Capítulo do Livro Telemicrosurgery: Síndromes compressivas
Publicado em: 4 de maio de 2020 por Dr. José Carlos Garcia Jr.
Categorias: Lesões Nervos
Capítulo escrito pelo Dr. José Carlos
José Carlos Garcia Jr, MD
This chapter is designed to demonstrate the anatomical and functional causes of nerve entrapment in upper limb and its possible surgical treatments. The robotic, endoscopic and open treatment of nerve entrapment syndromes will be presented. The surgeon needs to understand and recognize the anatomicalconsiderations and variations in the common locations of nerve compressions.
Knowing these entrapment syndromes, the surgeon will be able to access the correct surgical site. Robotic assisted surgery is already available as a treatment for some of these conditions, and as the field develops, more robotic solutions will be available for these common problems.
2. General Considerations
Patients with nerve entrapment syndromes often have concomitant neurologic conditions, and surgeons caring for such patients must be aware of them.
Some factors that may affect compression syndromes include:
1- Fructose and sorbitol substances increase the intra-fascicular pressure
2- Hereditary neuropathies
3- Acquired and congenital abnormalities (elbow varus-valgus)
4- Muscle hypertrophy in athletes
5- Repeated trauma
6 – Peripheral fibers are more susceptible to compression
7 – More myelin increases susceptibility when there is compression
8 – If the nerve has more fibers, the nerve will be more fragile.
9 – If the nerve has more connective tissue, it has lower compression risk
10 – Fractures
11 – Dislocations
12 – Presence of tumors and cysts
13 – Any increase in pressure around the nerve may cause venous congestion and circulatory compromise, affecting the nerve
In addition, the practice of reconstructive surgery carries a risk of iatrogenic injury and entrapment syndromes to neighboring neurologic structures.
The knowledge of the most common sites for nerve lesion around the upper limb allows surgeons to better recognize these entities,asFamiliarity with the relevant neural anatomy will also help surgeons to avoid potential neural injuries.
Sometimes entrapment syndromes may cause weakness and pain, and nerve lesions may result in sensory and motor loss.
Strength measurement is important in the neurologic evaluation of the patient, however sometimes it is possible to move structures using muscles with different innervation. The elbow, for example, can strongly flex with the action of the brachioradialis without having any function of the biceps and the brachialis. Some patients can abduct the shoulder through a full arc of motion by using either just the supraspinatus or the deltoid, in the face of complete paralysis of one or the other1.
Since different nerves may have the same root, diminished radial nerve function should alert the examiner to look closely at axillary nerve function, because they are both derived from the same cord(posterior). Similarly, loss of median nerve function that also affects the musculocutaneous nerve strongly suggests the lesion is at the level of the lateral cord.
One needs to evaluate patients for other conditions causing motor impairment besides those of a neurologic etiology. Certainly, the surgeon needs to consider that an inability to externally rotate the arm might represent a neurologic lesion, a suprascapular nerve entrapment affecting the rotator cuff, a rotator cuff tear, or any combination thereof.
The surgeon must carefully evaluate the patient presenting with pain in the upper extremity from a cervical radiculopathy in the context of motor weakness and sensory loss. In this situation, flexion and extension of the cervical spine or Spurling’s maneuver might reproduce or exacerbate the patient’s symptoms. Upper motor neuron lesions can also result in shoulder weakness. In these cases, the deep tendon reflexes may be hyperreflexic, pathologic reflexes may be present, and tone may be increased.
Referred pain should also be excluded during the clinical examination. Cardiac and other intrathoracic as well as intra-abdominal complaints may be manifested as upper limb pain.
3. Conservative Treatment
Conservative measures are sometimes effective and should be the first line treatment.
Stretching, global postural re-education, medications that stimulate the synthesis of the myelin sheath and the neuronal cell membrane, muscle relaxants, anti-depressives and corticosteroids may all be used.
4. Open Surgical treatment
Each part of the nerve has its own characteristics and knowledge of anatomy and function should lead the surgeon locate the precise spot of nerve impingement.
If at surgical exploration the nerve appears intact but compressed by scar, neurolysis is indicated. If a neuroma in continuity is present, that does not conduct a nerve action potential2, resection of the neuroma and primary grafting should be considered. If a rupture or transection of the nerve is discovered, primary reapproximation or grafting are options.
The specific structures and symptoms related to each nerve entrapment will be addressed in the following:
4.1 Musculocutaneous Nerve
The lateral free margin of the biceps aponeurosis can exert a compression force on the musculocutaneous nerve as the elbow extends. The nerve is caught between the biceps tendon and brachialis fascia causing pain in the lateral aspect of the forearm. This compression force can be markedly accentuated if the forearm is fully pronated.3
The neurolysis is accompanied by an excision of a triangular wedge of the biceps tendon overlying the nerve(fig.1).
4.2 Axillary Nerve
The quadrilateral space syndrome has been described as a potential cause of posterior shoulder pain resulting from compression of the axillary nerve within the quadrilateral space.
Fibrous bands 4 are one of the most commonly cited causes of compression of the contents of the quadrilateral space.
Surgical procedures include posterior exploration of the quadrilateral space and release of scar or fibrous bands to achieve decompression of the axillary nerve.5
4.3 Suprascapular Nerve
Suprascapular neuropathy can occur from a variety of causes, including:transverse scapular ligament anomalies,6 compression from adjacent ganglia,7 abnormal osseous morphology of the suprascapular notch,8,9 traction injury,10 repetitive or extreme shoulder motions, rotator cuff rupture,11,12 and trauma.13 Isolated nerve compression is a relatively rare phenomenon and, as such, is easily misdiagnosed.
The open approach to release of the structures that compress the nerve are is technically difficult to perform.14
4.4 Thoracic outlet syndrome
Thoracic outlet syndrome (TOS) is a generic name used to describe patients with neurovascular symptoms related to sites of compression of the brachial plexus or its accompanying vascular structures.15.
Predominantly neurological symptoms are involved in 92-95% of the cases, 16 and may arise in any of the following structures: anomalies of scalene muscle development or insertion (these include an enlarged scalenus anticus, enlarged scalenus medius, anomalous insertion of the muscles, overlapping insertion ofscalenus anticus and medius, or enlarged scalene tubercle), scalenus minimus, scalenus hipertrophy, cervical rib16, Sibson?s fascia, clavicle (usually the sequela of fractures), compression within the coracopectoral space (or pectoralis minor syndrome), syndrome median (compression of the axillary artery between the bundles of the brachial plexus), Langer’s syndrome (compression of the neurovascular bundle by an anomalous muscle, the axillar-pectoralis), iatrogenic, traumatic, positional, residual fibrous band from an incomplete cervical rib, anomaly of the subclavius tendon or tubercle of insertion, an anomaly not clearly identifiable as a developmental variation, or the absence of a clearly evident abnormality.17
The patient usually presents with paresthesia or nonspecific pain upon direct neurologic stimulation, or with a secondary reduction of muscles strength and loss of precision in coordination (most commonly in the rotator cuff). These symptoms may be exacerbated by direct stimulation or in specific maneuvers. 18,19
The surgical treatment depends on the structures involved in the pathology. Resection of cervical rib, calvicular osteotomies and osteosynthesis for fractures or fracture sequelae, release of the pectoralis minor, scalenectomy(fig.2) and simple release are all surgical otions. Excellent and good results have been achieved in around 86% of these surgical procedures16.
4.5 Spinal Accessory Nerve
The diagnosis may be suspected by trapezius atrophy and winging of the scapula, but is often missed, resulting in delayed treatment.20 The nerve release may be performed to remove scar tissue and neuromas, and grafting may be necessary. If the nerve presents complete lesions another options appear to achieve most satisfactory outcomes.
4.6 Long thoracic nerve
The causes of long thoracic nerve paralysis are diverse, ranging from acute or recurrent trauma to infections and surgical operations. In the majority of cases, the nerve lesion seems to be mechanical in origin.21-23
Spontaneous cases of entrapment at the scalenus medius may occur.24
Overexertion, including athletic activities and thoracic outlet syndrome may be other causes.
This nerve injury is usually manifested as winging of the scapula(fig.3).
Surgical options are available for treating injury to the long thoracic nerve in the early stages. Some have favored neurolysis of the nerve with decompression at the level of the scalenus medius.24 Another strategies is to perform neurotization (or nerve transfer) using one or two intercostal nerves, or the thoracodorsal nerve, or in late cases muscle transfer and scapula-thoracic fusion.25-27
4.7 Dorsal scapular nerve
Because the nerve is usually trapped as it exits the lower two-thirds of the scalenus medius, neck rotation or extension may reproduce or exacerbate symptoms. The entrapment is caused by either a hypertonic scalenus medius, abnormal insertion of the scalenus medius into the first rib, or mechanical friction on the nerve.
The surgical treatment may include scalenectomy and neurolysis.
4.8 Radial nerve
At the level of the lateral head of the triceps, the radial nerve may be compressed through the intermuscular septum28; however, the most common 4 structures that may compress the posterior interosseous nerve in the tunnel are the arcade of Frose, the sharp tendinous margin of the ECRB, the fibrous bands anterior to the radial head, and the radial recurrent vessels29. Other causes of nerve entrapment are: adhesions at the distal aspect of the of the distal humerus, muscular anomalies, vascular aberrations, bursae, ganglions30, fibrotic bands proximally within the midportion or at the distal end of the supinator muscle31, inflammatory thickening and adherence of the extensor carpi radialis brevis32 tendinous origin to the proximal edge of the supinator in its radial side33, thrombotic recurrent radial vessels, and thickened proliferated rheumatoid synovium from the radiocapitellar joint34,35.
The painful condition associated with compression of the posterior interosseous nerve, is known as radial tunnel syndrome, or resistant tennis elbow. 36,37.
If the patient shows just motor manifestations, it is termedposterior interosseous syndrome.
The surgeon have to take special care in the region of the nerve division as well as the arcade of Frose, where the nerve spreads out branches(fig.4).
The surgical treatment is the neurolysis and the release of the structures associated to the compression.
4.9 Ulnar nerve
Common areas of compression are the arcade of Struthers, medial intermuscular septum, medial epicondyle, narrow cubital tunnel, arcade of Osbourn (fibroaponeurotic tissue connecting the humeral and ulnar heads of the flexor carpi ulnaris), and aponeurosis of the deep flexor and pronator teres; furthermore, during elbow flexion, traction forces on the ulnar nerve are major causes of increased intraneural pressure.38
The cubital tunnel changes from oval to flattened ellipse39, where flexion pressures within the tunnel may increase by seven times.40
For throwing athletes, the ulnar nerve compression can be enhanced since the pressures in the cubital tunnel increases up to six times over the resting position when the arm is placed in the cockiedthrowing postition.
In these the surgical options are neurolysis alone, neurolysis and anterior translocation of the ulnar nerve (subcutaneous or submuscle) or neurolysis, and epicondylectomy.
In other conditions such as hypertrophied medial head of triceps (such as occurs in body builders), in the presence of the snapping triceps, the tardy ulnar palsy (a condition caused by the valgus? elbow deformity and consequent nerve stretching) 41, hypermobility or subluxation of the nerve (congenital or due to previous trauma) the only surgical possibilities are epicondylectomy and anterior translocation of the ulnar nerve(subcutaneous or submuscular). An excision of a triangular wedge of the triceps tendon may be necessary.
For anconeus epitrochlearis this anomalous muscle release is also necessary to liberate the ulnar nerve.
In our opinion, the subcutaneous anterior translocation of the ulnar nerve is the safer and faster procedure in most occasions.
The ulnar nerve can also be compressed in Guyon?s canal in the wrist, between the pisiform bone and the hamate bone, under the pisohamate ligament. The treatment is ligament release and neurolysis.
4.10 Median Nerve
Carpal tunnel syndrome is the most common nerve entrapment syndrome of the median nerve, however several syndromes of more proximal entrapment have been described. These include entrapment at the ligament of Struthers, lacertus fibrosus42, heads of the pronator teres muscle, sublimis bridge of the flexor digitorum sublimis muscle, and of the anterior interosseous nerve 43. The surgeon must be cognizant of these, because such syndromes are rare and often confused with radiculopathy or carpal tunnel syndrome.
The pronator teres syndrome is often confused with carpal tunnel syndrome, and two conditions may occur simultaneously(double crush syndrome)28.
In cases of isolated motor symptoms, the anterior interosseous nerve syndrome (motor branch of the median nerve) is suspected44. This motor syndrome is seen as an isolated entity in a ratio of 1 to 40 with the pronator syndrome and these two conditions occasionally 45.
Because of the Martin Gruber nerve anastomosis (present between the ulnar and median nerves or ulnar and anterior interosseous nerves) distal nerve entrapment syndromes can present with mixed symptoms.
Anatomic variations causing impingement include a reduplicate lacertus fibrosus, the Gantzer muscle, the palmaris profundus46, or flexor carpi radialis brevis46, vascular perforations, and tethers.
The release of the lacertus fibrosus, bridge of the flexor digitorum sublimis muscle, teres pronator(fig.5), carpal tunnel or anomalous structures are all surgical options.
5. Endoscopic treatment
Endoscopic treatment for nerve release has been used successfully in many nerve entrapment syndromes such as the carpal tunnel, suprascapular and cubital tunnel. Endoscopic release of the ulnar nerve requires advanced endoscopic skillsand the surgeon must believethat anterior translocation is unnecessary47.
The carpal tunnel endoscopic release is easy, fast and presents the advantages of a minimally invasive procedure48.
The suprascapular nerve release (fig.6) has a high rate successful outcomes, but demands a high level of arthroscopic/endoscopic expertise49,50.
Cadaveric studies have also reported of brachial plexus endoscopic exploration. For live patients, endoscopic decompression for pectoralis minor syndrome(fig.7) and anterior axilary nerve release(fig.8) have been reported.
A major limit of endoscopic treatment is the two-dimensional view (absence of depth perception) The instruments are also limited, and need to have 3 degrees of freedom in order to better access some nerve entrapments sites.
Future improvement of endoscopic devices may expand indications for endoscopic release of nerve entrapment.
6. Robotic Treatment
The robotic telesurgical system consists of a three-dimensional stereoscopic vision system with three robotic slave arms. The instruments have 3 degrees of freedom and are controlled by the surgeon from a console.
If the surgeon has to perform a nerve graft because neuroma, the tremor filtration is a very important advantage, allowing for robotic anastomosis of the nerve.
The techniques forusing endo-robotic (robotic endoscopic) surgery instead of open robotic surgery are still in development in cadaveric models. Our research suggests that in the near future, the surgeon will be able to decompress thoracic outlet syndrome, pronator teres syndrome, perform the anterior translocation of the ulnar nerve, as well as acubital tunnel release, all endorobotically.
We have successfully started endo-robotic procedures using novel port locations in cadaveric models, but these procedures are still experimental at this time.
For thoracic outlet syndrome we used anesthetic block landmarks in order to establish the portals.
The first supraclavicular portal was made at the lateral border of the sternocleidomastoid muscle, approximately 5 cm above its point of insertion on the clavicle, and the second one just above the middle of the clavicle.
For further procedures we are still studying the best choice of portal locations.
At this time, we are using open robotic surgery for some procedures in live patients (fig.9, 10 and 11).
Some endorobotic procedures, such as suprascapular nerve release, require new tools and different optical angles(30º and 70º) in order to be feasible. Some procedures, such as the carpal tunnel syndrome are already feasible(fig.12) 51, but the open and endoscopic techniques are faster and cheaper.
In the near future, we will be able to better choose between open/endoscopic and robotic/non robotic.
The robot is a great tool that can help the surgeon become more dextrous.
Robotic assisted surgery allows performance of high dexterity operations with the help of robotic arms and improves technique due to tremor filtration, motion scaling, and ergonomics. The surgeon actually performs a better, more precise, and highly controlled surgical procedure under high magnification, which may result in an optimal surgical outcome.
Other advantages are assepsia,instead of antisepsia, and protection of the patient and the surgeon from possible accidents that can cause contagious diseases.
Options for augmented reality also exist. In the future, while the surgeon is performing the surgery, he may simultaneously be able to access 3D patient exams, consult a colleague who is also using a robot on line, and browse the internet for further information.
The sub-micron in-vivo histology with real-time functional imaging and diagnosis may help the surgeon in making decision for compressive syndromes secondary to tumors and rheumatic diseases.
Specific antibodies and fluorescing markers will be helpful for recognizing structures we want to access and structures we want to avoid.
The principle problems of using the robotic surgery are surgery cost and the absence of tactile sensibility.
Many different tools need to be developed for future surgical procedures.
The absence of tactile sensibility is likely to be solved in the next generation of robots 52.
The anatomic characteristics of the pathologic process and the surgeon’s expertise and judgement in specific cases remain important in determining surgical approach (open vs endoscopic vs robotic).
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52. Garcia JC, Mantovani G, Gouzou S and Liverneaux P. Telerobotic anterior translocation of the ulnar nerve. J. Robotic Surg. 2011;(online first) http://www.springerlink.com/content/d054t4284kw81630
O livro apresenta o update do tratamento endoscópico robótico do nervo ulnar.