Where’s the Lesion?

Regardless of your practice philosophy, it is of utmost importance to address neurological lesions at their source. When I say this, I am referring to the patient that walks into your office with a list of complaints that may include neck pain and upper extremity numbness. It would be easy for the busy doctor to assess the patient’s neck pain with some orthopedic tests and an X-ray. The result? You find the patient has a loss of their cervical curvature with degeneration at C5-6 and some at C6-7 (are you surprised?). Addressing the patient, you indicate, “You have a pinched nerve in your neck that’s causing your hand numbness and waking you up at night.” Sounds easy and harmless enough…

Testing

I would like to suggest before you jump head first into a treatment regimen that may last 4, 6 or 8 weeks, test the possibility of other diagnoses – especially if you are dealing with radicular symptoms. Make note if the pain follows a dermatomal or cutaneous pattern. Did you rule out a disc problem (see my April article)? Did you test for a peripheral entrapment? In this article, I would like to focus on some of the most common upper extremity entrapment neuropathies that present in my office, and how I have treated them successfully.

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Peripheral Entrapment Neuropathies

Peripheral entrapment neuropathies are on the rise. Thanks to technology over usage dependency or addiction, many of us have been enjoying an increase in patient visits. Over usage can result in tendinopathies, as well as, neurological conditions such as CTS, TOS, and Ulnar nerve entrapment. With this being the case, we have to be prepared to accurately diagnose our patient and educate them on the mechanism of injury so the risk of recurrence can be reduced.

Key signs for early diagnosis in the evolution of CTS:

• Nocturnal numbness and tingling (N&T)frequently waking the patient up at night, affecting the thumb to the lateral half of the ring finger.
• N&T when performing offending repetitive activities (typing)

These symptoms indicate that there is significant irritation to the sensory branch of the median nerve. Additionally, these symptoms usually occur first, because the finer sensory fibers of the median nerve are affected first. In my experience during early intervention, CTS responds very well to a course of therapy that includes CMT to the cervical spine, wrist, and ergonomic modification to all offensive activities (work activities, smartphone use, and household chores). Vitamin B therapy will also likely help the patient in speeding recovery.

In cases when the condition has progressed further and the patient is dropping items or having difficulty with dexterity, the motor branch of the nerve is also typically affected. When you see this, check for atrophy of the abductor pollicus brevis muscle with the patient’s hands and fingers fully extended. Look for loss in height of the thenar eminence on the affected side. In my office, when I see that the patient demonstrates loss of motor function, I order an EMG/NCV to assess the extent of the damage, and to make sure the problem is not upstream (ie. Pronator teres). Depending on the electrodiagnostic results, I may give the patient options up to and including hand surgery, if a short course of therapy doesn’t improve the patient’s symptoms. I know this sounds extreme, but this is the hands we’re talking about.

Thoracic Outlet Syndrome

Thoracic outlet syndrome (TOS) has been another higher frequency complaint over the past two years. Patients are spending more time on the computer and their smartphones with shoulders, arms, head, and neck flexed. This results in shortening of cervical and pectoral musculature. Key symptoms that I look for are:

•  Nocturnal diffuse upper extremity N&T especially when they are lying supine with their head in a more upright position,
• Intermittently cold upper extremities lacking circulation,
• Asymmetric radial pulse strength, and
• Diffuse weakness in upper extremities

 TOS arising from muscular shortness (more common) responds well to manipulation and postural exercises including stretching of anterior and middle scalenes, as well as, the pectoralis minor muscles. Stretching of these muscles will often reproduce the patient’s upper extremity symptoms. TOS arising from a cervical rib (rare) may not respond the same way and is often associated with a vascular component caused by compression of the subclavian artery. This may require a referral. In my observation, TOS tends to mimic ulnar nerve entrapment at the elbow. If this is the case, your examination of the scalenes and pectoralis minor are not likely to reproduce the patient’s symptoms.

Ulnar Nerve Entrapment

Ulnar nerve entrapment can arise from the compression of the ulnar nerve most commonly at the medial elbow or at the tunnel of Guyon. Depending on the type of entrapment, symptoms can include numbness along the medial border of the forearm and hand including the 5th digit and the medial half of the ring finger. Ergonomic modification of the work station has been found to help reduce symptomatology quickly. Changes include:

• Move the keyboard and mouse off the desktop and onto a tray so that the patient does not have his/her elbow and wrist on the hard desk surface,
• Lower the arms of the chair so that the elbows are not held away from the body resting on the armrest in your car or at work, and
• Add a gel pad in front of the keyboard and mouse to support the wrists in a neutral position.

Treatment

Active treatment can include manipulation of associated anatomy, ulnar nerve flossing, Kinesio taping, and modalities. Ulnar nerve flossing can be performed with the patient in the seated position with the shoulder fully abducted, elbow flexed and forearm fully pronated. Using the patient’s opposite hand instruct them to extend the wrist of the affected hand using the last three digits only (if you still have trouble visualizing this see youtube). This exercise can be performed 10 times holding for a count of 2 sec 2 times per day. Vitamin B therapy is also recommended for this problem.

The importance of accurately diagnosing and getting positive results in short order cannot be understated, especially in today’s economy. With higher deductibles, co-pays, and co-insurance, patients are not likely to wait 4 weeks for results. This is why it is imperative that we isolate the lesion fast and offer the best course of action to produce the quickest results.