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.

Lidocaine 5% patch in the treatment of localized neuropathic pain due to nerve compression. Case reports / Emplastro de lidocaína a 5% no tratamento da dor neuropática localizada por compressão nervosa. Relato de casos

ABSTRACT BACKGROUND AND OBJECTIVES: Neuropathic pain is a chronic condition with a significant burden for patients, society, and healthcare systems. Due to neuropathic complexity, its management must be different than the one for nociceptive pain. First-line systemic treatments may be associated with dose-dependent adverse events and drug-drug interactions. On the other hand, topical treatments have less systemic adverse events, with the 5% lidocaine transdermal patch being recommended for firstor second line of treatment for neuropathic pain according to various international guidelines. The aim of this study is to present three cases of localized neuropathic pain due to nerve compression managed with 5% lidocaine transdermal patch. CASE REPORTS: The cases of three adult patients (>40 years old) with pain or tingling for a long period of time and their outcomes with treatment with 5% lidocaine transdermal patch for a prolonged duration were investigated. All three cases report a significant improvement in pain. CONCLUSION: The results of the reported cases revealed that a 5% lidocaine transdermal patch represents an effective, safe and tolerable and noninvasive option for the management of localized neuropathic pain due to peripheric nerve compression.

RESUMO JUSTIFICATIVA E OBJETIVOS: A dor neuropática é uma condição crônica com impactos significativos para o paciente, a sociedade e o sistema de saúde. Pela sua complexidade neuropática, a sua abordagem deve ser diferente da dor nociceptiva. Os tratamentos sistêmicos de primeira linha para a dor neuropática podem estar associados à incidência de eventos adversos dose-dependentes e interações farmacológicas. Por outro lado, os fármacos tópicos apresentam menor incidência de eventos adversos sistêmicos, sendo o emplastro de lidocaína a 5% recomendado como primeira ou segunda linha de tratamento para essa condição em diversos guidelines internacionais. O objetivo deste estudo foi apresentar três casos clínicos de dor neuropática localizada por compressão nervosa manejados com o emplastro de lidocaína a 5%. RELATO DOS CASOS: Três pacientes com idade superior a 40 anos e queixas de dor ou parestesia de longa duração foram manejados com emplastro de lidocaína a 5% em tratamento prolongado, com melhora da intensidade de dor expressiva. CONCLUSÃO: Os resultados dos casos reportados revelaram que o emplastro de lidocaína a 5% se apresentou como uma opção terapêutica eficaz, segura, bem tolerada e não invasiva no manejo da dor neuropática localizada por compressão nervosa periférica.

Use of 5% lidocaine patch in the management of post-traumatic localized neuropathic pain. Case reports / O uso do emplastro de lidocaína a 5% no manejo de dor neuropática localizada pós-traumática. Relato de casos

ABSTRACT BACKGROUND AND OBJECTIVES: Neuropathic pain is defined as a pain caused by a lesion or condition that affects the somatosensory nervous system. Taking its prevalence into account, in particular post-traumatic localized neuropathic pain, and to discuss ways to manage patients with this condition, considering efficacy and tolerability of proposed treatments, this report presents three clinical cases of patients with post-traumatic localized neuropathic pain treated with 5% lidocaine transdermal patch in both monotherapy and polytherapy. CASE REPORTS: This study reports the cases of three female patients aged between 29 and 81 years with complaints of pain due to trauma, who were managed with 5% lidocaine transdermal patch in prolonged treatment, with a significant improvement in pain. CONCLUSION: According to scientific evidence, the use of 5% lidocaine transdermal patch in post-traumatic localized neuropathic pain as shown efficacy with favorable safety and tolerance. Moreover, it was possible to demonstrate that a 5% lidocaine transdermal patch in a polytherapy format has contributed to improved outcomes with no effect in treatment tolerability.

RESUMO JUSTIFICATIVA E OBJETIVOS: A dor neuropática é definida como uma dor provocada por uma lesão ou doença que afeta o sistema nervoso somatossensitivo. Considerando a sua prevalência, em particular dor neuropática localizada pós-traumática, com o intuito de discutir formas de manejar os pacientes portadores dessa condição e avaliando tanto a eficácia quanto a tolerabilidade aos tratamentos propostos, este artigo apresenta três casos clínicos de pacientes portadores dessa condição, tratados com emplastro de lidocaína a 5%, tanto em monoterapia quanto no contexto da terapia multimodal. RELATOS DOS CASOS: Este estudo relata três casos de pacientes do sexo feminino com idades entre 29 e 81 anos e queixas de dor decorrente de trauma, que foram manejadas com emplastro de lidocaína a 5% em tratamento prolongado, com uma significativa melhora do nível de dor. CONCLUSÃO: Em concordância com as evidências da literatura científica, o uso do emplastro de lidocaína a 5% nos casos de dor neuropática localizada pós-traumática relatados mostrou-se eficaz no manejo dessa condição e apresentou perfil de segurança e tolerabilidade favorável. Além disso, foi possível observar também que o emplastro de lidocaína a 5%, quando adicionado em abordagem multimodal, contribuiu para uma melhora no quadro sem prejuízo da tolerabilidade do tratamento.

Endoscopic Release of the Ulnar Nerve at the Elbow: Technique Description and Case Series / Liberação endoscópica do nervo ulnar no cotovelo: Descrição da técnica e série de casos

Abstract Objective The endoscopic release of the ulnar nerve reproduces a simple (in situ) procedure with smaller incisions, less soft tissue damage, and higher preservation of nerve vascularization. Endoscopy allows the clear visualization of the entire path of the nerve and surrounding noble structures. Moreover, it reveals any signs of compression and allows a safe release of 10cm distally or proximally to the medial epicondyle. Methods A retrospective survey revealed that 15 subjects (1 with a bilateral injury) underwent an ulnar nerve compression release at the elbow using the endoscopic technique with Agee (Micro-Aire Sugical Instruments, Charlottesville, VA, EUA) equipment from January 2016 to January 2020. Results Symptoms of ulnar nerve compression improved in all patients; on average, they resumed their work activities in 26.5 days. There was no recurrence or need for another procedure. In addition, there were no severe procedure-related complications, such as infection and nerve or vascular injury. One patient had transient paresthesia of the sensory branches to the forearm, with complete functional recovery in 8 weeks. Conclusion Our study shows that the endoscopic release of the ulnar nerve at the elbow with the Agee equipment is a safe, reliable technique with good outcomes.

Resumo Objetivo A liberação endoscópica do nervo ulnar permite reproduzir uma liberação simples (in situ), mas através de incisões menores e com menor lesão de partes moles e uma maior preservação da vascularização do nervo. A visualização clara através da endoscopia permite observar todo o trajeto do nervo e das estruturas nobres circundantes, mostrando os sinais de compressão, possibilitando realizar a liberação de forma segura em um trajeto de 10 cm nos sentidos distal e proximal ao epicôndilo medial. Método Foram encontrados, de forma retrospectiva, no período entre janeiro de 2016 e janeiro de 2020, 15 pacientes (sendo 1 com lesão bilateral) submetidos a liberação da compressão do nervo ulnar no cotovelo pela técnica endoscópica com equipamento de Agee (Micro-Aire Sugical Instruments, Charlottesville, VA, EUA). Resultados Todos os pacientes tiveram melhora dos sintomas de compressão do nervo ulnar e o período de retorno ao trabalho foi de em média 26,5 dias. Não houve recidivas e não houve a necessidade de outro procedimento. Também não houve complicações graves decorrentes do procedimento, como infecção, lesão nervosa ou vascular. Em um paciente, houve parestesia transitória dos ramos sensitivos para o antebraço, com retorno completo da função em 8 semanas. Conclusão Os resultados mostram que a liberação endoscópica do nervo ulnar no cotovelo comoequipamentodeAgeeéuma técnica segura, confiável e com bons resultados.

Anatomical and histomorphometric study of the ulnar nerve at the wrist / Estudio anatómico e histomorfométrico del nervio ulnar en la muñeca

SUMMARY: The ulnar nerve (UN) is the main nerve responsible for innervation of the intrinsic musculature of the hand. It is of great importance to have a deep anatomical knowledge of the UN. The aim of this study is to enrich the knowledge of the UN anatomy at the wrist and provide useful reference information for clinical and surgical applications. In this descriptive cross-sectional study, 44 upper limbs of fresh cadavers were evaluated. The UN, the superficial branch of the ulnar nerve (SBUN), and the deep branch of the ulnar nerve (DBUN) were evaluated. Morphometric variables were measured using a digital caliper, and samples of nervous tissue were taken to evaluate the histomorphometry. Before entering the Guyon's canal, the UN had a diameter of 3.2 ± 0.4 mm. In 36 samples (82 %) the UN presented a bifurcation pattern and in the remaining 8 samples (18 %) a trifurcation was shown. The diameter of the DBUN was 1.9 ± 0.33 mm and that of the SBUN was 1.29 ± 0.22 mm. In the bifurcation patterns, the SBUN had a trunk of 5.71 ± 1.53 mm before bifurcating into the common digital nerve (fourth and fifth fingers) and an ulnar digital collateral nerve (fifth finger). The DBUN had an area of 2.84 ± 0.7 mm2 and was made up of 8 ± 1.4 fascicles and 3595 ± 465 axons. The SBUN area was 1.31 ± 0.27 mm2, it was made up of 6 ± 1.1 fascicles and 2856 ± 362 axons. The reported findings allow the hand surgeon to improve his understanding of the clinical signs of patients with UN pathologies at the wrist level and thus achieve greater precision while planning and performing surgical approaches and dissections.

El nervio ulnar (NU) es el principal nervio responsable de la inervación de la musculatura intrínseca de la mano. Es de gran importancia tener un profundo conocimiento anatómico del NU. El objetivo de este estudio fue enriquecer el conocimiento de la anatomía del NU en la muñeca y proporcionar información de referencia útil para aplicaciones clínicas y quirúrgicas. En este estudio descriptivo transversal se evaluaron 44 miembros superiores de cadáveres frescos. Se evaluó el NU, el ramo superficial del nervio ulnar (RSNU) y el ramo profundo del nervio ulnar (RPNU). Las variables morfométricas se midieron con un caliper digital y se tomaron muestras del nervio para evaluar la histomorfometría. Antes de ingresar al canal del nervio ulnar (canal Guyon), el ONU tenía un diámetro de 3,2 ± 0,4 mm. En 36 muestras (82 %) el ONU presentó un patrón de bifurcación y en las 8 muestras restantes (18 %) se presentó una trifurcación. El diámetro del RPNU fue de 1,9 ± 0,33 mm y el del RSNU de 1,29 ± 0,22 mm. En los patrones de bifurcación, el RSNU presentó un tronco de 5,71 ± 1,53 mm antes de bifurcarse en el nervio digital común (cuarto y quinto dedo) y un nervio digital colateral ulnar (quinto dedo). El RPNU tenía un área de 2,84 ± 0,7 mm2 y estaba formado por 8 ± 1,4 fascículos y 3595 ± 465 axones. El área del RSNU fue de 1,31 ± 0,27 mm2, estaba formado por 6 ± 1,1 fascículos y 2856 ± 362 axones. Los hallazgos reportados permiten al cirujano de mano mejorar su comprensión de los signos clínicos de los pacientes con patologías del NU a nivel de la muñeca y así lograr una mayor precisión en la planificación y realización de abordajes y disecciones quirúrgicas.

The posterior interosseous nerve at the proximal forearm: anatomical study and clinical correlation / El nervio interóseo posterior en el antebrazo proximal: estudio anatómico y correlación clínica

SUMMARY: The deep branch of the radial nerve (DBRN) runs through the radial tunnel, which is a muscle-aponeurotic structure that extends from the humeral lateral epicondyle to the distal margin of the supinator muscle (SM). The Posterior Interosseous Nerve (PIN) originates as a direct continuation of the DBRN as it emerges from the SM and supplies most of the muscles of the posterior compartment of the forearm. The PIN can be affected by compressive neuropathies, especially at the "Arcade of Frohse". Its preservation is of special interest in surgical approaches to proximal radius fractures and in compressive syndromes release, for which surgeons must have an adequate anatomical knowledge of its course. This descriptive cross-sectional study evaluated 40 upper limbs of fresh cadavers. The diameters of the DBRN, the length of the radial tunnel, and the distances to the supinator arch, PIN emergence and PIN bifurcation were measured. The deep branch of the radial nerve (DBRN) has a course of 23.8 ± 3.7 mm from its origin to the supinator arch, presenting a diameter of 2.2 ± 0.3 mm at that level. The length of the radial tunnel was 42.2 ± 4 mm. The PIN originated 70.7 ± 3.5 mm distal to the lateral epicondyle. Type I corresponds to the division of the PIN during its journey through the radial tunnel, presenting in 35 % of cases, and Type II corresponds to the division of the PIN distal to its emergence from the radial tunnel presenting in the remaining 65 %. This study enriches the knowledge of the PIN and provides useful reference information on a Latin American mestizo sample. We propose the division pattern of the PIN into two types. Future studies may use this classification not only as a qualitative variable, but also include quantitative morphometric measurements.

El ramo profundo del nervio radial (RPNR) discurre por el túnel radial, que es una estructura músculo- aponeurótica que se extiende desde el epicóndilo lateral del húmero humeral hasta el margen distal del músculo supinador (MS). El nervio interóseo Posterior (NIP) se origina como una continuación directa del RPNR cuando emerge del MS e inerva la mayoría de los músculos del compartimiento posterior del antebrazo. El NIP puede verse afectado por neuropatías compresivas, especialmente en la "Arcada de Frohse". Su conservación es de especial interés en los abordajes quirúrgicos de las fracturas proximales de radio y en la liberación de síndromes compresivos, para lo cual los cirujanos deben tener un adecuado conocimiento anatómico de su curso. Este estudio descriptivo transversal evaluó 40 miembros superiores de cadáveres frescos. Se midieron los diámetros de la RPNR, la longitud del túnel radial y las distancias al arco supinador, la emergencia del NIP y la bifurcación del NIP. El RPNR tenía un recorrido de 23,8 ± 3,7 mm desde su origen hasta el arco supinador, presentando un diámetro de 2,2 ± 0,3 mm a ese nivel. La longitud del túnel radial fue de 42,2 ± 4 mm. El NIP se originó 70,7 ± 3,5 mm distal al epicóndilo lateral. El tipo I corresponde a la división del NIP durante su recorrido por el túnel radial presentándose en el 35 % de los casos, y el tipo II corresponde a la división del NIP distal a su salida del túnel radial presentándose en el 65 % restante. Este estudio enriquece el conocimiento del NIP y proporciona información de referencia útil sobre una muestra de mestizos latinoamericanos. Proponemos el patrón de división del NIP en dos tipos. Futuros estudios pueden utilizar esta clasificación no solo como una variable cualitativa, sino también incluir medidas morfométricas cuantitativas.

Treatment of postoperative localized neuropathic pain with topical 5% lidocaine. Case report / Tratamento de dor neuropática pós-operatória localizada com lidocaína tópica a 5%. Relato de caso

ABSTRACT BACKGROUND AND OBJECTIVES: Post-surgical neuropathic pain (NP) is an important clinic condition, with recurring pain and that may be a result of transection, contusion, nerve inflammation or stretching and lasting for 3-6 months. Having into consideration the prevalence of postoperative localized NP, its impact in quality of life of patients, its complexity of diagnosis and treatment and available treatment options, the aim of this report was to present efficacy, safety and tolerability outcomes of 5% lidocaine transdermal patch use as a single treatment or in combination with other therapeutic options by describing and analyzing four clinical cases. CASES REPORT: Four patients aged between 43 and 70 years old and complains of postoperative localized NP were managed with 5% lidocaine transdermal patch in prolonged treatment, with significant improvement in pain scores. CONCLUSION: The outcomes of the described cases revealed that postoperative localized NP management was successful with 5% lidocaine transdermal patch. Moreover, it was possible to observe that its association to other treatments (pharmacological or not) has proved efficacy with no negative impact the tolerability of the treatment or the patient routine and comfort.

RESUMO JUSTIFICATIVA E OBJETIVOS: A dor neuropática (DN) pós-operatória é um problema clínico relevante, com dor persistente, que pode ser resultado de transecção, contusão, alongamento ou inflamação do nervo, durando geralmente cerca de 3-6 meses após a cirurgia. Tendo em consideração a prevalência estimada da DN localizada pós-operatória, seu impacto na qualidade de vida dos pacientes, sua complexidade diagnóstica e terapêutica, e as opções de tratamento disponíveis, o presente estudo teve como objetivo apresentar os desfechos de eficácia, segurança e tolerabilidade do uso do emplastro de lidocaína a 5% nesta condição clínica, seja como fármaco isolado ou em combinação com outras classes terapêuticas. RELATO DOS CASOS: Quatro pacientes com idades entre 43 e 70 anos e com história de DN localizada pós-operatória foram manejados com emplastro de lidocaína a 5% em tratamento prolongado, com melhora significativa do nível de dor. CONCLUSÃO: Os resultados dos casos apresentados neste estudo revelam que o manejo da DN localizada pós-operatória foi eficaz com a utilização do emplastro de lidocaína a 5%. Além disso, foi possível observar que sua associação com outros tratamentos (farmacológicos ou não) mostrou-se efetiva, sem impactar negativamente a tolerabilidade do tratamento ou o conforto do paciente.

Value of High-Frequency Ultrasound in the Diagnosis of Pronator Teres Syndrome / 中国医学科学院学报

Objective To investigate the clinical value of high-frequency ultrasound in the diagnosis of pronator teres syndrome (PTS). Methods The high-frequency ultrasound was employed to examine and measure the median nerve of the pronator teres muscle in 30 patients with PTS and 30 healthy volunteers (control group).The long-axis diameter (LA),short-axis diameter (SA) and cross-sectional area (CSA) of the median nerve were measured.The receiver operating characteristic curve of the median nerve ultrasonic measurement results was established,and the area under the curve (AUC) was calculated.The diagnostic efficiency of each index for PTS was compared with the surgical results as a reference. Results The PTS group showed larger LA[(5.02±0.50) mm vs.(3.89±0.41) mm;t=4.38,P=0.013],SA[(2.55±0.46) mm vs.(1.70±0.41) mm;t=5.19,P=0.009],and CSA[(11.13±3.72) mm2 vs.(6.88±2.68) mm2;t=8.42,P=0.008] of the median nerve than the control group.The AUC of CSA,SA,and LA was 94.3% (95%CI=0.912-0.972,Z=3.586,P=0.001),77.7% (95%CI=0.734-0.815,Z=2.855, P=0.006),and 78.8% (95%CI=0.752-0.821,Z=3.091,P=0.004),respectively.With 8.63 mm2 as the cutoff value,the sensitivity and specificity of CSA in diagnosing PTS were 93.3% and 90.0%,respectively. Conclusion High-frequency ultrasound is a practical method for diagnosing PTS,and the CSA of median nerve has a high diagnostic value.

Analgesic Effect and Mechanism of Osteoking on Dorsal Root Ganglion Compression Model Rats / 中国实验方剂学杂志

ObjectiveTo investigate the analgesic effect and mechanism of Osteoking （OK） on nerve compression in lumbar disc herniation. MethodThe rat model of chronic compression of dorsal root ganglion （CCD） was established to simulate clinical lumbar disc herniation. The CCD rats were randomly divided into model group， low， medium， and high dose OK groups （1.31， 2.63， 5.25 mL·kg-1·d-1）， and pregabalin group （5 mg·kg-1）， with eight rats in each group. Another eight SD rats were taken as the blank group， and the same volume of normal saline was given by gavage. Behavioral tests， side effect evaluation， network analysis， Western blot， immunofluorescence， and antagonist application were used to explore the effect. ResultCompared with the blank group， the mechanical hyperalgesia threshold， thermal hyperalgesia threshold， and the expression of inflammatory factors in the spinal dorsal horn of the model group are significantly increased （P<0.01）， and the related indicators of the affected foot footprints are significantly down-regulated （P<0.01）. The expression of signal transducer and activator of transcription 3 （STAT3）， vascular endothelial growth factor A （VEGFA）， and phosphorylated extracellular regulated protein kinase （p-ERK） in microglia in the spinal dorsal horn is significantly increased in the model group （P<0.01）. Compared with the model group， low， medium， and high dose OK groups can increase the mechanical hyperalgesia and thermal hyperalgesia thresholds of CCD rats （P<0.05， P<0.01） in a dose-dependent manner， improve the gait of CCD rats （P<0.05， P<0.01）， and reduce the expression of inflammatory factors in the spinal dorsal horn （P<0.05， P<0.01）. The expression of STAT3， VEGFA， and p-ERK in the spinal dorsal horn microglia of CCD rats is significantly decreased （P<0.05， P<0.01）， and the acetic acid-induced nociceptive response in rats is effectively reduced （P<0.05， P<0.01）. In addition， there is no tolerance. The results of the body mass test， organ index， forced swimming， and rotation show that OK has no obvious toxic or side effects. Further antagonist experiments show that MRS1523 and RS127445 can reverse the transient analgesic effect of OK compared with the high dose OK group （P<0.01）. ConclusionOK has a good analgesic effect on the CCD model without obvious toxic side effects， and its mechanism may be related to the activation of ADORA3 and HTR2B and the inhibition of STAT3， VEGFA， p-ERK， and other elements in microglia.

Applied anatomy of recurrent branch of median nerve and microsurgical treatment of its compression syndrome / 中华显微外科杂志

Objective:To observe the anatomy of the recurrent branch of median nerve, summarize the injury mechanism of the recurrent branch of median nerve, and explore the surgical method and clinical effect of the compression.Methods:From February 2018 to October 2021, 12 fresh hand specimens were used in Department of Hand Surgery in the Second Hospital of Tangshan, including 6 male specimens, 3 left and 3 right hands, and 6 female specimens, 3 left and 3 right hands. Anatomy of the recurrent branch of median nerve and observation of its location, measurement of the length of each muscle branch innervating thenar muscle and the easy-to-jam position of the recurrent branch of median nerve in the course of running. The measurement results uses nonparametric test of statistical analysis by side and gender. P<0.05 was considered statistically significant. From January 2020 to January 2022, 21 patients with entrapment of the recurrent median nerve of wrist were treated, 14 males and 7 females. The age ranged from 31 to 65 years old, with an average of 46.2 years old. All patients developed thenar muscular atrophy. Before operation, the recurrent branch of median nerve was marked into the muscle point, and the thenar projection on palm surface was pressed, which caused fatigue and soreness. Electromyography examination: the motor latency of median nerve endings was more than 4.5 ms, and both fibrillation potential and positive potential appeared. The motor conduction velocity of all patients was less than 30 m/s, and the motor nerve amplitude was less than 10 mV. Surgical exploration of the recurrent branch of median nerve revealed that the trunk of the recurrent branch of median nerve made the tendon arch thickened at the starting point of the superficial head of flexor pollicis brevis, and there was compression between the deep layer of the palmar aponeurosis and the thenar musculocutaneous membrane, which was completely released during the operation to relieve the compression factor. All 21 patients had followed-up in outpatient. Results:Distance from the origin of the recurrent branch of median nerve to the distal edge of transverse carpal ligament. The distance from the origin of the recurrent branch of median nerve to the distal edge of transverse carpal ligament were (0.30, 0.31, 0.32) cm and (0.31, 0.32, 0.32) cm in male left and right groups, respectively, with no statistical significance ( Z=-0.943, P=0.346); The female left and right groups were (0.28, 0.28, 0.28) cm and (0.29, 0.30, 0.30) cm, respectively, and the difference was statistically significant ( Z=-2.121, P=0.034). The length and transverse diameter of the trunk of the recurrent branch of the median nerve, the length of the superficial head branch of flexor pollicis brevis and the length of the palmar muscle branch of the thumb had no significant difference between the left and right sides of males and females( P > 0.05). The length of abductor pollicis brevis muscle branch: the male left and right groups were (1.45, 1.27, 1.31) cm and (1.54, 1.38, 1.47) cm, respectively, and there was no statistical difference ( Z=-1.528, P = 0.127); The female left and right groups were (1.21, 1.18, 1.15) cm and (1.25, 1.24, 1.25) cm respectively, and the difference was statistically significant ( Z=-1.993, P=0.046). All the 21 patients were entered in follow-up for 9-24 (average 15) months. After operation, the wounds of all patients healed in the first stage, the soreness at thenar disappeared, and the thenar muscle was full in appearance. In 21 patients, the thumb abduction function returned to normal, the thumb to palm opposition returned to normal in 19 cases, and was slightly limited in 2 cases. After operation, thenar muscle strength recovered to grade 5 in 19 cases and grade 4 in 2 cases. At the last follow-up, electromyography showed that the motor latency of median nerve endings was less than 4.5 ms, and the motor conduction velocity was greater than 40 m/s; Motor nerve amplitudes were all greater than 10 mV. According to the functional evaluation standard of carpal tunnel syndrome recommended by Gu Yudong, 19 cases were excellent, 2 cases were good, and the excellent and good rate was 100%. Conclusion:The length of each nerve branch of the recurrent median nerve innervates thenar muscle is different, and there are many factors that cause the recurrent median nerve to get stuck. It is of high clinical value to master the anatomical structure of the recurrent median nerve and the mechanism of the entrapment, and to completely loosen vulnerable parts by surgery.

Supernumerary muscles in the posterior leg compartment: a case report / Músculos supernumerarios en el compartimento posterior de la pierna: reporte de un caso

SUMMARY: The leg muscles are organized in anterior, lateral and posterior compartments. The posterior compartment is usually divided in two layers: superficial and deep. The deep muscles of the posterior compartment of the leg are known to mainly plantar flexion and toes flexion. In comparison to the other leg compartments, variations of the posterior one are rare. These variants often involve the presence or absence of one or more muscles, and they have differences among origin and insertion, which leads to confusion between anatomists. We aim to describe a case of a male cadaver that possessed three supernumerary muscles in the lateral and posterior compartments of both legs: the peroneus quartus muscle and two accessory bellies of the flexor digitorum longus. This presentation seems to be very rare and scarcely reported in the literature. These variants have the potential of causing nervous or vascular compression, thus leading to tarsal tunnel syndrome or a symptomatic peroneus quartus. The clinical and surgical implications of this abnormal presentation is discussed.

RESUMEN: Los músculos de la pierna están organizados en compartimentos anterior, lateral y posterior. El compartimento posterior por lo general es dividido en dos capas: superficial y profunda. Se sabe que los músculos profundos del compartimento posterior de la pierna se caracterizan principalmente por participar de la flexión plantar y la flexión de los dedos de los pies. En comparación con los otros compartimentos de la pierna, las variaciones musculares en el compartimiento posterior son raras. Estas variantes suelen implicar la presencia o ausencia de uno o más músculos y presentan diferencias en el origen y en la inserción, lo que conduce a confusión entre los anatomistas. Nuestro objetivo fue describir el caso de un cadáver masculino que poseía tres músculos supernumerarios en los compartimentos lateral y posterior de ambas piernas: el músculo fibular cuarto y dos vientres accesorios del músculo flexor largo de los dedos. Esta presentación parece ser muy rara y escasamente reportada en la literatura. Estas variantes musculares tienen el potencial de causar compresión nerviosa o vascular, lo que conduce al síndrome del túnel del tarso o un cuarto músculo fibular sintomático. Se discuten las implicaciones clínicas y quirúrgicas de esta presentación anormal.

Síndrome do piriforme: diagnóstico e tratamento: um estudo retrospectivo / Piriformis syndrome: diagnosis and treatment: a retrospective study

Introdução: A síndrome do piriforme (SP) é uma causa de dor ciática pouco entendida e conhecida, por isso, subdiagnosticada. Possui múltiplas possibilidades etiológicas e a abordagem terapêutica corrente privilegia o tratamento conservador. Objetivo: Neste estudo retrospectivo são destacados o diagnóstico, a etiologia, o diagnóstico diferencial e analisados os resultados do tratamento instituído. Métodos: 34 casos com seguimento mínimo de seis meses e máximo de 12 meses avaliados por uma escala simplificada de graduação de sintomas. Resultados: O tratamento clínico-conservador obteve excelentes resultados em 23 pacientes (67,6%), bom em nove pacientes (26,4%) e razoáveis (insatisfatórios) em dois pacientes (5,8%). Conclusões: Na dor com característica ciática, contínua ou intermitente e sem evidências de compressão radicular ou herniação discal lombar, deve-se pesquisar a possibilidade de síndrome do piriforme como um diagnóstico eminentemente clínico e de exclusão. O tratamento conservador apresenta resultados satisfatórios na maioria dos casos e a indicação cirúrgica está reservada como último recurso às falhas da terapia conservadora.

Introduction: Piriformis syndrome is a cause of sciatalgy barely understood and frequently unrecognized. It has multiple possible etiologic factors and the treatment of option is largely conservative. Objective: In this retrospective study, the diagnostic signs, the ethiology, the diferential diagnosis and the treatment results are discussed. Methods: 34 patients were followed-up for 6-12 months and evaluated by a simplified symptom rating scale. Results: Excellent results in 23 patients (67,6%), good in 9 patients (26,4%) and fair (unsatisfactory) in 2 patients (5,8%). Conclusions: In patients with sciatic pain without proved rachidian or discal lumbar disease, the possibility of Piriformis Syndrome must be investigated mainly by proper clinical examination and seen as a diagnosis of exclusion. The conservative treatment has satisfactory outcomes in most of cases and surgical procedure is reserved as a last resort in case of failure of the conservative management.

Anatomical Study of the Infrapatellar Branch of the Saphenous Nerve in Humans / Estudo anatômico do ramo infrapatelar do nervo safeno em humanos

Abstract Objective To perform an anatomical study of the location of the infrapatellar branch of the saphenous nerve in relation to the structures of the knee. Methods An anatomical study was performed by dissection of 18 humans knees (9 right and 9 left knees). After exposure of the infrapatellar branch and its direct and indirect branches, they were then measured. We adopted a quadrant in the medial region of the knee delimited by two transversal planes as a parameter of the study. Results In 17 of the 18 knees (94.4%) studied, a single infrapatellar branch was observed. The infrapatellar branch emerged as fibers of the womb of the sartorius muscle in 17 of the 18 knees (94.4%). In relation to the branch, we observed that in 100% of the knees the infrapatellar branch had at least one primary branch, resulting in a superior branch and an inferior branch. In 9 limbs (50% of the cases) this branch occurred outside the proposed quadrant, and, in the remaining limbs, it occurred within the quadrant. Conclusion The infrapatellar saphenous nerve branch was found in all dissected knees, and, in 94.4% of the cases, it was of the penetrating type; in 100% of the cases, it originated two primary direct branches. The direct and indirect branches presented great variability regarding their path.

Resumo Objetivo Realizar um estudo anatômico da localização do ramo infrapatelar do nervo safeno em relação às estruturas do joelho. Métodos Estudo anatômico realizado por meio de dissecação de 18 joelhos (9 direitos e 9 esquerdos). Após a exposição do ramo infrapatelar e de seus ramos diretos e indiretos, seguiram-se as medidas deles. Como parâmetro do estudo, adotamos um quadrante na região medial do joelho delimitado por dois planos transversais. Resultados Em 17 dos 18 joelhos estudados (94,4%), observou-se um único ramo infrapatelar. O ramo infrapatelar emergia por entre as fibras do ventre do músculo sartório em 17 dos 18 joelhos (94,4%). Em relação à ramificação, observamos que em 100% dos joelhos o ramo infrapatelar apresentava pelo menos uma ramificação primária, resultando num ramo superior e em outro inferior. Em 9 membros (50% dos casos), esta ramificação ocorria fora do quadrante proposto, e, no restante, dentro do quadrante. Conclusão O ramo infrapatelar do nervo safeno foi encontrado em todos os joelhos dissecados e, em 94,4% dos casos, ele era do tipo penetrante; em 100% dos casos, ele originava 2 ramos diretos primários. Seus ramos diretos e indiretos apresentaram grande variabilidade quanto ao trajeto.

Peripheral nerve entrapments - rare causes of a common condition: case series

Compressive syndromes of peripheral nerves both in the upper and lower limbs are part of daily clinical practice; however, the etiological diagnosis can be challenging and impact on the outcome of the patient. We report five cases with rare etiologies of nerve entrapments: one in the lower limb and four in the upper limbs with the final diagnosis made only during the operation. The patients evolved without post-operative complications and had good outcomes. This series includes the first report of sciatic compression by a lipoma in the popliteal fossa, two lipomas one with compression of infraclavicular brachial plexus and another with compressing the posterior interosseous nerve, and two reports of vascular lesions due to blunt traumas, which are also uncommon. This series adds to the literature more hypotheses of differential diagnoses in nerve entrapments, which is fundamental to surgical decisions and pre-operative planning—and perhaps most importantly prevents wrong diagnosis of idiopathic compressions, which would lead to a completely wrong approach and unfavorable outcomes.

Estratégia de tratamento nos tumores benignos de nervo / Treatment strategy for benign nerve tumors

Introdução: Os tumores de nervo periférico normalmente são benignos, raros, de crescimento lento e pouco sintomáticos. O objetivo é descrever estratégias para o diagnóstico e tratamento de pacientes com tumores benignos que afetam o nervo ulnar. Métodos: Estudo retrospectivo dos pacientes operados entre 2010 e 2015 com tumor benigno de nervo ulnar, segundo os sintomas, exames complementares, técnicas cirúrgicas realizadas e características demográficas. Resultados: O estudo incluiu 17(8%) pacientes, prevalência sexo feminino (65%) na quarta década de vida; e, natureza extrínseca, o lipoma, em seis casos (35%), seguido do tumor de origem intrínseca, o Schwannoma em 17% e hamartoma em 11%. A excisão tumoral foi total em 83% casos e parcial em 17% casos; em doze casos realizou-se a descompressão neural. Conclusão: Com as estratégias realizadas para o tratamento foi possível bons resultados funcionais em 88% dos pacientes operados. Os piores resultados foram nos tumores de origem vascular.

Introduction: Peripheral nerve tumors are usually benign, rare, slow-growing and little symptomatic. The objective is to describe strategies for the diagnosis and treatment of patients with benign tumors of the ulnar nerve. Methods: This retrospective study of patients who underwent surgery between 2010 and 2015 for the treatment of benign tumor of the ulnar nerve analyzed patient symptoms and demographic characteristics, complementary examinations, and surgical techniques performed. Results: The study included 17 (8%) patients, with a prevalence of women (65%) in the fourth decade of life. The tumors tended to be extrinsic, with lipoma in 6 cases (35%); others were intrinsic, including schwannoma in 17% and hamartoma in 11% of the cases. Tumor excision was complete in 83% of cases and partial in 17% of cases; nerve decompression was performed in 12 cases. Conclusion: The strategies performed here yielded good functional results in 88% of patients. The worst results were in tumors of vascular origin.

Anatomical Study of Radial Tunnel and its Clinical Implications in Compressive Syndromes / Estudo anatômico do túnel radial e suas implicações nas síndromes compressivas

Abstract Objective The purpose of the present study was to analyze the structures in the radial tunnel that can cause posterior interosseous nerve entrapment. Methods A total of 30 members of 15 adult cadavers prepared by intra-arterial injection of a 10% solution of glycerol and formalin were dissected. All were male, belonging to the laboratory of anatomy of this institution. Results The branch for the supinator muscle originated from the posterior interosseous nerve in all limbs. We identified the Frohse arcade with a well-developed fibrous constitution in 22 of the 30 dissected limbs (73%) and of muscular constitution in 8 (27%). The distal margin of the supinator muscle presented fibrous consistency in 7 of the 30 limbs (23.5%) and muscular appearance in 23 (76.5%). In the proximal margin of the extensor carpi radialis brevis muscle, we identified the fibrous arch in 18 limbs (60%); in 9 (30%) we noticed the arcade of muscular constitution; in 3 (10%) there was only the radial insertion, so that it did not form the arcade. Conclusion The Frohse arcade and the arcade formed by the origins of the extensor carpi radialis brevis are normal anatomical structures in adult cadavers. However, from the clinical point of view, these structures have the potential to cause entrapment of the posterior interosseous nerve.

Resumo Objetivo O objetivo do presente estudo foi analisar as estruturas contidas no túnel radial que podem causar neuropatia compressiva do nervo interósseo posterior. Métodos Foram dissecados 30 membros de 15 cadáveres adultos, preparados por injeção intra-arterial de uma solução de glicerina e formol a 10%. Todos do sexo masculino, pertencentes ao laboratório de anatomia desta instituição. Resultados O ramo para o músculo supinador originou-se do nervo interósseo posterior em todos os membros. Identificamos a arcada de Frohse com uma constituição fibrosa bem desenvolvida em 22 dos 30 membros dissecados (73%) e de constituição muscular em 8 (23%) A margem distal do músculo supinador apresentou consistência fibrosa em 7 dos 30 membros (23,5%) e uma aparência muscular em 23 (76,5%). Na margem proximal do músculo extensor radial curto do carpo, identificamos a arcada fibrosa em 18 membros (60%); em 9 (30%), notamos a arcada de constituição muscular; e em três (10%) havia apenas a inserção radial, de maneira que não formava a arcada. Conclusão A arcada de Frohse e a arcada formada pelas origens do músculo extensor radial curto do carpo são estruturas anatômicas normais em cadáveres adultos. No entanto, sob o ponto de vista clínico, essas estruturas têm potencial para causar a compressão do nervo interósseo posterior.

Persistent median artery inside the carpal tunnel: description and surgical implications

The median artery is usually a transient vessel during the embryonic period. However, this artery can persist in adult life as the persistent median artery. This paper aims to describe this relevant anatomical variation for surgeons, review the literature and discuss its clinical implications. A routine dissection was performed in the upper left limb of a male adult cadaver of approximately 50-60 years of age, embalmed in formalin 10%. The persistent median artery was identified emerging as a terminal branch of the common interosseous artery with a path along the ulnar side of the median nerve. In the wrist, the persistent median artery passed through the carpal tunnel, deep in the transverse carpal ligament. The dissection in the palmar region revealed no anastomosis with the ulnar artery forming the superficial palmar arch. The common digital arteries emerged from the ulnar artery and the persistent median artery. Such variation has clinical and surgical relevance in approaching carpal tunnel syndrome and other clinical disorders in the wrist.

Clinical application of wide awake technique in carpal tunnel syndrome / 中国骨伤

OBJECTIVE@#To explore the application and clinical effect of wide awake local anesthesia no tourniquet technique in the surgery of bilateral carpal tunnel syndrome.@*METHODS@#From March 2016 to August 2018, 20 patients (40 sides) with bilateral carpal tunnel syndrome were treated by wide awake technique. All patients were female, aged from 32 to 56 (50.8±6.4) years old. The anesthetic, intraoperative and postoperative pain and anxiety were evaluated, operative field bleeding in operation were assessed, postoperative skin healing of surgical area and anesthetic complications were observed, and Kelly grading were used to evaluate recovery of function.@*RESULTS@#Twenty patients were followed up from 6 to 9 months with an average of 7.8 months. There was light anxiety before injection (NRS score rangedfrom 1 to 3), slight pain occurred during injection on the first poke (NRS ranged from 2 to 3);no pain and anxiety during operation (NRS score was 0);mild or moderate pain (NRS score ranged from 1 to 6) without anxiety(NRS score was 0) after operation was occurred. Surgical skin healed well at the stageⅠwithout side effect of anesthetic. At final follow-up, according to Kelly grading, 30 sides got excellent results, 8 sides good and 2 sides fair.@*CONCLUSION@#Wide awake technique is safe and effective in treating neurolysis of bilateral carpal tunnel syndrome, and could receive good clinical effects.

Fibrotic changes in rat dorsal root ganglion following chronic sciatic nerve compression / 中国组织工程研究

BACKGROUND: Chronic nerve compression leads to muscle atrophy and fibrosis. Previous studies mainly focus on its pathogenesis. However, little is known about the dorsal root ganglia(DRG) responses to chronic nerve compression injury. OBJECTIVE: To investigate the effect of chronic sciatic nerve compression on fibrosis of the DRG. METHODS: Animal models of chronic sciatic nerve compression were made in rats according to the method described by Mackinnon. L4-6 ipsilateral and contralateral DRG were harvested 3 weeks post injury. Real-time RT-PCR, immunofluorescence and western blot were performed to determine the expression levels of transforming growth factor-β, connective tissue growth factor, and collagen type I in ipsilateral and contralateral DRG. RESULTS AND CONCLUSION: Three weeks after injury, the m RNA and protein expression of transforming growth factor-β, connective tissue growth factor and collagen type I were increased significantly in the ipsilateral DRG as compared with the contralateral DRG(P < 0.05). Transforming growth factor-β and connective tissue growth factor mainly expressed in DRG neurons and axons, while collagen type I formed a net structure that surrounded DRG neurons and axons. These findings indicate that chronic sciatic nerve compression can induce fibrotic changes in the DRG that appears to be associated with an increase in transforming growth factor-β and connective tissue growth factor expression in DRG neurons.

The Use of Alfa-Lipoic Acid-R (ALA-R) in Patients with Mild-Moderate Carpal Tunnel Syndrome: A Randomised Controlled Open Label Prospective Study

@#Introduction:Carpal tunnel syndrome is one of the most common peripheral neuropathies. Only a few studies evaluate the efficacy of “nutraceuticals” on peripheral nerves and neuropathic pain. The aim of the present investigation is to evaluate the role of Alfa-Lipoic Acid-R (ALA-R) on clinical and functional outcomes in patients affected by mild to moderate carpal tunnel syndrome. Material and Methods: The present investigation is a prospective randomised controlled open label study, performed at our Hand Surgery Department (Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome) from October 2018 to March 2019. The enrolled patients were divided in two groups: Group A (ALA-R 600mg once day for 60 days) and Group B (control Group, no drug administration). Results: 134 patients (74 F, 60 M) met the inclusion and exclusion criteria. In Group A, there was a statistically significant pain reduction compared to the control Group. Using the Boston Carpal Tunnel Questionnaire, there were no significant improvements in the other symptoms and function. Conclusion: ALA-R full dose administration for two months leads to positive short term results in terms of symptoms and function improvement, even if the surgical carpal tunnel release remains the treatment of choice.