Long-Term Outcomes after Surgical Treatment of Radial Sensory Nerve Neuromas: Patient-Reported Outcomes and Rate of Secondary Surgery.

BACKGROUND: This study aimed to (1) describe long-term patient-reported outcomes of surgically treated symptomatic radial sensory nerve neuromas on function, pain interference, pain intensity, and satisfaction; (2) assess which factors were associated with worse function, higher pain intensity, and more pain interference; and (3) describe the secondary surgery rate and factors associated with secondary surgery. METHODS: The authors conducted a retrospective review of patients surgically treated for radial sensory nerve neuroma from 2002 to 2016 (n = 54). Twenty-five of these 54 patients completed a follow-up survey including the Patient-Reported Outcomes Measurement Information System (PROMIS) upper extremity, pain interference, and depression scales; numerical rating scale pain and satisfaction instruments; and the global rating scale of change, at a mean period of 10.7 ± 4.3 years after neuroma surgery. RESULTS: The mean PROMIS scores were 45.0 ± 12.1 for upper extremity, 55.5 ± 10.3 for pain interference, and 49.9 ± 10.2 for depression, and were within 1 SD of the general population. Eight patients (32 percent) reported symptoms as unchanged or worse following neuroma surgery. The median numerical rating scale pain was 3 (interquartile range, 1 to 6) and the global rating scale of change satisfaction was 10 (interquartile range, 7 to 10). Older patients (p = 0.002) and patients with higher PROMIS pain interference (p < 0.001), higher numerical rating scale for pain (p = 0.012), and lower global rating scale of change scores (p = 0.01) had worse PROMIS upper extremity scores. The secondary surgery rate was 20 percent and was associated with the presence of multiple neuromas (p = 0.001). CONCLUSIONS: Radial sensory nerve neuromas remain difficult to treat. They have a high secondary surgery rate (20 percent), with only 68 percent of patients reporting improvement after surgical intervention. Patient-reported outcomes after surgery are similar to conditions of the general population; however, the range of outcomes is wide.

Cuando lo central parece periférico: síndrome del interóseo posterior como manifestación aislada de ictus hemorrágico / Posterior interosseous nerve syndrome as an isolated symptom of haemorrhagic stroke: The central mimicking the peripheral

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Compressive radial neuropathy by a synovial cyst during pregnancy: A clinical case report.

RATIONALE: Compressive radial neuropathy by a synovial cyst in the radial tunnel during pregnancy is a rare occurrence. The management of radial nerve compression caused by a synovial cyst in a pregnant patient is a surgical dilemma owing to the fetal and maternal risks of treatment. PATIENT CONCERNS AND DIAGNOSIS: A 37-year-old pregnant woman presented with progressive forearm pain at the gestational age of 12 weeks. A cyst was identified via musculoskeletal ultrasound and magnetic resonance imaging examinations in the radiocapitellar joint causing radial compressive neuropathy. INTERVENTIONS: After regional nerve block and surgical removal of the cyst, the patient's forearm pain was alleviated without neurological deficits. OUTCOME: symptoms from nerve compression were improved after surgical treatment LESSONS:: This report illustrates the case of a pregnant woman presenting a compressive neuropathy by an enlarged cyst possibly due to the unbalance of growth factors during pregnancy. With proper diagnosis and timely surgical intervention, such patients can achieve good neurologic recovery without maternal or fetal complications.

Posterior interosseous nerve entrapments: review of the literature. Is the entrapment distal to the arcade of Frohse a really rare condition?

INTRODUCTION: Spontaneous posterior interosseous nerve palsy is a rare condition. Entrapment is mostly at level of the arcade of Frohse, and a few cases of distal entrapment have been described. METHODS: A case of entrapment distal to the arcade of Frohse is described here. Cases of distal entrapment have been reviewed from the published literature in order to evaluate the frequency of atraumatic mechanical palsy. RESULTS: Seven cases of distal entrapment have been identified. Lesion is the cause of palsy in 58.7% of the cases and entrapment in 20.65%. The pathology is at the elbow in 33.7% of the cases, at the arcade of Frohse in 28.26%, and at the supinator canal in 10.33%. Entrapment is at the arcade of Frohse in 64.45%, proximal in 20%, and distal in 15.55%. CONCLUSION: Posterior interosseous nerve distal entrapment is a rare condition; therefore, further investigation is needed when radiological images at the arcade of Frohse do not show any entrapment.

Electrophysiologic Features of Radial Neuropathy in Childhood and Adolescence.

BACKGROUND: We analyzed the clinical and electrophysiologic patterns of nerve injury in pediatric patients with radial neuropathy. METHODS: This is a retrospective analysis of 19 children and adolescents with radial neuropathy. RESULTS: The mean subject age was 12 years (range one month to 19 years), 56% were female, and 53% had traumatic etiologies. Weakness in the finger and wrist extensors was the prevailing complaint (82%). Predominant localization was at the posterior interosseous nerve (37%), followed by the radial nerve below the spiral groove (32%), the radial nerve at the spiral groove (26%), and the radial nerve above the spiral groove (5%). Extensor indicis proprius compound muscle action potential amplitude was reduced in 86% of cases when tested, with a median axon loss estimate of 78%. The radial sensory nerve action potential amplitude was reduced in 53% of all cases, and in 83% of cases affecting the main radial trunk with a median axon loss estimate of 100%. For neuropathy affecting the main radial trunk, there was a high correlation of extensor indicis proprius median axon loss estimate and radial sensory nerve action potential median axon loss estimate (r = 0.72, P = 0.02). Neurogenic changes were seen in the extensor indicis proprius, extensor digitorum communis, extensor carpi radialis, and brachioradialis in 88%, 94%, 60%, and 44% of cases, respectively. Pathophysiology was demyelinating in 10%, axonal in 58%, and mixed in 32%. CONCLUSIONS: In contrast to adults, where localization at the spiral groove predominates, radial neuropathy in children and adolescents is commonly localized at the posterior interosseous nerve or at the distal main radial trunk. Pediatric radial neuropathy is frequently of traumatic etiology and axonal pathophysiology.

Multiple schwannomas of the digital nerves and superficial radial nerve: two unusual cases of segmental schwannomatosis.

Two cases of segmental sporadic schwannomatosis characterized by unusual location of multiple schwannomas in digital nerves (case 1) and the superficial radial nerve (case 2) are described in this paper. In the first of the described cases, 6 tumours located at the base of the middle finger and in its distal portion were excised from both digital nerves. In the second case, 3 tumours located in the proximal 1/3 and halfway down the forearm were removed from the superficial radial nerve. In both cases, symptoms such as palpable tumour mass, pain, paraesthesias, and positive Tinel-Hoffman sign resolved after operative treatment. Final diagnoses were made based on histopathological examination results. In the second of the described cases, the largest of the excised lesions had features enabling diagnosis of a rare tumour type - ancient schwannoma.

Triple hourglass-like fascicular constriction of the posterior interosseous nerve: a rare cause of PIN syndrome.

Supinator syndrome or posterior interosseous nerve (PIN) syndrome is a compression neuropathy of the deep branch of the radial nerve in the region of the Arcade of Frohse. An extremely rare cause of an acute onset supinator syndrome is the hourglass-like fascicular constriction of the posterior interosseous nerve due to torsion. To our knowledge, only a limited number of cases which describe the sonographic appearance of fascicular torsions are known in the literature. We present a rare case of a supinator syndrome associated with hourglass-like constrictions of the PIN diagnosed by means of sonography.

Surgical treatment of brachial plexus posterior cord lesion: a combination of nerve and tendon transfers, about nine patients.

Lesions of the posterior cord of the brachial plexus are rare. The symptoms are usually described as palsy of the deltoid and triceps brachii muscles and of the extensor muscles of the wrist, thumb and fingers. If there is no recovery, our strategy is to operate on these patients 6 months after the injury using a combination of nerve and tendon transfers. We present a series of nine patients, two with a partial palsy and seven with a complete palsy of the posterior cord. We performed five nerve transfers to the axillary nerve, four using intercostal nerves and one using the ulnar nerve. Six patients benefited from a transfer to one of the nerves to the triceps brachii (medial or lateral head), five using the ulnar nerve and one using two intercostal nerves. We performed eight tendon transfers for radial palsy. The results demonstrated significant restoration of the deltoid muscle (grade 4 strength, mean active abduction of 120°). Active elbow extension was restored in all patients with an average strength measured at 5.6kg and 48% of the contralateral strength. All tendon transfers were successful with recovery of active wrist extension (40°), long fingers extension and thumb abduction and extension (12.5cm between the tips of index and thumb). With this method, we were able to restore function to the upper limb of patients who presented with debilitating palsy of the posterior cord of the brachial plexus.

Epithelioid sarcoma presenting as radial mononeuropathy: anatomical, magnetic resonance neurography and diffusion tensor imaging appearances.

The authors report an unusual case of radial mononeuropathy caused by epithelioid sarcoma and describe the anatomical 3-Tesla MR neurography and the functional diffusion tensor imaging findings of the case, which were subsequently confirmed on surgical excision and histopathology.

High-resolution 3T MR neurography of radial neuropathy.

The radial nerve is a continuation of the posterior cord of the brachial plexus and one of the major nerves that provide motor and sensory innervations to the forearm. MR imaging evaluation of the radial nerve pathology has been described in scattered case reports. Current high-field MR scanners enable high resolution and high contrast imaging of the peripheral nerves. This article reviews the 3 Tesla magnetic resonance neurography imaging of radial nerve anatomy and various pathologies affecting it with relevant case examples.

[Bilateral wrist drop - central or peripheral lesion?]. / Bilaterale Fallhand - Zentrale oder Periphere Läsion?

The wrist drop, also called carpoptosis or drop hand, is a common clinical presentation in case of peripheral damage to the radial nerve. But what about the picture of a bilateral finger/wrist drop?! We report the case of a 61-year-old female patient who was admitted to the hospital for myocardial infarction. Subsequently she developed a right dominant bilateral wrist drop. Further neurological examination revealed a positive Wartenberg sign pointing towards a central motoric dysfunction. The following native cerebral CT scan demonstrated bilateral hypodense lesions in both hand knobs in the precentral gyri. Subsequent MRI confirmed acute cerebral infarction in these two but also several other, clinically silent, locations. Further diagnostic work-up revealed a hypokinetic cardiac apex suggesting cardiac embolism to be the cause for cerebral thrombembolism and the clinically leading symptom of right-dominant bilateral finger/wrist drop. Besides the case presentation also the differential diagnosis and clinical test for diagnostic work-up of wrist drops are presented and discussed.

Frohse's arcade syndrome revealing sarcoidosic myopathy.

We report the first case of an unusual sarcoidosic muscular involvement, complicated with radial nerve palsy. A 58-year-old woman suffering from a mediastinopulmonary sarcoidosis, was admitted for a driving deficit of the hands with a radially deviation during the wrist extension. She had been given a diagnosis of motor branch radial nerve entrapment syndrome. The patient had neurolysis with many muscle biopsies compatible with multiples sarcoidosic nodules, especially at the level of supinator muscle at the origin of the radial nerve compression.

A method to localize the radial nerve using the 'apex of triceps aponeurosis' as a landmark.

BACKGROUND: The relationship of the radial nerve is described with various osseous landmarks, but such relationships may be disturbed in the setting of humerus shaft fractures. Alternative landmarks would be helpful to more consistently and reliably allow the surgeon to locate the radial nerve during the posterior approach to the arm. QUESTIONS/PURPOSES: We investigated the relationship of the radial nerve with the apex of triceps aponeurosis, and describe a technique to locate the nerve. MATERIALS AND METHODS: We performed dissections of 10 cadavers and gathered surgical details of 60 patients (30 patients and 30 control patients) during the posterior approach of the humerus. We measured the distance of the radial nerve from the apex of the triceps aponeurosis along the long axis of the humerus in cadaveric dissections and patients. This distance was correlated with the height and arm length. For all patients, we recorded time until first observation of the radial nerve, blood loss, and postoperative radial nerve function. RESULTS: The mean distance of the radial nerve from the apex of the triceps aponeurosis was 2.5 cm, which correlated with the patients' height and arm length. The mean time until the first observation of the radial nerve from beginning the skin incision was 6 minutes, as compared with 16 minutes in the control group. Mean blood loss was 188 mL and 237 mL, respectively. With the numbers available, we observed no difference in the incidence of patients with postoperative nerve palsy: none in the study group and three in the control group. CONCLUSION: The apex of the triceps aponeurosis appears to be a useful anatomic landmark for localization of the radial nerve during the posterior approach to the humerus.

Moyamoya disease complicated by Graves' disease and type 2 diabetes mellitus: report of two cases.

The pathogenesis of moyamoya disease remains unknown. Examination of diseases concurrent with moyamoya disease may offer a clue to clarify the pathogenesis. Coexistence of moyamoya disease, Graves' disease, and diabetes mellitus is very rare. We present the first cases in the literature. A 38-year-old man with moyamoya disease and a 43-year-old woman with quasi-moyamoya disease, both concurrent with Graves' disease and type 2 diabetes mellitus, are presented. Both patients underwent antithyroid therapy and revascularization. After normalization of thyroid hormones level and blood glucose level followed by revascularization, the symptoms of cerebral ischemia were improved. The common etiological factors of these diseases are discussed. Genetic and autoimmune factor appeared to be involved in the pathogenesis of the three diseases, which may suggest that these factors play important roles in the pathogenesis of moyamoya disease. Further studies are required to define the pathogenesis of moyamoya disease, especially in cases with comorbidities as in the present patients.