1. Presented by: Mary L. Dombovy, MD, MHSA Paul K. Maurer, MD Anthony L. Petraglia, MD Patrick J. Reid, MD Matthew L. Dashnaw, MD, Pharm D M. Gordon Whitbeck, Jr., MD 2016 Brain & Spine Symposium: Neurosurgical Updates

2. Presented by Patrick J. Reid, MD Neurosurgeon Rochester Regional Health Peripheral Nerve Entrapment Or Is It?

3. CL 71-year-old female Neck and left arm pain Associated numbness and tingling of left arm 10-year history of gradually worsening symptoms Acute onset one afternoon, with persistent symptoms since

4. CL Subjective feeling of left arm weakness Only able to obtain 3-4 hours of sleep a night Unable to comfortably perform her usual daily activities

5. CL MRI of the cervical spine showed arthritis with bony spurs pressing on nerves traveling down the left arm Treatment: Steroids Opiate medication Vicodin, Dilaudid, etc.

6. CL In mild discomfort at rest Mild tenderness of the neck Good range of movement at neck Arms exhibited normal sensation and strength Positive Tinel’s and Phalen’s test on the left

7. CL Clinical diagnosis Left carpal tunnel syndrome rather than symptoms from compression of nerves in the neck “Double crush” syndrome Left neutral wrist splint EMG and nerve conduction studies

8. CL EMG and nerve conduction studies confirmed carpal tunnel syndrome No relief from neutral wrist splint Opted for carpal tunnel decompression 9 days after surgery complete resolution of neck and left arm pain Intermittent numbness and tingling of thumb and first 2 fingers Complete resolution of symptoms by 6 weeks

9. What is Carpal Tunnel Syndrome? An entrapment neuropathy the most common and widely known of the entrapment neuropathies in which the body's peripheral nerves are compressed or traumatized Symptoms caused by compression of a nerve in the wrist (median nerve) Formed in the neck, runs down the arm, and enters the hand through a tunnel which is roofed by a ligament Any thickening of the ligament squeezes the nerve causing symptoms

11. What are the symptoms? Usually insidious in onset Typically Burning, tingling, numbness May complain of swelling Nocturnal symptoms are classic As symptoms persist More frequent Occur during the day with routine tasks Decreased hand strength

13. What are the causes? Medical conditions Diabetes, rheumatoid arthritis, hypothyroidism, obesity, menopause, pregnancy Trauma Acute or chronic

14. How is it diagnosed? History Physical examination EMG and nerve conduction studies

15. What Are The Treatments? Treat the underlying cause Conservative Anti-inflammatory medications Neutral wrist splint

18. What are the treatments? Surgical One of the most common surgical procedures in the United States Generally recommended if symptoms last for 6 months or if there is significant weakness Involves severing the band of tissue around the wrist to reduce pressure on the median nerve Performed under local anesthesia Does not require an overnight hospital stay

19. Open Decompression

20. Endoscopic decompression

21. Results of surgery Symptom relief immediately after surgery Full recovery may take months Major risks infection and nerve damage Stiffness, and pain at the scar Occasionally the wrist loses strength patients should undergo physical therapy after surgery to restore wrist strength Some patients may need to adjust job duties or even change jobs after recovery from surgery. Recurrence is rare The majority of patients recover completely

22. How can it be prevented? At the workplace Perform stretching exercises, take frequent rest breaks, wear splints to keep wrists straight, and use correct posture and wrist position Workstations, tools and tool handles, and tasks can be redesigned to enable the worker's wrist to maintain a natural position during work Jobs can be rotated among workers Research has not conclusively shown that these workplace changes prevent the occurrence of carpal tunnel syndrome

24. Summary Carpal tunnel syndrome is the most common entrapment neuropathy Usually occurs in middle aged Very common in the geriatric population More common in females (4:1) Bilateral in over 50% Usually worse in the dominant hand Excellent surgical outcome if conservative treatments fail