1. Focal Peripheral Neuropathies Dr Jeremy Bland British Peripheral Nerve Society Charing Cross Hospital, 18 th October 2013

2. Frequencies of referral in Canterbury

3. Latinovic/Hughes 2006

4. Plan CTS - COMMON Investigation Treatment Ulnar neuropathy - Common Investigation Treatment Peroneal neuropathy – We are not sure what to do with it! Causes Treatment TTS – Rare to non-existent but talked about a lot! Existence! Quality of evidence HLPP – Just interesting for the BPNS

5. For Each Topic Survey results 12 Neurology, 22 Neurophysiology, 2 Other Numbers do not always add up Missing answers Multiple answers Where it seems to be interesting Neurology vs Neurophysiology Something thought provoking Discussion

6. CTS – Investigation with NCS

7. Why bother? – Choosing a treatment?

8. CTS – Investigation with u/s Use or recommend ultrasound Neurology 3 Neurophysiology 7 Other 1

9. Sensitivity vs clinical diagnosis 81 patients with right hand symptoms and symptom score > 0.8 – classical CTS – NCS sensitivity = 98%, u/s sensitivity = 81%

10. CTS – Management- Inject

11. Injections per hand Canterbury CTS clinic 5927 injections 5 serious complications

12. Ulnar – Investigation- NCS Investigate when suspected: Neurology 75% Neurophysiology 91% cf CTS – 27%

13. Uncertainties Sensitivity 37-86% (cf imaging 80-90%?) Accuracy of localisation 80% (compared to intra-operative studies) No demonstrably useful severity grading Padua classification not verified to be: Sensitive to change Prognostic

14. Ulnar – Management 73% neurophysiologists would go with surgery for persistent symptoms only 60% neurologists would wait for physical signs or evidence or progression

15. Ulnar Neuropathy at the elbow Beekman, R et al, 2004, Ulnar neuropathy at the elbow: follow-up and prognostic factors determining outcome, Neurology 63:1675-80 Non-prognostic clinical variables Age Sex Symptom duration Dominant arm Muscle weakness MRC sum score Muscle atrophy

16. Ulnar Prognosis (Beekman) No patient with an ulnar nerve diameter >3.5 mm improved on follow up whether treated surgically or not

17. Peroneal – Ganglion Cysts 6 people have come across these 1 neurologist, 5 neurophysiologists One person has seen 3 and one 2

18. Patient PH, Peroneal nerve

19. Peroneal – Management Very little consensus Only 1 person would suggest surgery for persistent symptoms only 10 Neurophysiologists would consider a demonstrable NCS abnormality an indication for surgery 3 people said never operate! 16 people declared ‘other criteria’ but no-one explained exactly what!

20. Tarsal Tunnel – quality of proof Hx consistent NCS abnormal Imaging abnormal Operated Got better NCS better

21. Cases PTN GC

22. HLPP

23. Sander et al, J Hand Surg, 2005; 30A 6 59 patients >1 CTR and/or ulnar transposition 0 cases HLPP Only 7 with 3 operations 14 with a Hx of an entrapment neuropathy in a 1 st degree relative

24. What else? Have you changed your mind about anything or will you alter practice in any way as a result of this session? Should we try to do a more definitive questionnaire? Should we revisit the topic (with questionnaires collected today or a new one or both) at a future BPNS meeting