Neuromuscular Diseases A Practical Guideline - part 5 docx

189 Thoracodorsal nerve Genetic testing NCV/EMG Laboratory Imaging Biopsy + Fig. 29. Thoracodorsal nerve anatomy. 1 Thoracodorsal nerve. 2 Latissimus dorsi muscle This is trial version www.adultpdf.com 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 This is trial version www.adultpdf.com 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 This is trial version www.adultpdf.com 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 This is trial version www.adultpdf.com 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 This is trial version www.adultpdf.com 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 This is trial version www.adultpdf.com 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 This is trial version www.adultpdf.com 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 This is trial version www.adultpdf.com 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 This is trial version www.adultpdf.com 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 This is trial version www.adultpdf.com [...]... medial ankle (nerve anterior to the prominence of medial malleolus) causes saphenous neuritic pain Anatomical sites Arthroscopy Bursitis of pes anserinus Compression in the subsartorial canal Hunter’s canal operations, vascular disease, venous stripping Gonyalgia paresthetica Knee surgery (infrapatellar branch): meniscectomy Neurolemmoma Neuropathia patellae: distal terminal branch of infrapatellar ramus... studies are available Diagnostic anesthetic blockade Diagnosis L1, 2 radiculopathy Iliohypogastric neuropathy Ilioinguinal neuropathy Differential diagnosis Anesthetic blockade Operative neurolysis Therapy Good Prognosis Magee RK (1942) Genitofemoral causalgia (a new syndrome) Can Med Assoc J 46: 326– 329 Staal A, van Gijn J, Spaans F (1999) The genitofemoral nerve In: Staal A, van Gijn J, Spaans F (eds)... polyradiculopathy Neoplastic: local tumors, perineuroma, malignant invasion Traumatic: Penetrating injury Vascular: Anticoagulant therapy Hematoma in psoas or iliacus muscle from rupture of an abdominal aortic aneurysm Trauma Saphenous nerve lesions: Bursitis of pes anserinus Entrapment, medial side of knee Entrapment by a branch of the femoral artery Meniscectomy, arthroscopy Neurolemmoma EMG: quadriceps and... motor vehicle accidents Surgery: Renal transplant, lower abdominal surgery, iliac bone for grafting, Laparoscopic hernioraphias Trauma Tumors and mass, retroperitoneal malignancies Upper thigh: Blunt trauma, lacerations, misplaced injections Diabetes Diagnosis EMG: differential diagnosis radiculopathy NCV SEP MRI Differential diagnosis Coxarthrosis Neurinoma Pelvic neoplasm Radiculopathy L2 Wartenberg... region and genitalia (Fig 32) Signs Weakness of lower abdominal muscles, hernia Causes Abdominal operations with a laterally placed incision Biopsy Endometriosis, leiomyoma, lipoma Herniotomy Iliac bone harvesting Pregnancy, child birth Spontaneous entrapment – “inguinal neuralgia“ Diagnosis Studies: no standard electrophysiologic techniques are available Therapy Local anesthetic infiltration Surgical... medial arch of the foot, and great toe Anatomy Numbness, but also severe neuropathic pain may occur Symptoms Sensory loss Tinel’s sign Loss of sudomotor function Signs Entrapment at Hunter’s canal causes pain in the lower thigh and leg Diagnosis is made by application of local anesthetics Infrapatellar branch: Lesion of the infrapatellar branch may cause a small sensory loss below the knee Entrapment above... Superior: Misplaced injection, trauma, hemorrhage, arthroplasty, aneurysm Pathogenesis Inferior: Rarely isolated, often associated with the sciatic nerve, occasionally with pudendal nerve Colorectal carcinoma, injections, trauma EMG, imaging Diagnosis Sacral plexus lesion Hip and pelvic pathology Differential diagnosis Grisold W, Karnel F, Kumpan W, et al (1999) Iliac artery aneurysm causing isolated superior... www.adultpdf.com 207 Hip dislocation Intraarticular foreign body Polyneuropathy Radicular lesion (S2–S4) Sacral plexus Structural abnormalities of the pelvic floor or viscera Differential diagnosis EMG of external anal sphincter Bulbocavernosus reflex Pudendal SEP Anorectal manometry, urodynamic examinations Imaging Diagnosis Amarenco G, Ismael SS, Bayle B, et al (2001) Electrophysiological analysis... pain, sometimes called “spermatic neuralgia” Can present as a post-operative inguinal neuralgia Paresthesias (may be painful) of the medial inguinal region, upper thigh, side of scrotum, and labia majora Symptoms Tenderness in the inguinal canal Cremaster reflex unreliable Signs Appendectomy Bone graft removal Hernioraphy Nephrectomy Trauma Tumors (uncommon) Tuberculosis Varicocele testis Causes No electrophysiologic... Obturator neuropathy: causes and outcome Muscle Nerve 25: 6 05 607 Staal A, van Gijn J, Spaans F (1999) The obturator nerve In: Staal A, van Gijn J, Spaans F (eds) Mononeuropathies; examination, diagnosis and treatment Saunders, London, pp 109–111 This is trial version www.adultpdf.com 213 Femoral nerve Genetic testing NCV/EMG Laboratory Imaging + +– Biopsy + Fig 39 Femoral nerve anatomy 1 Femoral nerve . muscles may be apparent. Abdominal cutaneous nerve entrapment Diabetic truncal neuropathy Herpes zoster Notalgia paresthetica Post-operatively: abdominal, retroperitoneal, and renal surgery. Traumatic. 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 This. present as a post-operative inguinal neuralgia. Paresthesias (may be painful) of the medial inguinal region, upper thigh, side of scrotum, and labia majora. Tenderness in the inguinal canal. Cremaster