Comparison of electrodiagnostic findings in acute traumatic versus chronic non-traumatic ulnar neuropathy at the elbow.

INTRODUCTION/AIMS: A common concept is that traumatic nerve injuries are more likely axonal, and that compressive neuropathies are more likely demyelinating. The purpose of this study was to compare traumatic versus non-traumatic ulnar neuropathy at the elbow (UNE) to look for electrodiagnostic differences between the two groups. METHODS: A retrospective 3 year review of UNE patients at two academic health science centers was conducted. Patients were grouped into acute traumatic UNE versus chronic non-traumatic UNE based on clinical history. Electrodiagnostic measurements were compared between the two groups. RESULTS: There were 50 subjects with acute traumatic UNE and 41 with chronic non-traumatic UNE. Mean age and sex distribution were similar but those with traumatic UNE had a 7 month duration of symptoms, while those with chronic UNE had 29 month duration (p < .001). All electrodiagnostic measurements were similar between the two groups including compound muscle action potential amplitudes, motor conduction velocities, frequency of conduction block, sensory nerve studies, and needle electromyography. DISCUSSION: We did not find a difference between the two groups. One should not make inferences regarding acuity or etiology based on electrodiagnostic features alone.

Postoperative ulnar neuropathy: a systematic review of evidence with narrative synthesis.

BACKGROUND: Postoperative ulnar neuropathy (PUN) is an injury manifesting in the sensory or motor distribution of the ulnar nerve after anaesthesia or surgery. The condition frequently features in cases of alleged clinical negligence by anaesthetists. We performed a systematic review and applied narrative synthesis with the aim of summarising current understanding of the condition and deriving implications for practice and research. METHODS: Electronic databases were searched up to October 2022 for primary research, secondary research, or opinion pieces defining PUN and describing its incidence, predisposing factors, mechanism of injury, clinical presentation, diagnosis, management, and prevention. RESULTS: We included 83 articles in the thematic analysis. PUN occurs after approximately 1 in 14 733 anaesthetics. Men aged 50-75 yr with pre-existing ulnar neuropathy are at highest risk. Preventative measures, based on consensus and expert opinion, are summarised, and an algorithm of suspected PUN management is proposed, based upon the identified literature. CONCLUSIONS: Postoperative ulnar neuropathy is rare and the incidence is probably decreasing over time with general improvements in perioperative care. Recommendations to reduce the risk of postoperative ulnar neuropathy are based on low-quality evidence but include anatomically neutral arm positioning and padding intraoperatively. In selected high-risk patients, further documentation of repositioning, intermittent checks, and neurological examination in the recovery room can be helpful.

Evaluation of neurological testing for hand-arm vibration syndrome.

BACKGROUND: The neurological component of hand-arm vibration syndrome (HAVS) uses the Stockholm Workshop Scale sensorineural (SWS SN) stages for classification. Proximal compressive neuropathies are common in HAVS and the symptoms are similar to SN HAVS. The SWS may not be a valid staging tool if a patient has comorbid proximal compression neuropathy. AIMS: To evaluate the prevalence of proximal compression neuropathy in patients presenting for HAVS assessment and examine the association between compressive neuropathies and SWS SN. METHODS: A standardized assessment protocol was used to assess 431 patients for HAVS at St. Michael's Hospital, Toronto, Ontario. The prevalence of median and ulnar compressive neuropathies was determined. The association between proximal compression neuropathies and SWS SN stage (0/1 versus 2/3) was evaluated using Chi-square and Fisher's exact tests as well as multivariable logistic regression. RESULTS: Most patients (79%) reported numbness and 20% had reduced sensory perception (SWS SN Stage 2/3). Almost half (45%) had median neuropathy at the wrist and 7% had ulnar neuropathy. There was no association between the SWS SN stage and median or ulnar neuropathy. CONCLUSIONS: Two neurological lesions should be investigated in patients presenting for HAVS assessment: compressive neuropathy and digital neuropathy. The prevalence of compressive neuropathies is high in patients being assessed for HAVS and therefore nerve conduction studies (NCS) should be included in HAVS assessment protocols. Comorbid proximal neuropathy does not affect the SWS SN stage; therefore, NCS and SWS SN seem to be measuring different neurological outcomes in HAVS patients.

Electrodiagnostic Predictors of Outcomes After In Situ Decompression of the Ulnar Nerve.

PURPOSE: Patients with severe ulnar neuropathy at the elbow frequently experience suboptimal surgical outcomes. Clinical symptoms alone may not accurately represent the severity of underlying nerve injury, calling for objective assessment tools, such as electrodiagnostic studies. The goal of our study was to determine whether specific electrodiagnostic parameters can be used to predict the outcomes after in situ decompression of the ulnar nerve. METHODS: This prospective study enrolled consecutive patients aged ≥18 years diagnosed with ulnar neuropathy at the elbow. Patients completed a baseline battery of motor, sensory, functional, and electrodiagnostic tests before undergoing in situ decompression of the ulnar nerve. They were reassessed at 6 weeks, 3 months, 6 months, and 12 months after surgery. Forty-two patients completed at least 2 follow-up assessments and were included in the study. RESULTS: When controlling for other electrodiagnostic measurements and demographic factors, none of the electrodiagnostic parameters were predictive of outcomes at 12 months after surgery. Patients with decreased compound muscle action potential amplitudes demonstrated slower trends of recovery in grip strength, pinch strength, and overall scores on the Michigan Hand Outcomes Questionnaire as well as its function, work, and activities of daily living subscales, Disabilities of the Arm, Shoulder, and Hand questionnaire, and the Carpal Tunnel Questionnaire. Decreased motor nerve conduction velocity was predictive of slower recovery of 2-point discrimination and pinch strength. CONCLUSIONS: Compound muscle action potential amplitude, but not other conventional electrodiagnostic parameters, was predictive of functional outcomes after in situ decompression of the ulnar nerve. This parameter should play a role in determining the timing and prognosis of treatment for ulnar neuropathy at the elbow. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Cutaneous silent period in ulnar neuropathy at the elbow.

INTRODUCTION/AIMS: The cutaneous silent period (CSP) reflects the function of A-delta sensory fibers. There are few studies on CSP in nerve entrapment syndromes. This study aims to evaluate the neurophysiological abnormalities of small-diameter sensory fibers in ulnar neuropathy at the elbow (UNE) by means of CSP. METHODS: We consecutively evaluated UNE patients at one electrodiagnostic laboratory. The CSP was obtained upon stimulating the fifth (D5) and third digits, recording from the first dorsal interosseous (FDI) and abductor pollicis brevis (APB) muscles. RESULTS: We enrolled 37 UNE patients (mean age 55.4 ± 11.2 y) and 30 controls (mean age 51.2 ± 11.1 y). The combinations of the D5-APB and D5-FDI mean onset latencies of CSP were significantly more prolonged in patients (83.7 ± 6.8 and 84.5 ± 8 ms, respectively) than in controls (78.2 ± 8.1 and 79.4 ± 7.6 ms, respectively). The D5-FDI duration of CSP was shorter in patients (52.2 ± 8.3 ms) than in controls (55.8 ± 7 ms). The mean of the onset latencies of D5-FDI and D5-APB was related to the clinical severity (P = .013 and .0025, respectively). D5-APB and D5-FDI onset latencies were more prolonged and the duration was shorter in the UNE group with absent ulnar sensory nerve action potentials (SNAPs) and axonal motor damage than in patients with preserved SNAPs and with demyelinating damage. DISCUSSION: CSP was able to demonstrate abnormalities of small-diameter myelinated sensory fibers. This damage was directly related to UNE severity and to axonal damage of motor fibers. Absence of a sensory large-diameter fiber response did not exclude preserved residual small fiber conduction.

Enhancing diagnostic accuracy using a side-to-side cross-sectional area ratio for the diagnosis of unilateral ulnar mononeuropathy at the elbow.

INTRODUCTION: Neuromuscular ultrasonography (NMUS) is a valuable adjunct to electrodiagnostic testing for the diagnosis of entrapment neuropathy. The aim of this study was to determine whether diagnostic accuracy of NMUS could be enhanced in patients with unilateral ulnar mononeuropathy at the elbow (UNE) by utilizing side-to-side ulnar nerve cross-sectional area (CSA) ratios. METHODS: Retrospective case-control analysis of unilateral UNE cases identified cutoff values for elbow segment ulnar nerve maximum CSA (MCSA) of the symptomatic/asymptomatic limb (M ratio), as well as side-to-side ratios comparing MCSA with ipsilateral CSA at the Guyon canal (E/G), middle forearm (E/F), and middle humerus (E/H). Diagnostic accuracy values were calculated. RESULTS: The optimal M-ratio cut-off was 1.22 (sensitivity, 92.9%; specificity, 97.8%; accuracy, 95.4%). Optimal cutoffs for inter-E/G, -E/F, and -E/H ratios were 1.07 (sensitivity, 98%; specificity, 78%; accuracy, 87.7%), 1.11 (sensitivity, 95%; specificity, 80%; accuracy, 87.2%), and 1.18 (sensitivity, 95%; specificity, 93%; accuracy, 94%), respectively. DISCUSSION: The M ratio and inter-E/H ratio exhibited high diagnostic accuracy for unilateral UNE. Prospective studies are needed to compare the accuracy of the new measures with a single MCSA measurement.

Perioperative Ulnar Neuropathy: A Contemporary Estimate of Incidence and Risk Factors.

BACKGROUND: Retrospective and prospective studies 2 decades ago from the authors' institution reported the incidence of perioperative ulnar neuropathy persisting for at least several months in a noncardiac adult surgical population to be between 30 and 40 per 100,000 cases. The aim of this project was to assess the incidence and explore risk factors for perioperative ulnar neuropathy in a recent cohort of patients from the same institution using a similar definition for ulnar neuropathy. METHODS: We performed a retrospective incidence and case-control study of all adults (≥18 years) undergoing noncardiac procedures with anesthesia services between 2011 and 2015. Each incident case of persistent ulnar neuropathy within 6 months of surgery was matched by age, sex, procedure date, and procedure type to 5 surgical patient controls. For the case-control study, separate conditional logistic regression analyses were performed to assess specific risk factors including the patient's body position and arm position, as well as body mass index (BMI), surgical duration, and selected patient comorbidities. RESULTS: Persistent ulnar neuropathy of at least 2 months duration was found in 22 of 324,124 anesthetics for patients who underwent these procedures during the study period for an incidence rate of 6.8 (95% confidence interval [CI], 4.3-10.3) per 100,000 anesthetics. The incidence of ulnar neuropathy was higher in men compared to women (10.7 vs 3.0 per 100,000; P = .016). From the matched case-control study, the odds of ulnar neuropathy increased with higher BMI (odds ratio [OR] = 1.67 [1.16-2.42] per 5 kg/m2 increase in BMI; P = .006), history of cancer (OR = 6.46 [1.64-25.49]; P = .008), longer procedures (OR = 1.53 [1.18-1.99] per hour; P = .001), and when 1 or both arms were tucked during surgery (OR = 6.16 [1.85-20.59]; P = .003). CONCLUSIONS: The incidence of persistent perioperative ulnar neuropathy observed in this study was lower than the incidence reported 2 decades ago from the same institution and using a similar definition for ulnar neuropathy. Several of the previously reported risk factors continue to be associated with the development of persistent perioperative ulnar neuropathy, providing ongoing targets for practice changes that might further decrease the incidence of this problem.

Diagnostic values of conventional conduction parameters in ulnar neuropathy at elbow.

BACKGROUND AND PURPOSE: Conventional parameters used in electrodiagnosis of ulnar neuropathy at elbow (UNE) are: (i) absolute across-elbow ulnar nerve motor conduction velocity (MCV), (ii) reduction rate of composed muscle action potential (CMAP) amplitude from above to below elbow stimulation, and (iii) MCV difference between forearm and across-elbow segment. We aimed to search the diagnostic accuracy values of these parameters on UNE, and their correlations with axonal dysfunction of ulnar nerve fibers. METHODS: Arms with clinical signs of UNE and two-fold healthy controls were included. We detected the best cut off points of the measured parameters and their possible combinations. Their diagnostic accuracy values and correlations with parameters reflecting the axonal functions were analyzed, statistically. RESULTS: Totally, 118 arms with UNE and 236 controls were included. Absolute across-elbow MCV yielded a higher accuracy than MCV difference and reduction rate of CMAP amplitude (p = 0.010 and p˂0.001, respectively). Besides, combining it with other parameters did not increase the diagnostic yield. Correlation analyses revealed that the only parameter having positive linear correlations with sensory nerve action potential amplitudes both in the control and the disease groups is the absolute across-elbow MCV. The absolute across-elbow MCVs have also positive linear correlation with CMAP amplitudes in disease group. CONCLUSION: The absolute across-elbow MCV is the most valuable conventional parameter for the electrodiagnosis of UNE. It is also the most correlated parameter with the electrodiagnostic parameters reflecting the axonal functions of the ulnar nerve fibers.

An electrodiagnostic grading system for ulnar neuropathy at the elbow.

INTRODUCTION: Ulnar neuropathy at the elbow (UNE) is the second most common entrapment neuropathy. Our goal was to create and analyze a grading system for UNE electrodiagnostic severity. METHODS: We retrospectively analyzed EMG reports with UNE. We then classified 112 limbs as having mild, moderate, or severe grade UNE based on electrodiagnostic findings. The association between presenting symptoms and signs, EMG findings, treatment type, and electrodiagnostic grade was statistically analyzed. RESULTS: Seventeen limbs (15.2%) had mild, 80 (71.4%) had moderate, and 15 (13.4%) had severe UNE. Symptoms (P = .016), exam findings (P < .001), and treatment type (P = .043) were significantly associated with electrodiagnostic grade. DISCUSSION: Our UNE grading system was significantly related to symptoms, physical exam, and treatment selection and may be useful to measure electrodiagnostic severity.

Epithelioid Hemangioendothelioma of the Ulnar Artery Presenting with Neuropathy.

We present a rare case of epithelioid hemangioendothelioma arising from the wall of ulnar artery in distal forearm. The presentation was interesting in a 34-year-old man, with progressively worsening symptoms of ulnar neuropathy. A mass was seen arising from the ulnar artery on imaging with ultrasound and magnetic resonance imaging. Soft tissue epithelioid hemangioendothelioma in extremities almost always arise from the veins. Existing literature do not have elaborated imaging findings of epithelioid hemangioendothelioma arising from the arterial wall. The aim of this paper is to briefly review the interesting presentation and imaging features of this rare entity. Knowledge of such vascular tumor would avoid the mishap during surgery. Our case will add an interesting presentation of such rare pathology to the existing literature.

The external elbow measure as surrogate of the anatomical width of cubital groove and possible risk factor of ulnar neuropathy at the elbow.

Introduction: There are no studies on elbow anthropometry in ulnar neuropathy at the elbow (UNE). We aimed to test the interrater agreement of external elbow measurements with caliper, the matching of external width of cubital groove (WCG) measures with those obtained through conventional radiography (XR) and ultrasonography (US). The final aim was to evaluate the differences of anthropometric elbow and body measures between UNE cases and controls with multicenter prospective study.Materials and methods: After common training of five observers for external elbow and body anthropometric measurements, we assessed the interrater agreement of measures in a single blind measurement session in 16 healthy volunteers. Then we verified if external WCG measures in eight and four of the above 16 subjects matched with those obtained with US and XR. Finally, we enrolled 40 consecutive idiopathic UNE cases in four electromyographic labs matched for sex and age with 40 controls to evaluate the differences of anthropometric measures.Results: There was high interrater agreement of all anthropometric body and elbow measures (Kendal's and interclass correlation coefficients between 0.84 and >0.9). We found high relations between WCG caliper measures and those obtained with US and XR (r > 0.9). WCG was smaller in cases than in controls (13.2 vs.15.7 mm, p < 0.001). There were no differences in body anthropometric measures (BMI and waist-to-hip ratio).Conclusion: The external measurement of WCG is reliable and reproducible and may be risk factor of UNE. Future studies should be performed in lager samples evaluating the relations with lifestyle and occupational factors.

The needle electromyography findings in the neurophysiological classification of ulnar neuropathy at the elbow

Background/aim: Although ulnar neuropathy at the elbow (UNE) is the second most common entrapment mononeuropathy, there are few reports on its neurophysiological classification. In this study, we tried to find out the role of needle electromyography (EMG) in the neurophysiological classification of UNE. Materials and methods: UNE patients who met the clinical and neurophysiological diagnostic criteria and healthy individuals were included in this study. Reference values of nerve conduction studies were obtained from healthy individuals. Needle EMG was performed to all UNE patients. According to the neurophysiological classification proposed by Padua, UNE patients were classified as mild, moderate, and severe. Results: Thirty-one controls and thirty-five UNE patients were included in the study. There was mild UNE in 23 patients, moderate UNE in 8, and severe UNE in 4. Abnormal needle EMG findings were present in all patients with moderate and severe UNE and in 12 patients with mild UNE. Conclusion: Abnormal needle EMG findings are seen in most of the UNE patients. Therefore, it is not practical to use needle EMG findings in the neurophysiological classification. Needle EMG abnormalities may also be present in patients with mild UNE due to axonal degeneration or motor conduction block.

Short segment sensory nerve stimulation in suspected ulnar neuropathy at the elbow: A pilot study.

INTRODUCTION: Routine ulnar nerve conduction studies may be normal in very mild ulnar neuropathies at the elbow (UNE). Short segment ulnar sensory stimulation across the elbow may detect mild abnormalities in these cases. METHODS: Short segment ulnar sensory nerve stimulation was performed in 20 controls and 15 patients with clinically suspected mild UNE. Greatest peak latency shift and amplitude drop between 2 adjacent stimulation sites were calculated. RESULTS: The upper limit of normal for peak latency shift and amplitude reduction between sites was 0.7 ms and 15%, respectively. Abnormal latency shift was detected in 12 of 15 patients and focal sensory conduction block in 6 of 15 patients. In 5 of 7 patients in whom all other studies were normal, sensory inching was abnormal. DISCUSSION: Ulnar sensory short segment stimulation may provide diagnostic confirmation and localization of the site of nerve compression in mild UNE, and may improve UNE detection when all other studies are normal. Muscle Nerve 59:125-129, 2019.

Diagnostic Accuracy of Sensory Clinical Findings of the Hand Dorsum and of Neurography of the Dorsal Ulnar Cutaneous Nerve in Ulnar Neuropathy at the Elbow.

OBJECTIVE: The main objective is to investigate the diagnostic accuracy and the relation of touch sensation and subjective sensory symptoms in the medial aspect of the hand dorsum, and neurography of the dorsal ulnar cutaneous nerve (DUCN) in ulnar neuropathy at the elbow (UNE). Secondary objective is to report the electrophysiological occurrence of anatomical variant of sensory innervation of the medial aspect of the hand dorsum from superficial radial nerve (SRN). DESIGN: Prospective, cohort study. SETTING: Electromyography laboratory. PARTICIPANTS: Consecutive participants (N=282), those with UNE (n=81) and those without UNE (n=201), were enrolled. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Accuracy and agreement between sensory clinical findings of the medial hand dorsum and neurography of DUCN in UNE diagnosis. RESULTS: DUCN neurographic and sensory findings had high specificity and relatively low sensitivity. Normal or abnormal sensory nerve action potential (SNAP) of DUCN matched with normal or abnormal touch sensation of the medial aspect of hand dorsum. Abnormal DUCN SNAP was related to the clinical severity of UNE and to the axonal damage of the ulnar nerve. Anatomical variant of the innervation of hand dorsum from SRN was demonstrated in 31 of 564 hands (6.2%) belonging to 26 of 282 participants (9.2%). If the variant was present, DUCN SNAP of the same side was more frequently absent or of low amplitude. CONCLUSIONS: The utility of DUCN neurography and sensory findings of the medial aspect of the dorsum of the hand is limited in the diagnosis of UNE. However, if DUCN SNAP is absent or low in amplitude, it is advisable to check the presence of the anatomical variant of the innervation of the medial aspect of the hand dorsum from SRN.

Predictive value of metacarpophalangeal stabilization tests for simulated ulnar nerve lesion measured by a sensor glove.

STUDY DESIGN: A within-subject research design was used in this study. The difference of the range of motion (ROM) with and without ulnar nerve block was analyzed. INTRODUCTION: For the clinical evaluation of the functional effects of ulnar nerve palsy at the hand the relevance of clinical tests is in discussion. PURPOSE OF THE STUDY: The aim of the study was to evaluate the predictive value of 2 clinical tests for a simulated ulnar nerve lesion by motion analysis with a sensor glove. METHODS: In 28 healthy subjects, dynamic measurements of the finger joints were performed by a sensor glove with and without ulnar nerve block at the wrist. In the 0° metacarpophalangeal (MCP) stabilization test, the subjects were asked to stabilize the MCP joints actively in 0° while moving the interphalangeal joints, whereas at the 90° MCP stabilization test, the subjects stabilized the MCP joints actively in the 90° position. RESULTS: In the 0° MCP stabilization test, no remarkable changes of the ROM were found at the MCP joints; at the proximal interphalangeal joints 2-5, the ROM decreased with ulnar nerve block, significantly at the index, middle, and ring fingers (P < .05). In the 90° MCP stabilization test, the average ROM of the MCP joints 2-5 significantly increased with ulnar nerve block (P < .05), whereas at the PIP joints, the average ROM decreased (P < .05). DISCUSSION: The 90° MCP stabilization test had a high predictive value for the discrimination between healthy subjects and subjects with a simulated peripheral ulnar nerve lesion. CONCLUSIONS: The results could be relevant for the determination of the functional effect of ulnar nerve palsy and the quantification of clawing in hand rehabilitation. LEVEL OF EVIDENCE: II.

Neurologic examination and instrument-based measurements in the evaluation of ulnar neuropathy at the elbow.

INTRODUCTION: The aim of the study was to compare the utility of instrument-based assessment of peripheral nerve function with the neurologic examination in ulnar neuropathy at the elbow (UNE). METHODS: We prospectively recruited consecutive patients with suspected UNE, performed a neurologic examination, and performed instrument-based measurements (muscle cross-sectional area by ultrasonography, muscle strength by dynamometry, and sensation using monofilaments). RESULTS: We found good correlations between clinical estimates and corresponding instrument-based measurements, with similar ability to diagnose UNE and predict UNE pathophysiology. DISCUSSION: Although instrument-based methods provide quantitative evaluation of peripheral nerve function, we did not find them to be more sensitive or specific in the diagnosis of UNE than the standard neurologic examination. Likewise, instrument-based methods were not better able to differentiate between groups of UNE patients with different pathophysiologies. Muscle Nerve 57: 951-957, 2018.

Optimal Measurement Level and Ulnar Nerve Cross-Sectional Area Cutoff Threshold for Identifying Ulnar Neuropathy at the Elbow by MRI and Ultrasonography.

PURPOSE: Imaging criteria for diagnosing compressive ulnar neuropathy at the elbow (UNE) have recently been established as the maximum ulnar nerve cross-sectional area (UNCSA) upon magnetic resonance imaging (MRI) and/or ultrasonography (US). However, the levels of maximum UNCSA and diagnostic cutoff values have not yet been established. We therefore analyzed UNCSA by MRI and US in patients with UNE and in controls. METHODS: We measured UNCSA at 7 levels in 30 patients with UNE and 28 controls by MRI and at 15 levels in 12 patients with UNE and 24 controls by US. We compared UNCSA as determined by MRI or US and determined optimal diagnostic cutoff values based on receiver operating characteristic curve analysis. RESULTS: The UNCSA was significantly larger in the UNE group than in controls at 3, 2, 1, and 0 cm proximal and 1, 2, and 3 cm distal to the medial epicondyle for both modalities. The UNCSA was maximal at 1 cm proximal to the medial epicondyle for MRI (16.1 ± 3.5 mm2) as well as for US (17 ± 7 mm2). A cutoff value of 11.0 mm2 for MRI and US was found to be optimal for differentiating between patients with UNE and controls, with an area under the receiver operating characteristic curve of 0.95 for MRI and 0.96 for US. The UNCSA measured by MRI was not significantly different from that by US. Intra-rater and interrater reliabilities for UNCSA were all greater than 0.77. The UNCSA in the severe nerve dysfunction group of 18 patients was significantly larger than that in the mild nerve dysfunction group of 12 patients. CONCLUSIONS: By measuring UNCSA with MRI or US at 1 cm proximal to the ME, patients with and without UNE could be discriminated at a cutoff threshold of 11.0 mm2 with high sensitivity, specificity, and reliability. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic III.

A novel points system to predict the prognosis of ulnar neuropathy at the elbow.

INTRODUCTION: In this study we aimed to identify prognostic factors of ulnar neuropathy at the elbow (UNE) and developed a scoring system to establish the prognosis. METHODS: We collected baseline clinical, electrophysiologic, and ultrasonographic data from 2 cohorts. The outcomes for all patients were determined on follow-up. Prognostic factors were determined using single and multiple variable analyses. A points system was developed to determine the risk for an unfavorable outcome. RESULTS: Of the 220 patients with UNE 178 (81%) could be re-evaluated. Four variables were retained in the prediction model for a points system. An unfavorable outcome was associated with right-sided UNE, more severe weakness of the abductor digiti minimi (ADM), and more pronounced ulnar nerve thickening. A compound muscle action potential amplitude reduction across the elbow of ≥16% (particularly if ≥ 50%) was associated with a more favorable outcome. CONCLUSION: Outcome in UNE may be predicted by scoring 4 parameters. Muscle Nerve 55: 698-705, 2017.

Occupation-based intervention versus rote exercise in modified constraint-induced movement therapy for patients with median and ulnar nerve injuries: a randomized controlled trial.

OBJECTIVE: To investigate effect of practice type during modified constraint-induced movement therapy on hand function in patients with chronic median and ulnar nerve injuries. DESIGN: A prospective, single-blinded, randomized controlled clinical trial. SETTING: Participants' private home. SUBJECTS: A convenience sample of 36 outpatient participants allocated randomly to three equal groups. INTERVENTIONS: Intervention groups underwent 3-hour intensive training of affected hand each day, 3-day a week, 4-week in association with immobilisation of healthy hand: occupation-based group practiced meaningful occupations while rote exercise-based group performed rote exercises during constraint-induced movement therapy. Control group performed different activities with affected hand for 1.5-hour each day during 4-week without restriction of healthy hand. MAIN MEASURES: A blinded assessor tested Canadian occupational performance measure, box and block, Static two-point discrimination, disabilities of arm, shoulder, hand questionnaire, and self-assessment manikin in a random order across sessions 3-time as baseline (pre-test), after 4-week intervention (post-test), and 1-month after intervention period (follow up). RESULTS: Scores significantly changed in intervention groups compared to control. Despite significantly more improvement in occupation-based than rote exercise-based group in subjective measures at post-test and follow up (Canadian occupational performance measure: mean change 4.7 vs. 2.1 for performance, P< 0.001 and mean change 5.3 vs. 2.6 for satisfaction, P< 0.001), it was significant just at follow up for box and block and static two-point discrimination. CONCLUSIONS: Practice content of constraint-induced movement therapy is a critical part of its effectiveness on improving outcomes following peripheral nerve repair in favour of occupation-based intervention in present study.

Anterior subcutaneous transposition for persistent ulnar neuropathy after neurolysis.

OBJECTIVE Little is known about optimal treatment if neurolysis for ulnar nerve entrapment at the elbow fails. The authors evaluated the clinical outcome of patients who underwent anterior subcutaneous transposition after failure of neurolysis of ulnar nerve entrapment (ASTAFNUE). METHODS A consecutive series of patients who underwent ASTAFNUE performed by a single surgeon between 2009 and 2014 was analyzed retrospectively. Preoperative and postoperative complaints in the following 3 clinical modalities were compared: pain and/or tingling, weakness, and numbness. Six-point satisfaction scores were determined on the basis of data from systematic telephonic surveys. RESULTS Twenty-six patients were included. The median age was 56 years (range 22-79 years). The median duration of complaints before ASTAFNUE was 23 months (range 8-78 months). The median interval between neurolysis and ASTAFNUE was 11 months (range 5-34 months). At presentation, 88% of the patients were experiencing pain and/or tingling, 46% had weakness, and 50% had numbness of the fourth and fifth fingers. Pain and/or tingling improved in 35%, motor function in 23%, and sensory disturbances in 19% of all the patients. Improvement in at least 1 of the 3 clinical modalities was found in 58%. However, a deterioration in 1 of the 3 modalities was noted in 46% of the patients. On the patient-satisfaction scale, 62% reported a good or excellent outcome. Patients with a good/excellent outcome were a median of 11 years younger than patients with a fair/poor outcome. No other factor was significantly related to satisfaction score. CONCLUSIONS A majority of the patients were satisfied after ASTAFNUE, even though their symptoms only partly resolved or even deteriorated. Older age is a risk factor for a poor outcome. Other factors that affect outcome might play a role, but they remain unidentified. One of these factors might be earlier surgical intervention. The modest results of ASTAFNUE should be mentioned when counseling patients after failure of neurolysis of ulnar nerve entrapment to manage their expectations. Patients, especially those who are elderly, might even consider not undergoing a secondary procedure. A randomized trial that includes a conservative treatment group and groups undergoing one of the several possible surgical procedures is needed to find the definitive answer for this clinical problem.