Neuropathy of the upper limbs

The innervation of the hand is carried out by a whole system of peripheral nerves, that is, located outside the brain and spinal cord. Their diseases are not inflammatory genesis (caused by various degenerative and dystrophic processes) called neuropathy. It is not a separate disease, but is a part of the symptom complex of various pathological conditions, so to determine the tactics of treatment it is not enough to establish the presence of pathology, but it is also necessary to identify the cause of its development. Neuropathy of the upper limbs is not as common as the lower extremities, since the legs are innervated by the longest, and consequently the most vulnerable, nerve fibers. Degenerative and dystrophic changes in the peripheral nerves often begin with the lower limbs, later the nerves of the hands, trunk, and face are involved, although sometimes the nerves of a specific part of the body, in our case, the hands, are immediately involved.

[1], [2],

Epidemiology

Statistics suggest that neuropathies of the upper limbs are not so rare. The most common type is carpal tunnel syndrome, which affects people, often, in the nature of activity, forced to produce flexion movements with a brush. Of all the tunnel syndromes, 2/3 of the complaints are for this localization. And before, many professions led to the development of this pathology, now they have been added to the widespread use of computers - both in professional activities and at home. As a result, 1 to 3.8% of adult inhabitants of the planet annually complain about its symptoms. For one man there are from three to ten women. The peak of the manifestation is at the age of 40-60 years.

Another vulnerable area of the median nerve is in the upper third of the forearm, degenerative-dystrophic changes in this part are called the syndrome of the round pronator. In addition to the above-described reasons, the development of this syndrome may be caused by a rare anomaly - the process of the humerus (Struzer ligament).

Often the function of the ulnar nerve is disturbed. This is also facilitated by compression injuries in everyday life, sports and production.

Tunnel syndromes develop in more than 45% of persons engaged in manual physical labor. And in this case, the overwhelming majority of the lesions are right-sided (about 83%).

[3], [4], [5], [6], [7]

Causes of the neuropathy of the upper extremities

The overwhelming majority of isolated degenerative and dystrophic changes in the nerve fibers of the hand occur as a result of banal squashing of one (mononeuropathy) or several nerves (polyneuropathy) innervating the upper limb. There are five such nerves: musculo-dermal and axillary, regulating the operation of the shoulder and partially the forearm, its upper and lower parts, respectively; median, ulnar and radial, controlling the operation of the arm from the shoulder to the toes.

Nipples can be pinched different parts of the nerves, which are both shallow under the skin, and in the center of the arm. The reasons for such an event can be a lot - about two hundred.

Perhaps, most often, neuropathies of one of these nerves or multiple arise due to the uncomfortable position in which the working hand for a long time, the monotonous movements performed by one or both hands. And if earlier the working hand of a person engaged in monotonous and heavy physical labor suffered, then with the onset of the computer age, office workers joined the risk group. Compression character of neuropathies in half of cases of its occurrence is related to professional activity. One of the most common pathologies is the carpal tunnel syndrome (associated with the compression of the median nerve at the site of its transition to the hand), which affects people who spend a lot of time at the computer, tailors, musicians, dentists and other professionals or athletes performing multiple monotonous bending movement of the hand.

Also, the neuropathy of the median nerve is often caused by unusually high stresses on the wrist, dislocations of the wrist joint and injuries to the forearm.

Often there is a syndrome of the cubital canal connected with monotonous flexion movements in the elbow and compression of the ulnar nerve. The reason for this is the habit of constantly resting the elbow on a solid surface, including in everyday life, for example, talking on the phone, or bending on the weight, for example, exposing the elbow to the window, while driving or hanging from the edge of the table, which again concerns office workers.

Neuropathy of the ulnar nerve is manifested by the syndrome of the Guyon canal - in this regard, the danger poses to professions associated with vibration; cycling, motorcycle racing; constant support on the cane (innervation of the palmar muscles suffers).

Neuropathy of the radial nerve can arise from the incorrect position of the hand during prolonged sleep ("sleep paralysis"), in conductors, runners and representatives of activities that often make monotonous movements in the elbow, in fractures of the clavicle and shoulder joint, the habit wear a heavy bag on the elbow.

The axillary or radial nerve is damaged by prolonged movement with crutches and so on.

In addition, the injuries of the upper limbs can lead to hand injuries - fractures, dislocations, resulting in direct damage to nerve fibers, adjacent muscular or bone tissue, vessels (lack of nutrition due to circulatory disorders, compression between swollen tissues, trauma to the sharp edges of broken bones).

Operations involving the nerve in the process of formation of scar tissue, the development of ischemia, edema; prolonged intravenous infusions; inflammatory diseases - arthritis, bursitis, lymphadenitis and others; cervical osteochondrosis; tumors of both the immediate nervous tissue, for example, interdigital neuroma, and localized near the nerve, often cause compression or ischemic neuropathy.

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Risk factors

Risk factors for its development include: frequent hypothermia, physical overstrain, contact with toxic substances, inflammatory complications of infectious diseases, systemic pathologies - endocrine, autoimmune, liver disease, kidney failure, deficiency of B vitamins due to alimentary or gastrointestinal diseases , vaccination, heredity, alcoholism, fluctuations in the hormonal background.

[9]

Pathogenesis

The pathogenesis of peripheral nerve damage is diverse, it is always based on the degenerative-dystrophic process caused by compression, metabolic, ischemic disorders, or as a result of direct injury (injury, rupture, incision, puncture) of nerve fibers. The structure of the peripheral nerves is similar to the electrical conductor - nerve cells (axons, neurites) are enclosed in a myelin sheath, reminiscent of an insulating one. By pathogenesis, neuropathy is divided into axonal, when axons themselves (nerve cells) are destroyed, and demyelinating, when the shell is exposed to destruction.

In case of infringement, stretching, squeezing, tearing, the axon usually is damaged. With minor compression, the anatomical structure of the nerve is preserved, and it is restored quickly and completely. In severe injuries, complete regeneration of the nerve is impossible even if the myelin sheath is intact.

In the second case, the myelin sheath, which acts as an insulator and conductor, is broken. In the pathogenesis of demyelinating neuropathy, genetic predisposition, rheumatoid arthritis, various forms of diabetes, violations of liver and kidney function, hypothyroidism are considered. Isolated lesions of the nerves of the upper extremities in such pathologies are rare, however, this can not be completely ruled out. The defeat of a single nerve can cause tuberculosis, polyarthritis, poisoning with toxic substances, including alcohol and medications.

[10], [11], [12], [13], [14], [15]

Symptoms of the neuropathy of the upper extremities

Peripheral nerve fibers are divided into motor (motor), sensory (sensitive) and vegetative. From what are mainly affected by pathological changes, such symptoms will prevail in the clinical picture, although isolated lesions of one type of fiber are practically not found, therefore, various variants of the symptom complex are possible.

Motor neuropathy is manifested by muscle weakness, lethargy, trembling, even with minor physical exertion, convulsions, over time, muscle mass decreases, visually the limb loses weight. The patient often finds it difficult to raise his hands upwards, especially through the sides, his coordination of movements is disturbed, it is impossible to hold the objects with his fingers.

The first signs of sensory symptoms are tingling at the fingertips, numbness spreading ever higher; there is a feeling that a dense glove is on hand; pain syndrome from mild discomfort to acute and burning pain (causalgia); loss of sensitivity in the direction from the periphery to the center (first - fingers, then the brush and above).

Vegetative symptoms - pallor of the skin, pigmentation, marbled skin; cold ends of fingers even in hot weather; hyper or hypohidrosis; loss of hair on the skin, thinning of the skin in places with impaired innervation; thickening and bundle of nails; skin ulceration.

Symptoms increase depending on the stage of the disease. Therefore, if you have any pain, numbness, loss of sensitivity and restriction of motor functions, even if there were no injuries, you need to see a doctor.

Damage to one nerve is called mononeuropathy. Types of lesions of the nerves of the upper limb are manifested by such symptoms:

• the musculocutaneous nerve controls the operation of the anterior part of the arm above the ulnar fold, with damage to the function of the shoulder and elbow joint;
• damage to the axillary nerve affects the innervation of the dorsal surface of the limb, breaking of the shoulder and extension of the shoulder joint;
• with the defeat of the median nerve, motor skills and sensitivity along the entire length of the arm are disturbed, but more often - the brush, the large, index and middle fingers;
• the neuropathy of the ulnar nerve is manifested by impaired movements with a brush, an anonymous and middle finger;
• The neuropathy of the radial nerve is manifested as a loss of sensitivity of the back surface of the hand, impaired finger motor activity, and also flexion in the elbow and carpal joints.

The first signs of the most common mononeuropathy of the median nerve - carpal tunnel syndrome - are numbness and tingling in the tips of the thumb, index and middle fingers of the working hand in the mornings, which passes through a couple of hours and does not look more like yourself during the day. Even if you have such symptoms, you need to seek medical help, since later the brushes begin to grow dull at night, and then in the daytime, it becomes problematic to keep the patient with hand objects, it will increasingly lose its functions.

Painful sensations at first have the character of tingling or burning, appear during a night rest or in the morning. The patient has to wake up and lower his sore arm (pains go away). First, one or two toes hurts, then the whole palm is gradually involved in the process, and even the arm to the elbow.

The motor of the brush is broken, fingers, and eventually the brush itself weakens, it becomes difficult to hold objects, especially small and thin.

In advanced stages of the disease, sensitivity decreases, the diseased limb is constantly numb, later it ceases to feel touches and even injections with a sharp object. Atrophic processes occur in muscles and skin.

Symptoms of the neuropathy of the ulnar nerve also begin with numbness and tingling, localized in the ulnar fossa, along the back edge of the forearm and hand, grabbing the ring finger and little finger. The pains of the same localization and motor disorders increase, then loss of sensation and muscle hypotrophy - in such a sequence the syndrome of the cubital canal develops.

With the syndrome of the Guyon canal, sensations are localized and accrued from the palmar surface.

At light degrees of a neuropathy serious motor and sensory disturbances still are not present, therefore probability of restoration depends on the timely reference for the help.

Complications and consequences

As already mentioned, in the initial stages of sensation with neuropathies are quite tolerable and, if you do not pay attention to them, the condition begins to aggravate. Muscles hypertrophy, the hand works worse and worse.

Without treatment, the process can end with irreversible muscle tissue atrophy. Visually the limb decreases in volume, the brush is deformed and becomes similar to the palm of primacy - flat, with the thumb pressed to it.

Sometimes, with partial damage to the median, even more rarely - ulnar nerve, a causalgic syndrome develops. This complicates injuries, when at the time of wound scarring the afferent receptors of nerve cells become irritated, which leads to intense, simply unbearable pain. Of course, in this state it is impossible to not seek help. Causalgia appears about the fifth day after the injury, and sometimes later, for example, after two weeks.

Axonal neuropathy is characterized by slow development and prolonged course. Without treatment, the process ends with complete atrophy of the muscles that lack innervation, and loss of mobility of the limb (the hand "withers").

Demyelinating neuropathy is characterized by a fairly rapid development of the disease, with a loss of sensitivity and loss of motor functions.

Therefore, the earlier treatment is started, the more chances to restore the function completely. In neglected cases, often the only method of treatment is surgery, and not always a complete cure.

[16], [17], [18], [19], [20], [21],

Diagnostics of the neuropathy of the upper extremities

At the first symptoms of discomfort - tingling, numbness, burning, soreness, limited motor skills, muscle weakness, you should contact a medical institution.

When a patient is questioned, not only the symptoms that concern him are considered, but also the occupational risks, the presence of bad habits, previous injuries and the possibility of intoxication. The presence of chronic diseases, the transferred infections, genetic predisposition is taken into account.

Clinical blood and urine tests, a blood glucose test, thyroid hormones, protein content, B vitamins are prescribed. Blood and urine tests for toxic substances can be prescribed.

Nerve trunks are directly palpated, a biopsy of nerve fibers is performed and the depth of their damage is determined. Cerebrospinal fluid examination, testing of nervous reflexes and reactions can be prescribed.

Instrumental diagnostics is carried out: electroneuromyography, radiography, ultrasound examination of internal organs.

Consultations can be appointed with other physicians, additional tests and studies.

[22], [23], [24],

Differential diagnosis

Differential diagnosis is carried out based on the results of the examination, the results of laboratory and instrumental studies.

Often in the long course of the disease, neuropathy can be determined even visually by breaking the symmetry and motor function of the upper limbs. Laboratory diagnostics helps to understand the cause of nerve damage, to establish the presence of metabolic disorders, autoimmune process, inflammations and infections. Specific analyzes allow us to identify the characteristic antibodies and antigens, the content of vitamins and proteins in the blood plasma.

Instrumental studies show a decrease in the speed of the nerve impulse or its absence (atrophy), a decrease in the activity of muscle fibers.

Special diagnostic tests can reveal which nerve was damaged. So, for example, with motor neuropathy of the ulnar nerve, the patient can not squeeze the affected hand into the fist due to the fact that the ring finger and little finger do not bend. He also can not spread his fingers out with a fan and then - bring them together, press his hand against the surface of the table and scratch it with a little finger. Sensory reflexes partially or completely disappear on the ring finger and little finger, on the forearm and the hand from the elbow.

External signs of the neuropathy of the radial nerve - hanging brush, problems with extension in the carpal and elbow joint, the thumb is not diverted from the hand, the mobility of the index and middle fingers is impaired. Fulfillment of the listed and other tasks allows to determine the localization of the violation.

Numbness of the fingers on the arm with compression neuropathy is differentiated from similar symptoms when the roots of the spinal cord of the corresponding level are compressed, at which the filling of the pulse on the radial artery decreases.

Neuropathy of the radial nerve is differentiated from de Kreven's disease, plexitis and other pathologies with similar symptoms. Usually put an end in determining the diagnosis helps radiography, computer and nuclear magnetic resonance imaging.

Treatment of the neuropathy of the upper extremities

Depending on the origin of the pathological changes of nerve fibers, the treatment is primarily aimed at eliminating the etiologic factor - reducing the compression of the nerve, correcting the level of glucose or thyroid hormones, supporting metabolic therapy, restoring trophic and functions of the affected muscles. With compression neuropathy, special orthoses, bandages, and tires are used to limit the pressure on the affected nerve during movement and at rest. If the reason is professional activity, habits, wearing a walking stick or crutches, then during the treatment it is necessary to exclude traumatic factors.

For more information on the treatment of upper extremity neuropathy, see this article.

Prevention

Neuropathies of the upper limb in most cases are of a compression nature and are caused by prolonged monotonous positions of the hands or repetitions of the same movement. To prevent the development of the pathological process associated with the infringement of the nerve, it is possible, observing a certain caution, periodically changing the position of the hands, doing warm-ups for them.

It is important to get rid of bad habits, to engage in any kind of sport, to follow a full-fledged diet, and also to monitor your health and promptly consult a doctor when anxiety symptoms appear, in time to identify a developing disease and prevent it from becoming chronic.

[25], [26], [27], [28],

Forecast

Neuropathy of the upper extremities of mild and moderate severity is curable by conservative methods.

To predict the outcome of a neglected disease is much more difficult, the chronic form will be felt by periodic exacerbations. Even surgical treatment does not always lead to a complete restoration of the sensory-motor functions of the hand.

[29], [30], [31]