Thermographic analysis and autonomic response in the hands of patients with leprosy

Abstract: Background: Low temperatures and slow blood flow may result from peripheral neuropathy caused by leprosy, and the simple detection of cold fingers could already be a preliminary classification for these patients. Objective: To investigate whether infrared thermography would be able to measure this change in temperature in the hands of people with leprosy. Method: The study assessed 17 leprosy patients who were under treatment at the National Reference Center for Sanitary Dermatology and Leprosy, Uberlândia/MG, and 15 people without leprosy for the control group. The infrared camera FLIR A325 and Therma CAM Researcher Professional 2.9 software were used to measure the temperature. The room was air-conditioned, maintaining the temperature at 25°C; the distance between the camera and the limb was 70 cm. The vasomotor reflex of patients was tested by a cold stress on the palm. Results: The study showed a significant interaction between the clinical form of leprosy and temperature, where the control group and the borderline-borderline form revealed a higher initial temperature, while borderline-lepromatous and lepromatous leprosy showed a lower temperature. Regarding vasomotor reflex, lepromatous leprosy patients were unable to recover the initial temperature after cold stress, while those with the borderline-tuberculoid form not only recovered but exceeded the initial temperature. Conclusion: Thermography proved a potential tool to assist in the early detection of neuropathies, helping in the prevention of major nerve damage and the installation of deformities and disabilities that are characteristic of leprosy.

Stimulus electrodiagnosis and motor and functional evaluations during ulnar nerve recovery

BACKGROUND: Distal ulnar nerve injury leads to impairment of hand function due to motor and sensorial changes. Stimulus electrodiagnosis (SE) is a method of assessing and monitoring the development of this type of injury. OBJECTIVE: To identify the most sensitive electrodiagnostic parameters to evaluate ulnar nerve recovery and to correlate these parameters (Rheobase, Chronaxie, and Accommodation) with motor function evaluations. METHOD: A prospective cohort study of ten patients submitted to ulnar neurorrhaphy and evaluated using electrodiagnosis and motor assessment at two moments of neural recovery. A functional evaluation using the DASH questionnaire (Disability of the Arm, Shoulder, and Hand) was conducted at the end to establish the functional status of the upper limb. RESULTS: There was significant reduction only in the Chronaxie values in relation to time of injury and side (with and without lesion), as well as significant correlation of Chronaxie with the motor domain score. CONCLUSION: Chronaxie was the most sensitive SE parameter for detecting differences in neuromuscular responses during the ulnar nerve recovery process and it was the only parameter correlated with the motor assessment.

Factors Influencing Outcomes after Ulnar Nerve Stability-Based Surgery for Cubital Tunnel Syndrome: A Prospective Cohort Study

PURPOSE: Simple decompression of the ulnar nerve has outcomes similar to anterior transposition for cubital tunnel syndrome; however, there is no consensus on the proper technique for patients with an unstable ulnar nerve. We hypothesized that 1) simple decompression or anterior ulnar nerve transposition, depending on nerve stability, would be effective for cubital tunnel syndrome and that 2) there would be determining factors of the clinical outcome at two years. MATERIALS AND METHODS: Forty-one patients with cubital tunnel syndrome underwent simple decompression (n=30) or anterior transposition (n=11) according to an assessment of intra-operative ulnar nerve stability. Clinical outcome was assessed using grip and pinch strength, two-point discrimination, the mean of the disabilities of arm, shoulder, and hand (DASH) survey, and the modified Bishop Scale. RESULTS: Preoperatively, two patients were rated as mild, another 20 as moderate, and the remaining 19 as severe according to the Dellon Scale. At 2 years after operation, mean grip/pinch strength increased significantly from 19.4/3.2 kg to 31.1/4.1 kg, respectively. Two-point discrimination improved from 6.0 mm to 3.2 mm. The DASH score improved from 31.0 to 14.5. All but one patient scored good or excellent according to the modified Bishop Scale. Correlations were found between the DASH score at two years and age, pre-operative grip strength, and two-point discrimination. CONCLUSION: An ulnar nerve stability-based approach to surgery selection for cubital tunnel syndrome was effective based on 2-year follow-up data. Older age, worse preoperative grip strength, and worse two-point discrimination were associated with worse outcomes at 2 years.

Ulnar sensory-motor amplitude ratio: a new tool to differentiate ganglionopathy from polyneuropathy / Razao de amplitude sensitivo-motora ulnar: novo parametro para diferenciar ganglionopatia de polineuropatia

The objective of this study was to evaluate if the ratio of ulnar sensory nerve action potential (SNAP) over compound muscle action potential (CMAP) amplitudes (USMAR) would help in the distinction between ganglionopathy (GNP) and polyneuropathy (PNP). Methods We reviewed the nerve conductions studies and electromyography (EMG) of 18 GNP patients, 33 diabetic PNP patients and 56 controls. GNP was defined by simultaneous nerve conduction studies (NCS) and magnetic resonance imaging (MRI) abnormalities. PNP was defined by usual clinical and NCS criteria. We used ANOVA with post-hoc Tukey test and ROC curve analysis to compare ulnar SNAP and CMAP, as well as USMAR in the groups. Results Ulnar CMAP amplitudes were similar between GNP x PNP x Controls (p=0.253), but ulnar SNAP amplitudes (1.6±3.2 x 11.9±9.1 × 45.7±24.7) and USMAR values (0.3±0.3 × 1.5±0.9 × 4.6±2.2) were significantly different. A USMAR threshold of 0.71 was able to differentiate GNP and PNP (94.4% sensitivity and 90.9% specificity). Conclusions USMAR is a practical and reliable tool for the differentiation between GNP and PNP. .

O objetivo deste estudo foi avaliar se a razão entre as amplitudes dos potenciais de ação sensitivo (SNAP) e motor (CMAP) do nervo ulnar (USMAR) auxiliaria na distinção entre ganglionopatia (GNP) e polineuropatia (PNP). Métodos Revisamos os estudos de neurocondução e eletromiografia de 18 pacientes com GNP, 33 com PNP diabética e 56 controles. GNP foi definida pela presença simultânea de anormalidades na neurocondução e na ressonância magnética cervical. PNP foi definida por critérios clínicos e neurofisiológicos usuais. Usamos o teste ANOVA com Tukey post-hoc e análise da curva ROC para comparar o SNAP e CMAP ulnares, assim como o USMAR entre os grupos. Resultados As amplitudes dos CMAPs ulnares foram similares entre GNP × PNP × Controles (p=0,253), mas as amplitudes dos SNAPs ulnares (1,6±3,2 × 11,9±9,1 × 45,7±24,7) e os valores de USMAR (0,3±0,3 × 1,5±0,9 × 4,6±2,2) foram significativamente diferentes. Um corte de 0,71 para a USMAR foi capaz de diferenciar GNP de PNP (sensibilidade de 94,4% e especificidade de 90,9%). Conclusões A USMAR é um parâmetro útil e confiável para o diagnóstico diferencial entre GNP e PNP. .

New sonographic measures of peripheral nerves: a tool for the diagnosis of peripheral nerve involvement in leprosy

To evaluate ultrasonographic (US) cross-sectional areas (CSAs) of peripheral nerves, indexes of the differences between CSAs at the same point (∆CSAs) and between tunnel (T) and pre-tunnel (PT) ulnar CSAs (∆TPTs) in leprosy patients (LPs) and healthy volunteers (HVs). Seventy-seven LPs and 49 HVs underwent bilateral US at PT and T ulnar points, as well as along the median (M) and common fibular (CF) nerves, to calculate the CSAs, ∆CSAs and ∆TPTs. The CSA values in HVs were lower than those in LPs (p < 0.0001) at the PT (5.67/9.78 mm2) and T (6.50/10.94 mm2) points, as well as at the M (5.85/8.48 mm2) and CF (8.17/14.14 mm2) nerves. The optimum CSA- receiver operating characteristic (ROC) points and sensitivities/specificities were, respectively, 6.85 mm2 and 68-85% for the PT point, 7.35 mm2 and 71-78% for the T point, 6.75 mm2 and 62-75% for the M nerve and 9.55 mm2 and 81-72% for the CF nerve. The ∆CSAs of the LPs were greater than those of the HVs at the PT point (4.02/0.85; p = 0.007), T point (3.71/0.98; p = 0.0005) and CF nerve (2.93/1.14; p = 0.015), with no difference found for the M nerve (1.41/0.95; p = 0.17). The optimum ∆CSA-ROC points, sensitivities, specificities and p-values were, respectively, 1.35, 49%, 80% and 0.003 at the PT point, 1.55, 55-85% and 0.0006 at the T point, 0.70, 58-50% and 0.73 for the M nerve and 1.25, 54-67% and 0.022 for the CF nerve. The ∆TPT in the LPs was greater than that in the HVs (4.43/1.44; p <0.0001). The optimum ∆TPT-ROC point was 2.65 (90% sensitivity/41% specificity, p < 0.0001). The ROC analysis of CSAs showed the highest specificity and sensitivity at the PT point and CF nerve, respectively. The PT and T ∆CSAs had high specificities (> 80%) and ∆TPT had the highest specificity (> 90%). New sonographic peripheral nerve measurements (∆CSAs and ∆TPT) provide an important methodological improvement in the detection of leprosy neuropathy.

Mobilização do osso pisiforme no tratamento da neuropraxia do nervo ulnar no canal de Guyon: relato de caso / Pisiform bone mobilization for treating ulnar nerve neuropraxia at Guyon's canal: case report

As neuropraxias do nervo ulnar são lesões bastante freqüentes que provocam efeitos deletérios, como diminuição de força muscular e parestesias; geralmente ocorrem no nível do epicôndilo medial e do túnel ulnar (canal de Guyon). São escassos os relatos referentes a técnicas de terapia manual para compressões do nervo ulnar no canal de Guyon. Este trabalho relata o uso da técnica de mobilização do pisiforme na compressão do nervo ulnar no canal de Guyon de um homem que sofreu luxação do punho direito aos 8 anos e, aos 25, queixava-se de um deficit para adução do dedo mínimo, que atrapalhava a realização de algumas atividades de vida diária. O paciente foi submetido a uma única sessão de mobilização articular do pisiforme. Após a aplicação da técnica, o sinal positivo do teste foi eliminado, restabelecendo-se a função de adução do 5o dedo. Embora carecendo de maior fundamentação teórica, pode-se afirmar que a técnica usada, de mobilização articular do osso pisiforme, é eficaz para melhora do quadro de paresia por neuropraxia do nervo ulnar no canal de Guyon...

A common ulnar nerve neuropraxia is lesion that may result in muscle strength decrease and/or paresthesia; it usually takes place at medial epicondylelevel and the ulnar tunnel (Guyon’s canal). Studies on manual therapy techniques for ulnar nerve compression in Guyon’s canal are scarce. This paper reports the use of a technique of pisiform bone mobilization for relieving ulnar nerve compression in Guyon’s canal, in a man who had suffered a luxation of the right wrist at the age of 8 and, at 25, complained of adduction deficit of the fifth finger that interfered in his daily life activities. He was submitted to one session of pisiform mobilization; after the session, the positive test sign was eliminated, thus restoring the fifth finger function. Though lacking further grounding, it may be said that the technique used, of mobilizing the pisiform bone joint, is effective to restore normal function after ulnar nerve compression at the Guyon’s canal...

Cooling modifies mixed median and ulnar palmar studies in carpal tunnel syndrome / Influência do resfriamento nos parâmetros de condução nervosa mista do mediano e ulnar na síndrome do túnel do carpo

Temperature is an important and common variable that modifies nerve conduction study parameters in practice. Here we compare the effect of cooling on the mixed palmar median to ulnar negative peak-latency difference (PMU) in electrodiagnosis of carpal tunnel syndrome (CTS). Controls were 22 subjects (19 women, mean age 42.1 years, 44 hands). Patients were diagnosed with mild symptomatic CTS (25 women, mean age 46.6 years, 34 hands). PMU was obtained at the usual temperature, >32°C, and after wrist/hand cooling to <27°C in ice water. After cooling, there was a significantly greater increase in PMU and mixed ulnar palmar latency in patients versus controls. We concluded that cooling significantly modifies the PMU. We propose that the latencies of compressed nerve overreact to cooling and that this response could be a useful tool for incipient CTS electrodiagnosis. There was a significant latency overreaction of the ulnar nerve to cooling in CTS patients. We hypothesize that subclinical ulnar nerve compression is associated with CTS.

Temperatura é uma variável comum e importante que modifica os parâmetros de condução nervosa na prática eletrodiagnóstica. Neste trabalho nós estudamos o efeito do esfriamento na diferença de latências palmares entre o nervo mediano e ulnar (PMU), segmento palma-pulso, utilizada rotineiramente para o eletrodiagnóstico da síndrome do túnel do carpo (STC). Foram estudados 22 controles (19 mulheres, média de idade 42,1 anos, 44 mãos) e 25 pacientes (25 mulheres, média de idade 46,6 anos, 34 mãos) com diagnóstico de STC leve. PMU foi obtida em temperatura usual (>32°C), e após resfriamento de mão/pulso em água com gelo (<27°C). Após o resfriamento houve aumento significativo na PMU e na latência mista palmar do nervo ulnar nos pacientes quando comparados aos controles. Nós concluímos que o resfriamento modifica significativamente a PMU e propomos que as latências obtidas em nervos submetidos à compressão reagem de maneira mais acentuada ao frio e isso poderia ser uma arma útil para o eletrodiagnóstico da STC incipiente. Da mesma forma, houve reação mais acentuada ao frio no estudo da latência mista palmar do nervo ulnar nos pacientes mas não nos controles, que poderia levantar a hipótese de compressão subclínica do nervo ulnar.

Early nerve damage in leprosy: an electrophysiological study of ulnar and median nerves in patients with and without clinical neural deficits.

BACKGROUND: Peripheral nerve trunk involvement in leprosy is very common. However, by the time it becomes clinically manifest, the damage is quite advanced. If the preclinical nerve damage can be detected early, the deformities and disabilities can be prevented to a large extent. AIMS: To assess the electrophysiological functions of the ulnar and median nerve trunks in cases of clinically manifest leprosy with and without manifest nerve damage at different durations of nerve damage. MATERIALS AND METHODS: Electrophysiological functions of ulnar and median nerves were studied in leprosy patients, both normal and at different stages of disease and damage. PB cases, having disease for six months or less, without neurological symptoms and clinically normal appearing nerve. STATISTICAL METHODS: Mean was taken of different values. The changes in values of different parameters were expressed as percentage change with reference to the control values (increase or decrease). RESULTS: Reduced nerve conduction velocities and changes in latency and amplitude were observed. Changes in sensory nerve conduction were more pronounced. Sensory latencies and amplitude changes were more severe than motor latencies and amplitudes in cases with manifest muscle palsies. Changes in MB cases were less marked. CONCLUSIONS: Further studies are needed to identify parameters likely to be helpful in the diagnosis of early nerve damage.

Association between chronic exposure to arsenic and slow nerve conduction velocity among adolescents in Taiwan.

The association between chronic exposure to arsenic and peripheral neuropathy has been controversial in previous studies, which may be due to the influence of factors, such as age, gender, chronic diseases, occupational injuries, and arsenic exposure. To clarify the question of this association, a cross-sectional study was designed. In total, 130 junior high school students aged 12-14 years were included and examined for the motor and sensory nerve conduction velocity of peripheral nerves in their right-upper and lower limbs. Concentrations of arsenic in well-water and history of drinking well-water were retrieved from a baseline database created in 1991. After adjustment for gender and height, a significant odds ratio of 2.9 (95% confidence interval [CI] 1.1-7.5) was observed for the development of slow nerve conduction velocity of the sural sensory action potential (SAP) among the study subjects with a cumulative arsenic dosage of>100.0 mg. In addition, a borderline statistical significance with odds ratio of 7.8 (95% CI 1.001-69.5) for the development of slow nerve conduction velocity of sural SAP was also observed among the study subjects who drank well-water containing arsenic concentrations of >50.0 microg/L and with a cumulative arsenic dosage of >100.0 mg. The study found that chronic exposure to arsenic might induce peripheral neuropathy. It also found that the slowing of the nerve conduction velocity of sural SAP might be an early marker of chronic arsenic neuropathy.

F wave latency--a frequent and early involved nerve conduction parameter in young diabetic subjects.

F-wave latency measurement is a sensitive parameter of diabetic neuropathy than the conduction velocities. This study was carried out to measure F-wave latency and to see which conduction parameters are affected frequently and early. A total number of 62 patients of which 32 newly diagnosed and 30 controls were included in the study. Ulnar motor nerve conduction velocity was found slowed in 6(18.75%) diabetic subjects, but F-wave latency was found prolonged in 16(50%) diabetic subjects. 28(87.5%) diabetic subjects had normal peroneal nerve conduction velocity but peroneal F wave was found prolonged in 17(53.12%) diabetic subjects. This result suggests that F-wave latency is more frequently & early involved conduction parameter in diabetic subjects.

Revisäo relacionada a alguns aspectos técnicos e fisiológicos das ondas F e análise dos dados obtidos em um grupo de indivíduos diabéticos / A review of technical and physiological aspects of F-wave studies and analyzis of the data obtained in a group of diabetic patients

Fazemos uma revisäo da literatura e discutimos aspectos fisiológicos relacionados aos tipos de neurônios motores envolvidos na gênese das ondas F. Säo revistos aspectos técnicos relativos ao número de ondas F a serem colhidas para uma melhor definiçäo dos parâmetros utilizados no estudo destes potenciais. Säo analisadas as latências, persistência e as velocidades de conduçäo das ondas F registradas nos nervos ulnares em um grupo de indivíduos normais e em um grupo de pacientes diabéticos

Surgical management of Guyon's canal syndrome, an ulnar nerve entrapment at the wrist: report of two cases

Guyon's canal syndrome, an ulnar nerve entrapment at the wrist, is a well-recognized entity. The most common causes that involve the ulnar nerve at the wrist are compression from a ganglion, occupational traumatic neuritis, a musculotendinous arch and disease of the ulnar artery. We describe two cases of Guyon's canal syndrome and discuss the anatomy, aetiology, clinical features, anatomical classification, diagnostic criteria and treatment. It is emphasized that the knowledge of both the surgical technique and anatomy is very important for a satisfactory surgical result

A case of hereditary sensory and autonomic neuropathy (HSAN) type II.

We describe a case of hereditary sensory and autonomic neuropathy (HSAN) type II in a child with a penetrating foot ulcer, acral sensory impairment, and anhidrosis. This is the first documentation of HSAN in Sri Lanka.

Two objective "archivable" tests for voluntary muscle testing in ulnar and median nerve paralysis.

Two tests are proposed for assessment of ulnar and median nerve function for use under field conditions: (i) "flap flexion" of fingers for ulnar nerve, and, (ii) tip-to-tip thumb opposition to the fourth finger for median nerve. These tests, which are a part of a series of simple clinical tests proposed for rapid neurological evaluation of the function of the nerves involved in leprosy, are simple, objective and easy to do. Because these tests depend on the strength of muscles tested, they might spare its direct assessment. In fact, it is difficult to assess and grade the strength of the little muscles of the hand and that is very much dependent on the examiner's own experience. Therefore, it is rather subjective. The tests described here may also be used for evaluating the results of corrective surgery of the hand. Whenever possible, making photographic records of these two tests, to be archived in the forms where everyone can see and compare them, seems to be easier and more objective than the subjective transcription of the feelings of an examiner assessing the strength of the small muscles of the hand. These two tests seem to be most objective for a scientific prospective study with a long term follow up. So, they could be used in assessing the results of leprosy neuritis by medical treatment, or, by medical treatment completed (when necessary only and not routinely) by surgical decompression of nerves and also of corrective surgery of claw hand, or, loss of opposition of the thumb.

Abductor pollicis longus deviation grant operation: a new procedure on the thumb in ulnar cum low median palsy for correction of subluxation of carpometacarpal (CMC) joint.

For correction of instability of the carpometacarpal joint (CMC joint) of the thumb in combined paralysis of ulnar and median nerves in leprosy bone fusing procedures have been used, but they are not desirable and can often be avoided. A procedure analogous to the "Extensor pollicis brevis deviation graft operation" for the correction of instability of the metacarpophalangeal joint of the thumb is described here. The new procedure appears to be useful to correct and stabilize the subluxated carpometacarpal joint of the thumb actively during the use of the hand. When thumb web contracture has occurred and the passive range of movement needed for successful opponents replacement of thumb is not available, this new procedure helps to prepare such a severe deformed thumb for correction at earlier time.

Leprosy neuropathy: correlation of clinical and electrophysiological tests.

This report describes the neurological and electrophysiological examination of 35 subjects with leprosy (average duration of symptoms 3.4 years, average time since diagnosis 7.5 months). Clinical examination in the distribution of non-dominant median and ulnar nerves was performed with the following clinical methods: touch sensation with 0.05 gm. Monofilament nylon, thermal sensation with a thermal sensitivity testing device, voluntary muscle testing and nerve palpation. At least one abnormality was found in 22 ulnar and 13 median nerves (63% and 37%, respectively). Nerve palpation was the most frequent clinical abnormality, while the other methods had similar frequencies of abnormality. Electrophysiological studies were performed on the ipsilateral side of the leprosy subjects and on 32 age-matched normal subjects. Electrophysiological responses from the leprosy subjects were evaluated by criteria established from normal subject data. Abnormal or absent responses were found in 21/35 ulnar sensory, 12/35 ulnar motor, 9/35 median sensory and 6/35 median motor responses among the leprosy subjects. The most important electrodiagnostic findings were: (i) low sensory amplitudes and (ii) drops in amplitude and NCV over the across-elbow segment of the ulnar nerve. Both clinical and nerve conduction abnormalities were positively associated with duration of leprosy symptoms. The four clinical methods were compared for concordance with nerve conduction data by cross-tabulation. The two sensory measures, monofilaments and the thermal sensitivity device, had the highest concordances. Usefulness of clinical tests for nerve damage in leprosy may vary depending on whether the purpose is for diagnosis, patient education or clinical follow-up.

Acute brachial neuropathy: electrophysiological study and clinical profile

Acute brachial neuropathy (ABN) is a rare disease, characterized by an acute or subacute onset of pain followed by weakness of shoulder or arm muscles without trauma or traction injury. So the diagnosis of this clinical entity is not easy. The purpose of this study was to analyze retrospectively the ABN in 14 cases focusing on the clinical profile and to evaluate the effectiveness of electrophysiologic study in diagnosis of ABN with a new result helpful in localizing a brachial plexus disorder. The most helpful electrophysiologic data of ABN in my patients seemed to be abnormalities of low amplitude, abnormal right to left difference of compound motor action potentials (CMAPs) and sensory nerve action potentials (SNAPs) in axillary nerve, ulnar or median nerves. Results of nerve conduction velocity, terminal and F-wave latency were not as useful. But the electromyogram was most helpful in localization of upper or lower plexus lesions and cervical radiculopathy. The most striking clinical feature of ABN was the rapid onset of pain followed by the development of muscle weakness of shoulder girdle after a variable period or within four days. In contrast to other reports, intrinsic hand muscle weakness was observed in 3 cases with sensory changes in ulnar nerve distribution. The cervical radiculopathies (C5-C7 roots) were simultaneously combined with ipsilateral axillary neuropathy in 3 cases. In this study, decreased amplitude, abnormal right to left difference of SNAPs and CMAPs, and neurogenic EMG findings with normal data of NCV, terminal and F-wave latencies suggest that the pathology of ABN might not be a demyelinating process, but axonopathy.

Doença de Charcot-Marie-Tooth: estudos eletromiográficos em 45 pacientes / Charcot-Marie-Tooth disease: electromyographic studies in 45 patients

Foi realizada eletroneuromiografia em 45 pacientes com doença de Charcot-Marie-Tooth (CMT). A classificaçäo em tipo I e tipo II da doença de CMT foi feita com base na neuroconduçäo motora do mediano e do ulnar. Assim 11 pacientes eram do tipo I e 34 eram do tipo II. NO tipo I näo houve relaçäo entre a queda da VCN motora do ulnar e mediano com o quadro clínico da doença. Devido a ausência do potencial de açäo sensitivo (PAS) do nervo sural em muitos casos, achamos impossível a classificaçäo da doença pela neuroconduçäo deste nervo. Muitos pacientes com doença de CMY II, tinham neuroconduçäo normal, porém a amplitude do PAS do sural estava ausente ou reduzida, mostrando tratar-se realmente de doença do nervo periférico e näo da ponta anterior da medula. Achamos que o estudo da neuroconduçäo é o mais importante na classificaçäo da doença de CMT

Entrapment neuropathies.

Relative frequency of entrapment neuropathies was studied from amongst the patients referred to an electrodiagnostic medicine laboratory for electrophysiological studies. During the study period electrophysiological procedures were done on 650 patients with various peripheral nerve disorders. The entrapment neuropathies constituted 8.5%. Carpal tunnel syndrome (CTS) was the commonest entrapment neuropathy (83.6%). Diagnosis of CTS was established in 84 Patients referred with the diagnosis of CTS. Electrophysiological tests confirmed the diagnosis of thoracic outlet syndrome in 4 (15.4%) of the 26 patients referred with this diagnosis and in 5 (19.3%) of them the diagnosis turned out to be CTS. Diagnosis of cubital tunnel syndrome was not suspected clinically in all the 3 patients, they were referred with the diagnosis of ulnar neuropathy. In both the patients with tarsal tunnel syndrome the initial diagnosis was peripheral neuropathy.

Vasculitic neuropathy: profile of twenty patients.

Twenty patients with vasculitic neuropathy were analyzed. Sixteen of the twenty presented with classic mononeuritis multiplex but four had distal, symmetrical, sensorimotor polyneuropathy. Though vasculitic neuropathy is classically associated with Collagen vascular syndromes like, polyarteritis nodosa, rheumatoid arthritis and systemic lupus erythematosis, only 13/20 of our patients had definitive Collagen vascular disease. A large proportion (7/20) had vasculitic neuropathy as the only clinical feature.