​​​Neurological Surgery and Interventional Pain Management • 540.450.0072 • 1818 Amherst Street, Winchester, VA 22601

​​VIRGINIA BRAIN & SPINE CENTER

Nerve

Anatomy
The peripheral nerves exit the spinal cord and travel throughout the body to transmit signals responsible for movement, sensation, and pain.  The nerves that travel to the arms originate in the neck whereas those that travel to the legs originate in the lower back.  The nerves exit the spinal cord and then travel within the soft tissues of the extremities to the skin and muscles.  At certain spots the nerves are vulnerable to trauma or pressure that could injure the nerve.  In general, these pressure points are located near the joints where there is repetitive motion and stress on the nerves.

Median Nerve
The median nerve is an important nerve that supplies muscles and sensation in the forearm and hand.  It primarily supplies sensation over the palmar aspect of the thumb and first two fingers.  It supplies some of the muscle strength to the thumb and fingers as well.  The nerve is frequently pinched at the point in the wrist where it enters the hand and can causes symptoms of carpal tunnel syndrome.  Injury to the median nerve can look very similar to pressure or dysfunction of the C6 nerve root in the neck.

Carpal Tunnel
The carpal tunnel is the most common site for entrapment of the median nerve.  The carpal tunnel refers to an area of the wrist that is covered by the transverse carpal ligament.  The median nerve and several muscle tendons pass below this ligament on their way from the forearm to the hand.  With repeated use or certain medical conditions, this ligament can become thick and push on the median nerve below.  This compression of the nerve will often result in pain, numbness, and/or weakness in the hand.

Ulnar Nerve
The ulnar nerve is one of the main nerves that supply strength and sensation to the forearm and hand.  It supplies most of the muscles that are within the hand and about half of the sensation.  The nerve is often pinched at or just below the elbow in the cubital tunnel. This can result in pain, numbness, or weakness involving the forearm and hand.  Injury to the ulnar nerve can look very similar to pressure or dysfunction of the C8 nerve root in the neck.

Cubital Tunnel
The cubital tunnel is the most common site for entrapment of the ulnar nerve.  The cubital tunnel refers to an area at the elbow that is covered by a band of connective tissue between the muscles that go to the forearm.  The ulnar nerve travels under this band of tissue and can become compressed.  This compression of the nerve will often result in pain, numbness, or weakness involving the hand and forearm.

Brachial Plexus
The brachial plexus is the collection of nerves in the shoulder region that go on to supply the arm and hand.  The nerve roots from C5 through T1 exit the neck and come together in the shoulder to form the plexus.  The nerve roots then travel together in different groups forming the nerves that supply strength and sensation to the arm and hand.  Each peripheral nerve is composed of branches from multiple nerve roots. 

Peroneal Nerve
The peroneal nerve is one of the main nerves that supply strength and sensation to the foot.  It supplies the muscles that flex the ankle.  The nerve can be injured or compressed where it travels around the outer aspect of the knee on its way down to the foot.  This can result in pain, numbness, and a foot drop.  Injury to the peroneal nerve can look very similar to pressure or dysfunction of the L5 nerve root in the lower back.

Diagnosis

Carpal Tunnel Syndrome

Carpal Tunnel Syndrome describes the symptoms that are due to compression of the median nerveat the wrist.  Common symptoms include pain and numbness involving the hand primarily over the thumb and first two fingers.  Patients often complain of numbness and/or weakness involving the hand.  This may cause difficulty with holding objects in the hand or using the hand for specific tasks such as holding utensils or buttoning shirts.  Carpal Tunnel Syndrome is most commonly associated with repeated stress on the wrist such as with typewriting.  However, specific risk factors are not always present.  Symptoms are often worse at night.  Treatment initially consists of avoiding activity that may be aggravating pressure on the nerve at the wrist and wearing a wrist splint to protect the nerve.  Pain may be treated with certain medications.  Diagnosis can be confirmed with an EMG/NCS which demonstrates delayed signal conduction of the nerve across the wrist.  If symptoms are severe enough and fail to improve with conservative measures then a simple surgery called a carpal tunnel release can be performed.

Ulnar Neuropathy
Ulnar neuropathy describes the complex of symptoms that are due to compression of the ulnar nerve.  This most commonly occurs at the elbow at the cubital tunnel and is sometimes called cubital tunnel syndrome.  Common symptoms include pain and numbness involving the hand primarily over the ring finger and little finger.  Patients often complain of numbness and/or weakness involving the hand.  This may cause difficulty with holding objects in the hand or using the hand for specific tasks such as holding utensils or buttoning shirts.  Specific risk factors are not always present.  Treatment may initially consist of avoiding activity that may be aggravating pressure on the nerve such as leaning on the elbow or keeping the elbow flexed.  Pain can be treated with medications.  Diagnosis can be confirmed with an EMG/NCS which demonstrates delayed signal conduction of the nerve across the elbow.  If symptoms are severe enough or fail to improve with conservative measures then a simple surgery called an ulnar nerve decompressioncan be performed.

Brachial Plexitis
Brachial plexitis, also known as Parsonage-Turner Syndrome, is inflammation and irritation of the nerves that make up the brachial plexus in the shoulder.  This is thought to be due to a viral infection that then attacks the nerves.  Patients typically present with shoulder pain that may extend into the arm.  This is often followed by significant weakness involving the muscles of the involved shoulder and arm.  There may be some numbness but the loss of muscle strength and mass is the predominant finding.  Treatment is conservative and does not involve surgery.  Patients may benefit from IV immunoglobulin.  Symptoms usually resolve spontaneously over the course of weeks to months.  Some permanent symptoms may remain.

Peroneal Nerve Entrapment
Peroneal nerve entrapment describes the complex of symptoms due to compression of the peroneal nerve at the knee.  Common symptoms include pain and numbness involving the calf and foot.  Patients may have a "foot drop" with difficulty flexing the ankle.  This can cause significant difficulty with walking.  Specific risk factors are not always present.  Treatment may initially consist of avoiding activity that aggravates pressure on the nerve such as crossing legs and knee high boots.  Diagnosis can be confirmed with an EMG/NCS which demonstrates delayed signal conduction of the nerve at the knee.  If symptoms are severe enough or fail to improve with conservative measures then a simple surgery called a peroneal nerve decompression can be performed.

Procedures

Carpal Tunnel Release

A carpal tunnel release is performed to relieve pressure on the median nerve at the wrist for symptoms of carpal tunnel syndrome.  This is a small outpatient procedure that takes 10-20 minutes to perform.  A one inch incision is made in the middle of the hand in order to expose the transverse carpal ligament.  This ligament is a band of nonfunctional tissue that travels on top of the nerve and compresses it.  This ligament is carefully cut over the nerve in order to relieve the pressure.  A probe is placed along the nerve to confirm that pressure is completely relieved.  The skin is then closed with stitches.  Depending on the severity and duration of symptoms, success rates of the surgery are about 90%.  The primary goal is to relieve the pressure on the nerve and prevent progressive symptoms.  Most patients will also experience significant improvement in the symptoms that are already present.  Complete resolution of symptoms cannot be guaranteed as permanent damage to the nerve may be present.   This is generally a very safe and effective surgery with minimal risks.

Ulnar Nerve Decompression
An ulnar nerve decompression is performed to relieve pressure on the ulnar nerve at the elbow for symptoms of ulnar neuropathy.  This is a small outpatient procedure that takes 20-30 minutes to perform.  A two to three inch incision is made on the inner aspect of the elbow in order to expose the cubital tunnel.  The cubital tunnel is made of the bones in the elbow and the connective tissue that travels between the muscles that go to the forearm.  The nerve is most often compressed by the connective tissue or muscles at the elbow.  The connective tissue is carefully cut over the nerve in order to relieve the pressure.  A probe is placed along the nerve to confirm that the pressure is completely relieved.  If tension remains on the nerve with bending the elbow then the nerve can be mobilized and repositioned outside of the cubital tunnel.  This transposition of the ulnar nerve is not often necessary.  After the nerve is decompressed, the skin is closed with stitches or dermabond (skin glue).  Depending on the severity and duration of symptoms, success rates of the surgery are about 90%.  The primary goal is to relieve the pressure on the nerve and prevent progressive symptoms.  Most patients will also experience significant improvement in the symptoms that are already present.  Complete resolution of symptoms cannot be guaranteed as permanent damage to the nerve may be present.   This is generally a very safe and effective surgery with minimal risks. 

Peroneal Nerve Decompression
A peroneal nerve decompression is performed to relieve pressure on the peroneal nerve at the knee for symptoms of peroneal nerve entrapment.  This is a small outpatient procedure that takes 20-30 minutes to perform.  A two to three inch incision is made on the outer aspect of the knee in order to expose the nerve. The nerve is most often compressed by the connective tissue or muscles at the knee.  The connective tissue is carefully cut over the nerve in order to relieve the pressure. After the nerve is decompressed, the skin is closed with stitches or dermabond (skin glue).  Depending on the severity and duration of symptoms, success rates will vary.  The primary goal is to relieve the pressure on the nerve and prevent progressive symptoms.  Most patients will also experience significant improvement in the symptoms that are already present.  Complete resolution of symptoms cannot be guaranteed as permanent damage to the nerve may be present.   This is generally a very safe and effective surgery with minimal risks.