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Introduction: Carpal tunnel syndrome is an entrapment neuropathy that affects 3% of adults in the United States. The current techniques used for diagnosis have limited specificity/sensitivity, and the techniques used for treatment have limited efficacy.Case Report: A 34-year-old female presented to the emergency department with two months of worsening painful paresthesias in her right thenar eminence. Ultrasound was performed showing a median nerve area of 20.4 square millimeters within the carpal tunnel. Median nerve block was performed within the carpal tunnel causing complete resolution of her pain.Conclusion: Emergency physicians skilled in point-of-care ultrasound and needle-guided procedures can diagnose and treat carpel tunnel syndrome.

Carpal tunnel syndrome (CTS), the most common mononeuropathy, results from compression of the median nerve within the fibro-osseous carpal tunnel. Diagnosis is typically based on clinical evaluation and confirmed by nerve conduction studies. However, ultrasound (US) has emerged as a valuable noninvasive adjunct for CTS confirmation, offering potential advantages over electrodiagnostic testing in terms of patient comfort and diagnostic accuracy. This review begins with a concise summary of carpal tunnel anatomy and CTS pathophysiology as a foundation for exploring the diverse applications of US in CTS evaluation. B-mode US assessment is presented with a focus on cross-sectional imaging and dynamic evaluations, including the transverse translocation and longitudinal gliding of the median nerve. We also review current methods for assessing vascularization in CTS and explore the usefulness of elastography in CTS evaluation. The advantages and limitations of each US method are elucidated, highlighting their practical utility in clinical practice. [ABSTRACT FROM AUTHOR]

Objective: To investigate whether nerve mobilization related to nerve mobility or the removal of edema using lymphatic drainage affects the cross-sectional area of the nerve, hand function, and symptom severity in carpal tunnel syndrome. Design: The study is a prospective randomized controlled trial. Data were analyzed between groups using ANOVA, Chi-squared test, and Kruskal–Wallis test. Setting: Treatment lasted 4 weeks. Splint group wore the splint daily. Splint+manual lymphatic drainage received lymphatic drainage 5 days a week. Splint+nerve mobilization performed neuromobilization exercises as home exercises 5 days a week. Evaluations were conducted before and after 4 weeks of treatment. Participants: The study included 80 patients with mild-to-moderate carpal tunnel syndrome. Interventions: The patients were randomly divided into three groups: splint (n = 27), splint+manual lymphatic drainage (n = 27), or the splint+nerve mobilization (n = 26). Main Outcome Measures: The main outcome measures were ultrasound assessments and the Boston Carpal Tunnel Questionnaire (Symptom Severity Scale and Boston Functional Status Scale). Results: Compared to the other groups, the nerve cross-sectional area decreased at both the carpal tunnel (p = 0.003) and mid-forearm (p = 0.014) levels in the drainage group. Nerve mobilization did not result in a significant change in the nerve cross-sectional area. All groups showed significant improvements in both symptom severity and functional status scores (p < 0.001). Conclusion: The reduction of edema through lymphatic drainage contributes to a decrease in the cross-sectional area of the median nerve. Additionally, all three methods appear to positively impact the functional capacity of the hand and alleviate symptoms. [ABSTRACT FROM AUTHOR]

Background and Purpose: Supracondylar humerus fractures (SCHFs) are the most common elbow fractures in children. Traumatic median nerve injury and isolated lesions of its pure forearm motor branch, anterior interosseus nerve (AIN), have both been independently reported as complications of displaced SCHFs. Our main objectives were to characterize the neurological syndrome to distinguish median nerve from AIN lesions and to determine the prognosis of median nerve lesions after displaced SCHFs. Methods: Ten children were prospectively followed for an average of 11.6 months. Patients received a standardized clinical examination and high‐resolution ultrasound of the median nerve every 1–3 months starting 1–2 months after trauma. Electrodiagnostic studies were performed within the first 4 months and after complete clinical recovery. Results: All children shared a clinical syndrome with predominant but not exclusive affection of AIN innervated muscles. High‐resolution ultrasound uniformly excluded persistent nerve entrapment and neurotmesis requiring revision surgery but visualized post‐traumatic median nerve neuroma at the fracture site in all patients. Electrodiagnostic studies showed axonal motor and sensory median nerve neuropathy. All children achieved complete functional recovery under conservative management. Motor recovery required up to 11 months and differed between involved muscles. Conclusions: It was shown that neurological deficits of the median nerve in displaced SCHFs exceeded an isolated AIN lesion. Notably, detailed neurological follow‐up examinations and sonographic exclusion of persistent nerve compression were able to guide conservative therapy in affected children. Under these conditions the prognosis of median nerve lesions was excellent despite severe initial deficits, development of neuroma and axonal injury. [ABSTRACT FROM AUTHOR]

Introduction: Intercostal nerve transfer is a surgical technique used to restore function in patients with total brachial plexus injury. Stem cell and secretome therapy has been explored as a potential treatment for brachial plexus injuries. This study aimed to compare the functional and histologic outcome of intercostal nerve transfer to median nerve with local stem cells or secretome injection in total type brachial plexus injuries. Materials and methods: This was a double-blinded, randomized controlled study (RCT). We included patients with neglected total type brachial plexus injury (BPI) who underwent nerve transfer and local injection of either umbilical cord-derived mesenchymal stem cells (UC-MSC) or secretome into median nerve–flexor digitorum superficialis (FDS) neuromuscular junction (NMJ). We measured preoperative and 8-month postoperative FDS muscle strength, SF-36, DASH score, and histologic assessment. We then analyzed the difference outcome between those two groups. Result: A total of 15 patients were included in this study. Our study found that after nerve transfer and implantation with either UC-MSC or secretome, significant postoperative improvements were observed in physical functioning, role limitations, energy/fatigue, emotional well-being, social functioning, pain, general health, and DASH scores, particularly in the overall cohort and the secretome group. When we compared the mean difference of clinical outcome from preoperative to postoperative between UC-MSC and secretome groups, the UC-MSC group showed better improvement of health change in SF-36 subgroup compared to secretome group. From the analysis, there was no significant difference in the histologic outcomes (inflammation, regeneration, and fibrosis) in overall cohort between preoperative and postoperative cohort. There was also no significant difference in mean change of the histologic outcomes (inflammation, regeneration, and fibrosis) preoperative and postoperatively between UC-MSC and secretome groups. Discussion and conclusion: Implantation of either UC-MSC or secretome along with nerve transfer may provide clinical improvement, while to achieve histologic improvement, further conditioning should be performed. [ABSTRACT FROM AUTHOR]

Background: Carpal tunnel syndrome is the commonest upper limb peripheral neuropathy. Diffusion tensor imaging evaluates the tissue microarchitecture and measures the movement of water protons. It is non-time-consuming, not invasive and not operator dependent. The aim of our study was to evaluate whether diffusion tensor imaging can diagnose carpal tunnel syndrome and whether DTI parameters can correlate with severity of carpal tunnel syndrome. Results: Seventy-two wrists were assessed, 36 diagnosed with carpal tunnel syndrome and 36 age and sex matched controls. FA & ADC were measured at four locations (distal radioulnar joint, proximal, middle and distal carpal tunnel), and the mean for the whole median nerve was calculated. FA & ADC showed statistically significant difference between cases and control at each of the measured four locations and the mean of the whole median nerve. FA & ADC at the hook of hamate (distal CT) showed the most significant difference between cases and control. For FA, the cut-off point at the hook of hamate was 0.5 (sensitivity 94.4%, specificity of 88.9%, positive predictive value 89.5% and negative predictive value 94.1%) and the cut-off point for the mean of the whole nerve was 0.545 (sensitivity 97.22%, specificity 77.78%, positive predictive value 81.4% and negative predictive value 96.6%). For ADC, the cut-off point at the hook of hamate was 1.44 (sensitivity 97.22%, specificity 86.11%, positive predictive value 87.5% and negative predictive value 96.9%) and the cut-off point for the mean of the whole nerve was 1.415 (sensitivity 86.11%, specificity, 83.33%, positive predictive value 83.8% and negative predictive value 85.7%). Conclusion: Diffusion tensor imaging can diagnose carpal tunnel syndrome with accuracy compared to the gold standard nerve conduction studies. Both FA and ADC showed statistically significant differences between cases & controls with FA measurements found to be more significant. [ABSTRACT FROM AUTHOR]

Introduction: Myasthenia gravis, which initially presents with prominent distal muscle weakness, is rare and is referred to as distal myasthenia gravis. Despite its clinical significance, the diagnosis of distal myasthenia gravis is often delayed or missed owing to mild and atypical symptoms. Case report: We report the case of a 52-year-old ethnic Han woman who presented with task-related isolated transient right-hand weakness that began 15 years ago and lasted for 9 years without aggravation or improvement. In subsequent years, she developed right-hand stiffness with limited dexterity. More recently, this developed into bilateral hand weakness and simultaneous generalized weakness with ambulation, prompting suspicion of myasthenia gravis. Under Hertz repetitive nerve stimulation, the right facial nerve, right accessory nerve, right ulnar nerve, right radial nerve, and right median nerve showed decrements between 19.5% and 35.4%. Tests for anti-acetylcholine receptor antibodies were positive. The patient was diagnosed with distal myasthenia gravis, which evolved into generalized myasthenia gravis. Conclusion: Distal myasthenia gravis can present with isolated and transient hand weakness as a lone symptom, and can persist for years before typical myasthenia gravis symptoms appear. The inclusion of myasthenia gravis in the differential diagnosis is necessary in patients with isolated distal weakness. [ABSTRACT FROM AUTHOR]

ABSTRACT To explore the anatomical factors potentially involved in the high incidence of carpal tunnel syndrome in humans, we have quantified the anatomical variations of the carpal tunnel and its inner structures in humans, non‐hominoid primates (monkeys), and hominoid primates (apes). In specimens of six humans, eight monkeys, and three apes, we assessed the size of the carpal tunnel, the tendons of the digit flexor muscles, and the median nerve. We compared the size of the carpal tunnel normalized by the wrist size, and the size of the median nerve and the tendons of the digit flexors normalized by the size of the carpal tunnel. Differences between humans and monkeys were calculated using the T test or Mann–Whitney U test, as appropriate. Data on the apes were not included in the statistical analyses due to the small sample size. The normalized size of the carpal tunnel was similar in all specimens. The normalized size of the tendons of the digit flexors was smaller in humans, while that of the median nerve was significantly larger. The median nerve was also larger in apes than in monkeys. The relatively larger median nerve observed in humans could suggest a greater vulnerability of the nerve to compression, which could predispose humans to carpal tunnel syndrome. However, the tendons of the digit flexor muscles were smaller in humans, and moreover, the proportional size of the median nerve was similar in apes, leading us to suggest that the factors predisposing humans to carpal tunnel syndrome must be sought beyond anatomical features and may be more closely related to functional or personal parameters. [ABSTRACT FROM AUTHOR]

Background: Kilohertz high-frequency alternating current (KHFAC) stimulation has demonstrated to induce rapid and reversible nerve blocks without causing nerve damage. Previous studies have explored frequency-dependent effects using a transcutaneous approach in humans from 5 to 20 kHz. Nevertheless, its application in humans is limited by the lack of stimulators approved for frequencies above 20 kHz. Therefore, this study aimed to assess the effects and safety of transcutaneous KHFAC stimulation using a novel prototype stimulator, comparing interventions at 30, 40, and 50 kHz to sham stimulation on experimental pain, sensory, motor, and neurophysiological outcomes. Methods: A randomized, double-blind, sham-controlled crossover study involving 34 healthy participants was conducted. Four interventions (30, 40, 50 kHz, and sham) were administered, and stimulation was applied for 20 min to the median nerve of the non-dominant hand. A prototype stimulator capable of delivering frequencies between 1 and 50 kHz, with a maximum peak-to-peak output current intensity of 400 mA was designed. The intensity applied during the stimulation was below motor threshold, evoking a 'strong but comfortable' tingling sensation. Primary outcomes included heat pain threshold (HPT), pressure pain threshold (PPT), and adverse effects. The secondary outcomes included static two-point discrimination sensitivity, isometric pinch strength, and median sensory nerve action potential (SNAP). Results: Compared with the sham stimulation, all the active interventions exhibited a significantly greater increase in the PPT during and immediately after the stimulation, while only a significant increase was observed at 40 kHz (4.1 N/cm2; 95%CI 0.3 to 7.9) at 15 min post-intervention. Compared to sham stimulation, the 40 kHz intervention had a significantly greater effect on the HPT at all time points, with the greatest difference (1.4 °C; 0.6 to 2.1) occurring immediately post-intervention. Adverse effects during active interventions included petechiae, erythema, and itching, which resolved at 24 h post-intervention. For secondary outcomes, only a significant reduction in the median SNAP velocity was observed in the sham stimulation group compared to the 50 kHz group. Conclusions: Active KHFAC stimulation, particularly at 40 kHz, delivered through a novel stimulator, effectively increased the PPT and HPT without affecting tactile or motor outcomes, inducing mild skin-related adverse effects. These findings have potential implications for people with pain-related pathologies. Trial registration: NCT05230836. [ABSTRACT FROM AUTHOR]

Introduction Method Results Discussion The epidermal growth factor receptor (EGFR; ErbB1), a membrane bound receptor tyrosine kinase, is hypothesized to have an inhibitory influence on peripheral nerve regeneration. This study examines the impact of EGFR inhibition on nerve regeneration using the commercially available small molecule inhibitor gefitinib.In vitro assays included neurite outgrowth of cultured dorsal root ganglion (DRG) neurons from adult C57Bl/6 wildtype mice on immobilized chondroitin sulfate proteoglycans (CSPG). Following forelimb median nerve injury, EGFR expression, number of regenerated neurons (using retrograde labeling) and myelination of motor and sensory neurons were compared between mice that received either gefitinib or vehicle. Functional recovery was assessed using grip strength.EGFR expression on DRG and spinal motor neurons was confirmed. Gefitinib significantly increased neurite outgrowth in medium sized (30–50 μm) DRG neurons, resulting in longer neurites (183 ± 36 μm) compared with CSPG alone (49 ± 9 μm). After median nerve injury, significantly greater numbers of sensory neurons (638 ± 112 vs. 301 ± 81), but not motor neurons (31 ± 12 vs. 42 ± 13) regenerated in animals treated with gefitinib compared with controls. Regenerated axons in gefitinib treated animals displayed significantly greater diameter and increased g‐ratio compared with controls. Grip strength recovered more quickly in animals receiving gefitinib compared with controls (27.6 vs. 19.1 g 18 days post‐injury).This study provides data supporting the role of EGFR as a negative regulator of sensory but not motor neuron regeneration. Further, it demonstrates versatile potential uses of existing pharmaceuticals. [ABSTRACT FROM AUTHOR]

Background: The efficacy and acupoint selection of acupuncture in treating chemotherapy-induced peripheral neuropathy (CIPN) remain controversial. This study aims to explore the specific efficacy and acupoint selection of acupuncture in treating CIPN through a meta-analysis and data mining. Methods: Searching for clinical trials on acupuncture treatment for CIPN in 8 databases, evaluating its efficacy and safety through a meta-analysis, and exploring its acupoint selection through data mining. Results: The meta-analysis included 21 studies and 2,121 patients, showing that compared with the control group, the acupuncture group could significantly improve neuropathic pain intensity (SMD = −0.66, 95% CI [−1.07, −0.25], p = 0.002), significantly reduce the NCI-CTCAE (MD = −0.29, 95%CI [−0.50, −0.08], p < 0.01), significantly reduce the FACT-NXT score (MD = 2.09, 95% CI [0.73,3.45], p < 0.05), significantly increase the motor conduction velocities (MCV) of median nerve (MD = 2.38, 95% CI [2.10, 2.67], p < 0.001), the sensory conduction velocities (SCV) of the median nerve (MD = 0.56, 95 %CI [−1.45, 2.57], p = 0.58), the SCV of the tibial nerve (MD = 1.78, 95% CI [0.50, 3.05], p < 0.01), and the SCV of sural nerves (MD = 4.60, 95% CI [0.17, 9.02], p < 0.05), as well as improving the quality of life score (MD =7.35, 95% CI [1.53, 13.18], p = 0.01). Data mining showed that the core acupoints for acupuncture treatment of CIPN were LI4, ST36, LI11, LR3, and SP6. Conclusion: Acupuncture can improve the neuropathic pain intensity, the intensity of the CIPN, MCV of the median nerve, SCV of the tibial nerve and peroneal nerve, quality of life, and has good safety in CIPN patients. LI4 (Hegu), ST36 (Zusanli), LI11 (Quchi), LR3 (Taichong), and SP6 (Sanyinjiao) are the core acupuncture points for treating CIPN, and this protocol has the potential to become a supplementary treatment for CIPN. Systematic review registration: https://www.crd.york.ac.uk/prospero, identifier CRD42024551137. [ABSTRACT FROM AUTHOR]

Background: Carpal tunnel release is a widely performed procedure. Despite a high success rate, iatrogenic neurovascular injuries can occur which lead to a painful and unsatisfying outcome. This study conducted a detailed examination of the anatomy of the carpal tunnel and the proximity of neurovascular structures that are particularly susceptible to injury, especially in the context of minimally invasive carpal tunnel release procedures. Patients and methods: The anatomy of the carpal tunnel of 104 wrists of 52 body donors was examined. The precise anatomical location and the presence of variations were recorded for the median nerve, ulnar nerve, ulnar artery and Berrettini branch. The distance between the median nerve, the ulnar artery, the ulnar nerve, and the Berrettini branch was measured in a proximo-distal and radio-ulnar direction in relation to the distal ulnar end of the carpal tunnel. Results: The authors identified four main dangerous anatomical situations. (1) A proximal separation of the Long-Finger/Ring-Finger branch of the median nerve together with a narrow safe-zone; (2) an ulnar take-off of the recurrent muscle branch of the median nerve with a close radio-ulnar distance to the distal ulnar end of carpal tunnel; (3) an ulnar arterial arch lying close to the transverse carpal ligament; and (4) a proximal Berrettini branch also lying close to the latter. All situations are illustrated by photographs. Additionally, the authors present a sonographic carpal tunnel assessment protocol in order to reduce the risk of injury of any neurovascular structure in the proximity of the carpal tunnel. Conclusion: Certain patients may inherently face an increased risk of neurovascular injuries during minimally invasive carpal tunnel releases due to their anatomical variations. Four potentially risky scenarios were clearly illustrated. Consequently, one may consider conducting a preoperative ultrasound assessment of neurovascular structures at risk, when endoscopic or ultrasound-guided tunnel release are planned. In high-risk patients, open surgery should be preferred. Level of evidence: II. [ABSTRACT FROM AUTHOR]

Purpose: The objective of this study was to determine the incidence, necessity for neurosurgical intervention, and overall results of the treatment of pediatric peripheral nerve injuries associated with dislocated supracondylar fractures of the distal humerus. Method: A retrospective analysis of pediatric patients with supracondylar fractures treated from April 2019 to April 2022 with a minimum follow-up of 3 months was conducted. Results: Of 453 included patients, there were 51 recorded peripheral nerve injuries. The ulnar nerve was the most frequently injured nerve. Nine patients required neurosurgical intervention, with the most common procedure being the release of entrapped nerves. The combination of a supracondylar fracture and arterial injury was identified as a significant risk factor for peripheral nerve injury (p < 0.001). Only one patient experienced an unsatisfactory outcome. Conclusion: Although the prognosis for peripheral nerve injuries in children with supracondylar fractures is generally favorable, these injuries must be properly identified. We recommend an active neurosurgical approach in children with persisting neurological deficits to minimize the risk of permanent neurological impairment. [ABSTRACT FROM AUTHOR]

The experience of pain that is induced by extremely cold temperatures can exert a modulatory effect on motor cortex circuitry. Although it is known that immersion of a single limb in very cold water can increase corticomotor excitability it is unknown how afferent input to the cortex shapes excitatory and inhibitory processes. Therefore, the purpose of this study was to examine motor‐evoked potentials (MEP), short‐latency afferent inhibition (SAI) and long‐latency afferent inhibition (LAI) in response to immersion of a single hand in cold water. Transcranial magnetic stimulation (TMS) was used to assess MEPs, and peripheral nerve stimulation of the median nerve paired with TMS was used to measure SAI and LAI in motor circuits of the ipsilateral hemisphere. Measurements were obtained from electromyography (EMG) of the first dorsal interosseous (FDI) at baseline, during cold‐water immersion, and during recovery from cold‐water immersion. The intervention caused unconditioned MEPs to increase during exposure to the cold stimulus (P = 0.008) which then returned to baseline levels once the hand was removed from the cold water. MEP responses were decoupled from SAI responses, where SAI was reduced during exposure to the cold stimulus (P = 0.005) and remained reduced compared to baseline when the hand was removed from the cold water (P = 0.002). The intervention had no effect on LAI. The uncoupling of SAI from MEPs during the recovery period suggests that the mechanisms underlying the modulation of corticospinal excitability by sensory input may be distinct from those affecting intracortical inhibitory circuits. Highlights: What is the central question of this study?Does immersion of a limb in very cold water influence corticospinal excitability and the level of afferent inhibition exerted on motor cortical circuits?What is the main finding and its importance?In additional to perception of temperature, immersion in 6°C water also induced perceptions of pain. Motor evoked potential (MEP) amplitude increased during immersion, and short‐latency afferent inhibition (SAI) of the motor cortex was reduced during immersion; however, these responses differed after the limb was removed from the cold stimulus, as MEPs returned to normal levels while SAI remained suppressed. [ABSTRACT FROM AUTHOR]

Background We explore a minimally invasive method (combined ultrasound detection, electrode placement and electrophysiologic nerve examination) to evaluate the early-stage quality of a nerve suture site. Methods Ten patients with median and/or ulnar nerve injuries who had undergone nerve suture were recruited. Postoperative ultrasound examination found that the nerve injury was sutured. Then, a stimulating electrode and recording electrode were located beside the nerve proximal and distal to the suture site guided by ultrasound. Measurement of nerve action potentials (NAP) were performed with these electrodes, followed by surgical exploration. The pre- and intraoperative electrophysiologic findings were compared, together with amplitude, latency, and wave shape of NAP. Results Of the 10 patients, 3 patients were diagnosed with median nerve injury, 2 with ulnar nerve injury, and 5 with the median nerve and ulnar nerve injury. NAP could not be detected pre- and intraoperatively in three median nerves from three patients and in two ulnar nerves from two patients. NAP was detected in 10 nerves from the remaining 5 patients. The pre- and intraoperative NAP results showed consistent results concerning the status of the nerve suture. Wilcoxon's signed-rank test indicated no significant difference in the amplitude and latency detected via sonographically placed electrodes and during surgical exploration. The number of negative-phase waves were equally distributed. Conclusion Ultrasound-guided electrode placement and NAP detection can substitute surgery and serve as a minimally invasive approach to evaluate the regeneration of a sutured nerve. [ABSTRACT FROM AUTHOR]

Objectives: To correlate the cross-sectional area (CSA) and elasticity of the median nerve (MN) measured at carpal tunnel inlet between healthy controls and various degrees of carpal tunnel syndrome (CTS) graded as per nerve conduction studies (NCS). Materials and methods: A total of 53 patients (with 81 wrists) presenting with clinical symptoms characteristic of CTS, having their diagnosis confirmed and severity graded by NCS, and 48 healthy controls (with 96 wrists) were included in the study. All the study participants underwent wrist ultrasound which included initial Grey-scale USG followed by strain and shear wave elastography. The CSA and elasticity (in terms of strain ratio and shear modulus) of MN were measured at the carpal tunnel inlet. Statistical analysis was performed using the Mann–Whitney U test to compare between the two groups and for subgroup analysis of cases. The diagnostic performance of each variable was evaluated using the receiver operating characteristic curves. Results: The mean CSA was 9.20 ± 1.64, 11.48 ± 1.05, 14.83 ± 1.19 and 19.87 ± 2.68 mm2, the mean shear modulus was 17.93 ± 2.81, 23.59 ± 2.63, 32.99 ± 4.14 and 54.26 ± 9.24 kPa and the mean strain ratio was 5.26 ± 0.68, 5.56 ± 0.70, 7.03 ± 0.47 and 8.81 ± 0.94 in control, mild, moderate and severe grades of CTS, respectively (p < 0.001). Conclusion: The combined utility of Grey-scale USG and Elastography may serve as a painless and cost-effective alternative to NCS in grading the severity of CTS. [ABSTRACT FROM AUTHOR]

Background: Neuromuscular ultrasound plays an increasing role in diagnosing carpal tunnel syndrome (CTS). There are limited data supporting the correlation between the electrodiagnostic studies and ultrasound measurements in CTS. Objective: To assess the association between different electrodiagnostic severities and ultrasound measurements of the median nerve in CTS. Design: A retrospective cohort study. Setting: An academic tertiary care center. Patients: Patients 18 years or older evaluated with upper limb electrodiagnostic studies and neuromuscular ultrasound. Main outcome measurement: Ultrasound measurements of the median nerve cross‐sectional area (CSA) at the wrist and the calculated wrist‐to‐forearm ratio (WFR) were compared with the electrodiagnostic severity (normal, mild, moderate, and severe). Mean analysis and analysis of variance test (α = 0.05) were performed to assess the association. Results: A total of 1359 limbs were identified. There was a statistically significant association between electrodiagnostic severity of CTS and median nerve CSA at the wrist (p <.001), as well as the WFR (p <.001). The mean median nerve CSA at the wrist and WFR were 7.01 ± 2.06 mm2 (95% CI: 6.80–7.20) and 1.24 ± 0.36 (95% CI: 1.16–1.24) in electrodiagnostically normal median nerves, 10.47 ± 2.82 mm2 (95% CI: 10.25–10.75) and 2.06 ± 0.67 (95% CI: 2.04–2.16) in electrodiagnostically mild CTS, 12.95 ± 4.74 mm2 (95% CI: 12.41–13.59) and 2.49 ± 1.04 (95% CI: 2.37, 2.63) in electrodiagnostically moderate CTS, and 14.69 ± 5.38 mm2 (95% CI: 13.95–15.44) and 2.71 ± 1.02 (95% CI: 2.56–2.84) in electrodiagnostically severe CTS, respectively. Conclusion: This study suggests a direct association between electrodiagnostic severity and ultrasound measurements of the median nerve in patients with suspected CTS. [ABSTRACT FROM AUTHOR]

A network meta-analysis of randomized controlled trials compared the effectiveness of corticosteroid injections with placebo injections and wrist splints for carpal tunnel syndrome, focusing on symptom relief and median nerve conduction velocity. Within 3 months of the corticosteroid injection, there was a modest statistically significant difference in symptom relief compared to placebo injections and wrist splints, as measured by the Symptom Severity Subscore of the Boston Carpal Tunnel Questionnaire; however, this did not meet the minimum clinically important difference. Pain reduction with corticosteroids was slightly better than with wrist splints, but it also failed to reach clinical significance. Electrodiagnostic assessments showed transient changes in distal motor and sensory latencies in favour of corticosteroids at 3 months, but these changes were not evident at 6 months. The best current evidence suggests that corticosteroid injections provide minimal transient improvement in nerve conduction and symptomatology compared with placebo or wrist splints. [ABSTRACT FROM AUTHOR]

Introduction: Carpal tunnel syndrome is the most common compression neuropathy. Grading the severity of carpal tunnel syndrome is an important factor in deciding on the type of treatment. This study aims to determine the relationships between the findings of the electrodiagnosis and ultrasonography methods based on the severity of carpal tunnel syndrome. Methods: In this prospective clinical study, 50 patients (96 wrists) who were referred to the Physical Medicine and Rehabilitation Department of the Shohada Tajrish Hospital, Tehran, Iran (from March 2021 to November 2022) were studied. All patients with a history and clinical examination related to CTS underwent electrodiagnosis studies. Based on the results of electrodiagnosis, patients were divided into three groups: mild, moderate, and severe. All eligible patients underwent ultrasound at the cross-section of the wrist (at the level of the pisiform bone, the entrance of the canal) and the middle of the forearm. Results: In this study, the cross-sectional area of the median nerve was measured in 96 wrists of 50 patients with a mean age of 51.78 ± 9.80 years. The mean CSA of the median nerve in the mild, moderate, and severe groups was reported as 0.12 ± 0.03, 0.14 ± 0.02, and 0.21 ± 0.06, respectively. The mean WFR in different groups of CTS was reported as 1.85 ± 0.56, 1.93 ± 0.56, and 2.45 ± 0.49, respectively. A significant relationship between ultrasound findings, including CSA-inlet and WFR, and electrodiagnosis findings was presented (P value < 0.05). Conclusion: Based on our findings, there is a statistically significant relationship between the sonographic findings, including the mean CSA-inlet and WFR, and the severity of CTS based on the electrodiagnosis study. Our findings revealed that as disease severity increases, sonographic parameters also increase significantly. [ABSTRACT FROM AUTHOR]

Background: Guillain-Barré syndrome (GBS) is a clinically heterogenous disease and encompasses several distinct clinical variants. Overlap between these variants can pose a diagnostic challenge. We report a case of finger drop variant and acute bulbar palsy overlap as an unusual manifestation of GBS. Case presentation: An 81-year-old man presented with dysarthria, dysphagia, and upper limb weakness. Neurological examination revealed impaired tongue protrusion, the finger drop sign, and diminished brachioradial and triceps muscle reflexes. Nerve conduction studies showed reduced amplitudes and decreased velocities in the median and ulnar nerves. Cerebrospinal fluid analysis revealed albuminocytological dissociation and an anti-ganglioside antibody study revealed positivity for GM1, asialo-GM1, GT1a, GD1b, and GQ1b. As GBS was suspected, we initiated intravenous immunoglobulin treatment, resulting in gradual improvement within the next 3 weeks. Conclusion: To the best of our knowledge, this is the first reported case of an overlap between the finger drop variant and acute bulbar palsy in GBS, highlighting the importance of considering GBS when patients present with a combination of atypical symptoms. Anti-ganglioside antibodies can be helpful and add diagnostic value in these complex cases. [ABSTRACT FROM AUTHOR]

Introduction: The median artery typically originates as a branch of the anterior interosseous artery. In its normal configuration, it is a small vessel that passes laterally between the flexor digitorum profundus and flexor pollicis longus muscles to reach the median nerve. From an embryological perspective, the median artery represents a remnant of the original axial arterial stem that extends into the limb. The persistence of this embryonic arterial pattern into adulthood, known as a persistent median artery (PMA), is an anatomical variation that has been the subject of numerous studies. The prevalence of PMA has been increasing over time, suggesting a potential microevolutionary change in the human population. Aim of the study: This study aims to investigate the prevalence and types of persistent median artery in a sample population from Pondicherry, India. Material and Methods: A total of 40 upper limb specimens from 12 cadavers and 16 separate upper limbs were included in the investigation. A vessel accompanying median nerve is considered a median artery. The frequency, origin, termination, type and relation to median nerve and anterior interosseous nerve were noted. Results: The presence of PMA was observed in seven forearms (17.5%), with a slight predilection for the left side (n=4). Common and anterior interosseous arteries are the source of PMA. All the PMA are of antebrachial type and none of them reached the palmar arches.Notably one PMA crossed the anterior interosseous nerve anteriorly and the other one posteriorly. Conclusion: Knowledge of the prevalence and anatomical variations of PMA is crucial for clinicians, as it can have significant implications in the diagnosis and management of carpal tunnel syndrome and other wrist pathologies. Additionally, awareness of PMA is essential for surgeons performing procedures in the carpal tunnel region to avoid potential complications. [ABSTRACT FROM AUTHOR]

Background/Objectives: The accurate quantification of peripheral nerve axonal regeneration after injury is critically important. Current strategies are limited to detecting early reinnervation. DTI is an MRI modality permitting the assessment of fractional anisotropy, which increases with axonal regeneration. The aim of this pilot study is to evaluate DTI as a potential predictive factor of clinical outcome after median nerve section and microsurgical repair. Methods: We included 10 patients with a complete section of the median nerve, who underwent microsurgical repair up to 7 days after injury. The follow-up period was 1 year, including the current strategy with clinical visits, the Rosén–Lundborg score and electroneuromyography. Additionally, DTI MRI of the injured wrist was planned 1, 3 and 12 months post-operatively and once for the contralateral wrist. Results: The interobserver reliability of DTI measures was almost perfect (ICC 0.802). We report an early statistically significant increase in the fractional anisotropy value after median nerve repair, especially in the region located distal to the suture. Meanwhile, Rosén–Lundborg score gradually increased between the third and sixth month, and continued to increase between the sixth and twelfth month. Conclusions: DTI outcomes three months post-operation could offer greater predictability compared to current strategies. This would enable faster decision-making regarding the need for a potential re-operation in cases of inadequate early reinnervation. [ABSTRACT FROM AUTHOR]

The aim of this study is to determine the maximum loss of median and ulnar nerve substances that can be treated by direct suture in elbow flexion and to quantify this elbow flexion. The other objective is to determine the participation of the wrist position in this direct suture in elbow flexion. We performed an experimental study on 6 ulnar nerve lesions and 6 median nerve lesions. For each defect, a direct tensionless suture was performed with elbow flexion and in three different positions of the wrist (wrist extension, neutral position, and wrist flexion). A 90° elbow flexion allowed direct suturing of defects up to 40 mm in the 3 positions of the wrist. A bowstringing effect (i.e., increase of the perpendicular distance of the nerve from the axis of rotation of the elbow) was noted starting from 25 mm of nerve defect. Wrist extension placed tension on the nerve suture for both nerves. The results of this first anatomical study clarified the conditions for direct suturing of ulnar and median nerve defects in the flexed elbow position and flexed wrist position. This is an approach to consider for limited nerve defects to the elbow or when allograft harvesting is to be avoided. [ABSTRACT FROM AUTHOR]

Introduction: In the arms of patients with Amyotrophic lateral sclerosis (ALS) two peculiar patterns of dissociated muscular atrophy have been described: the split-hand sign (with predominant atrophy of the lateral aspect of the hand, compared to hypothenar eminence) and the split-hand-plus sign (SHPS), a predominant abductor pollicis brevis (ABP) atrophy with sparing of flexor pollicis longus (FPL). Aims: In this case–control study, we evaluated the diagnostic utility of a neurophysiological indicator of SHPS and assessed its association with clinical features. Methods: We prospectively studied 59 incident ALS patients, 61 patients with ALS-mimic disorders (OND) and 61 non-neurological controls (NNCs). ABP and FPL compound muscle action potentials (CMAP) amplitudes were obtained by supramaximal stimulation of median nerve at elbow. Split-hand plus index (SHPI) was calculated according to the formula: APB-CMAP/FPL-CMAP. Results: SHPI was significantly lower in ALS compared to OND patients and NNCs (p < 0.0001). SHPI value < 1 was observed in 2% of NNCs and 9% of OND patients and demonstrated an accuracy of 71% in differentiating ALS from OND and an accuracy of 74% in differentiating ALS from NNC. SHPI was associated with higher LMN score, and higher disease severity as quantified by the ALSFRS-r. Conclusion: Our results indicate that SHPI is a reliable indicator to distinguish ALS patients from ONDs and NNCs. SHPI was significantly associated to the degree of lower motor neuron impairment but showed no association with upper motoneuron impairment. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study is to evaluate the functional outcome and quality of life in distal biceps tendon repair with single incision technique and anchor fixation method. Methods: A retrospective cohort study was made of patients with complete distal biceps tendon rupture. The chosen repair method was single incision technique with anchor fixation. The outcome was assessed with functional testing of the elbow with strength and ROM. Additionally Mayo elbow performance index, Oxford elbow score, Disability arm hand shoulder questionnaire and patient rated elbow evaluation scores were used to evaluate quality of life. Results: Of the 28 patients, the average strength in flexion and supination was decreased with 91% and 89% of the strength compared to the non-injured arm. ROM was preserved in flexion, extension, supination and pronation. The mean scores for quality of life evaluation were MEPS = 96 ± 7.8, OES = 46.8 ± 1.9, DASH = 1.0 ± 1.9 and PREE = 2.0 ± 3.6. LABCN injury was the most common temporary complication with 30% followed by pain with 23%. Two patients were identified with HO and 1 patient was identified with median nerve injury. There were no cases of radioulnar synostosis and PIN injury. Conclusion: Overall strength in flexion and supination were slightly decreased with preserved ROM. Patients reported nearly perfect quality of life as demonstrated with the scores. The complications rate was high with mainly minor complications. Distal biceps tendon repair with single incision technique and anchor fixation overall leads to a very satisfying outcome. [ABSTRACT FROM AUTHOR]

• Increased intraneural microvascular could be detected in patients with peripheral neuropathies using sonography. • Intraneural hypervascularization was frequently observed in patients with inflammatory neuropathies. • Superb microvascular imaging is the most sensitive technique for evaluating microvessel flow within peripheral nerves. We assessed microvessel flow within peripheral nerves using nerve sonography in patients with peripheral neuropathy. This study included consecutive patients with peripheral neuropathy who were admitted to our hospital. The patients were divided into two groups: inflammatory neuropathies for immune-mediated neuropathies, such as Guillain − Barré syndrome and chronic inflammatory demyelinating polyneuropathy, and the rest were defined as non-inflammatory neuropathies. We assessed nerve size and intraneural blood flow at four sites on each median and ulnar nerve. Blood flow was evaluated using color Doppler imaging, advanced dynamic flow (ADF), and superb microvascular imaging (SMI) techniques. Thirty-nine patients (median age, 60.0 years; 20 male) were enrolled in this study. An increase in intraneural blood flow was observed in five patients when evaluated by color Doppler, five patients by ADF, and 13 patients by SMI. An overall analysis of the three methods showed that intraneural blood flow was significantly higher in patients with inflammatory neuropathy than in those with non-inflammatory neuropathy (54.2% vs. 0%, p = 0.0005). Intraneural hypervascularization is more frequent in patients with inflammatory neuropathy than in those with non-inflammatory neuropathy. Evaluation of microvessel flow within peripheral nerves may contribute to the diagnosis of peripheral neuropathy. [ABSTRACT FROM AUTHOR]

Background Nerve transfers from one common donor nerve to recipient nerves with multiple target branches can yield slower and unpredictable recovery in the target nerves. Our hypothesis is that steal phenomenon exists when multiple nerve neurotization comes from one donor nerve. Methods In 30 Sprague-Dawley rats, the left ulnar nerve (UN) was selected as the donor nerve, and the musculocutaneous nerve (MCN) and median nerve (MN) as the recipient target nerves. The rats were separated into three groups (10 rats in each): group A, UN-to-MCN (one-target); group B, UN-to-MN (one-target); and group C, UN-to-MCN and MN (two-target). The right upper limbs were nonoperative as the control group. Outcome obtained at 20 weeks after surgery included grooming test, muscle weight, compound muscle action potential, tetanic muscle contraction force, axon counts, and retrograde labeling of the involved donor and target nerves. Results At 20 weeks after surgery, muscles innervated by neurotization resulted in significant worse outcomes than the control side. This was especially true in two-target neurotization in the parameter of muscle weight and forearm flexor muscle contraction force outcome when compared to one-target neurotization. Steal phenomenon does exist because flexor muscle contraction force was significantly worse during two-target neurotization. Conclusion This study proves the existence of steal phenomenon in multiple target neurotization but does not significantly affect the functional results. Postoperative rehabilitative measures (including electrical stimulation, induction exercise) and patient compliance (ambition and persistence) are other crucial factors that hold equivalent importance to long-term successful recovery. [ABSTRACT FROM AUTHOR]

to observe whether the mobilization of the scapula improves the mechanosensitivity of the median nerve in patients with cervicalgia. Localized cervical pain caused by compression of a nerve root without presenting irradiated features along the nerve path is diagnosed as cervicalgia. Muscles around the scapula can be directly responsible of this compression. 60 adults diagnosed with cervicalgia and with a positive upper limb neural test 1(ULNT1) were recruited. Participants in the experimental group received a scapula mobilization technique. Participants in the control group, with electrodes on both sides of the neck and connected to turned off analgesic current device, received an abduction-adduction mobilization of the calcaneus in the lower limb contralateral to the painful area. The variables measured were pain, goniometry of elbow extension in movement for the median neurodynamic test (ULNT1) and hand grip strength. Results showed that the increase in strength (p = 0.01) and elbow extension movement (p = 0.01) and the decrease in pain (p < 0.01) from the intervention group showed significant changes compared to the changes from control group. Scapula mobilization technique in subjects presenting with cervicalgia and a positive ULNT1 significantly appears to help improve the neural mechanosensitivity of the median nerve and pain. [ABSTRACT FROM AUTHOR]

BACKGROUND: According to the literature, the brachial plexus presents a high rate of anatomical variations in the human neural system. The musculocutaneous nerve, a vital component of the brachial plexus, exhibits significant anatomical variations that hold clinical relevance across multiple medical disciplines. This case report, with a comprehensive review, explores the different variations in the course, branching patterns, and clinical implications of the musculocutaneous nerve. Understanding these variations is essential for surgeons, radiologists, and clinicians to enhance surgical precision, improve diagnostic accuracy, and reduce the risk of iatrogenic complications. CASE REPORT: During an anatomical dissection we observed a very rare anatomical variation of the musculocutaneous nerve. Based on this discovery, we performed research in the literature with the aim of finding if this variation has been previously described. Firstly, we identified various classifications of anatomical variations of communicating branches between the musculocutaneous and median nerves, and then we observed that these variations corresponded to various rates of frequency. Our finding is a rare undescribed anatomical variant within the variants classified as Type II according to Le Minor, which is observed in 6.8-10.7% of cases. CONCLUSIONS: The peculiar position of anatomical variations and anastomosis has clinical and functional relevance. Healthcare professionals must be aware of these variations to minimize surgical complications, accurately diagnose neurovascular pathologies, and optimize patient management. Further research into the genetic and embryological underpinnings of these variations may provide additional insights into this intriguing aspect of human anatomy. [ABSTRACT FROM AUTHOR]

Background and Purpose: Enhancing afferent information from the paretic limb can improve post-stroke motor recovery. However, uncertainties exist regarding varied sensory peripheral neuromodulation protocols and their specific impacts. This study outlines the use of repetitive peripheral sensory stimulation (RPSS) and repetitive magnetic stimulation (rPMS) in individuals with stroke. Methods: This scoping review was conducted according to the JBI Evidence Synthesis guidelines. We searched studies published until June 2023 on several databases using a three-step analysis and categorization of the studies: pre-analysis, exploration of the material, and data processing. Results: We identified 916 studies, 52 of which were included (N = 1,125 participants). Approximately 53.84% of the participants were in the chronic phase, displaying moderate-to-severe functional impairment. Thirty-two studies used RPSS often combining it with task-oriented training, while 20 used rPMS as a standalone intervention. The RPSS primarily targeted the median and ulnar nerves, stimulating for an average of 92.78 min at an intensity that induced paresthesia. RPMS targeted the upper and lower limb paretic muscles, employing a 20 Hz frequency in most studies. The mean stimulation time was 12.74 min, with an intensity of 70% of the maximal stimulator output. Among the 114 variables analyzed in the 52 studies, 88 (77.20%) were in the "s,b" domain, with 26 (22.8%) falling under the "d" domain of the ICF. Discussion and Conclusion: Sensory peripheral neuromodulation protocols hold the potential for enhancing post-stroke motor recovery, yet optimal outcomes were obtained when integrated with intensive or task-oriented motor training. [ABSTRACT FROM AUTHOR]

To test the hypothesis that weight loss following bariatric surgery is associated with a reduced risk of developing carpal tunnel syndrome (CTS) compared with obese patients who do not undergo bariatric surgery. We performed a cohort study using data from the Swedish nationwide healthcare registries. Patients aged 18–79 years who underwent bariatric surgery from 2006 to 2019 were propensity score (PS)–matched to up to 2 obese bariatric surgery-free patients ("unexposed patients"). Cox proportional hazard regression was used to calculate hazard ratios (HR) with 95% confidence intervals (CIs) to compare the incidence of CTS among bariatric surgery patients to obese unexposed patients both overall and divided by subgroups of age, sex, bariatric surgery type, and duration of follow-up. In total, 40,619 bariatric surgery patients were PS-matched to 63,540 obese unexposed patients who did not undergo surgery. Bariatric surgery was not associated overall with CTS (HR 0.98, 95% CI 0.91–1.05). There was a 23% decreased risk of CTS incidence observed within >1–3 years after bariatric surgery (HR 0.77, 95% CI 0.68–0.88). Decreased CTS risks were observed among bariatric surgery patients aged 18–34 years (HR 0.87, 95% CI 0.74–1.01) and those who underwent sleeve gastrectomy (HR 0.81, 95% CI 0.63–1.03), but these risks did not reach significance level compared with obese unexposed patients. However, there was a 20% increased CTS risk after 6 years (HR 1.20, 95% CI 1.05–1.36). Our results suggest that marked weight does not have a lasting impact on the reduction of CTS incidence. [ABSTRACT FROM AUTHOR]

The presentation, management and outcomes of brachial plexus injuries are likely to be subject to regional differences across the globe. A comprehensive literature search was performed to identify relevant articles related to spinal accessory to suprascapular, intercostal to musculocutaneous, and ulnar and/or median nerve fascicle to biceps and/or brachialis motor branch nerve transfers for treatment of brachial plexus injuries. A total of 6007 individual brachial plexus injuries were described with a mean follow-up of 38 months. The specific indication for accessory to suprascapular and intercostal to musculocutaneous transfers were considerably different among regions (e.g. upper plexus vs. pan-plexal), while uniform for fascicular transfer for elbow flexion (e.g. upper plexus +/− C7). Similarly, functional recovery was highly variable for accessory to suprascapular and intercostal to musculocutaneous transfers, while British Medical Research Council grade ≥3 strength after fascicular transfer for elbow flexion was frequently obtained. Overall, differences in outcomes seem to be inherent to the specific transfer being utilized. Level of evidence: III [ABSTRACT FROM AUTHOR]

Objective: Schwannomas are benign, slow-growing tumors originating from Schwann cells in peripheral nerves, commonly affecting the median and ulnar nerves in the forearm and wrist. Surgical excision is the gold standard treatment. This study presents our treatment strategies and outcomes for large-sized ulnar and median nerve schwannomas at the forearm and wrist level. Methods: From 2012 to 2023, we enrolled 15 patients with schwannomas over 2 cm in size in the median or ulnar nerve at the forearm and wrist. The study included 12 patients with median nerve schwannomas (mean age: 61 years) and 3 with ulnar nerve schwannomas (mean age: 68 years), with a mean follow-up of 26.9 months. Results: After surgery, all patients with median nerve schwannomas experienced mild, transient numbness affecting fewer than two digits, resolving within six months without motor deficits. Ulnar nerve schwannoma excision caused mild numbness in two patients, also resolving within six months, but all three developed ulnar claw hand deformity, which persisted but improved at the last follow-up. Despite this, patients were satisfied with the surgery due to relief from severe tingling pain. Conclusions: Schwannomas of the median, ulnar, and other peripheral nerves should be removed by carefully dissecting the connecting nerve fascicles to avoid injury to healthy ones. Sensory deficits may occur but are unlikely to significantly impact quality of life. However, in motor-dominant nerves like the ulnar nerve, there is a risk of significant motor deficits that could affect hand function, though not completely. Therefore, thorough preoperative discussion and consideration of interfascicular nerve grafting are essential. [ABSTRACT FROM AUTHOR]

Abstract Background Carpal tunnel syndrome is the commonest upper limb peripheral neuropathy. Diffusion tensor imaging evaluates the tissue microarchitecture and measures the movement of water protons. It is non-time-consuming, not invasive and not operator dependent. The aim of our study was to evaluate whether diffusion tensor imaging can diagnose carpal tunnel syndrome and whether DTI parameters can correlate with severity of carpal tunnel syndrome. Results Seventy-two wrists were assessed, 36 diagnosed with carpal tunnel syndrome and 36 age and sex matched controls. FA & ADC were measured at four locations (distal radioulnar joint, proximal, middle and distal carpal tunnel), and the mean for the whole median nerve was calculated. FA & ADC showed statistically significant difference between cases and control at each of the measured four locations and the mean of the whole median nerve. FA & ADC at the hook of hamate (distal CT) showed the most significant difference between cases and control. For FA, the cut-off point at the hook of hamate was 0.5 (sensitivity 94.4%, specificity of 88.9%, positive predictive value 89.5% and negative predictive value 94.1%) and the cut-off point for the mean of the whole nerve was 0.545 (sensitivity 97.22%, specificity 77.78%, positive predictive value 81.4% and negative predictive value 96.6%). For ADC, the cut-off point at the hook of hamate was 1.44 (sensitivity 97.22%, specificity 86.11%, positive predictive value 87.5% and negative predictive value 96.9%) and the cut-off point for the mean of the whole nerve was 1.415 (sensitivity 86.11%, specificity, 83.33%, positive predictive value 83.8% and negative predictive value 85.7%). Conclusion Diffusion tensor imaging can diagnose carpal tunnel syndrome with accuracy compared to the gold standard nerve conduction studies. Both FA and ADC showed statistically significant differences between cases & controls with FA measurements found to be more significant.

Aims: The sensitivity and specificity of electrodiagnostic parameters in diagnosing carpal tunnel syndrome (CTS) have been reported differently, and this study aims to address this gap. Methods: This case-control study was conducted on 57 cases with CTS and 58 controls without complaints, such as pain or paresthesia on the median nerve. The main assessed electrodiagnostic parameters were terminal latency index (TLI), residual latency (RL), median ulnar F-wave latency difference (FdifMU), and median sensory latency-ulnar motor latency difference (MSUMLD). Results: The mean age in cases and controls were 50.7 years (SD 9.9) and 47.9 years (SD 12.1), respectively. The CTS severity was mild in 20 patients (34.4%), moderate in 19 patients (32.8%), and severe in 19 patients (32.8%). The sensitivity and specificity of the electrodiagnostic parameters in diagnosing CTS were as follows: TLI 75.4% and 87.8%; RL 85.9% and 82.5%; FdifMU 87.9% and 82.9%; and MSUMLD 94.8% and 60.0%, respectively. Conclusion: Our findings indicated that electrodiagnostic parameters are significantly associated with the clinical manifestation of CTS, and are associated with high diagnostic accuracy in CTS diagnosis. However, further studies are required to highlight the role of electrodiagnostic parameters and their combination in CTS detection. Cite this article: Bone Jt Open 2024;5(10):898–903.

The objective was to analyze the possible reasons for the failure of surgical treatment of carpal tunnel syndrome.One of the most common forms of compression mononeuropathy of the upper extremity is carpal tunnel syndrome. Despite being widely studied, the topic remains relevant due to the fact that this pathology makes up the majority of occupational diseases and its treatment is associated with significant healthcare costs. Carpal tunnell release is the «gold standard» for surgical treatment of carpal tunnel syndrome, but despite its high level of effectiveness, from 2 to 10 % of patients require revision surgery for recurrent carpal tunnel syndrome.

Abstract Objective Schwannomas are benign, slow-growing tumors originating from Schwann cells in peripheral nerves, commonly affecting the median and ulnar nerves in the forearm and wrist. Surgical excision is the gold standard treatment. This study presents our treatment strategies and outcomes for large-sized ulnar and median nerve schwannomas at the forearm and wrist level. Methods From 2012 to 2023, we enrolled 15 patients with schwannomas over 2 cm in size in the median or ulnar nerve at the forearm and wrist. The study included 12 patients with median nerve schwannomas (mean age: 61 years) and 3 with ulnar nerve schwannomas (mean age: 68 years), with a mean follow-up of 26.9 months. Results After surgery, all patients with median nerve schwannomas experienced mild, transient numbness affecting fewer than two digits, resolving within six months without motor deficits. Ulnar nerve schwannoma excision caused mild numbness in two patients, also resolving within six months, but all three developed ulnar claw hand deformity, which persisted but improved at the last follow-up. Despite this, patients were satisfied with the surgery due to relief from severe tingling pain. Conclusions Schwannomas of the median, ulnar, and other peripheral nerves should be removed by carefully dissecting the connecting nerve fascicles to avoid injury to healthy ones. Sensory deficits may occur but are unlikely to significantly impact quality of life. However, in motor-dominant nerves like the ulnar nerve, there is a risk of significant motor deficits that could affect hand function, though not completely. Therefore, thorough preoperative discussion and consideration of interfascicular nerve grafting are essential.

Background/Objectives: The accurate quantification of peripheral nerve axonal regeneration after injury is critically important. Current strategies are limited to detecting early reinnervation. DTI is an MRI modality permitting the assessment of fractional anisotropy, which increases with axonal regeneration. The aim of this pilot study is to evaluate DTI as a potential predictive factor of clinical outcome after median nerve section and microsurgical repair. Methods: We included 10 patients with a complete section of the median nerve, who underwent microsurgical repair up to 7 days after injury. The follow-up period was 1 year, including the current strategy with clinical visits, the Rosén–Lundborg score and electroneuromyography. Additionally, DTI MRI of the injured wrist was planned 1, 3 and 12 months post-operatively and once for the contralateral wrist. Results: The interobserver reliability of DTI measures was almost perfect (ICC 0.802). We report an early statistically significant increase in the fractional anisotropy value after median nerve repair, especially in the region located distal to the suture. Meanwhile, Rosén–Lundborg score gradually increased between the third and sixth month, and continued to increase between the sixth and twelfth month. Conclusions: DTI outcomes three months post-operation could offer greater predictability compared to current strategies. This would enable faster decision-making regarding the need for a potential re-operation in cases of inadequate early reinnervation.

Background: Musculocutaneous nerve (MCN) is a mixed nerve arising from the lateral cord of brachial plexus having root values C5, 6, and 7. It supplies the muscles of the flexor compartment of the arm namely; coracobrachialis, most part of brachialis and both heads of biceps brachii. It is cutaneous to the lower lateral part of forearm. Variations in the origin, course, branching pattern, termination, and connections of MCN are very common. Knowledge about these variations is important while evaluating unusual presentations of peripheral nerve injuries, during surgical procedures such as arthroscopy of shoulder joint, corrections of fracture humerus, brachial plexus block, and so on. Aims and Objectives: The study was conducted to find out any variations in the origin, course, branching pattern of the MCN. The secondary objective was to understand about the communication of the MCN with any other nerve. Materials and Methods: A descriptive study was conducted in 60 upper limb specimens dissected from 10% formalin embalmed 30 cadavers (adult) in the Department of Anatomy, Government Medical College, Kottayam. All limbs were carefully dissected and studied about the origin, course, termination, and variations of MCN. Results: Out of 60 specimens studied, in 46 specimens MCN Originate from lateral cord, eight from medial cord, and in six from the lateral root of the median nerve (MN). In 52 specimens, MCN supplies coracobrachialis but only in 34 it pierces this muscle. In four specimens, there is a communication between MCN and MN was seen. Conclusion: The MCN has significant variations and knowledge of these variations is clinically important in diagnosis and management of peripheral nerve injuries as well as surgical interventions in the arm.

Objective To establish the reference standard of the median nerve conduction study (NCS) in Korea. Methods A total of 648 median motor and 602 median sensory NCSs from 349 Korean healthy volunteers were tested and analyzed prospectively. Equipment calibration, assessment of intra- and inter-rater reliability, and the NCSs per se were conducted according to a predetermined protocol. A reference standard was established from uncertainty components for the following parameters: the onset and peak latencies; the baseline-to-peak and peak-to-peak amplitudes; the area and duration of the negative wave; and the nerve conduction velocity. The effects of sex, age and stimulation intensity were analyzed. Results Each measured value of 648 median motor and 602 median sensory nerves were obtained and presented with both mean and expanded uncertainties, as well as mean and standard deviations. The cut-off values with expanded uncertainty were determined for different age and sex groups. After adjusting for anthropometric covariates, all parameters except duration were affected by age, and sex appeared to influence both duration and area. While stimulation intensity significantly affected some parameters including latencies, the effect sizes were negligible. Conclusion We propose the median NCS reference standard using the largest Korean dataset ever available. The use of the traceable and reliable reference standard is anticipated to promote more accurate and dependable diagnosis and appropriate management of median neuropathies in Korea.

AbstractBackgroundMethodsResultsConclusionsPROSPERO Protocol numberTinel’s test is commonly used in the diagnosis of carpal tunnel syndrome (CTS) despite its questionable diagnostic test accuracy (DTA). This systematic review investigated the DTA of Tinel’s test in CTS using electrodiagnosis as the reference standard and explored the heterogeneity between included studies.Prospective studies evaluating Tinel’s test in adults with CTS were included. The principal measures were sensitivity and specificity. A literature search was conducted for studies published up to 7 June 2024. The methodological quality was assessed using the QUADAS-2 tool. Narrative synthesis of study results and heterogeneity was undertaken. Meta-analysis was not conducted due to the high variability in diagnostic thresholds.Fifteen out of 4099 identified studies met the inclusion criteria. Patient selection scored ‘high’ in risk of bias and applicability concerns. Examiner blinding was poorly reported. Sensitivity varied from 30 to 89%. Specificity varied from 41 to 100%. Heterogeneity was found across all studies in participant selection criteria, Tinel’s test performance, electrodiagnostic criteria, and diagnostic thresholds.Tinel’s test demonstrated variable diagnostic accuracy in CTS. Due to poor methodological quality and high variability among the studies, more DTA studies are necessary.CRD42020218165 dated 27 November 2020. [ABSTRACT FROM AUTHOR]

Introduction: The median and ulnar nerves have been suggested to play a significant role in hand function; however, there are insufficient data to determine the strength of this association. This study aimed to investigate the correlation between hand function as measured with the Grooved pegboard test (GPT) and conduction velocity and latency of the median and ulnar nerves. Methods: We collected convenience samples in the College of Medicine, KSAU-HS. We used GPT to characterize hand function and performed measured nerve conduction velocity (NCV) and latency of the ulnar and median nerves of both hands. We used the Edinburgh handedness inventory (EHI) to determine hand dominance. Results: We recruited 28 healthy medical students aged 20–29 years (mean: 21.46 ± 1.62 years). Most were right-handed (n = 25, 89.3%), with a mean EHI score of 302 ± 210. The mean GPT time was significantly faster in the dominant (65.5 ± 6.4 s) than in the non-dominant (75.0 ± 9.6 s) hand. The NCV for the ulnar nerve of the dominant hand was significantly correlated with GPT (r = -0.52, p = 0.005) while median nerve was not correlated (0.24, p = 0.21). Regression analysis and collinearity test showed that the ulnar NCV explained 20% of the variance in GPT of the dominant hand (R2 = 0.203, p = 0.016). Conclusion: The ulnar nerve conduction velocity, explained 20% of the variance in GPT times of the young men. Performance on this biomarker of neurological health seems to be more influenced by other factors in healthy young individuals. [ABSTRACT FROM AUTHOR]

Objective: Many clinicians are unfamiliar with a diagnosis of lacertus syndrome (LS). We investigated the value of the lacertus notch sign in diagnosing LS. Methods: We included 56 consecutive patients (112 upper extremities) who had neuropathic pain and neurological symptoms of the hand. The presence of LS and the lacertus notch sign in each upper extremity was assessed. Results: Of the 83 upper extremities with LS, 54 (65.1%) had a lacertus notch sign, whereas 29 (34.9%) did not. Of the 29 upper extremities without LS, 9 (31.0%) and 20 (69.0%) had and did not have a lacertus notch sign, respectively. The rates of lacertus notch presence in upper extremities with and without LS were significantly different. Of the 63 upper extremities with a lacertus notch sign, 54 (85.7%) were diagnosed with LS, whereas 9 (14.3%) were not. Of the 49 upper extremities without a lacertus notch sign, 20 (40.8%) were diagnosed with LS, and 29 (59.2%) were not. We observed significant differences in the rates of LS in upper extremities with and without lacertus notch. Conclusions: The presence of the lacertus notch sign is useful for diagnosing LS. When patients with neuropathic pain and neurological symptoms present with a lacertus notch sign, clinicians should consider the possibility of LS. [ABSTRACT FROM AUTHOR]

Introduction/Aims: T2 magnetic resonance imaging (MRI) mapping has been applied to carpal tunnel syndrome (CTS) for quantitative assessment of the median nerve. However, quantitative changes in the median nerve before and after surgery using T2 MRI mapping remain unclear. We aimed to investigate whether pathological changes could be identified by pre‐ and postoperative T2 MRI mapping of the median nerve in CTS patients after open carpal tunnel release. Methods: This was a prospective study that measured median nerve T2 and cross‐sectional area (CSA) values at the distal carpal tunnel, hamate bone, proximal carpal tunnel, and forearm levels pre‐ and postoperatively. Associations between T2, CSA, and nerve conduction latency were also evaluated. Results: A total of 36 patients with CTS (mean age, 64.5 ± 11.7 years) who underwent surgery were studied. The mean preoperative T2 values significantly decreased from 56.3 to 46.9 ms at the proximal carpal tunnel levels (p =.001), and from 52.4 to 48.7 ms at the hamate levels postoperatively (p =.04). Although there was a moderate association between preoperative T2 values at the distal carpal tunnel levels and distal motor latency values (r = −.46), other T2 values at all four carpal tunnel levels were not significantly associated with CSA or nerve conduction latency pre‐ or postoperatively. Discussion: T2 MRI mapping of the carpal tunnel suggested a decrease in nerve edema after surgery. T2 MRI mapping provides quantitative information on the median nerve before and after surgery. [ABSTRACT FROM AUTHOR]

This report describes two similar cases in which the distal forearm was compressed between the rib cage and floor for a prolonged period owing to immobility, resulting in severe compartment syndrome and extensive penetrating necrosis in the forearm. The cases were a 59-year-old man with cervical spondylolisthesis and a 65-year-old man suspected of having Parkinson's disease. A distinctive necrotic pattern characterized by necrosis in the volar and dorsal compartments, preservation of the lateral compartment, and retention of the radial artery was commonly observed in both cases. Despite the anticipated nonfunctional outcome of the salvaged limb, a two-lobed free latissimus dorsi musculocutaneous flap transfer with interposition of the thoracodorsal nerve in the median nerve defect was performed in both cases. Although the salvaged limbs were nonfunctional, the patients were able to use it for activities such as getting up and other daily tasks. [ABSTRACT FROM AUTHOR]

During routine dissection of the anterior compartment of the arm region, we encountered several variations in the muscular and neural structures in the right upper extremity of a female cadaver. We observed one superiorly positioned extramuscular head with fibers originating from both the biceps brachii (BB) and coracobrachialis (CB) muscles and one inferiorly positioned extramuscular head with fibers solely from the BB muscle. The musculocutaneous nerve did not penetrate the CB muscle, but instead provided a muscular branch that communicated with the median nerve (MN). Both the MN and brachial artery (BA) flow beneath the extra head. This case suggests that the described variations may contribute to the entrapment of the MN and compression of the BA. Understanding these variations is crucial before surgical intervention. The failure to recognize such anatomical nuances could lead to inadvertent nerve injury or compromised vascular perfusion, emphasizing the need for preoperative planning and intraoperative vigilance. [ABSTRACT FROM AUTHOR]

To investigate the effect of a pulsed Nd:YAG laser on the forearm local skin temperature (LST) and electrophysiology in healthy adults. A total of 30 healthy subjects with a mean age of 21 ± 0.74 years, mass of 63 ± 9.97 kg, and height of 163.7 ± 6.24 cm participated in this study. The anterior surface of the left non-dominant forearm was scanned with a pulsed Nd:YAG laser at 20 Jcm−2 for a total of 2000 J in 15 min. The right forearm was considered as the control and was scanned with a placebo laser for the same time as the active laser. Forearm minimal, average, and maximum LST were measured using a thermographic camera. Electrophysiological assessment of the median nerve [distal motor latency (DML), motor nerve conduction velocity (MNCV), and sensory nerve conduction velocity (SNCV)] was performed on both forearms before and after the application of the pulsed Nd:YAG laser. Paired and unpaired t tests were used to compare within and between groups, respectively. The level of significance was set at p > 0.05. There were significant increases in the minimum, average, and maximum LST, as well as the MNCV and SNCV with a significant decrease in DML after laser application compared to the control. The average increase in LST and nerve conduction velocity post-treatment was 275.55 K and 4.8 ms−1, respectively. The application of a pulsed Nd:YAG laser significantly increased the forearm LST, MNCV, and SNCV and significantly decreased the DML in healthy subjects. The average increase in the LST was 275.55 K with an average increase of 5 ms−1 in the motor and 4 ms−1 in the sensory NCVS. [ABSTRACT FROM AUTHOR]

Background: Musculocutaneous nerve (MCN) is a mixed nerve arising from the lateral cord of brachial plexus having root values C5, 6, and 7. It supplies the muscles of the flexor compartment of the arm namely; coracobrachialis, most part of brachialis and both heads of biceps brachii. It is cutaneous to the lower lateral part of forearm. Variations in the origin, course, branching pattern, termination, and connections of MCN are very common. Knowledge about these variations is important while evaluating unusual presentations of peripheral nerve injuries, during surgical procedures such as arthroscopy of shoulder joint, corrections of fracture humerus, brachial plexus block, and so on. Aims and Objectives: The study was conducted to find out any variations in the origin, course, branching pattern of the MCN. The secondary objective was to understand about the communication of the MCN with any other nerve. Materials and Methods: A descriptive study was conducted in 60 upper limb specimens dissected from 10% formalin embalmed 30 cadavers (adult) in the Department of Anatomy, Government Medical College, Kottayam. All limbs were carefully dissected and studied about the origin, course, termination, and variations of MCN. Results: Out of 60 specimens studied, in 46 specimens MCN Originate from lateral cord, eight from medial cord, and in six from the lateral root of the median nerve (MN). In 52 specimens, MCN supplies coracobrachialis but only in 34 it pierces this muscle. In four specimens, there is a communication between MCN and MN was seen. Conclusion: The MCN has significant variations and knowledge of these variations is clinically important in diagnosis and management of peripheral nerve injuries as well as surgical interventions in the arm. [ABSTRACT FROM AUTHOR]

Background: Increasing evidence indicates a higher prevalence of polyneuropathy (PNP) in Parkinson's disease (PD). However, the involvement of large fiber neuropathy in PD still remains poorly understood. Given the lack of longitudinal data, we investigated the course of PNP associated with PD. Methods: In total, 41 PD patients underwent comprehensive clinical evaluation including motor and non-motor assessments as well as nerve conduction studies at baseline and at 2 years of follow-up. The definition of PNP was based on electrophysiological standard criteria. Common causes of PNP were excluded. Results: At baseline, PNP was diagnosed in 65.85% of PD patients via electroneurography. Patients with PNP presented with higher age (p = 0.019) and PD motor symptom severity (UPDRS III; p < 0.001). Over the course of 2 years, PNP deteriorated in 21.95% of cases, and 26.83% remained without PNP. Deterioration of nerve amplitude was most prevalent in the median sensory nerve affecting 57.58% of all PD cases with an overall reduction of median sensory nerve amplitude of 45.0%. With regard to PD phenotype, PNP progression was observed in 33.33% of the tremor dominant and 23.81% of the postural instability/gait difficulties subtype. Decrease of sural nerve amplitude correlated with lower quality of life (PDQ-39, p = 0.037) and worse cognitive status at baseline (MoCA, p = 0.042). Conclusion: The study confirms the high PNP rate in PD, and demonstrates a significant electrophysiological progression also involving nerves of the upper extremities. Longitudinal studies with larger cohorts are urgently needed and should elucidate the link between PD and PNP with the underlying pathomechanisms. [ABSTRACT FROM AUTHOR]