1
|
Baldwin AJ, Kulenkampff C, Power DM. Distal Entrapment of Regenerating Peripheral Nerves After a Proximal Injury: A Case Series and Review of the Literature. Cureus 2023; 15:e50756. [PMID: 38213338 PMCID: PMC10782478 DOI: 10.7759/cureus.50756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/18/2023] [Indexed: 01/13/2024] Open
Abstract
A complication of peripheral nerve injuries, of which there exists limited discourse, is the entrapment of the nerve as it regenerates from the site of injury to its end target, resulting in the arrest of axon regeneration and a consequent reduction of functional recovery. This proof-of-concept paper reports a review of the relevant literature alongside a case series of patients who presented with this phenomenon and who were treated with targeted peripheral nerve decompression. Three cases were identified prospectively. The baseline function was recorded pre-and post-operatively. Recovery was assessed using various tools, including the Medical Research Council (MRC) motor grading, ten-test sensory testing, Tinel's sign progression, a visual analogue scale (VAS) for pain, and the Impact of Hand Nerve Disorders (I-HaND) patient-reported outcome measure (PROM). The first case sustained a brachial plexus injury and received decompression at the pronator fascia, carpal tunnel, cubital tunnel, and Guyon's canal. The second case sustained a sciatic nerve injury and was managed with peroneal and tarsal tunnel decompressions. The final case sustained a suprascapular nerve injury and underwent decompression at the suprascapular ligament. In all these cases, motor function, sensory function, and pain (depending on the nerve's original components) improved following decompression. A literature review revealed seven relevant studies, including four case reports, two cohort studies, and a pre-clinical animal study. These cases, and those identified in our review of the literature, suggest that targeted decompressive surgery can be an appropriate treatment for patients who display signs of stalled neural regeneration. This study adds to the limited evidence of this phenomenon and highlights the challenges in proving the efficacy of decompressive surgery for this specific complication. This study is limited by the number of cases included, the heterogeneity of nerve injuries presented, and its observational nature. There is a clear need for further research into this phenomenon, and the authors are working towards developing a prospective study that will investigate the indications, value, predictors of success, and practicality of decompression surgery for this complication of peripheral nerve injury.
Collapse
Affiliation(s)
- Alexander J Baldwin
- Department of Burns and Plastic Surgery, Stoke Mandeville Hospital, Aylesbury, GBR
- The Peripheral Nerve Injury Service, Queen Elizabeth Hospital Birmingham, Birmingham, GBR
| | - Chane Kulenkampff
- The Peripheral Nerve Injury Service, Queen Elizabeth Hospital Birmingham, Birmingham, GBR
| | - Dominic M Power
- The Peripheral Nerve Injury Service, Queen Elizabeth Hospital Birmingham, Birmingham, GBR
| |
Collapse
|
2
|
Arefi IA, Kosco E, Werner E, Maxwell A, Fickert A, Frank PW. Bilateral Gastrocnemius Tertius Muscles: Cadaveric Findings of a Rare Variant. Cureus 2023; 15:e45316. [PMID: 37846245 PMCID: PMC10577022 DOI: 10.7759/cureus.45316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/13/2023] [Indexed: 10/18/2023] Open
Abstract
The posterior compartment of the leg typically contains three muscles in the superficial flexor group: the gastrocnemius, plantaris, and soleus. The gastrocnemius has medial and lateral heads (MH and LH) that originate from the medial and lateral condyles of the femur, respectively. However, a third head (TH) of the gastrocnemius, is a rare accessory muscle bundle of the gastrocnemius muscle that covers the surface of the popliteal fossa. Bilateral THs of gastrocnemius were identified in a 67-year-old male during a routine educational cadaveric dissection. Both gastrocnemius TH muscles consisted of a superficial belly with distinct neurovasculature heads and originated from the lateral condyle of the femur and inserted into the Achilles tendon. To our knowledge, the co-existence of bilateral gastrocnemius TH muscles has only been reported once. The male donor was found to exhibit an anatomical anomaly and could be clinically underdiagnosed due to its clinically silent nature and the lack of reports. Insight into the potential implications of bilateral and unilateral gastrocnemius TH and identification during clinical evaluation offers a path for future research to better identify and manage cases of gastrocnemius TH and its effects.
Collapse
Affiliation(s)
- Isaac A Arefi
- Department of Medicine, University of Toledo College of Medicine and Life Sciences, Toledo, USA
| | - Ethan Kosco
- Department of Medicine, University of Toledo College of Medicine and Life Sciences, Toledo, USA
| | - Erica Werner
- Department of Medicine, University of Toledo College of Medicine and Life Sciences, Toledo, USA
| | - Aidan Maxwell
- Department of Medicine, University of Toledo College of Medicine and Life Sciences, Toledo, USA
| | - Andrew Fickert
- Department of Medicine, University of Toledo College of Medicine and Life Sciences, Toledo, USA
| | - Patrick W Frank
- Department of Anatomy, Drexel University College of Medicine, Philadelphia, USA
| |
Collapse
|
3
|
Omole AE, Awosika A, Khan A, Adabanya U, Anand N, Patel T, Edmondson CK, Fakoya AO, Millis RM. An Integrated Review of Carpal Tunnel Syndrome: New Insights to an Old Problem. Cureus 2023; 15:e40145. [PMID: 37304388 PMCID: PMC10250024 DOI: 10.7759/cureus.40145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/08/2023] [Indexed: 06/13/2023] Open
Abstract
Carpal tunnel syndrome (CTS) is a common entrapment neuropathy characterized by pain, numbness, and impaired function of the hand due to compression of the median nerve at the level of the wrist. Although CTS can develop from repetitive strain, injury, or medical conditions, there are also congenital and genetic risk factors that can predispose individuals to the condition. With respect to anatomical factors, some individuals are born with a smaller carpal tunnel, which increases their susceptibility to median nerve compression. Variations in specific genes, such as those encoding proteins involved in extracellular matrix remodeling, inflammation, and nerve function, have also been linked to an increased risk for CTS. CTS is associated with a high cost of health care maintenance and loss of work productivity. Therefore, it is vital that primary care physicians fully understand the anatomy, epidemiology, pathophysiology, etiology, and risk factors of CTS, so they can be proactive in prevention, diagnosing, and guiding proper treatment. This integrated review also provides insights into how biological, genetic, environmental, and occupational factors interact with structural elements to determine who is most likely to acquire and suffer from CTS. Keeping health practitioners abreast of all the factors that could impact CTS should go a long way in decreasing the health care and socioeconomic burden of CTS.
Collapse
Affiliation(s)
- Adekunle E Omole
- Anatomical Sciences, American University of Antigua, Saint John, ATG
| | - Ayoola Awosika
- College of Medicine, University of Illinois, Chicago, USA
| | - Anosh Khan
- Emergency Medicine, Spartan Health Sciences University, Vieux Fort, LCA
| | | | - Nikhilesh Anand
- Pharmacology, American University of Antigua, Saint John, ATG
| | - Tirath Patel
- Surgery, American University of Antigua, Saint John, ATG
| | | | - Adegbenro O Fakoya
- Cellular Biology and Anatomy, Louisiana State University Health Sciences Center, Shreveport, USA
| | - Richard M Millis
- Pathophysiology, American University of Antigua, Saint John, ATG
| |
Collapse
|
4
|
Daeschler SC, Pennekamp A, Tsilingiris D, Bursacovschi C, Aman M, Eisa A, Boecker A, Klimitz F, Stolle A, Kopf S, Schwarz D, Bendszus M, Kneser U, Kender Z, Szendroedi J, Harhaus L. Effect of Surgical Release of Entrapped Peripheral Nerves in Sensorimotor Diabetic Neuropathy on Pain and Sensory Dysfunction-Study Protocol of a Prospective, Controlled Clinical Trial. J Pers Med 2023; 13:jpm13020348. [PMID: 36836582 PMCID: PMC9962788 DOI: 10.3390/jpm13020348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 02/07/2023] [Accepted: 02/16/2023] [Indexed: 02/19/2023] Open
Abstract
BACKGROUND Nerve entrapment has been hypothesized to contribute to the multicausal etiology of axonopathy in sensorimotor diabetic neuropathy. Targeted surgical decompression reduces external strain on the affected nerve and, therefore, may alleviate symptoms, including pain and sensory dysfunction. However, its therapeutic value in this cohort remains unclear. AIM Quantifying the treatment effect of targeted lower extremity nerve decompression in patients with preexisting painful sensorimotor diabetic neuropathy and nerve entrapment on pain intensity, sensory function, motor function, and neural signal conduction. STUDY DESIGN This prospective, controlled trial studies 40 patients suffering from bilateral therapy-refractory, painful (n = 20, visual analogue scale, VAS ≥ 5) or painless (n = 20, VAS = 0) sensorimotor diabetic neuropathy with clinical and/or radiologic signs of focal lower extremity nerve compression who underwent unilateral surgical nerve decompression of the common peroneal and the tibial nerve. Tissue biopsies will be analyzed to explore perineural tissue remodeling in correlation with intraoperatively measured nerve compression pressure. Effect size on symptoms including pain intensity, light touch threshold, static and moving two-point discrimination, target muscle force, and nerve conduction velocity will be quantified 3, 6, and 12 months postoperatively, and compared (1) to the preoperative values and (2) to the contralateral lower extremity that continues non-operative management. CLINICAL SIGNIFICANCE Targeted surgical release may alleviate mechanical strain on entrapped lower extremity nerves and thereby potentially improve pain and sensory dysfunction in a subset of patients suffering from diabetic neuropathy. This trial aims to shed light on these patients that potentially benefit from screening for lower extremity nerve entrapment, as typical symptoms of entrapment might be erroneously attributed to neuropathy only, thereby preventing adequate treatment.
Collapse
Affiliation(s)
- Simeon C Daeschler
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG-Trauma Center Ludwigshafen/Rhine, Department of Hand and Plastic Surgery, University of Heidelberg, 67071 Ludwigshafen, Germany
| | - Anna Pennekamp
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG-Trauma Center Ludwigshafen/Rhine, Department of Hand and Plastic Surgery, University of Heidelberg, 67071 Ludwigshafen, Germany
| | - Dimitrios Tsilingiris
- Department of Internal Medicine 1 and Clinical Chemistry, University Hospital of Heidelberg, 69120 Heidelberg, Germany
| | - Catalina Bursacovschi
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG-Trauma Center Ludwigshafen/Rhine, Department of Hand and Plastic Surgery, University of Heidelberg, 67071 Ludwigshafen, Germany
| | - Martin Aman
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG-Trauma Center Ludwigshafen/Rhine, Department of Hand and Plastic Surgery, University of Heidelberg, 67071 Ludwigshafen, Germany
| | - Amr Eisa
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG-Trauma Center Ludwigshafen/Rhine, Department of Hand and Plastic Surgery, University of Heidelberg, 67071 Ludwigshafen, Germany
| | - Arne Boecker
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG-Trauma Center Ludwigshafen/Rhine, Department of Hand and Plastic Surgery, University of Heidelberg, 67071 Ludwigshafen, Germany
| | - Felix Klimitz
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG-Trauma Center Ludwigshafen/Rhine, Department of Hand and Plastic Surgery, University of Heidelberg, 67071 Ludwigshafen, Germany
| | - Annette Stolle
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG-Trauma Center Ludwigshafen/Rhine, Department of Hand and Plastic Surgery, University of Heidelberg, 67071 Ludwigshafen, Germany
| | - Stefan Kopf
- Department of Internal Medicine 1 and Clinical Chemistry, University Hospital of Heidelberg, 69120 Heidelberg, Germany
- German Center for Diabetes Research, 85764 Neuherberg, Germany
| | - Daniel Schwarz
- Department of Neuroradiology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Martin Bendszus
- Department of Neuroradiology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Ulrich Kneser
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG-Trauma Center Ludwigshafen/Rhine, Department of Hand and Plastic Surgery, University of Heidelberg, 67071 Ludwigshafen, Germany
| | - Zoltan Kender
- Department of Internal Medicine 1 and Clinical Chemistry, University Hospital of Heidelberg, 69120 Heidelberg, Germany
- German Center for Diabetes Research, 85764 Neuherberg, Germany
| | - Julia Szendroedi
- Department of Internal Medicine 1 and Clinical Chemistry, University Hospital of Heidelberg, 69120 Heidelberg, Germany
- German Center for Diabetes Research, 85764 Neuherberg, Germany
- Joint Heidelberg-ICD Translational Diabetes Program, Helmholtz-Zentrum, 85764 Neuherberg, Germany
| | - Leila Harhaus
- Department of Hand, Plastic and Reconstructive Surgery, Burn Center, BG-Trauma Center Ludwigshafen/Rhine, Department of Hand and Plastic Surgery, University of Heidelberg, 67071 Ludwigshafen, Germany
- Department of Handsurgery, Peripheral Nerve Surgery and Rehabilitation, BG Trauma Hospital, 67071 Ludwigshafen, Germany
- Department of Orthopedic Surgery, Section Upper Extremity, University Hospital Heidelberg, 69120 Heidelberg, Germany
| |
Collapse
|
5
|
Vondra P, Vlach M. Median nerve entrapments in the forearm - a case report of rare anterior interosseous nerve syndrome. Acta Chir Plast 2023; 65:70-73. [PMID: 37722903 DOI: 10.48095/ccachp202370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 09/20/2023]
Abstract
Nowadays, median nerve entrapment is a frequent issue. Many physicians are familiar with the most common median entrapment, which is the carpal tunnel syndrome (CTS). By contrast, less frequent entrapments, historically called "pronator syndrome" are still misdiagnosed as overuse syndrome, flexor tendinitis or other conditions. This article is meant to introduce proximal median nerve entrapments, followed by a case report of the rarest example - anterior interosseous nerve syndrome (AIN syndrome).
Collapse
|
6
|
Iborra Á, Villanueva M, Barrett SL, Vega-Zelaya L. The role of ultrasound-guided perineural injection of the tibial nerve with a sub-anesthetic dosage of lidocaine for the diagnosis of tarsal tunnel syndrome. Front Neurol 2023; 14:1135379. [PMID: 37139063 PMCID: PMC10150003 DOI: 10.3389/fneur.2023.1135379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 04/03/2023] [Indexed: 05/05/2023] Open
Abstract
Background Tarsal tunnel syndrome (TTS) involves entrapment of the tibial nerve at the medial ankle beneath the flexor retinaculum and its branches, the medial and lateral plantar nerves, as they course through the porta pedis formed by the deep fascia of the abductor hallucis muscle. TTS is likely underdiagnosed, because diagnosis is based on clinical evaluation and history of present illness. The ultrasound-guided lidocaine infiltration test (USLIT) is a simple approach that may aid in the diagnosis of TTS and predict the response to neurolysis of the tibial nerve and its branches. Traditional electrophysiological testing cannot confirm the diagnosis and only adds to other findings. Methods We performed a prospective study of 61 patients (23 men and 38 women) with a mean age of 51 (29-78) years who were diagnosed with idiopathic TTS using the ultrasound guided near-nerve needle sensory technique (USG-NNNS). Patients subsequently underwent USLIT of the tibial nerve to assess the effect on pain reduction and neurophysiological changes. Results USLIT led to an improvement in symptoms and nerve conduction velocity. The objective improvement in nerve conduction velocity can be used to document the pre-operative functional capacity of the nerve. USLIT may also be used as a possible quantitative indicator of whether the nerve has the potential to improve in neurophysiological terms and ultimately inform prognosis after surgical decompression. Conclusion USLIT is a simple technique with potential predictive value that can help the clinician to confirm the diagnosis of TTS before surgical decompression.
Collapse
Affiliation(s)
- Álvaro Iborra
- Unit for Ultrasound-Guided Surgery, Hospital Beata María Ana, Madrid, Spain
- Avanfi Institute, Madrid, Spain
- Department of Podiatry, School of Health Sciences, University of La Salle, Madrid, Spain
- *Correspondence: Álvaro Iborra
| | - Manuel Villanueva
- Unit for Ultrasound-Guided Surgery, Hospital Beata María Ana, Madrid, Spain
- Avanfi Institute, Madrid, Spain
| | | | - Lorena Vega-Zelaya
- Avanfi Institute, Madrid, Spain
- Clinical Neurophysiology, Hospital Universitario de La Princesa, Madrid, Spain
| |
Collapse
|
7
|
Jeong JH, Hwang JH. Pharmacopuncture for nerve entrapment syndrome: A protocol for systematic review. Medicine (Baltimore) 2022; 101:e31458. [PMID: 36451409 PMCID: PMC9704931 DOI: 10.1097/md.0000000000031458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Nerve entrapment syndrome occurs when the nerves become compressed or entrapped and restricted. This study aims to evaluate the effectiveness and safety of pharmacopuncture in patients with nerve entrapment syndrome. METHODS A search will be conducted from inception to August 2022 using the following 11 electronic databases: MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Allied and Complementary Medicine Database China National Knowledge Infrastructure, and 6 Korean databases. All randomized controlled trials (RCTs) evaluating pharmacopuncture treatment for various nerve entrapment syndromes will be considered, with no restrictions regarding the type of pharmacopuncture solution used. Two reviewers will perform the data extraction and quality assessment using a predefined data extraction form. The methodological quality of the included RCTs will be assessed using the Cochrane risk-of-bias tool. RESULTS This systematic review will provide high-quality evidence to determine the efficacy and safety of pharmacopuncture therapy for nerve entrapment syndrome. CONCLUSION Our findings will be informative for patients with nerve entrapment syndrome, as well as clinicians, policymakers, and researchers.
Collapse
Affiliation(s)
- Jin-Ho Jeong
- Namsangcheon Korean Medicine Clinic, Seoul, Republic of Korea
| | - Ji Hye Hwang
- Department of Acupuncture & Moxibustion Medicine, College of Korean Medicine, Gachon University, Seongnam, Republic of Korea
- *Correspondence: Ji Hye Hwang, Department of Acupuncture & Moxibustion Medicine, College of Korean Medicine, Gachon University, Seongnam 13120, Republic of Korea (e-mail: )
| |
Collapse
|
8
|
Abstract
Anterior interosseous nerve syndrome (AINS) is a rare form of peripheral neuropathy which involves disruption of the anterior interosseous nerve. The pathophysiology of AINS remains unclear. AINS typically initially presents with forearm pain and may gradually progress to palsy of the deep muscles of the anterior forearm. Diagnosis of AINS requires thorough patient history and physical exam. EMG is the preferred diagnostic study and classically reveals abnormal activity and prolonged latency periods within the evoked action potentials of the FPL and PQ. Due to the self-limiting nature of AINS, there is general agreement that conservative and symptomatic management should be explored for up to 6 months as first line therapy, which usually includes analgesics and nonsteroidal anti-inflammatory drugs, contracture prevention, hand therapy, and hand splinting. Surgical options such as internal neurolysis and minimally invasive endoscopic decompression may be explored if functional recovery from conservative management is limited.
Collapse
Affiliation(s)
| | - Katherine Russo
- Louisiana State University Health Sciences Center - Shreveport
| | - Lauren Rando
- Louisiana State University Health Sciences Center - Shreveport
| | | | | | - Alan D Kaye
- Anesthesiology, Louisiana State University Shreveport
| |
Collapse
|
9
|
Kanakarajan S, Dharmavaram S, Tadros A, Pushparaj H, Rose A. Abdominal cutaneous nerve entrapment syndrome: A cross sectional survey of treatment outcomes. Br J Pain 2022; 16:538-545. [PMID: 36389004 PMCID: PMC9644107 DOI: 10.1177/20494637221101719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023] Open
Abstract
Objective Abdominal Cutaneous Nerve Entrapment Syndrome (ACNES) is a common but under recognised cause of chronic abdominal wall Pain. This survey was carried out to understand the clinical course of the condition following interventions such as nerve blocks and surgical release of entrapped nerve. Design Retrospective, Cross-sectional survey. Setting Pain Management clinic at University teaching hospital. Subjects Adult patients who had interventions either nerve block or surgical release over a 6 year period. Methods After written informed consent, participants completed a questionnaire including Brief Pain Inventory (BPI), quality of health measure (EQ-5D-5L), and global impression of change scale as well as open-ended question about the outcomes. Baseline demographics, details of pain condition, interventions received were collected from the health records. Results The diagnosis of ACNES was established in 85.2% by ultrasound guided injections. The injection therapy with local anaesthetic and steroid was successful to 75.8% while the surgical release was successful in 90%. The cumulative duration of pain relief varied from 3 weeks to 5 years. A significant difference was noted in BPI (p = 0.001), EQ-5D-5L (p = 0.002) and health thermometer (p = 0.009) post interventions. Conclusions Ultrasound guided injections aid the accurate diagnosis of ACNES. Appropriate treatment of ACNES improves both pain control and quality of life.
Collapse
Affiliation(s)
| | | | - Amir Tadros
- Department of Plastic
Reconstructive Surgery, Aberdeen Royal
Infirmary, Aberdeen, UK
| | - Hemkumar Pushparaj
- Department of Pain Medicine, Walton Centre NHS Foundation
Trust, Liverpool, UK
| | - Anna Rose
- University of Aberdeen Medical
School, Aberdeen, UK
| |
Collapse
|
10
|
Oka Y, Tsukita K, Tsuzaki K, Takamatsu N, Uchibori A, Chiba A, Hamano T. Nerve ultrasound characteristics of immunoglobulin M neuropathy associated with anti-myelin-associated glycoprotein antibodies. Muscle Nerve 2022; 65:667-675. [PMID: 35353922 DOI: 10.1002/mus.27542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 03/21/2022] [Accepted: 03/22/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION/AIMS Immunoglobulin M neuropathy associated with anti-myelin-associated glycoprotein antibody (IgM/anti-MAG) neuropathy typically presents with chronic, distal-dominant symmetrical sensory or sensorimotor deficits. Ultrasonographic studies of IgM/anti-MAG neuropathy are limited, and were all performed on Western populations. We aimed to characterize the nerve ultrasonographic features of IgM/anti-MAG neuropathy in the Japanese population and evaluate whether they differ from the findings of the common subtypes of chronic inflammatory demyelinating polyneuropathy (CIDP). METHODS In this cross-sectional study, we retrospectively reviewed medical records and extracted the cross-sectional areas (CSAs) of C5-C7 cervical nerve roots and median and ulnar nerves of 6 IgM/anti-MAG neuropathy patients, 10 typical CIDP (t-CIDP) patients, 5 multifocal CIDP (m-CIDP) patients, and 17 healthy controls (HCs). RESULTS Cervical nerve root CSAs were significantly larger at every examined site on both sides in IgM/anti-MAG neuropathy than in m-CIDP and HCs but were comparable to those in t-CIDP. Peripheral nerve enlargements were greatest at common entrapment sites (ie, wrist and elbow) in IgM/anti-MAG neuropathy, a pattern shared with t-CIDP but not with m-CIDP. The degree of nerve enlargement at entrapment sites compared to non-entrapment sites was significantly higher in IgM/anti-MAG neuropathy than in t-CIDP. DISCUSSION Our study delineated the ultrasonographic features of IgM/anti-MAG neuropathy in the Japanese population and observed similar characteristics to those of t-CIDP, with subtle differences. Further studies comparing results from various populations are required to optimize the use of nerve ultrasound worldwide.
Collapse
Affiliation(s)
- Yuwa Oka
- Department of Neurology, Kansai Electric Power Hospital, Osaka, Japan.,Division of Clinical Neurology, Kansai Electric Power Medical Research Institute, Osaka, Japan.,Department of Neurology, Kitano Hospital, Tazuke Kofukai Medical Research Institute, Osaka, Japan
| | - Kazuto Tsukita
- Center for Sleep-Related Disorders and Department of Neurology, Kansai Electric Power Hospital, Osaka, Japan.,Division of Sleep Medicine, Kansai Electric Power Medical Research Institute, Osaka, Japan.,Department of Neurology, Graduate School of Medicine, Kyoto University, Kyoto, Japan.,Advanced Comprehensive Research Organization, Teikyo University, Itabashi, Japan
| | - Koji Tsuzaki
- Department of Neurology, Kansai Electric Power Hospital, Osaka, Japan.,Division of Clinical Neurology, Kansai Electric Power Medical Research Institute, Osaka, Japan
| | - Naoko Takamatsu
- Department of Neurology, Kansai Electric Power Hospital, Osaka, Japan.,Department of Neurology, Tokushima University Hospital, Tokushima, Japan
| | - Ayumi Uchibori
- Department of Neurology, Faculty of Medicine, Kyorin University, Tokyo, Japan
| | - Atsuro Chiba
- Department of Neurology, Faculty of Medicine, Kyorin University, Tokyo, Japan
| | - Toshiaki Hamano
- Department of Neurology, Kansai Electric Power Hospital, Osaka, Japan.,Division of Clinical Neurology, Kansai Electric Power Medical Research Institute, Osaka, Japan
| |
Collapse
|
11
|
Lam KHS, Lai WW, Ngai HY, Wu WKR, Wu YT. Commentary: Ultrasound-Guided Triamcinolone Acetonide Hydrodissection for Carpal Tunnel Syndrome: A Randomized Controlled Trial. Front Med (Lausanne) 2022; 8:833862. [PMID: 35096917 PMCID: PMC8793904 DOI: 10.3389/fmed.2021.833862] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Accepted: 12/21/2021] [Indexed: 12/11/2022] Open
Affiliation(s)
- King Hei Stanley Lam
- The Hong Kong Institute of Musculoskeletal Medicine, Kwoloon, Hong Kong SAR, China.,Department of Family Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China.,Department of Family Medicine, The University of Hong Kong, Pokfulam, Hong Kong SAR, China.,Taiwan Association of Prolotherapy and Regenerative Medicine, Taichung, Taiwan.,Center for Regional Anesthesia and Pain Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Wai Wah Lai
- The Hong Kong Institute of Musculoskeletal Medicine, Kwoloon, Hong Kong SAR, China.,Department of Family Medicine, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
| | - Ho Yin Ngai
- The Hong Kong Institute of Musculoskeletal Medicine, Kwoloon, Hong Kong SAR, China.,Department of Family Medicine, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
| | - Wing Keung Ricky Wu
- The Hong Kong Institute of Musculoskeletal Medicine, Kwoloon, Hong Kong SAR, China.,Department of Family Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong SAR, China.,Department of Family Medicine, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
| | - Yung-Tsan Wu
- Department of Physical Medicine and Rehabilitation, School of Medicine, National Defense Medical Center, Tri-Service General Hospital, Taipei, Taiwan.,Integrated Pain Management Center, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan.,Department of Research and Development, School of Medicine, National Defense Medical Center, Tri-Service General Hospital, Taipei, Taiwan
| |
Collapse
|
12
|
Abstract
Hand surgery is rapidly changing. The wide-awake approach, minimum dissection surgery and early protected movement have changed many things. This is an update of some of the important changes regarding early protected movement with K-wired finger fracture management, simplification of nerve decompression surgery, such as elbow median and ulnar nerve releases, and some new areas in performing surgery with wide-awake local anaesthesia without tourniquet.
Collapse
Affiliation(s)
- Donald Lalonde
- Plastic Surgery, Dalhousie University, Saint John, NB, Canada
| | - Egemen Ayhan
- Orthopaedics and Traumatology, University of Health Sciences Turkey, Ankara, Turkey
| | - Amir Adham Ahmad
- Department of Orthopaedics, Prince Court Medical Centre, Kuala Lumpur, Malaysia
| | - Steven Koehler
- Department of Orthopaedic Surgery and Rehabilitation Medicine, State University of New York, Brooklyn, NY, USA
| |
Collapse
|
13
|
Leider JD, Derise OC, Bourdreaux KA, Dierks GJ, Lee C, Varrassi G, Sherman WF, Kaye AD. Treatment of suprascapular nerve entrapment syndrome. Orthop Rev (Pavia) 2021; 13:25554. [PMID: 34745481 DOI: 10.52965/001c.25554] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 07/04/2021] [Indexed: 12/15/2022] Open
Abstract
Suprascapular nerve entrapment syndrome (SNES) is an often-overlooked etiology of shoulder pain and weakness. Treatment varies depending on the location and etiology of entrapment, which can be described as compressive or traction lesions. In some cases, treating the primary cause of impingement (ie. rotator cuff tear, ganglion cyst, etc.) is sufficient to relieve pressure on the nerve. In other cases where impingement is caused by dynamic microtrauma (as seen in overhead athletes and laborers), treatment is often more conservative. Conservative first-line therapy includes rehabilitation programs, nonsteroidal anti-inflammatory drugs, and lifestyle modification. Physical therapy is targeted at strengthening the rotator cuff muscles, trapezius, levator scapulae, rhomboids, serratus anterior, and deltoid muscle(s). If non-operative treatment fails to relieve suprascapular neuropathy, minimally invasive treatment options exist, such as suprascapular nerve injection, neurostimulation, cryoneurolysis, and pulsed radiofrequency. Multiple treatment modalities are often used synergistically due to variations in shoulder anatomy, physiology, pain response, and pathology as a sole therapeutic option does not seem successful for all cases. Often patients can be treated with non-invasive measures alone; however, injuries refractory to conservative treatment may require either arthroscopic or open surgery, particularly if the patient has an identifiable and reversible cause of nerve compression. Indications for invasive treatment include, but are not limited to, refractory to non-operative treatment, have a space-occupying lesion, or show severe signs and symptoms of muscle atrophy. Open decompression has fallen out of favor due to the advantages inherent in the less invasive arthroscopic approach.
Collapse
Affiliation(s)
| | - Olivia C Derise
- Louisiana State University Health Sciences Center, New Orleans
| | | | - Gregor J Dierks
- Louisiana State University Health Sciences Center, New Orleans
| | - Christopher Lee
- Creighton University School Of Medicine-Phoenix Regional Campus, Phoenix, AZ
| | | | | | | |
Collapse
|
14
|
Fujiwara T, Yazaki N, Ogura A, Tanaka H. A case of radial nerve paralysis associated with supracondylar fracture of the humerus in a child. JSES Rev Rep Tech 2021; 1:469-472. [PMID: 37588722 PMCID: PMC10426638 DOI: 10.1016/j.xrrt.2021.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Affiliation(s)
| | - Naoya Yazaki
- Department of Orthopedic Surgery, Shizuoka Saiseikai General Hospital, Shizuoka, Shizuoka, Japan
| | - Atomu Ogura
- Department of Orthopedic Surgery, Shizuoka Saiseikai General Hospital, Shizuoka, Shizuoka, Japan
| | - Hiromasa Tanaka
- Department of Hand Surgery, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| |
Collapse
|
15
|
van den Hurk L, van den Besselaar M, Scheltinga M. Exercise induced neuropathic lower leg pain due to a tibial bone exostosis. PHYSICIAN SPORTSMED 2021; 49:363-366. [PMID: 33818242 DOI: 10.1080/00913847.2021.1910006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Objectives: The differential diagnosis of chronic exercise induced lower leg pain in sporters includes compartment syndrome and medial tibial stress syndrome. However, severe discomfort may also be caused by nerve entrapment.Methods: Here we present a marathon runner who reports pain day and night in the lower leg. Deep palpation suggested the presence of a bony tumor deep in the calf musculature, and digital pressure on the soleal sling was painful and elicited paresthesias in the foot. A swab test indicated a hypo-esthetic sole of the foot. Imaging revealed the presence of a tibial exostosis that was hypothesized to narrow the soleal tunnel and irritate the tibial nerve.Results: Via a medial infragenual approach, the soleal tunnel was opened. A bony prominence was found in direct contact to the tibial nerve. Resection of the exostosis with tibial nerve neurolysis completely abolished all of his symptoms.Conclusion: An awkward lower leg discomfort that is present at night and worsens during exercise combined with altered foot sole skin sensation in the presence of a tibial bone exostosis may suggest tibial nerve neuropathy. If conservative therapies fail, resection and neurolysis is advised.
Collapse
Affiliation(s)
| | | | - Marc Scheltinga
- Department of Surgery, Máxima Medical Centre, Veldhoven, Netherlands
| |
Collapse
|
16
|
Rossmann T, Heber UM, Heber S, Reissig LF, Grisold W, Weninger WJ, Meng S. Cubital tunnel perfusion in different postures-An anatomical investigation. Muscle Nerve 2021; 64:749-754. [PMID: 34453352 PMCID: PMC9292220 DOI: 10.1002/mus.27408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Revised: 08/16/2021] [Accepted: 08/24/2021] [Indexed: 11/21/2022]
Abstract
Introduction/Aims For cubital tunnel syndrome, the avoidance of predisposing arm positions and the use of elbow splints are common conservative treatment options. The rationale is to prevent excessive stretching and compression of the nerve in the cubital tunnel, as this mechanical stress impedes intraneural perfusion. Data regarding those upper extremity postures to avoid, or whether elbow flexion alone is detrimental, are inconsistent. This study aimed to assess perfusion and size changes of the cubital tunnel during different postures in an experimental cadaver setup. Methods Axillary arteries in 30 upper extremities of fresh cadavers were injected with ultrasound contrast agent. High‐resolution ultrasound of the cubital tunnel was performed during five different arm postures that gradually increased tension on the ulnar nerve and caused cubital tunnel narrowing. Contrast enhancement within the tunnel was measured to quantify perfusion. Cubital tunnel cross‐sectional area was measured to detect compression. Results Increasing tension significantly reduced perfusion. When isolated, neither shoulder elevation, elbow flexion, pronation, nor extension of wrist and fingers impaired perfusion. However, combining two or more of these postures led to significant decreases. Significant narrowing of the cubital tunnel was seen in full elbow flexion and shoulder elevation. Discussion Combinations of some upper extremity joint positions reduce nerve perfusion, but isolated elbow flexion does not have a significant impact. We hypothesize that elbow splints alone may not influence cubital tunnel perfusion but may only prevent direct compression of the ulnar nerve. Advising patients about upper extremity postures that should be avoided may be more effective.
Collapse
Affiliation(s)
- Tobias Rossmann
- Division of Anatomy, Medical University of Vienna, Vienna, Austria.,Department of Neurosurgery, Neuromed Campus, Kepler University Hospital, Linz, Austria
| | - Ulrike M Heber
- Division of Anatomy, Medical University of Vienna, Vienna, Austria
| | - Stefan Heber
- Center for Physiology and Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Lukas F Reissig
- Division of Anatomy, Medical University of Vienna, Vienna, Austria
| | - Wolfgang Grisold
- Neurology Consultancy Unit, Division of Anatomy, Medical University of Vienna, Vienna, Austria
| | | | - Stefan Meng
- Division of Anatomy, Medical University of Vienna, Vienna, Austria.,Department of Radiology, Hanusch Hospital, Vienna, Austria
| |
Collapse
|
17
|
Abstract
Background Greater and lesser occipital neuralgias are primary neuralgias that are relatively uncommon, where the pain is felt in the distribution of these nerves. Objective This review paper was intended to describe the features and management of occipital neuralgia in the context of a challenging case. Material and Methods We looked at succinct literature from the past 30 years. We compared the features of our challenging case given in the current literature. In addition, an overview of the current literature is provided. Results The case, although proved to be a diagnostic challenge, we were able to reach a conclusion and render the patient almost complete pain relief by conservative management modalities. It proved to be a rare presentation of occipital neuralgia with unusual pain distribution, and we are able to describe a literature-based explanation for this entity to be a diagnostic and management challenge. Conclusion Primary headaches, i'n general, are a group of headache disorders that require exquisite diagnostic skills. The clinical history is a key factor when making an accurate diagnosis, and to establish an appropriate management plan.
Collapse
Affiliation(s)
| | - Amey G Patil
- Department of Restorative Dentistry and Department of Diagnostic Sciences, Center for TMD and Orofacial Pain, Rutgers School of Dental Medicine, Newark, NJ, USA
| | - Ruchika Sood
- Department of Diagnostic Sciences, Center for TMD and Orofacial Pain, Rutgers School of Dental Medicine, Newark, NJ, USA
| | - Giannina Katzmann
- Department of Diagnostic Sciences Rutgers School of Dental Medicine, Newark, NJ, USA
| |
Collapse
|
18
|
Kim K, Isu T, Kokubo R, Morimoto D, Iwamoto N, Morita A. Less Invasive Combined Micro- and Endoscopic Neurolysis of Superficial Peroneal Nerve Entrapment: Technical Note. Neurol Med Chir (Tokyo) 2021; 61:297-301. [PMID: 33790130 PMCID: PMC8120098 DOI: 10.2176/nmc.oa.2020-0200] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
As superficial peroneal nerve (S-PN) entrapment neuropathy is relatively rare, it may be an elusive clinical entity. For decompression surgery addressing idiopathic S-PN entrapment, narrow- area decompression may be insufficient and long-area decompression along the S-PN from the peroneus longus muscle (PLM) to the peroneal nerve exit site may be required. To render it is less invasive, we performed S-PN neurolysis in a combined microscope/endoscope procedure. We report our surgical procedure and clinical outcomes. We microsurgically decompressed the affected S-PN under local anesthesia without a proximal tourniquet. We made a small linear skin incision at the distal portion of the S-PN, performed distal decompression of the S-PN where it penetrated the deep fascia, and then performed proximal decompression under an endoscope. At the site where the S-PN exited the PLM, we placed additional small incisions and proceeded to microscopic decompression. We surgically treated three patients with S-PN entrapment. They were two men and one woman ranging in age from 66 to 85 years. The mean postoperative follow-up was 22 months. Their symptoms before treatment and at the latest follow-up visit were recorded on the numerical rating scale (NRS). The mean incision length was 5.5 cm and 17.3 cm of the S-PN was decompressed. All three patients reported postoperative symptom improvement. There were no complications. In patients with idiopathic S-PN entrapment, long-site neurolysis under local anesthesia using a microscope/endoscope combination is useful.
Collapse
Affiliation(s)
- Kyongsong Kim
- Department of Neurological Surgery, Chiba Hokuso Hospital, Nippon Medical School
| | - Toyohiko Isu
- Department of Neurosurgery, Kushiro Rosai Hospital
| | - Rinko Kokubo
- Department of Neurological Surgery, Chiba Hokuso Hospital, Nippon Medical School
| | | | | | - Akio Morita
- Department of Neurological Surgery, Nippon Medical School
| |
Collapse
|
19
|
Abstract
A 48-year-old woman presented with chronic right heel pain and paraesthesia over the foot. Magnetic resonance imaging of the right foot demonstrated isolated atrophy of the abductor digiti minimi. A diagnosis of Baxter's neuropathy was made and the patient was managed successfully via surgical release. We describe the clinical and radiological features of Baxter's neuropathy and, with brief examples, outline other causes of chronic heel pain.
Collapse
Affiliation(s)
| | - Teck Yew Chin
- Department of Diagnostic Radiology, Khoo Teck Puat Hospital, Singapore
| |
Collapse
|
20
|
Delzell PB, Patel M. Ultrasound-Guided Perineural Injection for Pronator Syndrome Caused by Median Nerve Entrapment. J Ultrasound Med 2020; 39:1023-1029. [PMID: 31705693 DOI: 10.1002/jum.15166] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 09/23/2019] [Accepted: 10/15/2019] [Indexed: 06/10/2023]
Abstract
Patients and physicians have increasingly sought minimally invasive procedures such as ultrasound-guided injection for the treatment of peripheral nerve entrapment syndromes. In this series, we assessed subjective outcome data in 14 patients who underwent ultrasound-guided perineural hydrodissection and steroid injection for pronator syndrome secondary to median nerve entrapment in the pronator tunnel. Excellent symptomatic relief (≥75% improvement) was achieved in 70% of nerves with 3-month follow-up data, with no significant change in symptoms between 3 and 6 months. These outcomes suggest that this technique could play a role in the management of pronator syndrome due to median nerve entrapment.
Collapse
Affiliation(s)
| | - Mital Patel
- Edward Hines Jr Veterans Administration Hospital, Hines, Illinois, USA
| |
Collapse
|
21
|
Abstract
Entrapment neuropathies are debilitating clinical conditions, creating significant morbidity in the upper and lower extremities in terms of pain, sensory abnormalities, and motor weakness, becoming a challenge to diagnose and treat. Because entrapments can have multiple origins, a misinterpretation of anatomy during examination can lead to incorrect diagnosis and treatment. This review addresses understanding of the anatomy of fascia that can play an important role in this syndrome. There is a specific microenvironment around the nerve composed of connective tissues that include deep fascia, intermuscular septa, epineurium, and perineurium. The microenvironmental modifications can be translated into change in mobility with consequence decreasing of the independency of the nerve from the surrounding structures lading to entrapments and "internal stretch lesion." The entrapments reported in this article reinforce the importance of fascia tissue in generating common symptoms that pose more difficult diagnostic challenges and may often be confused with more common clinical conditions. Clin. Anat. 32:883-890, 2019. © 2019 Wiley Periodicals, Inc.
Collapse
Affiliation(s)
- Antonio Stecco
- RUSK Rehabilitation, New York University School of Medicine, New York, New York
| | - Carmelo Pirri
- Physical and Rehabilitation Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Carla Stecco
- Molecular Medicine Department, University of Padua, Padua, Italy
| |
Collapse
|
22
|
Maatman RC, Boelens OB, Scheltinga MRM, Roumen RMH. Chronic localized back pain due to entrapment of cutaneous branches of posterior rami of the thoracic nerves (POCNES): a case series on diagnosis and management. J Pain Res 2019; 12:715-723. [PMID: 30863144 PMCID: PMC6388752 DOI: 10.2147/jpr.s178492] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Introduction and aim Chronic back pain (CBP) may be caused by a variety of conditions including dysfunctional muscles, ligaments or intervertebral discs, improper movement of vertebral column joints, or nerve root compression. Recently, CBP was treated successfully in a patient having an entrapment of cutaneous branches of the posterior rami of the thoracic nerves, termed posterior cutaneous nerve entrapment syndrome (POCNES). Our aim is to describe clinical presentation, differential diagnosis, and management of patients with such a neuropathic pain syndrome. Methods This study analyzed prospectively obtained data from consecutive patients suspected of having POCNES, presenting to two Dutch hospitals between January 2013 and September 2016. Patients received a diagnostic 2–5 mL 1% lidocaine injection just below the thoracolumbar fascia. Pain was scored using a numerical rating scale (0 = no pain to 10 = worst possible pain). A >50% pain reduction was defined as success. A neurectomy was proposed if pain reduction was temporary or insufficient after one to three injections. Long-term treatment effect was determined using a verbal rating scale (VRS; 1 = very satisfied, no pain, to 5 = pain worse). Results Fourteen patients (12 women, median age 26, age range 18–73) were diagnosed with POCNES. Eighty-one percent (n=11) reported a >50% pain drop after injection (NRS pain scores of median 8.0 [IQR 7.0–8.0] to median 3.0 [IQR 1.5–3.5], P<0.001). In one patient, repeated injections were successful long-term (VRS score of 2). Two patients declined surgery, whereas the remaining eleven underwent a neurectomy that was successful in seven (64%). A 57% long-term efficacy (median 29 months follow-up, range 5–48, VRS score 1–2) was attained in the entire study population. Conclusion POCNES should be considered in the differential diagnosis of chronic localized back pain. A treatment regimen including injections and neurectomy of the specific cutaneous branch results in long-term pain relief in more than half of these patients.
Collapse
Affiliation(s)
- Robbert C Maatman
- SolviMáx, Center of Expertise for ACNES, Center of Excellence for Chronic Abdominal Wall and Groin Pain, Department of Surgery, Máxima Medical Center, Veldhoven, The Netherlands,
| | - Oliver B Boelens
- Department of Surgery, Maasziekenhuis Pantein, Boxmeer, The Netherlands
| | - Marc R M Scheltinga
- SolviMáx, Center of Expertise for ACNES, Center of Excellence for Chronic Abdominal Wall and Groin Pain, Department of Surgery, Máxima Medical Center, Veldhoven, The Netherlands,
| | - Rudi M H Roumen
- SolviMáx, Center of Expertise for ACNES, Center of Excellence for Chronic Abdominal Wall and Groin Pain, Department of Surgery, Máxima Medical Center, Veldhoven, The Netherlands,
| |
Collapse
|
23
|
Jackson JA, Olsson D, Burdorf A, Punnett L, Järvholm B, Wahlström J. Occupational biomechanical risk factors for radial nerve entrapment in a 13-year prospective study among male construction workers. Occup Environ Med 2019; 76:326-331. [PMID: 30850390 PMCID: PMC6581089 DOI: 10.1136/oemed-2018-105311] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 02/14/2019] [Accepted: 02/18/2019] [Indexed: 11/17/2022]
Abstract
Objectives The aim was to assess the association between occupational biomechanical exposure and the occurrence of radial nerve entrapment (RNE) in construction workers over a 13-year follow-up period. Methods A cohort of 229 707 male construction workers who participated in a national occupational health surveillance programme (1971–1993) was examined prospectively (2001–2013) for RNE. Height, weight, age, smoking status and job title (construction trade) were obtained on health examination. RNE case status was defined by surgical release of RNE, with data from the Swedish national registry for out-patient surgery records. A job exposure matrix was developed, and biomechanical exposure estimates were assigned according to job title. Highly correlated exposures were summed into biomechanical exposure scores. Negative binomial models were used to estimate the relative risks (RR) (incidence rate ratios) of RNE surgical release for the biomechanical factors and exposure sum scores. Predicted incidence was assessed for each exposure score modelled as a continuous variable to assess exposure–response relationships. Results The total incidence rate of surgically treated RNE over the 13-year observation period was 3.53 cases per 100 000 person-years. There were 92 cases with occupational information. Increased risk for RNE was seen in workers with elevated hand-grip forces (RR=1.79, 95% CI 0.97 to 3.28) and exposure to hand-arm vibration (RR=1.47, 95% CI 1.08 to 2.00). Conclusions Occupational exposure to forceful handgrip work and vibration increased the risk for surgical treatment of RNE.
Collapse
Affiliation(s)
- Jennie A Jackson
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - David Olsson
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Alex Burdorf
- Department of Public Health, Erasmus MC, Rotterdam, The Netherlands
| | - Laura Punnett
- Department of Biomedical Engineering, University of Massachusetts Lowell, Lowell, Massachusetts, USA
| | - Bengt Järvholm
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Jens Wahlström
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| |
Collapse
|
24
|
Abstract
The purpose of this review is to describe and critically evaluate current knowledge regarding diagnosis, assessment, and management of chronic overload leg injuries which are often non-specific and misleadingly referred to as 'shin splints'. We aimed to review clinical entities that come under the umbrella term 'Exercise-induced leg pain' (EILP) based on current literature and systematically searched the literature. Specifically, systematic reviews were included. Our analyses demonstrated that current knowledge on EILP is based on a low level of evidence. EILP has to be subdivided into those with pain from bone stress injuries, pain of osteo-fascial origin, pain of muscular origin, pain due to nerve compression and pain due to a temporary vascular compromise. The history is most important. Questions include the onset of symptoms, whether worse with activity, at rest or at night? What exacerbates it and what relieves it? Is the sleep disturbed? Investigations merely confirm the clinical diagnosis and/or differential diagnosis; they should not be solely relied upon. The mainstay of diagnosing bone stress injury is MRI scan. Treatment is based on unloading strategies. A standard for confirming chronic exertional compartment syndrome (CECS) is the dynamic intra-compartmental pressure study performed with specific exercises that provoke the symptoms. Surgery provides the best outcome. Medial tibial stress syndrome (MTSS) presents a challenge in both diagnosis and treatment especially where there is a substantial overlap of symptoms with deep posterior CECS. Conservative therapy should initially aim to correct functional, gait, and biomechanical overload factors. Surgery should be considered in recalcitrant cases. MRI and MR angiography are the primary investigative tools for functional popliteal artery entrapment syndrome and when confirmed, surgery provides the most satisfactory outcome. Nerve compression is induced by various factors, e.g., localized fascial entrapment, unstable proximal tibiofibular joint (intrinsic) or secondary by external compromise of the nerve, e.g., tight hosiery (extrinsic). Conservative is the treatment of choice. The localized fasciotomy is reserved for recalcitrant cases.
Collapse
Affiliation(s)
- Heinz Lohrer
- a European SportsCare Network (ESN) - Zentrum für Sportorthopädie , Wiesbaden-Nordenstadt , Germany
| | | | - Vasileios Korakakis
- c Department of Rehabilitation , Aspetar, Orthopaedic and Sports Medicine Hospital , Doha , Qatar
| | - Nat Padhiar
- d William Harvey Research Institute, Centre for Sports & Exercise Medicine , Queen Mary University of London , London , UK
| |
Collapse
|
25
|
Abstract
Degeneration, whether from age or postsurgical, in the ventral and lateral epidural space can lead to irritation of both the nerve roots and of the nerves present in the epidural space, the peridural membrane and the posterior longitudinal ligament. This irritation is often accompanied by mild scarring. Neuroplasty is a specific procedure designed to relieve this irritation. The effectiveness of neuroplasty is not affected by the extent of spinal stenosis. Neuroplasty can be performed in the lumbar, thoracic and cervical spine, and using caudal, transforaminal and interlaminar approaches. Postprocedural home exercises are an integral part of the procedure. There are multiple high-grade studies positive for the effectiveness and safety of neuroplasty. Neuroplasty should be offered prior to surgery in patients with persistent back and/or extremity pain.
Collapse
Affiliation(s)
- Standiford Helm
- The Helm Center for Pain Management, Laguna Woods, CA 92637, USA
| | - Nebojsa Nick Knezevic
- Vice Chair for Research & Education, Department of Anesthesiology & Pain Management, Advocate Illinois Masonic Medical Center, Chicago, IL 60657, USA.,Clinical Associate Professor, Department of Anesthesiology, University of Illinois, Chicago, IL 60612, USA
| |
Collapse
|
26
|
Matsumoto J, Isu T, Kim K, Iwamoto N, Yamazaki K, Isobe M. Clinical Features and Surgical Treatment of Superficial Peroneal Nerve Entrapment Neuropathy. Neurol Med Chir (Tokyo) 2018; 58:320-325. [PMID: 29925720 PMCID: PMC6048352 DOI: 10.2176/nmc.oa.2018-0039] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Superficial peroneal nerve (S-PN) entrapment neuropathy (S-PNEN) is comparatively rare and may be an elusive clinical entity. There is yet no established surgical procedure to treat idiopathic S-PNEN. We report our surgical treatment and clinical outcomes. We surgically treated 5 patients (6 sites) with S-PNEN. The 2 men and 3 women ranged in age from 67 to 91 years; one patient presented with bilateral leg involvement. Mean post-operative follow-up was 25.3 months. We recorded their symptoms before- and at the latest follow-up visit after surgery using a Numerical Rating Scale and the Japan Orthopedic Association score to evaluate the affected area. We microsurgically decompressed the affected S-PN under local anesthesia without a proximal tourniquet. We made a linear skin incision along the S-PN and performed wide S-PN decompression from its insertion point at the peroneal tunnel to the peroneus longus muscle (PLM) to the point where the S-PN penetrated the deep fascia. One patient who had undergone decompression in the area of a Tinel-like sign at the initial surgery suffered symptom recurrence and required re-operation 4 months later. We performed additional extensive decompression to address several sites with a Tinel-like sign. All 5 operated patients reported symptom improvement. In patients with idiopathic S-PNEN, neurolysis under local anesthesia may be curative. Decompression involving only the Tinel area may not be sufficient and it may be necessary to include the area from the PLM to the peroneal nerve exit point along the S-PN.
Collapse
Affiliation(s)
| | - Toyohiko Isu
- Department of Neurosurgery, Kushiro Rosai Hospital
| | | | | | | | | |
Collapse
|
27
|
Abstract
Introduction A reoperation for a cubital tunnel syndrome is not uncommon. Patients often complain of sensorimotor symptoms in the ulnar nerve distribution after their primary surgery. The documented etiologies for such a phenomenon include a “new” kinking of the distal ulnar nerve and a “new” compression of the ulnar nerve by the fascial septum in between or tendinous bands over the muscles of the forearm. The deep fascial plane along which the ulnar nerve travels in the forearm has had scant attention. We present an anatomical study to provide a better understanding of such etiologies to aid physicians in performing successful primary ulnar nerve release that does not lead to risky reoperations and ultimately yields improved patient satisfaction. Materials and methods The forearms of 12 fresh frozen cadavers (24 arms) underwent dissection, during which the fascial relationships between the ulnar nerve and muscles of the anterior compartment were explored with a blunt technique. The relationship between the fascial planes and the ulnar nerve was quantitatively and qualitatively documented. The ranges of motion of the elbow were also observed for any potential compression points on the nerve during the movement. Results In all specimens (n = 24), the ulnar nerve entered the forearm between the humeral and ulnar heads of the flexor carpi ulnaris, after which it routed deep to a deep fascia between the anterior surface of the flexor carpi ulnaris and the posterior surface of the flexor digitorum superficialis. Ulnar nerve branches to the flexor carpi ulnaris pierced this fascial septum while en route to the posterior surface of the muscle. Medially, the branches to the flexor digitorum profundus also pierced this fascial plane. In most arms, the fascia became thinner near the junction between the proximal two-thirds and distal one-third of the forearm. On no side was the ulnar nerve found to be grossly compressed by this deep fascia. However, with the extension of the elbow, a degree of angulation of the proximal ulnar nerve was observed due to its compact connection with the deep fascia. Conclusion Our study revealed that there is an intimate relationship between the ulnar nerve and the deep fascia of the forearm. Since the ulnar branches to the overlying flexor carpi ulnaris pierce this deep structure, a care should be given to its anatomical course during surgery in this region to prevent denervation of the muscle.
Collapse
Affiliation(s)
- Paul J Choi
- Surgery, Seattle Science Foundation, Seattle, USA
| | - Chidinma Nwaogbe
- Molecular, Cellular & Biomedical Sciences, CUNY School of Medicine, New York, USA
| | | | - Georgi P Georgiev
- Orthopaedics and Traumatology, University Hospital Queen Giovanna, Sofia, BGR
| | - Rod J Oskouian
- Neurosurgery, Swedish Neuroscience Institute, Seattle, USA
| | - R Shane Tubbs
- Neurosurgery, Seattle Science Foundation, Seattle, USA
| |
Collapse
|
28
|
Shon HC, Park JK, Kim DS, Kang SW, Kim KJ, Hong SH. Supracondylar process syndrome: two cases of median nerve neuropathy due to compression by the ligament of Struthers. J Pain Res 2018; 11:803-807. [PMID: 29713193 PMCID: PMC5907893 DOI: 10.2147/jpr.s160861] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The supracondylar process is a beak-shaped bony process on the anteromedial aspect of the distal humerus. The ligament of Struthers is a fibrous band extending from the tip of the process to the medial epicondyle. The median nerve and brachial artery pass under the ligament of Struthers and consequently can be compressed, causing supracondylar process syndrome. As a rare cause of proximal median nerve entrapment, supracondylar process syndrome is triggered when the median nerve is located in the superficial or deep layer of the ligament of Struthers as a result of anatomical variation. The supracondylar process can be easily detected on X-ray images obtained in oblique views but may not be identified in only anteroposterior or lateral views. In this article, we present 2 cases of supracondylar process syndrome and describe the process of diagnosis and treatment and results of a literature review.
Collapse
Affiliation(s)
- Hyun-Chul Shon
- Department of Orthopaedic Surgery, Chungbuk National University Hospital, Chungbuk National University, Cheongju, Korea
| | - Ji-Kang Park
- Department of Orthopaedic Surgery, Chungbuk National University Hospital, Chungbuk National University, Cheongju, Korea
| | - Dong-Soo Kim
- Department of Orthopaedic Surgery, Chungbuk National University Hospital, Chungbuk National University, Cheongju, Korea
| | - Sang-Woo Kang
- Department of Orthopaedic Surgery, Chungbuk National University Hospital, Chungbuk National University, Cheongju, Korea
| | - Kook-Jong Kim
- Department of Orthopaedic Surgery, Chungbuk National University Hospital, Chungbuk National University, Cheongju, Korea
| | - Seok-Hyun Hong
- Department of Orthopaedic Surgery, Chungbuk National University Hospital, Chungbuk National University, Cheongju, Korea
| |
Collapse
|
29
|
Abstract
Introduction: The complex anatomy and biomechanics of the elbow joint can lead to diagnostic uncertainty when a clinician is determining the cause of a patient’s anterior elbow pain. We present a case of anterior elbow pain with an uncommon and often overlooked etiology. Elbow pain due to compression of the lateral antebrachial nerve (LACN) has an unknown incidence or prevalence. Case Report: A 27-year-old left-hand dominant male presented to our orthopedic elbow clinic complaining of bilateral elbow clicking and discomfort which had been present for several years. His painful symptoms were localized to the anterior aspect of both elbows and had slowly become more painful despite simple analgesia and physiotherapy. Examination revealed the full range of movement of both elbows with no instability or weakness. Plain imaging and magnetic resonance imaging scans of both elbows did not reveal any pathology, and the decision was made to explore the right elbow, as this was the most symptomatic. Under general anesthesia with tourniquet an anterior curvilinear antecubital fossa incision was made. The lateral border of the distal biceps tendon showed evidence of compression of the LACN at the musculotendinous junction. The tendon was partially resected, and the nerve confirmed to move freely without further entrapment. At 4 weeks after surgery, he was completely asymptomatic. The patient was later listed to undergo a similar procedure to the left side; however, he could not go ahead with surgery so far due to work commitment. Conclusion: Entrapment or compression of the LACN is an uncommon and often misdiagnosed differential diagnosis with patients presenting with anterior elbow pain, which can lead to permanent neurological damage if left untreated. A high index of suspicion is required to enable prompt diagnosis and investigation as surgical treatment has a high success rate, often with complete resolution of symptoms.
Collapse
Affiliation(s)
- Sean M Booth
- Department of Orthopaedics, University Hospital South Manchester, UK
| | - Abdulbaset Abosala
- Department of Orthopaedics, Dr Gray's Hospital, NHS Grampian, IV30 1SN, UK
| | - Chris Peach
- Department of Orthopaedics, University Hospital South Manchester, UK
| |
Collapse
|
30
|
Abstract
The purpose of this clinical commentary is to review the anatomy, etiology, evaluation, and treatment techniques for nerve entrapments of the hip region. Nerve entrapment can occur around musculotendinous, osseous, and ligamentous structures because of the potential for increased strain and compression on the peripheral nerve at those sites. The sequela of localized trauma may also result in nerve entrapment if normal nerve gliding is prevented. Nerve entrapment can be difficult to diagnose because patient complaints may be similar to and coexist with other musculoskeletal conditions in the hip and pelvic region. However, a detailed description of symptom location and findings from a comprehensive physical examination can be used to determine if an entrapment has occurred, and if so where. The sciatic, pudendal, obturator, femoral, and lateral femoral cutaneous are nerves that can be entrapped and serve a source of hip pain in the athletic population. Manual therapy, stretching and strengthening exercises, aerobic conditioning, and cognitive-behavioral education are potential interventions. When conservative treatment is ineffective at relieving symptoms surgical treatment with neurolysis or neurectomy may be considered. Level of Evidence 5.
Collapse
|
31
|
Abstract
Meralgia paresthetica is a neuropathic pain disorder resulting from an entrapment neuropathy of the lateral femoral cutaneous nerve. This condition results in pain, paresthesias and numbness over the anterolateral aspect of the thigh. We present a case of meralgia paresthetica and discuss both the clinical and histopathological findings as they relate to one another. We report a case of meralgia paresthetica refractory to conservative treatment who underwent neurectomy with successful treatment of symptoms. Histopathological examination revealed moderate loss of myelinated axons with some axonal atrophy. The distinct pathologic findings were axonal regeneration clusters and thinly myelinated axons as well as moderate perineurial thickening. These findings corresponded well to the patient’s preoperative symptoms of paresthesias and pain. This case serves to shed light on the pathophysiology of meralgia paresthetica and its clinical presentation. It also shows the role of surgical treatment in cases refractory to conservative management in order to alleviate painful symptoms
Collapse
Affiliation(s)
- Russell A Payne
- Department of Neurosurgery, Penn State Hershey Medical Center
| | | | | | - Elias Rizk
- Department of Neurosurgery, Penn State Hershey Medical Center
| |
Collapse
|
32
|
Anderson JC, Fritz ML, Benson JM, Tracy BL. Nerve Decompression and Restless Legs Syndrome: A Retrospective Analysis. Front Neurol 2017; 8:287. [PMID: 28729849 PMCID: PMC5498562 DOI: 10.3389/fneur.2017.00287] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Accepted: 06/02/2017] [Indexed: 12/17/2022] Open
Abstract
Introduction Restless legs syndrome (RLS) is a prevalent sleep disorder affecting quality of life and is often comorbid with other neurological diseases, including peripheral neuropathy. The mechanisms related to RLS symptoms remain unclear, and treatment options are often aimed at symptom relief rather than etiology. RLS may present in distinct phenotypes often described as “primary” vs. “secondary” RLS. Secondary RLS is often associated with peripheral neuropathy. Nerve decompression surgery of the common and superficial fibular nerves is used to treat peripheral neuropathy. Anecdotally, surgeons sometimes report improved RLS symptoms following nerve decompression for peripheral neuropathy. The purpose of this retrospective analysis was to quantify the change in symptoms commonly associated with RLS using visual analog scales (VAS). Methods Forty-two patients completed VAS scales (0–10) for pain, burning, numbness, tingling, weakness, balance, tightness, aching, pulling, cramping, twitchy/jumpy, uneasy, creepy/crawly, and throbbing, both before and 15 weeks after surgical decompression. Results Subjects reported significant improvement among all VAS categories, except for “pulling” (P = 0.14). The change in VAS following surgery was negatively correlated with the pre-surgery VAS for both the summed VAS (r = −0.58, P < 0.001) and the individual VAS scores (all P < 0.01), such that patients who reported the worst symptoms before surgery exhibited relatively greater reductions in symptoms after surgery. Conclusion This is the first study to suggest improvement in RLS symptoms following surgical decompression of the common and superficial fibular nerves. Further investigation is needed to quantify improvement using RLS-specific metrics and sleep quality assessments.
Collapse
Affiliation(s)
- James C Anderson
- Anderson Podiatry Center for Nerve Pain, Fort Collins, CO, United States
| | - Megan L Fritz
- Anderson Podiatry Center for Nerve Pain, Fort Collins, CO, United States.,Neuromuscular Function Lab, Department of Health and Exercise Science, Colorado State University, Fort Collins, CO, United States
| | | | - Brian L Tracy
- Neuromuscular Function Lab, Department of Health and Exercise Science, Colorado State University, Fort Collins, CO, United States
| |
Collapse
|
33
|
Hosahalli G, Sierakowski A, Venkatramani H, Sabapathy SR. Entrapment Neuropathy of the Infrapatellar Branch of the Saphenous Nerve: Treated by Partial Division of Sartorius. Indian J Orthop 2017; 51:474-476. [PMID: 28790478 PMCID: PMC5525530 DOI: 10.4103/0019-5413.209954] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
We describe a case of entrapment neuropathy of the infrapatellar branch of the saphenous nerve as it pierces sartorius muscle. This is a rare cause of anteromedial knee pain that is easily overlooked and may be mistaken as arising from other anatomical structures in that region. The pain was successfully treated by partially dividing the sartorius muscle and translocating the nerve away from the site of entrapment. It is important to consider entrapment neuropathy of the infrapatellar branch of the saphenous nerve as a differential diagnosis when assessing a patient with anteromedial knee pain.
Collapse
Affiliation(s)
- Gururaj Hosahalli
- Department of Plastic Surgery, Hand Surgery, Reconstructive Microsurgery and Burns, Ganga Hospital, Coimbatore, Tamil Nadu, India
| | - Adam Sierakowski
- Department of Plastic Surgery, Hand Surgery, Reconstructive Microsurgery and Burns, Ganga Hospital, Coimbatore, Tamil Nadu, India
| | - Hari Venkatramani
- Department of Plastic Surgery, Hand Surgery, Reconstructive Microsurgery and Burns, Ganga Hospital, Coimbatore, Tamil Nadu, India
| | - S Raja Sabapathy
- Department of Plastic Surgery, Hand Surgery, Reconstructive Microsurgery and Burns, Ganga Hospital, Coimbatore, Tamil Nadu, India,Address for correspondence: Dr. S Raja Sabapathy, Division of Plastic Surgery, Hand Surgery, Reconstructive Microsurgery and Burns, Ganga Hospital, 313, Mettupalayam Road, Coimbatore - 641 043, Tamil Nadu, India. E-mail:
| |
Collapse
|
34
|
Mansfield CJ, Bleacher J, Tadak P, Briggs MS. Differential examination, diagnosis and management for tingling in toes: fellow's case problem. J Man Manip Ther 2016; 25:294-299. [PMID: 29449772 DOI: 10.1080/10669817.2016.1260675] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Background The diagnosis of chronic exertional compartment syndrome can be challenging as other pathologies involving bone, muscle, nerve and vascular structures can mimic the syndrome. The purpose of this Fellow's Case Problem is to describe the clinical decision-making and physical therapy differential diagnosis regarding a 25-year-old patient with un-resolved neurovascular complaints following chronic exertional compartment syndrome surgical release. Diagnosis After surgery, the patient's previous complaint of numbness and tingling in the plantar surfaces of her first and second toes of right foot was still present. The patient's concordant symptoms in toes were reproduced proximally in the lumbar spine and distally in the tarsal tunnel. Discussion The lumbar spine can refer symptoms to the lower extremities and needs to be ruled out as the source of the patient's complaint whenever neurovascular symptoms such as numbness and tingling are present. The discovery of the relationship of the lumbar spine with the tingling in the toes addressed one of the patient's primary concerns that was not resolved from the surgery. Level of Evidence 4.
Collapse
Affiliation(s)
- Cody J Mansfield
- Orthopaedic Manual Therapy Fellowship, OSU Spots Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Jake Bleacher
- Orthopaedic Manual Therapy Fellowship, OSU Spots Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Paul Tadak
- Orthopaedic Manual Therapy Fellowship, OSU Spots Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Matthew S Briggs
- Orthopaedic Manual Therapy Fellowship, OSU Spots Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA.,Sports Medicine Research Institute, The Ohio State University Wexner Medical Center, Columbus, OH, USA.,Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| |
Collapse
|
35
|
Abstract
Introduction Transobturator slings can be successfully used to treat stress urinary incontinence and improve quality of life through a minimally invasive vaginal approach. Persistent postoperative pain can occur and pose diagnostic and therapeutic dilemmas. Following a sling procedure, a patient complained of pinching clitoral and perineal pain. Her symptoms of localized clitoral pinching and pain became generalized over the ensuing years, eventually encompassing the entire left vulvovaginal region. Aim The aim of this study was to highlight the clinical utility of conventional pain management techniques used for the evaluation and management of patients with postoperative pain following pelvic surgery. Methods We described a prototypical patient with persistent pain in and around the clitoral region complicating the clinical course of an otherwise successful sling procedure. We specifically discussed the utility of bedside sensory assessment techniques and selective nerve blocks in the evaluation and management of this prototypical patient. Results Neurosensory assessments and a selective nerve block enabled us to trace the source of the patient’s pain to nerve entrapment along the dorsal nerve of the clitoris. We then utilized a nerve stimulator-guided hydrodissection technique to release the scar contracture Conclusion This case demonstrates that the dorsal nerve of the clitoris is vulnerable to injury directly and/or indirectly. Assimilation of a time-honored pain management construct for the evaluation and management of patients’ pain may improve outcomes while obviating the need for invasive surgery.
Collapse
Affiliation(s)
- Chailee F Moss
- Department of Obstetrics and Gynecology, Ohio State University School of Medicine, Columbus, OH, USA
| | - Lynn A Damitz
- Department of Surgery, University of North Carolina at Chapel Hill, NC, USA
| | - Richard H Gracely
- Department of Endodontics, University of North Carolina at Chapel Hill, NC, USA
| | - Alice C Mintz
- Department of Endodontics, University of North Carolina at Chapel Hill, NC, USA
| | - Denniz A Zolnoun
- Department of Surgery, University of North Carolina at Chapel Hill, NC, USA; Department of Endodontics, University of North Carolina at Chapel Hill, NC, USA; Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | - A Lee Dellon
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| |
Collapse
|
36
|
Pinder EM, Ng CY. Scratch Collapse Test Is a Useful Clinical Sign in Assessing Long Thoracic Nerve Entrapment. J Hand Microsurg 2016; 8:122-4. [PMID: 27625547 DOI: 10.1055/s-0036-1585429] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2016] [Accepted: 06/01/2016] [Indexed: 10/21/2022] Open
Abstract
The scratch collapse test (SCT) is a relatively new clinical test in which a positive result implies entrapment neuropathy of the nerve tested. Initially described for carpal and cubital tunnel syndromes, subsequent authors have found it useful for the assessment of median, ulna, radial, axillary, and common peroneal nerves. We report a case illustrating the value of the SCT in the clinical assessment of thoracic nerve entrapment.
Collapse
Affiliation(s)
- Elizabeth M Pinder
- Upper Limb Unit, Wrightington Hospital, Wigan, Lancashire, United Kingdom
| | - Chye Yew Ng
- Upper Limb Unit, Wrightington Hospital, Wigan, Lancashire, United Kingdom
| |
Collapse
|
37
|
Elzinga KE, Curran MWT, Morhart MJ, Chan KM, Olson JL. Open Anterior Release of the Superior Transverse Scapular Ligament for Decompression of the Suprascapular Nerve During Brachial Plexus Surgery. J Hand Surg Am 2016; 41:e211-5. [PMID: 27113908 DOI: 10.1016/j.jhsa.2016.03.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Accepted: 03/19/2016] [Indexed: 02/02/2023]
Abstract
Reconstruction of the suprascapular nerve (SSN) after brachial plexus injury often involves nerve grafting or a nerve transfer. To restore shoulder abduction and external rotation, a branch of the spinal accessory nerve is commonly transferred to the SSN. To allow reinnervation of the SSN, any potential compression points should be released to prevent a possible double crush syndrome. For that reason, the authors perform a release of the superior transverse scapular ligament at the suprascapular notch in all patients undergoing reconstruction of the upper trunk of the brachial plexus. Performing the release through a standard anterior open supraclavicular approach to the brachial plexus avoids the need for an additional posterior incision or arthroscopic procedure.
Collapse
Affiliation(s)
- Kate E Elzinga
- Division of Plastic Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Matthew W T Curran
- Division of Plastic Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Michael J Morhart
- Division of Plastic Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - K Ming Chan
- Division of Physical Medicine and Rehabilitation, University of Alberta, Edmonton, Alberta, Canada
| | - Jaret L Olson
- Division of Plastic Surgery, University of Alberta, Edmonton, Alberta, Canada.
| |
Collapse
|
38
|
Bilgin Topçuoğlu Ö, Oruç Ö, Saraç S, Çetintaş Afşar G, Uluç K. Carpal Tunnel Syndrome in Obstructive Sleep Apnea Patients. ACTA ACUST UNITED AC 2016; 54:307-311. [PMID: 29321702 DOI: 10.5152/npa.2016.15907] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Accepted: 04/07/2016] [Indexed: 01/07/2023]
Abstract
Introduction Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy of the upper extremity. It is usually associated with the compression of the median nerve in the median groove. Because the main symptoms of CTS pain and numbness worsen at night, sleep disorders in CTS patients and the impact of preferred sleeping position on CTS development have been formerly studied. However, to the best of our knowledge, this is the first study assessing the frequency of CTS in obstructive sleep apnea (OSA) patients. This study aimed to determine the frequency of CTS in OSA patients and evaluate the causative relation between the two diseases. Methods Records of individuals who were admitted to our sleep laboratory were retrospectively scanned. Eighty patients who were diagnosed with OSA and did not have comorbidities that might cause OSA (e.g., diabetes mellitus, hypothyroiditis, rheumatic diseases, and cervical radiculopathy) were included in the study along with 80 healthy controls who matched for age, sex, and BMI of OSA patients. To maintain observer blindness, patients were not questioned regarding their symptoms or the clinical data that would be used in the study. All participants underwent nerve conduction studies. Those who were diagnosed with CTS were questioned regarding CTS symptoms and the preferred sleeping position. Subsequently, patients were given the Boston CTS questionnaire. Results CTS frequency in OSA patients was found to be 27.5%. There was no significant relation between preferred sleeping position or being a manual worker and having CTS. Conclusion CTS frequency in OSA patients is significantly higher than that in healthy individuals. In contrast to previous studies that have been performed in the absence of polysomnographic and electrophysiological data, in our study biomechanical factors were not associated with CTS presence. Therefore, we conclude that intermittent hypoxemia is the main etiological factor for CTS in OSA patients. Inflammation may be a common factor for etiopathogenesis for both diseases, but this hypothesis needs further investigation.
Collapse
Affiliation(s)
- Özgür Bilgin Topçuoğlu
- Clinic of Neurology, Süreyyapaşa Chest Diseases and Thorax Surgery Training and Research Hospital, İstanbul, Turkey.,Department of Neurology, Marmara University School of Medicine, İstanbul, Turkey
| | - Özlem Oruç
- Clinic of Chest Diseases, Süreyyapaşa Chest Diseases and Thorax Surgery Training and Research Hospital, İstanbul, Turkey
| | - Sema Saraç
- Clinic of Chest Diseases, Süreyyapaşa Chest Diseases and Thorax Surgery Training and Research Hospital, İstanbul, Turkey
| | - Gülgün Çetintaş Afşar
- Clinic of Chest Diseases, Süreyyapaşa Chest Diseases and Thorax Surgery Training and Research Hospital, İstanbul, Turkey
| | - Kayıhan Uluç
- Department of Neurology, Marmara University School of Medicine, İstanbul, Turkey
| |
Collapse
|
39
|
Abstract
Chronic leg pain is commonly treated by orthopaedic surgeons who take care of athletes. The sources are varied and include the more commonly encountered medial tibial stress syndrome, chronic exertional compartment syndrome, stress fracture, popliteal artery entrapment syndrome, nerve entrapment, Achilles tightness, deep vein thrombosis, and complex regional pain syndrome. Owing to overlapping physical examination findings, an assortment of imaging and other diagnostic modalities are employed to distinguish among the diagnoses to guide the appropriate management. Although most of these chronic problems are treated nonsurgically, some patients require operative intervention. For each condition listed above, the pathophysiology, diagnosis, management option, and outcomes are discussed in turn.
Collapse
Affiliation(s)
- M Tyrrell Burrus
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Brian C Werner
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Jim S Starman
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - F Winston Gwathmey
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Eric W Carson
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Robert P Wilder
- Physical Medicine and Rehabilitation Department, University of Virginia Health System, Charlottesville, Virginia, USA
| | - David R Diduch
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| |
Collapse
|
40
|
Abstract
We present a case of tibial nerve impingement by an anteroposterior screw inserted for stabilization of a posterior malleolar fracture. This specific complication has not previously been described in published studies, although numerous reports have described various forms of peripheral nerve entrapment. We discuss the merits of fixation of these fractures using a posterolateral approach.
Collapse
Affiliation(s)
- Ankit Patel
- Trauma and Orthopaedic Department, Tunbridge Wells Hospital, Kent, United Kingdom.
| | - Loren Charles
- Trauma and Orthopaedic Department, Tunbridge Wells Hospital, Kent, United Kingdom
| | - James Ritchie
- Trauma and Orthopaedic Department, Tunbridge Wells Hospital, Kent, United Kingdom
| |
Collapse
|
41
|
Abstract
We present a case of tibial nerve impingement by an anteroposterior screw inserted for stabilization of a posterior malleolar fracture. This specific complication has not previously been described in published studies, although numerous reports have described various forms of peripheral nerve entrapment. We discuss the merits of fixation of these fractures using a posterolateral approach.
Collapse
Affiliation(s)
- Ankit Patel
- Trauma and Orthopaedic Department, Tunbridge Wells Hospital, Kent, United Kingdom.
| | - Loren Charles
- Trauma and Orthopaedic Department, Tunbridge Wells Hospital, Kent, United Kingdom
| | - James Ritchie
- Trauma and Orthopaedic Department, Tunbridge Wells Hospital, Kent, United Kingdom
| |
Collapse
|
42
|
Abstract
Despite being the most common entrapment neuropathy and the most common reason for referral to the electromyography (EMG) laboratory, the diagnosis of carpal tunnel syndrome (CTS) continues to be challenging due to a large number of electrodiagnostic (EDX) tests available. We present a flowchart and propose a practical approach to the diagnosis of CTS using the available literature and the American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM) guidelines and the Practice Parameter for Electrodiagnostic Studies in Carpal Tunnel Syndrome.
Collapse
Affiliation(s)
- Keivan Basiri
- Department of Neurology, Isfahan Neurosciences Research Center, AlZahra Hospital, Medical School, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Bashar Katirji
- Department of Neurology, Neuromuscular Center and EMG Laboratory, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| |
Collapse
|
43
|
Affiliation(s)
- Jennifer Luz
- Spaulding Rehabilitation Hospital, Harvard Medical School, Department of Physical Medicine & Rehabilitation, Boston, MA, USA
| | - A Holly Johnson
- Massachusetts General Hospital, Harvard Medical School, Department of Orthopedics, Boston, MA, USA
| | - Minna J Kohler
- Massachusetts General Hospital, Harvard Medical School, Division of Rheumatology, Allergy, and Immunology, Yawkey Center for Outpatient Care, Boston, MA, USA
| |
Collapse
|
44
|
Abstract
Tarsal tunnel syndrome (TTS) is a compression neuropathy of the posterior tibial nerve in the tarsal tunnel. In about 80% of patients, a specific cause can be identified for TTS. We present a case of TTS secondary to an ossicle in close relation to the talus that, to our knowledge, has not previously been reported. A 26-year-old male presented with left ankle and foot pain that increased with activity and playing football. He had a tingling sensation and paresthesia in the sole and medial border of the foot along the distribution of the medial and lateral plantar nerves. Clinically, he had hard swelling at the floor of the tarsal tunnel, and Tinel's sign was positive. Computed tomography showed an accessory ossicle articulating with the posteromedial aspect of the talus, separating the flexor digitorum longus and flexor hallucis longus tendons, with tenosynovitis of the tibialis posterior, flexor digitorum longus and flexor hallucis longus tendons. Surgical release of the tarsal tunnel and excision of the ossicle were performed. Postoperatively, the patient showed dramatic improvement and had no complications or recurrence of symptoms after 8 months of follow-up. More interestingly, to the best of our knowledge, this ossicle has not been previously reported to cause TTS.
Collapse
Affiliation(s)
- Tamer Ahmed Sweed
- Registrar of Trauma and Orthopaedics, University of Birmingham, Queen Elizabeth Hospital, Edgbaston, Birmingham, UK.
| | - Seyed Asghar Ali
- Consultant of Trauma and Orthopaedics, University of Birmingham, Queen Elizabeth Hospital, Edgbaston, Birmingham, UK
| | - Surabhi Choudhary
- Consultant Radiologist, University of Birmingham, Queen Elizabeth Hospital, Edgbaston, Birmingham, UK
| |
Collapse
|
45
|
De Franco P, Erra C, Granata G, Coraci D, Padua R, Padua L. Sonographic diagnosis of anatomical variations associated with carpal tunnel syndrome. J Clin Ultrasound 2014; 42:371-374. [PMID: 24302518 DOI: 10.1002/jcu.22118] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2012] [Revised: 06/26/2013] [Accepted: 10/09/2013] [Indexed: 06/02/2023]
Abstract
Bifid median nerve is an anatomic variation that occurs in about 18% of patients with symptoms suggestive of carpal tunnel syndrome and in about 15% of symptom-free subjects. Reversed palmaris longus is a rare anatomic muscular variation. The simultaneous presence of a bifid median nerve and a reversed palmaris longus has been very rarely described, usually during surgical exploration or in cadavers. We present two cases where ultrasound showed the presence of both abnormalities, allowing a correct diagnosis and influencing the treatment plan.
Collapse
Affiliation(s)
- P De Franco
- Department of Neuroscience, Institute of Neurology, Catholic University, Rome, Italy
| | | | | | | | | | | |
Collapse
|
46
|
Cheatham SW, Kolber MJ, Salamh PA. Meralgia paresthetica: a review of the literature. Int J Sports Phys Ther 2013; 8:883-893. [PMID: 24377074 PMCID: PMC3867081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023] Open
Abstract
BACKGROUND AND PURPOSE Meralgia Paresthetica (MP) is a nerve entrapment which may cause pain, paresthesias, and sensory loss within the distribution of the lateral cutaneous nerve of the thigh. When the differential diagnosis of lateral or anterolateral thigh pain is inconclusive, MP should be considered as a potential source. MP produces similar signs and symptoms as those associated with more common diagnoses such as lumbar spine pathology. This clinical commentary will review the most relevant literature on MP with an emphasis on recognition and management of this condition. DESCRIPTION OF TOPIC WITH RELATED EVIDENCE The authors reviewed the most relevant published literature on MP from 1970 to 2013 located using the databases PubMed, CINAHL, and Proquest. DISCUSSION/RELATION TO CLINICAL PRACTICE MP still remains a diagnostic challenge since it can mimic other common diagnoses. Understanding the current literature surrounding the diagnosis and treatment of MP is essential for clinicians practicing in the outpatient environment. The consensus on the most effective non-surgical and surgical interventions is still limited, as is the research on physical therapy interventions for this condition. Perhaps the lack of research and global consensus represents a knowledge deficit that makes MP a challenge to diagnose and successfully treat. Future collaborative studies are needed to improve the clinical diagnostics and understanding of interventions for this pathology. LEVEL OF EVIDENCE 5.
Collapse
Affiliation(s)
| | | | - Paul A. Salamh
- Southeastern Orthopedics Physical Therapy, Raleigh, NC, USA
| |
Collapse
|
47
|
Abstract
The treatment of ulnar nerve compression at the elbow remains controversial. No single technique has yet proven its superiority. We describe a technique combining the advantages of the mini-invasive approach with those of transposition. We present the results of 30 patients, of mean age 52 years, who underwent anterior subcutaneous transposition of the ulnar nerve using a mini-invasive approach with a follow-up of more than six months. The incision measures 3 cm. The results were evaluated by measuring pain intensity, quick disabilities of the arm shoulder and hand (DASH), grip strength and pinch, and McGowan score, pre- and post-operatively. All parameters were improved post-operative. The mean pain score went from 5.5 to 4, the quick DASH from 48 to 38, mean grip strength from 28 to 31 kg, and mean pinch strength from 4.7 to 6.4 kg. The McGowan score was also improved; pre-operatively, there were 16 patients at stage III, seven patients stage II, seven patients stage I, and post-operatively there was one patient stage III, three patients stage II, 16 patients stage I, and 10 patients stage 0. Analysis of our series shows that a 3 cm incision without endoscopy allows subcutanous transposition, with results at least as good as those with other techniques. The advantages of our technique are that it is easy, has a limited approach, preserves blood supply, allows placement of the nerve in a favourable environment, and decreases nerve stretching during elbow flexion.
Collapse
Affiliation(s)
- T Lequint
- Hand Surgery Department, Strasbourg University Hospitals, France
| | | | | | | | | |
Collapse
|
48
|
Abstract
Peripheral nerve entrapments are frequent. They usually appear in anatomical tunnels such as the carpal tunnel. Nerve compressions may be due to external pressure such as the fibular nerve at the fibular head. Malignant or benign tumors may also damage the nerve. For each nerve from the upper and lower limbs, detailed clinical, electrophysiological, imaging, and therapeutic aspects are described. In the upper limbs, carpal tunnel syndrome and ulnar neuropathy at the elbow are the most frequent manifestations; the radial nerve is less frequently involved. Other nerves may occasionally be damaged and these are described also. In the lower limbs, the fibular nerve is most frequently involved, usually at the fibular head by external compression. Other nerves may also be involved and are therefore described. The clinical and electrophysiological examination are very important for the diagnosis, but imaging is also of great use. Treatments available for each nerve disease are discussed.
Collapse
Affiliation(s)
- P Bouche
- Department of Clinical Neurophysiology Salpêtrière Hospital, Paris, France.
| |
Collapse
|
49
|
Abstract
Context: Chronic lower leg pain in athletes can be a frustrating problem for patients and a difficult diagnosis for clinicians. Myriad approaches have been suggested to evaluate these conditions. With the continued evolution of diagnostic studies, evidence-based guidance for a standard approach is unfortunately sparse. Evidence Acquisition: PubMed was searched from January 1980 to May 2011 to identify publications regarding chronic lower leg pain in athletes (excluding conditions related to the foot), including differential diagnosis, clinical presentation, physical examination, history, diagnostic workup, and treatment. Results: Leg pain in athletes can be caused by many conditions, with the most frequent being medial tibial stress syndrome; chronic exertional compartment syndrome, stress fracture, nerve entrapment, and popliteal artery entrapment syndrome are also considerations. Conservative management is the mainstay of care for the majority of causes of chronic lower leg pain; however, surgical intervention may be necessary. Conclusion: Chronic lower extremity pain in athletes includes a wide differential and can pose diagnostic dilemmas for clinicians.
Collapse
|
50
|
Napadow V, Liu J, Li M, Kettner N, Ryan A, Kwong KK, Hui KKS, Audette JF. Somatosensory cortical plasticity in carpal tunnel syndrome treated by acupuncture. Hum Brain Mapp 2007; 28:159-71. [PMID: 16761270 PMCID: PMC6871379 DOI: 10.1002/hbm.20261] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2005] [Accepted: 02/06/2006] [Indexed: 11/08/2022] Open
Abstract
Carpal tunnel syndrome (CTS) is a common entrapment neuropathy of the median nerve characterized by paresthesias and pain in the first through fourth digits. We hypothesize that aberrant afferent input from CTS will lead to maladaptive cortical plasticity, which may be corrected by appropriate therapy. Functional MRI (fMRI) scanning and clinical testing was performed on CTS patients at baseline and after 5 weeks of acupuncture treatment. As a control, healthy adults were also tested 5 weeks apart. During fMRI, sensory stimulation was performed for median nerve innervated digit 2 (D2) and digit 3 (D3), and ulnar nerve innervated digit 5 (D5). Surface-based and region of interest (ROI)-based analyses demonstrated that while the extent of fMRI activity in contralateral Brodmann Area 1 (BA 1) and BA 4 was increased in CTS compared to healthy adults, after acupuncture there was a significant decrease in contralateral BA 1 (P < 0.005) and BA 4 (P < 0.05) activity during D3 sensory stimulation. Healthy adults demonstrated no significant test-retest differences for any digit tested. While D3/D2 separation was contracted or blurred in CTS patients compared to healthy adults, the D2 SI representation shifted laterally after acupuncture treatment, leading to increased D3/D2 separation. Increasing D3/D2 separation correlated with decreasing paresthesias in CTS patients (P < 0.05). As CTS-induced paresthesias constitute diffuse, synchronized, multidigit symptomatology, our results for maladaptive change and correction are consistent with Hebbian plasticity mechanisms. Acupuncture, a somatosensory conditioning stimulus, shows promise in inducing beneficial cortical plasticity manifested by more focused digital representations.
Collapse
Affiliation(s)
- Vitaly Napadow
- Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Charlestown, Massachusetts, USA.
| | | | | | | | | | | | | | | |
Collapse
|