Pronator syndrome and anterior interosseous nerve palsy due to neurolymphomatosis: a case report.

Pronator syndrome is a median nerve entrapment neuropathy that can be difficult to diagnose due to its variable presentation and objective findings. Neurolymphomatosis is an uncommon disease in which malignant lymphocytes infiltrate central or peripheral nerve endoneurium and is often missed for prolonged periods prior to diagnosis. We present a rare case of pronator syndrome and anterior interosseous nerve palsy due to neurolymphomatosis that was occult on initial MRI in spite of the presence of a median nerve mass discovered intra-operatively during neurolysis. This case demonstrates the value of ultrasound for the examination of peripheral nerve pathology and illustrates its utility as an adjunct to MRI, in part due to the ability to screen a large region.

SARS-COV-2 INFECTION AND INVOLVEMENT OF PERIPHERAL NERVOUS SYSTEM: A CASE SERIES OF CARPAL TUNNEL SYNDROME AGGRAVATION OR NEW ONSET WITH COVID-19 DISEASE AND A REVIEW OF LITERATURE.

COVID-19 may be asymptomatic or have a typical presentation with fever, cough, anosmia, lymphocytopenia. In some cases, it occurs with a "chimeric" presentation, with more subtle and ambiguous symptoms which may be initially misdiagnosed and are referred to in long covid condition. A possible central and peripheral nervous system involvement has been recognized. We present our experience and review the literature about association between carpal tunnel syndrome (CTS) and hand's arthritis presenting a case series of patients who firmly state that their condition of CTS arised or got worse during a typical presentation of COVID-19. The outbreak of COVID-19 has resulted in significant global healthcare implications. While the respiratory manifestations of COVID-19 have been widely studied, there is emerging evidence suggesting potential associations between COVID-19 and various other health conditions. This review of the literature aims to investigate the potential relationship between COVID-19 and the development or exacerbation of CTS. By synthesizing the available literature on this topic, we aim to provide a comprehensive overview of the current knowledge and enhance our understanding of the potential implications of COVID-19 on CTS. Case series: In this article we report 13 cases of typical presentations of COVID-19 with fever, myalgia, and respiratory system involvement, with a simultaneous aggravation of the median nerve pre-existing neuralgia and some cases that developed a median nerve neuralgia during COVID-19, which came to the attention of the hand surgeon. Some cases had stable symptomatic CTS and were on waiting list for surgical carpal tunnel release, some cases were previously asymptomatic and developed a median nerve neuralgia during COVID-19. All patients referred to a rapid worsening of acral paraesthesia and neuralgic pain of the same quality of CTS and in the median nerve topography. Some patients developed typical COVID-19 symptoms and died; the others were surgically treated. CTS could be an atypical presentations of COVID-19 or a condition of long-covid disease and clinical and epidemiological significance needs to be fully studied. We presented cases of worsening of the median nerve neuralgia which presented among other symptoms of COVID infection. We conclude a causal relation may exist and needs to be further investigated.

General Anxiety Is Associated with Problematic Initial Recovery After Carpal Tunnel Release.

BACKGROUND: Carpal tunnel release can stop the progression of idiopathic median neuropathy at the wrist (carpal tunnel syndrome). Intermittent symptoms tend to resolve after surgery, but loss of sensibility can be permanent. Both pathophysiology (severe neuropathy) and mental health (symptoms of despair or worry) contribute to problematic recovery after carpal tunnel release, but their relative associations are unclear. QUESTION/PURPOSE: Is problematic initial recovery after carpal tunnel release associated with psychologic distress rather than with disease severity? METHODS: We retrospectively studied 156 patients who underwent in-office carpal tunnel release between November 2017 and February 2020, and we recorded their symptoms of anxiety (Generalized Anxiety Disorder-7 [GAD]) and depression (Patient Health Questionnaire), signs of severe median neuropathy (loss of sensibility, thenar muscle atrophy, and palmar abduction weakness), and problematic recovery. The initial recovery (first 2 weeks) was categorized as problematic if the patient was upset about persistent numbness, experienced unsettling postoperative pain, developed hand stiffness, or experienced wound issues-all of which are routinely recorded in the medical record by the treating surgeon along with signs of severe median neuropathy. Twenty-four percent (38 of 156) of patients had a problematic initial recovery characterized by distress regarding persistent numbness (16% [25 of 156]), unsettling pain (8% [12 of 156]), hand stiffness (5% [8 of 156]), or wound issues (1% [2 of 156]); 6% (9 of 156) of patients had more than one issue. Associations between problematic initial recovery and age, gender, symptoms of anxiety and depression, disease severity, specific exam findings, and insurance were evaluated using t-tests, Mann-Whitney tests, and chi-square tests, with the plan to perform logistic regression if at least two variables had an association with p < 0.10. RESULTS: The only factor associated with problematic initial recovery was greater symptoms of anxiety (median GAD score 1.5 [interquartile range 0 to 7.8] for problematic initial recovery compared with a median score of 0 [IQR 0 to 2] for nonproblematic recovery; p = 0.04), so we did not perform a logistic regression. Physical examination findings consistent with severe median neuropathy were not associated with problematic initial recovery. CONCLUSION: The finding that problematic initial recovery after carpal tunnel release was related to symptoms of anxiety and not to the severity of median neuropathy highlights the need to study the ability of efforts to ameliorate anxiety symptoms before carpal tunnel release as an effective intervention to reduce unplanned visits and additional tests, therapy, and repeat surgery, while improving patient-reported outcomes and experience. LEVEL OF EVIDENCE: Level III, therapeutic study.

Ultrasound-Guided Perineural Injection for Pronator Syndrome Caused by Median Nerve Entrapment.

Patients and physicians have increasingly sought minimally invasive procedures such as ultrasound-guided injection for the treatment of peripheral nerve entrapment syndromes. In this series, we assessed subjective outcome data in 14 patients who underwent ultrasound-guided perineural hydrodissection and steroid injection for pronator syndrome secondary to median nerve entrapment in the pronator tunnel. Excellent symptomatic relief (≥75% improvement) was achieved in 70% of nerves with 3-month follow-up data, with no significant change in symptoms between 3 and 6 months. These outcomes suggest that this technique could play a role in the management of pronator syndrome due to median nerve entrapment.

Low-grade fibromyxoid sarcoma arising within the median nerve.

We report a case of low-grade fibromyxoid sarcoma arising within the median nerve. A 31-year-old woman presented with symptoms of carpal tunnel syndrome and an enlarging mass in her right palm over 1 year. MRI demonstrated a mass associated with the right median nerve with solid and cystic components. At surgery, the mass was located within the epineurium, could be bluntly dissected from the nerve fascicles, and was suspected to be a schwannoma. A 3.4 cm, tan-pink, glistening, smooth, homogenous mass was submitted to pathology. Microscopically, the tumor was a solid and cystic circumscribed nodule with a dense fibrous pseudocapsule. The tumor cells were uniformly bland and spindle-shaped, with small, hyperchromatic oval nuclei and were embedded in an alternating fibrous and myxoid stroma with a prominent curvilinear vasculature and perivascular sclerosis. The differential diagnosis for this lesion included myxoid neurofibroma, schwannoma, soft tissue perineurioma, low-grade malignant peripheral nerve sheath tumor and low-grade fibromyxoid sarcoma. The tumor cells expressed MUC4, GLUT-1, and vimentin and were negative for S-100 protein, epithelial membrane antigen, smooth muscle actin, desmin, claudin-1, neurofilament and SOX10. Fluorescence in situ hybridization, with a break-apart probe strategy, demonstrated FUS rearrangement, consistent in this morphological context with the low-grade fibromyxoid sarcoma-associated FUS-CREB3L2 or FUS-CREB3L1 fusions. Low-grade fibromyxoid sarcoma is exceptionally rare in the peripheral nerve, with only a single previously reported case. Nonetheless, as our case illustrates, this entity must be included in the differential diagnosis of unusual intraneural mesenchymal tumors. As in all other locations, intraneural low-grade fibromyxoid sarcomas should be excised with negative margins. Patients with this disease require long-term clinical follow-up, given this tumor's propensity for very late distant metastases to the lungs and other sites.

Quantification of weakness caused by distal median nerve lesion by dynamometry.

INTRODUCTION: In the assessment of hand and upper limb function, grip strength is of major importance. Use of the JAMAR dynamometer has been an accepted test of grip strength and routinely part of the physical examination. PURPOSE OF THE STUDY: The aim of this study was to determine by means of a median nerve block simulating a patient group if the measurement of different types of grip force can improve the quantification of impairment of the hand beyond the sole power grip measurements. METHODS: In 29 healthy volunteers, grip force measurement was done by the JAMAR dynamometer for power grip and by a pinch grip dynamometer for pincer grip, precision grip, pinch grip, and palmar abduction. At the power grip, the force of digit 2-5 was measured separately by a sensor glove. For each measurement, 3 trials were recorded subsequently. STUDY DESIGN: A within-subject research design was used in this prospective study. Each subject served as the control by preinjection measurements of grip and pinch strength. Subsequent measurements after median nerve block were used to examine within-subject change. RESULTS: In power grip, there was no significant reduction of maximum grip force with median nerve block compared with grip force without block. By measuring the finger forces by a sensor glove, a reduction of force at the individual fingers was found compared with the setting with no block, although significant only at the middle finger (P < .017). With median nerve block, average grip force decreased significantly 20% in pincer grip (P < .021), 29.5% in pinch grip (P < .002), 39.5% in precision grip (P < .001), and 70.7% in palmar abduction (P < .013). CONCLUSIONS: These experiments suggest a minor role of the measurement of the power grip force in the diagnostics of distal median nerve block with the dynamometer, which could not be substantially improved by the digit forces and the force distribution of the individual fingers. The assessment of other grip forms, such as pincer grasp, precision grip, pinch grip, and especially palmar abduction, leads to a relevant improvement in the diagnostics of distal median nerve lesion. LEVEL OF EVIDENCE: II.

[Diagnostic ability of power measurement of different grip forms for distal median nerve lesion]. / Stellenwert der Kraftmessung verschiedener Greifformen zur Diagnostik der peripheren Medianusläsion.

BACKGROUND: Peripheral lesions of the median nerve cause characteristic changes of the grip function of the hand. For evaluating grip force changes, measurement by dynamometers (JAMAR dynamometer and pinch dynamometer) is of high relevance. In this study the ability of grip force measurements of different grip forms was evaluated to discriminate between a simulated median nerve lesion and healthy subjects. MATERIAL AND METHODS: In 21 healthy subjects, the grip force of power grip was measured by the JAMAR dynamometer at the second stage including measurement of force at the fingertips and the thenar by a sensor glove. With a pinch dynamometer the power of palmar abduction, precision grip, pincer grip and pinch grip was determined. Measurements were performed with and without median nerve block at the wrist. RESULTS: In power grip of the JAMAR dynamometer at the second stage a significant reduction of the grip force of 13.4% was found (p < 0.03). The power distribution between the fingers D2-D5 did not change with median nerve block. The most relevant reduction of grip force in median nerve block compared with the healthy control was measured in palmar abduction (72.1%, p < 0.0002), followed by precision grip 31.0% (p < 0.0001), pincer grip 23.6% (p < 0.0004) and pinch grip 18.8% (p < 0.0002). CONCLUSIONS: For the discrimination between healthy subjects and subjects with a median nerve block there was a limited relevance of the measurement of the power grip and force distribution at the fingers by the JAMAR dynamometer. However, the best distinction was observed by dynamometric measurement of other grips than power grip, such as palmar abduction, precision grip, pincer grip and pinch grip. The results could be relevant for the clinical diagnostics and rehabilitation of median nerve lesion, complementing the widespread measurement of the power grip by other grip forms.

Median nerve penetration by a persistent median artery and vein mimicking carpal tunnel syndrome.

INTRODUCTION: Carpal tunnel syndrome (CTS) is a common clinical syndrome seen in the outpatient setting that is easily confirmed by electrodiagnostic testing. METHODS: We describe the case of a patient who presented with the classic symptoms and neurological examination for CTS, but had a normal nerve conduction study and electromyogram. RESULTS: Neuromuscular ultrasound of the median nerve on the symptomatic side revealed penetration of the nerve by a persistent median artery and vein in the mid-forearm, with a positive sonographic Tinel sign over this spot. This finding is an anatomical variation that has been described sparingly in the literature, mostly in cadavers. It has not been reported previously to be a mimic of CTS. CONCLUSIONS: This case demonstrates the diagnostic utility of neuromuscular ultrasound and the importance of considering an anatomical variation involving the median nerve in the differential diagnosis of CTS.

Sensory perturbations using suture and sutureless repair of transected median nerve in rats.

The effects of changes to cold, mechanical, and heat thresholds following median nerve transection with repair by sutures (Su) or Rose Bengal adhesion (RA) were compared to sham-operated animals. Both nerve-injured groups showed a transient, ipsilateral hyposensitivity to mechanical and heat stimuli followed by a robust and long-lasting hypersensitivity (6-7 weeks) with gradual recovery towards pre-injury levels by 90 days post-repair. Both tactile and thermal hypersensitivity were seen in the contralateral limb that was similar in onset but differed in magnitude and resolved more rapidly compared to the injured limb. Prior to injury, no animals showed any signs of aversion to cold plate temperatures of 4-16 °C. After injury, animals showed cold allodynia, lasting for 7 weeks in RA-repaired rats before recovering towards pre-injury levels, but were still present at 12 weeks in Su-repaired rats. Additionally, sensory recovery in the RA group was faster compared to the Su group in all behavioural tests. Surprisingly, sham-operated rats showed similar bilateral behavioural changes to all sensory stimuli that were comparable in onset and magnitude to the nerve-injured groups but resolved more quickly compared to nerve-injured rats. These results suggest that nerve repair using a sutureless approach produces an accelerated recovery with reduced sensorimotor disturbances compared to direct suturing. They also describe, for the first time, that unilateral forelimb nerve injury produces mirror-image-like sensory perturbations in the contralateral limb, suggesting that the contralateral side is not a true control for sensory testing. The potential mechanisms involved in this altered behaviour are discussed.

Impacts of elevated glycaemic haemoglobin and disease duration on the sensorimotor control of hands in diabetes patients.

BACKGROUND: To understand the impacts of disease chronicity and hyperglycaemia on sensorimotor control of hands of diabetic patients, this study investigated the differences in hand sensation, strength and motor control by applying the pinch-holding-up activity test for patients with diabetes mellitus (DM) with different levels of glycaemic control and disease chronicity. METHODS: One hundred and fifty-nine patients with clinically defined DM were included. Semmes-Weinstein monofilament, static two-point discrimination and moving two-point discrimination, maximal pinch strength precision pinch performance tests and nerve conduction studies (NCS) of the subjects were carried out. Forty-seven (29.6%) patients were in the HbA(1c) < 7% category, and 112 (70.4%) patients were in the >7% group. There were 87 (54.7%) patients with the disease duration <10 years, and 72 (45.3%) patients with disease duration ≧10 years. RESULTS: The severity of hyperglycaemia significantly impacts the results for Semmes-Weinstein monofilament, precision pinch force control, sensory and motor NCS tests (p < 0.05). In addition, the chronicity of disease influences the motor control of precision pinch performance and the amplitude of motor NCS (p < 0.05) for the diabetes patients. CONCLUSIONS: The evidence suggests that disease chronicity and hyperglycaemia have impacts on sensorimotor control in the hands of DM patients. In addition, the efficiency of prehensile forces of hand-to-object interactions in the pinch-holding-up activity test could be significant for identifying hand function, as well as pathologic changes in median nerve function, for patients with DM.

Asymptomatic Lambert-Eaton syndrome.

INTRODUCTION: All descriptions of the Lambert-Eaton syndrome are based on symptomatic patients. We incidentally encountered electromyographic evidence of this syndrome in a patient being studied for another reason. The patient had controlled hypothyroidism and smoked for 9 pack-years but never had symptoms of weakness or had evidence of cancer. METHODS: Detailed electrophysiological and serological evaluations were undertaken in this study. RESULTS: Neuromuscular transmission tests were consistent with a presynaptic disorder. Autoantibodies specific for P/Q-type voltage-gated calcium channels (VGCC) were detected in the serum and persisted throughout 7 years of follow-up. Multiple IgG markers of thyrogastric autoimmunity also were detected. CONCLUSIONS: This demonstration of asymptomatic Lambert-Eaton syndrome persisting for 8 years provided novel insight into the natural history of the disorder. It is plausible that patients with a subclinical syndrome would have abrupt neuromuscular decompensation when challenged with medications that compromise the safety factor for synaptic transmission.

Free anterolateral thigh flap with vascularized lateral femoral cutaneous nerve for the treatment of neuroma-in-continuity and recurrent carpal tunnel syndrome after carpal tunnel release.

Treatment of recurrent carpal tunnel syndrome (CTS) is challenging, especially in a case with recurrent CTS and a neuroma formation. Resection of the neuroma causing the syndrome, reconstruction of the nerve gap of the median nerve, and covering up the reconstructed median nerve with well-vascularized soft tissue for prevention of CTS re-recurrence are the essential procedures. We report a case of recurrent CTS with severe pain due to a neuroma-in-continuity successfully treated using a free anterolateral thigh (ALT) flap with a vascularized lateral femoral cutaneous nerve (LFCN). A 2 cm neuroma existed in the median nerve and was resected. The nerve gap was repaired using a vascularized LFCN included in the ALT flap. The ALT flap was transferred to the wrist to cover the median nerve. The severe pain disappeared completely and the sensory and motor impairment of the median nerve improved 5 months after the free flap surgery, as the Tinel's sign moved distally away from the wrist and disappeared. The result of the Semmes-Weinstein test improved from 5.08 to 4.31 and she was able to flex and extend the right wrist and fingers without pain. CTS did not recur 15 months after the surgery. A free ALT flap with vascularized LFCN allows nerve reconstruction for the median nerve gap created after neuroma resection and coverage of the median nerve with well-vascularized soft tissue to prevent adhesion and CTS recurrence.

Transient Proximal Median Nerve Entrapment in a Tetraplegic Hand Cyclist Following a 24-Hour Endurance Race.

Median nerve entrapment is a frequent disorder encountered by all clinicians at some point of their career. Affecting the distal median nerve, entrapment occurs most frequently at the level of the wrist resulting in a carpal tunnel syndrome. Median nerve entrapment may also occur proximally giving rise to the much less frequent pronator teres syndrome and even less frequent anterior interosseous nerve syndrome, which owing to the paucity of cases may prove challenging to diagnose. An unusual case of anterior interosseous syndrome precipitated by extraordinary exertion in a tetraplegic endurance athlete is presented with ancillary dynamometric, electrodiagnostic, ultrasonographic, and biochemical findings.

Median nerve entrapment during closed reduction of antebrachium fracture in a child.

This is a case report of a four-year-old boy who suffered a forearm fracture managed with closed reduction and casting for six weeks. Postoperatively, the patient showed symptoms of median nerve affection which was misinterpreted as neuropraxia. Ultrasonography of the forearm revealed that the median nerve was trapped in the radius fracture site. The patient underwent a second operation with neurolysis and nerve grafting. This case report highlights the use of ultrasonography in the diagnostics of nerve entrapment neuropathy.

Effectiveness of electrophysical modalities in the sensorimotor rehabilitation of radial, ulnar, and median neuropathies: A meta-analysis.

INTRODUCTION: People with ulnar, radial or median nerve injuries can present significant impairment of their sensory and motor functions. The prescribed treatment for these conditions often includes electrophysical therapies, whose effectiveness in improving symptoms and function is a source of debate. Therefore, this systematic review aims to provide an integrative overview of the efficacy of these modalities in sensorimotor rehabilitation compared to placebo, manual therapy, or between them. METHODS: We conducted a systematic review according to PRISMA guidelines. We perform a literature review in the following databases: Biomed Central, Ebscohost, Lilacs, Ovid, PEDro, Sage, Scopus, Science Direct, Semantic Scholar, Taylor & Francis, and Web of Science, for the period 1980-2020. We include studies that discussed the sensorimotor rehabilitation of people with non-degenerative ulnar, radial, or median nerve injury. We assessed the quality of the included studies using the Risk of Bias Tool described in the Cochrane Handbook of Systematic Reviews of Interventions and the risk of bias across studies with the GRADE approach described in the GRADE Handbook. RESULTS: Thirty-eight studies were included in the systematic review and 34 in the meta-analysis. The overall quality of evidence was rated as low or very low according to GRADE criteria. Low-level laser therapy and ultrasound showed favourable results in improving symptom severity and functional status compared to manual therapy. In addition, the low level laser showed improvements in pinch strength compared to placebo and pain (VAS) compared to manual therapy. Splints showed superior results to electrophysical modalities. The clinical significance of the results was assessed by effect size estimation and comparison with the minimum clinically important difference (MCID). CONCLUSIONS: We found favourable results in pain relief, improvement of symptoms, functional status, and neurophysiological parameters for some electrophysical modalities, mainly when applied with a splint. Our results coincide with those obtained in some meta-analyses. However, none of these can be considered clinically significant. TRIAL REGISTRATION: PROSPERO registration number CRD42020168792; https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=168792.

Self-Mutilation of the Fingers After a Supracondylar Humerus Fracture: The Deleterious Effects of a Median Nerve Palsy: A Case Report.

CASE: A toddler underwent percutaneous pin fixation for a type III supracondylar humerus fracture (SHF). At home, her cast fell off and her k-wires pulled out. Subsequently, she presented to the emergency department for biting the tip of her index finger off and chewing on her thumb and middle fingers. She was diagnosed with a median nerve (MN) palsy with associated paresthesia. CONCLUSION: In very young children, it may be difficult to cope with the sensation of paresthesias after a MN palsy after a SHF. Self-mutilation of the fingers may be an unfortunate complication from these paresthesias.

Localized hypertrophic neuropathy: a case report and review of the literature.

The case is presented of a 71-year-old man with a 6-year history of symptoms suggestive of carpal tunnel syndrome, which did not improve despite two surgical procedures. On further investigation, a fusiform enlargement of the median nerve was found above the elbow, which was found on biopsy to be localized hypertrophic neuropathy (LHN). This case is the first to be described affecting the median nerve. The literature regarding LHN is reviewed, with discussion of the differential diagnoses and possible etiology of this rare lesion.