Risk of peripheral neuropathy in patients with psoriasis and psoriatic arthritis. A prospective cohort study.

INTRODUCTION/AIMS: Laboratory and clinical data suggest a link between neurologically mediated inflammation and psoriasis, but the risk and features of peripheral neuropathy in psoriasis or psoriatic arthritis remain unknown. The aim of this exploratory study was to evaluate the risk and to describe the features of peripheral neuropathy in patients with psoriasis and psoriatic arthritis. METHODS: One hundred patients with psoriasis and/or psoriatic arthritis and 100 control subjects were consecutively enrolled. Diagnostic confirmation included electrophysiological examination, skin biopsy, and nerve ultrasound for confirmed polyneuropathy. RESULTS: Nine patients were diagnosed with confirmed polyneuropathy, while none of the control subjects had the condition (relative risk [RR] = 19.00, 95% confidence interval [CI] = 1.12-322.11). Specific relative risks for polyneuropathy were 22.09 (95% CI = 1.17-416.43) in psoriasis patients and 18.75 (95% CI = 1.07-327.62) in psoriatic arthritis patients. The observed polyneuropathy in all nine patients was length-dependent, symmetrical, and predominantly sensory, with minimal or no disability. Comorbidities and exposure to therapies known to increase the risk of polyneuropathy were more frequent in psoriasis and/or psoriatic arthritis patients compared to controls (42% vs. 4%, p = .0001). Analyzing data after excluding possible contributory causes, the risk of polyneuropathy in patients with psoriasis and/or psoriatic arthritis was not significant. DISCUSSION: Psoriasis and psoriatic arthritis appear to be associated with an increased risk of polyneuropathy. This increased risk seems to be linked to the higher prevalence of contributing factors for polyneuropathy, rather than a direct increase in neuropathy risk specifically related to psoriasis and psoriatic arthritis.

Current concepts of surgical approach for radial nerve entrapment around the elbow.

Radial nerve entrapment is an uncommon diagnosis. The entrapment can occur at any location within the course of the nerve distribution, but the most frequent location of entrapment occurs around the elbow and involves the posterior interosseous nerve. Several potential sites of radial nerve entrapment around the elbow are identified: the capsular tissue of the radiocapitellar joint; hypertrophic crossing branches of leash of henry; the leading proximal tendinous and medial edge of extensor carpi radialis brevis; the arcade of Frohse and distal border of the supinator between its two heads. The arcade of Frohse is the most common site of compression. The aim of this manuscript is to describe the common surgical methods to approach the radial nerve entrapments around the elbow and define the preferred surgical approach based on the site of compression.

Enlarged cross-sectional area in peripheral nerves in Swedish patients with hereditary V30M transthyretin amyloidosis.

INTRODUCTION: In hereditary transthyretin amyloidosis (ATTRv), two different fibrillar forms causing the amyloid deposition, have been identified, displaying substantially cardiac or neuropathic symptoms. Neuropathic symptoms are more frequent in early-onset patients, whereas late-onset patients, besides cardiac symptoms, seem to develop carpal tunnel syndrome, more often. With ultrasonography (US) of peripheral nerves, it is possible to distinguish structural changes, and enlarged cross-sectional area (CSA). The main purpose of this study was, for the first time, to elucidate US of peripheral nerves in Swedish ATTRv patients at an early stage of the disease, and to evaluate possible early enlarged CSA. MATERIAL AND METHODS: This prospective study included first visit data of 13 patients, aged 30-88 years, of which 11 with late-onset age. All had a positive V30M mutation. Eight men and six women (aged 28-74 years) served as controls. RESULTS: Significantly enlarged CSA was seen in ATTRv patients for the tibial nerve at the ankle (p = .001), the sural nerve (p < .001), the peroneal nerve at the popliteal fossa (p = .003), and the ulnar nerve at the middle upper arm (p = .007). CONCLUSION: US of peripheral nerves could be a valuable tool in disease evaluation and could facilitate monitoring of disease progression.

Ultrasound-Guided Near-Nerve Needle Sensory Technique for the Diagnosis of Tarsal Tunnel Syndrome.

BACKGROUND: Tarsal tunnel syndrome (TTS) is one of the most common entrapment syndromes. Although diagnosis is supported by imaging tests, it has so far been based on clinical findings. Neurophysiological tests are not effective for providing an accurate diagnosis. The objective of this study was to analyze the efficacy of the ultrasound-guided near-nerve needle sensory technique (USG-NNNS) for the diagnosis of TTS Methods: The study population comprised 40 patients referred for a neurophysiological study owing to clinical suspicion of TTS. Routine neurophysiological tests were performed and compared with the results of USG-NNNS. RESULTS: The diagnosis of TTS was achieved in 90% of cases. We found significant differences between lateral plantar sensory recordings with surface electrodes and USG-NNNS techniques for amplitude, nerve conduction velocity (NCV), and duration. As for the medial plantar sensory recordings, differences were found only for duration. No responses were obtained with surface electrode studies in 64.8% of cases. In addition, we observed normal sensory NCV with surface electrodes in 20 patients, although this decreased when the NNNS technique was used. CONCLUSIONS: This is the first report of the efficacy of the USG-NNNS technique for confirming the diagnosis of TTS.

Study of Wrist Ratio and Wrist-to-Palm Index Radio in Individuals Suffering from Carpal Tunnel Syndrome.

BACKGROUND: Carpal tunnel syndrome (CTS) is the commonest median nerve entrapment neuropathy, with preponderance in females. AIMS AND OBJECTIVE: The aim of the present study was to find out wrist ratio (WR) and wrist/palm ratio (WPR) in clinically diagnosed patients of CTS. METHODOLOGY: One hundred individuals (fifty patients of CTS and fifty as control group) aged between 30 and 50 years were recruited for the study. Early confirmation of clinically suspected patients of CTS was done by performing electrodiagnostic tests of median and ulnar nerves. Motor and sensory conduction velocities, distal motor and sensory latencies, and F-wave latencies were performed in the recruited volunteers. RESULTS: The values for mean wrist ratio in control groups were 0.694, 0.703 respectively, and in patients with carpal tunnel syndrome, it was 0.704 and 0.719 respectively in moderate and severe type. The mean wrist to palm ratio (WPR) in control group was 0.371, while in patients with CTS, it was 0.374, 0.382, 0.387, and 0.401 based on progression of severity. Both were statistically significant for the last two groups (wrist to index finger [WIF] >4.4 m/s, moderate, and WIF nonrecordable, severe). Statistically significant (P < 0.001) decrease of motor conduction velocities for median nerve was seen in the CTS group as compared to control group. Statistically significant (P < 0.001) increase in distal motor and sensory latencies was observed for both median and ulnar nerves in CTS group with more increase in distal motor latency than sensory latency. Increase in F-wave latencies of both nerves was seen in CTS group. CONCLUSION: The study results confirm selective slowing of sensory and motor conduction within wrist-to-palm segment in patients of CTS. Both WR and WPR have a progressive correlation with the severity of CTS, but statistically significant changes were seen in the groups with moderate and severe CTS. Thus, WR/WPR can act as one of the essential parameters in the diagnosis of CTS with moderate-to-severe CTS.

A Gantzer muscle arising from the brachialis and flexor digitorum superficialis: embryological considerations and implications for median nerve entrapment.

Gantzer muscles are variant muscles in the anterior forearm inserting into the flexor pollicis longus or, less often, the flexor digitorum profundus. The presence of Gantzer muscles can cause a compressive neuropathy affecting the anterior interosseous nerve (Kiloh-Nevin syndrome). These muscles must also be considered when anterior forearm fasciotomies are performed for the management of acute compartment syndrome. In this case report, a novel Gantzer muscle originated from the flexor digitorum superficialis as well as the investing fascia of the brachialis muscle; the latter site is a novel proximal attachment not previously reported. In addition, the Gantzer muscle possessed rare characteristics because it (1) possessed a split tendinous distal insertion into both the flexor pollicis longus and flexor digitorum profundus, (2) exhibited a triangular morphology, and (3) was innervated by the median nerve. Most importantly, the dual origin of this Gantzer muscle formed a tunnel containing branches of the median nerve; therefore, this report documents a unique anatomical scenario in which the Gantzer muscle may compress and cause entrapment of aspects of the median nerve.

Shear-wave elastography in the diagnosis of ulnar tunnel syndrome.

An interesting alternative to traditional diagnostic techniques of the upper extremity nerve entrapments might be an ultrasound elastography that has started to gain attention in recent research. The aim of this preliminary study was to verify whether a quantitative analysis of the ulnar nerve stiffness by shear-wave elastography can be used to diagnose ulnar tunnel syndrome (UTS), an ulnar nerve neuropathy at Guyon's canal. The study included 46 patients (39 women) and 39 healthy controls (34 women). All diagnoses in patients and controls were confirmed with nerve conduction studies. Measurements of nerve stiffness were taken at three levels: Guyon's canal (G), distal forearm (DF), and mid forearm (MF). Additionally, the ulnar nerve cross-sectional area at the canal's level was determined by ultrasonography. Patients with UTS presented with significantly greater nerve stiffness than the controls (mean, 99.41 kPa vs. 49.08 kPa, P < 0.001). No significant intergroup differences were found in the nerve elasticity at DF and MF levels (P < 0.836 and P < 0.881, respectively). An ulnar nerve stiffness value of 80 kPa and G:DF and G:MF ratios equal to 1.5 provided 100% sensitivity, specificity, and positive and negative predictive values in the detection of the syndrome. The mean nerve cross-sectional area in the Guyon's canal was significantly greater in patients than in the controls (4.63 mm2, range, 2-7 mm2 vs. 3.23 mm2, range, 2-5 mm2, P < 0.001). In conclusion, we believe that shear-wave elastography has the potential to become a useful adjunct diagnostic test for UTS.

Ulnar neuropathy at wrist: entrapment at a very "congested" site.

Ulnar tunnel syndrome indicates ulnar neuropathy at different sites within the wrist. Several classifications of ulnar tunnel syndrome are present in literature, based upon typical nerve anatomy. However, anatomical variations are not uncommon and can complicate assessment. The etiology is also complex, due to the numerous potential causes of entrapment. Clinical examination, neurophysiological testing, and imaging are all used to support the diagnosis. At present, many therapeutic approaches are available, ranging from observation to surgical management. Although ulnar neuropathy at the wrist has undergone extensive prior study, unresolved questions on diagnosis and treatment remain. In the current paper, we review relevant literature and present the current knowledge on ulnar tunnel syndrome.

Tarsal tunnel syndrome: still more opinions than evidence. Status of the art.

Tarsal tunnel syndrome is an entrapment neuropathy of the posterior tibial nerve or its terminal branches within its fibro-osseous tunnel beneath the flexor retinaculum on the medial side of the ankle. The condition is frequently underdiagnosed leading to controversies regarding its epidemiology and to an intense debate in the literature. With the advent of nerve imaging techniques, the diagnostic confirmation and the etiological identification have become more accurate. However, management of this entrapment neuropathy remains challenging because of many intervention strategies but limited robust evidence. Uncertainties still exist about the best conservative treatment, timing of surgical intervention, and best surgical approach. In the attempt to clarify these aspects and to provide the reader some understanding of the status of the art, we have reviewed the published literature on this controversial condition.

Thoracic outlet syndrome: wide literature for few cases. Status of the art.

Despite its low prevalence and incidence, considerable debate exists in the literature on thoracic outlet syndrome (TOS). From literature analysis on nerve entrapments, we realized that TOS is the second most commonly published entrapment syndrome in the literature (after carpal tunnel syndrome) and that it is even more reported than ulnar neuropathy at elbow, which, instead, is very frequent. Despite the large amount of articles, there is still controversy regarding its classification, clinical picture, diagnostic objective findings, diagnostic modalities, therapeutical strategies and outcomes. While some experts believe that TOS is underrated, overlooked and very frequent, others even doubt its existence as a nosological entity. In the attempt to shed more light on this condition, we performed a systematic review of the literature and report evidence and opinions around this controversial subject. Only articles focused on neurogenic TOS were considered. Understanding the status of the art and the underlying reasons of doubts and weaknesses could help clinical practice and set the stage for future research.

[Surgical decompression of the superficial radial nerve: Wartenberg syndrome]. / Die operative Dekompression des Ramus superficialis des Nervus radialis: Das Wartenberg-Syndrom.

OBJECTIVE: Open decompression of the superficial radial nerve is performed at the distal forearm in cases of circumscript entrapment. Broad-based entrapments can be treated by endoscopically assisted decompression. INDICATIONS: Entrapment of the nerve along its course between the brachioradialis and extensor carpi radialis longus muscles or tendons. Persistent neuropathic pain with Tinel's sign. Numbness distal to the entrapment in accordance to nerval innervation. Futile conservative treatment. Pathological electrophysiological findings. CONTRAINDICATIONS: Endogeneous neuropathy, bleeding disorders, anticoagulation medication. SURGICAL TECHNIQUE: Longitudinal skin incision at the Tinel's sign at the forearm. The subcutaneous tissue is dissected until forearm fascia is detected. The fascia is opened cautiously under direct visualization and the superficial radial nerve is identified. In cases of broad-based entrapments, endoscopically assisted decompression can be performed. The dissector with attached optical device is introduced proximally and distally. Blunt mobilization using the dissector and preparation with the Metzenbaum scissors release the superficial radial nerve sufficiently. POSTOPERATIVE MANAGEMENT: Bandaging allowing immediate motion, removal of sutures after 14 days, avoidance of excessive use for 2 weeks. RESULTS: Surgical decompression of the superficial radial nerve yields good to excellent results regarding pain reduction and sensory function.

Diagnosis and Treatment of Abdominal Cutaneous Nerve Entrapment Syndrome Using Ultrasonography

Abdominal cutaneous nerve entrapment syndrome is one of the abdominal wall-origin pain that develops in anterior cutaneous branches of 7th to 12th thoracic nerves passing through fibrous ring in rectus abdominis. Number of this condition has been misdiagnosed to visceral dysfunctions; therefore, delayed diagnosis leads to waste of cost and time. Injection of local anesthetics is a kind of useful technique for the purpose of the confirmed diagnosis with treatment in abdominal wall pain. Recently, the accuracy and safety of local anesthetics injection to muscle or nerve are significantly improved than the past times since ultrasound has been accepted as a substantial device in clinical area. Here, we report a case of abdominal cutaneous nerve syndrome, treated by ultrasound-guided nerve block accompanied with medical treatment.

Occupational mononeuropathies in industry.

Peripheral nerve injuries have the potential to cause significant disability and can be commonly associated with recreational and occupational activities. Acute nerve injuries are mainly related to violent trauma, while repeated mechanical trauma due to external forces or repetitive motions can produce chronic nerve compression injury. This chapter will present a narrative review of the existing evidence of the association between peripheral compressive nerve disorders and work-related risk factors. Carpal tunnel syndrome (CTS) is the most common peripheral neuropathy in the general population and in working populations employed in manual repetitive and forceful activities. The work-relatedness of CTS is essentially based on epidemiologic evidence and the results of experimental studies showing the capability of repetitive wrist extreme postures, associated with hand-wrist forceful exertions, to increase the pressure inside the carpal tunnel and to compress the median nerve. Assembly industry, food processing and packaging, hand-arm vibrating tools, and jobs involving high-repetition, high-force tasks put workers at risk for CTS. Less strong evidence exists of the association between ulnar elbow neuropathy and manual tasks or repetitive stretch on squatting and peroneal nerve neuropathy at the fibular head. Very few reports are available about the association between occupation and other compressive peripheral nerve injuries.