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Distal median neuropathy from carpal tunnel syndrome is the most well known lesion affecting the median nerve. Mass lesions may affect the nerve at the wrist. We present to our knowledge the first histologically confirmed case of an intraneural fibroma., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

We report a 42-year-old man with a rare carpal tunnel syndrome (CTS) secondary to an osteophyte of the trapezium. The patient presented with a 3-year history of CTS, consisting of progressive pain and paresthesias in his right hand, positive Tinel and Phalen signs, and an electrodiagnostic study demonstrating median nerve compression at the wrist. The procedure was an open carpal tunnel release. Intraoperatively, a bony protuberance was found beneath the transverse carpal ligament (TCL), resulting in compression of the median nerve. The median nerve was decompressed and the patient's symptoms resolved postoperatively. Surgical pathology revealed bony fragments, and a postoperative CT scan was supportive of an osteophytic remnant protruding from the trapezium. Carpal bone osteophytes are rarely reported causes of CTS., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

We report on the use and follow-up of direct peripheral nerve stimulation of the median nerve for the treatment of iatrogenic complex regional pain syndrome (CRPS). A 56-year-old woman presented with CRPS type II in the right forearm and hand, which had started after multiple carpal tunnel surgeries and had lasted for 2 years. The visual analogue scale (VAS) score was 8-10 out of 10. After a successful 15-day trial of median nerve peripheral nerve stimulation via a quadripolar lead in the right carpal tunnel space, an implantable pulse generator was inserted in the right infraclavicular space. The VAS score decreased to 1-2 out of 10 and the patient regained the ability to sleep. After 36 months of follow-up, the patient was still experiencing good pain relief without other treatment. We conclude that peripheral nerve stimulation is easy to use in pain management and could offer a valid treatment option for iatrogenic CRPS type II.

During open carpal tunnel release in patients with severe idiopathic carpal tunnel syndrome, an area of constriction in the substance of the median nerve is frequently noted. In a prospective study of 30 patients, the central point of the constricted part of the nerve was determined intraoperatively and found to be, on average, 2.5 (range 2.2-2.8)cm from the distal wrist crease. This point always corresponded to the location of the hook of the hamate bone. These intraoperative findings were compared with the "narrowest" point of the carpal canal as determined by anatomical and radiological studies in the literature.

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.

The outcome after nerve repair in adults is generally poor. We hypothesized that forearm deafferentation would enhance the sensory outcome by increasing the cortical hand representation. A prospective, randomized, double-blind study was designed to investigate the effects of cutaneous forearm anaesthesia combined with sensory re-education on the outcome after ulnar or median nerve repair. During a 2 week period, a local anaesthetic cream (EMLA (n = 7) or placebo (n=6) was applied repeatedly onto the flexor aspect of the forearm of the injured arm and combined with sensory re-education. Evaluation of sensory function was carried out at regular intervals and at 4 weeks after the last EMLA/placebo session. The EMLA group showed significant improvement compared to placebo in perception of touch/pressure, tactile gnosis and in the summarized outcome after 6 weeks. These results suggest that cutaneous forearm anaesthesia of the injured limb, in combination with sensory re-education, can enhance sensory recovery after nerve repair.

The midline of the ring finger is classically considered as the neural watershed between the median and ulnar nerve sensory territories on the palmar surfaces of the fingers. Variations of this division exist and may be explained by a communicating branch between the third and fourth common digital nerves. The palmar sensibility patterns of fingers were assessed with Semmes Weinstein filaments after either a complete median or an ulnar nerve transection in 43 patients. Eight out of nine observed sensibility patterns could be explained by known anatomic types and subtypes of the communicating branch. The type of communicating branch, but not its subtype, could be established in the one remaining pattern.

The long-term outcome from silicone tube nerve repair was compared with the outcome from routine microsurgical repair in a clinical randomized prospective study, comprising 30 patients with median or ulnar nerve injuries in the distal forearm. Postoperatively, the patients underwent neurophysiological and clinical assessments of sensory and motor function regularly over a 5-year period. After 5 years there was no significant difference in outcome between the two techniques except that cold intolerance was significantly less severe with the tubular technique. In the total group there was ongoing improvement of functional sensibility throughout the 5 years after repair. It is concluded that tubular repair of the median and ulnar nerves is at least as good as routine microsurgical repair, and results in less cold intolerance.

Two hundred and seventy-three patients with carpal tunnel syndrome without advanced neurophysiological changes (distal motor latency below 11 ms) were randomized to treatment by open carpal tunnel release with, or without, epineurotomy. Patients were examined clinically and by nerve conduction studies preoperatively and at 3, 6 and 12 months postoperatively. We found no statistically significant difference between simple decompression and decompression combined with epineurotomy with regard to either the clinical or the neurophysiological outcome.

A longitudinal dynamic cohort study was conducted on patients with median nerve injuries to evaluate the relative responsiveness of five sensibility tests: touch threshold using the WEST (monofilaments), static two-point discrimination, locognosia, a pick-up test and an object recognition test. Repeated assessments were performed starting at 6 months after surgery. In order to compare the relative responsiveness of each test, effect size and the standard response mean were calculated for sensibility changes occurring between 6 and 18 months after repair. Large effect sizes (>0.8) and standard response means (>0.8) were obtained for the WEST, locognosia, pick-up and object recognition tests. Two-point discrimination was hardly measurable at any time point and exhibited strong flooring effects. Further analysis of all time points was undertaken to assess the strength of the monotonic relationship between test scores and time elapsed since surgery. Comparison of monotonicity between the five tests indicated that the WEST performed best, whereas two-point discrimination performed worst. These results suggest that the monofilament test (WEST), locognosia test, Moberg pick-up test and tactile gnosis test capture sensibility changes over time well and should be considered for inclusion in the outcome assessment of patients with median nerve injury.

A 45-year-old right-handed woman was treated by endoscopic carpal tunnel release under local anaesthetic. When cutting the proximal half of the flexor retinaculum with the retrograde blade, she complained of an electric shock-like pain in her middle and ring fingers. Open exploration of the carpal tunnel was performed and a laceration of the middle/ring common digital nerve, which bifurcated at the unusually high level of the wrist crease, was found.

We reviewed 14 patients treated with either an ulnar or a hypothenar fat flap for recurrent carpal tunnel syndrome and scar tenderness. Nine patients were satisfied and there were few complications. One patient had delayed skin healing and another developed a hypertrophic scar.

This study prospectively assessed the level of correlation between functional and electrophysiological recovery after median and ulnar nerve lacerations. Motor and sensory recovery were recorded clinically and electrophysiologically every 3 months in 24 patients with 29 complete median or ulnar nerve lacerations. The strength of agreement between the clinical motor score and the electrophysiological score was "fair", but in 41% a discrepancy was identified (kappa factor 0.39). Regeneration was not detected earlier by electrophysiology than by a thoroughly performed clinical evaluation. This suggests that electrophysiologic testing is of value as an adjunct to clinical assessment for evaluating cases in which there is clinical doubt as to the progress of regeneration and secondary surgery is contemplated.

Ten forearm and hand specimens from fresh cadavers were dissected and examined under magnification for articular branches to the trapeziometacarpal joint arising from the thenar and palmar cutaneous branches of the median nerve, the superficial branch of the radial nerve and the lateral cutaneous nerve of forearm. In all but one specimen the thenar branch of the median nerve sent an articular branch to the trapeziometacarpal joint. Multiple branches from the palmar cutaneous branch of the median nerve, the superficial branch of the radial nerve and the lateral cutaneous nerve of forearm were also found. All these branches need to be divided during a "complete" denervation of the trapeziometacarpal joint., (Copyright 2002 The British Society for Surgery of the Hand.)

This study presents a predicted five-year reference interval for the outcome following repair of the median or ulnar nerve in adults. Forty-four patients were examined with the use of a recently introduced model instrument for documentation after nerve repair that includes "sensory", "motor", and "pain/discomfort" outcomes which together constitute a summarized "total score". Analysis of the "total score" showed that follow-up time and age significantly influence the outcome. There were obvious inferior "motor" results after ulnar nerve injury, but these did not significantly influence the "total score". Significant improvements in the "total score" were seen throughout the follow-up period., (Copyright 2001 The British Society for Surgery of the Hand.)

In this study, motor re-innervation of the median nerve by transfer of one-third, one-half, and two-thirds of either the agonistic ulnar nerve or the antagonistic radial nerve was investigated in both extremities of 20 rabbits. Recipient median nerve: Muscle contraction force of the flexor digitorum sublimus muscle after a one-third and a one-half of the ulnar nerve transfer achieved an average of 75 and 97% muscle power respectively as compared to conventional end-to-end neurorrhaphy. Muscle contraction force after one-third or one-half of the radial nerve transfer was significantly lower (36%). Donor nerves: Extensor carpi radialis muscle or flexor carpi ulnaris muscle contraction force 6 months postoperatively demonstrated a significant decrease after a one-half ulnar nerve and a two-thirds ulnar or radial nerve transfer, but not after a one-third transfer of either radial or ulnar nerves. Histologically, the number of axons in the re-innervated median nerve and both donor nerves distal to the coaptation site seemed to follow variable patterns. It was concluded that in the rabbit use of one-third of the agonistic ulnar nerve for re-innervation of the median nerve results in useful motor recovery with negligible donor site morbidity. Clinically, this technique may offer an alternative option for proximal nerve injuries or for free functioning muscle transplantations.

This prospective study was carried out to assess motor and sensory recovery after contralateral C7 root to median nerve neurotization in brachial plexus injuries with total root avulsions. The survey was carried out from 1993 to 1995 and the patients were followed up for at least 3 years. There were 96 male patients with ages ranging from 13 to 48 years. All had a unilateral brachial plexus injury with avulsion of all roots. This was confirmed by clinical assessment and exploration. The anterior part of the contralateral C7 root was used for neurotization via a reversed pedicular ulnar nerve graft and the proximal end of the graft was connected to the median nerve. Furthermore, phrenic nerve to suprascapular nerve and spinal accessory nerve (via a sural nerve graft) to musculocutaneous nerve neurotizations were also carried out to obtain shoulder abduction and elbow flexion. At the 3 year follow-up, most patients had encouraging recovery of sensory function in the hand but motor function of the forearm and hand muscles was rather poor. Acceptable motor function was found in only 50 to 60% of the patients who were younger than 18 years.

Intraneural synovial sarcomas are extremely rare in the main nerve trunks of the upper limb. We report on a 16-year-old youth who presented with a painless mass on the flexor aspect of the wrist with the clinical appearance of a ganglion. At operation there was a tumour of the median nerve that was shown on histology to be an intraneural synovial sarcoma.

In a patient with severe, recurrent bilateral carpal tunnel syndrome secondary to mucolipidosis, the 'turnover' palmaris brevis flap was used in conjunction with internal neurolysis. The procedure was effective in alleviating symptoms of recurrent carpal tunnel compression in both hands.

Relatively little is known about the effects of chronic transection on human peripheral nerves. In this study intraoperative biopsies were obtained from proximal and distal nerve stumps and intervening neuromas resected before peripheral nerve reconstruction. Biopsies were collected from ten patients following differing types of nerve injury, with delays to repair ranging from 8 to 53 months. Nerves were examined by light and electron microscopy. In general, reinnervation was poor, although even following the most severe injuries, all of the distal stumps contained some regrowing axons, which were always associated with Schwann cells. Denervated Schwann cells, arranged in typical bands of Büngner were consistently present in each distal stump. Our findings confirm that the morphology of chronically denervated human peripheral nerves is essentially similar to that described in experimental models.

Piezoresistive sensors, applied to the fingertips of non-sensate fingers, were used for the detection of touch and pressure in four patients with recent median nerve repairs, and in one patient using a myoelectric prosthesis. The signals from the sensors, produced by the tactile stimuli, were processed and transposed as electrical stimuli to sensate skin of the ipsi- or contralateral arm by the use of skin electrodes. With this setup the test subjects could rapidly learn to differentiate between tactile stimuli applied to different fingers, thereby regaining spatial resolution in the hand. All five patients rapidly improved their ability to regulate the power of pinch grip without the help of vision. The patient with a hand prosthesis rapidly learned to discriminate between four different levels of pressure, applied to the thumb by four different Semmes--Weinstein monofilaments (75, 125, 280 and 450 g). These results indicate that the system is of potential value for patients lacking sensibility or using prostheses.

Six sheep underwent repair of the median nerve in the forearm using freeze-thawed muscle autografts, along with the establishment and repair of a "fracture" adjacent to the site of nerve injury. The "fracture" was created by making a transverse osteotomy of the radius. It was repaired using an 8-hole dynamic compression plate. A further six sheep underwent similar treatment with the repair of the nerve delayed for 30 days after the establishment of the long-bone injury. Six months after the nerve repair, each group of sheep was assessed using electrophysiological and morphometric methods in order to establish objective indices of nerve recovery and regeneration. It was found that delay of the nerve repair and the presence of a complicating long-bone injury, both separately and additively, contributed to a poorer outcome in recovery of nerve function and maturation.

The performance of a variety of common office-based clinical tests for detection of carpal tunnel syndrome (CTS) was assessed in 119 subjects with and without electrophysiological evidence of CTS. Symptoms compatible with CTS and electrophysiological tests positive for median mononeuropathy at the wrist were observed in 57 hands, symptoms compatible with CTS and normal electrophysiological test results were observed in 58 hands, and no symptoms compatible with CTS and normal electrophysiological test results were observed in 123 hands. For all the diagnostic tests studied, the proportion of subjects who had a false positive clinical test result was much higher in the electrophysiologically normal subjects who had CTS compatible hand symptoms than in the electrophysiologically normal subjects who were asymptomatic. These results suggest that many studies that have evaluated diagnostic tests for CTS have produced falsely optimistic estimates of the test's performance because of their use of asymptomatic comparison subjects.

Thirteen painful end-neuromas of nerves of the palm and the dorsum of the hand were treated by resection of the neuroma and relocation of the nerve ends into the pronator quadratus muscle proximal to the wrist in ten patients. The effectiveness of this treatment was assessed by measurement of changes in level of spontaneous pain, pain on pressure, pain on movement and hyperaesthesia at the original site and at the site to which the nerve was relocated. Subjective comments on changes of hand function and ability to return to work were also recorded. All ten patients reported total relief or marked improvement in each of the four modalities of pain assessed. In the five patients in whom the neuromas were the only significant cause of hand dysfunction, there was sufficient improvement in hand function to allow the patients to return to work. In this series, the pronator quardratus muscle has proved a suitable site for relocation of sensory nerve ends after resection of painful neuromas in the proximal part of the hand and wrist.

The sensory recovery was monitored for up to 1 year after decompression of the median nerve in 69 patients with carpal tunnel syndrome. Special attention was paid to the rate of recovery, the importance of constant or intermittent numbness or paraesthesiae preoperatively and the influence of gender. Most patients with numbness/paraesthesiae and those with abnormal two-point discrimination recovered within 10 days. Perception of touch and vibration recovered within 3 weeks in most patients but those with abnormal nerve conduction/sensory amplitude recovered slowly during follow-up. After 1 year patients with intermittent preoperative symptoms were significantly more likely to achieve normal nerve conduction and perception of touch. Women were more likely to achieve normal nerve conduction and perception of touch. A comparison of recovery between matched men and women with identical preoperative status showed no significant difference. The results indicate the importance of early treatment of carpal tunnel syndrome.

The study group consisted of 100 persons referred with suspected carpal tunnel syndrome. Clinical and neurophysiological examinations were performed blinded from each other. The gold standard for the carpal tunnel syndrome (CTS) diagnosis was based on the results of these examinations but relief of CTS symptoms after surgery was also required. The sensitivity and specificity for the combined results of the clinical examinations were 94% and 80% respectively, and for the neurophysiological examinations, 85% and 87%. Of the neurophysiological methods used, the quotient of sensory nerve conduction velocity between palm to wrist and wrist to elbow was best and the cut-off for this test was studied by means of an ROC-curve. According to our results clinical examination by an experienced doctor seems to be sufficient if there are typical symptoms of carpal tunnel syndrome, but if there is a history of pain, atypical symptoms or earlier fractures in the arm, wrist or hand, it is important to add a neurophysiological examination.

Fourteen cases of peripheral nerve tumour which had been examined by MRI were reviewed. T1-weighted images showed the tumours to be of intermediate signal and T2-weighted images showed a high signal with some heterogeneity. These appearances are not specific to peripheral nerve tumours, although the diagnosis may be suggested if the lesion arises from a major nerve trunk. The association with a nerve trunk may be defined by MRI, thus assisting with surgical planning. Neurilemmomas, neurofibromas and malignant nerve sheath tumours could not be differentiated with certainty using MR alone. The MR features of lipofibromatous hamartoma are reported.

We report on clinical and electrophysiological findings and management in nine patients who developed carpal tunnel syndrome during the course of amyotrophic lateral sclerosis and late onset cerebellar ataxia, two neurodegenerative diseases. The patients were treated with surgical decompression (five cases) and local steroid injections (four cases). Only one showed lasting relief of symptoms and significantly improved distal conduction in the median nerve at follow-up after 2 to 3 months. The symptoms and conduction data remained unchanged in three patients who could be followed for more than 1 year. We think that axonal neuropathy plays an important role in the development of carpal tunnel syndrome in these patients and accounts for the failure of the standard treatments.

Twenty-three preserved cadaver upper limbs were dissected to show the level of the nerve supply to flexor carpi radialis and the extent of exposure of a new approach to the flexor surface of the distal radius. We describe a new approach to the flexor surface of the distal radius in which both the radial artery and the median nerve are protected by muscles or tendons.

In a prospective study of 80 operations in 61 patients for carpal tunnel syndrome, special attention was given to the course of the thenar motor branch and its variations. An anomalous origin of the branch was found in 21%. Multiple motor branches occurred in 12.5%. Seventeen patients had operations on both hands, but anomalies were often found in one side only. Special attention is drawn to an additional anomaly where the motor branch lies superficially to the retinaculum buried in a hypertrophic preligamentous muscle. If this anomaly is not borne in mind, the nerve can easily be injured during splitting of the flexor retinaculum. We found this variation in 9% of our patients, but it is rarely mentioned in the literature and in many large series it is not described at all.

In 1966, Wilhelm published a technique of denervation of the wrist joint based on his own anatomical studies of 1958. Other authors have published their experience in wrist denervations with similar results, but there are some discrepancies in descriptions of the innervation of the wrist. We have studied the innervation of the wrist by dissection under magnification on 20 cadaver limbs and by histological examination of five human foetal wrists. Based in our anatomical findings, we have demonstrated that Wilhelm's technique does not achieve total denervation of the wrist.

Freeze-thawed muscle grafts (FTMG) have been suggested as an alternative to nerve grafts in reconstruction of peripheral nerve defects. This study compares the results of immediate and delayed nerve repair with freeze-thawed muscle graft in a large animal model. Under general anaesthesia, ten adult sheep underwent excision of 3 cm of the right median nerve. Five had immediate nerve reconstruction with FTMGs (Group A) and five were repaired after 4 weeks (Group B). At 6 months, both the right (repaired) and left ("control") median nerves of each sheep were assessed. Nerve blood flow distal to the graft in both groups of repaired nerves was approximately 60% of that in their respective control nerves. Peak nerve conduction velocities were significantly slower in the repaired nerves. The mean fibre diameters of the immediate and delayed repairs were 5.06 and 3.90 mu respectively compared to a control mean of 8.58 mu. G-ratios confirmed that the repaired nerves in both groups were well myelinated. The authors conclude that the FTMG can be used in delayed as well as immediate nerve reconstruction with minimal impairment of final results.

A case of median nerve injury caused by an unsuspected foreign body is described. The mechanism was not recognized at the time of injury. The suspicion of a penetrating missile injury was raised only with the aid of radiographs. At operation the foreign body was found in the substance of the median nerve.

A prospective randomized study was undertaken of 50 consecutive patients undergoing surgery for idiopathic carpal tunnel syndrome to determine the value of splintage of the wrist following open carpal tunnel release. Patients were randomized to either be splinted for 2 weeks following surgery or to begin range-of-motion exercises on the first post-operative day. Subjects were evaluated at 2 weeks, 1 month, 3 months, and 6 months after surgery by motor and sensory testing, physical examination, and a questionnaire. Variables assessed included date of return to activities of daily living, dates of return to work at light duty and at full duty, pain level, grip strength, key pinch strength, and occurrence of complications. Patients who were splinted had significant delays in return to activities of daily living, return to work at light and full duty, and in recovery of grip and key pinch strength. Patients with splinted wrists experienced increased pain and scar tenderness in the first month after surgery; otherwise there was no difference between the groups in the incidence of complications. We conclude that splinting the wrist following open release of the flexor retinaculum is largely detrimental, although it may have a role in preventing the rare but significant complications of bowstringing of the tendons or entrapment of the median nerve in scar tissue. We recommend a home physiotherapy programme in which the wrist and fingers are exercised separately to avoid simultaneous finger and wrist flexion, which is the position most prone to cause bowstringing.

Superficial sensory communication between the ulnar and median nerves is well recognized. In the vast majority of cases this communication is from the ulnar nerve to the median nerve. We report a case in which a communicating branch passed from the median nerve to the ulnar nerve immediately proximal to the wrist to supply sensation to the little finger. The presence of this branch correlated with the presence of symptoms which had persisted in spite of conventional open carpal release 7 years earlier. Surgical decompression of this branch led to complete resolution of those symptoms.

Transected median nerves in the forearm of two male patients, 12 and 21 years of age, were treated with a chamber technique leaving a 3 to 5 mm gap between the nerve ends. The nerve ends were enclosed in a silicone tube of such a dimension that would not cause compression of the nerve. Post-operative examination including sensory evaluation and assessment of muscle contraction force was carried out after 3 years. In both cases there was excellent motor recovery of the thenar muscles. Outgrowth of sensory fibres was remarkably fast, resulting ultimately in functional sensibility allowing almost normal hand function. 2PD was < or = 6 mm (12-year-old patient) and 8 to 10 mm (21-year-old patient) respectively. In one case the silicone tube was re-explored because of minor local discomfort 2 years after the repair. The former gap was bridged by a smooth continuous nerve-like structure of the same diameter as the adjacent nerve trunk and with no signs of neuroma formation or compression of the nerve.

Assessing the functional outcome of peripheral nerve suture in the hand requires a battery of tests which are valid, reliable and comprehensively evaluate cutaneous sensibility. This study explores the relationship between a battery of sensory tests and the patient's capacity to perform everyday functional activities. An analysis of the interrelationship between all outcome variables reveals that the tests of sensibility do not predict the patients' ability to use their hands in everyday activities, thus indicating that patients are able to compensate for sensory deficit through the use of vision and bilateral use of the hands. An assessment of outcome should therefore include an additional measure of performance on daily living tasks.

Malignant peripheral nerve sheath tumours (MPNST) are spindle cell sarcomas normally situated in the deep soft tissues. Cutaneous MPNST is an uncommon variant, usually occurring in the head and neck. When it arises in the upper limb this tumour may pose a considerable diagnostic and therapeutic problem. We present a case of cutaneous MPNST arising in the hand. Tumour extension was exclusively perineural along three major nerve trunks from an interdigital origin. Current knowledge of the clinical behaviour of cutaneous MPNST is reviewed.

A clinical and electromyographic study of major nerve transections at the wrist in 22 patients has shown that electrical recovery nearly always occurs in the intrinsic muscles, despite the absence of clinically detectable function. There appears to be a level of electrical reinnervation above which clinically detectable intrinsic muscle power is usually present. This level would appear to be 50% of the contralateral maximum evoked muscle action potential; above this the "myth" of clinical recovery becomes a reality.

Two cases of subacute median nerve compression in children following trauma are presented. The first highlights problems of incised wounds around the wrist. The second illustrates an unusual presentation of nerve compression following a blunt injury.

An approach to the surgical management of recurrent carpal tunnel syndrome was evaluated in 30 patients with 35 involved wrists. This includes internal neurolysis of the median nerve and early post-operative mobilization of the wrist and fingers. The preferred surgical approach is through a second, more ulnar incision. Clinical assessment of sensorimotor function was converted into a numerical score ranging from zero (normal) to 9 (anaesthesia) and 10 (atrophy, severe). The average pre-operative score was mean 6.5 and median 7. At a mean follow-up of 23.5 months, the average post-operative score was mean 1.8 and median 0, a statistically significant improvement (P < 0.001).

The long-term prognosis of 60 patients operated on for carpal tunnel syndrome has been assessed in a prospective study with a median follow-up period of 5.5 years (range 2-11 years). Analysis of motor, sensory, trophic, and electrodiagnostic findings and assessment of pain were performed pre- and post-operatively using a standardized grading system. The results were generally favourable with a variable degree of improvement in 86% of cases. Statistical evaluation using multiple Dunn-Rankin tests revealed pain to be the most prominent pre-operative finding. On post-operative re-examination, pain was found to be improved to a significantly greater extent than any other variable. Analysis of several potential prognostic factors showed that pain lasting for more than 5 years prior to surgery indicates a poor prognosis. Only patients with diabetes mellitus exhibited a trend toward less pain relief.

A case is presented of an anomalous course of the palmar cutaneous branch of the median nerve. Wide and meticulous exposure is necessary to avoid injury to all variations of this nerve and the use of a "safe" incision will not always avoid risk of injury.