Nerve Compression Syndrome of the Extremities

Nerves extend from your brain and spinal cord, sending important messages throughout your body. If you have a pinched nerve (nerve compression) your body may send you warning signals such as pain. Damage from a pinched nerve may be minor or severe. It may cause temporary or long-lasting problems. The earlier you get a diagnosis and treatment for nerve compression, the more quickly you’ll find relief. In some cases, you can’t reverse the damage from a pinched nerve. But treatment usually relieves pain and other symptoms.

There are three major nerves in the arm that are responsible for carrying messages between your brain and hand:

Our surgeons have many years of experience performing nerve decompression surgery for nerves in the arm, and have done thousands of procedures. Their success rates exceed the national averages and our Institute prides itself on having extremely low complication rates. Many types of nerve decompression procedures for the median, radial, and ulnar nerves can be performed at our fully certified outpatient surgical facility.


Median Nerve Entrapment (Carpal Tunnel Syndrome)

Carpal tunnel syndrome is a hand and arm condition that causes numbness, tingling and other symptoms. A pinched nerve in your wrist causes carpal tunnel syndrome.

A number of factors can contribute to carpal tunnel syndrome, including the anatomy of your wrist, certain underlying health problems and possibly patterns of hand use.

Anatomy

The carpal tunnel is a narrow, tunnel-like structure in the wrist. The wrist (carpal) bones form bottom and sides of this tunnel. A strong band of connective tissue called the transverse carpal ligament covers the top of the tunnel.

The median nerve travels from the forearm into the hand through this tunnel in the wrist. The median nerve controls feeling in the palm side of the thumb, index finger, and long fingers. The nerve also controls the muscles around the base of the thumb. The tendons that bend the fingers and thumb also travel through the carpal tunnel. These tendons are called flexor tendons.

Symptoms

People with Carpal Tunnel Syndrome experience numbness, tingling, or burning sensations in the thumb, index finger, middle finger, and half of the ring finger.

Causes

Carpal tunnel syndrome occurs when the tissues surrounding the flexor tendons in the wrist swell and put pressure on the median nerve.

People engaged in repetitive motions throughout their day may suffer from carpal tunnel syndrome. Examples of those commonly diagnosed with carpal tunnel include:

  • People who use computers for many hours throughout the day
  • Carpenters
  • Check-out line technicians
  • Assembly-line workers
  • Musicians
  • Auto mechanics

Hobbies such as gardening, needlework, golfing and boating/rowing can sometimes contribute toward the symptoms of carpal tunnel syndrome. It is critical to have an excellent and experienced physician evaluate you for carpal tunnel syndrome.

Evaluation: Nerve conduction studies

After the physical examination has been performed, we will confirm the diagnosis with nerve conduction studies (including electromyography), which will give us information about nerve dysfunction due to a constricted tunnel. The electrical impulse to the muscle is also tested.

Together these tests give us valuable information about the extent of the disease and injury caused to the nerve, which will direct your case and the appropriate treatment.

Nonsurgical Treatment

If diagnosed and treated early, carpal tunnel syndrome can be relieved without surgery. In cases in which the diagnosis is uncertain or the condition is mild to moderate, we will always try simple treatment measures first.

  • Bracing or splinting. A brace or splint worn at night keeps the wrist in a neutral position. This prevents the nightly irritation to the median nerve that occurs when wrists are curled during sleep. Splints can also be worn during activities that aggravate symptoms.
  • Medications. Simple medications can help relieve pain. These medications include anti-inflammatory drugs (NSAIDs), such as ibuprofen.
  • Activity changes. Changing patterns of hand use to avoid positions and activities that aggravate the symptoms may be helpful. If work requirements cause symptoms, changing or modifying jobs may slow or stop progression of the disease.
  • Steroid injections. A corticosteroid injection will often provide relief, but symptoms may come back.

Surgical Treatment

In most cases, carpal tunnel surgery is done on an outpatient basis under local anesthesia. During surgery, a cut is made in your palm. The roof (transverse carpal ligament) of the carpal tunnel is divided. This increases the size of the tunnel and decreases pressure on the nerve.

Once the skin is closed, the ligament begins to heal and grow across the division. The new growth heals the ligament, and allows more space for the nerve and flexor tendons.

Endoscopic method: Some surgeons make a smaller skin incision and use a small camera, called an endoscope, to cut the ligament from the inside of the carpal tunnel. This may speed up recovery.

The end results of traditional and endoscopic procedures are the same. Your doctor will discuss the surgical procedure that best meets your needs.

Recovery

Right after surgery, you will be instructed to frequently elevate your hand above your heart and move your fingers. This reduces swelling and prevents stiffness.

Some pain, swelling, and stiffness can be expected after surgery. You may be required to wear a wrist brace for up three weeks. You may use your hand normally, taking care to avoid significant discomfort.

Minor soreness in the palm is common for several months after surgery. Weakness of pinch and grip may persist for up to six months.

Driving, self-care activities, and light lifting and gripping may be permitted soon after surgery. Your doctor will determine when you should return to work and whether there should be any restrictions on your work activities.


Radial Nerve Entrapment (Radial Tunnel Syndrome)

Radial nerve compression or injury may occur at any point along the anatomic course of the nerve and may have varied etiologies. The most frequent site of compression is in the proximal forearm in the area of the supinator muscle and involves the posterior interosseous branch. However, problems can occur proximally in relation to fractures of the humerus at the junction of the middle and proximal thirds, as well as distally on the radial aspect of the wrist.

Anatomy

The radial nerve is one of three nerves that provide motor and sensory function to the arm. The radial nerve begins at the brachial plexus, extends downward to the wrist and into the hand. As it travels down the arm it branches several times to provide movement to the muscles of the dorsal arm and sensation to the skin covering the forearm and the back of the hand. This nerve is responsible for extension of the arm, wrist, and into the hand.

Symptoms

Injury to the radial nerve usually causes symptoms in the back of the hand, near the thumb, index and middle fingers. Symptoms may include:

  • sharp or burning pain
  • numbness or tingling
  • trouble straightening the arm
  • trouble moving the wrist and fingers
  • “drooping” of the wrist and fingers (not being able to extend or straighten the wrist or fingers), also called “wrist drop”
  • weakness in a hand grip

Causes

Radial neuropathy occurs when there is damage to the radial nerve, which travels down the arm and controls movement of the triceps muscle at the back of the upper arm. It also controls the ability to bend the wrist backward and helps with the movement and sensation of the wrist and hand.

  • Injury
  • Improper use of crutches
  • Broken upper arm bone
  • Long-term or repeated constriction of the wrist (for example, from wearing a tight watch strap)
  • Pressure caused by hanging the arm over the back of a chair (for example, falling asleep in that position)
  • Pressure to the upper arm from arm positions during sleep or coma
  • Pinching of the nerve during deep sleep, such as when a person is intoxicated
  • Long-term pressure on the nerve, usually caused by swelling or injury of nearby body structures
  • In some cases, no cause can be found.

Evaluation: Nerve conduction studies

After the physical examination has been performed, we will confirm the diagnosis with nerve conduction studies (including electromyography), which will give us information about nerve dysfunction due to a constricted tunnel. The electrical impulse to the muscle is also tested.

Together these tests give us valuable information about the extent of the disease and injury caused to the nerve, which will direct your case and appropriate treatment.

Nonsurgical Treatment

Treatment of radial nerve entrapment depends on the underlying cause and location of the nerve compression. Symptoms may be controlled with:

  • Bracing or splinting. This entails application of a neutral position wrist splint.
  • Activity changes. Changing patterns of hand use to avoid positions and activities that aggravate the symptoms may be helpful. If work requirements cause symptoms, changing or modifying jobs may slow or stop progression of the disease.
  • Medications. Simple medications can help relieve pain. These medications include anti-inflammatory drugs (NSAIDs), such as ibuprofen.
  • Steroid injections. A corticosteroid injection will often provide relief, but symptoms may come back.

Surgical Treatment

When conservative treatments have not worked, surgery may be the best treatment option. The goal of surgery for radial tunnel syndrome is to relieve any abnormal pressure on the nerve where it passes through the radial tunnel.

Any parts of the tunnel pinching the radial nerve are cut, expanding the tunnel and relieving the pressure on the nerve. The surgery is usually performed on an outpatient basis.

Recovery

Right after surgery, you will be instructed to frequently elevate your hand above your heart and move your fingers. This reduces swelling and prevents stiffness.

Some pain, swelling, and stiffness can be expected after surgery. You may be required to wear a wrist brace for up to three weeks. You may use your hand normally, taking care to avoid significant discomfort.

Driving, self-care activities, and light lifting and gripping may be permitted soon after surgery. Your doctor will determine when you should return to work and whether there should be any restrictions on your work activities.


Ulnar Nerve Entrapment (Cubital Tunnel Syndrome)

Ulnar nerve entrapment occurs when the surrounding tissue compresses the ulnar nerve in the arm. This can lead to serious dysfunction, since the ulnar nerve is one of the three main nerves in your arm. It travels from your neck down into your hand, and can be constricted in several places along the way. Depending upon where it occurs, this pressure on the nerve can cause numbness or pain in your elbow, hand, wrist, or fingers.

Sometimes the ulnar nerve gets compressed at the wrist, beneath the collarbone, or as it comes out of the spinal cord in the neck. The most common place where the nerve gets compressed is behind the elbow. When the nerve compression occurs at the elbow, it is called “cubital tunnel syndrome.”

Anatomy

As the ulnar nerve travels past the elbow, it enters a tunnel of tissue (the cubital tunnel) that runs along the medial epicondyle; this is the same spot as the “funny bone.” Bumping into the ulnar nerve at this spot causes a shock-like feeling.

Once past the elbow, the ulnar nerve travels under muscles in your forearm, before entering a second tunnel (Guyon’s canal). This is a second common area of compression. As the ulnar nerve enters the hand, it gives sensation to the ring finger and little finger. It also controls the small muscles in the hand that spread the fingers and that help with fine motor movements.

Symptoms

Cubital tunnel syndrome can cause an aching pain on the inside of the elbow. Most of the symptoms, however, occur in your hand.

  • Ulnar nerve entrapment can give symptoms of “falling asleep” in the ring finger and little finger, especially when your elbow is bent. In some cases, it may be harder to move your fingers in and out, or to manipulate objects.
  • Numbness and tingling in the ring finger and little finger are common symptoms of ulnar nerve entrapment. Often, these symptoms come and go. They happen more often when the elbow is bent, such as when driving or holding the phone. Some people wake up at night because their fingers are numb.
  • Weakening of the grip and difficulty with finger coordination (such as typing or playing an instrument) may occur. These symptoms are usually seen in more severe cases of nerve compression.

If the nerve is very compressed or has been compressed for a long time, muscle wasting in the hand can occur. Once this happens, muscle wasting cannot be reversed. For this reason, it is important to see a hand surgeon if symptoms are severe or if they are less severe but have been present for more than six weeks.

Causes of Compression

The ulnar is especially vulnerable to compression at the elbow because it has to pass through a narrow space. We know that keeping your elbow bent for long periods—such as sleeping—can cause painful or numb symptoms.

  • Sleeping with your elbow bent
  • Leaning on your elbow for long periods of time
  • Fluid buildup in the tissue overlying the elbow
  • Direct injury to the nerve

Evaluation: Nerve conduction studies

These tests can determine how well the nerve is working and help identify where it is being compressed. During a nerve conduction test, the nerve is stimulated in one place and the time it takes for there to be a response is measured at several places. When a nerve is not working well, it takes too long for it to conduct.

Nerve conduction studies can also determine whether the compression is also causing muscle damage.  During the test, small needles are put into some of the muscles that the ulnar nerve controls. Muscle involvement is a sign of more severe nerve compression.

Nonsurgical Treatment

  • Non-steroidal anti-inflammatory medicines. If your symptoms have just started, we may recommend an anti-inflammatory medicine, such as ibuprofen, to help reduce swelling around the nerve.
  • Steroid injections. Steroids, like cortisone, are very effective anti-inflammatory medicines. Injecting steroids around the ulnar nerve is generally not used because there is a risk of damage to the nerve.
  • Bracing or splinting. We may prescribe a padded brace or split to wear at night to keep your elbow in a straight position.

Surgical Treatment

We will recommend surgery to take pressure off of the nerve if:

  • Nonsurgical methods have not improved your condition.
  • The ulnar nerve is very compressed.
  • Nerve compression has caused muscle wasting.

There are a few surgical procedures that will relieve pressure on the ulnar nerve at the elbow. Your surgeon will talk with you about the option that would be best for you. These procedures are most often done on an outpatient basis, but some patients do best with an overnight stay at the hospital.

Cubital tunnel release. In this operation, the ligament “roof” of the cubital tunnel is cut and divided. This increases the size of the tunnel and decreases pressure on the nerve.

After the procedure, the ligament begins to heal and new tissue grows across the division. The new growth heals the ligament, and allows more space for the ulnar nerve to slide through. In some cases, the nerve is moved in front of the medial epicondyle (ulnar nerve anterior transposition); this prevents it from getting caught on the bony ridge and stretching when you bend your elbow.

Surgical Recovery

Depending on the type of surgery you have, you may need to wear a splint for a few weeks after the operation. A submuscular transposition usually requires a longer time (three to six weeks) in a splint. We may recommend physical therapy exercises to help you regain strength and motion in your arm.



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