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Supplemental Digital Content is Available in the Text. A 53-year-old right-handed female weightlifter presented to our clinic for evaluation of left elbow pain and intermittent numbness in her first 3 digits. She reported an elbow injury while weight lifting and carrying heavy planters 6 months earlier. A magnetic resonance imaging obtained previously was interpreted as bicipital-radial bursitis, and she had previously undergone a comprehensive nonoperative management program for her pain and numbness. A diagnostic ultrasound performed in clinic revealed distal biceps tendinopathy, bicipital-radial bursitis, and "pseudotumor," which was dynamically compressed between the biceps tendon and radius with pronation and also caused a mass effect on the median nerve at the level of the pronator teres. Surgical excision of the mass resulted in near-complete resolution of her symptoms, and histology was consistent with scar tissue. This is the first case to the best of our knowledge to describe point-of-care ultrasound diagnosis of a biceps tendon "pseudotumor," as well as demonstrating dynamic impingement of this pseudotumor causing mass effect on the median nerve. [ABSTRACT FROM AUTHOR]

Background: The incidence of median nerve injuries in pediatric elbow dislocations is approximately 3% and avulsion of the open medial epicondylar epiphysis in the pediatric population is one predisposing factor that may explain this age predilection. These lesions can be difficult to diagnose in the acute phase because symptoms tend to be mild or delayed, consequently their management can be challenging and functional outcome poorer.Methods: We present the case of an unrecognized median nerve entrapment in a 16-year-old boy with posterior dislocation of the elbow and a medial epicondyle fracture, treated initially with close reduction and open stabilization with a cannulated screw. Assessment is supported by a review of similar reported cases available in literature.Results: We discuss the diagnostic approach and the surgical options that can be used for this type of injury.Conclusions: High clinical suspicion of entrapment is imperative in presence of signs of damage to the median nerve in the pediatric patient immediately after the reduction of an elbow dislocation. If diagnosis of entrapment is made the therapeutic choice between neurolysis and nerve graft depends on the lesion severity. In the presence of a Fourrier's type 4 lesion, neurolysis should be avoided, while nerve resection and grafting are recommended. [ABSTRACT FROM AUTHOR]

Introduction: The technique of radiofrequency neurotomy (RFN) of the facet joints has been used for decades to treat persistent low back pain to good effect in carefully selected patients. Traditionally, the target is the medial branches of the dorsal root supplying the facet joint. An alternative denervation target is the facet joint capsule. Capsule‐targeting techniques may spare the multifidus muscle, a possible unintended target of traditional RFN that is thought to be important in recovering from low back pain, and have shown promising results. Methods: A modified RFN technique that targets the capsule and spares the multifidus (multifidus‐sparing RFN) is described here, along with a brief report of its application in patients with symptomatic facet joint low back pain as compared to traditional medial branch RFN (MBRF). Results: Over a 2‐year period, a total of 401 initial multifidus‐sparing RFN and 94 initial MBRF procedures were performed on patients attending a multidisciplinary pain clinic. The proportion of repeat procedures was similar: 28.4% of multifidus‐sparing procedures and 23.4% of MBRF procedures. The median repeat interval was 12 months for both groups and interquartile range was 10 months (8–18 months) for multifidus‐sparing RFN and 4 months (11–15 months) for MBRF. Effectiveness and safety profiles appear to be similar, although limited, retrospective outcome information prevented robust analysis. Conclusion: Multifidus‐sparing RFN represents an intriguing technique to denervate the facet joint pain generator while maintaining normal multifidus function. Further study is warranted, particularly in order to identify the appropriate patient criteria and long‐term outcomes. [ABSTRACT FROM AUTHOR]

Posttraumatic acute carpal tunnel syndrome is a not a usual complication in traumatic hand injuries but requires more urgent and aggressive management. Compression of the median nerve should be systematically sought when there is a major and painful swelling of the hand, associated with one or several hand and wrist fractures. In rare case, a single metacarpal fracture or dislocation can be the only cause of median nerve compression and requires urgent diagnosis. If missed or neglected irreversible damage could occur to the median nerve. If surgery is perform in a timely manner outcomes are excellent, with complete recovery in most of the cases. We present the case of a 24-year-old man with an acute compression of the median nerve due to an intra-articular fracture of the 2nd metacarpal base. A bony fragment shifting from the base of 2nd metacarpal was found in the carpal tunnel participating, at least in part, in the compression of the median nerve. [ABSTRACT FROM AUTHOR]

Background: Median nerve (MN) variation in the carpal tunnel has been well documented by Lanz. Encountering rarely documented variants, that do not fit into existing classifications, increases the risk of iatrogenic injury.Methods: The random occurrence of two unclassifiable anatomical variants of the MN in the carpal tunnel gives motivation to search the literature for similar and identical cases.Case Reports: This article presents two cases of very rare anatomical variants of high division of the MN. First case is a pure high branching of the 3rd space common digital nerve (CDN). The second case is a high division of the MN to a thicker lateral component and a thinner medial component. The lateral component of the MN gives off the palmar cutaneous branch (PCB), the thenar motor branch (TMB), the 1st and 2nd space CDN's and contributes medially with a branch to the 3rd space CDN. The medial component of the MN bifurcates distally into a medial and lateral branch. The lateral branch from the medial component of the MN distally unites with the medial branch of the lateral component of the MN to form the 3rd space CDN. The medial branch from the medial component of the MN has a major contribution to the 4th space CDN from the ulnar nerve. In both cases, the medial component of the MN has a transmuscular course through the flexor digitorum superficialis (FDS) muscle.Discussion: Finding similar case reports from worldwide suggests the need to improve current classification of the MN variants in the carpal tunnel.Conclusions: One cannot rely entirely on the existing anatomical classifications of the MN in the carpal tunnel. There is an underappreciated risk of iatrogenic injury, especially in endoscopic carpal tunnel release, and a chance of missing out on repair of important anatomical structures in trauma cases. There is a possibility of augmenting group 3 of Lanz's classification by adding subgroup "3D High division of the MN with the medial component having a transmuscular course through the FDS muscle", stating the different distal branching patterns. [ABSTRACT FROM AUTHOR]

Background: Upper extremity injuries have a significant impact on social and professional life. They represent about 10% of visits to emergency departments. Nerve lacerations are one of the biggest problem because loss of innervation results in muscle atrophy, decreased sensibility, and therefore permanent dysfunction. Appropriate treatment is very important for patients to regain function.Materials and Methods: The study included 41 patients, 30 men and 11 women who underwent nerve repair surgery in the middle and distal forearm level in the years 2001-2017. The patients' age ranged from 9 to 73 years with an average of 37 years. They were divided into 3 groups with repaired median, ulnar and both nerves. We determined time from injury to nerve repair, assessed sensitivity in index and little finger with a two-point discriminator, and muscle strength by measuring adduction of the little finger and palmar abduction of the thumb.Results were rated based on Medical Research Council Scale (MRC). In addition, general hand disability was assessed according to the Disabilities of the Arm, Shoulder and Hand Questionnaire (DASH).Results: There was a statistically significant (p = 0.0197), positive correlation (r > 0) between the period from injury to surgery and the DASH score, and statistically significant difference (p = 0.0001) in return of muscular function between groups with median, ulnar and both nerves injury. Also correlation between patients age and score of DASH was statistically significant (p = 0.0140) with positive correlation (r > 0). There was no statistically significant difference in the return of sensitivity (p = 0.4337) and the DASH score (p = 0.3831) between these three groups.Conclusions: Patients with shorter time from injury to repair and at a younger age had better DASH results. The median nerve had the best motor function between the groups. There was no difference in sensitivity or DASH scores between groups. [ABSTRACT FROM AUTHOR]

Objective To determine the effectiveness of cervical medial branch thermal radiofrequency neurotomy in the treatment of neck pain or cervicogenic headache based on different selection criteria. Design Comprehensive systematic review. Methods A comprehensive literature search was conducted, and the authors screened and evaluated the studies. The Grades of Recommendation, Assessment, Development, and Evaluation system was used to assess all eligible studies. Outcome Measures The primary outcome measure assessed was the success rate of the procedure, defined by varying degrees of pain relief following neurotomy. Data are stratified by number of diagnostic blocks and degree of pain relief. Results Results varied by selection criteria, which included triple placebo-controlled medial branch blocks, dual comparative medial branch blocks, single medial branch blocks, intra-articular blocks, physical examination findings, and symptoms alone. Outcome data showed a greater degree of pain relief more often when patients were selected by triple placebo-controlled medial branch blocks or dual comparative medial branch blocks, producing 100% relief of the index pain. The degree of pain relief was similar when triple or dual comparative blocks were used. Conclusions Higher degrees of relief from cervical medial branch thermal radiofrequency neurotomy are more often achieved, to a statistically significant extent, if patients are selected on the basis of complete relief of index pain following comparative diagnostic blocks. If selected based on lesser degrees of relief, patients are less likely to obtain complete relief. [ABSTRACT FROM AUTHOR]

The article reports on the use of dynamic ultrasound (US) to visualize and document the abnormal tethering of the MN to the ulnar head of the pronator teres (UHPT) was also well delineated. Topics include abnormal tethering is caused by abnormal adhesion or friction between the posterior surface; and physical examination of weakness or motor atrophy, and has abnormal electrodiagnostic studies.

Background Cervical medial branch radiofrequency ablation (CMBRFA) is an effective treatment for facetogenic pain in patients selected by Spine Intervention Society (SIS) guidelines of 100% symptom improvement with dual medial branch blocks (MBBs) ± placebo block. Patient selection for CMBRFA using ≥80% symptom improvement after dual concordant MBBs is common; however, this has not been studied. Objective To evaluate the effectiveness of CMBRFA and compare outcomes in individuals selected by 80–99% vs 100% symptom improvement with dual concordant MBBs. Design Cross-sectional cohort study. Methods Medical records of 87 consecutive patients were reviewed; 50 met inclusion criteria. A standardized telephone survey was performed at six or more months post-CMBRFA to query numerical rating scale (NRS) pain and patient global impression of change (PGIC) scores. The primary outcomes were the proportion of patients reporting ≥50% reduction of index pain. Results At a mean follow-up time of 16.9 ± 12.7 months, 54% (95% confidence interval [CI] = 35–73%) and 54% (95% CI = 32–74%) of the 80–99% and 100% MBBs groups, respectively, reported ≥50% pain reduction. Between-group comparison showed a relative risk of 0.99 (95% CI = 0.59–1.66) for meeting the primary outcome. Seventy percent (95% CI = 56–81%) of patients reported a PGIC score consistent with "improved or very much improved" at follow-up. Conclusions CMBRFA is an effective treatment in patients who report ≥80% symptom relief with dual concordant MBBs. The present study demonstrated an overall ≥50% pain reduction rate of 54% and no significant difference between those selected by 80–99% vs 100% symptom relief with dual concordant MBBs. [ABSTRACT FROM AUTHOR]

Background: Compound muscle action potential (CMAP) scan and MScanFit have been used to understand the consequences of denervation and reinnervation. This study aimed to monitor these parameters during Wallerian degeneration (WD) after acute nerve transections (ANT).Methods: Beginning after urgent surgery, CMAP scans were recorded at 1-2 day intervals in 12 patients with ANT of the ulnar or median nerves, by stimulating the distal stump (DS). Stimulus intensities (SI), steps, returners, and MScanFit were calculated. Studies were grouped according to the examination time after ANT. Results were compared with those of 27 controls.Results: CMAP amplitudes and MScanFit progressively declined, revealing a positive correlation with one another. SIs were higher in WD groups than controls. Steps appeared or disappeared in follow-up scans. The late WD group had higher returner% than the early WD and control groups.Conclusions: MScanFit can monitor neuromuscular dysfunction during WD. SIs revealed excitability changes in DS. [ABSTRACT FROM AUTHOR]

Background: Reliable measurement of functional recovery is critical in translational peripheral nerve regeneration research. Behavioral functional assessments such as volitional grip strength testing (vGST) are limited by inherent behavioral variability. Isometric tetanic force testing (ITFT) is highly reliable but precludes serial measurements. Combining elements of vGST and ITFT, stimulated grip strength testing (sGST) involves percutaneous median nerve stimulation to elicit maximal tetanic contraction of digital flexors, thereby allowing for consistent measurement of maximal grip strength.Methods: We measured side-to-side equivalence of force using sGST, vGST, and ITFT to determine relative reliability and repeatability. We also performed weekly force measurements following median nerve repair.Results: sGST demonstrated greater reliability and inter-trial repeatability than vGST and similar reliability to ITFT, with the added benefit of serial measurements.Conclusions: sGST is a valid method for assessing functional recovery that addresses the limitations of the currently available modalities used in translational peripheral nerve regeneration research. [ABSTRACT FROM AUTHOR]

"Common habits develop into rare syndromes." This idiom holds true when one such colorful rubber band put on the wrist of a child gets forgotten, burrows through the skin, and presents with a swollen paralyzed hand with a circumferential scar on the wrist. We present two cases of rubber band syndrome (Dhaga syndrome) who presented with painful, swollen, complete claw hand. Until 2019, only 15 cases were reported with predominance of Indian children. MRI is the gold standard investigation where a high degree of clinical suspicion is diagnostic. Surgical exploration with removal of the constricting band and excision of neuroma in continuity of ulnar and median nerves for preventing neurological deficit and tenolysis of tendons depending on the depth of the band is unambiguous treatment of choice. Where history is not forthcoming, a circumferential scar on the wrist of a child demands exploration. [ABSTRACT FROM AUTHOR]

Introduction. The aim of this research was to test, in an animal model, the nerve regeneration technique with a hypoallergenic acellular dermal matrix used to wrap the microsurgical neural suture. Materials and Methods. Two groups of rats received the cut of limb right median nerves. The regeneration technique considers for both groups an end-to-end nerve suture. In the experimental group (A) was used also a wrapping protocol by a conduit of collagen matrix currently used in oral surgery. The animals underwent functional grasping tests (at 1, 3, 5, and 7 months) and a histological and quantitative analysis of distal nerve was performed at the end of experimental time. Result. After seven months, the grasping test reveals functional recovery in each tested animal; this improvement is more evident in Group A. The fibers appear well organized with restored myelin sheaths in both groups. Group A showed a great quantity of connective tissue surrounding the nerve. The quantitative morphology analysis in both groups shows a similar fibers density, fiber diameter, and myelin thickness. The differences between the groups in axon mean diameter are significant. In Group A M/d, D/d, and g-ratio is significantly higher compared to control group. Conclusions. Histological and functional assessments show a functional recovery of the injured nerve in the test groups, stressed by the results of the grasping tests and the meaningful increasing in fiber diameter and higher g-ratio. Moreover, a connective tissue cuff distinguishes the distal portion of the injured nerve. Considering the easy availability and handling of the material used in this study we can conclude that this experimental technique can be considered as a valid alternative to protect nerves in nerve wrap surgery. [ABSTRACT FROM AUTHOR]

Background/Aims: Mirror visual feedback is an intervention that focuses on watching the movements of the intact hand in the mirror to restore the movements of the injured hand. This method is developed based on the concept of the central reflection of the amputated or injured limb. This study aims to determine the effect of mirror visual feedback as a complementary method on the outcomes of sensory relearning in patients following median/ulnar nerve repair. Methods: This randomised clinical trial was conducted on 20 patients with median/ulnar nerve damage who were selected through convenience sampling and were then randomly assigned to a treatment and a control group. Both groups received traditional rehabilitation in three 40-minute sessions a week. In addition, the treatment group received mirror visual feedback 15 minutes a day, 5 days a week, for 8 weeks. The patients' sensory status was assessed using Semmes-Weinstein Monofilaments and two-point discrimination tests and their sensory function was assessed using stereognosis both before and after the intervention. Findings: The final analysis was performed on a total of 20 patients. The Semmes-Weinstein Monofilaments test and two-point discrimination scores obtained showed significant improvements following therapy in both groups. The changes in Semmes-Weinstein Monofilaments test (P=0.000], two-point discrimination (P=0.000) and stereognosis (active: P=0.001, passive: P=0.000) scores were significantly greater in the mirror therapy group compared to the controls. Conclusions: Mirror visual feedback in conjunction with traditional sensory retraining programmes led to greater improvements in superficial sensation and touch discrimination of the hand in the first phase of the sensory relearning programme. This may be due to the use of the neuroplasticity potential, the stimulation of the somatosensory areas and motor networks, the adjustment of early cortical reorganisation and the prevention of further changes. [ABSTRACT FROM AUTHOR]

While the success or failure of carpal tunnel release ultimately depends on the interplay of a wide array of factors, a broad understanding of the normal anatomy of the carpal tunnel accompanied by awareness of the possible variations of the individual structures that make up its contents is crucial to optimizing surgical outcomes. While anatomic variants such as extension of the flexor digitorum muscle bellies have been described as a cause of primary carpal tunnel syndrome (CTS), there have been no reports depicting its association with recurrent CTS following initially successful carpal tunnel release, a finding with potentially significant prognostic implications that can aid in operative planning. In such cases where muscle extension is identified preoperatively, careful debulking of the muscle belly may be beneficial in improving long-term surgical outcomes. [ABSTRACT FROM AUTHOR]

Introduction: The recovery of recurrent motor branch of the median nerve might be delayed in high level median nerve injuries due to the long reinnervation distance. The aim of this study is to define a novel nerve transfer to restore the opposition and pinch.Methods: Two fresh frozen hand cadavers were used for the study. The motor branch of the first palmar interosseous muscle of the ulnar nerve was identified and dissected. Thenar branch of the median nerve was dissected from its insertion site. The motor branch of the first palmar interosseous muscle of the ulnar nerve was transferred to the thenar motor branch of the median nerve. Axon counts were examined histopathologically. Clinically this nerve transfer was performed for two female patients with a high-level median nerve injury. Mehta opposition scores were 21 and 20, respectively and the results were satisfactory six months after the surgery.Discussion: Although exploration and repair are recommended as the first treatment for median nerve injuries, the waiting time until the motor branch is reinnervated is critical in high level lesions. Nerve transfers become very important for fast recovery.Conclusions: This new nerve transfer proposal may be an important step in nerve transfer surgery. [ABSTRACT FROM AUTHOR]

Hereditary neuropathy with liability to pressure palsy (HNPP) often manifests via peripheral nerve entrapment including median nerve compression at the carpal tunnel. However, there are few reports on surgical interventions for focal compression of the median nerve at the wrist in patients with HNPP. We report a case of a patient with HNPP who improved clinically, electrophysiologically, and ultrasonographically after carpal tunnel release (CTR). A 56-year-old woman presented with an 18-month history of pain in both thumbs. Nerve conduction study (NCS) revealed bilateral median neuropathy at the wrist. Ultrasonography demonstrated a markedly increased cross-sectional area (CSA) of both median nerves. Gene analysis revealed a deletion of the PMP22 gene. She received bilateral CTR. Follow-up NCS at one year demonstrated the improvement of motor and sensory conduction; follow-up ultrasonography revealed significantly reduced CSA. Our case suggests that surgical decompression can be applicable to well-selected patients with HNPP. [ABSTRACT FROM AUTHOR]

Objective: Remarkable progress has been made in the surgical treatment of capral tunnel syndrome recently. Popularity of endoscopic and minimally invasive techniques has been increased in particular. The aim of this study was to present the short-term outcomes of patients undertaken median nerve decompression surgery with palmar mini-incision using carpal tunnel knife with light (Blade-X®, Mavera Medical Devices, Ankara, Turkey). Material and Method: A total of 50 patients who were operated by using carpal tunnel knife, were retrospectively evaluated. Among those, 40 were female and 10 were male. Five patients had bilateral capral tunnel syndrome. Mean age was 59.75 (33-81 y). Mean duration of follow-up was 11,2 months (6-18 m). Preoperative clinical diagnosis was confirmed via electroneuromyography in all patients. Surgery was performed under local anesthesia without tourniquet with minimal palmar incision. Simple bandage was performed postoperatively and no immobilization was performed. Results: Mean duration of operation was 13 minutes (10-17 min). No complication was observed in any of the patients. Patients were able to use their hands for self-care after a mean of 7 days (5-13 d). Mean time to get back to work was 25 days (18-35 d) for those who are employed. All patients were satisfied except two patients experiencing scar pain. Conclusion: The most remarkable outcome of this minimally invasive method was rapid usage of the hands postoperatively and the functional recovery observed in the short-term. [ABSTRACT FROM AUTHOR]

Summary: Background and Aim: Trigger thumb is a common hand disability in children and is primarily treated with open surgery. A conscious median nerve block can usually meet the requirements for trigger thumb‐releasing surgery in adults; however, its effectiveness in children requires further clarification. The present study aims to demonstrate whether ultrasound‐guided lower forearm median nerve blockade is a viable option for children undergoing open surgery for trigger thumb. Methods: A prospective randomized study was designed to compare median nerve blocks guided by ultrasonography with those guided by anatomic landmarks. Following induction of general anesthesia, the children received a median nerve block performed either by ultrasound‐guided block of the lower forearm (group U) or landmark‐based blocking at the proximal wrist crease level (group T) with a 0.2% ropivacaine injection. The success rates were compared between groups as the primary endpoint; additional sufentanil and propofol administration, anesthesia recovery time, and other secondary endpoints were also compared. Results: A total of 100 children (age 1‐3 years) with ASA status I who were scheduled for open surgery for trigger thumb were included in this study (n = 50 per group). Thirty‐seven children in group T and 50 children in group U underwent successful blocks. The rate of unsuccessful blockade was significantly lower in group U than group T (0% and 26%, respectively), and rate of additional sufentanil and propofol administration was also lower in group U than in group T. Conclusion: Ultrasound‐guided lower forearm median nerve block can provide more effective analgesia, a higher success rate, and lower general and local anesthetic dosages than the anatomic landmark‐based blocking method in children undergoing open surgery for trigger thumb. [ABSTRACT FROM AUTHOR]

Introduction: The aim of this study was to assess alterations in median nerve (MN) biomechanics within the carpal tunnel resulting from ultrasound-guided hydrodissection in a cadaveric model.Methods: Twelve fresh frozen human cadaver hands were used. MN gliding resistance was measured at baseline and posthydrodissection, by pulling the nerve proximally and then returning it to the origin. Six specimens were treated with hydrodissection, and 6 were used as controls.Results: In the hydrodissection group there was a significant reduction in mean peak gliding resistance of 92.9 ± 34.8 mN between baseline and immediately posthydrodissection (21.4% ± 10.5%; P = 0.001). No significant reduction between baseline and the second cycle occurred in the control group: 9.6 ± 29.8 mN (0.4% ± 5.3%; P = 0.467).Discussion: Hydrodissection can decrease the gliding resistance of the MN within the carpal tunnel, at least in wrists unaffected by carpal tunnel syndrome. A clinical trial of hydrodissection seems justified. Muscle Nerve 57: 25-32, 2018. [ABSTRACT FROM AUTHOR]

Objective: To determine the natural history of the morphology of the median nerve after carpal tunnel decompression. Methods: Between October and December 2014, patients with suspected carpal tunnel were prospectively enrolled and underwent pre- and postoperative (3 and 6 months) high-definition ultrasonography, electrophysiology, and clinical testing. Results: A total of 81 patients were enrolled in the study; 75 (93%) could be reached for the 6-month follow-up, and 100% were clinically better at the 6-month follow-up. The mean cross-sectional area decreased from 14.3 ± 4.4 mm2 to 9.6 ± 2.3 mm2 (mean ± standard deviation [SD]). The mean distal motor latency decreased from 6.5 ± 2.2 msec to 4.4 ± 0.8 msec (mean ± SD). Distal motor latency improved statistically significantly after surgical decompression as well, but sooner. Conclusion: We present the second largest series of patients with sonographic followup after surgical decompression of the carpal tunnel. [ABSTRACT FROM AUTHOR]

The pre-ligamentous variant of the thenar motor branch (TMB) of the median nerve is extremely rare. In all previously reported cases, the branch arose from the radial or antero-radial aspect of the median nerve in the distal forearm and then pierced the antebrachial fascia to reach the thenar muscles. We report on a case in which the pre-ligamentous TMB not only arose from the ulnar side of the median nerve but it also remained deep to both the antebrachial fascia and the transverse carpal ligament until it reached the thenar muscles. The course of this variant puts the TMB at significant risk of injury during both open and endoscopic carpal tunnel release. Level of Evidence: Level V, risk study. [ABSTRACT FROM AUTHOR]

Introduction: The purpose of this study is to assess the functional connectivity of the motor cortical network in patients with brachial plexus avulsion injury (BPAI) after contralateral C7 nerve transfer, using resting-state functional magnetic resonance imaging (RS-fMRI). Methods: Twelve patients with total brachial plexus root avulsion underwent RS-fMRI after contralateral C7 nerve transfer. Seventeen healthy volunteers were also included in this fMRI study as controls. The hand motor seed regions were defined as region of interests in the bilateral hemispheres. The seed-based functional connectivity was calculated in all the subjects. Differences in functional connectivity of the motor cortical network between patients and healthy controls were compared. Results: The inter-hemispheric functional connectivity of the M1 areas was increased in patients with BPAI compared with the controls. The inter-hemispheric functional connectivity between the supplementary motor areas was reduced bilaterally. Conclusions: The resting-state inter-hemispheric functional connectivity of the bilateral M1 areas is altered in patients after contralateral C7 nerve transfer, suggesting a functional reorganization of cerebral cortex. [ABSTRACT FROM AUTHOR]

Objectives: To investigate the prognostic value of B-mode and Power Doppler (PD) ultrasound of the median nerve for the short- and long-term clinical outcomes of patients with carpal tunnel syndrome (CTS). Methods: Prospective study of 135 patients with suspected CTS seen 3 times: at baseline, then at short-term (3 months) and long-term (15–36 months) follow-up. At baseline, the cross-sectional area (CSA) of the median nerve was measured with ultrasound at 4 levels on the forearm and wrist. PD signals were graded semi-quantitatively (0–3). Clinical outcomes were evaluated at each visit with the Boston Questionnaire (BQ) and the DASH Questionnaire, as well as visual analogue scales for the patient’s assessment of pain (painVAS) and physician’s global assessment (physVAS). The predictive values of baseline CSA and PD for clinical outcomes were determined with multivariate logistic regression models. Results: Short-term and long-term follow-up data were available for 111 (82.2%) and 105 (77.8%) patients, respectively. There was a final diagnosis of CTS in 84 patients (125 wrists). Regression analysis revealed that the CSA, measured at the carpal tunnel inlet, predicted short-term clinical improvement according to BQ in CTS patients undergoing carpal tunnel surgery (OR 1.8, p = 0.05), but not in patients treated conservatively. Neither CSA nor PD assessments predicted short-term improvement of painVAS, physVAS or DASH, nor was any of the ultrasound parameters useful for the prediction of long-term clinical outcomes. Conclusions: Ultrasound assessment of the median nerve at the carpal tunnel inlet may predict short-term clinical improvement in CTS patients undergoing carpal tunnel release, but long-term outcomes are unrelated to ultrasound findings. [ABSTRACT FROM AUTHOR]

Introduction: Ultrasound measurement of the cross-sectional area (CSA) of the median nerve can give information about regeneration of the nerve after carpal tunnel release (CTR), but the changes at selected follow-up points up to 1 year compared to electrodiagnostic findings are not known. We postoperatively measured the CSA of the median nerve with ultrasound and compared the measurements with electrophysiological findings over 12 months after open CTR.Materials and Methods: In 21 hands that underwent open CTR, the CSA of the median nerve was measured at the inlet (proximal CSA) and outlet (distal CSA) of the carpal tunnel at 3- 6- and 12-month follow-up. The respective ratios [(CSA postoperatively/CSA preoperatively) × 100] were calculated and correlated with distal motor latency (DML) and sensory nerve conduction velocity (SCV).Results: The proximal CSA ratio was 88.9, 84.5, and 78.4 % at 3-, 6-, and 12-month follow-up, respectively. Each value was significantly lower than that before surgery. The distal CSA ratio was 104.3, 99.1, and 91.8 % at 3-, 6-, and 12-month follow-up, respectively. The values were not significantly different compared to preoperative values.Conclusions: The proximal CSA of the median nerve decreased continuously over the time after CTR while the distal CSA increased up to 3 months before it decreased continuously, too. [ABSTRACT FROM AUTHOR]

The article informs about dynamic examination and guided hydrodissection in ultrasonography in pronator teres syndrome. Topics include regarding the benefits of U.S. guided hydrodissection for management of peripheral entrapment neuropathy; and andomized controlled trial to investigate the effectiveness of this combinational injection technique for pronator teres syndrome.

A case study of a 25-year-old male was seen for pain and weakness in his right hand first and second fingers. Topics include sensory deficit over the right palm and fingers, and the medical history was otherwise noncontributory; and Physical examination revealed weakness of the pincer movement of the right thumb and index fingers.

Early diagnosis of acromegaly prevents irreversible comorbidities and facilitates surgical cure. Carpal tunnel syndrome (CTS) is common in acromegaly and patients have often undergone surgery for CTS prior to the diagnosis of acromegaly. We hypothesized that screening CTS-patients for acromegaly could facilitate active case-finding. We prospectively enrolled 196 patients [135 women, 56.9 (range 23-103) years] who presented with CTS for surgery. Patients were asked about 6 symptoms suggestive of acromegaly using a questionnaire calculating a symptom score (0-6 points), and insulin-like-growth factor 1 (IGF-1) was measured. If IGF-1 was increased, IGF-1 measurement was repeated, and random growth hormone (GH) and/or an oral glucose tolerance test (OGTT) with assessment of GH-suppression were performed. The mean symptom score was 1.7 ± 1.3 points. Three patients reported the maximal symptom score of 6 points, but none of them had an increased IGF-1. There was no correlation between the symptom score and IGF-1-SDS (standard deviation score) (r = 0.026; p = 0.71). Four patients had an IGF-1 > 2 SDS. In 2 patients acromegaly was ruled out using random GH and OGTT. One patient had normal IGF-1 and random GH at follow-up. One patient refused further diagnostics. In this prospective cohort of patients with CTS, the observed frequency of acromegaly was at most 0.51% (95% CI 0.03 to 2.83%). In this prospective study, none of the 196 patients with CTS had proven acromegaly. Thus, we see no evidence to justify general screening of patients with CTS for acromegaly. [ABSTRACT FROM AUTHOR]

Purpose: Our aim was to study the dynamics of the post-surgical canal and nerve volumes and their relationships to objective [electromyoneurography (EMNG)] and subjective (pain) outcomes.Methods: Forty-seven patients with carpal tunnel syndrome (CTS) (median age 52, range 23-75 years) with a prominent narrowing of the median nerve within the canal (observed during carpal tunnel release) were evaluated clinically using EMNG and magnetic resonance imagining (MRI) before and at 90 and 180 days post-surgery.Results: Canal and nerve volumes increased, EMNG findings improved and pain resolved during the follow-up. Increase in tunnel volume was independently associated with increased nerve volume. A greater post-surgical nerve volume was independently associated with a more prominent resolution of pain, but not with the extent of EMNG improvement, whereas EMNG improvement was not associated with pain resolution.Conclusions: Data confirm that MRI can detect even modest changes in the carpal tunnel and median nerve volume and that tunnel release results in tunnel and nerve-volume increases that are paralleled by EMNG and clinical improvements. Taken together, these observations suggest that MRI could be used to objectivise persistent post-surgical difficulties in CTS patients. Level of evidence 3 (follow-up study). [ABSTRACT FROM AUTHOR]

The effects of changes to cold, mechanical, and heat thresholds following median nerve transection with repair by sutures (Su) or Rose Bengal adhesion (RA) were compared to sham-operated animals. Both nerve-injured groups showed a transient, ipsilateral hyposensitivity to mechanical and heat stimuli followed by a robust and long-lasting hypersensitivity (6–7 weeks) with gradual recovery towards pre-injury levels by 90 days post-repair. Both tactile and thermal hypersensitivity were seen in the contralateral limb that was similar in onset but differed in magnitude and resolved more rapidly compared to the injured limb. Prior to injury, no animals showed any signs of aversion to cold plate temperatures of 4–16 °C. After injury, animals showed cold allodynia, lasting for 7 weeks in RA-repaired rats before recovering towards pre-injury levels, but were still present at 12 weeks in Su-repaired rats. Additionally, sensory recovery in the RA group was faster compared to the Su group in all behavioural tests. Surprisingly, sham-operated rats showed similar bilateral behavioural changes to all sensory stimuli that were comparable in onset and magnitude to the nerve-injured groups but resolved more quickly compared to nerve-injured rats. These results suggest that nerve repair using a sutureless approach produces an accelerated recovery with reduced sensorimotor disturbances compared to direct suturing. They also describe, for the first time, that unilateral forelimb nerve injury produces mirror-image-like sensory perturbations in the contralateral limb, suggesting that the contralateral side is not a true control for sensory testing. The potential mechanisms involved in this altered behaviour are discussed. [ABSTRACT FROM AUTHOR]

HISTORY: A 20 year old left handed male motorcyclist sustained a 3cm left volar wrist laceration closing a mirrored cabinet that shattered. He presented to the ED, where the laceration was irrigated and sutured, and he was given antibiotics. No imaging was done. Three days later, he went to UC for left palm numbness, swelling of fingers, and impaired wrist rotation. Patient was prescribed steroids and referred to Sports Medicine for follow up. Three days later at the Sports Medicine visit he reported constant numbness and tingling along the volar side of the left index, second finger, and thumb, inability to flex digits, and weakness and severe pain with specific movements of the left hand. He felt "something moving" inside his wrist when trying to move his thumb. PHYSICAL EXAMINATION: Inspection: Swelling along left digits 1-3, most noticeable along volar aspect, with stitches intact on volar wrist.Palpation: No tenderness or palpable foreign body. ROM: PROM intact. AROM revealed inability to make a closed fist, reduced flexion at first 3 digits, and intact flexion at 4th/5th digits. Strength: 3/5 flexor strength at left thumb and digits 1-3 and inability to maintain pincer grasp. Neurovascular: Decreased sensation along median nerve distribution and 2+ left radial pulse. DIFFERENTIAL DIAGNOSIS: Left median nerve injury Left flexor tendon injuryRetained foreign body TEST AND RESULTS: Left wrist xray:Density projecting volar to the thumb CMC joint, possibly reflecting a retained foreign body.MRI left wrist: Foreign body within the volar tissues of the wrist corresponding to anomaly seen on xrays. This extends through the transverse carpal ligament and lies immediately adjacent to the flexor pollicus longus tendon, the flexor digitorum superficialis tendon to the index finger, and the median nerve. There is abnormal signal within the median nerve concerning for nerve injury. FINAL WORKING DIAGNOSIS: Left median nerve laceration with retained foreign body. TREATMENT AND OUTCOMES:Left wrist removal of foreign body, left carpal tunnel release, left wrist median nerve repair. Wrist splint with three weeks of immobilization followed by slow advancement of activity. At 5 month follow-up he was exercising and riding a motorcycle without restriction. He had persistent mild sensory changes over left median nerve distribution. [ABSTRACT FROM AUTHOR]

Theoretical framework: Carpal Tunnel Syndrome (CTS) is a musculoskeletal disorder affecting the functionality of the upper limbs. Objective: To assess symptom severity and functional status, using the Boston Carpal Tunnel Questionnaire (BCTQ), and quality of life, using the SF-36 v2, in the preoperative period and two months after surgery. Methodology: Prospective study of 50 patients (60.7±11.7 years) who underwent decompression surgery. Participants were mostly women (52 %), with 62 % of them being post-menopausal women. Diabetes (8%), overweight (48%), and class I (26%) and class II obesity (4%) were found to be risk factors for CTS. Results: In the preoperative period, the affected hand had significantly less grip and pinch strength than the contralateral hand. The follow-up results suggest a decrease in symptom severity and an increase in functional status. Conclusion: Significant changes towards improving health-related quality of life were observed in the SF-36 v2 subscales: physical functioning, bodily pain, mental health, role-emotional, social functioning and vitality. [ABSTRACT FROM AUTHOR]

Background: Carpal tunnel syndrome is a common condition in which the median nerve passes through the carpal tunnel is compressed. Then, gradual paralysis occurs. This study aimed to compare patient outcomes after surgery for carpal tunnel syndrome in both groups with and without splint.. Methods: This study was conducted in Isfahan University of Medical Sciences, Iran, in Kashani hospital during 2011. 64 patients underwent surgery for carpal tunnel syndrome were selected and randomly divided into two groups of 32. For the first group, splints were considered after the surgery and for the second group, as the control group, splint was not given. Patients within 3, 6 and 12 weeks after surgery were followed and healing in the sense of motion and pain based on the visual analogue scale (VAS) measures were examined. Findings: Sensory conflict scores at the 3rd and 6th weeks in the group with splint were higher than the group without it; but, 12 weeks after the treatment, the results were identical. In any cases, motor involvement was not seen. At the 3rd week after the treatment, the mean pain score in the group without splint was higher than with splint group. The results of the 6th week after the treatment in both groups were almost identical; but, at the 12th week after the treatment, changes in pain intensity was not significantly different between the two groups (P = 0.97). Conclusion: Splinting after the surgical release of the median nerve probably causes a delay in the recovery of sensory, motor and pain; but due to the effect of material of used splint, the result is still uncertain and further broader interventions needs to be done in this regard. [ABSTRACT FROM AUTHOR]

Histological and physiological basis of the therapeutic efficacy of the vascularized autologous nerve graft in facial nerve regeneration remains poorly understood because of no established rat model. The left median nerve and median artery/vein of Lewis rats were collectively ligated, and harvested as a vascularized island median nerve, which was transplanted to a 7-mm gap in the left buccal branch of facial nerve. Nerve regeneration was investigated. The numbers of myelinated fibers, axon diameter, and myelin thickness were significantly higher in the vascularized nerve graft group than in the nonvascularized nerve graft group. Compound muscle action potential measurement showed that the parameters of vascularized group were similar to those in the intact control group. A vascularized median nerve graft resulted in better facial nerve regeneration outcomes. [ABSTRACT FROM AUTHOR]

Knowing of anatomical variations is very important during surgery, autopsy and cadaver dissection in the axillary region. In this study, a unilateral variation of the brachial nerve plexus, which is characterized by the absent of the musculocutaneous nerve (MCN), was found in the right arm of a male cadaver. The MCN normally originates from the lateral cord of the brachial nerve plexus and innervates the anterior brachial compartment muscles and lateral coetaneous of the forearm. In this case, the lateral cord of the brachial plexus was joined to the median nerve at the level of coracoid process with no evidence of any nerve braches from lateral cord to the anterior brachial compartment muscles. These muscles were innervated from some branches of median nerve directly. [ABSTRACT FROM AUTHOR]

The article discusses the study of "True" Lateral Imaging for Cervical Medial Branch Radiofrequency Neurotomy. Topics discussed include the effective use of radiofrequency thermal energy for the palliative relief of cervical facet pain has been known for decades; and the radiofrequency cannula is ideally placed in an exact manner both parallel to and as close as possible to the targeted cervical medial branch nerve before lesioning.

This case study report demonstrates the use of motion analysis with a modification of the Box and Blocks test. The goal was to quantify observed improvements in compensatory movements and simultaneous control in a subject using different prostheses before and after targeted muscle reinnervation (TMR) surgery. This is a single case study with data collection using a body-powered prosthesis pre-TMR surgery and 6 mo postfitting with a TMR myoelectric prosthesis. The Box and Blocks test was modified for cyclical motion within a motion capture laboratory. With the TMR myoelectric prosthesis, the subject was able to simultaneously activate the hand and elbow. Task performance was slower, but there was improved elbow flexion and less trunk compensatory motion than with the body-powered prosthesis. There are several limitations to the case study because there is no direct comparison of myoelectric performance before and after TMR surgery; however, the current report presents a potential method to quantify quality of motion and compensatory movements of prosthetic users. With further study, this test procedure has the potential to be a useful outcome measure for future standardized assessments of upper-limb prosthetic function. [ABSTRACT FROM AUTHOR]

Summary: We report the case of a 13-year-old boy with a traumatic elbow dislocation, open stage 2 (Cauchoix and Duparc), with distal ischemia. Exposure of the neurovascular humeral bundle through the wound accentutated the clinical emergency. This clinical observation consisted of elbow dislocation with all severity criteria: (i) opening of the skin, (ii) association with a fracture of the medial humeral epicondyle, and (iii) neurological deficit in the territory of the median nerve. The purpose of this report is to remind physicians that no investigation should delay surgery in elbow dislocation. Despite initial distal ischemia, no vascular exploration is required. Early reduction of the disloction is the key point of care. [ABSTRACT FROM AUTHOR]

We describe a patient who was injected water into the palm of his left hand. He injured the median nerve at the carpal tunnel. The injected water did not cause serious damage to the soft tissue, but caused the division of the median nerve brought about serious pain and sensory and motor disturbance. The patient was taken to the operating room to undergo a nerve graft operation on the same day. Two years after the injury, numbness was reduced his index, middle, and ring fingers up to the distal interphalangeal joint. Except for thumb abduction, we did not observe contracture of the joints of his left hand. The strength of his grip was 47 kg in the right hand and 42 kg in the left hand. His ability to make a perfect O improved from the previous year. His thenar muscle remained slightly atrophied. He still could not support anything with his left hand, but he no longer felt hindered in his work since he was accustomed to his work. [ABSTRACT FROM AUTHOR]

The article describes the approach practiced by the author from 1995. Mainly Hansen's patients and lower forearm injuries formed the bulk of these. In Opponen's transfer ECU was used only when others were not available as the wrist developed a tendency to radial deviation even when FCU was acting. PL with palmar aponeurosis as extension was used again in limited cases. The main stay was FDS and EIP. The Guyan's canal and lower end of ulna were the common pulleys. APB and EPL two slip inserts yielded good results. The approach describes the procedure under three distinct headings of choosing motor, Pulley and insert. Varying combinations of these can be used as per requirement. [ABSTRACT FROM AUTHOR]

Background: Carpal tunnel syndrome is a common disorder in hand surgery practice. Both surgical and conservative interventions are utilized for the carpal tunnel syndrome. Although certain indications would specifically indicate the need for surgery, there is a spectrum of patients for whom either treatment option might be selected. The purpose of this systematic review was to compare the efficacy of surgical treatment of carpal tunnel syndrome with conservative treatment Methods: We included all controlled trials written in English, attempting to compare any surgical interventions with any conservative therapies. We searched Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 1, 2010), MEDLINE (1980 to June 2010), EMBASE (1980 to June 2010), PEDro (searched in June 2010), international guidelines, computer searches based on key words and reference lists of articles. Two reviewers performed study selection, assessment of methodological quality and data extraction independently of each other. Weighted mean differences and 95% confidence intervals for patient self-reported functional and symptom questionnaires were calculated. Relative risk (RR) and 95% confidence intervals for electrophysiological studies and complication were also calculated. Results: We assessed seven studies in this review including 5 RCTs and 2 controlled trials. The methodological quality of the trials ranged from moderate to high. The weighted mean difference demonstrated a larger treatment benefit for surgical intervention compared to non surgical intervention at six months for functional status 0.35( 95% CI 0.22, 0.47) and symptom severity 0.43 (95% CI 0.29, 0.57). There were no statistically significant difference between the intervention options at 3 months but there was a benefit in favor of surgery in terms of function and symptom relief at 12 months ( 0.35, 95% CI 0.15, 0.55 and 0.37, 95% CI 0.19 to 0.56). The RR for secondary outcomes of normal nerve conduction studies was 2.3 (95% CI 1.2, 4.4), while RR was 2.03 (95% CI 1.28 to 3.22) for complication, both favoring surgery. Conclusion: Both surgical and conservative interventions had treatment benefit in carpal tunnel syndrome. Surgical treatment has a superior benefit, in symptoms and function, at six and twelve months. Patient underwent surgical release were two times more likely to have normal nerve conduction studies but also had complication and side effects as well. Given the treatment differential and potential for adverse effects and that conservative interventions benefitted a substantial proportion of patients, current practice of a trial of conservative management with surgical release for severe or persistent symptoms is supported by evidence. [ABSTRACT FROM AUTHOR]

Objective: To determine the value of ultrasonography in the assessment of patients with idiopathic carpal tunnel syndrome (CTS) and poor outcome after carpal tunnel release. Methods: A total of 88 consecutive patients with CTS (104 hands) underwent open surgical release of the median nerve. Ultrasound (US) examination was performed blind to any patient's data. The median nerve area at tunnel inlet and outlet, the retinaculum distance, and the flattening ratio were measured. The main outcome variable was the patient's overall satisfaction using a five-point Likert scale (1 = worse, 2 = no change, 3 = slightly better, 4 = much better, 5 = cured) at 3 months postoperatively. Pre- and postoperative ultrasonographic findings in relation to clinical outcome were analysed. Results: Improvement (scores 4 or 5 on the Likert scale) was recorded in 75 hands (72%). After carpal tunnel release, the cross-sectional area at tunnel inlet decreased from a mean of 14.2 to 13.3 mm2 in the group with clinical improvement and also from a mean of 12.5 to 11.6 mm2 in the group with no change or slight improvement. No significant changes in the cross-sectional area at tunnel outlet, retinaculum distance, and flattening ratio were observed. Conclusion: Reduction of the median nerve cross-sectional area at tunnel inlet at 3 months after carpal tunnel release was similar in patients reporting cure or great improvement and in those with slight or no improvement. Ultrasonography is of limited value in assessment of patients with poor outcome after median nerve release. [ABSTRACT FROM AUTHOR]

Abstract: We report an uncommon case of heterotopic ossification affecting the median nerve at the level of the distal forearm and carpal tunnel with some unusual features: its length, the concomitant involvement of the ulnar nerve at Guyon''s canal and a positive family history of heterotopic ossification. [Copyright &y& Elsevier]

Abstract: The purpose of the study was to evaluate the flexor digitorum superficialis flap in treatment of neuroma-in-continuity of the median nerve at the wrist. We reviewed six patients operated from September 2000 to March 2007. In all cases, daily disabling pain has been significantly reduced. Four patients are very satisfied. It is a local flap, easy to harvest with few morbidity. We compare it with the various options described for this pathology. [Copyright &y& Elsevier]

Abstract: The aim of the study is to evaluate the results of the median nerve release at wrist as a part of acute carpal tunnel syndrome. This is a retrospective study about 26 cases of acute carpal tunnel syndrome following isolated injury of the wrist. Clinical evaluation of the median nerve function was performed before and after release. A classical median nerve release was performed in emergency eventually associated with stabilization of bone lesions. The population included was young, the mean age was 26 (range 4–52) years, frequently male (sex-ratio 3.5:1). The wrist trauma was direct in 75% of all cases and oftentimes with high velocity. The median nerve was deficient in the first examination. The average time from injury to surgery range from three hours to five days. The release was performed in emergency. The latest follow-up showed a complete recovery of the nerve''s function in 85% and an incomplete in the rest (15%).The mean prognosis factor was the release time. Wrist trauma particularly with high velocity should lead to evaluation of median nerve function and to an emergency release when acute median neuropathy appeared. [Copyright &y& Elsevier]

We report an extremely rare case of proximal entrapment neuropathy of the median nerve above the elbow in a 44-year-old man who presented with paresthesia with median nerve distribution. Tinel's sign was located in the upper arm medial to the biceps and 5 cm proximal to the elbow. The patient underwent microsurgery under local anesthesia. The fascia covering the brachial- and the biceps brachii muscle entrapped median nerve. After operation, he reported symptom improvement. Lesions above the elbow should be considered as possible causative factors of entrapment neuropathy of the median nerve. [ABSTRACT FROM AUTHOR]

Abstract: The median nerve entrapment after elbow-dislocation is rare. We report two cases of fracture dislocation elbow completed by entrapment of median nerve occurred after reduction in two children. For both cases, the diagnosis of entrapment was made some months later after injury. Median nerve graft was performed after nerve resection. The nerve recovery was satisfactory at the final follow-up. This nerve complication should be suspected systematically before and after reduction of all dislocation of the elbow in the children. The indication of nerve release or nerve graft depends on the entrapment and the delay of the palsy. [Copyright &y& Elsevier]

Abstract: Objectives: We wished to evaluate the effectiveness of a free dermal fat graft for covering the median nerve in order to improve function after failure of carpal tunnel release. Methods: Eight patients with nine failures of carpal tunnel release were reviewed for this retrospective study. They all had significant perineural fibrosis. We performed a free dermal fat graft harvested from the inguinal region on the same side. The mean follow-up was 37 months (range 6 to 112). All patients had a clinical examination, a disability arm and shoulder scoring (DASH) and magnetic resonance imaging (MRI). Results: Five patients were satisfied or very satisfied with the procedure although only two patients returned to work. Mean grip strength was 13kg (43% of non-operated hand) and the two-point discrimination test was normal or subnormal six times on the eight wrists tested. The mean DASH score was 43 out of 100. MRI scans on eight wrists showed a fat signal in all patients and enhanced signal with gadolinium contrast in six cases. Conclusions: Free dermal fat graft offers a good covering for the median nerve over the carpal tunnel in cases of failure of carpal tunnel release. MRI showed viability of the graft. Clinical results show improvement but symptoms of median nerve irritation persisted. Permanent intraneural changes may explain these limited results. [Copyright &y& Elsevier]

We present a rare case of entrapment of the median nerve between sublimis tendons after fractures of the distal radius and ulna in an 80-year-old woman. The entrapped median nerve was elongated redundantly with two regions of constriction. To our knowledge, no case of median nerve palsy caused by such a factor has been previously reported. [ABSTRACT FROM AUTHOR]