Ulnar nerve compression in Guyon's canal caused by calcinosis in scleroderma

Idiopathic calcinosis cutis causing cubital tunnel syndrome: A case report and review of literature

Calcinosis cutis is a type of heterotopic calcification where abnormal calcium deposition occurs in skin or subcutaneous tissue. Among the subtypes of calcinosis cutis, the idiopathic variety occurs without underlying biochemical calcium abnormality. We report a rare case of idiopathic calcinosis cutis causing cubital tunnel syndrome. A 63-year-old female presented with pain and numbness in the ulnar aspect of her left hand. The X-ray of the left elbow showed deposition of radiopaque material on the posteromedial aspect. Her nerve conduction study showed evidence of ulnar nerve compression at the elbow supporting the diagnosis of ulnar nerve compression by the mass of calcium deposition. Surgical exploration was performed, and significant ulnar nerve compression was noted due to the mass effect of the calcium deposition. Excision of the mass and ulnar nerve decompression with anterior transposition was performed with satisfactory outcomes. Although calcinosis cutis causing cubital tunnel syndrome has been previously reported, all patients had some form of calcium dysregulation. We report the first case of ulnar nerve compression at the cubital tunnel due to idiopathic calcinosis cutis. Excision of the mass and ulnar nerve decompression with anterior transposition was successful in our patient despite the incomplete excision of the calcium deposition.

Surgical Debulking for Symptomatic Management of Calcinosis Cutis of the Hand and Upper Extremity in Systemic Sclerosis

PURPOSE

To determine whether elective calcinosis debulking surgery of the hands and/or upper extremities is a safe and effective treatment for painful symptomatic scleroderma. Our hypothesis was that calcinosis debulking surgery would result in improvement in patient-reported pain and range of motion (ROM) with relatively little postoperative surgical pain for scleroderma patients.

METHODS

We performed a retrospective review of scleroderma patients who underwent elective calcinosis debulking surgery by a single surgeon between August 2014 and August 2019. Patients were included if they had a documented diagnosis of limited or diffuse scleroderma and underwent elective or nonemergent hand or upper-extremity calcinosis debulking surgery with a minimum final follow-up of 12 months. Primary outcomes measured were preoperative to final follow-up changes in visual analog scale pain scores. Secondary outcomes were changes in numbness and ROM as well as in daily opioid requirements, postoperative opioids used to control surgical pain, and complications.

RESULTS

Thirty-nine patients underwent calcinosis debulking surgeries on 41 upper extremities. Median final follow-up was 22 months (range, 13-60 months). Significant decreases occurred in visual analog pain scores (preoperative median, 5 [range, 0-10); final follow-up median, 0 [range, 0-8]) and improved patient-reported ROM in 15% (no change, 85%; worse, 0%). There was no significant preoperative to final follow-up difference in patient-reported numbness (improved, 5%; no change, 85%; and worse, 10%). Thirteen patients incurred 17 complications.

CONCLUSIONS

Elective calcinosis debulking surgery of the hands and/or upper extremities in scleroderma decreased pain scores, improved patient-reported ROM in 15% of patients, and had no effect on patient-reported numbness at final follow-up.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Epidemiology and treatment of peripheral neuropathy in systemic sclerosis

OBJECTIVE

The epidemiology and treatment of peripheral neuropathy in systemic sclerosis (SSc) is poorly understood. The objectives of this study were to evaluate the incidence, prevalence, risk factors, and treatments of peripheral neuropathy in SSc.

METHODS

A systematic review of Medline, Embase and CINAHL databases for literature reporting peripheral neuropathy in SSc was performed. Studies evaluating incidence, prevalence, risk factors, and treatments were synthesized. Meta-analysis using a random effects model was used to evaluate the prevalence of peripheral neuropathy.

RESULTS

113 studies reported 949 subjects with at least one type of peripheral neuropathy out of 2143 SSc patients studied. The mean age was 48.5 years. The mean time between SSc onset and detection of peripheral neuropathy was 8.85 years. The pooled prevalence of neuropathy was 27.4% (95%CI 22.4% - 32.7%). Risk factors for peripheral neuropathy in SSc included advanced diffuse disease, anticentromere antibodies, calcinosis cutis, ischemia of the vasa nervosum, iron deficiency anemia, metoclopramide, pembrolizumab, silicosis and uremia. There were 73 subjects with successful treatments (n=36 restoring sensation, n=37 restoring motor or sensorimotor function). Treatments included decompression surgery, prednisone, cyclophosphamide, carbamazepine, transcutaneous electrical nerve stimulation, tricyclic antidepressants and IVIG.

CONCLUSION

All-cause peripheral neuropathy is not uncommon in SSc. Compression neuropathies can be treated with decompression surgery. Observational data reporting immunosuppressive and anticonvulsants to treat peripheral neuropathy in SSc is limited and conflicting. This data provides the signal of effect to justify RCT to evaluate the efficacy of these interventions.

[Pseudotumoral calcinosis of the wrist compressing the radial nerve in systemic sclerosis]

BACKGROUND

Pseudotumoral calcinosis, a rare complication of systemic scleroderma, is characterized by the presence in extra-articular tissue, but rarely intra-articular tissue, of large masses made up of hydroxyapatite crystals.

PATIENTS AND METHODS

We report an original case of intra- and extra-articular pseudotumoral calcinosis of the wrist diagnosed in a patient followed for mild systemic scleroderma. The calcinosis was revealed in a highly unusual way via ductal syndrome secondary to compression of the radial nerve in the wrist. Surgical treatment resulted in marked clinical and functional improvement.

COMMENT

Although subcutaneous calcinoses are a fairly common complication of systemic scleroderma, the pseudo-tumoral form remains extremely rare. It may be complicated by pain, recurrent infection, and functional restriction, but literature contains only very rare reports of its revelation via ductal syndrome.

Calcinosis of the Hand in Scleroderma: A Case Report

Calcinosis associated with scleroderma is a well recognized phenomenon. Fifteen to 44% of patients with systemic scleroderma and associated CREST (calcifications, raynaud's phenomenon, esophageal motility disorder, sclerodactyly and telangiectasias) syndrome have deposition of calcium in the fingers and hands. The tumourous effect may limit motion, cause neuropraxia, compound microangiopathy or present as calcific ulcers. This report describes the case of a patient with scleroderma and CREST syndrome in whom calcinosis in the hand resulted in severe, debilitating pain necessitating surgical evacuation of the deposits. The patient had complete pain relief in the postopertive period. A further surgical extirpation of calcium was required for recurring pain at six months after surgery. The patient has remained symptom free since that time. The rare occurence of excruciating pain prompted this report and literature review.

Ulnar tunnel syndrome

Ulnar neuropathy at or distal to the wrist, the so-called ulnar tunnel syndrome, is an uncommon but well-described condition. However, diagnosis of ulnar tunnel syndrome can be difficult. Paresthesias may be nonspecific or related to coexisting pathologies, such as carpal tunnel syndrome, cubital tunnel syndrome, thoracic outlet syndrome, C8-T1 radiculopathy, or peripheral neuropathy, which makes accurate diagnosis challenging. The advances in electrodiagnosis, ultrasonography, computed tomography, and magnetic resonance imaging have improved the diagnostic accuracy. This article offers an updated view of ulnar tunnel syndrome as well as its etiologies, diagnoses, and treatments.

Neurologic involvement in scleroderma: a systematic review

OBJECTIVES

To perform a systematic review of neurologic involvement in Systemic sclerosis (SSc) and Localized Scleroderma (LS), describing clinical features, neuroimaging, and treatment.

METHODS

We performed a literature search in PubMed using the following MeSH terms, scleroderma, systemic sclerosis, localized scleroderma, localized scleroderma "en coup de sabre", Parry-Romberg syndrome, cognitive impairment, memory, seizures, epilepsy, headache, depression, anxiety, mood disorders, Center for Epidemiologic Studies Depression (CES-D), SF-36, Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Patient Health Questionnaire-9 (PHQ-9), neuropsychiatric, psychosis, neurologic involvement, neuropathy, peripheral nerves, cranial nerves, carpal tunnel syndrome, ulnar entrapment, tarsal tunnel syndrome, mononeuropathy, polyneuropathy, radiculopathy, myelopathy, autonomic nervous system, nervous system, electroencephalography (EEG), electromyography (EMG), magnetic resonance imaging (MRI), and magnetic resonance angiography (MRA). Patients with other connective tissue disease knowingly responsible for nervous system involvement were excluded from the analyses.

RESULTS

A total of 182 case reports/studies addressing SSc and 50 referring to LS were identified. SSc patients totalized 9506, while data on 224 LS patients were available. In LS, seizures (41.58%) and headache (18.81%) predominated. Nonetheless, descriptions of varied cranial nerve involvement and hemiparesis were made. Central nervous system involvement in SSc was characterized by headache (23.73%), seizures (13.56%) and cognitive impairment (8.47%). Depression and anxiety were frequently observed (73.15% and 23.95%, respectively). Myopathy (51.8%), trigeminal neuropathy (16.52%), peripheral sensorimotor polyneuropathy (14.25%), and carpal tunnel syndrome (6.56%) were the most frequent peripheral nervous system involvement in SSc. Autonomic neuropathy involving cardiovascular and gastrointestinal systems was regularly described. Treatment of nervous system involvement, on the other hand, varied in a case-to-case basis. However, corticosteroids and cyclophosphamide were usually prescribed in severe cases.

CONCLUSIONS

Previously considered a rare event, nervous system involvement in scleroderma has been increasingly recognized. Seizures and headache are the most reported features in LS en coup de sabre, while peripheral and autonomic nervous systems involvement predominate in SSc. Moreover, recently, reports have frequently documented white matter lesions in asymptomatic SSc patients, suggesting smaller branches and perforating arteries involvement.

Ulnar tunnel syndrome

Ulnar tunnel syndrome could be broadly defined as a compressive neuropathy of the ulnar nerve at the level of the wrist. The ulnar tunnel, or Guyon's canal, has a complex and variable anatomy. Various factors may precipitate the onset of ulnar tunnel syndrome. Patient presentation depends on the anatomic zone of ulnar nerve compression: zone I compression, motor and sensory signs and symptoms; zone II compression, isolated motor deficits; and zone III compression; purely sensory deficits. Conservative treatment such as activity modification may be helpful, but often, surgical exploration of the ulnar tunnel with subsequent ulnar nerve decompression is indicated.

Lipoma of Guyon's canal causing ulnar neuropathy

Lipoma is a benign soft tissue tumor which rarely causes neuropathy. In closed compartments such as Guyon’s canal, even small volume loss can lead to compression of nerve. Hence in such areas, even innocuous tumors such as lipomas can cause neuropathy and warrant surgery. We present one such case of ulnar neuropathy caused by lipoma of Guyon’s canal.

Ulnar neuropathy at the wrist

Compression of the ulnar nerve at the level of the wrist is rare and often difficult to diagnose. This article describes the various types of lesions that may occur and discusses the different electrophysiologic techniques that may aid the electromyographer in localizing lesions to the wrist.

Lumbrical-interossei motor studies localize ulnar neuropathy at the wrist

Ulnar nerve entrapment at the wrist (UNW) is uncommon and often difficult to localize electrophysiologically. The difference between the motor latencies to the median-innervated second lumbrical (2L) and ulnar-innervated palmar interosseous (Pl) (Diff 2L-Pl) has been shown to be of localizing value in patients with median neuropathy at the wrist. In the last year, we evaluated 2 patients with clinically definite ulnar neuropathy at the wrist. We performed motor studies to the 2L-Pl on the 2 patients and 12 disease controls with ulnar neuropathy at the elbow as follows: Using the same electrodes to record both the 2L and Pl, the median and ulnar nerves were each stimulated supramaximally above the wrist using identical distances. In the disease control subjects, the Diff 2L-Pl was essentially the same as normal controls (mean [0.13], range [(-0.3)-0.4]). In both patients with UNW, the Diff 2L-Pl clearly supported the routine electrophysiological studies in localizing the lesion (ulnar latencies were 1.1 and 1.8 ms longer than the median latencies). We conclude that the lumbrical-interosseous latency difference is useful in localizing ulnar nerve entrapment to the wrist.

Ulnar neuropathy caused by a thrombosed ulnar vein. Case report and literature review

A previously unreported finding of ulnar nerve compression at the wrist caused by a thrombosed ulnar artery vena comitans is described. The value of magnetic resonance imaging (MRI) in evaluating wrist masses is reviewed.

Compression of the ulnar nerve in Guyon's canal by pseudotumoral calcinosis in systemic scleroderma

We report one case of ulnar nerve compression in Guyon's canal due to calcium deposits in a 50-year-old woman with long standing systemic scleroderma. To our knowledge, this is the second known case. The symptoms consisted of a motor and partial sensory disturbance. Calcification of the piso-triquetral joint was prolonging into Guyon's canal, lifting its contents, and into the subcutaneous tissue of the ulnar border of the wrist. Excision of calcium deposits and of the pisiform in combination with external neurolysis of the ulnar nerve resulted in complete relief of symptoms.

Variations of the ulnar nerve and ulnar artery in Guyon's canal: a cadaveric study

In 23 cadaveric hands the hypothenar region was studied and this report is about the anatomical boundaries and contents of Guyon's Canal. It was noted that the contents of Guyon's canal exit through two distinct areas termed the deep distal hiatus and superficial distal hiatus. A variation in the course of the deep branch of the ulnar artery, reported to be infrequent, was found to be present in 74% of the specimens. We concluded that the ulnar artery exists distal to the space described by Guyon. When a release of the ulnar nerve is undertaken, surgery should not only open the roof of Guyon's space but also the fibrous arcade of the deep distal hiatus.