Basic Science

Conference
Nerves & Arteries

Outline

Peripheral nerves: histology &

physiology
Peripheral nerve injury &
regeneration
NCV / EMG basics
Peripheral compression neuropathies
Vascular disorders

Peripheral Nerve
Histology
Neuron:
1. Cell Body
2. Dendrite
3. Axon
4. Presynaptic
terminal

Peripheral Nerve
Histology
Schwann Cells (PNS)

Surround cell body &

axons

Provide support and

nutrition, maintain
homeostasis, form
myelin, and assist in
signal transduction

Make myelin

Physiology

Electrical and
chemical signals
Resting Potential
-normal= -50 to
-80mV, maintained by
Na+/K+ pump
Action Potential
-depolarization
beyond threshold
transmits signal
rapidly

Peripheral Nerve
Cross Sectional Anatomy
Epineurium
Encompasses nerve
and runs between
fascicles
Vascular
Perineurium
Layer that covers
individual fascicles
Tensile strength
Endoneurium
Inner most collagenous
matrix that surrounds
axons within fascicles
Nourish & protect
axons

Traumatic Nerve Injury

Classification
1943: Seddon
Neuropraxia
Axonotmesis
Neurotmesis
1951: Sunderland
Type I- V

Traumatic Nerve Injury

Classification
1st Degree (Neuropraxia)

Interruption of
conduction at site
of injury
Axon preserved
No wallerian
degeneration
Motor fibers more
susceptible to injury
than sensory fibers

Traumatic Nerve Injury

Classification
1st Degree (Neuropraxia)

Large myelinated fibers more

susceptible than fine or nonmyelinated
fibers
Electrophysiologic Studies
NCV slowing or complete conduction block
Fibrillation potentials
Positive sharp waves

Traumatic Nerve Injury

Classification
1st Degree (Neuropraxia)

Complete functional recovery after 1st

degree injuries because axonal
continuity preserved and changes
responsible for the conduction loss are
fully reversible
Full restoration of function may take as
long as 3 to 4 months after the injury

Traumatic Nerve Injury

Classification
2nd Degree (Axonotmesis)

Axon and myelin sheath disruption

leads to conduction block with
Wallerian degeneration
Endoneurium, perineurium and
epineurium intact
Axon regenerates along intact
endoneurial tube

Traumatic Nerve Injury

Classification
2nd Degree (Axonotmesis)

Complete loss of motor and sensory

functions
Complete functional recovery
expected
Time to recovery depends on severity
and level of injury, as axons must
regenerate distally
Usually months to recovery

Traumatic Nerve Injury

Classification
3rd Degree (Axonotmesis)

Axons and endoneurial tube disrupted

Perineurium and epineurium intact
Complete loss of function
Onset of recovery delayed longer due
to more severe retrograde injury to cell
bodies, fibrosis
With longer delays in recovery, target
organs may undergo changes that
prevent full recovery

Traumatic Nerve Injury

Classification
4th Degree (Axonotmesis)

Only epineurium left intact

Nerve in continuity, but extensive
intraneural scarring and disruption of
fascicular structure
Wallerian degeneration
Complete loss of sensory and motor
function
Minimal useful recovery
Usually requires excision of damaged
segment and repair or reconstruction

Traumatic Nerve Injury

Classification
5th Degree (Neurotmesis)

Complete loss of continuity of nerve

Varying amounts of scar form between
severed ends, with neuroma formation
at proximal stump
Wallerian degeneration of distal stump
Spontaneous recovery negligible
Requires surgical repair

Causes of Nerve Injury

Compression
Stretch
Ischemic
Traumatic

Causes of Nerve Injury

Acute Compression

Immediate onset

Mechanical
deformation of nerve
fibers responsible for
pathologic changes
Chronic Compression

Delayed/ gradual
onset

Ischemia significant
factor in genesis of
injury

Clinical example

Doctor, why is
my thigh numb??

Meralgia
Parasthetica???

Causes of Nerve Injury

Extent and Severity of
Compression
Injuries:
Magnitude and rate
of applied force
Duration
Manner which
applied (localized or
over a long
segment)

Studies have shown that

excessive tourniquet
times and pressures
can lead to prolonged
EMG changes

Recommended:
UE no more than 50100mmHg above
systolic
LE no more than 2x
systolic
Limit duration <2hrs

Causes of Nerve Injury

Stretch
Acute

1.

Abrupt application of force of

considerable magnitude
Stinger = acute neuropraxia

Chronic

2.

Slow stretching of nerve over

period of time
Usually tolerate significantly
more

Variable degree of injury

Causes: Fracture displacement,
joint dislocation, trauma,
etc.

Physiology of Nerve
Degeneration
Wallerian
Degeneration

Breakdown of axon
distal to site injury
Begins within hours
post injury
Myelin and axons
deteriorates
Schwann cells
proliferate
Macrophages
phagocytize myelin and
axonal debris

Physiology of Nerve
Regeneration

Rate of regeneration
varies depending on the
type & location
In humans, an average
outgrowth of 1-2
mm/day is generally
quoted
Proximal budding occurs
after 1 month delay

Functional Recovery
after Nerve Injury
Clinical outcomes variable and related to:
1. AGE single most important factor
2. Level of injury - distance regenerating axons
must go to reach target organs, distal > prox
3. Length of injury zone
4. Type of injury sharp transection > crush
5. Timing of nerve repair
6. Status of end organ at time of re-innervation
7. Technical expertise of surgeon

Nerve Repair
Primary Repair
Preferable: 0-3 weeks
Immediate repair technically
easier though emergent repair not
necessary
Time limit of repair up to 18 months

Nerve Repair
Epineurial Repair
Standard
Orientation critical
9-0 monofilament
Grouped Fascicular Repair
Not clinically better than
epineurial
Indications
1. Median nerve in distal forearm
2. Ulnar nerve in distal forearm
3. Sciatic nerve in thigh

Nerve Repair
Tension
Encourages gapping
and scar formation
Reduces blood flow:
8% elongation =
46% decrease in
perfusion
Grafting better than
repair in tension
(autografts)

Rehabilitation of
Nerve Injuries

During re-innervation
continued motor and
sensory rehab critical
Sensory re-education
improves results
Assists brain in
reinterpreting
misdirected axon
impulses

EMG / NCV Studies

EMG / NCV

EMG
Determines health of muscle and,
indirectly, the nerve supply
Fibrillations

Spontaneous activity at rest; indicates

denervation

Insertional activity

Activity during needle insertion; high is bad

Motor unit potentials

Few, wide, and low amplitude = BAD

EMG / NCV

NCV
Provides additional info on nerve function
Nerve conduction measured (saltatory
conduction)
>50 meters/second normal in extremities
EMG/NCV
When get to assess nerve damage?
* as early as 3 weeks; monthly as
needed

Nerve Compression
Syndromes

Radial Tunnel
Syndrome
Symptoms
Proximal / lateral arm pain
No motor or sensory
dysfunction .. PAIN only
No PIN dysfunction
Normal EMG/NCS
Provocative test: resisted
long finger extension
Tenderness over radial
neck or supinator
Recurrent or unresponsive
lateral epicondylitis
Coexists in 5%

Radial Tunnel
Syndrome
Causes of Compression:
Recurrent radial
vessels (leash of
Henry)
ECRB leading edge
Arcade of Frohse
Distal Supinator

Treatment:
Longer periods of
conservative care 612mths (NSAIDS,
splinting, work
modifications)
Operative release
often disappointing
Careful patient
selection

Posterior Interosseous
Nerve Syndrome

Pain at lateral elbow

Weakness and radial
deviation with wrist
extension (ECRL
innervated above
PIN)
Motor neuropathy
EMG/NCS diagnostic
Sites of compression
same as radial tunnel

Posterior Interosseous
Nerve Syndrome
Treatment
Initial conservative
(MRI r/o mass)
Decompression: if no
recovery by 3 months
or progression
If condition persists
>18 months
irreversible muscle
fibrosis occurs

Pronator Syndrome
Compression neuropthy
of proximal median n.
Sites of Compression:
Supracondylar
process (1% of
population)
Ligament of Struthers
Bicipital aponeurosis
Deep head of PT **
Accessory head of FPL
Origin of FDS

Pronator Syndrome

Confused with CTS

No Tinels sign at wrist
No night symptoms
Sensory disturbance
over region of palmar
cutaneous branch and
anterior proximal
forearm

Provacative tests:
A. Flexion past 120 deg.
- Supracondylar process
or ligament of
Struthers
B. Resisted supination with
elbow flexion
- Bicipital aponeurosis
C. Resisted pronation with
elbow extended
- Pronator heads
D. Resisted MF PIP flexion
- FDS
EMG usually normal, though
may be positive in PQ &
FPL

Pronator Syndrome
Treatment:
Nonoperative
usually successful
Decompression
considered if fails to
respond after 3-6
months
Requires global
decompression
(proximal to distal)
of all potential areas

Anterior Interosseous
Nerve Syndrome
Sites of Compression:
Pronator teres
FDS Arcade
Lacertus Fibrosus
Enlarged bicipital bursa
Accessory FPL (Gantzers m.)
Diagnosis
Motor loss without sensory
involvement
Loss of FPL & FDP - Index
produce characteristic
finding
EMG/NCS diagnostic
R/O Brachial Neuritis if B/L
Parsonage-Turner Syndrome

Anterior Interosseous
Nerve Syndrome
Treatment:
Observe for 3-6
months
Surgical
decompression
for failures

Quadrilateral Space
Syndrome

Compression of Axillary
N. and posterior
humeral circumflex a
Traumatic and
atraumatic causes
Vague shoulder
discomfort and pain with
fatigue when arm held
above shoulder level
Reproduction of sx with
FABER position
Paresthesias and Deltoid
weakness
Arteriogram (FABER)
EMG/NCV may be
positive

Quadrilateral Space
Syndrome
Treatment:
Conservative for
6 months
Surgical
decompression if:
1. Fails conservative
2. Positive
arteriogram

Suprascapular Nerve
Entrapment

Overhead repetitive
sports
Suprascapular notch
Spinoglenoid notch
Trauma, traction,
space occupying
lesions, etc.
Predominantly
motor nerve

Suprascapular Nerve
Entrapment
Symptoms:
Vague dull, achy
pain posterior and
lateral shoulder or
asymptomatic
Weakness in ER and
Abduction with
overhead activity
Atrophy of
infraspinatus +/supraspinatus

Suprascapular Nerve
Entrapment
Diagnosis:
EMG/NCS helpful
MRI: space occupying
lesion (ganglion)
Treatment:
Conservative 4-6
months (unless space
occupying lesion
present)
Decompression if
failure of
nonoperative
treatment or
progression

Stinger Syndrome

Brachial Plexus stretch/

neuropraxia
Unilateral shoulder
and/or arm pain with
burning dysesthesias and
often muscle weakness
involving the biceps,
deltoid, and spinatus
muscles
Symptoms transient with
full recovery typical
More severe neuro injury
can occur
Majority go unreported

Stinger Syndrome
3 Mechanisms:
1.
Brachial plexus
stretch (traction
injuries)
2.
A direct blow to
the plexus
3.
Nerve root
compression in the
neural foramen
(extensioncompression)

Stinger Syndrome
Treatment
Symptomatic usually
May return to play if
PE normal
Remove from game
if any radiating arm
pain and neurologic
deficit or loss of
cervical range of
motion

Thoracic outlet
syndrome

Relatively common
Compression of lower trunk/medial cord
of brachial plexus and vascular structures
Sites of compression

Ant/medial scalene muscles

Cervical or first rib
Clavicle malunion or Pec minor
Subclavian artery disease

Presents with pain and parasthesias

(usually ulnar) with overhead activity
Complaints usually neurological

Thoracic outlet
syndrome

Symptoms

Presents with pain and parasthesias (usually

ulnar) with overhead activity
Complaints usually neurological

Physical Exam
Wright Test

Abduction / ER with neck rotated away leads to loss

of pulse and reproduction of symptoms

Adson Test

Extension of arm with neck extended towards side

Roos

Hands open/close repeatedly while held overhed

Thoracic outlet
syndrome

Difficult to diagnose
NCV/EMG invariably normal
Diagnosis dependent on history and
various non-specific provocative tests

Rx:
Usually conservative; PT, stretching,
postural training, mobilization, and
strengthening of shoulder girdle
Surgical: only in recalcitrant cases

Surgeon experience key

Effort Thrombosis

Rare
Has been described in baseball, swimming,
wrestling, and backpacking
Sx: tiredness, heaviness, possible swelling
with activities (may last for few days)
Work-up consisits of venography or CT/MR
venograms
May show thrombois of subclavian at level of
first rib
Treatment: Vascular procedures (thrombolysis)
and/or first rib resection

Popliteal Artery
Entrapment Syndrome

Less common diagnosis on differential of leg

pain in athletes/runners
Sx: pain, fatigue, cramping, paresthesias, swelling,
coldness

Causes

Variation in artery course

Hypertrophy or fibrous bands of medial gastroc

Symptoms

Calf cramping following light exercise which improves with

vigorous exercise
Tingling sensation in toes after vigorous exercise

Physical Exam

Diminished pulses with knee hyperextension and ankle

plantarflexion

Popliteal Artery
Entrapment Syndrome

Ranges from intermittent claudication to

possible life threatening limb ischemia
Intermittent occlusion from plantar flexion
motion
May note change in pulse with PF

Arteriogram/MRA
Rx: (depends on vessel)

No vessel injury: release (usually medial head gastroc)

Vessel injury: vascular surgical managment

Questions ??