Think of 'nerve' in diagnostic dilemma july2011 India

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Slide 1:

Pain

Slide 2:

Burning pain

Slide 4:

* Within limits , pain is crucial and important. When pain becomes excessive and prolonged , need treatment.

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Think nerve in diagnostic dilemma DR Pankaj Jindal MS orthopaedics Clinical fellow Hand surgery France Clinical fellow Hand surgery Michigan. USA Clinical fellow Hand surgery Louisville USA HAND SURGEON Peripheral nerve surgery PUNE India www.handsurgery.in handsurgeryindia@gmail.com

Pain:

Pain Fibromyalgia Brachialgia Lumbago sciatica syndrome Cervical spondylosis Methyl cobalamine Gabapentine Lysine Tryptomer

Slide 8:

Clinics in Plastic Surgery July 1989

Slide 12:

Library of Dr Jindal

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*Long standing *VERRRY Painful *Pin head size *Blue Is not Paronychia

Glomus tumor:

Glomus tumor glomus body consists of an arterio-venous shunt . glomus body has high sympathetic tone involved in body temperature regulation.

Tennis elbow OOOOFFFFF:

Tennis elbow OOOOFFFFF

Slide 18:

x NO Pain

Radial Tunnel Syndrome:

Radial Tunnel Syndrome

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Middle Finger Test

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Pain not on lateral epicondyle

next:

next

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Tender Ask yourself what structures lie here?

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Tender Ask yourself what structures lie here? *Pronator Teres *Median nerve

Slide 34:

Middle finger test

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Median nerve

Pronator Teres Syndrome:

Pronator Teres Syndrome Proximal forearm pain T/ N Thenar sensation

Shoulder Pain:

Shoulder Pain

Shoulder pain:

Shoulder pain Local Pathology…………….. X Deficiency …………………..X Distant Pathology………….

Slide 46:

Palmar wrist pressure precipitate pain in shoulder. Referred pain Carpal tunnel syndrome

Think of Carpal tunnel syndrome in the D/D of shoulder pain specially in a middle aged female with T/N in hand :

Think of Carpal tunnel syndrome in the D/D of shoulder pain specially in a middle aged female with T/N in hand

Slide 48:

Don’t touch Very painful

Slide 49:

Café Au Lait spots

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Neurilemmoma

Think of a nerve either local or farther as a source of pain:

Think of a nerve either local or farther as a source of pain www.handsurgery.in

Look at the patient’s gesture , he is telling the surface anatomy of a nerve :

Look at the patient’s gesture , he is telling the surface anatomy of a nerve

Clinical history:

Clinical history 25 yr F fell while playing. Developed tingling in all the limbs over next several months , MRI C spine and dorsal spine normal www.handsurgeryindia@gmail.com

……….Clinical ,,,,,,,,,,,,,,:

……….Clinical ,,,,,,,,,,,,,, Emg + for CTS consulted :: >2neurologists >2 neurosurgeons >8 ortho 2 rheumatologists 2 psychiatrists 2 sports physician

….. clinical:

….. clinical Problem approached differently. Each nerve was tested individually and considered as a compression neuropathy.

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B/L anterior scalenotomy

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B/L cervical rib resection

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B/L Ulnar nerve transposition

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B/L Tarsal tunnel syndrome B/L lateral popliteal nerve at fibular neck

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B/L Anterior tibial nerve decompression

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Femoral Nerve

Gluteal pain and posterior thigh pain:

Gluteal pain and posterior thigh pain Consulted spine surgeon Repeat 3T MRI . Nothing there Sinus tarsi tender Diagnostic Lidocaine injection test +

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Sinus Tarsi Syndrome

Burning in the soles :

Burning in the soles Diabetic Neuropathy

Cry of a nerve :

Cry of a nerve

Diabetic foot:

Diabetic foot

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Eureka

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We believe we can change the natural history of diabetic neuropathy.”

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Balance and protection against falls, depend on input from the feet.

Diabetic neuropathy: problem:

Diabetic neuropathy: problem Loss of sensation causes : Loss of balance. Fall # . Loss of temperature sense Burn , ulcer. Foreign body inside footwear go unattended. Inability to feel pedals of car.

Loss of Sensation: Result:

Loss of Sensation: Result Inability perceive hot and sharp Stairs climbing difficult At risk for ulcer infection and amputation

80% amputations in diabetics are originally ulcers :

80% amputations in diabetics are originally ulcers

Diabetic nerves are swollen :

Diabetic nerves are swollen

Now consider another thing . The path of nerves . and then, correlate the two things:

Now consider another thing . The path of nerves . and then, correlate the two things

Peripheral nerve : Route:

Peripheral nerve : Route Cross area of anatomic narrowing : Carpal tunnel at wrist Ulnar tunnel at elbow Fibular tunnel at knee Tarsal tunnel at ankle. Potentially narrow area & the D.M. nerve is s w o l l e n .

Chronic compression of ulnar nerve , median nerve, radial nerve : Results.:

Chronic compression of ulnar nerve , median nerve, radial nerve : Results . Glove distribution of numbness in upper limb. These symptoms are similar to Diabetic neuropathy in upper limb.

So glove type of anesthesia /Paresthesia is affection of three nerves : median ulnar radial :

So glove type of anesthesia /Paresthesia is affection of three nerves : median ulnar radial

What about the leg ?:

What about the leg ?

Compression neuropathy in lower limbs: symptom distribution. :

Compression neuropathy in lower limbs: symptom distribution . Lateral peroneal nerve compression on fibular head causes lateral leg and dorsal foot pain / paresthesia. Anterior tibial nerve compression on foot causes dorsal foot pain. Posterior tibial nerve compression causes plantar foot symptoms.

So stocking type of symptoms in the leg are due to affection of anterior tibial nerve posterior tibial nerve lateral popliteal nerve:

So stocking type of symptoms in the leg are due to affection of anterior tibial nerve posterior tibial nerve lateral popliteal nerve

Electrodiagnostic tests are used for diagnosis of compression neuropathy etc. :

Electrodiagnostic tests are used for diagnosis of compression neuropathy etc .

In a diabetic nerve , it is already damaged and diseased . on top of it, is swollen and compressed too.:

In a diabetic nerve , it is already damaged and diseased . on top of it, is swollen and compressed too.

Peripheral neuropathy is so advanced that no conduction is measurable in the peripheral nerve :

Peripheral neuropathy is so advanced that no conduction is measurable in the peripheral nerve

Also, conduction velocity and amplitude may be so reduced already that, identification of a superimposed nerve compression in a patient with neuropathy is not possible technically.:

Also, conduction velocity and amplitude may be so reduced already that, identification of a superimposed nerve compression in a patient with neuropathy is not possible technically.

Therefore , Clinical exam becomes critical.:

Therefore , Clinical exam becomes critical.

Compression neuropathy: Signs :

Compression neuropathy: Signs Tenderness Compression at site of Anatomical narrowing * Tinel’s sign +

Slide 94:

Tinel++ at P.T.Nerve

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Tinel+ at A.T. nerve

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Tender L.P.Nerve

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triad

Diabetic Neuropathy: Prognostic sign:

Diabetic Neuropathy: Prognostic sign + Tinel’s sign at sites of anatomical narrowing. Control sites for comparison. Tender nerve If Tinel’s sign + , 80% excellent result in terms of pain relief and sensory recovery.

Diabetic neuropathy: Limitation of medicines.:

Diabetic neuropathy: Limitation of medicines. Medicines help reduce pain and paresthesia but not restore sensation .

Diabetic neuropathy: TTS Surgery results:

Diabetic neuropathy: TTS Surgery results NO. of nerves Results Dellon 1992 31 pain 85% 2PD 72% Weinman 1995 33 pain 92% 2PD 72% Chaffe 2000 58 pain 86% touch 50% Aszmann 2000 16 2PD 69% Wood 2003 33 pain 90% 2PD 67% Biddinger 2004 22 Pain 86% 2PD 80%

Diabetic Neuropathy : Sx & non Sx:

Diabetic Neuropathy : Sx & non Sx 49 patients one side Sx : No ulcer. No amputation 49 patients other leg not operated 10 ulcers 4 amputation .

Diabetic Neuropathy: Indication Sx:

Diabetic Neuropathy: Indication Sx Pain not responding to medication, even if Tinel – . Numbness , Paresthesia, Sensory loss. Tinel +

Hypothesis :

Hypothesis Symptoms attributed to “Diabetic Neuropathy” is Reversible by decompression of Peripheral Nerves

Selection Criteria For Sx:

Selection Criteria For Sx Not all need surgery. Symptoms are more Distal. Symmetrical. Tinel’s sign + Impaired sensation. DM under control. …………….

Diabetic Neuropathy: Surgery to restore sensation, relieve pain, prevent ulceration, and amputation.:

Diabetic Neuropathy : Surgery to restore sensation, relieve pain, prevent ulceration, and amputation. Dr. Pankaj Jindal, Hand surgery , Peripheral nerve surgery , Pune

Slide 119:

She said she used to come every month for dressing ..now she comes once a year may be she retracts foot on cutting a callosity now

Heel pain:

Heel pain

Clumsiness of grip:

Clumsiness of grip

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next

Inability to extend pip of ring:

Inability to extend pip of ring

Slide 129:

kolhapure

:

Thank you www.handsurgery.in handsurgeryindia@gmail.com

.:

. Thank you

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