Peripheral nerve injuries in the pediatric population: a review of the literature. Part II: entrapment neuropathies

First Case of Combined Carpal and Cubital Tunnel Syndromes in an Adolescent: A Case Report and Literature Review

Carpal and cubital tunnel syndromes are the two most common compressive neuropathies, but both carpal and cubital tunnel syndromes are extremely rare in children. Therefore, the combination of carpal and cubital tunnel syndrome in the pediatric population is even more uncommon. These neuropathies have multiple causes, with the three main categories being mechanical injury, metabolic, and idiopathic. Here, we present the unique case of a 15-year-old female with no known genetic or physical risk factors who was diagnosed with atraumatic combined carpal and cubital tunnel syndrome with severe, chronic nerve entrapment and damage. After nearly two years of conservative management, the patient had a cubital tunnel and carpal tunnel release simultaneously. The transverse carpal ligament was grossly thickened intraoperatively, leading to difficulty in the identification of the median nerve. The ulnar nerve was severely compressed and flattened. Following decompression, both nerves continued to be erythematous and inflamed. After surgery, the patient had barriers to getting appropriate postoperative care. Specifically, the patient was unable to attend physical and hand therapy appointments, possibly leading to continued weakness, numbness, and intermittent pain. In our patient, the preoperative workup did not illuminate the severity of the median and ulnar nerve damage, possibly delaying surgical intervention. In addition to our case, we utilized the TriNetX database (TriNetX, Inc., Cambridge, Massachusetts, United States) to investigate the rate and treatment of compressive neuropathies in the pediatric population. The database was queried for pediatric patients who underwent carpal tunnel release, cubital tunnel release, and pediatric patients with both carpal and cubital tunnel syndrome diagnoses in childhood. We found that there were 20,819,207 pediatric patients on the TriNetX database, of whom 503 (0.002%) were diagnosed with both carpal and cubital tunnel syndrome. Based on our case and the current literature, a thorough history of pediatric patients with suspected carpal or cubital tunnel syndrome should include an evaluation of family history and activity level for pertinent risk factors. Widening the scope of the patient history could allow for more timely surgical intervention and improve long-term outcomes for the pediatric population. When evaluating children for either carpal tunnel or cubital tunnel syndrome, we recommend that healthcare providers evaluate both neuropathies simultaneously.

Peripheral nerve decompression for pain relief in the setting of previous obstetrical brachial plexus injury: a retrospective case series

PURPOSE

In children with previous obstetrical brachial plexus injury (OBPI), upper extremity pain is present in 45 to 66% of patients. Recent literature reports this as musculoskeletal or neuropathic in nature. The purpose of the study is to demonstrate that peripheral nerve decompression, and neurolysis may be an effective treatment for patients with upper extremity pain in the context of previous OBPI.

METHODS

A retrospective chart review was performed on patients undergoing peripheral nerve decompression and neurolysis after OBPI by senior author. The primary outcome assessed was pain, and secondary outcome measure was range of motion of the wrist and elbow. Outcome measures were assessed preoperatively as well as at their subsequent follow-up.

RESULTS

Six patients were included, with a mean age of 14 years old at time of decompression. Three patients underwent median nerve, two patients underwent ulnar nerve, and one patient underwent posterior interosseous nerve decompression. There was a substantial improvement in pain post-operatively, demonstrated by reduction or resolution of subjective pain in all patients and resolution of Tinel's sign. There was a modest improvement in range of motion.

CONCLUSION

This study demonstrates an improvement in subjective pain and range of motion after decompression and neurolysis in small subset of OBPI patients. It generates the hypothesis that peripheral nerve compression is a source of pain that can be addressed in this population. Future research should focus on confirming this hypothesis and assessing treatment options on a larger scale.

Pediatric Peroneal Nerve Palsy Secondary to Fibular Osteochondroma

Peripheral nerve injuries due to mass effect from bony lesions can occur when the nerve exists in an anatomically constrained location, such as the common peroneal nerve at the fibular head which passes into the tight fascia of the lateral leg compartment. We report a case of a pediatric patient who developed a common peroneal nerve palsy secondary to an osteochondroma of the fibular head and describe the clinical evaluation, radiographic findings, and surgical approach. Rapid diagnosis and nerve decompression after the onset of symptoms restored full motor function at the 8-month postoperative mark.

Carpal tunnel syndrome: updated evidence and new questions

Carpal tunnel syndrome is the most common entrapment neuropathy, affecting quality of life for many people. Although it is a well recognised condition, new insights into epidemiology, diagnosis, and treatment have emerged in the past 6 years. The availability of disease-modifying treatments for rare systemic disorders associated with carpal tunnel syndrome (eg, amyloidosis) should alert clinicians to these diagnostic possibilities. Besides clinical evaluation and electrophysiology, the role of ultrasonography as a diagnostic tool has been confirmed and new ultrasound techniques have been applied, the clinical use and feasibility of which require further investigation. Surgical and non-surgical interventions are beneficial for the treatment of carpal tunnel syndrome and several treatment options are now available, giving clinicians the possibility to choose the best approach for every patient. New diagnostic and therapeutic techniques require further validation.

Median Nerve Compression in the Distal Forearm by a Reversed Palmaris Longus Muscle in a Pediatric Patient: A Case Report

CASE

A 9-year-old girl presented with a 1-year history of volar wrist and hand pain accompanied by hand paresthesia. Magnetic resonance imaging described a superficial muscle belly in the distal forearm, compatible with a reversed palmaris longus (RPL). An initial trial of conservative treatment was unsuccessful, so the median nerve was explored in the distal forearm, with the release of the flexor retinaculum and resection of the RPL muscle belly. One year after surgery, the child had no symptoms.

CONCLUSION

To the best of our knowledge, there are only 12 reported cases of RPL, and none at such a young age or symptomatic in daily routine activities such as the case presented.

Idiopathic Pediatric Tibial Nerve Palsy

Tibial nerve entrapment is uncommon in the pediatric population, and presents diagnostic and treatment challenges. We present the unusual case of a 3-year-old male child with progressive lower leg atrophy of an unknown etiology. Preoperative electrodiagnostic testing and magnetic resonance imaging suggested proximal tibial neuropathy. Surgical exploration showed compression of the tibial nerve at the inferior fascial edge of the long head of the biceps femoris and at the soleal sling. Release and external neurolysis led to improvement of distal leg motor function.

Peripheral Nerve Compression Syndromes in Children

Nontraumatic neuropathies of the upper limb are rare in children. In this paper, we present the latest updates in this field and also critically review the diagnosis and treatment of nerve compression syndromes in children. This review describes the most common manifestations including idiopathic carpal tunnel syndrome (CTS), CTS occurring as a component of lysosomal storage diseases (mucopolysaccharidosis) and hereditary neuropathies, ulnar nerve neuropathy, and atraumatic radial nerve neuropathies.