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Özdemir A, Güleç A, Yurteri A, Odabaşı E, Acar MA. Effect of pronator teres muscle botulinum neurotoxin type-A injection on proximal median nerve entrapment. HAND SURGERY & REHABILITATION 2024; 43:101604. [PMID: 37797787 DOI: 10.1016/j.hansur.2023.09.371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 09/22/2023] [Accepted: 09/25/2023] [Indexed: 10/07/2023]
Abstract
PURPOSE We aimed to evaluate the effect of botulinum neurotoxin type-A (Btx-A) injection into the pronator teres muscle in proximal median nerve entrapment (PMNE). METHODS Intramuscular injection of 30 IU Btx-A into the pronator teres muscle was performed in 12 patients (14 extremities) diagnosed with PMNE. The injection was made under nerve stimulator control. One patient with thoracic outlet syndrome was excluded from the study and not included in the clinical evaluation. Grip and pinch strength, 2-point discrimination, Q-DASH score, and pain on VAS were evaluated and compared before and 6-8 months after injection. The patients were contacted again by phone after the first and fifth years and asked about PMNE symptomatology. RESULTS None of the patients had complications. No significant difference in pinch strength was observed following Btx-A injection, but there was significant improvement in grip strength, 2-point discrimination, and Q-DASH and VAS pain scores. CONCLUSION The outcomes of our study were promising: Btx-A injection improved symptoms in patients with PMNE. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Ali Özdemir
- Selcuk University Department of Orthopedics and Traumatology, Hand Surgery Department Akademi Mahallesi, Celal Bayar Cd. No:313, 42130 Selçuklu/Konya, Turkey.
| | - Ali Güleç
- Selcuk University Department of Orthopedics and Traumatology, Akademi Mahallesi, Celal Bayar Cd. No:313, 42130 Selçuklu/Konya, Turkey.
| | - Ahmet Yurteri
- Konya City Training And Researh Hospital, Akabe, Adana Çevre Yolu Cd. No:135/1, 42020 Karatay/Konya, Turkey.
| | - Egemen Odabaşı
- Beyhekim Training and Research Hospital, Beyhekim Mahallesi Devlethane Sokak No:2/C, Selçuklu/Konya, Turkey.
| | - Mehmet Ali Acar
- Selcuk University Department of Orthopedics and Traumatology, Hand Surgery Department Akademi Mahallesi, Celal Bayar Cd. No:313, 42130 Selçuklu/Konya, Turkey.
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Kong G, Brutus JP, Vo TT, Hagert E. The prevalence of double- and multiple crush syndromes in patients surgically treated for peripheral nerve compression in the upper limb. HAND SURGERY & REHABILITATION 2023; 42:475-481. [PMID: 37714514 DOI: 10.1016/j.hansur.2023.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 09/04/2023] [Accepted: 09/09/2023] [Indexed: 09/17/2023]
Abstract
OBJECTIVE The double crush syndrome describes a condition characterized by multifocal entrapment of a nerve. In the upper limb, the high prevalence of carpal tunnel syndrome makes it a common diagnosis of assumption in the setting of median neuropathy. More proximal compressions may tend to be overlooked, under-diagnosed and under-treated in the population. This study aims to map the prevalence of peripheral upper limb nerve compressions among patients undergoing peripheral nerve decompression. METHODS A prospective case series was conducted on 183 patients undergoing peripheral nerve decompression in a private hand surgery clinic. Level(s) of nerve compression in the median, ulnar and radial nerves were determined by history and physical examination. The prevalence of each nerve compression syndrome or combination of syndromes was analyzed. RESULTS A total of 320 upper limbs in 183 patients were analyzed. A double crush of the median nerve at the levels of the lacertus fibrosus and carpal tunnel was identified in 78% of upper limbs with median neuropathy, whereas isolated lacertus syndrome and carpal tunnel syndrome were present in only 5% and 17% of affected limbs respectively. Cubital tunnel syndrome affected 12.5% of upper limbs, and 80% of these had concomitant lacertus and carpal tunnel syndromes, compared to only 7.5% with isolated cubital tunnel syndrome. CONCLUSION A high prevalence should prompt clinicians towards more routine assessment for double crush syndrome to avoid misdiagnosis, inadequate treatment, recurrence, and revision surgeries.
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Affiliation(s)
- Geraldine Kong
- Hamad Medical Corporation, Dept. of Orthopedic Surgery, Doha, Qatar
| | | | | | - Elisabet Hagert
- Aspetar Orthopaedic and Sports Medicine Hospital, Doha, Qatar; Karolinska Institutet, Dept. of Clinical Science and Education, Sodersjukhuset, Stockholm, Sweden
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Hagert E, Jedeskog U, Hagert CG, Marín Fermín T. Lacertus syndrome: a ten year analysis of two hundred and seventy five minimally invasive surgical decompressions of median nerve entrapment at the elbow. INTERNATIONAL ORTHOPAEDICS 2023; 47:1005-1011. [PMID: 36757413 PMCID: PMC10014674 DOI: 10.1007/s00264-023-05709-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 01/23/2023] [Indexed: 02/10/2023]
Abstract
PURPOSE This study aims to assess the clinical presentation and surgical outcomes of lacertus syndrome (LS) and concomitant median nerve entrapments. METHODS A retrospective study of prospectively collected data was conducted on patients undergoing lacertus release (LR) from June 2012 to June 2021. Available DASH (Disability of the Arm Shoulder Hand questionnaire) scores and post-operative Visual Analogue Scale (VAS) of pain, numbness, subjective satisfaction with surgical outcome, and intra-operative return of strength were analyzed. RESULTS Two-hundred-seventy-five surgical cases were identified of which 205 cases (74.5%) underwent isolated LR, and 69 cases (25.1%) concomitant lacertus and carpal tunnel release. The three most common presenting symptoms in LS patients were loss of hand strength (95.6%), loss of hand endurance/fatigue (73.3%), and forearm pain (35.4%). Numbness in the median nerve territory of the hand was found in all patients with combined LS and carpal tunnel syndrome. Quick-DASH significantly improved (pre-operative 34.4 (range 2.3-84.1) to post-operative 12.4 (range 0-62.5), p < 0.0001) as did work and activity DASH (p < 0.0001). The postoperative VAS scores were pain VAS 1.9 and numbness VAS 1.8. Eighty-eight percent of patients reported good/excellent satisfaction with the surgical outcome. Intra-operative return of strength was verified in 99.2% of cases. CONCLUSION LS is a common median nerve compression syndrome typically presenting with loss of hand strength and hand endurance/fatigue. Minimally invasive LR immediately restores hand strength, significantly improves DASH scores, and yields positive outcomes regarding VAS pain, numbness, and subjective satisfaction with surgery in patients with proximal median nerve entrapment at a minimum six month follow-up.
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Affiliation(s)
- Elisabet Hagert
- Aspetar Orthopaedic and Sports Medicine Hospital, Sports City Street, Inside Aspire Zone, Al Buwairda St, 29222, Doha, Qatar.
- Dept of Clinical Science and Education, Karolinska Institutet, Sodersjukhuset, Stockholm, Sweden.
| | | | | | - Theodorakys Marín Fermín
- Aspetar Orthopaedic and Sports Medicine Hospital, Sports City Street, Inside Aspire Zone, Al Buwairda St, 29222, Doha, Qatar
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Cline JA, Frantz LM, Adams JM, Hearon BF. Experience With Proximal Median Nerve Entrapment by the Lacertus Fibrosus. Hand (N Y) 2023:15589447231153233. [PMID: 36859808 DOI: 10.1177/15589447231153233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/03/2023]
Abstract
BACKGROUND Unconscious bias of the clinician favors the diagnosis of carpal tunnel syndrome (CTS) in patients with median paresthesia. We hypothesized that more patients in this cohort would be diagnosed with proximal median nerve entrapment (PMNE) by strengthening our cognitive awareness of this alternative diagnosis. We also hypothesized that patients with PMNE may be successfully treated with surgical release of the lacertus fibrosus (LF). METHODS In this retrospective study, cases of median nerve decompression at the carpal tunnel and in the proximal forearm for the 2-year periods before and after adopting strategies to mitigate cognitive bias for CTS were enumerated. Patients diagnosed with PMNE and treated by LF release under local anesthesia were evaluated to determine surgical outcome at minimum 2-year follow-up. Primary outcome measures were changes in preoperative median paresthesia and proximal median-innervated muscle strength. RESULTS There was a statistically significant increase in PMNE cases identified after our heightened surveillance was initiated (z = 3.433, P < .001). In 10 of 12 cases, the patient had previous ipsilateral open carpal tunnel release (CTR) but experienced recurrent median paresthesia. In 8 cases evaluated an average of 5 years after LF release, there was improvement in median paresthesia and resolution of median-innervated muscle weakness. CONCLUSIONS Owing to cognitive bias, some patients with PMNE may be misdiagnosed with CTS. All patients with median paresthesia, particularly those with persistent or recurrent symptoms after CTR, should be assessed for PMNE. Surgical release limited to the LF may be an effective treatment for PMNE.
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Affiliation(s)
- Justin A Cline
- The University of Kansas School of Medicine, Wichita, KS, USA
| | - Lisa M Frantz
- The University of Kansas School of Medicine, Wichita, KS, USA
| | | | - Bernard F Hearon
- The University of Kansas School of Medicine, Wichita, KS, USA
- Advanced Orthopaedics Associates, Wichita, KS, USA
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How to Differentiate Pronator Syndrome from Carpal Tunnel Syndrome: A Comprehensive Clinical Comparison. Diagnostics (Basel) 2022; 12:diagnostics12102433. [PMID: 36292122 PMCID: PMC9600501 DOI: 10.3390/diagnostics12102433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 09/27/2022] [Accepted: 09/28/2022] [Indexed: 11/17/2022] Open
Abstract
The diagnostic process that allows pronator syndrome to be differentiated reliably from carpal tunnel syndrome remains a challenge for clinicians, as evidenced by the most common cause of pronator syndrome misdiagnosis: carpal tunnel syndrome. Pronator syndrome can be caused by compression of the median nerve as it passes through the anatomical structures of the forearm, while carpal tunnel syndrome refers to one particular topographic area within which compression occurs, the carpal tunnel. The present narrative review is a complex clinical comparison of the two syndromes with their anatomical backgrounds involving topographical relationships, morphology, clinical picture, differential diagnosis, and therapeutic options. It discusses the most frequently used diagnostic techniques and their correct interpretations. Its main goal is to provide an up-to-date picture of the current understanding of the disease processes and their etiologies, to establish an appropriate diagnosis, and introduce relevant treatment benefiting the patient.
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Löppönen P, Hulkkonen S, Ryhänen J. Proximal Median Nerve Compression in the Differential Diagnosis of Carpal Tunnel Syndrome. J Clin Med 2022; 11:3988. [PMID: 35887752 PMCID: PMC9317082 DOI: 10.3390/jcm11143988] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 06/28/2022] [Accepted: 07/05/2022] [Indexed: 12/04/2022] Open
Abstract
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.
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Affiliation(s)
- Pekka Löppönen
- Department of Orthopedics and Traumatology, Seinäjoki Central Hospital, FI-60220 Seinäjoki, Finland
| | - Sina Hulkkonen
- Department of Hand Surgery, Helsinki University Hospital, University of Helsinki, FI-00029 Helsinki, Finland; (S.H.); (J.R.)
| | - Jorma Ryhänen
- Department of Hand Surgery, Helsinki University Hospital, University of Helsinki, FI-00029 Helsinki, Finland; (S.H.); (J.R.)
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Harhaus L, Daeschler SC, Aman M, Böcker AH, Klimitz F, Bickert B. [Differential therapeutic Approaches in Treatment of Carpal Tunnel Syndrome]. HANDCHIR MIKROCHIR P 2022; 54:236-243. [PMID: 35688431 DOI: 10.1055/a-1839-8297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Carpal tunnel syndrome (CTS) is one of the most common compression neuropathies. The therapeutic concept should be tailored to each patient individually, with initial non-surgical treatment being the standard of care for early CTS. Primary surgical intervention should be considered in more advanced diseases stages, in case of concomitant pathologies (including space-occupying lesions, complex regional pain syndrome or diabetic neuropathy), if non-surgical strategies have failed or in pregnancy-related CTS. This work aims to discuss common surgical approaches, their clinical application as well as benefits and disadvantages in a pragmatic style. Further, we highlight surgical strategies to address recurrent CTS following failed primary surgery. In view of the recently updated S3 guidelines "Diagnosis and Therapy of Carpal Tunnel Syndrome", this topic is timely and relevant for hand and nerve surgeons.
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Affiliation(s)
- Leila Harhaus
- BG Unfallklinik Ludwigshafen Klinik für Hand-, Plastische und Rekonstruktive Chirurgie, Schwerbrandverletztenzentrum, Klinik für Plastische Chirurgie der Universität Heidelberg
| | - Simeon C Daeschler
- BG Unfallklinik Ludwigshafen Klinik für Hand-, Plastische und Rekonstruktive Chirurgie, Schwerbrandverletztenzentrum, Klinik für Plastische Chirurgie der Universität Heidelberg
| | - Martin Aman
- BG Unfallklinik Ludwigshafen Klinik für Hand-, Plastische und Rekonstruktive Chirurgie, Schwerbrandverletztenzentrum, Klinik für Plastische Chirurgie der Universität Heidelberg
| | - Arne Hendrik Böcker
- BG Unfallklinik Ludwigshafen Klinik für Hand-, Plastische und Rekonstruktive Chirurgie, Schwerbrandverletztenzentrum, Klinik für Plastische Chirurgie der Universität Heidelberg
| | - Felix Klimitz
- BG Unfallklinik Ludwigshafen Klinik für Hand-, Plastische und Rekonstruktive Chirurgie, Schwerbrandverletztenzentrum, Klinik für Plastische Chirurgie der Universität Heidelberg
| | - Berthold Bickert
- BG Unfallklinik Ludwigshafen Klinik für Hand-, Plastische und Rekonstruktive Chirurgie, Schwerbrandverletztenzentrum, Klinik für Plastische Chirurgie der Universität Heidelberg
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Mozaffarian K, Amini A, Farpour HR, Mozaffarian D. Is Carpal Tunnel Release an Effective Treatment for Patients with Suspected Concurrent Carpal Tunnel and Pronator Syndrome? J Hand Surg Asian Pac Vol 2022; 27:256-260. [PMID: 35404207 DOI: 10.1142/s2424835522500400] [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: 11/18/2022]
Abstract
Background: Some patients with a confirmed diagnosis of carpal tunnel syndrome (CTS) on clinical examination and electrodiagnostic testing (EDX) may also have one or more clinical features of pronator syndrome (PS). However, the EDX is negative for PS. We label these patients as suspected concurrent carpal tunnel and pronator syndrome (CCPS). We suspect that this is a presentation of reverse double crush syndrome that occurs when a symptomatic distal compression neuropathy converts an asymptomatic proximal compression into a symptomatic one. We believe both compressions can be relieved by decompressing the median nerve only at the wrist. The aim of our study is to determine whether carpal tunnel release (CTR) is an effective treatment for patients suffering from CCPS. Methods: This is a prospective, cohort study of the outcomes of CTR in two matched groups with 37 patients in each group. Group A included patients with suspected CCPS and group B included patients with isolated CTS. All patients were evaluated pre-operatively and 1 year after surgery using the Boston Carpal Tunnel Questionnaire (BCTQ). At one year, patients were also assessed for residual symptoms and positive provocative tests. Results: A significant improvement in the symptom and functional severity scales (SSS and FSS) of the BCTQ was noted in both groups. The degree of improvement in SSS was similar in both groups; however, group A showed a greater improvement in FSS. This could be attributed to higher pre-operative values in some items of FSS in group A. No patients in either group had residual symptoms severe enough to necessitate further treatment. Conclusion: The outcomes of CTR are similar in patients with isolated CTS and suspected CCPS and a CTR may be sufficient to address symptoms of CTS and PS in patients with CCPS. Level of Evidence: Level II (Therapeutic).
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Affiliation(s)
- Kamran Mozaffarian
- Department of Orthopedic Surgery, Shiraz University of Medical Sciences, Chamran Hospital, Shiraz, Iran
| | - Arash Amini
- Department of Orthopedic Surgery, Shiraz University of Medical Sciences, Chamran Hospital, Shiraz, Iran
| | - Hamid Reza Farpour
- Department of Physical Medicine and Rehabilitation, Shiraz University of Medical Sciences, Shiraz, Iran
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9
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Binder H, Zadra A, Popp D, Komjati M, Tiefenboeck TM. Outcome of Surgical Treated Isolated Pronator Teres Syndromes-A Retrospective Cohort Study and Complete Review of the Literature. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 19:80. [PMID: 35010338 PMCID: PMC8751094 DOI: 10.3390/ijerph19010080] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 12/01/2021] [Accepted: 12/17/2021] [Indexed: 06/14/2023]
Abstract
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.
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Affiliation(s)
- Harald Binder
- Department of Orthopaedics and Trauma Surgery, Division of Trauma Surgery, Medical University of Vienna, 1090 Vienna, Austria; (H.B.); (D.P.)
| | - Armin Zadra
- LKH Südsteiermark, Department of Orthopaedics, Bad Radkersburg, 8490 Südsteiermark, Austria;
| | - Domenik Popp
- Department of Orthopaedics and Trauma Surgery, Division of Trauma Surgery, Medical University of Vienna, 1090 Vienna, Austria; (H.B.); (D.P.)
| | - Micha Komjati
- First Department of Orthopaedics, Hospital of sacred Heart of Jesus, 1030 Vienna, Austria;
| | - Thomas M. Tiefenboeck
- Department of Orthopaedics and Trauma Surgery, Division of Trauma Surgery, Medical University of Vienna, 1090 Vienna, Austria; (H.B.); (D.P.)
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El-Haj M, Ding W, Sharma K, Novak C, Mackinnon SE, Patterson JMM. Median Nerve Compression in the Forearm: A Clinical Diagnosis. Hand (N Y) 2021; 16:586-591. [PMID: 31540555 PMCID: PMC8461194 DOI: 10.1177/1558944719874137] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Median nerve entrapment in the forearm (MNEF) without motor paralysis is a challenging diagnosis. This retrospective study evaluated the clinical presentation, diagnostic studies, and outcomes following surgical decompression of MNEF. Methods: The study reviewed 147 patient medical charts following MNEF surgical decompression. With exclusion of patients with combined nerve entrapments (radial and ulnar), polyneuropathy, neurotmetic nerve injury, or median nerve motor palsy, the study sample included 27 patients. Data collected include: clinical presentation and pain, strength, provocative testing, functional outcomes, and Disabilities of the Arm, Shoulder and Hand (DASH) scores. Results: The study included 27 patients (mean follow-up = 7 months), and 13 patients had previous carpal tunnel release (CTR). Clinical presentation included pain (n = 27) (forearm, n = 22; median nerve innervated digits, n = 21; and palm, n = 21) and positive clinical tests (forearm scratch collapse test, n = 27; pain with compression over the flexor digitorum superficialis arch/pronator, n = 24; Tinel sign, n = 11). Positive electrodiagnostic studies were found for MNEF (n = 2) and carpal tunnel syndrome (n = 11). Primary CTR was performed in 10 patients and revision CTR in 7 patients. Postoperatively, there were significant (P < .05) improvements in strength, pain, quality of life, and DASH scores. Conclusions: The MNEF without motor paralysis is a clinical diagnosis supported by pain drawings, pain quality, and provocative tests. Patients with persistent forearm pain and median nerve symptoms (especially after CTR) should be evaluated for MNEF. Surgical decompression provides satisfactory outcomes.
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Affiliation(s)
- Madi El-Haj
- Washington University School of Medicine, St. Louis, MO, USA
| | - Wei Ding
- Shanghai Ninth People’s Hospital, China
| | - Ketan Sharma
- Washington University School of Medicine, St. Louis, MO, USA
| | | | | | - J. Megan M. Patterson
- University of North Carolina School of Medicine, Chapel Hill, USA
- J. Megan M. Patterson, Department of Orthopaedics, University of North Carolina School of Medicine, 3135 Bioinformatics Building, Campus Box 7055, Chapel Hill, NC 27599-7055, 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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Sos C, Roulet S, Lafon L, Corcia P, Laulan J, Bacle G. Median nerve entrapment syndrome in the elbow and proximal forearm. Anatomic causes and results for a 55-case surgical series at a mean 7years' follow-up. Orthop Traumatol Surg Res 2021; 107:102825. [PMID: 33516890 DOI: 10.1016/j.otsr.2021.102825] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 10/26/2020] [Accepted: 11/17/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND Proximal median nerve (MN) neuropathy represents 1% of upper-limb compressive neuropathies. The literature reports two clinical presentations, depending on the location of the entrapment: pronator teres (PT), and anterior interosseous nerve (AIN) syndrome. HYPOTHESIS There is no correlation between symptoms and location of proximal compressive structures on the MN trunk or AIN. PATIENTS AND METHODS Clinical and paraclinical data from 55 surgical MN releases around the elbow and proximal forearm were analyzed retrospectively. Mean age at diagnosis was 56±15years. Preoperative sensory and motor deficit signs were present in 89% of cases. Reduced MN conduction velocity and/or neurogenic anomalies in the MN territory were present in 94% of cases. Intraoperative details of compressive structures were collected. Patients were followed up in consultation to assess progression of symptoms and deficits. RESULTS Mean follow-up was 84±70months. Objective motor deficit signs persisted in 18 of the 35 patients (18 cases), and objective sensory signs in 19 cases. A compressive anatomical structure was systematically found. There were at least two MN entrapment sites in 13 cases (24%). No isolated AIN entrapment was found. There was a significant correlation between symptom duration and persistence of objective sensory signs (p=0.002). DISCUSSION There was no correlation between entrapment site and clinical signs on examination. Surgery requires exploring all potential entrapment sites. Improvement may be incomplete in case of late treatment. LEVEL OF EVIDENCE IV; retrospective study.
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Affiliation(s)
- Clara Sos
- Service de Chirurgie Orthopédique et Traumatologique, Unité de Chirurgie de la Main et des Nerfs Périphériques, Hôpital Trousseau, Centre Hospitalo-Universitaire, Tours, France
| | - Steven Roulet
- Service de Chirurgie Orthopédique et Traumatologique, Unité de Chirurgie de la Main et des Nerfs Périphériques, Hôpital Trousseau, Centre Hospitalo-Universitaire, Tours, France
| | - Ludovic Lafon
- Service de Chirurgie Orthopédique, Traumatologique et Chirurgie de la Main, Clinique Fontvert, Sorgues, France
| | - Philippe Corcia
- Unité de Neurophysiologie Clinique, Hôpital Trousseau, Centre Hospitalo-Universitaire Tours, Tours, France
| | - Jacky Laulan
- Service de Chirurgie Orthopédique et Traumatologique, Unité de Chirurgie de la Main et des Nerfs Périphériques, Hôpital Trousseau, Centre Hospitalo-Universitaire, Tours, France
| | - Guillaume Bacle
- Service de Chirurgie Orthopédique et Traumatologique, Unité de Chirurgie de la Main et des Nerfs Périphériques, Hôpital Trousseau, Centre Hospitalo-Universitaire, Tours, France; UMR 1253, iBrain, Université de Tours, Inserm, Tours, France.
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Poetschke J, Schwarz D, Kremer T, Rein S. [Lesions of the anterior interosseous nerve: differentiating between compression neuropathy and neuritis]. HANDCHIR MIKROCHIR P 2021; 53:31-39. [PMID: 33588494 DOI: 10.1055/a-1349-4989] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND In cases of anterior interosseous nerve (AIN) syndrome, it is often difficult to differentiate between compression neuropathy and neuritis. MATERIAL AND METHODS This review analyses the clinical aspects of the neuritic AIN syndrome and the different diagnostic tools for securing the diagnosis and differentiating the condition from compression neuropathy. Based on these data, the current therapeutic options are proposed. RESULTS The AIN syndrome often results from neuritis of the AIN fascicles within the trunk of the median nerve. The differentiation between neuritis and compression neuropathy of the AIN is based on dedicated neurophysiological examinations as well as nerve sonography and MRI neurography. Although conservative treatment is the gold standard, microsurgical interventions have become more important in recent years. CONCLUSION A dedicated diagnostic workup of the AIN syndrome is paramount for optimal treatment. Conservative treatment remains the standard to date. However, if torsions and constrictions of nerve fascicles are detected, intrafascicular neurolysis should be considered, as current research shows the potential for an improved outcome in such cases.
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Affiliation(s)
- Julian Poetschke
- Klinikum Sankt Georg gGmbH Klinik für Plastische und Handchirurgie mit Schwerbrandverletztenzentrum
| | - Daniel Schwarz
- Abteilung für Neuroradiologie, AG MR-Neurographie, Neurologische Klinik, Universitätsklinikum Heidelberg
| | - Thomas Kremer
- Klinikum Sankt Georg gGmbH Klinik für Plastische und Handchirurgie mit Schwerbrandverletztenzentrum
| | - Susanne Rein
- Klinikum Sankt Georg gGmbH Klinik für Plastische und Handchirurgie mit Schwerbrandverletztenzentrum.,Martin-Luther-Universität Halle-Wittenberg, Halle (Saale)
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Özdemir A, Acar MA, Güleç A, Durgut F, Cebeci H. Clinical, Radiological, and Electrodiagnostic Diagnosis of Pronator Syndrome Concurrent With Carpal Tunnel Syndrome. J Hand Surg Am 2020; 45:1141-1147. [PMID: 32711963 DOI: 10.1016/j.jhsa.2020.06.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 04/28/2020] [Accepted: 06/03/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE This is a retrospective observational study that assessed the prevalence of positive diagnostic imaging and electrodiagnostic (EDX) findings in patients diagnosed with pronator syndrome (PS), who previously had a carpal tunnel syndrome (CTS) surgery. The other purpose of our study was to determine how often PS occurred and was missed in patients treated surgically for CTS. METHODS The files of 180 patients who underwent CTS surgery were reviewed retrospectively. We assessed all patients for a diagnosis of PS. We accepted the clinical findings and patient history as the reference standard for the diagnosis of PS. Anteroposterior and lateral radiographs of the elbow, bilateral upper limb magnetic resonance imaging (MRI) studies, and bilateral dynamic forearm ultrasound (US) were performed on patients with clinical symptoms and physical examinations that indicated PS. Bilateral upper limb EDX was also performed for these patients. One patient refused additional tests. RESULTS A total of 174 extremities in 146 patients were included in the study. Pronator syndrome was diagnosed by 2 hand surgeons in 22 extremities (19 patients) through a clinical evaluation that included a history and physical examination. Diagnostic testing was positive for findings of PS in 24% of extremities (5 of 21) tested by EDX, in 57% of extremities (12 of 21) tested by US, and 5% of extremities (1 of 21) tested by MRI. There was no lower humeral spur that could cause median nerve compression on any plain radiographs. CONCLUSIONS With clinical evaluation as the reference standard, EDX, US, and MRI are not helpful in making a diagnosis of PS concurrent with CTS. TYPE OF STUDY/LEVEL OF EVIDENCE Diagnostic IV.
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Affiliation(s)
- Ali Özdemir
- Department of Orthopedy and Traumatology, Selcuk University, Akademi Mahallesi, Selçuklu/Konya, Turkey.
| | - Mehmet Ali Acar
- Department of Orthopedy and Traumatology, Selcuk University, Akademi Mahallesi, Selçuklu/Konya, Turkey
| | - Ali Güleç
- Department of Orthopedy and Traumatology, Selcuk University, Akademi Mahallesi, Selçuklu/Konya, Turkey
| | - Fatih Durgut
- Department of Orthopedy and Traumatology, Selcuk University, Akademi Mahallesi, Selçuklu/Konya, Turkey
| | - Hakan Cebeci
- Department of Orthopedy and Traumatology, Selcuk University, Akademi Mahallesi, Selçuklu/Konya, Turkey
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Adler JA, Wolf JM. Proximal Median Nerve Compression: Pronator Syndrome. J Hand Surg Am 2020; 45:1157-1165. [PMID: 32893044 DOI: 10.1016/j.jhsa.2020.07.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 05/23/2020] [Accepted: 07/09/2020] [Indexed: 02/02/2023]
Abstract
Pronator syndrome (PS) is a compressive neuropathy of the median nerve in the proximal forearm, with symptoms that often overlap with carpal tunnel syndrome (CTS). Because electrodiagnostic studies are often negative in PS, making the correct diagnosis can be challenging. All patients should be initially managed with nonsurgical treatment, but surgical intervention has been shown to result in satisfactory outcomes. Several surgical techniques have been described, with most outcomes data based on retrospective case series. It is essential for clinicians to have a thorough understanding of median nerve anatomy, possible sites of compression, and characteristic clinical findings of PS to provide a reliable diagnosis and treat their patients.
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Affiliation(s)
- Jeremy A Adler
- Department of Orthopaedic Surgery, University of Chicago, Chicago, IL.
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Soubeyrand M, Melhem R, Protais M, Artuso M, Crézé M. Anatomy of the median nerve and its clinical applications. HAND SURGERY & REHABILITATION 2020; 39:2-18. [DOI: 10.1016/j.hansur.2019.10.197] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Revised: 09/25/2019] [Accepted: 10/28/2019] [Indexed: 12/11/2022]
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Stecco C, Giordani F, Fan C, Biz C, Pirri C, Frigo AC, Fede C, Macchi V, Masiero S, De Caro R. Role of fasciae around the median nerve in pathogenesis of carpal tunnel syndrome: microscopic and ultrasound study. J Anat 2019; 236:660-667. [PMID: 31797384 DOI: 10.1111/joa.13124] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/30/2019] [Indexed: 11/26/2022] Open
Abstract
This study investigated the connections between the median nerve paraneural sheath and myofascial structures near it, from both macroscopic and microscopic points of view. Four samples of median nerve and surrounding tissues were excised from nine non-embalmed upper limbs for microscopic analysis. Ultrasound images were analysed in 21 healthy subjects and 16 carpal tunnel syndrome patients to evaluate median nerve transversal displacement during finger motion at carpal tunnel and forearm levels. An anatomical continuity between epimysium and paraneural sheath and a reduction of paraneural fat tissue from proximal to distal was found in all samples. Median nerve displacements at both levels were significantly reduced in carpal tunnel syndrome subjects (P < 0.001). It was observed that the median nerve is not an isolated structure but is entirely connected to myofascial structures. Therefore, unbalanced tension of epimysial fasciae can affect the paraneural sheath, limiting nerve displacement, and consequently this must be included in carpal tunnel syndrome pathogenesis.
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Affiliation(s)
- Carla Stecco
- Department of Neurosciences, Institute of Human Anatomy, University of Padua, Padua, Italy
| | - Federico Giordani
- Department of Physical and Rehabilitation Medicine, University of Padua, Padua, Italy
| | - Chenglei Fan
- Department of Neurosciences, Institute of Human Anatomy, University of Padua, Padua, Italy
| | - Carlo Biz
- Department of Surgery, Oncology and Gastroenterology, Orthopedic Clinic, University of Padua, Padua, Italy
| | - Carmelo Pirri
- Physical and Rehabilitation Medicine, Department of Clinical Sciences and Translation Medicine, 'Tor Vergata' University, Rome, Italy
| | - Anna Chiara Frigo
- Biostatistics, Epidemiology and Public Health Unit, Department of Cardiac, Thoracic and Vascular Sciences, University Hospital of Padua, Padua, Italy
| | - Caterina Fede
- Department of Neurosciences, Institute of Human Anatomy, University of Padua, Padua, Italy
| | - Veronica Macchi
- Department of Neurosciences, Institute of Human Anatomy, University of Padua, Padua, Italy
| | - Stefano Masiero
- Department of Physical and Rehabilitation Medicine, University of Padua, Padua, Italy
| | - Raffaele De Caro
- Department of Neurosciences, Institute of Human Anatomy, University of Padua, Padua, Italy
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Vergara-Amador E, Castillo-Pérez S, Tovar-Cuellar W. Endoscopic release of the median nerve in the proximal third of the forearm. A new approach. Rev Esp Cir Ortop Traumatol (Engl Ed) 2019. [DOI: 10.1016/j.recote.2019.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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20
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Endoscopic release of the median nerve in the proximal third of the forearm. A new approach. Rev Esp Cir Ortop Traumatol (Engl Ed) 2019; 63:439-446. [PMID: 31266706 DOI: 10.1016/j.recot.2019.05.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 01/13/2019] [Accepted: 05/27/2019] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Pronator syndrome has classically required open surgery that leaves a large scar; initial endoscopic techniques required approaches of an average 4cm without achieving release of all structures. The purpose of this study was to describe a new endoscopic approach that allows the median nerve to be safely and completely decompressed, leaving a smaller and less visible scar. METHODS Description of a new approach for decompression of the median nerve in the proximal third of the forearm with minimal incision and endoscopic technique in cryopreserved cadaveric specimens, describing incision, endoscopic anatomy, safe corridors and decompression sites. RESULTS In 20 elbows of cadavers, an endoscopic approach of the median nerve in the proximal forearm with a 4mm endoscope and 0° of angulation was performed. The advantages and limitations of the technique and surgical details are presented for release in the most common compression points of the nerve in the forearm. We performed this technique in 3 patients with good results without complications. DISCUSSION Release of the median nerve and section of potential aponeurotic compression structures by endoscopy is possible. The ulnar head of the pronator and the aponeurotic arch of the flexor digitorum superficialis are frequently implicated in the syndrome. The scar is aesthetically good. It is a relatively new technique, with lower morbidity that allows faster recovery of patients. CONCLUSIONS It is possible to perform a complete decompression of the median nerve in the forearm using an endoscopic approach, safely with lower comorbidity for the patient.
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Affiliation(s)
- Seok-Woo Hong
- Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Hyun-Sik Gong
- Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
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