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.     

Anomalous pattern of median artery in the forearm of Indians

Various anomalous relations between the brachial plexus or its branches and arteries are reported. The present study was conducted on 134 limbs to note the origin and course of the median artery and its relation to the median nerve. In 2 limbs (1.5%), the median artery split the median nerve into two roots in the forearm and the artery passed through the nerve. In both of these limbs (1.5%), the median artery arose from the ulnar artery. The median artery in these 2 limbs (1.5%) was considerably large and supplied the hand. Both the origin of the median artery from the ulnar artery and the splitting of the median nerve by the median artery are rare anomalies which have not been reported in the available literature.     

Influence of 50 Hz-1 mT magnetic field on human median nerve

In this study, human median nerve was exposed to power frequency magnetic fields in order to provide clarification for possibly changeable nerve conduction mechanism. The nerve was exposed to 50 Hz magnetic field by utilizing a special Helmholtz applicator. The experiments were carried out with six healthy human-volunteers. Median motor distal amplitude/proximal amplitude ratios were recorded from adult human median nerve pre-exposure, during, and post-exposure to a 50 Hz, 1 mT magnetic field. The result of 18 measurements shows that median motor distal amplitude/proximal amplitude ratio significantly decreases in pre-exposure state as compare to post exposure of which. The results of this study may be useful for some nerve rehabilitation, excitation, and stimulation in more effective/safe physical therapy. Additionally, 50 Hz, 1 mT sinusoidal magnetic field should not be recognizing as safe for conduction mechanism on a nerve. These mechanisms would be cleared by new advanced engineering models in other future works.     

Struthers' ligament and associated median nerve variations in a cadaveric specimen.

A Ligament of Struthers has been identified and studied in a cadaveric arm. Its relationships to a rudimentary supracondylar process, the pronator teres muscle, the median nerve, and the medial epicondyle of the humerus are described. Compared to an extensively studied series of normals, the ligament in this case was associated with abnormally proximal branching of the median nerve, a finding which is surgically significant and not addressed in the literature to date.     

Cortical plasticity in patients with median nerve lesions studied with MEG

We have previously shown age- and time-dependent effects on brain activity in the primary somatosensory cortex (SI), in a functional magnetic resonance imaging (fMRI) study of patients with median nerve injury. Whereas fMRI measures the hemodynamic changes in response to increased neural activity, magnetoencephalography (MEG) offers a more concise way of examining the evoked response, with superior temporal resolution. We therefore wanted to combine these imaging techniques to gain additional knowledge of the plasticity processes in response to median nerve injury. Nine patients with median nerve trauma at the wrist were examined with MEG. The N1 and P1 responses at stimulation of the injured median nerve at the wrist were lower in amplitude compared to the healthy side (p?larger N1 amplitude (p?p?p?increased MEG response amplitude to ulnar nerve stimulation. This can be interpreted as a sign of brain plasticity.     

Scalp,basal epidural and intravascular far-field recordings after median nerve stimulation: evidence for a separate N18a potential

Far-field somatosensory evoked potentials (SSEPs) after median nerve stimulation were recorded from scalp- (Fz), epidural(ED) and intravascular electrodes (basilar artery [Bas]) to study the nature of the controversial N18a component of the widespread N18 potential. In healthy volunteers frequently an N18a potential was recorded at Fz. Simultaneous Fz and ED recordings at the pontomesencephalic junction as well as Bas-recordings at the caudal basilar artery showed N18a components identical in latency and shape. With intravascular recordings the shapes differed between the top of the basilar artery and the caudal artery recordings. These findings support the existence of a separate N18a potential. The generator of the N18a is likely to be localized within the upper brainstem.     

Scalp, basal epidural and intravascular far-field recordings after median nerve stimulation: evidence for a separate N18a potential

Far-field somatosensory evoked potentials (SSEPs) after median nerve stimulation were recorded from scalp- (Fz), epidural- (ED) and intravascular electrodes (basilar artery [Bas]) to study the nature of the controversial N18a component of the widespread N18 potential. In healthy volunteers frequently an N18a potential was recorded at Fz. Simultaneous Fz and ED recordings at the pontomesencephalic junction as well as Bas-recordings at the caudal basilar artery showed N18a components identical in latency and shape. With intravascular recordings the shapes differed between the top of the basilar artery and the caudal artery recordings. These findings support the existence of a separate N18a potential. The generator of the N18a is likely to be localized within the upper brainstem.     

Neuropeptides in the median eminence

The presence and possible sources of more than 30 neuropeptides in the median eminence are summarized. The median eminence is the brain area which contains neuropeptides in the highest number and in the highest concentrations in the central nervous system. This area constitutes the final common pathway for signals from the brain to the pituitary. Many peptidergic fibers enter the median eminence and terminate around the pericapillary space and release their neuropeptides into hypophysial portal blood vessels. Other peptidergic fibers traverse the median eminence and terminate in the posterior pituitary. According to their origin, fibers in the median eminence can be classified as intra- or extrahypothalamic fibers. The neuropeptide-containing fibers in the median eminence are mainly intrahypothalamic, they reach the median eminence through either the lateral retrochiasmatic area or the tuberoinfundibular tract. Depending on the site of their action, neuropeptides may be either neurohormones acting on the anterior pituitary cells or neurotransmitters affecting the release of substances from other nerve terminals within the median eminence.     

Free flap from the flexor aspect of the wrist for resurfacing defects of the hand and fingers

The distal portion of the flexor aspect of the forearm has been used as the donor site of full-thickness skin grafts, venous skin grafts, and Chinese forearm flaps. This article describes the use of a free flap harvested from the flexor aspect of the wrist and based on the superficial palmar branch of the radial artery to repair skin defects of the hand and fingers. The advantages of this flap are as follows: (1) the operative field is the same; (2) the radial artery is preserved; (3) it is thin, pliable, and hairless and thus can supply a gliding surface for tendons beneath it; (4) when it involves a palmaris longus tendon and/or the palmar cutaneous branch of the median nerve, it can be used as a vascularized tendon or nerve graft; and (5) in view of the flow-through type of the pedicle of the flap, the digital artery can be reconstructed simultaneously. However, it should be noted that a hypesthesia in the proximal central carpal area remains when the palmar cutaneous branch of the median nerve is harvested as a vascularized nerve graft. The scar of the donor site should be left in the distal wrist crease. If it is not lying in the distal wrist crease, it may suggest that the patient has tried to commit suicide.     

Apparent transverse compressive material properties of the digital flexor tendons and the median nerve in the carpal tunnel

Carpal tunnel syndrome is a frequently encountered peripheral nerve disorder caused by mechanical insult to the median nerve, which may in part be a result of impingement by the adjacent digital flexor tendons. Realistic finite element (FE) analysis to determine contact stresses between the flexor tendons and median nerve depends upon the use of physiologically accurate material properties. To assess the transverse compressive properties of the digital flexor tendons and median nerve, these tissues from ten cadaveric forearm specimens were compressed transversely while under axial load. The experimental compression data were used in conjunction with an FE-based optimization routine to determine apparent hyperelastic coefficients (μ and α) for a first-order Ogden material property definition. The mean coefficient pairs were μ=35.3 kPa, α=8.5 for the superficial tendons, μ=39.4 kPa, α=9.2 for the deep tendons, μ=24.9 kPa, α=10.9 for the flexor pollicis longus (FPL) tendon, and μ=12.9 kPa, α=6.5 for the median nerve. These mean Ogden coefficients indicate that the FPL tendon was more compliant at low strains than either the deep or superficial flexor tendons, and that there was no significant difference between superficial and deep flexor tendon compressive behavior. The median nerve was significantly more compliant than any of the flexor tendons. The material properties determined in this study can be used to better understand the functional mechanics of the carpal tunnel soft tissues and possible mechanisms of median nerve compressive insult, which may lead to the onset of carpal tunnel syndrome.     

Mentalis muscle responses to median nerve stimulation

Electrical stimulation may produce excitation or inhibition of the motor neurons, as represented the blink reflex and masseter silent period in response to trigeminal nerve stimulation. Clinically, a light touch on the palm may evoke a mentalis muscle response (MMR), i.e. a palmomental reflex. In this study, we attempted to characterize the MMR to median nerve stimulation. Electrical stimulation was applied at the median nerve with recordings at the mentalis muscles. An inhibition study was done with continuous stimuli during muscle contraction (I1 and I2 of MMRaverage). Excitation was done with a single shot during muscle relaxation (MMRsingle) or by continuous stimuli during muscle contraction (E1 and E2 of MMRaverage). The characteristic differences between MMRaverage and MMRsingle were as follows: earlier onset latencies of MMRaverage (MMRaverage < 45 ms; MMRsingle > 60 ms), and a lower amplitude of MMRaverage (MMRaverage < 50 microV; MMRsingle > 150 microV). The receptive field of MMRsingle was widespread over the body surface and that of MMRaverage was limited to the trigeminal, median and index digital nerves. Series of stimuli usually significantly decreased the amplitude of MMRsingle, as a phenomenon of habituation. On the other hand, it was difficult to evoke the earlier response (i.e. MMRaverage) without continuous stimuli and an average technique. MMRaverage had the components of both excitation (E) and inhibition (I); for example, E1-I1-E2-I2 or I1-E2-I2. E2 was the most consistent component. In patients with dorsal column dysfunction, median nerve stimulation could successfully elicit MMRsingle, but not MMRaverage. Contrarily, in patients with pain sensory loss, it was more difficult to reproduce MMRsingle than MMRaverage. It seemed that MMRaverage and MMRsingle did not have equivalents across the different modalities of stimulation.     

Distribution of catecholamines in the median eminence of rats following adrenalectomy]

Distribution of adrenergic and peptidergic nerve fibers in rat median eminence was studied three weeks after bilateral adrenalectomy. Fluorescence intensity in the external zone and in some of the nerve cell-bodies proved to be increased in the nucleus arcuatus. There were many nerve fibers with a bright fluorescence in the internal zone. A great number of the peptidergic nerve fibers appeared in the external zone. Reactions in the rostral, medial and caudal regions of the median eminence differed and were described.     

Commissural ring nerve: A female-specific neurosecretory tract supplied by bifurcating median neurons in the cockroach Periplaneta americana (L.) and the cricket Teleogryllus commodus (Walker)

Summary In the American cockroach, Periplaneta americana, and the Australian field cricket, Teleogryllus commodus, the two nerves supplying the bases of the cerci are joined by a branch that crosses behind the last abdominal ganglion. This commissural ring nerve is restricted to females, and it contains many axons filled with granular and agranular vesicles. The axons stem from somata located within the ganglion. There are one (Periplaneta) or two (Teleogryllus) groups of median neurons with bilaterally symmetrical bifurcations, and a group of postero-ventral neurons on each side. In T. commodus, these neurons are distinct from others associated with the cerci. In the two species, the ring nerve neurons contribute to a neuropile near the root of each cereal nerve. The bifurcating median neurons arborize on both sides before entering the ring nerve, while the postero-ventral ones branch more extensively ipsilateral to their somata. The possibilities are discussed that the bifurcating neurons may be homologous to dorsal unpaired median neurons, and that the ring nerve may be a neurohemal area.     

Modification of median nerve somatic evoked potentials by prior median nerve,peroneal nerve,and auditory stimulation

In a recovery function design, changes were measured in the somatic evoked potentials (SEP) to right median nerve (RMN) shocks preceded by stimulation of: the same nerve (RMN-RMN); the left median nerve having primary input to the homologous sensory area in the contralateral hemisphere (LMN-RMN); the right peroneal nerve having primary input to a different region of the same hemisphere (RPN-RMN); and the auditory nerve with primary input to a different sensory modality (AUD-RMN). Eight inter-stimulus intervals ranged from zero (simultaneous) to 2.5 sec. It was assumed that the degree of interaction between evoked potentials would be related to the degree to which common neural structures are activated or modulated in response to the stimuli. Results were: (a) the primary somatosensory response N20-P30 was little influenced by other somatic or auditory stimulation, interaction occurring predominantly in the RMN-RMN condition; (b) with increasing latency, components showed increasing interaction across modalities; (c) preceding homolateral stimulation (RPN-RMN) showed no greater interaction than preceding contralateral stimulation (LMN-RMN); (d) N55-P100 differed from the primary somatosensory response N20-P30 by showing greater interaction with other somatic stimuli; and (e) N140-P190 showed similarly shaped recovery functions across stimulus pairs but significant differences in magnitude of interaction. These results show that components with similar wave form and topographical characteristics can have different neurophysiological properties.     

Microfluorimetric quantitation of catecholamine fluorescence in rat median eminence. II. Turnover changes in hormonal states.

Catecholamine nerve terminals in the rat median eminence have been studied using the fluorescence histochemical technique of Falck and Hillarp in combination with quantitative microfluorimetry. The catecholamine fluorescence intensities recorded from various parts of the median eminence were all found to be within the linear part of the dopamine or noradrenaline concentration-fluorescence relationship as studied in an agar-albumin model system. The catecholamine fluorescence was also found to disappear with time in an exponential manner following tyrosine hydroxylase inhibition produced by alpha-methyl-p-tyrosine methylester (H44/68). Similar results were obtained when measuring the dopamine decline by mass fragmentography in the median eminence after H44/68 treatment. These results and analysis of fluorescence frequency histograms strongly indicate that the catecholamine fluorescence values recorded are proportional to the catecholamine concentration. It is concluded that the microfluorimetric technique used is a reliable method for catecholamine quantitation in discrete nerve terminal areas of the median eminence. The main advantages of the technique are that a high sensitivity and quantitative data on the transmitter content can be obtained in strict relation to the neuroanatomy. Measurement of the catecholamine fluorescence disappearance after H44/68 was used to evaluate catecholamine turnover during various endocrine states. The results showed that two dopamine systems with different transmitter turnover may be distinguished. Tuberinfundibular dopamine neurons projecting to the lateral palisade zone were thus shown to have a slower turnover than those projecting medially to the capillary loops. No definite changes in catecholamine turnover were observed after adrenalectomy and castration in the male, although there was a tendency toward increased noradrenaline turnover in both states. During pregnancy an increase in noradrenaline as well as dopamine turnover was noted. The present results therefore give further evidence for the view that catecholamine nerve terminals in the median eminence may participate in the regulation of gonadotrophin secretion.     

Sizes of granular vesicles in the rat median eminence,with special reference to the zona granulosa

Summary A quantitative evaluation has been made of the sizes of neuronal granular vesicles (GV) in different (sub-)zones of the rat median eminence. On the basis of the frequency distribution of the mean sizes of the GV in the individual nerve profiles, at least 4 tentative categories of nerve profiles may be distinguished. However, available data do not permit characterization of nerve fibre categories in terms of neurohormone and/or neurotransmitter storage. From dorsal to ventral the palisade zone shows a decrease in mean size of GV; furthermore, the relative number of nerve profiles characterized by small GV (mean size smaller than 112 nm) increases. In contrast, the GV in the zona granulosa, that part of the external zone of the median eminence ventral to the palisade zone, are of relatively large size. Qualitative observations indicate that the zona granulosa may be regarded as an area for both storage and release of biologically active substances. We are grateful to Mrs. R.M.Y. Hartsteen for technical assistance, to Miss P.C. Delfos and Mr. W. van den Oudenalder for photographic assistance and to Prof. J. Moll for helpful criticism.     

Pudendal and median nerve sensory perception threshold: A comparison between normative studies

Background: For the evaluation of sensory innervation, normative data are necessary as a comparison.

Aims: To compare our current perception thresholds (CPTs) with normative data from other research.

Methods: Healthy volunteers were assessed for 2000, 250, and 5?Hz CPTs of the median and pudendal nerve and data were compared with other studies.

Results: Normative data in the studied group n?=?41 (male: 21; female: 20) for the median nerve, 2?kHz, 250?Hz, and 5?Hz were respectively: 241.85?±?67.72 (140–444); 106.27?±?39.12 (45–229); 82.05?±?43.40 (13–271). Pudendal nerve CPTs 250?Hz were: 126.44?±?69.46 (6–333). For men 2?kHz: 349.95?±?125.76 (100–588); 5?Hz: 132.67?±?51.81 (59–249) and women 2?kHz: 226.20?±?119.65 (64–528); 5?Hz: 92.45?±?44.66 (35–215). For the median nerve no statistical differences for gender were shown. For the pudendal nerve, only 250?Hz showed no difference for gender (t-test: 0.516). Comparison of our data with CPTs of other normative data showed no agreement for the pudendal nerve. For the median nerve only 2?kHz showed agreement in three studies and for 5?Hz with one study.

Conclusion: Comparing normative data of multiple studies shows a variety of results and poor agreement. Therefore, referring to normative data of other studies should be handled with caution.     

Widespread N18 in median nerve SEP is preserved in a pontine lesion

Widespread N18 potential to median nerve stimulation was preserved in a patient who had profound unilateral disturbance of deep sensation and a lesion of the pontine medial lemniscus confirmed by MRI. It was concluded from this result that at least a significant part of the N18 potential was generated caudal to the pontine level or at higher levels via extralemniscal pathways. Careful review of studies in man with intraoperative recordings seemed to support that the N18 potential already exists at the medullary level. We suggested that the potential generated at the cuneate nucleus which was described in cats may correspond to part of the N18 potential.     

Validity of median nerve somatosensory evoked potentials in the diagnosis of supraclavicular brachial plexus lesions

Experience with median nerve SEPs in the diagnosis of brachial plexus lesions is analysed in 49 patients selected from a total material of 264 cases with brachial plexus problems tested by SEP techniques. Median nerve SEPs were always compared with the results of SEPs after stimulation of at least one other nerve relevant to the site of the lesion as suspected clinically and electromyographically. All patients presented with unilateral brachial plexus problems and all root lesions were verified by clinical presentation, EMG studies, myelogram or surgery. There were 19 brachial plexus injuries, 13 cases with cervical spondylopathic rediculopaties without myelopathy and 7 patients presented brachial plexopathy with systemic cancer. It was found that median nerve SEPs were always normal in injuries of upper trunk and root avulsions confined to one or two root levels. Median nerve SEPs were abnormal in multiple trunk lesions and multiple root avulsions. In patients with spondylopathic radiculopathies median nerve SEPs were normal apart from one case where involvement of multiple roots was present. Median nerve SEPs were useful in assessing patients presenting brachial plexus problems in the presence of systematic cancer apart from cases where lower trunk involvement was present.In general, median nerve SEPs are useful if they are combined with SEP testing of other nerves anatomically more closely related to the problem as outlined clinically and electromyographically.     

Resection of the hook of the hamate. Its place in the treatment of median and ulnar nerve entrapment in the hand.

Poor results can be anticipated with conventional surgical decompression of nerves entrapped within the hand in (1) those with underlying systemic disease causing primary neuropathy, (2) those with combined median and ulnar nerve palsies, and (3) those who have been previously operated upon for nerve entrapment within the hand. Eighteen patients belonging in these categories were surgically treated by resection of the hook of the hamate and (in some) by intraneural neurolysis. Using this technique, we have decreased our failure rate from 20 percent to less than one percent. We believe that failures can be eliminated if the patients destined to have poor results from the usual treatment are identified preoperatively and a more aggressive surgical decompression is used on this "at risk" group.