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Christy M, Dy CJ. Optimizing Outcomes in Revision Peripheral Nerve Surgery of the Upper Extremity. Clin Plast Surg 2024; 51:459-472. [PMID: 39216933 DOI: 10.1016/j.cps.2024.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
Peripheral nerve surgeries for compressive neuropathy in the upper extremity are generally successful. However, cases that either fail or have complications requiring revision surgery are challenging. During revision consideration, surgeons should perform a comprehensive preoperative workup to understand the etiology of the patient's symptoms and categorize symptoms as persistent, recurrent, or new in relation to the index procedure. Revision surgery often requires an open, extensile approach with additional procedures to optimize outcomes. Even with proper workup and treatment, clinical outcomes of revision surgeries are inferior compared to primary surgeries and patients should be well informed prior to undergoing such procedures.
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Affiliation(s)
- Michele Christy
- Department of Orthopaedic Surgery, Washington University in St. Louis, 660 South Euclid Avenue, Campus Box 8233, St Louis, MO 63110, USA
| | - Christopher J Dy
- Department of Orthopaedic Surgery, Washington University in St. Louis, 660 South Euclid Avenue, Campus Box 8233, St Louis, MO 63110, USA.
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Dibbs RP, Ali K, Sarrami SM, Koshy JC. Revision Peripheral Nerve Surgery of the Upper Extremity. Semin Plast Surg 2021; 35:119-129. [PMID: 34121947 DOI: 10.1055/s-0041-1727290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Peripheral nerve injuries of the upper extremity can result from a wide array of etiologies, with the two most common being compression neuropathy and traumatic injuries. These types of injuries are common and can be psychologically, functionally, and financially devastating to the patient. A detailed preoperative evaluation is imperative for appropriate management. Traumatic injuries can typically be treated with local burial techniques, targeted muscle reinnervation, and regenerative peripheral nerve interfaces. Median nerve compression is frequently managed with complete release of the antebrachial fascia/transverse carpal ligament and/or use of flap coverage such as the hypothenar fat pad flap and local muscle flaps. Ulnar nerve compression is commonly managed via submuscular transposition, subcutaneous transposition, neurolysis, and nerve wrapping. In this review, we discuss the preoperative evaluation, surgical techniques, and advantages and disadvantages of each treatment modality for patients with compressive and traumatic upper extremity nerve injuries.
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Affiliation(s)
- Rami P Dibbs
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Division of Plastic Surgery, Texas Children's Hospital, Texas
| | - Kausar Ali
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Division of Plastic Surgery, Texas Children's Hospital, Texas
| | - Shayan M Sarrami
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Division of Plastic Surgery, Texas Children's Hospital, Texas
| | - John C Koshy
- Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Division of Plastic Surgery, Texas Children's Hospital, Texas
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Zare M, Faeghi F, Hosseini A, Ardekani MS, Heidari MH, Zarei E. Comparison Between Three-Dimensional Diffusion-Weighted PSIF Technique and Routine Imaging Sequences in Evaluation of Peripheral Nerves in Healthy People. Basic Clin Neurosci 2018; 9:65-71. [PMID: 29942442 PMCID: PMC6015634 DOI: 10.29252/nirp.bcn.9.1.65] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Introduction: The present study aims to evaluate the Three-Dimensional Diffusion-Weighted reversed fast imaging with steady state free precession (3D DW-PSIF) sequence with respect to imaging of the peripheral nerves; the tibial, medial, and lateral plantar nerves in the lower extremity, ulnar and median nerve in the upper extremity, sciatic nerve, brachial plexus, and lumbosacral plexus, and also to compare its usefulness with the current two-dimensional sequences on a 1.5 T MR scanner. Methods: A total of 25 healthy subjects underwent MR imaging of peripheral nerves, 5 subjects in each area. In each imaging sequence, including T2W SPAIR and 3D DW-PSIF, images were evaluated for ability to identify the nerves in the related area using a 3-score scale (0–2). Then, by summing up the conspicuity scores, a total certainty score was recorded for each sequence. Results: With combining the results of all studies, the conspicuity mean (SD) score was 1.57(0.67) on the 3D DW-PSIF images, and 0.74(0.76) on the T2-weighted images (P<0.001). Regarding the lumbosacral plexus, the corresponding certainty mean (SD) scores were 1.80(0.40) and 1.07(0.74) (P<0.001) and with regard to the brachial plexus, they were 1.23(0.83) and 0.75(0.84), (P<0.001). Regarding the ankle/hind foot they were 1.87(0.35) and 0.40(0.50) (P<0.001) and in the wrist/proximal hand, 1.70(0.48) and 0.50(0.52) (P<0.001). Regarding the sciatic nerve, they were 1.80(0.44) and 0.20(0.44) (P=0.003). Conclusion: 3D DW PSIF provides better manifestation of nerves compared to routine imaging sequences particularly fat saturated T2W images. This novel imaging technique can be used in MR neurography examination protocol for exact localization of the nerve and evaluation of the nerve pathology.
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Affiliation(s)
- Mahsa Zare
- Department of Radiology Technology, School of Allied Medical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Fariborz Faeghi
- Department of Radiology Technology, School of Allied Medical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ashrafsadat Hosseini
- Department of Radiology, Shahid Sadoughi Hospital, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Mohammad Sobhan Ardekani
- Department of Radiology, Shahid Sadoughi Hospital, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Mohammad Hossein Heidari
- Department of Basic Sciences, School of Allied Medical Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Ehsan Zarei
- Department of Physical Education, School of Education & Psychology, Shiraz University, Shiraz, Iran
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Kowalska B. Assessment of the utility of ultrasonography with high-frequency transducers in the diagnosis of entrapment neuropathies. J Ultrason 2014; 14:371-92. [PMID: 26674099 PMCID: PMC4579721 DOI: 10.15557/jou.2014.0039] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2014] [Revised: 10/20/2014] [Accepted: 11/28/2014] [Indexed: 01/10/2023] Open
Abstract
The primary aim of this paper was to assess the relevance of high-frequency ultra-sound examination in qualifying patients for either surgical or conservative treatment of peripheral entrapment neuropathies. The study was conducted in a group of 55 patients aged 7–83 (mean age 43.6), including 28 males and 27 females, who in 2009–2011 were referred to an ultrasound examination due to a clinical suspicion of entrapment neuropathies. For the purposes of the analysis, the patients were divided into four groups: carpal tunnel syndrome (1), ulnar nerve entrapment (2) (cubital tunnel syndrome and Guyon's canal syndrome), posterior interosseous nerve syndrome (3) and other entrapment neuropathies (4). The cases of isolated idiopathic carpal tunnel syndrome were excluded from the analysis. All patients underwent the interview, physical examination and ultrasound examination. Ultrasound examinations were performed with Esaote MyLab 50 and MyLab 60 systems using high-frequency broadband linear transducers: 6–18 MHz. Sixty-seven percent of patients (37 persons) underwent a neurophysiological test. Nerve echostructure, its hyperemia as well as nerve cross-sectional area or, in the case of small nerves, diameter were assessed in all patients. Furthermore, the following were assessed in individual groups: notch sign in group 1, nerve instability in a dynamic ultrasound examination in group 2, nerve angulation in a dynamic ultrasound examination and tenderness on nerve compression at the site of the visualized pathology in group 3. The analyses of the collected material were performed by means of descriptive statistics. The results of clinical and surgical verification were consistent with ultrasound findings in 96.4%. The results indicate that high-frequency ultrasonography is a valuable method in qualifying patients for various types of treatment of peripheral neuropathies resulting from compression.
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Affiliation(s)
- Berta Kowalska
- Private Specialist Practice Berta Kowalska, Cracow, Poland
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Gerding AL, Fox TB, Lown L, Needleman L. Nerve Hematoma Mimicking DVT. JOURNAL OF DIAGNOSTIC MEDICAL SONOGRAPHY 2013. [DOI: 10.1177/8756479313493007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This case study describes a patient who underwent an upper extremity venous examination to evaluate for possible deep vein thrombosis (DVT). Sonography showed no evidence of thrombus in the veins of the deep or superficial system. Adjacent to the veins of the peripheral arm, however, an enlarged hypoechoic structure was visualized that had a very similar appearance to DVT. With further imaging, hyperechoic linear bands were visualized at the proximal end of the hypoechoic structure. The appearance suggested that this structure was related to the median nerve, but its normal appearance was altered by a large mass inside the nerve sheath. Given the patient’s history, the finding most likely represents a nerve hematoma.
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Affiliation(s)
| | - Traci B. Fox
- Thomas Jefferson University Hospital, Trenton, NJ, USA
| | - Lauren Lown
- Thomas Jefferson University Hospital, Trenton, NJ, USA
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Chhabra A, Soldatos T, Subhawong TK, Machado AJ, Thawait SK, Wang KC, Padua A, Flammang AJ, Williams EH, Carrino JA. The application of three-dimensional diffusion-weighted PSIF technique in peripheral nerve imaging of the distal extremities. J Magn Reson Imaging 2011; 34:962-7. [PMID: 21769979 DOI: 10.1002/jmri.22684] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2010] [Accepted: 05/23/2011] [Indexed: 11/08/2022] Open
Affiliation(s)
- Avneesh Chhabra
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Hospital, Baltimore, Maryland 21287, USA.
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High-Resolution MR Neurography: Evaluation Before Repeat Tarsal Tunnel Surgery. AJR Am J Roentgenol 2011; 197:175-83. [DOI: 10.2214/ajr.10.5763] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Bales JG, Meals R. Peripheral neuropathy of the upper extremity: medical comorbidity that confounds common orthopedic pathology. Orthopedics 2009; 32:orthopedics.44024. [PMID: 19824582 DOI: 10.3928/01477447-20090818-19] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
In the orthopedic patient, the diagnosis of a compression neuropathy may be straightforward. However, various medical comorbidities can obscure this diagnosis. It is paramount for the practicing orthopedic surgeon to have an appreciation for the medical pathology of common axonal neuropathies to properly diagnose, treat, and refer a patient with altered sensation in the upper extremity. The prevalence of diabetes in the United States is 10%, and roughly 20% of diabetic patients have peripheral neuropathy. In addition to diabetes, 32% of heavy alcohol users present with polyneuropathy. With advancements in the treatment of human immunodeficiency virus/acquired immunodeficiency syndrome clinicians may see the long-term effects of the virus manifested as axonal neuropathies and extreme allodynia. In some regions of the world, Hansen's disease usurps diabetes as the most common cause of polyneuropathy. Based on patient demographics and social habits, Lyme disease, multiple sclerosis, and syphilis can all manifest as polyneuropathies. Understanding the common medical causes of neuropathy will aid the orthopedic surgeon in differentiating simple compression neuropathies from diseases mimicking or confounding them.
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Affiliation(s)
- Joshua G Bales
- Department of Orthopedics, University of California at Los Angeles, CA 90095, USA
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Focal nerve inflammation induces neuronal signs consistent with symptoms of early complex regional pain syndromes. Exp Neurol 2009; 219:223-7. [DOI: 10.1016/j.expneurol.2009.05.024] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2009] [Revised: 05/15/2009] [Accepted: 05/18/2009] [Indexed: 12/25/2022]
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Pastare D, Therimadasamy AK, Lee E, Wilder-Smith EP. Sonography versus nerve conduction studies in patients referred with a clinical diagnosis of carpal tunnel syndrome. JOURNAL OF CLINICAL ULTRASOUND : JCU 2009; 37:389-393. [PMID: 19479718 DOI: 10.1002/jcu.20601] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
PURPOSE To compare the diagnostic value of high-resolution ultrasound (US) with nerve conduction studies (NCS) in patients with clinically defined carpal tunnel syndrome (CTS). METHODS A prospective study was conducted on 66 consecutive patients investigated for sensory hand symptoms. The gold standard was the clinical diagnosis of CTS. RESULTS NCS showed greater diagnostic sensitivity (82%) than US (62%) in supporting a diagnosis of CTS. With increasing neurophysiologic severity of median neuropathy, there was increasing convergence of the two test methods. Abnormal US as the only diagnostic supportive evidence of CTS was rare. However, the positive predictive value of US for CTS was 100%. CONCLUSION NCS show better sensitivity than US in supporting a diagnosis of CTS. However, because of its high positive predictive value, one may consider using US as a screening test, eliminating the need for NCS in the majority of clinical suspicion of CTS and reserving NCS for cases in which US is negative.
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Affiliation(s)
- D Pastare
- Neurology, National University Health Systems, 5 Lower Kent Ridge Road, 119074, Singapore
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Toros T, Karabay N, Ozaksar K, Sugun TS, Kayalar M, Bal E. Evaluation of peripheral nerves of the upper limb with ultrasonography: a comparison of ultrasonographic examination and the intra-operative findings. ACTA ACUST UNITED AC 2009; 91:762-5. [PMID: 19483229 DOI: 10.1302/0301-620x.91b6.22284] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We prospectively studied 26 consecutive patients with clinically documented sensory or motor deficiency of a peripheral nerve due to trauma or entrapment using ultrasound, and in 19 cases surgical exploration of the nerves was undertaken. The ultrasonographic diagnoses were correlated with neurological examination and the surgical findings. Reliable visualisation of injured nerves on ultrasonography was achieved in all patients. Axonal swelling and hypoechogenity of the nerve was diagnosed in 15 cases, loss of continuity of a nerve bundle in 17, the formation of a neuroma of a stump in six, and partial laceration of a nerve with loss of the normal fascicular pattern in five. The ultrasonographic findings were confirmed at operation in those who had surgery. Ultrasound may be used for the evaluation of peripheral nerve injuries in the upper limb. High-resolution ultrasound can show the exact location, extent and type of lesion, yielding important information that might not be obtainable by other diagnostic aids.
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Affiliation(s)
- T Toros
- Hand and Microsurgery Hospital, Kahramanlar-Izmir, Turkey.
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