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Nerve Surgery St Louis

Our vision at Neuropax Clinic is to be a leader in creating a health care delivery platform that works more effectively for patients suffering from chronic pain, peripheral diabetic neuropathy, carpal tunnel, tarsal tunnel, chronic migraines/headaches, cubital tunnel, radial tunnel and other serious complications related to peripheral nerve damage. We fulfill this vision by offering proven, advanced diagnostic and surgical techniques to help patients stop suffering and reclaim their quality of life.

Neuropax Clinic is also dedicated to bringing relief to our patients through the education of patients and physicians. We advance science and public awareness about the benefits of our surgical procedures and the results of those procedures.

How Do I Know If I Have Carpal Tunnel In St Louis?

Carpal tunnel syndrome is usually diagnosed using:

 

Medical history. The doctor will ask about any medical problems or illnesses, prior injuries, current symptoms, or daily activities that may be causing your symptoms.

Hand diagram. You may be asked to help fill in a diagram of your hand to show where you have numbness, tingling, or pain.

Physical exam, including comparing the strength of both hands.

More testing

If your symptoms are severe, if nonsurgical treatment has not improved symptoms, or if your symptoms aren't clearly caused by carpal tunnel syndrome, your doctor may recommend:

 

Nerve testing, which checks the median nerve.

X-rays. These can check for bone problems caused by past injury, arthritis, recently broken or dislocated bones, or tumors. X-rays aren't used to diagnose carpal tunnel syndrome. But they can be helpful for finding signs of arthritis or an old or new wrist or neck injury that may be adding to your symptoms.

Ultrasound, to look at the size of the median nerve. It is inexpensive, comfortable, and quick. But its use for carpal tunnel syndrome diagnosis is still unproven and fairly uncommon.

MRI. This imaging test can find swelling of the median nerve, narrowing of the carpal tunnel, or problems with circulation of blood through the carpal tunnel.

Blood tests. These are sometimes done to check for a thyroid problem, rheumatoid arthritis, or another medical problem.

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Proximal Median Issues in St Louis

Compression neuropathies of the median nerve in the proximal forearm are unusual lesions. Many patients have vague symptoms for many months or even years prior to confirming the diagnosis of either pronator syndrome or anterior interosseous syndrome of the forearm. Serial examinations clinically and electrodiagnostically may be necessary at intervals of 6 to 8 weeks as required for the evaluation of the patient's symptoms.

As with other compression neuropathies, the diagnosis is solely dependent on the diagnosis of neuropathy of the median nerve using whatever parameter satisfies the surgeon's diagnostic criteria and then having made that diagnosis, localizing the site of that neuropathy by physical examination or electrodiagnosis with the support of radiographic techniques as appropriate. Surgical exploration of proximal median nerve compression is normally followed by prompt and predictable recovery from the median neuropathy and clinical symptoms between 8 and 12 weeks after surgical exploration.

Prolonged symptom complexes after surgical exploration of the proximal median nerve are, in my experience, due to either (1) extremely severe median nerve injury secondary to pronator syndrome with prolonged recovery and distal nerve axomnetic recovery into the hand, or (2) sensory nerve dysesthesis of the small sensory nerves on the proximal volar surface of the forearm. The symptoms of either of these postoperative findings normally improve with time.  For more information, visit www.neuropaxclinic.com today.

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Do You Need Carpal Tunnel Surgery In St Louis

Most people with carpal tunnel syndrome are treated without surgery. Surgery is considered only when:

Symptoms haven't improved after several weeks to months of nonsurgical treatment. This assumes that you are having ongoing symptoms but no sign of nerve damage. Nerve damage would make surgery more urgent.

Severe symptoms restrict normal daily activities, such as when:

There is a persistent loss of feeling or coordination in the fingers or hand.

There is decreased strength in the thumb.

Sleep is severely disturbed by pain.

There is damage to the median nerve (shown by nerve test results and loss of hand, thumb, or finger function) or a risk of damage to the nerve.

Carpal Tunnel Syndrome: Should I Have Surgery?

Surgery choices

The most common surgery for relieving carpal tunnel symptoms involves cutting the transverse carpal ligament camera.gif to relieve pressure on the median nerve in the wrist. Two approaches for this surgery are:

Open carpal tunnel release surgery. Open surgery requires a longer recovery period and leaves a larger scar than endoscopic surgery. But there may be less chance of other complications.

Endoscopic carpal tunnel release surgery. Recovery is quicker than with open surgery. The scars heal more quickly, are smaller, and tend to be less painful at 3 months after surgery. But there may be a slightly higher chance of needing another surgery later.

Some surgeons are now doing small- or mini-open release surgery. This requires a smaller incision than standard open carpal tunnel release surgery. It may reduce healing time and scarring. But it also allows the surgeon to view the ligament directly during the surgery to minimize danger to the nerve itself. This procedure may be promising. But there are few studies comparing it to the open carpal tunnel or endoscopic procedures at this time.

What to think about

Nerve tests (nerve conduction velocity test and electromyogram) are often completed before surgery is done. Surgery is more likely to be successful if the results from nerve testing point to carpal tunnel syndrome.

Your decision about whether to use open or endoscopic surgery depends on your doctor's experience with the procedures. Endoscopic carpal tunnel surgery uses very technical equipment and is most successful when the doctor has done the procedure many times.

After surgery, it is important to avoid any activities that may have caused carpal tunnel syndrome. Or you can change the way you do them.

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Carpal Tunnel Surgery Information In St Louis

During open carpal tunnel release surgery, the transverse carpal ligament is cut, which releases pressure on the median nerve and relieves the symptoms of carpal tunnel syndrome.

An incision is made at the base of the palm of the hand. This allows the doctor to see the transverse carpal ligament. After the ligament is cut, the skin is closed with stitches. The gap where the ligament was cut is left alone and eventually fills up with scar tissue.

If you have open carpal tunnel release surgery, you typically do not need to stay in the hospital. It is usually done under local anesthetic, and you can go home on the same day.

What To Expect After Surgery

After surgery, the hand is wrapped. The stitches are removed 10 to 14 days after surgery. The pain and numbness may go away right after surgery or may take several months to subside. Try to avoid heavy use of your hand for up to 3 months.

When you return to work depends on whether the dominant hand (the hand you use most) was involved, what your work activities are, and how much effort you put into rehabilitative physical therapy.

If you have surgery on your nondominant hand and do not do repetitive, high-risk activities at work, you may return to work within 1 to 2 days, although 7 to 14 days is most common.

If you have surgery on your dominant hand and do repetitive activities at work, you may require 6 to 12 weeks for a full recovery before you can return to previous work duties. Physical therapy may speed your recovery.

Why It Is Done

Open carpal tunnel surgery is considered when:

Symptoms are still present after a long period of nonsurgical treatment. In general, surgery is not considered until after several weeks to months of nonsurgical treatment. But this assumes that you are having ongoing symptoms but no sign of nerve damage. Nerve damage would make surgery more urgent.

Severe symptoms (such as persistent loss of feeling or coordination in the fingers or hand, or no strength in the thumb) restrict normal daily activities.

There is damage to the median nerve (shown by nerve test results and loss of hand or finger function), or a risk of nerve damage.

Tumors or other growths need to be removed.

How Well It Works

Most people who have surgery for carpal tunnel syndrome have fewer or no symptoms of pain and numbness in their hand after surgery.1

In rare cases, the symptoms of pain and numbness may return (the most common complication), or there may be temporary loss of strength when pinching or gripping an object, due to the cutting of the transverse carpal ligament.

If the thumb muscles have been severely weakened or wasted away, hand strength and function may be limited even after surgery.

Risks

The risk and complication rates of open surgery are very low. Major problems such as nerve damage happen in fewer than 1 out of 100 surgeries (less than 1%).2 There is a small risk that the median nerve or other tissues may be damaged during surgery. After open surgery, recovery may be slower than after endoscopic surgery. And there may be some pain in the wrist and hand. You may also have some tenderness around the scar. There are also the risks of any type of surgery, including possible infection and risks of general anesthesia. But most open carpal tunnel surgery is done with local anesthesia or regional block rather than with general anesthesia.

 

What To Think About

Open carpal tunnel surgery cuts open the base of the palm and requires a longer recovery period than endoscopic surgery. Temporary nerve problems may be less likely with open surgery. But painful scar tissue may be more likely to develop after open surgery than after endoscopic surgery.1

 

Both endoscopic and open carpal tunnel release have benefits and risks. Studies do not show that one procedure is better than the other.2 Talk to your doctor about your options.  For more information, visit www.neuropaxclinic.com today.

Citations

Ashworth N (2011). Carpal tunnel syndrome, search date July 2011. Online version of BMJ Clinical Evidence (10).

 

Scholten RJPM, et al. (2007). Surgical treatment options for carpal tunnel syndrome. Cochrane Database of Systematic Reviews (4).

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Treatment For Carpal Tunnel Syndrome in St Louis

Carpal Tunnel Syndrome is a condition in which increased pressure on the median nerve in the wrist causes pain, numbness, tingling, or a combination of all three in the wrist.  These are most often experienced at night, but can be felt through day-to-day experiences like driving or reading a newspaper.  Patients have complained of weaker grip, occasional clumsiness, and a tendency to drop things.  In the most severe cases, sensation can be permanently lost.  What can be done in the treatment of this problem?

Treatment options include:

Home treatment, which includes wearing a wrist brace and changing the way certain actions are performed to relieve stress of the nerve.

Physical therapy. This includes ultrasound, stretching, and range-of-motion exercises. 

Medicines, such as nonsteroidal anti-inflammatory drugs (NSAIDs) to relieve pain and reduce inflammation. In some cases, oral corticosteroids or corticosteroid injections into the carpal tunnel may be considered.

Surgery. Surgery is often only recommended if this is a long-term problem or if there is a real risk of nerve damage if left untreated.  

b2ap3_thumbnail_Figure-2-Carpal-Tunnel.jpg

How do you know if surgery is right for you?  The treatment for Carpal Tunnel Syndrome can vary from person to person, as it's not a "one-size-fits-all" injury.  For some people, 1-2 weeks of rest will fix the issue.  For others, medicine may reduce the swelling and relieve the pressure on the joint and nerve.  Physical therapy and braces, or just a change in posture or how you arrange your desk can spell relief.  In the case of severe pain or risk of permanent loss of sensation, surgery may be needed to relieve the pressure on the nerve.  In any case, if you feel that you are experiencing Carpal Tunnel Syndrome, and have experienced any of the symptoms listed above, please visit Neuropax Clinic at www.neuropaxclinic.com and call 314-434-7784 to setup an appointment.  

 

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Meralgia Paresthetica: a Very Treatable Nerve Compression Syndrome

Meralgia Paresthetica / Lateral Femoral Nerve Compression

Meralgia Paresthetica is a constellation of symptoms caused by a compression neuropathy (pinched nerve) of the Lateral Femoral Nerve (LFN). The LFN arises from the second and third lumbar spinal levels (L2,L3). As the LFN travels from the spine to the thigh region, the nerve can be pinched at the anterior pelvic tunnel. This tunnel is made by the bone of anterior superior iliac spine, the dense fibers of the inguinal ligament and overlaying musculature. Pressure on this nerve causes feelings of burning, pain and numbness along the front and lateral part of the thigh, extending all the way from anterior and lateral hip, groin and gluteal area to the knee. In some, there can even be very deep groin and testicular or labial pain.

It is not uncommon for the severity of symptoms to be significantly debilitating, especially if the problem is not addressed. It is important to understand that this a very treatable problem. Its like having carpal tunnel of your hip. Early or old teachings that suggest there is nothing to do, still permeate the medical community regarding this problem.

This compression neuropathy (pinched nerve condition) can be caused by several different mechanisms. Anatomical studies have shown that at least 5% of the population has an abnormal nerve tunnel. This anatomic variant is highly vulnerable for compression but any nerve can become compressed or damaged. History of pelvic fracture, Blunt trauma in or near the nerve and tunnel, can cause direct trauma to the nerve or trauma to the surrounding tissues that leads to compression of the nerve as well.

Even just having surgery in the area of the hip, groin or abdomen can lead to changes in the tissue surrounding the nerve and lead to compression. Prior hip surgery, hernia surgery, bone graft harvest, cesarean sections are some of the most common.

Some professional activities (i.e. police officers, firefighters and construction workers, etc.) require wearing heavy and loaded belts around the waist. This exposes the nerve to excess and repetitive pressure, especially if anatomical nerve path abnormalities already exist. Various sports like karate/kickboxing, football, soccer, rugby and others can all produce injuries that result in this problem. Body habitus such as abdominal obesity or pregnancies can also contribute to repetitive stress and stretching of the nerve.

It is also important to recognize the affects of diabetes on this clinical problem. Diabetic patients, due to abnormal glucose metabolism, may develop swelling of the nerve, as well as narrowing of the tunnel itself. This alters the normally perfect relationship between the nerve and its tunnel, making it now too narrow for the more swollen nerve, resulting in lateral femoral cutaneous nerve neuropathy. Therefore, diabetic patients are at much higher risk for experiencing symptoms of Meralgia Paresthetica than the general population.

Once you have been identified to have symptoms consistent with Meralgia Paresthetica or compression of the Lateral Femoral Nerve (LFN) several diagnostic points should be addressed. In some cases, lower spine or lumbar spine pathology should be ruled out with an MRI. This study can also include a study of the pelvis to rule out any mass or tumor causing compression to the nerve along its course. Ultrasound guided, site specific, diagnostic injections are routinely utilized for confirming the diagnosis. In some cases, the addition of steroid to this injection can provide symptomatic relief for some variable length of time. If there is no spinal or pelvic pathology and the severity of symptoms are not too severe, conservative care is a very appropriate initial treatment. This may include: nerve modulator medicines (i.e. neurontin, amitriptyline, etc. ), topical compound cream, lifestyle changes, weight loss and physical therapy. If conservative therapies have been tried and fail after 3 months, surgical decompression should be considered. Accessory treatment modalities such as radio frequency ablation(RFA), sclerosing or spinal cord stimulators do not treat the problem and should not be utilized for this clinical problem.

Surgical decompression of the nerve is successful in 80-85% of cases. In the residual population that fail decompression, 80% of these patients will respond to going back and resecting (neurectomy) the nerve.

The success of the surgery depends on how long the nerve has been compressed, the severity of the compression, the extent of nerve damage due to injury and the possible presence of underlying medical or spine problems.

The surgery performed in an outpatient setting. The surgical incision is generally very small, however body habitus can dictate a larger incision. The post-operative course is consistent but is affected by the amount of decompression required. In general, people can return to light duty work after 2 to 3 weeks and unlimited/unrestricted activity at 6 weeks.  For more information on Meralgia Paresthetica and ways it can be treated, visit www.neuropaxclinic.com and call 314-434-7784 for more information.

 

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Guest — don graham sr 314 691 6211----barnhart mo 63012
i have had this pain going on 8 mo -one doctor said it is meralgia paresthetic-pain medicine gets me through the day my doctor is ... Read More
Thursday, 22 January 2015 18:29
Guest — Janis Mezatis
This information has been most helpful to me. I had a total hip replacement done a year and a half ago and have been suffering wit... Read More
Wednesday, 01 April 2015 00:38
Guest — Janis Mezatis
This information has been most helpful to me. I had a total hip replacement done a year and a half ago and have been suffering wit... Read More
Wednesday, 01 April 2015 00:38
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What Can Be Done For My Diabetic Neuropathy in St Louis?

Diabetic Neuropathy Treatment

Peripheral Diabetic Neuropathy (PDN) is a major, long-term complication of Type 1 and Type 2 Diabetes. Diabetic neuropathy often presents as tingling, loss of sensation, pain and numbness in the legs, feet, arms and hands. This loss of sensation can preclude sensation of injury, leading to development of wounds or ulcerations. When not adequately treated, the risks of infection and ultimately amputation are high.

Diabetic neuropathy has been considered an irreversible disorder with traditional treatments focused on preventing the progression of the condition; or reducing the pain symptoms with drugs or specialized footwear.  However, treatment with nerve decompression surgery to address the symptoms of diabetic peripheral neuropathy now have an established clinical track record.  Many clinical studies have been published reporting the value of nerve decompression surgery in the treatment of peripheral diabetic neuropathy.

Goals of the surgery are to restore sensation to the hands or feet, reduce or eliminate pain and to regain strength. If sensation is restored to the feet, the risk of having an ulceration or infection leading to an amputation is nearly eliminated.  Many patients are able to discontinue their medications relating to neuropathy after this procedure. 

If you suffer from diabetic neuropathy, physicians from Neuropax Clinic can determine whether surgery might be appropriate for you. A comprehensive evaluation will be performed to determine whether you have compressed nerves that may respond to surgery. We have already helped many patients regain sensation and get relief from pain with this surgical approach.

For more information on treatments for all nerve problems, visit www.neuropaxclinic.com and call 314-434-7784 to setup an appointment.

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Proximal Median Nerve Compression In St Louis

Many patients have come to me asking about problems with the Proximal Nerve, and how it can be affected and fixed.  Here are my thoughts on the nerve and what we can do for you!

PROXIMAL MEDIAN NERVE COMPRESSION


Repetitive tasks involving: throwing, gripping, pronation (turning your hand to a palm down position), and sudden extension at the elbow can produce injury resulting in compression of the median nerve at the elbow and forearm level. Weight lifting may result in building muscle mass and can lead to nerve compression. Trauma to the upper forearm may also result in scarring and can induce compressive neuropathies at and around the elbow. Your own inherent anatomy may be a variant that makes you vulnerable to this condition.  Further, it is common to be predisposed to this nerve compression if you are diabetic.  Diagnosing this condition is very dependent upon the clinical evaluation and is often missed by electro-diagnostic studies ( nerve conduction, EMG).
The median nerve arises from the  cervical nerve roots C6 to T1 in the neck. After leaving the brachial plexus and crossing the shoulder it passes down the medial aspect of the arm, crosses the elbow and enters the forearm.
Median nerve compression in the elbow area can result in two conditions: pronator syndrome and anterior interosseus nerve syndrome.  It is not uncommon for both conditions to be present at the same time.


Pronator Syndrome


Pronator syndrome produces symptoms of aching of the proximal forearm, elbow and distal arm (just above elbow).  This aching may be aggravated by forceful use of the extremity, especially involving pronation. Sensory loss in the fingers and palmar components of the median nerve distribution and weakness or clumsiness in the hand are often noted, especially in the thumb and index finger.  
Symptoms can be confusing with those seen in carpal tunnel syndrome. It is actually more common for proximal median nerve compression and carpal tunnel syndrome to both be present.  This is considered a double crush phenomenom which is when the same nerve is pinched at more than one level along its course.  
In pronator syndrome, night pain is less common (but does occur) while carpal tunnel syndrome often wakes patients with complaints of aching and numbness in the hands.
The physical examination may reveal tenderness and a Tinel sign over the pronator teres muscle. Weakness, if present, may involve the index finger, thumb flexion and pinch strength.  Atrophy in the thenar muscles (base of thumb in palm) may be noted in advanced cases.
Loss or decreased sensibility of the thumb and index/long fingers are consistent with both proximal median nerve compression and carpal tunnel syndrome.  Loss of sensation and/or pain in the palmar area on the thumb sites is suggestive of pronator syndrome. Provocative (exertional) tests on exam can be helpful in eliciting signs of pronator syndrome.
Plain x-rays are helpful to rule out a bony supracondylar process in the distal humerus or other post traumatic or degenerative pathology at the elbow as the cause for compression. Electrodiagnostic studies (EMG/NCS) are rarely conclusive but may be orderd to exclude or identify coexisting pathology.

 

Anterior Interosseus Nerve Syndrome (AIN Syndrome)


The anterior interosseus nerve (AIN) syndrome as an isolated compression syndrome is more rare.  AIN is a branch of the median nerve that branches from the median nerve after it passes through the pronator muscle.  The AIN has no cutaneous (skin) sensory component therefore numbness is not associated with this syndrome, it is purely a motor problem.
Anterior interosseus nerve syndrome includes complaints of absent or decreased flexion (bending) of the thumb and index finger. For instance, it is difficult to make an OK sign.  A weakened index finger-thumb pinch is generally noted as well.
EMG/NCS may be diagnostic in AIN syndrome. MRI is useful to identify any mass or lesion that may be causing this 


Treatment


The initial treatment for proximal median nerve compressions is conservative. However, if severity and duration of symptoms are significant at the time of initial presentation to the physician, you may require surgery at that point.    
Anterior interosseus nerve syndrome again is more rare, but usually resolves with time, particularly if it is secondary to minor trauma or irritation to the nerve. However proximal median compression in the diabetic limb usually, ultimately requires surgery and is generally found coexisting with other compressions in the same extremity.
If no improvement with time and therapy are noted or if a space occupying lesion/mass is identified on the MRI, surgical release is then recommended.
Postoperatively the arm, forearm and elbow are wrapped in a bulky dressing for one week.  After this point, flexion and extension exercises are started and slowly progressed. Return to full function and full duty work are fairly consistent but vary based on several factors but particularly the amount of deconditioning at the time of surgery.
The prognosis for full recovery is generally very good, however one must consider the amount of deconditioning that was present at the time of surgery.  Full recovery may take as long as 6 months even after surgical decompression.  If there is severe nerve damage, recovery may take longer and may be incomplete. Risks of the surgery are very rare but include: the persistent symptoms or pain, motor weakness, nerve injury, loss of function, and other generalized surgical risks such as hematoma, seroma or neuroma.

For more information on how to treat Poximal Median Nerve Compression, visit www.neuropaxclinic.com and call us at 314-434-7784 to set up an appointment!

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Diabetic Neuropathy Relief In St Louis

 

Peripheral Diabetic Neuropathy (PDN) is a major, long-term complication of Type 1 and Type 2 Diabetes. Diabetic neuropathy often presents as tingling, loss of sensation, pain and numbness in the legs, feet, arms and hands. This loss of sensation can preclude sensation of injury, leading to development of wounds or ulcerations. When not adequately treated, the risks of infection and ultimately amputation are high.

Diabetic neuropathy has been considered an irreversible disorder with traditional treatments focused on preventing the progression of the condition; or reducing the pain symptoms with drugs or specialized footwear.  However, treatment with nerve decompression surgery to address the symptoms of diabetic peripheral neuropathy now have an established clinical track record.  Many clinical studies have been published reporting the value of nerve decompression surgery in the treatment of peripheral diabetic neuropathy.

Goals of the surgery are to restore sensation to the hands or feet, reduce or eliminate pain and to regain strength. If sensation is restored to the feet, the risk of having an ulceration or infection leading to an amputation is nearly eliminated.  Many patients are able to discontinue their medications relating to neuropathy after this procedure. 

If you suffer from diabetic neuropathy, physicians from Neuropax Clinic can determine whether surgery might be appropriate for you. A comprehensive evaluation will be performed to determine whether you have compressed nerves that may respond to surgery. We have already helped many patients regain sensation and get relief from pain with this surgical approach.  Visit us at www.neuropaxclinic.com today and call 314-434-7784 to set up an appointment.

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Carpal Tunnel Surgery In St Louis

Carpal Tunnel Syndrome is an affliction where the median nerve, running from the forearm to the palm, becomes squeezed or compressed at the wrist.  This nerve is the controller for sensations on the palm side of the fingers and thumb, and some of the impulses that allow the small muscles of the hand to move.  The syndrome is names for the carpal tunnel, the narrow passageway of bones and ligaments at the heel of the hand that is the home for the median nerve and tendons.  The thickening of irritated tendons, and other swelling in this area, push on the median nerve, and are what cause the pain, numbness, and weakness that spell out carpal tunnel syndrome.  It's the best known of all of the entrapment neuropathies, which are where the body's peripheral nerves are traumatized, swollen or compressed.

You know that you may have carpal tunnel when you start to see frequent burning, tingling, or itching numbness in the palm of the hand and the fingers, especially the thumb and the index and middle fingers.  Other complaints include loss of feeling/responsiveness in the fingers, even without swelling apparent in the extremity.  A person with carpal tunnel syndrome may awaken feeling the need to constantly "shake out" their hands, a constant stiffness that persists throughout the day.  Decreased grip strength follows, making it difficult to hold things. 

If you feel these symptoms coming on, please contact Neuropax Clinic to set up an appointment.  Find more information on carpal tunnel syndrome, neuropathy pain, and any other peripheral nerve issues at www.neuropaxclinic.com and call us at 314-434-7784  to setup an appointment.

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What Is Winging of the Scapula?

What Is a Winged Scapula?

Winging of the scapula due to long thoracic nerve (LTN) injury is a fairly common diagnosis and should be treated as a significant functional problem. The LTN originates from the cervical 5,6 and 7 nerve roots and innervates the serratus anterior muscle. The main job  of the serratus anterior muscle is to hold the shoulder-blade against the chest wall to stabilize the shoulder during certain motions. A winged scapula is a condition in which the scapula (shoulder blade) sticks out from the back because the anterior serratus muscle is not working correctly.  It can be partial or complete and leads to mechanical destabilization of the shoulder when raising the arm or doing a push-up type motion. This problem can result in significant shoulder dysfunction and pain. Sports injuries, blunt or compression injury to the shoulder or base of neck, whiplash or any direct trauma to the neck and shoulder can cause a LTN injury resulting in a winged scapula. It is not uncommon for scapular winging to be accompanied by other forms of injury or conditions of the shoulder and/or brachial plexus. Specifically, Injury to the upper trunk of the brachial plexus is commonly associated with the proposed stretch or compression mechanisms causative of this injury.  
Susceptibility of the LTN to injury arises from some unique anatomical features. The nerve is small in diameter especially in contrast to the relatively robust adjacent nerves of the brachial plexus. The nerve root contributions or the actual LTN course through the middle scalene which provides a vulnerable point of injury to the nerve. Last, the length of the nerve provides some additional vulnerability to injury as well.

Diagnosis


Physical examination typically reveals medial deviation of the inferior angle of the scapula and prominent winging of the medial border of the scapula with backward pressure on the shoulder as in pushing off a wall. Superior elevation of the scapula is also noted. Overhead movements of the arm and shoulder cause significant discomfort and feelings of shoulder instability. The degree of winging can be quantified by angle of posterior projection of the inferior scapular border from the chest wall at the point of maximal winging. Most patients with long thoracic nerve injury also show weakness of the deltoid and biceps muscles on examination.
EMG (electrical) testing of the long thoracic nerve and the serratus anterior muscle can be very challenging.  This is related to the difficulty of placing a recording needle within the substance of the serratus anterior muscle given its relatively deep location on the chest wall.  Therefore, normal EMG results in the presence of obvious clinical winging is usually scrutinized. Ultrasounds guidance is beneficial to assure the correct.
Radiologic studies are important as well.  Standard x-rays, MRI of the shoulder and MR neurography of the neck to evaluate the upper trunk of the brachial plexus and the LTN all may be needed to help support the diagnosis and to rule out other causes.  
In the presence of scapular winging, compensatory muscular activity required to improve/maintain shoulder stability is associated with secondary pain and spasm. Resultant secondary conditions include muscle imbalances and tendonitis around the shoulder joint, adhesive capsulitis, sub acromial impingement and brachial plexus radiculitis.
Direct trauma to the nerve is more rare but does occur. When the nerve is cut during trauma or surgery, a repair needs to be performed. If repair fails, then nerve transfer or muscle transfers are then considered.

TREATMENT


Treatment as with many conditions, depends on the time of presentation and severity of symptoms.  Once an adequate working diagnosis has been made then there is a better understanding of the treatment pathway. Traditional management has relied heavily on conservative therapy which includes physical therapy, pain management and time. If conservative therapy fails then surgery can be considered.  
We now have a better understanding of winged scapula being caused by traction injury or compression to the LTN in the supraclavicular region, predominately at the middle scalene interface. Decompression and neurolyisis of the LTN and the Upper trunk of the brachial plexus is a proven viable surgical option in the appropriate patient population.
Historically, surgical options have focused on mechanical alterations only and included pectoralis tendon transfers and/or fixed tethering of the scapula to the chest wall (scapulothoracic arthrodesis).  These surgical options still are available if nerve regeneration does not occur with the more simple nerve decompression surgery.

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How Can I Tell If My Headache Is a Migraine?

There are 180 different types of defined headaches. Many people have headaches from time to time, but if you experience them on a daily or continual basis, your headaches may fall into the category of Chronic Migraine Headache. 30 million people in the US suffer from chronic migraines in some form. Many patients have centralized headaches that respond well to medicines. However, many people have headaches that are debilitating and don't respond well to current available pharmaceuticals.

It is estimated that up to 13 % (likely even higher) of all chronic headaches are related to occipital nerve neuralgia. Neuralgia is a general term for pain or irritation along the course of a nerve. We are addressing the irritation caused by nerve compression in this situation.

Although the Greater occipital nerve is the most common nerve involved, other nerves can be involved as well. The lesser occipital nerve and dorsal (or least) occipital nerve which are located in the back of the head/scalp. Headaches may originate from the forehead or frontal region as well. The nerves involved in this area include the supra-orbital and zygomatico-temporal nerves.

When no other underlying diseases or conditions are found, you may be a candidate for a nerve decompression surgery that can reduce or end your migraine headaches. This is an outpatient surgery with short recovery times. Results are often immediately evident but may take several weeks. Neuropax surgeons can assess if nerve decompression surgery would help to alleviate or significantly reduce your debilitating symptoms.

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What Is Carpal Tunnel Syndrome?

What is carpal tunnel syndrome?

Carpal tunnel syndrome (CTS) is a condition brought on by increased pressure on the median nerve at the wrist. In effect, it is a pinched nerve at the wrist. Symptoms may include numbness, tingling, and pain in the arm, hand, and fingers. There is a space in the wrist called the carpal tunnel where the median nerve and nine tendons pass from the forearm into the hand (see Figure 1). Carpal tunnel syndrome happens when pressure builds up from swelling in this tunnel and puts pressure on the nerve. When the pressure from the swelling becomes great enough to disturb the way the nerve works, numbness, tingling, and pain may be felt in the hand and fingers (see Figure 2). 

What causes carpal tunnel syndrome?

Usually the cause is unknown. Pressure on the nerve can happen several ways: swelling of the lining of the flexor tendons, called tenosynovitis; joint dislocations, fractures, and arthritis can narrow the tunnel; and keeping the wrist bent for long periods of time. Fluid retention during pregnancy can cause swelling in the tunnel and symptoms of carpal tunnel syndrome, which often go away after delivery. Thyroid conditions, rheumatoid arthritis, and diabetes also can be associated with carpal tunnel syndrome. There may be a combination of causes. 

Signs and symptoms of carpal tunnel syndrome


Carpal tunnel syndrome symptoms usually include pain, numbness, tingling, or a combination of the three. The numbness or tingling most often takes place in the thumb, index, middle, and ring fingers. The symptoms usually are felt during the night but also may be noticed during daily activities such as driving or reading a newspaper. Patients may sometimes notice a weaker grip, occasional clumsiness, and a tendency to drop things. In severe cases, sensation may be permanently lost and the muscles at the base of the thumb slowly shrink (thenar atrophy), causing difficulty with pinch.
( Although carpal tunnel is commonly found as an isolated condition, it can frequently co-exist with other compressed or pinched nerves. These can be in the wrist arm or neck regions.  For example, if you have numbness in the small finger as well, the Ulnar nerve needs to be checked.  Nerves are like long wires coming off the spine and can be pinched at more than one site along their path. Comprehensive evaluation by a peripheral nerve surgeon is ideal for these conditions.  See section on peripheral nerve decompression)

Diagnosis of carpal tunnel syndrome


A detailed history including medical conditions, how the hands have been used, and whether there were any prior injuries is important. An x-ray may be taken to check for the other causes of the complaints such as arthritis or a fracture. In some cases, laboratory tests may be done if there is a suspected medical condition that is associated with CTS. Electrodiagnostic studies (NCV–nerve conduction velocities and EMG–electromyogram) may be done to confirm the diagnosis of carpal tunnel syndrome as well as to check for other possible nerve problems.
( It is very important to understand that the electrodiagnostic studies are not always needed to confirm the diagnosis of carpal tunnel syndrome.  This is a diagnostic study that should be utilized only if necessary.  Further, like other diagnostic tests it has it own rate of false negative and false positive results. The whole clinical picture should be considered in diagnosing nerve compression syndromes, "pinched nerves", like carpal tunnel)   

Treatment of carpal tunnel syndrome


Symptoms may often be relieved without surgery. Identifying and treating medical conditions, changing the patterns of hand use, or keeping the wrist splinted in a straight position may help reduce pressure on the nerve. Wearing wrist splints at night may relieve the symptoms that interfere with sleep. A steroid injection into the carpal tunnel may help relieve the symptoms by reducing swelling around the nerve.
 
When symptoms are severe or do not improve, surgery may be needed to make more room for the nerve. Pressure on the nerve is decreased by cutting the ligament that forms the roof (top) of the tunnel on the palm side of the hand (see Figure 3). Incisions for this surgery may vary, but the goal is the same: to enlarge the tunnel and decrease pressure on the nerve.
Following surgery, soreness around the incision may last for several weeks or months. The numbness and tingling may disappear quickly or slowly. It may take several months for strength in the hand and wrist to return to normal. Carpal tunnel symptoms may not completely go away after surgery, especially in severe cases.
 
Image 1 Carpal Tunnel

Figure 1:  The carpal tunnel is found at the base of the palm. It is formed by the bones of the wrist and the transverse carpal ligament. Increased pressure in the tunnel affects the function of the median nerve.

 

Figure 2 Carpal Tunnel


Figure 2:  Aspects of median nerve function.

 

Figure 3 Carpal Tunnel


Figure 3:  The goal of surgery is to free the ligament to allow more room for the median nerve in the carpal tunnel.

© 2011 American Society for Surgery of the Hand. Developed by the ASSH Public Education Committee.

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What is Thoracic Outlet Syndrome?

What is thoracic outlet syndrome?

The thoracic outlet is a small space just behind and below your collarbone. The blood vessels and nerves that serve your arm and shoulder are located in this space. Thoracic outlet syndrome (TOS) is the presence of a mixture of hand, arm, shoulder and neck symptoms.  All of these symptoms are due to pressure (or compression) against the nerves (called the brachial plexus) or blood vessels within the scalene triangle at the thoracic outlet.
There are 3 types of TOS. (nerve, vein, or artery)
Ninety-five percent (95%) of all cases of TOS are Neurogenic, which is compression of the nerves to the arm and shoulder. Venous TOS occurs only 3 to 4 percent of the time and is due to obstruction or clotting of the main vein to the arm, the subclavian vein. Arterial TOS, is the rarest type, occurring in only 1 percent of cases, and it is due to disease in the artery leading to the arm, the subclavian artery. Almost all cases of arterial TOS are associated with an extra rib (cervical rib) or an abnormal first rib.

What are the symptoms?

The common symptoms depend on which structure is being compressed.
Neurogenic TOS (nTOS), the symptoms are pain, numbness, tingling, and/or weakness in the arm and hand. Also common is a tired feeling in your arm, which is made worse by working with your arms raised over your head. Neck pain and headaches in the back of your head are also frequent symptoms. Another common occurrence is pain that starts in your shoulder and runs down your arm, as well as pain in your fingertips. One can even experience facial pain, jaw pain, ear pain and pain on the front of your chest. Unfortunately, the symptoms of neurogenic TOS can be vague and non-specific.
Venous TOS (vTOS) is distinguished by swelling in your entire arm, plus pain and dark discoloration.
Arterial TOS (aTOS) presents with pain, coldness, and a pale discoloration of the hand. Cramps occur when using the arm for activity.


What causes thoracic outlet syndrome?

Neurogenic TOS is most often the result of neck trauma such as a whiplash injury. Motor vehicle accidents, traction injuries to shoulder, slipping and falling on floors or ice, blunt injury to base of neck or top of shoulder, or repetitive stress from working on assembly lines are the common causes.
The symptoms are due to trauma and scar tissue formation in; neck muscles (called scalene muscles) and the nerves (brachial plexus). Congenital deformities of the first rib or having an anomalous cervical rib or band significantly increases the risk of acquiring this condition. Ultimately, the cause is compression and tethering of the brachial plexus nerves at the thoracic outlet.
Venous TOS is commonly due to strenuous use of the arm and shoulder. Its underlying cause is congenital narrowing of the space through which the major arm vein (subclavian vein) passes from the shoulder area into the heart.
Arterial TOS is caused by a narrowing in the main artery to the arm (subclavian artery), usually secondary to a congenital extra rib (cervical rib) or to an abnormal first rib. Once the artery has been narrowed, one of two things will occur. The artery may enlarge, forming an aneurysm just beyond the narrowing, and a clot will form in the wall of the aneurysm; or the artery may remain narrowed and a clot will form inside the artery just beyond the narrowing. The danger of the clot is that pieces of it will break off (called emboli) and travel down the arm to block the circulation to your hand. When this occurs, the hand becomes cold, numb, painful, and discolored and you are in danger of losing your hand. Treatment to restore circulation is essential.

How is thoracic outlet diagnosed?

Diagnosing TOS can be complex. It begins by your physician asking you a series of questions to find out your symptoms, the distribution of these symptoms and and how the symptoms began. Depending on your symptoms, the doctor will be able to tell if you might have a nerve, vein, or artery compression. An appropriate physical examination will be beneficial in determining your diagnosis as well.  It is not uncommon that patients have seen several physicians and have been evaluated for cervical neck problems and shoulder problems prior to the referral for evaluation of thoracic outlet syndrome.
For neurogenic TOS, your physician will have you perform a number of provocative maneuvers. These consist of putting your neck and arms in different positions of stress to try to reproduce your symptoms. Other physical findings include tenderness in certain places in your neck, chest, or arms. New technologies such as 3-Tesla MR neurography are helpful in establishing level of injuries and anomalous anatomy and may be requested in addition to traditional xrays.
For venous TOS, physical examination consists primarily of noting swelling in your arm and prominent veins seen just under the skin at the spot where your shoulder joins your chest.
In arterial TOS, physical exam often finds the pulse at your wrist is diminished or absent. Your hand may have a pale color compared to your pink, good hand.
Venous and arterial TOS are best diagnosed with the aid of specific tests, venography for venous TOS and pulse volume or arteriography for arterial TOS.


How is thoracic outlet syndrome treated?

Your particular treatment will depend on the type of TOS you have. Determined by your symptoms, physical examination and test results.
Neurogenic (nTOS) is initially treated with physical therapy. The basic therapy methods include stretching exercises of your neck, posture correction, learning to avoid specific movements that bring on or aggravate your symptoms, and modifying your work site when appropriate. While some therapists may suggest strengthening exercises, most patients with neurogenic TOS are made worse by strengthening exercises. Treatment with a therapist for a few weeks is usually followed by a home exercise program, which you continue on your own for at least several more weeks.
The doctor may also prescribe medications such as muscle relaxants, non-steroidal anti-inflammatory drugs such as aspirin or ibuprofen, pain relievers, or steroids. In addition, some patients get relief by applying moist heat or massaging and stretching the affected area.
When early conservative therapies are failing and there are significant painful symptoms, a diagnostic and/or therapeutic injection may be utilized.  This involves an ultrasound guided injection that has numbing agents and steroid.  Our technique can give significant temporary relief or can sometimes actually resolve the condition. Further, we have developed novel techniques that utilize our biologic therapeutics.  Candidates are determined by responses to initial diagnostic injections and the symptoms they are experiencing.
When treatment begins in the early stages of neurogenic TOS, a majority of patients improve with the measures listed above. However, if your nTOS symptoms do not improve with these measures, and if your symptoms are interfering with sleep, work, recreation, or activities of daily living, more aggressive treatment may be recommended.  The surgeon may recommend surgical decompression.
Surgery for nTOS involves removing certain muscles in your neck and cleaning scar tissue off the nerves of the brachial plexus.  The anterior and middle scalene muscles are the muscles making the scalene                                                                                                                                                                                          triangle in the neck at the thoracic outlet. These muscles are a source of the pathology and injury to them will cause compression to the brachial plexus nerves.  There are many redundant muscles in the neck, allowing for us to release or resect one or both of these muscles.  Additionally, the nerves at this level need to be released from scar tissue or fibrosis that have formed around them.  This encasing tissue is much like shrink-wrap and causes both compression and tethering of the nerve.  Releasing this tissue relieves compression and re-establishes the much needed gliding surfaces of these nerves.
Resection of the first rib is unnecessary in nTOS except in the rare case (<1%) of a cervical rib or first rib anomaly.  Modern studies show there is no difference in outcomes, which advocates for not resecting a normal first rib.   Resection of the first rib is associated with a higher rate of complications and higher rates of post-operative chronic pain.  Further, without the rib resection the invasiveness of the surgery is less and the recovery is easier.   
Surgery for thoracic outlet syndrome, however, is never without risks. There are vital structures in this part of the body that can be injured during TOS decompression surgery.  Rates of complications are very low but they are not zero.  These rare problems include; persistence of pain, hematoma, phrenic nerve injury, surgical infection, nerve injury resulting hand or arm dysfunction, surgical site infection, arterial injury or pneumothorax
In addition, surgery does not always relieve the symptoms of neurogenic TOS. Our success rate is currently 80 to 90%.  Larger studies evaluating outcomes from surgery for neurogenic TOS demonstrate that only up to 70 percent of patients have improvement in their symptoms, while 30 percent may feel no better or worse.  We feel that our success rate is higher based upon rigorous patient selection and because we rarely recommend the first rib resection.
Venous TOS is not treated with physical therapy. Rather, the clot in the vein is initially treated with clot dissolving medication (called thrombolysis), with blood thinners (anticoagulants), or sometimes treated by surgically opening the vein and removing the clot. Once the clot has been removed, your surgeon may recommend that the first rib be removed so that the narrow space through which the vein passed can be enlarged to prevent the vein from clotting again. If the vein is badly narrowed, the narrow spot can be widened by having a balloon stretch out the vein, a procedure called an angioplasty. In some instances, the vein will be repaired operatively, at the time of the rib removal, with a patch (made from another vein) or with replacement of the diseased segment of vein.
Arterial TOS is treated in a very different way. If the subclavian artery in your thoracic outlet has become damaged by pressure, your vascular surgeon must repair the artery or replace it with an arterial graft. The replacement graft may be a vein from another part of your body or a plastic artery substitute. In addition to fixing the damaged artery, the abnormal rib must be removed to prevent the artery from being damaged again. Your vascular surgeon can perform all of this in one operation.

What can I do to stay healthy?

You can improve your recovery from TOS by practicing good posture, regularly stretching your chest muscles and the muscles in the front of your next, strengthening the muscles of your upper back and posterior shoulder, and losing weight if you are overweight. Also, if you are prone to TOS, it is wise to avoid repetitive lifting of heavy objects over your head.  For more information on Thoracic Outlet Surgery and the many other procedures available at Neuropax Clinic, visit http://www.neuropaxclinic.com/ today, and call 314-434-7784 for an appointment!

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