Monmouth’s Facial Pain Center on CBS News!

Click here to find out more about one of the patients featured in this story.

Find out more about headache and facial pain, and treatment options for trigeminal neuralgia, including surgical treatment.

Come to one of our trigeminal neuralgia support group meetings – check the Neuroscience Events Panel on the right side of the page.

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Parsonage-Turner Syndrome Revisited

Posted by Daniel Rubio, Drexel University College of Medicine Class of 2014

Parsonage-Turner Syndrome (PTS) is an inflammatory disorder that affects the brachial plexus an important network of nerves which lies deep in the armpit (axilla) giving off nerve brachnes including the axillary, radial, musculocutaneous, ulnar and median nerves which supply power to the shoulder and entire upper extremity.

What does PTS look like?

Unlike other brachial plexopathies, PTS begins spontaneously, without any prior injury to the arm, neck, or axilla.  The classical presentation is severe pain followed by patchy weakness in the shoulder, biceps, and the muscles controlling the thumb and first two fingers (index and middle).  It may also present with a finding known as winged scapula: the shoulder blade sticks out more from the back especially when pushing yourself off a wall.  Weakness may be so severe that the muscles may actually shrink (atrophy).  Pain may be found in the shoulder and along the outside of the upper arm and the thumb-side (lateral) of the forearm and hand.  Pain symptoms usually occur before the weakness and may last up to 4 weeks.  Patients may experience alteration in sensations in the upper extremity, specifically increased sensitivity to touch and temperature and/or tingling.  Symptoms may affect one or both sides, but they usually are asymmetric if they both sides.

 

What causes PTS?

Approximately 50% of patients describe some type of stressful event or illness prior to the onset of symptoms: infection, exercise, surgery, pregnancy, or vaccination.

Diagnosing PTS

Your neurologist can make the diagnosis based on signs and symptoms (especially if you do the above dance); however, sometimes further testing is required to ensure accurate diagnosis.  Suspicion of PTS should occur based upon pattern of initial sudden and severe pain followed by weakness in the upper extremity and slow recovery.  The neurologist may use nerve conduction studies and needle electromyography to document denervation to support clinical suspicion.  Blood tests and imaging rarely help make the diagnosis of PTS.

Help doctor! Fix me?

There is currently no specific treatment for PTS and management usually involves symptom relief.  Pain relief with short course of narcotics may be necessary.  A short course of steroids may be given, which may or may not help relieve symptoms or hasten recovery.  Physical therapy may be prescribed to maintain range of motion and decrease risk of atrophy.  Despite the above measures, there is no treatment to quicken recovery.

When will I be cured?

Recovery of symptoms begins 1-3 months following onset of symptoms; however, maximal recovery may take up to 1-3 years and some patients may be left with residual symptoms.

Feeling sunburnt in winter? It could be small fiber neuropathy.

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Nerves are composed of bundles of individual fibers (axons)

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Nerve fibers (axons) come in a variety of shapes and sizes.  Some are wrapped in insulation (myelinated) others are bare (unmyelinated).

Human nerve

You can see from the figure (above) that small unmyelinated fibers make up the majority of human sensory nerves.  These small unmyelinated fibers convey pain and temperature sensitivity.

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Small fiber neuropathy

Some diseases, particularly diabetes, preferentially affect these small unmyelinated fibers, leaving the other fibers relatively unaffected, resulting in small fiber neuropathy.

Symptoms of small fiber neuropathy are usually a mixture of numbness (sensory loss) and neuropathic pain.

The pain can be superficial and burning, deep aching, pins-and-needles, electrical shocks, or knife-like stabbing.  Innocuous contact (such as with clothing or bedclothes) can become painful like a sunburn.

Small fiber symptoms often worsen at night (when there are fewer distractions) and in the cold.

The symptoms usually begin in the feet, often first affecting the toes and/or soles.  As the condition worsens, the symptoms usually spread proximally up on to the legs and ultimately on to the hands, leading to a “glove and stocking” pattern.

Peripheral Neuropathy, Length Dependent

In most neuropathies, the ends of longest nerves are affected first (left), leading to a glove and stocking distribution of pain and numbness (right).

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Autonomic dysfunction from small fiber neuropathy can cause burning redness in the feet (“erythromelagia”):

erythromelagia

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Also, loss of innervation to the sweat glands can cause decreased sweating peripherally (where the neuropathy is worse), and lead to increased sweating on the head and trunk:

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Sweat test showing decreased sweating in t extremities (yellow) and increased sweating on the head and trunk (purple).

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A Diagnostic Challenge!

It is the large myelinated fibers which sub-serve strength and deep tendon reflexes.  Furthermore, it it these same large myelinated fibers which are tested during a conventional nerve conduction study.

So the physical signs and electrophysiologic findings we typically rely on to diagnose neuropathy may be absent in small fiber neuropathy.

The most widely available diagnostic test is the punch skin biopsy to quantify epidermal innervation.

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Skin biopsies, showing normal epidermal innervation (left) and epidermal denervation in small fiber neuropathy (right).

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Managing Small Fiber Neuropathy

So, you know you have sunburn from small fiber neuropathy, now what?

The most important first step is to look for an underlying (treatable) cause, particularly occult diabetes, with blood work that includes a glucose tolerance test.  In the case of diabetes, monitoring and controlling the blood glucose, is the most important next step.

Otherwise, treatment is usually limited to symptomatic measures, using drugs like gabapentin, pregabalin and/or duloxetine.

2nd Trigeminal Neuralgia Support Group Meeting at MMC

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** Location Change **

Moved to the Conference Room

Breast Center, at MMC

 

Please contact Shirley Lew to register, either call her at 732-923-6551 or click here to email.

Find out more about facial pain and headache, and surgical treatment of trigeminal neuralgia.

Numb tingling hands, it’s probably carpal tunnel syndrome

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Numbness and tingling in the hands is most often from Carpal tunnel syndrome (CTS).

CTS is caused by compression of the median nerve as it travels across the wrist with the tendons between the carpal bones and the flexor retinaculum (also know as the transverse carpal ligament):

flexor retinaculum

CTS is caused by compression of the median nerve under the flexor retinaculum also known as transverse carpal ligament.

Compression an injury to the median nerve causes numbness and tingling mostly affecting the thumb, index finger, middle  finger, and half of the ring finger.

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CTS usually causes numbness and tingling mostly in the thumb, index and middle fingers

More severe cases also cause weakness and wasting of the muscle at the base of the thumb that abducts the thumb away from the fingers (abductor pollicis brevis or APB):

thumb abduction

Thumb abduction, the movement that is weak in more severe cases of CTS, where there is involvement of both motor and sensory median nerve fibers.

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Wasting of APB muscle belly (“thenar eminence”) in severe CTS

In severe cases, the numbness can seem to affect the whole hand, and can even radiate up the forearm and arm:

Carpal-Tunnel-foream

Symptoms are often worse typing, driving, and frequently wake the affected patient up at night:

cts night

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CTS can usually be diagnosed on clinical grounds.  A helpful physical finding is a tingling in the wrist and fingers caused by a tap over the carpal tunnel (Tinel’s sign):
http://www.youtube.com/watch?v=VtrC9dnVrrQ&start=37&rel=0

In some cases, an electrodiagnostic study may be necessary to confirm the diagnosis:

cts emg

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CTS is usually “idiopathic” (we don’t know why it happened), but some cases are caused by diabetes, pregnancy, thyroid disease, joint swelling from rheumatoid arthritis, heavy manual work and work with vibrating tools.

Treatment usually begins with conservative measures, like avoiding exacerbating activities, and wearing a neutral position night splint:

cts splint

Patients who do not improve with these conservative measures can undergo a surgical procedure to release the compressed median nerve:

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Want to find out more?

Click here to take an on-line quiz to see if you have CTS.

Watch this on-line video tutorial explaining the causes and treatment of CTS:
http://www.youtube.com/watch?v=_p799CIpRL0&start=13&rel=0

If you think you might have CTS, you should make an appointment to see a neurologist.

Click here to use our physician finder service.

2012-13 Neurology Student Research Presented at Drexel University College of Medicine

Monmouth neurology students presenting their posters during medical student research day at Drexel University College of Medicine in Philadelphia on March 20, 2013:

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1: Addressing blood glucose control in diabetic peripheral neuropathy:  A missed opportunity for neurologists?

Darsi Pitchon and Seun Ku Kim

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Key points:

Most neurology visits for diabetic neuropathy did not include counseling about blood glucose levels, unless they were with a neuromuscular fellowship trained sub specialist.   Because neuropathy can be the presenting and/or predominant problem in diabetes, some of these patients may be primarily followed by their neurologist, so this is a missed treatment opportunity.

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2.  Acute myelopathy with normal CSF and imaging:

Denis Chang

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Chang

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Key Points:

Spinal cord infarction from fibrocartilaginous embolism can present with acute quadriparesis in young patients with normal CSF and MRI scans.  If this diagnosis is suspected, a follow-up MRI 2-3 days can be quite helpful.  This is not an inflammatory process, and will not improve with steroids or other immunosupressive medications, which can hurt more than they help.

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3. The benefits of an on-line neurology clinical course for 4th year clerkship students

Ilya Grinberg

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Key points:

The on-line video course used by the Monmouth neurology clerkship led to improved test scores on an on-line clinical test compared to students who did their clerkship at other sites.  The on-line clinical test is a low cost but effective method of evaluating students’ clinical skills in neurology over multiple clerkship sites.