Relationships between the global symptom score and electrophysiological findings after surgical release for carpal tunnel syndrome: Indications and outcomes

PURPOSE

Regarding surgical indications for carpal tunnel syndrome (CTS), the hypothesis that the recovery processes of subjective symptoms differ among pain, sensory, and motor symptoms and correlate with recovery in objective nerve conduction studies was examined in the present study.

METHODS

The global symptom score (GSS) is a method used to assess clinical outcomes and covers subjective symptoms, including pain (pain and nocturnal awakening), sensory (numbness and paresthesia), and motor (weakness/clumsiness) symptoms. The relationships between long-term changes in GSS and recovery in nerve conduction studies were investigated.

RESULTS

Forty patients (40 hands) were included (mean age 65 years; 80% female; 68% with moderate CTS: sensory nerve conduction velocity < 45 m/s and motor nerve distal latency > 4.5 ms). Pain and nocturnal awakening rapidly subsided within 1 month after surgery and did not recur in the long term (median 5.6 years). Paresthesia significantly decreased 3 months after surgery and in the long term thereafter. Weakness/clumsiness significantly decreased at 1 year. Sensory nerve distal latency, conduction velocity, and amplitude significantly improved 3 months and 1 year after surgery, and correlated with nocturnal awakening in the short term (3 months) in moderate CTS cases. The patient satisfaction rate was 91%.

CONCLUSION

Rapid recovery was observed in pain and nocturnal awakening, of which nocturnal awakening correlated with the recovery of sensory nerve conduction velocity. Patients with pain symptoms due to moderate CTS may benefit from surgical release.

Paresthesia Is Predictive of Symptom Recurrence After Fasciotomy for Exertional Compartment Syndrome of the Leg

BACKGROUND

Exertional compartment syndrome (ECS) is an underdiagnosed cause of lower extremity pain among athletes. The condition can be managed operatively by fasciotomy to relieve excess compartment pressure. However, symptom recurrence rates after fasciotomy are considerable, ranging from 3% to 17%.

HYPOTHESIS

Leg paresthesia and its distribution during ECS episodes would be a significant predictor of outcomes after fasciotomy.

STUDY DESIGN

Retrospective cohort study.

LEVEL OF EVIDENCE

Level 4.

METHODS

We conducted a retrospective chart review of patients who underwent fasciotomy for ECS at our center from 2010 to 2020 (institutional review board no. 21-00107). We measured postoperative outcomes including pain frequency and severity, Tegner activity level, and return to sport. Significant predictors of outcomes were identified using multivariable linear and logistic regression. P values <0.05 were considered significant.

RESULTS

A total of 78 legs (from 42 male and 36 female participants) were included in the study with average follow-up of 52 months (range, 3-126 months); 33 participants (42.3%) presented with paresthesia. Paresthesia was an independent predictor of worse outcomes, including more severe pain at rest (P = 0.05) and with daily activity (P = 0.04), reduced postoperative improvement in Tegner scores (P = 0.04), and lower odds of return to sport (P = 0.05). Those with paresthesia symptoms in the tibial nerve distribution had worse outcomes than those without paresthesia in terms of preoperative-to-present improvement in pain frequency (P < 0.01), pain severity at rest (P < 0.01) and with daily activity (P = 0.04), and return to sport (P = 0.04).

CONCLUSION

ECS patients who present with paresthesia have worse pain and activity outcomes after first-time fasciotomy, but prognosis is worst among those with tibial nerve paresthesia.

CLINICAL RELEVANCE

Paresthesia among ECS patients is broadly predictive of more severe recurrent leg pain, reduced activity level, and decreased odds of return to sport after fasciotomy.

Round ligament management during minimally invasive groin hernia repair in women: a systematic review and meta-analysis

BACKGROUND

Female sex has been associated with worse outcomes after groin hernia repair (GHR), including a higher rate of chronic pain and recurrence. Most of the studies in GHR are performed in males, and the recommendations for females extrapolate from these studies, even though females have anatomy intricacies. The round ligament of the uterus (RLU) is associated with pelvic stabilization and plays a role in sensory function. Transection of the RLU during GHR is controversial as it can allow easier mesh placement but can favor genitourinary complications and chronic pain. As no previous meta-analysis compared preserving versus transecting the RLU during minimally invasive (MIS) GHR, we aim to perform a systematic review and meta-analysis evaluating surgical outcomes comparing the approaches.

METHODS

Cochrane Central, Embase, and PubMed databases were systematically searched for studies comparing transection versus preservation of the RLU in MIS groin hernia surgeries. Outcomes assessed were operative time, bleeding, surgical site events, hospital stay, chronic pain, paresthesia, recurrence rates, and genital prolapse rates. Statistical analysis was performed using RevMan 5.4.1. Heterogeneity was assessed with I2 statistics. A review protocol for this meta-analysis was registered at PROSPERO (CRD 42023467146).

RESULTS

1738 studies were screened. A total of six studies, comprising 1131 women, were included, of whom 652 (57.6%) had preservation of the RLU during MIS groin hernia repair. We found no statistical difference regarding chronic pain, paresthesia, recurrence rates, and postoperative complications. We found a longer operative time for the preservation group (MD 6.84 min; 95% CI 3.0-10.68; P = 0.0005; I2 = 74%).

CONCLUSION

Transecting the RLU reduces the operative time during MIS GHR with no difference regarding postoperative complication rates. Although transection appears safe, further prospective randomized studies with long-term follow-up and patient-reported outcomes are necessary to define the optimal management of RLU during MIS GHR.

Transinguinal preperitoneal (TIPP) versus Lichtenstein for inguinal hernia repair: a systematic review and meta-analysis

PURPOSE

We aimed to perform a systematic review and meta-analysis comparing postoperative outcomes in inguinal hernia repair with TIPP versus Lichtenstein technique.

METHODS

Cochrane Central, Scopus, and PubMed were systematically searched for studies comparing TIPP and Lichtenstein´s technique for inguinal hernia repair. Outcomes assessed were operative time, bleeding, surgical site events, hospital stay, the Visual Analogue Pain Score, chronic pain, paresthesia rates, and recurrence. Statistical analysis was performed using RevMan 5.4.1. Heterogeneity was assessed with I2 statistics and random-risk effect was used if I2 > 25%.

RESULTS

790 studies were screened and 44 were thoroughly reviewed. A total of nine studies, comprising 8428 patients were included, of whom 4185 (49.7%) received TIPP and 4243 (50.3%) received Lichtenstein. We found that TIPP presented less chronic pain (OR 0.43; 95% CI 0.20-0.93 P = 0.03; I2 = 84%) and paresthesia rates (OR 0.27; 95% CI 0.07-0.99; P = 0.05; I2 = 63%) than Lichtenstein group. In addition, TIPP was associated with a lower VAS pain score at 14 postoperative day (MD - 0.93; 95% CI - 1.48 to - 0.39; P = 0.0007; I2 = 99%). The data showed a lower operative time with the TIPP technique (MD - 7.18; 95% CI - 12.50, - 1.87; P = 0.008; I2 = 94%). We found no statistical difference between groups regarding the other outcomes analyzed.

CONCLUSION

TIPP may be a valuable technique for inguinal hernias. It was associated with lower chronic pain, and paresthesia when compared to Lichtenstein technique. Further long-term randomized studies are necessary to confirm our findings. Study registration A review protocol for this meta-analysis was registered at PROSPERO (CRD42023434909).

Plexiform Schwannoma of Digital Nerve

Plexiform schwannoma is an uncommon benign tumour that grows in a plexiform pattern. We report a 47-year-old man with a mass on the palmar aspect of the metacarpophalangeal joint of the right index finger that had been growing gradually for more than 10 years. The mass was palpated from the distal carpal tunnel to the ulnar aspect of the proximal interphalangeal joint of the index finger, with tingling and numbness sensation. The tumour was a multinodular tumour involving the first common palmar digital nerve to the ulnar proper palmar digital nerve. It was resected and reconstructed with a sural nerve graft. Plexiform schwannoma is rare in the digital nerve, with only six cases reported. Generally, classic schwannomas can be enucleated without causing neurologic deficits; however, plexiform schwannoma may require nerve resection. There have been reports of recurrence of plexiform schwannoma; definitive resection and long-term follow-up are necessary. Level of Evidence: Level V (Therapeutic).

Complications of Cervical Endoscopic Spinal Surgery: A Systematic Review and Narrative Analysis

BACKGROUND

There are no systematic evidence-based medical data on the complications of endoscopic cervical spinal surgery. This narrative analysis compiled data from various studies that examined endoscopic complications, such as cervical disc herniation and foraminal stenosis. This study aimed to investigate the efficacy and safety of endoscopic surgery in cervical radiculopathy.

METHODS

We searched the PubMed/MEDLINE databases to identify articles on endoscopic spinal surgery, and keywords were set as "endoscopic cervical spinal surgery", "endoscopic cervical discectomy", "endoscopic cervical foraminotomy", and "percutaneous endoscopic cervical discectomy". We analyzed the evidence level and classified the prescribed complications according to the literature. Endoscopic cervical surgery was divided into three categories: full endoscopic anterior, endoscopic posterior, and unilateral biportal approaches. We excluded duplicate publications, studies without full text, studies without complications or incomplete information, and studies that did not provide the necessary data for extraction, animal experiments, or reviews.

RESULTS

Difficulties in swallowing, hematoma, and hoarseness are common complications associated with the anterior cervical approach. In contrast, complications of the posterior approach include nerve root injury, hematoma, and dysesthesia. However, endoscopic cervical spinal surgery, including the full endoscopic anterior, posterior, and unilateral biportal approaches, is a safe and effective treatment for cervical radiculopathy.

CONCLUSIONS

Complications of full endoscopic cervical spinal surgery differ significantly depending on the anterior and posterior approaches. In the anterior approach, swallowing difficulty, recurrent disc, hematoma, and dysphonia are the common complications. In contrast, transient dysesthesia, dural tears, upper limb motor deficits, and persistent arm pain are commonly reported with the posterior approach.

[A women with burning pain in her arms after a fall]

BACKGROUND

The central cord syndrome is an incomplete spinal cord injury that can develop after a minor trauma to the cervical spinal column.

CASE DESCRIPTION

A 73-year-old woman presented at our Emergency Department with pyelonephritis accompanied by weakness and a burning feeling in her arms and legs after a fall on her head. The weakness and pain did not improve during her hospital admission. On consultation with a neurologist, the patient was diagnosed with central cord syndrome. As the neurological loss of function did not resolve spontaneously, the patient underwent laminectomy and spondylodesis. Postoperatively her symptoms improved. After 22 days in hospital, the patient was discharged to a rehabilitation clinic.

CONCLUSION

In older patients with pre-existing degenerative cervical spinal stenosis, central cord stenosis resulting from minor trauma can cause severe and invalidating symptoms. The early tracing and treatment of patients with this syndrome is essential in order to increase the chance of neurological and functional recovery.

Atypical musculoskeletal manifestations on flexor hallucis longus tendon of gout causing tarsal tunnel syndrome in diabetic patients: A case report

RATIONALE

Deposition of tophus is a common feature in chronic gout; however, signs and symptoms are not always well-pronounced in cases of uncommon sites. We report a rare case with a tophaceous tendonitis on the flexor hallucis longus (FHL) tendon with tarsal tunnel syndrome (TTS). This is the first surgical case of TTS by gouty tophi in FHL.

PATIENT CONCERNS

A 55-year-old woman presented with a 6-month history of mild discomfort at the right foot, which gradually worsened in the past 3 weeks. The patient visited our outpatient clinic due to persistent and aggravating foot pain and swelling around the tarsal tunnel.

DIAGNOSIS

The patient was diagnosed with hyperuricemia and diabetes mellitus with chronic kidney disease, and did not receive regular antigout treatments. Paresthesia was found along the distribution of medial and plantar nerve and tinel test was positive on tarsal tunnel. Biochemical examination showed she had raised serum uric acid (10.6 mg/dL) and decreased estimated glomerular filtration rate (69 mL/min/1.73 m). Conventional radiography examination showed negative pathology except soft tissue swelling. Magnetic resonance imaging revealed a fusiform mass within the FHL tendon and fluid collection around tarsal tunnel.

INTERVENTIONS

Surgical exploration was performed to remove the mass. Inflammation fluid exploded out from FHL tendon sheath, which was later proven to have infiltration of monosodium urate crystal. Superficial dissection revealed a white chalky mass and posterior tibial nerve was significantly compressed by the tophus mass.

OUTCOMES

The mass was removed and the symptoms were relieved at immediate postoperative period.

LESSONS

A tophaceous tendonitis on FHL tendon can cause TTS and surgical decompression of the gout lesion can reduce the symptoms.

Accidental Use of the Median Nerve as an Interposition Material in First Carpometacarpal Joint Arthroplasty

Harvesting the median nerve accidentally as a tendon graft, is a major complication of upper extremity surgery which is noted only rarely in the literature. This article seems to be the first report of the median nerve being used as an interposition material in first carpometacarpal joint arthroplasty.

A new option for the reconstruction of orbital floor defects with heterologous cortical bone

BACKGROUND

The orbital floor is one of the most frequently injured areas of the maxillofacial skeleton during facial trauma. A retrospective analysis of patients who have undergone treatment of orbital floor fractures with heterologous cortical bone is presented.

METHODS

This retrospective study was carried out with 21 patients over a period of 4 years between 2010 and 2014. All patients with a traumatic orbital floor defect who underwent reconstruction with heterologous cortical bone were included. The operations were carried out under general anesthesia for all patients. A subciliary incision was used in 20 patients and an infraorbital approach was used in one patient. All patients underwent follow-up examinations clinically as well as radiologically, at 1, 3, 6 and 12 months postoperatively. Computed tomographic scans were taken at the postoperative 6th month, and at the first postoperative year if needed.

RESULTS

Preoperatively, the physical examination revealed diplopia in 17 patients (80.9%), gaze restriction in 14 patients (66.6%), enophthalmos in six patients (28.5%), and infraorbital nerve paresthesia in two patients (9.5%). None of the patients showed impaired visual acuity preoperatively or postoperatively. Diplopia and gaze restriction resolved postoperatively in all of the patients. All patients had a negative intraoperative forced duction test demonstrating free globe movement. Enophthalmos showed complete resolution in the postoperative period. In one of the two patients with preoperative infraorbital nerve paresthesia, this resolved at the postoperative fifth month. Scleral show appeared in six patients but resolved completely within 3-8 weeks with massage. There was no graft extrusion, resorption or displacement during the follow-up period.

CONCLUSIONS

Tecnoss Semi Soft Lamina is a good alternative for the reconstruction of blowout fractures due to its plasticity and biocompatible structure. Without donor site morbidity, it is a safe and appropriate heterologous bone graft material for maxillofacial applications such as orbital floor reconstruction. We cannot recommend its use for near-total, wide orbital floor defects as it may not provide enough support in such circumstances.

Decompressive surgery in a patient with hyperostosis corticalis generalisata for relief of cognitive disability and dysaesthesia

A 28-year-old man with genetically confirmed hyperostosis corticalis generalisata (Van Buchem disease) suffered from headache and progressive cognitive and sensibility disorders. Bone formation of the skull was ongoing, leading to narrowing of the intracranial space and foramen magnum. A large bilateral frontoparietal craniotomy and decompression of the foramen magnum resulted in almost complete relief of his symptoms. This is the first report on successful decompressive surgery as a treatment of cognitive impairment and dysaesthesia.

Arthroscopic treatment of femoral nerve paresthesia caused by an acetabular paralabral cyst

This report describes a rare case of femoral nerve paresthesia caused by an acetabular paralabral cyst of the hip joint. A 68-year-old woman presented with a 6-month history of right hip pain and paresthesia along the anterior thigh and radiating down to the anterior aspect of the knee. Radiography showed osteoarthritis with a narrowed joint space in the right hip joint. Magnetic resonance imaging showed a cyst with low T1- and high T2-weighted signal intensity arising from a labral tear at the anterior aspect of the acetabulum. The cyst was connected to the joint space and displaced the femoral nerve to the anteromedial side. The lesion was diagnosed as an acetabular paralabral cyst causing femoral neuropathy. Because the main symptom was femoral nerve paresthesia and the patient desired a less invasive procedure, arthroscopic labral repair was performed to stop synovial fluid flow to the paralabral cyst that was causing the femoral nerve paresthesia. After surgery, the cyst and femoral nerve paresthesia disappeared. At the 18-month follow-up, the patient had no recurrence. There have been several reports of neurovascular compression caused by the cyst around the hip joint. To the authors' knowledge, only 3 cases of acetabular paralabral cysts causing sciatica have been reported. The current patient appears to represent a rare case of an acetabular paralabral cyst causing femoral nerve paresthesia. The authors suggest that arthroscopic labral repair for an acetabular paralabral cyst causing neuropathy can be an option for patients who desire a less invasive procedure.

[Clinical research of ulnar styloid fracture complicated with wrist dorsal branch of ulnar nerve injury]

OBJECTIVE

To analyze the therapy and effectiveness of ulnar styloid fracture complicated with wrist dorsal branch of ulnar nerve injury.

METHODS

Between October 2005 and October 2012, 16 cases of ulnar styloid fracture complicated with wrist dorsal branch of ulnar nerve injury were treated. There were 14 males and 2 females with an average age of 42 years (range, 22-58 years). Fracture was caused by traffic accident in 8 cases, by mechanical crush in 5 cases, and by falling in 3 cases. According to the anatomical features of the ulnar styloid and imaging findings, ulnar styloid fractures were classified as type I (ulnar styloid tip fracture) in 1 case and type II (ulnar styloid base fracture) in 15 cases. The skin sensation of ulnar wrist was S0 in 5 cases, S1 in 1 case, S2 in 7 cases, and S3 in 3 cases according to the criteria of the British Medical Research Council in 1954 for the sensory functions of the ulnar wrist. The time from injury to operation was 6-72 hours (mean, 18 hours). Fracture was treated by operative fixation, and nerve was repaired by epineurium neurolysis in 13 cases of nerve contusion and by sural nerve graft in 3 cases of complete nerve rupture.

RESULTS

All incisions healed by first intention. Sixteen patients were followed up for an average time of 14 months (range, 6-24 months). The X-ray films showed that all of them achieved bone union at 4-10 weeks after operation (mean, 6 weeks). No patient had complications such as ulnar wrist chronic pain and an inability to rotate. According to Green-O'Brien wrist scoring system, the results were excellent in 13 cases and good in 3 cases; according to the criteria of the British Medical Research Council in 1954 for the sensory functions of the ulnar wrist, the results were excellent in all cases, including 11 cases of S4 and 5 cases of S3+. Two-point discrimination of the ulnar wrist was 5-9 mm (mean, 6.6 mm).

CONCLUSION

For patients with ulnar styloid fracture complicated with wrist dorsal branch of ulnar nerve injury, internal fixation and nerve repair should be performed. It can prevent ulnar wrist pain and promote sensory recovery.

Decompression of inferior alveolar nerve: case report

Paresthesia as a result of mechanical trauma is one of the most frequent sensory disturbances of the inferior alveolar nerve. This case report describes surgical treatment for paresthesia caused by a compressive phenomenon within the mandibular canal. The cause of the compression, a broken instrument left in the patient's mouth during previous endodontic therapy, was identified during routine radiography and computed tomography. Once the foreign object was removed by surgery, the paresthesia resolved quickly. This case highlights the potential for an iatrogenic mechanical cause of paresthesia.

Subjective and functional outcome after revision surgery in carpal tunnel syndrome

INTRODUCTION

In spite of carpal tunnel release's prevalent good postoperative results, the number of revision surgeries needed should not be underestimated. In this study, subjective and functional results after carpal tunnel revision surgery were determined.

MATERIALS AND METHODS

Thirty-eight patients were examined approximately 2 years after their revision surgery of the carpal tunnel release. The subjective outcome of the patients was assessed using two different questionnaires (Amadio and DASH). A clinical examination was undertaken on selected patients who had persistent complaints. The clinical assessment analyzed grip strength, thumb opposition, pulp-to-pulp-pinch, key-pinch, hook-grip, Moberg-Pickup-test, two-point-discrimination, Phalen-test, and the Hoffmann-Tinel-sign.

RESULTS

The subjective assessment showed that after the revision surgery, patients experienced load induced pain that occurred during daytime. However, the revision was able to improve the impaired sensibility. The functional outcome showed a persistent lack of strength when performing daily activities. The clinical assessment of the patients with relevant complaints confirmed the subjective outcome.

CONCLUSION

The revision surgery can improve the impaired sensibility, particularly, paresthesia nocturna. The persistent weakness of the hand can only partly be improved. In spite of remaining complaints, revision surgery can yield satisfactory results for the patients.

Peripheral paresthesia in patients with subacromial impingement syndrome

INTRODUCTION

Some patients presenting with subacromial impingement syndrome complain of tingling and numbness radiating to hand. In the current literature, there is no description of such paresthesia being a part of the clinical picture of impingement syndrome.

OBJECTIVE

This observational study aimed at looking whether these symptoms resolve with successful arthroscopic decompression of the impingement.

MATERIAL AND METHODS

One hundred consecutive patients undergoing arthroscopic surgery were enlisted for the study.

RESULTS

Fifty-four percent reported paresthesia during the course of the shoulder problem (63% of them had radial sided symptoms, 29.6% ulnar-sided symptoms and 7.4% involving all fingers). Significant association was observed between the occurrence of paresthesia and worst pain levels (P = 0.0053), age of the patient (P = 0.0104) and the acromial impingement grade (P = 0.0377). Nerve conduction studies done in seven patients (with paresthesia) selected by systematic random sampling did not show any significant attributable entrapment neuropathy. Up to 12 months follow-up, 48 of 54 (88%) had complete relief of pain and paresthesia and 50 (92.5%) were satisfied.

CONCLUSION

Some patients with subacromial impingement syndrome report associated peripheral paresthesia radiating to hand, which is strongly associated with the age, pain level and the grade of impingement. In most (88%) of such cases, these symptoms are relieved after treatment of the impingment lesion. The incidence and aetiology of such paresthesia is the subject of further studies.

[Free axillary flaps: a versatile area for harvesting of plicable flaps with a nearly undetectable scar]

BACKGROUND

This article is about 7 cases of free axillary flaps based on the lateral thoracic vessels.

PATIENTS AND METHODS

Preoperative ultrasound markings were performed. Indications were defects which needed very smooth and plicable flaps for coverage with a short and well detectable scar.

RESULTS

Flap loss was not noticed, dissection was demanding due to the very small venous drainage of the flaps and took all over 6.5 hours. A comparison with standard flaps of the subscapular vascular system is given.

CONCLUSIONS

The authors recommend the free axillary flap based on the lateral thoracic vessels as a versatile flap for special indications.

Painful os intermetatarseum in athletes: report of four cases and review of the literature

INTRODUCTION

A painful os intermetatarseum, which described the compression of the deep peroneal nerve by an os intermetatarseum, is a very rare condition. The authors reported four cases of painful os intermetatarseum in athletes and reviewed the present literature.

CASE PRESENTATION

We present four cases of a painful os intermetatarseum in athletes, who complained of pain over the dorsum of their foot associated with paresthesias in the first web space. Surgical excision of the os intermetatarseum relieved the pain in all patients. All patients returned to previous sporting activities.

CONCLUSION

We should consider a painful os intermetatarseum as being the cause of dorsal foot pain in athletes, and surgical excision of the os intermetatarseum is effective for these patients.

A novel approach to the diagnosis and management of meralgia paresthetica

OBJECTIVE

To review the results of conservative and surgical treatment of meralgia paresthetica (MP), with particular reference to the use of a simple clinical test for diagnosing this condition and the outcome of primary nerve decompression surgery.

METHODS

Records of all patients with a diagnosis of MP were reviewed. Information was obtained about clinical presentation and risk factors, diagnostic evaluation, management, and outcome. Actuarial analysis was used to determine the intervention-free interval after surgical decompression.

RESULTS

Between 2000 and 2005, MP was diagnosed in 45 patients. There were 27 men and 18 women, and the average age at presentation and duration of symptoms were 47 and 1.9 years, respectively. The pelvic compression test had a sensitivity of 95% and a specificity of 93.3% for this condition. Twenty-five patients were managed conservatively and 20 required operative intervention, which was bilateral in two patients. The average follow-up period was 25 months, and the actuarial 2- and 5-year intervention-free rates were 91 and 78%, respectively, with no specific risk factors for revision surgery.

CONCLUSION

The pelvic compression test is a sensitive and specific test for MP, helping to distinguish it from lumbosacral radicular pain. Most patients with this condition can be managed successfully with conservative measures, and those requiring surgery can be treated effectively with nerve decompression.

Cervical neurapraxia in elite athletes: evaluation and surgical treatment

Object

Neurapraxia, transient posttraumatic paralysis of the motor and/or sensory tracts in the spinal cord, may be a career-ending event in an athlete. Management, rehabilitation, and return-to-play decisions remain controversial.

Methods

Five elite football players were evaluated after experiencing episodes of neurapraxia. All patients experienced bilateral paresthesias—three in all four extremities and two in the upper extremities—lasting a few minutes to more than 24 hours. Transient motor deficits occurred in two individuals but caused no permanent sequelae. Neuroimaging confirmed the presence of herniated discs, focal cord compression, and no parenchymal changes in all cases.

All patients underwent anterior cervical microdiscectomy and fusion, and cervical plates were placed in four. After aggressive rehabilitation and confirmation of fusion ranging from 9 weeks to 8 months postoperatively, the players were allowed to return to active play. Two of the players developed recurrent career-ending disc herniations, one above and the other below the fusion level. One player required repeated spinal cord decompression.

Conclusions

Neurologically intact athletes with focal cord compression due to a single-level herniated disc may safely return to football after undergoing decompressive surgery and confirmation of fusion. It appears, however, that there may be an increased chance of repeated herniation above or below a fused level.

Meralgia paresthetica caused by hip-huggers in a patient with aberrant course of the lateral femoral cutaneous nerve

"Hip-huggers" may be a precipitating factor for meralgia paresthetica (MP), especially in thin persons with an aberrant pathway of the lateral femoral cutaneous nerve (LFCN). We describe a 25-year-old woman with a long-standing history of MP caused by an abnormal course of the LFCN and tight trousers, specifically hip-huggers. Ultrasonography was useful for detecting the lesion site and the abnormal pathway of the LFCN. After neurectomy of the LFCN, most of the symptoms of MP were relieved, but mild hypesthesia remained in the lateral thigh.

Damage to the inferior alveolar nerve as the result of root canal therapy

BACKGROUND

Endodontic treatment of mandibular molar teeth has the potential to damage the inferior alveolar nerve via direct trauma, pressure or neurotoxicity.

METHODS

The author reviewed all cases of involvement of the inferior alveolar nerve resulting from root canal therapy in patients seen in a tertiary referral center during an eight-year period (1998 through 2005). The author had encouraged practitioners to refer patients immediately to a university clinic.

RESULTS

The author saw 61 patients during the eight-year period. Eight patients were asymptomatic and received no treatment. Forty-two patients exhibited only mild symptoms or were seen more than three months after undergoing root canal therapy, and they received no surgical treatment. Only 10 percent of these patients experienced any resolution of symptoms. Eleven patients underwent surgical exploration. Five of these patients underwent exploration and received treatment within 48 hours, and all recovered completely. The remaining six patients underwent surgical exploration and received treatment between 10 days and three months after receiving endodontic therapy. Of these patients, four experienced partial recovery and two experienced no recovery at all.

CONCLUSIONS

Early surgical exploration and débridement may reverse the side effects of endodontic treatment on the inferior alveolar nerve.

CLINICAL IMPLICATIONS

If the radiograph obtained after endodontic therapy shows sealant in the inferior alveolar canal, then immediate referral to an oral and maxillofacial surgeon is indicated if the patient has continued symptoms of paresthesia or pain once the local anesthetic should have worn off. Immediate surgical exploration and débridement may provide satisfactory results.

[The iatrogenic carpal tunnel syndrome--case report]

An inadequate indication for a carpal tunnel revision procedure may be followed by disastrous sequelae for the patient. So it may be justified to talk of iatrogenic CTS. A patient suffering from bilateral CTS is presented who had been operated on six times in all. The following techniques had been used by an orthopedic surgeon, a neurologist, a neurosurgeon and a hand surgeon: microsurgical neurolysis, epineurectomy, neuroma resection, tenosynovectomy and finally a hypothenar fat flap. Initial cause for this fatal series was scar tenderness following lesion of the muscular and palmar branches of the median nerve in the first or second operation. Since sensory nerve conduction was normal after decompression had been performed, there would have been no indication for further surgery of the median nerve. Resection of the neuromas of the two injured branches was not followed by any relief for the patient nor did wrapping the nerve in a fat flap help. Such courses may lead to high costs in health care and occupational disability. They can be avoided by competent neurological and electrophysiological examination, correct interpretation of findings as well as critical consideration of the indication for revision procedures.

Clinical profile, electrodiagnosis and outcome in patients with carpal tunnel syndrome: a Singapore perspective

INTRODUCTION

Carpal tunnel syndrome (CTS ) is the most common entrapment neuropathy seen in our neurodiagnostic laboratory referrals. We describe the clinical profile, and outcome in patients with electrophysiological diagnosis of CTS seen in our centre over a six month period.

METHODS

A retrospective study was carried out and included 134 consecutive patients with CTS referred to the Neurodiagnostic Laboratory, National Neuroscience Institute, from October 2003 to March 2004, for the confirmatory testing. Severity grade was assigned following American Association of Electrodiagnostic Medicine criteria of CTS.

RESULTS

The majority of patients were female (81.3 percent) with mean age of presentation being 53.6 years. Chinese women constitute the majority racial group. Paraesthesia (70.1 percent) and numbness (19.4 percent) were the presenting sensory symptoms. In the nerve conduction study, 108 patients had bilateral CTS with 35 having unilateral symptoms. Dominant hand involvement was present in 92.3 percent. Overall, 40.3 percent had mild, 46.3 percent had moderate and 13.4 percent had severe CTS, with median duration of symptoms of two, four and 12 months, respectively. Follow-up data were available for 115 patients. 27 patients with surgical treatment showed resolution or improvement in 53.3 percent with moderate CTS, and 83.3 percent with severe CTS, at three-month follow-up. 14 patients turned up for six-month follow-up and 92.9 percent showed improvement in symptoms. 88 patients were managed conservatively; symptoms were unchanged or worsened in 80.6 percent with mild CTS, 65.9 percent with moderate CTS, and 62.5 percent with severe CTS at three-month follow-up. Of the 54 patients who turned up for six-month follow-up, the clinical symptom remain unchanged or worsened in 68.5 percent.

CONCLUSION

The severity of CTS is associated with longer duration of symptoms. Sensory symptoms and dominant hand involvement is more common. There is a high default rate in the clinical follow-up. Early surgical intervention results in either resolution or improvement in symptoms, whereas conservative management does not affect the natural history with symptoms that persisted or worsened with time.

Ulnarisläsion nach Osteosynthese der suprakondylären Humerusfraktur im Kindesalter

Since 1948, closed reduction and osteosynthesis for supracondylar humeral fractures using two K-wires from the medial and lateral side has been performed on a regular basis. Although this procedure is used routinely, many authors have described paralysis of the ulnar nerve after blindly inserting the medial K-wire. Only very few publications describe the treatment options after iatrogenic paralysis of this nerve. The patients described showed progressive paralysis of the ulnar nerve after K-wire osteosynthesis. Intraoperatively, all patients showed scarring but intact continuity. After surgical revision and neurolysis, all four patients showed complete restitution after 1 year. If patients show progressive paralysis of the ulnar nerve early operative revision after 3 months should be performed.

[Effect analysis of surgery for treating abnormal styloid process]

OBJECTIVE

To analyze the relationship between pharyngeal paraesthesia and abnormal styloid process, and to evaluate the surgery outcome.

METHODS

One hundred and four patients with styloid process abnormality, especially those with pharyngeal paraesthesia were studied preoperatively and postoperatively.

RESULTS

Among 104 patients who complained about foreign body sensation of the pharynx and a sore throat, after partial removal of styloid process, 71.2% (74/104) cured (symptoms disappeared), 12.5% (13/104) improved, while 16.3% (17/104) had no improvement. The responding rate was 83.7% (87/104).

CONCLUSIONS

Not all abnormality of styloid process subjects would have pharyngeal paraesthesia, so for this kind of cases a more comprehensive analysis is necessary. Surgery via mouth is preferable.

Sutureless Revision of Overhanging Filtering Blebs

We describe methods and outcomes of a technique for sutureless surgical revision of symptomatic corneal overhanging filtering blebs after trabeculectomy using mitomycin in 6 eyes in 6 patients. Separation of the bleb from the corneal surface was achieved by blunt or sharp dissection, as necessary, and the overhanging portion of the bleb was excised and a bandage contact lens was inserted. Outcome measures included symptomatic relief, retention of bleb function, and maintenance of intraocular pressure. Five eyes (83.3%) demonstrated symptomatic relief and a cosmetically acceptable appearance. One patient continued to have dysesthesia, and 1 patient had bleb leak that required suture repair. Sutureless surgical revision of overhanging filtering blebs is a safe and effective technique to reduce bleb-related dysesthesia and improve cosmesis without compromising filtration function.

Decompression of the lateral femoral cutaneous nerve in the treatment of meralgia paresthetica

Meralgia paresthetica (MP) is a painful mononeuropathy of the lateral femoral cutaneous nerve (LFCN). Neurolysis is reserved for patients with MP who respond poorly to medical management. This study retrospectively evaluated the outcomes of 41 patients who underwent either unilateral or bilateral neurolysis of the LFCN for a total of 48 procedures. Twenty-nine procedures involved neurolysis of the LFCN alone and 19 procedures involved neurolysis of the LFCN and resection of one or more additional nerves (ilioinguinal, iliohypogastric, genitofemoral). Overall, surgical outcome was considered by patients to be successful in 77 percent of cases. LFCN neurolysis alone had better results, compared to combined LFCN neurolysis and nerve resection. The conclusion is that neurolysis of the LFCN is an effective treatment for MP in properly selected patients.

Injury of the dorsal sensory branch of the ulnar nerve as a complication of arthroscopic repair of the triangular fibrocartilage

This report presents a case of direct injury to the dorsal sensory branch of the ulnar nerve caused by arthroscopic repair of the triangular fibrocartilage complex. The dorsal sensory branch of the ulnar nerve was strangulated by one of the three pull-out sutures of the joint capsule, just ulnar to the extensor carpi ulnaris tendon. Pain and dysaesthesia of the ulnar side of the wrist was completely relieved after excision of the injured nerve segment. This complication can be avoided by careful exploration of the dorsal sensory branch of the ulnar nerve prior to suturing or passage of instruments during arthroscopy.

Meralgia paresthetica: A retrospective analysis of 79 patients evaluated and treated according to a standard algorithm

BACKGROUND

The efficacy of various treatment modalities in meralgia paresthetica (MP) is not established. We retrospectively evaluated the management of spontaneous MP (i.e. MP not secondary to trauma or surgery) according to a standard algorithm.

METHODS

Initial management included oral medications, rest, and reduction of aggravating factors. Non-responders underwent a diagnostic local anesthetic nerve block test. Patients who responded with transient symptomatic relief were treated by local infiltration of corticosteroids. Surgical intervention was reserved for patients with positive nerve block test, who did not respond to nonoperative measures.

RESULTS

A negative nerve block test ruled out the diagnosis of MP in 6/86 patients. Of 79 patients with MP, 21 responded to the initial nonoperative treatment and 48 patients responded to local corticosteroids. 3 of the remaining 10 patients underwent surgery (nerve transection 2, neurolysis 1). During an average of 3 (1-13) years of follow-up, symptoms consistent with MP did not recur in any of the 72 patients in whom symptoms had resolved after treatment.

INTERPRETATION

The algorithm used proved to be useful in the management of spontaneous meralgia paresthetica.

Surgical Reduction of Symptomatic, Circumferential, Filtering Blebs

We describe methods and outcomes of surgical reduction of symptomatic, circumferential, filtering blebs after trabeculectomy with antifibrotic agents. The medical records of 15 eyes of 14 patients with symptomatic, circumferential blebs who underwent surgical bleb reduction for bleb dysesthesia under topical anesthesia were reviewed. Each bleb was incised segmentally and the cut edges of the conjunctiva and Tenon capsule were sutured to the underlying sclera. Outcome measures included symptomatic relief, retention of bleb function, and intraocular pressure maintenance. Fourteen eyes had successful reduction of bleb size, symptomatic relief, and cosmetically acceptable appearance. One eye continued to have dysesthesia and 1 had a transient bleb leak that resolved spontaneously. Surgical reduction of circumferential, symptomatic, filtering blebs is a safe and effective technique to reduce bleb dysesthesia and improve cosmesis without loss of bleb function.

Superficial peroneal nerve syndrome: an unusual nerve entrapment

✓Lower-extremity pain and paresthesia have multiple origins. Early recognition of the symptoms of peripheral nerve entrapment leads to timely treatment and avoids the cost of unnecessary studies. The authors report on a case of superficial peroneal nerve syndrome resulting from nerve herniation through a fascial defect, which was responsive to surgical treatment.

This 22-year-old man presented with pain and paresthesias over the lateral aspect of the right calf and the dorsum of the foot without motor weakness. Exercise led to the formation of a tender bulge approximately 12 cm above the lateral malleolus. Percussion of this site worsened his symptoms. Radiography and electromyography studies were nondiagnostic. The patient underwent surgical decompression that involved division of the fascia overlying the nerve and neurolysis of the superficial peroneal nerve. The operation resulted in symptom-free relief.

Superficial peroneal nerve syndrome is an entrapment neuropathy that results from mechanical compression of the nerve at or near the point where the nerve pierces the fascia to travel within the subcutaneous tissue. Surgical decompression of the mechanical entrapment usually provides relief from pain and paresthesia.

Osteochondroma of the cervical spine extending multiple segments with cord compression

Involvement of the cervical spinal cord by a solitary osteochondroma is rare. We describe a case of cervical osteochondroma extending from C5 to C7 in a 16-year-old male. The tumor, arising from the inner aspect of the C6 spinous process, projected longitudinally into the spinal canal and compressed the spinal cord; this caused clinical symptoms associated with myelopathy and radiculopathy. Total excision of the tumor by C5-C7 hemilaminectomy resulted in a good functional recovery.

A variant of Kaplan's accessory branch of the dorsal cutaneous branch of the ulnar nerve: a case report and review of the literature

Kaplan's accessory branch is an aberrant branch of the dorsal cutaneous branch of the ulnar nerve that arises proximal to the styloid process of the ulna and courses ulnar to the pisiform. Variations of this anomaly have been described as having an end point of connection to the sensory branch of the ulnar nerve, to the motor branch of the ulnar nerve (rare), to the digital nerve at the level of the midhypothenar eminence, or to the proximal interphalangeal joint of the small finger or as running as an independent branch to the volar aspect of the small finger. We report a variant of Kaplan's accessory branch that coursed through the insertion of the flexor carpi ulnaris, a groove on the ulnar aspect of the pisiform, and connected to the ulnar nerve trunk proximal to its bifurcation into its motor and sensory branch. Based on the findings of the case presented and a review of the literature we offer a classification system for this anomaly.

Transient Global Amnesia After General Anesthesia

Transient global amnesia (TGA) is an amnestic syndrome, clinically dramatic but benign in nature. The hallmark of TGA is brief inability to form new memories and recall past memories despite otherwise normal neurological function. In a significant number of patients with TGA a stressful precipitating factor can be identified. We report two cases of TGA after uneventful general anesthesia. Anesthesia per se does not appear to be a direct trigger of TGA, as our first patient had a second anesthetic the next day without recurrence of TGA. Because the presentation of TGA can be dramatic and may mimic an acute cerebral ischemic event, a thorough neurologic evaluation should be pursued.

Iatrogenic paresthesia in the third division of the trigeminal nerve: 12 years of clinical experience

BACKGROUND

Iatrogenic paresthesia in the third division of the trigeminal nerve remains a complex clinical problem with major medicolegal implications. However, most lawsuits can be prevented through better planning of procedures and by obtaining informed consent. The purpose of this article is to present the authors" clinical experience over the past 12 years, to review the principles of prevention and management of trigeminal paresthesia and to highlight the resulting medicolegal implications.

METHODS

The files of all 165 patients referred to the oral and maxillofacial surgery department for evaluation of iatrogenic paresthesia in the third division of the trigeminal nerve were reviewed. The characteristics of the subgroup of patients who had taken an attending dentist to court were compared with those of the other patients.

RESULTS

Surgical extraction of impacted molars was the main cause of paresthesia in 109 (66%) of the 165 subjects. The alveolar nerve was affected in 89 (54%) subjects, the lingual nerve in 67 (41%) subjects, and both nerves were affected in 9 (5%) subjects. There were more female than male patients (ratio 2.2:1). Lawsuits were initiated in 33 (20%) of the cases; patients who initiated lawsuits were younger, were more likely to have experienced anesthesia and were more likely to need microsurgery (all p < 0.001). Poor surgical planning and lack of informed consent were the most common errors on the part of the dentists.

CONCLUSIONS

An accurate evaluation of surgical indications and risk, good surgical technique, preoperative informed consent and sufficient postoperative follow-up should help to reduce the frequency of neurosensory deficits after dental treatment and attendant lawsuits.

Neurolysis for meralgia paresthetica: an operative series of 45 cases

BACKGROUND

Failure of symptom relief after neurolysis for meralgia paresthetica (MP) is reported frequently, yet systematic outcome analysis is limited in the modern literature. The present operative series of 45 cases aims to address this issue.

METHODS

From 1996 to 2000, all patients who had neurolysis for MP by our senior author were enrolled in the study. Nerve entrapment was confirmed preoperatively by electrophysiological studies or a positive response to local anesthetic and steroid injection. Attention to the anatomical variability of the lateral femoral cutaneous nerve was made during nerve exploration. Decompression of the nerve was performed at the level of the iliac fascia, the inguinal ligament, and the fascia of the thigh distally. The outcome of surgery was assessed 6 weeks after the procedure followed by 3 monthly intervals if symptoms persisted. Telephone interviews were conducted to assess long-term results.

RESULTS

Forty-five decompressive procedures were performed in 42 patients over the 5-year period. The average duration of symptoms was 31 (2.5-180) months. All patients were followed for an average of 4.1 years. Complete and partial symptom improvements were noted in 33 (73%) and 9 (20%) cases, respectively. No recurrence was reported. Analysis of clinical variables demonstrated that the duration of symptoms preoperatively did not affect the rate of complete symptom relief, but obese patients (body mass index > 30) was 6 times more likely to have (odds ratio 6.16, P = 0.04) incomplete relief after surgery at long-term follow-up.

CONCLUSION

High success rate was recorded in our series of 45 cases. Prolonged duration of symptoms did not preclude favorable outcome but obesity had a negative association with good outcome.

Successful inferior alveolar nerve decompression for dysesthesia following endodontic treatment: report of 4 cases treated by mandibular sagittal osteotomy

Endodontic overfilling involving the mandibular canal may cause an injury of the inferior alveolar nerve (IAN) resulting in disabling sensory disturbances such as pain, dysesthesia, paresthesia, hypoesthesia, or anesthesia. Two fundamental mechanisms are responsible for the injury: the chemical neurotoxicity and the mechanical compression caused by the extruded material. Although spontaneous resorption has been described for some materials, early surgical exploration with removal of the material and decompression of the IAN should be performed, irrespective of the material used, given that the importance of nerve damage increases with the duration of the injury. We report 4 cases of disabling dysesthesia and paresthesia following endodontic treatment of lower molars in which sagittal osteotomy was used to remove the endodontic paste and to perform nerve decompression. All the patients experienced immediate relief of dysesthesia and paresthesia.

Long-term clinical and neurologic recovery in the hand after surgery for severe cubital tunnel syndrome

PURPOSE

Functional outcomes of cubital tunnel surgery may decline as the severity of preoperative ulnar neuropathy increases. When functional recovery will be adequate, or whether tendon transfers should be required, may be unclear. We investigated the extent of functional recovery, the duration of the recovery process, and the necessity of restoring intrinsic muscle function in patients with severe cubital tunnel syndrome after surgery.

METHODS

We retrospectively studied outcomes after cubital tunnel release in 15 patients with marked intrinsic muscle atrophy, claw-hand deformity, immeasurable (electrically silent) sensory and motor nerve conduction velocities, and Semmes-Weinstein test (SWT) results ranging from purple (3.84-4.31) to red (4.56-6.65). We evaluated subjective (numbness and activities of daily living [ADL] disturbances), objective (manual muscle testing [MMT] of index-finger abduction, and SWT), and neurophysiologic (nerve conduction velocity) outcomes. Overall functional outcome was evaluated by Akahori's criteria.

RESULTS

At a median follow-up evaluation of 4.5 years all outcomes had improved. Numbness was gone in 5 patients and greatly reduced in 9 patients; 6 patients reported slight difficulties in ADLs; and 9 patients had no difficulties. Motor nerve conduction velocity was measurable (mean, 35.3 m/s) in all 15 patients and sensory nerve conduction velocity was measurable (mean, 43.4 m/s) in 12. Recoveries in nerve conduction velocities persisted beyond 2 years. The SWT results were blue (3.22-3.61) in 6 patients, purple (3.84-4.31) in 8 patients, and red (4.56-6.65) in 1 patient. MMT of index finger abduction was grade 4 or 5 in 11 of 15 patients. Half the patients over 70 years old, however, were grade 3 or less. Akahori's criteria were excellent in 3 patients, good in 6 patients, and fair in 6 patients.

CONCLUSIONS

Patients with severe intrinsic muscle atrophy and absent motor and sensory nerve conduction velocities can expect satisfactory long-term functional results after surgery. Function continues to improve beyond 2 years. Restoring index finger abduction is not always necessary for ADLs, although recovery requires several years and is poorer in the elderly.

Outcomes of Cubital Tunnel Surgery among Patients with Absent Sensory Nerve Conduction

OBJECTIVE

To report the outcomes of cubital tunnel surgery for patients with absent ulnar sensory nerve conduction.

METHODS

The charts of 34 patients who exhibited clinical symptoms of ulnar nerve entrapment at the elbow and who had electromyography-confirmed prolonged motor nerve conduction across the cubital tunnel in association with absent sensory nerve conduction were reviewed. The mean age was 63 years, and the mean symptom duration was 17 months. Four patients had bilateral symptoms. Surgery was performed for 38 limbs, i.e., neurolysis for 21 limbs and subcutaneous transposition for 17 limbs. Fifteen limbs demonstrated associated ulnar nerve-related motor weakness. The mean postoperative follow-up period was 4 years (range, 3 mo to 11 yr).

RESULTS

Sensory symptoms (i.e., pain, paresthesia, and two-point discrimination) improved in 20 limbs (53%), and muscle strength improved in 2 limbs (13%). Improvements in sensory symptoms were not related to patient age, symptom duration, cause, severity of prolonged motor nerve conduction, select psychological factors, associated medical diseases, associated cervical pathological conditions, or type of surgery. Improvements in sensory symptoms were significantly decreased among patients who had experienced cervical disease for more than 1 year and patients with bilateral symptoms.

CONCLUSION

Patients with cubital tunnel syndrome who have absent sensory nerve conduction seem to experience less improvement of sensory symptoms after surgery, compared with all patients with cubital tunnel syndrome described in the literature. Bilateral symptoms and delayed surgery secondary to associated cervical spine disease seem to be significant negative factors for postoperative improvement of sensory symptoms. Sensory symptoms improved similarly among patients who underwent neurolysis or subcutaneous transposition

Nerve injury and limb lengthening after hip replacement: treatment by shortening

Nineteen patients had a severe neurologic deficit and persistent dysesthetic pain after total hip replacement. During surgery their limbs had been lengthened by 1.3 to 4.1 cm. Patients with other reasons for nerve injury such as hematoma, dislocation, or direct operative trauma were excluded. Also excluded were patients whose lengthening was part of the operative plan to address previous shortening. None of the patients had neurologic deficits or dysesthetic pain preoperatively. Patients were offered revision hip surgery to shorten the limb. Seventeen patients proceeded to surgery. Two acetabular revisions, five modular femoral head exchanges, and 10 femoral component revisions were done. The average shortening was 1.5 cm (range, 0.5-3.6 cm). The trochanter was advanced in four patients and a constrained acetabular liner was used in four patients. Nine hips were stable without additional measures. There were no complications and nine patients had an excellent result. This was defined as elimination of their dysesthetic pain. Two patients had partial improvement and six patients had no improvement. Seven of 11 patients with motor deficits had improvement in strength with three making a full recovery. When painful neurologic symptoms accompany limb lengthening after total hip replacement, revision surgery may be helpful, although patients should be informed the rate of success is far from uniform.

[Surgical treatment of meralgia paresthetica: case report]

Meralgia paresthetica is characterized by pain, paresthesias or burning, and decreased touch and pain sensation on the anterolateral aspect of the thigh. It is due to neuropathy of the lateral femoral cutaneous nerve (LFCN). Conservative treatment is usually successful in relieving the symptoms in most of the patients. We describe a case of a woman, 37 years old, who required surgical treatment for intractable symptoms. Although neurolysis with transposition is the most common procedure, we preferred neurectomy with excision of a portion of the LFCN for its very low recurrence rate as opposed to neurolysis. The area of anesthesia generated by this procedure in the distribution of the LFCN tends to shrink with time. This patient achieved excellent outcome following this surgical technique.

A new technique for the treatment of lumbar far lateral disc herniation: technical note and preliminary results

A newly designed technique for a minimally invasive approach to the laterally herniated disc is presented. Fifteen patients suffering from far lateral disc herniation (extraforaminal) were operated according to this technique. Through a small skin incision (1.5 cm), the paraspinal muscles are spread by dilators, until a working channel of 9 mm inner diameter and 11 mm outer diameter can be placed. The next steps are done through this channel using the surgical microscope. No bone resections are necessary and the facet joints are left untouched. However, partial resection of the intertransverse ligament may be necessary. The mean follow-up period for these 15 patients was 11.5 months, and they were evaluated by using the visual analogue scale (VAS) and the Oswestry Disability Index (ODI). The average surgical time was 43 min. The ODI improved from 30.6 (preoperative) to 14.3 (postoperative). The VAS of leg pain improved from 7 (preoperative) to 3.6 (postoperative), which represented a statistically significant improvement at the significance level of (P<0.01). No intra-operative or early postoperative complications occurred. However, one recurrence did occur, which was treated by the same technique. This technique combines the advantages of three-dimensional visual control (operating microscope) with the minimal surgical trauma of endoscopic techniques, while avoiding some of the shortcomings of both the microsurgical and endoscopic techniques.