Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_186_библиотеки_им_акад_М_И_Перельмана

Erbpalsyiscausedbyatearofthesuperiororuppertrunkofthebrachialplexus(involvingC5and C6).Thismostoftenoccursininfantsduringdelivery,aresultoflateraltractionontheneckofthe baby due to shoulder dystocia. It presents with impaired shoulder abduction (due to deltoid and supraspinatus involvement; the arm hangs limply by the side), lateral rotation (infraspinatus involvement; the arm is medially rotated) and arm flexion and supination (biceps brachii involvement; the arm is extended and pronated). The majority of cases resolve with time and physicaltherapy.Surgicalrepairissecondlinetreatmentifneeded.

 Diabetes. Diabetic amyotrophy (also known as diabetic radiculoplexus neuropathy) typically presents acutely withasymmetric focal legpain followed by proximal legweakness. Associated autonomicsymptomsarecommon.Partialrecoveryoverweekstomonthsisstandard.  Idiopathic. Idiopathic lumbosacral plexopathy presents similarly to diabetic amyotrophy, but in patientswithoutdiabetes. Neoplasm.Neoplasticinvasionofthelumbosacralplexusismostoftenduetodirectextensionofa tumor(nearlyanyformofcarcinoma,melanoma,orlymphomacanbeimplicated),butitcanalsobe caused by leptomeningeal involvement or hematogenous or lymphatic spread. Neoplastic lumbosacralplexopathyis nearlyalwayspainful, characterizedbyshocklikepainsinthe involved lowerextremity. Radiation.Radiationlumbosacralplexopathytendstooccurmonthstoyearsafterpelvicradiation. Itis oftenbilateralandrarelypainful,presentinginsteadwithweaknessand,occasionally,sensory loss.  Retroperitoneal hematoma. These typically develop within the psoas muscle and can occur spontaneously or following femoral arterial or venous catheterizations (most often in patients on anticoagulation).Severebackandlegpainandfemoralneuropathyarecommon.

Carpaltunnelsyndrome(CTS)isaformofmedianneuropathyduetoentrapmentofthemediannerve (whichisderivedfromspinalnervesC5T1)withinthenarrowcarpaltunnelinthewrist.Thisisusually causedbyrepetitivetraumafromoccupationsthatrequirefrequentflexionandextensionofthewrist (although,surprisingly,spendingthedayhammeringawayatacomputerkeyboardhasnotbeen convincinglyfoundtocauseCTS!).Otherimportantriskfactorstokeepinmindincludehypothyroidism (duetoaccumulationofmucinousmaterialwithinthecarpaltunnel),pregnancy(duetofluidaccumulation andedema),andamyloidosis(due,nosurprise,toamyloiddeposition).

Patientswillcomplainofnumbnessandparesthesiasinthehand,oftendescribedastinglingandoften worseatnight.Examinationwillrevealthatthesensorysymptomsarelimitedtothefirstthreedigitsof thehandandthemedialsideoftheringfinger.Accompanyingpain,however,neednotbelimitedtothe mediannervedistributionandcanradiatethroughouttheentirehandandevenupthearm.Bilateral symptomsaresurprisinglycommon,affectingmorethanhalfofpatientswithCTS.