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Introduction Spontaneous radial nerve palsy with the surgical revelation of an hourglass-like constriction is a complicated condition. In general, the surgical strategy is decided in accordance with the results of surgical exploration. This study aimed to investigate the efficacies of various choices of surgical methods in the treatment of hourglass-like radial nerve constrictions. Material and methods Ten patients with spontaneous radial nerve palsy undergoing surgical exploration with the revelation of hourglass-like constrictions between November 2010 and December 2018 were reviewed in our hospital. Preoperative physical, electrophysiological and ultrasound examinations were performed for all patients. Varying levels, degrees and numbers of radial nerve constrictions were shown by surgical exposure. Epineurectomy and interfascicular neurolysis were performed in 4 cases with incomplete constrictions; resection and primary suture repair in 2 radial nerves with neurotmesis; resection and autologous nerve grafting in 4 patients with nerve defect > 2 cm. Both motor and sensory evaluations were performed at a follow-up visit. Results Ten patients underwent different history before the onset of symptom. Nerve ultrasound demonstrated swelling as well as constrictions of the radial nerve. All patients who were followed up presented with good to excellent recovery of motor function. The effectiveness of suture and autograft repair tended to be better than that of simple neurolysis. Conclusion The etiology of hourglass-like fascicular constrictive neuropathy of radial nerve involve with torsional factors. Nerve ultrasound is an important and useful measurement in diagnosing the pathology of spontaneous radial nerve palsy and in helping determine surgical approach. The surgical intervention is beneficial for the patients who do not recover in 4 weeks after onset of symptoms and for severe hourglass-like constrictions that are confirmed by preoperative ultrasound imaging. We recommend that nerve grafting be a suitable method in confrontation of nerve defect > 2 cm.

Vascularized bone grafts have shown favorable outcomes in Kienbock's disease, preventing the progression of lunate collapse and avascular necrosis. Here we describe our experience using a 4+5 extensor compartmental artery (ECA) vascularized bone graft combined with K-wire fixation. Between September 2010 and June 2013, 9 patients with Lichtman stage II-IIIA disease underwent arthroscopy prior to 4+5 ECA graft placement combined with temporary fixation (scaphocapitate and triquetrum-capitate joints). The average follow-up was 69 months (range, 51-92 months). Changes in pain, range of motion, grip strength, and pinch strength were analyzed. All patients had satisfactory recovery, especially pain relief and grip strength improvement (both P

In this study, we examined the prognostic factors affecting outcomes following nerve grafting in high radial nerve injuries. Thirty-three patients with radial nerve injuries at a level distal to the first branch to the triceps and proximal to the posterior interosseous nerve were retrospectively studied. After a follow-up of at least 1 year, 24 patients (73%) obtained M3+ wrist extension, 16 (48%) obtained M3+ finger extension and only ten (30%) obtained M3+ thumb extension. Univariate, multivariate and receiver operating characteristic analyses showed that a delay in the repair of less than 6 months, a defect length of less than 5 cm or when grafted with three or more donor nerve cables achieved better recovery. Number of cables used was related to muscle strength recovery but not time to reinnervation. Nerve grafting for high radial nerve injury achieved relatively good wrist extension but poor thumb extension and is affected by certain prognostic factors. Level of evidence: IV

Contralateral C7 nerve root transfer surgery, one of the most important surgical methods in treating brachial plexus avulsion injury, was first reported by Dr. Gu in 1986 and has been extended to treat hemiplegic paralysis. In Part I, we introduced the brief history of contralateral C7 nerve root transfer for adult brachial plexus injuries and the surgical anatomy of C7 nerve, together with the surgery procedures, which consisted of the application of sural nerve graft and the new route for direct neurorrhaphy. The indications, selection of recipient nerves, postoperative monitoring, potential complications, and factors that may affect the results were also described. In Part II, we focused on the application of contralateral C7 nerve transfer in treating spastic hemiplegia. The mechanism, clinical trials, indications, and exclusions for the treatment of spastic hemiplegia were all introduced. The latest surgical technique of creating a trans longus colli, prespinal route and progresses of further applying the concept to the hemiplegic lower extremity were also described. To conclude, contralateral C7 transfer is a complex procedure referable to cerebral plasticity, and the final results could be attributed to involvement of both peripheral regeneration and brain reorganization.

Background Spastic limb paralysis due to injury to a cerebral hemisphere can cause long-term disability. We investigated the effect of grafting the contralateral C7 nerve from the nonparalyzed side to the paralyzed side in patients with spastic arm paralysis due to chronic cerebral injury. Methods We randomly assigned 36 patients who had had unilateral arm paralysis for more than 5 years to undergo C7 nerve transfer plus rehabilitation (18 patients) or to undergo rehabilitation alone (18 patients). The primary outcome was the change from baseline to month 12 in the total score on the Fugl–Meyer upper-extremity scale (scores range from 0 to 66, with higher scores indicating better function). Results The mean increase in Fugl–Meyer score in the paralyzed arm was 17.7 in the surgery group and 2.6 in the control group (difference, 15.1; 95% confidence interval, 12.2 to 17.9; P

OBJECTIVEContralateral peripheral neurotization surgery has been successfully applied to rescue motor function of the hemiplegic upper extremity in patients with central neurological injury (CNI). It may contribute to strengthened neural pathways between the contralesional cortex and paretic limbs. However, the effect of this surgery in the lower extremities remains unknown. In the present study the authors explored the effectiveness and safety of contralateral peripheral neurotization in treating a hemiplegic lower extremity following CNI in adult rats.METHODSControlled cortical impact (CCI) was performed on the hindlimb motor cortex of 36 adult Sprague-Dawley rats to create severe unilateral traumatic brain injury models. These CCI rats were randomly divided into 3 groups. At 1 month post-CCI, the experimental group (Group 1, 12 rats) underwent contralateral L-6 to L-6 transfer, 1 control group (Group 2, 12 rats) underwent bilateral L-6 nerve transection, and another control group (Group 3, 12 rats) underwent an L-6 laminectomy without injuring the L-6 nerves. Bilateral L-6 nerve transection rats without CCI (Group 4, 12 rats) and naïve rats (Group 5, 12 rats) were used as 2 additional control groups. Beam and ladder rung walking tests and CatWalk gait analysis were performed in each rat at baseline and at 0.5, 1, 2, 4, 6, 8, and 10 months to detect the skilled walking functions and gait parameters of both hindlimbs. Histological and electromyography studies were used at the final followup to verify establishment of the traumatic brain injury model and regeneration of the L6-L6 neural pathway.RESULTSIn behavioral tests, comparable motor injury in the paretic hindlimbs was observed after CCI in Groups 1–3. Group 1 started to show significantly lower slip and error rates in the beam and ladder rung walking tests than Groups 2 and 3 at 6 months post-CCI (p < 0.05). In the CatWalk analysis, Group 1 also showed a higher mean intensity and swing speed after 8 months post-CCI and a longer stride length after 6 months post-CCI than Groups 2 and 3 (p < 0.05). Transection of L-6 resulted in transient skilled walking impairment in the intact hindlimbs in Groups 1 and 2 (compared with Group 3) and in the bilateral hindlimbs in Group 4 (compared with Group 5). All recovered to baseline level within 2 months. Histological study of the rat brains verified comparable injured volumes among Groups 1–3 at final examinations, and electromyography and toluidine blue staining indicated successful regeneration of the L6-L6 neural pathways in Group 1.CONCLUSIONSContralateral L-6 neurotization could be a promising and safe surgical approach for improving motor recovery of the hemiplegic hindlimb after unilateral CNI in adult rats. Further investigations are needed before extrapolating the present conclusions to humans.

Carpal tunnel syndrome (CTS) is a most common peripheral nerve entrapment neuropathy characterized by sensorimotor deficits in median nerve innervated digits. Block-design task-related functional magnetic resonance imaging (fMRI) studies have been used to investigate CTS-related neuroplasticity in the primary somatosensory cortices. However, considering the persistence of digital paresthesia syndrome caused by median nerve entrapment, spontaneous neuronal activity might provide a better understanding of CTS-related neuroplasticity, which remains unexplored. The present study aimed to investigate both local and extensive spontaneous neuronal activities with resting-state fMRI. A total of 28 bilateral CTS patients and 24 normal controls were recruited, and metrics, including amplitude of low-frequency fluctuation (ALFF) and voxel-wise functional connectivity (FC), were used to explore synaptic activity at different spatial scales. Correlations with clinical measures were further investigated by linear regression. Decreased amplitudes of low-frequency fluctuation were observed in the bilateral primary sensory cortex (SI) and secondary sensory cortex (SII) in CTS patients (AlphaSim corrected P < .05). This was found to be negatively related to the sensory thresholds of corresponding median nerve innervated fingers. In the voxel-wise FC analysis, with predefined seed regions of interest in the bilateral SI and primary motor cortex, we observed decreased interhemispheric and increased intrahemispheric FC. Additionally, both interhemispheric and intrahemispheric FC were found to be significantly correlated with the mean ALFF.

The ulnar-sided approach for arthroscopic peripheral triangular fibrocartilage complex (TFCC) repair may be associated with injury to the dorsal branch of the ulnar nerve (DBUN). The goal of this study was to develop a small incision to help minimize DBUN injury. Ten cadaveric upper limbs were used to measure the anatomic parameters of the DBUN. Based on these measured anatomical relationships, a 20 mm longitudinal incision with the ulnar styloid process as the midpoint was designed to explore and protect the DBUN. Three additional cadaveric upper limbs were used to test the feasibility of this method. Then this method was applied in 15 patients with TFCC injury (IB type). In 10 cadavers, the DBUN was located volar to the ulnar styloid process. The mean linear distance between the DBUN and the ulnar styloid process was 8.04 mm (range: 7.02–8.82 mm) in the transverse-volar direction and 13.78 mm (range: 11.06–16.02 mm) in the longitudinal-distal volar direction. In three additional cadavers, the DBUN was successfully explored and retracted with this incision, creating a safer space for passing sutures and tying knots. This modified method was used successfully in 15 patients, and the DBUN was protected during surgery. There were no complications, and most importantly, no injuries to the DBUN at the 6-month follow-up visit. Therefore, we recommend that a 20 mm longitudinal incision with the ulnar styloid process as the midpoint be made prior to passing sutures during the arthroscopic repair of TFCC tears to avoid injuring the various branches of the DBUN.

We proposed contralateral cervical seventh nerve transfer for spastic arm paralysis after central neurological injury in the New England Journal of Medicine (NEJM) in 2018. In this surgery, we applied a new surgical route for nerve transfer, the Huashan prespinal route. The objective of this study was to elaborate our new surgical technique, clarify its relationship to the vertebral artery, and provide anatomical data on this novel method. The effectiveness and safety of the Huashan prespinal route in contralateral C7 nerve transfer were evaluated anatomically. Nine cadavers (4 males, 5 females) were available for this study. Among these, anatomical parameters of the vertebral artery were obtained from 6 cadavers, and the anastomosis of the bilateral cervical seventh nerve was observed on 3 cadavers undergoing contralateral C7 nerve transfer via the Huashan prespinal route. Tension-free anastomosis of the bilateral cervical seventh nerve was achieved through the Huashan prespinal route. The tilt angle of the vertebral artery to the sagittal plane (with thyroid cartilage as the origin) was 25.5 ± 4.5°, at 22.5 ± 1.6° and 28.7 ± 4.3° on the left and right side, respectively. The safe drilling angle to penetrate through the longus colli muscles for the creation of a longus colli muscle tunnel to avoid injury to the vertebral artery in our surgical technique was above 33.2°. The cadaveric study confirms that the presented technique allowed simple, effective, and safe contralateral C7 nerve transfer. This technique can be used in the treatment of hemiplegia and brachial plexus injury. There is a safe scope of drilling angle for creating the longus colli muscle tunnel required for this surgical route. The anatomical parameters obtained in this study will be helpful for the performance of this operation.

Total brachial plexus avulsion injury (BPAI) results in the total functional loss of the affected limb and induces extensive brain functional reorganization. However, because the dominant hand is responsible for more cognitive-related tasks, injuries on this side induce more adaptive changes in brain function. In this article, we explored the differences in brain functional reorganization after injuries in unilateral BPAI patients.We applied resting-state functional magnetic resonance imaging scanning to 10 left and 10 right BPAI patients and 20 healthy control subjects. The amplitude of low-frequency fluctuation (ALFF), which is a resting-state index, was calculated for all patients as an indication of the functional activity level of the brain. Two-sample t-tests were performed between left BPAI patients and controls, right BPAI patients and controls, and between left and right BPAI patients.Two-sample t-tests of the ALFF values revealed that right BPAIs induced larger scale brain reorganization than did left BPAIs. Both left and right BPAIs elicited a decreased ALFF value in the right precuneus (P0.05, Alphasim corrected). In addition, right BPAI patients exhibited increased ALFF values in a greater number of brain regions than left BPAI patients, including the inferior temporal gyrus, lingual gyrus, calcarine sulcus, and fusiform gyrus.Our results revealed that right BPAIs induced greater extents of brain functional reorganization than left BPAIs, which reflected the relatively more extensive adaptive process that followed injuries of the dominant hand.

Brachial plexus injury (BPI) causes functional changes in the brain, but the structural changes resulting from BPI remain unknown. In this study, we compared grey matter volume between nine BPI patients and ten healthy controls by means of voxel-based morphometry. This was the first study of cortical morphology in BPI. We found that brain regions including the cerebellum, anterior cingulate cortex, bilateral inferior, medial, superior frontal lobe, and bilateral insula had less grey matter in BPI patients. Most of the affected brain regions of BPI patients are closely related to motor function. We speculate that the loss of grey matter in multiple regions might be the neural basis of the difficulties in the motor rehabilitation of BPI patients. The mapping result might provide new target regions for interventions of motor rehabilitation.

OBJECTIVESpinal accessory nerve (SAN) injury results in a series of shoulder dysfunctions and continuous pain. However, current treatments are limited by the lack of donor nerves as well as by undesirable nerve regeneration. Here, the authors report a modified nerve transfer technique in which they employ a nerve fascicle from the posterior division (PD) of the ipsilateral C-7 nerve to repair SAN injury. The technique, first performed in cadavers, was then undertaken in 2 patients.METHODSSix fresh cadavers (12 sides of the SAN and ipsilateral C-7) were studied to observe the anatomical relationship between the SAN and C-7 nerve. The length from artificial bifurcation of the middle trunk to the point of the posterior cord formation in the PD (namely, donor nerve fascicle) and the linear distance from the cut end of the donor fascicle to both sites of the jugular foramen and medial border of the trapezius muscle (d-SCM and d-Traps, respectively) were measured. Meanwhile, an optimal route for nerve fascicle transfer (NFT) was designed. The authors then performed successful NFT operations in 2 patients, one with an injury at the proximal SAN and another with an injury at the distal SAN.RESULTSThe mean lengths of the cadaver donor nerve fascicle, d-SCM, and d-Traps were 4.2, 5.2, and 2.5 cm, respectively. In one patient who underwent proximal SAN excision necessitated by a partial thyroidectomy, early signs of reinnervation were seen on electrophysiological testing at 6 months after surgery, and an impaired left trapezius muscle, which was completely atrophic preoperatively, had visible signs of improvement (from grade M0 to grade M3 strength). In the other patient in whom a distal SAN injury was the result of a neck cyst resection, reinnervation and complex repetitive discharges were seen 1 year after surgery. Additionally, the patient’s denervated trapezius muscle was completely resolved (from grade M2 to grade M4 strength), and her shoulder pain had disappeared by the time of final assessment.CONCLUSIONSNFT using a partial C-7 nerve is a feasible and efficacious method to repair an injured SAN, which provides an alternative option for treatment of SAN injury.

BACKGROUND Central neurological injury (CNI) is a major contributor to physical disability that affects both adults and children all over the world. The main sequelae of chronic stage CNI are spasticity, paresis of specific muscles, and poor selective motor control. Here, we apply the concept of contralateral peripheral neurotization in spasticity releasing and motor function restoration of the affected upper extremity. OBJECTIVE A clinical investigation was performed to verify the clinical efficacy of contralateral C7 neurotization for rescuing the affected upper extremity after CNI. METHODS In the present study, 6 adult hemiplegia patients received the nerve transfer surgery of contralateral C7 to C7 of the affected side. Another 6 patients with matched pathological and demographic status were assigned to the control group that received rehabilitation only. During the 2-year follow-up, muscle strength of bilateral upper extremities was assessed. The Modified Ashworth Scale and Fugl-Meyer Assessment Scale were used for evaluating spasticity and functional use of the affected upper extremity, respectively. RESULTS Both flexor spasticity release and motor functional improvements were observed in the affected upper extremity in all 6 patients who had surgery. The muscle strength of the extensor muscles and the motor control of the affected upper extremity improved significantly. There was no permanent loss of sensorimotor function of the unaffected upper extremity. CONCLUSION This contralateral C7 neurotization approach may open a door to promote functional recovery of upper extremity paralysis after CNI.

Restoration of digital flexion after brachial plexus injury or forearm injury has been a great challenge for hand surgeons. Nerve transfer and forearm donor muscle transfer surgeries are not always feasible. The present study aimed at evaluating the effectiveness of restoring digital flexion by brachialis muscle transfer. Ten lower brachial plexus- or forearm-injured patients were enrolled. After at least 12 months following surgery, the middle-finger-to-palm distance was less than 2.5 cm in six patients. In the other four patients with less satisfactory results, secondary tenolysis surgery was performed and the middle-finger-to-palm distances were reduced to 2.0–4.0 cm. The average grasp strength was 20 ± 4 kg. Elbow flexion was not adversely affected. In conclusion, brachialis muscle transfer is an effective method for reconstructing digital flexion, not only in lower brachial plexus injury, but also in forearm injury patients. Level of evidence: IV

We reported a rare peripheral nerve case, a patient developed carpal tunnel syndrome with a history of floating thumb in right hand. The median nerve was found expanded and spindle-shaped and a plexiform neurofibroma was diagnosed. Our case sheds light on anatomy and possible etiological association which may help clinical management.

Peripheral nerve compression is reported to induce cortical plasticity, which was well pictured by former researches. However, the longitudinal changes brought by surgical treatment are not clear. In this research, 18 subjects who suffered from bilateral carpal tunnel syndrome were evaluated using task-dependent fMRI and electromyography assessment before and after surgery. The third digit was tactually simulated by von Frey filaments. The results demonstrated that the pattern of activation was similar but a decreased extent of activation in the postcentral gyrus, inferior frontal lobe, superior frontal lobe, and parahippocampal gyrus after surgery was found. The correlation analysis showed a significant correlation between the decreased number of activated voxels and the improvement of EMG performance. This result implied a potential connection between fMRI measurement and clinical improvement.

BACKGROUND Functional recovery after peripheral nerve injury and repair is related with cortical reorganization. However, the mechanism of innervating dual targets by 1 donor nerve is largely unknown. OBJECTIVE To investigate the cortical reorganization when the phrenic nerve simultaneously innervates the diaphragm and biceps. METHODS Total brachial plexus (C5-T1) injury rats were repaired by phrenic nerve-musculocutaneous nerve transfer with end-to-side (n = 15) or end-to-end (n = 15) neurorrhaphy. Brachial plexus avulsion (n = 5) and sham surgery (n = 5) rats were included for control. Behavioral observation, electromyography, and histologic studies were used for confirming peripheral nerve reinnervation. Cortical representations of the diaphragm and reinnervated biceps were studied by intracortical microstimulation techniques before and at months 0.5, 3, 5, 7, and 10 after surgery. RESULTS At month 0.5 after complete brachial plexus injury, the motor representation of the injured forelimb disappeared. The diaphragm representation was preserved in the "end-to-side" group but absent in the "end-to-end" group. Rhythmic contraction of biceps appeared in "end-to-end" and "end-to-side" groups, and the biceps representation reappeared in the original biceps and diaphragm areas at months 3 and 5. At month 10, it was completely located in the original biceps area in the "end-to-end" group. Part of the biceps representation remained in the original diaphragm area in the "end-to-side" group. Destroying the contralateral motor cortex did not eliminate respiration-related contraction of biceps. CONCLUSION The brain tends to resume biceps representation from the original diaphragm area to the original biceps area following phrenic nerve transfer. The original diaphragm area partly preserves reinnervated biceps representation after end-to-side transfer.

For surgeries aimed at the dissection of full-length phrenic nerve, a full appreciation of its trajectory, blood supply and correlation with adjacent anatomical structures is necessary, especially for endoscopic manipulations. A fresh cadaver study was conducted with the purpose of avoiding surgical complications and ensuring further efficacy and efficiency of endoscopic manipulations. Ten fresh adult cadavers were dissected. Special attention was paid to the topography of the origin, the trajectory of the phrenic nerve, and its anatomic communication with the surrounding vessels and organs. In the second side of the cadavers, thoracic endoscopic manipulations and observations were also performed. The full length of the phrenic nerve was 24.6 ± 1.7 and 30.6 ± 1.8 cm on the right and left side, respectively; the blood supply of the phrenic nerve in the thoracic cavity came exclusively from the pericardiacophrenic artery; the distance between the origin of the pericardiacophrenic artery and that of the internal thoracic artery ranged from 0.5 to 5.2 cm on the right side, and from 1.4 to 5.6 cm on the left; most of the pericardiacophrenic veins intermingled with small vessels of pericardium and pleura, forming a venous network and joining the innominate vein. Endoscopic dissection of the thoracic phrenic nerve together with the accompanying pericardiacophrenic artery can be performed. Extreme attention should be paid during surgery to a section of about 6 cm in length of the artery originating from the internal thoracic artery, while the accompanying veins do not require to be spared.

There have been controversies on the contribution of contralesional hemispheric compensation to functional recovery of the upper extremity after a unilateral brain lesion. Some studies have demonstrated that contralesional hemispheric compensation may be an important recovery mechanism. However, in many cases where the hemispheric lesion is large, this form of compensation is relatively limited, potentially due to insufficient connections from the contralesional hemisphere to the paralyzed side. Here, we used a new procedure to increase the effect of contralesional hemispheric compensation by surgically crossing a peripheral nerve at the neck in rats, which may provide a substantial increase in connections between the contralesional hemisphere and the paralyzed limb. This surgical procedure, named cross-neck C7-C7 nerve transfer, involves cutting the C7 nerve on the healthy side and transferring it to the C7 nerve on the paretic side. Intracortical microstimulation, Micro-PET and histological analysis were employed to explore the cortical changes in contralesional hemisphere and to reveal its correlation with behavioral recovery. These results showed that the contralesional hemispheric compensation was markedly strengthened and significantly related to behavioral improvements. The findings also revealed a feasible and effective way to maximize the potential of one hemisphere in controlling both limbs.

Purpose: To investigate the results of ulnar-shortening osteotomy, arthroscopy wafer procedure, and distal metaphyseal ulnar-shortening osteotomy for the treatment of ulnar impaction syndrome. Methods: In all, 33 cases of ulnar impaction syndrome, which were treated with ulna orthopedic surgery in our hospital from June 2011 to May 2014, were studied retrospectively. They were divided into 3 groups: group A, including 10 cases who underwent ulnar-shortening osteotomy; group B, including 19 cases who underwent arthroscopy wafer procedure; group C, including 4 cases who underwent distal metaphyseal ulnar-shortening osteotomy. Wrist functions of these cases were evaluated before the surgery and after the surgery every 3 months. The evaluations included visual analogue scale, range of motion, grip strength, and the modified Mayo wrist scores. Results: The mean follow-up period was 25 months (SD, ±14). In group A, 9 cases underwent pain relief, 1 better. In group B, 13 relief, 5 better, and 1 no improvement. In group C, 1 relief, 2 better, and 1 no improvement. Conclusions: Ulnar diaphyseal shortening osteotomy, arthroscopy wafer procedure, and distal metaphyseal ulnar-shortening osteotomy are effective surgical options of ulnar impaction syndrome. Ulnar-shortening osteotomy is reliable procedure in pain relief. The shape of the distal radioulnar joint in the midcoronal plane should be considered in the decision-making stage.

Background: Deafferentation pain secondary to brachial plexus avulsion, spinal cord injury, and other peripheral nerve injuries is often refractory to conventional treatments. Stimulation of the primary motor cortex (M1) has been proven to be an effective treatment for intractable deafferentation pain. The mechanisms underlying the attenuation of deafferentation pain by motor cortex stimulation remain hypothetical. Objectives: The purpose of this case report is to: (1) summarize a case in which a patient suffering chronic intractable deafferentation pain for 25 years underwent rTMS treatment over M1, (2) describe the evidence from PET imaging, and (3) reveal a possible relief mechanism with cortical plasticity. Study design: Case report. Setting: University hospital. Results: This patient had successful pain control with no transient or lasting side effects. The pain relief remained stable for at least one week. At the end of the 20-day procedure, pain relief was obtained according to the Visual Analog Scale (VAS) (-34.6%) and the McGill Pain Questionnaire (MPQ) (-31.6%). In the PET/CT scans, the glucose metabolism was significantly reduced contralaterally to the pain side in the anterior cingulate cortex (ACC), insula, and caudate nucleus. There was no statistically significant difference in any other cortical area. Limitations: Single case of a patient with long-term intractable deafferentation pain having a PET study. Conclusion: This study implies that a single session of 20 Hz rTMS over the motor cortex could reduce the pain level in patients suffering from long-term, intractable deafferentation pain. The stimulation of the M1 induces deactivation in the ACC, insula, and caudate nucleus. The changes in these pain-related regions may mirror an adaptive mechanism to pain relief after rTMS treatment. Key words: Neuropathic pain management, deafferentation pain, transcranial magnetic stimulation, motor cortex stimulation, cortical plasticity, positron emission tomography

Ulnar impaction syndrome generally occurs with positive ulnar variance. The solution to the problem is to unload the ulnocarpal joint. Effective surgical options include diaphyseal ulnar shortening osteotomy, open wafer osteotomy, and arthroscopic wafer osteotomy. Recently, Slade and Gillon described an open procedure of ulnar shortening in the osteochondral region of the ulnar head. The procedure minimizes the risk of hemarthrosis and does not require hardware removal, which are problems with other surgical options. This article introduces a new arthroscopic technique of distal metaphyseal ulnar shortening osteotomy for ulnar impaction syndrome. This technique offers the advantages of minimizing surgical injury to the dorsal capsule of the distal radoulnar joint and so protects its stability.

Purpose: Phrenic nerve transfer (PNT) has proven to be an effective approach for the treatment of brachial plexus avulsion injuries (BPAI). But there have been major concerns about the possibility of deterioration of the pulmonary and diaphragm functions after PNT. In the current study, we performed end-to-side neurorrhaphy in PNT for BPAI patients while minimizing the potential damage to the diaphragm function. We prospectively assessed the efficacy of end-to-side neurorrhaphy for PNT in reconstructing the elbow flexion by regenerating the anterior division of the upper trunk (ADUT) or the musculocutaneous nerve (McN) in a series of 5 patients. Methods: From January to June 2008, 5 patients with BPAI underwent PNT with an end-to-side fashion, to regenerate the ADUT (3 patients) or the McN (2 patients). The operative delay after injury was from 1 to 6 months (mean, 2.5 months). The follow-up duration was 24 months. The regeneration outcomes of ADUT or McN were evaluated with an electromyography (EMG) test. The recovery of elbow flexion power was recorded according to the British Medical Research Council (MRC) grading system. Pulmonary function tests (PFTs) were used to assess the respiratory function. Chest fluoroscopy and phrenic nerve conduction studies were performed in the evaluation of phrenic nerve and diaphragm functions. Results: At the final visits after 2 years, all patients regained various degrees of biceps strength (M4 in 2 patients, M3 in 1 patient, M2 in 1 patient, and M1 in 1 patient). At 24 months after surgery, the average prolongation of latency of PN was 2.88 seconds, and the average decrease in amplitude from before the operation was 32.4%. The diaphragm function and PFTs were normal in all patients. Conclusions: PNT with end-to-side neurorrhaphy could provide functional biceps recovery in a majority of patients, with preservation of donor nerve function.

Purpose The optimal treatment for cubital tunnel syndrome is widely debated. The purpose of this study is to describe the technique of an endoscopic-assisted ulnar nerve decompression using carbon dioxide insufflation in association with subcutaneous anterior transposition and to assess the success or failure of the method of treatment. Methods In all, 8 male and 4 female patients with an average age of 42 years (range, 25-56) who presented signs, symptoms, and abnormal neurophysiological studies of cubital tunnel syndrome were recruited in the retrospective study. Between August 2008 and June 2009, they were operated on using a 0-degree lens endoscope. Preoperatively, they were classified according to the Dellon scale, and the Bishop rating system was used to evaluate the postoperative outcomes. Results Preoperatively, 5 patients were rated as mild, another 5 as moderate, and the remaining 2 as severe. The average length of the incision was 15 ± 3 mm, the mean length of the ulnar nerve decompression was 18 ± 2 cm, and the whole duration of surgery (skin to skin) lasted 30 ± 5 minutes. The endoscopic-assisted cubital tunnel release under carbon dioxide insufflation and subcutaneous anterior transposition surgeries in all patients were performed with no difficulty. All the patients had improvement in symptoms of cubital tunnel syndrome and 10 of 12 patients scored excellent according to the modified Bishop Rating System at a minimum of 1 year after surgery. Conclusions Endoscopy-assisted cubital tunnel release under carbon dioxide insufflation demonstrated similar results compared with conventional open surgeries, besides, it may avoid problems such as long incision, painful scarring, and have additional advantages of providing an extended endoscopic view, which is safe and mini-invasive with favorable results in a 12-month follow-up.