Presentation on theme: "Neural Prolotherapy REGIONAL ANATOMY"— Presentation transcript:
1Neural Prolotherapy REGIONAL ANATOMY UPPER EXTREMITIESLee Wolfer, MD, MS
2NEUROBIOLOGY AND NEUROKININS Monoaminergic SystemSerotonergicNoradrenergicDopaminergicCholinergicGlutamatergic SystemSystem controlling neural plasticity, synaptic sensitisation,and conscious nociceptive pain through mainly NMDA receptors“20th Century CNS sensitisation”Peptidergic SystemSystem controlling tissue homeostasis,neurogenic inflammationperipheral non-synaptic sensitisationand neuropathic pain
3Dermatomal versus Regional pain Nociceptive painNon-peptidergicNeuropathic painPeptidergic - Nervi Nervorum
4Lee, MK. An evidence based approach to human dermatomes Lee, MK. An evidence based approach to human dermatomes. Clin Anat, 2008The dermatome is a fundamental concept in human anatomy and of major importance in clinical practice.There are significant variations in current dermatome maps in standard anatomy texts.Our findings demonstrate that current dermatome maps are inaccurate and based on flawed studies.
5THE SENSORY INNERVATION OF THE SHOULDER SUPRASCAPULAR NERVERADIAL NERVEAXILLARYSUBSCAPULAR NERVEMUSCULOCUTANEOUS NERVEINTERMEDIATE SUPRACLAVICULAR NERVE
6Encyclopedia Anatomica 1771 Sensocrine nerve anatomy I have included this striking image as it illustrates the complexity of the superficial nerves. It also explains visually the challenges facing NPT and TrP treatments % of the subcutaneous nerves are peptidergic and are potentially causes of neuropathic pain
7BRACHIAL PLEXUS Key UE nerves NOTE sensory antebrachial : mbc and macs; musculo to LAC;
14Encyclopedia Anatomica 1771 Sensocrine nerve anatomy I have included this striking image as it illustrates the complexity of the superficial nerves. It also explains visually the challenges facing NPT and TrP treatments % of the subcutaneous nerves are peptidergic and are potentially causes of neuropathic pain
15MEDIAL SUPRACLAVICULAR NERVE “Tietze syndrome” and “Costo-chondritis” Note the Spalteholz image on the right. It is not clear from the drawing whether this shows the superficial nerves sub-fascial or sub-cutaneous
16“FROZEN SHOULDER” Suprascapular Nerve Impingement The suprascapular nerve is derived from the upper trunk of the brachial plexus from the roots of C5 and C6The nerve supplies the supraspinatus muscle and provides articular branches to the glenohumeral and acromioclavicular joints. It supplies sensory and sympathetic fibers to two-thirds of the shoulder capsule. Usually there are no sensory fibers to the skin. The nerve then travels thru spinoglenoid notch under ligament to supply the infraspinatus muscle. In about 50% of people there is another connective tissue band creating a second fibro-osseous opening for the nerve to traverse.Crossed body adduction; can you reach across ; neural tension test in axial plane; inf at infrascapular nerve, medial and under tip of acromion
17INFRASCAPULAR NERVE: INJECTION POINTS UNDER SCAPULAR SPINE, DEPTH ½ INCHCROSSED BODY ADDUCTION TEST STRESSES NERVE IN AXIAL PLANE
18“FROZEN SHOULDER” Suprascapular Nerve Impingement The suprascapular nerve is derived from the upper trunk of the brachial plexus from the roots of C5 and C6Right Supra-scapular Nerve Impingement (C5,6) This illustration features a posterior view of the deep muscles of the shoulder. The course of the supra scapular nerve is shown. A rotator cuff tendon and ‘paralabral spinoglenoid cyst’ has trapped the infra-scapular nerveParalabral cyst at spinoglenoid notch -- surgery
20AXILLARY NERVE Quadrangular space Teres minor Teres major Long head, triceps Humerus Superior lateral brachial cut n.Note the Quadrangular and Triangular spaces, which give access to the upper trunk of the radial nerve ; main motor branch curls around HH and sends brs into deltoid muscle. And the superior lateral br cut n. Test abduct to 90 degrees and ER. Radial nerve in triangular interval. Anconeus br and pabcn branch off here. Radial n goes thru LIMS.
21Axillary nerve (C5, C6) Inflammation of the Axillary nerve trunk can be elicited in abduction and ER causing a catching pain over the anterior Deltoid ‘Tight’ bands can be palpated in the Deltoid and Teres minor where the Axillary nerve branches penetrate the muscle.Axillary nerve: find long band in delt from cranial to caudad. Retest with abd/ER. T minor compartment syndrome. Start at scapular angle and to axilla. These are IM injections.
22Lower Subscapular nerve CCI to subscapularis muscle Triangular interval Stars for quad space; tri space and tri interval. Quad space is 3 FBs below angle acromion; tri interval is 1.5 cm below.
23Radial nerve “tennis elbow” CCIs: triangular interval @ entrance to LIMS Nerve test: “chicken wings” Stars for quad space; tri space and tri interval.
24Musculocutaneous nerve CCIs CORABRACHIALISBICEPSBRACHIALISARTICULAR BRLACNote the potential entrapment of the musculocutaneous nerve in the Coracobrachialis muscle, which may effect (delay) the repair of the lateral antebrachial nerve. Note the cutaneous branches arising from the proximal Radial nerve e.g. The Anconeus nerve which is mixed motor-sensory and can get trapped in the lateral head of the Triceps (aetiology tennis elbow?). It innervates the lateral elbow joint and lateral epicondyle (Hilton’s law)
25GREASE: WHY WE THINK DANNY ZUKO HAS GREAT HAIR OR:HOW TO TEST YOUR MUSCULOSKELETAL NERVE
26Posterior shoulder superior lateral brachial nerve
27This is just a rough guide and overlapping peptidergic nerve receptive fields are extensive
28Intercostalis nervesIntercost br. Swimmers get it w/ pull thru a/ crawl. Palpate w/ patient w/ crossed body adduction; palpate along lat dorsi and lateral border of scapula; friction syndrome;
29Nerves of the armNote the daunting complexity of the brachial and antebrachial nerves
30Medial brachial and antebrachial nerves “Golfers elbow” or “Throwers elbow” The medial brachial and antebrachial nerves arise from the medial cord of the Brachial plexus proximal to the Ulnar nerve
31Medial elbow with Bicipital Aponeurosis with risk of CECS Cecs pronator teres
32LEFT MEDIAL BRACHIAL AND ANTEBRACHIAL NERVES AND CCIs MAC nsKey is get CCIS near axilla: MBC; then MAC (2 branches, dorsal and volar); one branch runs on top of bicipital apo and beneath it.MEIntercostobrachial nMedial brachial cutaneousMAC
33Left Lateral elbow (tennis elbow) Anconeus and posterior antebrachial nerves arise from the Radial nerve and the lateral antebrachial nerve arises from the Musculocutaneous nerveLACLEPABCNOANCONEUS
34Radial, Median and Ulnar palmar nerves of the left wrist “Carpal tunnel syndrome”, “OA base thumb” A carpal tunnel syndrome with concomitant symptoms above the wrist should alert to the possibility of the palmar nerve involvement and this can be treated effectively non-surgically. The Radial palmar nerve is frequently involved in OA symptoms of the wrist.UMRR
35“De Quervain syndrome” Musculocutaneous and Radial cutaneous branches POST Br LACNote: Fill quadrangular and triangular spaces for DQR