Epidemiological Profile of Surgically-Treated Peripheral-Nerve Diseases

Objective To outline the epidemiological profile of surgical patients treated at the peripheral-nerve outpatient clinic of a public hospital in the state of Pernambuco, Brazil, from 2008 (the year this service was implemented in the hospital ) to 2016. Material and Methods A cross-sectional study with data collection from the medical records. A descriptive analysis was performed with the qualitative variables presented as relative and absolute frequencies, and the quantitative variables, as means and standard deviations. The studied variables were gender, age, diagnosis, and surgical techniques. Results In total, 506 medical records were analyzed. Of these, 269 were of male patients (53%), and 238 were of female patients (46%). The age of the sample ranged from 5 to 84 years (41 14 years). The most prevalent diagnoses were: carpal tunnel syndrome (38.9%) followed by traumatic brachial plexus injury (33.2%). The first diagnosis was more frequent among women, while the second, among men. This collaborates with the predominant findings of upper-limb lesions (91%), in which men accounted for 52,75% (244) and women, for 47,25% (217). Conclusion The present study provided relevant information regarding the reality of peripheral-nerve surgeries performed at a public hospital in the state of Pernambuco, Brazil. Public health issues increasingly require the continuity of public policies and government incentive.

Work-related risk factors for ulnar nerve entrapment in the Northern Finland Birth Cohort of 1966.

Ulnar nerve entrapment (UNE) is the second most common entrapment neuropathy in the upper extremity. The aetiology of UNE is multifactorial and is still not fully understood. The aim of the study was to identify occupational risk factors for UNE and to determine whether smoking modifies the effects of work-related factors on UNE. The study population consisted of the Northern Finland Birth Cohort of 1966 (NFBC1966). In total, 6325 individuals active in working life participated at baseline in 1997. Occupational risk factors were evaluated by a questionnaire at baseline. The data on hospitalizations due to UNE were obtained from the Care Register for Health Care between 1997 and 2018. The incidence rate of hospitalization due to UNE was 47.6 cases per 100,000 person-years. After adjusting for confounders, entrepreneurs (Hazard ratio (HR) = 3.68, 95% CI 1.20-11.27), smokers (HR = 2.51, 95% CI 1.43-4.41), workers exposed to temperature changes (HR = 1.72, 95% CI 1.00-2.93), workers with physically demanding jobs (HR = 3.02, 95% CI 1.39-6.58), and workers exposed to hand vibration (HR = 1.94, 95% CI 1.00-3.77) were at an increased risk of hospitalization for UNE. Exposure to work requiring arm elevation increased the risk of hospitalization due to UNE among smokers (HR = 2.62, 95% CI 1.13-6.07), but not among non-smokers. Work-related exposure to vibration and temperature changes, and physically demanding work increase the risk of hospitalization for UNE. Smoking may potentiate the adverse effects of work-related factors on UNE.

Socioeconomic Factors in Patients with Ulnar Nerve Compression at the Elbow: A National Registry-Based Study.

AIMS: To investigate demographics and socioeconomic status in patients with ulnar nerve compression and the influence of socioeconomic factors on patient-reported outcome measurements (PROM) as evaluated by QuickDASH (short version of Disabilities of Arm, Shoulder and Hand) after surgery for ulnar nerve compression at the elbow. METHODS: Patients operated for primary ulnar nerve compression from 2010 to 2016 were identified in the National Quality Registry for Hand Surgery Procedures (HAKIR). Patients filled out questionnaires before and at three and 12 months after surgery. A total of 1346 surgically treated cases were included. Data from HAKIR were linked to data from Statistics Sweden (SCB) on socioeconomic status (i.e., education level, earnings, social assistance, immigrant status, sick leave, unemployment, and marital status). RESULTS: Patients surgically treated for ulnar nerve compression at the elbow differed from the general population with lower levels of education, higher social assistance dependence, a high proportion of unemployment, and lower earnings. However, the results were not clear concerning the influence of socioeconomic factors on the outcome of surgery, except for long-term sick leave. CONCLUSION: Patients surgically treated for ulnar nerve compression at the elbow are socioeconomically deprived, but only a history of long-term sick leave influences the outcome of surgery. This information is crucial in the diagnosis and treatment of these patients.

Is ulnar nerve entrapment at wrist frequent among patients with carpal tunnel syndrome occupationally exposed to monotype wrist movements?

OBJECTIVES: Association between carpal tunnel syndrome (CTS) and ulnar nerve entrapment at wrist remains controversial. The aim of the study has been to investigate the prevalence of Guyon's canal syndrome amongst patients diagnosed with the CTS, occupationally exposed to repetitive wrist movements. MATERIAL AND METHODS: The retrospective analysis of 310 patients (268 females, 42 males) representing the mean age of 52±7 years old hospitalized for the suspected occupational CTS was performed. RESULTS: In the analyzed cohort, 4 patients had undergone decompression of the Guyon's canal in the right limbs. Nerve conduction studies (NCS) in the ulnar nerves performed during the hospitalization of those patients did not show any abnormalities. Nerve conduction studies revealed signs of the ulnar neuropathy (UN) at the wrist affecting exclusively sensory fibers for 6 patients. Only those 4 patients who had undergone the operation suffered from clinical symptoms of the UN before the surgery. In the case of the remaining patients, despite the NCS changes, signs suggestive of the UN at the wrist were not detected. In the case of the patients with the occupational CTS, no signs of the ulnar nerve dysfunction were recorded. CONCLUSIONS: The frequency of ulnar nerve entrapment at the wrist among patients with the CTS is lower than that already reported. The low prevalence of ulnar involvement (3.2%) for the CTS patients in our study may be related to the relatively small number of the CTS hands with the severe changes in the NCS and/or other personal factor including anatomical variation of the Guyon's canal borders and its contents. Int J Occup Med Environ Health 2017;30(6):861-874.

[Thalidomide induced peripheral neuropathy in multiple myeloma patients]. / Polekowa neuropatia obwodowa u pacjentów ze szpiczakiem plaZmocytowym leczonych talidomidem.

INTRODUCTION: Thalidomide, a sedative popular in the 1950s and withdrawn from the market in the 1960s because of its teratogenic effects, has emerged again on the market in the last decade as an effective agent in the treatment of multiple myeloma. Unfortunately, apart from positive treatment effects, numerous side effects have been shown in multiple myeloma patients, including drug-induced damage to peripheral nerves, leading to clinical neuropathy. OBJECTIVES: A clinical and electrophysiological assessment of the prevalence of peripheral neuropathy in patients with multiple myeloma treated with thalidomide. PATIENTS AND METHODS: The study included 43 patients (19 women and 24 men) with a clinical diagnosis of multiple myeloma and treated with thalidomide (average dose, 100 mg/d). Patients with a history of disorders or the presence of factors leading to nervous system damage were excluded from the study. An electrophysiological assessment of motor and sensory fibers of the median, ulnar, peroneal, and tibial nerves was performed. RESULTS: Polyneuropathy was present in 27 patients. In addition, carpal tunnel syndrome coexisting with polyneuropathy was observed in 6 patients. Carpal tunnel syndrome was reported in 4 patients. Moreover, supracondylar damage to the ulnar nerve was reported in 1 patient and Guyon syndrome--in 1 patient. The results of the electrophysiological study were normal in 10 patients. CONCLUSIONS: Our study showed that over 60% of patients treated with thalidomide have peripheral nerve changes typical for peripheral neuropathy. Owing to the high risk of peripheral neuropathy in patients treated with thalidomide, we recommend a routine electrophysiological study in all patients with multiple myeloma in order to diagnose neuropathy at an early stage. Dose reduction or the use of an equally effective but less neurotoxic drug allows to prevent polyneuropathy, while maintaining the basic parameters of cancer treatment.

Nerve compression syndromes of the hand and forearm associated with tumours of non-neural origin and tumour-like lesions.

Nerve compression syndromes caused by non-neural tumours or tumour-like lesions are rare. We retrospectively reviewed 541 consecutive patients operated on by the same surgeon to study nerve compression syndromes in the forearm and hand. There were 414 due to nerve compression and 127 caused by tumours. Twenty-two patients showed compression neuropathy associated with 17 tumours and six tumour-like lesions, with 13 different pathological types. The most common types were fatty and vascular tumours. Twenty-one tumours were extraneural and one was intraneural. The median nerve was affected in nine cases, the ulnar nerve or the dorsal sensory branch of the ulnar nerve in five cases, the posterior interosseous nerve or the superficial radial branch in four cases and the common digital nerves in two cases. There was a concomitant involvement of the median and ulnar nerves in two other patients. Clinically, there were eight different compression neuropathies, of which the most frequent was the carpal tunnel syndrome. The postoperative histology was consistent with preoperative magnetic resonance imaging findings in the vascular and fatty tumours. Pain disappeared completely in 15 out of 16 patients with preoperative pain. All patients had preoperative paraesthesia, which persisted after tumour excision in three patients: attenuated in two patients and unchanged in one. In three patients, we did not observe any change in paresis or amyotrophy. The mean postoperative follow-up was 31 months, without tumour recurrence. The quick Disabilities of the Arm, Shoulder and Hand (DASH) score went from 49.9 points preoperatively to 10.2 points after surgery.

Arthroscopic ulnar nerve decompression in the setting of elbow osteoarthritis.

PURPOSE: To present the technique and outcomes of arthroscopic ulnar nerve decompression at the elbow in a series of patients with associated osteoarthritis. METHODS: A retrospective chart review identified all patients with symptomatic ulnar compression neuropathy and osteoarthritis at the elbow treated with arthroscopic decompression between March 2002 and June 2007. Information regarding preoperative symptom severity and function, associated arthritis and other disorders of the involved extremity, postoperative symptoms and function, complications, and reoperations were reviewed from the medical record. All patients were followed up for at least 12 months, and data collection included clinical evaluations and survey correspondence. RESULTS: Thirteen patients (15 elbows) were available for review. The series consisted of patients with an average age of 51 years (range, 20-75 y). All patients had arthroscopic ulnar nerve decompression, osteophyte resection, and capsulectomy during the same procedure. An average postoperative follow-up of 47 months revealed 7 excellent, 5 good, 1 fair, and 2 poor results. Three patients had reoperations because of persistent or recurrent symptoms. These 3 patients had severe (Dellon classification) symptoms including muscular wasting on presentation. CONCLUSIONS: This technique appears to be a useful procedure for treatment of cubital tunnel syndrome at the time of elbow arthroscopic debridement arthroplasty. Additional follow-up and prospective comparative studies are indicated to further evaluate this technique. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Prevalence and risk factors for upper extremity entrapment neuropathies in polio survivors.

OBJECTIVE: To investigate the electrophysiological prevalence and associated risk factors of upper extremity entrapment neuropathies in a cohort of Taiwanese patients with prior paralytic poliomyelitis. DESIGN: Cross-sectional study involving a consecutive series of patients. SUBJECTS: Ninety-seven polio survivors. METHODS: Demographic factors, medical and work history were recorded. Symptoms and functional deficits of the hand, mobility impairment level, physical activity level and manual muscle testing were assessed, and nerve conduction studies were performed. RESULTS: The electrophysiological prevalence of nerve entrapment among the polio survivors was 80%. The most common electrodiagnostic dysfunction was median neuropathy at the wrist (62%), followed by ulnar neuropathy at the elbow (41%) and ulnar neuropathy at the wrist (38%). In multiple logistic regression, subjects who reported that their jobs involved repetitive hand movements, had a body mass index greater than 24 kg/m2, or used a cane/crutch were at increased risk of both median neuropathy at the wrist and ulnar neuropathy at the wrist. Subjects who used a wheelchair were also at increased risk of ulnar neuropathy at the wrist. CONCLUSION: These results indicate a high occurrence of upper extremity entrapment neuropathies in polio survivors. The documentation of risk factors in this study provides support for screening of at-risk subjects.

The double crush syndrome: a common occurrence in cyclists with ulnar nerve neuropathy-a case-control study.

OBJECTIVE: To evaluate the incidence of double crush syndrome in the upper limbs of cyclists with clinical diagnosis of ulnar nerve neuropathy. DESIGN: Case-control study. SETTING: Outpatient clinics and university setting. PARTICIPANTS: Consecutive sampling of 70 cyclists (140 upper limbs) with a mean age of 36 years (+/-11.3). Seventy-two upper limbs were excluded, leaving 40 upper limbs with a clinical diagnosis of ulnar nerve neuropathy [ULNN (+)] and 28 without symptoms of ulnar nerve neuropathy [ULNN (-)]. ASSESSMENT: Cyclists were examined clinically for the presence of proximal dysfunction using the following testing (independent variables): (1) thoracic outlet syndrome provocation testing: elevated arm stress test and modified Cyriax release test; (2) presence of an elevated first rib: cervical rotation lateral flexion test; and (3) presence of proximal symptoms: reports of neck pain and shoulder pain. MAIN OUTCOME MEASUREMENTS: The upper limbs of cyclists were categorized into 2 groups (dependent variable)-ULNN (+) and ULNN (-)-based on history, symptoms, motor, sensory, and provocative clinical testing. RESULTS: A significantly greater number of upper limbs of cyclists with ULNN (+) presented with positive provocative testing for thoracic outlet syndrome (elevated arm stress test P = 0.005; modified Cyriax release test P = 0.002) than did the upper limbs of cyclists with ULNN (-). The likelihood for the presence of neck pain, shoulder pain, and an elevated first rib was 3, 5, and 12 times greater, respectively, in the ULNN (+) than the ULNN (-) group. CONCLUSION: A statistically significant greater number of the upper limbs of cyclists with clinical diagnosis of ulnar nerve neuropathy presented with proximal dysfunctions suggestive of double crush syndrome.

Study of the ulnar nerve compromise at the wrist of patients with carpal tunnel syndrome.

INTRODUCTION: That the ulnar nerve compromise occurs concomitant with the carpal tunnel syndrome (CTS) has been cited by previous studies. It seems that the previously mentioned incidence is much higher than what we observe in our electrodiagnosis studies. MATERIAL AND METHOD: A prospective study was designed to evaluate the incidence of ulnar nerve compromise in patients with electrodiagnostic evidence of CTS according to age and sex, and also to determine the site of ulnar nerve involvement. RESULTS: One hundred and sixty five limbs with standard elestrodiagnostic criteria of CTS were evaluated In 9.7% of the tested limbs, the ulnar nerve was involved. The site of the involvement was the wrist area in 43.75%. The elbow region was involved in 43.75%, and in 12.5%, the forearm region was involved. The most prevalent age range of concomitant involvement was 45-54 years old. In patents who had sensory symptoms in the 4th and 5th fingers, the incidence of concomitant ulnar nerve compromise was significantly higher (p < 0.001) than the patients without these symptoms. DISCUSSION: In patients with CTS, concomitant ulnar nerve compromise is much lower than the incidence mentioned in previous researches. Apparently the rate of involvement in wrist and elbow are equal. It is recommended that in evaluation of patients for CTS especially when the patient has sensory symptoms in the hand, special attention is paid to ulnar nerve involvement and two nerve comparison tests are interpreted with caution.

[Combined idiopathic forearm entrapment syndromes]. / Kombinierte idiopathische Nervenkompressionssyndrome des Unterarms.

OBJECTIVE: The aim of this study was to investigate the frequency of combined entrapment syndromes of the forearm in a clinical collective with regard to the question of whether this is an especially configured subgroup. METHODS: We included 1 051 patients (747 females aged 52.93 +/- 14.08 years, 304 males aged 52.63 +/- 12.49 years) with clinically and electrophysiologically verified entrapment syndromes (carpal tunnel syndrome n = 957, sulcus ulnaris syndrome n = 143, supinator syndrome n = 12). We excluded patients with symptomatic entrapment syndromes, e. g., post-traumatic or patients with polyneuropathy. The clinical symptoms were compared. RESULTS: In 61 (5.8 %) patients we found combined entrapment syndromes (carpal tunnel syndrome/sulcus ulnaris syndrome n = 54, carpal tunnel syndrome/supinator syndrome n = 5, sulcus ulnaris syndrome/supinator syndrome n = 2). 32.9 % of the sulcus ulnaris syndromes and 41.7 % of the supinator syndromes were combined with carpal tunnel syndrome. CONCLUSIONS: In spite of the very different anatomy of the entrapment, combinations are more frequent than was to be expected from knowledge of the epidemiological data of carpal tunnel syndrome. Combined entrapment was more frequent at the handed side than carpal tunnel syndrome. Thus, forced use of the hand may be a cause for the more frequent appearance of combined entrapment syndromes.

Cigarette smoking and ulnar mononeuropathy at the elbow.

OBJECTIVE: To identify lifestyle risk factors for electrodiagnostically confirmed ulnar mononeuropathy at the elbow (UME). DESIGN: A case-control study involving 101 subjects (12 with definite UME, 42 with probable UME, and 47 controls) who responded to a questionnaire requesting information on subject vocation, repetitive upper limb activity, and alcohol and cigarette use. RESULTS: Subjects with definite UME reported greater tobacco usage as defined by cigarettes per day (mean +/- standard error; 20.1 +/- 5.2, 9.3 +/- 1.9, 8.6 +/- 1.5 cigarettes/day for definite, probable UME, and controls, respectively; P = 0.014) and pack-years (27.3 +/- 9.7, 12.5 +/- 3.0, 9.9 +/- 2.3, for definite, probable UME, and controls, respectively; P = 0.029). The association between cigarettes and definite UME persisted after adjustment for age, sex, and body mass index and was not confounded by alcohol use. Significant negative correlations between tobacco use and ulnar conduction velocities across the elbow and amplitudes above the elbow were identified. CONCLUSIONS: Cigarette smoking and UME seem to be associated. The presence of a plausible mechanism for injury and a dose-response effect suggests that this association may be causative.

[Hand symptoms and pregnancy]. / Håndgener og graviditet.

The purpose of the present study was to identify the incidence of hand symptoms related to pregnancy in a Danish population. Three hundred and thirty-five consecutive postpartum patients were interviewed by questionnaire. Hand symptoms had been noted by 16%, among these 30% described a classic median-nerve symptom distribution (carpal tunnel syndrome) and 24% of patients described an ulnar nerve distribution. Most symptoms were bilateral, commenced in the third trimester and resolved soon after delivery. There was a significant correlation of hand symptoms in pregnancy with the presence of swelling and a significant correlation to parity (first). Hand function and sleep had been disturbed in half of the patients. Half of the patients had mentioned their symptoms to their doctor and one had been sent to treatment. Hand symptoms during pregnancy are common, and their severity is often underestimated. Symptoms of the carpal tunnel syndrome are easily relieved by a night splint.

Ulnar neuropathy. Incidence, outcome, and risk factors in sedated or anesthetized patients.

BACKGROUND: Ulnar neuropathy is well-recognized as a potential complication of procedures performed on anesthetized patients. However, reported outcomes and risk factors for this problem are based on small series and anecdotes. METHODS: We retrospectively reviewed the perioperative courses of 1,129,692 consecutive patients who underwent diagnostic and noncardiac surgical procedures with concurrent anesthetic management at the Mayo Clinic from 1957 through 1991 (inclusive). The medical diagnoses of patients who had these procedures were scanned for 26 diagnoses associated with neuropathy. Persistent neuropathy of an ulnar nerve was defined as a sensory or motor deficit of greater than 3 months' duration. Risk factors anecdotally associated with persistent neuropathy were analyzed by comparing patients with an ulnar neuropathy with control subjects in a 1:3 case-control study. RESULTS: Persistent ulnar neuropathies were identified in 414 patients, a rate of 1 per 2,729 patients. Of these, 38 (9%) patients had bilateral neuropathies. Approximately equal numbers of the neuropathies included sensory loss only or mixed sensory and motor loss. Initial symptoms form most neuropathies were noted more than 24 h after the procedure. Factors associated with persistent ulnar neuropathy included male gender and a duration of hospitalization of more than 14 days (P < 0.01). Neuropathy was more likely to develop in very thin and obese patients than in patients with average body habitus. Neither the type of anesthetic technique nor the patient position was found to be associated with this neuropathy. Of the 382 patients who survived the 1st postoperative yr, 53% regained complete motor function and sensation and were asymptomatic. Of those with neuropathies persisting for more than 1 yr, most had moderate or greater disability from pain or weakness. CONCLUSIONS: These data suggest that perioperative ulnar neuropathies are associated with factors other than general anesthesia and intraoperative positioning. Men at the extremes of body habitus who have prolonged hospitalizations are particularly susceptible to development of ulnar neuropathies.

Relative frequency of nerve conduction abnormalities at carpal tunnel and cubital tunnel in France and the United States: importance of silent neuropathies and role of ulnar neuropathy after unsuccessful carpal tunnel syndrome release.

The two most frequently diagnosed nerve compression syndromes of the upper extremities are carpal tunnel syndrome and cubital tunnel syndrome. In order to determine the relative frequencies of nerve conduction abnormalities at the carpal tunnel and cubital tunnel in France and the United States, we evaluated all patients (nFR = 882 and nUS = 818) who had nerve conduction studies of the upper extremities over a six-yearFR or three-yearUS interval. In both France and the United States, the risk of electrophysiological abnormalities was 2 to 1 for the wrist relative to the elbow. Abnormal median nerves were twice as likely to be symptomatic as were abnormal ulnar nerves (silent ulnar neuropathy). Thus, the clinical risk for carpal tunnel syndrome relative to cubital tunnel syndrome was approximately 4 to 1. In many cases of persistent hand symptoms following carpal tunnel release, the problem may actually be related to an undiagnosed ulnar nerve lesion. Thus, a complete neurophysiological evaluation of the upper extremity necessitates both median and ulnar studies.