Entrapment Neuropathies

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Entrapment Neuropathies : 

Entrapment Neuropathies Hosam Atef, M.D. Lecturer of Anesthesia

Outline : 

Outline Carpal Tunnel Syndrome Median nerve entrapment Ulnar nerve entrapment At the elbow At the wrist Radial nerve entrapment TOS Sciatic nerve entrapment Peroneal nerve entrapment Tarsal tunnel syndrome Lateral femoral cutaneous neuropathy

Pathophysiology : 

Pathophysiology Peripheral Nerves Motor, sensory, and autonomic axons + supporting elements Schwann cells Unmyelinated fibers: multiple axons to one Schwann cell several axons lie in invagination of Schwann cell Myelinated fibers: single axon to multiple Schwann cells A single Schwann cell wraps multiple layers of its cell membrane around the axon, which produces the myelin sheath this segment of myelin is called an internode In between the internodes, there are the nodes of Ranvier

Pathophysiology : 

Pathophysiology Peripheral Nerves Connective and supporting tissue Several axons run together = fascicle Multiple fascicles = nerve Endoneurium = connective tissue inside a fascicle Perineurim = connective tissue circumferentially surrounding a single fascicle Epineurium = connective tissue that binds fascicles together into a nerve

Pathophysiology : 

Pathophysiology Peripheral Nerves Connective and supporting tissue Relevance Epineurium protects against compression Peroneal division of sciatic nerve is sensitive, because it contains less epineurium Epineurium and perineurium protect against stretch The undulating connective tissue is stretched first.

Pathophysiology : 

Pathophysiology

Pathophysiology : 

Pathophysiology Neuropraxia (conduction block) is a segmental block axonal conduction Nerve can conduct action potentials above and below, but not across the damaged area Nerve is in continuity but does not conduct Focal demyelination leads to current leak in internode Action potential cannot propagate across this area

Pathophysiology : 

Pathophysiology Conduction slowing (in the absence of histological change) Myelin is slightly damaged Widening of nodal areas (not destruction of internodal segment)- longer time to activate Conduction is slowed, but not completely blocked

Pathophysiology : 

Pathophysiology Conduction slowing (in the absence of histological change) Characteristic of entrapment neuropathies Not ‘true’ neuropraxia Old term, ‘axonostenosis’ not used Symptoms may not be present as in conduction block (i.e., cndxn block leads to loss of function)

Pathophysiology : 

Pathophysiology Axonotmesis Loss of axonal continuity Preservation of surrounding connective tissue Wallerian degeneration

Pathophysiology : 

Pathophysiology Axonotmesis Wallerian degeneration Distal part of nerve Axons breakdown into ovoids Secondary degeneration of myelin sheath 3-5 days to fully develop (<3-5 days-distal part retains excitability)

Pathophysiology : 

Pathophysiology Axonotmesis Wallerian degeneration Proximal nerve attempts to regrow Distal Schwann cells proliferate and form tubes Axons attempt to regrow through these tubes to original destination 1mm/day or 1 cm/week or 1 inch/month

Pathophysiology : 

Pathophysiology Neurotmesis Nerve transection Loss of axonal and connective tissue continuity Wallerian degeneration However, the loss of supporting element continuity may lead to neuroma formation

Pathophysiology : 

Pathophysiology Focal slowing of nerve conduction is the principle electrophysiological feature of entrapment neuropathy Mild degrees of pressure (suprasystolic) applied to the nerve for short periods produce reversible dysfunction due to ischemia Entrapped nerve may be more sensitive to bouts of ischemia than normal nerves

Pathophysiology : 

Pathophysiology Acute ischemia may be responsible for paresthesias and dysethesias Prolonged ischemia may lead to neural tissue infarction

Pathophysiology : 

Pathophysiology Focal slowing Segmental demyelination and remyelination Bulbous paranodal swellings are referred to as tadpoles Direct mechanical injury Chronic low pressure Friction Ischemia, fibrosis, blood-brain barrier play a minor role Short tourniquet application with high pressure is not a relevant model of human entrapment syndrome

Carpal Tunnel Syndrome : 

Carpal Tunnel Syndrome Cluster of signs and symptoms which follow entrapment of median nerve in the carpal tunnel Subclinical or clinical evidence of numbness, paresthesias, dyesthesias, or weakness in the median nerve distribution Underecognized till the advent of electrophysiological testing in the 1940’s

Carpal Tunnel Syndrome : 

Carpal Tunnel Syndrome Cluster of signs and symptoms which follow entrapment of median nerve in the carpal tunnel Commonly confused with thoracic outlet syndrome Carpal tunnel causes nerve compression resulting in demyelination followed by axonal degeneration Sensory and autonomic fibers usually affected first Motor compression follows later

Carpal Tunnel Syndrome : 

Carpal Tunnel Syndrome Epidemiology USA Incidence of 0.1%-0.3% Prevalence of 5% In high risk groups Incidence 15% Prevalence 50% Internationally Comparable in UK and Netherlands Rare in developing world Morbidity Irreversible loss of median nerve function Surgical failure rates range from 2-31% Conservative failure rates 1-50%

Carpal Tunnel Syndrome : 

Carpal Tunnel Syndrome Epidemiology Race Whites are higher risk (Among US Navy personnel, whites have 2-3 times risk compared to blacks) Very rare in non-white South Africans Sex: F:M ratio is 3-10:1 Age Peak age is 45-60 <10% of patients are under 31

Carpal Tunnel Syndrome : 

Carpal Tunnel Syndrome Carpal tunnel fibrosseous tunnel carpal bones, concave alignment anteriorly proximal distal Median nerve Median nerve

Carpal Tunnel Syndrome : 

Carpal Tunnel Syndrome Carpal tunnel flexor retinaculum( transverse carpal ligament) Continuation of arm fascia Roof of carpal tunnel Laterally attaches to scaphoid tubercle and trapezium Medially attaches to hook of the hamate and pisiform. proximal distal Median nerve Median nerve

Carpal Tunnel Syndrome : 

Carpal Tunnel Syndrome Carpal tunnel volar carpal ligament also contributes to this roof of the carpal tunnel Not as significant nor as thick proximal distal Median nerve Median nerve

Carpal Tunnel Syndrome : 

Carpal Tunnel Syndrome Carpal tunnel transmits long flexors of the fingers and thumb flexor digitorum superficialis tendons are arranged in 2 rows flexor digitorum profundus tendons are arranged in the same coronal plane flexor pollicis longus tendon median nerve Just under flexor retinaculum and abuts its inner surface Lateral side of the flexor digitorum superficialis between the flexor tendon of the middle finger and the flexor carpi radialis. Combination of lateral (C6-7) and medial (C8-T1) cords of brachial plexus proximal distal Median nerve Median nerve

Carpal Tunnel Syndrome : 

Carpal Tunnel Syndrome Median nerve position and morpology round or oval at the level of the distal radius elliptical at the pisiform and hamate position and morphology change with flexion and extension

Carpal Tunnel Syndrome : 

Carpal Tunnel Syndrome Median nerve position and morpology 20 mm excursion frictional forces between the median nerve, adjacent tendons, and the transverse carpal ligament compounded by morphologic changes irritate nerve wrist flexion: elliptical shape flattens wrist extension: least morphologic alteration

Carpal Tunnel Syndrome : 

Carpal Tunnel Syndrome Etiology: multiple risk factors Demographics Aging Female Increased BMI Square shaped wrist Short stature Dominant hand Race (white) Caffeine, alcohol, and nicotine

Carpal Tunnel Syndrome : 

Carpal Tunnel Syndrome Etiology: multiple risk factors Genetics Linked to body morphology Linked to inherited medical conditions (DM, Thyroid disease, hereditary neuropathies) Vocational Prolonged severe force through wrist, posturing of wrist, high amounts of repetitive movements, and exposure to vibration/cold Other factors Lack of aerobic exercise Pregnancy and breast feeding Use of wheelchairs and walking aids

Carpal Tunnel Syndrome : 

Carpal Tunnel Syndrome Etiology: multiple risk factors Medical conditions Wrist fracture Flexion/extension injury of wrist Space occupying lesions of wrist Diabetes Thyroid disorders Rheumatoid arthritis Recent menopause (including oopherectomy) Renal dialysis Acromegaly Amylodosis

Carpal Tunnel Syndrome : 

Carpal Tunnel Syndrome Clinical Intermittent symptoms and increase with certain activities (driving, reading the paper, crocheting, painting) Bilateral symptoms

Carpal Tunnel Syndrome : 

Carpal Tunnel Syndrome Clinical Pain Aching over ventral wrist, extending distally to finger and proximally along forearm CTS is often associated with epicondylitis due to increased use of forearm muscles Nocturnal pain and burning Sensory abnormalities Hypesthesia and paresthesias ‘hands fall asleep’ Thumb, index, middle, radial half of ring finger usually affected Patients are often unable to localize symptoms that specifically

Carpal Tunnel Syndrome : 

Carpal Tunnel Syndrome Clinical Muscular atrophy and weakness are late findings but abductor pollicis brevis may be involved early Loss of hand power, especially precision grip in hand Clumsiness Loss of afferent sensory input and proprioception is actually more of a problem Autonomic changes ‘tight or swollen’ feeling in hands Increased sensitivity to temperature changes Skin color changes

Carpal Tunnel Syndrome : 

Carpal Tunnel Syndrome Physical Exam Sensory Hypesthesia to multiple sensory abnormalities 2 point discrimination

Carpal Tunnel Syndrome : 

Carpal Tunnel Syndrome Physical Exam Sensory Semme-Weinstein pressure monofilaments: monofilaments of increasing diameter are placed perpendicular to against each digit, till they bend Changes limited to radial 3 ½ digits, palmar aspects

Carpal Tunnel Syndrome : 

Carpal Tunnel Syndrome Physical Exam Sensory Normal examination outside distal median nerve territory (thenar eminence, hypothenar eminence, dorsum of first web space)

Carpal Tunnel Syndrome : 

Carpal Tunnel Syndrome Physical Exam Motor Late findings Changes confined median nerve innervated hand L- lumbricals (1st and 2nd) O-opponens pollicis A-abductor pollicis brevis F-flexor pollicis brevis

Carpal Tunnel Syndrome : 

Carpal Tunnel Syndrome Physical Exam Special: no good clinical exam, only supportive Hoffman-Tinel Tap over carpal tunnel region to elicit tingling in nerve distribution Low sensitivity and specificity

Carpal Tunnel Syndrome : 

Carpal Tunnel Syndrome Physical Exam Special: no good clinical exam, only supportive Phalen Tingling in median nerve distribution reproduce by full wrist flexion for 1 minute 80% specificity but lower sensitivity Reverse Phalen Wrist is held in extension

Carpal Tunnel Syndrome : 

Carpal Tunnel Syndrome Physical Exam Special: no good clinical exam, only supportive Carpal compression test Firm pressure directly over carpal tunnel, with both thumbs, for 30 seconds Sensitivity 89% Specificity 96%

Carpal Tunnel Syndrome : 

Carpal Tunnel Syndrome Physical Exam Special: no good clinical exam, only supportive Square wrist sign Ratio of wrist thickness to wrist width is greater than 0.7 Poor sensitivity and specificity of 70%

Carpal Tunnel Syndrome : 

Carpal Tunnel Syndrome Clinical Features Imaging (MRI or Ultrasound) Not considered routine for CTS US high-resolUtion is a new technology which is gaining wider acceptance, since it is non-invasive Ultrasound: mn median nerve, u:ulnar nerve, p: pisiform, s:scaphoid

Carpal Tunnel Syndrome : 

Carpal Tunnel Syndrome Clinical Features MRI is useful in identifying a space occupying lesion or signal abnormality in median nerve No correlation with severity of lesion Diffuse swelling at pisiform Flattening at hamate Palmar bowing of flexor retinaculum Progressively worsening inflammation and signal in median nerve in T2 weighted MRI

Carpal Tunnel Syndrome : 

Carpal Tunnel Syndrome Clinical Features Electrodiagnosis First line investigation Prognosticates severity and can be used to follow disease process over time Compound motor action potentials (CMAPs) in a 56-year-old with bilateral CTS symptoms, R>L. Distal motor latency was 5.7 ms on the R and 4.3 ms on L. Median F-wave latency was 31.8 ms on the R and 29.3 ms on the L.

Carpal Tunnel Syndrome : 

Carpal Tunnel Syndrome Clinical Features Electrodiagnosis Positive in >90% of patients with clinical CTS. Normal median motor conduction velocity in the forearm Normal studies of ulnar nerve Compound motor action potentials (CMAPs) in a 56-year-old with bilateral CTS symptoms, R>L. Distal motor latency was 5.7 ms on the R and 4.3 ms on L. Median F-wave latency was 31.8 ms on the R and 29.3 ms on the L.

Carpal Tunnel Syndrome : 

Carpal Tunnel Syndrome Clinical Features Electrodiagnosis Distal motor latency is usually prolonged(>50% of CTS is normal) Stimulate the median nerve at the wrist, record at APB Latency > 3.7-4.5 ms is abnormal Compound motor action potentials (CMAPs) in a 56-year-old with bilateral CTS symptoms, R>L. Distal motor latency was 5.7 ms on the R and 4.3 ms on L. Median F-wave latency was 31.8 ms on the R and 29.3 ms on the L.

Carpal Tunnel Syndrome : 

Carpal Tunnel Syndrome Clinical Features Electrodiagnosis Distal sensory latency is abnormal Antidromic sensory study: stimulate at wrist and record at index or middle finger, 8 cm distally- >3.5msec Stimulate at palm and record at wrist- 8 c: a difference > 0.4 ms between median and ulnar is significant Conduction velocity across carpal tunnel slowed: <41m/sec Compound motor action potentials (CMAPs) in a 56-year-old with bilateral CTS symptoms, R>L. Distal motor latency was 5.7 ms on the R and 4.3 ms on L. Median F-wave latency was 31.8 ms on the R and 29.3 ms on the L.

Carpal Tunnel Syndrome : 

Carpal Tunnel Syndrome Treatment Physical therapy Aerobic exercise Modalities (iontophoresis, phonophoresis, ultrasound) Occupational therapy Work site ergonomic assessment (posture) Wrist-hand orthosis (worn at night for 3-4 weeks) 76% success at 6 weeks 22% success at 52 weeks Stretching/strengthening

Carpal Tunnel Syndrome : 

Carpal Tunnel Syndrome Treatment Pharmacotherapy NSAIDS Diuretics Intratunnel steroid and local anesthetic injection Oral steroids Vitamin B6 or B12- no proven benefit Reduce intake of caffeine, nicotine, and alcohol

Carpal Tunnel Syndrome : 

Carpal Tunnel Syndrome Treatment Surgical Indicated for failure of conservative care or severe category at initial presentation Release of transverse carpal ligament (also volar carpal ligament and deep forearm fascia) >90% early success 60% at 5 years open endoscopic

Carpal Tunnel Syndrome : 

Carpal Tunnel Syndrome Treatment Surgical Debate surrounds open vs. endoscopic Since disease is often progressive, a growing number of patients with mild to moderate disease may require this option open endoscopic

Other median nerve compression syndromes : 

Other median nerve compression syndromes At the shoulder Follows trauma or improper use of axillary crutches Other nerve compression syndromes may be present Forearm pronation is impaired Weak wrist flexion Weak wrist grasp Thumb flexion poor Difficulty with flexion of PIP joints

Other median nerve compression syndromes : 

Other median nerve compression syndromes At the shoulder Muscles affected Pronator tere Pronator quadratus Flexor carpi radialis Fpl Fds of all digits Fdp of index finger and long digits Muscles spared Brachioradialis Flexor carpi ulnaris Ulnar fdp

Other median nerve compression syndromes : 

Other median nerve compression syndromes At the elbow Ligament of struthers 5 cm above medial epicondyle of humerus Aberrant bone spur may be present Ligament bridges bone spur and medial epicondyle Brachial artery and median nerve run deep to ligament

Other median nerve compression syndromes : 

Other median nerve compression syndromes At the elbow Ligament of struthers Dx: Xray P/E: high median nerve compression- usually vague and non-specific Tx: neurolysis

Other median nerve compression syndromes : 

Other median nerve compression syndromes At the elbow Pronator syndrome As the median nerve passes across the elbow, it passes consecutively Deep to the lacertus fibrosus (fascial band extending from the biceps tendon to forearm fascia) Between the short and long heads of pronator teres Underneath the flexor digitorum superficialis arch Hence, 3 possible sources of compression Symptoms Aching or heaviness of forearm, deep and sharp Worse with repetitive elbow movements Clumsiness Loss of dexterity Paresthesias are less than CTS

Other median nerve compression syndromes : 

Other median nerve compression syndromes At the elbow Pronator syndrome Physical exam Usually ill defined Increased pain with pressure over the pronator teres Tinel’s sign Ask patient to fully pronate elbow and flex wrist Then the examiner attempts to supinate elbow and extend wrist, against resistance—increases pain. Dx: EDx Tx: activity modification, surgery (explore entrire pronator area)

Other median nerve compression syndromes : 

Other median nerve compression syndromes At the elbow Anterior interosseous nerve syndrome AIN arises from the median nerve, 5-8 cm distal to the lateral epicondyle AIN innervates FPL, FDP to index and long digits, pronator quadratus No superficial sensory fibers Deep pain and proprioception Etiology Trauma, inflammation

Other median nerve compression syndromes : 

Other median nerve compression syndromes At the elbow Anterior interosseous nerve syndrome Clinical Proximal forearm pain Physical exam Absence of flexion of thumb interphalangeal joint and the DIP joint of index finger

Ulnar nerve compression : 

Ulnar nerve compression At the elbow 2nd most frequent upper extremity neuropathy Clinical Intermittent hypesethesias in the ulnar nerve distribution Worsened with elbow flexion Symptoms vary and may abate with rest Night time shooting elbow pain Occasionally, motor sx’s predominate Weakness of grasp or pinch

Ulnar nerve compression : 

Ulnar nerve compression Physical Sensory loss in the ulnar aspect of the palm, volar surface of the fifth digit, and the ulnar half of the fourth digit Froment’s sign Weakness of FCU, interosseous, lumbricals, and hypothenar muscles Motor disability Weakness of pinch between thumb and adjacent digits Coordination of thumb and digits in precision taks Synchrony of digital felexion during grasp Strength of power grasp

Ulnar nerve compression : 

Ulnar nerve compression Etiology-elbow Bony or scar impingement at the elbow Recurrent subluzation of the ulnar nerve Cubital tunnel syndrome Treatment Activity modification Splinting Surgical treatment

Ulnar nerve compression : 

Ulnar nerve compression At the wrist Within or distal to Guyon’s canal Ulnar nerve enters the hand under Guyon’s canal Clinical features may be motor and sensory More distal Painless No sensory loss Paralysis of all intrinsic muscles, but spares hypothenar muscles Within Guyon’s canal Intrinsics and and hypothenar weakness Sensory loss of volar aspect of ulnar innervated digits Proximal Intrinsic and hypothenar atrophy Sensory loss of volar aspect of ulnar innervated digits and the dorsal sensory branch

Ulnar nerve compression : 

Ulnar nerve compression At the wrist Guyon’s canal is a closed space Nerve passes between the transverse carpal ligament and volar carpal ligament Bony margins include hook of the hamate and pisiform Guyon’s canal contains the ulnar artery, but no tendons

Ulnar nerve compression : 

Ulnar nerve compression At the wrist Guyon’s canal is a closed space Nerve passes between the transverse carpal ligament and volar carpal ligament Bony margins include hook of the hamate and pisiform Guyon’s canal contains the ulnar artery, but no tendons

Radial nerve compression : 

Radial nerve compression High radial nerve lesions proximal to its division into the posterior interosseous nerve and sensory branch Often traumatic High axillary lesions Triceps is affected Lesions distal to bifurcation Triceps is spared Brachioradialis Mild weakness of elbow flexion and supination Weakness of this muscle indicates high radial nerve injury Other muscles Wrist (ECR and ECU) and digital extension weakness

Radial nerve compression : 

Radial nerve compression Posterior interosseous nerve syndrome PIN is the deep muscular branch of radial nerve Bifurcation of radial to PIN and sensory branch is just distal to elbow PIN passes through the supinator under the arcade of Frohse Compressed by tumors, ganglia, or elbow synovitis Weakness of digital and wrist extensor, but with radial deviation Spares the ECR longus, ECR brevis, and supinator

Radial nerve compression : 

Radial nerve compression Suerficial branch of radial nerve Damaged post-surgically or following wrist fracture or wristwatch Anesthesia of the entire sensory zone of the radial nerve

Lower limb nerve compression syndrome : 

Lower limb nerve compression syndrome Sciatic Piriformis Nerve passes through or underneath the piriformis Affects the knee flexors and all muscles below the knee Affects sensation of the entire foot except the medial malleolus Rare, so evaluate other etiologies Tx: neurolysis

Lower limb nerve compression syndrome : 

Lower limb nerve compression syndrome Peroneal nerve At risk for injury as it wraps around the fibular head Superficial branch Peroneus longus and brevis (weakness of eversion) Sensory loss over lateral malleolus, lateral calf, dorsum of foot, medial three or four toes up to the interphalangeal joint Deep branch Larger number of muscles and smaller sensory supply TA, toe extensors, web space between the 1st and 2nd toes Ischemia, compression, or entrapment Occupation-long time squatting Weight loss or improperly fitting casts

Lower limb nerve compression syndrome : 

Lower limb nerve compression syndrome Peroneal nerve Clinical features Foot drop Paralysis or weakness of foot dorsiflexors and everters Partial sensory loss EDx NCVs and EMGs Tx Bracing to protect foot drop surgery

Lower limb nerve compression syndrome : 

Lower limb nerve compression syndrome Tarsal Tunnel 2 types Anterior Pain and sensory loss in the distal portions of the deep peroneal nerve Posterior (more common) Posterior tibial nerve is entrapped at the level of the medial malleolus Clinical features Pain ins the sole of the foot Burning, unpleasant quality Pain worse after a day of activitiy Nocturnal pain

Lower limb nerve compression syndrome : 

Lower limb nerve compression syndrome Tarsal Tunnel Diagnosis No specific factor in the history that identifies tarsal tunnel syndrome Tinel’s sign below and behind the medial malleolus Sensory loss theoretically affects the whole surface of the foot, but in reality affects the medial and lateral plantar areas Foot intrinsics are rarely weak FDB, FHB, Quadratus plantae, interossei, and lumbricals EDx: distal motor latency of medial and lateral plantar nerves are prolonged

Lower limb nerve compression syndrome : 

Lower limb nerve compression syndrome Tarsal Tunnel Treatment Conservative Surgery

Lower limb nerve compression syndrome : 

Lower limb nerve compression syndrome Tarsal Tunnel Posterior tibial nerve Passes through tarsal tunnel Divides into three divisions Medial plantar Lateral plantar Calcaneal

Miscellaneous nerve entrapment syndromes : 

Miscellaneous nerve entrapment syndromes Thoracic outlet syndrome Ilioinguinal nerve Saphenous nerve Femoral nerve Suprascapular nerve Musculocutaneous nerve

Mononeuritis Multiplex : 

Mononeuritis Multiplex Etiology Axonal destruction Usually due to ischemia, inflammation, or autoimmune 33% no identifiable cause

Mononeuritis Multiplex : 

Mononeuritis Multiplex Epidemiology Incidence is unknown Usually not recognized due to a the variety of etiologies and dominant symptoms of the overlying disease process Variable disability No relation of race nor sex Age is only related to incidence of underlying disease

Mononeuritis Multiplex : 

Mononeuritis Multiplex Clinical Pain lancinating dysesthesias Sensory Paresthesias Hyper or Hypesthesia Motor Paresis Abnormal motor control Past medical history is essential

Mononeuritis Multiplex : 

Mononeuritis Multiplex Clinical Physical exam is consistent with dysfunction of Axillary nerve Radial nerve Median nerve Ulnar nerve

Mononeuritis Multiplex : 

Mononeuritis Multiplex Laboratory and imaging Labs drawn in accordance with suspicion about primary process (CBC, Hepatitis screen, fasting blood sugar, ESR, Lyme titers, HIV) Imaging studies are not needed Electrodiagnosis: Sensory NCS: decreased amplitude, decreased conduction velocity only with large amount of fiber dropout Motor NCS: similar to axonal polyneuropathies or entrapment neuropathies, i.e., reduced amplitude with preservation of conduction velocity Needle exam: neuropathic with PSW, fibs, and motor unit action potential duration, polyphasia, amplitude increases Biopsy To distinguish axonal degeneration from demyelination Histologically, perivascular inflammation, axonal loss

Mononeuritis Multiplex : 

Mononeuritis Multiplex Treatment PT: ROM, splinting, TENS, caution with modalities (if patient is insensate) Pharmacotherapy AED’s TCA’s Opioids are not ideal for neuropathic pain Steroids (in the setting of vasculitis or temporal arteritis) Percutaneous procedures SIP: diagnostic peripheral nerve blocks, peripheral nerve catheter with local anesthetic infusion, SCS, PNS, pulsed mode RFTC of nerve, cervical epidural neuroplasty with continuous infusion, Intrathecal trial of clonidine SMP: stellate ganglion or T2-3 sympathetic block followed by RFTC

Mononeuritis Multiplex : 

Mononeuritis Multiplex Prognosis Recovery is usual after several months to years Recurrence is also possible

Thank you for your patience : 

Thank you for your patience Thank You

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