Diagnostic Considerations in Compressive Neuropathies

Improving Short-Term Outcomes of Cubital Tunnel Syndrome Decompression with Intraoperative Dexamethasone

OBJECTIVE

To evaluate the effect of intraoperative dexamethasone on short-term clinical outcomes following decompression procedures for cubital tunnel syndrome (CuTS) and its role in controlling postoperative inflammation.

METHODS

A retrospective analysis was conducted on 114 patients with severe CuTS, categorized into a dexamethasone group (n=55) and a control group (n=59). All patients underwent anterior ulnar nerve transposition. The dexamethasone group received 10 mg of dexamethasone injected subepineurally after decompression. Outcomes were assessed at 4 weeks and 6 months postoperatively using visual analog scale, patient-reported ulnar nerve evaluation, Modified Bishop score, two-point discrimination, and electromyography.

RESULTS

At 4 weeks, the dexamethasone group showed significantly better improvements in visual analog scale (3.56 ± 0.88 vs. 4.03 ± 0.99, P = 0.014), patient-reported ulnar nerve evaluation (40.87 ± 7.82 vs. 43.49 ± 7.16, P = 0.045), and Bishop scores (8.69 ± 1.18 vs. 7.49 ± 0.88, P < 0.001) compared to the control group. Electrophysiological testing at 6 months also revealed higher motor nerve conduction velocity (50.04 ± 3.92 vs. 46.49 ± 4.84 m/s, P < 0.001) and sensory nerve conduction velocity (49.06 ± 4.60 vs. 47.10 ± 5.63 m/s, P = 0.041) in the dexamethasone group. No adverse effects were observed.

CONCLUSIONS

Intraoperative dexamethasone effectively reduces inflammation and edema, promoting early nerve recovery and improved short-term outcomes in CuTS decompression. It is a safe and effective adjunctive treatment strategy.

Median nerve entrapment neuropathy: a review on the pronator syndrome

Pronator syndrome is a compression neuropathy of the median nerve within the anatomical structures of the elbow and forearm. It presents with neuropathic pain, numbness, and weakness of the forearm and hand, which are often exacerbated by repetitive pronation-supination movements. Patient presentation may mimic the signs and symptoms of carpal tunnel syndrome. Diagnosis requires comprehensive clinical assessment, employing provocative examination along with electrophysiological and imaging studies for accurate evaluation. Treatment strategies encompass conservative measures such as activity modification and physical therapy, whereas surgical intervention may be warranted in severe cases that are refractory to conservative treatment. By reviewing the current literature within the spectrum of median nerve entrapment neuropathies, this review aimed to enhance and summarize the current understanding by consolidating the existing knowledge for improved patient outcomes.

Diagnostic Dilemmas in Carpal Tunnel Syndrome and Cervical Spine Disorders: A Comprehensive Review

Carpal tunnel syndrome (CTS) and cervical spondylosis (CS) are both common diseases, yet differentiation between the two is sometimes necessary. However, there are few evidence-based reviews on the differentiation of these conditions. This review examined the literature on the diagnosis of CTS and CS, focusing on how to distinguish between them. The analysis is divided into four categories: clinical symptoms, physical examination, diagnostic imaging, and electrodiagnosis. A total of 281 studies are reviewed, revealing a major issue: the inclusion criteria for defining each disease varies widely across studies. Understanding this limitation, the conclusion drawn is that no single clinical symptom, test, or imaging evaluation can be deemed uniquely reliable for diagnosing CTS or CS. Therefore, it is essential to apply the most up-to-date knowledge, conduct thorough examinations, and perform necessary tests for each patient to achieve a confident and accurate diagnosis.

Dorsal Interosseous Muscle Weakness from Mid-palm Ganglion Cyst

Ulnar nerve compression is commonly seen at the elbow at the cubital tunnel and the wrist at the Guyon canal but is rarely seen in the hand. This case report describes an 18-year-old male presenting with seven months of atraumatic hand weakness and atrophy associated with heavy weightlifting. Exam demonstrated isolated interosseous muscle atrophy mostly sparing the abductor digiti minimi with intact sensation and negative nerve compression tests including Tinel at carpal and ulnar tunnels, Froment sign, Wartenberg test, cross finger test, and Spurling test. Electromyography and nerve conduction studies demonstrated prolonged distal latency, low amplitude potential, and large amplitude fibrillations with severely reduced motor unit firing in the first dorsal interosseous muscle consistent with ulnar nerve deep motor branch compromise. Magnetic resonance imaging revealed a ganglion cyst between the third metacarpal shaft and the flexor profundus tendon. Given the progressive symptoms, ganglion cyst excision and ulnar motor nerve branch neurolysis were performed.

The role of the exhaustion test in lacertus syndrome

BACKGROUND

Lacertus syndrome involves dynamic median nerve compression by the lacertus fibrosus, leading to sensory symptoms and loss of strength. Prevalence in the general population is unclear.

OBJECTIVE

This study aimed to determine the prevalence of lacertus syndrome in the Belgian population and to evaluate the effectiveness of the exhaustion test combined with the scratch collapse test.

METHODS

In a cross-sectional study from May 2023 to February 2024, 362 healthy individuals, aged 18 to 86 years underwent clinical examinations, including the scratch-collapse test and exhaustion test, to assess signs of lacertus syndrome.

RESULTS

11.3% of participants (95% CI: 8.2-15.1%) reported discomfort on lacertus fibrosus palpation. The scratch-collapse test at the lacertus fibrosus was positive in 7.2% of cases (95% CI: 4.8-10.4%), increasing to 25.7% (95% CI: 21.3-30.5%, p < 0.001) following the exhaustion test. There were no significant differences in gender, occupation, or hand dominance (all p > 0.05). Hagert's clinical triad and positive scratch-collapse test over the lacertus fibrosus were found in 2.21% (95% CI: 1.0-4.2%) of this general population after the exhaustion test.

CONCLUSION

The prevalence of lacertus syndrome was 2.21% after the exhaustion test, and 0.83% before. The exhaustion test led to significant conversion of negative to positive scratch-collapse test from 7.2% to 25.7%. The exhaustion test enhanced the scratch-collapse test's diagnostic accuracy, revealing a spectrum of lacertus syndrome symptoms, from unnoticed mild cases to severe manifestations, and confirmed the importance of Hagert's clinical triad in diagnosing lacertus syndrome.

A novel classification of intraoperative ulnar nerve instability to aid transposition surgery

HYPOTHESIS

The purpose of this study was to compare inter- and intraobserver agreement of a novel intraoperative subluxation classification for patients undergoing ulnar nerve surgery at the elbow. We hypothesize there will be strong inter- and intraobserver agreement of the 4-category classification system, and reviewers will have substantial confidence while reviewing the classification system.

METHODS

Four blinded fellowship-trained orthopedic hand surgeons reviewed 25 videos in total on 2 separate viewings, 21 days apart. Variables collected were ulnar subluxation classification (A, B, C, or D) and a confidence metric. Subsequent to primary data collection, classification grading was stratified into A/B or C/D subgroups for further analysis. Cohen κ scores were used to evaluate all variables collected in this study. The interpretation of κ scores included ≤0.0 as no agreement, 0.01-0.20 as none to slight, 0.21-0.40 as fair, 0.41-0.60 as moderate, 0.61-0.80 as substantial, and 0.81-1.0 as almost perfect agreement.

RESULTS

Interobserver agreement of subluxation classification as a 4-category scale demonstrated a moderate agreement on first viewing, second viewing, and when both viewings were combined (κ = 0.51, 0.51, and 0.51 respectively). Seventy-five percent (3 of 4) of reviewers had moderate intraobserver agreement for ulnar nerve subluxation classification, whereas 1 reviewer had substantial intraobserver classification (κ = 0.72). Overall, there was high confidence in 65% of classification scores in the second round of viewing, which improved from 58% in the first viewing round. When ulnar subluxation classification selections were regrouped into classes A/B or C/D, 100% of reviewers had substantial interobserver (κ = 0.74-0.75) and substantial to almost perfect intraobserver (κ = 0.71-0.91) agreement.

CONCLUSIONS

The 4-category classification was reproducible within and between reviewers. Agreement appeared to increase when simplifying the classification to 2 categories, which may provide guidance to surgical decision making. The validation of a reproducible classification scheme for intraoperative ulnar subluxation may aid with decision making and further postoperative outcomes research.

Prevalence and Awareness of Carpal Tunnel Syndrome Among Adults in Tabuk City of Saudi Arabia: A Cross-Sectional Study

Background Carpal Tunnel Syndrome (CTS) is a condition when the median nerve is entrapped and compressed within the wrist. It significantly affects the quality of life and work productivity of the affected individuals. Aim This study aimed to assess the prevalence of CTS and the risk factors associated with this condition among the general population in Tabuk City, Saudi Arabia, and to explore their knowledge of the causes, manifestations, and treatment options. Methods This cross-sectional study included male and female adult residents of Tabuk City aged 18 years and above who agreed to participate in the study. Data were collected using an online, self-administered questionnaire that was distributed to the public using different social media platforms. Results In this study, the prevalence of CTS was 3.4%. The presence of chronic diseases was a significant risk factor for the CTS (p = 0.003). Participants having chronic diseases were 6.370 times more likely to develop CTS (AOR: 6.370, 95% CI: 2.048 to 19.817). The participants had good levels of awareness about the causes (89.3%), clinical manifestations, and treatment of CTS (92.2%). There was a significant association between the level of knowledge about the causes of CTS and gender (p=0.014). Females (74.3%) showed a higher level of knowledge than males (25.7%). As well, the young (18-25) age group (67.9%) was more significantly aware of the causes of CTS in comparison to the other age groups (p=0.023). Conclusion The prevalence of carpal tunnel syndrome among the adult population in Tabuk City, Saudi Arabia, was 3.4%, and the significant underlying risk factors were chronic diseases such as diabetes mellitus, hypothyroidism, and rheumatoid arthritis. The level of awareness of CTS was satisfactory.