SCOPING: A Pilot Study Exploring the Role of A Series of Clinical Observational Parameters as Indicators of Nerve Regeneration.

Background: Following the repair of a mixed peripheral nerve, functional recovery requires successful nerve regeneration across the repair site and, eventually, reinnervation of distal targets. Reliably determining a failing nerve repair so that revision may be performed before irreversible muscle atrophy remains a challenge in peripheral nerve surgery. This study aimed to ascertain whether any commonly used clinical examination tests during surveillance after nerve repair can detect a failing repair and prompt earlier salvage intervention. Methods: A prospective observational cohort study was performed to evaluate commonly used clinical determinants of neuron regeneration that may provide early surrogate recovery measures. Sequential cutaneous thermography was used to identify temperature differences between denervated and normal skin in the hand operated on, with the contralateral hand as a control. Results: Six out of nine patients completed between 6 and 18 months of follow-up. Tinel sign progression was observed in all subjects. Tinel progression rate was associated with motor and sensory Medical Research Council grade. The delta temperature was calculated to document the size and direction of any temperature differentials in the hand detected by thermography, but we did not have sufficient data to calculate any correlations with motor and sensory Medical Research Council grade. Conclusions: Specifically, the progression of Tinel sign is associated with recovery measured by progression of the British Medical Research Council motor and sensory grades. The use of thermographic imaging demonstrates that there is a difference in temperature between an injured and noninjured nerve. Future studies could investigate to what extent thermographic imaging predicts final nerve repair outcomes.

Biomechanical Evaluation of an Atraumatic Polymer-assisted Peripheral Nerve Repair System Compared with Conventional Neurorrhaphy Techniques.

Background: Microsuturing, the gold standard for peripheral nerve repair, can create tension and damage at the repair site, potentially impacting regeneration and causing neuroma formation. A sutureless and atraumatic polymer-assisted system was developed to address this challenge and support peripheral nerve repair. The system is based on a biocompatible and biodegradable biosynthetic polymer and consists of a coaptation chamber and a light-activated polymer for securing to the nerve. In this study, we compare the system's biomechanical performance and mechanism of action to microsutures and fibrin repairs. Methods: The system's fixation force was compared with microsutures and fibrin glue, and evaluated across various nerve diameters through tensile testing. Tension and tissue morphology at the repair site were assessed using finite element modeling and scanning electron microscopy. Results: The fixation force of the polymer-assisted repair was equivalent to microsutures and superior to fibrin glue. This force increased linearly with nerve diameter, highlighting the correlation between polymer surface contact area and performance. Finite element modeling analysis showed stress concentration at the repair site for microsuture repairs, whereas the polymer-assisted repair dissipated stress along the nerve, away from the repair site. Morphological analysis revealed nerve alignment with no tissue trauma for the polymer-assisted repair, unlike microsutures. Conclusions: The mechanical performance of the polymer-assisted coaptation system is suitable for peripheral nerve repair. The achieved fixation forces are equivalent to those of microsutures and superior to fibrin glue, minimizing stress concentration at the repair site and avoiding trauma to the severed nerve ends.

Porcine submucosal extracellular matrix wrapping of the ulnar nerve in revision cubital tunnel surgery.

The wrapping technique aims to protect the nerve when the nerve bed is compromised or more commonly to prevent the recurrence of scar tethering following neurolysis. A wrap provides a physical barrier to scar and helps restore the paraneurial gliding layer. This study aimed to evaluate the results of the AxoGuard® nerve protector, a porcine-derived submucosal extracellular matrix (PECM), used as an adjunct in persistent or recurrent cubital tunnel syndrome (CuTS). This retrospective cohort study evaluated patients diagnosed, between 2012 and 2020, with neuropathic pain who underwent revision surgery. Patients were categorised into Group A (revision surgery only) and Group B (revision surgery and adjunctive PECM nerve wrapping). Disease severity was scored at the baseline and six months post-operatively using the McGowan classification. A linear regression model was used to assess the effect of wrapping the ulnar nerve on the clinical outcome at six months. Fifty-nine nerves were treated; among them, adjunctive PECM wrapping was used in 32 nerves. Disease severity at baseline was similar between the groups. After adjusting for differences in baseline characteristics, participants in Group B improved with a significant difference of 0.43 McGowan points over Group A (95% CI (0.01-0.86), p = 0.049). There were no implant-related complications. Group B improved with excellent or good outcomes in 84.4% patients at the final follow-up. Persistent or recurrent CuTS were associated with neuropathic pain and significant nerve scar tether. The use of PECM appears to lead to improved clinical symptoms, possibly by reducing adhesions and encouraging physiological glide. LEVEL OF EVIDENCE: Level III evidence.

Bridge Plate Distraction for Complex Distal Radius Fractures: A Cohort Study and Systematic Review of the Literature.

Background Dorsal bridge plating (DP) of the distal radius is used as a definitive method of stabilization in complex fracture configurations and polytrauma patients. Questions/Purposes This review aims to summarize the current understanding of DP and evaluate surgical outcomes. Methods Four databases were searched following the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines and registered with PROSPERO. Papers presenting outcome or complication data for DP were included. These were reviewed using the National Institutes of Health Quality Assessment and Methodological Index for Non-Randomised Studies tools. Results were collated and compared to a local cohort of DP patients. Results Literature review identified 416 patients with a pooled complication rate of 17% requiring additional intervention. The most prevalent complications were infection/wound healing issues, arthrosis, and hardware failure. Average range of motion was flexion 46.5 degrees, extension 50.7 degrees, ulnar deviation 21.4 degrees, radial deviation 17.3 degrees, pronation 75.8 degrees, and supination 72.9 degrees. On average, DP removal occurred at 3.8 months. Quality assessment showed varied results. There were 19 cases in our local cohort. Ten displayed similar results to the systematic review in terms of range of motion and radiographic parameters. Higher QuickDASH scores and complication rates were noted. Local DP showed earlier plate removal at 2.9 months compared to previous studies. Conclusion DP is a valid and useful technique for treating complex distal radius fractures. It displays a lower risk of infection and pain compared to external fixation which is commonly used to treat similar injuries. Patients can recover well following treatment both in function and range of motion. Further high-quality studies are required to fully evaluate the technique.

The effectiveness of acellular nerve allografts compared to autografts in animal models: A systematic review and meta-analysis.

BACKGROUND: Treatment of nerve injuries proves to be a worldwide clinical challenge. Acellular nerve allografts are suggested to be a promising alternative for bridging a nerve gap to the current gold standard, an autologous nerve graft. OBJECTIVE: To systematically review the efficacy of the acellular nerve allograft, its difference from the gold standard (the nerve autograft) and to discuss its possible indications. MATERIAL AND METHODS: PubMed, Embase and Web of Science were systematically searched until the 4th of January 2022. Original peer reviewed paper that presented 1) distinctive data; 2) a clear comparison between not immunologically processed acellular allografts and autologous nerve transfers; 3) was performed in laboratory animals of all species and sex. Meta analyses and subgroup analyses (for graft length and species) were conducted for muscle weight, sciatic function index, ankle angle, nerve conduction velocity, axon count diameter, tetanic contraction and amplitude using a Random effects model. Subgroup analyses were conducted on graft length and species. RESULTS: Fifty articles were included in this review and all were included in the meta-analyses. An acellular allograft resulted in a significantly lower muscle weight, sciatic function index, ankle angle, nerve conduction velocity, axon count and smaller diameter, tetanic contraction compared to an autologous nerve graft. No difference was found in amplitude between acellular allografts and autologous nerve transfers. Post hoc subgroup analyses of graft length showed a significant reduced muscle weight in long grafts versus small and medium length grafts. All included studies showed a large variance in methodological design. CONCLUSION: Our review shows that the included studies, investigating the use of acellular allografts, showed a large variance in methodological design and are as a consequence difficult to compare. Nevertheless, our results indicate that treating a nerve gap with an allograft results in an inferior nerve recovery compared to an autograft in seven out of eight outcomes assessed in experimental animals. In addition, based on our preliminary post hoc subgroup analyses we suggest that when an allograft is being used an allograft in short and medium (0-1cm, > 1-2cm) nerve gaps is preferred over an allograft in long (> 2cm) nerve gaps.

Lumbosacral Plexogram: An Aid to Reconstructive Nerve Possibilities in the Lower Extremity.

The lumbosacral plexus is the network of nerves responsible for the motor and sensory function of the pelvis and lower limb. Our observation is that the anatomy of this plexus is less familiar to surgeons than that of the brachial plexus. Damage to the lumbosacral plexus and its terminal branches may have a significant impact on locomotion, posture, and stability. We have designed a visual representation of the lumbosacral plexus to aid clinicians treating peripheral nerve disorders. The utility is illustrated with a case report in which a patient underwent nerve transfers in the lower limb to restore function. A visual representation of the lumbosacral plexus is a valuable adjunct to a clinical examination and helps make sense of clinical signs. The color-coding of each root level and the arrangement of muscles from proximal to distal helps with visual recall. A clear assessment of complex lumbosacral plexus patients is essential for diagnosis and planning. As with the case described, a sound knowledge of the "plexogram" can identify solutions for complex patients and result in significant functional improvements. We hope it helps advance the field of nerve surgery and, particularly, nerve transfers.

Educating Future Generations of Surgeons across Borders: Novel Global Linked Hybrid Live Cadaveric Peripheral Nerve Surgical Training Course.

Background: This study aimed to evaluate a novel, multi-site, technology-facilitated education and training course in peripheral nerve surgery. The program was developed to address the training gaps in this specialized field by integrating a structured curriculum, high-fidelity cadaveric dissection, and surgical simulation with real-time expert guidance. Methods: A collaboration between the Global Nerve Foundation and Esser Masterclass facilitated the program, which was conducted across three international sites. The curriculum was developed by a panel of experienced peripheral nerve surgeons and included both text-based and multimedia resources. Participants' knowledge and skills were assessed using pre- and postcourse questionnaires. Results: A total of 73 participants from 26 countries enrolled and consented for data usage for research purposes. The professional background was diverse, including hand surgeons, plastic surgeons, orthopedic surgeons, and neurosurgeons. Participants reported significant improvements in knowledge and skills across all covered topics (p < 0.001). The course received a 100% recommendation rate, and 88% confirmed that it met their educational objectives. Conclusions: This study underscores the potential of technology-enabled, collaborative expert-led training programs in overcoming geographical and logistical barriers, setting a new standard for globally accessible, high-quality surgical training. It highlights the practical and logistical challenges of multi-site training, such as time zone differences and participant fatigue. It also provides practical insights for future medical educational endeavors, particularly those that aim to be comprehensive, international, and technologically facilitated.

Phantom Limb Pain and Painful Neuroma After Dysvascular Lower-Extremity Amputation: A Systematic Review and Meta-Analysis.

BACKGROUND: Phantom limb pain (PLP) and symptomatic neuroma can be debilitating and significantly impact the quality of life of amputees. However, the prevalence of PLP and symptomatic neuromas in patients following dysvascular lower limb amputation (LLA) has not been reliably established. This systematic review and meta-analysis evaluates the prevalence and incidence of phantom limb pain and symptomatic neuroma after dysvascular LLA. METHODS: Four databases (Embase, MEDLINE, Cochrane Central, and Web of Science) were searched on October 5th, 2022. Prospective or retrospective observational cohort studies or cross-sectional studies reporting either the prevalence or incidence of phantom limb pain and/or symptomatic neuroma following dysvascular LLA were identified. Two reviewers independently conducted the screening, data extraction, and the risk of bias assessment according to the PRISMA guidelines. To estimate the prevalence of phantom limb pain, a meta-analysis using a random effects model was performed. RESULTS: Twelve articles were included in the quantitative analysis, including 1924 amputees. A meta-analysis demonstrated that 69% of patients after dysvascular LLA experience phantom limb pain (95% CI 53-86%). The reported pain intensity on a scale from 0-10 in LLA patients ranged between 2.3 ± 1.4 and 5.5 ± .7. A single study reported an incidence of symptomatic neuroma following dysvascular LLA of 5%. CONCLUSIONS: This meta-analysis demonstrates the high prevalence of phantom limb pain after dysvascular LLA. Given the often prolonged and disabling nature of neuropathic pain and the difficulties managing it, more consideration needs to be given to strategies to prevent it at the time of amputation.

Unusual Clinical Presentation of a Benign Peripheral Nerve Sheath Tumor of the Radial Nerve.

Diagnosis of simple benign peripheral nerve tumors (PNT) is usually based on imaging studies and in most cases, surgical excision leads to no significant functional deficit. The clinical presentation is often asymptomatic with incidental imaging findings. We present an unusual clinical presentation of a benign peripheral nerve sheath tumor of the radial nerve.

Development of a core outcome set for traumatic brachial plexus injury.

The aim of the present study was to reach international consensus on the minimum set of outcomes to measure and report in adult traumatic brachial plexus injury care and research. This would facilitate comparison of outcomes from different centres and meta-analysis in research. A list of outcomes was developed from a systematic review (n = 54) and patient interviews (n = 12). The outcomes were rated in a three-round online Delphi survey completed by international surgeons, patients and therapists. Two online consensus meetings with patients and clinicians ratified the final core outcome set. A total of 72 people (20 surgeons, 21 patients, 31 therapists) from 19 countries completed all survey rounds. Thirty-eight people from nine countries attended separate patient (n = 13) and clinician consensus (n = 25) meetings. Outcomes were included if recommended by more than 85% of contributors. Pain, voluntary movement and carrying out a daily routine are the core outcome domains that should be assessed and reported when treating and researching adults with a traumatic brachial plexus injury. LEVEL OF EVIDENCE: V.

Sensory nerve transfers in the upper limb after peripheral nerve injury: a scoping review.

Nerve transfer for motor nerve paralysis is an established technique for treating complex nerve injuries. However, nerve transfer for sensory reconstruction has not been widely used, and published research on this topic is limited compared to motor nerve transfer. The indications and outcomes of nerve transfer for the restoration of sensory function remain unproven. This scoping review examines the indications, outcomes and complications of sensory nerve transfer. In total, 22 studies were included; the major finding is that distal sensory nerve transfers are more successful than proximal ones in succeeding protective sensation. Although the risk of extension of the sensory deficit with donor site loss and morbidity from neuromas remain a barrier to wider adoption, these complications were not reported in the review. Further, the scarcity of studies and small patient series limit the ability to determine sensory nerve transfer success. However, sensory restoration remains an opportunity for surgeons to pursue.Level of evidence: II.

Versatility of the double fascicular transfer in reconstruction of elbow flexion paralysis: Intermediate term follow-up and patient-related outcome measures.

OBJECTIVES: The use of fascicle transfers in the reconstruction of traumatic brachial plexus injury is well established, but limited evidence is available regarding their use in atraumatic elbow flexion paralysis. This retrospective case review aimed to verify whether median and ulnar fascicle transfers are similarly effective in atraumatic versus traumatic elbow flexion paralysis when measured using the British Medical Research Council (MRC) scale, Brachial plexus Assessment Tool (BrAT) and Stanmore Percentage of Normal Elbow Assessment (SPONEA) scores at long-term follow-up. METHODS: All median and ulnar fascicle transfer cases performed at the Queen Elizabeth Hospital Birmingham between August 2007 and November 2018 were reviewed to compare the outcomes of transfers performed for traumatic and atraumatic indications. Data on patient demographics, mechanism and nature of injury, date of injury or symptom onset, date of operation, and other nerve transfers performed were collected. Outcome measures collected included the British MRC scale and two patient-reported outcome measures (PROMs), BrAT and SPONEA. RESULTS: In total, 34 patients with 45 median and ulnar fascicle transfers were identified. This included 27 traumatic and seven atraumatic brachial plexus insults. Thirty patients had sufficient follow-up to be included in MRC analysis and 17 patients had sufficient follow-up to be included in PROM analysis. No significant differences were found between traumatic and atraumatic subgroups for median MRC, BrAT, or SPONEA scores. CONCLUSIONS: This study suggests that nerve transfers might be considered effective reconstructive options in atraumatic pathology and provides validation for further research on the subject.

The Clinical Outcomes of Spinal Accessory to Suprascapular Nerve Transfer Through a Posterior Approach.

BACKGROUND: Spinal accessory nerve (SAN) to suprascapular nerve (SSN) transfer can restore function to the rotator cuff following brachial plexus injuries. The traditional anterior approach using the lateral branch of the SAN causes denervation of the lateral trapezius limiting shoulder elevation. Suprascapular nerve pathology at the suprascapular notch may be missed resulting in poor reinnervation of the rotator cuff. The posterior approach uses the medial SAN and allows decompression and visualization of the SSN at the notch and nerve transfer coaptation closer to the target muscles with a shorter reinnervation distance. METHODS: This is a review of 28 patients from 2014 to February 2020 who underwent SAN to SSN nerve transfer via a posterior approach. Patients were evaluated for SSN pathology, external rotation power, and range of motion. Data were evaluated for high-energy trauma (HET) and low-energy trauma/nontraumatic etiology subsets. RESULTS: A total of 8 HET (40%) patients had pathology identified at the suprascapular notch during the posterior approach, including SSN scarring, ruptures, neuromata-in-continuity, and ossification of ligaments. British Medical Research Council grade greater than or equal to 4 shoulder external rotation was achieved in 75% patients with median range of motion 137.5°. CONCLUSIONS: Spinal accessory nerve to SSN transfer using a posterior approach allows visualization of pathology involving the SSN and coaptation of a medial SAN transfer close to the target muscles. Following HET, 8 cases (40%) had posterior pathology identified. Spinal accessory nerve to SSN transfer through a posterior approach shows improved external rotation power and range of motion.

Outcomes Following Surgery for Common Peroneal Nerve Intraneural Ganglion Cysts: A Case Series and Systematic Review.

Background: Intraneural ganglia are a rare cause of common peroneal nerve palsy. Although several treatment modalities exist, surgical intervention is recommended, especially in the setting of neurological dysfunction. We present a case series and systematic review on the clinical outcomes following surgical excision of common peroneal nerve intraneural ganglia. Methods: We performed a retrospective chart review of all patients who had undergone surgery for common peroneal nerve intraneural ganglia at Queen Elizabeth Hospital in Birmingham, UK, from 2012 to 2022. Demographic and pre- and postoperative findings were collected. A comprehensive literature search of MEDLINE and EMBASE databases was also performed to identify similar studies. Data were subsequently extracted from included studies and qualitatively analyzed. Results: Five patients at our center underwent procedures to excise intraneural ganglia. There was a male preponderance. Pain, foot drop, and local swelling were the common presenting features. Postoperatively, all patients who completed follow-up demonstrated improved motor function with no documented cyst recurrence. The systematic review identified 6 studies involving 128 patients with intraneural ganglia treated with surgery. Similar findings were reported, with objective and subjective measures of foot and ankle function and symptoms improving after surgical intervention. The recurrence rate varied from 0% to 25%, although most recurrences were extraneural. Conclusions: Excision of intraneural ganglia is associated with symptomatic relief and functional improvement. Recurrence rates are relatively low and are rarely intraneural.

Motor and sensory nerve transfers in the lower extremity: Systematic review of current reconstructive possibilities.

BACKGROUND: Peripheral nerve injuries (PNI) are predominantly treated by anatomical repair or reconstruction with autologous nerve grafts or allografts. Motor nerve transfers for PNI in the upper extremity are well established; however, this technique is not yet widely used in the lower extremity. This literature review presents an overview of the current options and postoperative results for nerve transfers as a treatment for nerve injury in the lower extremity. METHODS: A systematic search in PubMed and Embase databases was performed. Full-text English articles describing surgical procedures and postoperative outcomes of nerve transfers in the lower extremity were included. The primary outcome was postoperative muscle strength measured using the British Medical Research Council (MRC) scale, with MRC> 3 considered good and postoperative return of sensation reported according to the modified Highet classification. RESULTS: A total of 36 articles for motor nerve transfer and 7 for sensory nerve transfer were included. Sixteen articles described motor nerve transfers for treating peroneal nerve injury, 17 for femoral nerve injury, 2 for tibial nerve injury, and one for obturator nerve injury. Transfers of multiple branches to restore deep peroneal nerve function led to a good outcome in 58% of patients and 43% when a single branch was used as a donor. The transfer of multiple branches for femoral nerve or obturator nerve repair was performed in all reported patients with a good outcome. CONCLUSIONS: The transfer of motor nerves for the recovery of PNI is a feasible technique with relatively low risks and great benefits. The correct indication, timing, and surgical technique are essential for optimizing results.

Resect, rewire, and restore: Nerve transfer salvage of neurological deficits associated with soft tissue tumors in a retrospective cohort series at a tertiary reconstructive center.

AIMS: We aimed to explore the effectiveness of nerve transfer as an intervention to restore neurological deficits caused by extremity tumors through direct nerve involvement, neural compression, or as a consequence of oncological surgery. METHODS: A retrospective cohort study of consecutive cases was conducted, including all patients who underwent nerve transfers to restore functional deficits in limbs following soft tissue tumor resection. The threshold for a successful nerve transfer was a BMRC motor grade of 4/5 and sensory grade of 3-3+/4 with protective sensation. RESULTS: In total, 29 nerve transfers (25 motor and 4 sensory) were completed in 11 patients, aged 12-70 years at referral, over a 6-year period to 2020. This included 22 upper limb and 3 lower limb motor nerve transfers. The timing of delayed nerve transfer reconstructions was 1-15 months following primary oncological resection, with immediate simultaneous reconstructions performed in 4 cases. The threshold for success was achieved in 82% of upper limb and 33% of lower limb motor nerve transfers, while all sensory transfers were successful in restoring protective sensation. CONCLUSION: Nerve transfer surgery, a well-established technique in restoring deficits following traumatic nerve injury, is further demonstrably relevant in extremity oncological reconstruction, especially as it can be performed remotely to the tumor location or resection site and introduces a healthy nerve or fascicle to rapidly reinnervate distal muscles without sacrificing major function. This study further illustrates the importance of early recognition and referral to specialist services where multi-disciplinary surgical resection and reconstructive planning can be conducted. LEVEL OF EVIDENCE: IV Clinical Case Series.

Muscle assessment in brachial plexus injury: A reliability study.

PURPOSE: Motor outcome following a brachial plexus injury is frequently measured to evaluate the success of surgical interventions. We aimed to identify whether the manual muscle testing using the Medical Research Council (MRC) method in adults with C5/6/7 motor weakness was reliable and whether its results correlated with functional recovery. METHODS: Two experienced clinicians examined 30 adults with C5/6/7 weakness following proximal nerve injury. The examination included using the modified MRC to assess motor outcome in the upper limb. Kappa statistics were calculated to evaluate inter-tester reliability. Correlation coefficients was calculated to explore the correlation between the MRC and the Disabilities of the Arm Shoulder and Hand (DASH) score and each EQ5D domain. RESULTS: We found that grades 3-5 of the modified and unmodified MRC motor rating scales have poor inter-rater reliability when assessing C5/6/7 innervated muscles in adults with a proximal nerve injury. The Deltoid Posterior and the Extensor Carpi Radialis Longus were the only muscles (using the modified MRC) to achieve a Kappa over 0.6 indicating substantial reliability. Higher combined MRC scores correlated significantly with a lower DASH and vice versa. Similarly, higher combined scores of MRC correlated significantly with a higher rating of overall health on the EQ5D VAS. CONCLUSIONS: This study demonstrates that the MRC motor rating scale has poor inter-rater reliability when assessing C5/C6/C7 innervated muscles in adults following proximal nerve injury. Other methods of assessing motor outcome following proximal nerve injury need to be considered.

Distal Entrapment of Regenerating Peripheral Nerves After a Proximal Injury: A Case Series and Review of the Literature.

A complication of peripheral nerve injuries, of which there exists limited discourse, is the entrapment of the nerve as it regenerates from the site of injury to its end target, resulting in the arrest of axon regeneration and a consequent reduction of functional recovery. This proof-of-concept paper reports a review of the relevant literature alongside a case series of patients who presented with this phenomenon and who were treated with targeted peripheral nerve decompression. Three cases were identified prospectively. The baseline function was recorded pre-and post-operatively. Recovery was assessed using various tools, including the Medical Research Council (MRC) motor grading, ten-test sensory testing, Tinel's sign progression, a visual analogue scale (VAS) for pain, and the Impact of Hand Nerve Disorders (I-HaND) patient-reported outcome measure (PROM). The first case sustained a brachial plexus injury and received decompression at the pronator fascia, carpal tunnel, cubital tunnel, and Guyon's canal. The second case sustained a sciatic nerve injury and was managed with peroneal and tarsal tunnel decompressions. The final case sustained a suprascapular nerve injury and underwent decompression at the suprascapular ligament. In all these cases, motor function, sensory function, and pain (depending on the nerve's original components) improved following decompression. A literature review revealed seven relevant studies, including four case reports, two cohort studies, and a pre-clinical animal study. These cases, and those identified in our review of the literature, suggest that targeted decompressive surgery can be an appropriate treatment for patients who display signs of stalled neural regeneration. This study adds to the limited evidence of this phenomenon and highlights the challenges in proving the efficacy of decompressive surgery for this specific complication. This study is limited by the number of cases included, the heterogeneity of nerve injuries presented, and its observational nature. There is a clear need for further research into this phenomenon, and the authors are working towards developing a prospective study that will investigate the indications, value, predictors of success, and practicality of decompression surgery for this complication of peripheral nerve injury.

High Median Nerve Paralysis: Is the Hand of Benediction or Preacher's Hand A Correct Sign?

High median nerve injuries are commonly presented in textbooks as adopting the typical posture of hand of benediction or preacher's hand. This study aimed to show that the hand of benediction or preacher's hand is incorrectly associated with a high median nerve paralysis. Methods: A retrospective review of four cases with a high median nerve injury is presented. Diagnosis of a high median nerve injury was performed by means of intraoperative findings, electrodiagnostic studies, or ultrasound imaging. None of the patients presented in this study had a hand of benediction on physical examination despite the presence of a high median nerve lesion. Results: All four patients with high median nerve injuries showed a similar hand posture when attempting to make a fist. Firstly, the index finger still flexed at the metacarpophalangeal joint because of the ulnar innervated interossei muscles. Secondly the thumb is completely abducted at the carpometocarpal joint and extended at the interphalangeal joint. Lastly, middle finger flexion is possible due to dual innervation of its flexor digitorum profundus by the ulnar nerve as well as due to the quadriga phenomenon. Conclusions: The clinical appearance of a high median nerve palsy is different from the classical hand of benediction or preacher's hand posture pointing finger. We have shown that this incorrect association can result in delayed referral of patients with high median nerve injuries.

Surgical Treatment of Peripheral Nerve Neuromas: A Systematic Review and Meta-Analysis.

BACKGROUND: Despite many treatment options available, no consensus on the optimal surgical management of symptomatic peripheral nerve neuroma has been reached. The aim of this systematic review and meta-analysis was to evaluate the effectiveness of different surgical techniques for treating painful neuromas and to help guide surgeons in electing optimal treatment. METHODS: Four databases (Embase, MEDLINE, Web of Science, and Cochrane Central) were searched. Studies that reported either numerical (visual analogue scale/numeric rating scale) or nonnumeric postoperative pain scores after surgical treatment of peripheral neuroma were identified. RESULTS: Thirty-two articles met the eligibility criteria and were analyzed for qualitative review. Thirty studies were included in qualitative analysis, for a total of 1150 neuromas. Surgical treatment of peripheral neuroma achieved good postoperative results in 70 percent of treated neuromas (95 percent CI, 64 to 77 percent). Proportions between techniques ranged between 60 and 92 percent. In a post hoc analysis, targeted muscle reinnervation (82 percent; 95 percent CI, 73 to 92 percent) performed significantly better than neurectomy ( p = 0.024). CONCLUSIONS: The choice of surgical management in treating symptomatic peripheral neuroma is challenging, yet surgical intervention achieves significant pain relief in the majority of cases. Targeted muscle reinnervation is promising for the management of painful neuromas.