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Part 2: Compressive Peripheral Nerve Injuries in SCI

Sacramento, 02/10/2016 /SubmitPressRelease123/

Paraplegics and quadriplegics are at risk for a variety of late complications involving the peripheral nervous system and central nervous system that places residual Upper extremity function at risk.  Medical providers and patients must be vigilant in aggressively working up upper extremity complaints of pain, weakness, and numbness.  Understanding that up to seventy-five percent of wheel chair dependent paraplegics develop Carpal Tunnel syndrome (the most common compressive neuropathy) it is important for all medical providers to understand that this treatable condition should be identified early.

Compressive neuropathies in quadriplegics and paraplegics may involve the radial Nerve, ulnar nerve, and median nerve.  Any symptom suggesting nerve compromise deserves an MRI of the Cervical Spine to rule out cervical stenosis or a syrinx.  Electromyography and nerve conduction studies (EMG/NCS) must be performed since this is the only test that will provide information regarding compression, nerve function, and nerve death.
The exact prevalence of compressive neuropathies in the upper extremities in manual wheelchair users with paraplegia or quadriplegia is unknown, however it is estimated to be present in 20-60% of this patient population.  Compressive neuropathy occurs when there is a compressive force over a nerve at some point over its course in the upper limb.  Initial symptoms of nerve compression include intermittent numbness and tingling which then progresses to constant numbness. Motor complaints progress from aching to weakness to atrophy, or muscle loss. Compressive neuropathy can result in progressive weakness, debilitating pain, and if left untreated leads to nerve death and loss of function.  Treated early, most long-term complications and functional loss can be avoided.

Paraplegics and quadriplegics rely heavily on their upper extremities for propelling a wheelchair, transfers, and other mobility related activities, and over time they can develop cumulative trauma disorders or overuse injuries. The most common is median neuropathy at the wrist, which is also known as Carpal Tunnel Syndrome. This generally presents as numbness in the first three fingers of the hand, but can also present as aching or pain in the hands or forearms. Eventually weakness of the muscles in the hand can develop.  Likely the reason this population is at increased risk of developing carpal tunnel is due to the repetitive pressure than occurs across the carpal tunnel (wrist area) when propelling a wheelchair. In addition, the wrist is held in an extended position (the wrist is bent backward) when operating a manual wheelchair that increases the pressure inside the carpal tunnel, thus compressing the median nerve.

Repetitive wheelchair use and transferring can also put patients at risk of developing compressive neuropathy of the ulnar nerve at the wrist or elbow. Typically this type of neuropathy results in numbness and tingling of the ring and little finger.  The ulnar nerve innervates the intrinsic muscles of the hand and is responsible for nearly ninety percent of grip strength.  All patients with hand numbness need ulnar nerve compression at the elbow ruled out.  Grip strength testing on a weekly basis with a dynamometer can monitor patients if conservative treatment is desired prior to surgical referral.
Quadriplegics often use a “hooking” maneuver to balance their upper body by hooking their arm around the back of their wheelchair when doing a pressure relief.  This places the radial nerve in peril.  Patients develop numbness between their thumb and index finger on the back of their hand, weakness with wrist extension and triceps. EMG/NCS is necessary to evaluate this diagnosis and surgical decompression may be necessary.

Overall, Spinal Cord patients use many different strategies to maintain their independence, and some of these maneuvers could place them at an increased risk of developing a compressive neuropathy including those common to the general population as well at uncommon sites of compression. Any new numbness, tingling, weakness, or pain in a spinal cord patient should be evaluated thoroughly.

A Life Care Plan developed by an Academic Physician Life Care Planner is essential for those with a catastrophic cervical and thoracic spinal cord injury. An Academic Life Care Planner understands that patients with quad/paraplegia with new onset UE pain/numbness/weakness need an aggressive work up. Too often are patients diagnosed late with a compressive peripheral neuropathy, such as carpal tunnel, and valuable upper extremity function is lost.  In addition, necessary care and support is necessary post-operatively to assist with activities of daily living and assist with pressure reliefs to avoid a catastrophic decubitus ulcer that are not uncommon post-operative complication following peripheral nerve surgery

Aljure J, Eltorai I, Bradley WE, Lin JE, Johnson B. Carpal tunnel syndrome in paraplegic patients. Paraplegia 1985:23:182-6.

G. Davidoff, R. Werner, W. Waring. Compressive Mononeuropathies of the Upper Extremity in Chronic Paraplegia. Paraplegia 1991:29:17-24.

D. Apple, R. Cody, A. Allen; Overuse Syndrome of the Upper Limb in People with Spinal Cord Injury. Chapter Five: Overuse Syndromes.

PE Julia, M Mazlina, H Nazirah; Compressive radial neuropathy induced by ‘hooking’ maneuvers in tetraplegic person. Spinal Cord. (2011). 49. 1082-1093


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Part 2: Compressive Peripheral Nerve Injuries in SCI


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