Two Cases of Doppler Sonography for Intraneural Vascularity of Ulnar Neuropathy at the Elbow: Before and After Surgery.

The finding of an intraneural blood flow (IBF) signal on Doppler sonography (DS) in non-surgical cases is interpreted in several ways and usually represents a pathologic condition with entrapment neuropathy. There have been no reports of the IBF signal on DS after surgery for ulnar neuropathy at the elbow (UNE). IBF was investigated before and after surgery in two cases diagnosed with UNE before surgery and confirmed after surgery. Both underwent electrodiagnostic (EDX) studies, grey scale sonography (GS), and DS before and after surgery and were diagnosed as having UNE by EDX study and GS. On DS, an IBF signal was not detected in both cases before surgery. After surgery, both cases improved their clinical and EDX findings, and an IBF signal and pulsatility were detected on DS. With respect to vascular problems, recovering venous and arterial blood supplies and dilated vessels would show much more blood flow during recovery of the affected ulnar nerve site following decompression surgery. The IBF signal would not always implicate pathology. When assessing recovery from UNE after surgery, it may be useful to evaluate intraneural vascularity at the affected site with DS.

Neural Perforasomes of the Upper Extremity.

BACKGROUND: In the setting of the rapid advancement of integumentary vascular knowledge, the authors hypothesized that the extrinsic blood supply to the major peripheral nerves of the upper extremity could be categorized into discrete neural "perforasomes." METHODS: Total limb perfusion of the arterial system was performed with gelatin-red lead oxide in cadaveric upper limbs. The perforating vessels to the radial, median, and ulnar nerves were identified, confirmed with fluoroscopy, and dissected. Distances to major anatomical landmarks of the upper extremity were measured. Additional cadaveric limbs' nerves were dissected and source arteries were selectively cannulated and injected to assess specific contribution to extrinsic nerve perfusion. The perfusion of each nerve was then calculated among all specimens. RESULTS: The radial, median, and ulnar nerve perforators were mapped. The corresponding neural perforasomes were mapped. The distal portions of the superficial radial nerve and the posterior interosseous nerve demonstrated a lack of staining. Similarly, at the carpal tunnel and at the proximal 25 percent of the median nerve (corresponding to the pronator teres), the nerve lacked vascular staining. At the Guyon canal and the flexor carpi ulnaris, the ulnar nerve demonstrated a lack of vascular staining. CONCLUSIONS: Peripheral nerves can be divided into neural perforasomes with limited overlap. The extrinsic perfusion of peripheral nerves is highly segmental. Absent stains within the nerves correspond to common sites of compression: carpal tunnel and pronator teres for the median nerve, supinator for the posterior interosseous nerve, and the Guyon canal and the flexor carpi ulnaris for the ulnar nerve.

Reliability of functioning free muscle transfer and vascularized ulnar nerve grafting for elbow flexion in complete brachial plexus palsy.

We compared outcomes of primary vascularized ulnar nerve grafts from the C5 root neurotizing biceps and brachialis muscles, and gracilis functioning free muscle transfer neurotized by the distal spinal accessory nerve, as a primary or salvage procedure after complete brachial plexus injury. At 45 months, three of eight primary vascularized ulnar nerve graft patients regained grade 4 elbow flexion, while one regained grade 3. All 13 primary gracilis transfer patients regained grade 4 elbow flexion. Four patients with vascularized ulnar nerve grafts failed and subsequently had salvage functioning free muscle transfer procedures resulting in delayed recovery. Although vascularized ulnar nerve graft-based primary reconstructions can provide useful elbow flexion, this was achieved in less than half the cases. We consider primary gracilis functioning free muscle transfer neurotized by the distal spinal accessory nerve as the most reliable reconstruction for the restoration of elbow flexion in complete brachial plexus injury. LEVEL OF EVIDENCE: IV.

Ultrasonic Observation and Clinical Application of Arcade of Struthers in the Mid-Arm.

BACKGROUND: The mid-arm structure named arcade of Struthers has been shrouded in controversy since it was identified. Most specimens in previous studies were European. The occurrence, component, extent, and position of this structure in the xanthoderm are not clear. Moreover, research into the arcade of Struthers has been at the anatomic level and there has been no ultrasonic research. The aim of this study was to elucidate and measure this anatomy by both anatomic dissection and ultrasonic observation to provide clear and definite criteria to classify the arcade of Struthers, as well as operation guidelines for identifying the arcade of Struthers in ultrasonic imaging and surgical decompression. METHODS: Sixty-four upper limb specimens of 32 adult cadavers were dissected. The tendinous arcade of Struthers (TAS) and muscular arcade of Struthers (MAS) were observed and measured, as well as the position at which the medial intermuscular septum was pierced by the ulnar nerve. The position at which the concomitant blood vessel began to accompany the ulnar nerve was also recorded. Twenty healthy adult participants were enrolled for ultrasonic research. The ulnar nerve was scanned from the cubital tunnel to the fossa axillaris for the anatomic structure crossing it. Once the arcade of Struthers was found, the distal and proximal limits were marked on the skin and it was then measured. RESULTS: Anatomic study showed TASs in 21 limbs, and MASs were found in 16 limbs. The total incidence of the arcade of Struthers was 57.8%. The length of TAS (2.12 ± 0.62 cm) and MAS (4.46 ± 1.96 cm) had a significant difference and the distance between its proximal limit and the medial humeral epicondyle were 8.93 ± 1.38 cm and 9.50 ± 1.69 cm, respectively. Ultrasonic study showed that the incidence of the arcade of Struthers was 50.0%. The distance between its proximal limit and the medial humeral epicondyle was 8.52 ± 1.88 cm and 9.45 ± 1.76 cm. The length was 1.85 ± 1.8 cm and 4.23 ± 1.93 cm, respectively. CONCLUSIONS: We believed that an arcade of Struthers described by multiple investigators did exist in Chinese people, and based on our study, it was classified into 2 types: TAS and MAS. Caution should be used to preserve the superior ulnar collateral artery when incising the arcade of Struthers. Ultrasonography can detect the existence ratio, dimension, and location of the arcade of Struthers.

The effect of upper limb position on ultrasonographic arterial flow to the ulnar nerve.

We measured the pulsatility indices in the inferior collateral and posterior recurrent ulnar arteries, which supply the ulnar nerve at the elbow, in 38 conscious adults. Compared with a straight 30° abducted arm, elbow flexion to 120° reduced the mean (SD) pulsatility index in the inferior artery and increased the pulsatility index in the posterior artery: from 3.36 (0.86) to 3.04 (0.94), p = 0.001, and from 3.14 (0.81) to 3.64 (1.05), p < 0.0005, respectively. The mean (95% CI) pulsatility index in the inferior artery was unaffected by shoulder abduction to 120°, but it was decreased in the posterior artery in men, from 3.06 (2.76-3.36) to 2.64 (2.34-2.95), but not women, from 3.22 (2.94-3.50) to 3.25 (2.97-3.53), p = 0.01 for men vs women. Researchers should measure arterial pulsatility indices under general anaesthesia and associate them with measures of nerve function.

The effect of vascular pedicle preservation on blood flow and clinical outcome following ulnar nerve transposition.

PURPOSE: To evaluate the efficacy of a technique to preserve the extrinsic vascular supply to the ulnar nerve after transposition and its effect on blood flow and clinical outcome. METHODS: We included 36 patients with cubital tunnel syndrome. The patients were randomly selected to undergo vascular pedicles-sparing surgery for anterior ulnar nerve transposition (VP group) or nerve transposition and artery ligation (non-VP group). Blood flow to the ulnar nerve was estimated intraoperatively at 3 locations in the cubital tunnel before and after transposition using a laser Doppler flowmeter. Clinical results at 3, 6, and 12 months after surgery were also compared between the 2 groups. RESULTS: The blood flow before ulnar nerve transposition was not significantly different between the groups. Blood flow at all 3 locations after the ulnar nerve transposition was significantly higher in the VP group than in the non-VP group. Blood flow in the non-VP group reduced to values between 28% and 52% from the pre-transposition baseline values. After surgery, no significant differences were observed in the clinical results between the groups, except for the Disabilities of the Arm, Shoulder and Hand scores at 12 months after surgery, which was greater in the non-VP group. CONCLUSIONS: The procedure of preserving the extrinsic vascular pedicles can prevent compromise of blood flow to the ulnar nerve immediately after nerve transposition. However, this procedure had no correlation to improved recovery of ulnar nerve function after surgery. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Multifocal enlargement and increased vascularization of peripheral nerves detected by sonography in CIDP: a pilot study.

OBJECTIVE: Detection of nerve enlargement in polyneuropathies by sonography is a new research area. No systematic investigation has been done yet in chronic inflammatory demyelinating polyneuropathy (CIDP). Therefore we investigated this in CIDP. METHODS: Eleven patients with CIDP fulfilling the international criteria on CIDP underwent ultrasonographic examination of the median, ulnar, fibular and posterior tibial nerves and sometimes the brachial plexus bilaterally, using a standardized protocol. We assessed presence of nerve thickening and increased nerve vascularization. RESULTS: In 7 of the 11 patients multiple nerve enlargements were detected: ulnar nerve 7, fibular nerve 5, posterior tibial nerve 4 and median nerve in 4 patients. The number of enlarged nerves was related with the MRC sum-score (p=0.03) and the total protein in the cerebrospinal fluid (CSF) at diagnosis (p=0.02). Increased vascularization was seen in 6 of the 11 patients: 4 in one nerve and in 2 in multiple nerves. The number of nerves with increased vascularization was associated with the number of enlarged nerves (p=0.01) and total protein in the CSF (p=0.006). CONCLUSION: Multiple nerve enlargements occur in CIDP showing a relation with a lower MRC sum-score, increased nerve vascularization and a higher total protein of the CSF. SIGNIFICANCE: Our findings of nerve enlargement and increased nerve vascularization may be tools to monitor disease activity in CIDP, but further studies are needed.

Anatomy of the nervous of forearm and hand of cebus libidinosus (Rylands, 2000) / Anatomía de los nervios del antebrazo y mano de cebus libidinosus (Rylands, 2000)

The knowledge on the macroscopic internal structure of Cebus will provide data for histological and biochemical studies and too will contribute to ethological studies. Behavior, memory, use of tools and encephalization index have put the Cebus genus near to chimpanzees in relation to these aspects. The objective of this study is to characterize the nervous model of the forearm and hand of the Cebus monkey. For this, the main nerves and their branches located in the forearm and hand of the Cebus monkey were anatomically characterized, taking into consideration their frequency, number, origin and distribution. The data were compared with the same nerves found in specialized literature in humans, also specialized in other non-human primates. In this study, 7 Cebus libidinosus monkeys were used. The monkeys were provided by IBAMA (Brazilian Institute for the Environment and Renewable Natural Resources), from the city of Sete Lagoas, State of Minas Gerais, in 1970, and housed at the anatomy collection of the Goißs Federal University (UFG). For the nerves of the forearm of Cebus, no variations were observed in the innervation pattern of the muscles, except for the deep flexor muscle of the fingers, which in Cebus and baboons is innervated by the ulnar nerve and in humans and chimpanzees by the median nerve; however, these nerves exchange fibers in the arm and in the brachial plexus. Innervation variations may occur in the fingers of Cebus in relation to other primates, but these variations have been reported with variations in humans. This identical innervation pattern in relation to the nerves of the arm and forearm and hand in Cebus justify its use as model for anthropological evolutionary studies.

El conocimiento sobre la estructura macroscópica del interior del Cebus proporcionará datos para los estudios histológicos y bioquímicos y también contribuirá a estudios etológicos. El comportamiento, la memoria, el uso de herramientas y el índice del encefalización del género Cebus se plantean en torno a los chimpancés, en relación con estos aspectos. El objetivo de este estudio fue caracterizar el modelo de los nervios del antebrazo y la mano del mono Cebus. Para ello, los principales nervios y sus ramos situados en el antebrazo y la mano se caracterizaron anatómicamente, teniendo en cuenta sus frecuencia, número, origen y distribución. En este estudio se utilizaron 7 monos Cebus libidinosus, todos adultos sanos, con variaciones en tamaño y edad. Los monos fueron suministradas por el Ibama (Instituto Brasileño de Medio Ambiente y los Recursos Naturales Renovables), ciudad de Sete Lagoas, Estado de Minas Gerais, en 1970 de la colección anatómica de la Universidad Federal de Goiás (UFG). En el antebrazo de Cebus no se observaron variaciones en las características de los nervios de los músculos, excepto para el músculo flexor profundo de los dedos, que en Cebus y babuinos, está inervado por el nervio ulnar y en los seres humanos y los chimpancés por el nervio mediano; sin embargo, estas fibras nerviosas cambian en el cuello y en el plexo braquial. Las variaciones de los nervios pueden ocurrir en los dedos de Cebus con respecto a otros primates, pero estos cambios están relacionados con las variaciones que ocurren en los seres humanos. Este patrón similar de los nervios de los nervios del brazo y antebrazo y mano en Cebus, justifica su uso como modelo evolutivo para estudios antropológicos.

Vascularized ulnar nerve graft: 151 reconstructions for posttraumatic brachial plexus palsy.

BACKGROUND: Vascularized nerve grafts were introduced in 1976. Subsequent studies have suggested the superiority of vascularized nerve grafts. In this study, the authors present 23 years' experience with vascularized ulnar nerve graft. The factors influencing outcomes and a comparison with conventional nerve grafts are presented. METHODS: Between 1981 and 2003, 151 reconstructions with ulnar nerve were performed in 67 patients for brachial plexus injuries. Patients were divided into four groups: those with vascularized ulnar nerve graft from ipsilateral donors, pedicled or free, and those with vascularized ulnar nerve graft from contralateral donors to median nerve or to single motor targets (e.g., axillary, musculocutaneous, triceps) (n = 25, 21, 13, and 8, respectively). RESULTS: Patients with long denervation times yielded inferior results compared with those operated on early. Pedicle and free ipsilateral ulnar nerve grafts yielded comparable results for biceps muscle neurotization. Neurotization of biceps with a vascularized ulnar nerve graft from the contralateral root was not as effective as neurotization from ipsilateral donors. There was a difference in muscle grading when the target was the median nerve versus single motor targets such as axillary, musculocutaneous, or triceps, but there were no differences between preoperative and postoperative muscle grading of median innervated muscles. CONCLUSIONS: Vascularized ulnar nerve grafting is the appropriate solution for brachial plexus injuries with C8 and T1 root avulsion, with outcomes that are superior to those achieved with conventional nerve grafts. Although few changes have been made over time, the use of ulnar nerve grafts for neurotization of multiple motor targets of the median nerve from contralateral donors is under consideration.

Complete anaesthesia in the cutaneous distribution of the ulnar nerve following submuscular anterior transposition - a case report.

Complete anaesthesia in the cutaneous distribution of the ulnar nerve following submuscular anterior transposition of the ulnar nerve has not been previously reported. We postulate vascular insult as the etiology of this condition and suggest there may be clinical importance to preserving the ulnar nerve blood supply during submuscular anterior transposition.

[Anatomical study on anterior transposition of ulnar nerve accompanied with arteries for cubital tunnel syndrome].

OBJECTIVE: To investigate the blood supply of the ulnar nerve in the elbow region and to design the procedure of anterior transposition of ulnar nerve accompanied with arteries for cubital tunnel syndrome. METHODS: The vascularity of the ulnar nerve was observed and measured in 20 adult cadaver upper limb specimens. And the clinical surgical procedure was imitated in 3 adult cadaver upper limb specimens. RESULTS: There were three major arteries to supply the ulnar nerve at the elbow region: the superior ulnar collateral artery, the inferior ulnar collateral artery and the posterior ulnar recurrent artery. The distances from arterial origin to the medial epicondyle were 14.2+/-0.9, 4.2+/-0.6 and 4.8+/-1.1 cm respectively. And the total length of the vessels travelling alone with the ulnar nerve were 15.0+/-1.3, 5.1+/-0.3 and 5.6+/-0.9 cm. The external diameter of the arteries at the beginning spot were 1.5+/-0.5, 1.2+/-0.3 and 1.4+/-0.5 mm respectively. The perpendicular distance of the three arteries were 1.2+/-0.5, 2.7+/-0.9 and 1.3+/-0. 5 cm respectively. CONCLUSION: It is feasible to perform anterior transposition of the ulnar nerve accompanied with arteries for cubital tunnel syndrome. And the procedure preserves the blood supply of the ulnar nerve following transposition.

Aberrant course of a communicating branch of the ulnar nerve to the median nerve contributing to hypothenar Hammer syndrome.

This presentation represents a unique anatomic predisposition to the development of hypothenar hammer syndrome (HHS). In this case, a communicating branch of the ulnar nerve to the median common digital nerve of the ring finger was identified crossing volar to the superficial palmar arch. This relationship caused thrombosis of the superficial palmar arch proximal to this crossing nerve branch. The aberrant course of this nerve created a structural anomaly contributing to HHS, which ultimately mandated surgical intervention.

Full-length ulnar nerve harvest by means of endoscopy for contralateral C7 nerve root transfer in the treatment of brachial plexus injuries.

BACKGROUND: To avoid long scar formation after contralateral C7 transfer for treatment of brachial plexus avulsion injuries, endoscopy was used for full-length harvest of the ulnar nerve. The surgical procedure and its clinical effect are reported here. METHODS: From July to August of 2001, two patients with total root avulsion were recruited. Three 2- to 3-cm-long incisions were made in the mid upper arm, elbow, and wrist, and the full-length ulnar nerve was harvested using the Endoscope Vessel Harvest System endoscope system. The surgical time was recorded, the vascularity of the dissected ulnar nerves was observed, and the recovery of the injured limb after contralateral C7 nerve root transfer was measured. RESULTS: Compared with the traditional technique, there were no significant differences in surgical time, vascularity of the dissected ulnar nerve, or recovery of the injured limb when the full-length ulnar nerve was harvested with endoscopy (as part of the contralateral C7 nerve root transfer operation), but the degree of scarring after surgery was markedly reduced. CONCLUSIONS: Although the same level of curative effect was ensured, the new endoscope-aided method for harvesting the full length of the ulnar nerve for contralateral C7 nerve root transfer was not complicated and caused markedly less scarring.

Angiosome territories of the nerves of the upper limbs.

BACKGROUND: The use of free vascularized nerve grafts requires intimate knowledge of the blood supply of peripheral nerves. The authors aimed to demonstrate radiographically the topography of the upper limb nerves with their blood supply, and to examine them as an application of the angiosome concept. An angiosome is a three-dimensional block of composite tissue supplied by a single source artery. METHODS: This anatomical study involved the meticulous dissection of four fresh upper limb specimens injected intraarterially with a gelatin-lead oxide mixture. The nerves were tagged circumferentially with copper wire and radiographs were taken of the nerves with their arterial blood supply. The median, ulnar, radial, musculocutaneous, and axillary nerves were examined. RESULTS: The authors showed that the nerves of the upper limb were supplied segmentally by source vessels, which reinforced the angiosome concept. The suitability of each nerve for harvest in free vascularized nerve transfer was assessed according to its pattern of blood supply. CONCLUSIONS: The authors' work has a wide range of clinical applications and provides an anatomical basis for neurovascular and neurocutaneous flaps and free vascularized nerve grafting.

Vascularized ulnar nerve graft.

The purpose of this article is to describe the indications, anatomy, and harvesting technique of vascularized ulnar nerve graft based on the superior ulnar collateral artery (SUCA) for reconstruction of upper extremity function. The ulnar nerve has an extrinsic blood supply consisting of multiple dominant systems: the SUCA, the inferior ulnar collateral artery, the posterior ulnar recurrent artery, and the ulnar artery. The entire length of the ulnar nerve can survive based on the SUCA and its venae comitantes. The vascularized ulnar nerve graft is used when there is a hopeless prognosis for ulnar nerve repair. This technique may be selected if there is a definite evidence of preganglionic injuries of the C8 and T1 roots in brachial plexus injuries. This technique can be recommended for reconstruction of a large defect of the median or radial nerves in selected cases, such as upper arm replantation.

Use of medial arm skin as a free flap.

BACKGROUND: Free transfer of the medial arm flap has not gained popularity despite the hidden donor-site scar as well as the hairless and elastic skin. This may be because of variations in vascular anatomy, leading to confusion during dissection of the flap. METHODS: In five preserved cadaver arms, the vascular pattern of medial arm skin was examined. Twenty-two upper extremity angiograms were examined, and 12 free medial arm flaps were elevated for various defects in 12 patients. RESULTS: In cadaver and clinical dissections, the authors found that blood supply to the flap is multiple: from the superior ulnar collateral artery, the direct cutaneous artery, or both. A superficial brachial artery may also be present, which was observed in four angiograms and two clinical cases (15 percent). Dissections showed that the medial arm skin may be elevated based on the superficial brachial artery, direct cutaneous artery, or superior ulnar collateral artery. A neurosensory flap may be obtained by including the medial brachial cutaneous nerve of the arm. CONCLUSIONS: A medial arm free flap is a plausible reconstructive option with good knowledge of the anatomical variations, as the defect on the medial arm is cosmetically more acceptable and has a better color match for head and neck reconstructions.