Atlas of Neuromuscular Diseases - part 5 ppt

189 Thoracodorsal nerve Genetic testing NCV/EMG Laboratory Imaging Biopsy + Fig. 29. Thoracodorsal nerve anatomy. 1 Thoracodorsal nerve. 2 Latissimus dorsi muscle 190 Fibers stem from C5–C7 roots. (Only 50% of cases have fibers from C7.) The fibers pass through the upper and middle trunks and the posterior cord, and continues with the lower subscapular nerve. Occasionally this nerve is a branch of the axillary and radial nerves. A motor branch goes to the latissimus dorsi muscle, and may also innervate the teres major muscle. Both muscles are adductors and inward rotators of the scapulohumeral joint and help to bring down the elevated arm (see Fig. 29). Few clinical symptoms, weakness compensated in part by pectoralis major and teres major muscles. Signs: Atrophy, and slight winging of the inferior margin of the scapula Motor: Latissimus dorsi: weakness in adduction and medial rotation of shoulder and arm. Isolated lesion is very uncommon. Neuralgic amyotrophy (rarely) Plexus lesions: injury in association with posterior cord or more proximal brachial plexus lesions. EMG Plexus: posterior cord lesions, upper/middle trunk lesions Radicular: C5–C7 lesion Conservative. Surgical interventions are not necessary because of the minor dysfunction. Due to this fact, this muscle can be used for grafting to the biceps brachii and outward rotators of humeroscapular joint. Good Symptoms Causes Diagnosis Differential diagnosis Therapy Prognosis Anatomy 191 Patients note painless atrophy. Weakness and atrophy of the pectoral muscle. Compensatory hypertrophy of other chest muscles. Lateral pectoral nerve: Receives fibers from C5–7 (lateral cord of plexus) and supplies upper part of pectoral muscle. Medial pectoral nerve: Receives fibers from C8/T1 and supplies lower part of pectoral muscle. Aplasia Entrapment in hypertrophies of minor pectoral muscle Neck dissection Weight lifting Bird SJ (1996) Acute focal neuropathy in male weight lifters. Muscle Nerve 19: 897–899 Pectoral nerve Causes Reference Anatomy Symptoms Signs 192 Thoracic spinal nerves Symptoms Signs Pathogenesis Anatomy Genetic testing NCV/EMG Laboratory Imaging Biopsy (+) + + The twelve pairs of thoracic spinal nerves innervate all the muscles of the trunk and surrounding skin, except the lumbar paraspinal muscles and overlying skin. Dorsal and ventral rami can be affected. Three groups: T1, T2–T6, T7–T12. a) T1 and C8: first intercostal nerve b) T2–T6: innervation of the chest wall T2 is the intercostobrachial nerve (see also brachial plexus) c) T7–11: Thoracoabdominal nerves T12 is the subcostal nerve Pain, sensory symptoms, depending on whether dorsal or ventral rami are affected. Muscle weakness may be difficult to assess, except in the case of abdominal muscles, where bulging occurs during coughing or pressure elevation. Metabolic: Diabetic truncal neuropathy Infectious: Herpes: Pre-herpetic neuralgia (1–20 days before onset) Herpetic neuralgia Post-herpetic neuralgia Lyme disease Compressive: Abdominal cutaneous nerve entrapment Notalgia paresthetica: involvement of dorsal radicular branches Thoracic disc disease (rare) Neoplastic: Invasion at the apex of the lung Schwannoma Vertebral metastases Traumatic: Trauma 193 Iatrogenic: Postoperative (abdominal surgery, post mastectomy, and thoracotomy) Laboratory: Fasting glucose, serology (herpes, borreliosis) CSF examination (e.g., pleocytosis and antibodies in Lyme disease) Imaging: vertebral column: plain X-ray, CT, MRI Electrophysiology: NCV of intercostal nerves is difficult and not routinely done. EMG: paraspinal muscles, intercostals, abdominal wall muscles Local painful conditions of the vertebral column (disc herniation, spondylodis- citis, metastasis) “Intercostal neuralgia” Muscle disease with abdominal weakness Slipping rib/Cyriax syndrome Depends on the etiology Daffner KR, Saver JL, Biber MP (2001) Lyme polyradiculoneuropathy presenting as increas- ing abdominal girth. Neurology 40: 373–375 Gilbert RW, Kim JH, Posner JB (1978) Epidural spinal cord compression from metastatic tumor; diagnosis and treatment. Ann Neurol 3: 40–51 Love JJ, Schorn VG (1965) Thoracic disc protrusions. JAMA 191: 627–631 Stewart JD (1999) Thoracic spinal nerves. In: Stewart JD (ed) Focal peripheral neuropathies. Lippincott, Philadelphia, pp 499–508 Vial C, Petiot P, Latombe D, et al (1993) Paralysie des muscles larges de l àbdomen due a une maladie de Lyme. Rev Neurol (Paris) 149: 810–812 Differential diagnosis Therapy References Diagnosis 194 Differential diagnosis The intercostal nerves are the ventral rami of the thoracic spinal nerves. They innervate the intercostal (first 6) and abdominal muscles (lower 6), as well as skin (via anterior and lateral branches). The first ventral ramus is part of the brachial plexus. Intercostobrachial nerve: Originates from the lateral cutaneous nerve of the second and third intercostal nerves to innervate the posterior part of the axilla. Often anastomizes with the medial cutaneous nerve of the upper arm (stem- ming from medial cord of brachial plexus). The 7–11th ventral rami are called the thoracoabdominal nerves. The 12th thoracic nerve is the subcostal nerve. Radicular pain (beltlike) Over the thorax cavity, no muscle weakness can be detected. However, bulging of abdominal muscles may be apparent. Abdominal cutaneous nerve entrapment Diabetic truncal neuropathy Herpes zoster Notalgia paresthetica Post-operatively: abdominal, retroperitoneal, and renal surgery. Traumatic lesions Thoracic disc trauma (rarely) Vertebral metastasis Laboratory: fasting glucose Serology (herpes, Lyme disease) Imaging: vertebral column, MRI Electrophysiology is difficult in trunk nerves and muscles Pain may be of intra-thoracic, intra-abdominal, or spinal origin. Compartment syndrome of the rectus abdominis muscle Intercostal nerves Symptoms Signs Pathogenesis Diagnosis Anatomy Genetic testing NCV/EMG Laboratory Imaging Biopsy (+) + – Osseous structures of vertebral column and ribs 195 Costochondritis Head zones (referred pain) Hernia “Intercostal neuralgia” Pseudoradicular pain Rupture of the rectus abdominis muscle Slipping rib Thoraconeuralgia gravidarum Depending on etiology Krishnamurthy KB, Liu GT, Logigian EL (1993) Acute Lyme neuropathy presenting with polyradicular pain, abdominal protrusion, and cranial neuropathy. Muscle Nerve 16: 1261–1264 Mumenthaler M, Schliack H, Stöhr M (1998) Läsionen der Rumpfnerven. In: Mumenthaler M, Schliack H, Stöhr M (eds) Läsionen peripherer Nerven und radikuläre Syndrome. Thieme, Stuttgart, pp 368–374 Staal A, van Gijn J, Spaans F (1999) The intercostal nerves. In: Staal A, van Gijn J, Spaans F (eds) Mononeuropathies. Saunders, Londons, pp 84–86 Stewart J (2000) Thoracic spinal nerves. In: Stewart J (ed) Focal peripheral neuropathies. Lippincott, Williams & Wilkins, Philadelphia, pp 499–508 Thomas JE (1972) Segmental zoster paresis: a disease profile. Neurology 22: 459–466 Therapy References 196 Symptoms Signs Differential diagnosis Anatomy Originates from lateral cutaneous nerve of second and third intercostal nerves to innervate the posterior part of the axilla. This nerve often anastomizes with the medial cutaneous nerve of the upper arm (from the medial cord of the brachial plexus). Pain in the axilla, chest wall, or thorax. Often occurs one or two months after mastectomy. Reduced movement of the shoulder enhances pain. Sensation is impaired in the axilla, chest wall, and proximal upper arm. Operations in the axilla (removal of lymph nodes) Following surgery for thoracic outlet syndrome Lung tumors Assa J (1974) The intercostobrachial nerve in radical mastectomy. J Surg Oncol 6: 123–126 Intercostobrachial nerve Reference 197 Iliohypogastric nerve Fig. 30. lliohypogastric nerve anatomy. 1 lliohypogastric nerve. 2 llioinguinal nerve. 3 Obturator nerve. 4 Genitofemo- ral nerve Fibers originate at L1, then emerge from the lateral border of the psoas, crossing the lower border of the kidney, then the lateral abdominal wall. Then the nerve crosses the transverse abdominal muscle above iliac crest and passes between the transverse and oblique internal abdominal muscles. Finally two branches are given off: the lateral anterior and anterior cutaneous nerves. Burning and stabbing pain in the ilioinguinal region, which may radiate to- wards the genital area or hip. Symptoms increase when walking. Difficult to examine. Spontaneous bulging of abdominal wall. Sensory deficit may be present. Tinel’s sign over a surgical scar may be observed. Slight flexion of hip while standing. Symptoms Signs Anatomy 198 Electrophysiology is not routinely available. Clinical distribution. Spontaneous entrapment in abdominal wall, surgery, hernioraphy, appendecto- my, abdominoplasty, nephrectomy, endometriosis. Steroids locally, scar removal, neurolysis. Diagnosis Therapy Differential diagnosis [...]... pp 393–464 Purves JK, Miller JD (1986) Inguinal neuralgia; a review of 50 patients Can J Surg 29: 58 5 58 7 Stulz P, Pfeiffer KM (1982) Peripheral nerve injuries resulting from common surgical procedures in the lower portion of the abdomen Arch Surg 117: 324–327 201 Genitofemoral nerve The nerve originates from the ventral primary rami of L1 and L2, then runs along the psoas muscle to the inguinal ligament... (1983) Gluteal compartment syndrome producing sciatic and gluteal mononeuropathies: a report of two cases Electrencephal Clin Neurophysiol 55 : 45 46 References 204 Pudendal nerve Genetic testing NCV/EMG +– Fig 35 Pudendal nerve anatomy a 1 Pudendal nerve 2 Perineal nerves 3 Dorsal nerve of clitoris 4 Inferior rectal nerves b 1 Perineal nerves 2 Pudendal nerves Laboratory Imaging + Biopsy 2 05 Fig 36 Pudendal... Originates with the posterior branches from ventral rami of L4–S1, to innervate the gluteus medius and minimus muscles Anatomy Inferior gluteal nerve: Originates with the posterior portions of L5 and S1, and ventral primary rami of S2 It innervates the piriformis and gluteus maximus muscles Superior: Causes Trendelenburg’s gait Excessive drop of the non-weight-bearing limb and a steppage gait on the unaffected... Biopsy + Fibers come from the lower part of the lumbosacral plexus, roots S1–3 The fibers descend together with the inferior gluteal nerve through the greater sciatic notch, below the piriformis muscle A branch leaves to the perineum and scrotum The sensory area includes the lower buttock, parts of the labia or scrotum, dorsal side of the thigh and proximal third of the calf The autonomic field is a... diagnosis Arnoldussen WJ, Korten JJ (1980) Pressure neuropathy of the posterior femoral cutaneous nerve Clin Neuro Neurosurg 82: 57 –60 Laban MM, Meerschaert JR, Taylor RS (1982) Electromyographic evidence of inferior gluteal nerve compromise; an early representation of recurrent colorectal carcinoma Arch Phys Med Rehabil 63: 33– 35 Müller-Vahl H (1986) Mononeuropathien durch ärztliche Maßnahmen Dtsch... difficult Sensory nerve conduction of saphenal nerve Saphenous SEP (stimulation inferomedial to patella) is more reliable Neuroimaging: CT scan for psoas hematoma (has to be done acutely if hematoma is suspected) or tumor infiltration of psoas muscle MRI-femoral nerve tumors Laboratory tests: fasting glucose, vasculitis serologies Diagnosis Aneurysm of iliac artery Irradiation of the inguinal area L2–L4 radiculopathy... Therapy 216 Prognosis Generally good, depending on the cause of the lesion References Biemond A (1970) Femoral neuropathy In: Vinken PJ, Bruyn GW (eds) Handbook of clinical neurology American Elsevier, New York, pp 303–310 Busis NA (1999) Femoral and obturator neuropathies Neurol Clin 17: 633– 653 Kim DH, Kline DG (19 95) Surgical outcome for intra- and extrapelvic femoral nerve lesions J Neurosurg 83: 783–790... burning, or numbness of the anterolateral and the lateral aspects of the thigh Symptoms do not extend to the knee Sometimes highly irritable (can be irritated by clothes) Standing or walking can also aggravate, whereas hip flexion provides relief Infrequently bilateral Allodynia (“Fear of putting hand in pocket”) Symptoms Deficits of superficial sensory sensation in the center of the lateral cutaneous... 22: 1129–1131 Staal A, van Gijn J, Spaans F (1999) The lateral cutaneous nerve of the thigh Mononeuropathies WB Saunders, London, pp 97–100 van Eerten PV, Polder TW, Broere CA (19 95) Operative treatment of meralgia paresthetica: transsection versus neurolysis Neurosurgery 37: 63– 65 Williams PH, Trzil KP (1991) Management of meralgia paresthetica J Neurosurg 74: 76–80 221 Cutaneous femoris posterior... the tibial bone) Buckling of the knee (on uneven surfaces) and falls (leg “collapses”) Sensory symptoms may be mild or absent Pain is variable, depending on the cause of the neuropathy Often felt in the inguinal region or iliac fossa Nerve trunk pain with or without sensory symptoms (e.g., in diabetes) Clinical syndrome Atrophy and weakness of quadriceps muscles Weakness of the psoas and quadriceps . nerve of the second and third intercostal nerves to innervate the posterior part of the axilla. Often anastomizes with the medial cutaneous nerve of the upper arm (stem- ming from medial cord of. nerve of second and third intercostal nerves to innervate the posterior part of the axilla. This nerve often anastomizes with the medial cutaneous nerve of the upper arm (from the medial cord of. neuralgia; a review of 50 patients. Can J Surg 29: 58 5 58 7 Stulz P, Pfeiffer KM (1982) Peripheral nerve injuries resulting from common surgical procedures in the lower portion of the abdomen. Arch