Comparing the outcome of monitored anaesthesia care and local anaesthesia for carpal tunnel syndrome surgery by neurosurgeons

@#Introduction: Carpal tunnel syndrome (CTS) is the commonest median nerve entrapment neuropathy of the hand, up to 90% of all nerve compression syndromes. The disease is often treated with conservative measures or surgery. The senior author initially intended to treat his own neurosurgical patients concurrently diagnosed with carpal tunnel syndrome in 2014, subsequently, he began to pick up more referrals from the primary healthcare group over the years. This has led to the setup of a peripheral and spine clinic to act as a hub of referrals. Objective: Department of Neurosurgery Sarawak aimed to evaluate the surgical outcome of carpal tunnel release done over five years. Methods: The carpal tunnel surgeries were done under local anaesthesia (LA) given by neurosurgeons (Bupivacaine 0.5% or Lignocaine 2%). Monitored anaesthesia care (MAC) was later introduced by our hospital neuroanaesthetist in the beginning of 2018 (Target-controlled infusion propofol and boluses of fentanyl). We looked into our first 17 cases and compared these to the two anaesthesia techniques (LA versus MAC + LA) in terms of patient’s pain score based on visual analogue scale (VAS). Results: Result showed MAC provided excellent pain control during and immediately after the surgery. None experienced anaesthesia complications. There was no difference in pain control at post-operation one month. Both techniques had equal good clinical outcome during patients’ clinic follow up. Conclusion: Neurosurgeons provide alternative route for CTS patients to receive surgical treatment. Being a designated pain free hospital, anaesthetist collaboration in carpal tunnel surgery is an added value and improves patients overall experience and satisfaction.

Sub-Brachialis Course of the Median Nerve in the Arm and its Possible Clinical Complications: A Case Report

The median nerve in its normal course in the arm crosses the brachial artery from lateral to medial side. It then passes superficial to the brachialis muscle and then enters the cubital fossa. During routine cadaveric dissection of the right upper limb, an unusual variation in the course of the median nerve was observed. The median nerve in the arm crossed the brachial artery from medial to lateral side and passed deep to the brachialis muscle. It then emerged from beneath the brachialis muscle and entered the cubital fossa. In the cubital fossa, it ran medial to the brachial artery as the normal course of the nerve. Further distribution of median nerve in the forearm and hand was observed to be normal. The anomaly reported here may result in the compression of the median nerve deep to the brachialis and hence resulting in mechanical disadvantages in the flexion at the wrist joint.

Entrapment Neuropathy of Median and Ulnar Nerve Due to Soft Tissue Chondroma: A Case Report

PURPOSE: Soft tissue chondroma is a rare benign tumor, found mainly on the palm and sole and grows slowly. Typically, mature hyaline cartilage is the dominant pathological feature. There are reports that assert soft tissue chondromas to be a cause of median nerve entrapment syndrome. However, this is the first case report showing soft tissue chondroma to be a cause of simultaneous median and ulnar neuropathy. METHODS: A 62 year-old woman presented with chief complaints of numbness and hypoesthesia of her right palm for 4 to 5 years, and a palpable mass on her right palm that had been increasing in size slowly for 3 years. Physical examination revealed a firm, mobile, non-tender and about 3 x 3 cm2 sized mass in the center of the right palm. Electromyography showed entrapment neuropathy of the median and ulnar nerve. Ultrasonography showed an approximately 5.7 cm2 mass below the flexor tendon of ring finger. Upon surgical excision, a 3 x 3 cm2 mass attached to the flexor digitorum profundus of ring finger and redness and hypertrophy of both the median and ulnar nerve were discovered. Mass excision was performed gently and the specimen was referred for histopathologic study. Mass excision resulted in median and ulnar nerve release. RESULTS: The pathology report confirmed the mass to be a soft tissue chondroma with mature hyaline cartilage. The patient exhibited post-operative improvement of her symptoms and did not show any complications. CONCLUSION: This is the first case report showing soft tissue chondroma to be a cause of simultaneous median and ulnar neuropathy.

Clinical and electrophysiological study of entrapment syndrome of recurrent branch of median nerve / 中华物理医学与康复杂志

Objective To investigate the clinical and electrophysiological characteristics of entrapment syndrome involving the median nerve's recurrent branch. Methods Fourteen cases (10 male, 4 female, mean age 34.7) of medial nerve recurrent branch entrapment syndrome were retrospectively analyzed in this study with regard to their clinical and electrophysiological data. Results Normal sensory conduction velocity ( SCV ) and normal amplitude of the sensory nerve action potential ( SNAP) were found, but there was a delay of the distal motor latency (DML) in all 14 cases. The compound muscle action potential (CMAP) amplitude was decreased in 11 cases, and normal motor conduction velocity (MCV) was demonstrated in 12 cases. Fibrillation potentials and/or positive sharp waves were detected in the abductor pollicis brevis muscle in 12 cases and in the opponens pollicis muscle in 14 cases. EMGs of the flexor digitorum superficialis and pronator quadratus muscle were normal in all 14 cases. Conclusion Electrophysiological examination could provide objective and reliable data for diagnosing and differentially diagnosing median nerve recurrent branch entrapment syndrome.

Peripheral Nerve Entrapments of Upper Extremity among the Crutch or Cane Users

OBJECTIVE: To determine the prevalence, location, and risk factors for the peripheral nerve entrapments of upper extremity among the crutch or cane users. METHOD: We performed the clinical and electrodiagnostic assessments of both upper extremities in 43 crutch or cane users and 49 able-bodied controls. RESULTS: The prevalence for the nerve entrapment of upper extremity among the crutch or cane users was 27.9% by the clinical criteria and 86.0% by the electrodiagnostic criteria. Electrodiagnostically, the median nerve entrapment was 76.7%, and the ulnar nerve entrapment was 72.1% among the crutch or cane users. The carpal tunnel was the most common site for the entrapment. Body weight, duration of disability, and duration of crutch or cane use were found to be significantly correlated with the emtrapments of median nerve, whereas duration of crutch or cane use alone was significantly correlated with the entrapments of ulnar nerve. CONCLUSION: The peripheral nerve entrapments of upper extremity is associated with the chronic crutch or cane use and the preventive strategies need to be developed for the patients with risks.

Upper Extremity Peripheral Nerve Entrapments among Wheelchair Users

Pain, numbness, and weakness in the upper extremity are the common problems among wheelchair users. The prevalence of nerve injury of the upper extremity in the wheelchair users has been reported variously by many authors in other nations. To determine the prevalence, location, and risk factors of upper extremity peripheral nerve entrapment among wheelchair users, we performed clinical and electrodiagnostic assessments on both upper extremities of wheelchair users (n=49) and able-bodied controls (n=49). The prevalence of nerve entrapment of the upper extremity among the wheelchair users was 15.6% according to clinical criteria, and 46.9% according to electrodiagnostic criteria. Electrodiagnostically, median nerve entrapment was identified in 28.6% of tested cases, and ulnar nerve entrapment was identified in 22.4% of tested cases among wheelchair users. The carpal tunnel was the most common site of nerve entrapment. The duration of wheelchair use was found to be correlated negatively with median wrist to palm and wrist to digit sensory conduction velocity, whereas age correlated positively with distal median and ulnar motor latency.

Chronic Median Nerve Entrapment After Posterior Fracture-Dislocation of the Elbow in a Chlid: A Case Report / 대한정형외과학회잡지

Median nerve injury after elbow dislocation is uncommon. The diagnosis of median nerve entrapment is often delayed. Median nerve paralysis is caused by entrapment within the elbow joint. If median nerve paralysis occurs following elbow dislocation or if it occurs following closed reduction, entrapment should be suspected. Optimal management of this problem consists of early surgical exploration and decompression. We report a case of a child who had entrapment of the median nerve in the elbow joint after closed reduction of posterior dislocation with fracture of the medial epicondyle. The diagnosis was made ten weeks after injury at surgical exploration. This case showed a characteristic radiologic sign in the anteroposterior radiograph. We released the entrapped median nerve with a successful result.