Effective surgical treatment of cubital tunnel syndrome based on provocative clinical testing without electrodiagnostics

This study evaluated the effectiveness of identifying surgically correctable ulnar nerve compression at the elbow based on provocative clinical testing alone in patients with cubital tunnel syndrome after failure of conservative treatment. Twenty-four patients were included in the study (mean age, 60 years). Three patients underwent bilateral procedures. Patients complaining of symptoms in the distribution of the ulnar nerve were tested by elicitation of Tinel's sign and combined flexion and pressure testing at the elbow and wrist. Two-point discrimination was determined. After a failed 6-week trial of conservative therapy patients underwent anterior submuscular transposition of the ulnar nerve with carpal tunnel release. Postoperatively, the change in two-point discrimination as measured at 6 months was significantly improved, with a mean improvement per digital nerve of 2.52 mm (p<0.001). Mean time to relief was 7.2 weeks. Complications included one hematoma and one seroma. A total of 26 of the 27 limbs chosen for surgical treatment by provocative clinical testing alone experienced relief of symptoms with anterior submuscular transposition of the ulnar nerve and carpal tunnel release. This study demonstrates the effectiveness of surgical therapy in patients with lesions identified by clinical examination without electrodiagnostic testing.     

The position of crossing branches of the medial antebrachial cutaneous nerve during cubital tunnel surgery in humans

The posterior branch of the medial antebrachial cutaneous nerve courses in proximity to the cubital tunnel and is particularly prone to injury during ulnar nerve release at the elbow. Inadvertent injury to medial antebrachial cutaneous nerve branches during surgery can result in the formation of painful neuromas that can be misdiagnosed as recurrent disease. It is important to understand the relevant anatomy of the medial antebrachial cutaneous nerve branches during cubital tunnel surgery to avoid significant postoperative morbidity. This prospective observational anatomic study examined the position of the posterior branch of the medial antebrachial cutaneous nerve in relationship to a standard approach to the cubital tunnel in a randomly selected group of 97 patients undergoing primary surgery over a 3-year period. Medial antebrachial cutaneous nerve branches were noted to cross at or proximal to the medial humeral epicondyle 61 percent of the time at an average proximal distance of 1.8 cm. Medial antebrachial cutaneous nerve branches were noted to cross distal to the medial humeral epicondyle 100 percent of the time at an average distal distance of 3.1 cm. Understanding the general position of crossing medial antebrachial cutaneous nerve branches during ulnar nerve release at the elbow may help to prevent iatrogenic injury to this cutaneous nerve.     

Recurrent anterior dislocation of the ulnar nerve at the cubital tunnel

Recurrent anterior dislocation of the ulnar nerve at the cubital tunnel is reported in two patients. This was due to traumatic attenuation of the flexor carpi ulnaris retinaculum. The mechanism of injury in both patients was a fall with the shoulder abducted and the elbow acutely flexed. Both patients had relief of their neurologic symptoms following anterior submuscular transposition of the ulnar nerve.     

Surgical strategy for improving forearm and hand function in late obstetric brachial plexus palsy

For the purpose of treatment, obstetric brachial plexus palsy can be subdivided into two distinct phases: initial obstetric brachial plexus palsy, and late obstetric brachial plexus palsy. In the latter, nerve surgery is no longer practical, and treatment often requires palliative surgery to improve function of the shoulder, elbow, forearm, and hand. Late obstetric brachial plexus palsy in the forearm and hand includes weakness or absence of wrist or metacarpophalangeal or interphalangeal joint extension; weakness or absence of finger flexion; forearm supination, or less commonly pronation contracture; ulnar deviation of the wrist; dislocation of the radial or ulnar head; thumb instability; or sensory disturbance of the hand. Palliative reconstruction for these forearm and hand manifestations is more difficult than for the shoulder or elbow because of the lack of powerful regional muscles for transfer. This report reviews the authors' experience performing more than 100 surgical procedures in 54 patients over a 9-year period (between 1988 and 1997) with a minimum of 2 years' follow-up. Surgical treatment is highly individualized, but the optimal age for forearm and hand reconstruction is usually later than for shoulder and elbow reconstruction because of the requirement for a preoperative exercise program. Multiple procedures for forearm and hand function were often performed on any given patient. Frequently, these were done simultaneously with reconstructive procedures for improving shoulder and/or elbow function. Traditional tendon transfer techniques do not provide satisfactory reconstruction for those deformities. Many of the authors' patients required more complex techniques such as nerve transfer and functioning free-muscle transplantation to augment traditional techniques of tendon and/or bone management. Sensory disturbance of the forearm and hand in late obstetric brachial plexus palsy seems a minor problem and further sensory reconstruction is unnecessary.     

The cubital tunnel syndrome caused by intraneural ganglion cyst of the ulnar nerve at the elbow: a case report

Background

Cubital tunnel syndrome is common nerve compression syndrome among peripheral nerve compression diseases. However, the syndrome caused by intraneural ganglion cysts has been rarely reported. Medical approaches, like ultrasound-guided aspiration and open surgical treatment remain to be discussed.

Case presentation

A 57-year-old woman presented with occasional pain, numbness and paralysis in her left hand and a palpable, painless mass in the ulnar side of her left elbow. Ultrasound-guided aspiration of the mass was performed to decompress the ulnar nerve. The patient experienced an evident release of pain in her hand, but symptoms of numbness and paralysis recurred 3 months later which greatly bothered the patient’s daily life. After evaluation, we had to perform an open surgery to excise the cyst. External neurolysis and anterior subcutaneous transposition were done. The patient was followed up for 2 years, and she made a complete recovery with no functional limitation.

Conclusions

The symptoms caused by intraneural ganglion cyst can be alleviated by accurate puncture. But puncture may be not complete and symptoms could recur. Complete external neurolysis can be counted as a complete and reliable treatment. Therefore, early diagnosis, careful preoperative imaging assessment and full decompression can be expected to receive a good rehabilitation.

     

Aneurysm of the median artery causing recurrent carpal tunnel syndrome and anatomic review

A patient is presented who had recurrent carpal tunnel syndrome symptoms in his left hand 1 year after having undergone release of the transverse carpal ligament. On exploration, this was found to be due to an aneurysm of a median artery and possibly scarring due to this compression around the branches of the bifurcated median nerve. This represents the first case in the literature to comment on (1) the absence of bilaterality of the anatomic finding and (2) carpal tunnel syndrome relative to median artery aneurysm. With this in mind, a plea is made for careful exploration of the carpal tunnel, maintaining an incision as far to the ulnar side of the median nerve as technically possible with thorough visualization of the contents of the tunnel and any anatomic variance involved. The incidence of the combination of aberrant median artery with high bifurcation of the median nerve is unknown, as is the incidence of aneurysm of the median artery.     

高频超声联合剪切波弹性成像对于上肢神经卡压综合征的诊断价值

摘要 目的：探讨高频超声联合剪切波弹性成像对于上肢神经卡压综合征的诊断价值。方法：收集2017年1月-2022年11月于我院收治的行手术治疗的66例上肢神经卡压综合征患者作为观察组,并将其按照疾病严重程度分为轻度组、中重度组,其中腕管综合征43例、轻度组18例、中重度组25例,肘管综合征23例、轻度组12例、中重度组11例,选取同时期66例健康人群作为对照组。所有受试者均行常规超声及剪切波弹性成像检查,在豌豆骨及肘管入口水平分别测量正中神经及尺神经前后径、左右径、横截面面积、杨氏模量。比较各个测量指标在各组间的差异。以临床诊断为金标准,分析高频超声及高频超声联合剪切波弹性成像对上肢神经卡压综合征临床分型价值。结果：观察组正中神经横截面积、杨氏模量均显著高于对照组,差异具有统计学意义（P<0.05);观察组尺神经左右径、横截面积、杨氏模量均显著高于对照组,差异具有统计学意义（P<0.05）;中重度组正中神经、尺神经杨氏模量均显著高于轻度组,差异具有统计学意义（P<0.05）;高频超声、高频超声联合剪切波弹性成像对腕管综合征临床分型的准确率为65.12%、81.40%,敏感度为61.11%、83.33%,特异度为68.0%、80.0%,精确度为57.89%、75.0%;高频超声、高频超声联合剪切波弹性成像对肘管综合征临床分型的准确率为52.17%、78.26%、敏感度为58.33%、83.33%、特异度为45.45%、72.73%、精确度为53.85%、76.92%。结论：高频超声联合剪切波弹性成像对上肢神经卡压综合征表现出较好的诊断价值,可实现以无创的方式对该疾病做出准确诊断。     

Intraoperative radial nerve injury during coronary artery surgery – report of two cases

Background

Peripheral nerve injury and brachial plexopathy are known, though rare complications of coronary artery surgery. The ulnar nerve is most frequently affected, whereas radial nerve lesions are much less common accounting for only 3% of such intraoperative injuries.

Case presentations

Two 52- and 50-year-old men underwent coronary artery surgery. On the first postoperative day they both complained of wrist drop on the left. Neurological examination revealed a paresis of the wrist and finger extensor muscles (0/5), and the brachioradialis (4/5) with hypoaesthesia on the radial aspect of the dorsum of the left hand. Both biceps and triceps reflexes were normoactive, whereas the brachioradialis reflex was diminished on the left. Muscles innervated from the median and ulnar nerve, as well as all muscles above the elbow were unaffected. Electrophysiological studies were performed 3 weeks later, when muscle power of the affected muscles had already begun to improve. Nerve conduction studies and needle electromyography revealed a partial conduction block of the radial nerve along the spiral groove, motor axonal loss distal to the site of the lesion and moderate impairment in recruitment with fibrillation potentials in radial innervated muscles below the elbow and normal findings in triceps and deltoid. Electrophysiology data pointed towards a radial nerve injury in the spiral groove. We assume external compression as the causative factor. The only apparatus attached to the patients' left upper arm was the sternal retractor, used for dissection of the internal mammary artery. Both patients were overweight and lying on the operating table for a considerable time might have caused the compression of their left upper arm on the self retractor's supporting column which was fixed to the table rail 5 cm above the left elbow joint, in the site where the radial nerve is directly apposed to the humerus.

Conclusion

Although very uncommon, external compression due to the use of a self retractor during coronary artery surgery can affect – especially in obese subjects – the radial nerve within the spiral groove leading to paresis and should therefore be included in the list of possible mechanisms of radial nerve injury.     

Anterior Subcutaneous versus Submuscular Transposition of the Ulnar Nerve for Cubital Tunnel Syndrome: A Systematic Review and Meta-Analysis

Objective

To pool reliable evidences for the optimum anterior transposition technique in the treatment of cubital tunnel syndrome by comparing the clinical efficacy of subcutaneous and submuscular anterior ulnar nerve transposition.

Methods

A comprehensive search was conducted in PubMed MEDLINE, Cochrane Library, EMBASE, Web of Science, OVID AMED, EBSCO and potentially relevant surgical archives. Risk of bias of each included studies was evaluated according to Cochrane Handbook for Systematic Reviews of Interventions. The risk ratio (RR) and 95% confidence intervals (CI) were calculated for the clinical improvement in function compared to baseline. Heterogeneity was assessed across studies, and subgroup analysis was also performed based on the study type and follow-up duration.

Results

Three studies with a total of 352 participants were identified, and the clinically relevant improvement was used as the primary outcomes. Our meta-analysis revealed that no significant difference was observed between two comparison groups in terms of postoperative clinical improvement in those studies (RR 1.04, 95% CI 0.86 to 1.25, P = 0.72). Meanwhile, subgroup analyses by study type and follow-up duration revealed the consistent results with the overall estimate. Additionally, the pre- and postoperative motor nerve conduction velocities were reported in two studies with a total of 326 patients, but we could not perform a meta-analysis because of the lack of concrete numerical value in one study. The quality of evidence for clinical improvement was ‘low’ or ‘moderate’ on the basis of GRADE approach.

Conclusions

Based on small numbers of studies with relatively poor methodological quality, the limited evidence is insufficient to identify the optimum anterior transposition technique in the treatment of cubital tunnel syndrome. The results of the present study suggest that anterior subcutaneous and submuscular transposition might be equally effective in patients with ulnar neuropathy at the elbow. Therefore, more high-quality randomized controlled trials with standardized clinical improvement metrics are required to further clarify this topic and to provide reproducible pre- and postoperative objective outcomes.     

Neuropathy in a patient with McArdle's syndrome and diabetes mellitus.

A juvenile-type diabetic patient of five years standing presented with a mononeuritis and gave a history of painful muscle swelling induced by exertion. Failure of the blood lactate to rise during ischaemic exercise and a normal blood glucose rise following intravenous glucagon confirmed the clinical diagnosis of muscle glycogenosis. The association of diabetes and McArdle's Syndrome has not previously been documented. An ulnar nerve palsy, which persisted for many months, followed the ischaemic exercise test possibly due to compression by muscular swelling, but may have been exacerbated by the co-existing diabetes.     

Arteriovenous malformation of a persistent median artery with a bifurcated median nerve

A patient with arteriovenous malformations of the volar forearm and hand arising from a persistent median artery with an associated bifid median nerve is presented. Surgeons should be aware of high median nerve bifurcations, particularly when a persistent median artery is identified, and should remember that additional structures that can lead to nerve compression may be present in the carpal tunnel. Specifically, more than one median nerve may need to be identified and protected in such cases.     

MR Neurography in Ulnar Neuropathy as Surrogate Parameter for the Presence of Disseminated Neuropathy

Purpose

Patients with ulnar neuropathy of unclear etiology occasionally present with lesion extension from elbow to upper arm level on MRI. This study investigated whether MRI thereby distinguishes multifocal neuropathy from focal-compressive neuropathy at the elbow.

Methods

This prospective study was approved by the institutional ethics committee and written informed consent was obtained from all participants. 122 patients with ulnar mononeuropathy of undetermined localization and etiology by clinical and electrophysiological examination were assessed by MRI at upper arm and elbow level using T2-weighted fat-saturated sequences at 3T. Twenty-one patients were identified with proximal ulnar nerve lesions and evaluated for findings suggestive of disseminated neuropathy (i) subclinical lesions in other nerves, (ii) unfavorable outcome after previous decompressive elbow surgery, and (iii) subsequent diagnosis of inflammatory or other disseminated neuropathy. Two groups served as controls for quantitative analysis of nerve-to-muscle signal intensity ratios: 20 subjects with typical focal ulnar neuropathy at the elbow and 20 healthy subjects.

Results

In the group of 21 patients with proximal ulnar nerve lesion extension, T2-w ulnar nerve signal was significantly (p<0.001) higher at upper arm level than in both control groups. A cut-off value of 1.92 for maximum nerve-to-muscle signal intensity ratio was found to be sensitive (86%) and specific (100%) to discriminate this group. Ten patients (48%) exhibited additional T2-w lesions in the median and/or radial nerve. Another ten (48%) had previously undergone elbow surgery without satisfying outcome. Clinical follow-up was available in 15 (71%) and revealed definitive diagnoses of multifocal neuropathy of various etiologies in four patients. In another eight, diagnoses could not yet be considered definitive but were consistent with multifocal neuropathy.

Conclusion

Proximal ulnar nerve T2 lesions at upper arm level are detected by MRI and indicate the presence of a non-focal disseminated neuropathy instead of a focal compressive neuropathy.     

MEDIAN NERVE INJURIES IN FRACTURES IN THE REGION OF THE WRIST

Injuries of the median nerve in fractures in the region of the wrist are not uncommon.Median nerve palsy is frequently the result of immobilizing the wrist in acute palmar flexion.Good reduction and immobilization of the wrist in neutral position are the best means of preventing median nerve injury.In any fracture in the region of the wrist, the status of the median, ulnar, and radial nerves should be examined before and after reduction of the fracture.The majority of patients with median nerve neuritis recover completely without operation. In some cases, the duration of the sympathetic nerve paralysis is unpredictable.Where neurological symptoms persist, neurolysis with or without sectioning of the transverse carpal ligament will improve the neurological status of the patient.     

Two novel methods to assess ulnar nerve conduction across the elbow

PurposeNerve conduction studies (NCS) are used as an electrodiagnostic method for diagnosing ulnar neuropathy of the elbow (UNE). The purpose of this study was to determine normal and reliability values of across elbow ulnar nerve conduction velocity using two novel methods.MethodsUlnar nerve conduction studies were performed on both upper extremities of 104 healthy subjects. Two different techniques were used to evaluate ulnar nerve function at the elbow: Technique 1 (W-BE-AE) determined mixed NCV across the elbow indirectly while Technique 2 (BE-AE) measured conduction time directly. Twenty subjects returned within one week for re-testing to generate reliability data.ResultsThe mean NCV for the BE-AE segment using Technique 1 was 59.68 m/s (±8.91 m/s). The mean peak latency for the BE-AE segment using Technique 2 was 2.03 ms (±0.24 ms). The interrater and intrarater reliability intraclass correlation coefficient (ICC) for Technique 1 was 0.454 and 0.756, respectively. For Technique 2, the interrater and intrarater reliability ICC was 0.76 and 0.814, respectively.ConclusionThis study identified normal values for ulnar nerve conduction across the elbow with reliability ranging from poor to good, depending on the technique. These two novel techniques provide alternative methods to traditional techniques to measure ulnar nerve conduction across the elbow.     

Thoracic pressure and nasal patency

Maximum nasal flow rate in the right and left nostrils was simultaneously determined during expiration with the help of two flowmeters in 10 healthy subjects in different postures and in two patients, one with Horner's syndrome and the other with facial palsy. It was found that pressure on the hemithorax from any surface (i.e., lateral, anterior, posterior, or superior) leads to reduced patency of the ipsilateral nostril but increased patency of the nostril on the opposite site. In the patient with Horner's syndrome, the nostril on the affected side remained blocked even on compression of the opposite hemithorax, and in the one with facial nerve palsy, the nostril on the affected side remained patent despite compression of the hemithorax on that side. The findings suggest that compression of hemithorax leads to changes in the congestion of the nasal mucosa that may be mediated through autonomic nerves.     

The Carpal Tunnel Syndrome—A Review of 100 Patients Treated Surgically

The carpal tunnel syndrome, or compression neuropathy of the median nerve at the wrist, is a common cause of burning pain, numbness and tingling in the hand. The diagnosis is suggested by nocturnal paresthesias in the thumb, index and long fingers associated with signs of irritability of the median nerve in the carpal tunnel at the wrist. Surgical treatment in the form of incision of the transverse carpal ligament should be performed before irreversible motor and sensory changes occur.     

The impact of extended electrodiagnostic studies in Ulnar Neuropathy at the elbow

Background  

This study aimed to explore the value of extended motor nerve conduction studies in patients with ulnar nerve entrapment at the elbow (UNE) in order to find the most sensitive and least time-consuming method. We wanted to evaluate the utility of examining both the sensory branch from the fifth finger and the dorsal branch of the ulnar nerve. Further we intended to study the clinical symptoms and findings, and a possible correlation between the neurophysiological findings and pain.     

Carpal tunnel syndrome caused by hand injuries.

Although carpal tunnel syndrome associated with injury to the wrist is common, it is possible to overlook symptoms of median nerve compression caused by an ascending tenosynovitis secondary to trauma distal to the wrist. One should look for these symptoms in such patients who complain of pain and weakness of the hand, and release the carpal tunnel if nerve compression is suspected.     

Giant solitary synovial osteochondromatosis of the elbow causing ulnar nerve neuropathy: a case report and review of literature

Introduction

Giant or solitary osteochondroma is part of a rare disorder known as synovial osteochondromatosis. It forms part of a spectrum of disease characterized by metaplastic changes within the joint synovium that are eventually extruded as loose bodies. It has been suggested that solitary synovial osteochondroma forms as progression of synovial osteochondromatosis through a process of either coalescence of multiple smaller bodies or the growth of a dominant synovial osteochondroma. Previous studies have shown that it occurs as a late phase of the disease. We report a rare case of giant synovial osteochondromatosis at the elbow causing ulnar nerve neuropathy and mechanical symptoms which has not been previously reported in the literature.

Case report

We report a case of a 56 year old Western European gentleman who presented with ulnar nerve neuropathy and swelling behind the elbow. The patient underwent MR imaging and subsequent biopsy that demonstrated synovial osteochondromatosis. Initially the patient declined surgery and opted for a watch and wait approach. Five years later he returned with worsening symptoms and underwent successful surgical resection of a giant solitary synovial osteochondroma.

Conclusion

The unique outcome in our patient despite the long interval between presentation and surgical treatment resulted in early full resolution of symptoms within a short period. It may suggest an improved prognosis as compared to multiple synovial osteochondromatosis in terms of mechanical and neurological outcomes.     

Finite element simulation of the mechanical impact of computer work on the carpal tunnel syndrome

Carpal tunnel syndrome (CTS) is a clinical disorder resulting from the compression of the median nerve. The available evidence regarding the association between computer use and CTS is controversial. There is some evidence that computer mouse or keyboard work, or both are associated with the development of CTS. Despite the availability of pressure measurements in the carpal tunnel during computer work (exposure to keyboard or mouse) there are no available data to support a direct effect of the increased intracarpal canal pressure on the median nerve.