ulnar to just above theulnar groove, where itdiverts to run anterior ME tosupply the skin of che medial forearm; invalve- ment of this distribution excludes UNE. Impaired sensation over the dorsum of the hand establishes the location of the lesion as proximal to the takeof? of the DUC, but sparing of the DUC terzitory does not exclude UNE because of possible selective sparing of its fascicles, Involvement of the palmar cutaneous branch distribution likewise suggests a lesion proxi- mal to the distal forearm, Impaired elbow range of motion or valgus deformity strongly suggests UNE. Reproduction of symptoms with elbow flexion and ulnar groove pressure can be informative. Examining for subluxation is seldom helpful, a tisis a common phenomenon in normal individuals. Ulnar nerve lesions can also occur at several sites othe in the distal forearm and hand. Compression most frequently occurs in the palm or wrist (ulnar neu- ropathy at the wrist [UNW]), but involvement in the forcarm and isolated lesions of the DUC branch (handcuff neuropathy, pricer palsy) have also been reported. The clinical presentation of UNW depends ‘on which Bbers are compressed. IF the lesion affects the main ulnar nerve at che wrist and all its branches, the clinical syndrome will closely resemble an UNE. However, examination will show normal sensation in che DUC distribution and no weakness of the ECU or FDR. The more common presentation of UNW involves the deep palmar branch alone or the deep palmar branch in conjunction with branches to the hypothenar muscles. In these cases, sensation will be normal. This pattern occurs in 75% SECTION || THE AUTONOMIC AND PERIPHERAL NERVOUS SYSTEMS of patients with UNW. Patients present with pain- less weakness and atrophy of ulnar intrinsic hand muscles, sparing sensation (another Ramsay Hunt syndrome). Motor neuron disease is often suspected because of the complete absence of sensory loss ot symptoms, The branch to the palmaris brevis muscle arises proximal to Guyons canal. The palmaris bre- vis siga is wrinkling of che hypothenar skin on small finger abduction duc to contraction of the palmaris brevis it reli Pseudoulnar neuropathy refers to isolated hand ‘weakness in an ulnar distribution duc toa lesion of the contralateral angular gyrus. Pseudoulnar sensory loss can also occur with contralateral hemispheric lesions. indicates the lesion is atthe wrist The Radial Nerve TThe radial nerve arises asa direc co posterior cord of the BP, It exits through the axilla and then runs down the medial aspect of the upper arm, Jus after passing the teres major muscle, it enters the triceps muscle. At about the mid-upper arm, it curves around the mid-humerus in the spiral groove. Branches innervating the long head of the triceps muscle aise before the nerve enters the spiral groove: those to the medial and lateral heads frequently arise in the groove. The nerve pierces the lateral intermus- collar sepeum, and chen descends through the lateral aapper arm, giving off a branch to the brachioradia- lis muscle, Ie runs between the brachialis, to which i sends an innervating branch in many individuals, and brachioradialis muscles just anterior to the lateral cpicondyle and then enters the forearm in the groove between the biceps tendon and the brachioradials, Innervating twigs are given off to the brachioradia- lis and the extensor carpi radialis longus and brevis (ECRB), after which the main trunk terminates by dividing into the posterior interosseous nerve (PIN, deep motor branch) and the superficial radial nerve. TThe superficial radial nerve descends along the lateral aspect ofthe Forearm; however, ie does not supply the skin in this region, which is instead supplied by the lateral antebrachial cutaneous nerve. The superficial radial branch terminates as sensory fibers that sup- ply the radial aspect of the dorsum of the hand and the radial three and one-half digits. At its takeoff, the PIN sends a branch to the supinator muscle and then passes over the fibrous edge of the ECRB and chrough asic in the supinator muscle (the arcade of Frohse),2 potential site of compression, It continues along the interosscous membrane supplying the extensor carpi alnaris, extensor muscles of the fingers and thumb, ation of thechneTER ss | PERIPHERAL NeuROHNATOMY ANDFoCALNeUROPATHES [EE and the abductor pollicis longus; it has no cutaneous sensory component. "The radial nerve may be injured anywhere along its course (Figure 46.8). In the auilla, ie may be trau- matized by crutches (triad neuropathy), shoulder dislocation fractures of the humerus, or penetrating Deep branch FIGURE 46.8 Carmen injuries, Severe radial nerve injury may occur due to the “windmill” pitching motion of competitive sof ball, Radial nerve “entrapment” in the upper arm at the lateral head ofthe triceps muscles may occur after ‘continuous repetitive arm exercise with sudden force- ful contraction, ot inary tote rad noes diibuton ofsensxy ls wit ara nae lesanEM) secon | Acute compression of the radial nerve in the spi- ral groove results from sustained compression over a period of several hours during sleep of a drug- or alcohol-induced stupor ("Saturday night” or “bride- ‘groom’s” palsy). Radial neuropathy at this level has also been reported in soldiers due to kneeling in AUTONOMIC AND PERIPHERAL NERVOUS SYSTEMS the shooting position. Weakness involves all mus- cles distal to the triceps. The most prominent com- plaint and finding in radial neuropathy is wrise drop (Figure 46.9). There is weakness of finger extension at the MCP joints. Extension of the IP joints is pre- 1 is carried out by the served because this mover: FIGURE 46.9 A. Wit hop seonday tral nov pal. B.Sonsoy df in tisnstare los the stated aes aly‘CHAPTER 46 | PERIPHERAL NEUROANATOMY AND FOCAL NEUROPATHIES Jumbricals and interosci. Confusion commonly arises on two points: (a) Because of mechanical fic tors, the interosci cannot exert normal power in the face of finger drop and may em weak—the patents thought wo also have ulnar neuropathy; and (b) weak- ness of thumb abduction occurs duc to dysfunction ofthe radial innervated abductor pollicis longus—the patient is thought :o also have median neuropathy. If the lesion is above the branch tothe brachio- radials, there i weakness of Bexion of the semipeo- nated forearm. In a lesion still higher, there is also involvement of the triceps. Sensory loss is variable and oficn minimal because of overlapping of eutanc- cous nerves (Figure 36.3). he involved area is usually limited tothe dorsum of the thumb, although it may jnvolve the dorsum of che radial half or swo-thieds of the hand, the frst inccrosseous space and the index finger, and the dorsum ofthe adjacent proximal pha- langes. Trophic changes are minimal. The triceps and brachioradilis elexes may be lost. The primary dif ferential diagnostic considerations include C7 radicue lopathy, PIN palsy, and lesions involving the midale teunk ot posterior cord of the BE. The radial nerve is particularly prone to involvement in systemic vsculi- ts, Pscudoradial nerve palsy is weakness in an appar- ctl radial dsttbution duc to a cerebral hemispheric lesion. A lesion of the PIN causes weakness of fin: ger extension (finger drop) without wrist drop (Figure 46.108). Compression may occurat the arcade of Frohse or within che supinator upinator chan!) cher etiologies include penetrating injures, facture, suse of Canadian (Forearm) crutches, local masses, and ‘cension ston’ lat anc ‘overuse syndrome in athletes, musicians, and uphol- sterees The wrist deviates radially on extension because of weakness of the PIN-innervated extensor carpi ulnars with preservation ofthe main trunk-innervated cexcensor carpi radials longus (Figure 46.108). ‘The supinator may or may not be involved. Some fingers may be affected more than others; mos often, the ring and small fingers are selectively dropped, producing 4 posture that superficially resembles an ulnar griffe (pseudoulnar law hand, Figure 46.114). A selective ‘thumb drop may occur (Figure 46.11B). Occasionally, cervical adiculomyelopathy will selectively drop the Fing and small fingers (Ono's hand, myelopathy hand, pscudopseudoulnar claw hand, Figure 46.114). A PIN lesion causes no eutancous sensory changes, but as with AIN paly, there may be pain cartied by aferent fibers innervating joints. Rarely, focal myopathy of the forearm extensors may mimic a PIN lesion. Selective vulnerability ofthe posterior interossous fascicles in revobumeral radial neuropathy may cause confusion with a PIN lesion. Neuropathy of the superficial radial nerve will cause pain and alterations of sensation in its distribution (Wartenberg’s syndrome or cheiralgia paresthetica); i may be injured by eight bands around the waist (handcuff neuropathy). ‘The radial tunnel syndzome (RTS) is a dubious entity allegedly due to compression of radial nerve branches in a nebulous anatomical passageway vari ‘ously sid to consist ofthe brous edge ofthe ECRB, distal border ofthe supinator muscle, or ibrous adhe- sions between the brachials and brachioradalis. The contention is that nerve entrapment causes chronic lateral elbow pain in the absence of any objective FIGURE 46.10 Pestwroinrosaousnouopaty causing (A) rer cop without wrist rp ard (Badal eoviton on wristEE] secrion | Tae auronomic ano PERIPHERAL NERVOUS SYSTEMS FIGURE 46.11 Ps ior itosseous rauopatiy causing slate frgrdop (A) irohing primarily tho fourth nat frgers (eseacounar claw) ant (8) ving primary the rb ard indexing neurologic dysfunction. Descriptions of clinical man- ifestations of RTS in the surgical literature are often identical ro descriptions of lateral epicondylitis, LOWER-EXTREMITY NERVES The Lumbosacral Plexus ‘The nerves innervating the lower extremity and hip region arise from the LSP, which is in fact ewo plex, ‘even three ifthe coceygeal plexus is counted as a com- ponent (Figures 46.12 and 46.13). The lumbar por- tion of the plexus originates from the anterior primary rami of L1-L4, It ies in or just posterior to the psoas muscle. The himbar plexus lies within the substance of the psoas major muscle. The L4 and LS roots give rise to the lumbosacral trunk, which joins the lumbar plexus to the sacral plexus. Roots from S1-S3 join the lumbosacral trunk co complece the plexus; the sacral portion lies along the posterolateral wall of the pelvis, between the piriformis muscle and the major vessels ‘The major motor nerves arising from the LSP are the femoral, obturator, sciatic, common fibular (pero- neal), tibial, superior gluteal, inferior gluteal, and pudendal. The major sensory branches are the siphe- rows, a continuation of the femoral nerve, the iliohy- pogastric, ilioinguinal, genirofemoral, and the lateral femoral cutaneous (LFC) nerve, which arises from the lumbar plexus, courses around the pelvic brim, and exits beneath the inguinal ligamene adjacent to the anterior superior iliac spine. Conditions affecting the LSP include diabetes, neoplasms, retroperitoneal hemorthage, and postradi- ation plexopathy. Diabetic lumbosacral radiculoplexas neuropathy (diabetic amyotrophy) is common: it causes a syndrome of pain, proximal bilateral but usu- ally very asymmezric leg weakness, and weight loss, Neoplasms may metastasize to the LSP, or directly invade it, and radiation therapy given as treatment for the tumor may itself damage the plexus. Whether there isa primary, spontaneous plexitis affecting the SP analogous to the entity of NA of the BP has been a matter of conjecture. Hemorrhage into the psoas muscle, a feared complication of anticoagulation, may severely damage the ISP. The Femoral Nerve The femoral nerve is the largest branch of the hambar plexus, It forms within the belly of the psoas muscle from the posterior divisions of che anterior primary rami of the L2-L4 roots, Leaving the cover of the psoas, it runs berween the psoas and the iiacus mus- cle and exits from the pelvis beneath the inguinal liga- _ment, lateral tothe femoral vessels. ts motor branches innervate the psoss,iliacus, sartorius, pectineus, and quadriceps muscles, Its sensory branches, the inter- mediate fanterior) and medial femoral cutaneous nerves, innervate the skin of the anterior thigh. The femoral nerve terminates as a large sensory branch, the saphenous nerve, which supplies an extensive ccataneous field along the medial aspect of the lower leg and the medial aspect of the foot. TThe femoral nerve may be involved in pelvic rumors, psoas abscesses or hematomas, fractures of the pelvis and upper femus, ancurysms of the femo- ral artery, and penetrating wounds; it may be affected in diabetic mononeuropathy and injured during labor or abdominal or pelvic surgery (Figure 46.14). A substantial number of femoral nerve palsies areCHAPTER 46 | PERIPHERAL NEUROANATOMY AND FOCAL NEUROPATHIES Noinguinal nerve = Lateral cutaneous, rere of thigh Genitotemoral nerves --" Femoral nerve --Lumbosacra FIGURE 46.12 Constituents fh unter pls. iatrogenic, from the lithotomy position or surg cal trauma, Femoral neuropathies may result from stretch asa resule of hip hyperextension (ce banging leg syndrome below). Femoral nerve motor dysfunction always causes impairment of kace extension, Walking forward and Gimbing stairs is dificult, alehough the patient may walk backwaed with ese. The patient may walk hod ing the knee sti, and ifthe knee bends, the patient say fll. Involvemene within the pelvis or abdomen may also affect che function of the psoas major, caus ing weakness of hip flexion, Femoral nerve lesions impair the patellar reflex and cause sensory loss over the anterior and medial aspects of the thigh and the medial aspect of the leg. The Obturator Nerve This nerve arises from the lumbar plexus from the anterior divisions of the anterior primary rami of L2-LA. Ik supplies the adductor muscles of the thigh, the gracilis, and the obturator externus and transmits sensation from a small area on che medial aspect of the thigh. Obturator lesions are rare, but when they ‘occur, there is weakness of adduction and external rotation of the thigh, with a small area of anesthesia er surface of the thigh. Causes include ‘orthopedic, gynecologic, or urologic surgery or injuries; obturator hernia rarely diabetes over the liopsoas hemorrhage; and The Lateral Femoral Cutaneous Nerve “The LEC is a sensory nerve formed by the poste- rior divisions of the L2-L3 anterior primary from the skin of the anterolateral aspect of the thigh. Pain, paresthesias, and loss in the distribution of the LFC (meralgia pares- thetica) are a very common clinical syndrome, The nerve probably becomes entrapped where ie passes rami, ItFIGURE 46.13 Constituents under or through the inguinal ligament just medial to the anterior superior ile spine, or where it pierces the fascia lata. Precipitating causes include weight ‘gin, prognaney, ascites, trauma, pressure by a belt or other tight abdominal garment, and possibly diabetes mellitus. The primary differential point is to exclude aan upper lumbar radiculopathy. The Sciatic Nerve The lumbosacral trunk arises from the lower part ‘of the lumbar plexus and fuses with elements of the sacral plexus to form the sciatic nerve. The sciatic, superior gluteal, and inferior gluteal nerves al exe the pelvis through the greater seiatc foramen. The sciatic usually exits beneath the piriformis muscle but may pierce it or rarely pass above it. The nerve courses in close proximity tothe posterior aspect ofthe hip joint and then enters the thigh. In its course through the thigh, it innervates the hamstring muscles and also sends a wig to the adductor magnus, SECTION || THE AUTONOMIC AND PERIPHERAL NERVOUS SYSTEMS posterior Sciatic nerve {common peroneal snd tial ha sca plows From its beginnings, the sciatic nerve is made up of two divisions: the fbular (peroneal, lateral) and the tibial (medial). The tibial division arses from the anterior divisions of the LSP, and he peroneal, from the posterior divisions. The pert gether in a common sheath, forming the sciatic nerve, until the level of the knee where they divide and pursue separate courses. The only portion of the hamstring muscle mass innervated by the pero- nal division isthe shore head of the biceps femoris: all other hamstring muscles are innervated by the tibial division. ‘Aficr the bifurcation in the popliteal fosss, the peroneal nerve moves laterally and winds around the fibular head (FH) and then descends toward the foot. The tibial nerve descends in the midline down the posterior aspect of the log to innervate the gas- troroleus, In its proximal course, it gives off a sural communicating branch, which joins it fellow from the common peroneal nerve to form che sural nerve seal and tibial divi-chneTER 6 | PERIPHERAL NeuRanWATOMY ANDFoCALNeUROPATHES ESI FIGURE 46.14 Corman star for ‘uy wo ‘the femoral rave ard distribution of sersory Tess witha lesan of te fomerl rae ard ts Iranhes |. Anterior tomaral = Saprencus nerve ~~EE] secrion | Tae autonomic ano PERIPHERAL NERVOUS SYSTEMS proper. The sural then moves laterally asi rans di tally, pierce cia to emerge into a super- ficial posivion about 15 em proximal to the lateral malleolus, and then curves around and beneath the lateral malleolus wo supply the skin of che lateral aspect of the foot and toes. Distal passes beneath the medial malleolis, und retinaculum, which forms the roof ofthe tarsal un- nel. The tibial nerve terminates by dividing into the medial and lateral plantar nerves, which innervate the abductors and shore flexors of the tes and supply sensation tothe skin of Injury to the main trunk of the sciatic nerve may reult in weakness of both the common pero- neal and dbial innervated muscles, but often, the deficit involves predominantly or solely one division, most often the peroneal. Hamstring muscle weake ness clearly indicates that the lesion involves che main sunk of the sciatic nerve. When the deficit is imited to the peroncal division, the only way to prove the lesion involves the sciatic nerve rather than the pero- neal isto demonstrate abnormality inthe shore head of the biceps femoris by needle electromyography. With complete sciatic lesions, sensory loss involves all but the anccromedial aspect of the leg (caphenous distribution). Knee flexion is grea impaired, the only muscles participating in his movement being the sartorius and grails, Flexion and extension ofthe ankle and toc joints and inver- son and evecsion ofthe foot ae lost. The patient can- not stand on cither heel or tes. Tophic disturbances and neuropathic pain ae frequent. The sciatic nerve may be injured in pelvic fac tures, hip fracture oF dislocation, total hip arthro- plasry and other orthopedic procedures on the hip, insraglateal injections, gluteal hemorrhage or com. partment syndrome, and penetrating wounds, It may be entapped by heterotopic ossification or impinged by a methylmethacrylate spur. The nerve may be compressed by prolonged siting in the lotus posi tion (lotus neuropathy) or prolonged pressure from a toilet seat, both termed “another Saturday sight palsy” In the hanging leg syndrome, sciatic n thy, with accompanying femoral neuropathy, devel ‘ops fom having the legs hanging off the bed wi hips hyperextended while intoxicated oF in coma The piriformis syndrome is sciatic compression by the c asic exits the pelvis. The cstence of this syndzome is controversial, Exteral compression ofthe nerve in the hip may occur with pressure duc toa fat wallet or eoins ora pistol in the tibial nerve «the flexor 1 sale formis muse hip pocket (pistol packers palsy). Such instances do not qualify 2s pisiformis syndrome, Ina series of 380 patients with sciatic nerve injuries, 6096 were at the buttock level and 409% were in the thigh. Injection injuries made up more than half of the buttock level cases. In future case series, the incidence of injection injuries is likely o fll dramatically due to the advent of patient controlled anesthesia Common Peroneal Neuropathy at the Fibular Head ‘The primary root origin of the peroneal nerve is L5, with lesser contributions from LA (primarily to the tibialis ancerior) and from S1 (primarily to the small foot muscles). Afier traversing the LSP the peroneal joins the posterior eibial nerve to form the sciatic nerve In the mid-thigh, the peroneal division sends a twig to the short head of the biceps femoris. Just distal wo the sciatic bifurcation, the common pero neal gives off its sural communicating branch and the lateral cutaneous nerve of the calf, which sends sensory innervation to the lateral lower leg. The common peroneal nerve then winds around the FH, pierces the peroneus longus muscle (the “fibula tun nel’), and divides ineo superficial and deep b (Figure 46.15). The superficial branch innervates the peroneus longus and brevis and terminates as the superficial sensory branch, which provides sensation to the dorsum of the foot (Figure 46.16). The deep peroneal branch innervate the tibialis anterior, pet foneus tertius and long and short toe extensors, and provides sensation to the web space beeween the fist and second toes. An accessory peroneal is a common anomaly, affecting about 20% of the population: the branch arises fiom the superficial peroneal, passes behind the lateral malleolus, and innervates the lateral portion of the extensor digitorum brevis Common peroneal mononeutopathy at the fibular head causes weakness of dorsiflexion of the foot and toes and weakness of ankle eversion. Severe peroneal neuropathy causes a foot drop. Sensation is lost over the dorsum of ‘The peroneal nerve atthe FH is superficial, cov cred only by skin and subcutaneous tissue, making it exceptionally vulnerable to external compression. The nerve is also tethered a its point of passage through the peroneus longus muscle, making it susceptible to stretch as wel, Habitual leg crossing is classical cause of common peroneal neuropathy atthe fibular head (CPNFH). Occasionally, askin dimple marks the precise site of compression. This type of CPNFH is foo.cuneren | PERIPHERAL EUROANATOMY AND cL NeuROPATMes ETH Common peroneal nerves, __ Deep peranes! nerve FIGURE 46.15 Corina sites fori ote peroneal nerve ad istrton of sensory oss with peroeal nen lesion particularly common in slender or depressed patiencs fo those who have recenely lost weight (slimmer palsy). Any number of external forces may substi- tute for the patient's opposite kneecap as the agent of compression, including plaster casts, knee braces, ot ‘tight bandages. In immobile, comatose, paralyzed, or anesthetized patients, an ordinary matress can exert ‘enough force to injure the nerve. Prolonged squat- ting is another common cause of CPNFH, possibly from a combination of stretch, compression, andFIGURE 46.16 Ds neal vps tion of soso los in a ight conan po kinking —a particular hazard for roofers, carpet lay- zs, women who squat in labor (pushing palsy), and farmers (stawberry picker’ palsy). Sudden, forceful plantar lexion or inversion of the ankle may st the nerve and cause Focal damage atthe point where iis techered in its pasage through the peroneas lon- «gus. CPNFH i surprisingly common in patents with severe ankle injures. Transient foot deop is report caly common in NFL kickers (punters pay). Rare causes of CPNFH include tue entrapment in the fibular nae, Baker’s est, nerve cumor, ganglion, and lipoma. In a study of 318 cases of CPNFH that underwent surgery, 4496 w sion without fracture or dslocation and 7% to stetch ‘or contusion with fac due to lacerations, 9% were duc to entrapment, 4% ‘were iatrogenic injuries, and 4% were duc to gunshot wounds The most common differential diagnostic exer cise is between CDNFH and L5 radiculopathy in che patient with foot drop. The presence of back and leg pain, weakness of foot inversion, postive rot st signs, and depresion of the medial hamatzing rellex favor radiculopathy: The absence of pain, weakness limited to ankle evesion and footitoe dorsifexion, the medial hamstring reflex favor due to stretch or conta: re or dislocation, 12% were ech SECTION || THE AUTONOMIC AND PERIPHERAL NERVOUS SYSTEMS CPNFH. The pattern of sensory changes is rarely helpful Inspection for skin dimple, discoloration corcallus over the FH, percussion co elicit Tine’ sign, and careful palpation ofthe popliteal fossaand FH ace likewise important. In most patients with CPNFH, 4 meticulous history will uncover an explanatory ‘mechanism ehrough external prssute or stretch, In rare patients, sciatie neuropathy, deep peroneal new- ropathy, or lumbosacral plexopathy may simulate CPNFH. A number of generalized conditions may require consideration, especially if for drop is bila cra, including polyneuropathy, motor neuron dis- cas, and several types of primary muscle disease (eg. discal myopathy. inclusion body myositis, myoronic dystrophy, and scapuloperoneal syndzome) The Tibial Nerve The sibial nerve is the leger of the two terminal branches of the sciatie nerve Is formed by a fusion of all ive of che anterior divisions of the sacral plexus (4-82 or $3) Ie supplies the long head of che biceps femoris and the semimembranosus,semiendinosis, gastrocnemius, poplitcus, soleus, plantaris, tibialis posterior, and flexors digitorum longus and hallucs Jongus muscles and, though the medial and lateral plantar nerves, che plancar flexors ofthe toes and the small muscles of the foat. Through the sual nerve, i transmits sensation from the posterolateral aspects of the leg and ankle and che lateral aspecs ofthe heel and foot. Calcaneal nerves supply sensation to the posterior and medial aspocts and phintar surface of the heel; dhe medial and laceral plantar nerves supply the plantar surface ofthe foot. Tf the tibial nerve is injured, there is weakness distal co the lesion, with sensory loss ove the plantar and lateral aspects ofthe foot, the hee, and the poste- rolateral aspects ofthe leg and ankle, The patient may bee unable to planta flexor invert the Foor or 0 flex, adduct, or abduct the tes. eophie changes and pain are common. The Achilles reflex is lost. Tibial nerve injuries are relacvely infrequene because of ics deep location and protected course, bur ic may be involved in lesions in or below the popliteal space. Eriologies of tibial neuropathy in the popliteal fossa include teauma, specially when associated with hemorthage, synovial (Baker3) gst, ineancural ganglion, nerve tumors, idiopathic hypertrophic neuropathy, and entrapment by a rendinous arch at the origin of che soleus muscle or by fibrous bands berween the heads of the gastrocnemius muscle. Popltel fossa lesions cause pain and tenderness and a posiive Tinel’sCHAPTER 46 | PERIPHERAL NEUROANATOMY AND FOCAL NEUROPATHIES sign in che popliteal fossa, helpful in distinguishing clinically from tibial nerve compression at the ankle and from $1 radiculopathy. Proximal main erunk tibial neuropathies are most often due « ischemia Compression by the Aexor retinaculum behind the medial malleolus (lancinate ligament) may cause burning pain and sensory loss in the toes and sole of the foot and paresis or paralysis of the small muscles of the foot (tarsal tunnel syndrome (TTS). TTS is sometimes seen as che lower-extremity analog of CTS and the diagnosis made to explain pain of no other apparent origin even in absence of any neurologic deficit, for which division of the lancinace ligame say be ped uted to tenosynovitis of the long flexor tendons, bony prominences in che tunnel, ext: poor shoes, stretch injury with ankle sprain or dis- location, and space-occupying lesions (lipoma, vari- costies, ganglion, anomalous muscles). Patients may have sensory symptoms provoked by weight bearing and relieved by rest. Physial findings are few. There is seldo In bona fide TTS, chere may be sensory loss over the sole, especially in the medial plantar distribution, usually sparing the heel (caleaneal branch); tender- ness behind medial malleolus; and a Tinels siga over the tarsal passively holding the ankle maximally everted and dorsilexed with che tocs pulled up to elicit paresthesas, is sid to be useful. Rarely, individual nerve branches may be damaged in the foot. Medial plantar neuropathy has been attributed to compression a fibromuscular tunnel behind the naviculartuberos- distal tothe tarsal tunnel, Selective lateral plantar nncuropathy has aso been described. med. The condition has been atsib- al trauma, if ever, weakness of inerinsic foot muscles, rane. A test similar to Phalen' the entrance to Other Lower-Extremity Nerves Focal neuropathies occasionally involve other nerves. The iliohypogastric nerve arses from L1 and is mainly sensory. It supplies the skin of the gluteal region and the hypogastric region, just above the symphysis pubis. The ilioinguinal nerve i also a branch of Ll Like the iliohypogastric nerve, itis mainly sensory, innervating the skin ofthe upper, medial thigh, upper part ofthe root of che penis and che seroeum in the sale, and che mons pubis and the labia mara in the female. The genitofemoral nerve arses from L1-L2. le supplies ehe eremaster muscle and transmits sensa- tion from the skin of the scrotum of labia and from a small area on the upper thigh. The posterior femoral ‘cutaneous nerve arses from ior divisions of| the post S1-S2 and the anterior divisions of S2-S3. It rans- mits sensation from the posterior aspect of the thigh and upper leg. Its gluteal branches supply the skin of the lower gluteal region; the perineal Branches are dis- tributed to the upper and medial aspect ofthe thigh; the inferior pudendal branch supplies the skin of the perineal region rogeth and the labia majora in the female, Lesions of these nerves may cause pain and loss of sensation in their areas of distrib TThe superior gluteal nerve arises from the pos- terior divisions of L4-S1 and innervates the gluteus medias, gluteus minimus, and tensor fascia cles, The inferior gluteal nerve arises from posterior divisions of L5-S2 and innervates the gluteus maxi- mus. The pudendal nerve arises from the anterior divisions of S2-S4 and exits through the lesser sci- atic foramen. It has three major divisions. The infe- rior rectal (hemorrhoidal) nerve is distributed to the ‘external anal sphincter and to the skin and mucosa about the anus, The perineal nerve divides into dcop (muscular) and superficial branches, The deep branches supply the bulbocavernosus, ischiocaver- rrosus, and other perineal muscles, together with the ‘external urethral sphincter; the superficial branches form the posterior scrotal (or labial) nerves that erans- mit sensation from the scrocum in the male and the labia in the female. The dorsal nerve of the penis (or clitoris) supplies the corpus cavernosum and the skin and mucous membrane of the dorsum of the penis (or clitoris), including the glans. The pudendal nerve also eransmits sensation from the bladder, sr with the scrotum in the male BIBLIOGRAPHY AL Qastn MM, Roberton GA. Pat anes interrsoue nerve syadiome:a ease prt. J Hend Sig Am 1931844042, Almeida DE, Seromin L, Zanga $8, eal Fool conduc in act of tare tanned stone, Mice Nowe 452-455, Aniscye ® Clak D,PusoasB, et lel sts for eupal wn el syndrome in contemporary pracce: Arb Orlyp Trae Surg 2011 131:471-474 ‘Anco C,Aradhys Clinical diagnose of peripheral nerve com Presion in the upper excemiye Ortop Clin North. Am 1996327-227-236, Bama J, Kev L. valtion and weaement of peroneal ne repathy. Chor Re Mekelet Med 2008; 1147-153, Bhanusha MY, Muley SA Disheicand ponies lmbosca radiculoplesneropathy. Nerf India 2008 56:420-425, Boonypist K, Kati. Matifocl moor neuropathy presenting ‘th repay ule, Mule Mere 2000231887 1890Borchel GH, Cate FM, Obsetrical brachial pens pally. Plt Recma Sarg 200912411 Sapp Ve 155 ‘Brars PW Mae JC, Bier J Localization in Clinical Nearly, “the. Philadelphia: Wolters Kluwer, 2011 Brown WE, Wason BY, AAEM cis icpore #27: acute roe Tuer radial neuropathies, Mae Nowe 1993;16706-711 Burnham RS, Stadwand RD. Uppesextemity pipet nerve ‘hrspments among wheelchair shies presence, locaton, nd ek com Ach Phys Med Re 1994753519 524 Busi NA. Femoral and obrurtor ncuopathien, Nowra! Cin 19917-638-653 Buzznd EF Some varices of taumatic and woxic ulnar newts ane 1922199:317-319, {Campbell WW. Dignoss and management of common com: Pression and entrapment neuropathies Neal Clin N Am 1997115549-567, Campbell WWW. Treatment and mangement of segmental ne romucul dieder. Ine Berorias TE, eck Newvmucalar Disondons Trent and Management, 1s od. Philp Eleviee Saunders, 2011 ‘Campbell WW, BuschbacherR Pigeon RM, eta: Seesve fe drop in cervical adcalopathy: he psedopseudoular caw Brand Mase Nee 1995:18 108-110, (Campbell WW, Landau ME. Controversial entpmentnetopa- ‘his, Newser Clin N Ae 200819597. (Cenato P Lensnt A, Baia C eal. Dacula sesory asia 2 pant fom a anal onal infer of dhe postenel knob ‘Nearly 2005,64:1981-1982, (Chaioe 2 RagorF Ahir Hea Focal neurological complica vionsofhandeuappiation J Foren So 2001;46.1124-1125 Davide J, Bast FHI, Nenley JA. Masulcsrancous nerve Coeapment eiated. Shuler How Surg 19873250258, Damost DM. Eatnpmese neuropathies of the per extent, 1 Bg J Med 1993;3292013- 2018 Dawion DM, Halle M, Wilbouta AJ, eds. Enirpment Neaopai, ede. Philadelphia, PA: Lippincore Willams 8 ‘wikis, 1999. Dramis A, Pimpainrar A. Suprasspur neuropathy in voll players Ase Ore Bel 2005;7:289-272, England JD. Enespment neuopathien Carr Opin Newel 199912:597- 602. Exdem §, Demi M, Ta E Foc myopathy mimicking poor intersseous nerve syndiome. Muse Nove 2001;24969-972, {Gopaa SK, Benscead 7). Synpeoms experince by ptens with ‘apa cunnel syndrome, Gn J Newel ei 1997:26338-302, Hinchey JA, Preston DC, Logiginn EL. Ilopathic himboss ‘al neuropathy a caus of prsiten leg pain. Mase Nome 1969-1484 1486. Hopkins AA sore cause of a presue play: mobile tle hone user shoulder droop. 7 Neral Newonrg Pye 199661:346, ‘shag S; QuinetR, Saba J. Phrenic nerve pralss secondary to Tyme neuroborelos Neral 2002:5 1810-181 Iyer VG. Paimaris Seve sgn im lar neeopachy 1998, Mace Nerse 199821675 677, Jjecde KA. Neulogje manifestation of neoplastic and maaton- induced pleopathis, Semin Newel 201030254262 Jamieson WG, Chissck B. Thoncic oule sydiomefct or Fancy? A review of 409 conscutne patients who underwent ‘petaon. Ca Sur 199639321-326. Kayppa LI, Vastarald M, avogenie ett anterior puis Long-term outcome in 26 paints. Chas 1996;109.31-34, Kim DH, Maric JA, Tiel RL ea. Management and outcomes ‘OF 42 sunpclsapasapalar nerve injures and encapments, Nearoargey 2008:7120-127 SECTION || THE AUTONOMIC AND PERIPHERAL NERVOUS SYSTEMS Kim DH, Morove JA, Tiel RL, etal. Management and out come in 318 operative common peroneal nerve loons a the Louisiana State Univesity Health Scenes Conte. Newer 2004;541421-1428. ‘iagawa R, Kim D, Reid N, eal Sui mangement of obtu- ‘ator ere lesions. Nearer 200965(4 Suppl: A26-A28, ola, Nicol V,Tegentho® M. Sopratcaplar nerve nap ‘ent in acanoi. Ar Newel 200653781 Kopll HP, Thorpron WAL. Peripheral Enoapment Newpathi, 2d ed. Huncingion: Robert Keiget, 1976. emneuky L, Linden D, Beat P Bist sciatic serve "Saturday ight ply" J Newel 2001-248:425, Kamat N;Foges WN, etal Dygpes at the predominane mani= feation of bill phrenic neuropathy Mayo Clie Pre 2004;791 365-1365. lahmann H, Grol W, Autier Fetal. Neue amy otopiy with phrnie acre invekement. Mule Newe 999.22437-402 1ajaiG, Phremann CW, Aizemuller G, etal The shoulders of ‘profesional beach vleball layers: high prenlence fifi ‘pinaus muscle atrophy. Am J Sports Med 2009:37:1375-1383. Levin KH, Common focal mononesropsthies and thst lestrod agnois. J Clin Newophyol 199310181-189. Lin PT, Anderson P8, Disa BJ, al Batra elated phrenic esiopatlyextang penn biel pega pels ‘Naaaig 200565:1499-1501 Legian EL, Buss NA, Bayer AR, eta. Lumbvcl sparing in ‘up une syndrome: anatomic, physiologic, and dagnosic implcacons. Newly 1987:37:1498-1505, late HG. Cri cad wales ciate. JAMA 19783240738. “Mataglis FL. Mascloctancous neuropathy afer trees phy telat: Mad J Aa 1986148:133-194 Masagin FL. Tibial nerve entrapment in the popliteal fos. ‘Male Neve 2000:25-1885-1886 ‘Masala FL, Vener Stokes BA eal. Compression ofthe bi ‘nerve bythe endinous arch of rg ofthe soleus muscle. Clin Esp Near! 1981,1881-85, ‘Mond M,Cion R Federico A. Rare mononesropthics ofthe ‘per limb in hodyulder. Muscle Nee 199821809. 812 Miler RG. The cabal tunnel syndrome: diagnose and preie lnclzation. An Newa 1979656-59. Nakano KK. Nere entrapment syndrome. Ger Opin Rha 1997:9165-173. Nord KM, Kapoor Piss} eal: Fale postive ate of thoracic Tulet syndme ciagnoaic maneuvers Hlcomogr Clin ‘Nearaphya! 2008:18857-74 (Oien Md to the examination af the prphral neous tom, Sehed, Landon, UK: Saunders Have 2010 (OFerall EK Busche K DishollP,ta A paen with ilar sciatic newopathis. Cf Newel Se 200734365 367. Ob SJ, Lee KW. “Medial plantar neuropathy. Newolag 1987:37:1408-1410, Trladai D, Delantonio R, Cit A, et a, Asry neuropathy In oleball players: repo of ro cases an erature reves. J Newel Newosun Pychiary 199660 345-347, Dann Jv Mal N Hayek S, eal Merlin Patechese. Pain Pract 2011 1:303-308 let AB, Maney EW. Palmare bovis sign in neuropathy of the deep palmar bratch of the ulnar ner. nn Neal 1978:3:468-469 Robinson LR Henderson M, Handcuff ncuropahyinvolng the ows ulnar cuancous nerve. Mise Nese 199417.113-116, Rorenbauim RB, Ochos Jl. Capel Tame! Syndrome and Ocer ‘Dierden of the Median Nome, Bown, Mat Buserworth. Heineman, 1993.‘CHAPTER 46 | PERIPHERAL NEUROANATOMY AND FOCAL NEUROPATHIES Scher K, Skeen MB, Stine SA, etal. Hanging log ridome: ‘combined Hata fmol and sce neupethies. Newly 2006,66:1124-1125. Sdyataman R). Dirt Digna in Newey. Assan 108 Pas, 2006, Scot B Serr R. Meal paresthei: ini and eleewophys- ‘logical dagnoisin 120 cases. Made Neve 2006:3:650-654, Shupito BF, Prawon DC. Eneapmene and compresive nerops ‘ic. Med Clin Noh Am 2003:87683-696, Shira WC, Lin JC, Chang MEK, ctl. Compre rail ace paey “ndaced by sary shooting sii? cnc and eeecopl ogi study. J Newel Newsy Pacha 199356890-893. Sion G,Zaget EL, Kline DG, Windnl pitcher rail nerops ‘hy. Nearer 199434 1087-1089. Soutkes M,Steart JD, Common peroneal neuopathy: 2 sudy of sete enter and semory invalvement. Newsboy t9ptets1029-1033, Spinner RJ, Amado PC. Comprensive acurpathie of the upper tem. Cl Pla Surg 2003;30135-178 Spinner RP, Tiel RL, Kline DG, Predominant ifsspinaus mus cle weakns in sprascapalr nerve compesion J Newsy 2000.93516. Sevens JC, Smith BE, Weaver A a: Symptomsof 100 patients ith electromyography vecied cipal tunnel syndrome. ‘Maace Neve 19992-1448. 1456 Seren JC, Wie JC, Smith BE etal The quency of apa eas ‘a syndrome in compute wets aa medial fay. Newly 2001:56:1568-1570. Sear]. Foc Pipher Newopahi, Ah od, West Vancouvet ‘Canad: JB} Publishing 2010, StojvieT, de SJ, Hurevent Jf, al Prec nee ploy a= Yeats of chron inflammatory demyelinating padi: eatopthy. Mle Nee 20087397 99. ‘SreibE. Upper arm ail nerve ply fer scala fre: xprt of thee eases: Naralogy 1992342:1632-1635 Subramoay SH. AAEE cue report #14: neue amyouophy {acute brachial neuropathy). Male Nee 1986113944, “Thoma A, Levis C. Compresion neuropathies ofthe lower exten ig Clin Pe Surg 200330-189-201, ‘Thomas JE, Casino TL, Fale JD. Dicrentil diagnosis bere Tadaton and sumor pleopahy of the petra Nearlagy sss: 7, “hue, Feher MD, Rosor MN, Sate nerve damage due co Tot sat enapmene another Saturday aight pl. Newel Nears Psyciar 1989;521118-1115, ‘van Aen N: Clinical and pathophysiologic concepts of neuralgc yorrophy: Nat ew Newel 2011:7:315-322. \Van Slob AM, Bobnen AM, Bernsen RM a Icence res tial decrninats in mela paresthesia in general prac Near! 2006:351:298-297 ‘Westch J. Priet paly. 0 Eng) Med 19853121655, Wilbourn AJ. Thoracic “culet syadiomes.Newal Clin 1999117477497, \Wilbourn A. Plsopathi. Neurol Clin 2007:25:139-171 ‘Wier JC, Stevens JC. Neurolgie doers manquerding carpal funn syndrome: 12 cass of led carpal noel ele. Maya (lie Proc 200075409413. Yeremeyers E, Kline DG, Kim DH. larogenic sciatic neve injuries at buttock and thigh levels the Loulslana State Univenisy experience eviews Naronrger 20086504 Supa AG3-ASG, Vilma C, Hskandai MM, Col M. Taumatic musculocua neous nerepaty: a eae epee. Ach Oryp Trauma Surg 200511251446, ‘Yeen EC, 50 YT, Sciatic neuropathy: Neural lin 199917 ‘617-631