Systematic Review of the Use of Power Doppler Ultrasound in the Imaging of Peripheral Nerve Compression Neuropathy.

BACKGROUND: Power Doppler ultrasonography has been used as an adjunct in the diagnosis of peripheral nerve compression neuropathy. To better characterize its sensitivity and specificity, the authors performed a systematic review of its use in carpal and cubital tunnel syndrome diagnosis. METHODS: The authors systematically reviewed published literature on the use of power Doppler ultrasound to diagnose peripheral compression neuropathy using Ovid MEDLINE, Embase.com, Scopus, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effects, Health Technology Assessment Database, NHS Economic Evaluation Database, World Health Organization International Clinical Trial Repository Platform, and Clinicaltrials.gov. No filters for language, date, or publication type were used. RESULTS: After reviewing 1538 identified studies, 27 publications were included involving 1751 participants with compression neuropathy (2048 median and 172 ulnar). All but three studies examined patients with carpal tunnel syndrome. Heterogeneity between study design and methodology was a noted limitation. Sensitivity and specificity of power Doppler ultrasound in the diagnosis of carpal tunnel syndrome ranged from 2.2 to 93.4 percent, and 89 to 100 percent, respectively, whereas sensitivity for cubital tunnel syndrome was 15.3 to 78.9 percent. There was variability in power Doppler signal detection based on location, with higher sensitivities at the carpal tunnel inlet and in areas of increased nerve swelling. CONCLUSIONS: Power Doppler ultrasound is unreliable as a screening test but appears to increase diagnostic accuracy of ultrasonography in compression neuropathies. It is most beneficial in moderate to severe disease and may be valuable in detecting early cases and in disease surveillance.

The superficial anatomical landmarks are not reliable for predicting the recurrent branch of the median nerve.

PURPOSE: The variability of the recurrent branch (RB) of the median nerve lends itself to an increased risk of injury when performing the minimally invasive approach for carpal tunnel release without its direct visualization. This risk is less so when it is released via the more invasive open approach as the RB can be easily identified, but the drawback is that of longer postoperative patient recovery time. Therefore, performing these releases via the less invasive approach should be more favorable for patients providing it could be done safely. Hence with there being a positive link between the hypertrophy of the thenar musculature and the course of RB according to previous studies. METHODS: We dissected 28 hands of 14 donated bodies fixed using Thiel's method to try to demonstrate these findings of the associations among the RB, palmar creases and other superficial anatomical landmarks. Fisher's exact test was conducted to verify the relationship between those structures statistically. RESULTS: Statistically significant links were found between the type of the RB and the type of the palmar creases (p value = 0.0094) and between the RB type and the palmaris longus muscle presence (p value = 0.028). CONCLUSION: It was inferred that palmar creases and other superficial anatomical landmarks listed in the text could not be used to predict the variability of the RB and the choice of mini-invasive approach should not be based on their course.

A meta-analysis of surgical decompression in the treatment of diabetic peripheral neuropathy.

BACKGROUND: Over the last decade, surgical decompression procedures have been commonly used in the treatment of diabetic peripheral neuropathy (DPN). However, the effectiveness of them remains to be proved. METHODS: A comprehensive literature search of databases including PubMed-Medline, Ovid-Embase, and Cochrane Library was performed to collect the related literatures. The Medical Subject Headings used were "diabetic neuropathy," "surgical decompression," and "outcomes." The methodological index for nonrandomized studies was adopted for assessing the studies included in this review. Analyses were performed with Review Manager (Version 5.3, The Nordic Cochrane Centre, the Cochrane Collaboration, Copenhagen, 2014). RESULTS: A total of 12 literatures (including 8 prospective and 4 retrospective) encompassing 1825 patients with DPN were included in the final analysis. Only 1 literature was identified as a randomized-controlled trial. The remaining 11 literatures were observational studies; 7 of them were classified as upper-extremity nerve decompression group and 4 of them were classified as lower-extremity nerve decompression group. Meta-analysis shows that Boston questionnaire symptom severity and functional status of upper extremities, and distal motor latency and sensory conduction velocity of median nerve of DPN patients are significantly improved after carpal tunnel release. Besides, visual analog scale and 2-point discrimination are considered clinically and statistically significant in lower extremities after operation. CONCLUSIONS: The findings from our review have shown the efficacy of surgical decompression procedures in relieving the neurologic symptoms and restoring the sensory deficits in DPN patients. As there are few high-quality randomized-controlled trials or well-designed prospective studies, more data are needed to elucidate the role of surgical procedures for DPN treatment in the future.

Anatomic Relationship Between the Hook of the Hamate and the Distal Transverse Carpal Ligament: Implications for Ultrasound-Guided Carpal Tunnel Release.

OBJECTIVE: During ultrasound-guided carpal tunnel release, osseous landmarks may supplement direct visualization of the distal transverse carpal ligament (dTCL) to ensure a complete release. The purpose of this study was to determine the relationship between the apex of the hook of the hamate (aHH) and the dTCL within the transverse safe zone (TSZ) of the carpal tunnel. DESIGN: Twenty unembalmed cadaveric specimens were dissected to determine the aHH-dTCL distance and the aHH-SPA distance (the distance between the aHH and the superficial palmar arch) at the ulnar and radial limits of the TSZ (the distance between the hook of the hamate or ulnar artery to the median nerve). RESULTS: The aHH-dTCL distance averaged 11-12 mm across the TSZ (maximum, 18.2 mm), whereas the aHH-SPA distance was significantly greater on the radial side of the TSZ compared with the ulnar side (22.6 ± 3.6 mm vs. 14.0 ± 4.0 mm). CONCLUSIONS: The dTCL lies approximately 11-12 mm distal to the aHH across the TSZ, with an upper limit of 18.2 mm. Along with direct sonographic visualization of the dTCL, the aHH can be used with other osseous landmarks to estimate the position of the dTCL during ultrasound-guided carpal tunnel release.

[Functional results after wrist denervation]. / Funktionelle Ergebnisse nach Handgelenksdenervation.

GOAL: The goal of this retrospective study was to examine the functional results after complete and partial denervation of the wrist, the time of postoperative pain reduction and the overall satisfaction of the patient related to the extend of denervation and preoperative diagnosis. PATIENTS AND METHODS: 43 out of 70 patients with chronic wrist pain who underwent complete or partial wrist denervation from 1993 to 2000 were included in this study. The mean follow-up time was 51 (18-97) months. Prior to denervation a test denervation was performed with the injection of local anesthetics. In order to better differentiate between the overall treatment outcomes we categorized patients in three different groups based on their diagnosis. Group I consisted of 11 patients with radiocarpal arthrosis and carpal instability after SLAC- and SNAC-wrist. In group II 19 patients had radiocarpal arthrosis without carpal instability. Group III consisted of 13 patients without arthrotic changes in the wrist. Apart from the diagnosis we categorized the patients in a group A (29 patients) with complete denervation of the wrist and a group B (14 patients) with only partial denervation of the wrist. Pain reduction was assessed using the visual analog scale. Furthermore we evaluated wrist movement, grip strength, DASH-score, time of disability and the overall patient satisfaction with the procedure. The results were measured by using the Mayo-wrist- and Krimmer-wrist-score. Results of the preoperative test denervation were compared to the postoperative results. Statistical examination was performed between the different groups and comparing pre- to postoperative findings. RESULTS: 10 out of 26 patient, who's test denervation results were evaluated, reported good, 10 patients satisfactory and 6 modest pain reduction after test denervation. Only 13 (65%) of the 20 patients with good/satisfactory pain reduction after test denervation benefited from the operation. After the denervation pain was reduced in 30 patients (70%). Ten of these patients (33%) reported an increase of pain after 22 month on average. 20 patients (66%) were pain free at the time of reexamination. 22 patients (76%) in group A and 8 patients (57%) in group B reported postoperative pain reduction. 7 patients (64%) in group I, 12 patients (63%) in group II and 11 patients (85%) in group III reported postoperative pain reduction. Only in group III pain was statistically significantly decreased. Active range of motion for extension/flexion decreased in all groups postoperatively. Grip strength increased in all groups through the operation without statistical significance. The average DASH score of patients in group I was 37.8, in group II 45.5 and in group III 27.1. 6 patients (55%) in group I, 10 patients (53%) in group II and 10 patients (77%) in group III reported to be satisfied with the denervation. CONCLUSION: A positive test denervation is not a warranty for postoperative pain reduction after denervation of the wrist. Patients without arthrotic changes of the wrist benefit more from denervation than patients with arthrotic changes. Since the majority of patients with arthrotic changes still profited from a denervation we think of the operation as a valid alternative, since it leaves the possibility open for other, more difficult treatment options such as partial or total wrist fusion.

The carpal tunnel.

The carpal bones are deeply convex anteriorly. This bony gutter is converted by the flexor retinaculum into a tube - the carpal tunnel, which conveys the median nerve, together with the long flexor tendons of the fingers and thumb, into the hand. It is of special interest to the surgeon because it is the site of a common nerve entrapment, the carpal tunnel syndrome.

Anatomy of neurovascular structures around the carpal tunnel during dynamic wrist motion for endoscopic carpal tunnel release.

OBJECTIVE: The purpose of this study is to investigate the anatomic relationship between neurovascular structures and the transverse carpal ligament (TCL) so as to avoid complications during an endoscopic carpal tunnel release procedure. METHODS: Fresh cadaver hands from seven men and 12 women (age range, 48-74 yr) were used. The neurovascular structures just over and under the TCL were meticulously dissected under loupe magnification. Several anatomic landmarks were calculated (average length of the TCL; average distance between the TCL distal margin and the neurovascular structures; and average lengths of the superficial palmar arch, ramus communicantes, recurrent motor branch, and palmar cutaneous branch of the median nerve). The ulnar neurovascular structure was studied with the wrist positioned in neutral, ulnar flexion, and radial flexion. RESULTS: The anatomic relationships between the TCL and vascular and neural structures were measured. The ulnar neurovascular structures usually passed just over ulnar to the superior portion of the hook of the hamate. However, in 11 hands, a looped ulnar artery coursed 1 to 4 mm radial to the hook of the hamate and continued to the superficial palmar arch. The looped ulnar artery migrates on the ulnar side of Guyon's canal (-2-2 mm radial to the hook of the hamate) with the wrist in radial flexion (of the wrist). During ulnar flexion of the wrist, the ulnar artery shifts more radially beyond the hook of the hamate (2-7 mm). CONCLUSION: It is appropriate to transect the ligament over 4 mm apart from the lateral margin of the hook of the hamate without placing the edge of the scalpel toward the ulnar side. We would also recommend not transecting the TCL in the ulnar flexed wrist position to protect the ulnar neurovascular structure. The proximal portal could be made just ulnar to the palmaris longus tendon to spare the neurovascular structures in the proximal portion of the TCL.

[Anatomical study of the nerve supply of the trapeziometacarpal joint. Fifteen dissections]. / Etude anatomique de l'innervation de l'articulation trapézo-métacarpienne. A propos de 15 dissections.

PURPOSE OF THE STUDY: When the radiological signs are minimal in patients with a painful carpal syndrome involving the trapeziometacarpal joint (TMCJ), selective articular denervation can be proposed as an alternative after failure of conservative treatment. Results have been variable, sometimes disappointing, suggesting the anatomic basis of denervation should be revisited. The purpose of this work was to study the nerve supply to the TMCJ in order to acquire the indispensable elements necessary for performing effective selective articular denervation. MATERIAL AND METHODS: This anatomical study was performed by dissection under magnification (4.5-x350) of 15 upper limb cadaver specimens. The median nerve, its thenar and volar cutaneous branches and the terminal sensorial branches of the radial nerve were dissected. Articular branches to the TMCJ were carefully identified. Histological samples were taken to verify the neurological nature of the elements dissected. RESULTS: All TMCJs dissected exhibited radial and median nerve supply. Branches of the median nerve predominated in number and caliber. The volar cutaneous branch gave rise to articular branches in eleven dissections and the thenar branch gave rise to articular branches via a retrograde arciform trajectory between the short abductor and the opponens digiti pollicis in thirteen. For five dissections, the TMCJ branches arose directly from the median nerve within the carpal tunnel. At histological analysis the dissected elements were identified as nerves. DISCUSSION: There have been few anatomic studies concerning the nerve supply of the TMCJ. Unlike the findings reported by Cozzi in 1960, we did not find the dorsal sensorial branch of the radial nerve to play an exclusive or preponderant role in the innervation of the TMCJ. The median nerve supply to the TMCJ appeared to be more significant, particularly for the volar cutaneous and especially thenar branches. CONCLUSION: Total and definitive selective denervation of the TMCJ appears to be a most difficult procedure which would require a very wide access and extensive dissection, including the thenar branch which would raise the risk of significant complications.

The carpal tunnel: ultrasound display of normal imaging anatomy and pathology.

Ultrasound successfully displays the normal anatomy and pathology of the median nerve in the carpal tunnel. This article reviews the sonographic characteristics of carpal tunnel anatomy, including the superficially situated median nerve, the contained tendons and vessels, and the boundary-forming fibro-osseous landmarks. It emphasizes ultrasound evaluation of the median nerve and the criteria for diagnosis of compressive neuropathy in carpal tunnel syndrome. The techniques for performing sonography for carpal tunnel syndrome are detailed. Ultrasonic imaging is more comfortable for patients, less time-consuming, and less expensive than MR imaging, and achieves equal accuracy in skilled hands.

Surface landmarks to locate the thenar branch of the median nerve: an anatomical study.

The thenar branch of the median nerve can be injured during carpal tunnel release. The purpose of this study was to identify surface landmarks to consistently predict the location of the thenar branch of the median nerve. Surface landmarks were marked and incised in 28 cadaveric hands. The incisions were made along the longitudinal line of the third web space and the horizontal cardinal line from the hamate hook to the ulnar border of the thumb. The origin of the thenar branch was determined in relation to these longitudinal and horizontal vectors. The origin of the thenar nerve branch was consistently observed in the radial proximal quadrant formed by the aforementioned longitudinal and horizontal vectors. The thenar branch origin was observed to be an average of 8.6 +/- 1.9 mm radial to the longitudinal axis along the third web space. The origin of the thenar branch was observed to be an average of 6.3 +/- 2.0 mm proximal to the horizontal axis between the hamate hook and the ulnar border of the thumb. The thenar branch was observed precisely at the intersection of the longitudinal vector from the second web space to the scaphoid tubercle and the horizontal vector from the hamate hook to the radial edge of the proximal metacarpophalangeal crease in all 28 cadaveric hands. On the basis of these 28 cadaveric dissections, the location of the thenar branch of the median nerve can be predicted by the intersection of the longitudinal vector from the second web space to the scaphoid tubercle and the horizontal vector from the hamate hook to the radial aspect of the metacarpophalangeal crease.

Anatomy of the ulnar artery as it relates to the transverse carpal ligament.

The anatomic relationship between the ulnar artery and transverse carpal ligament (TCL) as an aid in planning for minimally invasive carpal tunnel surgery was investigated. The anatomic course of the ulnar artery and its branches toward the TCL and the location of the median nerve were determined in 24 fresh cadaver hands perfused with a silicone compound. The ulnar artery coursed from 7 mm ulnar to 2 mm radial to the hook of hamate. The average distance between the superficial palmar arch and the distal margin of the TCL was 12 mm as measured along the flexor tendon of the ring finger. The location of the median nerve extended an average of 11 mm radial to the hook of hamate. A small arterial branch (average diameter, 0.7 mm) from the ulnar artery ran transversely just over the TCL in 6 of the 24 specimens. This branch was consistently located within 15 mm proximal to the TCL distal margin. These and other microscopic observations indicated that transecting the ligament at approximately 5 mm radial to the radial margin of the hook of hamate may minimize postoperative bleeding and avoid iatrogenic vascular and neural injury.

Correlation of segmental carpal tunnel pressures with changes in hand and wrist positions in patients with carpal tunnel syndrome and controls.

We investigated pressures at 1 cm intervals along the carpal tunnel in 39 patients with carpal tunnel syndrome (CTS) and 12 controls. Pressures were measured for relaxed and gripping hand positions in combination with neutral, extended, and flexed wrist positions. Patient pressures exceeded control pressures, were below the previously reported 30 mmHg threshold for four of five locations in the relaxed neutral position and were typically greater in extension than in flexion. In the neutral position, both patient and control pressures were slightly above threshold levels just distal to the tunnel. Maximum intratunnel pressures were generally found in the central part of the tunnel and minimum pressures in the distal tunnel. Gripping hand pressures in the tunnel were lowest with the wrist flexed. In both controls and CTS patients, only in the neutral wrist and relaxed hand positions were pressures highest at the point where nerve conduction studies have indicated the nerve is most likely to be compromised (in the midpalm just distal to the distal margin of the carpal tunnel).

Selective motor neuropathy of the median nerve caused by a ganglion in the carpal tunnel.

Carpal tunnel syndrome is the commonest peripheral compressive neuropathy. Typically, sensory symptoms predominate at presentation with motor dysfunction seen in more chronic cases. Isolated motor compression is rare. We present a case of selective median nerve motor neuropathy caused by a carpal tunnel ganglion.

Denervation of the radiocarpal joint. A follow-up study in 22 patients.

Denervation surgery has been a mainstay of our management of chronic pain in the wrist. If there is useful movement at the wrist we prefer denervation to arthrodesis. We have reviewed 22 patients at a mean of 50 months after such denervation surgery at the wrist. This was the only treatment in 16 patients; the other six also had other treatments. Pain was reduced in 16 patients, and 17 were satisfied or improved. None of the patients wished to have a supplementary arthrodesis. We stress the importance of preoperative blockade tests and of a very detailed knowledge of the local anatomy.

Carpectomia proximal / Proximal row carpectomy

Os autores apresentam sua experiência com a realizaçao da técnica de carpectomia proximal em 16 pacientes com diferentes patologias ao nível da primeira fileira do carpo, com tempo de seguimento pós-operatório médio de dois anos. Concordam com a literatura e concluem que o método, na maioria dos casos, diminui a dor, permite a manutençao de arco de movimento satisfatório e boa força de preensao. É, assim, alternativa para a artrodese do punho, que pode ser realizada posteriormente em caso de insucesso.