The double crush in nerve entrapment syndromes

10 Hypotheses in Hand Surgery

I have put together 10 topics and labeled them as hypotheses, which outline my preferred practices. The topics relate to questionable nerve compression, double crush syndrome of nerves, motion therapy after surgery, delayed primary tendon repair, proximal pole fracture of the scaphoid, short splint, and indications for postoperative hand elevation. I found no proof whether my preferred methods are better than or inferior to alternative methods that others use. The 10 hypotheses are presented to stimulate thinking, clinical observation, or investigations and highlight several areas of research. Investigation into these hypotheses may avoid unnecessary treatment or improve postsurgical comfort for patients and long-term outcomes of treatment.

Proximal Median Nerve Compression in the Differential Diagnosis of Carpal Tunnel Syndrome

Carpal tunnel syndrome (CTS) is the most common median nerve compression neuropathy. Its symptoms and clinical presentation are well known. However, symptoms at median nerve distribution can also be caused by a proximal problem. Pronator syndrome (PS) and anterior interosseous nerve syndrome (AINS) with their typical characteristics have been thought to explain proximal median nerve problems. Still, the literature on proximal median nerve compressions (PMNCs) is conflicting, making this classic split too simple. This review clarifies that PMNCs should be understood as a spectrum of mild to severe nerve lesions along a branching median nerve, thus causing variable symptoms. Clear objective findings are not always present, and therefore, diagnosis should be based on a more thorough understanding of anatomy and clinical testing. Treatment should be planned according to each patient's individual situation. To emphasize the complexity of causes and symptoms, PMNC should be named proximal median nerve syndrome.

Perioperative management of patients with amyotrophic lateral sclerosis: A narrative review

Amyotrophic lateral sclerosis, or motor neuron disease, is an uncommon progressive neurological disorder. Professionals working in the perioperative field may encounter patients with amyotrophic lateral sclerosis only rarely. The relevant published literature on amyotrophic lateral sclerosis is broad in scope, but a contemporary review focused on the perioperative period is absent. This structured narrative review seeks to provide a summary of the contemporary management of patients and then focuses on eliciting if there are perioperative management considerations specific to amyotrophic lateral sclerosis that can be optimised. A comprehensive structured narrative literature review, including grey literature searching, indicated worsening ventilatory failure is of prime concern but that patients may present with a broad range of neurological symptoms, and that cardiovascular and cognitive dysfunction specific to amyotrophic lateral sclerosis may exist and be occult. Exacerbation of neuromuscular weakness during the perioperative period is multifaceted and requires the application of a high standard of the core principles of surgical and anaesthetic management of neuromuscular disease. Standard perioperative approaches require rigorous attention and potential exists for significant alteration. There is a potential high risk of postoperative increased morbidity from neurological decline and mortality from pulmonary complications. A meticulous approach to planning preoperative assessment, shared decision-making, intraoperative and postoperative care is required.

Role of electromyography and ultrasonography in the diagnosis of double crush lumbar radiculopathy and common fibular injury: illustrative cases

BACKGROUND

Double crush syndrome consists of two compression sites along a peripheral nerve and is rare in the lower extremities. Electrodiagnostic and ultrasound (US) studies may be helpful in evaluating foot drop involving overlapping pathologies.

OBSERVATIONS

Case 1 involved a man who presented with left dorsiflexor weakness and left foot numbness. Electromyography (EMG) revealed a left common fibular nerve entrapment neuropathy and left L5 radiculopathy. US and magnetic resonance imaging (MRI) revealed a large cystic lesion of the left common fibular nerve treated by cyst removal. The left foot drop persisted postoperatively. Lumbar computed tomography myelography revealed severe left foraminal stenosis at L5–S1. Multilevel lumbar laminectomies and facetectomies with an L5–S1 fusion were performed. Within 1 month postoperatively, the left foot drop had improved. Case 2 involved a man who developed a right foot drop caused by right lumbar foraminal stenosis at L4–5 and L5–S1. EMG and US of the right common fibular neuropathy showed large fascicles involving the right common fibular nerve. MRI revealed a hyperintense signal of the right common fibular nerve. Spontaneous improvement occurred within 6 months without surgery.

LESSONS

Spine surgeons should recognize double crush in the lower extremities. EMG and US are valuable in detecting peripheral nerve abnormalities, especially in cases with overlapping lumbar pathology.

Unilateral Axillary Lymphadenopathy After COVID-19 Vaccine Causing Medial Cord Plexopathy: A Case Report

CASE

The global reach of coronavirus disease 2019 has led to the rollout of new generation messenger ribonucleic acid (mRNA) vaccines. As populations are vaccinated, some side effects will become more apparent. We present a case of unilateral lymphadenopathy resulting in a transient plexopathy presenting as neuralgic pain, paresthesia, and numbness in the hand.

CONCLUSION

Multiple image modalities and electrodiagnostic studies were used to infer the diagnosis. This condition was expectantly managed, and the patient's symptoms resolved within weeks.

Regional Anesthesia in the Elite Athlete

Elite athletes are exposed to an elevated risk of musculoskeletal injury which may present a significant threat to an athlete's livelihood. The perioperative anesthetic plan of care for these injuries in the general population often incorporates regional anesthesia procedures due to several benefits. However, some concern exists regarding the potential for regional anesthesia to adversely impact functional recovery in an elite athlete who may have a lower tolerance for this risk. This article aims to review the data behind this concern, discuss strategies to improve the safety of these procedures and explore the features of consent in this patient population.

Carpal Tunnel Syndrome and Diabetes—A Comprehensive Review

Carpal tunnel syndrome (CTS) is the most common compression neuropathy in the general population and is frequently encountered among individuals with type 1 and 2 diabetes. The reason(s) why a peripheral nerve trunk in individuals with diabetes is more susceptible to nerve compression is still not completely clarified, but both biochemical and structural changes in the peripheral nerve are probably implicated. In particular, individuals with neuropathy, irrespective of aetiology, have a higher risk of peripheral nerve compression disorders, as reflected among individuals with diabetic neuropathy. Diagnosis of CTS in individuals with diabetes should be carefully evaluated; detailed case history, thorough clinical examination, and electrophysiological examination is recommended. Individuals with diabetes and CTS benefit from surgery to the same extent as otherwise healthy individuals with CTS. In the present review, we describe pathophysiological aspects of the nerve compression disorder CTS in relation to diabetes, current data contributing to the explanation of the increased risk for CTS in individuals with diabetes, as well as diagnostic methods, treatment options, and prognosis of CTS in diabetes.

Revision of Carpal Tunnel Surgery

Carpal tunnel release is one of the most commonly performed upper extremity procedures. The majority of patients experience significant improvement or resolution of their symptoms. However, a small but important subset of patients will experience the failure of their initial surgery. These patients can be grouped into persistent, recurrent, and new symptom categories. The approach to these patients starts with a thorough clinical examination and is supplemented with electrodiagnostic studies. The step-wise surgical management of revision carpal tunnel surgery consists of the proximal exploration of the median nerve, Guyon’s release with neurolysis, the rerelease of the transverse retinaculum, evaluation of the nerve injury, treatment of secondary sites of compression, and potential ancillary procedures. The approach and management of failed carpal tunnel release are reviewed in this article.

Identifying Risk Factors for Recurrence After Cubital Tunnel Release

PURPOSE

This study investigated specific risk factors for recurrent surgery of ulnar nerve entrapment (ie, ipsilateral clinical symptoms within 5 years after initial cubital tunnel release [CuTR]) in a large cohort. We hypothesized that recurrence is associated with lifestyle variables (eg, smoking, drinking alcohol, a high body mass index [BMI]) or comorbidities).

METHODS

A retrospective cohort study was performed using the Current Procedural Terminology codes for all patients who underwent CuTR between January 2012 and November 2018. Demographic data, including sex, age, weight, height, BMI, comorbidities, smoking, and alcohol consumption, were collected. The primary outcome was the need for revision surgery after initial CuTR. Univariate and multivariate analyses were performed to identify potential risk factors for revision surgery.

RESULTS

Of the 678 patients who underwent CuTR, 120 patients (18%) needed revision surgery within 5 years. Sixty-six patients required subfascial transposition (55%) and 47 patients (39%) received in situ releases. Also, sex, BMI, smoking, alcohol consumption, and comorbidities (except for spinal disc herniation) were similar between the primary and revision subgroup. Age at first occurrence was significantly lower in the revision group (48 years for revision vs 52 years for primary surgery). Moreover, cervical spinal disc herniation was associated with revision surgery (13% vs 6% in the primary group).

CONCLUSIONS

Age and medical history of cervical spinal disc herniation are associated with an increased risk of revision surgery. More importantly, BMI, smoking, alcohol consumption, and other comorbidities are not associated with increased risk of revision surgery within our sample.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

“Idiopathic” Shoulder Pain and Dysfunction from Carpal Tunnel Syndrome and Cubital Tunnel Syndrome

As a referral center for chronic pain, we see many patients with “idiopathic” shoulder pain and limited range of motion. The combination of mild or subclinical carpal tunnel syndrome and cubital tunnel syndrome may be an underrecognized etiology of symptoms in such patients. Here, we report our treatment algorithm and results for such patients.

Double Crush Syndrome of the Lower Limb in L5 Radiculopathy and Peroneal Neuropathy: A Case Report

Double crush syndrome (DCS) is a clinical condition involving impingement of the spinal and peripheral nerves. DCS of the lower limbs has been recognized; however, no detailed reports have been published. Herein, we report a rare case of the coexistence of L5 radiculopathy and peroneal nerve entrapment neuropathy. The patient suffered from pain in the left lower leg and left foot combined with muscle weakness in the left leg without a Tinel-like sign in the peroneal tunnel area. MRI showed a deficit in the left L5 nerve root sleeve, and X-ray imaging revealed L5 spondylolysis. Lumbar fusion surgery was performed at L5-S1. Subsequently, the patient’s symptoms were partially improved, but the pain and toe and ankle motor weakness persisted. In addition, a Tinel-like sign appeared at the entrapment point of the peroneal nerve. The entrapped peroneal nerve was decompressed, and the patient’s symptoms improved. The patient had L5 radiculopathy owing to the improvement in his symptoms in the upper leg before and after lumbar surgery. It is unclear why no Tinel-like sign was detected before the first surgery, but we hypothesized that L5 nerve disorder may mask the symptoms triggered by compression of the peroneal nerve due to the complex pathology of DCS and dynamic factors. Distinguishing between radiculopathy and relative peripheral neuropathy should always be a consideration. DCS may mask characteristic symptoms, and it is important to carefully follow up the patient to detect changes in his or her condition.

Carpal Tunnel Syndrome in Diabetes Mellitus

The aim of the present brief review was to discuss carpal tunnel syndrome (CTS) in diabetes mellitus (DM). Generally, CTS is more common in DM, especially in subjects with coexisting diabetic polyneuropathy (DPN) and/or long DM duration. There is no agreement if it is more frequent in type 1 or type 2 DM. The precise underlying mechanisms are not entirely clear but appear to involve hyperglycaemia-induced median nerve oedema, increased sensitivity to exogenous trauma and nerve myelin ischaemia and axonal degeneration. More recently, increased vascular endothelial growth factor (VEGF) and advanced glycation endproducts (AGEs) appear to also play an important role. Median nerve conduction study remains the cornerstone of CTS diagnosis in DM, being more sensitive than clinical examination. CTS can be treated medically or surgically. The latter appears now to be equally effective in subjects with vs. without DM in terms of recurrence rates and quality of life.

Outcome of Surgical Treated Isolated Pronator Teres Syndromes-A Retrospective Cohort Study and Complete Review of the Literature

PURPOSE

This study aims to elucidate the occurrence of postoperative carpal tunnel syndrome (CTS), the functional outcome of patients with primary pronator teres syndrome (PTS), and review complete literature regarding this topic.

MATERIAL AND METHODS

A retrospective chart review was conducted in patients with PTS at a single center. In all patients, a numeric Visual Analog Scale (VAS) score, Pinch-Test, Jamar hand dynamometer test (JAMAR), and the Disabilities of the Arm Shoulder and Hand (DASH) score were analyzed preoperatively and at final follow-up to assess outcome. Additionally, a complete review of the literature was performed, including all data dealing with pronator teres syndrome.

RESULTS

Ten female and two male patients were included with a mean age of 49 years. Significant improvement in DASH and numeric VAS was detected at latest postoperative follow-up. In three patients, clinical signs of CTS pathology were detected during the follow-up period. One patient needed to be treated surgically, and in the other two patients, a conservative management was possible. In one patient (8%), a PTS recurrence was detected. All patients presented satisfied at latest follow-up.

CONCLUSION

In one-fourth of our patients, a CTS occurred during the follow-up period. Therefore, focusing on double-crush syndrome in unclear or mixed symptoms is necessary to avoid multiple operations. Furthermore, it seems that assessment with NCV is not enough for diagnosing PTS; therefore, further research is needed to clarify this problem.

Double Crush Syndrome of the Upper Extremity

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The double crush hypothesis originally proposed that compression of a peripheral nerve at a proximal site increases its susceptibility to additional distal lesions.

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The etiology of double crush syndrome is likely multifactorial as mechanical, systemic, pharmacologic, or environmental factors may increase a patient's susceptibility to this syndrome.

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To date, there remains no standardized definition of double crush syndrome, and there is no consensus on its exact pathophysiology or diagnostic criteria.

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Patients with double crush syndrome should be counseled that surgical repair may produce inferior outcomes compared with those who are treated for isolated entrapment neuropathies.

Error traps in pediatric regional anesthesia

Ultrasound-guided nerve blocks have revolutionized the way we provide regional anesthesia. By providing effective perioperative pain control, regional anesthesia reduces opioid consumption, decreases length of stay, and increases patient/parental satisfaction. However, error traps (circumstances that lead to erroneous actions) can defeat its inherent benefits and may result in adverse outcomes. This article focuses on promoting a culture of safety by highlighting five common avoidable error traps encountered while providing regional anesthesia for pediatric patients. They include failure to confirm intended block site, failure to optimize ultrasound images and identify artifacts, failure to recognize when regional anesthesia is an acceptable option, failure to implement alternative imaging techniques when anatomy is challenging, and failure to recognize disease states with abnormal anatomy that may require alternative blocks. These issues are easily addressed if the pediatric regionalist is cognizant of the appropriate ways to mitigate them, and, as such, we review strategies to avoid them.

The management of failed cubital tunnel decompression

Cubital tunnel decompression is a commonly performed operation with a much higher failure rate than carpal tunnel release.

Failed cubital tunnel release generally occurs due to an inadequate decompression in the primary procedure, new symptoms due to an iatrogenic cause, or development of new areas of nerve irritation.

Our preferred technique for failed release is revision circumferential neurolysis with medial epicondylectomy, as this eliminates strain, removes the risk of subluxation, and avoids the creation of secondary compression points.

Adjuvant techniques including supercharging end-to-side nerve transfer and nerve wrapping show promise in improving the results of revision surgery.

Limited quality research exists in this subject, compounded by the lack of consensus on diagnostic criteria, classification, and outcome assessment.

Cite this article: EFORT Open Rev 2021;6:735-742. DOI: 10.1302/2058-5241.6.200135

Examination of Spinal Canal Anatomy with MRI Measurements in Lomber Disc Herniation Patients: An Anesthesiologist Viewpoint

Background and Aim:

The aim of this study is to investigate the magnetic resonance imaging (MRI) of patients with lumbar disc herniation (LDH) to identify the challenges associated with neuraxial anesthesia.

Materials and Methods:

The MRI images in the supine position of 203 patients admitted to hospital with complaints of lower back pain were studied. Medial sagittal slices of the lumbar spine were imaged from L1 to S1. LDH is classified as either bulging, extrusion, or protrusion.

Results:

For this study, 83 males and 120 females with a mean age of 43.18 ± 14.68 years were recruited. The highest herniation level was observed at L4–L5 in 145 (71.4%) patients: 76 instances of disc bulging (37.4%), 56 instances of extrusion (27.6%), and 13 instances of protrusion (6.4%). The longest distance between the skin and spinal cord was 60.06 ± 1.61 mm at L5–S1; the longest distance at width of the epidural space was 6.09 ± 1.95 mm at L3–L4. According to the disc herniation groups, no significant differences were found between the skin-to-dura distance, width of the epidural space, and depth of skin level to spinous process (P > 0.05). Moreover, the anterior dura to cord distances was significantly different from normal patients (P < 0.05). Indeed, there was a statistically weak and negative correlation between both the length and age of the lumbar spinal canal (P < 0.05, r = −0.295).

Conclusions:

Lumbar disc pathologies can cause anatomical derangements in the spinal canal, which may cause neurologic deficits by neuraxial blockade.

The Myth of Median Nerve in Forearm and Its Role in Double Crush Syndrome: A Cadaveric Study

Purpose: This study aims to histologically compare the median nerve in the arm, forearm, and wrist, to help understand how cervical radiculopathy in a double crush phenomenon causes distal nerve dysfunction at the carpal tunnel and median nerve with concurrent absence of symptoms at the forearm.

Methods: The study was performed on 12 fresh cadaveric upper limbs free from any injury or operation. Male cadavers in the age range of 35–40 years were used. The dissection of the median nerve and the histological examination of the specimens from the arm, forearm, and wrist were conducted to evaluate variations in the epineurium thickness (μm), perineurium thickness (μm), number of fascicles per nerve trunk, area percent of myelin covering, and area percent of neurolemmal sheath.

Results: Morphometric and statistical results of the cadaveric median nerve trunk revealed that the mean epineurium and perineurium thickness measured in H&E-stained sections in the forearm were significantly greater than those in the arm and wrist specimens. Further, the mean percent area of the myelin covering in the forearm was significantly lower than that in the arm and wrist specimens in the sections stained with osmium oxide (p < 0.001). There were, however, no significant differences in the neurolemmal sheath among the arm, forearm, and wrist specimens in the silver-stained sections.

Conclusion: The histological differences explained the high concomitant occurrence of carpal tunnel syndrome (CTS) and cervical radiculopathy and the concurrent absence of symptoms at the forearm. Hence, we suggest cautious evaluation of patients with upper limb symptoms, since the management of these conditions requires a different approach.

Effectiveness and safety of motion style acupuncture treatment of the pelvic joint for herniated lumbar disc with radiating pain: A prospective, observational pilot study

CONTEXT

Conservative treatment is effective for treating and managing herniated lumbar disc with radiating leg pain.

OBJECTIVES

To investigate the effects of motion style acupuncture treatment (MSAT) on the pelvic joint for this condition.

DESIGN

This prospective observational study was a pilot study for a future randomized, controlled trial (RCT).

SETTING

[masked for review].

PATIENTS/INTERVENTIONS

We enroled 40 patients and allocated them to two groups (both n = 20). Groups 1 and 2 received integrative Korean medicine treatment (KMT) and integrative KMT with MSAT for pelvic joint, respectively. Primary outcome was the Numeric Rating Scale (NRS) score for low back pain. Secondary outcomes were the Oswestry Disability Index (ODI), Visual analogue Scale (VAS), and EuroQol 5-Dimension-5-level (EQ-5D-5 L) scores. Efficacy was assessed by comparing the baseline and Day 4 results. Safety was assessed based on the frequency and severity of all adverse events.

RESULTS

On Day 14, except for ODI in Group 1, the NRS, VAS, and EQ-5D-5 L scores showed significant improvements in both groups. On Day 90, both groups showed significant improvements in the NRS, ODI, and EQ-5D-5 L scores. There was a significant between-group difference in the NRS score on Day 7. On Day 14, Group 2 had a significantly lower VAS score for radiating leg pain than Group 1. Twelve patients reported adverse events associated with integrative KMT; however, there was no association with pelvic joint MSAT.

CONCLUSION

Adding MSAT for pelvic joint to conventional integrative KMT may ameliorate radiating leg pain and improve the quality of life.

Management of anesthesia for surgery in prone position for a patient with hereditary neuropathy with liability to pressure palsies. A case report and narrative literature review

The reported case describes a patient with hereditary neuropathy with liability to pressure palsies (HNPP) requiring a neurosurgical laminotomy procedure for an arachnoid cyst with medullary compression. HNPP is a rare pathology requiring meticulous anesthetic and surgical management. We give a detailed overview of the planning, simulation, and performance of the anesthesia procedure in order to minimize all potential risk factors for perioperative nerve injury. During the preparation of this case, where the positioning was extremely challenging, we reviewed the available literature for guidance. A few papers report the use of neuraxial anesthesia in patients previously diagnosed with HNPP. No reports could be found on the management of general anesthesia and positioning for major surgery in those patients.

Erector Spinae Plane Block versus Continuous Perineural Local Anesthetic Infusion for Postoperative Pain Control After Supraclavicular Decompression for Neurogenic Thoracic Outlet Syndrome: A Matched Case-Control Comparison

OBJECTIVE

The purpose of this study was to determine if single injection erector spinae plane blocks are associated with improved pain control, opioid use, numbness, length of stay, or patient satisfaction compared to intraoperatively placed continuous perineural infusion of local anesthetic after decompression of neurogenic thoracic outlet syndrome.

METHODS

This is a retrospective cohort study at a tertiary academic center of eighty patients that underwent supraclavicular decompression for thoracic outlet syndrome between May 2019 and January 2020. Forty consecutive patients treated with single-injection preoperative erector spinae plane blocks were retrospectively compared to 40 age- and gender-matched controls treated with continuous perineural infusion.

RESULTS

The primary outcome of mean pain scores was not significantly different between the erector spinae and perineural infusion groups over the three-day study period (4.2-5.3 vs 3.0-5.1 P=0.08). On post-operative day 0, mean pain scores were significantly higher in the erector spinae group (4.2 vs 3.0, P=0.02). While statistically significant, the score was still lower in the erector spinae group on day 0 than on day 1,2, or 3 in either group. Opioid use, nausea, length of stay and patient satisfaction were also similar. Upper extremity numbness was significantly less severe in the erector spinae group (36% vs 73% moderate-extreme, P=0.03) at 6-month follow-up.

CONCLUSIONS

Seventy-two-hour perineural local anesthetic infusion did not provide superior analgesia compared to preoperative single-injection erector spinae blocks. Furthermore, there was significantly less long-term postoperative numbness associated with erector spinae blocks compared to perineural local anesthetic infusion.

Diagnostics of infrapatellar saphenous neuralgia-a reversible cause of chronic anteromedial pain following knee surgery

Objectives

To evaluate the impact of diagnostic nerve block and ultrasound findings on therapeutic choices and predict the outcome after concomitant surgery in patients with suspected neuropathy of the infrapatellar branch of the saphenous nerve (IPBSN).

Methods

Fifty-five patients following knee surgery with suspicion of IPBSN neuralgia were retrospectively included. Ultrasound reports were assessed for neuroma and postsurgical scarring (yes/no). Responders and non-responders were assigned following anesthetic injection of the IPBSN. The type of procedure (neurectomy/interventional pain procedure/other than nerve-associated therapy) and pain score at initial follow-up were recorded and patients were assigned as positive (full pain relief) or negative (partial/no pain relief) to therapeutic nerve treatment. Factors associated with a relevant visual analog scale (VAS) reduction were assessed using uni- and multivariate logistic regression models and chi-square for quantitative and qualitative variables (p ≤ 0.05).

Results

Responders (37/55) more often had an entrapment or an evident neuroma of the IPBSN (97% vs. 6%). A positive Hoffmann-Tinel sign (p = 0.002) and the absence of knee joint instability (p = 0.029) predicted a positive response of the diagnostic nerve block (90%; 26/29). In the follow-up after therapeutic nerve treatment, all patients with full pain relief showed neuromas or entrapment of the IPBSN. Patients negatively responding to therapeutic nerve treatment more frequently showed an additional knee joint instability (25% vs. 4%).

Conclusion

Selective denervation for neuropathic knee pain is beneficial in selected patients with significant VAS reduction after diagnostic nerve block. Non-responders following diagnostic nerve block but sonographic evidence of IPBSN pathologies need to be evaluated for other causes such as knee joint instability.

Key Points

• Sonographic diagnosis of neuroma or entrapment of the IPBSN is frequently seen in patients with anteromedial knee pain and leads to a good response to diagnostic nerve block following knee surgery.

• The vast majority of patients with clinical signs of IPBSN neuropathy and response to a diagnostic nerve block sustained full pain relief following therapeutic nerve treatment.

• Patients not responding to therapeutic IPBSN treatment have to be evaluated for other causes of anteromedial knee pain such as knee joint instability.

Complications Associated with Peripheral Nerve Blocks

Outpatient orthopedic surgery is gradually becoming the standard across the country, as it has been found to significantly lower costs without compromising patient care. Peripheral nerve blocks (PNBs) are largely what have made this transition possible by providing patients excellent pain control in the immediate postoperative period. However, with the increasing use of PNBs, it is important to recognize that they are not without complications. Although rare, these complications can cause patients a significant amount of morbidity. It is important for surgeons to know the risks of peripheral nerve blocks and to inform their patients.

Surgical treatment of common peroneal neuropathy in schwannomatosis: illustrative cases

BACKGROUND

Neurofibromatosis syndromes such as neurofibromatosis type 1, neurofibromatosis type 2, and schwannomatosis often result in painful symptoms related to tumor burden.

OBSERVATIONS

Painful symptoms classically associated with common points of peripheral nerve entrapment, such as common peroneal neuropathy at the fibular tunnel, may present in patients both with and without focal tumor involvement.

LESSONS

Surgical decompression at the point of entrapment, with or without resection of tumor, may provide symptomatic relief. Examples of surgical decompression at the point of entrapment, both with and without resection of tumor, are presented.

Percutaneous cryoneurolysis for acute pain management: current status and future prospects

Introduction: Conventional nerve blocks utilize local anesthetic drugs to provide pain relief for hours or days following surgery or trauma. However, postoperative and trauma pain can last weeks or months. Ultrasound-guided percutaneous cryoneurolysis is an anesthetic modality that offers substantially longer pain relief compared to local anesthetic-based nerve blocks.Areas covered: In this review, we discuss the history, mechanism of action, and use of ultrasound-guided percutaneous cryoneurolysis by anesthesiologists in the setting of acute pain management.Expert opinion: Ultrasound-guided percutaneous cryoneurolysis offers the potential to provide weeks or months of pain relief following surgery or trauma. Compared to continuous local anesthetic-based peripheral nerve blocks, currently the gold standard for providing long duration postoperative analgesia, cryoneurolysis has benefits that include: 1) longer duration measured in weeks or months rather than days; 2) no external reservoir of local anesthetic to be carried by the patient; 3) no risk of infection; and 4) no risk of catheter dislodgement. However, cryoneurolysis can induce a prolonged motor block in addition to the sensory block, decreasing the appropriate indications to those in which potential sensory and motor deficits are acceptable. Additionally, cryoneurolysis of multiple nerves can have a substantial time requirement relative to conventional nerve blocks.

Does Compression Sensory Axonopathy in the Proximal Tibia Contribute to Noncontact Anterior Cruciate Ligament Injury in a Causative Way?-A New Theory for the Injury Mechanism

Anterior cruciate ligament injury occurs when the ligament fibers are stretched, partially torn, or completely torn. The authors propose a new injury mechanism for non-contact anterior cruciate ligament injury of the knee. Accordingly, non-contact anterior cruciate ligament injury could not happen without the acute compression microinjury of the entrapped peripheral proprioceptive sensory axons of the proximal tibia. This would occur under an acute stress response when concomitant microcracks-fractures in the proximal tibia evolve due to the same excessive and repetitive compression forces. The primary damage may occur during eccentric contractions of the acceleration and deceleration moments of strenuous or unaccustomed fatiguing exercise bouts. This primary damage is suggested to be an acute compression/crush axonopathy of the proprioceptive sensory neurons in the proximal tibia. As a result, impaired proprioception could lead to injury of the anterior cruciate ligament as a secondary damage, which is suggested to occur during the deceleration phase. Elevated prostaglandin E2, nitric oxide and glutamate may have a critical neuro-modulatory role in the damage signaling in this dichotomous neuronal injury hypothesis that could lead to mechano-energetic failure, lesion and a cascade of inflammatory events. The presynaptic modulation of the primary sensory axons by the fatigued and microdamaged proprioceptive sensory fibers in the proximal tibia induces the activation of N-methyl-D-aspartate receptors in the dorsal horn of the spinal cord, through a process that could have long term relevance due to its contribution to synaptic plasticity. Luteinizing hormone, through interleukin-1β, stimulates the nerve growth factor-tropomyosin receptor kinase A axis in the ovarian cells and promotes tropomyosin receptor kinase A and nerve growth factor gene expression and prostaglandin E2 release. This luteinizing hormone induced mechanism could further elevate prostaglandin E2 in excess of the levels generated by osteocytes, due to mechanical stress during strenuous athletic moments in the pre-ovulatory phase. This may explain why non-contact anterior cruciate ligament injury is at least three-times more prevalent among female athletes.

Less Invasive Combined Micro- and Endoscopic Neurolysis of Superficial Peroneal Nerve Entrapment: Technical Note

As superficial peroneal nerve (S-PN) entrapment neuropathy is relatively rare, it may be an elusive clinical entity. For decompression surgery addressing idiopathic S-PN entrapment, narrow- area decompression may be insufficient and long-area decompression along the S-PN from the peroneus longus muscle (PLM) to the peroneal nerve exit site may be required. To render it is less invasive, we performed S-PN neurolysis in a combined microscope/endoscope procedure. We report our surgical procedure and clinical outcomes. We microsurgically decompressed the affected S-PN under local anesthesia without a proximal tourniquet. We made a small linear skin incision at the distal portion of the S-PN, performed distal decompression of the S-PN where it penetrated the deep fascia, and then performed proximal decompression under an endoscope. At the site where the S-PN exited the PLM, we placed additional small incisions and proceeded to microscopic decompression. We surgically treated three patients with S-PN entrapment. They were two men and one woman ranging in age from 66 to 85 years. The mean postoperative follow-up was 22 months. Their symptoms before treatment and at the latest follow-up visit were recorded on the numerical rating scale (NRS). The mean incision length was 5.5 cm and 17.3 cm of the S-PN was decompressed. All three patients reported postoperative symptom improvement. There were no complications. In patients with idiopathic S-PN entrapment, long-site neurolysis under local anesthesia using a microscope/endoscope combination is useful.

Endoscopic-Assisted Transaxillary Approach for First Rib Resection in Thoracic Outlet Syndrome

Purpose

To assess the feasibility, safety, and clinical outcomes of an endoscopic-assisted transaxillary approach of first rib resection for thoracic outlet syndrome (TOS) and to compare the differences in demographic and clinical data between satisfactory and unsatisfactory outcomes using this approach.

Methods

We retrospectively identified patients who underwent endoscopic-assisted first rib partial resection. A transaxillary approach for the first rib resection and neurovascular decompression were undertaken under magnified visualization. Endoscopic classification of neurovascular bundle (NVB) patterns and interscalene distance (ISD) between anterior and middle scalene muscles were evaluated intraoperatively. We assessed the Roos and DASH scores.

Results

We reviewed 131 cases of TOS (48 women and 83 men; mean age 26.2 years; range 12 to 57). Roos classification revealed 80.2% excellent or good results. DASH scores improved significantly from 40.7 ± 20.0 to 15.7 ± 19.6 (P < .001). The complication rate was low (5.3%), with 4 pneumothorax and 3 other complications. Intraoperative NVB classification revealed 30 cases of parallel type, in which the artery and nerve travel in parallel; 69 oblique types, and 30 vertical types, in which the nerve was completely behind the middle scalene muscle or abnormal band. The ISD was narrower (5.4 ± 3.6 mm) than in previous cadaveric studies. The ISD in the parallel patterns was wider than that in the vertical patterns. In the satisfactory group, we found a significantly larger number of men, younger patients, athletes, and patients with a lower preoperative DASH score.

Conclusions

An endoscopic-assisted transaxillary approach for first rib resection in TOS provides an excellent magnified visualization, safely allowing sufficient decompression of the neurovascular bundle and satisfactory surgical outcomes. Younger male athletes with TOS may be better candidates for this procedure.

Level of Evidence

IV, therapeutic case series.

Adjuvant chemotherapy as a risk factor for chronic postoperative pain after video-assisted thoracoscopic surgery: a 10-year single-centre retrospective study

OBJECTIVES

The association between adjuvant chemotherapy (AC) and chronic postoperative pain (CPP) after video-assisted thoracoscopic surgery (VATS) for lung cancer resection has not yet been reported. We, therefore, investigated the association between AC and the long-term incidence of CPP after VATS.

METHODS

We retrospectively reviewed 3015 consecutive patients who underwent VATS for lung cancer between 2007 and 2016. The patients were divided into 2 groups: those who received (AC group) and those who did not receive (non-AC group) AC within 3 months after VATS. Propensity score analysis was performed to adjust for baseline differences between the 2 groups. The cumulative incidence of CPP at the intervals of 3 months, over 36 months, was compared before and after matching. A Cox proportional hazards regression analysis was used to investigate the predictors of CPP after VATS.

RESULTS

We included and assessed 2222 patients in this study. Of these, 320 patients (14.4%) received AC within 3 months post-VATS. The cumulative incidence of CPP during 36 months post-surgery was significantly higher in the AC group than in the non-AC group, before and after matching (log-rank test; P = 0.002 and 0.027, respectively). Cox proportional hazards regression analysis also showed that AC was a significant risk factor for CPP (hazard ratio 1.62, 95% confidence interval 1.16-2.28; P = 0.005).

CONCLUSIONS

Our results indicate that AC is an important risk factor for CPP after VATS. Further understanding of the risk factors for CPP may facilitate its prediction and treatment.

Cryoneurolysis and Percutaneous Peripheral Nerve Stimulation to Treat Acute Pain

Two regional analgesic modalities currently cleared by the U.S. Food and Drug Administration hold promise to provide postoperative analgesia free of many of the limitations of both opioids and local anesthetic-based techniques. Cryoneurolysis uses exceptionally low temperature to reversibly ablate a peripheral nerve, resulting in temporary analgesia. Where applicable, it offers a unique option given its extended duration of action measured in weeks to months after a single application. Percutaneous peripheral nerve stimulation involves inserting an insulated lead through a needle to lie adjacent to a peripheral nerve. Analgesia is produced by introducing electrical current with an external pulse generator. It is a unique regional analgesic in that it does not induce sensory, motor, or proprioception deficits and is cleared for up to 60 days of use. However, both modalities have limited validation when applied to acute pain, and randomized, controlled trials are required to define both benefits and risks.

Quantitative Evaluation of the Echo Intensity of Paraneural Area and Myofascial Structure around Median Nerve in Carpal Tunnel Syndrome

The aim of this study was to investigate whether the echo intensity (EI) of the paraneural area (PA), the median nerve (MN) at the carpal tunnel, the EI of the myofascial structure (MS) around MN, the ‘PA and MN’ at the mid-forearm, and the MN transversal displacement at both sites differs between persons with carpal tunnel syndrome (CTS) and control subjects. Methods: In total, 16 CTS patients and 16 controls, age- and gender-matched, were recruited. Cross-sectional ultrasound images of MN were obtained to evaluate the EI of the PA, the MN at carpal tunnel, the EI of MS, and the ‘PA and MN’ at the mid-forearm in a natural position, then images were taken after a whole-hand grasp movement, to evaluate MN transversal displacement. Inter-rater and intra-rater reliability in control, and differences in the EI and MN displacement between CTS and control, were analyzed. In addition, the correlations between ultrasound parameters and MN displacement were evaluated. Results: The quantitative EI of PA, MN, EI of MS, ‘PA and MN’ had high inter-rater and intra-rater reliability in the control. The EI of PA, MS and ‘PA and MN’ were significantly higher in CTS subjects (p < 0.01), whilst there was no significant difference in the EI of MN at the carpal tunnel. MN displacement was significantly decreased both at the carpal tunnel and the mid-forearm in CTS subjects (p < 0.01). In addition, there were negative correlations among the EI of PA (rs = −0.484, p = 0.004), EI of MS (rs = −0.479, p = 0.002), EI of ‘PA and MN’ (rs = −0.605, p < 0.001) and MN transversal displacement. Conclusions: The higher EI of PA and MS around MN in CTS may indicate greater fibrosis along the course of MN, reducing fascial adaptability, influencing the synergy and coordination of the MS, and increasing the shear stress between MS and MN, and it may further increase the abnormal pressure on the MN not only at the carpal tunnel, but also at the mid-forearm. These results may partly explain the role of PA and MS in CTS pathogenesis.

Double crush syndrome: Epidemiology, diagnosis, and treatment results

BACKGROUND

Double Crush Syndrome (DCS) is a clinical condition that involves multiple compression sites along a single peripheral nerve. The present study aims to describe the epidemiology of DCS and surgical results.

METHODS

A retrospective observational analytic study included patients with clinical diagnosis of cervical radiculopathy and carpal tunnel syndrome who underwent surgery between January 2009 and January 2019. General demographic characteristics were noted, and 3 groups were distinguished: spinal surgery, carpal tunnel release, and bimodal decompression (BD); statistical differences were analyzed between them.

RESULTS

The sample comprised 32 patients. DCS prevalence was 10.29%. Mean age at presentation was 59.25±10.98 years. There was female predominance (75%). Paresthesia was the main symptom (65.6%). Post-surgical results of BD showed significant improvement in sensory nerve conduction velocity, motor nerve conduction velocity (both P=0.008), and disability on Douleur Neuropathique 4 questions, Neck Disability Index, and Boston Carpal Tunnel Questionnaire (P=0.001, 0.004, 0.008, respectively).

CONCLUSIONS

Diagnosis and management of DCS are a challenge. It is necessary to determine the site with maximal compression and risk of complications to decide on treatment. If first-line surgery is adequate, proximal and distal symptomatology can be improved. To maximize success, we recommend BD, according to the present results.

Common Peroneal Nerve Injury and Recovery after Total Knee Arthroplasty: A Systematic Review

Background

Common peroneal nerve palsy (CPNP) after total knee arthroplasty (TKA) may impact extremity pain and function. Incidence and rates of recovery of CPNP after TKA vary in the current literature. The purpose of this systematic review was to evaluate the incidence of incomplete and complete CPNP after TKA and rates of incomplete and complete recovery of nerve function in the absence of further surgical treatment.

Methods

PubMed, Embase, and Cochrane Central were searched for studies published in the years 1970-2019. Studies evaluating incidence and recovery rates of CPNP in the absence of further surgical treatment were screened according to inclusion and exclusion criteria. Outcomes of interest included incidence of complete and incomplete CPNP and rates of incomplete and complete nerve recovery.

Results

Eleven studies were included for qualitative analysis. In total, there were 47,585 TKAs performed, with 203 postoperative CPNPs, for a cumulative incidence of 0.4%. One hundred twenty-nine CPNPs were classified as complete or incomplete palsies. At a mean follow-up of 3.6 years (range, 0-11 years), 24 (39%) complete CPNPs had complete recovery, 34 (56%) had incomplete recovery, and 3 were lost to follow-up. In contrast, 45 (66%) with incomplete CPNPs had complete recovery, 18 (27%) had incomplete recovery, and 5 patients were lost to follow-up.

Conclusions

Incidence of CPNP after TKA was 0.4%. Recovery of nerve function after CPNP in the setting of TKA varies by the degree of initial nerve palsy. These data may be used to inform decisions on further interventions and for the purposes of perioperative patient counseling after TKA.

Chiropractic Management of a Patient With Radial Nerve Entrapment Symptoms: A Case Study

Objective

This report describes the case of a patient with chronic radial nerve entrapment symptoms managed with chiropractic care. We propose a complementary functional neurologic assessment of muscle function in different positions that could reveal muscle dysfunctions absent with standard test position.

Clinical Features

A 45-year-old man presented to a private chiropractic clinic with a throbbing pain 5 cm above the right lateral elbow epicondyle radiating onto the back of the lower arm and increasing after using a mouse when working on a computer. A Mill test and a Cozen test created pain near the lateral epicondylitis. The use of complementary functional neurologic assessment for radial nerve entrapment showed changes in manual muscle testing after tests were done in different positions to increase the compression on the nerve.

Intervention and Outcome

Chiropractic management was performed, including myofascial therapy, spinal and proximal radioulnar joint adjustments, neural mobilization, and the use of a splint. After 7 days (2 treatments), the patient showed no elbow pain even if he worked on his computer using a mouse. After a 2-year follow-up, no recurrence was reported.

Conclusion

In this case of radial nerve entrapment symptoms, the patient benefited from chiropractic management using standard chiropractic, applied kinesiology, and neural mobilization techniques. The complementary functional neurologic assessment of radial nerve entrapment proposed revealed muscles dysfunctions absent with the standard test position. These changes in manual muscle testing were useful to determine the possible sites of entrapment in order to direct the therapeutic efforts to these locations.

Simultaneous Posterior Shoulder Dislocation and Acromioclavicular Joint Separation: Single-Stage Arthroscopic Treatment of Combined Injuries: A Case Report

CASE

We report on a patient who received arthroscopic treatment after a unique traumatic combined injury comprising a posterior shoulder dislocation with posterior labrum damage, a reverse Hill-Sachs lesion, and a concomitant Rockwood type-V acromioclavicular joint dislocation.

CONCLUSION

Arthroscopy was applied to address all pathologies in a single-stage procedure. The outcome of reduced operating and patient recovery time suggests that our intervention is ideal for this specific indication.

Influences of Neck and/or Wrist Pain on Hand Grip Strength of Industrial Quality Proofing Workers

Background

The aim of this study was to analyze the interaction between neck and/or wrist pain and hand grip strength (HGS) and to investigate factors (age, sex, neck disorders, and carpal tunnel syndrome) influencing the HGS of industrial quality proofing workers (N = 145).

Methods

Standardized questionnaires [Neck Disability Index (NDI), Boston Carpal Tunnel Questionnaire] were used to evaluate existing neck and/or wrist pain. HGS measurements were performed in different wrist positions.

Results

Significant differences between participants with and without neck pain were found in different wrist positions, in neutral wrist position right [without neck pain (n = 48) 46.34 (43.39 - 49.30); with neck pain (n = 97) 38.46 (36.20 - 40.72), F _(1,144)  = 16.82, p < 0.001, ŋ _p ² = 0.11] and left [without neck pain 44.06 (41.19 - 46.94); with neck pain 37.36 (35.13 - 39.58), F _(1,144)  = 12.70, p < 0.001, ŋ _p ² = 0.08]. A significant difference between participants with and without wrist pain was found for neutral wrist position right [without wrist pain (n = 105) 42.53 (40.37 - 44.70); with wrist pain (n = 40) 37.24 (33.56 - 40.91), F _(1,144)  = 6.41, p = 0.01, ŋ _p ² = 0.04]. Regression analysis showed significant results especially for steps two (age and weight, NDI) and three (age and weight, NDI, Boston Carpal Tunnel Questionnaire) for neutral position right (R² = 0.355, R² = 0.357, respectively).

Conclusion

Neck pain has an impact on HGS but should be evaluated in consideration of age and sex.

Perioperative Automated Noninvasive Blood Pressure- (NIBP-) Related Peripheral Nerve Injuries: An Anesthetist's Dilemma-A Case Report and Review of the Literature

Peripheral nerve injury following regional or general anesthesia is a relatively uncommon entity but, potentially, a serious complication of anesthesia. Most nerve injuries are related to either regional anesthesia or position-related complications, and they are rarely seen in association with the use of automated blood pressure monitoring. We describe a patient who developed neurological dysfunction of all the three major nerves, median, ulnar, and radial, after general anesthesia. The distribution of sensory motor deficit along with the nerve conduction study demonstrated the location of the anatomical nerve lesions coinciding with the automatic noninvasive blood pressure (NIBP) cuff. No other cause of nerve injury was identified except for the use of the NIBP cuff. In the absence of another identifiable cause, we strongly suspected the NIBP cuff compression as a possible cause for the nerve injuries. In this article, we will discuss the possible risk factors, mechanisms, diagnosis, and prevention of perioperative nerve injury.

Shoulder Double Crush Syndrome: A Retrospective Study of Patients With Concomitant Suprascapular Neuropathy and Cervical Radiculopathy

Purpose

While the double crush phenomena (compression along two points on a nerve) has been established between median neuropathy and cervical radiculopathy, combined suprascapular neuropathy (SSN) and cervical C5/C6 radiculopathy-so-called shoulder double crush syndrome-has not been well examined. We aim to identify the incidence of shoulder double crush syndrome in patients undergoing arthroscopic suprascapular nerve release for SSN.

Methods

One hundred consecutive patients >18 years of age who were positive for SSN on electromyography and motor nerve conduction studies (EMG/NCS) and underwent a suprascapular nerve release were included. Patients with evidence of shoulder double crush syndrome were identified based on x ray, cervical spine magnetic resonance imaging (MRI) and examination findings. Demographics, electrodiagnostics results, treatment courses, and clinical outcomes (visual analog scores and rotator cuff strength) following arthroscopic suprascapular nerve release were compared between patients with double crush syndrome versus isolated SSN.

Results

Thirty one percent of patients had evidence of shoulder crush syndrome. Two significant electrophysiologic differences were noted in shoulder double crush patients compared to isolated SSN patients. Patients with double crush had an increased incidence of median neuropathy (51% vs 30%, P = .04). Double crush patients had less supraspinatus motor amplitude difference between the affected side and non-affected side compared to isolated SSN patients (2.62 mV vs 3.44 mV, P = .03). In general, most double crush patients were treated conservatively with regard to their cervical spine pathology.

Conclusion

A significant percentage of patients with SSN have evidence of shoulder double crush syndrome. Patients with SSN and concomitant median neuropathy should have a detailed neck examination performed.

The Interdisciplinary Management of Foot Drop

BACKGROUND

Foot drop can be caused by a variety of diseases and injuries. Although it is a common condition, its overall incidence has not been reported to date. Foot drop markedly restricts the everyday activities of persons suffering from it. There is, therefore, a need for an optimized strategy for its diagnosis and treatment that would be standardized across the medical specialties encountering patients with this problem.

METHODS

This article consists of a review on the basis of pertinent publications re- trieved by a search in the Pubmed/MEDLINE and Cochrane databases, as well as a description of the authors' proposed strategy for the diagnosis and treatment of foot drop.

RESULTS

Foot drop can be due to a disturbance at any central or peripheral location along the motor neural pathway that terminates in the dorsiflexor muscles of the foot, or at multiple locations in series. Optimal localization of the lesion(s) is a pre- requisite for appropriate treatment and a successful outcome. The most common causes are L5 radiculopathy and peroneal nerve injury. An operation by a neuro- surgeon or spinal surgeon is a reasonable option whenever there is a realistic chance that the nerve will recover. In our opinion, any patient with a subjectively disturbing foot drop and a clinically suspected compressive neuropathy of the peroneal nerve should be informed about the option of surgical decompression of the nerve at the fibular head, which can be performed with little risk. In case of a permanent foot drop, some patients can benefit from muscle-transfer surgery. For spastic foot drop, the option of botulinum toxin injections should be evaluated.

CONCLUSION

The care of patients with foot drop could be optimized by interdisciplin- ary foot-drop clinics involving all of the relevant specialists. The goals of treatment should always be improved mobility in everyday life and the prevention of falls, pain, and abnormal postures.

Neurodynamic evaluation and nerve conduction studies in patients with forward head posture

Forward head posture (FHP) is one of the most frequently seen problems. The aim of this study was to evaluate the neurodynamic tests and peripheral nerve conductions of upper extremity in patients with FHP. The study population included 100 patients with upper extremity and neck problems and 34 healthy individuals as a control group. Craniovertebral angle measurement was used to determine forward head posture. Stretch tests for radial, ulnar and median nerves were performed. Nerve conductions of bilateral median, radial, ulnar and medial antebrachial cutaneous (MAC) nerves were examined in all patients included in the study. The most significant nerve conduction differences in moderate-to-severe FHP patients were a decrease in the sensory nerve action potential (SNAP) and compound muscle action potential (CMAP) amplitudes of median nerves, a decrease in the SNAP amplitude of ulnar nerves, a delay in the F response latency of ulnar nerves and prolongation in the SNAP latency of the MAC nerve. FHP makes patients more prone to peripheral entrapments.

A quantitative evaluation of sciatic nerve stiffness after compression by shear wave elastography in diabetic rats

Background

Our study investigates the feasibility of using quantitative evaluation for nerve entrapment visualization by shear wave elastography (SWE) in diabetic rats.

Methods

A total of 24 male Sprague-Dawley (SD) rats were included in this study. Before injection of streptozotocin (STZ), the experimental groups were assigned as the diabetic nerve compression (DNC) group (DNC, n=18) and the control group (CON, n=6). The DNC model was created by wrapping a silicone tube around the nerve, and then the DNC group was divided into the DNC 2-week (DNC2W, n=6), 4-week (DNC4W, n=6), and 8-week (DNC8W, n=6) groups according to the different duration time of sciatic nerve compression. The nerve stiffness was detected by SWE. Meanwhile, motor nerve conduction velocity (MNCV) was detected. These 2 indicators and histology of sciatic nerves were compared across the different groups.

Results

The stiffness of the nerve depicted by SWE at the compression site increased markedly along with the duration time of compression (P<0.01). The MNCV decreased along with the duration time of nerve compression (P<0.05). The nerve stiffness depicted by SWE was negatively correlated with MNCV (r=−0.926; P<0.01). Myelinated fiber density significantly decreased as the duration time of nerve compression increased (P<0.01). Some differences were found between DNC4W and DNC8W groups, and CON and DNC2W groups (P<0.05) in average axon diameter, myelin sheath thickness, and g ratio.

Conclusions

The increased values of SWE, along with the increased duration of nerve compression, could reflect the severity of nerve entrapment in diabetic rats. Therefore, SWE may be used as a noninvasive and effective method to quantitatively evaluate the severity of diabetic nerve entrapment.

Feasibility of Point Shear Wave Elastography for Evaluating Diabetic Peripheral Neuropathy

OBJECTIVES

In the mode of Virtual Touch quantification (Siemens AG, Erlangen, Germany), point shear wave elastography (p-SWE) is widely used for noninvasive assessments of tissue stiffness, which may be useful in the evaluation of diabetic peripheral neuropathy (DPN).

METHODS

Thirty patients with type 2 diabetes and 20 control participants (7 with myoma of the uterus and 13 with kidney stones) were enrolled in this prospective study. The 30 patients were further divided into patients with DPN and patients without DPN. Conventional ultrasound examinations and p-SWE were used to examine the tibial nerve in the popliteal fossa.

RESULTS

Tibial nerve stiffness values in the overall patient group, patients with DPN, and patients without DPN were all significantly higher than in the control group (P < .05). The cutoff value of p-SWE for assessing DPN was 2.60 m/s; at that threshold, sensitivity was 63.33%, and specificity was 92.50%.

CONCLUSIONS

Point SWE was useful for the noninvasive assessment of DPN and had high specificity. The increased stiffness in patients without DPN indicated that the tibial nerve might be affected by diabetes.

The utility of electrodiagnostic inching study and conservative treatment in supracondylar process syndrome: A case report

RATIONALE

Supracondylar process is a rare bony anomaly that can cause neurovascular symptoms. Previous reports on supracondylar process syndrome mostly suspect the condition by physical examination and simple radiograph with little assistance of electrodiagnostic methods and report efficiency of surgical treatment.

PATIENTS CONCERNS

A 45-year-old woman working at an assembly line packing boxes presented with tingling pain at her middle and ring fingers that started 2 months ago. She had positive Tinel sign at the medial side of the distal arm.

DIAGNOSIS

Electrodiagnostic inching study on median nerve was conducted and the conduction velocity at the segment between 3 cm to 5 cm proximal to the elbow crease was decreased to 27m/s. Following imaging studies revealed supracondylar process at 4.2 cm proximal to the medial epicondyle. She was successfully treated with conservative treatment.

INTERVENTIONS

Oral medications including Non-steroidal anti-inflammatory drug and pregabalin were prescribed along with superficial and deep heat modalities. The extent of manual labor was modified. Additionally, self-massage and stretching/nerve-gliding exercises were delivered.

OUTCOMES

The symptoms substantially improved and she could sleep without trouble, however, complete resolution was not achieved. After a year, she was nearly symptom-free after changing occupations with only occasional tingling after manual labor of unusual intensity.

LESSONS

This case report enlightens the versatility of electrodiagnostic inching study in localizing median neuropathy at the distal arm and the effectiveness of conservative treatment in supracondylar process syndrome.

Mimickers of Carpal Tunnel Syndrome

Carpal tunnel syndrome is the most common compression neuropathy. Despite the prevalence of carpal tunnel syndrome, many other conditions present with similar symptoms (numbness, tingling, thenar atrophy, and weakness). Carpal tunnel syndrome is differentiated from other etiologies through a detailed history and physical examination, aided by electrodiagnostic and adjunctive imaging studies. Misdiagnosis can lead to unnecessary operative procedures and persistent symptoms.

Diabetes mellitus as a risk factor for compression neuropathy: a longitudinal cohort study from southern Sweden

INTRODUCTION

Compression neuropathies (CN) in the upper extremity, the most common being carpal tunnel syndrome (CTS) and ulnar nerve entrapment (UNE), are frequent among patients with diabetes mellitus (DM). Earlier studies have shown contradicting results regarding DM as a risk factor for CN. Thus, the aim of the present population-based, longitudinal study was to explore potential associations between DM, CTS, and UNE during long-term follow-up.

RESEARCH DESIGN AND METHODS

A total of 30 466 participants aged 46-73 years, included in the population-based Malmö Diet and Cancer Study during 1991-1996, were followed up in Swedish national registries regarding incident CTS and UNE until 2016. Associations between prevalent DM at baseline and incident CTS or UNE were calculated using Cox proportional hazard models, adjusted for baseline confounders, such as sex, age at study entry, smoking, hypertension, use of antihypertensive treatment, alcohol consumption, and body mass index (BMI). HbA1c and fasting plasma glucose levels had been measured at baseline in a subgroup of 5508 participants and were related to incident CTS and UNE in age and sex-adjusted binary logistic regression models.

RESULTS

A total of 1081 participants developed CTS and 223 participants developed UNE during a median follow-up of 21 years. Participants with incident CTS or UNE had higher prevalence of DM and higher BMI at baseline. Using multivariate Cox regression models, prevalent DM at baseline was independently associated with both incident CTS (HR 2.10; 95% CI 1.65 to 2.70, p<0.0001) and incident UNE (HR 2.20; 95% CI 1.30 to 3.74, p=0.003). Higher levels of HbA1c and plasma glucose were associated with an increased risk for CTS, but not for UNE.

CONCLUSION

This study establishes DM as a major risk factor in the development of both CTS and UNE. Furthermore, a higher BMI is associated with both CTS and UNE. Finally, hyperglycemia seems to affect the median and ulnar nerves differently.

Carpal tunnel syndrome caused by thrombosed persistent median artery - A case report

Background

A rare case of carpal tunnel syndrome caused by a thrombosed persistent median artery is presented here.

Case

The diagnosis was delayed due to the overlapping cervical radiculopathy. Acute severe pain and nocturnal paresthesia were chief complaints. Ultrasonography, magnetic resonance imaging, and computed tomography angiography revealed that the median nerve was compressed by the occluded median artery. Instead of surgery, conservative therapy was tried. It worked well for six months.

Conclusions

The importance of using modalities for decision making of diagnosis and treatment is emphasized in this report.

Venous Thoracic Outlet Syndrome Caused by Double Compression of the Axillosubclavian Vein: A Case Report

Introduction

In venous thoracic outlet syndrome (VTOS), pathology around the axillosubclavian vein causes venous compression with the subsequent development of upper extremity symptoms. This case report describes the analysis of all possible compression sites and subsequent treatment of VTOS patients with multiple compression points.

Report

A 22 year old male presented with severe pain and swelling in his right arm, which persisted after a conservatively managed primary upper extremity deep vein thrombosis. Compression of the axillosubclavian vein was seen both at the level of the pectoralis minor and the costoclavicular spaces. Both compression points were successfully treated by combining thoracic outlet decompression surgery with pectoralis minor tenotomy.

Discussion

This report underlines the importance of considering the possibility of multiple compression sites in patients with VTOS. Incomplete surgical release of all compression points leaves patients prone to re-thrombosis and/or persistent post-thrombotic syndrome. Timely recognition of all abnormalities on venography may allow for adjustment of surgical treatment accordingly.