Mononeuropathy and Plexopathy

Neuropathy is a nerve pathology presenting with sensory, motor, or autonomic impairment secondary to dysfunction of the affected nerve. The peripheral nerves (outside the brain and spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord), are derived from several plexuses, with the brachial and lumbosacral plexuses supplying the major innervation to the extremities. Mononeuropathy (affecting a single nerve) and plexopathy (affecting the plexus) can occur from trauma, compression, and systemic diseases. The clinical presentation varies according to location, type of nerves affected, and cause of the damage. Diagnosis requires a thorough physical examination, and diagnostic tests Diagnostic tests Diagnostic tests are important aspects in making a diagnosis. Some of the most important epidemiological values of diagnostic tests include sensitivity and specificity, false positives and false negatives, positive and negative predictive values, likelihood ratios, and pre-test and post-test probabilities. Epidemiological Values of Diagnostic Tests include laboratory tests, imaging and a confirmatory nerve conduction study, and electromyography. Management depends on the etiology but centers around physical therapy, supportive care, and treatment of underlying issues.

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Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

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Overview

Definitions

Neuropathy is a term used to describe nerve pathology presenting with sensory, motor, or autonomic impairment secondary to dysfunction of the affected nerve.

  • Mononeuropathy describes a condition in which a single nerve is affected.
  • Peripheral mononeuropathy is damage to a peripheral nerve (outside the brain and spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord).
  • Polyneuropathies affect multiple nerves, and diabetes is the most common cause. 
  • Distinct from both mononeuropathy and polyneuropathy Polyneuropathy Polyneuropathy is any disease process affecting the function of or causing damage to multiple nerves of the peripheral nervous system. There are numerous etiologies of polyneuropathy, most of which are systemic and the most common of which is diabetic neuropathy. Polyneuropathy, mononeuropathy multiplex is a condition:
    • Involving ≥ 2 single nerves (often in different parts of the body)
    • Associated with chronic disease (e.g., leprosy Leprosy Leprosy, also known as Hansen's disease, is a chronic bacterial infection caused by Mycobacterium leprae complex bacteria. Symptoms primarily affect the skin and peripheral nerves, resulting in cutaneous manifestations (e.g., hypopigmented macules) and neurologic manifestations (e.g., loss of sensation). Leprosy) due to multiple nerves being affected at the same time
  • Plexopathy is a disorder affecting the network of nerves or a plexus, of which the brachial plexus and the lumbosacral plexus are commonly affected.

Etiology

There are numerous etiologies for mononeuropathy, which can be acute or chronic. 

  • Acute etiologies are most often due to trauma, and chronic etiologies are frequently due to a trapped nerve.
  • Causes include:
    • Lesions to individual peripheral nerves (e.g., ischemia/infarct, tumors)
    • Hereditary
    • Trauma (e.g., nerve transection or neurotmesis, compression)
    • Inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation (e.g., infectious process such as herpes zoster Herpes Zoster Varicella-zoster virus (VZV) is a linear, double-stranded DNA virus in the Herpesviridae family. Shingles (also known as herpes zoster) is more common in adults and occurs due to the reactivation of VZV. Varicella-Zoster Virus/Chickenpox)
    • Radiation injury
    • Toxins
    • Nutritional deficiency
    • Medications
    • Diseases or conditions such as:
      • Diabetes mellitus Diabetes mellitus Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus
      • Pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-hCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care 
      • Guillain-Barré syndrome Guillain-Barré syndrome Guillain-Barré syndrome (GBS), once thought to be a single disease process, is a family of immune-mediated polyneuropathies that occur after infections (e.g., with Campylobacter jejuni). Guillain-Barré Syndrome
      • Inflammatory diseases
      • Alcoholism

Epidemiology

  • Prevalence of neuropathy in older populations: approximately 8%
  • Carpal tunnel syndrome Carpal Tunnel Syndrome Carpal tunnel syndrome (CTS) is a complex of signs and symptoms caused by compression of the median nerve as it crosses the carpal tunnel. Presentation is with pain and paresthesia of the dermatomal target tissues innervated by the median nerve as well as weakness and atrophy of the nerve's myotomal targets. Carpal Tunnel Syndrome: most common mononeuropathy
  • Charcot-Marie-Tooth disease: most common genetic sensorimotor polyneuropathy Polyneuropathy Polyneuropathy is any disease process affecting the function of or causing damage to multiple nerves of the peripheral nervous system. There are numerous etiologies of polyneuropathy, most of which are systemic and the most common of which is diabetic neuropathy. Polyneuropathy

Upper-Limb Neuropathies

Neuropathies in the upper extremities can affect the brachial plexus (causing brachial plexopathy) or the individual nerves that branch off to supply different areas.

Brachial plexus

  • A network of nerves serving as a conduit for signals between the spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord and the shoulder, arm Arm The arm, or "upper arm" in common usage, is the region of the upper limb that extends from the shoulder to the elbow joint and connects inferiorly to the forearm through the cubital fossa. It is divided into 2 fascial compartments (anterior and posterior). Arm, and hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand
  • Formed from the anterior rami of the spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord segments C5–T1, which are the roots of the brachial plexus
  • Causes of brachial plexopathy:
    • Acute: trauma (e.g., fall, shoulder injury) or obstetric injury (e.g., stretching of the brachial plexus occurs in shoulder dystocia)
    • Chronic: inflammation or tumor
  • Presentation:
    • In general, the condition causes arm Arm The arm, or "upper arm" in common usage, is the region of the upper limb that extends from the shoulder to the elbow joint and connects inferiorly to the forearm through the cubital fossa. It is divided into 2 fascial compartments (anterior and posterior). Arm paralysis or loss of sensation in the C5 and C6 dermatomes.
    • Erb palsy: 
      • Commonly, C5 and C6 (occasionally C7) affected
      • Forearm Forearm The forearm is the region of the upper limb between the elbow and the wrist. The term "forearm" is used in anatomy to distinguish this area from the arm, a term that is commonly used to describe the entire upper limb. The forearm consists of 2 long bones (the radius and the ulna), the interosseous membrane, and multiple arteries, nerves, and muscles. Forearm extended and pronated, arm Arm The arm, or "upper arm" in common usage, is the region of the upper limb that extends from the shoulder to the elbow joint and connects inferiorly to the forearm through the cubital fossa. It is divided into 2 fascial compartments (anterior and posterior). Arm rotated medially, wrist flexed (waiter’s tip posture)
    • Klumpke’s palsy:
      • Affects C8/T1 (more rare than Erb palsy)
      • Caused by hyperabduction of the arm Arm The arm, or "upper arm" in common usage, is the region of the upper limb that extends from the shoulder to the elbow joint and connects inferiorly to the forearm through the cubital fossa. It is divided into 2 fascial compartments (anterior and posterior). Arm
      • Hand paralysis with flexed wrist and interphalangeal joints (claw hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand)
      • Severe injury → flail arm Arm The arm, or "upper arm" in common usage, is the region of the upper limb that extends from the shoulder to the elbow joint and connects inferiorly to the forearm through the cubital fossa. It is divided into 2 fascial compartments (anterior and posterior). Arm and Horner syndrome Horner syndrome Horner syndrome is a condition resulting from an interruption of the sympathetic innervation of the eyes. The syndrome is usually idiopathic but can be directly caused by head and neck trauma, cerebrovascular disease, or a tumor of the CNS. Horner Syndrome
    • Brachial plexitis:
      • Other names: neuralgic amyotrophy, Parsonage- Turner syndrome Turner syndrome Turner syndrome is a genetic condition affecting women, in which 1 X chromosome is partly or completely missing. The classic result is the karyotype 45,XO with a female phenotype. Turner syndrome is associated with decreased sex hormone levels and is the most common cause of primary amenorrhea. Turner Syndrome
      • Increasing deep burning pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain in the deltoid area
      • Followed by muscular weakness, often within 2 weeks of the pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain
      • Weakness commonly affects serratus anterior, deltoid, biceps, or triceps.
      • Recovery from 2 months to 1 year

Median neuropathy

  • Median nerve: formed from the brachial plexus, with contributions from C5–T1, supplying:
    • Motor: 
      • Flexor muscles of the forearm and hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand
      • Muscles for flexion, abduction, opposition, and extension of the thumb
    • Sensory: 
      • Dorsal aspect of the distal 1st 2 digits of the hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand
      • Volar aspect of the thumb, the index and middle fingers, ½ of the ring finger, and the palm
      • Medial forearm
  • Carpal tunnel syndrome Carpal Tunnel Syndrome Carpal tunnel syndrome (CTS) is a complex of signs and symptoms caused by compression of the median nerve as it crosses the carpal tunnel. Presentation is with pain and paresthesia of the dermatomal target tissues innervated by the median nerve as well as weakness and atrophy of the nerve's myotomal targets. Carpal Tunnel Syndrome (distal nerve injured at the wrist):
    • Paresthesias in the median nerve territory, 1st 3 digits and the radial ½ of the 4th digit
    • Dropping objects from hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand (thumb, index, and/or middle fingers)
    • Atrophy of thenar eminence
    • Chronic injury: inability to abduct and oppose thumb, termed the ape- hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand deformity
  • Pronator teres or pronator syndrome (forearm injured):
    • Seen in cyclists
    • Pain in the forearm 
    • Loss of sensation in the lateral palm and thenar eminence
    • Elbow extension and repeated pronation produce symptoms.
  • Anterior interosseous neuropathy (forearm injured):
    • Muscle weakness (flexor pollicis longus, deep flexors of 2nd and 3rd fingers, and pronator quadratus)
    • ↓ Thumb and index finger pincer movement (cannot make an O sign)
    • Forearm Forearm The forearm is the region of the upper limb between the elbow and the wrist. The term "forearm" is used in anatomy to distinguish this area from the arm, a term that is commonly used to describe the entire upper limb. The forearm consists of 2 long bones (the radius and the ulna), the interosseous membrane, and multiple arteries, nerves, and muscles. Forearm pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain
    • Sensation not affected
  • Hand of benediction or preacher’s hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand (wrist or elbow injury):
    • Extended 2nd and 3rd fingers when asked to make a fist 
    • Cannot flex 2nd and 3rd fingers

Ulnar neuropathy

  • Ulnar nerve: 
    • Motor: 
      • Flexor carpi ulnaris and medial ½ of the flexor digitorum profundus (FDP) in the anterior or flexor compartment
      • 3rd and 4th lumbricals, dorsal interossei, palmar interossei, adductor pollicis, flexor pollicis brevis and palmaris brevis in the hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand
    • Sensory: 
      • Medial forearm
      • Medial wrist
      • Medial 1½ digits
  • Presentation:
    • Ulnar nerve injury at the elbow (distal nerve injury):
      • Sensory > motor symptoms, with sensory changes often from sustained flexed elbow
      • Sensory changes in volar aspect (4th and 5th digits) and ulnar aspect of the hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand
      • Tingling or numbness of the 4th and 5th digits
      • ↓ Hand grip
      • Medial elbow pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain
    • Ulnar injury at the wrist:
      • Hand weakness and atrophy
      • Loss of dexterity
      • Sensory changes vary.
      • Ulnar claw: clawing of 4th and 5th digits when asked to extend fingers (unable to extend interphalangeal joints)
Table: Ulnar claw versus hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand of benediction
Ulnar claw Hand of benediction
Nerve Ulnar nerve (wrist area) Median nerve (wrist/elbow)
Presentation Clawing when asked to extend the fingers Hand of benediction when asked to make a fist (but can extend fingers)
Affected fingers 4th and 5th fingers extended at MCP joints and flexed at IP joints 2nd and 3rd fingers
Mechanism
  • Unopposed action of the extensor digitorum muscle, extending the MCP
  • Weak interossei and ulnar lumbricals → flexed IP joints
Loss of motor function of the 2nd and 3rd fingers
IP: interphalangeal
MCP: metacarpophalangeal

Radial neuropathy

  • Radial nerve: 
    • Motor: all muscles of the posterior or extensor compartment of the forearm
    • Sensory: inferior or posterior lateral cutaneous nerve (from the radial nerve), which innervates the skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin over the posterior arm Arm The arm, or "upper arm" in common usage, is the region of the upper limb that extends from the shoulder to the elbow joint and connects inferiorly to the forearm through the cubital fossa. It is divided into 2 fascial compartments (anterior and posterior). Arm
  • Presentation:
    • Weak wrist extensors: unable to extend the wrist (wrist drop) 
    • Weak finger extensors and brachioradialis
    • Weak thumb abduction (abductor pollicis longus affected)
    • Sensory changes to the posterior forearm, lateral 3 digits, and dorsolateral palm

Suprascapular neuropathy

  • Suprascapular nerve comes from the upper trunk of the brachial plexus, supplying:
    • Motor: supraspinatus and infraspinatus muscles
    • Sensory: glenohumeral and acromioclavicular joints
  • Causes of suprascapular neuropathy:
    • Trauma (e.g., fall, motor vehicle accident, football tackle)
    • Compression (e.g., from tumor, cyst)
  • Presentation:
    • Shoulder pain Shoulder Pain Acute shoulder injuries are a common reason for visits to primary care physicians and EDs. Common acute shoulder injuries include acromioclavicular joint injuries, clavicle fractures, glenohumeral dislocations, proximal humerus fractures, and rotator cuff tears. Acute Shoulder Pain
    • Weak shoulder abduction (due to affected supraspinatus)
    • Weak external shoulder rotation (due to affected infraspinatus)

Axillary neuropathy

  • Axillary nerve comes from the posterior cord of the brachial plexus, supplying:
    • Motor: deltoid and teres minor muscles
    • Sensory: lateral shoulder
  • Injury:
    • Trauma (e.g., shoulder dislocation, humeral fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures)
    • Sleeping in prone position (arms above the head)
  • Presentation:
    • Sensory loss in the lateral shoulder
    • Varying degrees of weakness in shoulder abduction and external rotation (as other muscles aid in similar functions)

Long thoracic neuropathy

  • Long thoracic nerve arises from the 5th, 6th, and 7th cervical roots, supplying the serratus anterior muscle (fixes the lateral scapula to the chest wall Chest wall The chest wall consists of skin, fat, muscles, bones, and cartilage. The bony structure of the chest wall is composed of the ribs, sternum, and thoracic vertebrae. The chest wall serves as armor for the vital intrathoracic organs and provides the stability necessary for the movement of the shoulders and arms. Chest Wall).
  • Causes of long thoracic neuropathy:
    • Trauma or compression:
      • Chest wall or shoulder injuries
      • Surgeries such as mastectomy with axillary node dissection, chest tube insertion, cardiothoracic surgeries
    • Neuralgic amyotrophy
    • Traction from repetitive movements
  • Presentation:
    • Winging of the scapula (upon pressing outstretched arms against a wall)
    • Finding can be seen with other neuropathies (e.g., spinal accessory, dorsal scapular).

Spinal accessory neuropathy

  • Spinal accessory nerve, a motor nerve from upper cervical nerve roots, supplies the:
    • Sternocleidomastoid 
    • Trapezius
  • Causes of neuropathy:
    • Most commonly from procedures 
      • Biopsy of cervical lymph nodes in the posterior triangle
      • Radical neck dissection
    • Trauma (e.g., sports)
  • Presentation: 
    • Drooped shoulder 
    • Weak abduction (cannot abduct beyond 90 degrees)
    • Weak and atrophied sternocleidomastoid muscle (proximal nerve injury)
    • Weak and atrophied trapezius (distal nerve injury)
    • Winging of scapula

Musculocutaneous neuropathy

  • Musculocutaneous nerve arises from the lateral cord of the brachial plexus (C5–C7) and supplies the following:
    • Motor: coracobrachialis, biceps, and brachialis muscles
    • Sensory: lateral forearm
  • Causes of neuropathy:
    • Strenuous exercise
    • Trauma
    • Malpositioned arm Arm The arm, or "upper arm" in common usage, is the region of the upper limb that extends from the shoulder to the elbow joint and connects inferiorly to the forearm through the cubital fossa. It is divided into 2 fascial compartments (anterior and posterior). Arm (during anesthesia Anesthesia Anesthesiology is the field of medicine that focuses on interventions that bring a state of anesthesia upon an individual. General anesthesia is characterized by a reversible loss of consciousness along with analgesia, amnesia, and muscle relaxation. Anesthesiology: History and Basic Concepts)
  • Presentation:
    • Weak elbow flexion
    • Sensory loss in lateral forearm

Phrenic Neuropathy

Phrenic nerve

  • Nerve supplies:
    • The primary motor control of the diaphragm Diaphragm The diaphragm is a large, dome-shaped muscle that separates the thoracic cavity from the abdominal cavity. The diaphragm consists of muscle fibers and a large central tendon, which is divided into right and left parts. As the primary muscle of inspiration, the diaphragm contributes 75% of the total inspiratory muscle force. Diaphragm
    • Motor: right and left phrenic nerves (originate from cervical spinal cord Spinal cord The spinal cord is the major conduction pathway connecting the brain to the body; it is part of the CNS. In cross section, the spinal cord is divided into an H-shaped area of gray matter (consisting of synapsing neuronal cell bodies) and a surrounding area of white matter (consisting of ascending and descending tracts of myelinated axons). Spinal Cord: C3–C5)
    • Sensory: central part of diaphragm Diaphragm The diaphragm is a large, dome-shaped muscle that separates the thoracic cavity from the abdominal cavity. The diaphragm consists of muscle fibers and a large central tendon, which is divided into right and left parts. As the primary muscle of inspiration, the diaphragm contributes 75% of the total inspiratory muscle force. Diaphragm
  • Causes of phrenic neuropathy: 
    • Malignancies or masses (e.g., lung cancer Lung cancer Lung cancer is the malignant transformation of lung tissue and the leading cause of cancer-related deaths. The majority of cases are associated with long-term smoking. The disease is generally classified histologically as either small cell lung cancer or non-small cell lung cancer. Symptoms include cough, dyspnea, weight loss, and chest discomfort. Lung Cancer)
    • Thoracic or cardiac surgery Cardiac surgery Cardiac surgery is the surgical management of cardiac abnormalities and of the great vessels of the thorax. In general terms, surgical intervention of the heart is performed to directly restore adequate pump function, correct inherent structural issues, and reestablish proper blood supply via the coronary circulation. Cardiac Surgery (iatrogenic is often unilateral)
    • Infections such as HIV, Lyme disease Lyme disease Lyme disease is a tick-borne infection caused by the gram-negative spirochete Borrelia burgdorferi. Lyme disease is transmitted by the black-legged Ixodes tick (known as a deer tick), which is only found in specific geographic regions. Patient presentation can vary depending on the stage of the disease and may include a characteristic erythema migrans rash. Lyme Disease, herpes zoster Herpes Zoster Varicella-zoster virus (VZV) is a linear, double-stranded DNA virus in the Herpesviridae family. Shingles (also known as herpes zoster) is more common in adults and occurs due to the reactivation of VZV. Varicella-Zoster Virus/Chickenpox, and TB TB Tuberculosis (TB) is an infectious disease caused by Mycobacterium tuberculosis complex bacteria. The bacteria usually attack the lungs but can also damage other parts of the body. Approximately 30% of people around the world are infected with this pathogen, with the majority harboring a latent infection. Tuberculosis spreads through the air when a person with active pulmonary infection coughs or sneezes. Tuberculosis 
    • Diseases such as diabetes and multiple sclerosis Multiple Sclerosis Multiple sclerosis (MS) is a chronic inflammatory autoimmune disease that leads to demyelination of the nerves in the CNS. Young women are more predominantly affected by this most common demyelinating condition. Multiple Sclerosis

Presentation

  • Overall, can present with shortness of breath due to diaphragmatic dysfunction or unilateral or bilateral diaphragmatic paralysis
  • If one side is damaged, the contralateral side functions normally, allowing inspiration.
  • Associated with exertional dyspnea Dyspnea Dyspnea is the subjective sensation of breathing discomfort. Dyspnea is a normal manifestation of heavy physical or psychological exertion, but also may be caused by underlying conditions (both pulmonary and extrapulmonary). Dyspnea
  • Irritation to the phrenic nerve can cause hiccups.
  • Exam and other findings:
    • ↓ Breath sounds and dullness (to percussion) on the affected side
    • Epigastrium moves inward during inspiration.
    • Elevated hemidiaphragm (in unilateral injury)

Lower-Limb Neuropathies

Lumbosacral plexus

  • Network of nerves formed from the 12th thoracic (T12), 1st–5th lumbar (L1–L5), and 1st–3rd sacral (S1–S3) spinal nerve roots 
  • Lumbar plexus:
    • From the anterior rami of the L1–L4 nerve roots
    • Unites with the sacral plexus via the lumbosacral trunk (which consists of a portion of L4 nerve root anterior rami and all L5 anterior rami)
  • Sacral plexus: the lumbosacral trunk and the anterior rami of the S1–S4 nerve roots 
  • Innervate the muscles of the lower extremities
  • Causes of plexopathy:
    • Malignancy
    • Diabetes
    • Radiation
    • Idiopathic
    • Occasionally trauma
  • Lumbosacral plexopathy:
    • Lumbar plexus lesions:
      • Weak hip flexion
      • Weak adduction
      • Knee extension
      • Sensory loss over the anterior thigh Thigh The thigh is the region of the lower limb found between the hip and the knee joint. There is a single bone in the thigh called the femur, which is surrounded by large muscles grouped into 3 fascial compartments. Thigh and leg Leg The lower leg, or just "leg" in anatomical terms, is the part of the lower limb between the knee and the ankle joint. The bony structure is composed of the tibia and fibula bones, and the muscles of the leg are grouped into the anterior, lateral, and posterior compartments by extensions of fascia. Leg
    • Lumbosacral trunk and sacral plexus lesions:
      • Weak posterior thigh Thigh The thigh is the region of the lower limb found between the hip and the knee joint. There is a single bone in the thigh called the femur, which is surrounded by large muscles grouped into 3 fascial compartments. Thigh, leg Leg The lower leg, or just "leg" in anatomical terms, is the part of the lower limb between the knee and the ankle joint. The bony structure is composed of the tibia and fibula bones, and the muscles of the leg are grouped into the anterior, lateral, and posterior compartments by extensions of fascia. Leg, and foot muscles
      • Loss of sensation over the 1st and 2nd sacral segments
    • Entire plexus (rare):
      • Weak and atrophied lower extremity muscles
      • Areflexia
      • Anesthesia (perianal region to the toes)

Sciatic neuropathy

  • Sciatic nerve:
    • Biggest and longest nerve from the lumbosacral plexus, gives off many branches and divides into the:
      • Common peroneal nerve
      • Tibial nerve
    • Comes from the 4th and 5th lumbar and the 1st and 2nd sacral roots
    • Supplies:
      •  Motor: hamstring muscles and all the muscles below the knee through the tibial and peroneal nerves
      • Sensory: posterior aspect of the thigh Thigh The thigh is the region of the lower limb found between the hip and the knee joint. There is a single bone in the thigh called the femur, which is surrounded by large muscles grouped into 3 fascial compartments. Thigh, the posterolateral leg Leg The lower leg, or just "leg" in anatomical terms, is the part of the lower limb between the knee and the ankle joint. The bony structure is composed of the tibia and fibula bones, and the muscles of the leg are grouped into the anterior, lateral, and posterior compartments by extensions of fascia. Leg, and the entire sole
  • Common site of injury: sciatic notch ( gluteal region Gluteal region The gluteal region is located posterior to the pelvic girdle and extends distally into the upper leg as the posterior thigh. The gluteal region consists of the gluteal muscles and several clinically important arteries, veins, and nerves. The muscles of the gluteal region help to move the hip joint during walking, running, standing, and sitting. Gluteal Region)
  • Causes of neuropathy:
    • Trauma (e.g., hip dislocation, fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures, or surgeries)
    • Compression (e.g., prolonged bed rest because of coma Coma Coma is defined as a deep state of unarousable unresponsiveness, characterized by a score of 3 points on the GCS. A comatose state can be caused by a multitude of conditions, making the precise epidemiology and prognosis of coma difficult to determine. Coma)
    • Buttock injections
    • Deep-seated mass in the pelvis Pelvis The pelvis consists of the bony pelvic girdle, the muscular and ligamentous pelvic floor, and the pelvic cavity, which contains viscera, vessels, and multiple nerves and muscles. The pelvic girdle, composed of 2 "hip" bones and the sacrum, is a ring-like bony structure of the axial skeleton that links the vertebral column with the lower extremities. Pelvis (e.g., hematoma)
  • Presentation:
    • Leg pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain
    • Leg weakness
    • Sensory loss in peroneal, tibial and sural territories (medial calf and foot arch spared)
    • Normal knee jerk 
    • Absent ankle jerk
Schematic diagram of the course and main branches of the lumbosacral plexus

Schematic diagram of the course and main branches of the lumbosacral plexus

Image by BioDigital, edited by Lecturio

Common peroneal neuropathy

  • The common peroneal nerve, also called the common fibular nerve, supplies:
    • Motor function to the short head of the biceps femoris
    • Sensation in the posterolateral leg Leg The lower leg, or just "leg" in anatomical terms, is the part of the lower limb between the knee and the ankle joint. The bony structure is composed of the tibia and fibula bones, and the muscles of the leg are grouped into the anterior, lateral, and posterior compartments by extensions of fascia. Leg
  • Site of injury: commonly injured at the head of the fibula (below the knee)
  • Causes of neuropathy:
    • Frequent leg Leg The lower leg, or just "leg" in anatomical terms, is the part of the lower limb between the knee and the ankle joint. The bony structure is composed of the tibia and fibula bones, and the muscles of the leg are grouped into the anterior, lateral, and posterior compartments by extensions of fascia. Leg crossing
    • Prolonged lying down
    • Squatting
    • Leg cast
  • Presentation:
    • Sensory loss over the dorsum of the foot and lateral shin
    • Weak foot eversion and dorsiflexion
    • Foot drop (affected foot drags on ground while walking)
    • Normal reflexes
Anterior leg - innervation

Anterior view of the leg Leg The lower leg, or just "leg" in anatomical terms, is the part of the lower limb between the knee and the ankle joint. The bony structure is composed of the tibia and fibula bones, and the muscles of the leg are grouped into the anterior, lateral, and posterior compartments by extensions of fascia. Leg, featuring the common peroneal nerve and its main branches

Image by BioDigital, edited by Lecturio

Tibial neuropathy

  • Tibial nerve:
    • Along with the other of the 2 divisions of the sciatic nerve, supplies:
      • Motor: leg Leg The lower leg, or just "leg" in anatomical terms, is the part of the lower limb between the knee and the ankle joint. The bony structure is composed of the tibia and fibula bones, and the muscles of the leg are grouped into the anterior, lateral, and posterior compartments by extensions of fascia. Leg or calf muscles (posterior compartment) and intrinsic foot muscles
      • Sensory: posterolateral leg Leg The lower leg, or just "leg" in anatomical terms, is the part of the lower limb between the knee and the ankle joint. The bony structure is composed of the tibia and fibula bones, and the muscles of the leg are grouped into the anterior, lateral, and posterior compartments by extensions of fascia. Leg, heel, lateral foot, plantar surface of the foot
    • Descends down to the ankle (inferior and posterior to the medial malleolus in the ankle) passing beneath the flexor retinaculum through the tarsal tunnel
  • Common site of injury: tarsal tunnel of the ankle
  • Causes of neuropathy:
    • Fractures or dislocation:
      • Talus
      • Calcaneus
      • Medial malleolus
    • Rheumatoid arthritis Rheumatoid arthritis Rheumatoid arthritis (RA) is a symmetric, inflammatory polyarthritis and chronic, progressive, autoimmune disorder. Presentation occurs most commonly in middle-aged women with joint swelling, pain, and morning stiffness (often in the hands). Rheumatoid Arthritis
    • Tumor
  • Presentation:
    • Tingling, numbness, aching on the sole of the foot and toes (occasionally, the heel)
    • Symptoms worse on standing
    • + Tinel’s sign (posterior to the medial malleolus)
    • Severe: atrophy of foot muscles
Tibial nerve

Posterior view of the leg Leg The lower leg, or just "leg" in anatomical terms, is the part of the lower limb between the knee and the ankle joint. The bony structure is composed of the tibia and fibula bones, and the muscles of the leg are grouped into the anterior, lateral, and posterior compartments by extensions of fascia. Leg, featuring the tibial nerve as it passes through the medial aspect of the popliteal fossa Popliteal fossa The popliteal fossa or the "knee pit" is a diamond-shaped, fat-filled, shallow depression on the posterior aspect of the knee joint. The popliteal fossa is located at the dorsal aspect of the knee and contains an increased number of lymph nodes as well as structures of the neurovascular system that travel from the thigh to the lower leg. Popliteal Fossa

Image by BioDigital, edited by Lecturio

Femoral neuropathy

  • Femoral nerve:
    • Derived from the 2nd, 3rd, and 4th lumbar roots
    • Supplies:
      • Motor: muscles of anterior compartment, iliacus, pectineus
      • Sensory: skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin of anterior thigh Thigh The thigh is the region of the lower limb found between the hip and the knee joint. There is a single bone in the thigh called the femur, which is surrounded by large muscles grouped into 3 fascial compartments. Thigh and lower ⅔ of medial thigh Thigh The thigh is the region of the lower limb found between the hip and the knee joint. There is a single bone in the thigh called the femur, which is surrounded by large muscles grouped into 3 fascial compartments. Thigh
  • Site of injury: pelvis Pelvis The pelvis consists of the bony pelvic girdle, the muscular and ligamentous pelvic floor, and the pelvic cavity, which contains viscera, vessels, and multiple nerves and muscles. The pelvic girdle, composed of 2 "hip" bones and the sacrum, is a ring-like bony structure of the axial skeleton that links the vertebral column with the lower extremities. Pelvis and anterior thigh Thigh The thigh is the region of the lower limb found between the hip and the knee joint. There is a single bone in the thigh called the femur, which is surrounded by large muscles grouped into 3 fascial compartments. Thigh
  • Causes of neuropathy:
    • Hip or pelvic fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures
    • Hip replacement
    • Lithotomy position
    • Diabetes mellitus Diabetes mellitus Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus
  • Presentation:
    • Weak quadriceps
    • Sensory loss in the anterior and medial thigh Thigh The thigh is the region of the lower limb found between the hip and the knee joint. There is a single bone in the thigh called the femur, which is surrounded by large muscles grouped into 3 fascial compartments. Thigh, medial shin, arch of the foot
    • ↓ Knee jerk

Lateral femoral cutaneous neuropathy

  • Meralgia paresthetica
  • Lateral femoral cutaneous nerve:
    • Derived from L2–L3
    • Sensory: skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin of the anterolateral thigh Thigh The thigh is the region of the lower limb found between the hip and the knee joint. There is a single bone in the thigh called the femur, which is surrounded by large muscles grouped into 3 fascial compartments. Thigh 
  • Site of injury: inguinal ligament
  • Causes of neuropathy:
    • Tight-fitting belts
    • Obesity
    • Pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-hCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care
    • Idiopathic
  • Presentation:
    • Paresthesias and pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain radiating down the lateral aspect of the thigh Thigh The thigh is the region of the lower limb found between the hip and the knee joint. There is a single bone in the thigh called the femur, which is surrounded by large muscles grouped into 3 fascial compartments. Thigh 
    • No weakness of the quadriceps

Obturator neuropathy

  • Obturator nerve:
    •  From the branches of L2–L4 ventral rami
    • Supplies:
      • Motor: muscles of the medial compartment (adductors) and contributes to internal and external rotators
      • Sensory: skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin of upper ⅓ of the medial thigh Thigh The thigh is the region of the lower limb found between the hip and the knee joint. There is a single bone in the thigh called the femur, which is surrounded by large muscles grouped into 3 fascial compartments. Thigh
  • Causes of neuropathy:
    • Pelvic trauma
    • Pelvic surgery
  • Presentation:
    • Pain and weakness with leg Leg The lower leg, or just "leg" in anatomical terms, is the part of the lower limb between the knee and the ankle joint. The bony structure is composed of the tibia and fibula bones, and the muscles of the leg are grouped into the anterior, lateral, and posterior compartments by extensions of fascia. Leg adduction
    • Sensory loss over the medial thigh Thigh The thigh is the region of the lower limb found between the hip and the knee joint. There is a single bone in the thigh called the femur, which is surrounded by large muscles grouped into 3 fascial compartments. Thigh

Related videos

Diagnosis

History and physical

  • Complete history (include past medical history, exposure to toxins, substance use, and family history)
  • Detailed physical examination:
    • Motor deficits:
      • Weakness
      • Cramps
      • Fasciculations
      • Muscle atrophy
    • Sensory deficits:
      • Touch changes
      • Vibration changes
      • Pain sensation changes
      • Changes in temperature perception
    • Autonomic deficiency:
      • Sweating
      • Heat intolerance
      • Blood pressure changes

Workup

  • Laboratory studies, depending on clinical picture, include (but not limited to):
    • Fasting glucose, HbA1c to screen for diabetes mellitus
    • CMP
    • CBC and inflammatory markers
    • Serologies such as HIV, hepatitis C Hepatitis C Hepatitis C is an infection of the liver caused by the hepatitis C virus (HCV). The infection can be transmitted through infectious blood or body fluids and may be transmitted during childbirth or through IV drug use or sexual intercourse. Hepatitis C virus can cause both acute and chronic hepatitis, ranging from a mild to a serious, lifelong illness including liver cirrhosis and hepatocellular carcinoma (HCC). Hepatitis C Virus, Lyme disease Lyme disease Lyme disease is a tick-borne infection caused by the gram-negative spirochete Borrelia burgdorferi. Lyme disease is transmitted by the black-legged Ixodes tick (known as a deer tick), which is only found in specific geographic regions. Patient presentation can vary depending on the stage of the disease and may include a characteristic erythema migrans rash. Lyme Disease
    • Toxicology 
  • Nerve conduction studies and electromyography (EMG): 
    • Nerve conduction studies and EMG are often considered definitive diagnostic tests Diagnostic tests Diagnostic tests are important aspects in making a diagnosis. Some of the most important epidemiological values of diagnostic tests include sensitivity and specificity, false positives and false negatives, positive and negative predictive values, likelihood ratios, and pre-test and post-test probabilities. Epidemiological Values of Diagnostic Tests for mononeuropathies.
    • Demyelination is quantified via slowing of conduction velocity across affected nerve segments.
  • Imaging based on presentation, such as:
    • Lumbosacral MRI for lumbosacral spine disease with nerve-root compression
    • Chest x-ray for respiratory symptoms from phrenic nerve injury
  • Lumbar picture: for unusual presentation or suspected inflammatory conditions

Management

Principles

  • General management for mononeuropathy is modification of lifestyle and adequate control of any underlying illness. 
  • Treatment varies with the nerve involved, degree of impairment, and mechanism of injury.
  • More severe conditions may require surgical intervention. 

Treatment options

  • Splinting or immobilization (e.g., wrist splinting for carpal tunnel syndrome)
  • Physical therapy and exercise
  • Pain control:
    • NSAIDs
    • Corticosteroid injection
  • Surgery (if conservative management fails) such as:
    • Surgical release (e.g., release of flexor retinaculum in carpal tunnel syndrome)
    • Nerve grafting
Carpal tunnel splint

Carpal tunnel splint:
A wrist splint is often used in individuals with carpal tunnel syndrome.

Image: “A carpal tunnel splint to keep the wrist straight. Taken of own hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand” by SPUI. License: Public Domain

Clinical Relevance

  • Polyneuropathy: disease process affecting the function of or causing damage to multiple nerves of the peripheral nervous system Nervous system The nervous system is a small and complex system that consists of an intricate network of neural cells (or neurons) and even more glial cells (for support and insulation). It is divided according to its anatomical components as well as its functional characteristics. The brain and spinal cord are referred to as the central nervous system, and the branches of nerves from these structures are referred to as the peripheral nervous system. General Structure of the Nervous System. There are numerous etiologies of polyneuropathy Polyneuropathy Polyneuropathy is any disease process affecting the function of or causing damage to multiple nerves of the peripheral nervous system. There are numerous etiologies of polyneuropathy, most of which are systemic and the most common of which is diabetic neuropathy. Polyneuropathy, and most are systemic; the most common is diabetic neuropathy. The presentation varies, but generally manifests as sensorimotor disturbances ( pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain, paresthesia, numbness, weakness, loss of coordination and balance), which have a gradual onset and progressive course. Diagnosis is made clinically, but laboratory studies, electrodiagnostic testing, and/or nerve biopsy may be required in some cases. Management varies depending on the etiology of the polyneuropathy Polyneuropathy Polyneuropathy is any disease process affecting the function of or causing damage to multiple nerves of the peripheral nervous system. There are numerous etiologies of polyneuropathy, most of which are systemic and the most common of which is diabetic neuropathy. Polyneuropathy.  
  • Carpal tunnel syndrome Carpal Tunnel Syndrome Carpal tunnel syndrome (CTS) is a complex of signs and symptoms caused by compression of the median nerve as it crosses the carpal tunnel. Presentation is with pain and paresthesia of the dermatomal target tissues innervated by the median nerve as well as weakness and atrophy of the nerve's myotomal targets. Carpal Tunnel Syndrome: caused by compression of the median nerve as it crosses the carpal tunnel. Features of this syndrome include pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain and paresthesia of the dermatomal target tissues innervated by the median nerve as well as weakness and atrophy of its myotomal targets. A clinical diagnosis may be made on the basis of history and physical examination and confirmed with electrodiagnostic testing. Splinting and physical therapy are recommended, whereas more severe cases may require surgical correction. 
  • Brachial plexus injuries Brachial plexus injuries The brachial plexus is a network of nerves that originate from the lower cervical and upper thoracic nerve roots. The causes of brachial plexopathies include traumatic injuries, birth-related injuries, iatrogenic procedures, neoplastic processes, and previous treatment with radiation. Brachial Plexus Injuries: conditions that impair the brachial plexus. Causes of brachial plexopathies include traumatic injuries, birth-related injuries, iatrogenic procedures, neoplastic processes, or previous treatment with radiation. Presentation is with sensory and motor deficits related to the site of the lesion and the nerves involved. Diagnosis is made based on clinical findings, imaging, and electrodiagnostic studies. Treatment is related to the underlying cause and may be medical or surgical. 
  • Peripheral nerve injuries in the cervicothoracic region: commonly involve the nerves arising from the cervical plexus and brachial plexus. Causes of injury vary and may include surgical injury, trauma, compression, nerve entrapment, stretch or traction from repetitive movement, infection, and metabolic causes. Clinical presentation depends on motor and sensory innervation of the affected nerves. Diagnosis is mostly clinical but can also be confirmed through imaging and electrodiagnostic studies. Management can be conservative (physical therapy and avoiding precipitating movements) or surgical, depending on the specific injury.

References

  1. ​​Akhondi, H., Varacallo, M. (2021). Anterior interosseous syndrome. StatPearls. Retrieved October 25, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK525956/
  2. Alsaffar, R. M., Hameed, S. (2021). Benediction sign. StatPearls. Retrieved October 25, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK554458/
  3. Azhary, H., Farooq, M. U., Bhanushali, M., Majid, A., Kassab, M. Y. (2010). Peripheral neuropathy: differential diagnosis and management. American Family Physician 81:887–892. https://pubmed.ncbi.nlm.nih.gov/20353146/
  4. Basit, H., Ali, C. D. M., Madhani, N. B. (2021). Erb palsy. StatPearls. Retrieved October 25, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK513260/
  5. Becker, R. E., Manna, B. (2021). Anatomy, shoulder and upper limb, ulnar nerve. StatPearls. Retrieved October 25, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK499892/
  6. Doherty, T. (2021). Ulnar neuropathy at the elbow and wrist. UpToDate. Retrieved October 21, 2021, from https://www.uptodate.com/contents/ulnar-neuropathy-at-the-elbow-and-wrist
  7. Hammi, C., Yeung, B. (2021). Neuropathy. StatPearls. Retrieved October 25, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK542220/
  8. Mandoorah, S., Mead, T. (2021). Phrenic Nerve Injury. StatPearls. Retrieved October 25, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK482227/
  9. Merryman, J., Varacallo, M. (2021). Klumpke Palsy. StatPearls. Retrieved October 25, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK531500/
  10. Misra, U. K., Kalita, J., Nair, P. P. (2008). Diagnostic approach to peripheral neuropathy. Annals of Indian Academy of Neurology 11:89–97. https://doi.org/10.4103/0972-2327.41875
  11. Murphy, K. A., Morrisonponce, D. (2021). Anatomy, shoulder and upper limb, median nerve. StatPearls. Retrieved October 25, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK448084/
  12. Ropper, A. H., Samuels, M.A., Klein, J. P., Prasad, S. (Eds.) (2019). Diseases of the peripheral nerves.Chapter 43 of Adams and Victor’s Principles of Neurology, 11th ed. McGraw-Hill. https://accessmedicine.mhmedical.com/content.aspx?bookid=1477&sectionid=215146064
  13. Ross, E. (2018). Pain syndromes other than headache. DeckerMed Medicine. Retrieved August 14, 2021, from https://doi.org/10.2310/PSYCH.6177 
  14. Rutkove, S. (2019). Overview of upper extremity peripheral neuropathy syndromes, UpToDate. Retrieved September 19, 2021, from https://www.uptodate.com/contents/overview-of-upper-extremity-peripheral-nerve-syndromes 
  15. Selcen, D. (2021). Neonatal brachial plexus palsy. UpToDate. Retrieved October 23, 2021, from https://www.uptodate.com/contents/neonatal-brachial-plexus-palsy
  16. Sommer, C., et al. (2018). Polyneuropathies. Dtsch Arztebl Int 115(6):83–90. https://pubmed.ncbi.nlm.nih.gov/29478436/

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