Surgery for mononeuropathies.

Advancement in microsurgical techniques and innovative approaches including greater use of nerve and tendon transfers have resulted in better peripheral nerve injury (PNI) surgical outcomes. Clinical evaluation of the patient and their injury factors along with a shift toward earlier time frame for intervention remain key. A better understanding of the pathophysiology and biology involved in PNI and specifically mononeuropathies along with advances in ultrasound and magnetic resonance imaging allow us, nowadays, to provide our patients with a logical and sophisticated approach. While functional outcomes are constantly being refined through different surgical techniques, basic scientific concepts are being advanced and translated to clinical practice on a continuous basis. Finally, a combination of nerve transfers and technological advances in nerve/brain and machine interfaces are expanding the scope of nerve surgery to help patients with amputations, spinal cord, and brain lesions.

Treatment of spontaneous anterior interosseous nerve palsy.

OBJECTIVE: The purpose of this study was to clarify the clinical outcomes of spontaneous anterior interosseous nerve palsy (AINP) treated nonsurgically or surgically. METHODS: The authors retrospectively evaluated the clinical course of 27 patients affected with AINP, treated nonsurgically or surgically. Thirteen patients underwent surgical treatment (interfascicular neurolysis), and 14 patients underwent conservative nonsurgical treatment. The mean patient age at the onset of symptoms was 49 years (range 17-77 years). The mean follow-up duration from onset to the latest follow-up examination was 23 months (range 12-38 months). RRESULTS: In 12 of 14 patients receiving conservative treatment, signs of recovery from the palsy were obtained within 6 months. These patients showed a recovery of manual muscle test (MMT) grade ≥ 3. In contrast, 2 patients who took more than 12 months from symptom onset to initial recovery showed poor recovery (MMT grade ≤ 2). Surgical treatment was performed in 13 patients because of no sign of recovery from palsy. The mean period from symptom onset to the operation was 8.4 months (range 6-14 months). Ten of 13 patients who underwent surgical treatment within 8 months after symptom onset showed good recovery, with MMT grade ≥ 4. However, 3 patients who underwent surgical treatment more than 12 months after onset showed recovery with MMT grade ≤ 3. CONCLUSIONS: Conservative treatment for AINP may be continued when patients show signs of recovery within 6 months after symptom onset. In contrast, surgical treatment may be performed within 8 months from the onset of symptoms when the patients show no recovery signs for 6 months. ABBREVIATIONS: AIN = anterior interosseous nerve; AINP = anterior interosseous nerve palsy; FDP1 = flexor digitorum profundus of the index finger; FPL = flexor pollicis longus; MMT = manual muscle test; NSG = nonsurgical treatment group; SG = surgical treatment group.

Suprascapular Neuropathy From Malpositioned Baseplate Screws in Primary Reverse Shoulder Arthroplasty: Two Case Reports.

CASES: Two patients presented to different surgeons complaining of persistent shoulder pain after reverse total shoulder arthroplasty. Workups for fracture, instability, and periprosthetic infection were negative. Advanced imaging, nerve conduction studies, and diagnostic injections localized symptoms to the suprascapular nerve. Revision arthroplasty with removal of the offending screws improved pain in both patients. CONCLUSION: Suprascapular nerve irritation because of the malposition of baseplate screws in reverse total shoulder arthroplasty can be a source of postoperative pain. Removal of the offending screw without formal nerve exploration may result in symptomatic improvement.

[Reconstruction of Lower Extremity Palsy after Pelvic Fractures with the Muscle Transfers]. / Rekonstrukce paréz dolní koncetiny po zlomeninách pánve svalovými transfery.

PURPOSE OF THE STUDY The prevalence of nerve structure injuries accompanying pelvic and acetabular fractures is stated to be 5-25 %, with most frequent injuries to motor nerve structures associated with fractures of the posterior wall of the acetabulum. Prognostically worse outcomes of regeneration are documented mainly in iatrogenic, intraoperative injuries to nerve structures. This study aims to document the functional effect of muscle transfers restoring the movement of lower extremities with irreversible nerve lesion caused by the pelvic and acetabular fracture. MATERIAL AND METHODS A total of 18 patients with irreversible palsy of lower extremities in L4-S1 segments underwent a reconstruction surgery in the period 2006-2016, of whom 13 patients with the mean age of 42 (21-79) years arrived for a follow-up. The group included 10 patients with the loss of function of peroneal portion of the sciatic nerve, one patient sustained femoral nerve lesion and two patients suffered complete sciatic nerve lesion (both the peroneal and tibial portion). The patients were evaluated at the average follow-up of 77 (24-129) months after the reconstruction surgery. The average time interval from pelvic fracture to reconstruction by muscle transfer was 47 (18-151) months. Due to a wide spectrum of functional damage, the patients were evaluated in terms of the overall effect of the reconstruction surgery on the activities of daily living using the LEFS (The Lower Extremity Functional Scale). The surgical techniques used transposition of tensor fascie latae for femoral nerve lesion, transposition of tibialis posteriormuscle for palsy of the peroneal division of the sciatic nerve and tenodesis of tibialis anterior tendon and peroneus longustendon for the palsy of the peroneal and tibial portion of sciatic nerve. RESULTS The effect of movement restoration on daily living evaluated using the LEFS achieved 65 points (53-79) which is 85% of the average value of LEFS in healthy population. The transposition of active muscles tibialis posterior and tensor fasciae latae resulted in all the patients in active movement restoration. A loss of correction of foot position following the performed tenodesis of the paralysed tibialis anterior muscle was observed in one patient, with no significant impact on function. No infection complication was reported in the group. In 78% of patients the intervention was performed as day surgery. DISCUSSION There is a better prognosis for restoration in incomplete nerve lesion than in complete lesions and also in the loss of sensation than in the loss of motor function. The mini-invasive stabilisation of pelvic ring according to literature does not increase the risk of nerve lesions, while on the other hand a higher incidence of femoral nerve damage by INFIX fixator is documented. The type of muscle transfer is selected based on the availability of active muscles suitable for transposition and also with respect to functional requirements of the patient. CONCLUSIONS Irreversible palsy of lower extremity after the pelvic fracture is easily manageable as to the restoration of function. Surgical interventions using the preserved active muscles to restore the lost movement should be a component part of comprehensive surgical care for patients who sustained a pelvic fracture and should be performed centrally at a centre availing of comprehensive expertise. Key words: nerve lesion, tendon transfer, acetabulum, pelvis, fracture.

Ultrasound-guided treatment of peripheral entrapment mononeuropathies.

The advent of high-resolution neuromuscular ultrasound (US) has provided a useful tool for conservative treatment of peripheral entrapment mononeuropathies. US-guided interventions require careful coordination of transducer and needle movement along with a detailed understanding of sonoanatomy. Preprocedural planning and positioning can be helpful in performing these interventions. Corticosteroid injections, aspiration of ganglia, hydrodissection, and minimally invasive procedures can be useful nonsurgical treatments for mononeuropathies refractory to conservative care. Technical aspects as well as the current understanding of the indications and efficacy of these procedures for common entrapment mononeuropathies are reviewed in this study. Muscle Nerve, 2019.

A comprehensive analysis of pectoralis major transfer for long thoracic nerve palsy.

BACKGROUND: In the treatment of long thoracic nerve palsy with pectoralis major transfer, it remains unknown whether direct transfer of the pectoralis to the scapula or indirect transfer with an interpositional graft provides superior outcomes. METHODS: A 3-tiered study was performed to gain a comprehensive understanding. (1) A survey of the membership of the American Shoulder and Elbow Surgeons (ASES) was conducted to reach a Level V consensus. (2) A systematic review was conducted to identify all series evaluating direct and indirect transfer of the pectoralis major tendon to create a Level IV consensus. (3) A retrospective review was performed to provide Level III evidence. RESULTS: (1) Surgeons were evenly split between whole and split tendon transfers, direct and indirect transfers, and graft types. More experienced surgeons were more likely to prefer an indirect transfer. (2) Analysis of 10 Level IV studies (131 shoulders) revealed that patients who underwent indirect transfer were significantly more likely to develop recurrent winging (P = .009) and had lower active forward elevation (P < .001) and ASES scores (P = .0016). (3) Twenty-four patients were included in our retrospective review with a mean follow-up of 4.3 years (77% follow-up), of whom 14 underwent indirect transfer and 10 underwent direct transfer. There were no significant differences in recurrence of winging, range of motion, or ASES scores. CONCLUSIONS: Level V and III evidence suggests that there is no functional difference between direct and indirect transfer. Level IV evidence must be interpreted with caution.

Endoscopically assisted piriformis-to-knee surgery of sciatic, peroneal, and tibial nerves: technical note.

BACKGROUND: Proximal lesions of the sciatic nerve are often difficult to diagnose and to treat properly. In particular, if there are posttraumatic or postoperative alterations, imaging might not identify the level and location of lesion. Due to the sciatic nerve anatomy, the same is true for clinical and electrophysiological evaluation with a risk of delayed surgery and, thus, unsuccessful surgery. Therefore, in some unclear cases, surgical exploration of the whole sciatic nerve and its divisions could be the only means to determine the correct diagnosis and allow prompt treatment to produce the best clinical outcome. OBJECTIVE: To describe a novel minimally invasive technique to explore and treat patients with proximal sciatic, peroneal, and tibial nerve lesions. Intraoperative findings, surgical considerations, and complications are presented. METHODS: From January 2012 to November 2013, 9 consecutive patients with lesions of the sciatic, peroneal, and tibial nerves underwent endoscopy and were treated. The technical considerations of these cases are presented with regard to the retrospectively collected clinical and surgical data to evaluate the pros and cons of the technique. RESULTS: A subgluteal incision, as the primary endoscopic port, was used in all 9 patients. An additional mid-thigh and fibular head incision was thought necessary in 3 patients. An extension of the approach by a secondary transgluteal incision was performed in 4 patients. In 2 of these sciatic lesions, autologous nerve grafts were placed. One perineurioma was detected and bioptically secured. There were no complications. Six patients experienced pain relief; in 6, we observed motor improvement. The mean follow-up was 9.5 months. CONCLUSION: The endoscopically assisted single- to multiportal sciatic exploration technique provides excellent visualization that enables nerve inspection, lesion detection, and decompression, and obviates the need for more extensive approaches in cases of unclear sciatic nerve pathology. By adding several ports, whole-length exploration of the sciatic from the notch to fibular head level is feasible.

Tendon transfers for radial, median, and ulnar nerve palsy.

Tendon transfers are used to restore balance and function to a paralyzed, injured, or absent neuromuscular-motor unit. In general, tendon transfer is indicated for restoration of muscle function after peripheral nerve injury, injury to the brachial plexus or spinal cord, or irreparable injury to tendon or muscle. The goal is to improve the balance of a neurologically impaired hand. In the upper extremity, tendon transfers are most commonly used to restore function following injury to the radial, median, and ulnar nerves. An understanding of the general principles of tendon transfer is important to maximize the outcome.

Surgical treatment of spontaneous anterior interosseous nerve palsy: a comparison between minimal incision surgery and wide incision surgery.

Recent reports have suggested that fascicular constriction located proximal to the elbow may be the primary aetiology of spontaneous anterior interosseous nerve palsy (sAINP), and recommended interfascicular neurolysis ranging from the proximal forearm to distal upper arm (wide incision surgery: WIS) for its treatment. On the basis of these reports, it was hypothesised that, if the aetiology of sAINP was fascicular constriction, neurolysis limited proximal to the elbow (minimal incision surgery: MIS) should have similar results to those of WIS. Twenty-five surgically treated sAINP cases were retrospectively evaluated. The mean age of onset was 42.8 years, the mean preoperative period was 5.3 months, and mean follow-up period after operation was 31 months. Eleven patients underwent MIS, while 14 underwent WIS according to the patient's intention (intention-to-treat). Twenty-one patients had fascicular constriction, and no entrapment neuropathy was seen in this series. At the latest follow-up, 82% of the patients had British Medical Research Council grade of ≥4 in flexor-pollicis-longus, while 80% had grade of ≥4 in flexor-digitorum-profundus-of-the-index-finger. There were no significant differences between the results of either group. These result suggested that the aetiology of sAINP may not be external compression, but fascicular constriction, and MIS may be its favourable surgical treatment.

Variation in recommendation for surgical treatment for compressive neuropathy.

PURPOSE: It is our impression that there is substantial, unexplained variation in hand surgeon recommendations for treatment of peripheral mononeuropathy. We tested the null hypothesis that specific patient and provider factors do not influence recommendations for surgery. METHODS: Using a web-based survey, hand surgeons recommended surgical or nonsurgical treatment for patients in 2 different scenarios. Six elements of the first scenario (symptoms, circumstances, mindset, diagnosis, objective testing, and expectations) had 2 possibilities that were each independently and randomly assigned to each rater. For the second scenario, 2 different scenarios were randomly assigned to each rater. Multivariable logistic regression sought factors associated with a recommendation for surgery. RESULTS: A total of 186 surgeons of the Science of Variation Group completed a survey regarding recommendation of surgery for 2 different patients based on clinical scenarios. Recommendations for surgery did not vary significantly according to provider characteristics. For the various elements in scenario 1, recommendation for surgery was more likely for patients who were self-employed and continued to work and who had objective electrodiagnostic abnormalities. For the 2 vignettes used in scenario 2, a recommendation for surgery was associated with abnormal electrophysiology. CONCLUSIONS: The findings of this study suggest that-at least in a survey setting-surgeons prefer to offer peripheral nerve decompression to patients with abnormal electrophysiology, particularly those with effective coping strategies. CLINICAL RELEVANCE: The role of objective verification of pathophysiology is debated, but it is an influential factor in recommendations for hand surgery.

Obturator nerve transfer for femoral nerve reconstruction: anatomic study and clinical application.

BACKGROUND: Femoral nerve lesion causes significant disability. In many cases, the availability of the proximal stump is in question and further complicates surgical management by severely limiting reconstructive options and precluding nerve graft reconstruction. The purpose of this report is to describe the successful restoration of quadriceps function by distal nerve transfer at the level of the thigh without functional donor morbidity and the findings of cadaveric dissections of the obturator and femoral nerve branches. METHODS: Eight fresh frozen cadaveric lower limbs were dissected at the region of the groin and thigh. Two patients were referred to us with complete femoral nerve palsy and unavailability of the proximal femoral nerve for reconstruction by conventional methods. Distal nerve transfers were performed using the anterior branch of the obturator nerve and in one case, the motor branch to the tensor fasciae latae to reinnervate the rectus femoris and vastus medialis muscles. RESULTS: As measured in cadaveric specimens, the transferable lengths of each donor nerve branch when used to innervate any combination of quadriceps muscles provide plenty of length for tension-free end-to-end coaptations. One patient recovered 3 to 4/5 Medical Research Council grade knee extension and the other 4+/5 knee extension. The latter patient is able to walk, run, and use stairs normally, whereas the former still has difficulty with fast ambulation, running, and stairs. CONCLUSION: The authors present a novel reconstructive approach that yields good clinical outcomes, as well as an anatomic study that demonstrates the feasibility of this technique.

Pectoralis major tendon transfer for the treatment of scapular winging due to long thoracic nerve palsy.

BACKGROUND: Painful scapular winging due to chronic long thoracic nerve (LTN) palsy is a relatively rare disorder that can be difficult to treat. Pectoralis major tendon (PMT) transfer has been shown to be effective in relieving pain, improving cosmesis, and restoring function. However, the available body of literature consists of few, small-cohort studies, and more outcomes data are needed. MATERIALS AND METHODS: Outcomes of 26 consecutive patients with electromyelogram-confirmed LTN palsy who underwent direct (n = 4) or indirect transfer (n = 22) of the PMT for dynamic stabilization of the scapula were reviewed. All patients were followed up clinically for an average of 21.8 months (range, 3-62 months) with evaluations of active forward flexion, active external rotation, American Shoulder and Elbow Surgeons (ASES) score, visual analog scale (VAS) pain score, and observation of scapular winging. RESULTS: Preoperative to postoperative results included increases in the mean active forward flexion from 112° to 149° (P < .001) an in mean active external rotation from 53.8° to 62.8° (P = .045), an improvement in the mean ASES score from 28 to 67.0 (P < .001), and an improvement in the mean VAS pain score from 7.7 to 3.0 (P < .001). Recurrent scapular winging occurred in 5 patients. There was no difference in outcome by length of follow-up. CONCLUSIONS: PMT transfer is an effective treatment for painful scapular winging resulting from LTN palsy. This is the largest reported series of consecutive patients treated with PMT transfer for the correction of scapular winging.

Recovery of sensory disturbance after arthroscopic decompression of the suprascapular nerve.

BACKGROUND: The existence of sensory branches of the suprascapular nerve (SSN) has recently been reported, and sensory disturbance at the lateral and posterior aspect of the shoulder has been focused on as a symptom of SSN palsy. We have performed arthroscopic release of SSN at the suprascapular notch in patients with sensory disturbance since 2006. The purposes of this study were to introduce the arthroscopic surgical technique and investigate postoperative recovery of sensory disturbance. MATERIALS AND METHODS: The study included 11 men and 14 women (25 shoulders), with an average age of 63.9 years (range, 41-77 years). Arthroscopic decompression of the SSN was performed using a suprascapular nerve (SN) portal as a landmark for approaching the suprascapular notch. Sensory disturbance of the shoulder was evaluated preoperatively and postoperatively. The average follow-up was 18.5 months (range, 12-30 months). RESULTS: The arthroscopic procedures were performed safely. The preoperative sensory disturbance fully recovered postoperatively in all shoulders. CONCLUSION: Arthroscopic release of the SSN is a useful procedure for SSN entrapment at the suprascapular notch. The sensory disturbance at the lateral and posterior aspect of the shoulder can be used as one of the criteria of diagnosing SSN palsy, especially in shoulders with massive rotator cuff tear, in which diagnosing and assessing the treatment results of associated SSN palsy is usually difficult.

Ultrasound diagnosis of peroneal nerve variant in a child with compressive mononeuropathy.

We report on a 6-year-old child presenting with subacute foot drop. Neurophysiologic and radiologic studies revealed a peroneal nerve compression secondary to fibular exostosis. Before undergoing surgical removal of the exostosis, the patient underwent further neurophysiologic and ultrasonographic evaluation that showed the presence of an accessory peroneal nerve branch that caused gastrocnemius involvement. Findings at surgery confirmed the supposed anatomical variant. Both nerve components were carefully preserved during the operative procedure. The association of ultrasonographic and neurophysiologic studies was crucial in identifying the etiopathologic mechanism and anatomical picture and provided clinicians and surgeons with important information in planning the procedure.

Phrenic nerve palsy in children associated with confirmed intrathoracic tuberculosis: diagnosis and clinical course.

In this descriptive retrospective cases series of eight cases phrenic nerve palsy in children caused by tuberculosis lymph gland infiltration of the phrenic nerve. The lymph gland enlargement was in all cases caused by culture confirmed Mycobacterium tuberculosis. The phrenic nerve palsy was on the left side in all eight cases with the presenting feature a raised diaphragm on chest radiography that was accompanied by consolidation of the left upper lobe (88%) The diagnosis of phrenic nerve palsy was confirmed by fluoroscopy of the chest. On computer tomography the outstanding features were left sided hilar and paratracheal lymph gland enlargement with displacement of the mediastinum to the right. Mediastinal displacement lead to anterior displacement of the descending aorta, which further compressed the left main bronchus. Two children had accompanying respiratory failure requiring assisted ventilation and in two additional cases the airway compression was so severe that glandular enucleation of the enlarged glands was indicated. Of the eight children five remained symptomatic after completion of TB treatment to which steroids were added for the initial month. Diaphragmatic plication was indicated in all five cases. On clinical follow-up two children had repeated respiratory tract infections secondary to underlying lung damage while the other six remained asymptomatic.

Hypertrophic mononeuropathy.

Hypertrophic localized mononeuropathy is a condition that comes to clinical attention as a painless focal swelling of a peripheral nerve in an arm or leg and is associated with a slow but progressive loss of motor and sensory function. Whether the proliferation of perineurial cells is neoplastic or degenerative--an ongoing controversy among nerve pathologists--for some patients resection of the involved portion of a nerve with autologous interposition grafting results in better functional outcome than allowing disease to follow its natural course. Patients with a painless focal enlargement of a nerve associated with progressive weakness and/or sensory loss may benefit from surgery for resection and grafting.

Inappropriate surgeries resulting from misdiagnosis of early amyotrophic lateral sclerosis.

Initial symptoms of amyotrophic lateral sclerosis (ALS) may mimic radiculopathy, myelopathy, mononeuropathy, or arthropathy. A retrospective review of 260 consecutive patients with ALS evaluated between 1996 and 2004 revealed that 55 (21%) had had surgery within the 5 years prior to ALS diagnosis. Thirty-four of these 55 (61%) had surgery for symptoms and signs that retrospectively were attributable to early manifestations of ALS. Misdiagnosis of early ALS may lead to unnecessary surgeries with their attendant potential complications.