Supracondylar Apophysis of the Humerus: Rare Cause of High Compression of the Median Nerve / Apófise supracondilar do úmero: Causa rara de compressão alta do nervo mediano

Abstract Supracondylar apophysis (SA) is a bony prominence that originates from the anteromedial aspect of the distal humerus with a lower projection and which, although usually asymptomatic, due to the relationship with adjacent structures can cause symptoms. We describe the case of a 42-year-old woman with pain complaints radiating from her elbow to her hand, with 6 months of evolution. On objective examination, the patient had a sensory deficit in the median nerve territory and decreased grip strength. Radiographs of the distal humerus were performed, in which a bone spike was visible, and magnetic resonance imaging showed thickening of the median nerve epineurium. Electromyography showed severe axonal demyelination of the median nerve proximal to the elbow. A median nerve compression caused by a SA was diagnosed. The patient underwent surgery and, 1 year after the operation, she had a complete clinical recovery. Supracondylar apophysis is a rare, but possible and treatable cause of high median nerve compression.

Resumo A apófise supracondilar (ASC) é uma proeminência óssea que tem origem na face anteromedial do úmero distal com projeção inferior e que, apesar de habitualmente assintomática, pela relação com as estruturas adjacentes pode causar sintomatologia. Descrevemos o caso de uma mulher de 42 anos, com queixas álgicas irradiadas do cotovelo à mão, com 6 meses de evolução. Ao exame objetivo, a paciente apresentava um déficit sensorial no território do nervo mediano e diminuição da força de preensão. Foram realizadas radiografias do úmero distal nas quais era visível uma espícula óssea, e na ressonância magnética era evidente o espessamento do epineuro do nervo mediano. A eletromiografia apresentou uma desmielinização axonal grave do nervo mediano proximal ao cotovelo. Foi diagnosticada uma compressão do nervo mediano por uma ASC. A paciente foi submetida à cirurgia e 1 ano pós-operatório apresentou recuperação clínica total. A ASC é uma causa rara, mas possível e tratável da compressão alta do nervo mediano.

Is there an association between electroneuromyography and ultrasound in the diagnosis of carpal tunnel syndrome? / Existe associação entre a eletroneuromiografia e a ultrassonografia no diagnóstico da Síndrome do Túnel do Carpo?

Abstract Objective To verify whether there is an association between the results of the severity in electroneuromyography and the positivity in ultrasound in the diagnosis of carpal tunnel syndrome. Methods Sixty-eight patients were included in the study, 61 women and 7 men, with a mean age of 54.4 years. The ultrasound results (positive or negative) were crossed with the results of electroneuromyography (mild, moderate or severe), and the existence of association was verified. Results One hundred and thirty-six hands with suspicion or symptoms of carpal tunnel syndrome were evaluated. Positive ultrasound diagnosis was observed in 72 hands and negative in 64; 123 hands presented positive electroneuromyography for carpal tunnel syndrome, and there were 13 negative results. The severe degree in electroneuromyography was prevalent. Conclusion There was a statistically significant association between electroneuromyography and ultrasonography (p < 0.05), and ultrasound positivity was higher for more severe levels of carpal tunnel syndrome given by electroneuromyography.

Resumo Objetivo Verificar se existe associação entre os resultados da gravidade da eletroneuromiografia e a positividade da ultrassonografia no diagnóstico da síndrome do túnel do carpo. Métodos Sessenta e oito pacientes foram incluídos no estudo, sendo 61 mulheres e 7 homens, com média de idade de 54,4 anos. Os resultados da ultrassonografia (positivo ou negativo) foram cruzados com os resultados da eletroneuromiografia (leve, moderado ou grave) e verificada a existência de associação. Resultados Cento e trinta e seis mãos com suspeita ou sintomas de síndrome do túnel do carpo foram avaliadas. O diagnóstico ultrassonográfico positivo foi observado em 72 mãos e negativo em 64; 123 mãos apresentaram eletroneuromiografia positiva para síndrome do túnel do carpo e 13 apresentaram resultado negativo. O grau grave da eletroneuromiografia foi prevalente. Conclusão Houve associação estatisticamente significativa entre eletroneuromiografia e ultrassonografia (p < 0,05), sendo que a positividade da ultrassonografia foi maior para níveis mais graves de síndrome do túnel do carpo dados pela eletroneuromiografia.

Morton's Neuroma / 대한정형외과학회잡지

Morton's neuroma, also known as interdigital neuroma, is a common cause of forefoot pain. It is a compressive neuropathy of the interdigital nerve, which is compressed by the overlying transverse metatarsal ligament. It is not a true tumor. The symptoms are forefoot pain that radiates into the toes, according to the involved nerve branches. Its histological findings are fibrosis around the nerve, demyelination. The clinical diagnosis can be obtained from a detailed history and physical examination, such as the compressive test. Moreover, ultrasonography and magnetic resonance imaging can also be used. Conservative treatment is the common initial treatment modality for interdigital neuroma. Surgical excision or decompression is indicated after a failure of conservative treatments.

Median nerve neuropathy

The median nerve is the most important nerve in the upper extremity, as it is responsible for most of the sensation of the hand, the fine motor functions of the thumb, and finger grasping. Median neuropathies most commonly occur as compressive neuropathy or entrapment neuropathy, but sometimes as neuritis without any compressive lesion. Carpal tunnel syndrome (CTS), anterior interosseous nerve syndrome, and pronator teres syndrome are the subtypes of median nerve neuropathies, of which CTS is the most common. Median neuropathies can be diagnosed clinically by careful history-taking and a physical examination. Typical symptoms of CTS include night pain (crying), a tingling sensation of the radial digits, numbness or paresthesia, clumsiness, and atrophy of the thenar muscles. Electrophysiologic testing can be used for confirmation of the diagnosis and for documentation before surgical treatment. Imaging modalities including ultrasonography or magnetic resonance imaging can be used to ensure diagnostic accuracy and to detect unusual causes of compression. Conservative treatments include rest, bracing, nerve stretching, non-steroidal anti-inflammatory drugs, and steroid injections. If nonsurgical approaches are unsatisfactory or the nerve damage is severe, surgical treatment should be considered. Carpal tunnel release for CTS is a relatively simple procedure that involves division of the transverse carpal ligament and decompression of the median nerve. Early diagnosis and proper management are important, as muscle atrophy and sensory loss may persist when surgical release is delayed in patients with advanced disease.

Compressão do nervo ulnar na região do cotovelo ­ síndrome do túnel cubital: revisão da literatura / Compression of the Ulnar Nerve in the Elbow Region - Cubital Tunnel Syndrome: Review of the Literature

A síndrome do túnel cubital é responsável pela neuropatia do nervo ulnar, sendo superada em frequência apenas pela síndrome do túnel do carpo. O nervo ulnar apresenta anatomia complexa podendo sofrer compressão em distintos pontos ao longo de seu trajeto, por isso o entendimento das nuances clínicas e da anatomia pormenorizada assim como da técnica cirúrgica meticulosa torna-se essencial no tratamento desta patologia.

The cubital tunnel syndrome is responsible for the ulnar nerve neuropathy, this condition is surpassed in frequency only by carpal tunnel syndrome. The ulnar nerve has complex anatomy andmay suffer compression at different points along its path, so understanding the clinical nuances and detailed anatomy as well asmeticulous surgical technique becomes essential in the treatment of this pathology.

Carpal tunnel syndrome: long-term nerve conduction studies in 261 hands / Síndrome do tunel do carpo: estudo evolutivo de parâmetros de condução nervoso em 261 mãos

OBJECTIVE: To compare a long-term carpal tunnel syndrome (CTS) on nerve conduction studies (NCS) in hands treated non-surgically. METHOD: We retrospectively selected 261 symptomatic CTS hands (166 patients), all of them confirmed by NCS. In all cases, at least 2 NCS were performed in an interval greater than 12 months. Cases with associated polyneuropathy were excluded. NCS parameters for CTS electrodiagnosis included a sensory conduction velocity (SCV) <46.6 m/s (wrist to index finger, 14 cm) and distal motor latency (DML) >4.25 ms (wrist to APB, 8 cm). RESULTS: 92.8 percent were women; mean age was 49 years (20-76); the mean interval between NCS was 47 months (12-150). In the first exam, the median sensory nerve action potential (SNAP) and the compound action muscular potential were absent in 9.8 percent and 1.9 percent, respectively. In the second/last exam, SCV worsened in 54.2 percent, remained unchanged in 11.6 percent and improved in 34.2 percent. SNAP amplitude worsened in 57.7 percent, remained unchanged in 13.1 percent and improved in 29.2 percent. DML worsened in 52.9 percent, remained unchanged in 7.6 percent and improved in 39.5 percent. Overall, NCS parameters worsened in 54.9 percent, improved in 34.3 percent and remained unchanged in 10.8 percent. CONCLUSION: Long-term changing in NCS of CTS hands apparently were not related to clinical symptomatology and could lead to some difficulty in clinical correlation and prognosis. Aging, male gender and absent SNAP were more related to NCS worsening, regardless the mean interval time between the NCS.

OBJETIVO: Comparar evolutivamente parâmetros de condução nervosa (CN) na síndrome do túnel do carpo (STC) em mãos não submetidas à cirurgia. MÉTODO: Foram selecionadas retrospectivamente 261 mãos (166 pacientes) com STC sintomática confirmadas por CN e que posteriormente realizaram exame controle com intervalo >12 meses; foram excluídos casos com polineuropatia. Os parâmetros eletrodiagnósticos anormais foram: velocidade de condução sensitiva (VCS) <46,6 m/s, segmento pulso-II dedo, e latência distal motora (LDM) >4,25 ms, segmento pulso-APB (8 cm). RESULTADOS: 92,8 por cento eram mulheres; a média de idade foi 49 anos (20-76); o tempo médio entre os exames foi 47 meses (12-150); 9,8 por cento e 1,9 por cento não apresentaram potenciais de ação do nervo sensitivo (PANS) e potenciais de ação muscular compostos, no primeiro exame. No segundo exame a VCS piorou em 54,2 por cento, ficou igual em 11,6 por cento e melhorou em 34,2 por cento; a amplitude do PANS piorou em 57,7 por cento, ficou igual em 13,1 por cento e melhorou em 29,2 por cento; a LDM piorou em 52,9 por cento, ficou igual em 7,6 por cento e melhorou em 39,5 por cento. Incluindo todos os parâmetros eletrofisiológicos, houve piora em 54,9 por cento, melhora em 34,3 por cento e permaneceram sem alterações 10,8 por cento. CONCLUSÃO: As anormalidades da CN na STC podem oscilar ao longo do tempo e aparentemente independem da sintomatologia clínica, dificultando a correlação e prognóstico; idade mais avançada, sexo masculino e PANS ausentes no primeiro exame foram as variáveis que tiveram menor percentual de melhora evolutiva, independentemente do intervalo entre os exames.

Incomplete Compressive Neuropathy of Posterior Interosseous Nerve Caused by Ganglion : A Case Report

Ganglion is a common benign tumor and is likely to cause paralysis of posterior interosseous nerve by compressiononce occurred in proximal radial area. A 25- year old female patient, who was suffering from forearm pain and trouble with extending her fingers after intramuscular stimulation, visited this hospital. We diagnosed as the common extensor muscle rupture by physical examination. But, on the basis of preoperative MRI, she was diagnosed with incomplete posterior interosseous nerve paralysis caused by ganglion of the proximal radius. We performed the surgical excision and obtained a satisfactory result without any evidence of recurrence at the 1 year follow-up after surgery. Incomplete compressive neuropathy of posterior interosseous nerve sometimes confused with spontaneous rupture of the common extensor muscle, which can lead to inappropriate surgical treatment. Careful preoperative examination is essential to avoid misdiagnosis. We report this case with review of the relevant literature, because of rarity of incomplete compressive neuropathy of posterior interosseous nerve by ganglion.

Spinal and Peripheral GABA-A and B Receptor Agonists for the Alleviation of Mechanical Hypersensitivity following Compressive Nerve Injury in the Rat / 대한통증학회지

BACKGROUND: This study was conducted to investigate the roles of the spinal and peripheral gamma-aminobutyric acid (GABA)-ergic systems for the mechanical hypersensitivity produced by chronic compression of the dorsal root ganglion (CCD). METHODS: CCD was performed at the left 5th lumbar dorsal root ganglion. The paw withdrawal threshold (PWT) to von Frey stimuli was measured. The mechanical responsiveness of the lumbar dorsal horn neurons was examined. GABAergic drugs were delivered with intrathecal (i.t.) or intraplantar (i.pl.) injection or by topical application onto the spinal cord. RESULTS: CCD produced mechanical hypersensitivity, which was evidenced by the decrease of the PWT, and it lasting for 10 weeks. For the rats showing mechanical hypersensitivity, the mechanical responsiveness of the lumbar dorsal horn neurons was enhanced. A similar increase was observed with the normal lumbar dorsal horn neurons when the GABA-A receptor antagonist bicuculline was topically applied. An i.t. injection of GABA-A or GABA-B receptor agonist, muscimol or baclofen, alleviated the CCD-induced hypersensitivity. Topical application of same drugs attenuated the CCD-induced enhanced mechanical responsiveness of the lumbar dorsal horn neurons. CCD-induced hypersensitivity was also improved by low-dose muscimol applied (i.pl.) into the affected hind paw, whereas no effects could be observed with high-dose muscimol or baclofen. CONCLUSIONS: The results suggest that the neuropathic pain associated with compression of the dorsal root ganglion is caused by hyperexcitability of the dorsal horn neurons due to a loss of spinal GABAergic inhibition. Peripheral application of low-dose GABA-A receptor agonist can be useful to treat this pain.

Early Decompressive Surgery for Compressive Neuropathy by Hematoma after Posterior Spinal Decompressive Surgery / 대한척추외과학회지

STUDY DESIGN: A retrospective analysis was performed to identify the diagnostic and therapeutic factors related to postoperative compressive neuropathy by hematoma after posterior spinal decompressive surgery. OBJECTIVES: To document by analysis the clinical course of postoperative compressive neuropathy by hematoma, the efficacy of early surgical decompression, and to recommend methods of prevention. SUMMARY OF LITERATURE REVIEW: Various diagnostic and treatment modalities have been applied to postoperative compressive neuropathy after spinal surgery. However, the timing of surgical decompression remains controversial. MATERIALS AND METHODS: Five cases of postoperative compressive neuropathy after posterior spinal decompressive surgery, which occurred from May 1996 to May 2000, were investigated in terms of causes, clinical courses, and management profiles after early surgical decompression, and final outcome. RESULTS: Five cases (2.14%) among 234 patients were managed by re-decompression including the evacuation of hematoma. Four cases, which had been managed by earlier surgical decompression showed neurologic improvement after 2 postoperative weeks, and achieved favorable clinical results without grave neurologic sequelae. However, in one case, in which surgical decompression had been delayed, weakness of the peroneii remained. CONCLUSION: Early evacuation of hematoma achieved a more favorable result than a delayed operation. Early diagnosis and prompt surgical decompression is recommended to reduce neurologic sequelae.