Treatment of dysesthesia of the sensory branch of the radial nerve by distal posterior interosseous neurectomy

Outcomes Following Isolated Posterior Interosseous Nerve Neurectomy: A Systematic Review

BACKGROUND

Posterior interosseous nerve neurectomies (PINN) are an option in the treatment of chronic dorsal wrist pain. However, the literature describing PINN consists primarily of small case series, and the procedure is typically done as an adjunct treatment; therefore, the outcomes of the PINN itself are not well known. We performed a systematic review of the literature to provide characteristics of patients following a PINN.

METHODS

A systematic review of the literature was performed. Papers published in the PubMed database in English on isolated PINN were included. Articles in which a PINN was performed as an adjunct were excluded. Primary outcomes were return to work, patient satisfaction, pain/function scores, wrist range of motion, complications, and pain recurrence. Weighted averages were used to calculate continuous data, whereas categorical data were noted in percentages.

RESULTS

The search yielded 427 articles including 6 studies and 135 patients (136 cases). The average age was 43.6 years (range, 17-75), and most patients were female (54.1%). At an average final follow-up of 51 months, 88.9% of patients were able to return to work. After initial improvement, a recurrence of pain occurred in 25.5% of patients at an average of 12.3 months. Excluding recurrence of pain, the complication rate was 0.9%, including 1 reflex sympathetic dystrophy. Overall, 88.4% of patients experienced a subjective improvement and were satisfied with the procedure.

CONCLUSIONS

Isolated PINN have shown excellent clinical outcomes, with few patients experiencing recurrent pain at long-term follow-up. PINN can provide relief in patient's chronic wrist pain.

Management of painful scar-tethered cutaneous nerves of the upper limb

We report the results of treatment by division and proximal relocation of 44 painful, scar-tethered cutaneous nerves of the upper limb in 22 patients. In all patients, neuropathic pain had developed either following surgery or trauma, but without apparent direct nerve injury. The mean duration of pain symptoms prior to relocation was 17 (range 7-44) months. Adequate treatment involved relocation of 35 nerves at a first operation for each of the 22 patients, with six patients requiring further surgery to relocate 9 nerves. At a minimum follow-up of 6 months, nerve relocation resulted in complete resolution of all forms of pain at the primary site in 21/22 (95%) patients and no pain or hypersensitivity at the final relocation site in 19 of the 22 patients (86%).

The Froment-Rauber nerve: a case report and review

INTRODUCTION

The Froment-Rauber nerve is a rarely described anomalous nerve arising from 1 of the terminal branches of the radial nerve that provides innervation to intrinsic hand muscles. We describe a 26-year-old man who had a traumatic radial nerve injury that resulted in first dorsal interosseous muscle wasting. He presented to our clinic 2.5 years post-injury, after having had unnecessarily undergone surgical exploration of the ulnar nerve.

METHODS

The patient's history, clinical examination, and multiple electrodiagnostic tests were reviewed.

RESULTS

All findings were consistent with a diagnosis of anomalous innervation via a Froment-Rauber nerve.

CONCLUSIONS

Understanding this rare phenomenon may aid in diagnosing confusing clinical cases and prevent unnecessary procedures.

Proprioception of the wrist following posterior interosseous sensory neurectomy

PURPOSE

The posterior interosseous sensory nerve innervates the dorsal capsule of the wrist, which may provide nociceptive and proprioceptive sensation. Posterior interosseous sensory neurectomy (PISN) is commonly used as a primary or adjunctive procedure to provide wrist analgesia for a variety of wrist conditions. Currently, there is little information in the literature regarding the proprioceptive role of the posterior interosseous sensory nerve and the resultant effects of PISN on wrist proprioception. The purpose of our investigation was to examine the effect of PISN on wrist proprioception.

METHODS

For 23 consecutive patients who had posterior interosseous sensory neurectomy, proprioception of their surgical wrists was compared to their nonsurgical wrists as well as to the normal wrists of 23 healthy volunteers. Using a custom testing device, wooden dowels were used to set subjects' wrists at specific angles within the testing jig, and then subjects were asked to mimic the position with their other hand at the following angles: neutral (0 degrees ), flexion (20 degrees , 40 degrees , 60 degrees ), extension (20 degrees , 40 degrees , 60 degrees ), 10 degrees of radial deviation, and 10 degrees of ulnar deviation. The following statistical comparisons were made:(1) patients' surgical versus controls' assessed wrists and(2) patients' surgical wrists versus patients' nonsurgical wrists.

RESULTS

There were no statistically significant differences in wrist proprioception except in 40 degrees of extension with more accurate estimations by surgical wrists when compared to control wrists.

CONCLUSIONS

Posterior interosseous sensory neurectomy does not appear to be associated with decreased proprioception of the wrist as measured by a custom testing device.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Relocation of painful neuromas in Zone III of the hand and forearm

Painful nerves are a difficult and complex clinical problem. We describe the result of treatment by proximal relocation of 51 painful end neuromas and scarred nerves of the forearm in 33 patients. The relocated nerves included 29 superficial radial nerves, 16 lateral antebrachial cutaneous nerves, two medial cutaneous nerves and four posterior cutaneous nerves. These relocations achieved no, or only mild, pain in 100% of nerves at the original site and 94% of nerves at the relocation site. It also achieved no, or only mild, hypersensitivity in 96% of nerves at the original site and 98% of nerves at the relocation site. The technical difficulties encountered in this region, in particular on the radial aspect of the wrist, are discussed.

Neurolysis of the distal superficial radial nerve for dysaesthesia due to nerve tethering

The subcutaneous course of the superficial radial nerve over the radial border of the wrist and hand renders it very susceptible to injury. Both traumatic and iatrogenic injury can produce tethering of this nerve, presenting as dysaesthesia. This study was designed to evaluate the efficacy of neurolysis of the distal superficial radial nerve for this condition. Twenty-five cases of tethered superficial radial nerves underwent neurolysis. At final follow-up (mean 3.5 years), fourteen cases reported symptomatic resolution while eleven continued to experience dysaesthesia. Intra-operatively, evidence of external abnormality, scarring, or compression was identified in only six cases, and its presence did not correlate with symptomatic outcome. Although the majority of patients were improved postoperatively, the success rate was lower than anticipated. Therefore, while neurolysis of the superficial radial nerve offers the opportunity for pain relief, it does not reliably produce success.

Relocation of neuromas of the lateral antebrachial cutaneous nerve of the forearm into the brachialis muscle

Painful neuromas following injury to the radial side of the wrist can be treated by relocation away from the zone of injury and implantation into muscle. Relocation to the brachialis muscle is useful for isolated neuromas of the lateral antebrachial cutaneous nerve and involves a shorter dissection than relocation to the brachioradialis. It is also useful in patients undergoing multiple procedures to avoid disturbing previous relocations to the brachioradialis. This paper describes the successful relocation of painful neuromas of the lateral antebrachial cutaneous nerve to the brachialis muscle in seven patients.

[Is surgery likely to be successful as a treatment for traumatic lesions of the superficial radial nerve?]

In the last 10 years 22 patients with lesions of the superficial branch of the radial nerve have been treated surgically in our neurosurgical department. The patients' main complaints were burning pain and paraesthesia in the region supplied by the superficial branch of the radial nerve. In most cases the lesion was due to tendolysis performed earlier to treat de Quervain tendovaginitis stenosans. In 8 cases external neurolysis was done with conservation of continuity; in 4 cases the nerve was reconstructed after resection of the neuroma (end-to-end-suture or implantation of a vicryl conduit); and in 10 cases the neuroma was resected and transposition of the proximal nerve end was performed. Nineteen patients were available for evaluation of the postoperative results, after an average follow-up of 51 months. Surprisingly, only 5 reported good subjective improvement of pain after surgery. Seven patients reported an unchanged status postoperatively, and in 1 case the pain was even worse after the surgical intervention. Satisfactory results (complete or partial pain relief in 75% of cases) was found to have been achieved in the subgroup of patients treated by resection of the neuroma of the superficial branch of the radial nerve and transposition of the nerve stump. In conclusion, we recommend caution when surgical interventions are considered for traumatic lesions of the superficial radial nerve, because the prospects of success are limited. In addition, we do not consider nerve reconstruction desirable in these circumstances.

The accuracy of distal posterior interosseous and anterior interosseous nerve injection

PURPOSE

To standardize a technique of delivering a local anesthetic to the posterior interosseous nerve (PIN) and anterior interosseous nerve (AIN) by using the anatomic landmarks of the wrist and to evaluate the accuracy of the technique in a cadaver model.

METHODS

Techniques for PIN and AIN injection and for PIN injection alone are described. Techniques were tested in a fresh frozen cadaver model by using methylene blue injections. Stained nerves were dissected under loupe magnification. Digital photographic images were taken of each nerve. Staining was quantified by calculating the mean density and area stained.

RESULTS

For both techniques methylene blue was delivered accurately to the PIN in 100% of the samples. Methylene blue was delivered accurately to the AIN in 100% of samples in which it was injected.

CONCLUSIONS

These techniques saturated successfully the PIN and AIN and may be useful as diagnostic and therapeutic tools for chronic wrist pain and in evaluating presurgically the effectiveness of partial wrist denervation.

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.

Surgical management and outcome in patients with radial nerve lesions

OBJECT

The goal of this paper was to review surgical management and outcomes in patients treated for radial nerve (RN) lesions at Louisiana State University Health Sciences over a period of 30 years.

METHODS

Two hundred sixty patients with RN injuries were evaluated. The most common mechanisms of injuries involving the RN included fracture of the humerus, laceration, blunt contusions, and gunshot wounds. One hundred and eighty patients (69%) underwent surgery. Lesions not in continuity required primary or secondary end-to-end suture repairs or graft repairs. With the use of direct intraoperative nerve action potential recording, RN injuries in which the lesion was in continuity required external or internal neurolysis or resection of the lesion followed by end-to-end suture or graft repair. A minimum of 1.5 years follow-up review was available in 90% of the patients who underwent surgery. Motor function recovery to Grade 3 or better was observed in 10 (91%) of 11 patients who underwent primary suture repair, 25 (83%) of 30 who underwent secondary suture repair, 43 (80%) of 54 who received graft repair, and 63 (98%) of 64 in whom neurolysis was performed. Sixteen (71%) of 21 patients with superficial sensory RN injury achieved satisfactory pain relief after complete resection of a neuroma or neurolysis.

CONCLUSIONS

This study clearly demonstrates that excellent functional recovery can be achieved with proper surgical management of RN injuries.

The anatomy of the posterior interosseous nerve as a graft

Thirty upper limbs from skeletally mature embalmed cadavers were studied to determine the anatomic reliability of the posterior interosseous nerve as a donor nerve graft. The posterior interosseous nerve branches 0.43 +/- 0.52 cm from the distal edge of the superficial head of the supinator and 8 +/- 1.6 cm from the lateral epicondyle form a common leash. There are 6 branches, which are arranged from the ulnar to the radial side at their origin from this leash. The first and second branches supply the extensor digitorum communis, the third branch supplies the extensor carpi ulnaris, the fourth branch supplies the extensor digiti minimi, and the fifth branch arises from the undersurface of the common leash and divides into 2 sub-branches (medial and lateral) 10.1 +/- 3.2 cm distal to the lateral epicondyle and 12.8 +/- 2.2 cm proximal to Lister's tubercle. These 2 sub-branches make an inverted V shape around the extensor pollicis longus. The medial branch supplies the extensor pollicis longus and extensor indicis proprius. The lateral branch supplies the extensor pollicis longus and extensor pollicis brevis and ends at the wrist capsule. At a mean distance of 8.1 +/- 1.2 cm proximal to Lister's tubercle the lateral sub-branch gives off its last muscular branch to the extensor pollicis longus and becomes a pure sensory terminus. As the terminal part of the lateral sub-branch approaches the wrist capsule it expands at a mean distance of 1.9 +/- 0.5 cm proximal to Lister's tubercle. The sixth branch arises from the radial side of the common leash and divides into 3 sub-branches. The first sub-branch supplies the abductor pollicis longus and extensor pollicis brevis, the second supplies the abductor pollicis longus, and the third supplies the superficial head of the supinator. This study showed that the mean length obtainable for harvesting the lateral sub-branch of the fifth branch of the posterior interosseous nerve is 6.2 +/- 0.7 cm, which represents the length of the nerve between the last muscular branch to the extensor pollicis longus to the point at which the nerve expands.

Release of ulnar nerve compression at the elbow through a transverse incision

The purpose of this study was to modify the classical longitudinal skin incision to avoid injury to the cutaneous nerve branches on the medial side of the elbow when a surgical release of the ulnar nerve was performed. Injury to the medial antebrachial cutaneous nerve is not a rare complication after release of the ulnar nerve at the elbow. This will leave an area of hyposthesia on the posteromedial aspect of the proximal forearm, to which the patient will usually get accustomed. Some patients may have an area of skin dysesthesia and a painful amputation neuroma requiring surgical treatment. To avoid these complications and yet to obtain adequate exposure for ulnar nerve release, we have used a transverse incision in 20 patients without any sequelae of hyposthesia or amputation neuromas and have attained a far superior esthetic result.

Radial tunnel syndrome. A retrospective review of 30 decompressions of the radial nerve

Radial tunnel syndrome results from compression of the radial nerve by the free edge of the supinator muscle or closely related structures in the vicinity of the elbow joint. Despite numerous reports on the surgical management of this disorder, it remains largely unrecognized and often neglected. The symptoms of radial tunnel syndrome can resemble those of tennis elbow, chronic wrist pain or tenosynovitis. Reliable objective criteria are not available to differentiate between these pathologies. These difficulties are discussed in relation to 29 patients who underwent 30 primary explorations and proximal decompressions of the radial nerve. Excellent or good results were obtained in 70%, fair results in 13% and poor results in 17% of patients. The results can be satisfactory despite the prolonged duration of symptoms. We believe that a diagnosis of radial tunnel syndrome should always be born in mind when dealing with patients with forearm and wrist pain that has not responded to more conventional treatment. Patients with occupations requiring repetitive manual tasks seem to be particularly at risk of developing radial tunnel syndrome and it is also interesting to note that 66% of patients with on-going medico-legal claims had successful outcomes following surgery.

The terminal branch of posterior interosseous nerve: a useful donor for digital nerve grafting

The anatomical relationships of the terminal branch of posterior interosseous nerve have been studied in 57 cadaver and amputation specimens. Removal of the nerve leaves the patient with no apparent sensory deficit. In all dissections the nerve was present and its location was constant. The mean obtainable length was 3.7 cm (range 2.7-5.1 cm) and its cross-sectional area made the nerve suitable for grafting of digital nerves.

[Neuritis and neuroma of the sensory branches of the radial nerve. Apropos of 44 cases]

The authors present a series of 44 cases of sensory disorders in the radial nerve territory. Eighteen cases of pure painful neuromata gave, excellent results according to Herndon criteria in 11 cases with various techniques. Wartenberg neuritis (22 cases) was found to respond favorably to conservative treatment in the majority of cases (19 cases). A legal problem can arise from association with De Quervain disease if the condition has not been recognized before surgical release of the first compartment. Finally 9 cases are presented with intricate pathology of neuroma plus neuritis. Treatment addressing both conditions provided good results.