Surgical treatment and outcomes in 45 cases of posterior interosseous nerve entrapments and injuries

Vascular supply of the radial nerve and its terminal branches: an anatomical study

PURPOSE

The aim of this cadaveric study was to further describe the vascular supply of the radial, posterior interosseous and superficial radial nerves.

METHODS

11 cadaveric upper limbs, injected with colored latex, were dissected. Vascular afferents to the radial nerve, superficial radial nerve (SRN) and posterior interosseous nerve (PIN) were described and located. Their origin was identified and its distance to interepicondylar line was measured.

RESULTS

The radial nerve had an average of 3 vascular afferents (1-5), of septomuscular origin in 54% of cases. 46% came from adjacent arteries. The PIN had an average of 8 vascular afferents (6-14), arising from septomuscular branches in 82% of cases. The PIN was vascularized in 100% of cases by a large arterial plexus originating from the supinator muscle between its two heads. The SRN had an average of 4 vascular afferents (3-7). Before crossing the septum of the brachioradialis, vascularization was predominantly septomuscular; after crossing the septum, the nerve was exclusively vascularized by septocutaneous arteries.

CONCLUSION

This is the first study to describe the vascularization of the radial nerve and its terminal branches along their entire length. Our results are in line with the data available in the literature. An arterial plexus between the two heads of the supinator was surrounding the PIN in all cases. This vascular plexus might be involved in dynamic compression of the posterior interosseous nerve.

Updates on Common Mononeuropathies

This article provides an overview of the most common mononeuropathies. It includes a description of the neuroanatomy and function of each nerve which allows clinical localization of the lesion. It also describes the clinical presentation, findings in electrodiagnostic studies, updates in imaging including neuromuscular ultrasound and magnetic resonance neurography, and recommended treatment. While mononeuropathies may be part of polyneuropathy, this scenario is beyond the scope of this article. The most common mononeuropathy is carpal tunnel syndrome. Its prevalence in the United States is estimated at 50 per 1,000. The second most common entrapment neuropathy is ulnar neuropathy at the elbow. The incidence was calculated as 20.9% in a 2005 study. The most common compressive neuropathy of the lower extremity is peroneal neuropathy. Other common mononeuropathies included in this article are radial neuropathy, tibial neuropathy, and femoral neuropathy.

Posterior interosseous nerve lesion due to lipoma. Review of the literature and rare case presentation

BACKGROUND

Posterior interosseous nerve lesion is a rare mononeuropathy of the upper limb. Atraumatic posterior interosseous nerve lesions are commonly caused by lipomas of the forearm, manifesting as slow-progressing wrist and finger drop.

PATIENTS AND METHODS

In this review and case report study, we present a systematic review of the literature for patients presenting with posterior interosseous palsy due to lipomas and a rare case of patient with acute posterior interosseous nerve lesion caused by a lipoma. Our primary interest was in the timing of clinical presentation. For the review process, we followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines.

RESULTS

After reviewing the literature, we identified thirty patients with posterior interosseous nerve lesions caused by lipomas. In 28 patients, the symptoms presented progressively, ranging from 1 month to a maximum of 240 months. We found only one case of a patient with acute presentation and another patient with acute worsening of chronic weakness due to trauma.

CONCLUSIONS

Atraumatic posterior interosseous nerve lesions are frequently secondary to forearm lipomas. In the majority of cases, the symptoms will develope progressively. However, in this study, we also report a rare case of a patient presenting with acute posterior interosseous nerve lesion due to a lipoma.

Imaging characteristics of posterior interosseous nerve syndrome

Posterior interosseous nerve syndrome (PINs) is a rare nerve compression syndrome that affects the deep branch of the radial nerve in the supinator muscle region. In this article, we aimed to report a case of a 58-year-old male who had clinical symptoms, electromyographic, ultrasound, and MRI features suggestive of PINs due to compressing the arcade of Frohse. He subsequently underwent surgical correlation at our hospital, and the clinical symptoms were improved significantly.

Demographics of Common Compressive Neuropathies in the Upper Extremity

BACKGROUND

The purpose of this study was to compare the demographic differences of the most common peripheral nerve compressions in the upper extremity-carpal tunnel syndrome (CTS), ulnar nerve compression (UNC) at the elbow, combined CTS and UNC, radial tunnel syndrome (RTS), and posterior interosseous nerve syndrome (PINS)-as a means to better understand the etiologies of each.

METHODS

A retrospective chart review was performed of all patients over the age of 18 years seen at our institution in the 2018 calendar year. International Classification of Diseases, Tenth Revision codes were used to identify patients with diagnoses of upper extremity peripheral nerve compressions. Demographic details and relevant comorbidities were recorded for each patient and compared with controls, who were seen the same calendar year with no neuropathies. χ2 analyses, independent-samples t tests, and multivariate logistic regressions were performed (P < .05).

RESULTS

A total of 7448 patients were identified. Those with CTS were mainly women, former smokers, and diabetic (all P < .001) and with a greater average body mass index (BMI) (P = .006) than controls. Patients with UNC were more often men and younger when compared with controls (both P < .001). A history of smoking, diabetes, and average BMI were similar between patients with UNC and controls (all P > .05). Those patients with combined CTS/UNC were mainly men, former smokers, and diabetic (all P < .001) when compared with controls. Patients with RTS/PINS were also mostly men (P = .007), diabetic (P = .042), and were more often current smokers (P < .001).

CONCLUSIONS

The demographics of patients with various compressive neuropathies were not homogeneous, suggesting different etiologies.

Una causa rara del síndrome del nervio interóseo posterior: Lipoma intraneural

El síndrome del nervio interóseo posterior (NIP) es una condición definida por la neuropatía por compresión de esta rama del nervio radial causada por traumatismos, lesiones ocupantes de espacio, neuritis braquial, o compresión espontánea. Su presentación clínica se caracteriza por un inicio insidioso de los síntomas, generalmente un déficit en la extensión de los dedos sin alteración sensitiva. En este artículo, presentamos un caso clínico de una mujer de 72 años con un lipoma intraneural que causó compresión extrínseca por 11 meses y tuvo una recuperación completa después de la extirpación quirúrgica. Además de la escasez de casos clínicos descritos en la literatura (solo tres hasta la fecha), también destacamos la excelente evolución de la paciente, independientemente de su edad y de la duración de los síntomas.

Isolating the Superficial Peroneal Nerve Motor Branch to the Peroneus Longus Muscle with Concentric Stimulation during Diagnostic Motor Nerve Biopsy

Motor nerve biopsies are performed in the workup of neuropathies of unknown origin when motor neuron disease is suspected. Biopsy of a motor branch of the superficial peroneal nerve innervating the peroneus longus muscle has been described as a convenient alternative to other commonly biopsied motor nerves. To date, neuromonitoring techniques have not been described for this procedure. We describe the surgical neurophysiology techniques necessary for preservation of motor function and associated data during muscle biopsy of a motor branch of the superficial peroneal nerve innervating the peroneus longus muscle. We present a case of a patient who underwent uncomplicated biopsy of the motor branch of the superficial peroneal nerve innervating the peroneus longus muscle during workup for suspected motor neuropathy. The surgical neurophysiology techniques and data are presented in detail. No postsurgical sensory or motor deficit was related to the procedure. Surgical neurophysiology is critical to confirm the appropriate motor branch to the peroneus longus muscle and facilitates safe and accurate motor nerve biopsy.

Ultrasound of the Radial Nerve: A Pictorial Review

This pictorial review focuses on the ultrasound (US) appearance of the normal and pathological radial nerve (RN) and its branches and provides tips with which to locate them and avoid misinterpretation of normal findings. A wide range of our pathological cases are reviewed and presented to help in familiarizing the reader with common and uncommon clinical scenarios that affect the RN and its main branches.

Posterior interosseous nerve syndrome caused by a ganglion cyst and its surgical release with intraoperative neurophysiological monitoring: A case report

RATIONALE

Intraoperative neurophysiological monitoring (IONM) has been utilized not only for the rapid detection of neural insults during surgeries, but also to verify the neurophysiological integrity of nerve lesions in the surgical field.

PATIENT CONCERNS

A 32-year-old woman presented with a wrist and finger drop that had lasted about 3 months.

DIAGNOSES

The result of the initial electrodiagnostic test was consistent with posterior interosseous nerve (PIN) syndrome. Ultrasonography and magnetic resonance imaging of the proximal forearm showed a cystic mass at the anterolateral aspect of the radial head, which was diagnosed as a ganglion cyst.

INTERVENTIONS

Surgical release of the ganglion cyst with IONM was performed. During the surgery, we induced nerve action potentials and compound motor action potentials across the ganglion cyst, which demonstrated neural continuity.

OUTCOMES

Three months after the surgery, the patient showed partial recovery of wrist and finger extensor muscle power. An electrodiagnostic test conducted 3 months after the surgery showed reinnervation potentials in PIN-innervated muscles.

LESSONS

IONM during peripheral nerve surgeries can support surgical decisions and confirm the location and degree of nerve damage.

Fracture related ulnar and sciatic nerve transections: a report of two cases and literature review

INTRODUCTION

Case reports, case series, and case control studies have looked at the incidence of complete nerve transection in the setting of fracture and the need for surgical exploration dating back to the 1920s. We present two cases of nerve laceration accompanying traumatic fracture with a thorough review of the literature.

METHODS

We used the following search terms: "ulnar nerve" OR "sciatic nerve" AND "laceration" OR "transection" AND "fracture." Results were reviewed and included for discussion if they specifically reported ulnar or sciatic nerve laceration accompanying traumatic fracture.

RESULTS

Our search yielded 15 papers reporting a total of 10 ulnar nerve lacerations and nine sciatic nerve lacerations. We present two additional cases. The first is a patient with a humerus fracture and complete ulnar nerve transection. The second case is a patient who suffered a femur fracture and complete transection of the sciatic nerve.

CONCLUSION

Nerve laceration accompanying traumatic fracture is rare. We review the reported cases of nerve laceration and present two cases treated at our institution. Though uncommon, nerve laceration should be considered in the setting of traumatic fracture with neurological injury, particularly open fractures.

Paralisias parciais idiopáticas do interósseo posterior - 8 casos

Introdução: As paralisias idiopáticas parciais do nervo interósseo posterior, atingindo apenas o polegar ou alguns dedos, são muito raras, sendo aparentemente causadas por uma compressão ao nível do músculo supinador.

Material e método: Observámos, nos últimos 10 anos, 8 casos, atingindo apenas alguns dedos (3 casos) ou o polegar (5) e não evoluindo para paralisias mais completas.

Resultados: Dois casos do polegar, com diagnóstico clínico precoce, curaram espontaneamente. Dos outros 6, observados tardiamente, 4 foram submetidos a cirurgia paliativa com bons resultados (2 polegares, um d3d4 e outro d4d5) e 2 recusaram cirurgia (um polegar e outro d4).

Conclusão: As paralisias parciais do interósseo existem e devem ser diferenciadas de roturas dos tendões extensores. Algumas recuperam espontaneamente. Nas outras, se vistas tardiamente, a cirurgia paliativa pode dar um bom resultado.

Motor Nerve Transfers

Brachial plexus and peripheral nerve injuries are exceedingly common. Traditional nerve grafting reconstruction strategies and techniques have not changed significantly over the last 3 decades. Increased experience and wider adoption of nerve transfers as part of the reconstructive strategy have resulted in a marked improvement in clinical outcomes. We review the options, outcomes, and indications for nerve transfers to treat brachial plexus and upper- and lower-extremity peripheral nerve injuries, and we explore the increasing use of nerve transfers for facial nerve and spinal cord injuries. Each section provides an overview of donor and recipient options for nerve transfer and of the relevant anatomy specific to the desired function.

The optimal distance between two electrode tips during recording of compound nerve action potentials in the rat median nerve

The distance between the two electrode tips can greatly influence the parameters used for recording compound nerve action potentials. To investigate the optimal parameters for these recordings in the rat median nerve, we dissociated the nerve using different methods and compound nerve action potentials were orthodromically or antidromically recorded with different electrode spacings. Compound nerve action potentials could be consistently recorded using a method in which the middle part of the median nerve was intact, with both ends dissociated from the surrounding fascia and a ground wire inserted into the muscle close to the intact part. When the distance between two stimulating electrode tips was increased, the threshold and supramaximal stimulating intensity of compound nerve action potentials were gradually decreased, but the amplitude was not changed significantly. When the distance between two recording electrode tips was increased, the amplitude was gradually increased, but the threshold and supramaximal stimulating intensity exhibited no significant change. Different distances between recording and stimulating sites did not produce significant effects on the aforementioned parameters. A distance of 5 mm between recording and stimulating electrodes and a distance of 10 mm between recording and stimulating sites were found to be optimal for compound nerve action potential recording in the rat median nerve. In addition, the orthodromic compound action potential, with a biphasic waveform that was more stable and displayed less interference (however also required a higher threshold and higher supramaximal stimulus), was found to be superior to the antidromic compound action potential.

Compression and entrapment neuropathies

Peripheral nerve entrapments are frequent. They usually appear in anatomical tunnels such as the carpal tunnel. Nerve compressions may be due to external pressure such as the fibular nerve at the fibular head. Malignant or benign tumors may also damage the nerve. For each nerve from the upper and lower limbs, detailed clinical, electrophysiological, imaging, and therapeutic aspects are described. In the upper limbs, carpal tunnel syndrome and ulnar neuropathy at the elbow are the most frequent manifestations; the radial nerve is less frequently involved. Other nerves may occasionally be damaged and these are described also. In the lower limbs, the fibular nerve is most frequently involved, usually at the fibular head by external compression. Other nerves may also be involved and are therefore described. The clinical and electrophysiological examination are very important for the diagnosis, but imaging is also of great use. Treatments available for each nerve disease are discussed.

[The main tunnel syndromes]

Several tunnel syndromes are responsible for substantial functional impairment. The diagnosis has to be made and treatment is most often very simple--nerve decompression--with excellent results. Of these syndromes, the most common are median and ulnar tunnel syndromes of the wrist and ulnar tunnel syndrome of the elbow, but other syndromes must be identified at the risk of therapy failure due to poorly adapted treatment. Finally, good knowledge of this pathology must lead to prevention of the iatrogenic forms (sequelae of inguinal hernia treatment, ileac crest graft harvesting) by educating all surgeons interested in peripheral nerve surgery.

Granular cell nerve tumor in the hand: case report

Granular cell tumor of a digital nerve is extremely rare; I could identify only 2 previous reports in the literature. I present a case of a granular cell tumor arising from an index digital nerve that was treated with wide resection and nerve graft reconstruction.

Evaluation and management of peripheral nerve injury

Common etiologies of acute traumatic peripheral nerve injury (TPNI) include penetrating injury, crush, stretch, and ischemia. Management of TPNI requires familiarity with the relevant anatomy, pathology, pathophysiology, and the surgical principles, approaches and concerns. Surgical repair of TPNI is done at varying time intervals after the injury, and there are a number of considerations in deciding whether and when to operate. In neurapraxia, the compound muscle and nerve action potentials on stimulating distal to the lesion are maintained indefinitely; stimulation above the lesion reveals partial or complete conduction block. The picture in axonotmesis and neurotmesis depends on the time since injury. The optimal timing for an electrodiagnostic study depends upon the clinical question being asked. Although conventional teaching usually holds that an electrodiagnostic study should not be done until about 3 weeks after the injury, in fact a great deal of important information can be obtained by studies done in the first week. Proximal nerve injuries are problematic because the long distance makes it difficult to reinnervate distal muscles before irreversible changes occur. Decision making regarding exploration must occur more quickly, and exploration using intraoperative nerve action potential recording to guide the choice of surgical procedure is often useful.