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Elbow Neurological Conditions: Difference between revisions

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Disorders of the central nervous system, of the cervical spinal nerves, or of the major peripheral nerves of the upper limb may present with features that include pain in the elbow, but they rarely, if ever, do they present with pain in the elbow as the only feature. Major disorders such as cervical radiculopathy, complex regional pain syndrome, and peripheral neuropathy will present with pain over a region greater than or other than the elbow, and with neurological symptoms and signs such as numbness, weakness, dysaesthesia or allodynia. The presence of such features converts the presentation from one of simply elbow pain to one of a neurological disorder. Under those conditions, the patient should be managed according to guidelines for neurological disorders; not according to the present guidelines which pertain explicitly to elbow pain.
{{stub}}
== Introduction==
The ulnar, radial, and median nerves all traverse the elbow, and disease processes of the elbow can affect any of these nerves.


Neurological conditions that may be specifically related to the elbow are radial tunnel syndrome, posterior interosseous nerve entrapment, ulnar neuropathy, and painful neuroma.
== Ulnar Neuropathy ==
Ulnar neuropathy is the most common compressive neuropathy of the elbow at an annual incidence rate of 21 per 100,000.  


There are two main causes, direct trauma and idiopathic.


Idiopathic - nerve damage occurs due to:
* External compression;
* Traction during elbow flexion;
* A tight humeroulnar aponeurotic arcade; or
* A combination of these factors


RADIAL TUNNEL SYNDROME
Clinical presentation
* Numbness or paresthesia in the 5th and in the ulnar half of the 4th finger
* Feeling of weakness of the ulnar-innervated muscles, weakened grip or hand clumsiness
* Pain on the medial aspect of the elbow radiating to the forearm or hand.


Compression is normally at the retroepicondylar groove (80-85%) or under the humeroulnar aponeurotic arcade (20-25%) <ref>Omejec G et al. What causes ulnar neuropathy at the elbow? Clinical neurophysiology. 2016. 127(1): 919 - 924</ref>. Ulnar nerve entrapment under the humeroulnar aponeurotic arcade affects primarily the dominant arms of older blue collar workers. External compression of the ulnar nerve in the retroepicondylar groove occurs mainly in the non-dominant arms of younger administrative workers and is due to external compression.


Surgical treatment involves decompression or nerve transposition at the cubital tunnel. A meta-analysis found that decompression was more effective and associated with fewer complications and lower risk of operation compared to transposition.<ref>{{#pmid:33231636}}</ref>


== Radial Tunnel Syndrome and Posterior Interosseous Nerve Entrapment ==
[[File:PIN.jpg|frame|300px|Posterior Interosseous Nerve]]
The posterior interosseous nerve is a pure motor branch of radial nerve. Clinical features include deep seated pain within the elbow and weakness of extension of the 3rd, 4th, and 5th digits.


It has been argued that lateral elbow pain can result from entrapment of the radial nerve in the radial tunnel as it passes through the arcade of Fröhse in the supinator muscle1. This afflication has been advanced as a cause of refractory tennis elbow<sup>2,3</sup>. However, detracting views argue that there is little evidence to support this belief.Van Rossum et al<sup>4</sup> studied 10 sequential patients with refractory lateral epicondylitis. Detailed EMG studies were performed, and distal motor latencies of the radial nerve innervated muscles were measured. No evidence of radial nerve compression was found. In a similar study, Verhaar and Spaans<sup>5</sup> found only one of 16 patients with nerve conduction abnormalities. Thus, the objective evidence is inconsistent with the proposed basis of this syndrome.Further evidence against the concept of radial tunnel syndrome stems from surgical experience with the procedures. One study reported experience with 37 consecutive cases who underwent radial tunnel release<sup>6</sup>. Only 13 patients obtained substantial relief; only 16 returned to work; complications were encountered in 12. The authors concluded that the diagnostic criteria for this condition were unreliable.The other study followed two groups of patients. The study retrospectively considered two groups of patients7. The first group had a decompression procedure of the tarsal tunnel for suspected radial tunnel syndrome; the second had lengthening of the extensor carpi radialis brevis on the basis of suspicion of lateral epicondylitis. The first and perhaps most interesting observation is that there was no significant difference in the clinical features of the two groups in terms of site of tenderness, tenderness over the radial nerve of the forearm and superficial radial nerve paraesthesiae. The second observation of note is that, despite the similarity in their presentation, both groups did just as well at operation. A detailed consideration of the effects of the operations revealed that the operation directed at the epicondyle would have no effect on the radial tunnel , but the converse effect was not true. The radial tunnel operation was demonstrated to effectively release the common extensor origin. Therefore, it is argued that the improvement in what was probably a homogenous group of patients was achieved by release of the extensor tendon and not the decompression of the radial tunnel.
Radial tunnel syndrome is a theoretical construct where there is entrapment of the radial nerve in the radial tunnel as it passes through the arcade of Frohse in the supinator muscle. There is not much evidence to support this, with only case reports <ref>Moradi A et al. Arch Bone Jt Surg. 2015 Jul; 3(3): 156–162.</ref>. There are no [[Electromyography|EMG]] studies that validate this<ref>van Rossum J et al. Tennis elbow-A radial tunnel syndrome? J Bone Joint Surg Br. 1978;60(2):197–8.</ref>. MRI studies of patients with RTS usually show no pathology but in some cases they may show muscle edema or atrophy along the distribution of the radial and posterior interosseous nerves (finger extensors, supinator and less, pronator muscles) but the validity of the MRI findings is controversial <ref>Ferdinand BD et al. MR Imaging Features of Radial Tunnel Syndrome: Initial Experience. Radiology. 2006;240(1):161–8.</ref>


See Rinkel et al for a somewhat recent systematic review of the effectiveness of interventions for cubital tunnel syndrome, radial tunnel syndrome, and bursitis of the elbow<ref>Rinkel WD et al. Current evidence for effectiveness of interventions for cubital tunnel syndrome, radial tunnel syndrome, instability, or bursitis of the elbow: a systematic review. Clin J Pain , 2013, Vol.29(12), p.1087-1096 </ref>


==Anterior Interosseous Nerve Entrapment==
The anterior interosseous nerve is a pure motor branch of the medial nerve. Clinical features include weakness of the flexor digitorum profundus of the 2nd and 3rd fingers. There is no sensory loss, however the patient may report paraesthetic pain at the elbow or over the proximal volar aspect of the forearm.


'''POSTERIOR INTEROSSEOUS NERVE ENTRAPMENT'''Posterior interosseous nerve entrapment is a syndrome that should be readily differentiated from a non-neurological lesion at the elbow by simple virtue of the fact that there is weakness of wrist extension and weakness in finger extension as primary manifestations<sup>8</sup><sup>,9</sup>.
==Neuroma==
*Post-traumatic
**History of surgery or nerve injury
*Clinical presentation
**Sharp stabbing, shooting pain
**Point tenderness over the course of the nerve
**Neurological signs – loss of sensation, paraesthesias, muscle power loss
*Investigation
**MRI or ultrasound scan imaging


'''ULNAR NEUROPATHY'''Patients with compression of the ulnar nerve are described as presenting with pain and aching over the medial elbow and proximal forearm. This is invariably accompanied by neurological abnormalities, principally tingling and paraesthesiae over the 4<sup>th</sup> and 5<sup>th</sup> fingers of the hand<sup>10</sup>. The wider distribution of pain than that seen in uncomplicated medial epicondylitis, and the association with neurological symptoms should make differentiation of ulnar nerve compression from medial epicondylitis relatively straightforward.
==References==
=NEUROMA=
<references/>
Small nerves may be injured anywhere in the body, and if regeneration is imperfect, a painful neuroma may result. The distinctive clinical features will be a history of surgery or nerve injury, associated with pain of a stabbing or shooting quality, with point tenderness over the course of the affected nerve, palpation of which triggers the pain. If the nerve has been substantially injured there will be loss of sensation in the territory innervated by the sensory fibres of the nerve, and loss of function of any muscles innervated by the nerve if it contains motor fibres. Any nerve that crosses the elbow might be so affected.
{{Reliable sources}}
[[Category:Mononeuropathies]]


Any nerve that crosses the elbow might be so affected. Accordingly, physicians such be alerted to the possibility of painful neuroma in patients who present with a history of possible nerve injury, with stabbing pain, and with point tenderness over the course of a small nerve.
[[Category:Elbow and Forearm Conditions]]
 
[[Category:Stubs]]
On the grounds that neuroma formation is not a musculoskeletal condition, its management is not covered by these guidelines. Nevertheless, it is a condition that should be recognized if encountered. Options for management lie with neurosurgeons, plastic surgeons, or pain clinics.==
=REFERENCES=
 
# Rath AM, Perez M, Mainguene C, Masquelet AC, Chevrel JP. Anatomic basis of the physiopathology of the epicondylalgias: a study of the deep branch of the radial nerve. Surg.Radiol.Anat. 1993; 15:15-19.
# Noteboom T, Cruver R, Keller J, Kellogg B, Nitz AJ. Tennis elbow: a review. J.Orthop.Sports Phys.Ther. 1994; 19:357-366.
# Gellman H. Tennis elbow (lateral epicondylitis). Orthop.Clin.North Am. 1992; 23:75-82.
# van Rossum J, Buruma OJ, Kamphuisen HA, Onvlee GJ. Tennis elbow--a radial tunnel syndrome? J.Bone Joint Surg.Br. 1978; 60-B:197-198.
# Heyse Moore GH. Resistant tennis elbow. J.Hand Surg.Br. 1984; 9:64-66.
# Verhaar J, Spaans F. Radial tunnel syndrome: an investigation of compression neuropathy as a possible cause. J Bone Joint Surg 1991; 73A:539-544.
# Atroshi I, Johnsson R, Ornstein E. Radial tunnel release. Unpredictable outcome in 37 consecutive cases with a 1-5 year follow-up. Acta Orthop Scand 1995; 66:255-257.
# Plancher KD, Peterson RK, Steichen JB. Compressive neuropathies and tendinopathies in the athletic elbow and wrist. Clin.Sports Med. 1996; 15:331-371.
# Kleinert JM, Mehta S. Radial nerve entrapment. Orthop.Clin.North Am. 1996; 27:305-315.
# Khoo D, Carmichael SW, Spinner RJ. Ulnar nerve anatomy and compression. Orthop.Clin.North Am. 1996; 27:317-338.

Latest revision as of 15:17, 11 March 2023

This article is a stub.

Introduction

The ulnar, radial, and median nerves all traverse the elbow, and disease processes of the elbow can affect any of these nerves.

Ulnar Neuropathy

Ulnar neuropathy is the most common compressive neuropathy of the elbow at an annual incidence rate of 21 per 100,000.

There are two main causes, direct trauma and idiopathic.

Idiopathic - nerve damage occurs due to:

  • External compression;
  • Traction during elbow flexion;
  • A tight humeroulnar aponeurotic arcade; or
  • A combination of these factors

Clinical presentation

  • Numbness or paresthesia in the 5th and in the ulnar half of the 4th finger
  • Feeling of weakness of the ulnar-innervated muscles, weakened grip or hand clumsiness
  • Pain on the medial aspect of the elbow radiating to the forearm or hand.

Compression is normally at the retroepicondylar groove (80-85%) or under the humeroulnar aponeurotic arcade (20-25%) [1]. Ulnar nerve entrapment under the humeroulnar aponeurotic arcade affects primarily the dominant arms of older blue collar workers. External compression of the ulnar nerve in the retroepicondylar groove occurs mainly in the non-dominant arms of younger administrative workers and is due to external compression.

Surgical treatment involves decompression or nerve transposition at the cubital tunnel. A meta-analysis found that decompression was more effective and associated with fewer complications and lower risk of operation compared to transposition.[2]

Radial Tunnel Syndrome and Posterior Interosseous Nerve Entrapment

Posterior Interosseous Nerve

The posterior interosseous nerve is a pure motor branch of radial nerve. Clinical features include deep seated pain within the elbow and weakness of extension of the 3rd, 4th, and 5th digits.

Radial tunnel syndrome is a theoretical construct where there is entrapment of the radial nerve in the radial tunnel as it passes through the arcade of Frohse in the supinator muscle. There is not much evidence to support this, with only case reports [3]. There are no EMG studies that validate this[4]. MRI studies of patients with RTS usually show no pathology but in some cases they may show muscle edema or atrophy along the distribution of the radial and posterior interosseous nerves (finger extensors, supinator and less, pronator muscles) but the validity of the MRI findings is controversial [5]

See Rinkel et al for a somewhat recent systematic review of the effectiveness of interventions for cubital tunnel syndrome, radial tunnel syndrome, and bursitis of the elbow[6]

Anterior Interosseous Nerve Entrapment

The anterior interosseous nerve is a pure motor branch of the medial nerve. Clinical features include weakness of the flexor digitorum profundus of the 2nd and 3rd fingers. There is no sensory loss, however the patient may report paraesthetic pain at the elbow or over the proximal volar aspect of the forearm.

Neuroma

  • Post-traumatic
    • History of surgery or nerve injury
  • Clinical presentation
    • Sharp stabbing, shooting pain
    • Point tenderness over the course of the nerve
    • Neurological signs – loss of sensation, paraesthesias, muscle power loss
  • Investigation
    • MRI or ultrasound scan imaging

References

  1. ↑ Omejec G et al. What causes ulnar neuropathy at the elbow? Clinical neurophysiology. 2016. 127(1): 919 - 924
  2. ↑ Wade et al.. Safety and Outcomes of Different Surgical Techniques for Cubital Tunnel Decompression: A Systematic Review and Network Meta-analysis. JAMA network open 2020. 3:e2024352. PMID: 33231636. DOI. Full Text.
  3. ↑ Moradi A et al. Arch Bone Jt Surg. 2015 Jul; 3(3): 156–162.
  4. ↑ van Rossum J et al. Tennis elbow-A radial tunnel syndrome? J Bone Joint Surg Br. 1978;60(2):197–8.
  5. ↑ Ferdinand BD et al. MR Imaging Features of Radial Tunnel Syndrome: Initial Experience. Radiology. 2006;240(1):161–8.
  6. ↑ Rinkel WD et al. Current evidence for effectiveness of interventions for cubital tunnel syndrome, radial tunnel syndrome, instability, or bursitis of the elbow: a systematic review. Clin J Pain , 2013, Vol.29(12), p.1087-1096

Literature Review

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