1. Neural Prolotherapy REGIONAL ANATOMY
UPPER EXTREMITIES
Lee Wolfer, MD, MS

2. NEUROBIOLOGY AND NEUROKININS
Monoaminergic System
Serotonergic
Noradrenergic
Dopaminergic
Cholinergic
Glutamatergic System
System controlling neural plasticity, synaptic sensitisation,
and conscious nociceptive pain through mainly NMDA receptors
“20th Century CNS sensitisation”
Peptidergic System
System controlling tissue homeostasis,
neurogenic inflammation
peripheral non-synaptic sensitisation
and neuropathic pain

3. Dermatomal versus Regional pain
Nociceptive pain
Non-peptidergic
Neuropathic pain
Peptidergic - Nervi Nervorum

4. Lee, MK. An evidence based approach to human dermatomes
Lee, MK. An evidence based approach to human dermatomes. Clin Anat, 2008
The 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.

5. THE SENSORY INNERVATION OF THE SHOULDER
SUPRASCAPULAR NERVE
RADIAL NERVE
AXILLARY
SUBSCAPULAR NERVE
MUSCULOCUTANEOUS NERVE
INTERMEDIATE SUPRACLAVICULAR NERVE

6. Encyclopedia 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

7. BRACHIAL PLEXUS Key UE nerves
NOTE sensory antebrachial : mbc and macs; musculo to LAC;

8. Rad Sup rad & digital brs Ulnar  palmar & DUC
Ax  SLBrC n.
Ax  SLBrC n.
Rad  PBrC n
Rad  ILBrC n.
Rad  ILBrC n.
ICBr &
MBrC n
Rad  PABC n.
Musc  LAC n.
MAC
Musc  LAC n.
Rad Sup rad & digital brs
Ulnar  palmar & DUC
Median  palmar & digital brs

9. SUPRACLAVICULAR FOSSA Key points: Locate posterior intermediate medial CCIs
Id sc fossa

10. Proposed mechanism of ‘whiplash injury’ Neuropraxia/intussusception injury of the supraclavicular nerves

11. L Supraclavicular Nerves CCI’s
Posterior
Medial
Intermediate

12. POSTERIOR SUPRACLAVICULAR NERVE

13. INTERMEDIATE SUPRACLAVICULAR NERVE

14. Encyclopedia 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

15. MEDIAL 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 C6
The 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

17. INFRASCAPULAR NERVE: INJECTION POINTS
UNDER SCAPULAR SPINE, DEPTH ½ INCH
CROSSED 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 C6
Right 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 nerve
Paralabral cyst at spinoglenoid notch -- surgery

19. Netter: Posterior shoulder Quadrangular space, triangular space & interval
Subscapular nerve

20. AXILLARY 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.

21. Axillary 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.

22. Lower 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.

23. Radial nerve “tennis elbow” CCIs: triangular interval @ entrance to LIMS Nerve test: “chicken wings”
Stars for quad space; tri space and tri interval.

24. Musculocutaneous nerve CCIs
CORABRACHIALIS
BICEPS
BRACHIALIS
ARTICULAR BR
LAC
Note 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)

25. GREASE: WHY WE THINK DANNY ZUKO HAS GREAT HAIR
OR:
HOW TO TEST YOUR MUSCULOSKELETAL NERVE

26. Posterior shoulder superior lateral brachial nerve

27. This is just a rough guide and overlapping peptidergic nerve receptive fields are extensive

28. Intercostalis nerves
Intercost 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;

29. Nerves of the arm
Note the daunting complexity of the brachial and antebrachial nerves

30. Medial 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

31. Medial elbow with Bicipital Aponeurosis with risk of CECS
Cecs pronator teres

32. LEFT MEDIAL BRACHIAL AND ANTEBRACHIAL NERVES AND CCIs
MAC ns
Key is get CCIS near axilla: MBC; then MAC (2 branches, dorsal and volar); one branch runs on top of bicipital apo and beneath it. ME
Intercostobrachial n
Medial brachial cutaneous
MAC

33. Left Lateral elbow (tennis elbow) Anconeus and posterior antebrachial nerves arise from the Radial nerve and the lateral antebrachial nerve arises from the Musculocutaneous nerve
LAC LE
PABCN O
ANCONEUS

34. Radial, 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. U M R R

35. “De Quervain syndrome” Musculocutaneous and Radial cutaneous branches
POST Br LAC
Note: Fill quadrangular and triangular spaces for DQ R