Transcript NEURAL PROLOTHERAPY

Neural Prolotherapy
REGIONAL ANATOMY
UPPER EXTREMITIES
Lee Wolfer, MD, MS
NEUROBIOLOGY AND NEUROKININS
Monoaminergic System
Serotonergic
Noradrenergic
Dopaminergic
Cholinergic
Glutamatergic System
System controlling neural plasticity, synaptic sensitisation,
and conscious nociceptive pain through mainly NMDA receptors
“20th Century CNS sensitisation”
Peptidergic System
System controlling tissue homeostasis,
neurogenic inflammation
peripheral non-synaptic sensitisation
and neuropathic pain
Dermatomal versus Regional pain
Nociceptive pain
Non-peptidergic
Neuropathic pain
Peptidergic - Nervi Nervorum
Lee, MK. An evidence based approach
to human dermatomes. Clin Anat, 2008
The dermatome is a fundamental concept in
human anatomy and of major importance in
clinical practice.
There are significant variations in current
dermatome maps in standard anatomy texts.
Our findings demonstrate that current
dermatome maps are inaccurate and based on
flawed studies.
THE SENSORY INNERVATION OF THE
SHOULDER
• SUPRASCAPULAR NERVE
• RADIAL NERVE
• AXILLARY
• SUBSCAPULAR NERVE
• MUSCULOCUTANEOUS NERVE
• INTERMEDIATE SUPRACLAVICULAR
NERVE
Encyclopedia Anatomica 1771
Sensocrine nerve anatomy
BRACHIAL PLEXUS
Key UE nerves
Ax  SLBrC n.
Ax  SLBrC n.
Rad  PBrC n
Rad  ILBrC n.
Musc  LAC n.
ICBr &
MBrC n
MAC
Ulnar 
palmar &
DUC
Median 
palmar &
digital brs
Rad  ILBrC n.
Rad  PABC n.
Musc  LAC n.
Rad Sup rad &
digital brs
SUPRACLAVICULAR
FOSSA
Key points:
Locate
posterior
intermediate
medial
CCIs
Proposed mechanism of ‘whiplash injury’
Neuropraxia/intussusception injury of the
supraclavicular nerves
L Supraclavicular Nerves CCI’s
Posterior
Medial
Intermediate
POSTERIOR SUPRACLAVICULAR NERVE
INTERMEDIATE SUPRACLAVICULAR NERVE
Encyclopedia Anatomica 1771
Sensocrine nerve anatomy
MEDIAL SUPRACLAVICULAR NERVE
“Tietze syndrome” and “Costo-chondritis”
“FROZEN SHOULDER”
Suprascapular Nerve Impingement
The suprascapular nerve is derived from the upper trunk of the brachial
plexus from the roots of C5 and C6
The nerve supplies the supraspinatus
muscle and provides articular branches
to the glenohumeral and
acromioclavicular joints.
It supplies sensory and sympathetic fibers
to two-thirds of the shoulder capsule.
Usually there are no sensory fibers to the
skin. The nerve then travels thru
spinoglenoid notch under ligament to
supply the infraspinatus muscle.
In about 50% of people there is another
connective tissue band creating a
second fibro-osseous opening for the
nerve to traverse.
INFRASCAPULAR NERVE: INJECTION POINTS
UNDER SCAPULAR SPINE, DEPTH ½ INCH
CROSSED BODY ADDUCTION TEST STRESSES NERVE IN AXIAL PLANE
“FROZEN SHOULDER”
Suprascapular Nerve Impingement
The suprascapular nerve is derived from the upper trunk of the brachial
plexus from the roots of C5 and C6
Right Supra-scapular Nerve
Impingement (C5,6)
This illustration features a
posterior view of the deep
muscles of the shoulder.
The course of the supra
scapular nerve is shown.
A rotator cuff tendon and
‘paralabral spinoglenoid
cyst’ has trapped the infrascapular nerve
Netter: Posterior shoulder
Quadrangular space, triangular space & interval
AXILLARY
NERVE
Quadrangular
space
Teres minor
Teres major
Long head,
triceps
Humerus
Superior lateral
brachial cut n.
Axillary nerve (C5, C6)
Inflammation of the
Axillary nerve trunk can be
elicited in abduction and
ER causing a catching pain
over the anterior Deltoid
‘Tight’ bands can be
palpated in the Deltoid and
Teres minor where the
Axillary nerve branches
penetrate the muscle.
Lower
Subscapular
nerve CCI
to subscapularis
muscle
Triangular
interval
Radial nerve
“tennis elbow”
Radial nerve
LIMS
CCIs:
triangular
interval
@ entrance to
LIMS
Nerve test:
“chicken
wings”
CORABRACHIALIS
BICEPS
BRACHIALIS
ARTICULAR BR
LAC
Musculocutaneous
nerve
CCIs
GREASE: WHY WE
THINK DANNY ZUKO
HAS GREAT HAIR
OR:
HOW TO TEST YOUR
MUSCULOSKELETAL
NERVE
Posterior
shoulder
superior
lateral
brachial
nerve
Intercostalis nerves
Nerves of the
arm
Medial
brachial and
antebrachial
nerves
“Golfers
elbow” or
“Throwers
elbow”
Medial elbow with
Bicipital Aponeurosis with risk of CECS
LEFT MEDIAL BRACHIAL AND
ANTEBRACHIAL NERVES AND CCIs
MAC ns
Intercostobrachial n
Medial brachial cutaneous
MAC
ME
Left Lateral elbow (tennis elbow)
Anconeus and posterior antebrachial nerves arise from
the Radial nerve and the lateral antebrachial nerve
arises from the Musculocutaneous nerve
LAC
LE
PABCN
O
ANCONEUS
Radial, Median and Ulnar palmar
nerves of the left wrist
“Carpal tunnel syndrome”, “OA base
thumb”
U
M
R
R
“De Quervain
syndrome”
POST Br LAC
Musculocutaneous and
Radial cutaneous branches
R