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The treatment and management of radial neuropathy can be achieved via the following methods:
- Physical therapy or occupational therapy
- Surgery(depending on the specific area and extent of damage)
- Splinting
The first line of treatment is often to treat the patients pain with neuropathic drugs such as tricyclic antidepressants, serotonin reuptake inhibitors, and anticonvulsants. The second lines of drugs to treat pain are non-steroidal anti-inflammatories, tramadol, and opioids. Other techniques used to facilitate healing of the nerve and pain are either static or dynamic splinting that can both help protect the injured part as well as improve function. Sometimes surgery is an option, although the prognosis is still very poor of regaining function of the affected nerve. The goal of surgery is to join healthy nerve to unhealthy nerve. The most common surgical techniques include external neurolysis, end-to-end repair, nerve grafting, and nerve transfer from somewhere else in the body.
Non-surgical treatment of radial tunnel syndrome includes rest, NSAID, therapy with modalities, work modification, ergonomic modification, injection if associated with lateral epicondylitis.
Patients whose conditions are more adapted to surgical intervention are those who do not respond to prolonged conservative treatment. The patient must have pain with resisted supination, positive middle finger test, positive electrodiagnostic findings, and pain relief after anesthetic injection into the radial tunnel. Based on 2002 data, surgical decompression leads to 60-70% good or excellent results.
Surgical decompression can give excellent results if the clinical picture and the EMG suggest a compression neuropathy.
In brachial plexus neuritis, conservative management may be more appropriate.
Spontaneous recovery has been reported, but is said to be delayed and incomplete.
There is a role for physiotherapy and this should be directed specifically towards the pattern of pain and symptoms. Soft tissue massage, stretches and exercises to directly mobilise the nerve tissue may be used.
In terms of prognosis radial neuropathy is not necessarily permanent, though sometimes there could be partial loss of movement/sensation.Complications may be possible deformity of the hand in some individuals.
If the injury is axonal (the underlying nerve fiber itself is damaged) then full recovery may take months or years ( or could be permanent). EMG and nerve conduction studies are typically performed to diagnose the extent and distribution of the damage, and to help with prognosis for recovery.
When an underlying medical condition is causing the neuropathy, treatment should first be directed at this condition. For example, if weight gain is the underlying cause, then a weight loss program is the most appropriate treatment. Compression neuropathy occurring in pregnancy often resolves after delivery, so no specific treatment is usually required. Some compression neuropathies are amenable to surgery: carpal tunnel syndrome and cubital tunnel syndrome are two common examples. Whether or not it is appropriate to offer surgery in any particular case depends on the severity of the symptoms, the risks of the proposed operation, and the prognosis if untreated. After surgery, the symptoms may resolve completely, but if the compression was sufficiently severe or prolonged then the nerve may not recover fully and some symptoms may persist. Drug treatment may be useful for an underlying condition (including peripheral oedema), or for ameliorating neuropathic pain.
While pain symptoms may be effectively controlled using medications such as NSAID, amitriptyline, or vitamin B6 supplementation, effective treatment generally requires resolving the underlying cause.
Mild to moderate symptoms, such as pain or paresthesia, are treated conservatively with non-surgical approaches. Physiotherapy treatments can prove effective at treating cubital tunnel syndrome symptoms and can include:
- Joint mobilizations
- Neural flossing/gliding
- Strengthening/stretching exercises
- Activity modification
It is important to identify positions and activities that aggravate symptoms and to find ways to avoid them. For example, if the person experiences symptoms when holding a telephone up to the head, then the use of a telephone headset will provide immediate symptomatic relief and reduce the likelihood of further damage and inflammation to the nerve. For cubital tunnel syndrome, it is recommended to avoid repetitive elbow flexion and also avoiding prolonged elbow flexion during sleep, as this position puts stress of the ulnar nerve.
Surgery is recommended for those who are not improved with conservative therapy or those with serious or progressive symptoms. The surgical approaches vary, and may depend on the location or cause of impingement. Cubital and ulnar tunnel release can be performed wide awake with no general anaesthesia, no regional anaesthesia, no sedation and no tourniquet, and are usually done by Plastic Surgeons
Practical surgical procedures used for treating synkinesis are neurolysis and selective myectomy. Neurolysis has been shown to be effective in relieving synkinesis but only temporarily and unfortunately symptoms return much worse than originally. Selective myectomy, in which a synkinetic muscle is selectively resected, is a much more effective technique that can provide permanent relief and results in a low recurrence rate; unfortunately, it also has many post-operative complications that can accompany including edema, hematoma, and ecchymosis. Therefore, surgical procedures are very minimally used by doctors and are used only as last-resort options for patients who do not respond well to non-invasive treatments.
Electrical stimulation can promote nerve regeneration. The frequency of stimulation is an important factor in the success of both quality and quantity of axon regeneration as well as growth of the surrounding myelin and blood vessels that support the axon. Histological analysis and measurement of regeneration showed that low frequency stimulation had a more successful outcome than high frequency stimulation on regeneration of damaged sciatic nerves.
Surgery can be done in case a nerve has become cut or otherwise divided. Recovery of a nerve after surgical repair depends mainly on the age of the patient. Young children can recover close-to-normal nerve function. In contrast, a patient over 60 years old with a cut nerve in the hand would expect to recover only protective sensation, that is, the ability to distinguish hot/cold or sharp/dull. Many other factors also affect nerve recovery. The use of autologous nerve grafting procedures that involve redirection of regenerative donor nerve fibers into the graft conduit has been successful in restoring target muscle function. Localized delivery of soluble neurotrophic factors may help promote the rate of axon regeneration observed within these graft conduits.
An expanding area of nerve regeneration research deals with the development of scaffolding and bio-conduits. Scaffolding developed from biomaterial would be useful in nerve regeneration if they successfully exhibit essentially the same role as the endoneurial tubes and Schwann cell do in guiding regrowing axons.
In cases of a minor deviation of the wrist, treatment by splinting and stretching alone may be a sufficient approach in treating the radial deviation in RD. Besides that, the parent can support this treatment by performing passive exercises of the hand. This will help to stretch the wrist and also possibly correct any extension contracture of the elbow. Furthermore, splinting is used as a postoperative measure trying to avoid a relapse of the radial deviation.
Botox (botulinum toxin) is a new and versatile tool for the treatment of synkinesis. Initially used for reducing hyperkinesis after facial palsy, Botox was later attempted on patients with post-facial palsy synkinesis to reduce unwanted movements. The effects of Botox have shown to be remarkable, with synkinetic symptoms disappearing within 2 or 3 days. The most common treatment targets are the orbicularis oculi, depressor anguli oris (DAO), mentalis, platysma and the contralateral depressor labii inferioris muscles. Due to the short span of Botox effects though, patients must come back to the doctor for re-injection approximately every 3 months. More notable is that in a majority of patients, various synkinetic movements completely disappeared after 2-3 sessions of trimonthly Botox injections.
A more specific synkinesis, crocodile tears syndrome (hyperlacrimation upon eating), has been shown to respond exceedingly well to Botox injection. Botox is injected directly into the lacrimal gland and has shown to reduce hyperlacrimation within 24–48 hours. The procedure was shown to be simple and safe with very little chance of side-effects (although on rare occasions ptosis can occur due to botulinum toxin diffusion). Furthermore, reduction in hyper-lacrimation was shown to last longer than the expected 3 months (about 12 months).
Since Botox can mimic facial paralysis, an optimized dose has been determined that reduces involuntary synkinesis of the muscle while not affecting muscle tone.
People who suffer from neurotmesis often face a poor prognosis. They will more than likely never regain full functionality of the affected nerve, but surgical techniques do give people a better chance at regaining some function. Current research is focused on new ways to regenerate nerves and advance surgical techniques.
Currently, tendon transfers are being studied as a means of improving radial, medial, and ulnar nerve palsy.
In high median nerve palsy patients, recovery time varies from as early as four months to 2.5 years. Initially, patients are immobilized in a neutral position of the forearm and elbow flexed at 90° in order to prevent further injury. Additionally, gentle exercises and soft tissue massage are applied. The next goal is strengthening and flexibility, usually involving wrist extension and flexion; however, it is important not to overuse the muscles in order to prevent re-injury. If surgery is required, post operative therapy initially involves decreasing pain and sensitivity to the incision area. Adequate grip and elbow strength must be achieved before returning to pre-operative activity.
Depending on the severity of the lesion, physicians may recommend either conservative treatment or surgery. The first step is simply to rest and modify daily activities that aggravate the symptoms. Patients may be prescribed anti-inflammatory drugs, Physical or Occupational therapy, splints for the elbow and wrists, and corticosteroid injections as well. This is the most common treatment for CTS. Especially involving compression at the wrist, such as in CTS, it is possible to recover without treatment. Physical therapy can help build muscle strength and braces or splints help recover. In pronator teres syndrome, specifically, immobilization of the elbow and mobility exercise within a pain-free range are initially prescribed. However, if the patient is not relieved of symptoms after a usual 2 to 3 month refractory period, then decompression surgery may be required. Surgery involves excising the tissue or removing parts of the bone compressing the nerve.
Many tendon transfers have been shown to restore opposition to the thumb and provide thumb and finger flexion. In order to have optimal results the individual needs to follow the following principles of tendon transfer: normal tissue equilibrium, movable joints, and a scar-free bed. If these requirements are met then certain factors need to be considered such as matching up the lost muscle mass, fiber length, and cross-sectional area and then pick out muscle-tendon units of similar size, strength, and potential excursion.
For patients with low median nerve palsy, it has been shown that the flexor digitorum superficialis of the long and ring fingers or the wrist extensors best approximate the force and motion that is required to restore full thumb opposition and strength. This type of transfer is the preferred method for median nerve palsy when both strength and motion are required. In situations when only thumb mobility is desired, the extensor indicis proprius is an ideal transfer.
For high median nerve palsy, the brachioradialis or the extensor carpi radialis longus transfer is more appropriate to restore lost thumb flexion and side-to-side transfer of the flexor digitorum profundus of the index finger are generally sufficient. To restore independent flexion of the index finger could be performed by using the pronator teres or extensor carpi radialis ulnaris tendon muscle units. All of the mentioned transfers are generally quite successful because they combine a proper direction of action, pulley location, and tendon insertion.
Neurapraxia is often treated and cured by non-operative means. The primary goals of treatment are to maintain the proper nutrition of the paralyzed muscles, prevent contraction by the antagonists of the paralyzed muscles, and to consistently keep the joints mobile. A splint is often used in cases of neurapraxia because it is able to maintain a relaxed position of the paralyzed muscle. The splint prevents the paralyzed muscle from being overstretched either by the force of gravity or by other non-paralyzed antagonists. During the recovery period of neurapraxia, it is essential that the joints constantly undergo passive movement in order to preserve proper mobility. If joints are kept mobile, the limb has the best possible chance of benefit from the return of nervous function. Non-steroidal anti-inflammatory medications can also help to reduce swelling at the injury site. In addition to these non-operative remedies, it is suggested that muscles affected by neurapraxia be kept warm at all times. Circulation in the limb is stimulated with the use of heat.
Once voluntary movement has returned to the muscle, recovery and treatment continues by the participation in active exercises. Physical Therapy and Occupational Therapy are common sources of treatment during these early stages of restoration of active movement. Almost all cases of neurapraxia can be completely treated by non-operative means.
More severe types (Bayne type III en IV) of radial dysplasia can be treated with surgical intervention. The main goal of centralization is to increase hand function by positioning the hand over the distal ulna, and stabilizing the wrist in straight position. Splinting or soft-tissue distraction may be used preceding the centralization.
In classic centralization central portions of the carpus are removed to create a notch for placement of the ulna. A different approach is to place the metacarpal of the middle finger in line with the ulna with a fixation pin.
If radial tissues are still too short after soft-tissue stretching, soft tissue release and different approaches for manipulation of the forearm bones may be used to enable the placement of the hand onto the ulna. Possible approaches are shortening of the ulna by resection of a segment, or removing carpal bones. If the ulna is significantly bent, osteotomy may be needed to straighten the ulna. After placing the wrist in the correct position, radial wrist extensors are transferred to the extensor carpi ulnaris tendon, to help stabilize the wrist in straight position. If the thumb or its carpometacarpal joint is absent, centralization can be followed by pollicization. Postoperatively, a long arm plaster splinter has to be worn for at least 6 to 8 weeks. A removable splint is often worn for a long period of time.
Radial angulation of the hand enables patients with stiff elbows to reach their mouth for feeding; therefore treatment is contraindicated in cases of extension contracture of the elbow. A risk of centralization is that the procedure may cause injury to the ulnar physis, leading to early epiphyseal arrest of the ulna, and thereby resulting in an even shorter forearm. Sestero et al. reported that ulnar growth after centralization reaches from 48% to 58% of normal ulnar length, while ulnar growth in untreated patients reaches 64% of normal ulnar length. Several reviews note that centralization can only partially correct radial deviation of the wrist and that studies with longterm follow-up show relapse of radial deviation.
Treatment is directed at the pathology causing the paralysis. If it is because of trauma such as a gunshot or knife wound, there may be other life-threatening conditions such as bleeding or major organ damage which should be dealt with on an emergent basis. If the syndrome is caused by a spinal fracture, this should be identified and treated appropriately. Although steroids may be used to decrease cord swelling and inflammation, the usual therapy for spinal cord injury is expectant.
Cubital tunnel syndrome may be prevented or reduced by maintaining good posture and proper use of the elbow and arms, such as wearing an arm splint while sleeping to maintain the arm is in a straight position instead of keeping the elbow tightly bent. A recent example of this is popularization of the concept of cell phone elbow.
First options for treatment are conservative, using hot or cold packs, rest and NSAID's at first. If no improvement is made, a splint or brace can be used to keep the deviated arm straight. When none of the conservative treatments work surgical intervention is designated.
Treatment is usually unnecessary. In severe cases, surgery with a bilateral levator excision and frontalis brow suspension may be used.
There are many treatments to facilitate the process of recovery in people who have brachial plexus injuries. Improvements occur slowly and the rehabilitation process can take up to many years. Many factors should be considered when estimating recovery time, such as initial diagnosis of the injury, severity of the injury, and type of treatments used. Some forms of treatment include nerve grafts, medication, surgical decompression, nerve transfer, physical therapy, and occupational therapy.
Treatment for brachial plexus injuries includes orthosis/splinting, occupational or physical therapy and, in some cases, surgery. Some brachial plexus injuries may heal without treatment. Many infants improve or recover within 6 months, but those that do not have a very poor outlook and will need further surgery to try to compensate for the nerve deficits. The ability to bend the elbow (biceps function) by the third month of life is considered an indicator of probable recovery, with additional upward movement of the wrist, as well as straightening of thumb and fingers an even stronger indicator of excellent spontaneous improvement. Gentle range of motion exercises performed by parents, accompanied by repeated examinations by a physician, may be all that is necessary for patients with strong indicators of recovery.
The exercises mentioned above can be done to help rehabilitate from mild cases of the injury. However, in more serious brachial plexus injuries surgical interventions can be used. Function can be restored by nerve repairs, nerve replacements, and surgery to remove tumors causing the injury. Another crucial factor to note is that psychological problems can hinder the rehabilitation process due to a lack of motivation from the patient. On top of promoting a lifetime process of physical healing, it is important to not overlook the psychological well-being of a patient. This is due to the possibility of depression or complications with head injuries.
Although treatment may be unnecessary, there may be social implications, especially in young children when venturing from a supportive home environment to a public environment (e.g., starting school). Continued support, including monitoring behavior and educating the child about his or her appearance as seen by others, is encouraged. Gradual or sudden withdrawal from interaction with others is a sign that may or may not be related to such behavior. Studies are being conducted to elucidate these implications.
Corticosteroid injections can be effective for temporary relief from symptoms while a person develops a long-term strategy that fits their lifestyle. This form of treatment is thought to reduce discomfort in those with CTS due to its ability to decrease median nerve swelling. The use of ultrasound while performing the injection is more expensive but leads to faster resolution of CTS symptoms. The injections are done under local anesthesia. This treatment is not appropriate for extended periods, however. In general, local steroid injections are only used until more definitive treatment options can be used. Corticosteroid injections do not appear to be very effective for slowing disease progression.