Decompression with Brachioradialis Tenotomy Improves Pain and Quality of Life in Patients with Radial Sensory Nerve Compression.

BACKGROUND: Decompression of the superficial sensory branch of the radial nerve (SBRN) with complete brachioradialis tenotomy may treat pain in both simple and complex cases of SBRN compression neuropathy. METHODS: A retrospective chart review was performed of consecutive patients undergoing this procedure between 2008 and 2020 including postoperative outcomes within 90 days. Data were collected and analyzed, including patient and injury demographics, pain descriptors, and patient-reported pain questionnaire, including reported pain severity and impact on quality of life using visual analogue scale (VAS) instruments. Within-group presurgical and postsurgical analyses and between-group statistical analyses were performed. RESULTS: Thirty-three of 58 patients met inclusion criteria. Median time from symptom onset to surgery was 300 days, and median postoperative follow-up time was 37 days. Twenty-five percent of patients ( n = 8) underwent isolated SBRN decompression. The remainder had concomitant decompression of another radial [ n = 16 (48%) or peripheral [ n = 12 (36%)] entrapment point. Ten of 33 patients (30%) had resolution of pain at final follow-up ( P = 0.004). Median change in worst pain over the previous week was -4 ( P < 0.001), and average pain over the last month was -2.75 ( P < 0.001) on the VAS. The impact of pain on quality of life showed a median change of -3 ( P < 0.001) on the VAS. CONCLUSION: Decompression of the sensory branch of the radial nerve including a complete brachioradialis tenotomy improves pain and quality-of-life VAS scores in patients with both simple compression neuropathy syndrome and complex nerve compression syndrome. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Patient perspectives and self-rated knowledge of nerve transfer surgery for restoring upper limb function in spinal cord injury.

BACKGROUND: Nerve transfer surgery has the potential to restore upper limb function in patients with spinal cord injury (SCI); however, there has been limited exploration of patient perception of nerve transfer. OBJECTIVE: To explore the perspectives of patients with chronic SCI (>2 years from injury) on nerve transfer surgery, and to determine if an educational intervention improved participants' perceived knowledge levels about the procedure. DESIGN: Mixed-methods study including qualitative semi-structured interviews and self-reported rating scales. Pre- and post-interviews were completed following an educational presentation. SETTING: Two local SCI clinics. PARTICIPANTS: Ten patients with chronic traumatic SCI and neurological level of injury C3-C7 (motor complete or incomplete), recruited via snowball sampling (six male, four female). INTERVENTION: An educational slide presentation on nerve transfer concepts. MAIN OUTCOME MEASURES: The primary study outcome measure is the participants' responses to interview questions. The secondary study outcome measure is their self-reported knowledge levels of nerve transfer before and after education. RESULTS: Regaining upper limb function was a priority for all participants. Although most participants had heard of nerve transfer, none were offered it at the time of their SCI, and only two stated that they had any peers who had undergone the procedure. The educational module significantly increased self-rated scores on understanding of nerve transfer (p < .05). Although all participants were open to nerve transfer after the educational module, they described weighing different factors, including (1) potential for loss versus gain of function, (2) inadequate knowledge about nerve transfer, (3) recovery time, and (4) determining their eligibility for the surgery. CONCLUSIONS: These findings suggest that people with SCI have limited understanding of nerve transfer as a potential option and would benefit from educational opportunities to help them make informed decisions. This study may inform the development of patient resources to improve pre-surgical consultation and informed decision-making.

Outcome Analysis of Medial Triceps Motor Nerve Transfer to Axillary Nerve in Isolated and Brachial Plexus-Associated Axillary Nerve Palsy.

BACKGROUND: Since 2007, the authors have performed the triceps-to-axillary nerve transfer using the medial triceps branch to reconstruct axillary nerve function in brachial plexus and isolated axillary nerve palsies. METHODS: A retrospective chart review was undertaken of patients reconstructed with this transfer, recording patient and injury demographics and time to surgery. Preoperative and postoperative function was graded using the Medical Research Council scale and the Disabilities of the Arm, Shoulder, and Hand questionnaire. RESULTS: Postoperatively, 31 patients (64.6 percent) reached Medical Research Council grade 3 or higher at final follow-up. The median Disabilities of the Arm, Shoulder, and Hand score was 59.9 (interquartile range, 38.8 to 70.5) preoperatively and 25.0 (interquartile range, 11.3 to 61.4) at final follow-up. Sixteen patients (33 percent) had isolated axillary nerve injury; the median Medical Research Council grade was 4.25 (interquartile range, 3 to 4.25), with 14 patients (87.6 percent) achieving grade 3 or higher. Thirty-two patients (77 percent) had brachial plexus-associated injury; median Medical Research Council grade was 3 (interquartile range, 2 to 3), with 17 patients (53.1 percent) achieving grade 3 or higher. CONCLUSION: Medial triceps nerve branch is a strong donor for triceps-to-axillary nerve transfer; however, injury factors may limit the motor recovery in this complex patient population, particularly in axillary nerve palsy associated with brachial plexus injury. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Lower Motor Neuron Abnormality in Chronic Cervical Spinal Cord Injury: Implications for Nerve Transfer Surgery.

Nerve transfer surgery (NT) constitutes an exciting option to improve upper limb functions in chronic spinal cord injury (SCI), but requires intact sublesional lower motor neuron (LMN) health. The purpose of this study was to characterize patterns of LMN abnormality in nerve-muscle groups that are the potential recipients of NT, using a standardized electrodiagnostic examination, in individuals with chronic SCI (injury duration >2 years, injury levels C4-T1). The LMN abnormality was determined using a semihierarchical approach, combining the amplitude compound muscle action potential (CMAP) and abnormal spontaneous activity on needle electromyography (EMG). Ten participants (46 potential recipient muscles) were included (median age, 42.5 years; six males and four females; median duration from injury, 15.5 years). A high frequency of LMN abnormality was observed (87%), although there was substantial variation within and between individuals. No statistically significant discordance was observed between LMN abnormality on CMAP and EMG (p = 0.24), however, 50% of muscles with normal CMAP demonstrated abnormal spontaneous activity. The high frequency of LMN abnormality in recipient nerve-muscle groups has implications to candidate selection for NT surgery in chronic SCI and supports the important role of the pre-operative electrodiagnostic examination. Our results further support the inclusion of both CMAP and needle EMG parameters for characterization of LMN health. Although the number of nerve-muscle groups with normal LMN health was small (13%), this underscores the neurophysiological potential of some patients with chronic injuries to benefit from NT surgery.

Medical Malpractice in Nerve Injury of the Upper Extremity.

Background: Medical malpractice accounts for more than $55 billion of annual health care costs. Updated malpractice risk to surgeons and physicians related to upper extremity peripheral nerve injury has not been published. Methods: A comprehensive database analysis of upper extremity nerve injury claims between 1995 and 2014 in the United States was conducted using the Medical Professional Liability Association Data Sharing Project, representing 24 major insurance companies. Results: Nerve injury in the upper extremity accounted for 614 (0.3%) malpractice claims (total of 188 323). Common presenting diagnoses included carpal tunnel syndrome (41%), upper extremity fractures (19%), and traumatic nerve injuries to the shoulder or upper limb (8%). Improper performance (49% of total claims) and claims without evidence of medical error (19%) were the most common malpractice suits. Orthopedic surgeons were the most frequently targeted specialists (42%). In all, 65% of nerve injury claims originated from operative procedures in a hospital, 59% of claims were dismissed or withdrawn prior to trial, and 30% resulted in settlements. Thirty-three percent of claims resulted in an indemnity payment to an injured party, with an average payout of $203 592 per successful suit. Only 8% of claims resulted in a completed trial and verdict, and verdicts were overwhelmingly in favor of the defendant (83%). Conclusions: Most malpractice claims from peripheral nerve injuries in the United States arise from the management of common diagnoses, occur in the operating room, and allege improper performance. Strategies to reduce malpractice risk should emphasize the management of common conditions and patient-physician communication.

The Role of FLIR ONE Thermography in Complex Regional Pain Syndrome: A Case Series.

ABSTRACT: Complex regional pain syndrome remains a debated syndrome characterized by symptoms and signs, including pain, sensory disturbances, thermal asymmetry, edema, and motor impairments. Thermography is a tool that assesses skin surface temperature distribution. Current literature focuses on the role of thermography for diagnostic purposes; however, its role in monitoring the response to treatment in complex regional pain syndrome is unclear. We present a case series of four patients with complex regional pain syndrome where a FLIR ONE thermal imaging camera (FLIR Systems, Inc, Wilsonville, OR) was used to assist in the diagnosis of complex regional pain syndrome, capture the effects of diagnostic nerve blocks to evaluate a peripheral nerve contribution to complex regional pain syndrome, as well as monitor and assess treatment efficacy with prednisone and surgery. Four patients were screened by clinical assessment to meet the Budapest Criteria. The thermal images revealed improvement in the temperature distribution after therapeutic intervention. We also noted temporary but immediate changes on thermal imaging with diagnostic nerve blocks. Our cases suggest that the FLIR ONE thermal imaging camera has the potential to be an accessible monitoring tool to assist in diagnosis and assess treatment efficacy in complex regional pain syndrome over time.

Preferences in Sleep Position Correlate With Nighttime Paresthesias in Healthy People Without Carpal Tunnel Syndrome.

BACKGROUND: Carpal tunnel syndrome has been associated with sleep position preferences. The aim of this study is to assess self-reported nocturnal paresthesias and sleeping position in participants with and without carpal tunnel syndrome diagnosis to further clinical knowledge for preventive and therapeutic interventions. METHODS: A cross-sectional survey study of 396 participants was performed in young adults, healthy volunteers, and a patient population. Participants were surveyed on risk factors for carpal tunnel syndrome, nocturnal paresthesias, and sleep preferences. Binary logistic regression analysis was performed comparing participants with rare and frequent nocturnal paresthesias. Subanalyses for participants without carpal tunnel syndrome under and over 21 years of age were performed on all factors significantly associated with subclinical compression neuropathy in the overall population. RESULTS: Thirty-three percent of the study population experienced nocturnal paresthesias at least weekly. Increased body mass index ( P < .001) and sleeping with the wrist flexed ( P = .030) were associated with a higher frequency of nocturnal paresthesias. Side sleeping was associated with less frequent nocturnal symptoms ( P = .003). In participants without carpal tunnel syndrome, subgroup analysis illustrated a relationship between nocturnal paresthesias and wrist position. In participants with carpal tunnel syndrome, sleeping on the side had a significantly reduced frequency of nocturnal paresthesias. CONCLUSION: This study illustrates nocturnal paresthesias in people without history of carpal tunnel syndrome including people younger than previously reported. In healthy patients with upper extremity subclinical compression neuropathy, sleep position modification may be a useful intervention to reduce the frequency of nocturnal symptoms prior to developing carpal tunnel syndrome.

The Use of Nerve Transfers to Restore Upper Extremity Function in Cervical Spinal Cord Injury.

BACKGROUND: Nerve transfer surgery to restore upper extremity function in cervical spinal cord injury (SCI) is novel and may transform treatment. Determining candidacy even years post-SCI is ill defined and deserves investigation. OBJECTIVE: To develop a diagnostic algorithm, focusing on electrodiagnostic (EDX) studies, to determine eligibility for nerve transfer surgery. DESIGN: Retrospective descriptive case series. SETTING: Tertiary university-based institution. PATIENTS: Individuals with cervical SCI (n = 45). METHODS: The electronic medical records of people referred to the Plastic Surgery Multidisciplinary Upper Extremity Surgery in SCI clinic from 2010-2015 were reviewed. People were considered for nerve transfers to restore elbow extension or finger flexion and/or extension. Data including demographic, clinical evaluation, EDX results, surgery, and outcomes were collected and analyzed. MAIN OUTCOME MEASUREMENTS: EDX data, including nerve conduction studies and electromyography, for bilateral upper extremities of each patient examined was used to assess for the presence of lower motor neuron injury, which would preclude late nerve transfer. RESULTS: Based on our criteria and the results of EDX testing, a substantial number of patients presenting even years post-SCI were candidates for nerve transfers. Clinical outcome results are heterogeneous but promising and suggest that further refinement of eligibility, long-term follow-up, and standardized assessment will improve our understanding of the role of nerve transfer surgery to restore function in people with midcervical SCI. CONCLUSIONS: Many patients living with SCI are candidates for nerve transfer surgery to restore upper extremity function. Although the ultimate efficacy of these surgeries is not yet determined, this study attempts to report the criteria we are using and may ultimately determine the timing for intervention and which transfers are most useful for this heterogeneous population. LEVEL OF EVIDENCE: IV.

Femoral nerve transfers for restoring tibial nerve function: an anatomical study and clinical correlation: a report of 2 cases.

Sciatic nerve injuries cause debilitating functional impairment, particularly when the injury mechanism and level preclude reconstruction with primary grafting. The purpose of this study was to demonstrate the anatomical feasibility of nerve transfers from the distal femoral nerve terminal branches to the tibial nerve and to detail the successful restoration of tibial function using the described nerve transfers. Six cadaveric legs were dissected for anatomical analysis and the development of tension-free nerve transfers from femoral nerve branches to the tibial nerve. In 2 patients with complete tibial and common peroneal nerve palsies following sciatic nerve injury, terminal branches of the femoral nerve supplying the vastus medialis and vastus lateralis muscles were transferred to the medial and lateral gastrocnemius branches of the tibial nerve. Distal sensory transfer of the saphenous nerve to the sural nerve was also performed. Patients were followed up for lower-extremity motor and sensory recovery up to 18 months postoperatively. Consistent branching patterns and anatomical landmarks were present in all dissection specimens, allowing for reliable identification, neurolysis, and coaptation of donor femoral and saphenous nerve branches to the recipients. Clinically, the patients obtained Medical Research Council Grade 3 and 3+ plantar flexion by 18 months postoperatively. Improved strength was accompanied by improved ambulation in both patients and by a return to competitive sports in 1 patient. Sensory recovery was demonstrated by an advancing Tinel sign in both patients. This study illustrates the clinical success and anatomical feasibility of femoral nerve to tibial nerve transfers after proximal sciatic nerve injury.

Surgical and Clinical Decision Making in Isolated Long Thoracic Nerve Palsy.

BACKGROUND: Isolated long thoracic nerve palsy results in scapular winging and destabilization. In this study, we review the surgical management of isolated long thoracic nerve palsy and suggest a surgical technique and treatment algorithm to simplify management. METHODS: In total, 19 patients who required surgery for an isolated long thoracic nerve palsy were reviewed retrospectively. Preoperative demographics, electromyography (EMG), and physical examinations were reviewed. Intraoperative nerve stimulation, surgical decision making, and postoperative outcomes were reviewed. RESULTS: In total, 19 patients with an average age of 32 were included in the study. All patients had an isolated long thoracic nerve palsy caused by either an injury (58%), Parsonage-Turner syndrome (32%), or shoulder surgery (10%); 18 patients (95%) underwent preoperative EMG; 10 with evidence of denervation (56%); and 13 patients had motor unit potentials in the serratus anterior (72%). The preoperative EMG did not correlate with intraoperative nerve stimulation in 13 patients (72%) and did correlate in 5 patients (28%); 3 patients had a nerve transfer (3 thoracodorsal to long thoracic at lateral chest, 1 pec to long thoracic at supraclavicular incision). In the 3 patients who had a nerve transfer, there was return of full forward flexion of the shoulder at an average of 2.5 months. CONCLUSIONS: A treatment algorithm based on intraoperative nerve stimulation will help guide surgeons in their clinical decision making in patients with isolated long thoracic nerve palsy. Intraoperative nerve stimulation is the gold standard in the management of isolated long thoracic nerve palsy.

Surgical Treatment of Neuromas Improves Patient-Reported Pain, Depression, and Quality of Life.

BACKGROUND: Surgical management of neuromas is difficult, with no consensus on the most effective surgical procedure to improve pain and quality of life. This study evaluated the surgical treatment of neuromas by neurectomy, crush, and proximal transposition on improvement in pain, depression, and quality of life. METHODS: Patients who underwent neuroma excision and proximal transposition were evaluated. Preoperative and postoperative visual analogue scale scores for pain (worst and average), depression, and quality of life were assessed using linear regression, and means were compared using paired t tests. The Disabilities of the Arm, Shoulder, and Hand questionnaire score was calculated preoperatively and postoperatively for upper extremity neuroma patients. Patients with long-term follow-up were analyzed using repeated measures analysis of variance comparing preoperative, postoperative, and long-term visual analogue scale scores. RESULTS: Seventy patients (37 with upper extremity neuromas and 33 with lower extremity neuromas) met inclusion criteria. Statistically significant improvements in visual analogue scale scores were demonstrated for all four patient-rated qualities (p < 0.01) independent of duration of initial clinical follow-up. The change in preoperative to postoperative visual analogue scale scores was related inversely to the severity of preoperative scores for pain and depression. Neuroma excision and proximal transposition were equally effective in treating lower and upper extremity neuromas. Upper extremity neuroma patients had a statistically significant improvement in Disabilities of the Arm, Shoulder, and Hand questionnaire scores after surgical treatment (p < 0.02). CONCLUSIONS: Surgical neurectomy, crush, and proximal nerve transposition significantly improved self-reported pain, depression, and quality-of-life scores. Surgical intervention is a viable treatment of neuroma pain and should be considered in patients with symptomatic neuromas refractory to nonoperative management. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Cases of Early Infectious Flexor Tenosynovitis Treated Non-Surgically With Antibiotics, Immobilization, and Elevation.

BACKGROUND: Early infectious flexor tenosynovitis has been treated with urgent surgery by most surgeons since Bunnell wrote the first textbook of hand surgery in 1945. Some surgeons have good experience with non-surgical management of early presenting disease in some cases. METHODS: This retrospective chart review included 12 inpatients with early infectious flexor synovitis who received conservative treatment with antibiotics, immobilization, and elevation without surgical drainage. RESULTS: The mean time to resolution of infective symptoms for the 12 patients was 5 days (range: 2-11 days) for those receiving conservative management. Half of them required hand therapy. Eight of the 12 patients had good documentation of a full return of hand function. CONCLUSIONS: In some patients with early infectious flexor synovitis, urgent surgery may not be required. We present a brief synopsis of 12 such cases.

HISTORIQUE: La plupart des chirurgiens opèrent d'urgence les ténosynovites infectieuses précoces des fléchisseurs depuis que Bunnell a rédigé le premier manuel sur les chirurgies de la main en 1945. Certains chirurgiens possèdent une bonne expérience de la prise en charge non chirurgicale de certains cas à présentation précoce. MÉTHODOLOGIE: La présente analyse rétrospective des dossiers médicaux portait sur 12 patients hospitalisés à cause d'une synovite infectieuse précoce des fléchisseurs qui avaient reçu un traitement prudent au moyen d'antibiotiques, d'une immobilisation et d'une élévation, sans drainage chirurgical. RÉSULTATS: La période moyenne jusqu'à la résolution des symptômes des 12 patients ainsi traités était de cinq jours (plage de deux à 11 jours). La moitié d'entre eux ont dû subir une chirurgie de la main. Huit des 12 patients présentaient une reprise complète de la fonction de la main bien étayée. CONCLUSIONS: Chez certains patients atteints d'une synovite infectieuse précoce des fléchisseurs, la chirurgie d'urgence n'est pas nécessaire. Les auteurs présentent un synopsis de ces 12 cas.

Resident perceptions on pregnancy during training: 2008 to 2015.

BACKGROUND: Perceptions of residents regarding pregnancy during training were compared over time and across surgical, internal medicine, obstetrics/gynecology, and anesthesia specialties. METHODS: A single-institution survey was distributed to female residents in 2008 and to female and male residents in 2015. Nonparametric comparisons of Likert scale response distributions were performed on the supportiveness for pregnancy of the residency program and childbearing influences of female residents in 2008 and 2015, between specialties for each survey year, and between male and female residents in 2015. RESULTS: The response rates of female residents were 74.8% and 50.5% in 2008 and 2015. In 2015, program directors and division chiefs were perceived to be more supportive of resident pregnancy than in 2008. Surgical residents had lower perceptions of support compared with other specialties. Residents in programs with female leadership perceived a more supportive environment for pregnancy. CONCLUSIONS: Despite persisting negative stigma, residents across specialties report more support for pregnancy.

Free Functional Muscle Transfers to Restore Upper Extremity Function.

Free functional muscle transfer provides an option for functional restoration when nerve reconstruction and tendon transfers are not feasible. To ensure a successful outcome, many factors need to be optimized, including proper patient selection, timing of intervention, donor muscle and motor nerve selection, optimal microneurovascular technique and tension setting, proper postoperative management, and appropriate rehabilitation. Functional outcomes of various applications to the upper extremity and the authors' algorithm for the use of free functional muscle transfer are also included in this article.

Secondary healing of fingertip amputations: a review.

Most literature on fingertips reviews new surgical techniques of coverage while many surgeons prefer the results of secondary healing. This article reviews the current best evidence and concepts about secondary healing in fingertip injuries.

Restricting arm use enhances compensatory reactions of leg muscles during walking.

A number of recent studies have indicated that whole-body coordinated reactions are employed to regain balance following disturbances during walking. However, it is not always the case that all body segments are available to contribute to balance corrective strategies. We hypothesize that balance corrective strategies will adapt to task and environment constraints such that greater responses are generated in the available body segments when other body segments are unable to participate. In this study, we tested the hypothesis that voluntarily restricting the arms during walking would result in an increase in the amplitude of the electromyographic responses evoked in leg muscles when subjects are perturbed at the torso during walking. To do so, subjects were asked to walk on a motorized treadmill while either crossing their arms across their front or back, or with their arms swinging normally. Periodic perturbations, forwards and backwards, were applied at the pelvis randomly throughout the step cycle. This resulted in short latency responses in leg muscles. The amplitude of these responses was increased when subjects walked with their arms crossed, as compared with normal, unrestricted walking. Facilitation of these evoked responses was restricted to the early part of the stance phase, particularly at heel-strike. The pattern of muscle activation and the latency of the responses were not affected by restricting the arms. We suggest that this finding indicates that whole-body balance corrective strategies employed during walking are selected based upon the demands of the general features of the task, but that components of the strategy are scaled according to the specific context-dependent needs of the task.