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.

Diagnostic Contradictions in Carpal Tunnel Syndrome / Contradições diagnósticas na síndrome do túnel do carpo

Abstract Objective Given the divergence of opinions on the need for complementary tests such as ultrasonography (US) and electroneuromyography (ENMG) for the diagnosis of carpal tunnel syndrome (CTS), we aimed to elucidate which of them presents greater accuracy for the confirmation of the presence or not of this condition. Methods A total of 175 patients from a hand surgery outpatient clinic were clinically evaluated, and the results of clinical trials (Tinel, Phalen and Durkan), US (normal or altered), and ENMG (normal, mild, moderate and severe) were noted, crossed, and submitted to a statistical analysis to verify the agreement between them. Results with the sample had a mean age of 53 years, with a prevalence of female patients (159 cases). Of the patients with positive clinical test, 43.7% had normal US and 41.7% had no alterations on the ENMG. Negative results were found on the Tinel in 46.9%, on the Phalen in 47.4%, and on the Durkan in 39.7%. In the crossing between the results of the ENMG and those of the other diagnostic methods, there was little statistical agreement between them. Conclusion There was no agreement between the results of the clinical examinations, the US and the ENMG in the diagnosis of CTS, and there is no clinical or complementary examination for CTS that accurately determines the therapeutic approach. Level of Evidence IV, Case Series.

Resumo Objetivo Diante da divergência sobre a necessidade de exames complementares, como ultrassonografia (US) e eletroneuromiografia (ENMG) para o diagnóstico da síndrome do túnel do carpo (STC), objetivamos elucidar qual deles apresenta maior precisão na confirmação da presença ou não desta afecção. Métodos Um total de 175 pacientes de um ambulatório de cirurgia da mão foram avaliados clinicamente, e os resultados dos testes clínicos (Tinel, Phalen e Durkan), da US (normal ou alterada) e da ENMG (normal, leve, moderada e grave) foram anotados, cruzados, e submetidos a análise estatística para verificar a concordância entre eles. Resultados A idade média da amostra era de 53 anos, sendo prevalente o sexo feminino (159 casos). Dos pacientes com teste clínico positivo, 43,7% apresentavam US normal, e 41,7%, ENMG sem alterações. Foram encontrados resultados negativos no Tinel em 46,9% no Phalen em 47,4%, e no Durkan em 39,7%. No cruzamento entre a ENMG e os demais métodos diagnósticos, houve pouca concordância estatística. Conclusão Não houve concordância entre os resultados dos exames clínicos, da US e da ENMG no diagnóstico da STC, e não há exame clínico ou complementar para STC que determine a conduta terapêutica com precisão. Nível de Evidência IV, Série de Casos.

An Intraindividual Comparison of Open versus Paine Retinaculotome Release for Bilateral Carpal Tunnel Syndrome / Comparação intraindividual dos resultados da liberação aberta ou com retinaculótomo de Paine na síndrome do túnel do carpo bilateral

Abstract The main purpose of this research was to do an intraindividual comparison of outcomes between the open ulnar incision (OUI) and the Paine retinaculotome with palmar incision (PRWPI) techniques in patients with bilateral carpal tunnel syndrome (CTS). The patients underwent OUI surgery on one hand and PRWPI surgery on the contralateral hand. The patients were evaluated with the Boston carpal tunnel questionnaire, visual analogue scale for pain, palmar grip strength, and fingertip, key, and tripod pinch strengths. Both hands were examined in the preoperative and postoperative periods after 2 weeks, 1 month, and 3 and 6 months. Eighteen patients (36 hands) were evaluated. The symptoms severity scale (SSS) scores were higher, in the preoperative period, in the hands that underwent surgery with PRWPI (p-value =0,023), but lower in the 3rd month postoperative (p-value = 0.030). The functional status scale (FSS) scores were lower in the periods of 2 weeks, 3 months, and 6 months (p-value = 0,016) on the hands that underwent surgery with PRWPI. In a different two-group module study, the PRWPI group presents the SSS scores average on the 2nd week and 1st month, and the FSS scores average on the 2nd week, less 0.8 and 1.2 points respectively comported to open group. The hands that underwent surgery with PRWPI presented significantly lower SSS scores at 3 months postoperative, and lower FSS scores at 2 weeks, and 3 and 6 months postoperative, compared to open surgery group.

Resumo O principal objetivo desta pesquisa foi fazer uma comparação intraindividual dos resultados entre as técnicas de incisão ulnar aberta e retinaculótomo de Paine com incisão palmar em pacientes com síndrome do túnel do carpo (STC) bilateral. Os pacientes foram submetidos à cirurgia aberta em uma mão e cirurgia com retinaculótomo de Paine na mão contralateral. Os pacientes foram avaliados com o Boston carpal tunnel questionnaire, escala visual analógica para dor e força de preensão palmar, pinça lateral, pinça polpa-polpa e trípode. As duas mãos foram examinadas antes da cirurgia e 2 semanas, 1 mês, 3 e 6 meses após a cirurgia. Dezoito pacientes (36 mãos) foram avaliados. As pontuações da escala de gravidade dos sintomas (EGS) foram maiores no pré-operatório nas mãos submetidas à cirurgia com retinaculótomo de Paine (p = 0,023), mas menores no 3° mês após o procedimento (p = 0,030). As pontuações da escala de estado funcional (EEF) foram menores às 2 semanas, 3 meses e 6 meses (p = 0,016) nas mãos submetidas à cirurgia com retinaculótomo de Paine. Em um estudo de módulo de diferença de dois grupos, o grupo submetido à cirurgia com retinaculótomo de Paine apresentou pontuações médias de EGS na 2ª semana e 1° mês e de EEF na segunda semana inferiores a 0,8 e 1,2 pontos, respectivamente, em comparação ao grupo submetido ao procedimento aberto. As mãos submetidas à cirurgia com retinaculótomo de Paine apresentaram escores significativamente menores de EGS em 3 meses e de EEF em 2 semanas, e aos 3 e 6 meses após a cirurgia em comparação a técnica aberta.

Síndromes compresivos del nervio mediano. Revisión y actualización de la bibliografía / Median nerve compression syndromes. Literature review and update

El nervio mediano desciende por el brazo y, en el codo, comienza a atravesar estructuras que pueden generar compresión, como el ligamento de Struthers, el lacertus fibrosus, el pronador redondo, el flexor superficial de los dedos. Finalmente, en la muñeca, se encuentra otro sitio de compresión producido por el ligamento transverso del carpo. Todas estas estructuras pueden provocar signos y síntomas de atrapamiento nervioso y favorecer el deterioro funcional del nervio. Nuestro objetivo es dar a conocer una actualización sobre estos sitios de atrapamiento del nervio mediano, y cómo realizar un diagnóstico preciso e indicar un trata-miento adecuado. Nivel de Evidencia: IV

The median nerve is a nervous structure that begins to cross structures at the level of the elbow that might cause compression. The Struthers ligament, lacertus fibrosus, pronator teres, and flexor digitorum superficialis are among them. Finally, the transverse carpal ligament creates another compression site in the wrist. All these structures can develop pathological signs and symptoms of nerve entrapment, which favors nerve functional degradation. Our objective is to provide an update on these median nerve entrap-ment sites, as well as information on how to establish an accurate diagnosis and provide adequate treatment. Level of Evidence: IV

Giant lipofibromatous hamartoma of median nerve in a child

Lipofibromatous hamartoma (LFH) is a rare fibrofatty tumor of adipocytes within peripheral nerves, affecting mainly children. It typically presents as a palpable mass surrounding the nerves of the upper limbs, causing pain and neurological deficits in the affected nerve distribution. We report the case of a child with a 2-years presentation of a mass in the right wrist associated with pain and paresthesia, who underwent investigation with magnetic resonance imaging (MRI). It showed thickening of the median nerve with spaghetti-like appearance associated with lipomatous tissue in a coaxial cable-like pattern, both features characteristic of LFH. This case illustrates the importance of MRI in the differential diagnosis of limb masses in the pediatric population.

Time to Diabetic Retinopathy and Its Risk Factors among Diabetes Mellitus Patients in Jimma University Medical Center, Jimma, Southwest Ethiopia

Diabetic retinopathy is a complication of diabetes, caused by high blood sugar levels damaging the eye. Globally, diabetic retinopathy affects more than 103.12 million people. Diabetic retinopathy is among the leading causes of vision loss at the global level, including in Ethiopia. Therefore, the study aimed to assess the time to develop diabetic retinopathy and identify factors associated with diabetic retinopathy among diabetes patients. METHODS: A retrospective study was conducted from September 1, 2021, to January 30, 2022. Data was collected using semi structured questionnaire. The Cox proportional hazard model were used to determine the median time to develop diabetic retinopathy and identify predictors of diabetic retinopathy. Data was analyzed using R software. RESULTS: A total of 373 diabetes patients were included in this study. The prevalence of diabetic retinopathy was 41.3%. The median time was 41 months, ranging from 39 to 73 months. Elder age (HR=3.17, 95%CI: 1.53, 6.58), being male (HR=2.34, 95%CI: 1.35,6.15), previous family history of diabetes (HR=4.16, 95%CI: 2.19, 8.37), longer duration of diabetes (HR=2.86, 95%CI: 1.41, 5.31) received only insulin therapy (HR=3.91, 95%CI: 1.36, 7.94), and high systolic blood pressure (HR=2.32; 95%CI: 1.12, 4.39) were statistically significant factors related to development of diabetes retinopathy. CONCLUSIONS: More than half of diabetic patinets in this study were developed retinopathy diabetes within a few months of being diagnosed. As a result, we advocate that the best way to preserve our vision from diabetic retinopathy is to maintain our diabetes under control, and the high-risk population receive early screening for diabetes

Electrodiagnostic Testing Characteristics of Diabetic People with Carpal Tunnel Syndrome / Características eletrofisiológicas das pessoas diabéticas com síndrome do túnel do carpo

Abstract Objective The present study aimed to correlate electroneuromyography (ENMG) findings in diabetic and nondiabetic subjects with carpal tunnel syndrome (CTS). Methods In total, 154 patients were evaluated in a hand surgery outpatient clinic. All ENMG tests were bilaterally performed by a single neurologist. Qualitative variables were described for all patients with CTS according to their diabetic status, and the chi-squared test was used to reveal any association. A joint model was adjusted to determine the influence of diabetes on ENMG severity in CTS patients. Results The sample consisted of 117 women and 37 men, with an average age of 56.9 years old. Electroneuromyography demonstrated bilateral CTS in 82.5% of the patients. Diabetes was identified in 21.4% of the cases. Severe ENMG was prevalent. Conclusion There was no association between diabetes and ENMG severity in patients with CTS. Level of evidence IV, case series.

Resumo Objetivo O presente trabalho teve por objetivo verificar se existe correlação entre a síndrome do túnel do carpo (STC) e eletroneuromiografia (ENMG) de pacientes diabéticos e não diabéticos. Métodos Foram avaliados 154 pacientes em um ambulatório de cirurgia da mão. Todas as ENMGs avaliadas foram realizadas por um único neurologista, bilateralmente. As variáveis qualitativas foram descritas para todas as pessoas em acompanhamento devido à STC segundo a presença de diabetes e foi verificada a associação com uso do teste qui-quadrado. Foi ajustado o modelo conjunto para verificar a influência da diabetes na gravidade da ENMG em pacientes com STC. Resultados Foram incluídos no presente estudo 117 mulheres e 37 homens, com média de idade de 56,9 anos. Eletroneuromiografia demonstrando STC bilateral foi observada em 82,5% das pessoas. Pessoas diabéticas foram identificadas em 21,4% dos casos. Eletroneuromiografia com padrão grave foi prevalente. Conclusão Não houve associação entre a presença de diabetes e a gravidade da ENMG em pessoas com STC. Nível de evidência IV, série de casos.

Is there an association between the Hand Diagram and Electrodiagnostic Testing for Carpal Tunnel Syndrome? / Existe associação entre o diagrama da parestesia da mão e a eletroneuromiografia no diagnóstico da Síndrome do Túnel do Carpo?

Abstract Objective Verify if there is an association between the hand diagram of paresthesia (HDP) and the results of electroneuromyography (ENMG) in the diagnosis of carpal tunnel syndrome. Methods A total of 92 people filled in a schematic drawing of the hand with the exact location of the paresthesia (167 hands). The main author classified the diagrams according to the criteria of Katz et al.5 The results of the HDP were crossed with the positive results of ENMG for the diagnosis of carpal tunnel syndrome. Results The possible pattern of the HDP was prevalent both in isolation and after crossing with the degrees of ENMG. Conclusion There was no association between the HDP and ENMG in the diagnosis of carpal tunnel syndrome.

Resumo Objetivo Verificar se existe associação entre o diagrama da parestesia da mão (DPM) e os resultados da eletroneuromiografia (ENMG) no diagnóstico da síndrome do túnel do carpo. Métodos Um total de 92 pessoas preencheram um desenho esquemático da mão com o local exato da parestesia (167 mãos). O autor principal classificou os diagramas de acordo com os critérios de Katz et al. Os resultados do DPM foram cruzados com os resultados positivos da ENMG para o diagnóstico da síndrome do túnel do carpo. Resultados O padrão possível do DPM foi prevalente tanto isoladamente quanto após o cruzamento com os graus da ENMG. Conclusão Não houve associação entre o DPM e a ENMG no diagnóstico da síndrome do túnel do carpo.

An accessory abductor digiti minimi as possible risk factor of the median and ulnar nerves compression / Músculo abductor digiti minimi accesorio como posible factor de riesgo de la compresión de los nervios mediano y ulnar

SUMMARY: During routine dissection of a left upper limb of a 68-year-old male human cadaver, an unusual muscle was observed originating from the radius and flexor retinaculum, and continued in the hypothenar region with the muscle belly of the abductor digiti minimi. We checked that it was an accessory abductor digiti minimi (ADM). Its muscular belly was in close relation to the median and ulnar nerves. We review the literature regarding such muscle variations and discuss the potential for compression of the median and ulnar nerves. Although the accessory ADM is usually asymptomatic and only rarely results in nerve compression, it should be taken into account by surgeons when establishing a differential diagnosis in the compression neuropathies of the median and ulnar nerves. An ultrasound scanning can help establish the differential diagnosis.

RESUMEN: Durante la disección de rutina de un miembro superior izquierdo de un cadáver humano masculino de 68 años, se observó un músculo inusual que se originaba en el radio y el retináculo flexor del carpo, y continuuaba en la región hipotenar con el vientre muscular del abductor digiti minimi manus. Verificamos que se trataba del músculo abductor digiti minimi accessorius (ADMA). Su vientre muscular se encontraba en estrecha relación con los nervios mediano y ulnar. Revisamos la literatura sobre variaciones musculares y discutimos la potencial compresión de los nervios mediano y ulnar. Aunque el ADMA suele ser asintomático y rara vez produce compresión nerviosa, los cirujanos deben tenerlo en cuenta al establecer un diagnóstico diferencial en las neuropatías de compresión de los nervios mediano y ulnar. Una ecografía puede ayudar a establecer el diagnóstico diferencial.

Doble compresión del nervio mediano en el brazo: Revisión crítica de la bibliografía / Double crush syndrome of the median nerve in the arm: A critical review of the literature

La compresión mecánica de un nervio periférico en dos sitios diferentes a lo largo de su trayecto se define como síndrome de doble compresión. Esta enfermedad se basa en la teoría de la mayor susceptibilidad que tendría un nervio a nivel distal cuando este también se encuentra comprimido, en forma asintomática, a nivel proximal, debido a una alteración en el flujo axonal. Si bien la descompresión del túnel carpiano es una cirugía con resultados previsibles, hay pacientes operados por síndrome del túnel carpiano que no mejoran después de una cirugía, como cabría esperar. Si se excluye de este análisis a las comorbilidades, como diabetes, casos avanzados con atrofia muscular o descompresiones insuficientes, muchos de estos fracasos terapéuticos podrían estar fundamentados por el escaso diagnóstico de un segundo sitio de compresión concomitante. No obstante, existe gran controversia alrededor del síndrome de doble compresión que involucra no solo a su existencia, sino también a su incidencia y fisiopatología. El objetivo de esta publicación es presentar una revisión bibliográfica crítica del síndrome de doble compresión centrada en el compromiso del nervio mediano tanto en la muñeca como en el codo.

Double crush syndrome is the mechanical compression of a peripheral nerve at two different sites and is based on the hypothesis that a nerve that has been compressed at a distal site is especially susceptible to also be compressed, asymptomatically, at a more proximal site. While carpal tunnel release is a surgical procedure with predictable results, some patients do not improve as expected after surgery. If comorbidities such as diabetes, advanced cases presenting with muscle atrophy or incomplete decompressions are excluded from the analysis, many of these treatment failures could be explained by a second concomitant compression site, which is often underdiagnosed. The very existence of double crush syndrome is highly questioned, but also its incidence and pathophysiology. The objective of our paper is to perform a critical review of the literature available on double crush syndrome involving mainly the median nerve in the wrist and the elbow.

Ketamina para analgesia de la plexopatía lumbosacra secundaria a la reparación de un aneurisma de aorta abdominal / Ketamine for analgesia of lumbosacral plexopathy secondary to the repair of an abdominal aortic aneurysm / Ketamina para analgesia da plexopatia lombossacra secundária reparar um aneurisma da aorta abdominal

Introducción. El dolor agudo posoperatorio luego de una cirugía abierta de reparación de un aneurisma de la aorta abdominal usualmente es de gran intensidad; adicionalmente, pueden presentarse complicaciones in-traoperatorias que aumentan la nocicepción. Aunque los opioides son la base del tratamiento analgésico, su utilización está limitada por el riesgo de depresión respiratoria y su potencial de abuso. La ketamina es una opción que proporciona analgesia y disminuye la utilización de opioides. Presentación del caso. Paciente masculino de 62 años con aneurisma de la aorta abdominal a quien se le realizó reparación endovascular y por laparotomía. En el posoperatorio presentó embolismo distal con dolor se-vero que requirió explante de endoprótesis y revascularización. El dolor fue descrito como severo a insoportable, de tipo corrientazo e incidental y con alodinia plantar, disminución de la propiocepción y ausencia de pul-sos; la electromiografía reportó polineuropatía axonal de expresión mode-rada a severa con compromiso asimétrico sugestivo de lesión del plexo. Discusión. Se consideró isquemia bilateral de plexo lumbosacro y se adi-cionó ketamina en infusión (bolo=1 mg/kg más infusión 0.5 mg/kg/hora), con lo cual se obtuvo mejoría significativa sin efectos secundarios y dismi-nución de la necesidad de opioides. Conclusión. La analgesia multimodal con ketamina es útil para tratar el dolor posoperatorio en cirugía de reparación de aneurisma abdominal con reducción de las necesidades de opioides.

Introduction. acute postoperative pain after abdominal aortic aneurysm is of high intensity; intraoperative complications may occur that increase nociception. Although opioids are the basis of analgesic treatment, their use is limited by the risk of respi-ratory depression and its potential for abuse. Ketamine is an option that provides analgesia and decreases the use of opioids.Case presentation. 62-year-old male patient with abdominal aortic aneurysm who underwent endovascular and open re-pair. In the postoperative period he developed contralateral distal embolism with severe pain in the right buttock that re-quired the stent explant and new revascularization. The pain was described as severe, incidental, with plantar allodynia, de-creased proprioception and absence of pulses; electromyogra-phy reported moderate to severe axonal polyneuropathy with asymmetric compromise suggestive of plexus injury. Discussion. bilateral lumbosacral plexus ischemia was suspec-ted, and ketamine was started (bolus = 1mg / kg plus infusion 0.5 mg / kg / hour), with significant improvement. Conclusion. multimodal analgesia with ketamine is useful for postoperative analgesia in abdominal aneurysm repair surgery with improved analgesia and reduced opioid requirements.

Introdução. A dor aguda no pósoperatório após uma cirurgia aberta para reparar um aneurisma da aorta abdominal é geral-mente de grande intensidade; Alémdisso, podem ocorrer com-plicações intraoperatórias que aumentam a nocicepção. Embo-ra os opióides sejam a base do tratamento analgésico, seu uso é limitado pelo risco de depressão respiratória e seu potencial de abuso. A ketamina é uma opção que fornece analgesia e diminui o uso de opióides.Apresentação de caso. Paciente do sexo masculino, 62 anos, com aneurisma da aorta abdominal, submetido a reparo endo-vascular e laparotomia. No pós-operatório, apresentava embo-lia distal com dor intensa que exigia stent e explante de revas-cularização. A dor foi descrita como severa a insuportável, de curto prazo e incidental e com alodinia plantar, diminuição da propriocepção e ausência de pulsos; A eletromiografia relatou polineuropatia axonal moderada a grave com comprometi-mento assimétrico sugestivo de lesão do plexo.Discussão. Considerou-se isquemia bilateral do plexo lombos-sacro e a ketamina foi adicionada como infusão (bolus = 1 mg / kg mais infusão 0,5 mg / kg / hora), o que resultou em melhora significativa sem efeitos colaterais e diminuição da necessidade de opioides.Conclusão. A analgesia multimodal com ketamina é útil no tra-tamento da dor pós-operatória em cirurgias de reparo de aneu-risma abdominal com necessidade reduzida de opióides.

Palmar Digital Neuropathy With Anatomical Variation of Median Nerve: Usefulness of Orthodromic Technique: A Case Report

Anatomic variation of palmar digital nerve pathways were reported in several cases. Selective exploration of palmar digital nerves with a nerve conduction study has been challenging, because of technical issues. We report a patient who received bilateral carpal tunnel release operation, complaining of a tingling sensation, and hypoesthesia on the middle and ring fingers. An electrodiagnostic study revealed a sensory neuropathy of palmar digital nerve of the left median nerve, supplying the ulnar side of the middle finger, and radial side of the ring finger. She underwent re-operation of open left carpal tunnel release, and a branching site of common digital nerves of the median nerve was identified not at the palm, but at a far proximal site around the distal wrist crease. Usefulness of an orthodromic sensory conduction study was clarified to eliminate volume conducted response or co-activation of nearby nerves in the patient with selective involvement of palmar digital nerve.

Resonancia magnética en el atrapamiento del nervio supraescapular por quiste supraglenoideo / Magnetic resonance in nerve entrapment suprascapular supraglenoid cyst

El síndrome de atrapamiento del nervio supraescapular es una causa infrecuente de dolor en el hombro y de difícil diagnóstico clínico. Puede ser consecuencia de traumatismo, infección, compresión extrínseca o estiramiento secundario a movimientos repetitivos. Los quistes supraglenoideos deben considerarse en el diagnóstico diferencial pues son una causa frecuente de compresión del nervio supraescapular que ocurre casi exclusivamente en hombres. Se evaluaron con resonancia magnética (RM) y en forma retrospectiva siete pacientes con diagnóstico de atrapamiento del nervio supraescapular por quiste supraglenoideo. La RM mostró la causa y localización de la compresión nerviosa así como la distribución del edema muscular en todos los casos. Puede evaluar el grado de severidad de la enfermedad y realizar el diagnóstico diferencial con otras causas que provocarían atrapamiento del nervio supraescapular. (AU)

Suprascapular nerve entrapment has been regarded as a relatively uncommon condition that is easily overlooked in the differential diagnosis of shoulder discomfort. The common feature is nerve damage, caused either by trauma, extrinsic compression or by stretching secondary to repeated movements. Ganglion cysts account for the majority of the masses causing entrapment and seem to occur exclusively in men. Seven cases of suprascapular nerve entrapment caused by supraglenoid cyst compression were reviewed with MRI. MRI showed the cause and location of nerve compression as well as the distribution of muscular edema in all cases. MR imaging also allows an evaluation of the severity of the disease. It is also very efficient in excluding several differential diagnoses. (AU)

A correlation between clinical severity and functional state with nerve conduction studies findings in patients with carpal tunnel syndrome: a systematic review / Correlação entre gravidade clínica e estado funcional com achados eletroneuromiograficos, em pacientes com síndrome do túnel do carpo: uma revisão sistemática

Carpal Tunnel Syndrome is the most common compressive neuropathy in the general population, and it may lead to disabling symptoms and significant functional limitation. This systematic review covered Pubmed, Medline, Embase, Cochrane, CINAHL, LILACS, and SCIELO databases, with no time or language delimitations. The PICO strategy defined the search strategy with keywords extracted from the Medical Subjects Headings, and the quality of the studies was evaluated by the Agency for Healthcare Research and Quality (AHRQ) scale. Overall, 857 studies were identified, of which only 10 fulfilled the inclusion criteria. Despite the good results shown, a noticeable heterogeneity was observed among the studies included, associated with methodological discrepancy and to limited sample size in a few of them. Four studies showed no correlation between electrophysiological findings and clinical symptoms and signs, whereas three could demonstrate such association and other three studies had equivocal results. Other studies are necessary, with better methodological standards and more homogeneous and precise evaluations, so as to improve the level of scientific evidence

A síndrome do Túnel do Carpo é a neuropatia compressiva mais frequente na população geral que pode levar a sintomas incapacitantes e significativa limitação funcional. Uma revisão sistemática foi realizada nas bases de dados Pubmed, Medline, Embase, Cochrane, CINAHL, LILACS e SCIELO, sem delimitação de tempo ou idioma. Utilizou-se da estratégia PICO para a pesquisa, palavras-chave extraídas dos Descritores de Ciências da Saúde (Decs) e a qualidade dos estudos foi avaliada através da escala Agency for Healthcare Research and Quality (AHRQ). Identificaram-se 857 estudos dos quais, somente 10 obedeceram aos critérios de inclusão. Apesar dos bons resultados apresentados, verificou-se uma expressiva heterogeneidade existente entre os estudos incluídos, associado à discrepância metodológica, e um limitado tamanho amostral em alguns deles. São necessários estudos com melhor padrão metodológico, bem como avaliações mais homogêneas e precisas, a fim de melhorar o nível de evidência científica

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.

Ultrasonography Detected Missed Lunate Volar Dislocation Associated With Median Neuropathy: A Case Report

Lunate and perilunate dislocations are uncommon, but they have clinical importance because complications, such as median neuropathy and avascular necrosis of the lunate, can occur. Although early diagnosis enabling early surgical treatment is crucial for preventing long-term sequelae, these dislocations are frequently missed in the initial assessment. Imaging tools, such as plain radiography, magnetic resonance imaging, ultrasonography, and electrodiagnostic studies, have been used for diagnosis. The proper choice of initial evaluation tools is important for making an accurate early diagnosis. Here we present a case of lunate dislocation associated with median neuropathy in which ultrasonography, along with the electrodiagnostic study and plain radiography, played an important diagnostic role in detecting structural abnormalities. This case report reveals the complementary diagnostic role of ultrasonography in initial assessment and provides ultrasonographic images of lunate dislocation as a cause of median neuropathy.

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.

Diagnostic Value of the Second Lumbrical-Interosseous Distal Motor Latency Comparison Test in Severe Carpal Tunnel Syndrome

OBJECTIVE: To examine the usefulness of the second lumbrical-interosseous (2L-INT) distal motor latency (DML) comparison test in localizing median neuropathy to the wrist in patients with absent median sensory and motor response in routine nerve conduction studies. METHODS: Electrodiagnostic results from 1,705 hands of patients with carpal tunnel syndrome (CTS) symptoms were reviewed retrospectively. All subjects were evaluated using routine nerve conduction studies: median sensory conduction recorded from digits 1 to 4, motor conduction from the abductor pollicis brevis muscle, and the 2L-INT DML comparison test. RESULTS: Four hundred and one hands from a total of 1,705 were classified as having severe CTS. Among the severe CTS group, 56 hands (14.0%) showed absent median sensory and motor response in a routine nerve conduction study, and, of those hands, 42 (75.0%) showed an abnormal 2L-INT response. CONCLUSION: The 2L-INT DML comparison test proved to be a valuable electrodiagnostic technique in localizing median mononeuropathy at the wrist, even in the most severe CTS patients.

Proximal Median Neuropathy Caused by Axillary Brachial Plexus Block

An axillary brachial plexus block (BPB) is commonly used in local anesthesia, especially for hand surgery. Infraclavicular brachial plexopathy is a potential complication of axillary BPB. A 44-year-old man with an injury to his left third fingertip presented with weakness of the left thumb and index finger flexion after orthopedic surgery under axillary BPB. This was a rare case of proximal median neuropathy caused by axillary BPB. The diagnosis was confirmed by a detailed neurological examination and electrodiagnostic studies.