Prevalence of Concomitant Distal Suprascapular Nerve Injury in Patients with Root-level Brachial Plexus Palsy: A Clinical Anatomic Study of Injury Pattern.

BACKGROUND: Root-level suprascapular nerve palsy is commonly reconstructed via spinal accessory nerve transfer in brachial plexus injury, yet some patients fail to recover. We hypothesize that this relates to concomitant undetected lesions distal to the nerve transfer coaptation. METHODS: 67 patients with plexus injury and C5/6 root involvement were included in this prospective study between March 2021 and October 2022. During spinal accessory to suprascapular nerve transfer the entire suprascapular nerve was explored, via cresenteric clavicular osteotomy, and anatomic variations and injury patterns categorized. RESULTS: Proximal root involvement was C5-C6 (n=8), C5-C7 (n=13), C5-C8 (n=17), C5-T1(29). Mean time from injury to surgery was 5.6 months. The suprascapular nerve was found to be injured in 16/67 cases (24%). In 9 cases (13%) the lesion was proximal to the suprascapular fossa. In 3 cases (4%) the suprascapular nerve was injured both proximally and within the fossa, and in 4 cases (6%) in the fossa or distal to it. Therefore, in 7 cases (10%), a traditional suprascapular nerve transfer would not successfully bypass the zone of injury of the suprascapular nerve in the fossa. Of the 16 cases of concomitant suprascapular nerve injury, 1/8 in occurred in C5-C6 root injury, 4/13 of C5-C7 root injury, 5/17 of C5-C8 root injury and 6/39 in total paralysis. CONCLUSIONS: Concomitant distal suprascapular nerve injury in brachial plexus stretch palsy occurred in 24% of the cases. This warrants attention from the surgeon to identify distal lesions and to perform the nerve transfer beyond any secondary lesions.

Distal nerve transfers for peripheral nerve injuries: indications and outcomes.

Distal nerve transfer is a refined surgical technique involving the redirection of healthy sacrificable nerves from one part of the body to reinstate function in another area afflicted by paralysis or injury. This approach is particularly valuable when the original nerves are extensively damaged and standard repair methods, such as direct suturing or grafting, may be insufficient. As the nerve coaptation is close to the recipient muscles or skin, distal nerve transfers reduce the time to reinnervation. The harvesting of nerves for transfer should usually result in minimal or no donor morbidity, as any anticipated loss of function is compensated for by adjacent muscles or overlapping cutaneous territory. Recent years have witnessed notable progress in nerve transfer procedures, markedly enhancing the outcomes of upper limb reconstruction for conditions encompassing peripheral nerve, brachial plexus and spinal cord injuries.

Spinal Cord Injury: Epidemiology, Spontaneous Recovery, and Hand Therapy for the Reconstructive Hand Surgeon.

People with spinal cord injury (SCI) prioritize hand function above all else as a reconstructive goal, yet remain a markedly undertreated population by hand surgeons. This review article provides an overview of the epidemiology of SCI and the unmet clinical need of these patients. Further, this article outlines the natural history of SCI, including the expected spontaneous recovery over time and the expectations of hand function when treated with hand therapy alone. This review aims to equip reconstructive hand surgeons with a sound understanding of the basic principles of SCI and recovery and provide a rationale for when to intervene with surgery. In the last decade, this field has changed dramatically with the advent of reliable nerve transfers, making referral and surgical intervention time-sensitive. Therefore this review aims to highlight the expectations from hand therapy alone in this group, the urgent need for early referral to allow nerve transfer options to be viable, and the strategies for overcoming the barriers to these referrals. This offers the opportunity for surgeons to expand their tetraplegia practices while maximizing the considerable contributions to the hand function and quality of life of these patients.

Decompression with Brachioradialis Tenotomy Improves Pain and Quality of Life in Patients with Radial Sensory Nerve Compression.

BACKGROUND: Decompression of the superficial sensory branch of the radial nerve (SBRN) with complete brachioradialis tenotomy may treat pain in both simple and complex cases of SBRN compression neuropathy. METHODS: A retrospective chart review was performed of consecutive patients undergoing this procedure between 2008 and 2020 including postoperative outcomes within 90 days. Data were collected and analyzed, including patient and injury demographics, pain descriptors, and patient-reported pain questionnaire, including reported pain severity and impact on quality of life using visual analogue scale (VAS) instruments. Within-group presurgical and postsurgical analyses and between-group statistical analyses were performed. RESULTS: Thirty-three of 58 patients met inclusion criteria. Median time from symptom onset to surgery was 300 days, and median postoperative follow-up time was 37 days. Twenty-five percent of patients ( n = 8) underwent isolated SBRN decompression. The remainder had concomitant decompression of another radial [ n = 16 (48%) or peripheral [ n = 12 (36%)] entrapment point. Ten of 33 patients (30%) had resolution of pain at final follow-up ( P = 0.004). Median change in worst pain over the previous week was -4 ( P < 0.001), and average pain over the last month was -2.75 ( P < 0.001) on the VAS. The impact of pain on quality of life showed a median change of -3 ( P < 0.001) on the VAS. CONCLUSION: Decompression of the sensory branch of the radial nerve including a complete brachioradialis tenotomy improves pain and quality-of-life VAS scores in patients with both simple compression neuropathy syndrome and complex nerve compression syndrome. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

What is Operative? Conceptualizing Neuralgia: Neuroma, Compression Neuropathy, Painful Hyperalgesia, and Phantom Nerve Pain.

Neuralgia, or nerve pain, is a common presenting complaint for the hand surgeon. When the nerve at play is easily localized, and the cause of the pain is clear (eg, carpal tunnel syndrome), the patient may be easily treated with excellent results. However, in more complex cases, the underlying pathophysiology and cause of neuralgia can be more difficult to interpret; if incorrectly managed, this leads to frustration for both the patient and surgeon. Here we offer a way to conceptualize neuralgia into 4 categories-compression neuropathy, neuroma, painful hyperalgesia, and phantom nerve pain-and offer an illustrative clinical vignette and strategies for optimal management of each. Further, we delineate the reasons why compression neuropathy and neuroma are amenable to surgery, while painful hyperalgesia and phantom nerve pain are not.

Bilateral Ulnar Nerve Injury in the Wrist: Comparison of First Webspace Muscle Reconstruction by Opponens Nerve Transfer in the Right Hand Versus Direct Ulnar Nerve Repair in the Left Hand.

We report a case of a bilateral glass injury to the wrist with transection of flexor tendons and the ulnar nerve and artery in a 60-year-old male patient. Two days after his accident, we repaired all divided structures, and on the right hand, we added the transfer of the opponens motor branch to the deep terminal division of the ulnar nerve aimed at first dorsal interosseous and adductor pollicis muscle reinnervation. After surgery, the patient was followed over 24 months. Postoperative dynamometry of the hand, which included grasping, key-pinch, subterminal-key-pinch, pinch-to-zoom, and first dorsal interosseous muscle strength, indicated recovery only in the nerve transfer side.

The Cutaneous Branches of the Median and Ulnar Nerves in the Palm.

PURPOSE: The dermatomal distributions of the ulnar and median nerves on the palmar skin of the hand have been studied thoroughly. However, the anatomic course of the median and ulnar cutaneous nerve branches and how they supply the skin of the palm is not well understood. METHODS: The cutaneous branches of the median and ulnar nerves were dissected bilaterally in 9 fresh cadavers injected arterially with green latex. RESULTS: We observed 3 groups of cutaneous nerve branches in the palm of the hand: a proximal row group consisting of long branches that originated proximal to the superficial palmar arch and reached the distal palm, first web space, or hypothenar region; a distal row group consisting of branches originating between the superficial palmar arch and the transverse fibers of the palmar aponeurosis (these nerves had a longitudinal trajectory and were shorter than the branches originating proximal to the palmar arch); and a metacarpophalangeal group, composed of short perpendicular branches originating on the palmar surface of the proper palmar digital nerves at the web space. The radial and ulnar borders of the hand distal to the palmar arch were innervated by short transverse branches arising from the proper digital nerves of the index and little finger. Nerve branches did not perforate the palmar aponeurosis in 16 of 18 cases. CONCLUSIONS: The palm of the hand was consistently innervated by 20-35 mm long cutaneous branches originating proximal to the palmar arch and shorter branches originating distal to the palmar arch. These distal branches were either perpendicular or parallel to the proper palmar digital nerves. CLINICAL RELEVANCE: Transfer of long proximal row branches may present an opportunity to restore sensibility in nerve injuries.

Increasing Awareness of Complications of Nerve Injury Following Shoulder Surgery: Preventing Delays in Referral and Treatment.

BACKGROUND: Nerve injuries remain a challenging complication after shoulder surgery. While most resolve spontaneously, some require surgical intervention. This study describes the characteristics of patients sustaining nerve injuries following shoulder surgery, evaluates referral patterns to nerve surgeons, and characterizes nerve surgeries performed and their outcomes. Increased awareness of these injuries allows patients and providers to be better informed regarding the appropriate management when these complications occur. METHODS: A retrospective review of referrals with nerve injuries following shoulder surgery between 2007 and 2015 was performed. The final analysis included 65 patients. Data reviewed included demographics, procedure and anesthesia type, and diagnosis of nerve injury. Time to referral to nerve surgeon and proportional changes in the Disabilities of the Arm, Shoulder, and Hand (DASH) scores were determined. Outcomes were categorized as failed, partially successful, and successful based on final follow-up. RESULTS: Patients were referred following arthroscopic shoulder surgeries (35.4%), shoulder arthroplasties (24.6%), open shoulder procedures (21.5%), and combined open and arthroscopic procedures (18.5%). The mean time to referral was 7.6 months. Nerve injuries involved brachial plexus (33) and individual and multiple peripheral nerve branches (23 and 7, respectively). Twenty-five (38%) nerve injuries demonstrated spontaneous recovery. Thirty-five patients underwent surgical intervention, of which 27 were successful, 3 were partially successful, and 3 failed. CONCLUSIONS: This is the largest series of patients with iatrogenic nerve injury following shoulder surgeries to date. Our data demonstrate a lack of timely referral to nerve surgeons, especially after arthroscopy. There continues to be a variable injury pattern even among similar surgeries. Despite this, timely surgical intervention, when indicated, can lead to favorable outcomes.

A cut throat: a case of C5-C8 brachial plexus root transection providing evidence of T1 innervation of thumb and finger extensors.

The T1 nerve root is not routinely thought of as innervating the extensors of the thumb and fingers. Work by Bertelli and Ghizoni proposed that the pattern of brachial plexus paralysis with intact hand function and thumb and finger extensors traditionally attributed to C5/6/7 root injury is in fact a C5/6/7/8 injury, with only T1 remaining intact - a 'T1 hand'. This case presents a 19-year-old male who was stabbed in the neck; exploratory surgery determined complete transection of the brachial plexus, with only the T1 nerve root remaining intact. Clinical examination demonstrated grade M4 pronation (with pronator quadratus), wrist extension (with extensor carpi ulnaris), thumb and finger extension (with extensor policis longus and brevis, extensor digitorum communis and extensor index proprius), wrist flexion (with palmaris longus), finger flexion (with flexor digitorum superficialis and profundus), thumb flexion (with flexor policis longus), and thenar and hypothenar muscles. Extensor carpi radialis longus and brevis, flexor carpi radialis and flexor carpi ulnaris were paralyzed. Triceps scored M2. This case provides unequivocal evidence that the T1 root provides significant innervation to the extrinsic thumb and finger extensors.

Anatomy of Profunda Brachial Artery in the Axilla and Its Relationship With the Radial Nerve: Fresh-Cadaver Anatomical Study and Clinical Observations.

PURPOSE: Dissection of the radial nerve in the axilla and upper portion of and posterior aspect of arm may be necessary for brachial plexus reconstruction, in axillary nerve paralysis, and in radial nerve injuries. The radial nerve is in intimate contact with the profunda brachial artery (PBA). The authors sought to describe the relationship of the PBA with the radial nerve. MATERIALS AND METHODS: We dissected the PBA and the radial nerve bilaterally in 20 upper limbs from 10 fresh cadavers after subclavian artery injection with green latex. We studied the relationship of the PBA with the radial nerve, its branching patterns, and its diameters. In addition, we performed surgery on 5 patients with brachial plexus, radial, or axillary nerve injury in whom we dissected the PBA. RESULTS: The PBA was present in all dissections, originating from the brachial artery (n = 19 specimens) close to the latissimus dorsi tendon or from the subscapular artery (n = 1 specimen). In 15 dissections, the PBA bifurcated into an anterior (AB) and a posterior (PB) branch. In one dissection, the AB was absent. The AB traveled toward the triceps medial head. The PB flanked the radial nerve posteriorly and traveled around the humerus, with the radial nerve passing between the medial and the lateral head of the triceps. The AB and PB were longer than the PBA and measured on average 53 mm (SD ± 33 mm) and 39 mm (SD ± 26 mm), respectively. Intraoperatively, the radial nerve could be exposed in the upper arm by pulling the triceps medial head anteriorly together with the AB. The PB was lateral to the radial nerve in the posterior arm approach. CONCLUSIONS: In the upper arm, the radial nerve was not flanked by a single branch as postulated in anatomical textbooks but by 2 branches resulting from the bifurcation of the PBA. CLINICAL RELEVANCE: Awareness of PBA anatomy is essential during radial nerve dissection from the anterior or posterior arm approach.

Living With Cervical Spinal Cord Injury During the COVID-19 Pandemic: A Qualitative Study.

Objective: To understand how COVID-19 has affected the daily lives of people living with cervical spinal cord injury (SCI). Design: Cross sectional qualitative study. Setting: Academic medical center in the Midwestern United States. Participants: Ten community-dwelling individuals (8 men, 2 women), average 11.6 years post-mid-cervical level SCI (N=10). Interventions: Not applicable. Main Outcome Measures: Semistructured interviews were completed by phone. The research team used thematic analysis and inductive strategies to analyze the data in this exploratory investigation. Results: People with cervical SCI living in the United States during the spring of 2020 experienced changes to their daily lives. Participants described how interactions with caregivers for activities of daily living were complicated by fear about contracting and/or transmitting COVID-19. The pandemic limited this population's access to medical care and adversely affected their mental and physical health. Telemedicine was seen as a helpful alternative to in-person visits. Some participants felt that their previous life-altering experience (SCI) better prepared them to cope with the pandemic and "roll with things." Conclusions: Learning about how people with SCI cope, persevere, and survive to overcome adversity during the pandemic should inform future research to support those with SCI. Improving telemedicine and rewarding and recognizing caregivers for their role in maintaining health are important first steps. We must continue to be creative about improving our health care systems and access for people with disabilities, particularly during this and future public health crises.

Outcome Analysis of Medial Triceps Motor Nerve Transfer to Axillary Nerve in Isolated and Brachial Plexus-Associated Axillary Nerve Palsy.

BACKGROUND: Since 2007, the authors have performed the triceps-to-axillary nerve transfer using the medial triceps branch to reconstruct axillary nerve function in brachial plexus and isolated axillary nerve palsies. METHODS: A retrospective chart review was undertaken of patients reconstructed with this transfer, recording patient and injury demographics and time to surgery. Preoperative and postoperative function was graded using the Medical Research Council scale and the Disabilities of the Arm, Shoulder, and Hand questionnaire. RESULTS: Postoperatively, 31 patients (64.6 percent) reached Medical Research Council grade 3 or higher at final follow-up. The median Disabilities of the Arm, Shoulder, and Hand score was 59.9 (interquartile range, 38.8 to 70.5) preoperatively and 25.0 (interquartile range, 11.3 to 61.4) at final follow-up. Sixteen patients (33 percent) had isolated axillary nerve injury; the median Medical Research Council grade was 4.25 (interquartile range, 3 to 4.25), with 14 patients (87.6 percent) achieving grade 3 or higher. Thirty-two patients (77 percent) had brachial plexus-associated injury; median Medical Research Council grade was 3 (interquartile range, 2 to 3), with 17 patients (53.1 percent) achieving grade 3 or higher. CONCLUSION: Medial triceps nerve branch is a strong donor for triceps-to-axillary nerve transfer; however, injury factors may limit the motor recovery in this complex patient population, particularly in axillary nerve palsy associated with brachial plexus injury. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Donor activation focused rehabilitation approach to hand closing nerve transfer surgery in individuals with cervical level spinal cord injury.

STUDY DESIGN: Case Series. OBJECTIVES: To describe the donor activation focused rehabilitation approach (DAFRA) in the setting of the hand closing nerve transfers in cervical spinal cord injury (SCI) so that therapists may apply it to treatment of individuals undergoing this procedure. SETTING: United States of America-Academic Level 1 Trauma Center. METHODS: We reviewed the records of individuals with cervical SCI who underwent nerve transfer to restore hand closing and post-surgery DAFRA therapy at our institution. The three post-surgery phases of DAFRA included (1) early phase (0-12 months) education, limb preparation, and donor activation exercises, (2) middle phase (12-24 months) volitional recipient muscle activation and (3) late phase (18 + months) strengthening and incorporation of motion in activities of daily living. RESULTS: Subtle gains in hand closing were first observed at a mean of 8.4 months after hand closing nerve transfer surgery. Remarkable improvements including discontinuation of assistive devices, independence with feeding and urinary function, and measurable grip were observed. Function continued to improve slowly for one to two more years. CONCLUSIONS: A deliberate, slow-paced (monthly for >2 years post-surgery) and incremental therapy program-DAFRA-can be used to improve outcomes after nerve transfer to restore hand closing in cervical SCI. SPONSORSHIP: This work was made possible by funding from the Craig H. Neilsen Foundation Spinal Cord Injury Research on the Translation Spectrum (SCIRTS) Grant: Nerve Transfers to Restore Hand Function in Cervical Spinal Cord Injury (PI: Ida Fox).

Using the modified frailty index to predict negative outcomes in free-flap breast reconstruction: A National Surgical Quality Improvement Project-based study.

BACKGROUND: Post-mastectomy free-flap breast reconstruction is becoming increasingly common in the United States. However, predicting which patients may suffer complications remains challenging. We sought to apply the validated modified frailty index (mFI) to free-flap breast reconstruction in breast cancer patients and determine its utility in predicting negative outcomes. METHODS: We conducted a retrospective study using National Surgical Quality Improvement Project (NSQIP). All patients who had a CPT code of 19364, indicative of free tissue transfer for breast cancer reconstruction, were included. Data on preoperative characteristics and postoperative outcomes were collected. Patients were separated based on the number of mFI factors present into three categories: 0, 1, and > 2 factors. Preoperative demographics, clinical status, and other comorbidities were also studied. Negative outcomes were compared using multivariate logistic regression. RESULTS: 11,852 patients (mean age 50.9 ± 9.5) were found; 24.2% had complications, comparable to previous literature. mFI is predictive of all types of negative outcomes. 22.5% of all patients with 0 mFI, 27.7% of patients with 1 mFI and 34.2% of patients with at least two mFI had a negative outcome. The most common factors contributing to the mFI were history of hypertension (24.8%) and diabetes (6.1%). mFI was found to be an isolated risk factor for negative outcomes, along with steroid use, American Society of Anesthesiology (ASA) classification, body mass index, and immediate, and bilateral operations. CONCLUSIONS: This NSQIP-based study for patients undergoing free flap breast reconstruction shows that the mFI holds predictive value regarding negative outcomes. This provides more information to properly counsel patients before free flap breast reconstruction surgery.

Adductor magnus muscle transfer to restore knee extension: Anatomical studies and clinical applications.

BACKGROUND: Loss of knee extension causes significant impairment. Though nerve-based reconstruction is preferable in cases of femoral nerve palsy or injury, these surgeries are not always appropriate if the pathology involves the quadriceps muscles or presentation too late for muscle reinnervation. Muscle transfers are another option that has been underutilized in the lower extremity. We describe the successful restoration of knee extension by adductor magnus muscle transfer without functional donor morbidity, along with anatomical considerations. METHODS: Ten fresh frozen cadaveric lower limbs were dissected at the groin and thigh. In addition, three patients presented with femoral nerve palsy for which nerve-based reconstruction was not appropriate because of late presentation. In these patients, adductor magnus muscle transfers were performed, along with sartorius, gracilis, and tensor fasciae latae transfers if available and healthy. RESULTS: In cadavers, the pedicle for the adductor magnus is at the level of the gracilis and adequate for muscle transfer, with sufficient weavable tendon length. The only major structure at risk is the femoral neurovascular bundle, which is in a reliable anatomic position. Two patients recovered 4/5 active knee extension and ambulation without assistive devices. A third required reoperation for a loosened tendon weave, after which the noted improved stability and strength with ambulation but did not regain strong active knee extension and continued to require a cane. CONCLUSIONS: We present a novel reconstructive approach for loss of quadriceps function in patients, which yields good clinical outcomes, with anatomic and technical details to demonstrate the utility of this technique. Ongoing evaluation of optimal technique and rehabilitation to maximize functional outcomes is still needed.

Video-based Learning in Surgery: Establishing Surgeon Engagement and Utilization of Variable-duration Videos.

OBJECTIVE: To measure surgeon engagement and preferred video duration in a video-based learning program for nerve surgery. BACKGROUND: Educational videos can improve, standardize, and democratize best practices in surgery. To improve care internationally, educators must optimize their videos for learning. However, surgeon engagement and optimal video duration remain undefined. METHODS: A YouTube channel and a video-based learning website, PASSIO Education (passioeducation.com), were examined from 2011 to 2017. We assessed views, geographic location, audience engagement (average percent of video watched), audience retention (percent of viewers at each timepoint), and usage of short (median 7.4, range 4.1-20.3 min) and long (median 17.2, range 6.1-47.7 min) video formats for the same procedures. A survey of PASSIO Education membership examined preferred video duration. RESULTS: Our 117 nerve surgery videos attained over 3 million views with 69% originating outside of the United States. While YouTube achieved more international exposure, PASSIO Education attained a greater mean engagement of 48.4% (14.3% absolute increase, P < 0.0001). Surveyed surgeons (n = 304) preferred longer videos when preparing for infrequent or difficult cases compared with routine cases (P < 0.0001). Engagement declined with video duration, but audience retention between short and long video formats was correlated (τB = 0.52, P < 0.0001). CONCLUSIONS: For effective spread of best practices, we propose the joint use of YouTube for audience outreach and a surgeon-focused platform to maximize educational value. Optimal video duration is surgeon- and case-dependent and can be addressed through offering multiple video durations and interactive viewing options.

Reconstruction of Severe Palm Injury with Sensate Medial Plantar Artery Flap and Nerve Grafting.

A 28-year-old, healthy man presented with an abrasion injury of the left palm, including a full-thickness glabrous skin defect, an open injury of the carpal tunnel with 50% transection of the median nerve, and a multilevel traction/avulsion injury of the thenar motor branch. He underwent repair with a free medial plantar artery flap, nerve transfer of the palmar cutaneous nerve to the medial plantar cutaneous nerve, grafting of the median nerve, and direct neurotization of the thenar muscles via an end-to-side nerve graft from the median nerve. At 8 months postoperative, both donor and recipient areas had healed completely, and the patient had regained meaningful 2-point discrimination of the palm and fingers, achieved innervation of the thenar muscles, and returned to work as a cook.

Using electrodiagnostics to define injury patterns amenable to nerve transfer surgery in tetraplegia: an illustrative case report.

INTRODUCTION: Spinal cord injury is a devastating condition affecting a person's independence and quality of life. Nerve transfers are increasingly used to restore critical upper extremity function. Electrodiagnostic studies guide operative planning but the implications for clinical outcomes is not well defined. This case study delineates how clinical examination and electrodiagnostics can define the varying patterns of neuronal injury to guide timing and strategy for optimal outcomes in nerve transfers. CASE PRESENTATION: We discuss a 20-year-old man with a C6-7 spinal cord injury (SCI). We illustrate how history, physical examination, and electrodiagnostic studies predicted patterns of upper and lower motor neuron injury, confirmed intraoperatively via direct nerve stimulation. We undertook brachialis nerve transfer to the median fascicles supplying flexor digitorum superficialis and anterior interosseous nerve (to restore digit flexion), and supinator nerve transfer to posterior interosseous nerve (to restore digit extension). Preoperative electrodiagnostics of the right upper extremity demonstrated a pure upper motor neuron injury to median innervated muscles, and mixed upper and lower motor neuron injury to radial innervated muscles. These findings were confirmed via intraoperative direct neuromuscular stimulation. The preoperative studies provided important information regarding the anatomic basis and time sensitivity of the proposed nerve transfers. At 2 years post operatively the reconstructed digit flexion and extension resulted in improved hand function and independence. DISCUSSION: Upper and lower motor neuron injuries can coexist in individuals with SCI. This example provides proof-of-concept that preoperative electrodiagnostic studies predict LMN injury, and surgery can achieve positive outcomes if completed soon after SCI.

The Effect of Surgical Video on Resident Performance of Carpal Tunnel Release: A Cadaveric Simulation-Based, Prospective, Randomized, Blinded Pilot Study.

BACKGROUND: Surgical videos are increasingly common, although their role in residency curricula remains unclear. The aim of this study was to evaluate the impact of an educational surgical video on resident performance of an open carpal tunnel release through an Objective Structured Assessment of Technical Skills and serial questionnaires. METHODS: Twenty-two residents representing six postgraduate years were randomized to receive text-based materials with or without a surgical video before performing a carpal tunnel release on human cadavers. Procedures were video recorded, anonymized, and independently evaluated by three hand surgeons using the Objective Structured Assessment of Technical Skills global rating scale, a procedure-specific technical rating scale, a record of operative errors, and pass/fail designation. Residents completed questionnaires before and after the procedure to track confidence in their technical skills. RESULTS: Residents in their first and second postgraduate years (n = 10) who watched the surgical video committed fewer operative errors (median, 4 versus 1.3; p = 0.043) and were more confident in their abilities following the procedure (median, 75 versus 32; p = 0.043) than those receiving text resources alone. There were no significant differences in Objective Structured Assessment of Technical Skills performance or questionnaire responses among more senior residents (n = 12). The technical rating scale was internally consistent (Cronbach α = 0.95; 95 percent CI, 0.91 to 0.98), reliable (intraclass correlation coefficient, 0.73; 95 percent CI, 0.40 to 0.88), and correlated with surgical experience (Spearman ρ = 0.57; p = 0.006). CONCLUSION: Watching an educational surgical video to prepare for a cadaveric procedure significantly reduced operative errors and improved confidence among junior trainees performing a carpal tunnel release.