Diagnosis and Treatment of Painful Neuropathies and Nerve Entrapment Syndromes

Michel Kliot MD, ProfessorNorthwestern University Feinberg School of Medicine Director, Peripheral Nerve Center

Neuropathic Pain Treatment

Daniela Maria Menichella MD/PhDDepartment of NeurologyNorthwestern University Feinberg School of MedicineChicago, IL

Pain is the most common symptom

• Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage (external or internal to the body stimulus)

• Acute Pain: Associated with a stimulus (eg pinprick, flame) and subsides after stimulus removed

• Chronic Pain: Outlasts the stimulus and healing process

Physiological PainAn unpleasant sensory and emotional experience associated with actual or potential tissue damage(IASP definition of pain)

• Nociceptive Pain

• Inflammatory Pain

• Neuropathic pain arises from lesions to or dysfunction of the nervous system.

Possible Descriptions of Neuropathic Pain

• Sensations- numbness- tingling- burning- paresthetic- paroxysmal- lancinating- electriclike- raw skin- shooting- deep, dull, bonelike ache

• Signs/Symptoms- allodynia: pain from a stimulus

that does not normally evoke pain• thermal• mechanical

- hyperalgesia: exaggerated response to a normally painful stimulus

Hyperalgesia

heightened sense of pain to noxious stimuli

Allodynia

pain resulting from normally not painful stimuli

• Increased excitability of nociceptive neurons • Changes in gene expression

Sensitization: A Common Mechanism

BRAIN

Descending Modulation

Central SensitizationPNS

CNS

SpinalCord

Peripheral Sensitization

DorsalHorn

Cortical Potentiation

Dorsal Root Ganglia

Dysregulation of nociceptive and pain neural circuitry

Copyright © 2014 American Academy of Neurology . Published by Lippincott Williams & Wilkins.

Summary of areas of brain activation due to brush-evoked pain in neuropathic pain patients

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Aetiology-Based Classification of Neuropathic Pain

Treatment of Neuropathic Pain•Pharmacological Treatment•Interventional Therapy•Psychological Therapy

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Summary of Evidence-Based Recommendations For the pharmacological treatment of Neuropathic Pain 2010

FIRST LINE:

Copyright © 2014 American Academy of Neurology . Published by Lippincott Williams & Wilkins. 14

Summary of Evidence-Based Recommendations For the pharmacological treatment of Neuropathic Pain 2010

SECOND LINE:

Summary of Evidence-Based Recommendations For the pharmacological treatment of Neuropathic Pain 2014

• First-line treatment: tricyclic antidepressant (Amytriptyline, Nortriptyline), calcium channel alpha-2 delta ligands (Pregabalin and Gabapentin) and serotonin norepinephrine reuptake inhibitors (Duloxetine, Venlafaxine).

• Second-line treatment: combination of first-line drugs plus topical agents (Lidocaine or capsaicin).

• Third-line treatment: Opiod (Tramadol) and in particular cases of peripheral neuropathic pain Botulin Toxin A.

• Overall, the group found not much evidence for the effect of cannabinoids.

• Compared to earlier recommendations the new guideline downgrade the use opioid. Botulin Toxin A is new in the list.

• The complete data set has been submitted for publication.

New Guidelines for the treatment of Neuropathic Pain: IASP-Neuropathic Pain Special Interest Group (NeuPSIG).

Conclusion• The management of patients with neuropathic pain is challenging because

of the multiplicity of mechanisms underlying this debilitating condition. • Evidence-based recommendations for the pharmacological treatment of

neuropathic pain have been recently proposed.• Because of the multiplicity of mechanisms underlying neuropathic pain it is

possible that each of the painful symptoms may correspond to distinct mechanisms and therefore respond to specific treatments.

• Classification of patient according sensory phenotypes will direct rational therapies based on underlying mechanisms of pain and hopefully lead to a more effective and personalized management of patient with neuropathic pain.

• Molecular mechanisms underlying neuropathic pain and novel therapeutic targets can be investigated using animal models.

• Chemokine signaling is a new candidate responsible for hyper-excitability in a distinct subpopulation of DRG neurons in diabetes and a possible novel therapeutic target for PDN.

Copyright © 2014 American Academy of Neurology . Published by Lippincott Williams & Wilkins.

EVIDENCE-BASED TREATMENT OF CHRONIC NEUROPATHIC PAIN USING NONOPIOID PHARMACOTHERAPY 2010

TABLE 4-1 Summary of the Results of Published and Available Unpublished Randomized Controlled Trials Involving First-Line Nonopioid Medications for Patients With Neuropathic Pain

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Other More Invasive Treatments- Local Injections (local anesthetic, steroid…) with image guidance

- Spinal Cord or Peripheral Nerve Stimulators

- Spinal Cord Pumps

Diagnostic blocksEpidural steroids

Radiofrequency technigues

Neurostimulationtechniques

Neuroaxial medication

Interventional Therapies

Focal Peripheral Nerve Pathology Entrapments, Masses, And Traumatic Injuries

Michel Kliot MDProfessor of NeurosurgeryDirector of Peripheral Nerve CenterNorthwestern University Feinberg School of MedicineChicago, IL

Nerve Pain, Numbness, And/Or Weakness Caused By

•Compression and/or stretching of nerves from entrapment syndromes, trauma, or masses

Nerve Entrapment

Carpal Tunnel Syndrome Ulnar Nerve Entrapment At Elbow

Traumatic Nerve Injury

Nerve Masses

Entrapment Syndromes• Common

– Carpal Tunnel Syndrome– Ulnar Nerve Entrapment At The Elbow or

Cubital Tunnel Syndrome• Uncommon

– Thoracic Outlet Syndrome– Meralgia Paresthetica– Pyriformis Syndrome

Masses

• Benign Tumors: More Common– Neurofibromas– Schwannomas

• Malignant Tumors: Rare

• Ganglion Cysts

Traumatic Nerve injuries

• Open cut injuries

• Closed stretch injuries most commonly involving the brachial plexus

NM Peripheral Nerve Center

• Neurosurgeons• Neurologists• Radiologists (Neuro/MSK)• Rehabilitation Specialists• Plastic Surgeons• Orthopedic Surgeons• Otolaryngologist Surgeons• Intraoperative Monitoring• Anesthesiologists• Pathologists• Oncologists• …!!!

A good peripheral nerve surgeon has to be both a neurologist and surgeon

Spinal Radiculopathy VS Peripheral Nerve EntrapmentCervical Radiculopathy Median Nerve Entrapment (CTS)

Differences

Spinal Radiculopathy• Neck or back pain• Symptoms and physical findings

in distribution of more than one nerve

• Usually make diagnosis with a spine MRI

Peripheral Nerve Entrapment• Numbness, tingling, and/or

weakness• Symptoms and findings in

distribution of a single peripheral nerve involved

• Diagnosis confirmed with EMG/NCV usually and/or imaging (ultrasound/MRI) studies

When a patient meets a doctor there are at least 3 distinctly different possible outcomes:

1. Improves

2. Stays the Same

3. Deteriorates

First do no harm Wanting

to help

Diagnostic/TreatmentApproach/Philosophy

A clinical diagnosis – made on the basis of a history, symptoms and findings – is strengthened when supported by one or more diagnostic studies or interventions.

Diagnosis

Giving Clinical Advice

Although one’s clinical approach changes over time with experience

It is always useful to ask what one would do for a family member or if

you were in the patient’s shoes

Peripheral Nerve Surgeon’s Grading Schema

•Injuries that might improve with medical treatment

•Injuries that might benefit from a surgical repair

Clinical Grading of a Chronic Peripheral Nerve Problem (e.g Entrapment neuropathy)

Medical Treatment• Mild: Intermittent tolerable symptoms without axonal loss / stable or

improving

• Moderate: Constant tolerable symptoms without axonal loss / stable or improving

Surgical Treatment• Moderate: Constant intolerable symptoms without axonal loss / stable or

deteriorating

• Severe: Clinical and electrodiagnostic evidence of axonal loss

Carpal Tunnel Syndrome

Carpal Tunnel Syndrome:Symptoms

• Numbness and/or dysesthesias in 1st through 3rd fingers

• Wrist and/or hand pain (can radiate as proximal as shoulder)

• Weakness and/or reduced dexterity (opening jars)• Increased symptoms at night• positive flick sign

Carpal Tunnel Syndrome:Clinical Findings

• Reduced sensation in 1st through 3rd fingers compared to 5th finger

• Abnormal 2 pt discrimination (> 6mm)• Weakness and/or atrophy of thenar muscles

(esp. APB)• Tinel’s response• Phalen’s Sign (reverse)

Diagnostic Studies - CTS

EMG/NCV MRI

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• Nerve mobility

Other diagnostic cluesNERVE ULTRASOUND

Normalmedian nerve

Mild CTS

Treatment Grading of a Chronic Peripheral Nerve Problem (e.g Entrapment neuropathy)Medical Treatment

• Mild: Intermittent tolerable symptoms without axonal loss / stable or improving

• Moderate: Constant tolerable symptoms without axonal loss / stable or improving

Surgical Treatment

• Moderate: Constant intolerable symptoms without axonal loss / stable or deteriorating

• Severe: Clinical and electrodiagnostic evidence of axonal loss

CTS: Medical Therapy

• Splinting• Activity modifications• Hand Therapy (Namaste)• Ultrasound• Steroid Injections

CTS: Surgical Treatment

• Open Decompression

• Endoscopic Decompression

Reasons Why I Prefer Open Carpal Tunnel Release

• Most familiar and comfortable with this approach

• I like to see clearly what I am cutting to avoid cutting critical nerve branches like the recurrent motor nerve to the thenar muscles

• No clear cut evidence that endoscopic approach is any better and may have a higher complication rate

Open Carpal Tunnel Release

Open Carpal Tunnel Release

• Surgery versus non-surgical therapy for carpal tunnel syndrome: a randomised parallel-group trial

(Patients with mild or moderate CTS)

JG Jarvik, BA Comstock, M Kliot, JA Turner, L Chan, PJ Haegerty, W Hollingworth, CL Kerrigan, and RA Deyo

Bottom Line: A very good operation if you fail non-surgical treatment

• % of patients showing improvement in hand function, symptoms, and pain (recovered normal or near normal function) grouped by:

- intent to treat surg 46% / non-surg 27%- treatment given surg 53% / non-surg 13%

- 61% of patients avoided surgery- Patients that fail non-surgical

treatment can benefit from surgery

Ulnar Nerve Entrapment At The Elbow(Cubital Tunnel Syndrome)

• Numbness in pinky made worse with elbow flexion

• Weakness in hand muscles with loss of dexterity

Thoracic Outlet Syndrome (TOS)

• Upper extremity pain with numbness and weakness usually in hand

• Symptoms increase with arm raised up to the ceiling

TOS Non-Surgical Therapy

• Neck stretching exercises• Avoiding certain postures• Botox injections into the surrounding neck

muscles combined with muscle stretching exercises

Meralgia Paresthetica

• Burning pain along antero-lateral thigh stopping above knee

• Usually can treat by not wearing belts or tight pants and losing weight

Pyriformis Syndrome

• Buttock and sciatica pain increased with direct pressure

• Usually responds to physical therapy

• Botox injections into the pyriformis muscle can help

• Rarely requires a surgical decompression

Left Pyriformis With Ultrasound Guidance

Left Pyriformis With Ultrasound Guidance

Post Op Day 1He Continues To Do Well…

Peripheral Nerve Masses

• Most nerve tumors are benign (Schwannomas and Neurofibromas)

• Many are asymptomatic and stop growing and can be followed with serial clinical exams and imaging studies

• Those that grow and/or are symptomatic are operated upon

• Ganglion cysts can grow and invade nerves

Many Nerve Tumors Stop Growing For Very Long Periods Of Time And Therefore Can Be Watched If Asymptomatic

1993 2014

Many Nerve Tumors Are Symptomatic, Benign, And Very Resectable Without Causing Functional DeficitsSciatic Neurofibroma

Intraneural Ganglion Cyst

Early Surgery For Open Nerve Trauma• Sharp transections• STAB WOUNDS

e.g., glass, knife, razor

Direct Repair

Repair With Nerve Graft

MR DTI: Axonal Regeneration:Partial Left Peroneal Nerve Injury Repaired With Three 8.5 cm Sural Nerve grafts

Brachial Plexus Stretch Injury

Right Brachial Plexus Repair With Grafts C5 Spinal Nerve To Musculocutaneous Nerve

NM Peripheral Nerve Center

Conditions We Treat

Some of the conditions we treat include:• Carpal tunnel syndrome• Thoracic Outlet, Pyriformis• Suppinator and Pronator Teres Syndromes • Meralgia Paresthetica• Peripheral nerve tumors• Schwannomas• Neurofibromas• Ganglian Cysts• Traumatic peripheral nerve injuries• Neuropathic and Myopathic diseases

Interested in making a talking more about your condition?

For appointments call 312-695-8143

Thank You!

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