Endoscopic Cubital Tunnel Release in Leprosy Neuritis of the Ulnar Nerve / Liberação endoscópica do túnel cubital na neurite hansênica do nervo ulnar

Abstract Objectives To better characterize the role of endoscopic cubital tunnel release in leprosy neuritis and determine whether there is an improvement in pain, sensitivity, and strength with the use of this minimally invasive technique. Methods A total of 44 endoscopic procedures for ulnar nerve decompression at the elbow were performed in patients who were previously diagnosed with leprosy neuritis. The inclusion criteria were surgical indication for ulnar nerve release and clinical treatment failure for 4 weeks in patients with cubital tunnel syndrome who had their ulnar nerve function, whether motor or sensitive, deteriorated progressively despite the treatment with prednisone 1 mg/kg/day and physiotherapy. For endoscopic release, the CTS Relief Kit (Linvatec. Largo, FL, USA) and a standard 4mm 30° arthroscope were used. Results The study included 39 patients, 29 (74.4%) males and 10 (25.6%) females. The age of the patients ranged from 12 to 64 years (33 ± 14.97). Five patients underwent bilateral release. The release demonstrated a statistically significant improvement in pain (p 0.002), in sensitivity (p< 0.001), and in strength (p< 0.001). The best results were obtained when ulnar release was performed less than 6 months after surgery indication. None of the procedures were converted from endoscopic to open. No major complications (infection, vascular injury, and nervous injury) were reported. One patient had ulnar nerve subluxation. Conclusion The endoscopic release of the ulnar nerve at the elbow in leprosy neuritis entails true and safe benefits for the patient, such as improvement in pain, sensitivity and strength.

Resumo Objetivos Os objetivos deste estudo foram caracterizar melhor o papel da liberação endoscópica do túnel cubital na neurite hansênica e determinar se há melhora da dor, sensibilidade e força com esta técnica minimamente invasiva. Métodos Um total de 44 procedimentos endoscópicos para descompressão do nervo ulnar no cotovelo foram realizados em pacientes previamente diagnosticados com neurite por hanseníase. Os critérios de inclusão foram indicação cirúrgica para liberação do nervo ulnar e insucesso do tratamento clínico por 4 semanas em pacientes com síndrome do túnel cubital que sofreram deterioração progressiva da função motora ou sensitiva do nervo ulnar apesar do tratamento de 1 mg/kg/dia de prednisona e fisioterapia. A liberação endoscópica foi realizada com CTS Relief Kit (Linvatec. Largo, FL, EUA) e um artroscópio padrão de 4 mm e 30°. Resultados O estudo incluiu 39 pacientes, sendo 29 (74,4%) homens e 10 (25,6%) mulheres. A idade dos pacientes variou de 12 a 64 anos (33 ± 14,97). Cinco pacientes foram submetidos à liberação bilateral. A liberação provocou melhora estatisticamente significativa de dor (p= 0,002), sensibilidade (p <0,001) e força (p <0,001). Os melhores resultados foram obtidos quando a liberação ulnar foi realizada em menos de 6 meses após a indicação da cirurgia. Nenhum procedimento foi convertido de endoscópico para aberto. Não foram relatadas complicações maiores (infecção, lesão vascular e lesão nervosa). Um paciente apresentou subluxação do nervo ulnar. Conclusão A liberação endoscópica do nervo ulnar no cotovelo na neurite hansênica traz benefícios verdadeiros e seguros para o paciente, como melhora da dor, sensibilidade e força.

Neurophysiological comparative response to clinical and surgical treatment of the ulnar neuropathy in leprosy / Padrões neurofisiológicos da resposta tardia ao tratamento clínico e cirúrgico da neuropatia ulnar na hanseníase

Leprosy neuropathy may develop into subacute and chronic inflammatory scenarios, called reactions, which may cause entrapments in the anatomic tunnels. Objective: This study describes the late nerve conduction findings in patients with ulnar neuropathy at the elbow that were submitted to clinical and surgery treatments. Methods: A total of 27 nerves of 21 patients with borderline leprosy during type 1 (reversal) reaction were selected in a non- competing retrospective cohort for three years. The nerves with treated clinically active neuropathy (Group A1) were randomized for inclusion of surgical treatment (Group A2) after one month of clinical treatment without clear signs of clinical and neurophysiological improvement. Fifteen nerves were randomly chosen for surgery while 12 were clinically treated, after steroids treatment without expected response. Nerve conduction was measured before and after treatment on four occasions. Results: The authors observed significant improvement in the following variables in the surgically treated nerves: compound motor action potential amplitude (CMAP) at elbow and above elbow and conduction velocity (CV) along the forearm. Conclusion: The improvement of CMAP amplitudes and conduction velocity (CV) along the forearm express the late effect of nerve decompression. Persistence of temporal dispersion (TD) along the elbow was related to the new reaction or to incomplete surgical solution. However, moderate reduction in CV along the elbow, without TD, was considered an indication of na expected partial remyelination. Previous gradation of the nerve lesion based on the CMAP amplitude was related to the most severe results

A neuropatia de hanseníase pode desenvolver quadros inflamatórios subagudos e crônicos denominados reações, os quais podem evoluir para compressões nos túneis anatômicos. Objetivo: Descrever os achados de condução nervosa (CN) tardios em pacientes com neuropatia ulnar no cotovelo submetidos aos tratamentos clínico e cirúrgico. Método: Vinte e sete nervos de 21 pacientes foram selecionados em uma coorte retrospectiva não-concorrente por um a três anos, sendo formados dois grupos. Após o tratamento clínico sem sinais inequívocos de melhora os nervos foram randomizados para manter o tratamento clinico (Grupo A1) ou adicionar a descompressão do nervo (Grupo A2). Resultados: Os autores observaram melhora significativa nas seguintes variáveis no Grupo A2, tratado com a adição da descompressão cirúrgica, amplitude do potencial de ação motor composto (PAMC) no cotovelo e acima do cotovelo e velocidade de condução (VC) ao longo do antebraço. Conclusão: O ganho em amplitudes dos PAMCs no cotovelo e acima do cotovelo e da velocidade de condução (VC) ao longo do antebraço são a expressão do efeito tardio da descompressão do nervo ulnar. A persistência de dispersão temporal (DT) através do cotovelo foi relacionada a nova reação ou solução cirúrgica incompleta. Entretanto, a persistência de redução moderada da VC através do cotovelo sem a DT foi discutida e considerada como remielinização parcial esperada. A graduação previa da lesão do nervo baseada na amplitude dos PAMCs apresentou relação direta aos resultados menos favoráveis

The Effectiveness of Arthroscopic Debridement with Mini-Open Ulnar Nerve Decompression in Primary Osteoarthritis of the Elbow with Ulnar Neuropathy / 대한정형외과학회잡지

PURPOSE: The aim of this study was to determine the effectiveness of arthroscopic debridement with mini-open ulnar nerve decompression in primary osteoarthritis of the elbow with ulnar neuropathy. MATERIALS AND METHODS: Between May of 2006 and July of 2014, a total of 43 patients who had undergone surgery for primary osteoarthritis of the elbow with ulnar neuropathy were included in this study. We divided the subjects into two groups according to the method of surgery: group 1 (n=18) received mini-open ulnar nerve decompression only, and group 2 (n=25) received arthroscopic debridement with mini-open ulnar nerve decompression. Patients were assessed for the following clinical outcomes: visual analogue scales (VAS) score, range of motion of the elbow joint, Mayo elbow performance score (MEPS), and disabilities of the arm, shoulder and hand (DASH) at the time before surgery and 6 months after surgery. We analyzed the recovery of the ulnar nerve by the McGowan grade and Bishop rating score preoperatively and at 6 months after the surgery. RESULTS: The VAS score, range of motion of the elbow joint, MEPS, and DASH showed significant statistical difference after the surgery (p <0.05). However, between the 2 groups, there was no significant difference. For the McGowan grade, all cases of both groups–except one case each group–showed at least one grade improvement. Moreover, group 2 showed a greater significant difference than group 1 (p=0.001). At the final follow-up, according to the Bishop rating score, group 2 had a greater significant difference than group 1 (p=0.036). CONCLUSION: Arthroscopic debridement with mini-open ulnar nerve decompression in primary osteoarthritis of the elbow with ulnar neuropathy is a useful technique, which has several advantages, including the benefits associated with a minimally invasive surgery and also the improvement of elbow joint function and excellent recovery of the ulnar nerve.

Upper limb nerve injuries caused by intramuscular injection or routine venipuncture

The reported cases of upper limb nerve injury followed by needle procedure such as intramuscular injection or routine venipuncture are rare. However, it should not be overlooked, because neurological injury may cause not only minor transient pain but also severe sensory disturbance, hand deformity and motor dysfunction with poor recovery. Recognizing competent level of anatomy and adept skill of needle placement are crucial in order to prevent this complication. If a patient notices any experience of abnormal pain or paresthesia during the needle procedures, an administrator should be alert to the possibility of nerve injury and should withdraw the needle immediately. Careful monitoring of the injection site for hours is required for early detection of nerve injury.

Diagnostic Cutoff Value for Ultrasonography in the Ulnar Neuropathy at the Elbow

OBJECTIVE: To determine the diagnostic cutoff values of ultrasonographic measurements in ulnar neuropathy at the elbow (UNE). METHODS: Twenty-five elbows of 23 patients (9 females, 16 males) diagnosed with UNE and 30 elbows of 30 healthy controls (15 females, 15 males) were included in our study. The ulnar nerve cross-sectional area (CSA) was measured at the Guyon canal, midforearm, and maximal swelling point (MS) around the elbow (the cubital tunnel inlet in healthy controls). CSA measurements of the ulnar nerve at each point, the Guyon canal-to-MS ulnar nerve area ratio (MS/G), and the midforearm-to-MS ulnar nerve ratio (MS/F) were calculated. RESULTS: Among the variables, only CSA at MS, MS/G, and MS/F displayed significant differences between the control and patient groups. The cutoff value for diagnosing UNE was 8.95 mm2 for the CSA at MS (sensitivity 93.8%, specificity 88.3%), 1.99 for the MS/G (sensitivity 75.0%, specificity 73.3%), and 1.48 for the MS/F (sensitivity 93.8%, specificity 95.0%). CONCLUSION: These findings may be helpful to diagnose UNE.

Misdiagnosed Handlebar Palsy: Giant Cell Tumor of the Tendon Sheath in Guyon's Canal / 대한스포츠의학회지

Ulnar tunnel syndrome (UTS) is a compressive neuropathy of the upper extremity that shows various clinical symptoms according to the anatomic region of the compression site. Numerous factors may cause UTS, and most publications are case reports describing various etiologies; thus, obtaining a correct diagnosis is often challenging. Giant cell tumor of the tendon sheath (GCTTS) is well described to be a common benign soft tissue tumor of the hand; however, it is rarely reported to cause UTS. We report a case of GCTTS in Guyon's canal causing UTS that was misdiagnosed as handlebar palsy.

Estudo prospectivo da sensibilidade tátil em mãos de uma população brasileira usando pressure-specified sensory device / Prospective study on tactile sensitivity in the hands of a brazilian population using the pressure-specified sensory device

OBJETIVO: Avaliar os limiares de percepção da pressão em polpas de dois dedos (indicador e mínimo), em uma população brasileira, sem lesão nervosa ou neuropatia. MÉTODOS: Usamos Pressure-Specified Sensory Device, um equipamento computadorizado para obter limiares de percepção da pressão normal, tanto estáticos quanto dinâmicos, e discriminação de dois pontos. RESULTADOS: Testamos a sensibilidade nos dedos, em 30 voluntários. Os testes de significância foram realizados utilizando o teste t de Student. Os valores médios (g/mm²) para os limiares de pressão estática de um e dois pontos (s1PD, s2PD) e discriminação dinâmica de um e dois pontos (m1PD, m2PD) no dedo indicador dominante foram: s1PD = 0,4, m1PD = 0,4, s2PD = 0,48, m2PD = 0,51. CONCLUSÃO: Não há diferença significativa na sensibilidade entre as mãos dominante e não dominante.

OBJECTIVE: To evaluate the pressure perception thresholds on the pulp of two fingers (index and little fingers), among a Brazilian population with no nerve injury or neuropathy. METHODS: We used the Pressure-Specified Sensory Device (a computerized device) to derive static and dynamic normal pressure perception thresholds and two-point discrimination distances. RESULTS: We tested finger sensitivity on 30 volunteers. Significance analyses were performed using the Student t test. The mean values (g/mm²) for static one and two-point pressure thresholds (s1PD, s2PD) and dynamic one and two-point discrimination (m1PD, m2PD) in the dominant index finger were: s1PD = 0.4, m1PD = 0.4, s2PD = 0.48, m2PD = 0.51. CONCLUSION: There was no significant difference in sensitivity between the dominant and nondominant hands.

Ulnar Nerve Conduction Study of the First Dorsal Interosseous Muscle in Korean Subjects

OBJECTIVE: To derive normative values for ulnar nerve conduction study of the active recording electrode on the first dorsal interosseous muscle (FDI) and the reference electrode on the proximal phalanx of the thumb. METHOD: Ulnar nerve motor conduction study with FDI and abductor digiti minimi muscle (ADM) recording was performed in 214 hands of 107 healthy subjects. Ulnar NCS was performed with 2 different recording electrode montages (ADM-base of 5th finger; FDI-thumb) and differences in latency and amplitude were compared. Using this technique, the initial positivity of ulnar compound muscle action potential (CMAP) was not observed in any response with FDI recording. RESULTS: The maximal values for distal motor latency to the ADM and FDI muscle were 3.8 ms and 4.4 ms, respectively. The maximal difference of distal motor latency between the bilateral FDI recordings was 0.6 ms. The maximal ipsilateral latency difference between ADM and FDI was 1.4 ms. CONCLUSION: Placement of the reference electrode on the thumb results in a CMAP without an initial positivity and the normative values obtained may be useful in the diagnosis of ulnar neuropathy at the wrist.

Ulnar Neuropathy within Guyon's Tunnel in a Golf Player : A case report

One of common injury sites in golfers is the wrist, but ulnar neuropathies at wrist in golfers have been rarely reported. We report a case of ulnar neuropathy within the Guyon's tunnel occurred in a single golfer diagnosed with electrodiagnosis and ultrasound. A 59-year old man suffered from difficulty with extension of left 4th and 5th finger joints and weakness of hand grasping, which had occurred 2 weeks ago and aggravated slowly. He had no sensory disturbance. During recent two months, he had practiced golf for three to four hours daily. Electrodiagnostic study showed that the deep branch of left ulnar nerve was compromised at the wrist (type IIA). Ultrasound study revealed a ganglion cyst within the Guyon's tunnel. Therefore we diagnosed the patient as having ulnar neuropathy (only deep branch involvement) associated with a ganglion cyst within the Guyon's tunnel.

Avaliação da neurólise ulnar na neuropatia hansênica / Assessment of ulnar neurolysis in leprous neuropathy

Os autores avaliam os resultados de 35 procedimentos de descompressão cirúrgica do nervo ulnar realizados em 28 pacientes hansênicos. Os parâmetros utilizados incluíram a escala analógica visual, a escala comportamental, a avaliação da força muscular, a estesiometria e a avaliação do efeito do procedimento no que tange à diminuição da corticoterapia no pós-operatório. Observou-se resolução imediata da dor após a realização da cirurgia, melhora da força muscular em metade dos pacientes, melhora da sensibilidade em metade dos pacientes. A diminuição da dosagem da prednisona após a cirurgia foi constante e significativa após a operação.

In this study, the authors assess the results of 35 surgical ulnar nerve decompression procedures performed on 28 leprous patients. The parameters employed included the visual analogue scale, the behavioral scale, the muscle strength evaluation, the esthesiometry and the evaluation of the effect of the procedure on decreasing postoperative corticoid therapy doses. Early resolution of pain was seen after surgery, muscle strength increased in half of the patients, sensitivity increased in half of the patients, with ongoing and significant decrease of prednisone doses after surgery.

The Utility of 6 cm Segmental NCS in Ulnar Neuropathy at the Elbow

OBJECTIVE: To verify the efficacy of 6cm segmental nerve conduction study in ulnar neuropathy at the elbow (UNE). METHOD: Ulnar nerve conduction studies were performed unilaterally in twenty five asymptomatic healthy adult volunteers and twenty five symptomatic patients with UNE. Twenty five symptomatic patients with UNE were diagnosed by standard ulnar nerve conduction studies, and needle EMG study. In the same healthy controls and patients groups, 6 cm and 10 cm segmental study were then performed at the elbow. The sensitivity and specificity of 6 cm segmental study were compared with those of 10 cm segmental study in these patients. RESULTS: The sensitivity and specificity came out to be 76% and 92% for the 6 cm segmental study and, 52% and 96% for the 10 cm segmental study. CONCLUSION: The sensitivity of 6 cm segmental NCS was much higher compared with 10 cm segmental NCS, whereas the specificity was similar in both tests. For screening of the UNE, 6 cm segmental NCS seems to be a more efficacious test.