Sonoanatomy of sensory branches of the ulnar nerve below the elbow in healthy subjects.

PubMed

Kim, Ki Hoon; Lee, Seok Jun; Park, Byung Kyu; Kim, Dong Hwee

2018-04-01

We identify sensory branches of the ulnar nerve-palmar ulnar cutaneous nerve (PUCN), dorsal ulnar cutaneous nerve (DUCN), and superficial sensory branch-using ultrasonography. In 60 forearms of 30 healthy adult volunteers, the origin and size of the PUCN, DUCN, and superficial sensory branch were measured by ultrasonography. The relative pathway of the DUCN to the ulnar styloid process was also investigated. The PUCN was observed in 47 forearms (78%), and the DUCN was observed in all forearms. Average distances from the pisiform to the origin of the PUCN and DUCN were 11.9 ± 1.4 and 7.0 ± 1.0 cm, respectively. Superficial and deep divisions split 0.9 ± 0.3 cm distal to the pisiform. Cross-sectional areas of the PUCN, DUCN, and superficial sensory branch were 0.3 ± 0.1, 1.5 ± 0.5, and 3.9 ± 1.0 mm 2 , respectively. Sensory branches of the ulnar nerve can be visualized by ultrasonography, helping to differentiate ulnar nerve injury originating at either wrist or elbow. Muscle Nerve 57: 569-573, 2018. © 2017 Wiley Periodicals, Inc.

Anatomical considerations of fascial release in ulnar nerve transposition: a concept revisited.

PubMed

Mahan, Mark A; Gasco, Jaime; Mokhtee, David B; Brown, Justin M

2015-11-01

Surgical transposition of the ulnar nerve to alleviate entrapment may cause otherwise normal structures to become new sources of nerve compression. Recurrent or persistent neuropathy after anterior transposition is commonly attributable to a new distal compression. The authors sought to clarify the anatomical relationship of the ulnar nerve to the common aponeurosis of the humeral head of the flexor carpi ulnaris (FCU) and flexor digitorum superficialis (FDS) muscles following anterior transposition of the nerve. The intermuscular septa of the proximal forearm were explored in 26 fresh cadaveric specimens. The fibrous septa and common aponeurotic insertions of the flexor-pronator muscle mass were evaluated in relation to the ulnar nerve, with particular attention to the effect of transposition upon the nerve in this region. An intermuscular aponeurosis associated with the FCU and FDS muscles was present in all specimens. Transposition consistently resulted in angulation of the nerve during elbow flexion when this fascial septum was not released. The proximal site at which the nerve began to traverse this fascial structure was found to be an average of 3.9 cm (SD 0.7 cm) from the medial epicondyle. The common aponeurosis encountered between the FDS and FCU muscles represents a potential site of posttransposition entrapment, which may account for a subset of failed anterior transpositions. Exploration of this region with release of this structure is recommended to provide an unconstrained distal course for a transposed ulnar nerve.

Stimulus electrodiagnosis and motor and functional evaluations during ulnar nerve recovery

PubMed Central

Fernandes, Luciane F. R. M.; Oliveira, Nuno M. L.; Pelet, Danyelle C. S.; Cunha, Agnes F. S.; Grecco, Marco A. S.; Souza, Luciane A. P. S.

2016-01-01

BACKGROUND: Distal ulnar nerve injury leads to impairment of hand function due to motor and sensorial changes. Stimulus electrodiagnosis (SE) is a method of assessing and monitoring the development of this type of injury. OBJECTIVE: To identify the most sensitive electrodiagnostic parameters to evaluate ulnar nerve recovery and to correlate these parameters (Rheobase, Chronaxie, and Accommodation) with motor function evaluations. METHOD: A prospective cohort study of ten patients submitted to ulnar neurorrhaphy and evaluated using electrodiagnosis and motor assessment at two moments of neural recovery. A functional evaluation using the DASH questionnaire (Disability of the Arm, Shoulder, and Hand) was conducted at the end to establish the functional status of the upper limb. RESULTS: There was significant reduction only in the Chronaxie values in relation to time of injury and side (with and without lesion), as well as significant correlation of Chronaxie with the motor domain score. CONCLUSION: Chronaxie was the most sensitive SE parameter for detecting differences in neuromuscular responses during the ulnar nerve recovery process and it was the only parameter correlated with the motor assessment. PMID:26786072

[Preliminary investigation of treatment of ulnar nerve defect by end-to-side neurorrhaphy].

PubMed

Luo, Y; Wang, T; Fang, H

1997-11-01

In the repair of the defect of peripheral nerve, it was necessary to find an operative method with excellent therapeutic effect but simple technique. Based on the experimental study, one case of old injury of the ulnar nerve was treated by end-to-side neurorraphy with the intact median nerve. In this case the nerve defect was over 3 cm and unable to be sutured directly. The patient was followed up for fourteen months after the operation. The recovery of the sensation and the myodynamia was evaluated. The results showed that: the sensation and the motor function innervated by ulnar nerve were recovered. The function of the hand was almost recovered to be normal. It was proved that the end-to-side neurorraphy between the distal stump with the intact median nerve to repair the defect of the ulnar nerve was a new operative procedure for nerve repair. Clinically it had good effect with little operative difficulty. This would give a bright prospect to repair of peripheral nerve defect in the future.

Complete dislocation of the ulnar nerve at the elbow: a protective effect against neuropathy?

PubMed

Leis, A Arturo; Smith, Benn E; Kosiorek, Heidi E; Omejec, Gregor; Podnar, Simon

2017-08-01

Recurrent complete ulnar nerve dislocation has been perceived as a risk factor for development of ulnar neuropathy at the elbow (UNE). However, the role of dislocation in the pathogenesis of UNE remains uncertain. We studied 133 patients with complete ulnar nerve dislocation to determine whether this condition is a risk factor for UNE. In all, the nerve was palpated as it rolled over the medial epicondyle during elbow flexion. Of 56 elbows with unilateral dislocation, UNE localized contralaterally in 17 elbows (30.4%) and ipsilaterally in 10 elbows (17.9%). Of 154 elbows with bilateral dislocation, 26 had UNE (16.9%). Complete dislocation decreased the odds of having UNE by 44% (odds ratio = 0.475; P =  0.028), and was associated with less severe UNE (P = 0.045). UNE occurs less frequently and is less severe on the side of complete dislocation. Complete dislocation may have a protective effect on the ulnar nerve. Muscle Nerve 56: 242-246, 2017. © 2016 Wiley Periodicals, Inc.

Two unusual anatomic variations create a diagnostic dilemma in distal ulnar nerve compression.

PubMed

Kiehn, Mark W; Derrick, Allison J; Iskandar, Bermans J

2008-09-01

Diagnosis of peripheral neuropathies is based upon patterns of functional deficits and electrodiagnostic testing. However, anatomic variations can lead to confounding patterns of physical and electrodiagnostic findings. Authors present a case of ulnar nerve compression due to a rare combination of anatomic variations, aberrant branching pattern, and FCU insertion at the wrist, which posed a diagnostic and therapeutic dilemma. The literature related to isolated distal ulnar motor neuropathy and anatomic variations of the ulnar nerve and adjacent structures is also reviewed. This case demonstrates how anatomic variations can complicate the interpretation of clinical and electrodiagnostic findings and underscores the importance of thorough exploration of the nerve in consideration for possible variations. (c) 2008 Wiley-Liss, Inc.

Iatrogenic Peripheral Nerve Injuries-Surgical Treatment and Outcome: 10 Years' Experience.

PubMed

Rasulić, Lukas; Savić, Andrija; Vitošević, Filip; Samardžić, Miroslav; Živković, Bojana; Mićović, Mirko; Baščarević, Vladimir; Puzović, Vladimir; Joksimović, Boban; Novakovic, Nenad; Lepić, Milan; Mandić-Rajčević, Stefan

2017-07-01

Iatrogenic nerve injuries are nerve injuries caused by medical interventions or inflicted accidentally by a treating physician. We describe and analyze iatrogenic nerve injuries in a total of 122 consecutive patients who received surgical treatment at our Institution during a period of 10 years, from January 1, 2003, to December 31, 2013. The final outcome evaluation was performed 2 years after surgical treatment. The most common causes of iatrogenic nerve injuries among patients in the study were the operations of bone fractures (23.9%), lymph node biopsy (19.7%), and carpal tunnel release (18%). The most affected nerves were median nerve (21.3%), accessory nerve (18%), radial nerve (15.6%), and peroneal nerve (11.5%). In 74 (60.7%) patients, surgery was performed 6 months after the injury, and in 48 (39.3%) surgery was performed within 6 months after the injury. In 80 (65.6%) patients, we found lesion in discontinuity, and in 42 (34.4%) patients lesion in continuity. The distribution of surgical procedures performed was as follows: autotransplantation (51.6%), neurolysis (23.8%), nerve transfer (13.9%), direct suture (8.2%), and resection of neuroma (2.5%). In total, we achieved satisfactory recovery in 91 (74.6%), whereas the result was dissatisfactory in 31 (25.4%) patients. Patients with iatrogenic nerve injuries should be examined as soon as possible by experts with experience in traumatic nerve injuries, so that the correct diagnosis can be reached and the appropriate therapy planned. The timing of reconstructive surgery and the technique used are the crucial factors for functional recovery. Copyright © 2017 Elsevier Inc. All rights reserved.

Supercharged end-to-side anterior interosseous to ulnar motor nerve transfer for intrinsic musculature reinnervation.

PubMed

Barbour, John; Yee, Andrew; Kahn, Lorna C; Mackinnon, Susan E

2012-10-01

Functional motor recovery after peripheral nerve injury is predominantly determined by the time to motor end plate reinnervation and the absolute number of regenerated motor axons that reach target. Experimental models have shown that axonal regeneration occurs across a supercharged end-to-side (SETS) nerve coaptation. In patients with a recovering proximal ulnar nerve injury, a SETS nerve transfer conceptually is useful to protect and preserve distal motor end plates until the native axons fully regenerate. In addition, for nerve injuries in which incomplete regeneration is anticipated, a SETS nerve transfer may be useful to augment the regenerating nerve with additional axons and to more quickly reinnervate target muscle. We describe our technique for a SETS nerve transfer of the terminal anterior interosseous nerve (AIN) to the pronator quadratus muscle (PQ) end-to-side to the deep motor fascicle of the ulnar nerve in the distal forearm. In addition, we describe our postoperative therapy regimen for these transfers and an evaluation tool for monitoring progressive muscle reinnervation. Although the AIN-to-ulnar motor group SETS nerve transfer was specifically designed for ulnar nerve injuries, we believe that the SETS procedure might have broad clinical utility for second- and third-degree axonotmetic nerve injuries, to augment partial recovery and/or "babysit" motor end plates until the native parent axons regenerate to target. We would consider all donor nerves currently utilized in end-to-end nerve transfers for neurotmetic injuries as candidates for this SETS technique. Copyright © 2012 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.

Analyzing cost-effectiveness of ulnar and median nerve transfers to regain forearm flexion.

PubMed

Wali, Arvin R; Park, Charlie C; Brown, Justin M; Mandeville, Ross

2017-03-01

OBJECTIVE Peripheral nerve transfers to regain elbow flexion via the ulnar nerve (Oberlin nerve transfer) and median nerves are surgical options that benefit patients. Prior studies have assessed the comparative effectiveness of ulnar and median nerve transfers for upper trunk brachial plexus injury, yet no study has examined the cost-effectiveness of this surgery to improve quality-adjusted life years (QALYs). The authors present a cost-effectiveness model of the Oberlin nerve transfer and median nerve transfer to restore elbow flexion in the adult population with upper brachial plexus injury. METHODS Using a Markov model, the authors simulated ulnar and median nerve transfers and conservative measures in terms of neurological recovery and improvements in quality of life (QOL) for patients with upper brachial plexus injury. Transition probabilities were collected from previous studies that assessed the surgical efficacy of ulnar and median nerve transfers, complication rates associated with comparable surgical interventions, and the natural history of conservative measures. Incremental cost-effectiveness ratios (ICERs), defined as cost in dollars per QALY, were calculated. Incremental cost-effectiveness ratios less than $50,000/QALY were considered cost-effective. One-way and 2-way sensitivity analyses were used to assess parameter uncertainty. Probabilistic sampling was used to assess ranges of outcomes across 100,000 trials. RESULTS The authors' base-case model demonstrated that ulnar and median nerve transfers, with an estimated cost of $5066.19, improved effectiveness by 0.79 QALY over a lifetime compared with conservative management. Without modeling the indirect cost due to loss of income over lifetime associated with elbow function loss, surgical treatment had an ICER of $6453.41/QALY gained. Factoring in the loss of income as indirect cost, surgical treatment had an ICER of -$96,755.42/QALY gained, demonstrating an overall lifetime cost savings due to

Interfascicular suture with nerve autografts for median, ulnar and radial nerve lesions.

PubMed

Pluchino, F; Luccarelli, G

1981-05-01

Interfascicular nerve suture with autografts is the operation of choice for repairing peripheral nerve injuries because it ensures more precise alignment of the fasciculi and so better chances of reinnervation of the sectioned nerve. The procedure as described by Millesi et al has been used at the Istituto Neurologico di Milano in 30 patients with traumatic lesions of the median, ulnar and radial nerves. All have been followed up for 2 to 7 years since operation. The results obtained are compared with those of other series obtained with interfascicular suture and with epineural suture. Microsurgery is essential. The best time to operate is discussed.

[Evaluation of iatrogenic accessory nerve injury in forensic medical practice].

PubMed

Somogyi, E; Irányi, J

1996-04-14

The authors give a survey of the clinical and medical-legal characteristics of the accessory nerve injury. In the past two decades the conception of the successfulness of the surgical treatment of the accessory nerve injury became prevailing. About the medical-legal aspects of the iatrogenic injury of the nerve reported in connection of the reconstructive surgery chiefly also departments of neurosurgery, orthopedics and traumatology. In the case of the authors a 70 year old patient suffered 10 years ago a iatrogenic accessory nerve injury. The mild trapezius palsy recovered spontaneously practically with cosmetic disadvantage. In connection with the development of extreme dorso-lumbal scoliosis associated with torsion the trapezius atrophy worsened. Physical therapy was partly successful. But the patient became unfit for manual work. Their observations sustain the data of authors who established that in the case of accessory nerve injury not only the surgical but also conservative treatment is usually successful. In opposite to certain data of the literature the authors establish that the iatrogenic injuries of the accessory nerve may lead to significant lifelong disability. The diagnosis is not always made in time with consequent delay in repair. This may be regarded as an unfavorable issue during medical-legal discussions. The authors recommend in interest to prevent nerve injury in the posterior triangle of the neck to perform operation in special department.

Reliability, reference values and predictor variables of the ulnar sensory nerve in disease free adults.

PubMed

Ruediger, T M; Allison, S C; Moore, J M; Wainner, R S

2014-09-01

The purposes of this descriptive and exploratory study were to examine electrophysiological measures of ulnar sensory nerve function in disease free adults to determine reliability, determine reference values computed with appropriate statistical methods, and examine predictive ability of anthropometric variables. Antidromic sensory nerve conduction studies of the ulnar nerve using surface electrodes were performed on 100 volunteers. Reference values were computed from optimally transformed data. Reliability was computed from 30 subjects. Multiple linear regression models were constructed from four predictor variables. Reliability was greater than 0.85 for all paired measures. Responses were elicited in all subjects; reference values for sensory nerve action potential (SNAP) amplitude from above elbow stimulation are 3.3 μV and decrement across-elbow less than 46%. No single predictor variable accounted for more than 15% of the variance in the response. Electrophysiologic measures of the ulnar sensory nerve are reliable. Absent SNAP responses are inconsistent with disease free individuals. Reference values recommended in this report are based on appropriate transformations of non-normally distributed data. No strong statistical model of prediction could be derived from the limited set of predictor variables. Reliability analyses combined with relatively low level of measurement error suggest that ulnar sensory reference values may be used with confidence. Copyright © 2014 Elsevier Masson SAS. All rights reserved.

Quantitative magnetic resonance imaging analysis of the cross-sectional areas of the anconeus epitrochlearis muscle, cubital tunnel, and ulnar nerve with the elbow in extension in patients with and without ulnar neuropathy.

PubMed

Eng, Hing Y; Gunio, Drew A; Benitez, Carlos L

2018-05-10

The purpose of this study was to assess the cross-sectional area of the anconeus epitrochlearis muscle (AEM), cubital tunnel, and ulnar nerve with the elbow in extension in patients with and without ulnar neuropathy. We performed a retrospective, level IV review of elbow magnetic resonance imaging (MRI) studies. Elbow MRI studies of 32 patients with an AEM (26 men and 6 women, aged 18-60 years), 32 randomly selected patients without an AEM (aged 16-71 years), and 32 patients with clinical ulnar neuritis (22 men and 10 women, aged 24-76 years) were reviewed. We evaluated the ulnar nerve cross-sectional area proximal to, within, and distal to the cubital tunnel; AEM cross-sectional area; and cubital tunnel cross-sectional area. We found no significant difference in the nerve caliber between patients with and without an AEM. No correlation was found between the AEM cross-sectional area and ulnar nerve cross-sectional area within the cubital tunnel (r = 0.14). The mean cubital tunnel cross-sectional area was larger in patients with an AEM. Only 4 of the 32 patients with an AEM had findings of ulnar neuritis on MRI. Of the 32 patients with a clinical diagnosis of ulnar neuritis, only 2 had an AEM. With the elbow in extension, the presence or cross-sectional area of an AEM does not correlate with the area of the ulnar nerve or cubital tunnel. Only a small number of individuals with MRI evidence of an AEM had clinical evidence of ulnar neuropathy. Likewise, MRI evidence of an AEM was found in only a small number of individuals with clinical evidence of ulnar neuropathy. Copyright © 2018 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.

Establishment of a Method to Measure Length of the Ulnar Nerve and Standardize F-wave Values in Clinically Normal Beagles

PubMed Central

HIRASAWA, Shun; SHIMIZU, Miki; MARUI, Yuumi; KISHIMOTO, Miori; OKUNO, Seiichi

2014-01-01

We designed a new method of measuring the length of the ulnar nerve and determining standard values for F-wave parameters of the ulnar nerve in clinically normal beagles. Nerve length must be precisely measured to determine F-wave latency and conduction velocity. The length of the forelimb has served as the length of the ulnar nerve for F-wave assessments, but report indicates that F-wave latency is proportional to the length of the pathway traveled by nerve impulses. Therefore, we measured the surface distance from a stimulus point to the spinous process of the first thoracic vertebra (nerve length 1) and the anterior horn of the scapula (nerve length 2) as landmarks through the olecranon and the shoulder blade acromion. The correlation coefficients between the shortest F-wave latency and the length of nerves 1, 2 or the forelimb were 0.61, 0.7 and 0.58. Nerve length 2 generated the highest value. Furthermore, the anterior horn of the scapula was easily palpated in any dog regardless of well-fed body. We concluded that nerve length 2 was optimal for measuring the length of the ulnar nerve. PMID:25649942

Ultrasound biomechanical anatomy of the soft structures in relation to the ulnar nerve in the cubital tunnel of the elbow.

PubMed

Michelin, Paul; Leleup, Grégoire; Ould-Slimane, Mourad; Merlet, Marie Caroline; Dubourg, Benjamin; Duparc, Fabrice

2017-11-01

Chronic ulnar nerve entrapment worsened by elbow flexion is the most common injury, but rare painful conditions may also be related to ulnar nerve instability. The posterior bundle of the medial collateral ligament (pMCL) and the retinaculum, respectively form a soft floor and a ceiling for the cubital tunnel. The aim of our study was to dynamically assess these soft structures of the cubital tunnel focusing on those involved in the biomechanics of the ulnar nerve. Forty healthy volunteers had a bilateral ultrasonography of the cubital tunnel. Elbows were scanned in full extension, 45° and 90°, and maximal passive flexion. Morphological changes of the nerve and related structures were dynamically assessed on transverse views. Both the pMCL and the retinaculum tightened with flexion. During elbow flexion, the tightening of the pMCL superficially moved the ulnar nerve remote from the osseous floor of the retroepicondylar groove. A retinaculum was visible in all 69 tunnels with stable nerves (86.3%), tightened in flexion, but absent in 11 tunnels with unstable nerves (13.7%). The retinaculum was fibrous in 60 elbows and muscular in nine, the nine muscular variants did not significantly influence the biomechanics of stable nerves. Stable nerves flattened in late flexion between the tightened pMCL and retinaculum, whereas unstable nerves transiently flattened when translating against the anterior osseous edge of the groove. The retinaculum and the pMCL are key structures in the biomechanics of the ulnar nerve in the cubital tunnel of the elbow.

Factors Influencing Outcomes after Ulnar Nerve Stability-Based Surgery for Cubital Tunnel Syndrome: A Prospective Cohort Study

PubMed Central

Kang, Ho Jung; Oh, Won Taek; Koh, Il Hyun; Kim, Sungmin

2016-01-01

Purpose Simple decompression of the ulnar nerve has outcomes similar to anterior transposition for cubital tunnel syndrome; however, there is no consensus on the proper technique for patients with an unstable ulnar nerve. We hypothesized that 1) simple decompression or anterior ulnar nerve transposition, depending on nerve stability, would be effective for cubital tunnel syndrome and that 2) there would be determining factors of the clinical outcome at two years. Materials and Methods Forty-one patients with cubital tunnel syndrome underwent simple decompression (n=30) or anterior transposition (n=11) according to an assessment of intra-operative ulnar nerve stability. Clinical outcome was assessed using grip and pinch strength, two-point discrimination, the mean of the disabilities of arm, shoulder, and hand (DASH) survey, and the modified Bishop Scale. Results Preoperatively, two patients were rated as mild, another 20 as moderate, and the remaining 19 as severe according to the Dellon Scale. At 2 years after operation, mean grip/pinch strength increased significantly from 19.4/3.2 kg to 31.1/4.1 kg, respectively. Two-point discrimination improved from 6.0 mm to 3.2 mm. The DASH score improved from 31.0 to 14.5. All but one patient scored good or excellent according to the modified Bishop Scale. Correlations were found between the DASH score at two years and age, pre-operative grip strength, and two-point discrimination. Conclusion An ulnar nerve stability-based approach to surgery selection for cubital tunnel syndrome was effective based on 2-year follow-up data. Older age, worse preoperative grip strength, and worse two-point discrimination were associated with worse outcomes at 2 years. PMID:26847300

Pure neuritic leprosy presenting as ulnar nerve neuropathy: a case report of electrodiagnostic, radiographic, and histopathological findings.

PubMed

Payne, Russell; Baccon, Jennifer; Dossett, John; Scollard, David; Byler, Debra; Patel, Akshal; Harbaugh, Kimberly

2015-11-01

Hansen's disease, or leprosy, is a chronic infectious disease with many manifestations. Though still a major health concern and leading cause of peripheral neuropathy in the developing world, it is rare in the United States, with only about 150 cases reported each year. Nevertheless, it is imperative that neurosurgeons consider it in the differential diagnosis of neuropathy. The causative organism is Mycobacterium leprae, which infects and damages Schwann cells in the peripheral nervous system, leading first to sensory and then to motor deficits. A rare presentation of Hansen's disease is pure neuritic leprosy. It is characterized by nerve involvement without the characteristic cutaneous stigmata. The authors of this report describe a case of pure neuritic leprosy presenting as ulnar nerve neuropathy with corresponding radiographic, electrodiagnostic, and histopathological data. This 11-year-old, otherwise healthy male presented with progressive right-hand weakness and numbness with no cutaneous abnormalities. Physical examination and electrodiagnostic testing revealed findings consistent with a severe ulnar neuropathy at the elbow. Magnetic resonance imaging revealed diffuse thickening and enhancement of the ulnar nerve and narrowing at the cubital tunnel. The patient underwent ulnar nerve decompression with biopsy. Pathology revealed acid-fast organisms within the nerve, which was pathognomonic for Hansen's disease. He was started on antibiotic therapy, and on follow-up he had improved strength and sensation in the ulnar nerve distribution. Pure neuritic leprosy, though rare in the United States, should be considered in the differential diagnosis of those presenting with peripheral neuropathy and a history of travel to leprosy-endemic areas. The long incubation period of M. leprae, the ability of leprosy to mimic other conditions, and the low sensitivity of serological tests make clinical, electrodiagnostic, and radiographic evaluation necessary for diagnosis

Reversed Palmaris Longus Muscle Causing Volar Forearm Pain and Ulnar Nerve Paresthesia.

PubMed

Bhashyam, Abhiram R; Harper, Carl M; Iorio, Matthew L

2017-04-01

A case of volar forearm pain associated with ulnar nerve paresthesia caused by a reversed palmaris longus muscle is described. The patient, an otherwise healthy 46-year-old male laborer, presented after a previous unsuccessful forearm fasciotomy for complaints of exercise exacerbated pain affecting the volar forearm associated with paresthesia in the ulnar nerve distribution. A second decompressive fasciotomy was performed revealing an anomalous "reversed" palmaris longus, with the muscle belly located distally. Resection of the anomalous muscle was performed with full relief of pain and sensory symptoms. Copyright © 2017 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.

Change in the temporal coordination of the finger joints with ulnar nerve block during different power grips analyzed with a sensor glove.

PubMed

Wachter, N J; Mentzel, M; Häderer, C; Krischak, G D; Gülke, J

2018-02-01

Ulnar nerve injuries can cause deficient hand movement patterns. Their assessment is important for diagnosis and rehabilitation in hand surgery cases. The purpose of this study was to quantify the changes in temporal coordination of the finger joints during different power grips with an ulnar nerve block by means of a sensor glove. In 21 healthy subjects, the onset and end of the active flexion of the 14 finger joints when gripping objects of different diameters was recorded by a sensor glove. The measurement was repeated after an ulnar nerve block was applied in a standardized setting. The change in the temporal coordination of the metacarpophalangeal (MCP), proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints with and without the nerve block was calculated within the same subject. In healthy subjects, the MCP joints started their movement prior to the PIP joints in the middle and ring finger, whereas this occurred in the reverse order at the index and little finger. The DIP joint onset was significantly delayed (P<0.01). With the ulnar nerve block, this coordination shifted towards simultaneous onset of all joints, independent of the grip diameter. The thumb and index finger were affected the least. With an ulnar nerve block, the PIP joints completed their movement prior to the MCP joints when gripping small objects (G1 and G2), whereas the order was reversed with larger objects (G3 and G4). The alterations with ulnar nerve block affected mainly the little finger when gripping small objects. With larger diameter objects, all fingers had a significant delay at the end of the PIP joint movement relative to the MCP and DIP joints, and the PIP and DIP joint sequence was reversed (P<0.01). Based on the significant changes in temporal coordination of finger flexion during different power grips, there are biomechanical effects of loss of function of the intrinsic muscles caused by an ulnar nerve block on the fine motor skills of the hand. This can be

Handlebar palsy--a compression syndrome of the deep terminal (motor) branch of the ulnar nerve in biking.

PubMed

Capitani, Daniel; Beer, Serafin

2002-10-01

We describe 3 patients who developed a severe palsy of the intrinsic ulnar supplied hand muscles after bicycle riding. Clinically and electrophysiologically all showed an isolated lesion of the deep terminal motor branch of the ulnar nerve leaving the hypothenar muscle and the distal sensory branch intact. This type of lesion at the canal of Guyon is quite unusual, caused in the majority of cases by chronic external pressure over the ulnar palm. In earlier reports describing this lesion in bicycle riders, most patients experienced this lesion after a long distance ride. Due to the change of riding position and shape of handlebars (horn handle) in recent years, however, even a single bicycle ride may be sufficient to cause a lesion of this ulnar branch. Especially in downhill riding, a large part of the body weight is supported by the hand on the corner of the handlebar leading to a high load at Guyon's canal. As no sensory fibres are affected, the patients are not aware of the ongoing nerve compression until a severe lesion develops. Individual adaptation of the handlebar and riding position seems to be crucial for prevention of this type of nerve lesion.

[Transverse radioulnar branch of the dorsal ulnar nerve: anatomic description and arthroscopic implications from 45 cadaveric dissections].

PubMed

Ehlinger, M; Rapp, E; Cognet, J-M; Clavert, P; Bonnomet, F; Kahn, J-L; Kempf, J-F

2005-05-01

We conducted an anatomic study of the transverse branch of the dorsal ulnar nerve to describe its morphology and position in relation to arthroscopic exploration portals. Forty-five non-side-matched anatomic specimens of unknown age and gender were preserved in formol. The dorsal branch of the ulnar nerve was identified and dissected proximally to distally in order to reveal the different terminal branches. The morphometric analysis included measurement of the length and diameter of the transverse branch and measurement of wrist width. We also measured the smallest distance between the transverse branch and the ulnar styloid process, and between the branch and usual arthroscopic portals (4-5, 6R, 6U) in the axis of the forearm. The transverse branch was inconstant. It was found in 12 of the 45 dissection specimens (27%). In two-thirds of the specimens, the branch ran over less than 50% of the wrist width, tangentially to the radiocarpal joint. Mean nerve diameter was 1 mm. It was found 5-6 mm from the ulnar styloid process and was distal to it in 83% of the specimens. The dissections demonstrated two anatomic variants. Type A corresponded to a branch running distally to the ulnar styloid process, parallel to the joint line (10/12 specimens). Type B exhibited a trajectory proximal to the ulnar styloid process, crossing the ulnar head (2/12 specimens). The relations with the arthroscopic portals (4-5, 6R, 6U) showed that the mean distance from the branch to the portal was 3.75 mm for the 4-5 portal (distally in 11/12 specimens), 3.68 mm for the 6R portal (distally in 10/12 specimens), and 4.83 mm for the 6U portal (distally in 7 specimens and proximally in 5). To our knowledge, there has been only one report specifically devoted to this transverse branch. Two other reports simply mention its existence. According to the literature, the transverse branch of the dorsal ulnar nerve occurs in 60-80% of the cases. We found two anatomic variations different than those

Extravasation of calcium solution leading to calcinosis cutis surrounding the dorsal cutaneous branch of the ulnar nerve.

PubMed

Tuncer, S; Aydin, A; Erer, M

2006-06-01

A case of calcinosis cutis caused by calcium extravasation around the wrist is presented. During excision, the lesion was seen to be surrounding the dorsal branch of the ulnar nerve. The possibility of peripheral nerve involvement in extravasation injuries is emphasized.

Prevalence of ulnar-to-median nerve motor fiber anastomosis (Riché-Cannieu communicating branch) in hand: An electrophysiological study

PubMed Central

Ahadi, Tannaz; Raissi, Gholam Reza; Yavari, Masood; Majidi, Lobat

2016-01-01

Background: Two main muscles studied in the hand for evaluation of median nerve injuries are opponens pollicis (OP) and abductor pollicis brevis (APB). However, Riché-Cannieu communicating branch (RCCB) may limit the use of these muscles in electrodiagnosis. This condition is confusing in the case of median nerve injuries. This study was conducted to evaluate the prevalence of RCCB. Methods: Twenty-three consecutive cases of complete median nerve injury were studied. Evoked responses via stimulation of median and ulnar nerves in the wrist and recording with needle in the thenar area were studied. Results: Of the patients, 82.6% exhibited RCCB. In 14 (60.8%) cases the OP and in 19(82.6%) cases APB was supplied by the ulnar nerve. Conclusion: RCCB was detected to be 60.8% in OP and 82.6% in APB, so OP is preferable to APB in the study of median nerve. PMID:27390694

Sonographic measurements of the ulnar nerve at the elbow with different degrees of elbow flexion.

PubMed

Patel, Prutha; Norbury, John W; Fang, Xiangming

2014-05-01

To determine whether there were differences in the cross-sectional area (CSA) and the flattening ratio of the normative ulnar nerve as it passes between the medial epicondyle and the olecranon at 30° of elbow flexion versus 90° of elbow flexion. Bilateral upper extremities of normal healthy adult volunteers were evaluated with ultrasound. The CSA and the flattening ratio of the ulnar nerve at the elbow as it passes between the medial epicondyle and the olecranon were measured, with the elbow flexed at 30° and at 90°, by 2 operators with varying ultrasound scanning experience by using ellipse and direct tracing methods. The results from the 2 different angles of elbow flexion were compared for each individual operator. Finally, intraclass correlations for absolute agreement and consistency between the 2 raters were calculated. An outpatient clinic room at a regional rehabilitation center. Twenty-five normal healthy adult volunteers. The mean CSA and the mean flattening ratio of the ulnar nerve at 30° of elbow flexion and at 90° of elbow flexion. First, for the ellipse method, the mean CSA of the ulnar nerve at 90° (9.93 mm(2)) was slightly larger than at 30° (9.77 mm(2)) for rater 1. However, for rater 2, the mean CSA of the ulnar nerve at 90° (6.80 mm(2)) was slightly smaller than at 30° (7.08 mm(2)). This was found to be statistically insignificant when using a matched pairs t test and the Wilcoxon signed-rank test, with a significance level of .05. Similarly, the difference between the right side and the left side was not statistically significant. The intraclass correlations for absolute agreement between the 2 raters were not very high due to different measurement locations, but the intraclass correlations for consistency were high. Second, for the direct tracing method, the mean CSA at 90° (7.26 mm(2)) was slightly lower than at 30° (7.48 mm(2)). This was found to be statistically nonsignificant when using the matched pairs t test and the

Neurotization of the biceps muscle by end-to-side neurorraphy between ulnar and musculocutaneous nerves. A series of five cases.

PubMed

Franciosi, L F; Modestti, C; Mueller, S F

1998-01-01

Three patients with avulsed C5, C6, and C7 roots and two patients with avulsed C5 and C6 roots after trauma of the brachial plexus, were treated by neurotization of the biceps using nerve fibers derived from the ulnar nerve and obtained by end-to-side neurorraphy between the ulnar and musculocutaneous nerves. The age of patients ranged from 19 to 45. The interval between the accident and surgery was 2 to 13 months. Return of biceps contraction was observed 4 to 6 months after surgery. Four patients recovered grade 4 elbow flexion. One 45-year-old patient did not obtain any biceps contraction after 9 months.

Median and ulnar neuropathies in university guitarists.

PubMed

Kennedy, Rachel H; Hutcherson, Kimberly J; Kain, Jennifer B; Phillips, Alicia L; Halle, John S; Greathouse, David G

2006-02-01

Descriptive study. To determine the presence of median and ulnar neuropathies in both upper extremities of university guitarists. Peripheral nerve entrapment syndromes of the upper extremities are well documented in musicians. Guitarists and plucked-string musicians are at risk for entrapment neuropathies in the upper extremities and are prone to mild neurologic deficits. Twenty-four volunteer male and female guitarists (age range, 18-26 years) were recruited from the Belmont University School of Music and the Vanderbilt University Blair School of Music. Individuals were excluded if they were pregnant or had a history of recent upper extremity or neck injury. Subjects completed a history form, were interviewed, and underwent a physical examination. Nerve conduction status of the median and ulnar nerves of both upper extremities was obtained by performing motor, sensory, and F-wave (central) nerve conduction studies. Descriptive statistics of the nerve conduction study variables were computed using Microsoft Excel. Six subjects had positive findings on provocative testing of the median and ulnar nerves. Otherwise, these guitarists had normal upper extremity neural and musculoskeletal function based on the history and physical examinations. When comparing the subjects' nerve conduction study values with a chart of normal nerve conduction studies values, 2 subjects had prolonged distal motor latencies (DMLs) of the left median nerve of 4.3 and 4.7 milliseconds (normal, < 4.2 milliseconds). Prolonged DMLs are compatible with median neuropathy at or distal to the wrist. Otherwise, all electrophysiological variables were within normal limits for motor, sensory, and F-wave (central) values. However, comparison studies of median and ulnar motor latencies in the same hand demonstrated prolonged differences of greater than 1.0 milliseconds that affected the median nerve in 2 additional subjects, and identified contralateral limb involvement in a subject with a prolonged

Iatrogenic facial nerve injuries during chronic otitis media surgery: a multicentre retrospective study.

PubMed

Linder, T; Mulazimoglu, S; El Hadi, T; Darrouzet, V; Ayache, D; Somers, T; Schmerber, S; Vincent, C; Mondain, M; Lescanne, E; Bonnard, D

2017-06-01

To give an insight into why, when and where iatrogenic facial nerve (FN) injuries may occur and to explain how to deal with them in an emergency setting. Multicentre retrospective study in eight tertiary referral hospitals over 17 years. Twenty patients with partial or total FN injury during surgery for chronic otitis media (COM) were revised. Indication and type of surgery, experience of the surgeon, intra- and postoperative findings, value of CT scanning, patient management and final FN outcome were recorded. In 12 cases, the nerve was completely transected, but the surgeon was unaware in 11 cases. A minority of cases occurred in academic teaching hospitals. Tympanic segment, second genu and proximal mastoid segments were the sites involved during injury. The FN was not deliberately identified in 18 patients at the time of injury, and nerve monitoring was only applied in one patient. Before revision surgery, CT scanning correctly identified the lesion site in 11 of 12 cases and depicted additional lesions such as damage to the lateral semicircular canal. A greater auricular nerve graft was interposed in 10 cases of total transection and in one partially lesioned nerve: seven of them resulted in an HB III functional outcome. In two of the transected nerves, rerouting and direct end-to-end anastomosis was applied. A simple FN decompression was used in four cases of superficially traumatised nerves. We suggest checklists for preoperative, intraoperative and postoperative management to prevent and treat iatrogenic FN injury during COM surgery. © 2016 John Wiley & Sons Ltd.

Compressive Neuropathy of the Ulnar Nerve: A Perspective on History and Current Controversies.

PubMed

Eberlin, Kyle R; Marjoua, Youssra; Jupiter, Jesse B

2017-06-01

The untoward effects resulting from compression of the ulnar nerve have been recognized for almost 2 centuries. Initial treatment of cubital tunnel syndrome focused on complete transection of the nerve at the level of the elbow, resulting in initial alleviation of pain but significant functional morbidity. A number of subsequent techniques have been described including in situ decompression, subcutaneous transposition, submuscular transposition, and most recently, endoscopic release. This manuscript focuses on the historical aspects of each of these treatments and our current understanding of their efficacy. Copyright © 2017 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.

Median nerve fascicle transfer versus ulnar nerve fascicle transfer to the biceps motor branch in C5-C6 and C5-C7 brachial plexus injuries: nonrandomized prospective study of 23 consecutive patients.

PubMed

Cho, Alvaro Baik; Paulos, Renata Gregorio; de Resende, Marcelo Rosa; Kiyohara, Leandro Yoshinobu; Sorrenti, Luiz; Wei, Teng Hsiang; Bolliger Neto, Raul; Mattar Júnior, Rames

2014-10-01

The purpose of this study was to observe whether the results of the median nerve fascicle transfer to the biceps are equivalent to the classical ulnar nerve fascicle transfer, in terms of elbow flexion strength and donor nerve morbidity. Twenty-five consecutive patients were operated between March 2007 and July 2013. The patients were divided into two groups. In Group 1 (n = 8), the patients received an ulnar nerve fascicle transfer to the biceps motor branch. In Group 2 (n = 15), the patients received a median nerve fascicle transfer to the biceps motor branch. Two patients with follow-up less than six months were excluded. Both groups were similar regarding age (P = 0.070), interval of injury (P = 0.185), and follow-up period (P = 0.477). Elbow flexion against gravity was achieved in 7 of 8 (87.5%) patients in Group 1, versus 14 of 15 (93.3%) patients in Group 2 (P = 1.000). The level of injury (C5-C6 or C5-C7) did not affect anti-gravity elbow flexion recovery in both the groups (P = 1.000). It was concluded that the median nerve fascicle transfer to the biceps is as good as the ulnar nerve fascicle transfer, even in C5-C7 injuries. © 2014 Wiley Periodicals, Inc.

Shear-wave elastography: a new potential method to diagnose ulnar neuropathy at the elbow.

PubMed

Paluch, Łukasz; Noszczyk, Bartłomiej; Nitek, Żaneta; Walecki, Jerzy; Osiak, Katarzyna; Pietruski, Piotr

2018-06-01

The primary aim of this study was to verify if shear-wave elastography (SWE) can be used to diagnose ulnar neuropathy at the elbow (UNE). The secondary objective was to compare the cross-sectional areas (CSA) of the ulnar nerve in the cubital tunnel and to determine a cut-off value for this parameter accurately identifying persons with UNE. The study included 34 patients with UNE (mean age, 59.35 years) and 38 healthy controls (mean age, 57.42 years). Each participant was subjected to SWE of the ulnar nerve at three levels: in the cubital tunnel (CT) and at the distal arm (DA) and mid-arm (MA). The CSA of the ulnar nerve in the cubital tunnel was estimated by means of ultrasonographic imaging. Patients with UNE presented with significantly greater ulnar nerve stiffness in the cubital tunnel than the controls (mean, 96.38 kPa vs. 33.08 kPa, p < 0.001). Ulnar nerve stiffness of 61 kPa, CT to DA stiffness ratio equal 1.68, and CT to MA stiffness ratio of 1.75 provided 100% specificity, sensitivity, positive and negative predictive value in the detection of UNE. Mean CSA of the ulnar nerve in the cubital tunnel turned out to be significantly larger in patients with UNE than in healthy controls (p < 0.001). A weak positive correlation was found in the UNE group between the ulnar nerve CSA and stiffness (R = 0.31, p = 0.008). SWE seems to be a promising, reliable and simple quantitative adjunct test to support the diagnosis of UNE. • SWE enables reliable detection of cubital tunnel syndrome • Significant increase of entrapped ulnar nerve stiffness is observed in UNE • SWE is a perspective screening tool for early detection of compressive neuropathies.

Predictors of surgical revision after in situ decompression of the ulnar nerve.

PubMed

Krogue, Justin D; Aleem, Alexander W; Osei, Daniel A; Goldfarb, Charles A; Calfee, Ryan P

2015-04-01

This study was performed to identify factors associated with the need for revision surgery after in situ decompression of the ulnar nerve for cubital tunnel syndrome. This case-control investigation examined all patients treated at one institution with open in situ decompression for cubital tunnel syndrome between 2006 and 2011. The case patients were 44 failed decompressions that required revision, and the controls were 79 randomly selected patients treated with a single operation. Demographic data and disease-specific data were extracted from the medical records. The rate of revision surgery after in situ decompression was determined from our 5-year experience. A multivariate logistic regression model was used based on univariate testing to determine predictors of revision cubital tunnel surgery. Revision surgery was required in 19% (44 of 231) of all in situ decompressions performed during the study period. Predictors of revision surgery included a history of elbow fracture or dislocation (odds ratio [OR], 7.1) and McGowan stage I disease (OR, 3.2). Concurrent surgery with in situ decompression was protective against revision surgery (OR, 0.19). The rate of revision cubital tunnel surgery after in situ nerve decompression should be weighed against the benefits of a less invasive procedure compared with transposition. When considering in situ ulnar nerve decompression, prior elbow fracture as well as patients requesting surgery for mild clinically graded disease should be viewed as risk factors for revision surgery. Patient factors often considered relevant to surgical outcomes, including age, sex, body mass index, tobacco use, and diabetes status, were not associated with a greater likelihood of revision cubital tunnel surgery. Copyright © 2015 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.

Clarification of Eponymous Anatomical Terminology: Structures Named After Dr Geoffrey V. Osborne That Compress the Ulnar Nerve at the Elbow.

PubMed

Wali, Arvin R; Gabel, Brandon; Mitwalli, Madhawi; Tubbs, R Shane; Brown, Justin M

2017-05-01

In 1957, Dr Geoffrey Osborne described a structure between the medial epicondyle and the olecranon that placed excessive pressure on the ulnar nerve. Three terms associated with such structures have emerged: Osborne's band, Osborne's ligament, and Osborne's fascia. As anatomical language moves away from eponymous terminology for descriptive, consistent nomenclature, we find discrepancies in the use of anatomic terms. This review clarifies the definitions of the above 3 terms. We conducted an extensive electronic search via PubMed and Google Scholar to identify key anatomical and surgical texts that describe ulnar nerve compression at the elbow. We searched the following terms separately and in combination: "Osborne's band," "Osborne's ligament," and "Osborne's fascia." A total of 36 papers were included from 1957 to 2016. Osborne's band, Osborne's ligament, and Osborne's fascia were found to inconsistently describe the etiology of ulnar neuritis, referring either to the connective tissue between the 2 heads of the flexor carpi ulnaris muscle as described by Dr Osborne or to the anatomically distinct fibrous tissue between the olecranon process of the ulna and the medial epicondyle of the humerus. The use of eponymous terms to describe ulnar pathology of the elbow remains common, and although these terms allude to the rich history of surgical anatomy, these nonspecific descriptions lead to inconsistencies. As Osborne's band, Osborne's ligament, and Osborne's fascia are not used consistently across the literature, this research demonstrates the need for improved terminology to provide reliable interpretation of these terms among surgeons.

Reliability of the nerve conduction monitor in repeated measures of median and ulnar nerve latencies

DOE Office of Scientific and Technical Information (OSTI.GOV)

Washington, I A

According to the Bureau of Labor Statistics, carpal tunnel syndrome (CTS), one of the most rapidly growing work-related injuries, cost American businesses up to $10 billion dollars in medical costs each year (1992). Because conservative therapy can be implemented and CTS is more reversible in it early stages, early detection will not only save industry unnecessary health care costs, but also prevent employees from experiencing debilitating pain and unnecessary surgery. In response to the growing number of cases of CTS, many companies have introduced screening tools to detect early stages of carpal tunnel syndrome. Neurotron Medical (New Jersey) has designedmore » a portable nerve conduction monitor (Nervepace S-200) which measures motor and sensory nerve latencies. The slowing of these latencies is one diagnostic indicator of carpal tunnel syndrome. In this study, we determined the reliability of the Nervepace Monitor in measure ulnar and median nerve latencies during repeated testing. The testing was performed on 28 normal subjects between the ages of 20 and 35 who had no prior symptoms of CTS. They were tested at the same time each day for three consecutive days. Nerve latencies between different ethnic groups and genders were compared. Results show that there was no significant daily variation of the median motor and lunar sensory latencies or the median sensory latencies. No significant differences of latencies was observed among ethnic groups; however, a significant difference of latencies between male and female subjects was observed (p<0.05).« less

Accessory superficial ulnar artery: a case report.

PubMed

Solan, Shweta

2013-12-01

Variations in the arterial system of the upper limb have been well documented. A thorough knowledge on variations of arteries of upper extremity is necessary during performance of vascular and reconstructive surgeries and also, during evaluation of angiographic images. A case of accessory superficial ulnar artery was reported. The ulnar artery had a high origin from the brachial artery, in the upper third of the arm and it proceeded superficially and lateral to ulnar nerve in forearm, but it had a normal termination in the hand. The brachial artery had a usual course in the arm, but in the cubital fossa, it divided into the radial and deep ulnar arteries. This deep ulnar artery ended by dividing into ulnar recurrent and common interosseous arteries. Knowledge on this variation is important for the radiologists, orthopaedic and plastic surgeons, for appropriate planning of operative procedures involving the arteries of the upper limb.

Cooling modifies mixed median and ulnar palmar studies in carpal tunnel syndrome.

PubMed

Araújo, Rogério Gayer Machado de; Kouyoumdjian, João Aris

2007-09-01

Temperature is an important and common variable that modifies nerve conduction study parameters in practice. Here we compare the effect of cooling on the mixed palmar median to ulnar negative peak-latency difference (PMU) in electrodiagnosis of carpal tunnel syndrome (CTS). Controls were 22 subjects (19 women, mean age 42.1 years, 44 hands). Patients were diagnosed with mild symptomatic CTS (25 women, mean age 46.6 years, 34 hands). PMU was obtained at the usual temperature, >32 degrees C, and after wrist/hand cooling to <27 degrees C in ice water. After cooling, there was a significantly greater increase in PMU and mixed ulnar palmar latency in patients versus controls. We concluded that cooling significantly modifies the PMU. We propose that the latencies of compressed nerve overreact to cooling and that this response could be a useful tool for incipient CTS electrodiagnosis. There was a significant latency overreaction of the ulnar nerve to cooling in CTS patients. We hypothesize that subclinical ulnar nerve compression is associated with CTS.

Effect of therapeutic ultrasound intensity on subcutaneous tissue temperature and ulnar nerve conduction velocity.

PubMed

Kramer, J F

1985-02-01

Twenty subjects completed 5 min. periods of sonation, at each of six US intensities, over the ulnar nerve in the proximal forearm. All posttreatment NCV's differed significantly from the respective pretreatment velocities. The immediate posttreatment NCV associated with placebo US was significantly (p less than 0.01) less than that observed immediately pretreatment (2.81 m/s), while the five clinical US intensities produced significantly increased immediate posttreatment velocities: 0.5 w/cm2 (2.23 m/s) at (p less than 0.05), and 1.0 w/cm2 (2.78 m/s), 1.5 w/cm2 (3.15 m/s), 2.0 w/cm2 (4.47 m/s) and 2.5 w/cm2 (2.97 m/s) at (p less than 0.01). The posttreatment velocities associated with the five clinical intensities were all significantly greater (p less than 0.01) than that associated with placebo US. Subcutaneous tissue temperatures were directly related to the intensity of US. Not until US intensity had reached 1.5 w/cm2 did the heating effect of US negate the cooling effect of the US transmission gel, to produce significantly increased subcutaneous tissue temperatures after 5 min. sonation. The decreased ulnar motor NCV's associated with placebo US are attributed to the cooling effect of the US transmission gel. The increased ulnar motor NCV's associated with the clinical intensities of US are attributed to the deep heating effect of US. The breakdown of this linear relationship at 2.5 w/cm2 intensity suggests that at this point heating on the nerve and/or the mechanical effects of US were of sufficient magnitude so as to limit the increase in conduction velocity. Sonation over an area of approximately 4.5 times the soundhead for 5 min., along the proximal forearm, at clinical intensities did not have a bipositive effect on motor NCV.

Optimal Measurement Level and Ulnar Nerve Cross-Sectional Area Cutoff Threshold for Identifying Ulnar Neuropathy at the Elbow by MRI and Ultrasonography.

PubMed

Terayama, Yasushi; Uchiyama, Shigeharu; Ueda, Kazuhiko; Iwakura, Nahoko; Ikegami, Shota; Kato, Yoshiharu; Kato, Hiroyuki

2018-06-01

Imaging criteria for diagnosing compressive ulnar neuropathy at the elbow (UNE) have recently been established as the maximum ulnar nerve cross-sectional area (UNCSA) upon magnetic resonance imaging (MRI) and/or ultrasonography (US). However, the levels of maximum UNCSA and diagnostic cutoff values have not yet been established. We therefore analyzed UNCSA by MRI and US in patients with UNE and in controls. We measured UNCSA at 7 levels in 30 patients with UNE and 28 controls by MRI and at 15 levels in 12 patients with UNE and 24 controls by US. We compared UNCSA as determined by MRI or US and determined optimal diagnostic cutoff values based on receiver operating characteristic curve analysis. The UNCSA was significantly larger in the UNE group than in controls at 3, 2, 1, and 0 cm proximal and 1, 2, and 3 cm distal to the medial epicondyle for both modalities. The UNCSA was maximal at 1 cm proximal to the medial epicondyle for MRI (16.1 ± 3.5 mm 2 ) as well as for US (17 ± 7 mm 2 ). A cutoff value of 11.0 mm 2 for MRI and US was found to be optimal for differentiating between patients with UNE and controls, with an area under the receiver operating characteristic curve of 0.95 for MRI and 0.96 for US. The UNCSA measured by MRI was not significantly different from that by US. Intra-rater and interrater reliabilities for UNCSA were all greater than 0.77. The UNCSA in the severe nerve dysfunction group of 18 patients was significantly larger than that in the mild nerve dysfunction group of 12 patients. By measuring UNCSA with MRI or US at 1 cm proximal to the ME, patients with and without UNE could be discriminated at a cutoff threshold of 11.0 mm 2 with high sensitivity, specificity, and reliability. Diagnostic III. Copyright © 2018 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.

Accessory Superficial Ulnar Artery: A Case Report

PubMed Central

Solan, Shweta

2013-01-01

Variations in the arterial system of the upper limb have been well documented. A thorough knowledge on variations of arteries of upper extremity is necessary during performance of vascular and reconstructive surgeries and also, during evaluation of angiographic images. A case of accessory superficial ulnar artery was reported. The ulnar artery had a high origin from the brachial artery, in the upper third of the arm and it proceeded superficially and lateral to ulnar nerve in forearm, but it had a normal termination in the hand. The brachial artery had a usual course in the arm, but in the cubital fossa, it divided into the radial and deep ulnar arteries. This deep ulnar artery ended by dividing into ulnar recurrent and common interosseous arteries. Knowledge on this variation is important for the radiologists, orthopaedic and plastic surgeons, for appropriate planning of operative procedures involving the arteries of the upper limb. PMID:24551682

Ulnar malignant peripheral nerve sheath tumour diagnosis in a mixed-breed dog as a model to study human: histologic, immunohistochemical, and clinicopathologic study

PubMed Central

2013-01-01

Canine Malignant Peripheral Nerve Sheath Tumors (MPNSTs) are uncommonly reported in the ulnar, since they are underestimated relative to the more common spindle cell tumours of soft tissue. In dogs, MPNST accounts for 27% of nervous system tumours. In man, MPNST represents 5-10% of all soft tissue sarcomas and is often associated with neurofibromatosis type 1 (NF-1).An 8-year-old, 9 kg, female mixed-breed dog with a subcutaneous mass on the upper right side of the ulnar region was presented to the small animal research and teaching hospital of Tehran University. The dog was anorexic with general weakness. The mass (7 × 4 cm) was removed surgically and processed routinely. Microscopically, the mass was composed of highly cellular areas with a homogeneous population of round or spindle cells, high cellular pleomorphism, high mitotic index and various morphologic patterns. Furthermore, spindle cells arranged in densely or loosely sweeping fascicles, interlacing whorls, or storiform patterns together with wavy cytoplasm, nuclear palisades, and round cells were arranged in sheets or cords with a meshwork of intratumoral nerve fibers. In addition, in this case the presence of neoplastic cells within the blood vessels was observed. Immunohistochemically, tumor was positive for vimentin and S-100 protein. The histopathologic features coupled with the S-100 and vimentin immunoreactivity led to a diagnosis of malignant neurofibroma. To the best of our knowledge, primary ulnar MPNST has not been reported in animals. This is the first documentation of an ulnar malignant peripheral nerve sheath tumour in a dog. Virtual slides The virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/1310907815984587 PMID:23688209

A reliable technique for ultrasound-guided perineural injection in ulnar neuropathy at the elbow.

PubMed

Hamscha, Ulrike M; Tinhofer, Ines; Heber, Stefan; Grisold, Wolfgang; Weninger, Wolfgang J; Meng, Stefan

2017-08-01

Ulnar neuropathy at the elbow (UNE) is a common peripheral compression neuropathy and, in most cases, occurs at 2 sites, the retroepicondylar groove or the cubital tunnel. With regard to a potential therapeutic approach with perineural corticosteroid injection, the aim of this study was to evaluate the distribution of injection fluid applied at a standard site. We performed ultrasound-guided (US-guided) perineural injections to the ulnar nerve halfway between the olecranon and the medial epicondyle in 21 upper limbs from 11 non-embalmed cadavers. In anatomic dissection we investigated the spread of injected ink. Ink was successfully injected into the perineural sheath of the ulnar nerve in all 21 cases (cubital tunnel: 21 of 21; retroepicondylar groove: 19 of 21). US-guided injection between the olecranon and the medial epicondyle is a feasible and safe method to reach the most common sites of ulnar nerve entrapment. Muscle Nerve 56: 237-241, 2017. © 2016 Wiley Periodicals, Inc.

A study on operative findings and pathogenic factors in ulnar neuropathy at the elbow.

PubMed

Kojima, T; Kurihara, K; Nagano, T

1979-01-01

A study was made of operative findings obtained in 44 cases of ulnar nerve neuropathy at the elbow in an attempt to help elucidate the pathogenetic factors for the condition. Distinction must be made between Lig. epitrochleo-anconeum or a ligament-like thickening at the same site and the tendinous arch of M. flexor carpi ulnaris. These 2 sites constitute the entrapment points for the condition. A thick tendinous arch, Lig. epitrochleo-anconeum of M. anconeus epitrochlearis deters the ulnar nerve from being mobile, thereby contributing to the development of neuropathy with trauma acting as a precipitating factor. Dislocation of the ulnar nerve cannot be considered a factor of major etiologic significance. An important part is played by the tendinous arch in the pathogenesis of neuropathy, regardless of whether it is in association with ganglion, osteochondromatosis or osteoarthritis. In surgery for ulnar neuropathy decompression of the nerve is of primary necessity. Division of the tendinous arch is mandatory. Medial epicondylectomy may be added as required.

Ulnar neuropathy at wrist: entrapment at a very "congested" site.

PubMed

Coraci, Daniele; Loreti, Claudia; Piccinini, Giulia; Doneddu, Pietro E; Biscotti, Silvia; Padua, Luca

2018-05-19

Ulnar tunnel syndrome indicates ulnar neuropathy at different sites within the wrist. Several classifications of ulnar tunnel syndrome are present in literature, based upon typical nerve anatomy. However, anatomical variations are not uncommon and can complicate assessment. The etiology is also complex, due to the numerous potential causes of entrapment. Clinical examination, neurophysiological testing, and imaging are all used to support the diagnosis. At present, many therapeutic approaches are available, ranging from observation to surgical management. Although ulnar neuropathy at the wrist has undergone extensive prior study, unresolved questions on diagnosis and treatment remain. In the current paper, we review relevant literature and present the current knowledge on ulnar tunnel syndrome.

The potential complications of open carpal tunnel release surgery to the ulnar neurovascular bundle and its branches: A cadaveric study.

PubMed

Boughton, O; Adds, P J; Jayasinghe, J A P

2010-07-01

This study investigated the ulnar artery and the ulnar nerve and its branches in the palm to assess how frequently they may be at risk of damage during open carpal tunnel release surgery. Twenty-one formalin-embalmed cadaveric hands were dissected, and the proximity of the ulnar neurovascular bundle to two different lines of incision, the 3rd and 4th interdigital web space axis and the ring finger axis, was assessed and compared. It was found that an incision in the latter (ring finger) axis put the ulnar artery at risk in 12 of 21 specimens, whereas an incision in the former axis (3rd/4th interdigital web space) put the ulnar artery at risk in only two specimens. In 15 hands at least one structure (the ulnar artery or a branch of the ulnar nerve) was at risk in the ring finger axis compared to only seven hands in the axis of the 3rd/4th interdigital web space. We conclude that the ulnar artery and branches of the ulnar nerve are at increased risk of damage with an incision in the axis of the ring finger. The importance of using a blunt dissection technique under direct vision during surgery to identify and preserve these structures and median nerve branches is emphasized. (c) 2010 Wiley-Liss, Inc.

Ulnar Collateral Ligament Reconstruction

PubMed Central

Erickson, Brandon J.; Harris, Joshua D.; Chalmers, Peter N.; Bach, Bernard R.; Verma, Nikhil N.; Bush-Joseph, Charles A.; Romeo, Anthony A.

2015-01-01

Context: Ulnar collateral ligament (UCL) injuries lead to pain and loss of performance in the thrower’s elbow. Ulnar collateral ligament reconstruction (UCLR) is a reliable treatment option for the symptomatic, deficient UCL. Injury to the UCL usually occurs because of chronic accumulation of microtrauma, although acute ruptures occur and an acute-on-chronic presentation is also common. Evidence Acquisition: Computerized databases, references from pertinent articles, and research institutions were searched for all studies using the search terms ulnar collateral ligament from 1970 until 2015. Study Design: Clinical review. Level of Evidence: Level 5. Results: All studies reporting outcomes for UCLR are level 4. Most modern fixation methodologies appear to be biomechanically and clinically equivalent. Viable graft choices include ipsilateral palmaris longus tendon autograft, gracilis or semitendinosus autograft, and allograft. Clinical studies report excellent outcomes of UCLR for both recreational and elite level athletes with regard to return to sport and postoperative performance. Complications, although rare, include graft rerupture or attenuation, ulnar nerve symptoms, stiffness, pain, and/or weakness leading to decreased performance. Conclusion: Injuries to the UCL have become commonplace among pitchers. Nonoperative treatment should be attempted, but the limited studies have not shown promising results. Operative treatment can be performed with several techniques, with retrospective studies showing promising results. Complications include ulnar neuropathy as well as failure to return to sport. Detailed preoperative planning, meticulous surgical technique, and a comprehensive rehabilitation program are essential components to achieving a satisfactory result. PMID:26502444

The scalene reflex: relationship between increased median or ulnar nerve pressure and scalene muscle activity.

PubMed

Monsivais, J J; Sun, Y; Rajashekhar, T P

1995-07-01

Neck pain, headaches, upper thoracic pain, and dystonic scalene muscles are common findings in patients who have severe entrapment neuropathies of the upper extremities. This problem was taken to the laboratory in an attempt to discover the correlation between distal entrapment neuropathies, brachial plexus entrapments, and prominent scalenus muscles. When increased pressure (over 40 mmHg) was applied to the median and ulnar nerves in the forelimbs of eight goats, increased electromyographic activity was noted in the ipsilateral scalenus muscle. Pressures ranging from 100 to 150 mmHg caused increased electromyographic activity on the contralateral scalene muscle, and the authors postulate that it is mediated by the gamma afferent and efferent system. This relationship may explain the commonly found neck pain and muscle spasm in patients with peripheral neuropathies, and it represents a link between the somatic efferent nerves and the gamma motor neuron system. At present, the same phenomenon has been documented in 30 humans with the diagnosis of brachial plexus entrapment.

Ultrasonographic nerve enlargement of the median and ulnar nerves and the cervical nerve roots in patients with demyelinating Charcot-Marie-Tooth disease: distinction from patients with chronic inflammatory demyelinating polyneuropathy.

PubMed

Sugimoto, Takamichi; Ochi, Kazuhide; Hosomi, Naohisa; Takahashi, Tetsuya; Ueno, Hiroki; Nakamura, Takeshi; Nagano, Yoshito; Maruyama, Hirofumi; Kohriyama, Tatsuo; Matsumoto, Masayasu

2013-10-01

Demyelinating Charcot-Marie-Tooth disease (CMT) and chronic inflammatory demyelinating polyneuropathy (CIDP) are both demyelinating polyneuropathies. The differences in nerve enlargement degree and pattern at multiple evaluation sites/levels are not well known. We investigated the differences in nerve enlargement degree and the distribution pattern of nerve enlargement in patients with demyelinating CMT and CIDP, and verified the appropriate combination of sites/levels to differentiate between these diseases. Ten patients (aged 23-84 years, three females) with demyelinating CMT and 16 patients (aged 30-85 years, five females) with CIDP were evaluated in this study. The nerve sizes were measured at 24 predetermined sites/levels from the median and ulnar nerves and the cervical nerve roots (CNR) using ultrasonography. The evaluation sites/levels were classified into three regions: distal, intermediate and cervical. The number of sites/levels that exhibited nerve enlargement (enlargement site number, ESN) in each region was determined from the 24 sites/levels and from the selected eight screening sites/levels, respectively. The cross-sectional areas of the peripheral nerves were markedly larger at all evaluation sites in patients with demyelinating CMT than in patients with CIDP (p < 0.01). However, the nerve sizes of CNR were not significantly different between patients with either disease. When we evaluated ESN of four selected sites for screening from the intermediate region, the sensitivity and specificity to distinguish between demyelinating CMT and CIDP were 0.90 and 0.94, respectively, with the cut-off value set at four. Nerve ultrasonography is useful to detect nerve enlargement and can clarify morphological differences in nerves between patients with demyelinating CMT and CIDP.

The impact of extended electrodiagnostic studies in Ulnar Neuropathy at the elbow

PubMed Central

Todnem, Kari; Michler, Ralf Peter; Wader, Tony Eugen; Engstrøm, Morten; Sand, Trond

2009-01-01

Background This study aimed to explore the value of extended motor nerve conduction studies in patients with ulnar nerve entrapment at the elbow (UNE) in order to find the most sensitive and least time-consuming method. We wanted to evaluate the utility of examining both the sensory branch from the fifth finger and the dorsal branch of the ulnar nerve. Further we intended to study the clinical symptoms and findings, and a possible correlation between the neurophysiological findings and pain. Methods The study was prospective, and 127 UNE patients who were selected consecutively from the list of patients, had a clinical and electrodiagnostic examination. Data from the most symptomatic arm were analysed and compared to the department's reference limits. Student's t - test, chi-square tests and multiple regression models were used. Two-side p-values < 0.05 were considered as significant. Results Ulnar paresthesias (96%) were more common than pain (60%). Reduced ulnar sensitivity (86%) and muscle strength (48%) were the most common clinical findings. Adding a third stimulation site in the elbow mid-sulcus for motor conduction velocity (MCV) to abductor digiti minimi (ADM) increased the electrodiagnostic sensitivity from 80% to 96%. Additional recording of ulnar MCV to the first dorsal interosseus muscle (FDI) increased the sensitivity from 96% to 98%. The ulnar fifth finger and dorsal branch sensory studies were abnormal in 39% and 30% of patients, respectively. Abnormal electromyography in FDI was found in 49% of the patients. Patients with and without pain had generally similar conduction velocity parameter means. Conclusion We recommend three stimulation sites at the elbow for MCV to ADM. Recording from FDI is not routinely indicated. Sensory studies and electromyography do not contribute much to the sensitivity of the electrodiagnostic evaluation, but they are useful to document axonal degeneration. Most conduction parameters are unrelated to the presence of pain

Median and ulnar neuropathies in U.S. Army Medical Command Band members.

PubMed

Shaffer, Scott W; Koreerat, Nicholas R; Gordon, Lindsay B; Santillo, Douglas R; Moore, Josef H; Greathouse, David G

2013-12-01

Musicians have been reported as having a high prevalence of upper-extremity musculoskeletal disorders, including carpal tunnel syndrome. The purpose of this study was to determine the presence of median and ulnar neuropathies in U.S. Army Medical Command (MEDCOM) Band members at Fort Sam Houston, Texas. Thirty-five MEDCOM Band members (30 males, 5 females) volunteered to participate. There were 33 right-handed musicians, and the mean length of time in the MEDCOM Band was 12.2 yrs (range, 1-30 yrs). Subjects completed a history form, were interviewed, and underwent a physical examination of the cervical spine and bilateral upper extremities. Nerve conduction studies of the bilateral median and ulnar nerves were performed. Electrophysiological variables served as the reference standard for median and ulnar neuropathy and included distal sensory latencies, distal motor latencies, amplitudes, conduction velocities, and comparison study latencies. Ten of the 35 subjects (29%) presented with abnormal electrophysiologic values suggestive of an upper extremity mononeuropathy. Nine of the subjects had abnormal median nerve electrophysiologic values at or distal to the wrist; 2 had bilateral abnormal values. One had an abnormal ulnar nerve electrophysiologic assessment at the elbow. Nine of these 10 subjects had clinical examination findings consistent with the electrophysiological findings. The prevalence of mononeuropathies in this sample of band members is similar to that found in previous research involving civilian musicians (20-36%) and far exceeds that reported in the general population. Prospective research investigating screening, examination items, and injury prevention measures in musicians appears to be warranted.

Ulnar nerve dysfunction

MedlinePlus

... Philadelphia, PA: Elsevier; 2016:chap 107. Shy ME. Peripheral neuropathies. In: Goldman L, Schafer AI, eds. Goldman's Cecil ... Editorial team. Hand Injuries and Disorders Read more Peripheral Nerve Disorders Read more NIH MedlinePlus Magazine Read more A. ...

Ulnar neuropathy and ulnar neuropathy-like symptoms in relation to biomechanical exposures assessed by a job exposure matrix: a triple case-referent study.

PubMed

Svendsen, Susanne Wulff; Johnsen, Birger; Fuglsang-Frederiksen, Anders; Frost, Poul

2012-11-01

We aimed to evaluate relations between occupational biomechanical exposures and (1) ulnar neuropathy confirmed by electroneurography (ENG) and (2) ulnar neuropathy-like symptoms with normal ENG. In this triple case-referent study, we identified all patients aged 18-65 years, examined with ENG at a neurophysiological department on suspicion of ulnar neuropathy, 2001-2007. We mailed a questionnaire to 546 patients with ulnar neuropathy, 633 patients with ulnar neuropathy-like symptoms and two separate groups of community referents, matched on sex, age and primary care centre (risk set sampling). The two patient groups were also compared to each other directly. We constructed a Job Exposure Matrix to provide estimates of exposure to non-neutral postures, repetitive movements, hand-arm vibrations and forceful work. Conditional and unconditional logistic regressions were used. The proportion who responded was 59%. Ulnar neuropathy was related to forceful work with an exposure-response pattern reaching an OR of 3.85 (95% CI 2.04 to 7.24); non-neutral postures strengthened effects of forceful work. No relation was observed with repetitive movements. Ulnar neuropathy-like symptoms were related to repetitive movements with an OR of 1.89 (95% CI 1.01 to 3.52) in the highest-exposure category (≥2.5 h/day); forceful work was unrelated to the outcome. Ulnar neuropathy and ulnar neuropathy-like symptoms differed with respect to associations with occupational biomechanical exposures. Findings suggested specific effects of forceful work on the ulnar nerve. Thus, results corroborated the importance of an electrophysiological diagnosis when evaluating risk factors for ulnar neuropathy. Preventive effects may be achieved by reducing biomechanical exposures at work.

Outcomes of a novel minimalist approach for the treatment of cubital tunnel syndrome.

PubMed

Lan, Zheng D; Tatsui, Claudio E; Jalali, Ali; Humphries, William E; Rilea, Katheryn; Patel, Akash; Ehni, Bruce L

2015-06-01

We describe a minimalist approach to perform in situ decompression of the ulnar nerve. Our technique employs a unique small skin incision strategically placed to minimize postoperative scarring over the ulnar nerve and potentially decrease the risk of iatrogenic injury to the medial antebrachial cutaneous nerve. We retrospectively report the outcome of patients who have undergone this procedure at our institution, the Michael E. DeBakey Veterans Affairs Medical Center, from January 1 2007 through November 29 2010. All individuals underwent in situ decompression via the previously described minimalist approach. Outcome variables were Louisiana State University Medical Center (LSU) ulnar neuropathy grade, patient satisfaction, subjective improvement, complications and re-operation rate. A total of 44 procedures were performed in this cohort of 41 patients. Overall, patients' postoperative LSU grades showed a statistically significant improvement (p=0.0019) compared to preoperative grades. Improvement of at least one grade in the LSU scale was observed in 50% of the procedures with a preoperative grade of four or less. Overall procedure satisfaction rate was 88% (39 of 44) with 70% (31 of 44) of the procedures resulting in improvement of symptoms. There were no intraoperative or postoperative complications. One patient required re-operation due to failure of neurological improvement. Our minimalistic approach to perform in situ decompression of the ulnar nerve at the cubital tunnel is both safe and effective. We observed a statistically significant improvement in LSU ulnar neuropathy grades and a success rate comparable to those reported for other more extensive surgical techniques while providing the benefit of a smaller incision, less scarring, decreased risk of iatrogenic nerve injury and minimal complications. Copyright © 2015 Elsevier Ltd. All rights reserved.

Treatment for Ulnar Neuritis Around the Elbow in Adolescent Baseball Players: Factors Associated With Poor Outcome.

PubMed

Maruyama, Masahiro; Satake, Hiroshi; Takahara, Masatoshi; Harada, Mikio; Uno, Tomohiro; Mura, Nariyuki; Takagi, Michiaki

2017-03-01

Ulnar neuritis around the elbow is one of the injuries seen in throwing athletes. Outcomes of nonsurgical treatment and factors associated with failure outcomes have not been reported. To investigate the outcomes of treatments for ulnar neuritis in adolescent baseball players. Case series; Level of evidence, 4. We assessed 40 male baseball players with a mean age of 15.0 years (range, 13-17 years) who presented with ulnar neuritis. There were 19 pitchers and 21 fielders whose throwing side was affected. All patients had elbow pain, and 13 patients had hand numbness on the ulnar side. The mean Kerlan-Jobe Orthopaedic Clinic (KJOC) overhead athlete shoulder and elbow score was 52.5 at the first follow-up visit (n = 36 patients). Thirteen patients were identified with ulnar nerve subluxation, and 23 patients had concomitant elbow ulnar collateral ligament (UCL) injury. All patients underwent nonsurgical treatment, which included rehabilitation exercises and prohibition of throwing. If the nonsurgical treatment failed, we recommended surgical treatment. We investigated the outcomes of the nonsurgical and surgical treatments. Return to sports was evaluated, combined with factors associated with return to sports in nonsurgical treatment by univariate and multivariate statistical analysis. The mean follow-up period was 23.6 months (range, 6-39 months). After nonsurgical treatment, 24 patients (60%) returned to the previous competition level after a mean of 2.4 months. Two patients returned to a recreational level. One patient gave up playing baseball at 2 months. The remaining 13 patients underwent surgery and returned to sports after a mean of 2.0 months postoperatively, and 12 had no limitation of sports activities. Multivariate logistical regression analysis demonstrated that hand numbness, ulnar nerve subluxation, and UCL injury were associated with failure of nonsurgical treatment ( P < .05). In addition, KJOC score of <45 at the first follow-up tended to be

Simultaneous Median and Ulnar Compression Neuropathy Secondary to a Giant Palmar Lipoma: A Case Report and Review of the Literature

PubMed Central

Unal, Melih; Demirayak, Engin; Acar, Baver

2018-01-01

Lipomas are benign tumors that rarely settle in the hand. They usually present with mass, pain, and nerve compression symptoms. Although isolated median or ulnar nerve compression neuropathy secondary to a lipoma of the hand has been widely reported, simultaneous median and ulnar nerve compression neuropathy are exceedingly rare and there are only three reported cases in the current literature to date. Herein, a case of a 50-year-old woman with a giant palmar lipoma that caused median and ulnar compression neuropathy is presented. The removal of the tumor resulted in the complete recovery of the patient’s symptoms. A deep-seated palmar lipoma should be kept in mind in patients with unilateral compression neuropathy symptoms with a palmar mass. PMID:29666776

End-to-side neurorrhaphy repairs peripheral nerve injury: sensory nerve induces motor nerve regeneration.

PubMed

Yu, Qing; Zhang, She-Hong; Wang, Tao; Peng, Feng; Han, Dong; Gu, Yu-Dong

2017-10-01

End-to-side neurorrhaphy is an option in the treatment of the long segment defects of a nerve. It involves suturing the distal stump of the disconnected nerve (recipient nerve) to the side of the intimate adjacent nerve (donor nerve). However, the motor-sensory specificity after end-to-side neurorrhaphy remains unclear. This study sought to evaluate whether cutaneous sensory nerve regeneration induces motor nerves after end-to-side neurorrhaphy. Thirty rats were randomized into three groups: (1) end-to-side neurorrhaphy using the ulnar nerve (mixed sensory and motor) as the donor nerve and the cutaneous antebrachii medialis nerve as the recipient nerve; (2) the sham group: ulnar nerve and cutaneous antebrachii medialis nerve were just exposed; and (3) the transected nerve group: cutaneous antebrachii medialis nerve was transected and the stumps were turned over and tied. At 5 months, acetylcholinesterase staining results showed that 34% ± 16% of the myelinated axons were stained in the end-to-side group, and none of the myelinated axons were stained in either the sham or transected nerve groups. Retrograde fluorescent tracing of spinal motor neurons and dorsal root ganglion showed the proportion of motor neurons from the cutaneous antebrachii medialis nerve of the end-to-side group was 21% ± 5%. In contrast, no motor neurons from the cutaneous antebrachii medialis nerve of the sham group and transected nerve group were found in the spinal cord segment. These results confirmed that motor neuron regeneration occurred after cutaneous nerve end-to-side neurorrhaphy.

End-to-side neurorrhaphy repairs peripheral nerve injury: sensory nerve induces motor nerve regeneration

PubMed Central

Yu, Qing; Zhang, She-hong; Wang, Tao; Peng, Feng; Han, Dong; Gu, Yu-dong

2017-01-01

End-to-side neurorrhaphy is an option in the treatment of the long segment defects of a nerve. It involves suturing the distal stump of the disconnected nerve (recipient nerve) to the side of the intimate adjacent nerve (donor nerve). However, the motor-sensory specificity after end-to-side neurorrhaphy remains unclear. This study sought to evaluate whether cutaneous sensory nerve regeneration induces motor nerves after end-to-side neurorrhaphy. Thirty rats were randomized into three groups: (1) end-to-side neurorrhaphy using the ulnar nerve (mixed sensory and motor) as the donor nerve and the cutaneous antebrachii medialis nerve as the recipient nerve; (2) the sham group: ulnar nerve and cutaneous antebrachii medialis nerve were just exposed; and (3) the transected nerve group: cutaneous antebrachii medialis nerve was transected and the stumps were turned over and tied. At 5 months, acetylcholinesterase staining results showed that 34% ± 16% of the myelinated axons were stained in the end-to-side group, and none of the myelinated axons were stained in either the sham or transected nerve groups. Retrograde fluorescent tracing of spinal motor neurons and dorsal root ganglion showed the proportion of motor neurons from the cutaneous antebrachii medialis nerve of the end-to-side group was 21% ± 5%. In contrast, no motor neurons from the cutaneous antebrachii medialis nerve of the sham group and transected nerve group were found in the spinal cord segment. These results confirmed that motor neuron regeneration occurred after cutaneous nerve end-to-side neurorrhaphy. PMID:29171436

Anatomical risk evaluation of iatrogenic injury to the infrapatellar branch of the saphenous nerve during medial meniscus arthroscopic surgery.

PubMed

Koch, Guillaume; Kling, Agathe; Ramamurthy, Nitin; Edalat, Faramarz; Cazzato, Roberto Luigi; Kahn, Jean-Luc; Garnon, Julien; Clavert, Philippe

2017-06-01

To determine the relationship of the medial meniscus with the infrapatellar branches of the saphenous nerve, the primary goal is to define and characterize different risk areas for these nerves during medial meniscus surgery. After dissecting 20 embalmed cadaver knees, we defined 7 readily identifiable anatomical landmarks. For each knee, we recorded 2 morphological criteria and 16 measurements. The most common anatomical course is a main trunk that is 8 mm anterior to the tuberculum adductorium and 60 mm posterior to the midpoint of the medial patellar margin. It has two main infrapatellar branches. The nerve division is 23 mm above the joint line. The path is oblique with an angle of 55.5°. The anterior meniscal landmark is 24 mm from the upper branch and 42.5 mm from the lower branch. The posterior meniscal landmark is 55 mm from the upper branch and 38 mm from the lower branch. We defined a common anatomical course for the saphenous nerve and its infrapatellar branches. Then, three different areas were defined at risk for iatrogenic nerve injuries during medial meniscus.

Nerve ultrasound reliability of upper limbs: Effects of examiner training.

PubMed

Garcia-Santibanez, Rocio; Dietz, Alexander R; Bucelli, Robert C; Zaidman, Craig M

2018-02-01

Duration of training to reliably measure nerve cross-sectional area with ultrasound is unknown. A retrospective review was performed of ultrasound data, acquired and recorded by 2 examiners-an expert and either a trainee with 2 months (novice) or a trainee with 12 months (experienced) of experience. Data on median, ulnar, and radial nerves were reviewed for 42 patients. Interrater reliability was good and varied most with nerve site but little with experience. Coefficient of variation (CoV) range was 9.33%-22.5%. Intraclass correlation coefficient (ICC) was good to excellent (0.65-95) except ulnar nerve-wrist/forearm and radial nerve-humerus (ICC = 0.39-0.59). Interrater differences did not vary with nerve size or body mass index. Expert-novice and expert-experienced interrater differences and CoV were similar. The ulnar nerve-wrist expert-novice interrater difference decreased with time (r s  = -0.68, P = 0.001). A trainee with at least 2 months of experience can reliably measure upper limb nerves. Reliability varies by nerve and location and slightly improves with time. Muscle Nerve 57: 189-192, 2018. © 2017 Wiley Periodicals, Inc.

Distal nerve transfer versus supraclavicular nerve grafting: comparison of elbow flexion outcome in neonatal brachial plexus palsy with C5-C7 involvement.

PubMed

Heise, Carlos O; Siqueira, Mario G; Martins, Roberto S; Foroni, Luciano H; Sterman-Neto, Hugo

2017-09-01

Ulnar and median nerve transfers to arm muscles have been used to recover elbow flexion in infants with neonatal brachial plexus palsy, but there is no direct outcome comparison with the classical supraclavicular nerve grafting approach. We retrospectively analyzed patients with C5-C7 neonatal brachial plexus palsy submitted to nerve surgery and recorded elbow flexion recovery using the active movement scale (0-7) at 12 and 24 months after surgery. We compared 13 patients submitted to supraclavicular nerve grafting with 21 patients submitted to distal ulnar or median nerve transfer to biceps motor branch. We considered elbow flexion scores of 6 or 7 as good results. The mean elbow flexion score and the proportion of good results were better using distal nerve transfers than supraclavicular grafting at 12 months (p < 0.01), but not at 24 months. Two patients with failed supraclavicular nerve grafting at 12 months showed good elbow flexion recovery after ulnar nerve transfers. Distal nerve transfers provided faster elbow flexion recovery than supraclavicular nerve grafting, but there was no significant difference in the outcome after 24 months of surgery. Patients with failed supraclavicular grafting operated early can still benefit from late distal nerve transfers. Supraclavicular nerve grafting should remain as the first line surgical treatment for children with neonatal brachial plexus palsy.

Analysis of the Papal Benediction Sign: The ulnar neuropathy of St. Peter.

PubMed

Futterman, Bennett

2015-09-01

The origin of the Papal Benediction Sign has been a source of controversy for many generations of medical students. The question has been whether the Papal Benediction Sign posture is the result of an injury to the median nerve or to the ulnar nerve. The increasingly popular use of online "chat rooms" and the vast quantities of information available on the internet has led to an increasing level of confusion. Looking in major anatomy texts, anatomy and board review books as well as numerous internet sites the answer remains unresolved. Through the analysis of functional anatomy of the hand, cultural and religious practices of the early centuries of the Common Era and church art a clear answer emerges. It will become apparent that this hand posture results from an ulnar neuropathy. Copyright © 2015 Wiley Periodicals, Inc.

Iatrogenic facial palsy: the cost.

PubMed

Pulec, J L

1996-11-01

The cost of iatrogenic facial paralysis can be high. Ways to avoid facial nerve injury during surgery and, should it occur, ways to minimize the disability and cost are discussed. These include adequate preparation and training by the surgeon, the exercise of sound judgment, the presence of high morals by the surgeon, adequate preoperative diagnosis and surgical instrumentation and thorough preoperative oral and written informed consent. Should facial nerve injury occur, immediate consultation and reparative decompression, anastomosis or grafting should be performed to obtain the best ultimate result. The value of prompt, competent, sympathetic and continuing concern offered by the surgeon to the patient cannot be over emphasized.

3-Tesla MRI-assisted detection of compression points in ulnar neuropathy at the elbow in correlation with intraoperative findings.

PubMed

Hold, Alina; Mayr-Riedler, Michael S; Rath, Thomas; Pona, Igor; Nierlich, Patrick; Breitenseher, Julia; Kasprian, Gregor

2018-03-06

Releasing the ulnar nerve from all entrapments is the primary objective of every surgical method in ulnar neuropathy at the elbow (UNE). The aim of this retrospective diagnostic study was to validate preoperative 3-Tesla MRI results by comparing the MRI findings with the intraoperative aspects during endoscopic-assisted or open surgery. Preoperative MRI studies were assessed by a radiologist not informed about intraoperative findings in request for the exact site of nerve compression. The localizations of compression were then correlated with the intraoperative findings obtained from the operative records. Percent agreement and Cohen's kappa (κ) values were calculated. From a total of 41 elbows, there was a complete agreement in 27 (65.8%) cases and a partial agreement in another 12 (29.3%) cases. Cohen's kappa showed fair-to-moderate agreement. High-resolution MRI cannot replace thorough intraoperative visualization of the ulnar nerve and its surrounding structures but may provide valuable information in ambiguous cases or relapses. Copyright © 2018 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

"In Situ Vascular Nerve Graft" for Restoration of Intrinsic Hand Function: An Anatomical Study.

PubMed

Mozaffarian, Kamran; Zemoodeh, Hamid Reza; Zarenezhad, Mohammad; Owji, Mohammad

2018-06-01

In combined high median and ulnar nerve injury, transfer of the posterior interosseous nerve branches to the motor branch of the ulnar nerve (MUN) is previously described in order to restore intrinsic hand function. In this operation a segment of sural nerve graft is required to close the gap between the donor and recipient nerves. However the thenar muscles are not innervated by this nerve transfer. The aim of the present study was to evaluate whether the superficial radial nerve (SRN) can be used as an "in situ vascular nerve graft" to connect the donor nerves to the MUN and the motor branch of median nerve (MMN) at the same time in order to address all denervated intrinsic and thenar muscles. Twenty fresh male cadavers were dissected in order to evaluate the feasibility of this modification of technique. The size of nerve branches, the number of axons and the tension at repair site were evaluated. This nerve transfer was technically feasible in all specimens. There was no significant size mismatch between the donor and recipient nerves Conclusions: The possible advantages of this modification include innervation of both median and ulnar nerve innervated intrinsic muscles, preservation of vascularity of the nerve graft which might accelerate the nerve regeneration, avoidance of leg incision and therefore the possibility of performing surgery under regional instead of general anesthesia. Briefly, this novel technique is a viable option which can be used instead of conventional nerve graft in some brachial plexus or combined high median and ulnar nerve injuries when restoration of intrinsic hand function by transfer of posterior interosseous nerve branches is attempted.

Recovery from distal ulnar motor conduction block injury: serial EMG studies.

PubMed

Montoya, Liliana; Felice, Kevin J

2002-07-01

Acute conduction block injuries often result from nerve compression or trauma. The temporal pattern of clinical, electrophysiologic, and histopathologic changes following these injuries has been extensively studied in experimental animal models but not in humans. Our recent evaluation of a young man with an injury to the deep motor branch of the ulnar nerve following nerve compression from weightlifting exercises provided the opportunity to follow the course and recovery of a severe conduction block injury with sequential nerve conduction studies. The conduction block slowly and completely resolved, as did the clinical deficit, over a 14-week period. The reduction in conduction block occurred at a linear rate of -6.1% per week. Copyright 2002 Wiley Periodicals, Inc.

Anterior subcutaneous transposition of ulnar nerve with fascial flap and complete excision of medial intermuscular septum in cubital tunnel syndrome: a prospective patient cohort.

PubMed

Hamidreza, Aslani; Saeid, Abrishami; Mohammadreza, Dehghanfard; Zohreh, Zaferani; Mehdi, Saeidpour

2011-10-01

Regarding the frequency of cubital tunnel syndrome, varieties of treatment modalities, and ambiguity of anterior subcutaneous transposition of ulnar nerve method, we aimed to evaluate the efficacy of this procedure in patients with cubital tunnel syndrome referred to Taleghani hospital between 2006 and 2009. This study was a case series including all referred patients with definite diagnosis of cubital tunnel syndrome, treated by anterior subcutaneous transposition. Treatment results were measured according to modified Bishop rating system, and were ranked into excellent, good, fair, and poor. Variables such as gender, age (less/more than 45 years), causation, and initial severity, determined by Dellon criteria preoperatively, were analyzed by Fisher's exact test. This study was performed on 26 eligible cases including 29 elbows, 38% males and 62.1% females, with mean age of 44.5 years (ranging 23-72 years). In a 12 months follow-up post-operatively, 62% showed excellent, 20.7% good, and 17.3% fair, with no poor result. In a 1-12 months follow-up post-operatively, results showed improvement, and initial severity and old age were demonstrated to significantly affect treatment results (P<0.07). Though considered standard of care, the present study suggests that criteria for surgical techniques of ulnar nerve decompression, e.g. simple decompression vs. more extensive repair as in the present cohort, should be revised by controlled prospective studies. Copyright © 2011 Elsevier B.V. All rights reserved.

Ulnar neuropathy and medial elbow pain in women's fastpitch softball pitchers: a report of 6 cases.

PubMed

Smith, Adam M; Butler, Thomas H; Dolan, Michael S

2017-12-01

Elite-level women's fastpitch softball players place substantial biomechanical strains on the elbow that can result in medial elbow pain and ulnar neuropathic symptoms. There is scant literature reporting the expected outcomes of the treatment of these injuries. This study examined the results of treatment in a series of these patients. We identified 6 female softball pitchers (4 high school and 2 collegiate) with medial elbow pain and ulnar neuropathic symptoms. Trials of conservative care failed in all 6, and they underwent surgical treatment with subcutaneous ulnar nerve transposition. These patients were subsequently monitored postoperatively to determine outcome. All 6 female pitchers had early resolution of elbow pain and neuropathic symptoms after surgical treatment. Long-term follow-up demonstrated that 1 patient quit playing softball because of other injuries but no longer reported elbow pain or paresthesias. One player was able to return to pitching at the high school level but had recurrent forearm pain and neuritis 1 year later while playing a different sport and subsequently stopped playing competitive sports. Four patients continued to play at the collegiate level without further symptoms. Medial elbow pain in women's softball pitchers caused by ulnar neuropathy can be treated effectively with subcutaneous ulnar nerve transposition if nonsurgical options fail. Further study is necessary to examine the role of overuse, proper training techniques, and whether pitching limits may be necessary to avoid these injuries. Copyright © 2017 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.

Ulnar nerve lesion at the wrist and sport: A report of 8 cases compared with 45 non-sport cases.

PubMed

Seror, P

2015-04-01

Reporting clinical and electrodiagnostic characteristics of sport-related ulnar neuropathies at the wrist. Eight sport-related and 45 non-sport-related cases from 53 ulnar neuropathies at the wrist cases over 14 years. Sport-related ulnar neuropathies at the wrist cases were due to cycling (5 cases), kayaking (2 cases), and big-game fishing (1 case). No patient had sensory complaints in ulnar digits, and all had motor impairment. Conduction across the wrist with recording on the first dorsal interosseous muscle was impaired in all cases, with conduction block in 5. Two cyclists showed bilateral ulnar neuropathies at the wrist. All cases recovered within 2 to 6 months with sport discontinuation. Distal lesions of the deep motor branch were more frequent in sport- than non-sport-related cases. The 8 sport-related ulnar neuropathies at the wrist cases involved the deep motor branch. Conduction study to the first dorsal interosseous muscle across the wrist is the key to electrodiagnostics. Bilateral cases in cyclists does not require wrist imaging. Copyright © 2015 Elsevier Masson SAS. All rights reserved.

How to Avoid Facial Nerve Injury in Mastoidectomy?

PubMed Central

Ryu, Nam-Gyu

2016-01-01

Unexpected iatrogenic facial nerve paralysis not only affects facial disfiguration, but also imposes a devastating effect on the social, psychological, and economic aspects of an affected person's life at once. The aims of this study were to postulate where surgeons had mistakenly drilled or where obscured by granulations or by fibrous bands and to look for surgical approach with focused on the safety of facial nerve in mastoid surgery. We had found 14 cases of iatrogenic facial nerve injury (IFNI) during mastoid surgery for 5 years in Korea. The medical records of all the patients were obtained and analyzed injured site of facial nerve segment with surgical technique of mastoidectomy. Eleven patients underwent facial nerve exploration and three patients had conservative management. 43% (6 cases) of iatrogenic facial nerve injuries had occurred in tympanic segment, 28.5% (4 cases) of injuries in second genu combined with tympanic segment, and 28.5% (4 cases) of injuries in mastoid segment. Surgeons should try to identify the facial nerve using available landmarks and be kept in mind the anomalies of the facial nerve. With use of intraoperative facial nerve monitoring, the avoidance of in order to avoid IFNI would be possible in more cases. Many authors emphasized the importance of intraoperative facial nerve monitoring, even in primary otologic surgery. However, anatomical understanding of intratemporal landmarks with meticulous dissection could not be emphasized as possible to prevent IFNI. PMID:27626078

Nerve injury following shoulder dislocation: the emergency physician's perspective.

PubMed

Ameh, Victor; Crane, Steve

2006-08-01

We describe the case of a 57-year-old woman who presented to the emergency department with a right anterior shoulder dislocation following a fall onto the right shoulder and right upper arm. She also complained of numbness in the right forearm and dorsum of the right hand. The examination revealed a bruise to the upper aspect of the right arm resulting from the impact following the fall. The patient also had a right wrist drop and loss of sensation in the lateral border of the right forearm and on the dorsum of the right hand, suggesting a radial nerve injury. She also had altered sensation in the ulnar distribution of her right hand, suspicious of concomitant ulnar nerve injury. No loss of sensation in the distribution of the axillary nerve (regimental patch) was observed. These findings were carefully documented and the patient subsequently had the shoulder reduced under entonox and morphine. The neurological deficits remained unchanged. The patient was sent home from the emergency room with arrangements for orthopaedic and physiotherapy follow-up. After a 3-month period, she had clinical and electromyography evidence of persistent radial and ulnar nerve deficit. She continues to have physiotherapy. This case highlights the need for awareness of the potential for nerve damage following shoulder dislocation and also to ensure that appropriate follow-up plan is instituted on discharge from the emergency department.

[Incarcerated epitrochlear fracture with a cubital nerve injury].

PubMed

Moril-Peñalver, L; Pellicer-Garcia, V; Gutierrez-Carbonell, P

2013-01-01

Injuries of the medial epicondyle are relatively common, mostly affecting children between 7 and 15 years. The anatomical characteristics of this apophysis can make diagnosis difficult in minimally displaced fractures. In a small percentage of cases, the fractured fragment may occupy the retroepitrochlear groove. The presence of dysesthesias in the territory of the ulnar nerve requires urgent open reduction of the incarcerated fragment. A case of a seven-year-old male patient is presented, who required surgical revision due to a displaced medial epicondyle fracture associated with ulnar nerve injury. A review of the literature is also made. Copyright © 2013 SECOT. Published by Elsevier Espana. All rights reserved.

Ulnar-Sided Wrist Pain due to Long Ulnar Styloid: A Case Report

PubMed Central

Ahsan, Zahab S.; Rivlin, Michael; Jupiter, Jesse B.

2016-01-01

Ulnar styloid impaction syndrome involves repetitive friction between an excessively long ulnar styloid and the carpus, resulting in chondromalacia, synovitis, and pain. The arthroscopic diagnosis, evaluation, and management of this syndrome are not well characterized. We present a patient with chronic wrist pain of unknown origin, culminating with arthroscopic findings demonstrating substantial loss of articular cartilage on both the lunate and triquetrum. The patient successfully underwent operative ulnar styloid excision, ultimately resolving chronic wrist pain symptomology. PMID:27777823

Quantification of human upper extremity nerves and fascicular anatomy.

PubMed

Brill, Natalie A; Tyler, Dustin J

2017-09-01

In this study we provide detailed quantification of upper extremity nerve and fascicular anatomy. The purpose is to provide values and trends in neural features useful for clinical applications and neural interface device design. Nerve cross-sections were taken from 4 ulnar, 4 median, and 3 radial nerves from 5 arms of 3 human cadavers. Quantified nerve features included cross-sectional area, minor diameter, and major diameter. Fascicular features analyzed included count, perimeter, area, and position. Mean fascicular diameters were 0.57 ± 0.39, 0.6 ± 0.3, 0.5 ± 0.26 mm in the upper arm and 0.38 ± 0.18, 0.47 ± 0.18, 0.4 ± 0.27 mm in the forearm of ulnar, median, and radial nerves, respectively. Mean fascicular diameters were inversely proportional to fascicle count. Detailed quantitative anatomy of upper extremity nerves is a resource for design of neural electrodes, guidance in extraneural procedures, and improved neurosurgical planning. Muscle Nerve 56: 463-471, 2017. © 2016 Wiley Periodicals, Inc.

The surgical anatomy of the infrapatellar branch of the saphenous nerve in relation to incisions for anteromedial knee surgery.

PubMed

Kerver, A L A; Leliveld, M S; den Hartog, D; Verhofstad, M H J; Kleinrensink, G J

2013-12-04

Iatrogenic injury to the infrapatellar branch of the saphenous nerve is a common complication of surgical approaches to the anteromedial side of the knee. A detailed description of the relative anatomic course of the nerve is important to define clinical guidelines and minimize iatrogenic damage during anterior knee surgery. In twenty embalmed knees, the infrapatellar branch of the saphenous nerve was dissected. With use of a computer-assisted surgical anatomy mapping tool, safe and risk zones, as well as the location-dependent direction of the nerve, were calculated. The location of the infrapatellar branch of the saphenous nerve is highly variable, and no definite safe zone could be identified. The infrapatellar branch runs in neither a purely horizontal nor a vertical course. The course of the branch is location-dependent. Medially, it runs a nearly vertical course; medial to the patellar tendon, it has a -45° distal-lateral course; and on the patella and patellar tendon, it runs a close to horizontal-lateral course. Three low risk zones for iatrogenic nerve injury were identified: one is on the medial side of the knee, at the level of the tibial tuberosity, where a -45° oblique incision is least prone to damage the nerves, and two zones are located medial to the patellar apex (cranial and caudal), where close to horizontal incisions are least prone to damage the nerves. The infrapatellar branch of the saphenous nerve is at risk for iatrogenic damage in anteromedial knee surgery, especially when longitudinal incisions are made. There are three low risk zones for a safer anterior approach to the knee. The direction of the infrapatellar branch of the saphenous nerve is location-dependent. To minimize iatrogenic damage to the nerve, the direction of incisions should be parallel to the direction of the nerve when technically possible. These findings suggest that iatrogenic damage of the infrapatellar branch of the saphenous nerve can be minimized in anteromedial

Long-term outcomes in patients with ulnar neuropathy at the elbow treated according to the presumed aetiology.

PubMed

Omejec, Gregor; Podnar, Simon

2018-06-01

Ulnar neuropathy at the elbow (UNE) consists mainly of two conditions: entrapment under the humeroulnar aponeurosis (HUA) and extrinsic compression in the retrocondylar (RTC) groove. These in our opinion need different treatment: surgical HUA release and avoidance of inappropriate arm positioning, respectively. We treated our UNE patients accordingly, and studied their long-term outcomes. We invited our cohort of UNE patients to a follow-up examination consisting of history, neurological, electrodiagnostic (EDx) and ultrasonographic (US) examinations performed by four blinded investigators. At a mean follow-up time of 881 days, we performed a complete evaluation in 117 of 165 (65%) patients, with 96 (90%; 35 HUA and 61 RTC) treated according to our recommendations. An improvement was reported by 83% of HUA and 84% of RTC patients. In both groups the ulnar nerve mean compound muscle action potential (CMAP) amplitude, and the minimal motor nerve conduction velocity increased, while the maximal ulnar nerve cross-sectional area (CSA) decreased. After 2.5 years similar proportions of HUA and RTC patients reported clinical improvement that was supported by improvement in EDx and US findings. These results suggest that patients with UNE improve following both surgical decompression and non-operative treatment. A clinical trial comparing treatment approaches in neuropathy localised to the HUA and RTC will be needed to possibly confirm our opinion that the therapeutic approach should be tailored according to the presumed aetiology of UNE. Copyright © 2018 International Federation of Clinical Neurophysiology. Published by Elsevier B.V. All rights reserved.

Sonographic identification of peripheral nerves in the forearm

PubMed Central

Jackson, Saundra A.; Derr, Charlotte; De Lucia, Anthony; Harris, Marvin; Closser, Zuheily; Miladinovic, Branko; Mhaskar, Rahul; Jorgensen, Theresa; Green, Lori

2016-01-01

Background: With the growing utilization of ultrasonography in emergency medicine combined with the concern over adequate pain management in the emergency department (ED), ultrasound guidance for peripheral nerve blockade in ED is an area of increasing interest. The medical literature has multiple reports supporting the use of ultrasound guidance in peripheral nerve blocks. However, to perform a peripheral nerve block, one must first be able to reliably identify the specific nerve before the procedure. Objective: The primary purpose of this study is to describe the number of supervised peripheral nerve examinations that are necessary for an emergency medicine physician to gain proficiency in accurately locating and identifying the median, radial, and ulnar nerves of the forearm via ultrasound. Methods: The proficiency outcome was defined as the number of attempts before a resident is able to correctly locate and identify the nerves on ten consecutive examinations. Didactic education was provided via a 1 h lecture on forearm anatomy, sonographic technique, and identification of the nerves. Participants also received two supervised hands-on examinations for each nerve. Count data are summarized using percentages or medians and range. Random effects negative binomial regression was used for modeling panel count data. Results: Complete data for the number of attempts, gender, and postgraduate year (PGY) training year were available for 38 residents. Nineteen males and 19 females performed examinations. The median PGY year in practice was 3 (range 1–3), with 10 (27%) in year 1, 8 (22%) in year 2, and 19 (51%) in year 3 or beyond. The median number (range) of required supervised attempts for radial, median, and ulnar nerves was 1 (0–12), 0 (0–10), and 0 (0–17), respectively. Conclusion: We can conclude that the maximum number of supervised attempts to achieve accurate nerve identification was 17 (ulnar), 12 (radial), and 10 (median) in our study. The only

Epidemiology of Medial Ulnar Collateral Ligament Reconstruction: A 10-Year Study in New York State.

PubMed

Hodgins, Justin L; Vitale, Mark; Arons, Raymond R; Ahmad, Christopher S

2016-03-01

Despite an increase in the prevalence of medial ulnar collateral ligament (UCL) reconstruction of the elbow in professional baseball and popularity within the media, there are no population-based studies examining the incidence of UCL reconstruction. To examine the epidemiological trends of UCL reconstruction on a statewide level over a 10-year period. The primary endpoint was the yearly rate of UCL reconstruction over time; secondary endpoints included patient demographics, institution volumes, and concomitant procedures on the ulnar nerve. Descriptive epidemiology study. The New York Statewide Planning and Research Cooperative System (SPARCS) database contains records for each ambulatory discharge in New York State. This database was used to identify all UCL reconstructions in New York State from 2002 to 2011 using the outpatient CPT-4 (Current Procedural Terminology, 4th Revision) code. Assessed were patient age, sex, ethnicity, insurance status, and associated procedures, as well as hospital volume. There was a significant yearly increase in the number of UCL reconstructions (P < .001) performed in New York State from 2002 to 2011. The volume of UCL reconstructions increased by 193%, and the rate per 100,000 population tripled from 0.15 to 0.45. The mean ± SD age was 21.6 ± 8.89 years, and there was a significant trend for an increased frequency in UCL reconstruction in patients aged 17 to 18 and 19 to 20 years (P < .001). Male patients were 11.8 times more likely to have a UCL reconstruction than female patients (P < .001), and individuals with private insurance were 25 times more likely to have a UCL reconstruction than those with Medicaid (P = .0014). There was a 400% increase in concomitant ulnar nerve release/transposition performed over time in the study period, representing a significant increase in the frequency of ulnar nerve procedures at the time of UCL reconstruction (P < .001). The frequency of UCL reconstruction is steadily rising in New York

A Survey of the Opinion and Experience of UK Dentists: Part 1: The Incidence and Cause of Iatrogenic Trigeminal Nerve Injuries Related to Dental Implant Surgery.

PubMed

Yilmaz, Zehra; Ucer, Cemal; Scher, Edwin; Suzuki, Jon; Renton, Tara

2016-10-01

Dental implant-related iatrogenic trigeminal nerve (TG) injuries are proportionally increasing with dental implant surgery. This study, which is presented in greater detail over a series of articles, assessed the experience of implant-related TG nerve injuries among UK dentists. Incidence and cause of inferior alveolar nerve (IAN), mental nerve (MN), and lingual nerve (LN) injuries, together with preoperative assessment and the consent process, are presented in this article. A survey was distributed among 405 dentists attending an Association of Dental Implantology congress in the United Kingdom, of which 187 completed the survey. Most responding dentists were full-time general practitioners. Implant dentistry training was predominately through industry-organized courses. Eighty dentists encountered implant-related IAN injuries, whereas 8 encountered LN injuries. Inaccurate radiological identification of the IAN/MN and their anatomical variations (48%) were seen to be the most frequent cause of TG injuries. Disclosure of the relative risk and benefits of alternative implant treatment strategies as part of the informed consent process was not deemed to be essential by 47 (25%) of the participants. Inadequate radiological assessment was the most common cause of TG nerve injury. The use of small field of view cone beam computer tomography (CBCT) is therefore recommended when placing implants in the posterior mandible. Implant surgeons should acquire evidence-based skills in the prevention, diagnosis, and management of TG nerve injury as well as specific training on justification and interpretation of CBCT scans.

Proximity of the Triangular Fibrocartilage Complex to Key Surrounding Structures and Safety Assessment of an Arthroscopic Repair Technique: A Cadaveric Study.

PubMed

Kuremsky, Marshall A; Habet, Nahir; Peindl, Richard D; Gaston, R Glenn

2016-12-01

To quantify the distance of the dorsal ulnar sensory branch, floor of the extensor carpi ulnaris (ECU) subsheath, and ulnar neurovascular bundles from the triangular fibrocartilage complex (TFCC), and secondarily to assess the safety of an all-inside arthroscopic repair of the TFCC with a commonly used meniscal repair device with respect to the aforementioned structures. A custom K-wire with 1-mm gradation was used to determine the distance of at-risk structures from the periphery of the TFCC in 13 above-elbow human cadaver specimens. An all-inside repair of the TFCC at the location of a Palmer 1B tear was then performed using a commonly employed meniscal repair device. The distance from the deployed devices to the structure in closest proximity was then measured using digital calipers. The mean distance from the deployed device to the nearest structure of concern for iatrogenic injury was 9.4 mm (range, 5-15 mm). The closest structure to iatrogenic injury was usually, but not always, the dorsal ulnar sensory nerve in 9 of 13 wrists (69.2%) at 9.3 mm (range, 5-15 mm); on 3 occasions it was instead the ulnar nerve (23.1%) at 9.5 mm (range, 9-10 mm), and on 1 occasion 6 mm from the flexor digitorum profundus to the little finger (7.7%). Forearm rotation had no significant effect on measured distances (ulnar nerve: P = .98; dorsal sensory: P = .89; ECU: P = .90). The largest influence of forearm rotation was a 0.4-mm difference between pronation and supination with respect to the distance of the TFCC periphery on the ECU subsheath. An all-inside arthroscopic TFCC repair using a commonly used meniscal repair device appears safe with respect to nearby neurovascular structures and tendons under typical arthroscopic conditions. An all-inside arthroscopic TFCC repair using a commonly employed meniscal repair device appears safe in terms of proximity to important structures although further clinical investigation is warranted. Copyright © 2016 Arthroscopy

Diagnostic value of the near-nerve needle sensory nerve conduction in sensory inflammatory demyelinating polyneuropathy.

PubMed

Odabasi, Zeki; Oh, Shin J

2018-03-01

In this study we report the diagnostic value of the near-nerve needle sensory nerve conduction study (NNN-SNCS) in sensory inflammatory demyelinating polyneuropathy (IDP) in which the routine nerve conduction study was normal or non-diagnostic. The NNN-SNCS was performed to identify demyelination in the plantar nerves in 14 patients and in the median or ulnar nerve in 2 patients with sensory IDP. In 16 patients with sensory IDP, routine NCSs were either normal or non-diagnostic for demyelination. Demyelination was identified by NNN-SNCS by dispersion and/or slow nerve conduction velocity (NCV) below the demyelination marker. Immunotherapy was initiated in 11 patients, 10 of whom improved or remained stable. NNN-SNCS played an essential role in identifying demyelinaton in 16 patients with sensory IDP, leading to proper treatment. Muscle Nerve 57: 414-418, 2018. © 2017 Wiley Periodicals, Inc.

Pattern analysis of nerve enlargement using ultrasonography in chronic inflammatory demyelinating polyneuropathy.

PubMed

Jang, Jae Hong; Cho, Charles S; Yang, Kyung-Sook; Seok, Hung Youl; Kim, Byung-Jo

2014-09-01

Focal nerve enlargement is a characteristic finding in chronic inflammatory demyelinating polyneuropathy (CIDP). We performed this study to assess the distribution of nerve enlargement through ultrasonographic examination of peripheral nerves and to correlate the ultrasonographic findings with clinical features. To compare the ultrasonographic features of 10 subjects with CIDP with those of 18 healthy controls, we bilaterally measured the cross-sectional areas (CSA) of the vagus, brachial plexus, musculocutaneous, median, ulnar, radial, sciatic, tibial, common peroneal, and sural nerves. We also analyzed correlations between CSAs and various clinical and electrophysiological features. Mean CSAs were significantly larger in CIDP patients than controls, especially at proximal and non-entrapment sites. CSAs were significantly correlated with muscle strength at initial presentation, but not at the time of ultrasonography. The CSAs of the median and ulnar nerves at the mid-forearm, tibial nerve at 7 cm proximal to the medial malleolus, and sural nerve correlated with the nerve conduction velocity of the corresponding region. Ultrasonography revealed widely distributed nerve enlargement, especially in proximal regions and non-entrapment sites, in patients with CIDP compared with healthy controls. Nerve enlargement correlated well with the electrophysiologic function of the nerve, but not current clinical status. Pattern analysis of nerve enlargement using ultrasonography is a supportive tool in the diagnosis of CIDP. Copyright © 2014 International Federation of Clinical Neurophysiology. Published by Elsevier Ireland Ltd. All rights reserved.

Nerve stress during reverse total shoulder arthroplasty: a cadaveric study.

PubMed

Lenoir, Hubert; Dagneaux, Louis; Canovas, François; Waitzenegger, Thomas; Pham, Thuy Trang; Chammas, Michel

2017-02-01

Neurologic lesions are relatively common after total shoulder arthroplasty. These injuries are mostly due to traction. We aimed to identify the arm manipulations and steps during reverse total shoulder arthroplasty (RTSA) that affect nerve stress. Stress was measured in 10 shoulders of 5 cadavers by use of a tensiometer on each nerve from the brachial plexus, with shoulders in different arm positions and during different surgical steps of RTSA. When we studied shoulder position without prostheses, relative to the neutral position, internal rotation increased stress on the radial and axillary nerves and external rotation increased stress on the musculocutaneous, median, and ulnar nerves. Extension was correlated with increase in stress on all nerves. Abduction was correlated with increase in stress for the radial nerve. We identified 2 high-risk steps during RTSA: humeral exposition, particularly when the shoulder was in a position of more extension, and glenoid exposition. The thickness of polyethylene humeral cups used was associated with increased nerve stress in all but the ulnar nerve. During humeral preparation, the surgeon must be careful to limit shoulder extension. Care must be taken during exposure of the glenoid. Extreme rotation and oversized implants should be avoided to minimize stretch-induced neuropathies. Copyright © 2017 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.

Portal placement in elbow arthroscopy by novice surgeons: cadaver study.

PubMed

Claessen, Femke M A P; Kachooei, Amir R; Kolovich, Gregory P; Buijze, Geert A; Oh, Luke S; van den Bekerom, Michel P J; Doornberg, Job N

2017-07-01

In this anatomical cadaver study, the distance between major nerves and ligaments at risk for injury and portal sites created by trainees was measured. Trainees, inexperienced in elbow arthroscopy, have received a didactic lecture and cadaver instruction prior to portal placement. The incidence of iatrogenic injury from novice portal placement was also determined. Anterolateral, direct lateral, and anteromedial arthroscopic portals were created in ten cadavers by ten inexperienced trainees in elbow arthroscopy. After creating each portal, the trajectory of the portal was marked with a guide pin. Subsequently, the cadavers were dissected and the distances between the guide pin in the anterolateral, direct lateral, and anteromedial portals and important ligaments and nerves were measured. The difference between the distance of the direct lateral portal and the posterior antebrachial cutaneous nerve (PABCN) (22 mm, p < 0.001), the lateral antebrachial cutaneous nerve (4.0 mm, p < 0.001), and the radial nerve (25 mm, p < 0.001) was different from the average reported distances in the literature. A difference was found between the distance of the anterolateral portal and the PABCN (32 mm, p < 0.001) compared to previous studies. Three major iatrogenic complications were observed, including: laceration of the posterior bundle of the medial ulnar collateral ligament, lateral ulnar collateral ligament midsubstance laceration, and median nerve partial laceration. Surgeons increasingly consider arthroscopic treatment as an option for elbow pathology. In the present study a surgical complication rate of 30 % was found with novice portal placement during elbow arthroscopy. Furthermore, as the results from this study have indicated, accurate, precise, and safe portal placement in elbow arthroscopy is not easily achieved by didactic lecture and cadaver instruction session alone. Level of evidence V.

The First Experience of Triple Nerve Transfer in Proximal Radial Nerve Palsy.

PubMed

Emamhadi, Mohammadreza; Andalib, Sasan

2018-01-01

Injury to distal portion of posterior cord of brachial plexus leads to palsy of radial and axillary nerves. Symptoms are usually motor deficits of the deltoid muscle; triceps brachii muscle; and extensor muscles of the wrist, thumb, and fingers. Tendon transfers, nerve grafts, and nerve transfers are options for surgical treatment of proximal radial nerve palsy to restore some motor functions. Tendon transfer is painful, requires a long immobilization, and decreases donor muscle strength; nevertheless, nerve transfer produces promising outcomes. We present a patient with proximal radial nerve palsy following a blunt injury undergoing triple nerve transfer. The patient was involved in a motorcycle accident with complete palsy of the radial and axillary nerves. After 6 months, on admission, he showed spontaneous recovery of axillary nerve palsy, but radial nerve palsy remained. We performed triple nerve transfer, fascicle of ulnar nerve to long head of the triceps branch of radial nerve, flexor digitorum superficialis branch of median nerve to extensor carpi radialis brevis branch of radial nerve, and flexor carpi radialis branch of median nerve to posterior interosseous nerve, for restoration of elbow, wrist, and finger extensions, respectively. Our experience confirmed functional elbow, wrist, and finger extensions in the patient. Triple nerve transfer restores functions of the upper limb in patients with debilitating radial nerve palsy after blunt injuries. Copyright © 2017 Elsevier Inc. All rights reserved.

Correlation of nerve ultrasound, electrophysiological and clinical findings in chronic inflammatory demyelinating polyneuropathy.

PubMed

Kerasnoudis, A; Pitarokoili, K; Behrendt, V; Gold, R; Yoon, M-S

2015-01-01

We present the nerve ultrasound findings in chronic inflammatory demyelinating polyneuropathy (CIDP) and examine their correlation with electrophysiology and functional disability. A total of 75 healthy controls and 48 CIDP patients underwent clinical, sonographic and electrophysiological evaluation a mean of 3.9 years(SD+/-2.7) after disease onset. Nerve ultrasound revealed statistically significant higher cross-sectional area (CSA) values of the median (P<.0001), ulnar (P<.0001), radial (P<.0001), tibial (P<.0001), fibular nerve(P<.0001) in most of the anatomic sites and brachial plexus (supraclavicular, P<.0001;interscalene space, P = .0118),when compared to controls. The electroneurography documented signs of permanent axonal loss in the majority of peripheral nerves. A correlation between sonographic and electrophysiological findings was found only between the motor conduction velocity and CSA of the tibial nerve at the ankle (r = -.451, P = .007). Neither nerve sonography nor electrophysiology correlated with functional disability. The CSA of the median nerve in carpal tunnel and the ulnar nerve in Guyon's canal correlated with disease duration (P = .036, P = .027 respectively). CIDP seems to show inhomogenous CSA enlargement in brachial plexus and peripheral nerves, with weak correlation to electrophysiological findings. Neither nerve sonography nor electrophysiology correlated with functional disability in CIDP patients. Multicenter, prospective studies are required to proof the applicability and diagnostic values of these findings. Copyright © 2014 by the American Society of Neuroimaging.

Role of "Sural Sparing" Pattern (Absent/Abnormal Median and Ulnar with Present Sural SNAP) Compared to Absent/Abnormal Median or Ulnar with Normal Sural SNAP in Acute Inflammatory Demyelinating Polyneuropathy.

PubMed

Surpur, Spurthi Sunil; Govindarajan, Raghav

2017-01-01

Sural sparing defined as absent/abnormal median sensory nerve action potential (SNAP) amplitude or absent/abnormal ulnar SNAP amplitude with a normal sural SNAP amplitude is thought to be a marker for inflammatory demyelinating polyneuropathies. If sural sparing pattern specifically defined as absent/abnormal median and ulnar SNAP amplitude with normal sural SNAP amplitude (AMUNS) is sensitive and specific when compared with either absent/abnormal median and normal sural (AMNS) or absent/abnormal ulnar and normal sural (AUNS) for acute inflammatory demyelinating polyneuropathy (AIDP), chronic inflammatory demyelinating polyneuropathy (CIDP), select non-diabetic axonopathies (AXPs), and diabetic neuropathies (DNs). Retrospective analysis from 2001 to 2010 on all newly diagnosed AIDP, CIDP, select non-diabetic AXP, and DN. There were 20 AIDP and 23 CIDP. Twenty AXP and 50 DN patients between 2009 and 2010 were included as controls. AMUNS was seen in 65% of AIDP, 39% CIDP compared with 10% of AXP and 6% for DN with sensitivity of 51%, specificity of 92%, whereas the specificity of AMNS/AUNS was 73% and its sensitivity was 58%. If a patient has AMUNS they are >12 times more likely to have AIDP ( p  < 0.001). Sural sparing is highly specific but not sensitive when compared with either AMNS or AUNS in AIDP but does not add to sensitivity or specificity in CIDP.

Communicating branches between lingual and hypoglossal nerve: observation using Sihler's staining technique.

PubMed

Iwanaga, Joe; Watanabe, Koichi; Saga, Tsuyoshi; Tabira, Yoko; Nakamura, Moriyoshi; Fisahn, Christian; Tubbs, R Shane; Kusukawa, Jingo; Yamaki, Koh-Ichi

2017-07-01

Many dental procedures are at risk of injuring the lingual nerve. We performed this study to better elucidate the microanatomy that exists between the ipsilateral lingual and hypoglossal nerves so that iatrogenic injury can be avoided. Adult human cadaveric tongues (ten sides) underwent Sihler's staining to identify the microanatomy between the lingual and hypoglossal nerves. The lingual nerve entered the middle part of the anterior two-thirds of the tongue from its lateral side and divided into two to four thick branches. These branches were then disseminated to the anterior, middle, and posterior parts of the anterior two-thirds of the tongue via 7-14 thin nerve bundles as terminal branches. The hypoglossal nerve entered the tongue at the posterior border of its anterior two-thirds and traveled forward to the apex of the tongue on all sides. All specimens were found to have communicating branches between the lingual and hypoglossal nerves at its anterior, middle, and posterior thirds. Our results indicate that the ipsilateral lingual and hypoglossal nerves constantly have three connections on each side between them. This knowledge might aid the dentist in minimizing iatrogenic nerve injury.

Echogenicity and ultrasound visibility of peripheral nerves of the upper extremity.

PubMed

Stolz, Lori A; Acuna, Josie Galarza; Gaskin, Kevin; Murphy, Amanda M; Friedman, Lucas; Stears-Ellis, Summer; Javedani, Parisa; Stolz, Uwe; Adhikari, Srikar

2018-05-02

Regional anesthesia with ultrasound-guidance is an excellent option for pain control if nerves are adequately visualized. Gender, body mass index (BMI), history of diabetes, neck and forearm circumference may affect echotexture and visualization. This study evaluates patient characteristics for their ability to predict the echogenicity or visibility of upper extremity peripheral nerves. This is a prospective observational study. A convenience sample of adult emergency department patients were enrolled. Gender, BMI, history of diabetes, neck circumference and arm circumference were recorded. Sonographic images of the brachial plexus at interscalene and supraclavicular levels, the median, the radial and ulnar nerves were recorded. Three reviewers independently graded the echogenicity and visibility using subjective scales. 395 peripheral nerves were included. Nerves of the forearm (median, ulnar, radial nerves) were found to be more echogenic (OR=9.3; 95% CI: 5.7, 15.3) and visible (OR=10.0; 6.3, 16.0) than more proximal nerves (brachial plexus at interscalene and supraclavicular levels). Gender, BMI, and history of diabetes mellitus were not significantly related to nerve visibility (p=0.9, 0.2, 0.2, respectively) or echogenicity (p=0.3, 0.8, 0.3). Neck circumference was not related to visibility or echogenicity of proximal nerves. Increased forearm circumference improved echogenicity (OR=1.25; 1.09, 1.43) but not visibility of forearm nerves. Gender, BMI and presence of diabetes were not related to echogenicity or visibility of upper extremity nerves. Increasing forearm circumference was associated with increased echogenicity of the adjacent nerves, but not visibility. Neck circumference was not associated with either nerve visibility or echogenicity of brachial plexus nerve bundles.

Neurologic examination and instrument-based measurements in the evaluation of ulnar neuropathy at the elbow.

PubMed

Omejec, Gregor; Podnar, Simon

2018-06-01

The aim of the study was to compare the utility of instrument-based assessment of peripheral nerve function with the neurologic examination in ulnar neuropathy at the elbow (UNE). We prospectively recruited consecutive patients with suspected UNE, performed a neurologic examination, and performed instrument-based measurements (muscle cross-sectional area by ultrasonography, muscle strength by dynamometry, and sensation using monofilaments). We found good correlations between clinical estimates and corresponding instrument-based measurements, with similar ability to diagnose UNE and predict UNE pathophysiology. Although instrument-based methods provide quantitative evaluation of peripheral nerve function, we did not find them to be more sensitive or specific in the diagnosis of UNE than the standard neurologic examination. Likewise, instrument-based methods were not better able to differentiate between groups of UNE patients with different pathophysiologies. Muscle Nerve 57: 951-957, 2018. © 2017 Wiley Periodicals, Inc.

Axillary nerve injury.

PubMed

Perlmutter, G S

1999-11-01

Axillary nerve injury remains the most common peripheral nerve injury to affect the shoulder. It most often is seen after glenohumeral joint dislocation, proximal humerus fracture, or a direct blow to the deltoid muscle. Compression neuropathy has been reported to occur in the quadrilateral space syndrome, although the true pathophysiology of this disorder remains unclear. The axillary nerve is vulnerable during any operative procedure involving the inferior aspect of the shoulder and iatrogenic injury remains a serious complication of shoulder surgery. During the acute phase of injury, the shoulder should be rested, and when clinically indicated, a patient should undergo an extensive rehabilitation program emphasizing range of motion and strengthening of the shoulder girdle muscles. If no axillary nerve recovery is observed by 3 to 6 months after injury, surgical exploration may be indicated, especially if the mechanism of injury is consistent with nerve rupture. Patients who sustain injury to the axillary nerve have a variable prognosis for nerve recovery although return of function of the involved shoulder typically is good to excellent, depending on associated ligamentous or bony injury.

Superficial ulnar artery perforator flap.

PubMed

Schonauer, Fabrizio; Marlino, Sergio; Turrà, Francesco; Graziano, Pasquale; Dell'Aversana Orabona, Giovanni

2014-09-01

Superficial ulnar artery is a rare finding but shows significant surgical implications. Its thinness and pliability make this flap an excellent solution for soft tissue reconstruction, especially in the head and neck region. We hereby report a successful free superficial ulnar artery perforator forearm flap transfer for tongue reconstruction. A 64-year-old man presenting with a squamous cell carcinoma of the left tongue underwent a wide resection of the tumor, left radical neck dissection, and reconstruction of the tongue and the left tonsillar pillar with the mentioned flap. No complications were observed postoperatively. The flap survived completely; no recurrence at 6 months of follow-up was detected. Superficial ulnar artery perforator flap has shown to be a safe alternative to other free tissue flaps in specific forearm anatomic conditions.

Defining the local nerve blocks for feline distal thoracic limb surgery: a cadaveric study

PubMed Central

Enomoto, Masataka; Lascelles, B Duncan X; Gerard, Mathew P

2016-01-01

Objectives Though controversial, onychectomy remains a commonly performed distal thoracic limb surgical procedure in cats. Peripheral nerve block techniques have been proposed in cats undergoing onychectomy but evidence of efficacy is lacking. Preliminary tests of the described technique using cadavers resulted in incomplete staining of nerves. The aim of this study was to develop nerve block methods based on cadaveric dissections and test these methods with cadaveric dye injections. Methods Ten pairs of feline thoracic limbs (n = 20) were dissected and superficial branches of the radial nerve (RSbr nn.), median nerve (M n.), dorsal branch of ulnar nerve (UDbr n.), superficial branch of palmar branch of ulnar nerve (UPbrS n.) and deep branch of palmar branch of ulnar nerve (UPbrDp n.) were identified. Based on these dissections, a four-point block was developed and tested using dye injections in another six pairs of feline thoracic limbs (n = 12). Using a 25 G × 5/8 inch needle and 1 ml syringe, 0.07 ml/kg methylene blue was injected at the site of the RSbr nn., 0.04 ml/kg at the injection site of the UDbr n., 0.08 ml/kg at the injection site of the M n. and UPbrS n., and 0.01 ml/kg at the injection site of the UPbrDp n. The length and circumference of each nerve that was stained was measured. Results Positive staining of all nerves was observed in 12/12 limbs. The lengths stained for RSbr nn., M n., UDbr n., UPbrS n. and UPbrDp n. were 34.9 ± 5.3, 26.4 ± 4.8, 29.2 ± 4.0, 39.1 ± 4.3 and 17.5 ± 3.3 mm, respectively. The nerve circumferences stained were 93.8 ± 15.5, 95.8 ± 9.7, 100 ± 0.0, 100 ± 0.0 and 93.8 ± 15.5%, respectively. Conclusions and relevance This described four-point injection method may be an effective perioperative analgesia technique for feline distal thoracic limb procedures. PMID:26250858

Iatrogenic trigeminal post-traumatic neuropathy: a retrospective two-year cohort study.

PubMed

Klazen, Y; Van der Cruyssen, F; Vranckx, M; Van Vlierberghe, M; Politis, C; Renton, T; Jacobs, R

2018-06-01

With the growing demand for dental work, trigeminal nerve injuries are increasingly common. This retrospective cohort study examined 53 cases of iatrogenic trigeminal nerve injury seen at the Department of Oral and Maxillofacial Surgery, University Hospitals of Leuven between 2013 and 2014 (0.6% among 8845 new patient visits). Patient records were screened for post-traumatic trigeminal nerve neuropathy caused by nerve injury incurred during implant surgery, endodontic treatment, local anaesthesia, tooth extraction, or specifically third molar removal. The patients ranged in age from 15 to 80years (mean age 42.1years) and 68% were female. The referral delay ranged from 1day to 6.5years (average 10months). The inferior alveolar nerve (IAN) was most frequently injured (28 cases), followed by the lingual nerve (LN) (21 cases). Most nerve injuries were caused during third molar removal (24 cases), followed by implant placement (nine cases) and local anaesthesia injuries (nine cases). Pain symptoms were experienced by 54% of patients suffering IAN injury, compared to 10% of patients with LN injury. Persistent neurosensory disturbances were identified in 60% of patients. While prevention remains the key issue, timely referral seems to be a critical factor for the successful treatment of post-traumatic neuropathy. Copyright © 2018 The Author(s). Published by Elsevier Ltd.. All rights reserved.

Revision ulnar collateral ligament reconstruction using a suspension button fixation technique.

PubMed

Lee, Gregory H; Limpisvasti, Orr; Park, Maxwell C; McGarry, Michelle H; Yocum, Lewis A; Lee, Thay Q

2010-03-01

Revision ulnar collateral ligament reconstruction remains a challenging problem. The objective of this study was to biomechanically evaluate an ulnar collateral ligament reconstruction technique using a suspension button fixation technique that can be used even in the case of ulnar cortical bone loss. An ulnar suspension fixation technique for ulnar collateral ligament reconstruction can restore elbow kinematics and demonstrate failure strength comparable to that of currently available techniques. Controlled laboratory study. Nine pairs of cadaveric elbows were dissected free of soft tissue and potted. After simulating ulnar cortical bone loss, ulnar collateral ligament reconstruction was performed in 1 elbow of each pair using palmaris longus autograft and a 30-mm RetroButton suspended from the far (lateralmost) ulnar cortex. A docking technique was used for humeral fixation of the graft. Elbow valgus angle was quantified using a Microscribe 3DLX digitizer at multiple elbow flexion angles. Valgus angle was measured with the ulnar collateral ligament intact, transected, and reconstructed. In addition, load-to-failure testing was performed in 1 elbow of each pair. Release of the ulnar collateral ligament caused a significant increase in valgus angle at each flexion angle tested (P < .002). Reconstructed elbows demonstrated no significant differences in valgus angle from the intact elbow at all flexion angles tested. Load-to-failure tests showed that reconstructed elbows had an ultimate torque (10.3 + or - 5.7 N x m) significantly less than intact elbows (26.4 + or - 10.6 N x m) (P = .001). Ulnar collateral ligament reconstruction using a suspension button fixation technique reliably restored elbow kinematics to the intact state. Load-to-failure testing demonstrated comparable fixation strength to several historic controls of primary reconstruction techniques despite the simulated ulnar cortical bone loss. Ulnar collateral ligament reconstruction using a suspension

Wound and Sural Nerve Complications of the Sinus Tarsi Approach for Calcaneus Fractures.

PubMed

Li, Shaoliang

2018-05-01

Background The purpose of this study was to evaluate the optimal timing and measures of the sinus tarsi approach for calcaneus fractures to avoid iatrogenic injury of the sural nerve and to assess for wound complications. A case series of 53 patients with calcaneus fractures treated by a single surgeon with the sinus tarsi approach was retrospectively analyzed. On the basis of the delay time from injury to surgery, patients were classified into 4 groups: immediate (0-3 days), early (4-6 days), intermediate (7-14 days), and late (14-18 days). All patients were followed for at least 1 year to observe wound conditions. The rate of wound complications and iatrogenic sural nerve injury was described. Incisions were classified into 2 groups: group A included patients with incisions extending posterior to the lateral malleolus, and group B included patients with incisions confined anterior to the lateral malleolus. The rates of nerve injury were compared between both groups. Forty-three patients with 52 Sanders type II fractures were included. The average time to surgery from injury was 8.8 days (range, 0-18 days). The overall postoperative rate of wound complications was 5.8% (3 of 52). In the immediate group, deep infections and wound necrosis were found in 2 of 8 fractures (25%). In the early group, 1 of 15 fractures developed superficial infection (6.7%). In the intermediate and late groups, no wound complication was identified. Iatrogenic sural nerve injury was recorded in 5 of 52 patients (9.6%). Group A had 33% (4 of 12) nerve injuries and group B had 2.5% (1 of 40) ( P = .009). In 70% of cases, a main branch of the sural nerve was directly under the incision. The sinus tarsi approach was generally effective and safe for calcaneus fractures. However, it was relatively risky to perform open reduction and internal fixation by the sinus tarsi approach within 6 days of injury. Because the sural nerve is in the vicinity of the approach, iatrogenic injury should be

Where Is the Ulnar Styloid Process? Identification of the Absolute Location of the Ulnar Styloid Process Based on CT and Verification of Neutral Forearm Rotation on Lateral Radiographs of the Wrist.

PubMed

Shin, Seung-Han; Lee, Yong-Suk; Kang, Jin-Woo; Noh, Dong-Young; Jung, Joon-Yong; Chung, Yang-Guk

2018-03-01

The location of the ulnar styloid process can be confusing because the radius and the hand rotate around the ulna. The purpose of this study was to identify the absolute location of the ulnar styloid process, which is independent of forearm pronation or supination, to use it as a reference for neutral forearm rotation on lateral radiographs of the wrist. Computed tomography (CT) images of 23 forearms taken with elbow flexion of 70° to 90° were analyzed. The axial CT images were reconstructed to be perpendicular to the distal ulnar shaft. The absolute location of the ulnar styloid process in this study was defined as the position of the ulnar styloid process on the axial plane of the ulnar head relative to the long axis of the humeral shaft with the elbow set in the position for standard lateral radiographs of the wrist. To identify in which direction the ulnar styloid is located on the axial plane of the ulnar head, the angle between "the line of humeral long axis projected on the axial plane of the ulna" and "the line passing the center of the ulnar head and the center of the ulnar styloid" was measured (ulnar styloid direction angle). To identify how volarly or dorsally the ulnar styloid should appear on the true lateral view of the wrist, the ratio of "the volar-dorsal diameter of the ulnar head" and "the distance between the volar-most aspect of the ulnar head and the center of the ulnar styloid" was calculated (ulnar styloid location ratio). The mean ulnar styloid direction angle was 12° dorsally. The mean ulnar styloid location ratio was 1:0.55. The ulnar styloid is located at nearly the ulnar-most (the opposite side of the humerus with the elbow flexed) and slightly dorsal aspects of the ulnar head on the axial plane. It should appear almost midway (55% dorsally) from the ulnar head on the standard lateral view of the wrist in neutral forearm rotation. These location references could help clinicians determine whether the forearm is in neutral or rotated

Wisdom tooth extraction causing lingual nerve and styloglossus muscle damage: a mimic of multiple cranial nerve palsies.

PubMed

Carr, Aisling S; Evans, Matthew; Shah, Sachit; Catania, Santi; Warren, Jason D; Gleeson, Michael J; Reilly, Mary M

2017-06-01

The combination of tongue hemianaesthesia, dysgeusia, dysarthria and dysphagia suggests the involvement of multiple cranial nerves. We present a case with sudden onset of these symptoms immediately following wisdom tooth extraction and highlight the clinical features that allowed localisation of the lesion to a focal, iatrogenic injury of the lingual nerve and adjacent styloglossus muscle. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Preoperative transcutaneous electrical nerve stimulation for localizing superficial nerve paths.

PubMed

Natori, Yuhei; Yoshizawa, Hidekazu; Mizuno, Hiroshi; Hayashi, Ayato

2015-12-01

During surgery, peripheral nerves are often seen to follow unpredictable paths because of previous surgeries and/or compression caused by a tumor. Iatrogenic nerve injury is a serious complication that must be avoided, and preoperative evaluation of nerve paths is important for preventing it. In this study, transcutaneous electrical nerve stimulation (TENS) was used for an in-depth analysis of peripheral nerve paths. This study included 27 patients who underwent the TENS procedure to evaluate the peripheral nerve path (17 males and 10 females; mean age: 59.9 years, range: 18-83 years) of each patient preoperatively. An electrode pen coupled to an electrical nerve stimulator was used for superficial nerve mapping. The TENS procedure was performed on patients' major peripheral nerves that passed close to the surgical field of tumor resection or trauma surgery, and intraoperative damage to those nerves was apprehensive. The paths of the target nerve were detected in most patients preoperatively. The nerve paths of 26 patients were precisely under the markings drawn preoperatively. The nerve path of one patient substantially differed from the preoperative markings with numbness at the surgical region. During surgery, the nerve paths could be accurately mapped preoperatively using the TENS procedure as confirmed by direct visualization of the nerve. This stimulation device is easy to use and offers highly accurate mapping of nerves for surgical planning without major complications. The authors conclude that TENS is a useful tool for noninvasive nerve localization and makes tumor resection a safe and smooth procedure. Copyright © 2015 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Radial nerve palsy

PubMed Central

Bumbasirevic, Marko; Palibrk, Tomislav; Lesic, Aleksandar; Atkinson, Henry DE

2016-01-01

As a result of its proximity to the humeral shaft, as well as its long and tortuous course, the radial nerve is the most frequently injured major nerve in the upper limb, with its close proximity to the bone making it vulnerable when fractures occur. Injury is most frequently sustained during humeral fracture and gunshot injuries, but iatrogenic injuries are not unusual following surgical treatment of various other pathologies. Treatment is usually non-operative, but surgery is sometimes necessary, using a variety of often imaginative procedures. Because radial nerve injuries are the least debilitating of the upper limb nerve injuries, results are usually satisfactory. Conservative treatment certainly has a role, and one of the most important aspects of this treatment is to maintain a full passive range of motion in all the affected joints. Surgical treatment is indicated in cases when nerve transection is obvious, as in open injuries or when there is no clinical improvement after a period of conservative treatment. Different techniques are used including direct suture or nerve grafting, vascularised nerve grafts, direct nerve transfer, tendon transfer, functional muscle transfer or the promising, newer treatment of biological therapy. Cite this article: Bumbasirevic M, Palibrk T, Lesic A, Atkinson HDE. Radial nerve palsy. EFORT Open Rev 2016;1:286-294. DOI: 10.1302/2058-5241.1.000028. PMID:28461960

Development of Kinematic Graphs of Median Nerve during Active Finger Motion: Implications of Smartphone Use

PubMed Central

2016-01-01

Background Certain hand activities cause deformation and displacement of the median nerve at the carpal tunnel due to the gliding motion of tendons surrounding it. As smartphone usage escalates, this raises the public’s concern whether hand activities while using smartphones can lead to median nerve problems. Objective The aims of this study were to 1) develop kinematic graphs and 2) investigate the associated deformation and rotational information of median nerve in the carpal tunnel during hand activities. Methods Dominant wrists of 30 young adults were examined with ultrasonography by placing a transducer transversely on their wrist crease. Ultrasound video clips were recorded when the subject performing 1) thumb opposition with the wrist in neutral position, 2) thumb opposition with the wrist in ulnar deviation and 3) pinch grip with the wrist in neutral position. Six still images that were separated by 0.2-second intervals were then captured from the ultrasound video for the determination of 1) cross-sectional area (CSA), 2) flattening ratio (FR), 3) rotational displacement (RD) and 4) translational displacement (TD) of median nerve in the carpal tunnel, and these collected information of deformation, rotational and displacement of median nerve were compared between 1) two successive time points during a single hand activity and 2) different hand motions at the same time point. Finally, kinematic graphs were constructed to demonstrate the mobility of median nerve during different hand activities. Results Performing different hand activities during this study led to a gradual reduction in CSA of the median nerve, with thumb opposition together with the wrist in ulnar deviation causing the greatest extent of deformation of the median nerve. Thumb opposition with the wrist in ulnar deviation also led to the largest extent of TD when compared to the other two hand activities of this study. Kinematic graphs showed that the motion pathways of median nerve during

[Study of peripheral nerve injury in trauma patients].

PubMed

Castillo-Galván, Marina Lizeth; Martínez-Ruiz, Fernando Maximiliano; de la Garza-Castro, Oscar; Elizondo-Omaña, Rodrigo Enrique; Guzmán-López, Santos

2014-01-01

To determine the prevalence, location, mechanism, and characteristics of peripheral nerve injury (PNI) in trauma patients. A retrospective study of medical records with PNI diagnosis secondary to trauma in the period of 2008-2012. The following information was collected: gender, age, occupation, anatomic location, affected nerve, mechanism of injury, degree of injury, costs, and hospitalization time. The prevalence of PNI is 1.12%. The location of the nerve injury was 61% upper limb, the highest incidence was presented to the brachial plexus (35%) and ulnar nerve (18%). The mechanism of the lesion was sharp injury (19%). The PNI are commonly present in people of a productive age. Neurotmesis was the most frequent degree of lesion. The patients stayed at hospital 2.51 ± 1.29 days and the average cost was 12,474.00 Mexican pesos ± 5,595.69 (US$ 1,007.54 ± 452.21) for one nerve injury.

Sensory nerve action potentials and sensory perception in women with arthritis of the hand.

PubMed

Calder, Kristina M; Martin, Alison; Lydiate, Jessica; MacDermid, Joy C; Galea, Victoria; MacIntyre, Norma J

2012-05-10

Arthritis of the hand can limit a person's ability to perform daily activities. Whether or not sensory deficits contribute to the disability in this population remains unknown. The primary purpose of this study was to determine if women with osteoarthritis (OA) or rheumatoid arthritis (RA) of the hand have sensory impairments. Sensory function in the dominant hand of women with hand OA or RA and healthy women was evaluated by measuring sensory nerve action potentials (SNAPs) from the median, ulnar and radial nerves, sensory mapping (SM), and vibratory and current perception thresholds (VPT and CPT, respectively) of the second and fifth digits. All SNAP amplitudes were significantly lower for the hand OA and hand RA groups compared with the healthy group (p < 0.05). No group differences were found for SNAP conduction velocities, SM, VPT, and CPT. We propose, based on these findings, that women with hand OA or RA may have axonal loss of sensory fibers in the median, ulnar and radial nerves. Less apparent were losses in conduction speed or sensory perception.

Sensory nerve action potentials and sensory perception in women with arthritis of the hand

PubMed Central

2012-01-01

Background Arthritis of the hand can limit a person’s ability to perform daily activities. Whether or not sensory deficits contribute to the disability in this population remains unknown. The primary purpose of this study was to determine if women with osteoarthritis (OA) or rheumatoid arthritis (RA) of the hand have sensory impairments. Methods Sensory function in the dominant hand of women with hand OA or RA and healthy women was evaluated by measuring sensory nerve action potentials (SNAPs) from the median, ulnar and radial nerves, sensory mapping (SM), and vibratory and current perception thresholds (VPT and CPT, respectively) of the second and fifth digits. Results All SNAP amplitudes were significantly lower for the hand OA and hand RA groups compared with the healthy group (p < 0.05). No group differences were found for SNAP conduction velocities, SM, VPT, and CPT. Discussion We propose, based on these findings, that women with hand OA or RA may have axonal loss of sensory fibers in the median, ulnar and radial nerves. Less apparent were losses in conduction speed or sensory perception. PMID:22575001

Treatment of peroneal nerve injuries with simultaneous tendon transfer and nerve exploration.

PubMed

Ho, Bryant; Khan, Zubair; Switaj, Paul J; Ochenjele, George; Fuchs, Daniel; Dahl, William; Cederna, Paul; Kung, Theodore A; Kadakia, Anish R

2014-08-06

Common peroneal nerve palsy leading to foot drop is difficult to manage and has historically been treated with extended bracing with expectant waiting for return of nerve function. Peroneal nerve exploration has traditionally been avoided except in cases of known traumatic or iatrogenic injury, with tendon transfers being performed in a delayed fashion after exhausting conservative treatment. We present a new strategy for management of foot drop with nerve exploration and concomitant tendon transfer. We retrospectively reviewed a series of 12 patients with peroneal nerve palsies that were treated with tendon transfer from 2005 to 2011. Of these patients, seven were treated with simultaneous peroneal nerve exploration and repair at the time of tendon transfer. Patients with both nerve repair and tendon transfer had superior functional results with active dorsiflexion in all patients, compared to dorsiflexion in 40% of patients treated with tendon transfers alone. Additionally, 57% of patients treated with nerve repair and tendon transfer were able to achieve enough function to return to running, compared to 20% in patients with tendon transfer alone. No patient had full return of native motor function resulting in excessive dorsiflexion strength. The results of our limited case series for this rare condition indicate that simultaneous nerve repair and tendon transfer showed no detrimental results and may provide improved function over tendon transfer alone.

Spinal cord projections of the rat main forelimb nerves, studied by transganglionic transport of WGA-HRP and by the disappearance of acid phosphatase.

PubMed

Castro-Lopes, J M; Coimbra, A

1991-03-01

The spinal cord projections of the 3 main forelimb nerves-median, radial and ulnar, were studied in the rat dorsal horn with transganglionic transport of wheat germ agglutinin-horseradish peroxidase (WGA-HRP), or using the disappearance of fluoride resistant acid phosphatase (FRAP) after nerve section. The projection patterns in lamina II were similar following the two procedures. The median and the radial nerve fibers projected to the medial and the intermediate thirds, respectively, of the dorsal horn lamina II in spinal cord segments C4-C8. The ulnar nerve projected to segments C6-C8 between the areas occupied by the other two nerves. The FRAP method also showed that the lateral part of lamina II, which was not filled by radial nerve fibers, received the projections from the dorsal cutaneous branches of cervical spinal nerves. In addition, FRAP disappeared from the medial end of segment T1 after skin incisions extending from the medial brachium to the axilla, which seemed due to severance of the cutaneous branchlets of the lateral anterior thoracic nerve. The FRAP procedure is thus sensitive enough to detect fibers in lamina II arising from small peripheral nerves, and may be used as an alternative to the anterograde tracing methods whenever there are no overlapping projections.

True Ulnar Artery Aneurysm in the Proximal Forearm: Case Report and Literature Review.

PubMed

McHugh, Seamus Mark; Moloney, Michael Anthony; Greco, Elisa; Wheatcroft, Mark

2017-10-01

Ulnar artery aneurysms are rare with less than 150 previously reported. Previously ulnar aneurysms have been most commonly noted as occurring in the distal ulnar artery close to the palmar arch. We present the case of a 47-year-old male with a background history of human immunodeficiency virus (HIV) who attended our outpatient clinic with symptoms of distal embolization from a proximal ulnar artery aneurysm. Preoperatively, the aneurysm was thought to arise from the distal brachial artery, and only intraoperatively was the diagnosis of ulnar aneurysm made. The aneurysm was excised, and a reverse vein bypass graft anastomosed end to side on the brachial artery, and end to end on the distal ulnar. True ulnar artery aneurysms also involving the more proximal ulnar artery have been previously reported associated with vasculitic disorders. HIV has been previously associated with aneurysm formation in a number of anatomical locations. This case is noteworthy as it reports on the presentation and successful operative management of a true ulnar artery aneurysm arising in the proximal forearm in the setting of HIV, which has not been previously reported in medical literature. We present successful operative management of a true ulnar aneurysm in the proximal forearm using a reverse venous interposition bypass. Diagnosis of a proximal ulnar artery aneurysm may represent a diagnostic challenge given its rarity as it may mimic brachial artery aneurysm. Copyright © 2017 Elsevier Inc. All rights reserved.

[Progressive cerebral infraction initially presenting with pseudo-ulnar nerve palsy in a patient with severe internal carotid artery stenosis].

PubMed

Kakinuma, Kanako; Nakajima, Masashi; Hieda, Soutarou; Ichikawa, Hiroo; Kawamura, Mitsuru

2010-09-01

A 63-year-old man with hypercholesterolemia developed sensory and motor disturbances in the ulnar side of the right hand, and over three days the weakness evolved to entire right arm. Examination on the 6th day after onset showed mild lower facial palsy in addition to the upper limb weakness on the right. The weakness involved entire right arm sparing shoulder girdle muscles, which was worse in the 4th and 5th digits with claw hand deformity of the hand. Magnetic resonance imaging showed multiple small infracts in the centrum semiovale as well as in the medial side of the precentral knob on the left. Magnetic resonance angiography, ultrasonography, and 3D-CT angiography of the neck showed severe stenosis associated with unstable plaque of the left internal carotid artery. Hemodynamic mechanisms including microemboli and hypoperfusion associated with severe internal carotid artery stenosis are likely to cause stroke in evolution after initial presentation of pseudo-ulnar palsy in the present case.

The effects of general anaesthesia on nerve-motor response characteristics (rheobase and chronaxie) to peripheral nerve stimulation.

PubMed

Tsui, B C

2014-04-01

Using a simple surface nerve stimulation system, I examined the effects of general anaesthesia on rheobase (the minimum current required to stimulate nerve activity) and chronaxie (the minimum time for a stimulus twice the rheobase to elicit nerve activity). Nerve stimulation was used to elicit a motor response from the ulnar nerve at varying pulse widths before and after induction of general anaesthesia. Mean (SD) rheobase before and after general anaesthesia was 0.91 (0.37) mA (95% CI 0.77-1.04 mA) and 1.11 (0.53) mA (95% CI 0.92-1.30 mA), respectively. Mean (SD) chronaxie measured before and after general anaesthesia was 0.32 (0.17) ms (95% CI 0.26-0.38 ms) and 0.29 (0.13) ms (95% CI 0.24-0.33 ms), respectively. Under anaesthesia, rheobase values increased by an average of 20% (p = 0.05), but chronaxie values did not change significantly (p = 0.39). These results suggest that threshold currents used for motor response from nerve stimulation under general anaesthesia might be higher than those used in awake patients. © 2014 The Association of Anaesthetists of Great Britain and Ireland.

Iatrogenics in Orthodontics and its challenges.

PubMed

Barreto, Gustavo Mattos; Feitosa, Henrique Oliveira

2016-01-01

Orthodontics has gone through remarkable advances for those who practice it with dignity and clinical quality, such as the unprecedented number of patients treated of some type of iatrogenic problems (post-treatment root resorptions; occlusal plane changes; midline discrepancies, asymmetries, etc). Several questions may raise useful reflections about the constant increase of iatrogenics. What is causing it? Does it occur when dentists are properly trained? In legal terms, how can dentists accept these patients? How should they be orthodontically treated? What are the most common problems? This study analyzed and discussed relevant aspects to understand patients with iatrogenic problems and describe a simple and efficient approach to treat complex cases associated with orthodontic iatrogenics.

Iatrogenics in Orthodontics and its challenges

PubMed Central

Barreto, Gustavo Mattos; Feitosa, Henrique Oliveira

2016-01-01

ABSTRACT Introduction: Orthodontics has gone through remarkable advances for those who practice it with dignity and clinical quality, such as the unprecedented number of patients treated of some type of iatrogenic problems (post-treatment root resorptions; occlusal plane changes; midline discrepancies, asymmetries, etc). Several questions may raise useful reflections about the constant increase of iatrogenics. What is causing it? Does it occur when dentists are properly trained? In legal terms, how can dentists accept these patients? How should they be orthodontically treated? What are the most common problems? Objective: This study analyzed and discussed relevant aspects to understand patients with iatrogenic problems and describe a simple and efficient approach to treat complex cases associated with orthodontic iatrogenics. PMID:27901237

Sensation, mechanoreceptor, and nerve fiber function after nerve regeneration.

PubMed

Krarup, Christian; Rosén, Birgitta; Boeckstyns, Michel; Ibsen Sørensen, Allan; Lundborg, Göran; Moldovan, Mihai; Archibald, Simon J

2017-12-01

Sensation is essential for recovery after peripheral nerve injury. However, the relationship between sensory modalities and function of regenerated fibers is uncertain. We have investigated the relationships between touch threshold, tactile gnosis, and mechanoreceptor and sensory fiber function after nerve regeneration. Twenty-one median or ulnar nerve lesions were repaired by a collagen nerve conduit or direct suture. Quantitative sensory hand function and sensory conduction studies by near-nerve technique, including tactile stimulation of mechanoreceptors, were followed for 2 years, and results were compared to noninjured hands. At both repair methods, touch thresholds at the finger tips recovered to 81 ± 3% and tactile gnosis only to 20 ± 4% (p < 0.001) of control. The sensory nerve action potentials (SNAPs) remained dispersed and areas recovered to 23 ± 2% and the amplitudes only to 7 ± 1% (P < 0.001). The areas of SNAPs after tactile stimulation recovered to 61 ± 11% and remained slowed. Touch sensation correlated with SNAP areas (p < 0.005) and was negatively related to the prolongation of tactile latencies (p < 0.01); tactile gnosis was not related to electrophysiological parameters. The recovered function of regenerated peripheral nerve fibers and reinnervated mechanoreceptors may differentially influence recovery of sensory modalities. Touch was affected by the number and function of regenerated fibers and mechanoreceptors. In contrast, tactile gnosis depends on the input and plasticity of the central nervous system (CNS), which may explain the absence of a direct relation between electrophysiological parameters and poor recovery. Dispersed maturation of sensory nerve fibers with desynchronized inputs to the CNS also contributes to the poor recovery of tactile gnosis. Ann Neurol 2017. Ann Neurol 2017;82:940-950. © 2017 American Neurological Association.

Factors predicting sensory and motor recovery after the repair of upper limb peripheral nerve injuries

PubMed Central

He, Bo; Zhu, Zhaowei; Zhu, Qingtang; Zhou, Xiang; Zheng, Canbin; Li, Pengliang; Zhu, Shuang; Liu, Xiaolin; Zhu, Jiakai

2014-01-01

OBJECTIVE: To investigate the factors associated with sensory and motor recovery after the repair of upper limb peripheral nerve injuries. DATA SOURCES: The online PubMed database was searched for English articles describing outcomes after the repair of median, ulnar, radial, and digital nerve injuries in humans with a publication date between 1 January 1990 and 16 February 2011. STUDY SELECTION: The following types of article were selected: (1) clinical trials describing the repair of median, ulnar, radial, and digital nerve injuries published in English; and (2) studies that reported sufficient patient information, including age, mechanism of injury, nerve injured, injury location, defect length, repair time, repair method, and repair materials. SPSS 13.0 software was used to perform univariate and multivariate logistic regression analyses and to investigate the patient and intervention factors associated with outcomes. MAIN OUTCOME MEASURES: Sensory function was assessed using the Mackinnon-Dellon scale and motor function was assessed using the manual muscle test. Satisfactory motor recovery was defined as grade M4 or M5, and satisfactory sensory recovery was defined as grade S3+ or S4. RESULTS: Seventy-one articles were included in this study. Univariate and multivariate logistic regression analyses showed that repair time, repair materials, and nerve injured were independent predictors of outcome after the repair of nerve injuries (P < 0.05), and that the nerve injured was the main factor affecting the rate of good to excellent recovery. CONCLUSION: Predictors of outcome after the repair of peripheral nerve injuries include age, gender, repair time, repair materials, nerve injured, defect length, and duration of follow-up. PMID:25206870

Approaches to Peripheral Nerve Repair: Generations of Biomaterial Conduits Yielding to Replacing Autologous Nerve Grafts in Craniomaxillofacial Surgery

PubMed Central

Knipfer, Christian; Hadlock, Tessa

2016-01-01

Peripheral nerve injury is a common clinical entity, which may arise due to traumatic, tumorous, or even iatrogenic injury in craniomaxillofacial surgery. Despite advances in biomaterials and techniques over the past several decades, reconstruction of nerve gaps remains a challenge. Autografts are the gold standard for nerve reconstruction. Using autografts, there is donor site morbidity, subsequent sensory deficit, and potential for neuroma development and infection. Moreover, the need for a second surgical site and limited availability of donor nerves remain a challenge. Thus, increasing efforts have been directed to develop artificial nerve guidance conduits (ANCs) as new methods to replace autografts in the future. Various synthetic conduit materials have been tested in vitro and in vivo, and several first- and second-generation conduits are FDA approved and available for purchase, while third-generation conduits still remain in experimental stages. This paper reviews the current treatment options, summarizes the published literature, and assesses future prospects for the repair of peripheral nerve injury in craniomaxillofacial surgery with a particular focus on facial nerve regeneration. PMID:27556032

Ulnar osteosarcoma in dogs: 30 cases (1992-2008).

PubMed

Sivacolundhu, Ramesh K; Runge, Jeffrey J; Donovan, Taryn A; Barber, Lisa G; Saba, Corey F; Clifford, Craig A; de Lorimier, Louis-Philippe; Atwater, Stephen W; DiBernardi, Lisa; Freeman, Kim P; Bergman, Philip J

2013-07-01

To examine the biological behavior of ulnar osteosarcoma and evaluate predictors of survival time in dogs. Retrospective case series. 30 dogs with primary ulnar osteosarcoma. Medical records were reviewed. Variables recorded and examined to identify predictors of survival time were signalment, tumor location in the ulna, tumor length, serum alkaline phosphatase activity, surgery type, completeness of excision, tumor stage, tumor grade, histologic subtype, development of metastases, and use of chemotherapy. 30 cases were identified from 9 institutions. Eleven dogs were treated with partial ulnar ostectomy and 14 with amputation; in 5 dogs, a resection was not performed. Twenty-two dogs received chemotherapy. Median disease-free interval and survival time were 437 and 463 days, respectively. Negative prognostic factors for survival time determined via univariate analyses were histologic subtype and development of lung metastases. Telangiectatic or telangiectatic-mixed subtype (n = 5) was the only negative prognostic factor identified via multivariate analysis (median survival time, 208 days). Dogs with telangiectatic subtype were 6.99 times as likely to die of the disease. The prognosis for ulnar osteosarcoma in this population was no worse and may have been better than the prognosis for dogs with osteosarcoma involving other appendicular sites. Partial ulnar ostectomy was associated with a low complication rate and good to excellent function and did not compromise survival time. Telangiectatic or telangiectatic-mixed histologic subtype was a negative prognostic factor for survival time. The efficacy of chemotherapy requires further evaluation.

Facial nerve paralysis in children

PubMed Central

Ciorba, Andrea; Corazzi, Virginia; Conz, Veronica; Bianchini, Chiara; Aimoni, Claudia

2015-01-01

Facial nerve palsy is a condition with several implications, particularly when occurring in childhood. It represents a serious clinical problem as it causes significant concerns in doctors because of its etiology, its treatment options and its outcome, as well as in little patients and their parents, because of functional and aesthetic outcomes. There are several described causes of facial nerve paralysis in children, as it can be congenital (due to delivery traumas and genetic or malformative diseases) or acquired (due to infective, inflammatory, neoplastic, traumatic or iatrogenic causes). Nonetheless, in approximately 40%-75% of the cases, the cause of unilateral facial paralysis still remains idiopathic. A careful diagnostic workout and differential diagnosis are particularly recommended in case of pediatric facial nerve palsy, in order to establish the most appropriate treatment, as the therapeutic approach differs in relation to the etiology. PMID:26677445

[Ulnar nerve tunnel syndrome of the elbow and an occupational disorder. Analysis of socio-professional and physical parameters].

PubMed

Pellieux, S; Fouquet, B; Lasfargues, G

2001-05-01

The ulnar nerve tunnel syndrome at the elbow is the second frequently tunnel syndrome, registered as an occupational disorder. The musculoskeletal troubles of the upper limb are now a public health challenge. These disorders allow manifold risk factors related to the work state, extrinsic to the patient, and related to individual factors, or intrinsic. In the same venture, 25 patients with a UNTS, declared as an occupational disorder, have been compared to 48 individuals (T). Intrinsic (physical and psychological) and extrinsic parameters have been evaluated by a questionnaire, physical examination completed by an investigation in the venture. The Nottingham Health Profile was performed by all the individuals. All the cases of UNTS were observed after an increase of the production and a change in the work organization. Only 50% of the declared UNTS have a typical topography of the pain. No UNTS patient had neurological objective motor and sensitive deficit. 52% of the UNTS patients had diffused physical disorders comparatively to 17% of the T population. Stress events were observed more frequently in the UNTS population than in the T population: in the living area, in respectively 96% and 52% of the cases, at the work place in 12% and 2%. 50% of the UNTS population was distress comparatively to 17% of the T population. The NHP score was significantly higher in the UNTS population than the T population. These data confirm the mutual influences of individual factors, physical and psychological, and of workplace factors in the occurrence of painful disorders related to an occupational activity. The therapeutic approach of these patients must be done with a physical, psychological and social evaluation.

Nerve injuries do occur in elbow arthroscopy.

PubMed

Hilgersom, Nick F J; van Deurzen, Derek F P; Gerritsma, Carina L E; van der Heide, Huub J L; Malessy, Martijn J A; Eygendaal, Denise; van den Bekerom, Michel P J

2018-01-01

The purpose is to create more awareness as well as emphasize the risk of permanent nerve injury as a complication of elbow arthroscopy. Patients who underwent elbow arthroscopy complicated by permanent nerve injury were retrospectively collected. Patients were collected using two strategies: (1) by word-of-mouth throughout the Dutch Society of Shoulder and Elbow Surgery, and the Leiden University Nerve Centre, and (2) approaching two medical liability insurance companies. Medical records were reviewed to determine patient characteristics, disease history and postoperative course. Surgical records were reviewed to determine surgical details. A total of eight patients were collected, four men and four women, ageing 21-54 years. In five out of eight patients (62.5%), the ulnar nerve was affected; in the remaining three patients (37.5%), the radial nerve was involved. Possible causes for nerve injury varied among patients, such as portal placement and the use of motorized instruments. A case series on permanent nerve injury as a complication of elbow arthroscopy is presented. Reporting on this sequel in the literature is little, however, its risk is not to be underestimated. This study emphasizes that permanent nerve injury is a complication of elbow arthroscopy, concurrently increasing awareness and thereby possibly aiding to prevention. IV, case series.

Iatrogenic diaphragmatic lesion: laparoscopic repair.

PubMed

Celia, A; Del Biondo, D; Zaccolini, G; Breda, G

2010-09-01

The increasing use of laparoscopy as first line surgical choice turned the iatrogenic diaphragmatic injury during transperitoneal nephrectomy from an unfrequent complication into a potential risk. We report the laparoscopic management of a iatrogenic diaphragmatic injury during a laparoscopic transperitoneal nephrectomy in a 66-year-old woman with a xantogranulomatous pyelonephritis due to an infected Staghorn stone.

Diagnostic utility of F waves in clinically diagnosed patients of carpal tunnel syndrome.

PubMed

Joshi, Anand G; Gargate, Ashwini R

2013-01-01

Sensory nerve conduction velocity (SNCV) of median nerve measured across the carpal tunnel, difference between distal sensory latencies (DSLs) of median and ulnar nerves and difference between distal motor latencies (DMLs) of median and ulnar nerves are commonly used nerve conduction parameters for diagnosis of carpal tunnel syndrome (CTS). These are having high degree of sensitivity and specificity. Study of median nerve F-wave minimal latency (FWML) and difference between F-wave minimal latencies (FWMLs) of median and ulnar nerves have also been reported to be useful parameters for diagnosis of CTS. However, there is controversy regarding superiority of F-wave study for diagnosis of CTS. So the aim of present study was to compare sensitivity and specificity of median FWML and difference between FWMLs of median and ulnar nerves with that of above mentioned electrophysiological parameters and to find out which parameters are having more sensitivity and specificity, for early diagnosis of CTS. Median and ulnar nerves sensory and motor conduction, median and ulnar nerves F-wave studies were carried out bilaterally in 125 clinically diagnosed patients of carpal tunnel syndrome. These parameters were also studied in 45 age matched controls. Difference between DSLs of median and ulnar nerves, median SNCV and difference between DMLs of median and ulnar nerves were having highest sensitivity and specificity while median FWML and difference between FWMLs of median and ulnar nerves was having lowest sensitivity and specificity for diagnosis of CTS. So in conclusion F-wave study is not superior parameter for diagnosis of CTS.

Median and ulnar muscle and sensory evoked potentials.

PubMed

Felsenthal, G

1978-08-01

The medical literature was reviewed to find suggested clinical applications of the study of the amplitude of evoked muscle action potentials (MAP) and sensory action potentials (SAP). In addition, the literature was reviewed to ascertain the normal amplitude and duration of the evoked MAP and SAP as well as the factors affecting the amplitude: age, sex, temperature, ischemia. The present study determined the normal amplitude and duration of the median and ulnar MAP and SAP in fifty normal subjects. The amplitude of evoked muscle or sensory action potentials depends on multiple factors. Increased skin resistance, capacitance, and impedance at the surface of the recording electrode diminishes the amplitude. Similarly, increased distance from the source of the action potential diminishes its amplitude. Increased interelectrode distance increases the amplitude of the bipolarly recorded sensory action potential until a certain interelectrode distance is exceeded and the diphasic response becomes tri- or tetraphasic. Artifact or poor technique may reduce the potential difference between the recording electrodes or obscure the late positive phase of the action potential and thus diminish the peak to peak amplitude measurement. Intraindividual comparison indicated a marked difference of amplitude in opposite hands. The range of the MAP of the abductor pollicis brevis in one hand was 40.0--100% of the response in the opposite hand. For the abductor digiti minimi, the MAP was 58.5--100% of the response of the opposite hand. The median and ulnar SAP was between 50--100% of the opposite SAP. Consequent to these findings the effect of hand dominance on the amplitude of median and ulnar evoked muscle and sensory action potentials was studied in 41 right handed volunteers. The amplitudes of the median muscle action potential (p less than 0.02) and the median and ulnar sensory action potentials (p less than 0.001) were significantly less in the dominant hand. There was no

Nerve compression injuries due to traumatic false aneurysm.

PubMed Central

Robbs, J V; Naidoo, K S

1984-01-01

Experience with 17 patients with delayed onset of compression neuropraxia due to hemorrhage following nonoperative treatment of penetrating arterial injuries is presented. Fifteen cases involved the arteries of the neck shoulder girdle and upper extremity and two the gluteal vessels. This resulted in dysfunction of components of the brachial plexus, median ulnar, and sciatic nerves. Follow-up extended from 3 to 18 months. Of 10 brachial plexus lesions two recovered fully, five partially, and three not at all. Of seven peripheral nerve injuries, full recovery occurred in two patients and none in five. Adverse prognostic factors for neurological recovery are sepsis, involvement of intrinsic hand innervation and the sciatic nerve. An improved prognosis may be expected for upper trunk lesions of the brachial plexus and radial nerve lesions. The complication is essentially avoidable and a careful appraisal of the circulatory status must be made in all patients with penetrating trauma in the neck and shoulder girdle and buttock. PMID:6732331

A Comparison of Ulnar Shortening Osteotomy Alone Versus Combined Arthroscopic Triangular Fibrocartilage Complex Debridement and Ulnar Shortening Osteotomy for Ulnar Impaction Syndrome

PubMed Central

Song, Hyun Seok

2011-01-01

Background This study compared the results of patients treated for ulnar impaction syndrome using an ulnar shortening osteotomy (USO) alone with those treated with combined arthroscopic debridement and USO. Methods The results of 27 wrists were reviewed retrospectively. They were divided into three groups: group A (USO alone, 10 cases), group B (combined arthroscopic debridement and USO, 9 cases), and group C (arthroscopic triangular fibrocartilage complex [TFCC] debridement alone, 8 cases). The wrist function was evaluated using the modified Mayo wrist score, disabilities of the arm, shoulder and hand (DASH) score and Chun and Palmer grading system. Results The modified Mayo wrist score in groups A, B, and C was 74.5 ± 8.9, 73.9 ± 11.6, and 61.3 ± 10.2, respectively (p < 0.05). The DASH score in groups A, B, and C was 15.6 ± 11.8, 19.3 ± 11.9, and 33.2 ± 8.5, respectively (p < 0.05). The average Chun and Palmer grading score in groups A and B was 85.7 ± 8.9 and 84.7 ± 6.7, respectively. The difference in the Mayo wrist score, DASH score and Chun and Palmer grading score between group A and B was not significant (p > 0.05). Conclusions Both USO alone and combined arthroscopic TFCC debridement with USO improved the wrist function and reduced the level of pain in the patients treated for ulnar impaction syndrome. USO alone may be the preferred method of treatment in patients if the torn flap of TFCC is not unstable. PMID:21909465

Peripheral nerves are pathologically small in cerebellar ataxia neuropathy vestibular areflexia syndrome: a controlled ultrasound study.

PubMed

Pelosi, L; Mulroy, E; Leadbetter, R; Kilfoyle, D; Chancellor, A M; Mossman, S; Wing, L; Wu, T Y; Roxburgh, R H

2018-04-01

Sensory neuronopathy is a cardinal feature of cerebellar ataxia neuropathy vestibular areflexia syndrome (CANVAS). Having observed that two patients with CANVAS had small median and ulnar nerves on ultrasound, we set out to examine this finding systematically in a cohort of patients with CANVAS, and compare them with both healthy controls and a cohort of patients with axonal neuropathy. We have previously reported preliminary findings in seven of these patients with CANVAS and seven healthy controls. We compared the ultrasound cross-sectional area of median, ulnar, sural and tibial nerves of 14 patients with CANVAS with 14 healthy controls and 14 age- and gender-matched patients with acquired primarily axonal neuropathy. We also compared the individual nerve cross-sectional areas of patients with CANVAS and neuropathy with the reference values of our laboratory control population. The nerve cross-sectional area of patients with CANVAS was smaller than that of both the healthy controls and the neuropathy controls, with highly significant differences at most sites (P < 0.001). Conversely, the nerve cross-sectional areas in the upper limb were larger in neuropathy controls than healthy controls (P < 0.05). On individual analysis, the ultrasound abnormality was sufficiently characteristic to be detected in all but one patient with CANVAS. Small nerves in CANVAS probably reflect nerve thinning from loss of axons due to ganglion cell loss. This is distinct from the ultrasound findings in axonal neuropathy, in which nerve size was either normal or enlarged. Our findings indicate a diagnostic role for ultrasound in CANVAS sensory neuronopathy and in differentiating neuronopathy from neuropathy. © 2018 EAN.

Generalized mechanical pain sensitivity over nerve tissues in patients with strictly unilateral migraine.

PubMed

Fernández-de-las-Peñas, César; Arendt-Nielsen, Lars; Cuadrado, María Luz; Pareja, Juan A

2009-06-01

No study has previously analyzed pressure pain sensitivity of nerve trunks in migraine. This study aimed to examine the differences in mechanical pain sensitivity over specific nerves between patients with unilateral migraine and healthy controls. Blinded investigators assessed pressure pain thresholds (PPT) over the supra-orbital nerves (V1) and peripheral nerve trunks of both upper extremities (median, radial, and ulnar nerves) in 20 patients with strictly unilateral migraine and 20 healthy matched controls. Pain intensity after palpation over both supra-orbital nerves was also assessed. A pressure algometer was used to quantify PPT, whereas a 10-point numerical pain rate scale was used to evaluate pain to palpation over the supra-orbital nerve. The analysis of covariance revealed that pain to palpation over the supra-orbital nerve was significantly higher (P<0.001) on the symptomatic side (mean: 3.4, SD: 1.5) as compared with the nonsymptomatic side (mean: 0.5, SD: 1.2) in patients with migraine and both the dominant (mean: 0.2, SD: 0.4) and nondominant (mean: 0.3, SD: 0.5) sides in healthy controls. PPT assessed over the supra-orbital nerve on the symptomatic side (mean: 1.05, SD: 0.2 kg/cm) was significantly lower (P<0.05) than PPT measurements on the nonsymptomatic side (mean: 1.35, SD: 0.3 kg/cm) and either the dominant (mean: 1.9, SD: 0.2 kg/cm) or nondominant (mean: 1.9, SD: 0.3 kg/cm) sides in controls (P<0.001). Finally, PPT assessed over the median, ulnar, and radial nerves were significantly lower in patients with migraine as compared with controls (P<0.001), without side-to-side differences (P>0.6). In patients with unilateral migraine, we found increased mechano-sensitivity of the supra-orbital nerve on the symptomatic side of the head. Outside the head, the same patients showed increased mechano-sensitivity of the main peripheral nerves of both upper limbs, without asymmetries. Such diffuse hypersensitivity of the peripheral nerves lends further

[Tenotomy of carpal and digital flexor tendons for correction of congenital neuromyodysplasia in a calf].

PubMed

Sohrt, J T; Heppelmann, M; Rehage, J; Staszyk, C

2013-01-01

In a 7-day-old heifer calf, a bilateral flexural deformity of the forelimbs involving the digital flexor tendons, the suspensory ligament and the ulnar and radial carpal flexor tendons was diagnosed. After 2 weeks of conservative treatment consisting of manual stretching of the legs and the application of splints and wooden blocks, which were glued to the soles and extended beyond the tip of the claws, the right forelimb could be extended sufficiently to allow weight bearing, whereas the left forelimb could be passively extended to only approximately 120°. Therefore, tenotomy of the ulnar carpal flexor tendon, the digital flexor tendons and the suspensory ligament was carried out in the left leg. A support bandage was then applied to the leg for 8 weeks, after which the carpus and fetlock could be completely extended passively. Flexural deformity of the carpus caused by contracture of the carpal flexor tendons was treated by means of a tenotomy of the ulnar carpal flexor tendon proximal to the accessory carpal bone, which allowed preservation of the carpal tunnel and avoided the risk of iatrogenic damage to nerves and the carpal joint capsule.

Iatrogenic Urinary Tract Injuries: Etiology, Diagnosis, and Management

PubMed Central

Esparaz, Anthony M.; Pearl, Jeffrey A.; Herts, Brian R.; LeBlanc, Justin; Kapoor, Baljendra

2015-01-01

Iatrogenic injury to the urinary tract, including the kidneys, ureters, bladder, and urethra, is a potential complication of surgical procedures performed in or around the retroperitoneal abdominal space or pelvis. While both diagnostic and interventional radiologists often play a central and decisive role in the identification and initial management of a variety of iatrogenic injuries, discussions of these injuries are often directed toward specialists such as urologists, obstetricians, gynecologists, and general surgeons whose procedures are most often implicated in iatrogenic urinary tract injuries. Interventional radiologic procedures can also be a source of an iatrogenic urinary tract injury. This review describes the clinical presentation, risk factors, imaging findings, and management of iatrogenic renal vascular and urinary tract injuries, as well as the radiologist's role in the diagnosis, treatment, and cause of these injuries. PMID:26038626

Diffuse reflectance spectroscopy for optical nerve identification. Preliminary ex vivo results for feedback controlled oral and maxillofacial laser surgery

NASA Astrophysics Data System (ADS)

Stelzle, Florian; Zam, Azhar; Adler, Werner; Douplik, Alexandre; Tangermann-Gerk, Katja; Nkenke, Emeka; Neukam, Friedrich Wilhelm; Schmidt, Michael

Objective: Laser surgery has many advantages. However, due to a lack of haptic feedback it is accompanied by the risk of iatrogenic nerve damage. The aim of this study was to evaluate the possibilities of optical nerve identification by diffuse reflectance spectroscopy to set the base for a feedback control system to enhance nerve preservation in oral and maxillofacial laser surgery. Materials and Methods: Diffuse reflectance spectra of nerve tissue, skin, mucosa, fat tissue, muscle, cartilage and bone (15120 spectra) of ex vivo pig heads were acquired in the wavelength range of 350-650 nm. Tissue differentiation was performed by principal components analysis (PCA) followed by linear discriminant analysis (LDA). Specificity and sensitivity were calculated by receiver operating characteristic (ROC) analysis and the area under curve (AUC). Results: Nerve tissue could correctly be identified and differed from skin, mucosa, fat tissue, muscle, cartilage and bone in more than 90% of the cases (AUC results) with a specificity of over 78% and a sensitivity of more than 86%. Conclusion: Nerve tissue can be identified by diffuse reflectance spectroscopy with high precision and reliability. The results may set the base for a feedback system to prevent iatrogenic nerve damage performing oral and maxillofacial laser surgery.

Complete Spinal Accessory Nerve Palsy From Carrying Climbing Gear.

PubMed

Coulter, Jess M; Warme, Winston J

2015-09-01

We report an unusual case of spinal accessory nerve palsy sustained while transporting climbing gear. Spinal accessory nerve injury is commonly a result of iatrogenic surgical trauma during lymph node excision. This particular nerve is less frequently injured by blunt trauma. The case reported here results from compression of the spinal accessory nerve for a sustained period-that is, carrying a load over the shoulder using a single nylon rope for 2.5 hours. This highlights the importance of using proper load-carrying equipment to distribute weight over a greater surface area to avoid nerve compression in the posterior triangle of the neck. The signs and symptoms of spinal accessory nerve palsy and its etiology are discussed. This report is particularly relevant to individuals involved in mountaineering and rock climbing but can be extended to anyone carrying a load with a strap over one shoulder and across the body. Copyright © 2015 Wilderness Medical Society. Published by Elsevier Inc. All rights reserved.

The Sihler staining study of the infraorbital nerve and its clinical complication.

PubMed

Yang, Hun-Mu; Won, Sung-Yoon; Lee, Young-Il; Kim, Hee-Jin; Hu, Kyung-Seok

2014-11-01

The infraorbital nerve (ION) is a cardinal cutaneous nerve that provides general sensation to the mid face. Its twigs are vulnerable to iatrogenic damage during medical and dental manipulations. The aims of this study were to elucidate the distribution pattern of the ION and thus help to prevent nerve damage during medical procedures and to enable accurate prognostic evaluation where complications do occur. This was achieved by treating 7 human hemifaces with the Sihler modified staining protocol, which enables clear visualization of the course and distribution of nerves without the accidental displacement of these structures that can occur during classic dissection. The twigs of the ION can be classified into the usual 5 groups: inferior palpebral, innervating the lower eyelid in a fan-shaped area; external and internal nasal, reaching the nosewing and philtrum including the septal area between the nostrils, respectively; as well as medial and lateral superior labial, supplying the superior labial area from the midline to the mouth corner. Of particular note, the superior labial twigs fully innervated the infraorbital triangle formed by the infraorbital foramen, the most lateral point of the nosewing, and the mouth corner. In the superior 3-quarter area, the ION twigs made anastomoses with the buccal branches of the facial nerve, forming an infraorbital nervous plexus. The infraorbital triangle may be considered a dangerous zone with respect to the risk for iatrogenic complications associated with the various medical interventions such as implant placement.

Major Peripheral Nerve Injuries After Elbow Arthroscopy.

PubMed

Desai, Mihir J; Mithani, Suhail K; Lodha, Sameer J; Richard, Marc J; Leversedge, Fraser J; Ruch, David S

2016-06-01

To survey the American Society for Surgery of the Hand membership to determine the nature and distribution of nerve injuries treated after elbow arthroscopy. An online survey was sent to all members of the American Society for Surgery of the Hand under an institutional review board-approved protocol. Collected data included the number of nerve injuries observed over a 5-year period, the nature of treatment required for the injuries, and the outcomes observed after any intervention. Responses were anonymous, and results were securely compiled. We obtained 372 responses. A total of 222 nerve injuries were reported. The most injured nerves reported were ulnar, radial, and posterior interosseous (38%, 22%, and 19%, respectively). Nearly half of all patients with injuries required operative intervention, including nerve graft, tendon transfer, nerve repair, or nerve transfer. Of the patients who sustained major injuries, those requiring intervention, 77% had partial or no motor recovery. All minor injuries resolved completely. Our results suggest that major nerve injuries after elbow arthroscopy are not rare occurrences and the risk of these injuries is likely under-reported in the literature. Furthermore, patients should be counseled on this risk because most nerve injuries show only partial or no functional recovery. With the more widespread practice of elbow arthroscopy, understanding the nature and sequelae of significant complications is critically important in ensuring patient safety and improving outcomes. Copyright © 2016 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.

How does ulnar shortening osteotomy influence morphologic changes in the triangular fibrocartilage complex?

PubMed

Yamanaka, Yoshiaki; Nakamura, Toshiyasu; Sato, Kazuki; Toyama, Yoshiaki

2014-11-01

Ulnar shortening osteotomy often is indicated for treatment of injuries to the triangular fibrocartilage complex (TFCC). However, the effect of ulnar shortening osteotomy on the changes in shape of the TFCC is unclear. In our study, quantitative evaluations were performed using MRI to clarify the effect of ulnar shortening on triangular fibrocartilage (TFC) thickness attributable to disc regeneration of the TFC and TFC angle attributable to the suspension effect of ulnar shortening on the TFC. The purposes of this study were (1) to compare preoperative and postoperative TFC thickness and TFC angle on MR images to quantitatively evaluate the effect of ulnar shortening osteotomy on disc regeneration and the suspension effect on the TFC; and (2) to assess whether changes in TFC thickness and TFC angle correlated with the Mayo wrist score. Between 1995 and 2008, 256 patients underwent ulnar shortening osteotomy for TFCC injuries. The minimum followup was 24 months (mean, 51 months; range, 24-210 months). A total of 79 patients (31%) with complete followup including preoperative and postoperative MR images and the Mayo wrist score was included in this retrospective study. Evaluation of the postoperative MR images and the Mayo wrist score were performed at the final followup. The remaining 177 patients did not undergo postoperative MRI, or they had a previous fracture, large tears of the disc proper, or were lost to followup. Two orthopaedists, one of whom performed the surgeries, measured the TFC thickness and the TFC angle on coronal MR images before and after surgery for each patient. Correlations of the percent change in the TFC thickness and the magnitude of TFC angle change with age, sex, postoperative MR images, extent of ulnar shortening, preoperative ulnar variance, and postoperative Mayo wrist score were assessed. Stepwise regression analysis showed a correlation between the percent change in TFC thickness and preoperative ulnar variance (R2=0.21; β=-0.33; 95

Different nerve ultrasound patterns in charcot-marie-tooth types and hereditary neuropathy with liability to pressure palsies.

PubMed

Padua, Luca; Coraci, Daniele; Lucchetta, Marta; Paolasso, Ilaria; Pazzaglia, Costanza; Granata, Giuseppe; Cacciavillani, Mario; Luigetti, Marco; Manganelli, Fiore; Pisciotta, Chiara; Piscosquito, Giuseppe; Pareyson, Davide; Briani, Chiara

2018-01-01

Nerve ultrasound in Charcot-Marie-Tooth (CMT) disease has focused mostly on the upper limbs. We performed an evaluation of a large cohort of CMT patients in which we sonographically characterized nerve abnormalities in different disease types, ages, and nerves. Seventy patients affected by different CMT types and hereditary neuropathy with liability to pressure palsies (HNPP) were evaluated, assessing median, ulnar, fibular, tibial, and sural nerves bilaterally. Data were correlated with age. Nerve dimensions were correlated with CMT type, age, and nerve site. Nerves were larger in demyelinating than in axonal neuropathies. Nerve involvement was symmetric. CMT1 patients had larger nerves than did patients with other CMT types. Patients with HNPP showed enlargement at entrapment sites. Our study confirms the general symmetry of ultrasound nerve patterns in CMT. When compared with ultrasound studies of nerves of the upper limbs, evaluation of the lower limbs did not provide additional information. Muscle Nerve 57: E18-E23, 2018. © 2017 Wiley Periodicals, Inc.

Nerve stimulator-guided sciatic-femoral nerve block in raptors undergoing surgical treatment of pododermatitis.

PubMed

d'Ovidio, Dario; Noviello, Emilio; Adami, Chiara

2015-07-01

To describe the nerve stimulator-guided sciatic-femoral nerve block in raptors undergoing surgical treatment of pododermatitis. Prospective clinical trial. Five captive raptors (Falco peregrinus) aged 6.7 ± 1.3 years. Anaesthesia was induced and maintained with isoflurane in oxygen. The sciatic-femoral nerve block was performed with 2% lidocaine (0.05 mL kg(-1) per nerve) as the sole intra-operative analgesic treatment. Intraoperative physiological variables were recorded every 10 minutes from endotracheal intubation until the end of anaesthesia. Assessment of intraoperative nociception was based on changes in physiological variables above baseline values, while evaluation of postoperative pain relied on species-specific behavioural indicators. The sciatic-femoral nerve block was feasible in raptors and the motor responses following electrical stimulation of both nerves were consistent with those reported in mammalian species. During surgery no rescue analgesia was required. The anaesthesia plane was stable and cardiorespiratory variables did not increase significantly in response to surgical stimulation. Iatrogenic complications, namely nerve damage and local anaesthetic toxicity, did not occur. Recovery was smooth and uneventful. The duration (mean ± SD) of the analgesic effect provided by the nerve block was 130 ± 20 minutes. The sciatic-femoral nerve block as described in dogs and rabbits can be performed in raptors as well. Further clinical trials with a control groups are required to better investigate the analgesic efficacy and the safety of this technique in raptors. © 2014 Association of Veterinary Anaesthetists and the American College of Veterinary Anesthesia and Analgesia.

Extralaryngeal branching of the recurrent laryngeal nerve: a meta-analysis of 28,387 nerves.

PubMed

Henry, Brandon Michael; Vikse, Jens; Graves, Matthew J; Sanna, Silvia; Sanna, Beatrice; Tomaszewska, Iwona M; Tubbs, R Shane; Tomaszewski, Krzysztof A

2016-11-01

The recurrent laryngeal nerves (RLN) are branches of the vagus nerve that go on to innervate most of the intrinsic muscles of the larynx. Historically, the RLN has been considered to branch after it enters the larynx, but numerous studies have demonstrated that it often branches before. The wide variability of this extralaryngeal branching (ELB) has significant implications for the risk of iatrogenic injury. We aimed to assess the anatomical characteristics of ELB comprehensively. Articles on the ELB of the RLN were identified by a comprehensive database search. Relevant data were extracted and pooled into a meta-analysis of the prevalence of branching, branching pattern, distance of ELB point from the larynx, and presence of positive motor signals in anterior and posterior ELB branches. A total of 69 articles (n = 28,387 nerves) from both intraoperative and cadaveric modalities were included in the meta-analysis. The overall pooled prevalence of ELB was 60.0 % (95 % CI 52.0-67.7). Cadaveric and intraoperative subgroups differed with prevalence rates of 73.3 % (95 % CI 61.0-84.0) and 39.2 % (95 % CI 29.0-49.9), respectively. Cadavers most often presented with a ELB pattern of bifurcation, with a prevalence of 61.1 %, followed by no branching at 23.4 %. Branching of the RLN occurred most often at a distance of 1-2 cm (74.8 % of cases) prior to entering the larynx. A positive motor signal was most often noted in anterior RLN branches (99.9 %) but only in 1.5 % of posterior branches. The anatomy of the RLN is highly variable, and ELB is likely to have been underreported in intraoperative studies. Because of its high likelihood, the possibility of ELB needs to be assessed in patients to prevent iatrogenic injury and long-term postoperative complications.

Do Clinical Results and Return-to-Sport Rates After Ulnar Collateral Ligament Reconstruction Differ Based on Graft Choice and Surgical Technique?

PubMed Central

Erickson, Brandon J.; Cvetanovich, Gregory L.; Frank, Rachel M.; Bach, Bernard R.; Cohen, Mark S.; Bush-Joseph, Charles A.; Cole, Brian J.; Romeo, Anthony A.

2016-01-01

Background: Ulnar collateral ligament reconstruction (UCLR) has become a common procedure performed in overhead-throwing athletes of many athletic levels. Purpose/Hypothesis: The purpose of this study was to determine whether clinical outcomes and return-to-sport (RTS) rates differ among patients undergoing UCLR based on graft choice, surgical technique, athletic competition level, handedness, and treatment of the ulnar nerve. We hypothesized that no differences would exist in clinical outcomes or RTS rates between technique, graft choice, or other variables. Study Design: Cohort study; Level of evidence, 3. Methods: All patients who underwent UCLR from January 1, 2004 through December 31, 2014 at a single institution were identified. Charts were reviewed to determine patient age, sex, date of surgery, sport played, handedness, athletic level, surgical technique, graft type, and complications. Patients were contacted via telephone to obtain the RTS rate, Conway-Jobe score, Timmerman-Andrews score, and Kerlan-Jobe Orthopaedic Clinic (KJOC) Shoulder and Elbow score. Results: Eighty-five patients (mean age at surgery, 19.3 ± 4.7 years; 92% male; 78% right hand–dominant) underwent UCLR between 2004 and 2014 and were available for follow-up. Overall, 87% were baseball pitchers, 49.4% were college athletes, and 41.2% were high school athletes. No significant difference existed between the docking and double-docking techniques, graft choice, handedness, sex, activity level, and treatment of the ulnar nerve with regard to clinical outcomes, RTS, or subsequent surgeries (all P > .05). More complications were seen in the docking technique compared with the double-docking technique (P = .036). Hamstring autograft was used more commonly with the docking technique (P = .023) while allograft was used more commonly with the double-docking technique (P = .0006). Conclusion: Both the docking and double-docking techniques produce excellent clinical outcomes in patients undergoing

Do Clinical Results and Return-to-Sport Rates After Ulnar Collateral Ligament Reconstruction Differ Based on Graft Choice and Surgical Technique?

PubMed

Erickson, Brandon J; Cvetanovich, Gregory L; Frank, Rachel M; Bach, Bernard R; Cohen, Mark S; Bush-Joseph, Charles A; Cole, Brian J; Romeo, Anthony A

2016-11-01

Ulnar collateral ligament reconstruction (UCLR) has become a common procedure performed in overhead-throwing athletes of many athletic levels. The purpose of this study was to determine whether clinical outcomes and return-to-sport (RTS) rates differ among patients undergoing UCLR based on graft choice, surgical technique, athletic competition level, handedness, and treatment of the ulnar nerve. We hypothesized that no differences would exist in clinical outcomes or RTS rates between technique, graft choice, or other variables. Cohort study; Level of evidence, 3. All patients who underwent UCLR from January 1, 2004 through December 31, 2014 at a single institution were identified. Charts were reviewed to determine patient age, sex, date of surgery, sport played, handedness, athletic level, surgical technique, graft type, and complications. Patients were contacted via telephone to obtain the RTS rate, Conway-Jobe score, Timmerman-Andrews score, and Kerlan-Jobe Orthopaedic Clinic (KJOC) Shoulder and Elbow score. Eighty-five patients (mean age at surgery, 19.3 ± 4.7 years; 92% male; 78% right hand-dominant) underwent UCLR between 2004 and 2014 and were available for follow-up. Overall, 87% were baseball pitchers, 49.4% were college athletes, and 41.2% were high school athletes. No significant difference existed between the docking and double-docking techniques, graft choice, handedness, sex, activity level, and treatment of the ulnar nerve with regard to clinical outcomes, RTS, or subsequent surgeries (all P > .05). More complications were seen in the docking technique compared with the double-docking technique ( P = .036). Hamstring autograft was used more commonly with the docking technique ( P = .023) while allograft was used more commonly with the double-docking technique ( P = .0006). Both the docking and double-docking techniques produce excellent clinical outcomes in patients undergoing UCLR. No difference in outcome scores was seen between surgical technique

Iatrogenic Hepatopancreaticobiliary Injuries: A Review

PubMed Central

Vachhani, Prasanti G.; Copelan, Alexander; Remer, Erick M.; Kapoor, Baljendra

2015-01-01

Iatrogenic hepatopancreaticobiliary injuries occur after various types of surgical and nonsurgical procedures. Symptomatically, these injuries may lead to a variety of clinical presentations, including tachycardia and hypotension from hemobilia or hemorrhage. Iatrogenic injuries may be identified during the intervention, immediately afterwards, or have a delayed presentation. These injuries are categorized into nonvascular and vascular injuries. Nonvascular injuries include biliary injuries such as biliary leak or stricture, pancreatic injury, and the development of fluid collections such as abscesses. Vascular injuries include pseudoaneurysms, arteriovenous fistulas, dissection, and perforation. Imaging studies such as ultrasound, computed tomography, magnetic resonance imaging, and digital subtraction angiography are critical for proper diagnosis of these conditions. In this article, we describe the clinical and imaging presentations of these iatrogenic injuries and the armamentarium of minimally invasive procedures (percutaneous drainage catheter placement, balloon dilatation, stenting, and coil embolization) that are useful in their management. PMID:26038625

Ulnar hammer syndrome: a systematic review of the literature.

PubMed

Vartija, Larisa; Cheung, Kevin; Kaur, Manraj; Coroneos, Christopher James; Thoma, Achilleas

2013-11-01

Ulnar hammer syndrome is an uncommon form of arterial insufficiency. Many treatments have been described, and debate continues about the best option. The goal of this systematic review was to determine whether ulnar hammer syndrome has an occupational association, to identify the most reliable diagnostic test, and to determine the best treatment modality. A comprehensive literature search was conducted using the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, MEDLINE, CINAHL, and EMBASE. Data from articles meeting inclusion criteria were collected in duplicate. Methodological quality of studies was assessed using the Methodological Index for Nonrandomized Studies scale. Thirty studies were included in the systematic review. No randomized controlled trials were identified. There is low-quality evidence suggestive of an association between exposure to repetitive hand trauma and vibration and ulnar hammer syndrome. Various diagnostic investigations were used, but few were compared, making it difficult to determine the most reliable diagnostic test. Numerous nonoperative and operative treatments were reported. With nonoperative treatment, 12 percent had complete resolution and 70 percent had partial resolution of their symptoms. Of patients treated operatively, 42.5 percent had complete resolution and 42.5 percent had partial resolution of their symptoms. The heterogeneity in study design and outcome measures limits definitive conclusions about occupational association, best diagnostic test, and treatment for ulnar hammer syndrome. However, there is low-quality evidence that suggests that most patients with ulnar hammer syndrome will have partial relief of symptoms with nonoperative treatment, and operative treatment results in complete or partial resolution of symptoms in the majority of cases. Therapeutic, IV.

Nerve transfers for restoration of upper extremity motor function in a child with upper extremity motor deficits due to transverse myelitis: case report.

PubMed

Dorsi, Michael J; Belzberg, Allan J

2012-01-01

Transverse myelitis (TM) may result in permanent neurologic dysfunction. Nerve transfers have been developed to restore function after peripheral nerve injury. Here, we present a case report of a child with permanent right upper extremity weakness due to TM that underwent nerve transfers. The following procedures were performed: double fascicle transfer from median nerve and ulnar nerve to the brachialis and biceps branches of the musculocutaneous nerve, spinal accessory to suprascapular nerve, and medial cord to axillary nerve end-to-side neurorraphy. At 22 months, the patient demonstrated excellent recovery of elbow flexion with minimal improvement in shoulder abduction. We propose that the treatment of permanent deficits from TM represents a novel indication for nerve transfers in a subset of patients. Copyright © 2011 Wiley Periodicals, Inc.

The utility of ultrasound in the assessment of traumatic peripheral nerve lesions: report of 4 cases.

PubMed

Zeidenberg, Joshua; Burks, S Shelby; Jose, Jean; Subhawong, Ty K; Levi, Allan D

2015-09-01

Ultrasound technology continues to improve with better image resolution and availability. Its use in evaluating peripheral nerve lesions is increasing. The current review focuses on the utility of ultrasound in traumatic injuries. In this report, the authors present 4 illustrative cases in which high-resolution ultrasound dramatically enhanced the anatomical understanding and surgical planning of traumatic peripheral nerve lesions. Cases include a lacerating injury of the sciatic nerve at the popliteal fossa, a femoral nerve injury from a pseudoaneurysm, an ulnar nerve neuroma after attempted repair with a conduit, and, finally, a spinal accessory nerve injury after biopsy of a supraclavicular fossa lesion. Preoperative ultrasound images and intraoperative pictures are presented with a focus on how ultrasound aided with surgical decision making. These cases are set into context with a review of the literature on peripheral nerve ultrasound and a comparison between ultrasound and MRI modalities.

Case of fibrolipomatous hamartoma of the digital nerve without macrodactyly.

PubMed

Nanno, Mitsuhiko; Sawaizumi, Takuya; Takai, Shinro

2011-01-01

Fibrolipomatous hamartoma of nerves without macrodactyly is a rare lesion characterized by fibrofatty proliferation causing epineural and perineural fibrosis with fatty infiltration around the nerve bundles. We report an unusual case of fibromatous hamartoma of the ulnar digital nerve of the thumb in a 43-year-old woman. Magnetic resonance imaging revealed a large fusiform mass along the nerve. The findings were unusual and pathognomonic and included a coaxial cable-like appearance on axial sections and a spaghettilike appearance on coronal sections on both T1- and T2-weighted images; these findings were useful for the diagnosis and preoperative evaluation of this lesion. Surgical exploration revealed a yellow, cordlike mass of the digital nerve enlarged by fat. Gross excision could not be done without extensive damage to the nerve. Therefore, a limited excision with biopsy of the fibrolipomatous tissue around the nerve bundles was performed. The histological appearance was consistent with fibrolipomatous hamartoma. There was no recurrence of the mass and no neurological deficit 3 years after surgery. Some authors have suggested that invasive excision can cause catastrophic sensory or motor deficits because of the extensive fatty infiltration of the nerve fascicles. In conclusion, the recommended treatment for this lesion is limited excision with only biopsy to confirm the diagnosis.

Retropharyngeal Contralateral C7 Nerve Transfer to the Lower Trunk for Brachial Plexus Birth Injury: Technique and Results.

PubMed

Vu, Anthony T; Sparkman, Darlene M; van Belle, Christopher J; Yakuboff, Kevin P; Schwentker, Ann R

2018-05-01

Brachial plexus birth injuries with multiple nerve root avulsions present a particularly difficult reconstructive challenge because of the limited availability of donor nerves. The contralateral C7 has been described for brachial plexus reconstruction in adults but has not been well-studied in the pediatric population. We present our technique and results for retropharyngeal contralateral C7 nerve transfer to the lower trunk for brachial plexus birth injury. We performed a retrospective review. Any child aged less than 2 years was included. Charts were analyzed for patient demographic data, operative variables, functional outcomes, complications, and length of follow-up. We had a total of 5 patients. Average nerve graft length was 3 cm. All patients had return of hand sensation to the ulnar nerve distribution as evidenced by a pinch test, unprompted use of the recipient limb without mirror movement, and an Active Movement Scale (AMS) of at least 2/7 for finger and thumb flexion; one patient had an AMS of 7/7 for finger and thumb flexion. Only one patient had return of ulnar intrinsic hand function with an AMS of 3/7. Two patients had temporary triceps weakness in the donor limb and one had clinically insignificant temporary phrenic nerve paresis. No complications were related to the retropharyngeal nerve dissection in any patient. Average follow-up was 3.3 years. The retropharyngeal contralateral C7 nerve transfer is a safe way to supply extra axons to the severely injured arm in brachial plexus birth injuries with no permanent donor limb deficits. Early functional recovery in these patients, with regard to hand function and sensation, is promising. Therapeutic V. Copyright © 2018 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.

Distal Nerve Transfers: A Perspective on the Future of Reconstructive Microsurgery.

PubMed

Chuang, David Chwei-Chin

2018-05-16

 Nerve transfer can be broadly separated into two categories: proximal nerve graft and/or transfer and distal nerve transfer. The superiority of proximal nerve graft/transfer over distal nerve transfer strategy has been debated extensively, but which strategy is the best has not yet been defined. Each technique has its own advantages and disadvantages. However, proximal nerve graft/transfer is still the main reconstructive procedure based on the principle of "no diagnosis, then no treatment." Proximal nerve transfer can avoid iatrogenic injury where the lesion is still in continuity and neurolysis is the only procedure without further cutting the nerve.  Our clinical and experimental study show that proximal nerve grafts/transfers yield at least equal or better results compared to distal nerve transfers. Proximal nerve grafts/transfers remain the mainstay of my reconstructive strategy. Proximal nerve graft/transfer offers more accurate diagnosis and proper treatment to restore shoulder and elbow functions simultaneously. Distal nerve transfers can offer more efficient elbow flexion.  Combined, both strategies in primary nerve reconstruction are especially recommended when there is no healthy or not enough donor nerve available Distal nerve transfers should be considered as a complementary option for proximal nerve grafts/ transfers. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Ulnar Impaction Syndrome: A case series investigating the appropriate diagnosis, management, and post-operative considerations.

PubMed

Woitzik, Erin; deGraauw, Chris; Easter, Brock

2014-12-01

Ulnar sided wrist pain is a common site for upper extremity disability. Ulnar impaction syndrome results in a spectrum of triangular fibrocartilage complex (TFCC) injuries and associated lunate, triquetrum, and ligamentous damage. Patients commonly present with insidious ulnar sided wrist pain and clicking, and a history of trauma or repetitive axial loading and rotation. In this case series, three patients presented to a sports chiropractor for evaluation and were subsequently diagnosed with ulnar impaction syndrome. Treatment strategies consist of conservative management, arthroscopic debridement or repair, arthroscopic wafer procedure, or ulnar shortening osteotomy. For the athlete, intervention should be individualized and sport-specific, considering athletic priorities, healing potential, return to play, and long-term health concerns.

Neuromuscular ultrasound in patients with carpal tunnel syndrome and normal nerve conduction studies.

PubMed

Aseem, Fazila; Williams, Jessica W; Walker, Francis O; Cartwright, Michael S

2017-06-01

Nerve conduction studies (NCS) are sensitive for carpal tunnel syndrome (CTS), but a small proportion of patients with clinical CTS have normal NCS. This retrospective study was designed to assess the neuromuscular ultrasound findings in a group of CTS patients. The electronic medical record was reviewed by a neurologist to identify patients who had a diagnosis of CTS with normal NCS, including either mixed median-ulnar comparison or transcarpal sensory studies, and complete neuromuscular ultrasound evaluation for CTS. Fourteen individuals (22 wrists) met all criteria. A total of 92.3% had median nerve cross-sectional area enlargement at the wrist (mean 16.3 mm 2 ), 100% had increased wrist-to-forearm median nerve area ratio (mean 2.4), 82.4% had decreased median nerve echogenicity, 75.0% had decreased median nerve mobility, and 7.1% had increased median nerve vascularity. A large proportion of patients with clinical CTS but normal NCS have abnormal neuromuscular ultrasound findings. Muscle Nerve 55: 913-915, 2017. © 2016 Wiley Periodicals, Inc.

The Effect of Intra-articular Cocktail Versus Femoral Nerve Block for Patients Undergoing Hip Arthroscopy.

PubMed

Childs, Sean; Pyne, Sonia; Nandra, Kiritpaul; Bakhsh, Wajeeh; Mustafa, S Atif; Giordano, Brian D

2017-12-01

To compare clinical efficacy and complication rate as measured by postoperative falls and development of peripheral neuritis between intra-articular blockade and femoral nerve block in patients undergoing arthroscopic hip surgery. An institutional review board approved retrospective review was conducted on a consecutive series of patients who underwent elective arthroscopic hip surgery by a single surgeon, between November 2013 and April 2015. Subjects were stratified into 2 groups: patients who received a preoperative femoral nerve block for perioperative pain control, and patients who received an intra-articular "cocktail" injection postoperatively. Demographic data, perioperative pain scores, narcotic consumption, incidence of falls, and iatrogenic peripheral neuritis were collected for analysis. Postoperative data were then collected at routine clinical visits. A total of 193 patients were included in this study (65 males, 125 females). Of them, 105 patients received preoperative femoral nerve blocks and 88 patients received an intraoperative intra-articular "cocktail." There were no significant differences in patient demographics, history of chronic pain (P = .35), worker's compensation (P = .24), preoperative pain scores (P = .69), or intraoperative doses of narcotics (P = .40). Patients who received preoperative femoral nerve blocks reported decreased pain during their time in PACU (P = .0001) and on hospital discharge (P = .28); however, there were no statistically significant differences in patient-reported pain scores at postoperative weeks 1 (P = .34), 3 (P = .64), and 6 (P = .70). Administration of an intra-articular block was associated with a significant reduction in the rate of postoperative falls (P = .009) and iatrogenic peripheral neuritis (P = .0001). Preoperative femoral nerve blocks are associated with decreased immediate postoperative pain, whereas intraoperative intra-articular anesthetic injections provide effective postoperative

Salvage of cervical motor radiculopathy using peripheral nerve transfer reconstruction.

PubMed

Afshari, Fardad T; Hossain, Taushaba; Miller, Caroline; Power, Dominic M

2018-05-10

Motor nerve transfer surgery involves re-innervation of important distal muscles using either an expendable motor branch or a fascicle from an adjacent functioning nerve. This technique is established as part of the reconstructive algorithm for traumatic brachial plexus injuries. The reproducible outcomes of motor nerve transfer surgery have resulted in exploration of the application of this technique to other paralysing conditions. The objective of this study is to report feasibility and increase awareness about nerve transfer as a method of improving upper limb function in patients with cervical motor radiculopathy of different aetiology. In this case series we report 3 cases with different modes of injury to the spinal nerve roots with significant and residual motor radiculopathy that have been successfully treated with nerve transfer surgery with good functional outcomes. The cases involved iatrogenic nerve root injury, tumour related root compression and degenerative root compression. Nerve transfer surgery may offer reliable reconstruction for paralysis when there has been no recovery following a period of conservative management. However the optimum timing of nerve transfer intervention is not yet identified for patients with motor radiculopathy.

Ulnar Rotation Osteotomy for Congenital Radial Head Dislocation.

PubMed

Liu, Ruiyu; Miao, Wusheng; Mu, Mingchao; Wu, Ge; Qu, Jining; Wu, Yongtao

2015-09-01

To evaluate an ulnar rotation osteotomy for congenital anterior dislocation of the radial head. Nine patients (5 boys and 4 girls aged 6 to 13 years) with congenital anterior dislocation of the radial head were treated with ulnar rotation osteotomy. Magnetic resonance imaging of the elbow showed the proximal radioulnar joint on the anterior-lateral side of the ulna rather than on the lateral side in patients with congenital anterior dislocation of the radial head. On the basis of this finding, we performed an osteotomy on the ulna and laterally rotated the proximal radioulnar joint achieving radial head reduction and restoring the anatomical relationship between the radial head and the capitellum. Clinical and radiographical evaluation of the elbow was performed before surgery and at postoperative follow-up. All patients were followed for 13 to 45 months after surgery. Elbow radiography showed that the radiocapitellar joint was reduced in all patients at the last follow-up visit and that the carrying angle was decreased relative to that in the preoperative condition. Elbow stability and the range of elbow flexion motion were improved at the last follow-up. We did not observe ulnar osteotomy site nonunion or elbow osteoarthritis in these patients. Furthermore, radial head dislocation did not recur. At early follow-up, ulnar rotation osteotomy was a safe and effective method for the treatment of congenital anterior dislocation of the radial head. Therapeutic IV. Copyright © 2015 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.

Disability following combat-sustained nerve injury of the upper limb.

PubMed

Rivera, J C; Glebus, G P; Cho, M S

2014-02-01

Injuries to the limb are the most frequent cause of permanent disability following combat wounds. We reviewed the medical records of 450 soldiers to determine the type of upper limb nerve injuries sustained, the rate of remaining motor and sensory deficits at final follow-up, and the type of Army disability ratings granted. Of 189 soldiers with an injury of the upper limb, 70 had nerve-related trauma. There were 62 men and eight women with a mean age of 25 years (18 to 49). Disabilities due to nerve injuries were associated with loss of function, neuropathic pain or both. The mean nerve-related disability was 26% (0% to 70%), accounting for over one-half of this cohort's cumulative disability. Patients injured in an explosion had higher disability ratings than those injured by gunshot. The ulnar nerve was most commonly injured, but most disability was associated with radial nerve trauma. In terms of the final outcome, at military discharge 59 subjects (84%) experienced persistent weakness, 48 (69%) had a persistent sensory deficit and 17 (24%) experienced chronic pain from scar-related or neuropathic pain. Nerve injury was the cause of frequent and substantial disability in our cohort of wounded soldiers.

In vivo axial humero-ulnar rotation in normal and dysplastic canine elbow joints.

PubMed

Rohwedder, Thomas; Fischer, Martin; Böttcher, Peter

2018-04-01

To prospectively compare relative axial (internal-external) humero-ulnar rotation in normal and dysplastic canine elbow joints. Six normal elbows (five dogs) and seven joints (six dogs) with coronoid disease were examined. After implantation of 0.8 mm tantalum beads into humerus and ulna, biplanar x-ray movies of the implanted elbows were taken while dogs were walking on a treadmill. Based on the 2D bead coordinates of the synchronized x-ray movies virtual 3D humero-ulnar animations were calculated. Based on these, relative internal-external humero-ulnar rotation was measured over the first third of stance phase and expressed as maximal rotational amplitude. Amplitudes from three consecutive steps were averaged and groupwise compared using an unpaired t-test. In normal elbow joints mean axial relative humero-ulnar rotation was 2.9° (SD 1.1). Dysplastic joints showed a significantly greater rotational amplitude (5.3°, SD 2.0; p = 0.0229, 95% confidence interval 0.4-4.4). Dysplastic elbow joints show greater relative internal-external humero-ulnar rotation compared to normal elbows, which might reflect rotational joint instability. Increased relative internal-external humero-ulnar rotation might alter physiological joint contact and pressure patterns. Future studies are needed to verify if this plays a role in the pathogenesis of medial coronoid disease. Schattauer GmbH.

Risk factors for revision surgery following isolated ulnar nerve release at the cubital tunnel: a study of 25,977 cases.

PubMed

Camp, Christopher L; Ryan, Claire B; Degen, Ryan M; Dines, Joshua S; Altchek, David W; Werner, Brian C

2017-04-01

The literature investigating risk factors for failure after decompression of the ulnar nerve at the elbow (cubital tunnel release [CuTR]) is limited. The purpose of this study was to identify risk factors for failure of isolated CuTR, defined as progression to subsequent ipsilateral revision surgery. The 100% Medicare Standard Analytic Files from 2005 to 2012 were queried for patients undergoing CuTR. Patients undergoing any concomitant procedures were excluded. A multivariate binomial logistic regression analysis was used to evaluate patient-related risk factors for ipsilateral revision surgery. Adjusted odds ratios (ORs) and 95% confidence intervals were calculated for each risk factor. A total of 25,977 patients underwent primary CuTR, and 304 (1.4%) of those with ≥2 years of follow-up required revision surgery. Although the rate of primary procedures is on the rise (P = .002), the revision rate remains steady (P = .148). Significant, independent risk factors for revision surgery included age <65 years (OR, 1.5; P < .001), obesity (OR, 1.3; P = .022), morbid obesity (OR, 1.3; P = .044), tobacco use (OR, 2.0; P < .001), diabetes (OR, 1.3; P = .011), hyperlipidemia (OR, 1.2; P = .015), chronic liver disease (OR, 1.6; P = .001), chronic anemia (OR, 1.6; P = .001), and hypercoagulable disorder (OR, 2.1; P = .001). The incidence of failure requiring ipsilateral revision surgery after CuTR remained steadily low (1.4%) during the study period. There are numerous patient-related risk factors that are independently associated with an increased risk for revision surgery, the most significant of which are tobacco use, younger age, hypercoagulable disorder, liver disease, and anemia. Copyright © 2017 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.

Coexistence of Nerve Enlargement and Neuratrophy Detected by Ultrasonography in Leprosy Patients.

PubMed

Chen, Xiaohua; Zhang, Liangfu; Huang, Meiying; Zhai, Xiuli; Wen, Yan; Pan, Chunzhi

2018-05-17

The purpose of this study was to evaluate peripheral neural impairment in leprosy patients by ultrasonography (US). The cross-sectional areas (CSAs) of the median (M), ulnar (U) and common fibular (CF) nerves were compared in 71 leprosy patients and 29 healthy controls, and the data were analyzed between the leprosy, multibacillary (MB)/paucibacillary (PB), reaction (R)/no reaction (NR), disability (D)/no disability (ND), and longer/shorter duration groups after treatment. We found that for the nerves located in upper limbs, the CSAs were significantly increased in the leprosy patients vs the controls; the PB group vs the MB group; the R group vs the NR group; the ND group vs the D group; and the longer duration group vs the shorter duration group at some positions of the M nerve and U nerve. In contrast, for the nerves located in lower limbs, the CSAs were significantly reduced in the leprosy patients vs the controls and in the longer duration group vs the shorter duration group at some positions of the CF nerve. This result indicated that nerve enlargement and neuratrophy coexist in leprosy patients.

Influence of recreational activity and muscle strength on ulnar bending stiffness in men

NASA Technical Reports Server (NTRS)

Myburgh, K. H.; Charette, S.; Zhou, L.; Steele, C. R.; Arnaud, S.; Marcus, R.

1993-01-01

Bone bending stiffness (modulus of elasticity [E] x moment of inertia [I]), a measure of bone strength, is related to its mineral content (BMC) and geometry and may be influenced by exercise. We evaluated the relationship of habitual recreational exercise and muscle strength to ulnar EI, width, and BMC in 51 healthy men, 28-61 yr of age. BMC and width were measured by single photon absorptiometry and EI by mechanical resistance tissue analysis. Maximum biceps strength was determined dynamically (1-RM) and grip strength isometrically. Subjects were classified as sedentary (S) (N = 13), moderately (M) (N = 18), or highly active (H) (N = 20) and exercised 0.2 +/- 0.2; 2.2 +/- 1.3; and 6.8 +/- 2.3 h.wk-1 (P < 0.001). H had greater biceps (P < 0.0005) and grip strength (P < 0.05), ulnar BMC (P < 0.05), and ulnar EI (P = 0.01) than M or S, who were similar. Amount of activity correlated with grip and biceps strength (r = 0.47 and 0.49; P < 0.001), but not with bone measurements, whereas muscle strength correlated with both EI and BMC (r = 0.40-0.52, P < 0.005). EI also correlated significantly with both BMC and ulnar width (P < 0.0001). Ulnar width and biceps strength were the only independent predictors of EI (r2 = 0.67, P < 0.0001). We conclude that levels of physical activity sufficient to increase arm strength influence ulnar bending stiffness.

A novel variation of the recurrent laryngeal nerve.

PubMed

Wu, Gaosong; Wang, Kun

2017-06-02

Injury to the recurrent laryngeal nerve is one of the most severe complications of thyroid surgery. Several anatomic variations of the nerve increase the likelihood of iatrogenic damage. A 50-year-old woman was presented to our department with a nodule in the right thyroid lobe, and she reported no voice changes. She had no history of surgery or radiation to the head or neck. Fine-needle aspiration was recorded as papillary thyroid carcinoma. The preoperative laryngoscopy revealed left vocal cord paralysis. Right thyroid lobectomy was performed. A scarce course of the left recurrent laryngeal nerve was found during the operation that ascended along the medial edge of the superior thyroid pole and finally disappeared beneath the superior cornu of the thyroid cartilage without any tracheal, esophageal, or laryngeal branches. The patient was discharged on the third postoperative day with the diagnoses of papillary thyroid carcinoma and congenital left vocal cord paralysis. The novel variation of the recurrent laryngeal nerve may challenge the current concept of the anatomy of the nerve. The vocal folds mobility should be examined routinely before surgery in patients undergoing thyroid operation.

A Fully Implanted Drug Delivery System for Peripheral Nerve Blocks in Behaving Animals

PubMed Central

Pohlmeyer, Eric A.; Jordon, Luke R.; Kim, Peter; Miller, Lee E.

2009-01-01

Inhibiting peripheral nerve function can be useful for many studies of the nervous system or motor control. Accomplishing this in a temporary fashion in animal models by using peripheral nerve blocks permits studies of the immediate effects of the loss, and/or any resulting short-term changes and adaptations in behavior or motor control, while avoiding the complications commonly associated with permanent lesions, such as sores or self-mutilation. We have developed a method of quickly and repeatedly inducing temporary, controlled motor deficits in rhesus macaque monkeys via a chronically implanted drug delivery system. This assembly consists of a nerve cuff and a subdermal injection dome, and has proved effective for delivering local anesthetics directly to peripheral nerves for many months. Using this assembly for median and ulnar nerve blocks routinely resulted in over 80% losses in hand and wrist strength for rhesus monkeys. The assembly was also effective for inducing ambulatory motor deficits in rabbits through blocks of the sciatic nerve. Interestingly, while standard anesthetics were sufficient for the rabbit nerve blocks, the inclusion of epinephrine was essential for achieving significant motor blockade in the monkeys. PMID:19524613

Medial ulnar collateral ligament reconstruction of the elbow in major league baseball players: Where do we stand?

PubMed Central

Erickson, Brandon J; Bach Jr, Bernard R; Bush-Joseph, Charles A; Verma, Nikhil N; Romeo, Anthony A

2016-01-01

The ulnar collateral ligament (UCL) is a vital structure to the overhead athlete, especially the baseball pitcher. For reasons not completely understood, UCL injuries have become increasingly more common in major league baseball (MLB) pitchers over the past 10 years. UCL reconstruction (UCLR) is the current gold standard of treatment for these injuries in MLB pitchers who wish to return to sport (RTS) at a high level and who have failed a course of non-operative treatment. Results following UCLR in MLB pitchers have been encouraging, with multiple RTS rates now cited at greater than 80%. Unfortunately, with the rising number of UCLR, there has also been a spike in the number of revision UCLR in MLB pitchers. Similar to primary UCLR, the etiology of the increase in revision UCLR, aside from an increase in the number of pitchers who have undergone a primary UCLR, remains elusive. The current literature has attempted to address several questions including those surrounding surgical technique (method of exposure, graft choice, management of the ulnar nerve, concomitant elbow arthroscopy, etc.), post-operative rehabilitation strategies, and timing of RTS following UCLR. While some questions have been answered, many remain unknown. The literature surrounding UCLR in MLB pitchers will be reviewed, and future directions regarding this injury in these high level athletes will be discussed. PMID:27335810

Differential involvement of forearm muscles in ALS does not relate to sonographic structural nerve alterations.

PubMed

Schreiber, Stefanie; Schreiber, Frank; Debska-Vielhaber, Grazyna; Garz, Cornelia; Hensiek, Nathalie; Machts, Judith; Abdulla, Susanne; Dengler, Reinhard; Petri, Susanne; Nestor, Peter J; Vielhaber, Stefan

2018-07-01

We aimed to assess whether differential peripheral nerve involvement parallels dissociated forearm muscle weakness in amyotrophic lateral sclerosis (ALS). The analysis comprised 41 ALS patients and 18 age-, sex-, height- and weight-matched healthy controls. Strength of finger-extension and -flexion was measured using the Medical Research Council (MRC) scale. Radial, median and ulnar nerve sonographic cross-sectional area (CSA) and echogenicity, expressed by the hypoechoic fraction (HF), were determined. In ALS, finger extensors were significantly weaker than finger flexors. Sonographic evaluation revealed peripheral nerve atrophy, affecting various nerve segments in ALS. HF was unaltered. This systematic study confirmed a long-observed physical examination finding in ALS - weakness in finger-extension out of proportion to finger-flexion. This phenomenon was not related to any particular sonographic pattern of upper limb peripheral nerve alteration. In ALS, dissociated forearm muscle weakness could aid in the disease's diagnosis. Nerve ultrasound did not provide additional information on the differential involvement of finger-extension and finger-flexion strength. Copyright © 2018 International Federation of Clinical Neurophysiology. Published by Elsevier B.V. All rights reserved.

The course of the superficial peroneal nerve in relation to the ankle position: anatomical study with ankle arthroscopic implications

PubMed Central

Golanó, Pau; Sierevelt, Inger N.; van Dijk, C. Niek

2010-01-01

Despite the fact that the superficial peroneal nerve is the only nerve in the human body that can be made visible; iatrogenic damage to this nerve is the most frequently reported complication in anterior ankle arthroscopy. One of the methods to visualize the nerve is combined ankle plantar flexion and inversion. In the majority of cases, the superficial peroneal nerve can be made visible. The portals for anterior ankle arthroscopy are however created with the ankle in the neutral or slightly dorsiflexed position and not in combined plantar flexion and inversion. The purpose of this study was to undertake an anatomical study to the course of the superficial peroneal nerve in different positions of the foot and ankle. We hypothesize that the anatomical localization of the superficial peroneal nerve changes with different foot and ankle positions. In ten fresh frozen ankle specimens, a window, only affecting the skin, was made at the level of the anterolateral portal for anterior ankle arthroscopy in order to directly visualize the superficial peroneal nerve, or if divided, its terminal branches. Nerve movement was assessed from combined 10° plantar flexion and inversion to 5° dorsiflexion, standardized by the Telos stress device. Also for the 4th toe flexion, flexion of all the toes and for skin tensioning possible nerve movement was determined. The mean superficial peroneal nerve movement was 2.4 mm to the lateral side when the ankle was moved from 10° plantar flexion and inversion to the neutral ankle position and 3.6 mm to the lateral side from 10° plantar flexion and inversion to 5° dorsiflexion. Both displacements were significant (P < 0.01). The nerve consistently moves lateral when the ankle is manoeuvred from combined plantar flexion and inversion to the neutral or dorsiflexed position. If visible, it is therefore advised to create the anterolateral portal medial from the preoperative marking, in order to prevent iatrogenic damage to the superficial

Myelinated sensory and alpha motor axon regeneration in peripheral nerve neuromas

NASA Technical Reports Server (NTRS)

Macias, M. Y.; Lehman, C. T.; Sanger, J. R.; Riley, D. A.

1998-01-01

Histochemical staining for carbonic anhydrase and cholinesterase (CE) activities was used to analyze sensory and motor axon regeneration, respectively, during neuroma formation in transected and tube-encapsulated peripheral nerves. Median-ulnar and sciatic nerves in the rodent model permitted testing whether a 4 cm greater distance of the motor neuron soma from axotomy site or intrinsic differences between motor and sensory neurons influenced regeneration and neuroma formation 10, 30, and 90 days later. Ventral root radiculotomy confirmed that CE-stained axons were 97% alpha motor axons. Distance significantly delayed axon regeneration. When distance was negligible, sensory axons grew out sooner than motor axons, but motor axons regenerated to a greater quantity. These results indicate regeneration differences between axon subtypes and suggest more extensive branching of motor axons within the neuroma. Thus, both distance from injury site to soma and inherent motor and sensory differences should be considered in peripheral nerve repair strategies.

Delayed presentation of traumatic facial nerve (CN VII) paralysis.

PubMed

Napoli, Anthony M; Panagos, Peter

2005-11-01

Facial nerve paralysis (Cranial Nerve VII, CN VII) can be a disfiguring disorder with profound impact upon the patient. The etiology of facial nerve paralysis may be congenital, iatrogenic, or result from neoplasm, infection, trauma, or toxic exposure. In the emergency department, the most common cause of unilateral facial paralysis is Bell's palsy, also known as idiopathic facial paralysis (IFP). We report a case of delayed presentation of unilateral facial nerve paralysis 3 days after sustaining a traumatic head injury. Re-evaluation and imaging of this patient revealed a full facial paralysis and temporal bone fracture extending into the facial canal. Because cranial nerve injuries occur in approximately 5-10% of head-injured patients, a good history and physical examination is important to differentiate IFP from another etiology. Newer generation high-resolution computed tomography (CT) scans are commonly demonstrating these fractures. An understanding of this complication, appropriate patient follow-up, and early involvement of the Otolaryngologist is important in management of these patients. The mechanism as well as the timing of facial nerve paralysis will determine the proper evaluation, consultation, and management for the patient. Patients with total or immediate paralysis as well as those with poorly prognostic audiogram results are good candidates for surgical repair.

Surgical Anatomy of the Cervical Part of the Hypoglossal Nerve.

PubMed

Kariuki, Brian Ngure; Butt, Fawzia; Mandela, Pamela; Odula, Paul

2018-03-01

Iatrogenic injuries to cranial nerves, half of which affect the hypoglossal nerve, occur in up to 20% of surgical procedures involving the neck. The risk of injury could be minimized by in-depth knowledge of its positional and relational anatomy. Forty-one hypoglossal nerves were dissected from cadaveric specimens and positions described in relation to the internal carotid artery (ICA), external carotid artery (ECA), carotid bifurcation, mandible, hyoid bone, mastoid process, and the digastric tendon. The distance of the nerve from where it crossed the ICA and ECA to the carotid bifurcation was 29.93 (±5.99) mm and 15.19 (±6.68) mm, respectively. The point where it crossed the ICA was 12.24 (±3.71) mm superior to the greater horn of hyoid, 17.16 (±4.40) mm inferior to the angle of the mandible, and 39.08 (±5.69) mm from tip of the mastoid. The hypoglossal nerve loop was inferior to the digastric tendon in 73% of the cases. The hypoglossal nerves formed high loops in this study population. Caution should be exercised during surgical procedures in the neck. The study also revealed that the mastoid process is a reliable fixed landmark to locate the hypoglossal nerve.

High-Frequency Transcutaneous Peripheral Nerve Stimulation Induces a Higher Increase of Heat Pain Threshold in the Cutaneous Area of the Stimulated Nerve When Confronted to the Neighbouring Areas

PubMed Central

Buonocore, M.; Camuzzini, N.; Cecini, M.; Dalla Toffola, E.

2013-01-01

Background. TENS (transcutaneous electrical nerve stimulation) is probably the most diffused physical therapy used for antalgic purposes. Although it continues to be used by trial and error, correct targeting of paresthesias evoked by the electrical stimulation on the painful area is diffusely considered very important for pain relief. Aim. To investigate if TENS antalgic effect is higher in the cutaneous area of the stimulated nerve when confronted to neighbouring areas. Methods. 10 volunteers (4 males, 6 females) underwent three different sessions: in two, heat pain thresholds (HPTs) were measured on the dorsal hand skin before, during and after electrical stimulation (100 Hz, 0.1 msec) of superficial radial nerve; in the third session HPTs, were measured without any stimulation. Results. Radial nerve stimulation induced an increase of HPT significantly higher in its cutaneous territory when confronted to the neighbouring ulnar nerve territory, and antalgic effect persisted beyond the stimulation time. Conclusions. The location of TENS electrodes is crucial for obtaining the strongest pain relief, and peripheral nerve trunk stimulation is advised whenever possible. Moreover, the present study indicates that continuous stimulation could be unnecessary, suggesting a strategy for avoiding the well-known tolerance-like effect of prolonged TENS application. PMID:24027756

Comparative responsiveness and minimal clinically important differences for idiopathic ulnar impaction syndrome.

PubMed

Kim, Jae Kwang; Park, Eun Soo

2013-05-01

Patient-reported questionnaires have been widely used to predict symptom severity and functional disability in musculoskeletal disease. Importantly, questionnaires can detect clinical changes in patients; however, this impact has not been determined for ulnar impaction syndrome. We asked (1) which of Patient-Rated Wrist Evaluation (PRWE), DASH, and other physical measures was more responsive to clinical improvements, and (2) what was the minimal clinically important difference for the PRWE and DASH after ulnar shortening osteotomy for idiopathic ulnar impaction syndrome. All patients who underwent ulnar shortening osteotomy between March 2008 and February 2011 for idiopathic ulnar impaction syndrome were enrolled in this study. All patients completed the PRWE and DASH questionnaires, and all were evaluated for grip strength and wrist ROM, preoperatively and 12 months postoperatively. We compared the effect sizes observed by each of these instruments. Effect size is calculated by dividing the mean change in a score of each instrument during a specified interval by the standard deviation of the baseline score. In addition, patient-perceived overall improvement was used as the anchor to determine the minimal clinically important differences on the PRWE and DASH 12 months after surgery. The average score of each item except for wrist flexion and supination improved after surgery. The PRWE was more sensitive than the DASH or than physical measurements in detecting clinical changes. The effect sizes and standardized response means of the outcome measures were as follows: PRWE (1.51, 1.64), DASH (1.12, 1.24), grip strength (0.59, 0.68), wrist pronation (0.33, 0.41), and wrist extension (0.28, 0.36). Patient-perceived overall improvement and score changes of the PRWE and DASH correlated significantly. Minimal clinically important differences were 17 points (of a possible 100) for the PRWE and 13.5 for the DASH (also of 100), and minimal detectable changes were 7.7 points

Iatrogenic orthodontic dental trauma: a case report.

PubMed

Gencay, Koray; Tuna, Elif Bahar; Yaman, Duygu; Ozgen, Mehmet; Demirel, Korkud

2013-01-01

Iatrogenic trauma can be defined as any adverse condition in a patient resulting from treatment by a physician or dentist. Orthodontic treatment carries with it the risks of tissue damage and treatment failure. The aim of this article is to present traumatic oral tissue lesions resulting from iatrogenic orthodontic origin with a 2-year follow-up period based on orthodontic intervention followed by periodontal surgery. The management of traumatic injuries is dependent on the severity of the involvement of the periodontal tissues. While, in most cases, the elimination of the offending agent and symptomatic therapy is sufficient, in severe cases, or when the injury resulted in permanent defects, periodontal/regenerative therapy may be necessary. The dentist must be aware of these risks in order to help the patient make a fully informed choice whether to proceed with orthodontic treatment. The skill, experience, and up-to-date knowledge of dentists are the main factors to prevent possible iatrogenic traumas.

Improved Facial Nerve Identification During Parotidectomy With Fluorescently Labeled Peptide

PubMed Central

Hussain, Timon; Nguyen, Linda T.; Whitney, Michael; Hasselmann, Jonathan; Nguyen, Quyen T.

2016-01-01

Objectives/Hypothesis Additional intraoperative guidance could reduce the risk of iatrogenic injury during parotid gland cancer surgery. We evaluated the intraoperative use of fluorescently labeled nerve binding peptide NP41 to aid facial nerve identification and preservation during parotidectomy in an orthotopic model of murine parotid gland cancer. We also quantified the accuracy of intraoperative nerve detection for surface and buried nerves in the head and neck with NP41 versus white light (WL) alone. Study Design Twenty-eight mice underwent parotid gland cancer surgeries with additional fluorescence (FL) guidance versus WL reflectance (WLR) alone. Eight mice were used for additional nerve-imaging experiments. Methods Twenty-eight parotid tumor-bearing mice underwent parotidectomy. Eight mice underwent imaging of both sides of the face after skin removal. Postoperative assessment of facial nerve function measured by automated whisker tracking were compared between FL guidance (n = 13) versus WL alone (n = 15). In eight mice, nerve to surrounding tissue contrast was measured under FL versus WLR for all nerve branches detectable in the field of view. Results Postoperative facial nerve function after parotid gland cancer surgery tended to be better with additional FL guidance. Fluorescent labeling significantly improved nerve to surrounding tissue contrast for both large and smaller buried nerve branches compared to WLR visualization and improved detection sensitivity and specificity. Conclusions NP41 FL imaging significantly aids the intraoperative identification of nerve braches otherwise nearly invisible to the naked eye. Its application in a murine model of parotid gland cancer surgery tended to improve functional preservation of the facial nerve. PMID:27171862

The Non-Recurrent Laryngeal Nerve: a meta-analysis and clinical considerations

PubMed Central

Sanna, Silvia; Graves, Matthew J.; Vikse, Jens; Sanna, Beatrice; Tomaszewska, Iwona M.; Tubbs, R. Shane; Walocha, Jerzy A.; Tomaszewski, Krzysztof A.

2017-01-01

Background The Non-Recurrent Laryngeal Nerve (NRLN) is a rare embryologically-derived variant of the Recurrent Laryngeal Nerve (RLN). The presence of an NRLN significantly increases the risk of iatrogenic injury and operative complications. Our aim was to provide a comprehensive meta-analysis of the overall prevalence of the NRLN, its origin, and its association with an aberrant subclavian artery. Methods Through March 2016, a database search was performed of PubMed, CNKI, ScienceDirect, EMBASE, BIOSIS, SciELO, and Web of Science. The references in the included articles were also extensively searched. At least two reviewers judged eligibility and assessed and extracted articles. MetaXL was used for analysis, with all pooled prevalence rates calculated using a random effects model. Heterogeneity among the included studies was assessed using the Chi2 test and the I2 statistic. Results Fifty-three studies (33,571 right RLNs) reported data on the prevalence of a right NRLN. The pooled prevalence estimate was 0.7% (95% CI [0.6–0.9]). The NRLN was found to originate from the vagus nerve at or above the laryngotracheal junction in 58.3% and below it in 41.7%. A right NRLN was associated with an aberrant subclavian artery in 86.7% of cases. Conclusion The NRLN is a rare yet very clinically relevant structure for surgeons and is associated with increased risk of iatrogenic injury, most often leading to temporary or permanent vocal cord paralysis. A thorough understanding of the prevalence, origin, and associated pathologies is vital for preventing injuries and complications. PMID:28344898

Defining ulnar variance in the adolescent wrist: measurement technique and interobserver reliability.

PubMed

Goldfarb, Charles A; Strauss, Nicole L; Wall, Lindley B; Calfee, Ryan P

2011-02-01

The measurement technique for ulnar variance in the adolescent population has not been well established. The purpose of this study was to assess the reliability of a standard ulnar variance assessment in the adolescent population. Four orthopedic surgeons measured 138 adolescent wrist radiographs for ulnar variance using a standard technique. There were 62 male and 76 female radiographs obtained in a standardized fashion for subjects aged 12 to 18 years. Skeletal age was used for analysis. We determined mean variance and assessed for differences related to age and gender. We also determined the interrater reliability. The mean variance was -0.7 mm for boys and -0.4 mm for girls; there was no significant difference between the 2 groups overall. When subdivided by age and gender, the younger group (≤ 15 y of age) was significantly less negative for girls (boys, -0.8 mm and girls, -0.3 mm, p < .05). There was no significant difference between boys and girls in the older group. The greatest difference between any 2 raters was 1 mm; exact agreement was obtained in 72 subjects. Correlations between raters were high (r(p) 0.87-0.97 in boys and 0.82-0.96 for girls). Interrater reliability was excellent (Cronbach's alpha, 0.97-0.98). Standard assessment techniques for ulnar variance are reliable in the adolescent population. Open growth plates did not interfere with this assessment. Young adolescent boys demonstrated a greater degree of negative ulnar variance compared with young adolescent girls. Copyright © 2011 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.

Clinical effects of internal fixation for ulnar styloid fractures associated with distal radius fractures: A matched case-control study.

PubMed

Sawada, Hideyoshi; Shinohara, Takaaki; Natsume, Tadahiro; Hirata, Hitoshi

2016-11-01

Ulnar styloid fractures are often associated with distal radius fractures. However, controversy exists regarding whether to treat ulnar styloid fractures. This study aimed to evaluate clinical effects of internal fixation for ulnar styloid fractures after distal radius fractures were treated with the volar locking plate system. We used prospectively collected data of distal radius fractures. 111 patients were enrolled in this study. A matched case-control study design was used. We selected patients who underwent fixation for ulnar styloid fractures (case group). Three control patients for each patient of the case group were matched on the basis of age, sex, and fracture type of distal radius fractures from among patients who did not undergo fixation for ulnar styloid fractures (control group). The case group included 16 patients (7 men, 9 women; mean age: 52.6 years; classification of ulnar styloid fractures: center, 3; base, 11; and proximal, 2). The control group included 48 patients (15 men, 33 women; mean age: 61.1 years; classification of ulnar styloid fractures: center, 10; base, 31; and proximal, 7). For radiographic examination, the volar tilt angle, radial inclination angle, and ulnar variance length were measured, and the union of ulnar styloid fractures was judged. For clinical examination, the range of motions, grip strength, Hand20 score, and Numeric Rating Scale score were evaluated. There was little correction loss for each radiological parameter of fracture reduction, and these parameters were not significantly different between the groups. The bone-healing rate of ulnar styloid fractures was significantly higher in the case group than in the control group, but the clinical results were not significantly different. We revealed that there was no need to fix ulnar styloid fractures when distal radius fractures were treated via open reduction and internal fixation with a volar locking plate system. Copyright © 2016 The Japanese Orthopaedic Association

Surgical Management of Iatrogenic Pigment Dispersion Glaucoma.

PubMed

Mierlo, Camille Van; Pinto, Luis Abegão; Stalmans, Ingeborg

2015-01-01

Iatrogenic pigment dispersion syndrome generally originates from a repetitive, mechanical trauma to the pigmented posterior epithelium of the iris. This trauma can arise after intraocular surgery, most commonly due to an abnormal contact between the intraocular lens (IOL) and the iris. Whether surgical removal of this primary insult can lead to a successful intraocular pressure (IOP) control remains unclear. Case-series. Patients with IOP elevation and clinical signs of pigment dispersion were screened for a diagnosis of iatrogenic IOL-related pigment dispersion. Three patients in which the IOL or the IOL-bag complex caused a pigment dispersion through a repetitive iris chafing were selected. In two cases, replacement of a sulcus-based single-piece IOL (patient 1) or a sub-luxated in-the-bag IOL (patient 2) by an anterior-chamber (AC) iris-fixed IOL led to a sustained decrease in IOP. In the third case, extensive iris atrophy and poor anatomical AC parameters for IOL implantation precluded further surgical intervention. IOL-exchange appears to be a useful tool in the management of iatrogenic pigment dispersion glaucoma due to inappropriate IOL implantation. This cause-oriented approach seems to be effective in controlling IOP, but should be offered only if safety criteria are met. How to cite this article: Van Mierlo C, Abegao Pinto L, Stalmans I. Surgical Management of Iatrogenic Pigment Dispersion Glaucoma. J Curr Glaucoma Pract 2015;9(1):28-32.

Radial and ulnar bursae of the wrist: cadaveric investigation of regional anatomy with ultrasonographic-guided tenography and MR imaging.

PubMed

Aguiar, Rodrigo O C; Gasparetto, Emerson L; Escuissato, Dante L; Marchiori, Edson; Trudell, Debbie J; Haghighi, Parviz; Resnick, Donald

2006-11-01

To demonstrate the anatomy of the radial and ulnar bursae of the wrist using MR and US images. Ultrasonographic-guided tenography of the tendon sheath of flexor pollicis longus (FPL) and the common tendon sheath of the flexor digitorum of the fifth digit (FD5) of ten cadaveric hands was performed, followed by magnetic resonance imaging and gross anatomic correlation. Patterns of communication were observed between these tendon sheaths and the radial and ulnar bursae of the wrist. The tendon sheath of the FPL communicated with the radial bursa in 100% (10/10) of cases, and the tendon sheath of the FD5 communicated with the ulnar bursa in 80% (8/10). Communication of the radial and ulnar bursae was evident in 100% (10/10), and presented an "hourglass" configuration in the longitudinal plane. The ulnar and radial bursae often communicate. The radial bursa communicates with the FPL tendon sheath, and the ulnar bursa may communicate with the FD5 tendon sheath.

The Snapping Elbow Syndrome as a Reason for Chronic Elbow Neuralgia in a Tennis Player - MR, US and Sonoelastography Evaluation.

PubMed

Łasecki, Mateusz; Olchowy, Cyprian; Pawluś, Aleksander; Zaleska-Dorobisz, Urszula

2014-01-01

Ulnar neuropathy is the second most common peripheral nerve neuropathy after median neuropathy, with an incidence of 25 cases per 100 000 men and 19 cases per 100 000 women each year. Skipping (snapping) elbow syndrome is an uncommon cause of pain in the posterior-medial elbow area, sometimes complicated by injury of the ulnar nerve. One of the reason is the dislocation of the abnormal insertion of the medial triceps head over the medial epicondyle during flexion and extension movements. Others are: lack of the Osboune fascia leading to ulnar nerve instability and focal soft tissue tumors (fibromas, lipomas, etc). Recurrent subluxation of the nerve at the elbow results in a tractional and frictional neuritis with classical symptoms of peripheral neuralgia. As far as we know snapping triceps syndrome had never been evaluated in sonoelastography. A 28yo semi-professional left handed tennis player was complaining about pain in posterior-medial elbow area. Initial US examination suggest golfers elbow syndrome which occurs quite commonly and has a prevalence of 0.3-0.6% in males and 0-3-1.1% in women and may be associated (approx. 50% of cases) with ulnar neuropathy. However subsequently made MRI revealed unusual distal triceps anatomy, moderate ulnar nerve swelling and lack of medial epicondylitis symptoms. Followed (second) US examination and sonoelastography have detected slipping of the both ulnar nerve and the additional band of the medial triceps head. Snapping elbow syndrome is a poorly known medical condition, sometimes misdiagnosed as the medial epicondylitis. It describes a broad range of pathologies and anatomical abnormalities. One of the most often reasons is the slipping of the ulnar nerve as the result of the Osborne fascia/anconeus epitrochlearis muscle absence. Simultaneously presence of two or more "snapping reasons" is rare but should be always taken under consideration. There are no sonoelastography studies describing golfers elbow syndrome

Compact fluorescence and white-light imaging system for intraoperative visualization of nerves

NASA Astrophysics Data System (ADS)

Gray, Dan; Kim, Evgenia; Cotero, Victoria; Staudinger, Paul; Yazdanfar, Siavash; tan Hehir, Cristina

2012-02-01

Fluorescence image guided surgery (FIGS) allows intraoperative visualization of critical structures, with applications spanning neurology, cardiology and oncology. An unmet clinical need is prevention of iatrogenic nerve damage, a major cause of post-surgical morbidity. Here we describe the advancement of FIGS imaging hardware, coupled with a custom nerve-labeling fluorophore (GE3082), to bring FIGS nerve imaging closer to clinical translation. The instrument is comprised of a 405nm laser and a white light LED source for excitation and illumination. A single 90 gram color CCD camera is coupled to a 10mm surgical laparoscope for image acquisition. Synchronization of the light source and camera allows for simultaneous visualization of reflected white light and fluorescence using only a single camera. The imaging hardware and contrast agent were evaluated in rats during in situ surgical procedures.

Optimal management of ulnar collateral ligament injury in baseball pitchers

PubMed Central

Hibberd, Elizabeth E; Brown, J Rodney; Hoffer, Joseph T

2015-01-01

The ulnar collateral ligament stabilizes the elbow joint from valgus stress associated with the throwing motion. During baseball pitching, this ligament is subjected to tremendous stress and injury if the force on the ulnar collateral ligament during pitching exceeds the physiological limits of the ligament. Injuries to the throwing elbow in baseball pitchers result in significant time loss and typically surgical intervention. The purpose of this paper is to provide a review of current information to sports medicine clinicians on injury epidemiology, injury mechanics, injury risk factors, injury prevention, surgical interventions, nonsurgical interventions, rehabilitation, and return to play outcomes in baseball pitchers of all levels. PMID:26635490

Desensitizing the posterior interosseous nerve alters wrist proprioceptive reflexes.

PubMed

Hagert, Elisabet; Persson, Jonas K E

2010-07-01

The presence of wrist proprioceptive reflexes after stimulation of the dorsal scapholunate interosseous ligament has previously been described. Because this ligament is primarily innervated by the posterior interosseous nerve (PIN) we hypothesized altered ligamento-muscular reflex patterns following desensitization of the PIN. Eight volunteers (3 women, 5 men; mean age, 26 y; range 21-28 y) participated in the study. In the first study on wrist proprioceptive reflexes (study 1), the scapholunate interosseous ligament was stimulated through a fine-wire electrode with 4 1-ms bipolar pulses at 200 Hz, 30 times consecutively, while EMG activity was recorded from the extensor carpi radialis brevis, extensor carpi ulnaris, flexor carpi radialis, and flexor carpi ulnaris, with the wrist in extension, flexion, radial deviation, and ulnar deviation. After completion of study 1, the PIN was anesthetized in the radial aspect of the fourth extensor compartment using 2-mL lidocaine (10 mg/mL) infiltration anesthesia. Ten minutes after desensitization, the experiment was repeated as in study 1. The average EMG results from the 30 consecutive stimulations were rectified and analyzed using Student's t-test. Statistically significant changes in EMG amplitude were plotted along time lines so that the results of study 1 and 2 could be compared. Dramatic alterations in reflex patterns were observed in wrist flexion, radial deviation, and ulnar deviation following desensitization of the PIN, with an average of 72% reduction in excitatory reactions. In ulnar deviation, the inhibitory reactions of the extensor carpi ulnaris were entirely eliminated. In wrist extension, no differences in the reflex patterns were observed. Wrist proprioception through the scapholunate ligament in flexion, radial deviation, and ulnar deviation depends on an intact PIN function. The unchanged reflex patterns in wrist extension suggest an alternate proprioceptive pathway for this position. Routine excision of

Surgical anatomy of the radial nerve in the deltopectoral approach for revision shoulder arthroplasty and periprosthetic fracture fixation: a cadaveric study.

PubMed

Fu, Michael C; Hendel, Michael D; Chen, Xiang; Warren, Russell F; Dines, David M; Gulotta, Lawrence V

2017-12-01

Radial nerve injury is a rare but clinically significant complication of revision shoulder arthroplasty and fixation of native and periprosthetic proximal humeral fractures. Understanding of the anatomic relationship between the radial nerve as it enters the humeral spiral groove and anterior shoulder landmarks in a deltopectoral approach is necessary to avoid iatrogenic radial nerve injury. Eight forequarter cadaveric specimens were dissected through a deltopectoral approach. Distances between the radial nerve entry into the proximal spiral groove and the coracoid process, distal lesser tuberosity/inferior subscapularis insertion, superior latissimus insertion, and inferior latissimus insertion were measured. Means, standard deviations, and ranges were determined for each distance. The radial nerve entry into the proximal spiral groove averaged 133.1 mm (range, 110.3-153.0 mm) from the coracoid process, 101.9 mm (range, 76.5-124.3 mm) from the distal lesser tuberosity/inferior subscapularis insertion, 81.0 mm (range, 63.4-101.5 mm) from the superior latissimus insertion, and 39.6 mm (range, 25.5-55.4 mm) from the inferior latissimus insertion. The proximal spiral groove was distal to the inferior latissimus insertion in all specimens. The risk of iatrogenic injury to the radial nerve at the spiral groove may be minimized through proper identification and protection or avoidance of circumferential fixation. However, if encircling fixation with cerclage cables is necessary, instrumentation proximal to the inferior edge of the latissimus dorsi insertion may reduce the risk of radial nerve injury. Copyright © 2017 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.

Improved facial nerve identification during parotidectomy with fluorescently labeled peptide.

PubMed

Hussain, Timon; Nguyen, Linda T; Whitney, Michael; Hasselmann, Jonathan; Nguyen, Quyen T

2016-12-01

Additional intraoperative guidance could reduce the risk of iatrogenic injury during parotid gland cancer surgery. We evaluated the intraoperative use of fluorescently labeled nerve binding peptide NP41 to aid facial nerve identification and preservation during parotidectomy in an orthotopic model of murine parotid gland cancer. We also quantified the accuracy of intraoperative nerve detection for surface and buried nerves in the head and neck with NP41 versus white light (WL) alone. Twenty-eight mice underwent parotid gland cancer surgeries with additional fluorescence (FL) guidance versus WL reflectance (WLR) alone. Eight mice were used for additional nerve-imaging experiments. Twenty-eight parotid tumor-bearing mice underwent parotidectomy. Eight mice underwent imaging of both sides of the face after skin removal. Postoperative assessment of facial nerve function measured by automated whisker tracking were compared between FL guidance (n = 13) versus WL alone (n=15). In eight mice, nerve to surrounding tissue contrast was measured under FL versus WLR for all nerve branches detectable in the field of view. Postoperative facial nerve function after parotid gland cancer surgery tended to be better with additional FL guidance. Fluorescent labeling significantly improved nerve to surrounding tissue contrast for both large and smaller buried nerve branches compared to WLR visualization and improved detection sensitivity and specificity. NP41 FL imaging significantly aids the intraoperative identification of nerve braches otherwise nearly invisible to the naked eye. Its application in a murine model of parotid gland cancer surgery tended to improve functional preservation of the facial nerve. NA Laryngoscope, 126:2711-2717, 2016. © 2016 The American Laryngological, Rhinological and Otological Society, Inc.

Intra-temporal facial nerve centerline segmentation for navigated temporal bone surgery

NASA Astrophysics Data System (ADS)

Voormolen, Eduard H. J.; van Stralen, Marijn; Woerdeman, Peter A.; Pluim, Josien P. W.; Noordmans, Herke J.; Regli, Luca; Berkelbach van der Sprenkel, Jan W.; Viergever, Max A.

2011-03-01

Approaches through the temporal bone require surgeons to drill away bone to expose a target skull base lesion while evading vital structures contained within it, such as the sigmoid sinus, jugular bulb, and facial nerve. We hypothesize that an augmented neuronavigation system that continuously calculates the distance to these structures and warns if the surgeon drills too close, will aid in making safe surgical approaches. Contemporary image guidance systems are lacking an automated method to segment the inhomogeneous and complexly curved facial nerve. Therefore, we developed a segmentation method to delineate the intra-temporal facial nerve centerline from clinically available temporal bone CT images semi-automatically. Our method requires the user to provide the start- and end-point of the facial nerve in a patient's CT scan, after which it iteratively matches an active appearance model based on the shape and texture of forty facial nerves. Its performance was evaluated on 20 patients by comparison to our gold standard: manually segmented facial nerve centerlines. Our segmentation method delineates facial nerve centerlines with a maximum error along its whole trajectory of 0.40+/-0.20 mm (mean+/-standard deviation). These results demonstrate that our model-based segmentation method can robustly segment facial nerve centerlines. Next, we can investigate whether integration of this automated facial nerve delineation with a distance calculating neuronavigation interface results in a system that can adequately warn surgeons during temporal bone drilling, and effectively diminishes risks of iatrogenic facial nerve palsy.

Use of locking compression plates in ulnar fractures of 18 horses.

PubMed

Jacobs, Carrie C; Levine, David G; Richardson, Dean W

2017-02-01

To describe the outcome, clinical findings, and complications associated with the use of the locking compression plate (LCP) for various types of ulnar fractures in horses. Retrospective case series. Client owned horses (n = 18). Medical records, radiographs, and follow-up for horses having an ulnar fracture repaired using at least 1 LCP were reviewed. Fifteen of 18 horses had fractures of the ulna only, and 3 horses had fractures of the ulna and proximal radius. All 18 horses were discharged from the hospital. Complications occurred in 5 horses; incisional infection (n = 4, 22%), implant-associated infection (n = 2, 11%), and colic (n = 1, 6%). Follow-up was available for all horses at a range of 13-120 months and 15 horses (83%) were sound for their intended purpose and 3 horses (17%) were euthanatized. One horse was euthanatized for complications associated with original injury and surgery. The LCP is a viable method of internal fixation for various types of ulnar fractures, with most horses in this series returning to soundness. © 2017 The American College of Veterinary Surgeons.

Electrodiagnosis of ulnar neuropathy at the elbow (Une): a Bayesian approach.

PubMed

Logigian, Eric L; Villanueva, Raissa; Twydell, Paul T; Myers, Bennett; Downs, Marlene; Preston, David C; Kothari, Milind J; Herrmann, David N

2014-03-01

In ulnar neuropathy at the elbow (UNE), we determined how electrodiagnostic cutoffs [across-elbow ulnar motor conduction velocity slowing (AECV-slowing), drop in across-elbow vs. forearm CV (AECV-drop)] depend on pretest probability (PreTP). Fifty clinically defined UNE patients and 50 controls underwent ulnar conduction testing recording abductor digiti minimi (ADM) and first dorsal interosseous (FDI), stimulating wrist, below-elbow, and 6-, 8-, and 10-cm more proximally. For various PreTPs of UNE, the cutoffs required to confirm UNE (defined as posttest probability = 95%) were determined with receiver operator characteristic (ROC) curves and Bayes Theorem. On ROC and Bayesian analyses, the ADM 10-cm montage was optimal. For PreTP = 0.25, the confirmatory cutoffs were >23 m/s (AECV-drop), and <38 m/s (AECV-slowing); for PreTP = 0.75, they were much less conservative: >14 m/s, and <47 m/s, respectively. (1) In UNE, electrodiagnostic cutoffs are critically dependent on PreTP; rigid cutoffs are problematic. (2) AE distances should be standardized and at least 10 cm. Copyright © 2013 Wiley Periodicals, Inc.

Should Euthanasia Be Considered Iatrogenic?

PubMed

Barone, Silvana; Unguru, Yoram

2017-08-01

As more countries adopt laws and regulations concerning euthanasia, pediatric euthanasia has become an important topic of discussion. Conceptions of what constitutes harm to patients are fluid and highly dependent on a myriad of factors including, but not limited to, health care ethics, family values, and cultural context. Euthanasia could be viewed as iatrogenic insofar as it results in an outcome (death) that some might consider inherently negative. However, this perspective fails to acknowledge that death, the outcome of euthanasia, is not an inadvertent or preventable complication but rather the goal of the medical intervention. Conversely, the refusal to engage in the practice of euthanasia might be conceived as iatrogenic insofar as it might inadvertently prolong patient suffering. This article will explore cultural and social factors informing families', health care professionals', and society's views on pediatric euthanasia in selected countries. © 2017 American Medical Association. All Rights Reserved.

A look inside the nerve - Morphology of nerve fascicles in healthy controls and patients with polyneuropathy.

PubMed

Grimm, Alexander; Winter, Natalie; Rattay, Tim W; Härtig, Florian; Dammeier, Nele M; Auffenberg, Eva; Koch, Marilin; Axer, Hubertus

2017-12-01

Polyneuropathies are increasingly analyzed by ultrasound. Summarizing, diffuse enlargement is typical in Charcot-Marie Tooth type 1 (CMT1a), regional enlargement occurs in inflammatory neuropathies. However, a distinction of subtypes is still challenging. Therefore, this study focused on fascicle size and pattern in controls and distinct neuropathies. Cross-sectional area (CSA) of the median, ulnar and peroneal nerve (MN, UN, PN) was measured at predefined landmarks in 50 healthy controls, 15 CMT1a and 13 MMN patients. Additionally, largest fascicle size and number of visible fascicles was obtained at the mid-upper arm cross-section of the MN and UN and in the popliteal fossa cross-section of the PN. Cut-off normal values for fascicle size in the MN, UN and PN were defined (<4.8mm 2 , <2.8mm 2 and <3.5mm 2 ). In CMT1a CSA and fascicle values are significantly enlarged in all nerves, while in MMN CSA and fascicles are regionally enlarged with predominance in the upper arm nerves. The ratio of enlarged fascicles and all fascicles was significantly increased in CMT1a (>50%) in all nerves (p<0.0001), representing diffuse fascicle enlargement, and moderately increased in MMN (>20%), representing differential fascicle enlargement (enlarged and normal fascicles at the same location) sparing the peroneal nerve (regional fascicle enlargement). Based on these findings distinct fascicle patterns were defined. Normal values for fascicle size could be evaluated; while CMT1a features diffuse fascicle enlargement, MMN shows regional and differential predominance with enlarged fascicles as single pathology. Pattern analysis of fascicles might facilitate distinction of several otherwise similar neuropathies. Copyright © 2017 International Federation of Clinical Neurophysiology. Published by Elsevier B.V. All rights reserved.

Optical stimulation of the facial nerve: a surgical tool?

NASA Astrophysics Data System (ADS)

Richter, Claus-Peter; Teudt, Ingo Ulrik; Nevel, Adam E.; Izzo, Agnella D.; Walsh, Joseph T., Jr.

2008-02-01

One sequela of skull base surgery is the iatrogenic damage to cranial nerves. Devices that stimulate nerves with electric current can assist in the nerve identification. Contemporary devices have two main limitations: (1) the physical contact of the stimulating electrode and (2) the spread of the current through the tissue. In contrast to electrical stimulation, pulsed infrared optical radiation can be used to safely and selectively stimulate neural tissue. Stimulation and screening of the nerve is possible without making physical contact. The gerbil facial nerve was irradiated with 250-μs-long pulses of 2.12 μm radiation delivered via a 600-μm-diameter optical fiber at a repetition rate of 2 Hz. Muscle action potentials were recorded with intradermal electrodes. Nerve samples were examined for possible tissue damage. Eight facial nerves were stimulated with radiant exposures between 0.71-1.77 J/cm2, resulting in compound muscle action potentials (CmAPs) that were simultaneously measured at the m. orbicularis oculi, m. levator nasolabialis, and m. orbicularis oris. Resulting CmAP amplitudes were 0.3-0.4 mV, 0.15-1.4 mV and 0.3-2.3 mV, respectively, depending on the radial location of the optical fiber and the radiant exposure. Individual nerve branches were also stimulated, resulting in CmAP amplitudes between 0.2 and 1.6 mV. Histology revealed tissue damage at radiant exposures of 2.2 J/cm2, but no apparent damage at radiant exposures of 2.0 J/cm2.

A compact fluorescence and white light imaging system for intraoperative visualization of nerves

NASA Astrophysics Data System (ADS)

Gray, Dan; Kim, Evgenia; Cotero, Victoria; Staudinger, Paul; Yazdanfar, Siavash; Tan Hehir, Cristina

2012-03-01

Fluorescence image guided surgery (FIGS) allows intraoperative visualization of critical structures, with applications spanning neurology, cardiology and oncology. An unmet clinical need is prevention of iatrogenic nerve damage, a major cause of post-surgical morbidity. Here we describe the advancement of FIGS imaging hardware, coupled with a custom nerve-labeling fluorophore (GE3082), to bring FIGS nerve imaging closer to clinical translation. The instrument is comprised of a 405nm laser and a white light LED source for excitation and illumination. A single 90 gram color CCD camera is coupled to a 10mm surgical laparoscope for image acquisition. Synchronization of the light source and camera allows for simultaneous visualization of reflected white light and fluorescence using only a single camera. The imaging hardware and contrast agent were evaluated in rats during in situ surgical procedures.

Strategies of preventing ureteral iatrogenic injuries in obstetrics-gynecology

PubMed Central

Cirstoiu, M; Munteanu, O

2012-01-01

The incidence of ureteral lesions varies between 0.1% and 30% depending on the type of the surgical intervention. However, the surgical interventions in Obstetrics and Gynecology are responsible for 50% of the total iatrogenic ureteral lesions. Sadly, only 1/3 of the iatrogenic ureteral lesions are recognized during surgeries and 25% of the unrecognized cases of ureteral lesions lead towards the loss of the damaged kidney, while a delayed diagnostic may also lead to a progressive deterioration of the renal function. On this matter, of decreasing the rate of morbidity and the following forensic risks, the gynecologist surgeon must be able to anticipate the potential apparition of a specific ureteral lesion, based on the known risk factors of the patient, so that he can then prevent the iatrogenic ureteral lesion. PMID:23125877

Classification of ulnar triangular fibrocartilage complex tears. A treatment algorithm for Palmer type IB tears.

PubMed

Atzei, A; Luchetti, R; Garagnani, L

2017-05-01

The classical definition of 'Palmer Type IB' triangular fibrocartilage complex tear, includes a spectrum of clinical conditions. This review highlights the clinical and arthroscopic criteria that enable us to categorize five classes on a treatment-oriented classification system of triangular fibrocartilage complex peripheral tears. Class 1 lesions represent isolated tears of the distal triangular fibrocartilage complex without distal radio-ulnar joint instability and are amenable to arthroscopic suture. Class 2 tears include rupture of both the distal triangular fibrocartilage complex and proximal attachments of the triangular fibrocartilage complex to the fovea. Class 3 tears constitute isolated ruptures of the proximal attachment of the triangular fibrocartilage complex to the fovea; they are not visible at radio-carpal arthroscopy. Both Class 2 and Class 3 tears are diagnosed with a positive hook test and are typically associated with distal radio-ulnar joint instability. If required, treatment is through reattachment of the distal radio-ulnar ligament insertions to the fovea. Class 4 lesions are irreparable tears due to the size of the defect or to poor tissue quality and, if required, treatment is through distal radio-ulnar ligament reconstruction with tendon graft. Class 5 tears are associated with distal radio-ulnar joint arthritis and can only be treated with salvage procedures. This subdivision of type IB triangular fibrocartilage complex tear provides more insights in the pathomechanics and treatment strategies. II.

Evaluation of the thickness of the medial ulnar collateral ligament in junior high and high school baseball players.

PubMed

Nagamoto, Hideaki; Yamamoto, Nobuyuki; Kurokawa, Daisuke; Takahashi, Hiroyuki; Muraki, Takayuki; Tanaka, Minoru; Koike, Yoichi; Sano, Hirotaka; Itoi, Eiji

2015-07-01

Thickening of the medial ulnar collateral ligament in the throwing arm of adult baseball players is a well-known phenomenon. However, onset of the thickening is unclear among young baseball players. The purpose of this study was to evaluate the thickness of the medial ulnar collateral ligament in junior high and high school baseball players. Seventy-one uninjured and asymptomatic junior high and high school baseball players were included in the study. Participants underwent physical examination after completing a questionnaire, followed by ultrasonographic evaluation. The thickness of the medial ulnar collateral ligament was measured bilaterally. The thickness of the throwing and non-throwing sides in high school and junior high school baseball players, and within each group, was compared and statistically analyzed. The medial ulnar collateral ligament in the throwing arm of high school baseball players was thicker than that in the non-throwing arm (5.5 vs. 4.4 mm), although no significant difference was seen in junior high school baseball players. High school baseball players showed a significantly thicker medial ulnar collateral ligament in the throwing arm than junior high school baseball players. Thickening of the medial ulnar collateral ligament in the throwing arm of asymptomatic and uninjured baseball players may begin by the time the players reach high school.

Microsurgical Decompression of Inferior Alveolar Nerve After Endodontic Treatment Complications.

PubMed

Bianchi, Bernardo; Ferri, Andrea; Varazzani, Andrea; Bergonzani, Michela; Sesenna, Enrico

2017-07-01

Iatrogenic injury in oral surgery is the most frequent cause of sensory disturbance in the distribution of the inferior alveolar nerve (IAN) and mental nerve.Inferior alveolar nerve damage can occur during third molar extraction, implant location, orthognathic surgery, preprosthetic surgery, salivary gland surgery, local anesthetic injections or during the resection of benign or malignant tumors.Injuries to the IAN can be caused also by endodontic treatment of mandibular molars and premolars when filling material is forced into the tooth and mandibular canal.The sensory disturbances that could follow a damage of the IAN could be hypoesthesia, dysesthesia, hyperesthesia, anesthesia, and sometimes a painful anesthesia that strike ipsilateral lower lip, chin, and teeth. These can undermine life quality by affecting speech, chewing, and social interaction.Treatment of these complications is sometimes difficult and could consist in observation or in surgical decompression of the involved nerve to relieve the patient's symptoms and improve sensory recovery. The most debated points are the timing of intervention and the effective role of decompression in clinical outcome-improvement.The purpose of this article is to show authors' experience with 2 patients treated with microsurgical nerve decompression to remove endodontic material from the mandibular canal and providing also a comprehensive review of the literature.

Peripheral nerve magnetic stimulation: influence of tissue non-homogeneity

PubMed Central

Krasteva, Vessela TZ; Papazov, Sava P; Daskalov, Ivan K

2003-01-01

Background Peripheral nerves are situated in a highly non-homogeneous environment, including muscles, bones, blood vessels, etc. Time-varying magnetic field stimulation of the median and ulnar nerves in the carpal region is studied, with special consideration of the influence of non-homogeneities. Methods A detailed three-dimensional finite element model (FEM) of the anatomy of the wrist region was built to assess the induced currents distribution by external magnetic stimulation. The electromagnetic field distribution in the non-homogeneous domain was defined as an internal Dirichlet problem using the finite element method. The boundary conditions were obtained by analysis of the vector potential field excited by external current-driven coils. Results The results include evaluation and graphical representation of the induced current field distribution at various stimulation coil positions. Comparative study for the real non-homogeneous structure with anisotropic conductivities of the tissues and a mock homogeneous media is also presented. The possibility of achieving selective stimulation of either of the two nerves is assessed. Conclusion The model developed could be useful in theoretical prediction of the current distribution in the nerves during diagnostic stimulation and therapeutic procedures involving electromagnetic excitation. The errors in applying homogeneous domain modeling rather than real non-homogeneous biological structures are demonstrated. The practical implications of the applied approach are valid for any arbitrary weakly conductive medium. PMID:14693034

Liver transplantation in the treatment of severe iatrogenic liver injuries

PubMed Central

Lauterio, Andrea; De Carlis, Riccardo; Di Sandro, Stefano; Ferla, Fabio; Buscemi, Vincenzo; De Carlis, Luciano

2017-01-01

The place of liver transplantation in the treatment of severe iatrogenic liver injuries has not yet been widely discussed in the literature. Bile duct injuries during cholecystectomy represent the leading cause of liver transplantation in this setting, while other indications after abdominal surgery are less common. Urgent liver transplantation for the treatment of severe iatrogenic liver injury may-represent a surgical challenge requiring technically difficult and time consuming procedures. A debate is ongoing on the need for centralization of complex surgery in tertiary referral centers. The early referral of patients with severe iatrogenic liver injuries to a tertiary center with experienced hepato-pancreato-biliary and transplant surgery has emerged as the best treatment of care. Despite widespread interest in the use of liver transplantation as a treatment option for severe iatrogenic injuries, reported experiences indicate few liver transplants are performed. This review analyzes the literature on liver transplantation after hepatic injury and discusses our own experience along with surgical advances and future prospects in this uncommon transplant setting. PMID:28932348

Ulnar neuropathy at or distal to the wrist: traumatic versus cumulative stress cases.

PubMed

Chiodo, Anthony; Chadd, Edmund

2007-04-01

To identify clinical and electromyographic characteristics of ulnar neuropathy at or below the wrist, comparing those caused by unitary trauma with those caused by suspected cumulative stress. Retrospective case series. University hospital electromyography laboratory. Patients with electrodiagnostic evidence of an ulnar neuropathy at or distal to the wrist over a 3-year period. Forty-seven hands from 42 patients (age range, 20-80y; mean, 52y) were identified and evaluated in this study. Record review of clinical history, physical examination, electromyography, and treatment. Etiology of injury, physical signs and symptoms, and electromyographic testing results. Ulnar neuropathy at or distal to the wrist is commonly mischaracterized because of other mononeuropathies in the upper extremity and because of peripheral polyneuropathy. Ulnar neuropathy because of cumulative stress presents typically with sensory symptoms (63%) and a normal examination (71%), whereas trauma cases present with motor with or without sensory symptoms (92%) with motor abnormalities (92%) confirmed on examination. Traumatic cases are characterized by electromyography by decreased sensory and motor-evoked amplitudes, prolonged motor distal latencies, and abnormal needle examination. The amplitude changes are noted comparing with laboratory norms and comparing side to side. No characteristic pattern of abnormalities on electromyography is noted in the cumulative stress cases. Patients with no motor symptoms, regardless of etiology, are more apt to have sensory distal latency prolongation, whereas those with motor symptoms have motor amplitude and needle examination abnormalities. Traumatic ulnar neuropathy at or distal to the wrist is characterized by motor symptoms and sensory and motor axonal loss by electromyography, whereas cumulative stress cases have sensory symptoms and electromyographic findings that are highly variable and noncharacteristic. Patients with no motor symptoms are more apt

Vaginismus--iatrogenic precipitation and maintenance.

PubMed

Pedersen, B L; Møhl, B

1992-10-01

Four cases of vaginismus are presented. Two of them illustrate an iatrogenic precipitation of vaginismus, one misdiagnosis of vaginismus, and one shows the use of unnecessary hymenectomy as the first choice of treatment of vaginismus. The etiology of vaginismus and the indications of first pelvic examinations are discussed.

Restoring motor control and sensory feedback in people with upper extremity amputations using arrays of 96 microelectrodes implanted in the median and ulnar nerves.

PubMed

Davis, T S; Wark, H A C; Hutchinson, D T; Warren, D J; O'Neill, K; Scheinblum, T; Clark, G A; Normann, R A; Greger, B

2016-06-01

An important goal of neuroprosthetic research is to establish bidirectional communication between the user and new prosthetic limbs that are capable of controlling >20 different movements. One strategy for achieving this goal is to interface the prosthetic limb directly with efferent and afferent fibres in the peripheral nervous system using an array of intrafascicular microelectrodes. This approach would provide access to a large number of independent neural pathways for controlling high degree-of-freedom prosthetic limbs, as well as evoking multiple-complex sensory percepts. Utah Slanted Electrode Arrays (USEAs, 96 recording/stimulating electrodes) were implanted for 30 days into the median (Subject 1-M, 31 years post-amputation) or ulnar (Subject 2-U, 1.5 years post-amputation) nerves of two amputees. Neural activity was recorded during intended movements of the subject's phantom fingers and a linear Kalman filter was used to decode the neural data. Microelectrode stimulation of varying amplitudes and frequencies was delivered via single or multiple electrodes to investigate the number, size and quality of sensory percepts that could be evoked. Device performance over time was assessed by measuring: electrode impedances, signal-to-noise ratios (SNRs), stimulation thresholds, number and stability of evoked percepts. The subjects were able to proportionally, control individual fingers of a virtual robotic hand, with 13 different movements decoded offline (r = 0.48) and two movements decoded online. Electrical stimulation across one USEA evoked >80 sensory percepts. Varying the stimulation parameters modulated percept quality. Devices remained intrafascicularly implanted for the duration of the study with no significant changes in the SNRs or percept thresholds. This study demonstrated that an array of 96 microelectrodes can be implanted into the human peripheral nervous system for up to 1 month durations. Such an array could provide intuitive control of a

Restoring motor control and sensory feedback in people with upper extremity amputations using arrays of 96 microelectrodes implanted in the median and ulnar nerves

NASA Astrophysics Data System (ADS)

Davis, T. S.; Wark, H. A. C.; Hutchinson, D. T.; Warren, D. J.; O'Neill, K.; Scheinblum, T.; Clark, G. A.; Normann, R. A.; Greger, B.

2016-06-01

Objective. An important goal of neuroprosthetic research is to establish bidirectional communication between the user and new prosthetic limbs that are capable of controlling >20 different movements. One strategy for achieving this goal is to interface the prosthetic limb directly with efferent and afferent fibres in the peripheral nervous system using an array of intrafascicular microelectrodes. This approach would provide access to a large number of independent neural pathways for controlling high degree-of-freedom prosthetic limbs, as well as evoking multiple-complex sensory percepts. Approach. Utah Slanted Electrode Arrays (USEAs, 96 recording/stimulating electrodes) were implanted for 30 days into the median (Subject 1-M, 31 years post-amputation) or ulnar (Subject 2-U, 1.5 years post-amputation) nerves of two amputees. Neural activity was recorded during intended movements of the subject’s phantom fingers and a linear Kalman filter was used to decode the neural data. Microelectrode stimulation of varying amplitudes and frequencies was delivered via single or multiple electrodes to investigate the number, size and quality of sensory percepts that could be evoked. Device performance over time was assessed by measuring: electrode impedances, signal-to-noise ratios (SNRs), stimulation thresholds, number and stability of evoked percepts. Main results. The subjects were able to proportionally, control individual fingers of a virtual robotic hand, with 13 different movements decoded offline (r = 0.48) and two movements decoded online. Electrical stimulation across one USEA evoked >80 sensory percepts. Varying the stimulation parameters modulated percept quality. Devices remained intrafascicularly implanted for the duration of the study with no significant changes in the SNRs or percept thresholds. Significance. This study demonstrated that an array of 96 microelectrodes can be implanted into the human peripheral nervous system for up to 1 month durations. Such an

Risk of cardiovascular events in people prescribed glucocorticoids with iatrogenic Cushing's syndrome: cohort study.

PubMed

Fardet, Laurence; Petersen, Irene; Nazareth, Irwin

2012-07-30

To investigate whether there is an increased risk of cardiovascular events in people who exhibit iatrogenic Cushing's syndrome during treatment with glucocorticoids. Cohort study. 424 UK general practices contributing to The Health Improvement Network database. People prescribed systemic glucocorticoids and with a diagnosis of iatrogenic Cushing's syndrome (n = 547) and two comparison groups: those prescribed glucocorticoids and with no diagnosis of iatrogenic Cushing's syndrome (n = 3231) and those not prescribed systemic glucocorticoids (n = 3282). Incidence of cardiovascular events within a year after diagnosis of iatrogenic Cushing's syndrome or after a randomly selected date, and association between iatrogenic Cushing's syndrome and risk of cardiovascular events. 417 cardiovascular events occurred in 341 patients. Taking into account only the first event by patient (coronary heart disease n = 177, heart failure n = 101, ischaemic stroke n = 63), the incidence rates of cardiovascular events per 100 person years at risk were 15.1 (95% confidence interval 11.8 to 18.4) in those prescribed glucocorticoids and with a diagnosis of iatrogenic Cushing's syndrome, 6.4 (5.5 to 7.3) in those prescribed glucocorticoids without a diagnosis of iatrogenic Cushing's syndrome, and 4.1 (3.4 to 4.8) in those not prescribed glucocorticoids. In multivariate analyses adjusted for sex, age, intensity of glucocorticoid use, underlying disease, smoking status, and use of aspirin, diabetes drugs, antihypertensive drugs, lipid lowering drugs, or oral anticoagulant drugs, the relation between iatrogenic Cushing's syndrome and cardiovascular events was strong (adjusted hazard ratios 2.27 (95% confidence interval 1.48 to 3.47) for coronary heart disease, 3.77 (2.41 to 5.90) for heart failure, and 2.23 (0.96 to 5.17) for ischaemic cerebrovascular events). The adjusted hazard ratio for any cardiovascular event was 4.16 (2.98 to 5.82) when the group prescribed glucocorticoids and with

Ultrasonographic findings in hereditary neuropathy with liability to pressure palsies.

PubMed

Bayrak, Ayse O; Bayrak, Ilkay Koray; Battaloglu, Esra; Ozes, Burcak; Yildiz, Onur; Onar, Musa Kazim

2015-02-01

The aims of this study were to evaluate the sonographic findings of patients with hereditary neuropathy with liability to pressure palsies (HNPP) and to examine the correlation between sonographic and electrophysiological findings. Nine patients whose electrophysiological findings indicated HNPP and whose diagnosis was confirmed by genetic analysis were enrolled in the study. The median, ulnar, peroneal, and tibial nerves were evaluated by ultrasonography. We ultrasonographically evaluated 18 median, ulnar, peroneal, and tibial nerves. Nerve enlargement was identified in the median, ulnar, and peroneal nerves at the typical sites of compression. None of the patients had nerve enlargement at a site of noncompression. None of the tibial nerves had increased cross-sectional area (CSA) values. There were no significant differences in median, ulnar, and peroneal nerve distal motor latencies (DMLs) between the patients with an increased CSA and those with a normal CSA. In most cases, there was no correlation between electrophysiological abnormalities and clinical or sonographic findings. Although multiple nerve enlargements at typical entrapment sites on sonographic evaluation can suggest HNPP, ultrasonography cannot be used as a diagnostic tool for HNPP. Ultrasonography may contribute to the differential diagnosis of HNPP and other demyelinating polyneuropathies or compression neuropathies; however, further studies are required.

[Features of peripheral nerve injuries in workers exposed to vibration: an analysis of 197 cases].

PubMed

Situ, J; Lin, C M; Qin, Z H; Zhu, D X; Lin, H; Zhang, F F; Zhang, J J

2016-12-20

Objective: To investigate the features of peripheral nerve injuries in workers exposed to vibration. Methods: A total of 197 male workers [median age: 34 years (21 - 50 years) ; median working years of vibration exposure: 7.3 years (1 - 20 years) ] engaged in grinding in an enterprise were enrolled. Their clinical data and electromyography results were analyzed to investigate the features of peripheral nerve impairment. Results: Of all workers, 96 (48.73%) had abnormal electromyography results. Of all workers, 88 (44.7%) had simple mild median nerve injury in the wrist, who accounted for 91.7% (88/96) of all workers with abnormal electromy-ography results. Six workers had ulnar nerve injury, superficial radial nerve injury, or/and superficial peroneal nerve injury and accounted for 6.3% of all workers with abnormal electromyography results. Of all workers, 88 had a reduced amplitude of median nerve sensory transduction, and 28 had slowed median nerve sensory transduction. A total of 46 workers were diagnosed with occupational hand-arm vibration disease and hospitalized for treatment. They were followed up for more than 4 months after leaving their jobs, and most of them showed improvements in neural electromyography results and returned to a normal state. Conclusion: Workers exposed to vibration have a high incidence rate of nerve injury in the hand, mainly sensory function impairment at the distal end of the median nerve, and all injuries are mild peripheral nerve injuries. After leaving the vibration job and being treated, most workers can achieve improvements and return to a normal state.

Historic origin of the "Arcade of Struthers".

PubMed

De Jesus, Ramon; Dellon, A Lee

2003-05-01

John Struthers wrote in 1848 and 1854 about sites of compression of the median nerve from axilla to elbow. He is best known for describing the rare median nerve entrapment by a ligament from a supracondylar process extending to the medial humeral epicondyle. In 1973, observation of ulnar nerve entrapment associated with a midshaft humeral fracture and subsequent anatomic dissections led to the creation of the term "Arcade of Struthers." Review of Struthers' original writings fails to identify either the use of word "arcade" or description of ulnar nerve compression. Review of published anatomic dissections identifies variations in the origin of the medial head of the triceps, not described by Struthers, that may cause failure of an anterior transposition of the ulnar nerve. Continued use of the term "Arcade of Struthers" is historically incorrect.

High-resolution nerve ultrasound and magnetic resonance neurography as complementary neuroimaging tools for chronic inflammatory demyelinating polyneuropathy

PubMed Central

Pitarokoili, Kalliopi; Kronlage, Moritz; Bäumer, Philip; Schwarz, Daniel; Gold, Ralf; Bendszus, Martin; Yoon, Min-Suk

2018-01-01

Background: We present a clinical, electrophysiological, sonographical and magnetic resonance neurography (MRN) study examining the complementary role of two neuroimaging methods of the peripheral nervous system for patients with chronic inflammatory demyelinating polyneuropathy (CIDP). Furthermore, we explore the significance of cross-sectional area (CSA) increase through correlations with MRN markers of nerve integrity. Methods: A total of 108 nerve segments on the median, ulnar, radial, tibial and fibular nerve, as well as the lumbar and cervical plexus of 18 CIDP patients were examined with high-resonance nerve ultrasound (HRUS) and MRN additionally to the nerve conduction studies. Results: We observed a fair degree of correlation of the CSA values for all nerves/nerve segments between the two methods, with a low random error in Bland–Altman analysis (bias = HRUS-CSA − MRN-CSA, −0.61 to −3.26 mm). CSA in HRUS correlated with the nerve T2-weighted (nT2) signal increase as well as with diffusion tensor imaging parameters such as fractional anisotropy, a marker of microstructural integrity. HRUS-CSA of the interscalene brachial plexus correlated significantly with the MRN-CSA and nT2 signal of the L5 and S1 roots of the lumbar plexus. Conclusions: HRUS allows for reliable CSA imaging of all peripheral nerves and the cervical plexus, and CSA correlates with markers of nerve integrity. Imaging of proximal segments as well as the estimation of nerve integrity require MRN as a complementary method. PMID:29552093

Iatrogenic Aortic Valve Perforation after Ventricular Septal Defect Repair

PubMed Central

Ren, Chonglei; Wang, Mingyan; Wang, Yao; Gao, Changqing

2017-01-01

Iatrogenic aortic valve (AV) perforation during non-aortic cardiac operations is a rare complication. The suture-related inadvertent injury to an AV leaflet can produce leaflet perforation with aortic regurgitation after ventricular septal defect repair (VSDR). We report three consecutive patients who had iatrogenic aortic leaflet perforation during VSDR in other hospitals and referred to our hospital for reoperation. In all three cases, the perforated AV leaflets were preserved and repaired by autologous pericardial patch or direct local closure. PMID:29057770

Prevalence of the accessory deep peroneal nerve: A cadaveric study and meta-analysis.

PubMed

Tomaszewski, Krzysztof A; Roy, Joyeeta; Vikse, Jens; Pękala, Przemysław A; Kopacz, Paweł; Henry, Brandon Michael

2016-05-01

The accessory deep peroneal nerve (ADPN) is a common anatomical variant arising from the superficial peroneal nerve (SPN) and, when present, is often responsible for partial or complete innervation of the extensor digitorum brevis muscle (EDBM). The nerve lies posterior to the peroneus brevis muscle, traveling posterior to the lateral malleolus to terminate in the ankle by giving off sensory branches to the ankle and joints. Although the EDBM is usually supplied by the deep peroneal nerve (DPN), in the presence of an ADPN, electrodiagnostic procedures may be complicated. Due to the lack of detailed anatomical knowledge on the topography of the ADPN, its presence posterior to the lateral malleolus can be iatrogenically injured during surgical procedures on the ankle using a lateral approach. Therefore, this meta-analysis aimed to provide a comprehensive, evidence-based assessment of the anatomical characteristics of the ADPN, supplemented with data from our own cadaveric dissection. A comprehensive search of all major electronic databases, including Pubmed, Embase, Scopus, Web of Science, ScienceDirect, SciELO, and BIOSIS was performed. All articles with data on prevalence, symmetry and innervation of the EDBM by the ADPN were included. The anatomical data was then extracted and pooled into a meta-analysis using MetaXL 2.0. In addition, we dissected 21 cadavers (n=42 lower limbs) bilaterally to find the ADPN. A total of 19 studies (n=6070 lower limbs) were included in the meta-analysis. The pooled prevalence of the ADPN was 18.8% (95%CI:14.2-24.0) with a 39.3% prevalence rate for cadaveric studies. The ADPN was present more commonly unilaterally (67.0%) and when it was present, provided branches to the EDBM in 79.5% of cases. In our cadaveric study, the ADPN was identified in 5 of the 42 lower limbs dissected (11.9%); on the right side in 3 lower limbs and on the left side in 2 lower limbs. The ADPN is a clinically important nerve and has been inculpated in

Recurrent Hemarthrosis due to Iatrogenic AVF Treated With Onyx Embolization.

PubMed

Koleilat, Issam; Phair, John

2017-07-01

A 78-year-old gentleman presented with recurrent symptomatic hemarthrosis after total knee arthroplasty. His workup revealed an iatrogenic arteriovenous fistula (iAVF). The iAVF was embolized with the Onyx Liquid Embolization System with resolution of his symptoms up to 10 months of follow-up. This is the first description to our knowledge of an iatrogenic hemarthrosis after total knee arthroplasty successfully treated with Onyx solution embolization.

Remodeling of motor units after nerve regeneration studied by quantitative electromyography.

PubMed

Krarup, Christian; Boeckstyns, Michel; Ibsen, Allan; Moldovan, Mihai; Archibald, Simon

2016-02-01

Peripheral nerve has the capacity to regenerate after nerve lesions; during reinnervation of muscle motor units are gradually reestablished. The aim of this study was to follow the time course of reestablishing and remodeling of motor units in relation to recovery of force after different types of nerve repair. Reinnervation of muscle was compared clinically and electrophysiologically in complete median or ulnar nerve lesions with short gap lengths in the distal forearm repaired with a collagen nerve conduit (11 nerves) or nerve suture (10 nerves). Reestablishment of motor units was studied by quantitative EMG and recording of evoked compound muscle action potential (CMAP) during a 24-month observation period after nerve repair. Force recovered partially to about 80% of normal. Denervation activity gradually decreased during reinnervation though it was still increased at 24 months. Nascent motor unit potentials (MUPs) at early reinnervation were prolonged and polyphasic. During longitudinal studies, MUPs remained prolonged and their amplitudes gradually increased markedly. Firing of MUPs was unstable throughout the study. CMAPs gradually increased and the number of motor units recovered to approximately 20% of normal. There was weak evidence of CMAP amplitude recovery after suture ahead of conduit repair but without treatment related differences at 2 years. Surgical repair of nerve lesions with a nerve conduit or suture supported recovery of force and of motor unit reinnervation to the same extent. Changes occurred at a higher rate during early regeneration and slower after 12 months but should be followed for at least 2 years to assess outcome. EMG changes reflected extensive remodeling of motor units from early nascent units to a mature state with greatly enlarged units due to axonal regeneration and collateral sprouting and maturation of regenerated nerve and reinnervated muscle fibers after both types of repair. Remodeling of motor units after peripheral nerve

Legal liability in iatrogenic orbital injury.

PubMed

Svider, Peter F; Kovalerchik, Olga; Mauro, Andrew C; Baredes, Soly; Eloy, Jean Anderson

2013-09-01

In this study, we detailed factors governing legal outcomes in iatrogenic orbital injury, with the purpose of discussing strategies to minimize liability and enhance patient safety. Retrospective analysis. Jury verdict and settlement reports were searched from publically available federal and state court records using the Westlaw database (Thomson Reuters, New York, NY). After exclusion of nonrelevant cases, 20 cases of iatrogenic orbital injuries were examined for factors such as legal outcome, damages awarded, defendant specialty, alleged causes of malpractice, and patient demographic information. The majority (60.0%) of cases were resolved in the defendant's favor. Payment was considerable for the cases decided in support of the plaintiff, averaging $1.13 million. Out-of-court settlements averaged $1.78 million (range, $487,500-$3.9 million), whereas jury-awarded damages averaged $472,661 (range, $75,000-$763,214). Complications stemming from endoscopic sinus surgery were most common (50.0%). Diplopia was the most common medical complaint (50.0%), whereas permanent deficits and having to undergo additional surgery were each present in 65.0% of cases. The potential for permanent sequelae of iatrogenic orbital injury makes this complication susceptible to malpractice litigation. Otolaryngologists were the most common defendants. Although cases were resolved in the defendant's favor 60% of the time, payments made were considerable, averaging $1.13 million. Steps to minimize liability and improve patient safety include an informed consent process explicitly listing risks, including diplopia and blindness, and obtaining timely ophthalmology consultation when a complication is recognized. Copyright © 2013 The American Laryngological, Rhinological and Otological Society, Inc.

Fasciocutaneous Propeller Flap Based on Perforating Branch of Ulnar Artery for Soft Tissue Reconstruction of the Hand and Wrist.

PubMed

Jang, Hyo Seok; Lee, Young Ho; Kim, Min Bom; Chung, Joo Young; Seok, Hyun Sik; Baek, Goo Hyun

2018-03-01

A skin defect of the hand and wrist is a common manifestation in industrial crushing injuries, traffic accidents or after excision of tumors. We reconstructed a skin defect in the ulnar aspect of the hand and wrist with a perforator-based propeller flap from the ulnar artery. The aims of our study are to evaluate the utility and effectiveness of this flap and to discuss the advantages and disadvantages of the flap in hand and wrist reconstruction with a review of the literature. Between April 2011 and November 2016, five cases of skin defect were reconstructed with a perforator-based propeller flap from the ulnar artery. There were four males and one female. The age of patients ranged from 36 to 73 years. Skin defect sites were on the dorso-ulnar side of the hand in three cases and palmar-ulnar side of the wrist in two cases. The size of the skin defect ranged from 4 × 3 cm to 8 × 5 cm. We evaluated the viability of the flap, postoperative complication and patient's satisfaction. There was no failure of flap in all cases. The size of the flap ranged from 4 × 4 cm to 12 × 4 cm. One patient, who had a burn scar contracture, presented with limited active and passive motion of the wrist after the operation. The other patients had no complications postoperatively. Cosmetic results of the surgery were excellent in one patient, good in three patients, and fair in one patient. The fasciocutaneous propeller flap based on a perforating branch of the ulnar artery is a reliable treatment option for the ulnar side skin defect of the hand and wrist.

Two cases of feline ectromelia: autopodium ectromelia associated with humero-ulnar synostosis and zeugopodium ectromelia.

PubMed

Macrì, Francesco; De Majo, Massimo; Rapisarda, Giuseppe; Mazzullo, Giuseppe

2009-08-01

Congenital limb deformities are rarely reported in cats. This paper describes the radiographic findings of congenital forelimb malformations in two cats. The radiographic changes were suggestive of an autopodium ectromelia associated with humero-ulnar synostosis in one case and zeugopodium ectromelia in the other case. Congenital feline limb deformities are poorly documented and, to the authors' knowledge, this is the first time that humero-ulnar synostosis has been reported in cats.

Neurophysiological localisation of ulnar neuropathy at the elbow: Validation of diagnostic criteria developed by a taskforce of the Danish Society of clinical neurophysiology.

PubMed

Pugdahl, K; Beniczky, S; Wanscher, B; Johnsen, B; Qerama, E; Ballegaard, M; Benedek, K; Juhl, A; Ööpik, M; Selmar, P; Sønderborg, J; Terney, D; Fuglsang-Frederiksen, A

2017-11-01

This study validates consensus criteria for localisation of ulnar neuropathy at elbow (UNE) developed by a taskforce of the Danish Society of Clinical Neurophysiology and compares them to the existing criteria from the American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM). The Danish criteria are based on combinations of conduction slowing in the segments of the elbow and forearm expressed in Z-scores, and difference between the segments in m/s. Examining fibres to several muscles and sensory fibres can increase the certainty of the localisation. Diagnostic accuracy for UNE was evaluated on 181 neurophysiological studies of the ulnar nerve from 171 peer-reviewed patients from a mixed patient-group. The diagnostic reference standard was the consensus diagnosis based on all available clinical, laboratory, and electrodiagnostic information reached by a group of experienced Danish neurophysiologists. The Danish criteria had high specificity (98.4%) and positive predictive value (PPV) (95.2%) and fair sensitivity (76.9%). Compared to the AANEM criteria, the Danish criteria had higher specificity (p<0.001) and lower sensitivity (p=0.02). The Danish consensus criteria for UNE are very specific and have high PPV. The Danish criteria for UNE are reliable and well suited for use in different centres as they are based on Z-scores. Copyright © 2017 International Federation of Clinical Neurophysiology. Published by Elsevier B.V. All rights reserved.

The pattern of peripheral nerve injuries among Pakistani soldiers in the war against terror.

PubMed

Razaq, Sarah; Yasmeen, Rehana; Butt, Aamir Waheed; Akhtar, Noreen; Mansoor, Sahibzada Nasir

2015-05-01

To determine the pattern of peripheral nerve injuries in Pakistani soldiers in the War against terror. Case series. Department of Electrodiagnosis at Armed Forces Institute of Rehabilitation Medicine (AFIRM), Rawalpindi, Pakistan, from June 2008 to June 2011. All new cases of war wounded soldiers with peripheral nerve injuries were consecutively enrolled. Physical examination and electrodiagnostic study was carried out by experienced physiatrists. Data was entered in pretested especially designed questionnaire which was analysed using SPSS version 17.0. Seddon's classification system was used to assess the severity of injury. There were 418 cases of peripheral nerve injuries with 504 different nerve segments. Mean age was 29.41 ±8 years. Blast was the main cause of nerve injury in 244 (48.5%) cases followed by gunshot in 215 (42.7%) and 45 (8.9%) cases had nerve injuries secondary to fall, burial under debris and motor vehicle accidents. Eighty six (17%) cases had multiple nerve injuries. Most commonly injured nerve was ulnar (20.6%) followed by sciatic (16.7%), median (16.5%), radial (16.3%), peroneal (8.7%), brachial plexus (8.5%), axillary (4.8%), tibial (2%), femoral (1.8%), long thoracic (0.4%) and others (3.8%). Axonotmesis was seen in 459 (91.1%) cases, 44 (8.7%) cases revealed neurotmesis and 1 (0.2%) case had neuropraxia. Peripheral nerve injuries are a major component of war related injuries mainly involving the upper limbs. Electrodiagnostic studies help in assessing severity and determining prognosis. Precise documentation of severity of nerve injuries is important to estimate the burden on our resources and to extend rehabilitation services.

Effects of socioeconomic position and clinical risk factors on spontaneous and iatrogenic preterm birth

PubMed Central

2014-01-01

Background The literature shows a variable and inconsistent relationship between socioeconomic position and preterm birth. We examined risk factors for spontaneous and iatrogenic preterm birth, with a focus on socioeconomic position and clinical risk factors, in order to explain the observed inconsistency. Methods We carried out a retrospective population-based cohort study of all singleton deliveries in Nova Scotia from 1988 to 2003. Data were obtained from the Nova Scotia Atlee Perinatal Database and the federal income tax T1 Family Files. Separate logistic models were used to quantify the association between socioeconomic position, clinical risk factors and spontaneous preterm birth and iatrogenic preterm birth. Results The study population included 132,714 singleton deliveries and the rate of preterm birth was 5.5%. Preterm birth rates were significantly higher among the women in the lowest (versus the highest) family income group for spontaneous (rate ratio 1.14, 95% confidence interval (CI) 1.03, 1.25) but not iatrogenic preterm birth (rate ratio 0.95, 95% CI 0.75, 1.19). Adjustment for maternal characteristics attenuated the family income-spontaneous preterm birth relationship but strengthened the relationship with iatrogenic preterm birth. Clinical risk factors such as hypertension were differentially associated with spontaneous (rate ratio 3.92, 95% CI 3.47, 4.44) and iatrogenic preterm (rate ratio 14.1, 95% CI 11.4, 17.4) but factors such as diabetes mellitus were not (rate ratio 4.38, 95% CI 3.21, 5.99 for spontaneous and 4.02, 95% CI 2.07, 7.80 for iatrogenic preterm birth). Conclusions Socioeconomic position and clinical risk factors have different effects on spontaneous and iatrogenic preterm. Recent temporal increases in iatrogenic preterm birth appear to be responsible for the inconsistent relationship between socioeconomic position and preterm birth. PMID:24670050

Effects of socioeconomic position and clinical risk factors on spontaneous and iatrogenic preterm birth.

PubMed

Joseph, K S; Fahey, John; Shankardass, Ketan; Allen, Victoria M; O'Campo, Patricia; Dodds, Linda; Liston, Robert M; Allen, Alexander C

2014-03-27

The literature shows a variable and inconsistent relationship between socioeconomic position and preterm birth. We examined risk factors for spontaneous and iatrogenic preterm birth, with a focus on socioeconomic position and clinical risk factors, in order to explain the observed inconsistency. We carried out a retrospective population-based cohort study of all singleton deliveries in Nova Scotia from 1988 to 2003. Data were obtained from the Nova Scotia Atlee Perinatal Database and the federal income tax T1 Family Files. Separate logistic models were used to quantify the association between socioeconomic position, clinical risk factors and spontaneous preterm birth and iatrogenic preterm birth. The study population included 132,714 singleton deliveries and the rate of preterm birth was 5.5%. Preterm birth rates were significantly higher among the women in the lowest (versus the highest) family income group for spontaneous (rate ratio 1.14, 95% confidence interval (CI) 1.03, 1.25) but not iatrogenic preterm birth (rate ratio 0.95, 95% CI 0.75, 1.19). Adjustment for maternal characteristics attenuated the family income-spontaneous preterm birth relationship but strengthened the relationship with iatrogenic preterm birth. Clinical risk factors such as hypertension were differentially associated with spontaneous (rate ratio 3.92, 95% CI 3.47, 4.44) and iatrogenic preterm (rate ratio 14.1, 95% CI 11.4, 17.4) but factors such as diabetes mellitus were not (rate ratio 4.38, 95% CI 3.21, 5.99 for spontaneous and 4.02, 95% CI 2.07, 7.80 for iatrogenic preterm birth). Socioeconomic position and clinical risk factors have different effects on spontaneous and iatrogenic preterm. Recent temporal increases in iatrogenic preterm birth appear to be responsible for the inconsistent relationship between socioeconomic position and preterm birth.

Motor Nerve Conduction Velocity In Postmenopausal Women with Peripheral Neuropathy.

PubMed

Singh, Akanksha; Asif, Naiyer; Singh, Paras Nath; Hossain, Mohd Mobarak

2016-12-01

The post-menopausal phase is characterized by a decline in the serum oestrogen and progesterone levels. This phase is also associated with higher incidence of peripheral neuropathy. To explore the relationship between the peripheral motor nerve status and serum oestrogen and progesterone levels through assessment of Motor Nerve Conduction Velocity (MNCV) in post-menopausal women with peripheral neuropathy. This cross-sectional study was conducted at Jawaharlal Nehru Medical College during 2011-2013. The study included 30 post-menopausal women with peripheral neuropathy (age: 51.4±7.9) and 30 post-menopausal women without peripheral neuropathy (control) (age: 52.5±4.9). They were compared for MNCV in median, ulnar and common peroneal nerves and serum levels of oestrogen and progesterone estimated through enzyme immunoassays. To study the relationship between hormone levels and MNCV, a stepwise linear regression analysis was done. The post-menopausal women with peripheral neuropathy had significantly lower MNCV and serum oestrogen and progesterone levels as compared to control subjects. Stepwise linear regression analysis showed oestrogen with main effect on MNCV. The findings of the present study suggest that while the post-menopausal age group is at a greater risk of peripheral neuropathy, it is the decline in the serum estrogen levels which is critical in the development of peripheral neuropathy.

Variations in the surface anatomy of the spinal accessory nerve in the posterior triangle.

PubMed

Symes, A; Ellis, H

2005-12-01

Iatrogenic injury to the spinal accessory nerve has been widely documented and can have medico-legal implications. The resulting syndrome of pain, paralysis and winging of the scapula are often the source of considerable morbidity. This paper researches the degree of accuracy achievable in mapping the surface anatomy of the spinal accessory nerve in the region of the posterior triangle with a view to creating a cartographical aid to surgical procedures. The necks of 25 adult cadavers were dissected bilaterally to expose the spinal accessory nerve. Variations in the course and distribution of the spinal accessory nerve in the posterior triangle were recorded along with its relationship to the borders of sternocleidomastoid and trapezius. Considerable variation was seen in the surface and regional anatomy of the nerve and in the contribution of the cervical plexus to the spinal accessory nerve in the posterior triangle. Measurements of the running course and exit point of the nerve into and from the posterior triangle differed significantly from those previously recorded. Delineation of an accurate surface anatomy was not possible. Creating a map to define the surface anatomy of the spinal accessory nerve in the posterior triangle is an unrealistic goal given its wide variations in man. Avoidance of damage to the spinal accessory nerve cannot be achieved by slavishly adhering to surface markings given in textbooks, but only by cautious dissection during operations on the posterior triangle.

Iatrogenic Hepatitis C Virus Transmission and Safe Injection Practices.

PubMed

Defendorf, Charles M; Paul, Sindy; Scott, George J

2018-05-01

Hepatitis C virus (HCV) infection poses significant adverse health effects. Improper use of vials, needles, syringes, intravenous bags, tubing, and connectors for injections and infusions is a current preventable cause of iatrogenic HCV transmission. Numerous cases have demonstrated the need for continued vigilance and the widespread nature of this iatrogenic infection risk across a variety of medical practice settings in the United States. Failure to implement the evidence-based Centers for Disease Control and Prevention (CDC) infection prevention guidelines exposes patients to preventable harm. The guidelines establish the requirement to notify patients in cases of suspected virus transmission, as well as to screen those patients who would not otherwise have been at risk for HCV seroconversion and other bloodborne pathogens. Legal and regulatory ramifications, including state, criminal, and tort laws, hold physicians and other health care professionals accountable to use safe injection practices. This article reviews the major health risks of HCV infection, significant effects of iatrogenic infection transmission, CDC guidelines for safe injection practices, and legal regulations and ramifications designed to promote safe injection practices.

[Neurophysiological identification of the cranial nerves in endoscopic endonasal surgery of skull base tumors].

PubMed

Shkarubo, A N; Ogurtsova, A A; Moshchev, D A; Lubnin, A Yu; Andreev, D N; Koval', K V; Chernov, I V

2016-01-01

Intraoperative identification of the cranial nerves is a useful technique in removal of skull base tumors through the endoscopic endonasal approach. Searching through the scientific literature found one pilot study on the use of triggered electromyography (t-EMG) for identification of the VIth nerve in endonasal endoscopic surgery of skull base tumors (D. San-Juan, et al, 2014). The study objective was to prevent iatrogenic injuries to the cranial nerves without reducing the completeness of tumor tissue resection. In 2014, 5 patients were operated on using the endoscopic endonasal approach. Surgeries were performed for large skull base chordomas (2 cases) and trigeminal nerve neurinomas located in the cavernous sinus (3). Intraoperatively, identification of the cranial nerves was performed by triggered electromyography using a bipolar electrode (except 1 case of chordoma where a monopolar electrode was used). Evaluation of the functional activity of the cranial nerves was carried out both preoperatively and postoperatively. Tumor resection was total in 4 out of 5 cases and subtotal (chordoma) in 1 case. Intraoperatively, the IIIrd (2 patients), Vth (2), and VIth (4) cranial nerves were identified. No deterioration in the function of the intraoperatively identified nerves was observed in the postoperative period. In one case, no responses from the VIth nerve on the right (in the cavernous sinus region) were intraoperatively obtained, and deep paresis (up to plegia) of the nerve-innervated muscles developed in the postoperative period. The nerve function was not impaired before surgery. The t-EMG technique is promising and requires further research.

Impact of keyboard typing on the morphological changes of the median nerve

PubMed Central

Yeap Loh, Ping; Liang Yeoh, Wen; Nakashima, Hiroki; Muraki, Satoshi

2017-01-01

Objectives: The primary objective was to investigate the effects of continuous typing on median nerve changes at the carpal tunnel region at two different keyboard slopes (0° and 20°). The secondary objective was to investigate the differences in wrist kinematics and the changes in wrist anthropometric measurements when typing at the two different keyboard slopes. Methods: Fifteen healthy right-handed young men were recruited. A randomized sequence of the conditions (control, typing I, and typing II) was assigned to each participant. Wrist anthropometric measurements, wrist kinematics data collection and ultrasound examination to the median nerve was performed at designated time block. Results: Typing activity and time block do not cause significant changes to the wrist anthropometric measurements. The wrist measurements remained similar across all the time blocks in the three conditions. Subsequently, the wrist extensions and ulnar deviations were significantly higher in both the typing I and typing II conditions than in the control condition for both wrists (p<0.05). Additionally, the median nerve cross-sectional area (MNCSA) significantly increased in both the typing I and typing II conditions after the typing task than before the typing task. The MNCSA significantly decreased in the recovery phase after the typing task. Conclusions: This study demonstrated the immediate changes in the median nerve after continuous keyboard typing. Changes in the median nerve were greater during typing using a keyboard tilted at 20° than during typing using a keyboard tilted at 0°. The main findings suggest wrist posture near to neutral position caused lower changes of the median nerve. PMID:28701627

Impact of keyboard typing on the morphological changes of the median nerve.

PubMed

Yeap Loh, Ping; Liang Yeoh, Wen; Nakashima, Hiroki; Muraki, Satoshi

2017-09-28

The primary objective was to investigate the effects of continuous typing on median nerve changes at the carpal tunnel region at two different keyboard slopes (0° and 20°). The secondary objective was to investigate the differences in wrist kinematics and the changes in wrist anthropometric measurements when typing at the two different keyboard slopes. Fifteen healthy right-handed young men were recruited. A randomized sequence of the conditions (control, typing I, and typing II) was assigned to each participant. Wrist anthropometric measurements, wrist kinematics data collection and ultrasound examination to the median nerve was performed at designated time block. Typing activity and time block do not cause significant changes to the wrist anthropometric measurements. The wrist measurements remained similar across all the time blocks in the three conditions. Subsequently, the wrist extensions and ulnar deviations were significantly higher in both the typing I and typing II conditions than in the control condition for both wrists (p<0.05). Additionally, the median nerve cross-sectional area (MNCSA) significantly increased in both the typing I and typing II conditions after the typing task than before the typing task. The MNCSA significantly decreased in the recovery phase after the typing task. This study demonstrated the immediate changes in the median nerve after continuous keyboard typing. Changes in the median nerve were greater during typing using a keyboard tilted at 20° than during typing using a keyboard tilted at 0°. The main findings suggest wrist posture near to neutral position caused lower changes of the median nerve.

Massive thoracoabdominal aortic thrombosis in a patient with iatrogenic Cushing syndrome.

PubMed

Kim, Dong Hun; Choi, Dong-Hyun; Lee, Young-Min; Kang, Joon Tae; Chae, Seung Seok; Kim, Bo-Bae; Ki, Young-Jae; Kim, Jin Hwa; Chung, Joong-Wha; Koh, Young-Youp

2014-01-01

Massive thoracoabdominal aortic thrombosis is a rare finding in patients with iatrogenic Cushing syndrome in the absence of any coagulation abnormality. It frequently represents an urgent surgical situation. We report the case of an 82-year-old woman with massive aortic thrombosis secondary to iatrogenic Cushing syndrome. A follow-up computed tomography scan showed a decreased amount of thrombus in the aorta after anticoagulation therapy alone.

Risk of cardiovascular events in people prescribed glucocorticoids with iatrogenic Cushing’s syndrome: cohort study

PubMed Central

Petersen, Irene; Nazareth, Irwin

2012-01-01

Objective To investigate whether there is an increased risk of cardiovascular events in people who exhibit iatrogenic Cushing’s syndrome during treatment with glucocorticoids. Design Cohort study. Setting 424 UK general practices contributing to The Health Improvement Network database. Participants People prescribed systemic glucocorticoids and with a diagnosis of iatrogenic Cushing’s syndrome (n=547) and two comparison groups: those prescribed glucocorticoids and with no diagnosis of iatrogenic Cushing’s syndrome (n=3231) and those not prescribed systemic glucocorticoids (n=3282). Main outcome measures Incidence of cardiovascular events within a year after diagnosis of iatrogenic Cushing’s syndrome or after a randomly selected date, and association between iatrogenic Cushing’s syndrome and risk of cardiovascular events. Results 417 cardiovascular events occurred in 341 patients. Taking into account only the first event by patient (coronary heart disease n=177, heart failure n=101, ischaemic stroke n=63), the incidence rates of cardiovascular events per 100 person years at risk were 15.1 (95% confidence interval 11.8 to 18.4) in those prescribed glucocorticoids and with a diagnosis of iatrogenic Cushing’s syndrome, 6.4 (5.5 to 7.3) in those prescribed glucocorticoids without a diagnosis of iatrogenic Cushing’s syndrome, and 4.1 (3.4 to 4.8) in those not prescribed glucocorticoids. In multivariate analyses adjusted for sex, age, intensity of glucocorticoid use, underlying disease, smoking status, and use of aspirin, diabetes drugs, antihypertensive drugs, lipid lowering drugs, or oral anticoagulant drugs, the relation between iatrogenic Cushing’s syndrome and cardiovascular events was strong (adjusted hazard ratios 2.27 (95% confidence interval 1.48 to 3.47) for coronary heart disease, 3.77 (2.41 to 5.90) for heart failure, and 2.23 (0.96 to 5.17) for ischaemic cerebrovascular events). The adjusted hazard ratio for any cardiovascular event was 4

Iatrogenic perforation of perivaterian duodenal diverticulum: report of a case

PubMed Central

Cavanagh, James E.

1996-01-01

The author reports a case of iatrogenic perforation of a duodenal diverticulum, an extremely rare occurrence, during percutaneous radiologic extraction of a retained common-bile-duct stone. Perforation was related to the perivaterian location of the duodenal diverticulum. Because an inflammatory reaction was present, tube duodenostomy was chosen over excision, closure and drainage to prevent the complication of lateral duodenal fistula and sepsis. Whenever iatrogenic duodenal perforation is suspected, prompt radiologic documentation and early surgical consultation should be sought. PMID:8697327

Management of iatrogenic crystalline lens injury occurred during intravitreal injection.

PubMed

Erdogan, Gurkan; Gunay, Betul Onal; Unlu, Cihan; Gunay, Murat; Ergin, Ahmet

2016-08-01

To evaluate the approach to management of iatrogenic crystalline lens injury occurred during intravitreal injection (IVI). The patients who were managed operatively or followed-up without intervention after the iatrogenic lens injury due to IVI were included in the study. Capsular breaks remained either quiescent or resulted in cataract formation in the patients with inadvertent crystalline lens capsule damage. Phacoemulsification surgery was performed in patients with cataract formation with lower fluidic settings. A total of 9 cases included in the study. Seven cases underwent phacoemulsification with intraocular lens implantation. Two cases remained as quiescent lens injury during the follow-up. In 2 cases, dislocation of lens fragments occurred during phacoemulsification where pars plana vitrectomy was performed at the same session. After iatrogenic crystalline lens injury, capsular damage could remain quiescent or progress to cataract formation. Although phacoemulsification surgery can be performed with appropriate parameters, lens fragment dislocation can be observed in cases with traumatic lens damage secondary to IVI.

The effect of early relearning on sensory recovery 4 to 9 years after nerve repair: a report of a randomized controlled study.

PubMed

Vikström, Pernilla; Rosén, Birgitta; Carlsson, Ingela K; Björkman, Anders

2018-01-01

Twenty patients randomized to early sensory relearning (nine patients) or traditional relearning (11 patients) were assessed regarding sensory recovery 4 to 9 years after median or ulnar nerve repair. Outcomes were assessed with the Rosen score, questionnaires, and self-reported single-item questions regarding function and activity. The patients with early sensory relearning had significantly better sensory recovery in the sensory domain of the Rosen score, specifically, discriminative touch or tactile gnosis and dexterity. They had significantly less self-reported problems in gripping, clumsiness, and fine motor skills. No differences were found in questionnaires between the two groups. We conclude that early sensory relearning improves long-term sensory recovery following nerve repair. I.

Iatrogenic Buschke's disease (Michelin man syndrome)

PubMed

Ahmad, N; Lawrence, J R; Macdonald, J W

1988-02-01

Scleredema [corrected] adultorum as originally described by Buschke in 1900, is cutaneous thickening of unknown aetiology. Since then several cases have been reported which have illustrated different aspects of the disease but the exact aetiology, pathogenesis and prognosis remain uncertain. Disease of possible iatrogenic origin appears not to have been described previously.

Low Peripheral Nerve Conduction Velocities and Amplitudes Are Strongly Related to Diabetic Microvascular Complications in Type 1 Diabetes

PubMed Central

Charles, Morten; Soedamah-Muthu, Sabita S.; Tesfaye, Solomon; Fuller, John H.; Arezzo, Joseph C.; Chaturvedi, Nishi; Witte, Daniel R.

2010-01-01

OBJECTIVE Slow nerve conduction velocity and reduction in response amplitude are objective hallmarks of diabetic sensorimotor polyneuropathy. Because subjective or clinical indicators of neuropathy do not always match well with the presence of abnormal nerve physiology tests, we evaluated associations to nerve conduction in patients with type 1 diabetes. RESEARCH DESIGN AND METHODS Nerve conduction studies were performed in the distal sural and ulnar sensory nerves and the peroneal motor nerve in 456 individuals with type 1 diabetes who participated in the follow-up visit of the EURODIAB Prospective Complications Study (EPCS). We used multivariate regression models to describe associations to decreased nerve conduction measures. RESULTS In addition to an effect of duration of diabetes and A1C, which were both associated with low nerve conduction velocity and response amplitude, we found that the presence of nephropathy, retinopathy, or a clinical diagnosis of neuropathy was associated with low nerve conduction velocity and amplitude. In the case of nonproliferative retinopathy, the odds ratio (OR) for being in lowest tertile was 2.30 (95% CI 1.13–4.67) for nerve conduction velocity. A similar OR was found for each 2% difference in A1C (2.39 [1.68–3.41]). CONCLUSIONS We show that the presence of other microvascular diabetes complications, together with diabetes duration and A1C, are associated with low nerve conduction velocity and amplitude response and that cardiovascular disease or risk factors do not seem to be associated with these measures. PMID:20823346

Partial lesions of the intratemporal segment of the facial nerve: graft versus partial reconstruction.

PubMed

Bento, Ricardo F; Salomone, Raquel; Brito, Rubens; Tsuji, Robinson K; Hausen, Mariana

2008-09-01

In cases of partial lesions of the intratemporal segment of the facial nerve, should the surgeon perform an intraoperative partial reconstruction, or partially remove the injured segment and place a graft? We present results from partial lesion reconstruction on the intratemporal segment of the facial nerve. A retrospective study on 42 patients who presented partial lesions on the intratemporal segment of the facial nerve was performed between 1988 and 2005. The patients were divided into 3 groups based on the procedure used: interposition of the partial graft on the injured area of the nerve (group 1; 12 patients); keeping the preserved part and performing tubulization (group 2; 8 patients); and dividing the parts of the injured nerve (proximal and distal) and placing a total graft of the sural nerve (group 3; 22 patients). Fracture of the temporal bone was the most frequent cause of the lesion in all groups, followed by iatrogenic causes (p < 0.005). Those who obtained results lower than or equal to III on the House-Brackmann scale were 1 (8.3%) of the patients in group 1, none (0.0%) of the patients in group 2, and 15 (68.2%) of the patients in group 3 (p <0.001). The best surgical technique for therapy of a partial lesion of the facial nerve is still questionable. Among these 42 patients, the best results were those from the total graft of the facial nerve.

A clear map of the lower cranial nerves at the superior carotid triangle.

PubMed

Cavalcanti, Daniel D; Garcia-Gonzalez, Ulises; Agrawal, Abhishek; Tavares, Paulo L M S; Spetzler, Robert F; Preul, Mark C

2010-07-01

The lower cranial nerves must be identified to avoid iatrogenic injury during skull base and high cervical approaches. Prompt recognition of these structures using basic landmarks could reduce surgical time and morbidity. The anterior triangle of the neck was dissected in 30 cadaveric head sides. The most superficial segments of the glossopharyngeal, vagus and its superior laryngeal nerves, accessory, and hypoglossal nerves were exposed and designated into smaller anatomic triangles. The midpoint of each nerve segment inside the triangles was correlated to the angle of the mandible (AM), mastoid tip (MT), and bifurcation of the common carotid artery. A triangle bounded by the styloglossus muscle, external carotid artery, and facial artery housed the glossopharyngeal nerve. This nerve segment was 0.06 ± 0.71 cm posterior to the AM and 2.50 ± 0.59 cm inferior to the MT. The vagus nerve ran inside the carotid sheath posterior to internal carotid artery and common carotid artery bifurcation in 48.3% of specimens. A triangle formed by the posterior belly of digastric muscle, sternocleidomastoid muscle, and internal jugular vein housed the accessory nerve, 1.90 ± 0.60 cm posterior to the AM and 2.30 ± 0.57 cm inferior to the MT. A triangle outlined by the posterior belly of digastric muscle, internal jugular vein, and common facial vein housed the hypoglossal nerve, which was 0.82 ± 0.84 cm posterior to the AM and 3.64 ± 0.70 cm inferior to the MT. Comprehensible landmarks can be defined to help expose the lower cranial nerves to avoid injury to this complex region. Copyright © 2010 Elsevier Inc. All rights reserved.

Evidence-based outcomes following inferior alveolar and lingual nerve injury and repair: a systematic review.

PubMed

Kushnerev, E; Yates, J M

2015-10-01

The inferior alveolar nerve (IAN) and lingual (LN) are susceptible to iatrogenic surgical damage. Systematically review recent clinical evidence regarding IAN/LN repair methods and to develop updated guidelines for managing injury. Recent publications on IAN/LN microsurgical repair from Medline, Embase and Cochrane Library databases were screened by title/abstract. Main texts were appraised for exclusion criteria: no treatment performed or results provided, poor/lacking procedural description, cohort <3 patients. Of 366 retrieved papers, 27 were suitable for final analysis. Treatment type for injured IANs/LNs depended on injury type, injury timing, neurosensory disturbances and intra-operative findings. Best functional nerve recovery occurred after direct apposition and suturing if nerve ending gaps were <10 mm; larger gaps required nerve grafting (sural/greater auricular nerve). Timing of microneurosurgical repair after injury remains debated. Most authors recommend surgery when neurosensory deficit shows no improvement 90 days post-diagnosis. Nerve transection diagnosed intra-operatively should be repaired in situ; minor nerve injury repair can be delayed. No consensus exists regarding optimal methods and timing for IAN/LN repair. We suggest a schematic guideline for treating IAN/LN injury, based on the most current evidence. We acknowledge that additional RCTs are required to provide definitive confirmation of optimal treatment approaches. © 2015 John Wiley & Sons Ltd.

Nerve supply of the subscapularis during anterior shoulder surgery: definition of a potential risk area.

PubMed

Leschinger, Tim; Hackl, Michael; Zeifang, Felix; Scaal, Martin; Müller, Lars Peter; Wegmann, Kilian

2017-01-01

The purpose of the study was to evaluate the position of the subscapular nerves relative to surgical landmarks during exposure and to analyze the pattern of innervation of the subscapularis to avoid injury during anterior shoulder surgery. 20 embalmed human cadaveric shoulder specimens were used in the study. The muscular insertions of the subscapular nerves were marked and their closest branches to the musculotendinous junction and the coracoid process were measured in horizontal and vertical distances. In addition, the innervation pattern of each specimen was documented. 14/20 specimens showed an innervation of the subscapularis with an upper, middle and lower subscapular nerve branch. Even though the nerve branches were in average more than 2 cm medial to the musculotendinous junction, minimal distances of 1.1-1.3 cm were found. The mean vertical distance as measured from the medial base of the coracoid to the nerve innervation point into the muscle was 0.7 cm for the upper nerve branch, 2.2 cm for the middle nerve branch and 4.4 cm for the lower nerve branch. The subscapularis has a variable nerve supply, which increases the risk of muscle denervation during open shoulder surgery. Dissection or release should be avoided at the anterior aspect of the subscapularis muscle more than 1 cm medial to the musculotendinous junction. In approaches with a horizontal incision of the subscapularis, splitting should be performed at a vertical distance of 3.2-3.6 cm to the coracoid base to avoid iatrogenic subscapular nerve injuries.

Three lateral divergent or parallel pin fixations for the treatment of displaced supracondylar humerus fractures in children.

PubMed

Lee, Young Ho; Lee, Sang Ki; Kim, Byung Sung; Chung, Moon Sang; Baek, Goo Hyun; Gong, Hyun Sik; Lee, Joon Kyu

2008-06-01

To evaluate the efficacy of lateral or parallel pin fixation using 3 smooth Kirschner wires (K-wires) or smooth Steinmann pins for the operative management of displaced supracondylar humeral fracture in a consecutive series of children. Sixty-one consecutive displaced or angled supracondylar humeral fractures (Gartland type II or III) in children (mean age, 5 years 6 months) treated by 2 orthopaedic surgeons between 2001 and 2004 according to the following protocol: close reduction under general anesthesia with fluoroscopic guidance and only lateral percutaneous pinning using 3 divergent or parallel Kirschner wires or Steinmann pins. Minimum 2 years' follow-up was done in all 61 patients (range, 2.0-3.3 years). Clinical assessment was obtained at final follow-up using Flynn criteria, and radiologic assessment was obtained using the Baumann and lateral humerocapitellar angles of both arms. Statistical analysis was performed by means of the Student t test (P < 0.05). The study group consisted of 61 patients, of whom 24 (39%) presented with Gartland type II fractures, and the remaining 37 (61%) presented with a type III fracture. A comparison of perioperative and final radiographs shows no loss of reduction of any fracture. There was also no clinically evident cubitus varus, hyperextension, or loss of motion. Eight patients had preoperative nerve palsy. Five of these nerve injuries resolved immediately after surgery, and the other 3 resolved completely within 12 weeks of surgery. After an average of 28 months postoperation, 56 (91.8%) patients had achieved an excellent clinical result, and 5 (8.2%) achieved a good result. There were no iatrogenic nerve palsies, and no patient required additional surgery. One patient had a minor pin-track infection. Our series demonstrates that only 3 lateral divergent or parallel pin fixations are effective and safe for avoiding iatrogenic ulnar nerve injury and are appropriate treatment options for displaced or angled supracondylar

The risk of iatrogenic pneumothorax after electromyography.

PubMed

Kassardjian, Charles D; O'gorman, Cullen M; Sorenson, Eric J

2016-04-01

Pneumothorax is a potentially serious complication of electromyography (EMG). Data on the frequency of pneumothorax after EMG are lacking. The purpose of this study was to determine the frequency, timing, and risk factors for iatrogenic pneumothorax after EMG. Cases of pneumothorax after EMG were reviewed for clinical, electrophysiological, and radiological data. Of 64,490 EMG studies, 7 patients had an association between the EMG and pneumothorax. All patients were symptomatic and presented within 24 hours of EMG. Sampling of serratus anterior and diaphragm was causative in 1 patient each. In 5 patients, multiple high-risk muscles were sampled. The highest frequency of pneumothorax was observed with examination of serratus anterior (0.445%) and diaphragm (0.149%). The frequency of symptomatic iatrogenic pneumothorax after EMG appears to be low, and examinations of serratus anterior and diaphragm carry the highest risk. Electromyographers should be aware of the risk of pneumothorax and should counsel patients accordingly. © 2015 Wiley Periodicals, Inc.

Exploration of Hand Grasp Patterns Elicitable Through Non-Invasive Proximal Nerve Stimulation.

PubMed

Shin, Henry; Watkins, Zach; Hu, Xiaogang

2017-11-29

Various neurological conditions, such as stroke or spinal cord injury, result in an impaired control of the hand. One method of restoring this impairment is through functional electrical stimulation (FES). However, traditional FES techniques often lead to quick fatigue and unnatural ballistic movements. In this study, we sought to explore the capabilities of a non-invasive proximal nerve stimulation technique in eliciting various hand grasp patterns. The ulnar and median nerves proximal to the elbow joint were activated transcutanously using a programmable stimulator, and the resultant finger flexion joint angles were recorded using a motion capture system. The individual finger motions averaged across the three joints were analyzed using a cluster analysis, in order to classify the different hand grasp patterns. With low current intensity (<5 mA and 100 µs pulse width) stimulation, our results show that all of our subjects demonstrated a variety of consistent hand grasp patterns including single finger movement and coordinated multi-finger movements. This study provides initial evidence on the feasibility of a proximal nerve stimulation technique in controlling a variety of finger movements and grasp patterns. Our approach could also be developed into a rehabilitative/assistive tool that can result in flexible movements of the fingers.

Surgical anatomy of the radial nerve at the elbow.

PubMed

Artico, M; Telera, S; Tiengo, C; Stecco, C; Macchi, V; Porzionato, A; Vigato, E; Parenti, A; De Caro, R

2009-02-01

An anatomical study of the brachial portion of the radial nerve with surgical implications is proposed. Thirty specimens of arm from 20 fresh cadavers (11 male, 9 female) were used to examine the topographical relations of the radial nerve with reference to the following anatomical landmarks: acromion angle, medial and lateral epicondyles, point of division between the lateral and long heads of the triceps brachii, lateral intermuscular septum, site of division of the radial nerve into its superficial and posterior interosseous branches and entry and exit point of the posterior interosseous branch into the supinator muscle. The mean distances between the acromion angle and the medial and lateral levels of crossing the posterior aspect of the humerus were 109 (+/-11) and 157 (+/-11) mm, respectively. The mean length and calibre of the nerve in the groove were 59 (+/-4) and 6 (+/-1) mm, respectively. The division of the lateral and long heads of the triceps was found at a mean distance of 126 (+/-13) mm from the acromion angle. The mean distances between the lateral point of crossing the posterior aspect of the humerus and the medial and lateral epicondyles were 125 (+/-13) and 121 (+/-13) mm, respectively. The mean distance between the lateral point of crossing the posterior aspect of the humerus and the entry point in the lateral intermuscular septum (LIS) was 29 (+/-6) mm. The mean distances between the entry point of the nerve in the LIS and the medial and lateral epicondyles were 133 (+/-14) and 110 (+/-23) mm, respectively. Our study provides reliable and objective data of surgical anatomy of the radial nerve which should be always kept in mind by surgeons approaching to the surgery of the arm, in order to avoid iatrogenic injuries.

Iatrogenic Skin Disorders and Related Factors in Newborn Infants.

PubMed

Csoma, Zsanett Renáta; Meszes, Angéla; Ábrahám, Rita; Kemény, Lajos; Tálosi, Gyula; Doró, Péter

2016-09-01

Recent technological advances and diagnostic and therapeutic innovations have resulted in an impressive improvement in the survival of newborn infants requiring intensive care. Consequently, with the use of modern invasive diagnostic and therapeutic procedures, the incidence of iatrogenic events has also increased. The aim of this study was to assess various iatrogenic complications in neonates requiring intensive care and determine possible contributing factors to the injuries. Our prospective cross-sectional cohort survey was conducted in a central regional level III neonatal intensive care unit (NICU). Correlations between intensive therapeutic interventions, complications, factors influencing attendance and prognosis, and the prevalence of iatrogenic skin injuries (ISIs) were investigated over a 2-year study period. Between January 31, 2012, and January 31, 2014, 460 neonates were admitted to the NICU, 83 of whom exhibited some kind of ISI. The major risk factors for ISIs were low birthweight, young gestational age, long NICU stay, use of the intubation-surfactant-extubation (INSURE) technique, surfactant use, mechanical ventilation, insertion of an umbilical arterial catheter, circulatory and cardiac support with dopamine or dobutamine, pulmonary hemorrhage, intracranial hemorrhage, patent ductus arteriosus, bronchopulmonary dysplasia, and positive microbiology culture results. To prevent ISIs, careful consideration of risk factors and the creation of protocols ensuring efficient treatment of injuries are needed. © 2016 Wiley Periodicals, Inc.

Cricothyroid Muscle Botulinum Toxin Injection to Improve Airway for Bilateral Recurrent Laryngeal Nerve Paralysis, A Case Series.

PubMed

Benninger, Michael S; Hanick, Andrea; Hicks, Douglas M

2016-01-01

Bilateral vocal fold paralysis most commonly results from iatrogenic trauma to the recurrent laryngeal nerve during surgical procedures in the anterior neck. Patients may require tracheostomy because of acute or gradual onset of dyspnea and airway compromise. The intralaryngeal injection of Botox has been considered as a possible therapy for these airway symptoms of bilateral vocal fold paralysis. Chronic unopposed activity of intact cricothyroid muscles could potentially result in gradual medialization of the vocal folds in patients with bilateral recurrent laryngeal nerve paralysis. This case series describes three patients who successfully underwent injections of botulinum toxin into the bilateral cricothyroid muscles to offer sustained relief of dyspnea resulting from bilateral vocal fold paralysis. Copyright © 2016 The Voice Foundation. Published by Elsevier Inc. All rights reserved.

Disorders of the lower cranial nerves

PubMed Central

Finsterer, Josef; Grisold, Wolfgang

2015-01-01

Lesions of the lower cranial nerves (LCN) are due to numerous causes, which need to be differentiated to optimize management and outcome. This review aims at summarizing and discussing diseases affecting LCN. Review of publications dealing with disorders of the LCN in humans. Affection of multiple LCN is much more frequent than the affection of a single LCN. LCN may be affected solely or together with more proximal cranial nerves, with central nervous system disease, or with nonneurological disorders. LCN lesions have to be suspected if there are typical symptoms or signs attributable to a LCN. Causes of LCN lesions can be classified as genetic, vascular, traumatic, iatrogenic, infectious, immunologic, metabolic, nutritional, degenerative, or neoplastic. Treatment of LCN lesions depends on the underlying cause. An effective treatment is available in the majority of the cases, but a prerequisite for complete recovery is the prompt and correct diagnosis. LCN lesions need to be considered in case of disturbed speech, swallowing, coughing, deglutition, sensory functions, taste, or autonomic functions, neuralgic pain, dysphagia, head, pharyngeal, or neck pain, cardiac or gastrointestinal compromise, or weakness of the trapezius, sternocleidomastoid, or the tongue muscles. To correctly assess manifestations of LCN lesions, precise knowledge of the anatomy and physiology of the area is required. PMID:26167022

[Dynamic radioulnar convergence after Darrach operation, soft tissue stabilizing operations of the distal ulna and ulnar head prosthesis implantation--an experimental biomechanical study].

PubMed

Sauerbier, M; Hahn, M E; Fujita, M; Neale, P G; Germann, G; An, K N; Berger, R A

2002-08-01

The most common method of treating the arthrotic distal radioulnar joint (DRUJ) is resection of the entire ulnar head (Darrach procedure). Complications related to instability of the distal forearm resulting from loss of the ulnar head are usually manifested by pain and weak grip strength and have remained the drawbacks of this procedure. In an attempt to mechanically stabilize the distal forearm, an endoprosthesis was developed to replace the ulnar head after Darrach resection. The purpose of this study was to: 1) evaluate the dynamic effects of the Darrach procedure on radioulnar convergence; and 2) evaluate the mechanical efficacy of two soft tissue stabilizing techniques (Pronator quadratus advancement flap and ECU/FCU tenodesis) for the unstable distal ulnar stump and 3) the stability after the implantation of an ulnar head endoprosthesis following a Darrach resection on radioulnar convergence. With a dynamic PC-controled forearm simulator the rotation of 7 fresh-frozen cadaver upper extremities was actively and passively performed while loading relevant muscles. Resultant total forearm torque and the 3-dimensional kinematics of the ulna, radius and third metacarpal were recorded simultaneously. The implantation of the ulnar head endoprosthesis effectively restored the stability of the DRUJ. There were significantly better results after the implantation of the prosthesis compared with the Darrach and the soft tissue stabilization procedures. This study provides laboratory validity to the option of implanting an ulnar head endoprosthesis as an attempt to stabilize the distal forearm after Darrach resection in lieu of performing soft tissue stabilization techniques.

Management of iatrogenic tegmen plate defects: our clinical experience and surgical technique.

PubMed

Wahba, Hassan; Ibrhaim, Samer; Youssef, Tamer Ali

2013-09-01

The objective of our study is to present our recommended approach for surgical management of iatrogenic tegmen plate defects. Patients diagnosed to have symptomatic iatrogenic tegmen plate defects were treated by one of the authors using a one-stage trans-mastoid standardized surgical procedure at Ain Shams University Hospitals. Patients' information records included history, complete examination, computed tomography (CT) and magnetic resonance imaging (MRI) of the temporal bone, and the followup data after the procedure to assess the final outcome in each case. Twelve patients with symptomatic iatrogenic tegmen plate defects were included in our study. The tegment plate defect size in the 12 patients varied from 2.2 to 15 mm (mean 5.6 ± 1.3). Postoperative followup of the patients ranged from 6 months up to 2 years (mean 1.6 ± 0.8). One patient only developed wound infection and was treated with antibiotics and regular dressings, with no other immediate postoperative complications (intracranial hematoma or meningitis). In the entire patient group, no local recurrence of middle fossa encephalocele was recorded. Our surgical trans-mastoid approach using multilayered autologous grafts is successful in closing iatrogenic tegmen plate defects more than 2.2 mm and less than 15 mm.

Sonography of iatrogenic pneumothorax in pediatric patients

PubMed Central

2013-01-01

Pneumothorax is defined as the presence of air in the pleural cavity. The incidence of iatrogenic pneumothorax in the pediatric population is 0.3–0.48 in 1000 patients. A conventional chest X-ray, in some cases supplemented with chest computed tomography, is a typical imaging examination used to confirm the diagnosis of pneumothorax. Within the last years, the relevance of transthoracic lung ultrasound in the diagnostic process of this disease entity has greatly increased. This is confirmed by the opinion of a group of experts in ultrasound lung imaging in patients in a life-threatening condition, who strongly recommend a transthoracic ultrasound examination for the diagnosis of pneumothorax in such patients. These data constituted the basis for initiating the prospective studies on the application of this method in pneumothorax diagnosis in patients of pediatric hematology and oncology wards. Aim The aim of the study was to present the possibility of using the transthoracic lung ultrasound in the diagnostic process of pneumothorax in pediatric patients, with particular attention paid to its iatrogenic form. The article discusses sonographic criteria for pneumothorax diagnosis in pediatric patients, including the sensitivity and specificity of the method, in relation to conventional chest X-ray. Material and methods The prospective studies included a group of patients treated in the Clinic of Pediatrics, Pediatric Hematology, Oncology and Endocrinology of the Academic Clinical Centre (Medical University of Gdańsk, Poland) in whom a central venous catheter was placed in the subclavian veins. The studies lasted for one year – from 1 July 2011 to 30 June 2012. The examined group comprised 63 patients – 25 girls (39.7%) and 38 boys (60.3%) aged from 1 to 17. The analysis included the results of 115 ultrasound examinations conducted in this group. Results In t he examined group with suspected or diagnosed neoplasm, iatrogenic pneumothorax was identified in 4 out

Cross sectional study to evaluate the effect of duration of type 2 diabetes mellitus on the nerve conduction velocity in diabetic peripheral neuropathy.

PubMed

Hussain, Gauhar; Rizvi, S Aijaz Abbas; Singhal, Sangeeta; Zubair, Mohammad; Ahmad, Jamal

2014-01-01

To study the nerve conduction velocity in clinically undetectable and detectable peripheral neuropathy in type 2 diabetes mellitus with variable duration. This cross sectional study was conducted in diagnosed type 2 diabetes mellitus patients. They were divided in groups: Group I (n=37) with clinically detectable diabetic peripheral neuropathy of shorter duration and Group II (n=27) with clinically detectable diabetic peripheral neuropathy of longer duration. They were compared with T2DM patients (n=22) without clinical neuropathy. Clinical diagnosis was based on neuropathy symptom score (NSS) and neuropathy disability score (NDS) for signs. Nerve conduction velocity was measured in both upper and lower limbs. Median, ulnar, common peroneal and posterior tibial nerves were selected for motor nerve conduction study and median and sural nerves were selected for sensory nerve conduction study. The comparisons were done between nerve conduction velocities of motor and sensory nerves in patients of clinically detectable neuropathy and patients without neuropathy in type 2 diabetes mellitus population. This study showed significant electrophysiological changes with duration of disease. Nerve conduction velocities in lower limbs were significantly reduced even in patients of shorter duration with normal upper limb nerve conduction velocities. Diabetic neuropathy symptom score (NSS) and neuropathy disability score (NDS) can help in evaluation of diabetic sensorimotor polyneuropathy though nerve conduction study is more powerful test and can help in diagnosing cases of neuropathy. Copyright © 2013 Diabetes India. Published by Elsevier Ltd. All rights reserved.

Drilling through lateral transmuscular portal lowers the risk of suprascapular nerve injury during arthroscopic SLAP repair.

PubMed

Kocaoglu, Baris; Ulku, Tekin Kerem; Sayilir, Safiye; Ozbaydar, Mehmet Ugur; Bayramoglu, Alp; Karahan, Mustafa

2017-10-01

The aim of our study was to evaluate the risk of medial glenoid perforation and possible injury to suprascapular nerve during arthroscopic SLAP repair using lateral transmuscular portal. Ten cadaveric shoulder girdles were isolated and drilled at superior glenoid rim from both anterior-superior portal (1 o'clock) and lateral transmuscular portal (12 o'clock) for SLAP repairs. Drill hole depth was determined by the manufacturer's drill stop (20 mm), and any subsequent drill perforations through the medial bony surface of the glenoid were directly confirmed by dissection. The bone tunnel depth and subsequent distance to the suprascapular nerve, scapular height and width, were compared for investigated locations. Four perforations out of ten (40 %) occurred through anterior-superior portal with one associated nerve injury. One perforation out of ten (10 %) occurred through lateral transmuscular portal without any nerve injury. The mean depth was calculated as 17.6 mm (SD 3) for anterior-superior portal and 26.5 mm (SD 3.6) for lateral transmuscular portal (P < 0.001). It is anatomically possible that suprascapular nerve could sustain iatrogenic injury during labral anchor placement during SLAP repair. However, lateral transmuscular portal at 12 o'clock drill entry location has lower risk of suprascapular nerve injury compared with anterior-superior portal at 1 o'clock drill entry location.

Resistance of the peripheral nervous system to the effects of chronic canine hypothyroidism.

PubMed

Rossmeisl, J H

2010-01-01

Hypothyroidism has been implicated in the development of multiple peripheral mono- and polyneuropathies in dogs. The objectives of this study were to evaluate the clinical and electrophysiologic effects of experimentally induced hypothyroidism on the peripheral nervous system of dogs. Chronic hypothyroidism will induce peripheral nerve sensorimotor dysfunction. Eighteen purpose-bred, female dogs. Prospective, longitudinal study: Hypothyroidism was induced by radioactive iodine administration in 9 dogs, and the remaining 9 served as untreated controls. Neurological examinations were performed monthly. Electrophysiologic testing consisting of electromyography (EMG); motor nerve conduction studies of the sciatic-tibial, radial, ulnar, and recurrent laryngeal nerves; sciatic-tibial and ulnar F-wave studies; sensory nerve conduction studies of the tibial, ulnar, and radial nerves; and evaluation of blink reflex and facial responses were performed before and 6, 12, and 18 months after induction of hypothyroidism and compared with controls. Clinical evidence of peripheral nervous dysfunction did not occur in any dog. At 6 month and subsequent evaluations, all hypothyroid dogs had EMG and histologic evidence of hypothyroid myopathy. Hypothyroid dogs had significant (Pulnar and sciatic-tibial compound muscle action potentials over time, which were attributed to the concurrent myopathy. No significant differences between control and hypothyroid dogs were detected in electrophysiologic tests of motor (P>or=.1) or sensory nerve conduction velocity (P>or=.24) or nerve roots (P>or=.16) throughout the study period, with values remaining within reference ranges in all dogs. Chronic hypothyroidism induced by thyroid irradiation does not result in clinical or electrophysiologic evidence of peripheral neuropathy, but does cause subclinical myopathy.

Incidence of iatrogenic pneumothorax in the United States in teaching vs. non-teaching hospitals from 2000 to 2012.

PubMed

John, Jason; Seifi, Ali

2016-08-01

Iatrogenic pneumothorax is a patient safety indicator (PSI) representing a complication of procedures such as transthoracic needle aspiration, subclavicular needle stick, thoracentesis, transbronchial biopsy, pleural biopsy, and positive pressure ventilation. This study examined whether there was a significant difference in rate of iatrogenic pneumothorax in teaching hospitals compared to non-teaching hospitals from 2000 to 2012. We performed a retrospective cohort study on iatrogenic pneumothorax incidence from 2000 to 2012 using the Healthcare Cost and Utilization Project (HCUP) database. Pairwise t tests were performed. Odds ratios and P values were calculated, using a Bonferroni-adjusted α threshold, to examine differences in iatrogenic pneumothorax incidence in teaching vs. non-teaching hospitals. Our study revealed that after the year 2000, teaching hospitals had significantly greater iatrogenic pneumothorax incidence compared to non-teaching hospitals in every year of the study period (P<.001). Iatrogenic pneumothorax occurred with significantly greater incidence in teaching hospitals compared to non-teaching hospitals from 2000 to 2012. This trend may have been enhanced by the residency duty-hour regulations implemented in 2003 in teaching institutions, or due to higher rates of procedures in teaching institutions due to the nature of a tertiary center. Iatrogenic pneumothorax was more prevalent in teaching hospitals compared to non-teaching hospitals after the year 2000. Further randomized control studies are warranted to evaluate the etiology of this finding. Published by Elsevier Inc.

Anatomy and function of the hypothenar muscles.

PubMed

Pasquella, John A; Levine, Pam

2012-02-01

The hypothenar eminence is the thick soft tissue mass located on the ulnar side of the palm. Understanding its location and contents is important for understanding certain aspects of hand function. Variation in motor nerve distribution of the hypothenar muscles makes surgery of the ulnar side of the palm more challenging. To avoid injury to nerve branches, knowledge of these differences is imperative. This article discusses the muscular anatomy and function, vascular anatomy, and nerve anatomy and innervation of the hypothenar muscles. Copyright © 2012 Elsevier Inc. All rights reserved.

[Reconstructive surgery in iatrogenic bile duct injuries].

PubMed

Krawczyk, M; Kania, M; Zieniewicz, K; Nyckowski, P; Patkowski, W; Karwowski, A

1997-01-01

The paper presents the results of surgical treatment performed in 54 patients with iatrogenic injury of biliary tract. All cases of injury were made during open and laparoscopic cholecystectomy. We concluded that Roux-en-Y hepatico-jejunostomy should be recommended. There were no deaths after surgery. This technic was successful therapeutic management more than 95% of cases.

Human prion diseases: surgical lessons learned from iatrogenic prion transmission.

PubMed

Bonda, David J; Manjila, Sunil; Mehndiratta, Prachi; Khan, Fahd; Miller, Benjamin R; Onwuzulike, Kaine; Puoti, Gianfranco; Cohen, Mark L; Schonberger, Lawrence B; Cali, Ignazio

2016-07-01

The human prion diseases, or transmissible spongiform encephalopathies, have captivated our imaginations since their discovery in the Fore linguistic group in Papua New Guinea in the 1950s. The mysterious and poorly understood "infectious protein" has become somewhat of a household name in many regions across the globe. From bovine spongiform encephalopathy (BSE), commonly identified as mad cow disease, to endocannibalism, media outlets have capitalized on these devastatingly fatal neurological conditions. Interestingly, since their discovery, there have been more than 492 incidents of iatrogenic transmission of prion diseases, largely resulting from prion-contaminated growth hormone and dura mater grafts. Although fewer than 9 cases of probable iatrogenic neurosurgical cases of Creutzfeldt-Jakob disease (CJD) have been reported worldwide, the likelihood of some missed cases and the potential for prion transmission by neurosurgery create considerable concern. Laboratory studies indicate that standard decontamination and sterilization procedures may be insufficient to completely remove infectivity from prion-contaminated instruments. In this unfortunate event, the instruments may transmit the prion disease to others. Much caution therefore should be taken in the absence of strong evidence against the presence of a prion disease in a neurosurgical patient. While the Centers for Disease Control and Prevention (CDC) and World Health Organization (WHO) have devised risk assessment and decontamination protocols for the prevention of iatrogenic transmission of the prion diseases, incidents of possible exposure to prions have unfortunately occurred in the United States. In this article, the authors outline the historical discoveries that led from kuru to the identification and isolation of the pathological prion proteins in addition to providing a brief description of human prion diseases and iatrogenic forms of CJD, a brief history of prion disease nosocomial transmission

Human prion diseases: surgical lessons learned from iatrogenic prion transmission

PubMed Central

Bonda, David J.; Manjila, Sunil; Mehndiratta, Prachi; Khan, Fahd; Miller, Benjamin R.; Onwuzulike, Kaine; Puoti, Gianfranco; Cohen, Mark L.; Schonberger, Lawrence B.; Cali, Ignazio

2016-01-01

The human prion diseases, or transmissible spongiform encephalopathies, have captivated our imaginations since their discovery in the Fore linguistic group in Papua New Guinea in the 1950s. The mysterious and poorly understood “infectious protein” has become somewhat of a household name in many regions across the globe. From bovine spongiform encephalopathy (BSE), commonly identified as mad cow disease, to endocannibalism, media outlets have capitalized on these devastatingly fatal neurological conditions. Interestingly, since their discovery, there have been more than 492 incidents of iatrogenic transmission of prion diseases, largely resulting from prion-contaminated growth hormone and dura mater grafts. Although fewer than 9 cases of probable iatrogenic neurosurgical cases of Creutzfeldt-Jakob disease (CJD) have been reported worldwide, the likelihood of some missed cases and the potential for prion transmission by neurosurgery create considerable concern. Laboratory studies indicate that standard decontamination and sterilization procedures may be insufficient to completely remove infectivity from prion-contaminated instruments. In this unfortunate event, the instruments may transmit the prion disease to others. Much caution therefore should be taken in the absence of strong evidence against the presence of a prion disease in a neurosurgical patient. While the Centers for Disease Control and Prevention (CDC) and World Health Organization (WHO) have devised risk assessment and decontamination protocols for the prevention of iatrogenic transmission of the prion diseases, incidents of possible exposure to prions have unfortunately occurred in the United States. In this article, the authors outline the historical discoveries that led from kuru to the identification and isolation of the pathological prion proteins in addition to providing a brief description of human prion diseases and iatrogenic forms of CJD, a brief history of prion disease nosocomial

The subdiaphragmatic part of the phrenic nerve - morphometry and connections to autonomic ganglia.

PubMed

Loukas, Marios; Du Plessis, Maira; Louis, Robert G; Tubbs, R Shane; Wartmann, Christopher T; Apaydin, Nihal

2016-01-01

Few anatomical textbooks offer much information concerning the anatomy and distribution of the phrenic nerve inferior to the diaphragm. The aim of this study was to identify the subdiaphragmatic distribution of the phrenic nerve, the presence of phrenic ganglia, and possible connections to the celiac plexus. One hundred and thirty formalin-fixed adult cadavers were studied. The right phrenic nerve was found inferior to the diaphragm in 98% with 49.1% displaying a right phrenic ganglion. In 22.8% there was an additional smaller ganglion (right accessory phrenic ganglion). The remaining 50.9% had no grossly identifiable right phrenic ganglion. Most (65.5% of specimens) exhibited plexiform communications with the celiac ganglion, aorticorenal ganglion, and suprarenal gland. The left phrenic nerve inferior to the diaphragm was observed in 60% of specimens with 19% containing a left phrenic ganglion. No accessory left phrenic ganglia were observed. The left phrenic ganglion exhibited plexiform communications to several ganglia in 71.4% of specimens. Histologically, the right phrenic and left phrenic ganglia contained large soma concentrated in their peripheries. Both phrenic nerves and ganglia were closely related to the diaphragmatic crura. Surgically, sutures to approximate the crura for repair of hiatal hernias must be placed above the ganglia in order to avoid iatrogenic injuries to the autonomic supply to the diaphragm and abdomen. These findings could also provide a better understanding of the anatomy and distribution of the fibers of that autonomic supply. © 2015 Wiley Periodicals, Inc.

Relationship between Smoking and Outcomes after Cubital Tunnel Release.

PubMed

Crosby, Nicholas E; Nosrati, Naveed N; Merrell, Greg; Hasting, Hill

2018-04-01

Several studies have drawn a connection between cigarette smoking and cubital tunnel syndrome. One comparison article demonstrated worse outcomes in smokers treated with transmuscular transposition of the ulnar nerve. However, very little is known about the effect that smoking might have on patients who undergo ulnar nerve decompression at the elbow. The purpose of this study is to evaluate the effect of smoking preoperatively on outcomes in patients treated with ulnar nerve decompression. This study used a survey developed from the comparison article with additional questions based on outcome measures from supportive literature. Postoperative improvement was probed, including sensation, strength, and pain scores. A thorough smoking history was obtained. The study spanned a 10-year period. A total of 1,366 surveys were mailed to former patients, and 247 surveys with adequate information were returned. No significant difference was seen in demographics or comorbidities. Patients who smoked preoperatively were found to more likely relate symptoms of pain. Postoperatively, nonsmoking patients generally reported more favorable improvement, though these findings were not statistically significant. This study finds no statistically significant effect of smoking on outcomes after ulnar nerve decompression. Finally, among smokers, there were no differences in outcomes between simple decompression and transposition.

Sensory neuropathy may cause central neuronal reorganization but does not respecify perceptual quality or localization of sensation.

PubMed

Ginanneschi, Federica; Mondelli, Mauro; Rossi, Alessandro

2012-10-01

Functional reorganization in the somatosensory network after peripheral nerve lesions has been suspected to modify the clinical expression of symptoms. However, no conclusive evidence exists to support this notion. We addressed this question by investigating the topographic distribution of the subjective sensory report in various chronic human mononeuropathies. We report the clinical results of 86 patients who were diagnosed with meralgia paresthetica, 86 patients with ulnar neuropathy at the elbow, and 203 patients with carpal tunnel syndrome. In the carpal tunnel syndrome group, 10% of the patients exhibited a spread of sensory symptoms beyond the innervation territory of the median nerve. As previously reported, this spread was contingent upon an indirect compressive lesion of the ulnar nerve at the wrist. In all of the patients who were affected with meralgia paresthetica or ulnar neuropathy at the elbow, the peripheral referral of sensation was always within the anatomic distribution of the affected nerve. In human neuropathies, the projected sensory symptoms are restricted to the innervation territories of the affected nerves, with no extraterritorial spread. Thus, the somatosensory localization function remains accurate, despite the central reorganization that presumably occurs after nerve injury. We conclude that reorganization of the sensory connections within the central nervous system after peripheral nerve injury in humans is a clinically silent adaptive phenomenon.

Sensory and motor neuropathy in a Border Collie.

PubMed

Harkin, Kenneth R; Cash, Walter C; Shelton, G Diane

2005-10-15

A 5-month-old female Border Collie was evaluated because of progressive hind limb ataxia. The predominant clinical findings suggested a sensory neuropathy. Sensory nerve conduction velocity was absent in the tibial, common peroneal, and radial nerves and was decreased in the ulnar nerve; motor nerve conduction velocity was decreased in the tibial, common peroneal, and ulnar nerves. Histologic examination of nerve biopsy specimens revealed considerable nerve fiber depletion; some tissue sections had myelin ovoids, foamy macrophages, and axonal degeneration in remaining fibers. Marked depletion of most myelinated fibers within the peroneal nerve (a mixed sensory and motor nerve) supported the electrodiagnostic findings indicative of sensorimotor neuropathy. Progressive deterioration in motor function occurred over the following 19 months until the dog was euthanatized. A hereditary link was not established, but a littermate was similarly affected. The hereditary characteristic of this disease requires further investigation.

Comparison between open and arthroscopic-assisted foveal triangular fibrocartilage complex repair for post-traumatic distal radio-ulnar joint instability.

PubMed

Luchetti, R; Atzei, A; Cozzolino, R; Fairplay, T; Badur, N

2014-10-01

The aim of this study was to assess the objective and subjective functional outcomes after foveal reattachment of proximal or complete ulnar-sided triangular fibrocartilage complex lesions by two surgical procedures: an open technique or an arthroscopically assisted repair. The study was done prospectively on 49 wrists affected by post-traumatic distal radio-ulnar joint instability. Twenty-four patients were treated with the open technique (Group 1) and 25 by the arthroscopically assisted technique (Group 2). Magnetic resonance imaging demonstrated a clear foveal detachment of the triangular fibrocartilage complex in 67% of the cases. Arthroscopy showed a positive ulnar-sided detachment of the triangular fibrocartilage complex (positive hook test) in all cases. Distal radio-ulnar joint stability was obtained in all but five patients at a mean follow-up of 6 months. Both groups had improvement of all parameters with significant differences in wrist pain scores, Mayo wrist score, Disability of the Arm, Shoulder and Hand questionnaire and Patient-Rated Wrist/Hand Evaluation questionnaire scores. There were no significant post-operative differences between the two groups in the outcome parameters except for the Disability of the Arm Shoulder and Hand questionnaire score, which was significantly better in Group 2 (p < 0.001). © The Author(s) 2013.

Photoplethysmography using a smartphone application for assessment of ulnar artery patency: a randomized clinical trial

PubMed Central

Di Santo, Pietro; Harnett, David T.; Simard, Trevor; Ramirez, F. Daniel; Pourdjabbar, Ali; Yousef, Altayyeb; Moreland, Robert; Bernick, Jordan; Wells, George; Dick, Alexander; Le May, Michel; Labinaz, Marino; So, Derek; Motazedian, Pouya; Jung, Richard G.; Chandrasekhar, Jaya; Mehran, Roxana; Chong, Aun-Yeong

2018-01-01

BACKGROUND: Radial artery access is commonly performed for coronary angiography and invasive hemodynamic monitoring. Despite limitations in diagnostic accuracy, the modified Allen test (manual occlusion of radial and ulnar arteries followed by release of the latter and assessment of palmar blush) is used routinely to evaluate the collateral circulation to the hand and, therefore, to determine patient eligibility for radial artery access. We sought to evaluate whether a smartphone application may provide a superior alternative to the modified Allen test. METHODS: We compared the modified Allen test with a smartphone heart rate–monitoring application (photoplethysmography readings detected using a smartphone camera lens placed on the patient’s index finger) in patients undergoing a planned cardiac catheterization. Test order was randomly assigned in a 1:1 fashion. All patients then underwent conventional plethysmography of the index finger, followed by Doppler ultrasonography of the radial and ulnar arteries (the diagnostic standard). The primary outcome was diagnostic accuracy of the heart rate–monitoring application. RESULTS: Among 438 patients who were included in the study, we found that the heart rate–monitoring application had a superior diagnostic accuracy compared with the modified Allen test (91.8% v. 81.7%, p = 0.002), attributable to its greater specificity (93.0% v. 82.8%, p = 0.001). We also found that this application had greater diagnostic accuracy for assessment of radial or ulnar artery patency in the ipsilateral and contralateral wrist (94.0% v. 84.0%, p < 0.001). INTERPRETATION: A smartphone application used at the bedside was diagnostically superior to traditional physical examination for confirming ulnar patency before radial artery access. This study highlights the potential for smartphone-based diagnostics to aid in clinical decision-making at the patient’s bedside. Trial registration: Clinicaltrials.gov, no. NCT02519491. PMID

Photoplethysmography using a smartphone application for assessment of ulnar artery patency: a randomized clinical trial.

PubMed

Di Santo, Pietro; Harnett, David T; Simard, Trevor; Ramirez, F Daniel; Pourdjabbar, Ali; Yousef, Altayyeb; Moreland, Robert; Bernick, Jordan; Wells, George; Dick, Alexander; Le May, Michel; Labinaz, Marino; So, Derek; Motazedian, Pouya; Jung, Richard G; Chandrasekhar, Jaya; Mehran, Roxana; Chong, Aun-Yeong; Hibbert, Benjamin

2018-04-03

Radial artery access is commonly performed for coronary angiography and invasive hemodynamic monitoring. Despite limitations in diagnostic accuracy, the modified Allen test (manual occlusion of radial and ulnar arteries followed by release of the latter and assessment of palmar blush) is used routinely to evaluate the collateral circulation to the hand and, therefore, to determine patient eligibility for radial artery access. We sought to evaluate whether a smartphone application may provide a superior alternative to the modified Allen test. We compared the modified Allen test with a smartphone heart rate-monitoring application (photoplethysmography readings detected using a smartphone camera lens placed on the patient's index finger) in patients undergoing a planned cardiac catheterization. Test order was randomly assigned in a 1:1 fashion. All patients then underwent conventional plethysmography of the index finger, followed by Doppler ultrasonography of the radial and ulnar arteries (the diagnostic standard). The primary outcome was diagnostic accuracy of the heart rate-monitoring application. Among 438 patients who were included in the study, we found that the heart rate-monitoring application had a superior diagnostic accuracy compared with the modified Allen test (91.8% v. 81.7%, p = 0.002), attributable to its greater specificity (93.0% v. 82.8%, p = 0.001). We also found that this application had greater diagnostic accuracy for assessment of radial or ulnar artery patency in the ipsilateral and contralateral wrist (94.0% v. 84.0%, p < 0.001). A smartphone application used at the bedside was diagnostically superior to traditional physical examination for confirming ulnar patency before radial artery access. This study highlights the potential for smartphone-based diagnostics to aid in clinical decision-making at the patient's bedside. Trial registration: Clinicaltrials.gov, no. NCT02519491. © 2018 Joule Inc. or its licensors.

Rehabilitation of the Burned Hand

DTIC Science & Technology

2009-01-01

injury in the upper extremity are the shoulder for brachial plexus injuries , the elbow for ulnar nerve lesions, and the wrist for injuries to the ulnar or...median nerves. A brachial plexus injury may result from improper positioning of the shoulder for prolonged periods of time. Shoulder abduction greater...in the early postinjury period as a result of edema, tendon injury , or scar contracture. An immediate consequence of a Rehabilitation Therapies and

[Common fibular nerve lesions. Etiology and treatment. Apropos of 146 cases with surgical treatment].

PubMed

Piton, C; Fabre, T; Lasseur, E; André, D; Geneste, M; Durandeau, A

1997-01-01

Common peroneal nerve lesion on the lateral aspect of the knee is one of the most frequent neurologic injury of the lower limb. We reported the results of surgical procedure for each etiological group. In the peroneal nerve entrapment group, we individualised 62 fibular tunnel syndroms (55 idiopathic, 4 postural, 3 dynamic), and 16 external compression. Traumatic causes were represented by 22 varus injuries of the knee and by 11 fractures, 16 iatrogenic lesions, 2 wounds, 5 wound sequelae, 2 contusions and 1 burn. Tumoral group was represented by 7 intraneural ganglionic cyst and 2 extraneural tumour (1 exostosis and 1 chondromatosis of the proximal tibio fibular joint). All patients underwent surgical procedure. Neurolysis was performed when the nerve was in continuity. Suture or nerve grafting was performed in the other cases. In the case of intraneural ganglionic cyst, a complete tumoral excision was realised. Eighty-three per cent of excellent and good results were obtained for the fibular tunnel syndrom, 62.5 per cent for external compression, 36 per cent for varus injury of the knee, 78 per cent for the other traumatic causes and 89 per cent for tumoral lesions. This report confirms that the result depends on the etiology of the common peroneal nerve lesion. We propose surgical treatment within 2 to 4 months for the patients without clinical and electrophysiological improvement. If there is doubt on the continuity of the nerve, we propose an earlier surgical treatment. Our results were in general satisfactory except when a nerve graft was necessary furthermore if it was a traction injury and if the length of the graft was longer than 6 centimeters.

Spontaneous displacement of olecranon fracture through geode salvaged by elbow replacement.

PubMed

Jaiswal, Anuj; Thakur, Raman; Relwani, Jaikumar; Ogufere, Wallace

2010-04-01

We present a case of pathological fracture of olecranon through a giant geode. Fracture was initially undisplaced and was treated conservatively. It later progressed to a transolecranon dislocation as a result of a pseudarthrosis at the fracture site. The patient presented 4 years later when she developed symptoms of ulnar nerve palsy. She was treated by a total elbow arthroplasty with ulnar nerve transposition. The current report highlights this unusual case and reviews the relevant literature.

Iatrogenic surgical microscope skin burns: A systematic review of the literature and case report.

PubMed

Lopez, Joseph; Soni, Ashwin; Calva, Daniel; Susarla, Srinivas M; Jallo, George I; Redett, Richard

2016-06-01

Cutaneous burns associated with microscope-use are perceived to be uncommon adverse events in microsurgery. Currently, it is unknown what factors are associated with these iatrogenic events. In this report, we describe the case of a 1-year-old patient who suffered a full thickness skin burn from a surgical microscope after a L4-S1 laminectomy. Additionally, we present a systematic review of the literature that assessed the preoperative risk, outcome, and management of iatrogenic microscope skin burns. Lastly, a summary of the Food and Drug Administration's (FDA) Manufacturer and User Facility Device Experience (MAUDE) database of voluntary adverse events was reviewed and analyzed for clinical cases of microscope thermal injuries. The systematic literature review identified only seven articles related to microsurgery-related cutaneous burns. From these seven studies, 15 clinical cases of iatrogenic skin burns were extracted for analysis. The systematic review of the FDA MAUDE database revealed only 60 cases of cutaneous burns associated with surgical microscopes since 2004. Few cases of microscope burns have been described in the literature; this report is, to our knowledge, one of the first comprehensive reports of this iatrogenic event in the literature. Copyright © 2015 Elsevier Ltd and ISBI. All rights reserved.

Acute iatrogenic dislocation following hip impingement arthroscopic surgery.

PubMed

Matsuda, Dean K

2009-04-01

This is the first case report of an iatrogenic anterior hip dislocation after arthroscopic surgery for femoroacetabular impingement with over 1 year of follow-up. This case report describes the clinical course of a patient with symptomatic cam-pincer femoroacetabular impingement. She underwent arthroscopic rim trimming, labral debridement after a failed attempt at labral refixation from suture cut-through, and femoral head-neck resection osteoplasty. The procedure involved supranormal hip distraction for extraction of an iatrogenic loose body (detached metallic radiofrequency probe tip). The patient had an anterior hip dislocation in the recovery room. Immediate closed reduction under general anesthesia and bracing were performed but failed despite the ability to obtain a concentric but grossly unstable reduction. After 3 failed attempts, a mini-open capsulorrhaphy was performed that successfully restored stability. Her postoperative management and outcome are presented. All of the major static stabilizers of the hip (osseous, labral, and capsuloligamentous) were surgically altered, and a multifactorial causation is proposed. Lessons learned are discussed in hopes of minimizing the occurrence of this rare but dramatic complication.

Outcomes and Return to Sport After Ulnar Collateral Ligament Reconstruction in Adolescent Baseball Players.

PubMed

Saper, Michael; Shung, Joseph; Pearce, Stephanie; Bompadre, Viviana; Andrews, James R

2018-04-01

The number of ulnar collateral ligament (UCL) reconstructions in adolescent athletes has increased over the past 2 decades. Clinical results in this population have not been well studied. The purpose of this study was to evaluate the outcomes and return to sport after UCL reconstruction in a large group of adolescent baseball players. We hypothesized that excellent clinical outcomes and high rates of return to sport would be observed in this population at a minimum 2-year follow-up. Case series; Level of evidence, 4. We reviewed 140 adolescent (aged ≤19 years) baseball players who underwent UCL reconstruction with the American Sports Medicine Institute (ASMI) technique by a single surgeon. Medical records were reviewed for patient demographics, injury characteristics, operative details, and surgical complications. Patient-reported outcomes were assessed using the Conway scale, the Andrews-Timmerman (A-T) score, the Kerlan-Jobe Orthopaedic Clinic (KJOC) score, and a 0- to 100-point subjective scale for elbow function and satisfaction. Return to sporting activity was assessed using a custom-designed questionnaire. The mean age at the time of surgery was 18.0 years (range, 13-19 years), and the mean follow-up was 57.9 months (range, 32.4-115.4 months). Over half (60%) of patients were high school athletes. The mean duration of symptoms before surgery was 6.9 months (range, 0.5-60.0 months). Partial tears were identified in 57.9% of patients, and 41.3% of patients had preoperative ulnar nerve symptoms. Graft type included the ipsilateral palmaris in 77.1% of patients. Concomitant procedures were performed in 25% of patients. Outcomes on the Conway scale were "excellent" in 86.4% of patients. The mean A-T and KJOC scores were 97.3 ± 6.1 and 85.2 ± 14.6, respectively. Mean patient satisfaction was 94.4. Overall, 97.8% of patients reported returning to sport at a mean of 11.6 months (range, 5-24 months), and 89.9% of patients returned to sport at the same level of

Outcomes and Return to Sport After Ulnar Collateral Ligament Reconstruction in Adolescent Baseball Players

PubMed Central

Saper, Michael; Shung, Joseph; Pearce, Stephanie; Bompadre, Viviana; Andrews, James R.

2018-01-01

Background: The number of ulnar collateral ligament (UCL) reconstructions in adolescent athletes has increased over the past 2 decades. Clinical results in this population have not been well studied. Purpose/Hypothesis: The purpose of this study was to evaluate the outcomes and return to sport after UCL reconstruction in a large group of adolescent baseball players. We hypothesized that excellent clinical outcomes and high rates of return to sport would be observed in this population at a minimum 2-year follow-up. Study Design: Case series; Level of evidence, 4. Methods: We reviewed 140 adolescent (aged ≤19 years) baseball players who underwent UCL reconstruction with the American Sports Medicine Institute (ASMI) technique by a single surgeon. Medical records were reviewed for patient demographics, injury characteristics, operative details, and surgical complications. Patient-reported outcomes were assessed using the Conway scale, the Andrews-Timmerman (A-T) score, the Kerlan-Jobe Orthopaedic Clinic (KJOC) score, and a 0- to 100-point subjective scale for elbow function and satisfaction. Return to sporting activity was assessed using a custom-designed questionnaire. Results: The mean age at the time of surgery was 18.0 years (range, 13-19 years), and the mean follow-up was 57.9 months (range, 32.4-115.4 months). Over half (60%) of patients were high school athletes. The mean duration of symptoms before surgery was 6.9 months (range, 0.5-60.0 months). Partial tears were identified in 57.9% of patients, and 41.3% of patients had preoperative ulnar nerve symptoms. Graft type included the ipsilateral palmaris in 77.1% of patients. Concomitant procedures were performed in 25% of patients. Outcomes on the Conway scale were “excellent” in 86.4% of patients. The mean A-T and KJOC scores were 97.3 ± 6.1 and 85.2 ± 14.6, respectively. Mean patient satisfaction was 94.4. Overall, 97.8% of patients reported returning to sport at a mean of 11.6 months (range, 5

Completed Ulnar Shaft Stress Fracture in a Fast-Pitch Softball Pitcher.

PubMed

Wiltfong, Roger E; Carruthers, Katherine H; Popp, James E

2017-03-01

Stress fractures of the upper extremity have been previously described in the literature, yet reports of isolated injury to the ulna diaphysis or olecranon are rare. The authors describe a case involving an 18-year-old fast-pitch softball pitcher. She presented with a long history of elbow and forearm pain, which was exacerbated during a long weekend of pitching. Her initial physician diagnosed her as having forearm tendinitis. She was treated with nonsurgical means including rest, anti-inflammatory medications, therapy, and kinesiology taping. She resumed pitching when allowed and subsequently had an acute event immediately ceasing pitching. She presented to an urgent care clinic that evening and was diagnosed as having a complete ulnar shaft fracture subsequently needing surgical management. This case illustrates the need for a high degree of suspicion for ulnar stress fractures in fast-pitch soft-ball pitchers with an insidious onset of unilateral forearm pain. Through early identification and intervention, physicians may be able to reduce the risk of injury progression and possibly eliminate the need for surgical management. [Orthopedics. 2017; 40(2):e360-e362.]. Copyright 2016, SLACK Incorporated.

In vitro sealing of iatrogenic fetal membrane defects by a collagen plug imbued with fibrinogen and plasma.

PubMed

Engels, A C; Hoylaerts, M F; Endo, M; Loyen, S; Verbist, G; Manodoro, S; DeKoninck, P; Richter, J; Deprest, J A

2013-02-01

We aimed to demonstrate local thrombin generation by fetal membranes, as well as its ability to generate fibrin from fibrinogen concentrate. Furthermore, we aimed to investigate the efficacy of collagen plugs, soaked with plasma and fibrinogen, to seal iatrogenic fetal membrane defects. Thrombin generation by homogenized fetal membranes was measured by calibrated automated thrombography. To identify the coagulation caused by an iatrogenic membrane defect, we analyzed fibrin formation by optical densitometry, upon various concentrations of fibrinogen. The ability of a collagen plug soaked with fibrinogen and plasma was tested in an ex vivo model for its ability to seal an iatrogenic fetal membrane defect. Fetal membrane homogenates potently induced thrombin generation in amniotic fluid and diluted plasma. Upon the addition of fibrinogen concentrate, potent fibrin formation was triggered. Measured by densiometry, fibrin formation was optimal at 1250 µg/mL fibrinogen in combination with 4% plasma. A collagen plug soaked with fibrinogen and plasma sealed an iatrogenic membrane defect about 35% better than collagen plugs without these additives (P = 0.037). These in vitro experiments suggest that the addition of fibrinogen and plasma may enhance the sealing efficacy of collagen plugs in closing iatrogenic fetal membrane defects. © 2013 John Wiley & Sons, Ltd.

20-year experience with iatrogenic penile injury.

PubMed

Amukele, Samuel A; Lee, Gene W; Stock, Jeffrey A; Hanna, Moneer K

2003-10-01

We review our experience with the management of iatrogenic penile injuries. Apart from circumcision, serious damage to the penis can occur following hypospadias repair, surgery for priapism or total loss of the penis following surgical repair of bladder exstrophy. A retrospective analysis of patients with iatrogenic penile amputation referred to us between 1980 and 2000 was undertaken. Causes of injury and choice of management were reviewed. Of the 13 cases treated during the 20-year period mechanism of primary injury was circumcision in 4, hypospadias repair in 6, priapism in 1, bladder exstrophy repair in 1 and penile carcinoma in 1. A variety of techniques were used for phallic reconstruction. Penile degloving, division of suspensory ligament and rotational skin flaps achieved penile augmentation and enhancement. Reasonable cosmesis and penile length were achieved in all cases. In indicated cases microsurgical phalloplasty was technically feasible. However long-term followup showed various complications including erosions from the use of a penile stiffener. The ultimate goal of reconstructive surgery is to have a penis with normal function and appearance. The management of penile injury requires a wide variety of surgical techniques that are tailored to the individual patient. Expedient penile reconstruction is successful and therapeutic delay is associated with complications.

Update on strategies limiting iatrogenic hypoglycemia

PubMed Central

Bonaventura, Aldo; Montecucco, Fabrizio; Dallegri, Franco

2015-01-01

The prevalence of type 2 diabetes mellitus (T2DM) is increasing all over the world. Targeting good glycemic control is fundamental to avoid the complications of diabetes linked to hyperglycemia. This narrative review is based on material searched for and obtained via PubMed up to April 2015. The search terms we used were: ‘hypoglycemia, diabetes, complications’ in combination with ‘iatrogenic, treatment, symptoms.’ Serious complications might occur from an inappropriate treatment of hyperglycemia. The most frequent complication is iatrogenic hypoglycemia that is often associated with autonomic and neuroglycopenic symptoms. Furthermore, hypoglycemia causes acute cardiovascular effects, which may explain some of the typical symptoms: ischemia, QT prolongation, and arrhythmia. With regards to the latter, the night represents a dangerous period because of the major increase in arrhythmias and the prolonged period of hypoglycemia; indeed, sleep has been shown to blunt the sympatho-adrenal response to hypoglycemia. Two main strategies have been implemented to reduce these effects: monitoring blood glucose values and individualized HbA1c goals. Several drugs for the treatment of T2DM are currently available and different combinations have been recommended to achieve individualized glycemic targets, considering age, comorbidities, disease duration, and life expectancy. In conclusion, according to international guidelines, hypoglycemia-avoiding therapy must reach an individualized glycemic goal, which is the lowest HbA1c not causing severe hypoglycemia and preserving awareness of hypoglycemia. PMID:26099256

[Iatrogenic hyperthyroidism secondary to weight loss medication. Predictive factors for their precocious detention].

PubMed

Goday, A; Recasens, A; Manresa, J M; Vila, J; Moix, S

1998-05-01

To establish the differential clinical characteristics between the Iatrogenic hyperthyroidism for not conventional medication for obesity treatment (weight losers) and the endogenous by Graves Basedow disease. Observational and analytical study, populational based, in the one which prospectively were compared cases with Iatrogenic hyperthyroidism (secondary to weight losers) with those with endogenous hyperthyroidism (Graves Basedow disease) as controls. Consisted of the variable clinical record of 100 correlative patients that consulted in specialized attention of endocrinology for Iatrogenic hyperthyroidism secondary to weight losers and for Graves Basedow disease. The differences observed between Iatrogenic hyperthyroidism (secondary to weight losers) (n = 43) as compared to endogenous hyperthyroidism (Graves Basedow disease) (n = 57) were: smaller age (31.8 +/- 10 as compared to 37.8 +/- 12.6 years), greater body mass index (27.6 +/- 7.2 as compared to 23.4 +/- 3.1), smaller goiter frequency (16.3% as compared to 84.2%) as well as absence of signs of ophthalmopathy (0% as compared to 57.9%). Both groups had low levels of TSH, and the difference rests in the values of free T4, low in the first group and increased in the endogenous hyperthyroidism. The odds ratio were: IMC > 27: 3.92 (0.91-16.72), age < 33 years: 5.58 (1.42-21.99), absence of goiter: 23.29 (6.39-84.85). The precedent of weight losers use was not selective of the first group, being detected in a 12.3% of cases of endogenous hyperthyroidism, though in periods of time remoter in relationship to the beginning of the clinic. In the differential diagnosis of a case of hyperthyroidism, it can be suspected Iatrogenic hyperthyroidism (secondary to weight losers) for medication for the obesity in patients of the feminine sex with overweight, without previous or familiar history of thyroid disease, and in those which in the physical exploration is not verified goiter neither ophthalmopathy.

Ansa to recurrent laryngeal neurorrhaphy in the setting of laryngeal nerve sacrifice: a cadaveric study to evaluate a reconstructive option.

PubMed

Scharpf, Joseph; Haffey, Timothy; Rajasekaran, Karthik; Lorenz, Robert; McBride, Jennifer

2015-01-01

In certain cases, the recurrent laryngeal nerve (RLN) has to be sacrificed. This often results in an inadequate length of residual RLN to be used in a reinnervation procedure. We investigated the length of the distal stump of the RLN from the inferior border of the inferior pharyngeal constrictor muscle (IPCM), where it is frequently compromised, to its entrance into the larynx. Our objective was to determine whether this residual nerve stock was sufficient for margin clearance and neurorrhaphy. Cadaveric study Recurrent laryngeal nerves were identified in fresh frozen cadavers. The IPCM was divided, revealing the distal stump of the RLN, which was measured. Dissection was performed in 20 cadavers (40 nerves). The average length of the right RLN and the left RLN from the IPCM until it entered the larynx was 15mm and 14mm, respectively. All residual RLN remnants were of sufficient length for neurorrhaphy. Concomitant RLN reinnervation procedures in the setting of nerve sacrifice are not well described. A barrier to reinnervation in this setting may be insufficient residual nerve length for a neurorrhaphy. Often, when the RLN is sacrificed intraoperatively either iatrogenically or due to tumor invasion, it is close to the cricoarytenoid joint, at the inferior border of the IPCM. This study demonstrates that by splitting the IPCM, sufficient length can be obtained for neurorrhaphy. Copyright © 2015 Elsevier Inc. All rights reserved.

Role of neopterin as a biochemical marker for peripheral neuropathy in pediatric patients with type 1 diabetes: Relation to nerve conduction studies.

PubMed

Elbarbary, Nancy Samir; Ismail, Eman Abdel Rahman; El-Hilaly, Rana Ahmed; Ahmed, Fatma Salama

2018-06-01

Neopterin, a marker of inflammation and cellular immune response, is elevated in conditions of T-cell or macrophages activation. Diabetic peripheral neuropathy (DPN) is associated with inflammatory/immune processes and therefore, we hypothesized that neopterin could be used as a marker of neuropathy in type 1 diabetes mellitus (T1DM). To measure neopterin levels in children and adolescents with T1DM and assess its possible relation to DPN and nerve conduction studies (NCS). Sixty patients aged ≤18 years and >5 years disease duration were subjected to neurological assessment by neuropathy disability score (NDS) and NCS for median, ulnar, posterior tibial and common peroneal nerves. Mean fasting blood glucose, lipid profile, HbA1c, high sensitivity C-reactive protein (hs-CRP) and serum neopterin levels were assessed. Patients were compared with 30 age- and sex-matched healthy controls. The frequency of DPN according to NDS was 40 (66.7%) patients out of 60 while NCS confirmed that only 30 of those 40 patients had this complication (i.e. 50% out of the total studied patients). Neopterin levels were significantly higher in patients with DPN than those without (median [IQR], 53.5 [35-60] nmol/L versus 17 [13-32] nmol/L) and healthy controls (5.0 [3.2-7.0] nmol/L) (p < 0.001). Significant positive correlations were found between neopterin levels and HbA1c (r = 0.560, p = 0.005), serum creatinine (r = 0.376, p = 0.003), total cholesterol (r = 0.405, p = 0.026) and hs-CRP (r = 0.425, p = 0.012) among patients with DPN. Neopterin levels were positively correlated to motor latency of tibial and common peroneal nerves as well as motor and sensory latencies of median and ulnar nerves. Logistic regression analysis revealed that neopterin was a significant independent variable related to DPN (Odds ratio, 2.976). Neopterin cutoff value 32 nmol/L could differentiate patients with and without DPN with 100% sensitivity and 96

The Effect of Botulinum Toxin on an Iatrogenic Sialo-Cutaneous Fistula

PubMed Central

Hong, Seung Eun; Kwon, Jung Woo; Kang, So Ra

2016-01-01

A sialo-cutaneous fistula is a communication between the skin and a salivary gland or duct discharging saliva. Trauma and iatrogenic complications are the most common causes of this condition. Treatments include aspiration, compression, and the administration of systemic anticholinergics; however, their effects are transient and unsatisfactory in most cases. We had a case of a patient who developed an iatrogenic sialo-cutaneous fistula after wide excision of squamous cell carcinoma in the parotid region that was not treated with conventional management, but instead completely resolved with the injection of botulinum toxin. Based on our experience, we recommend the injection of botulinum toxin into the salivary glands, especially the parotid gland, as a conservative treatment option for sialo-cutaneous fistula. PMID:28913292

Risk factors associated with iatrogenic opioid and benzodiazepine withdrawal in critically ill pediatric patients: a systematic review and conceptual model.

PubMed

Best, Kaitlin M; Boullata, Joseph I; Curley, Martha A Q

2015-02-01

Analgesia and sedation are common therapies in pediatric critical care, and rapid titration of these medications is associated with iatrogenic withdrawal syndrome. We performed a systematic review of the literature to identify all common and salient risk factors associated with iatrogenic withdrawal syndrome and build a conceptual model of iatrogenic withdrawal syndrome risk in critically ill pediatric patients. Multiple databases, including PubMed/Medline, EMBASE, CINAHL, and the Cochrane Central Registry of Clinical Trials, were searched using relevant terms from January 1, 1980, to August 1, 2014. Articles were included if they were published in English and discussed iatrogenic withdrawal syndrome following either opioid or benzodiazepine therapy in children in acute or intensive care settings. Articles were excluded if subjects were neonates born to opioid- or benzodiazepine-dependent mothers, children diagnosed as substance abusers, or subjects with cancer-related pain; if data about opioid or benzodiazepine treatment were not specified; or if primary data were not reported. In total, 1,395 articles were evaluated, 33 of which met the inclusion criteria. To facilitate analysis, all opioid and/or benzodiazepine doses were converted to morphine or midazolam equivalents, respectively. A table of evidence was developed for qualitative analysis of common themes, providing a framework for the construction of a conceptual model. The strongest risk factors associated with iatrogenic withdrawal syndrome include duration of therapy and cumulative dose. Additionally, evidence exists linking patient, process, and system factors in the development of iatrogenic withdrawal syndrome. Most articles were prospective observational or interventional studies. Given the state of existing evidence, well-designed prospective studies are required to better characterize iatrogenic withdrawal syndrome in critically ill pediatric patients. This review provides data to support the

Value of free-run electromyographic monitoring of lower cranial nerves in endoscopic endonasal approach to skull base surgeries.

PubMed

Thirumala, Parthasarathy D; Mohanraj, Santhosh Kumar; Habeych, Miguel; Wichman, Kelley; Chang, Yue-Fang; Gardner, Paul; Snyderman, Carl; Crammond, Donald J; Balzer, Jeffrey

2012-08-01

Objective The main objective of this study was to evaluate the value of free-run electromyography (f-EMG) monitoring of cranial nerves (CNs) VII, IX, X, XI, and XII in skull base surgeries performed using endoscopic endonasal approach (EEA) to reduce iatrogenic CN deficits. Design We retrospectively identified 73 patients out of 990 patients who had EEA in our institution who had at least one CN monitored. In each CN group, we classified patients who had significant (SG) f-EMG activity as group I and those who did not as group II. Results We monitored a total of 342 CNs. A total of 62 nerves had SG f-EMG activity including CN VII = 18, CN IX = 16, CN X = 13, CN XI = 5, and CN XII = 10. No nerve deficit was found in the nerves that had significant activity during procedure. A total of five nerve deficits including (CN IX = 1, CN X = 2, CN XII = 2) were observed in the group that did not display SG f-EMG activity during surgery. Conclusions f-EMG seems highly sensitive to surgical manipulations and in locating CNs. It seems to have limited value in predicting postoperative neurological deficits. Future studies to evaluate the EMG of lower CNs during EEA procedures need to be done with both f-EMG and triggered EMG.

Value of Free-Run Electromyographic Monitoring of Lower Cranial Nerves in Endoscopic Endonasal Approach to Skull Base Surgeries

PubMed Central

Thirumala, Parthasarathy D.; Mohanraj, Santhosh Kumar; Habeych, Miguel; Wichman, Kelley; Chang, Yue-Fang; Gardner, Paul; Snyderman, Carl; Crammond, Donald J.; Balzer, Jeffrey

2012-01-01

Objective The main objective of this study was to evaluate the value of free-run electromyography (f-EMG) monitoring of cranial nerves (CNs) VII, IX, X, XI, and XII in skull base surgeries performed using endoscopic endonasal approach (EEA) to reduce iatrogenic CN deficits. Design We retrospectively identified 73 patients out of 990 patients who had EEA in our institution who had at least one CN monitored. In each CN group, we classified patients who had significant (SG) f-EMG activity as group I and those who did not as group II. Results We monitored a total of 342 CNs. A total of 62 nerves had SG f-EMG activity including CN VII = 18, CN IX = 16, CN X = 13, CN XI = 5, and CN XII = 10. No nerve deficit was found in the nerves that had significant activity during procedure. A total of five nerve deficits including (CN IX = 1, CN X = 2, CN XII = 2) were observed in the group that did not display SG f-EMG activity during surgery. Conclusions f-EMG seems highly sensitive to surgical manipulations and in locating CNs. It seems to have limited value in predicting postoperative neurological deficits. Future studies to evaluate the EMG of lower CNs during EEA procedures need to be done with both f-EMG and triggered EMG. PMID:23904999

Motor evoked responses from the thigh muscles to the stimulation of the upper limb nerves in patients with late poliomyelitis.

PubMed

Ertekin, Cumhur; On, Arzu Yagiz; Kirazli, Yeşim; Kurt, Tülay; Gürgör, Nevin

2002-04-01

To demonstrate a clear-cut M response recorded from the severely affected thigh muscles to the stimulation of the upper limb nerves in a serial of patients with late poliomyelitis. Fifteen patients with late poliomyelitis, 7 patients with spinal cord disorders and 11 control subjects were included. Evoked muscle responses were investigated in quadriceps femoris and/or thigh adductor muscles to the stimulation of the brachial plexus, median and ulnar nerves. Evoked muscle responses were obtained from the thigh muscles in all 12 late polio patients with proximal lower extremity involvement. The response could not be recorded from the thigh muscles neither in the 3 polio patients with upper extremity involvement nor in the healthy control subjects and in patients with other spinal cord disorders of anterior horn cell. It is proposed that the electrical stimulation of the arm nerves produce interlimb descending muscle responses in the severely affected atrophic thigh muscles of the patients with late polio. This finding suggests that there might be a focal and/or specific loss of inhibitory interneurons between injured and normal motor neurons and increased facilitatory synaptic action at the end of long propriospinal descending fibers in the case of late poliomyelitis.

Comparison of Facial Nerve Paralysis in Adults and Children

PubMed Central

Cha, Chang Il; Hong, Chang Kee; Park, Moon Suh

2008-01-01

Purpose Facial nerve injury can occur in the regions ranging from the cerebral cortex to the motor end plate in the face, and from many causes including trauma, viral infection, and idiopathic factors. Facial nerve paralysis in children, however, may differ from that in adults. We, therefore, evaluated its etiology and recovery rate in children and adults. Materials and Methods We retrospectively evaluated the records of 975 patients, ranging in age from 0 to 88 years, who displayed facial palsy at Kyung Hee Medical Center between January 1986 and July 2005. Results The most frequent causes of facial palsy in adults were Bell's palsy (54.9%), infection (26.8%), trauma (5.9%), iatrogenic (2.0%), and tumors (1.8%), whereas the most frequent causes of facial palsy in children were Bell's palsy (66.2%), infection (14.6%), trauma (13.4%), birth trauma (3.2%), and leukemia (1.3%). Recovery rates in adults were 91.4% for Bell's palsy, 89.0% for infection, and 64.3% for trauma, whereas recovery rates in children were 93.1% for Bell's palsy, 90.9% for infection, and 42.9% for trauma. Conclusion These results show that causes of facial palsy are similar in adults and children, and recovery rates in adults and children are not significantly different. PMID:18972592

Multifocal sensory demyelinating neuropathy: Report of a case.

PubMed

Oh, Shin J

2017-10-01

Multifocal sensory demyelinating neuropathy has not been adequately reported in the literature. A 42-year-old man with numbness of the left hand for 3 years and of the right hand for 6 months had a pure multifocal sensory neuropathy involving both hands, most prominently affecting 2-point discrimination, number writing, and object recognition of the left hand. Near-nerve needle sensory and mixed nerve conduction studies were performed on the left ulnar nerve. Studies of the left ulnar nerve documented a demyelinating neuropathy characterized by temporal dispersion and marked decrease in the amplitudes of the sensory and mixed compound nerve potentials in the above-elbow-axilla segment. With intravenous immunoglobulin treatment, there was improvement in his neuropathic condition. In this study I describe a case of multifocal sensory demyelinating neuropathy as a counterpart of multifocal motor neuropathy. Muscle Nerve 56: 825-828, 2017. © 2016 Wiley Periodicals, Inc.

Iatrogenic Blood-borne Viral Infections in Refugee Children from War and Transition Zones

PubMed Central

2013-01-01

Pediatric infectious disease clinicians in industrialized countries may encounter iatrogenically transmitted HIV, hepatitis B virus, and hepatitis C virus infections in refugee children from Central Asia, Southeast Asia, and sub-Saharan Africa. The consequences of political collapse and/or civil war—work migration, prostitution, intravenous drug use, defective public health resources, and poor access to good medical care—all contribute to the spread of blood-borne viruses. Inadequate infection control practices by medical establishments can lead to iatrogenic infection of children. Summaries of 4 cases in refugee children in Australia are a salient reminder of this problem. PMID:23739597

Transthyretin amyloid polyneuropathies mimicking a demyelinating polyneuropathy.

PubMed

Lozeron, Pierre; Mariani, Louise-Laure; Dodet, Pauline; Beaudonnet, Guillemette; Théaudin, Marie; Adam, Clovis; Arnulf, Bertrand; Adams, David

2018-06-15

To clearly define transthyretin familial amyloid polyneuropathies (TTR-FAPs) fulfilling definite clinical and electrophysiologic European Federation of Neurological Societies/Peripheral Nerve Society criteria for chronic inflammatory demyelinating polyneuropathy (CIDP). From a cohort of 194 patients with FAP, 13 of 84 patients (15%) of French ancestry had late-onset demyelinating TTR-FAP. We compared clinical presentation and electrophysiology to a cohort with CIDP and POEMS (polyneuropathy, organomegaly, endocrinopathy, monoclonal protein, and skin changes) syndrome. We assessed nerve histology and the correlation between motor/sensory amplitudes/velocities. Predictors of demyelinating TTR-FAP were identified from clinical and electrophysiologic data. Pain, dysautonomia, small fiber sensory loss above the wrists, upper limb weakness, and absence of ataxia were predictors of demyelinating TTR-FAP ( p < 0.01). The most frequent demyelinating features were prolonged distal motor latency of the median nerve and reduced sensory conduction velocity of the median and ulnar nerves. Motor axonal loss was severe and frequent in the median, ulnar, and tibial nerves ( p < 0.05) in demyelinating FAP. Ulnar nerve motor amplitude <5.4 mV and sural nerve amplitude <3.95 μV were distinguishing characteristics of demyelinating TTR-FAP. Nerve biopsy showed severe axonal loss and occasional segmental demyelination-remyelination. Misleading features of TTR-FAP fulfilling criteria for CIDP are not uncommon in sporadic late-onset TTR-FAP, which highlights the limits of European Federation of Neurological Societies/Peripheral Nerve Society criteria. Specific clinical aspects and marked electrophysiologic axonal loss are red flag symptoms that should alert to this diagnosis and prompt TTR gene sequencing. © 2018 American Academy of Neurology.

Risk of injury to the sural nerve during posterolateral approach to the distal tibia: An ultrasound simulation study.

PubMed

Mizia, Ewa; Pękala, Przemysław A; Chomicki-Bindas, Piotr; Marchewka, Wojciech; Loukas, Marios; Zayachkowski, Alexander G; Tomaszewski, Krzysztof A

2018-05-08

Introduction When surgeons operate on the foot and ankle, the most common complication that may arise is injury of the cutaneous nerves. The sural nerve (SN) is potentially at risk of being injured when treating fractures involving the distal tibia using the posterolateral approach. The aim of this study was to evaluate how differences in length and position of the surgical treatment of fractures involving the distal tibia can affect the risk of SN injury. Materials and Methods The study involved 40 healthy volunteers (n=80 lower limbs). Ultrasound simulation of each potential surgical incision site was used to locate the SN and to assess the risk of injury. Results The study showed that the SN predominantly travels more posteriorly at levels more proximal from the tip of the lateral malleolus. At these more proximal points of the SN's course, it was proven that there was an overall increased incidence of iatrogenic injury to the SN in incisions made closer to the Achilles tendon. Based on these results, a quasi 3 dimensional figure was created showing the anatomical structures of this region to identify areas at high risk for SN injury. Conclusions By revealing how length and position of the surgical incision can influence the risk of SN injury, we hope to provide information to surgeons on the optimal technique to avoid iatrogenic SN injury while operating on the distal tibia via a posterolateral approach. This article is protected by copyright. All rights reserved. © 2018 Wiley Periodicals, Inc.

Segmental arterial mediolysis--an iatrogenic vascular disorder induced by ractopamine.

PubMed

Slavin, Richard E; Yaeger, Micheal J

2012-01-01

Segmental arterial mediolysis, an uncommon arterial disorder most often occurring in the splanchnic muscular arteries of the abdomen, is a cause of catastrophic hemorrhages. Its histology and initial clinical presentations suggested that it represented a localized norepinephrine-induced vasospastic response to perturbations in vascular tone and blood volume distribution caused by coexisting vasoconstrictor conditions. However, later presentations were at odds with some aspects of this hypothesis. Nine greyhound dogs were administered a single dose of ractopamine. Two dogs developing persistent conduction abnormalities with biochemical evidence of heart injury were euthanized and necropsied--one 4 days and the other 17 days after dosage This report is based on findings and comparisons of the canine abdominal and coronary arteries to segmental arterial mediolysis. Lesions having features of early-injurious-stage segmental arterial mediolysis were identified in the canine arteries 4 days postractopamine, and arteries examined after 17 days showed alterations typically occurring in reparative-stage segmental arterial mediolysis. It is suspected that ractopamine, a Beta-2 adrenergic agonist, created segmental arterial mediolysis by neuromodulating the peripheral sympathetic nervous system to release norepinephrine from varicosities of efferent nerves serving splanchnic arteries that stimulate alpha-1 receptors to induce injury at the adventitial medial junction and medial muscle apoptosis. This finding and other cited examples suggest that segmental arterial mediolysis may be a disorder principally caused by iatrogenic or accidental exposure to alpha-1 adrenergic receptor agonists or Beta-2 agonists able to release norepinephrine from the peripheral nervous system. Copyright © 2012 Elsevier Inc. All rights reserved.

Investigation of Laser Induced Breakdown Spectroscopy (LIBS) for the Differentiation of Nerve and Gland Tissue—A Possible Application for a Laser Surgery Feedback Control Mechanism

NASA Astrophysics Data System (ADS)

Mehari, F.; Rohde, M.; Knipfer, C.; Kanawade, R.; Klämpfl, F.; W., Adler; Oetter, N.; Stelzle, F.; Schmidt, M.

2016-06-01

Laser surgery provides clean, fast and accurate modeling of tissue. However, the inability to determine what kind of tissue is being ablated at the bottom of the cut may lead to the iatrogenic damage of structures that were meant to be preserved. In this context, nerve preservation is one of the key challenges in any surgical procedure. One example is the treatment of parotid gland pathologies, where the facial nerve (N. VII) and its main branches run through and fan out inside the glands parenchyma. A feedback system that automatically stops the ablation to prevent nerve-tissue damage could greatly increase the applicability and safety of surgical laser systems. In the present study, Laser Induced Breakdown Spectroscopy (LIBS) is used to differentiate between nerve and gland tissue of an ex-vivo pig animal model. The LIBS results obtained in this preliminary experiment suggest that the measured spectra, containing atomic and molecular emissions, can be used to differentiate between the two tissue types. The measurements and differentiation were performed in open air and under normal stray light conditions.

A Pilot Study of a Novel Automated Somatosensory Evoked Potential (SSEP) Monitoring Device for Detection and Prevention of Intraoperative Peripheral Nerve Injury in Total Shoulder Arthroplasty Surgery.

PubMed

Chui, Jason; Murkin, John M; Drosdowech, Darren

2018-05-21

Peripheral nerve injury is a potentially devastating complication after total shoulder arthroplasty (TSA) surgery. This pilot study aimed to assess the feasibility of using an automated somatosensory evoked potential (SSEP) device to provide a timely alert/intervention to minimize intraoperative nerve insults during TSA surgery. A prospective, single-arm, observational study was conducted in a single university hospital. The attending anesthesiologist monitored the study participants using the EPAD automated SSEP device and an intervention was made if there was an alert during TSA surgery. The median, radial, and ulnar nerve SSEP on the operative arm, as well as the median nerve SSEP of the nonoperative arm were monitored for each patient. All patients were evaluated for postoperative neurological deficits 6 weeks postoperatively. In total, 21 patients were consented and were successfully monitored. In total, 4 (19%) patients developed intraoperative abnormal SSEP signal changes in the operative arm, in which 3 were reversible and 1 was irreversible till the end of surgery. Median and radial nerves were mostly involved (3/4 patients). The mean cumulative duration of nerve insult (abnormal SSEP) was 21.7±26.2 minutes. Univariate analysis did not identify predictor of intraoperative nerve insults. No patients demonstrated postoperative peripheral neuropathy at 6 weeks. A high incidence (19%) of intraoperative nerve insult was observed in this study demonstrating the feasibility of using an automated SSEP device to provide a timely alert and enable an intervention in order to minimize peripheral nerve injury during TSA. Further randomized studies are warranted.

Anatomy of the Pudendal Nerve and Other Neural Structures Around the Proximal Hamstring Origin in Males.

PubMed

Cvetanovich, Gregory L; Saltzman, Bryan M; Ukwuani, Gift; Frank, Rachel M; Verma, Nikhil N; Bush-Joseph, Charles A; Nho, Shane J

2018-03-29

To define the anatomy of the pudendal nerve in relationship to the proximal hamstring and other nearby neurological structures during proximal hamstring repair. Six fresh-frozen human cadaveric hemi-pelvises from male patients ages 64.0 ± 4.1 years were dissected in prone position with hips in 10° flexion to identify the relationship of proximal hamstring origin to surrounding neurologic structures including the pudendal nerve, sciatic nerve, and posterior femoral cutaneous nerve. Two independent observers used digital calipers to measure distances. The pudendal nerve emerged at the inferior border of the piriformis muscle 6.3 ± 1.4 cm from the superior aspect of the proximal hamstring origin. It passed the superior border of the sacrotuberous ligament 3.0 ± 0.6 cm from the superior aspect and 3.9 ± 0.7 cm from the medial aspect of the hamstring origin. It crossed the inferior border of the sacrotuberous ligament 3.0 ± 0.4 cm from the superior aspect and 2.7 ± 0.7 cm from the medial aspect of the proximal hamstring origin. The shortest distance from the hamstring origin to the pudendal nerve was 2.6 ± 0.5 cm from the superior aspect and 2.3 ± 0.8 cm from the medial aspect. The shortest distance from the hamstring origin to the pudendal nerve was located deep to the sacrotuberous ligament in all cadavers. The sciatic nerve was an average of 1.1 ± 0.1 cm lateral to the lateral aspect of the proximal hamstring origin. The posterior femoral cutaneous nerve was located between the hamstring origin and the sciatic nerve, 0.7 ± 0.2 cm lateral to the lateral aspect of the proximal hamstring origin. The proximal hamstring origin lies in close proximity to surrounding nerves, including the pudendal, sciatic, and posterior femoral cutaneous nerves. Knowledge that the pudendal nerve lies 2 to 3 cm superior and medial to the proximal hamstring origin may help to prevent iatrogenic damage during surgical dissection and retraction when performing proximal

Endovascular management of arterial injuries after blunt or iatrogenic renal trauma

PubMed Central

Chevallier, Olivier; Gehin, Sophie; Midulla, Marco; Berthod, Pierre-Emmanuel; Galland, Christophe; Briche, Pascale; Duperron, Céline; Majbri, Nabil; Mousson, Christiane; Falvo, Nicolas

2017-01-01

The kidney is the third most common abdominal organ to be injured in trauma, following the spleen and liver, respectively. The most commonly used classification scheme is the American Association for the Surgery of Trauma (AAST) classification of blunt renal injuries, which grades renal injury according to the size of laceration and its proximity to the renal hilum. Arteriovenous fistula and pseudoaneurysm are the most common iatrogenic biopsy-related or surgery-related vascular injuries in native kidneys. The approach to renal artery injuries has changed over time from more aggressive intervention to more conservative observational or endovascular management, including selective transcatheter arterial embolization (TAE) and the placement of stents/stent grafts. In this article, we describe the role and technical aspects of endovascular interventions in the management of arterial injuries after blunt or iatrogenic renal trauma. PMID:28932700

High prevalence of iatrogenic hyperthyroidism in elderly patients with atrial fibrillation in an anticoagulation clinic.

PubMed

Krishnan, Sandeep Kumar; Dohrmann, Mary L; Brietzke, Stephen A; Fleming, David A; Flaker, Greg C

2011-01-01

In elderly patients with established atrial fibrillation (AF) who are receiving thyroid replacement, regular testing for thyroid function is often not performed, placing the patient at risk for iatrogenic hyperthyroidism. Of 215 patients followed in an anticoagulation clinic, 41 were receiving thyroid replacement and 15 of these were found to have hyperthyroidism. Eight had documented AF coincident with abnormal thyroid function. In addition, only 22 patients on thyroid replacement had an annual TSH. In conclusion, iatrogenic hyperthyroidism may frequently be missed in AF patients because of inadequate monitoring of serum TSH. Thyroid replacement is common in elderly patients with AF followed in an anticoagulation clinic. Laboratory evidence of hyperthyroidism occurred in 37%, usually in patients with higher doses of thyroid replacement, and often associated with AF. The frequency of iatrogenic hyperthyroidism may be underestimated in patients with AF since many patients who receive thyroid replacement therapy are not monitored regularly with serum TSH.

Iatrogenic salivary duct injury in head and neck cancer patients: Report of four cases and review of the literature

PubMed Central

Kulyapina, Alena; Ochandiano-Caicoya, Santiago; Navarro-Cuellar, Carlos; Navarro-Vila, Carlos

2014-01-01

Introduction: The lesions of the salivary ducts may be idiopathic, post- traumatic, or iatrogenic and lead to sialocele formation with persistent painful facial swelling or cutaneous fistula formation. No consensus on treatment of this condition exists: the options of treatment include needle aspiration, pressure dressings, antisialogogue therapy, radiotherapy, botulinum toxin and surgical approaches as duct repair, diversion, ligation, different drainage systems and even parotidectomy/submaxilectomy. The management and special features of iatrogenic salivary duct injury in patients with oral cancer who underwent head and neck reconstructive surgery has not been described yet. Material and Methods: We present four cases of iatrogenic lesions of salivary ducts and its management in patients with oral cancer. Conclusions: The iatrogenic lesions of salivary ducts are to be taken into account in patients with oral cancer as the distal ends of salivary ducts could be involved in the margins of surgical resection. Different options of treatment of this complication are described. Key words:Sialocele, oral cancer, salivary duct. PMID:25136433

The Anastomoses of the Recurrent Laryngeal Nerve in the Larynx: A Meta-Analysis and Systematic Review.

PubMed

Henry, Brandon Michael; Pękala, Przemysław A; Sanna, Beatrice; Vikse, Jens; Sanna, Silvia; Saganiak, Karolina; Tomaszewska, Iwona M; Tubbs, R Shane; Tomaszewski, Krzysztof A

2017-07-01

The recurrent laryngeal nerve and its branches form a great variety of anastomoses. These nerve communications can alter the innervation patterns of the laryngeal muscles and can affect both the diagnosis and treatment of paralyzed vocal cords. The aim of this study was to assess the prevalence and anatomical characteristics of the laryngeal nerve connections, and to review their function and clinical significance. Meta-analysis and systematic review. The major electronic databases were thoroughly searched to identify all studies reporting data on the anastomoses of the laryngeal nerves. Data on the prevalence of each type of anastomosis were extracted and pooled into a meta-analysis using MetaXL version 3.0 (EpiGear International Pty. Ltd., Wilston, Queensland, Australia). Twenty-two cadaveric studies (n = 1404 hemilarynges) were included in the meta-analysis. The two most common communications were Galen's anastamosis and the arytenoid plexus. The pooled prevalence estimate for Galen's anastamosis was 76.7% (95% confidence interval [CI]: 59.0-90.0), of which the single trunk type was most common (92.3%). The arytenoid plexus had a pooled prevalence estimate of 79.7% (95% CI: 41.1-100). Owing to the high prevalences and variability of nerve connections in the larynx, detailed anatomical knowledge of these anastomoses can be crucial for the accurate interpretation of laryngoscopy results, reducing iatrogenic injury during surgical procedures, and facilitating the development of novel strategies for treating laryngeal paralyses. Copyright © 2017 The Voice Foundation. Published by Elsevier Inc. All rights reserved.

Long-term outcome of dogs treated with ulnar rollover transposition for limb-sparing of distal radial osteosarcoma: 27 limbs in 26 dogs.

PubMed

Séguin, Bernard; O'Donnell, Matthew D; Walsh, Peter J; Selmic, Laura E

2017-10-01

To determine outcomes in dogs with distal radial osteosarcoma treated with ulnar rollover transposition (URT) limb-sparing surgery including: viability of the ulnar graft, complications, subjective limb function, disease-free interval (DFI), and survival time (ST). Retrospective case series. Twenty-six client-owned dogs with distal radial osteosarcoma and no involvement of the ulna. Data of dogs treated with URT were collected at the time of surgery and retrospectively from medical records and by contacting owners and referring veterinarians. URT technique was performed on 27 limbs in 26 dogs. The ulnar graft was determined to be viable in 17 limbs, nonviable in 3, and unknown in 7. Complications occurred in 20 limbs. Infection was diagnosed in 12 limbs. Biomechanical complications occurred in 15 and local recurrence in 2 limbs. Limb function graded by veterinarians or owners was poor in 2 limbs, fair in 4, good in 14, excellent in 3, and unknown in 4. Median DFI was 245 days and median ST was 277 days. The URT technique maintained the viability of the ulnar graft. The complication rate was high but limb function appeared acceptable. Although sufficient length of the distal aspect of the ulna must be preserved to perform this technique, local recurrence was not increased compared to other limb-sparing techniques when cases were appropriately selected. © 2017 The American College of Veterinary Surgeons.

Iatrogenic left main coronary artery dissection due to pin-hole balloon rupture: Not to be panicked….

PubMed

Jeyakumaran, Balakumaran; Raj, Ajay; Pandit, Bhagya Narayan; Kumar, Tarun; Deora, Surender

2015-12-01

Iatrogenic left main coronary artery (LMCA) dissection is a rare complication and may have devastating consequences if not immediately intervened. The management includes urgent revascularization mostly with percutaneous coronary intervention (PCI) with bail-out stenting and rarely requires coronary artery bypass graft (CABG) surgery. In clinically and hemodynamically stable patients, a conservative approach may be preferred. Here, we present a rare case of iatrogenic retrograde LMCA dissection due to pin-hole rupture of angioplasty balloon that was managed conservatively.

The design of and chronic tissue response to a composite nerve electrode with patterned stiffness.

PubMed

Freeberg, M J; Stone, M A; Triolo, R J; Tyler, D J

2017-06-01

�� >  0.15 for all measures). Axonal density and myelin sheath thickness was not significantly different within the electrode compared to sections greater than 2 cm proximal to implanted cuffs (p  >  0.14 for all measures). We present the design and verification of a novel nerve cuff electrode, the C-FINE. Laminar manufacturing processes allow C-FINE stiffness to be configured for specific applications. Here, the central region in the configuration tested is stiff to reshape or conform to the target nerve, while edges are highly flexible to bend along its length. The C-FINE occupies less volume than other NCEs, making it suitable for implantation in highly mobile locations near joints. Design constraints during simulated transient swelling were verified in vitro. Maintenance of nerve health in various challenging anatomical locations (sciatic and median/ulnar nerves) was verified in a chronic feline model in vivo.

The design of and chronic tissue response to a composite nerve electrode with patterned stiffness

NASA Astrophysics Data System (ADS)

Freeberg, M. J.; Stone, M. A.; Triolo, R. J.; Tyler, D. J.

2017-06-01

between implant and explant (p  >  0.15 for all measures). Axonal density and myelin sheath thickness was not significantly different within the electrode compared to sections greater than 2 cm proximal to implanted cuffs (p  >  0.14 for all measures). Significance. We present the design and verification of a novel nerve cuff electrode, the C-FINE. Laminar manufacturing processes allow C-FINE stiffness to be configured for specific applications. Here, the central region in the configuration tested is stiff to reshape or conform to the target nerve, while edges are highly flexible to bend along its length. The C-FINE occupies less volume than other NCEs, making it suitable for implantation in highly mobile locations near joints. Design constraints during simulated transient swelling were verified in vitro. Maintenance of nerve health in various challenging anatomical locations (sciatic and median/ulnar nerves) was verified in a chronic feline model in vivo.

[Clinical application of self-made drainage tube with balloon for iatrogenic colonic perforation].

PubMed

Liu, Bing-rong; Li, Hui; Zhao, Li-xia; Song, Ji-tao; Wang, Yan-jun; Chen, Jing; Liu, Wei

2012-07-01

To investigate the clinical efficacy of colonic bypass drainage by self-made drainage tube with balloon for iatrogenic colonic perforation. A retrospective analysis of 8 patients with iatrogenic colonic perforations from January 2009 to March 2011 was performed. Self-made drainage tubes with balloon were placed in the bowel lumen endoscopically after perforations were closed with endoclips or endoloops under endoscope. The inflatable balloon at the front-end of the tube was fixed at the mouth side of colonic perforation to achieve continuous drainage of stool and intestinal juice. Endoscopic bypass continuous drainage by using self-made drainage tube with balloon was successfully carried out in all the 8 patients. All the perforations healed and no surgical intervention required. Bypass drainage continued for 3-10 days(mean 7.6 days). One patient received colonoscopy 3 days after the procedure, and displacement of the drainage tube was noticed requiring endoscopic adjustment. All the drainage tubes were removed uneventfully, and no ulceration or perforation occurred at balloon fixed site after removal. After follow up ranging from 12 to 36 months, no chronic fistula, adhesive obstruction, or abdominal infection occurred. Colonic bypass drainage by self-made drainage tube with balloon for iatrogenic colonic perforation is simple, feasible, safe and reliable.

Distribution of bupivacaine hydrochloride after sciatic and femoral nerve blocks in cats: A magnetic resonance imaging study.

PubMed

Evangelista, Marina C; de Lassalle, Julie; Chevrier, Christine; Carmel, Eric N; Fantoni, Denise T; Steagall, Paulo V M

2017-12-01

The objective of this study was to evaluate the distribution of bupivacaine hydrochloride using magnetic resonance imaging (MRI) after electrical nerve stimulator (ENS)-guided sciatic (ScN) and femoral (FN) nerve blocks in cats. Six adult cats (body weight 4.8±0.6kg) were anesthetized with acepromazine-buprenorphine-propofol-isoflurane. Transverse and sagittal plan sequences of pelvic limbs were obtained using a high-field magnet (1.5T). Afterwards, the ScN and FN blocks (one block per limb) were performed using 0.1mL/kg of bupivacaine 0.5% per site and the MRI sequence was repeated after each block. The injection was considered successful when bupivacaine was in contact with the nerve. Injectate location and complications were recorded. The length (mm) of contact (spread) between bupivacaine and nerves was measured and classified as fair (<15mm) or adequate (≥15mm). Five out of six ScN injections were successful; of these, four had adequate spread over the nerve [26 (13-39) mm]. All FN injections were successful, but in one case bupivacaine was administered over the motor branch of FN, distally to the bifurcation between the femoral and saphenous nerve. It was not possible to measure neither the length of contact between bupivacaine and FN nor to identify iatrogenic trauma caused by the injections. MRI can be used for the evaluation of bupivacaine distribution, but not complications, following ENS-guided ScN and FN blocks in cats. Despite most of the injections were considered successful, individual variability regarding the injectate location may explain differences in efficacy in the clinical setting. Copyright © 2017 Elsevier Ltd. All rights reserved.

A longitudinal study of pain, personality, and brain plasticity following peripheral nerve injury.

PubMed

Goswami, Ruma; Anastakis, Dimitri J; Katz, Joel; Davis, Karen D

2016-03-01

We do not know precisely why pain develops and becomes chronic after peripheral nerve injury (PNI), but it is likely due to biological and psychological factors. Here, we tested the hypotheses that (1) high Pain Catastrophizing Scale (PCS) scores at the time of injury and repair are associated with pain and cold sensitivity after 1-year recovery and (2) insula gray matter changes reflect the course of injury and improvements over time. Ten patients with complete median and/or ulnar nerve transections and surgical repair were tested ∼3 weeks after surgical nerve repair (time 1) and ∼1 year later for 6 of the 10 patients (time 2). Patients and 10 age-/sex-matched healthy controls completed questionnaires that assessed pain (patients) and personality and underwent quantitative sensory testing and 3T MRI to assess cortical thickness. In patients, pain intensity and neuropathic pain correlated with pain catastrophizing. Time 1 pain catastrophizing trended toward predicting cold pain thresholds at time 2, and at time 1 cortical thickness of the right insula was reduced. At time 2, chronic pain was related to the time 1 pain-PCS relationship and cold sensitivity, pain catastrophizing correlated with cold pain threshold, and insula thickness reversed to control levels. This study highlights the interplay between personality, sensory function, and pain in patients following PNI and repair. The PCS-pain association suggests that a focus on affective or negative components of pain could render patients vulnerable to chronic pain. Cold sensitivity and structural insula changes may reflect altered thermosensory or sensorimotor awareness representations.

Reproducibility of current perception threshold with the Neurometer(®) vs the Stimpod NMS450 peripheral nerve stimulator in healthy volunteers: an observational study.

PubMed

Tsui, Ban C H; Shakespeare, Timothy J; Leung, Danika H; Tsui, Jeremy H; Corry, Gareth N

2013-08-01

Current methods of assessing nerve blocks, such as loss of perception to cold sensation, are subjective at best. Transcutaneous nerve stimulation is an alternative method that has previously been used to measure the current perception threshold (CPT) in individuals with neuropathic conditions, and various devices to measure CPT are commercially available. Nevertheless, the device must provide reproducible results to be used as an objective tool for assessing nerve blocks. We recruited ten healthy volunteers to examine CPT reproducibility using the Neurometer(®) and the Stimpod NMS450 peripheral nerve stimulator. Each subject's CPT was determined for the median (second digit) and ulnar (fifth digit) nerve sensory distributions on both hands - with the Neurometer at 5 Hz, 250 Hz, and 2000 Hz and with the Stimpod at pulse widths of 0.1 msec, 0.3 msec, 0.5 msec, and 1.0 msec, both at 5 Hz and 2 Hz. Intraclass correlation coefficients (ICC) were also calculated to assess reproducibility; acceptable ICCs were defined as ≥ 0.4. The ICC values for the Stimpod ranged from 0.425-0.79, depending on pulse width, digit, and stimulation; ICCs for the Neurometer were 0.615 and 0.735 at 250 and 2,000 Hz, respectively. These values were considered acceptable; however, the Neurometer performed less efficiently at 5 Hz (ICCs for the second and fifth digits were 0.292 and 0.318, respectively). Overall, the Stimpod device displayed good to excellent reproducibility in measuring CPT in healthy volunteers. The Neurometer displayed poor reproducibility at low frequency (5 Hz). These results suggest that peripheral nerve stimulators may be potential devices for measuring CPT to assess nerve blocks.

Ultrasound imaging of the thenar motor branch of the median nerve: a cadaveric study.

PubMed

Petrover, David; Bellity, Jonathan; Vigan, Marie; Nizard, Remy; Hakime, Antoine

2017-11-01

Anatomic variations of the median nerve (MN) increase the risk of iatrogenic injury during carpal tunnel release surgery. We investigated whether high-frequency ultrasonography could identify anatomic variations of the MN and its thenar motor branch (MBMN) in the carpal tunnel. For each volar wrist of healthy non-embalmed cadavers, the type of MN variant (Lanz classification), course and orientation of the MBMN, and presence of hypertrophic muscles were scored by 18-MHz ultrasound and then by dissection. MBMN was identified by ultrasound in all 30 wrists (15 subjects). By dissection, type 1, 2 and 3 variants were found in 84%, 3%, and 13% of wrists, respectively. Ultrasound had good agreement with dissection in identifying the variant type (kappa =0.9). With both techniques, extra-, sub-, and transligamentous courses were recorded in 65%, 31%, and 4% of cases, respectively. With both techniques, the bifid nerve, hypertrophic muscles, and bilateral symmetry for variant type were identified in 13.3%, 13.3%, and 86.7% of wrists, respectively. Agreement between ultrasound and dissection was excellent for the MBMN course and orientation (kappa =1). Ultrasound can be used reliably to identify anatomic variations of the MN and MBMN. It could be a useful tool before carpal tunnel release surgery. • Ultrasound can identify variations of the motor branch of the median nerve. • Ultrasound mapping should be used prior to carpal tunnel release surgery. • All sub-, extra-, and transligamentous courses were accurately identified. • Type 3 variants (bifid nerve), hypertrophic muscles, and bilateral symmetry were accurately identified.

Percutaneous Treatment of Iatrogenic Pseudoaneurysms by Cyanoacrylate-Based Wall-Gluing

DOE Office of Scientific and Technical Information (OSTI.GOV)

Del Corso, Andrea, E-mail: adelcorso2000@hotmail.com; Vergaro, Giuseppe

Purpose. Although the majority of iatrogenic pseudoaneurysms (PSAs) are amenable to ultrasound (US)-guided thrombin injection, patients with those causing neuropathy, claudication, significant venous compression, or soft tissue necrosis are considered poor candidates for this option and referred to surgery. We aimed to test the effectiveness and feasibility of a novel percutaneous cyanoacrylate glue (NBCA-MS)-based technique for treatment of symptomatic and asymptomatic iatrogenic PSA. Material and Methods. During a 3-year period, we prospectively enrolled 91 patients with iatrogenic PSA [total n = 94 (femoral n = 76; brachial n = 11; radial n = 6; axillary n = 1)]. PSA weremore » asymptomatic in 66 % of cases, and 34 % presented with symptoms due to neuropathy, venous compression, and/or soft tissue necrosis. All patients signed informed consent. All patients received NBCA-MS-based percutaneous treatment. PSA chamber emptying was first obtained by US-guided compression; superior and inferior walls of the PSA chamber were then stuck together using NBCA-MS microinjections. Successfulness of the procedure was assessed immediately and at 1-day and 1-, 3-, and 12-month US follow-up. Results. PSA occlusion rate was 99 % (93 of 94 cases). After treatment, mean PSA antero-posterior diameter decrease was 67 {+-} 22 %. Neuropathy and vein compression immediately disappeared in 91 % (29 of 32) of cases. Patients with tissue necrosis (n = 6) underwent subsequent outpatient necrosectomy. No distal embolization occurred, nor was conversion to surgery necessary. Conclusion. PSA treatment by way of NBCA-MS glue injection proved to be safe and effective in asymptomatic patients as well as those with neuropathy, venous compression, or soft-tissue necrosis (currently candidates for surgery). Larger series are needed to confirm these findings.« less

Functional restoration of diaphragmatic paralysis: an evaluation of phrenic nerve reconstruction.

PubMed

Kaufman, Matthew R; Elkwood, Andrew I; Colicchio, Alan R; CeCe, John; Jarrahy, Reza; Willekes, Lourens J; Rose, Michael I; Brown, David

2014-01-01

Unilateral diaphragmatic paralysis causes respiratory deficits and can occur after iatrogenic or traumatic phrenic nerve injury in the neck or chest. Patients are evaluated using spirometry and imaging studies; however, phrenic nerve conduction studies and electromyography are not widely available or considered; thus, the degree of dysfunction is often unknown. Treatment has been limited to diaphragmatic plication. Phrenic nerve operations to restore diaphragmatic function may broaden therapeutic options. An interventional study of 92 patients with symptomatic diaphragmatic paralysis assigned 68 (based on their clinical condition) to phrenic nerve surgical intervention (PS), 24 to nonsurgical (NS) care, and evaluated a third group of 68 patients (derived from literature review) treated with diaphragmatic plication (DP). Variables for assessment included spirometry, the Short-Form 36-Item survey, electrodiagnostics, and complications. In the PS group, there was an average 13% improvement in forced expiratory volume in 1 second (p < 0.0001) and 14% improvement in forced vital capacity (p < 0.0001), and there was corresponding 17% (p < 0.0001) and 16% (p < 0.0001) improvement in the DP cohort. In the PS and DP groups, the average postoperative values were 71% for forced expiratory volume in 1 second and 73% for forced vital capacity. The PS group demonstrated an average 28% (p < 0.01) improvement in Short-Form 36-Item survey reporting. Electrodiagnostic testing in the PS group revealed a mean 69% (p < 0.05) improvement in conduction latency and a 37% (p < 0.0001) increase in motor amplitude. In the NS group, there was no significant change in Short-Form 36-Item survey or spirometry values. Phrenic nerve operations for functional restoration of the paralyzed diaphragm should be part of the standard treatment algorithm in the management of symptomatic patients with this condition. Assessment of neuromuscular dysfunction can aid in determining the most effective therapy

Endovascular management of iatrogenic native renal arterial pseudoaneurysms.

PubMed

Sildiroglu, Onur; Saad, Wael E; Hagspiel, Klaus D; Matsumoto, Alan H; Turba, Ulku Cenk

2012-12-01

Our purpose was to evaluate iatrogenic renal pseudoaneurysms, endovascular treatment, and outcomes. This retrospective study (2003-2011) reported the technical and clinical outcomes of endovascular therapy for renal pseudoaneurysms in eight patients (mean age, 46 (range 24-68) years). Renal parenchymal loss evaluation was based on digital subtraction angiography and computed tomography. We identified eight iatrogenic renal pseudoaneurysm patients with symptoms of hematuria, pain, and hematoma after renal biopsy (n = 3), surgery (n = 3), percutaneous nephrolithotomy (n = 1), and endoscopic shock-wave lithotripsy (n = 1). In six patients, the pseudoaneurysms were small-sized (<20 mm) and peripherally located and were treated solely with coil embolization (n = 5). In one patient, coil embolization was preceded by embolization with 500-700 micron embospheres to control active bleeding. The remaining two patients had large-sized (≥50 mm), centrally located renal pseudoaneurysms treated with thrombin ± coils. Technical success with immediate bleeding cessation was achieved in all patients. There were no procedure-related deaths or complications (mean follow-up, 23.5 (range, 1-67) months). Treatment of renal pseudoaneurysms using endovascular approach is a relatively safe and viable option regardless of location (central or peripheral) and size of the lesions with minimal renal parenchymal sacrifice.

The Uncommon Localization of Herpes Zoster

PubMed Central

Cukic, Vesna

2016-01-01

Introduction: Herpes zoster is an acute, cutaneous viral infection caused by the reactivation of varicella-zoster virus (VZV) that is the cause of varicella. It is an acute neurological disease which can often lead to serious postherpetic neuralgia (PHN). Different nerves can be included with the skin rash in the area of its enervation especially cranial nerves (CV) and intercostal nerves. Case report: In this report we present a patient with herpes zoster which involved ulnar nerve with skin rash in the region of ulnar innervations in women with no disease previously diagnosed. The failure of her immune system may be explained by great emotional stress and overwork she had been exposed to with neglecting proper nutrition in that period. Conclusion: Herpes zoster may involve any nerve with characteristic skin rash in the area of its innervations, and failure in immune system which leads reactivation of VZV may be caused by other factors besides the underlying illness. PMID:26980938

Results of Operative Treatment of Brachial Plexus Injury Resulting from Shoulder Dislocation: A Study with A Long-Term Follow-Up.

PubMed

Gutkowska, Olga; Martynkiewicz, Jacek; Mizia, Sylwia; Bąk, Michał; Gosk, Jerzy

2017-09-01

Injury to the infraclavicular brachial plexus is an uncommon but serious complication of shoulder dislocation. This work aims to determine the effectiveness of operative treatment in patients with this type of injury. Thirty-three patients (26 men and 7 women; mean age, 45 years and 3 months) treated operatively for brachial plexus injury resulting from shoulder dislocation between the years 2000 and 2013 were included in this retrospective case series. Motor function of affected limbs was assessed pre- and postoperatively with the use of the British Medical Research Council (BMRC) scale. Sensory function in the areas innervated by ulnar and median nerves was evaluated with the BMRC scale modified by Omer and Dellon and in the remaining areas with the Highet classification. Follow-up lasted 2-10 years (mean, 5.1 years). Good postoperative recovery of nerve function was observed in 100% of musculocutaneous, 93.3% of radial, 66.7% of median, 64% of axillary, and 50% of ulnar nerve injuries. No recovery was observed in 5.6% of median, 6.7% of radial, 10% of ulnar, and 20% of axillary nerve injuries. Injury to a single nerve was associated with worse treatment outcome than multiple nerve injury. Obtaining improvement in peripheral nerve function after injury resulting from shoulder dislocation may require operative intervention. The type of surgical procedure depends on intraoperative findings: sural nerve grafting in cases of neural elements' disruption, internal neurolysis when intraneural fibrosis is observed, and external neurolysis in the remaining cases. The outcomes of surgical treatment are good, and the risk of intra- and postoperative complications is low. Copyright © 2017 Elsevier Inc. All rights reserved.

Patient specific pointer tool for corrective osteotomy: Quality of symmetry based planning and case study of ulnar reconstruction surgery.

PubMed

Mueller, Samuel; Kahrs, Lueder A; Gaa, Johannes; Ortmaier, Tobias; Clausen, Jan-Dierk; Krettek, Christian

2017-07-01

Malunion after forearm fractures are described to appear in 2% to 10% of cases. Reconstructive surgeries ensure adequate anatomical repositioning. Their importance derives from the fact that malunion can often lead to severe pain as well as deformities causing loss of function and aesthetic issues not only in the forearm, but also the wrist and elbow joint. In this paper a clinical case will be presented using a Patient Specific Instrument (PSI) as navigational aid for reconstructive surgery after malunion of a proximal ulnar fracture combined with allograft surgery of the radial head and radial condyle due to chronic traumatic radial head luxation (Monteggia fracture). A planning method based on symmetry is described and evaluated on twelve Computed Tomographic (CT) data sets of intact forearms. The absolute point to point deviation at distal end of the ulnar styloid process was used as a characteristic value for accuracy evaluation. It is 7.9±4.9mm when using only the proximal end of the ulna for registration. The simulated change of ulnar variance is -1.4±1.9mm. Design and concept of the PSI are proven in a clinical trial. Copyright © 2017 Elsevier Ltd. All rights reserved.

Risk of iatrogenic injury to the infrapatellar branch of the saphenous nerve during hamstring tendon harvesting: A meta-analysis.

PubMed

Pękala, Przemysław A; Tomaszewski, Krzysztof A; Henry, Brandon Michael; Ramakrishnan, Piravin Kumar; Roy, Joyeeta; Mizia, Ewa; Walocha, Jerzy A

2017-11-01

Our goal was to conduct a comprehensive analysis of studies reporting data on the rate of injury to the infrapatellar branch of the saphenous nerve following hamstring tendon graft harvesting with respect to the type of incision over the pes anserinus. A broad search through all major electronic databases was conducted to identify articles eligible for inclusion. All available data were extracted and pooled into the analysis. Eleven studies (n = 1,050 patients) were included in the meta-analysis. The study revealed that a vertical incision during hamstring tendon harvesting over the pes anserinus was associated with the highest rate of injury with a pooled rate of 51.4% (95% confidence interval [CI], 34.6-67.2%). This was followed by oblique and horizontal incisions with pooled rates of 26.0% (95% CI,1.3-61.3%) and 22.4% (95% CI, 5.4-45.5%), respectively. We highly recommend the use of the shortest possible oblique incision during hamstring tendon harvesting over the pes anserinus. Muscle Nerve 56: 930-937, 2017. © 2017 Wiley Periodicals, Inc.

3.0 Tesla MRI in the early evaluation of inferior alveolar nerve neurological complications after mandibular third molar extraction: a prospective study

PubMed Central

Pranno, N; Barchetti, F; Sorrentino, V; Lo Mele, L

2014-01-01

Objectives: To evaluate the use of 3.0 T MRI in the prognosis of inferior alveolar nerve (IAN) sensory disorders after mandibular third molar extraction, in the early post-operative period. Methods: 343 IANs were examined before and 3 days after surgery. Two radiologists evaluated the course of the nerve and the relative signal intensity (RSI). Cohen's kappa coefficient (κ) and intraclass correlation coefficient (ICC) were used to evaluate the interobserver (k = 0.891) and intra-observer variability (ICC = 0.927; 0.914, respectively). The IANs were divided into four groups on the basis of neurosensory disorders recovery time. ANOVA was used to evaluate the differences among the RSIs of the four groups, and multiple comparisons were performed with Tukey's range test. Results: No differences in the course of IANs were found before and after surgery. In 280 IANs, no iatrogenic paraesthesia was found (Group A). 63 IANs showed a neurosensory impairment. 38 IANs showed recovery of post-operative paraesthesia at 3-month follow-up (Group B). 16 IANs showed a full recovery of iatrogenic paraesthesia at 6-month follow-up (Group C). Seven IANs displayed a full recovery at 12-month follow-up and two IANs showed persistence of neurosensory disorders at 18-month follow-up (Group D). The one-way ANOVA results indicated statistically significant difference among all groups (p < 0.05), except between Groups C and D (p = 0.504). Conclusions: The early evaluation of RSI values represents a valid tool to determine the prognosis of IAN sensory disorders after mandibular third molar extraction. PMID:24947977

Nerve stripper-assisted sural nerve harvest.

PubMed

Hassanpour, Esmail; Yavari, Masoud; Karbalaeikhani, Ali; Saremi, Hossein

2014-03-01

Sural nerve has the favorite length and size for nerve graft interposition. Here two techniques, that is, "stocking seam" and "stair-step" or "stepladder," have been used for harvesting sural nerve. The first technique results in an unsightly scar at the posterior calf, and the latter one takes a long time to perform and exert undue traction to the graft during harvesting. The purpose of this article is to describe our experience in harvesting the sural nerve by a nerve stripper. A nerve stripper was used for harvesting sural nerve in 35 adult patients (in 6 patients, sural harvesting was done bilaterally), 27 men and 8 women. Thirty-one sural nerve harvests were done by closed technique (i.e., harvesting of sural nerve only by two incisions, one in the posterior of the lateral malleolus and the other in popliteal fossa), in 8 others by limited open technique, and in 2 cases, there was early laceration of the sural nerve at the beginning of the study. The contralateral sural nerve was harvested in one patient and medial antebrachial nerve in another by open technique. The mean length of the retrieved sural nerve was 34.5 cm in the closed technique group and 35 cm in the limited open technique group. We detected advancing Tinel's sign in all nerve stripper-assisted sural nerve harvested group members in both the closed and limited open groups. Sural nerve harvesting by the nerve stripper is a reliable and simple technique, and it is applicable as a routine technique. Applying controlled rotatory movements of the nerve stripper instead of pushing can result in satisfactory harvesting of the sural nerve without early laceration. Georg Thieme Verlag KG Stuttgart · New York.

MR imaging of the elbow in the injured athlete.

PubMed

Wenzke, Daniel R

2013-03-01

This article summarizes key MR imaging findings in common athletic elbow injuries including little leaguer's elbow, Panner disease, osteochondritis dissecans, olecranon stress fracture, occult fracture, degenerative osteophyte formation, flexor-pronator strain, ulnar collateral ligament tear, lateral ulnar collateral ligament and radial collateral ligament tear, lateral epicondylitis, medial epicondylitis, biceps tear, bicipitoradial bursitis, triceps tear, olecranon bursitis, ulnar neuropathy, posterior interosseous nerve syndrome, and radial tunnel syndrome. The article also summarizes important technical considerations in elbow MR imaging that enhance image quality and contribute to the radiologist's success. Copyright © 2013 Elsevier Inc. All rights reserved.

A conservative management of iatrogenically damaged distal root of the mandibular second molar.

PubMed

Bansal, Rashmi; Roy, Sonali; Chandra, Praveen; Gurtu, Anuraag; Pandey, Rahul

2017-01-01

Trauma to the adjacent hard and soft tissue is the most common iatrogenic injury during extraction of the mandibular third molar. As every functional component of the dental arch is of prime importance in contemporary dental practice, the major concern must be in conserving the tooth and its structure as much as possible. The present case discusses the application of this conservative approach for management of iatrogenically damaged distal root of the mandibular second molar during extraction of impacted third molar, in which excessive guttering of alveolar bone and fractured apical third of distal root of 37 was observed radiographically. A conservative and noninvasive approach was successfully achieved to restore the damaged root by the bioactive material. Sealing of the remaining root with mineral trioxide aggregate allowed regeneration of soft and hard tissue around it.

Patients' views on early sensory relearning following nerve repair-a Q-methodology study.

PubMed

Vikström, Pernilla; Carlsson, Ingela; Rosén, Birgitta; Björkman, Anders

2017-09-26

Descriptive study. Early sensory relearning where the dynamic capacity of the brain is used has been shown to improve sensory outcome after nerve repair. However, no previous studies have examined how patients experience early sensory relearning. To describe patient's views on early sensory relearning. Statements' scores were analyzed by factor analysis. Thirty-seven consecutive adult patients with median and/or ulnar nerve repair who completed early sensory relearning were included. Three factors were identified, explaining 45% of the variance: (1) "Believe sensory relearning is meaningful, manage to get an illusion of touch and complete the sensory relearning"; (2) "Do not get an illusion of touch easily and need support in their sensory relearning" (3) "Are not motivated, manage to get an illusion of touch but do not complete sensory relearning". Many patients succeed in implementing their sensory relearning. However, a substantial part of the patient population need more support, have difficulties to create illusion of touch, and lack motivation to complete the sensory relearning. To enhance motivation and meaningfulness by relating the training clearly to everyday occupations and to the patient's life situation is a suggested way to proceed. The three unique factors indicate motivation and sense of meaningfulness as key components which should be taken into consideration in developing programs for person-centered early sensory relearning. 3. Copyright © 2017 Hanley & Belfus. Published by Elsevier Inc. All rights reserved.

Shoulder internal rotation elbow flexion test for diagnosing cubital tunnel syndrome.

PubMed

Ochi, Kensuke; Horiuchi, Yukio; Tanabe, Aya; Waseda, Makoto; Kaneko, Yasuhito; Koyanagi, Takahiro

2012-06-01

Shoulder internal rotation enhances symptom provocation attributed to cubital tunnel syndrome. We present a modified elbow flexion test--the shoulder internal rotation elbow flexion test--for diagnosing cubital tunnel syndrome. Fifty-five ulnar nerves in cubital tunnel syndrome patients and 123 ulnar nerves in controls were examined with 5 seconds each of elbow flexion, shoulder internal rotation, and shoulder internal rotation elbow flexion tests before and after treatment (surgery in 18; conservative in others). For the shoulder internal rotation elbow flexion test position, 90° abduction, maximum internal rotation, and 10° flexion of the shoulder were combined with the elbow flexion test position. The test was considered positive if any symptom for cubital tunnel syndrome developed <5 seconds. Influence of the shoulder internal rotation elbow flexion test was evaluated by nerve conduction studies in 10 cubital tunnel syndrome nerves and 7 control nerves. The sensitivities/specificities of the 5-second elbow flexion, shoulder internal rotation, and shoulder internal rotation elbow flexion tests were 25%/100%, 58%/100%, and 87%/98%, respectively. Sensitivity differences between the shoulder internal rotation elbow flexion test and the other two tests were significant. Shoulder internal rotation elbow flexion test results and cubital tunnel syndrome symptoms were significantly correlated. Influence of the shoulder internal rotation elbow flexion test on the ulnar nerve was seen in 8 of 10 cubital tunnel syndrome nerves but not in controls. The 5-second shoulder internal rotation elbow flexion test is specific, easy and quick provocative test for diagnosing cubital tunnel syndrome. Copyright © 2012 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Mosby, Inc. All rights reserved.

EMG circuit design and AR analysis of EMG signs.

PubMed

Hardalaç, Firat; Canal, Rahmi

2004-12-01

In this study, electromyogram (EMG) circuit was designed and tested on 27 people. Autoregressive (AR) analysis of EMG signals recorded on the ulnar nerve region of the right hand in resting position was performed. AR method, especially in the calculation of the spectrums of stable signs, is used for frequency analysis of signs, which give frequency response as sharp peaks and valleys. In this study, as the result of AR method analysis of EMG signals frequency-time domain, frequency spectrum curves (histogram curves) were obtained. As the images belonging to these histograms were evaluated, fibrillation potential widths of the muscle fibers of the ulnar nerve region of the people (material of the study) were examined. According to the degeneration degrees of the motor nerves, nine people had myopathy, nine had neuropathy, and nine were normal.

Effects of grip force on median nerve deformation at different wrist angles

PubMed Central

Nakashima, Hiroki; Muraki, Satoshi

2016-01-01

The present study investigated the effects of grip on changes in the median nerve cross-sectional area (MNCSA) and median nerve diameter in the radial-ulnar direction (D1) and dorsal-palmar direction (D2) at three wrist angles. Twenty-nine healthy participants (19 men [mean age, 24.2 ± 1.6 years]; 10 women [mean age, 24.0 ± 1.6 years]) were recruited. The median nerve was examined at the proximal carpal tunnel region in three grip conditions, namely finger relaxation, unclenched fist, and clenched fist. Ultrasound examinations were performed in the neutral wrist position (0°), at 30°wrist flexion, and at 30°wrist extension for both wrists. The grip condition and wrist angle showed significant main effects (p < 0.01) on the changes in the MNCSA, D1, and D2. Furthermore, significant interactions (p < 0.01) were found between the grip condition and wrist angle for the MNCSA, D1, and D2. In the neutral wrist position (0°), significant reductions in the MNCSA, D1, and D2 were observed when finger relaxation changed to unclenched fist and clenched fist conditions. Clenched fist condition caused the highest deformations in the median nerve measurements (MNCSA, approximately −25%; D1, −13%; D2, −12%). The MNCSA was significantly lower at 30°wrist flexion and 30°wrist extension than in the neutral wrist position (0°) at unclenched fist and clenched fist conditions. Notably, clenched fist condition at 30°wrist flexion showed the highest reduction of the MNCSA (−29%). In addition, 30°wrist flexion resulted in a lower D1 at clenched fist condition. In contrast, 30°wrist extension resulted in a lower D2 at both unclenched fist and clenched fist conditions. Our results suggest that unclenched fist and clenched fist conditions cause reductions in the MNCSA, D1, and D2. More importantly, unclenched fist and clenched fist conditions at 30°wrist flexion and 30°wrist extension can lead to further deformation of the median nerve. PMID:27688983

Iatrogenic Cushing's syndrome caused by intranasal steroid use.

PubMed

Dursun, Fatma; Kirmizibekmez, Heves

2017-01-01

Cushing's syndrome (CS) is common after oral steroid use and has also been reported following topical or inhaled use, but it is extremely uncommon after intranasal administration. This is the case of a 6-year-old child who developed Cushing's syndrome after intranasal application of dexamethasone sodium phosphate for a period of 6 months. Pediatricians and other clinical practitioners should be aware that high-dose and long-term nasal steroid administration may cause iatrogenic Cushing's syndrome characterized by complications of glucocorticoid excess as well as serious and even life-threatening complications of adrenal insufficiency.

External auditory canal cholesteatoma and keratosis obturans: the role of imaging in preventing facial nerve injury.

PubMed

McCoul, Edward D; Hanson, Matthew B

2011-12-01

We conducted a retrospective study to compare the clinical characteristics of external auditory canal cholesteatoma (EACC) with those of a similar entity, keratosis obturans (KO). We also sought to identify those aspects of each disease that may lead to complications. We identified 6 patients in each group. Imaging studies were reviewed for evidence of bony erosion and the proximity of disease to vital structures. All 6 patients in the EACC group had their diagnosis confirmed by computed tomography (CT), which demonstrated widening of the bony external auditory canal; 4 of these patients had critical erosion of bone adjacent to the facial nerve. Of the 6 patients with KO, only 2 had undergone CT, and neither exhibited any significant bony erosion or expansion; 1 of them developed osteomyelitis of the temporal bone and adjacent temporomandibular joint. Another patient manifested KO as part of a dermatophytid reaction. The essential component of treatment in all cases of EACC was microscopic debridement of the ear canal. We conclude that EACC may produce significant erosion of bone with exposure of vital structures, including the facial nerve. Because of the clinical similarity of EACC to KO, misdiagnosis is possible. Temporal bone imaging should be obtained prior to attempts at debridement of suspected EACC. Increased awareness of these uncommon conditions is warranted to prompt appropriate investigation and prevent iatrogenic complications such as facial nerve injury.

Iatrogenic spleen injury during minimally invasive left colonic flexure mobilization: the quest for evidence-based results.

PubMed

Mangano, Alberto; Gheza, Federico; Giulianotti, Pier C

2018-04-13

To assess the frequency, risk factors and outcomes of iatrogenic spleen injury during minimally invasive colo-rectal surgery with a particular focus on the routine splenic flexure mobilization tehcnique. Exclusion criteria: 1. topic not pertinent to the main topic of the review; 2. All case reports, editorials, conference highlights were excluded. After a title and abstract first selection and a final full-text analysis has been performed. The results of the selected articles are presented. The iatrogenic splenic injury rate during colorectal surgery is 0.96%. The iatrogenic injuries cause around 20% of all splenectomy. Ligaments over-traction is the most frequent mechanism of damage. The routine splenic flexure mobilization is a matter of scientific debate. open surgery, male sex, peripheral vascular disease, malignant neoplasia, diverticulitis, emergency surgery and teaching-hospital status. There is a risk difference according to the procedure: transverse colectomy has the highest risk, followed by left colectomy and total colectomy. The routine mobilization of the left colonic flexure is a debated topic. However, according to some authors (including our experience), this procedure is not a risk factor and it may be advantageous: a) it doesn't excessively prolong the total operative time; b) better surgical skills development; c) the tension-related ischemia is avoided; d) wider oncological dissection. Technical accuracy with cautious dissection/visualization can reduce the rate of iatrogenic splenic damage. Laparoscopy decreases the rate of splenic injury by almost 3,5 times. Robotic surgery may have the potential to further reduce this complication but more data are needed on the topic.

Rapid Diagnosis of an Ulnar Fracture with Portable Hand-Held Ultrasound

NASA Technical Reports Server (NTRS)

Kirkpatrick, Andrew W.; Brown, Ross; Diebel, Lawrence N.; Nicolaou, Savvas; Marshburn, Tom; Dulchavsky, Scott A.

2002-01-01

Orthopedic fractures are a common injury in operational activities, injuries that often occur in isolated or hostile environments. Clinical ultrasound devices have become more user friendly and lighter allowing them to be easily transported with forward medical teams. The bone-soft tissue interface has a very large acoustic impedance, with a high reflectance that can be used to visualize breaks in contour including fractures. Herein reported is a case of an ulnar fracture that was quickly visualized in the early phase of a multi-system trauma resuscitation with a hand-held ultrasound device. The implications for operational medicine are discussed.

Iatrogenic popliteal artery injury in non arthroplasty knee surgery.

PubMed

Bernhoff, K; Björck, M

2015-02-01

We have investigated iatrogenic popliteal artery injuries (PAI) during non arthroplasty knee surgery regarding mechanism of injury, treatment and outcomes, and to identify successful strategies when injury occurs. In all, 21 iatrogenic popliteal artery injuries in 21 patients during knee surgery other than knee arthroplasty were identified from the Swedish Vascular Registry (Swedvasc) between 1987 and 2011. Prospective registry data were supplemented with case-records, including long-term follow-up. In total, 13 patients suffered PAI during elective surgery and eight during urgent surgery such as fracture fixation or tumour resection. Nine injuries were detected intra-operatively, five within 12 to 48 hours and seven > 48 hours post-operatively (two days to 23 years). There were 19 open vascular and two endovascular surgical repairs. Two patients died within six months of surgery. One patient required amputation. Only six patients had a complete recovery of whom had the vascular injury detected at time of injury and repaired by a vascular surgeon. Patients sustaining vascular injury during elective procedures are more likely to litigate (p = 0.029). We conclude that outcomes are poorer when there is a delay of diagnosis and treatment, and that orthopaedic surgeons should develop strategies to detect PAI early and ensure rapid access to vascular surgical support. ©2015 The British Editorial Society of Bone & Joint Surgery.

An update on the causes, assessment and management of third division sensory trigeminal neuropathies.

PubMed

Carter, E; Yilmaz, Z; Devine, M; Renton, T

2016-06-24

Introduction Sensory neuropathies of the mandibular division of the trigeminal (V3) nerve can be debilitating, causing difficulty with daily function. It has a variety of causes, including iatrogenic injury, usually caused by third molar removal, local anaesthetic administration, implant placement or endodontic treatment. Non-iatrogenic causes include infection, primary or secondary neoplasia and various medical conditions.Objective To review the aetiology, evaluation and management of V3 neuropathy in a retrospective case-series of patients referred to a specialist nerve injury clinic over an eight-year period, particularly focusing on the non-iatrogenic causes of this presentation.Methods A retrospective analysis of the case notes of 372 patients referred to the specialist nerve injury clinic between 2006 and 2014 was carried out to establish the cause of the neuropathy and subsequent management or referral. The assessment protocol of trigeminal neuropathy used in the clinic is also outlined.Results Most patients (89.5%) presented with neuropathy due to iatrogenic injury. Of the non-iatrogenic causes (10.5%), malignancy accounted for a fifth of presentations, and infection almost two-fifths, demonstrating the importance of prompt identification of a cause and management by the clinician, or referral to the appropriate specialty. Other, more rare causes are also presented, including multiple sclerosis, sickle-cell anaemia and Paget's disease, highlighting the importance to the clinician of considering differential diagnoses.Conclusions This case series demonstrates the less frequent, but nevertheless important, non-iatrogenic causes which clinicians should consider when assessing patients with trigeminal neuropathy.

[Sural nerve removal using a nerve stripper].

PubMed

Assmus, H

1983-03-01

In 19 patients the sural nerve was removed for nerve grafting by a specially designed nerve stripper. This technique provides a safe and time-saving removal of the nerve in length up to 34 cm (depending on the length of the stripper used). From a single short incision at the level of the lateral malleolus the nerve is stripped proximally tearing some small branches of the distal nerve. The relatively blunt tip avoids inadvertent transection of the nerve at a lower level or dissection of the nerve at a point where branching occurs. Finally the nerve is cut by the divided cylinder at the tip of the stripper.

[Treatment of ulnar collateral ligament avulsion fracture of thumb metacarpophalangeal joint using a combination of Kirschner wire and silk tension band].

PubMed

Gao, Shunhong; Feng, Shiming; Jiao, Cheng

2012-12-01

To investigate the effectiveness of Kirschner wire combined with silk tension band in the treatment of ulnar collateral ligament avulsion fracture of the thumb metacarpophalangeal joint. Between September 2008 and October 2011, 14 patients with ulnar collateral ligament avulsion fracture of the thumb metacarpophalangeal joint were treated using a combination of Kirschner wire and silk tension band. There were 8 males and 6 females, aged 23-55 years (mean, 40.8 years). The causes of injury were machinery twist injury in 5 cases, manual twist injury in 4 cases, falling in 4 cases, sports injury in 1 case. The time from injury to operation was 2 hours-14 days. All the patients presented pain over the ulnar aspect of the metacarpophalangeal joint of the thumb, limitation of motion, and joint instability with pinch and grip. The lateral stress testing of the metacarpophalangeal joint was positive. Function training was given at 2 weeks after operation. All incisions healed by first intention. The lateral stress testing of the metacarpophalangeal joint was negative. All the patients were followed up 6-18 months (mean, 13.1 months). The X-ray films showed good fracture reduction and healing with an average time of 7 weeks (range, 4-10 weeks). At last follow-up, the thumbs had stable flexion and extension of the metacarpophalangeal joint, normal opposition function and grip and pinch strengths. According to Saetta et al. criteria for functional assessment, the results were excellent in 11 cases and good in 3 cases; the excellent and good rate was 100%. It is an easy and simple method to treat ulnar collateral ligament avulsion fracture of the thumb metacarpophalangeal joint using Kirschner wire combined with silk tension band, which can meet the good finger function.

The safe zone for avoiding suprascapular nerve injury during shoulder arthroscopy: an anatomical study on 500 dry scapulae.

PubMed

Gumina, Stefano; Albino, Paolo; Giaracuni, Marco; Vestri, Annarita; Ripani, Maurizio; Postacchini, Franco

2011-12-01

Suprascapular nerve injury may be a complication during shoulder arthroscopy. Our aim was to verify the reliability of the existing data, assess the differences between scapulae in the 2 genders and in the same subject, obtain a safe zone useful to avoid iatrogenic nerve lesions, and analyze the existing correlations between the scapular dimensions and the safe zone. We examined 500 dried scapulae, measuring 6 distances for each one, referring to the scapular body, glenoid, and the course of the suprascapular nerve, also catalogued according to gender and side. Differences due to gender were assessed comparing mean ± sd of each distance in males and females; paired t test was used to compare distances deriving from each couple. Successively, we calculated our safe zone and Pearson's correlation. We found nonsignificant differences between the right and left distances deriving from each couple; differences due to gender were stated. We defined 3 kinds of safe zones referring to: 500 scapulae; males (139 scapulae) and females (147 scapulae). The correlation indexes calculated between the axis of the scapular body and glenoid, and the posterosuperior distance (referring to the suprascapular nerve) were 0.624, 0.694, 0.675, 0.638; while those with the posterior distance were 0.230, 0.294, 0.232, 0.284. Knowledge of the safe zone, for avoiding suprascapular nerve injury, is important; gender and specific scapular dimensions should be evaluated, as they influence the dimensions of the safe zone. The linear predictors should be used to obtain specific values of the posterosuperior limit in each patient. Copyright © 2011 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Mosby, Inc. All rights reserved.

[False traumatic aneurysm of the ulnar artery in a teenager].

PubMed

Nour, M; Talha, H; El Idrissi, R; Lahraoui, Y; Ouazzani, L; Oubejja, H; Erraji, M; Zerhouni, H; Ettayebi, F

2014-12-01

Most aneurysms of hand arteries are traumatic. It is a generally rare unrecognized pathology. Complications are serious (embolism and thromboses of interdigital arteries). Two main causes can be recalled: acute trauma, with development of a false aneurysm; repeated microtrauma (hand hammer syndrome), with occurrence of an arterial dysplasic aneurysm. The diagnosis is based on the presence of a pulsatile mass, with finger dysesthesia, unilateral Raynaud's phenomenon. It is confirmed by duplex Doppler. Arteriography is necessary but can be replaced by an angio-MR. We report a case of false traumatic aneurysm of the ulnar artery in a teenager. This case illustrates this rare condition and opens discussion on therapeutic options. Copyright © 2014 Elsevier Masson SAS. All rights reserved.

Arm span and ulnar length are reliable and accurate estimates of recumbent length and height in a multiethnic population of infants and children under 6 years of age.

PubMed

Forman, Michele R; Zhu, Yeyi; Hernandez, Ladia M; Himes, John H; Dong, Yongquan; Danish, Robert K; James, Kyla E; Caulfield, Laura E; Kerver, Jean M; Arab, Lenore; Voss, Paula; Hale, Daniel E; Kanafani, Nadim; Hirschfeld, Steven

2014-09-01

Surrogate measures are needed when recumbent length or height is unobtainable or unreliable. Arm span has been used as a surrogate but is not feasible in children with shoulder or arm contractures. Ulnar length is not usually impaired by joint deformities, yet its utility as a surrogate has not been adequately studied. In this cross-sectional study, we aimed to examine the accuracy and reliability of ulnar length measured by different tools as a surrogate measure of recumbent length and height. Anthropometrics [recumbent length, height, arm span, and ulnar length by caliper (ULC), ruler (ULR), and grid (ULG)] were measured in 1479 healthy infants and children aged <6 y across 8 study centers in the United States. Multivariate mixed-effects linear regression models for recumbent length and height were developed by using ulnar length and arm span as surrogate measures. The agreement between the measured length or height and the predicted values by ULC, ULR, ULG, and arm span were examined by Bland-Altman plots. All 3 measures of ulnar length and arm span were highly correlated with length and height. The degree of precision of prediction equations for length by ULC, ULR, and ULG (R(2) = 0.95, 0.95, and 0.92, respectively) was comparable with that by arm span (R(2) = 0.97) using age, sex, and ethnicity as covariates; however, height prediction by ULC (R(2) = 0.87), ULR (R(2) = 0.85), and ULG (R(2) = 0.88) was less comparable with arm span (R(2) = 0.94). Our study demonstrates that arm span and ULC, ULR, or ULG can serve as accurate and reliable surrogate measures of recumbent length and height in healthy children; however, ULC, ULR, and ULG tend to slightly overestimate length and height in young infants and children. Further testing of ulnar length as a surrogate is warranted in physically impaired or nonambulatory children. © 2014 American Society for Nutrition.

Perioperative deaths: a further comparative review of coroner's autopsies with particular reference to the occurrence of fatal iatrogenic injury.

PubMed

Lau, G

2000-07-01

In previous triennial reviews of Coroner's perioperative autopsies conducted during the periods 1989 to 1991 and 1992 to 1994, it was observed that the necropsy incidence of such deaths rose from 2% to 2.6% (P < 0.05). Concurrently, the rate of iatrogenic deaths had nearly doubled from 15.2% to 28.8% (P < 0.02). These findings spurred a review of the subsequent triennium (1995 to 1997), in order to monitor the apparent rise in these trends and to study the frequency and occurrence of iatrogenic deaths in relation to the number of invasive procedures performed, as well as during emergency and elective procedures. A retrospective (descriptive and comparative) study, comprising a clinico-pathological review of a series of 270 perioperative deaths (defined as deaths occurring during or after invasive therapeutic or diagnostic procedures, up to a week after discharge, and excluding cases of major trauma from suicides, homicides, as well as road and industrial accidents) reported to the Coroner, for which autopsies were conducted at the Department of Forensic Medicine from 1995 to 1997. The necropsy incidence of 4.4% (270/6074) represented a significant rise over the previous triennia (P < 0.01). As in previous years, there was a predominance of males (M:F = 1.65:1) and middle-aged to elderly patients (range 0 to 92 years, mean 55.8 years, median 63 years), most of whom had died after a variable, but usually brief, postoperative interval [0 to 97, 4.2, 1 day(s)] and a more variable period of hospitalisation (< 1 to 289, 12.6, 7 days). A total of 408 invasive procedures were performed, amounting to an average of 1.5 per patient; 101 patients (37.4%) underwent multiple (> 1) interventions, which were initially classified as elective procedures in 27 cases. There were 66 (24.4%) iatrogenic deaths, of which 2 (0.7%) were due to anaesthetic mishaps; 18/64 iatrogenic deaths, unrelated to anaesthesia, occurred after the first postoperative day. The proportions of such deaths

Iatrogenic hypervitaminosis D as an unusual cause of persistent vomiting: a case report.

PubMed

Bansal, Rinkesh Kumar; Tyagi, Pankaj; Sharma, Praveen; Singla, Vikas; Arora, Veronica; Bansal, Naresh; Kumar, Ashish; Arora, Anil

2014-02-26

Vitamin D is increasingly recognized to have several beneficial effects. Vitamin D deficiency is widely prevalent. Physicians often treat patients with high doses of vitamin D for various ailments without any monitoring for adverse effects and the prescribed doses often far exceed requirements resulting in toxicity. We present here a classic case of iatrogenic hypervitaminosis D, which presented with persistent vomiting and acute renal failure. Here we present a case of a 45-year-old Asian Indian woman who presented to us with persistent vomiting the cause of which was iatrogenic hypervitaminosis D. She was treated with intravenous fluid, diuretics and calcitonin and had clinical improvement. We suggest that in any patient presenting with persistent vomiting and hypercalcemia, particularly in the presence of normal parathyroid hormone, a diagnosis of overdose of vitamin D should be suspected. Its treatment not only alleviates symptoms but also prevents ongoing acute kidney injury.

A Retrospective Study of the Characteristics and Clinical Significance of A-Waves in Amyotrophic Lateral Sclerosis.

PubMed

Fang, Jia; Cui, Liying; Liu, Mingsheng; Guan, Yuzhou; Ding, Qingyun; Shen, Dongchao; Li, Dawei; Tai, Hongfei

2017-01-01

A-wave was observed in patients with motor neuron disease (1). However, data on the characteristics and clinical significance of A-waves in patients with amyotrophic lateral sclerosis (ALS) have been scarce. The F-wave studies of 83 patients with ALS and 63 normal participants which were conducted previously at the Department of Neurology in Peking Union Medical College Hospital were retrospectively reviewed to determine the occurrence of A-waves in ALS. A-waves occurred more frequently in ALS patients than in normal controls. For the median and peroneal nerves, the frequencies of nerves with A-waves and frequencies of patients with A-waves were comparable between the ALS patients and normal controls. For the ulnar and tibial nerves, the frequencies of nerves with A-waves and frequencies of patients with A-waves were significantly increased in the ALS patients compared with those of the normal participants. Disease progression rate was slower in the ALS patients with A-waves (0.73 ± 0.99) than that in the ALS patients without A-waves (0.87 ± 0.55, P  = 0.007). No correlations were found between the amplitudes of F-waves with A-waves and those of A-waves in the ulnar nerves ( r  = 0.423, P  = 0.149). No correlations were found between the persistence of F-waves with A-waves and the persistence of A-waves in the ulnar nerves as well ( r  = 0.219, P  = 0.473). The occurrence of A-waves may indicate dysfunction of lower motor neurons and possibly imply a relatively slower degenerative process.

A Retrospective Study of the Characteristics and Clinical Significance of A-Waves in Amyotrophic Lateral Sclerosis

PubMed Central

Fang, Jia; Cui, Liying; Liu, Mingsheng; Guan, Yuzhou; Ding, Qingyun; Shen, Dongchao; Li, Dawei; Tai, Hongfei

2017-01-01

A-wave was observed in patients with motor neuron disease (1). However, data on the characteristics and clinical significance of A-waves in patients with amyotrophic lateral sclerosis (ALS) have been scarce. The F-wave studies of 83 patients with ALS and 63 normal participants which were conducted previously at the Department of Neurology in Peking Union Medical College Hospital were retrospectively reviewed to determine the occurrence of A-waves in ALS. A-waves occurred more frequently in ALS patients than in normal controls. For the median and peroneal nerves, the frequencies of nerves with A-waves and frequencies of patients with A-waves were comparable between the ALS patients and normal controls. For the ulnar and tibial nerves, the frequencies of nerves with A-waves and frequencies of patients with A-waves were significantly increased in the ALS patients compared with those of the normal participants. Disease progression rate was slower in the ALS patients with A-waves (0.73 ± 0.99) than that in the ALS patients without A-waves (0.87 ± 0.55, P = 0.007). No correlations were found between the amplitudes of F-waves with A-waves and those of A-waves in the ulnar nerves (r = 0.423, P = 0.149). No correlations were found between the persistence of F-waves with A-waves and the persistence of A-waves in the ulnar nerves as well (r = 0.219, P = 0.473). The occurrence of A-waves may indicate dysfunction of lower motor neurons and possibly imply a relatively slower degenerative process. PMID:29033889

Combined analysis of cortical (EEG) and nerve stump signals improves robotic hand control.

PubMed

Tombini, Mario; Rigosa, Jacopo; Zappasodi, Filippo; Porcaro, Camillo; Citi, Luca; Carpaneto, Jacopo; Rossini, Paolo Maria; Micera, Silvestro

2012-01-01

Interfacing an amputee's upper-extremity stump nerves to control a robotic hand requires training of the individual and algorithms to process interactions between cortical and peripheral signals. To evaluate for the first time whether EEG-driven analysis of peripheral neural signals as an amputee practices could improve the classification of motor commands. Four thin-film longitudinal intrafascicular electrodes (tf-LIFEs-4) were implanted in the median and ulnar nerves of the stump in the distal upper arm for 4 weeks. Artificial intelligence classifiers were implemented to analyze LIFE signals recorded while the participant tried to perform 3 different hand and finger movements as pictures representing these tasks were randomly presented on a screen. In the final week, the participant was trained to perform the same movements with a robotic hand prosthesis through modulation of tf-LIFE-4 signals. To improve the classification performance, an event-related desynchronization/synchronization (ERD/ERS) procedure was applied to EEG data to identify the exact timing of each motor command. Real-time control of neural (motor) output was achieved by the participant. By focusing electroneurographic (ENG) signal analysis in an EEG-driven time window, movement classification performance improved. After training, the participant regained normal modulation of background rhythms for movement preparation (α/β band desynchronization) in the sensorimotor area contralateral to the missing limb. Moreover, coherence analysis found a restored α band synchronization of Rolandic area with frontal and parietal ipsilateral regions, similar to that observed in the opposite hemisphere for movement of the intact hand. Of note, phantom limb pain (PLP) resolved for several months. Combining information from both cortical (EEG) and stump nerve (ENG) signals improved the classification performance compared with tf-LIFE signals processing alone; training led to cortical reorganization and

Iatrogenic Cushing's syndrome in children presenting at Children's Hospital Lahore using nappy rash ointments.

PubMed

Sattar, Hina; Manzoor, Jaida; Mirza, Liaqat; Sheikh, Abdul Malik; Butt, Taeed Ahmad

2015-05-01

To study the characteristics of infants and children presenting with iatrogenic Cushing's Syndrome due to nappy rash ointments. The descriptive study was conducted at the Children's Hospital, Lahore, from April to September 2013, and comprised patients presenting with cushingoid features and history of using nappy rash ointments. Patients having Cushing's Syndrome due to causes other than iatrogenic were excluded and so were those taking oral or parenteral steroids due to skin allergy, renal or respiratory disease. Demographic data, history and examination of all patients were recorded on a proforma and results were analysed using SPSS 16. Of the total 18 patients, 13(72%) were girls and 5(27%) were boys. Eight (44.4%) patients were younger than 6 months, 6(33.3%) were between 6 months to 1 year, while 4(22.2%) were between 12 and 18 months of age. Clobetasol alone was the most frequently used agent responsible in 13(72%) cases. Duration of use of steroid ointment was as short as 3 weeks to as much as 1 year. All the patients were using disposable diapers. Ointment was prescribed by a doctor in 5(27%) cases and self-prescribed (relative or neighbour) in 13(72%). Self-medication and prolonged use of potent steroid ointments are major contributors in development of iatrogenic Cushing's Syndrome in infants and children. Younger age, female gender and use of disposable diapers were other important predisposing factors.

Iatrogenic hypervitaminosis D as an unusual cause of persistent vomiting: a case report

PubMed Central

2014-01-01

Introduction Vitamin D is increasingly recognized to have several beneficial effects. Vitamin D deficiency is widely prevalent. Physicians often treat patients with high doses of vitamin D for various ailments without any monitoring for adverse effects and the prescribed doses often far exceed requirements resulting in toxicity. We present here a classic case of iatrogenic hypervitaminosis D, which presented with persistent vomiting and acute renal failure. Case presentation Here we present a case of a 45-year-old Asian Indian woman who presented to us with persistent vomiting the cause of which was iatrogenic hypervitaminosis D. She was treated with intravenous fluid, diuretics and calcitonin and had clinical improvement. Conclusions We suggest that in any patient presenting with persistent vomiting and hypercalcemia, particularly in the presence of normal parathyroid hormone, a diagnosis of overdose of vitamin D should be suspected. Its treatment not only alleviates symptoms but also prevents ongoing acute kidney injury. PMID:24571630

Incarcerated medial epicondyle fracture following pediatric elbow dislocation: 11 cases.

PubMed

Dodds, Seth D; Flanagin, Brody A; Bohl, Daniel D; DeLuca, Peter A; Smith, Brian G

2014-09-01

To describe outcomes after surgical management of pediatric elbow dislocation with incarceration of the medial epicondyle. We conducted a retrospective case review of 11 consecutive children and adolescents with an incarcerated medial epicondyle fracture after elbow dislocation. All patients underwent open reduction internal fixation using a similar technique. We characterized outcomes at final follow-up. Average follow-up was 14 months (range, 4-56 mo). All patients had clinical and radiographic signs of healing at final follow-up. There was no radiographic evidence of loss of reduction at intervals or at final follow-up. There were no cases of residual deformity or valgus instability. Average final arc of elbow motion was 4° to 140°. All patients had forearm rotation from 90° supination to 90° pronation. Average Mayo elbow score was 99.5. Four of 11 patients had ulnar nerve symptoms postoperatively and 1 required a second operation for ulnar nerve symptoms. In addition, 1 required a second operation for flexion contracture release with excision of heterotopic ossification. Three patients had ulnar nerve symptoms at final follow-up. Two of these had mild paresthesia only and 1 had both mild paresthesia and weakness. Our results suggest that open reduction internal fixation of incarcerated medial epicondyle fractures after elbow dislocation leads to satisfactory motion and function; however, the injury carries a high risk for complications, particularly ulnar neuropathy. Therapeutic IV. Copyright © 2014 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.

Pisiform excision for pisotriquetral instability and arthritis.

PubMed

Campion, Heather; Goad, Andrea; Rayan, Ghazi; Porembski, Margaret

2014-07-01

To evaluate wrist strength and kinematics after pisiform excision and preservation of its soft tissue confluence for pisotriquetral instability and arthritis. We evaluated 12 patients, (14 wrists) subjectively and objectively an average of 7.5 years after pisiform excision. Three additional patients were interviewed by phone. Subjective evaluation included inquiry about pain and satisfaction with the treatment. Objective testing included measuring wrist flexion and extension range of motion, grip strength, and static and dynamic flexion and ulnar deviation strengths of the operative hand compared with the nonsurgical normal hand. Four patients had concomitant ulnar nerve decompression at the wrist. All patients were satisfied with the outcome. Wrist flexion averaged 99% and wrist extension averaged 95% of the nonsurgical hand. Mean grip strength of the operative hand was 90% of the nonsurgical hand. Mean static flexion strength of the operative hand was 94% of the nonsurgical hand, whereas mean dynamic flexion strength was 113%. Mean static ulnar deviation strength of the operative hand was 87% of the nonsurgical hand. The mean dynamic ulnar deviation strength of the operative hand was 103% of the nonsurgical hand. Soft tissue confluence-preserving pisiform excision relieved pain and retained wrist motion and static and dynamic strength. Associated ulnar nerve compression was a confounding factor that may have affected outcomes. Therapeutic IV. Copyright © 2014 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.

Innervation of the wrist joint and surgical perspectives of denervation.

PubMed

Van de Pol, Gerrit J; Koudstaal, Maarten J; Schuurman, Arnold H; Bleys, Ronald L A W

2006-01-01

Because our experience with the techniques used in denervation surgery of the wrist joint often has proven insufficient in treating chronic pain we conducted an anatomic study to clarify the exact contributions of the nerves supplying the wrist joint. Our goal was to reveal all periosteal and capsular nerve connections and if necessary adjust our technique used in denervation surgery. Innervation of the wrist joint was investigated by microdissection and histologic examination of 18 human wrists. An acetylcholinesterase method was used to identify the nerves, both in whole-mount preparations and in sections. We found that the main innervation to the wrist capsule and periosteal nerve network came from the anterior interosseous nerve, lateral antebrachial cutaneous nerve, and posterior interosseous nerve. The palmar cutaneous branch of the median nerve, the deep branch of the ulnar nerve, the superficial branch of the radial nerve, and the dorsal branch of the ulnar nerve also were found to have connections with the capsule. The periosteal nerve branches did not appear to play a major role in the innervation of the capsule and ligaments; here the specific articular nerve branches proved more important. The posterior and medial antebrachial cutaneous nerves did not connect to the wrist capsule or periosteum but rather terminated in the extensor and flexor retinaculum. Based on our findings we propose to denervate the wrist by making 2 incisions. With one palmar and one dorsal incision it should be possible to disconnect the periosteum from the capsule and interrupt the majority of the capsular nerve branches.

Stabilization of Volar Ulnar Rim Fractures of the Distal Radius: Current Techniques and Review of the Literature

PubMed Central

O'Shaughnessy, Maureen A.; Shin, Alexander Y.; Kakar, Sanjeev

2016-01-01

Background Distal radius fractures involving the lunate facet can be challenging to manage. Reports have shown the volar carpal subluxation/dislocation that can occur if the facet is not appropriately stabilized. Literature Review Recent emphasis in the literature has underscored the difficulty in managing this fracture fragment, suggesting standard volar plates may not be able to adequately stabilize the fragment. This article reviews the current literature with a special emphasis on fixation with a specifically designed fragment-specific hook plate to secure the lunate facet. Case Description An extended flexor carpi radialis volar approach was made which allows access to the distal volar ulnar fracture fragment. Once provisionally stabilized with Kirschner wire fixation, a volar hook plate was applied to capture this fragment. Additional fracture stabilization was used as deemed necessary to stabilize the remaining distal radius fracture. Clinical Relevance The volar marginal rim fragment remains a challenge in distal radius fracture management. Use of a hook plate to address the volar ulnar corner allows for stable fixation without loss of reduction at intermediate-term follow-up. PMID:27104076

Value of Free-Run Electromyographic Monitoring of Extraocular Cranial Nerves during Expanded Endonasal Surgery (EES) of the Skull Base.

PubMed

Thirumala, Parthasarathy D; Mohanraj, Santhosh Kumar; Habeych, Miguel; Wichman, Kelley; Chang, Yue-Fang; Gardner, Paul; Snyderman, Carl; Crammond, Donald J; Balzer, Jeffrey

2013-06-01

Objective To evaluate the value of free-run electromyography (f-EMG) monitoring of extraocular cranial nerves (EOCN) III, IV, and VI during expanded endonasal surgery (EES) of the skull base in reducing iatrogenic cranial nerve (CN) deficits. Design We retrospectively identified 200 patients out of 990 who had at least one EOCN monitored during EES. We further separated patients into groups according to the specific CN monitored. In each CN group, we classified patients who had significant (SG) f-EMG activity as Group I and those who did not as Group II. Results A total of 696 EOCNs were monitored. The number of muscles supplied by EOCNs that had SG f-EMG activity was 88, including CN III = 46, CN IV = 21, and CN VI = 21. There were two deficits involving CN VI in patients who had SG f-EMG activity during surgery. There were 14 deficits observed, including CN III = 3, CN IV = 2, and CN VI = 9 in patients who did not have SG f-EMG activity during surgery. Conclusions f-EMG monitoring of EOCN during EES can be useful in identifying the location of the nerve. It seems to have limited value in predicting postoperative neurological deficits. Future studies to evaluate the EMG of EOCN during EES need to be done with both f-EMG and triggered EMG.

Value of Free-Run Electromyographic Monitoring of Extraocular Cranial Nerves during Expanded Endonasal Surgery (EES) of the Skull Base

PubMed Central

Thirumala, Parthasarathy D.; Mohanraj, Santhosh Kumar; Habeych, Miguel; Wichman, Kelley; Chang, Yue-fang; Gardner, Paul; Snyderman, Carl; Crammond, Donald J.; Balzer, Jeffrey

2013-01-01

Objective To evaluate the value of free-run electromyography (f-EMG) monitoring of extraocular cranial nerves (EOCN) III, IV, and VI during expanded endonasal surgery (EES) of the skull base in reducing iatrogenic cranial nerve (CN) deficits. Design We retrospectively identified 200 patients out of 990 who had at least one EOCN monitored during EES. We further separated patients into groups according to the specific CN monitored. In each CN group, we classified patients who had significant (SG) f-EMG activity as Group I and those who did not as Group II. Results A total of 696 EOCNs were monitored. The number of muscles supplied by EOCNs that had SG f-EMG activity was 88, including CN III = 46, CN IV = 21, and CN VI = 21. There were two deficits involving CN VI in patients who had SG f-EMG activity during surgery. There were 14 deficits observed, including CN III = 3, CN IV = 2, and CN VI = 9 in patients who did not have SG f-EMG activity during surgery. Conclusions f-EMG monitoring of EOCN during EES can be useful in identifying the location of the nerve. It seems to have limited value in predicting postoperative neurological deficits. Future studies to evaluate the EMG of EOCN during EES need to be done with both f-EMG and triggered EMG. PMID:23943720

Effects of nerve cells and adhesion molecules on nerve conduit for peripheral nerve regeneration

PubMed Central

Fiorellini, Joseph P.

2017-01-01

Background For peripheral nerve regeneration, recent attentions have been paid to the nerve conduits made by tissue-engineering technique. Three major elements of tissue-engineering are cells, molecules, and scaffolds. Methods In this study, the attachments of nerve cells, including Schwann cells, on the nerve conduit and the effects of both growth factor and adhesion molecule on these attachments were investigated. Results The attachment of rapidly-proliferating cells, C6 cells and HS683 cells, on nerve conduit was better than that of slowly-proliferating cells, PC12 cells and Schwann cells, however, the treatment of nerve growth factor improved the attachment of slowly-proliferating cells. In addition, the attachment of Schwann cells on nerve conduit coated with fibronectin was as good as that of Schwann cells treated with glial cell line-derived neurotrophic factor (GDNF). Conclusions Growth factor changes nerve cell morphology and affects cell cycle time. And nerve growth factor or fibronectin treatment is indispensable for Schwann cell to be used for implantation in artificial nerve conduits. PMID:29090249

Frequency and trends of contact allergy to and iatrogenic contact dermatitis caused by topical drugs over a 25-year period.

PubMed

Gilissen, Liesbeth; Goossens, An

2016-11-01

Allergic contact dermatitis is the most common adverse reaction caused by topical drugs. To study the demographic characteristics and lesion locations of patients with iatrogenic dermatitis, and to analyse contact allergy to active principles and trends in frequencies over the years. Between 1990 and 2014, 14 911 patients were patch tested with the European baseline series. Patients with a presumed iatrogenic cause were often tested with a pharmaceutical series, and, if indicated, with photo-patch tests. Most were also tested with the topical products to which they had been exposed, along with their ingredients. Eight thousand three hundred and seventy-four (56%) patients tested positively, and 2600 (17.4%, 95%CI: 16.8-18.0%) of all patients suffered from iatrogenic contact dermatitis. The most important primary sites of dermatitis were the legs, face, and hands. The most common sensitizers included topical antibiotics, antiseptics, and corticosteroids. The most frequent baseline allergens in this subgroup were budesonide, neomycin, and benzocaine, although with a decreasing trend over the years. Many other allergens from different pharmacological classes were identified. With a prevalence of 17.4% of consecutive patients, iatrogenic contact dermatitis is a frequent diagnosis in patients attending a general patch test clinic, involving one-third of the patients with at least one positive reaction. © 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

The Reliability of the Tracheoesophageal Groove and the Ligament of Berry as Landmarks for Identifying the Recurrent Laryngeal Nerve: A Cadaveric Study and Meta-Analysis

PubMed Central

Sanna, Beatrice; Graves, Matthew J.; Sanna, Silvia; Vikse, Jens

2017-01-01

Purpose. The aim of this meta-analysis was to provide a comprehensive evidence-based assessment, supplemented by cadaveric dissections, of the value of using the Ligament of Berry and Tracheoesophageal Groove as anatomical landmarks for identifying the Recurrent Laryngeal Nerve. Methods. Seven major databases were searched to identify studies for inclusion. Eligibility was judged by two reviewers. Suitable studies were identified and extracted. MetaXL was used for analysis. All pooled prevalence rates were calculated using a random effects model. Heterogeneity among included studies was assessed using the Chi2 test and the I2 statistic. Results. Sixteen studies (n = 2,470 nerves), including original cadaveric data, were analyzed for the BL/RLN relationship. The RLN was most often located superficial to the BL with a pooled prevalence estimate of 78.2% of nerves, followed by deep to the BL in 14.8%. Twenty-three studies (n = 5,970 nerves) examined the RLN/TEG relationship. The RLN was located inside the TEG in 63.7% (95% CI: 55.3–77.7) of sides. Conclusions. Both the BL and TEG are landmarks that can help surgeons provide patients with complication-free procedures. Our analysis showed that the BL is a more consistent anatomical landmark than the TEG, but it is necessary to use both to prevent iatrogenic RLN injuries during thyroidectomies. PMID:28271065

Outcomes of Iatrogenic Genitourinary Injuries During Colorectal Surgery.

PubMed

Eswara, Jairam R; Raup, Valary T; Potretzke, Aaron M; Hunt, Steven R; Brandes, Steven B

2015-12-01

To describe, categorize, and determine the outcomes of repairs of genitourinary (GU) injuries that occur during colorectal surgery. Presently, little is known regarding these injuries or the long-term outcomes of their repair. We performed a retrospective review of patients undergoing colorectal surgery between 2003 and 2013 who experienced iatrogenic GU injuries requiring surgical repair. GU repair failures were defined as development of urine leak, urinary fistula, or anastomotic stricture requiring secondary GU intervention. Possible risk factors associated with repair failures were examined and included age, American Society of Anesthesiology score, comorbidities, type of colorectal surgery, radiation, and chemotherapy. Of 42,570 colorectal surgeries performed, 75 GU injuries were identified (0.18%). Mean age was 57.5 years (range, 22-91), and median follow-up was 19.5 months (range, 1-128). Fifty-nine (59/75, 79%) patients required a single GU repair whereas 16 of 75 (21%) patients experienced repair failure requiring additional GU intervention. The most common GU injuries were cystotomy (26/75, 35%), incomplete ureteral transection (22/75, 29%), complete proximal and distal ureteral injuries (13/75, 17%; 11/75, 15%), urethral injury (2/75, 3%), and injury to a pre-existing ileal conduit (1/75, 1). Twenty-seven patients (36%) had prior radiation and 35 patients (47%) had prior chemotherapy. Preoperative radiation and chemotherapy were both associated with failure of the GU repair (P = .003; P = .013). Delayed repair of the GU injury was also associated with repair failure (P = .001). Iatrogenic GU injuries during colorectal surgery are rare, affecting only 0.18% of colorectal procedures. Preoperative external beam radiation therapy/chemotherapy and delayed GU repair are associated with worse outcomes of repairs of these injuries. Copyright © 2015 Elsevier Inc. All rights reserved.

Elbow ulnar collateral ligament injuries in athletes: Can we improve our outcomes?

PubMed Central

Redler, Lauren H; Degen, Ryan M; McDonald, Lucas S; Altchek, David W; Dines, Joshua S

2016-01-01

Injury to the ulnar collateral ligament (UCL) most commonly occurs in the overhead throwing athlete. Knowledge surrounding UCL injury pathomechanics continues to improve, leading to better preventative treatment strategies and rehabilitation programs. Conservative treatment strategies for partial injuries, improved operative techniques for reconstruction in complete tears, adjunctive treatments, as well as structured sport specific rehabilitation programs including resistive exercises for the entire upper extremity kinetic chain are all important factors in allowing for a return to throwing in competitive environments. In this review, we explore each of these factors and provide recommendations based on the available literature to improve outcomes in UCL injuries in athletes. PMID:27114930

Oesophageal stent placement to treat a massive iatrogenic duodenal defect after laparoscopic cholecystectomy.

PubMed

Greenbaum, Alissa; Parasher, Gulshan; Demarest, Gerald; Auyang, Edward

2017-05-05

Iatrogenic duodenal injury occurring during laparoscopic cholecystectomy (LC) is managed surgically, though rarely a large, persistent fistula is refractory to surgical interventions. We present the case of a 40-year-old woman transferred to our centre following elective LC for a reported perforated duodenal ulcer. An uncontained leak was found to originate from a 1.5 cm duodenal defect, with no evidence of ulceration. A duodenostomy tube was placed. One month after abdominal closure, the patient continued to have a persistent, large duodenal fistula. A through-the-scope covered oesophageal stent was placed under endoscopic and fluoroscopic guidance. Five weeks later, it was successfully retrieved and no subsequent extravasation of contrast from the duodenum was noted. Unrecognised iatrogenic duodenal injuries sustained during LC can be catastrophic. In cases of massive duodenal defects and high-output biliary fistula uncontrolled after surgical intervention, endoscopic-guided and fluoroscopic-guided placement of a fully covered oesophageal stent may be lifesaving. © BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Raman spectroscopic detection of peripheral nerves towards nerve-sparing surgery

NASA Astrophysics Data System (ADS)

Minamikawa, Takeo; Harada, Yoshinori; Takamatsu, Tetsuro

2017-02-01

The peripheral nervous system plays an important role in motility, sensory, and autonomic functions of the human body. Preservation of peripheral nerves in surgery, namely nerve-sparing surgery, is now promising technique to avoid functional deficits of the limbs and organs following surgery as an aspect of the improvement of quality of life of patients. Detection of peripheral nerves including myelinated and unmyelinated nerves is required for the nerve-sparing surgery; however, conventional nerve identification scheme is sometimes difficult to identify peripheral nerves due to similarity of shape and color to non-nerve tissues or its limited application to only motor peripheral nerves. To overcome these issues, we proposed a label-free detection technique of peripheral nerves by means of Raman spectroscopy. We found several fingerprints of peripheral myelinated and unmyelinated nerves by employing a modified principal component analysis of typical spectra including myelinated nerve, unmyelinated nerve, and adjacent tissues. We finally realized the sensitivity of 94.2% and the selectivity of 92.0% for peripheral nerves including myelinated and unmyelinated nerves against adjacent tissues. Although further development of an intraoperative Raman spectroscopy system is required for clinical use, our proposed approach will serve as a unique and powerful tool for peripheral nerve detection for nerve-sparing surgery in the future.

Early sensory re-education of the hand after peripheral nerve repair based on mirror therapy: a randomized controlled trial.

PubMed

Paula, Mayara H; Barbosa, Rafael I; Marcolino, Alexandre M; Elui, Valéria M C; Rosén, Birgitta; Fonseca, Marisa C R

2016-01-01

Mirror therapy has been used as an alternative stimulus to feed the somatosensory cortex in an attempt to preserve hand cortical representation with better functional results. To analyze the short-term functional outcome of an early re-education program using mirror therapy compared to a late classic sensory program for hand nerve repair. This is a randomized controlled trial. We assessed 20 patients with median and ulnar nerve and flexor tendon repair using the Rosen Score combined with the DASH questionnaire. The early phase group using mirror therapy began on the first postoperative week and lasted 5 months. The control group received classic sensory re-education when the protective sensation threshold was restored. All participants received a patient education booklet and were submitted to the modified Duran protocol for flexor tendon repair. The assessments were performed by the same investigator blinded to the allocated treatment. Mann-Whitney Test and Effect Size using Cohen's d score were used for inter-group comparisons at 3 and 6 months after intervention. The primary outcome (Rosen score) values for the Mirror Therapy group and classic therapy control group after 3 and 6 months were 1.68 (SD=0.5); 1.96 (SD=0.56) and 1.65 (SD=0.52); 1.51 (SD=0.62), respectively. No between-group differences were observed. Although some clinical improvement was observed, mirror therapy was not shown to be more effective than late sensory re-education in an intermediate phase of nerve repair in the hand. Replication is needed to confirm these findings.

Early sensory re-education of the hand after peripheral nerve repair based on mirror therapy: a randomized controlled trial

PubMed Central

Paula, Mayara H.; Barbosa, Rafael I.; Marcolino, Alexandre M.; Elui, Valéria M. C.; Rosén, Birgitta; Fonseca, Marisa C. R.

2016-01-01

BACKGROUND: Mirror therapy has been used as an alternative stimulus to feed the somatosensory cortex in an attempt to preserve hand cortical representation with better functional results. OBJECTIVE: To analyze the short-term functional outcome of an early re-education program using mirror therapy compared to a late classic sensory program for hand nerve repair. METHOD: This is a randomized controlled trial. We assessed 20 patients with median and ulnar nerve and flexor tendon repair using the Rosen Score combined with the DASH questionnaire. The early phase group using mirror therapy began on the first postoperative week and lasted 5 months. The control group received classic sensory re-education when the protective sensation threshold was restored. All participants received a patient education booklet and were submitted to the modified Duran protocol for flexor tendon repair. The assessments were performed by the same investigator blinded to the allocated treatment. Mann-Whitney Test and Effect Size using Cohen's d score were used for inter-group comparisons at 3 and 6 months after intervention. RESULTS: The primary outcome (Rosen score) values for the Mirror Therapy group and classic therapy control group after 3 and 6 months were 1.68 (SD=0.5); 1.96 (SD=0.56) and 1.65 (SD=0.52); 1.51 (SD=0.62), respectively. No between-group differences were observed. CONCLUSION: Although some clinical improvement was observed, mirror therapy was not shown to be more effective than late sensory re-education in an intermediate phase of nerve repair in the hand. Replication is needed to confirm these findings. PMID:26786080

The Course of the Terminal Posterior Interosseous Nerve and Its Relationship with Wrist Arthroscopy Portals

PubMed Central

Pan, Yongwei; Hung, Leung-kim

2016-01-01

Purpose The terminal branches of the posterior interosseous nerve (PIN) are the main articular branch on the dorsal aspect of the wrist. Its relationship to dorsal wrist arthroscopic portals has not yet been elucidated. The purpose of this study was to quantitatively describe the anatomical relationships between the dorsal wrist arthroscopic portals and the PIN. Methods Dorsal wrist arthroscopic portals were established in 28 cadaver extremities, after which the limbs were dissected. Measurements were taken from the portals to the PIN. Results The PIN passed ulnar to the 3/4 portal with a mean distance of 4.8 mm (range: 1.2–12.0, standard deviation [SD] = 2.6). The PIN passed radial to the 4/5 portal with a mean interval of 9.0 mm (range: 3.8–12.7, SD = 2.3). The main trunk of PIN or its closest terminal branch was a mean of 7.2 mm (range: 0.0–13.2 mm, SD = 3.1) radial to the midcarpal radial (MCR) portal. In 2 of the 28 specimens, one terminal branch of PIN lay directly over this portal. The distance between the midcarpal ulnar (MCU) portal and the PIN or its closest terminal branch was only a mean of 1.6 mm (range: 0–6.4 mm, SD = 2.0). In 15 of the 28 specimens, the PIN lay directly over the MCU portal, or the portal was located between the terminal branches of PIN. Conclusion The MCU portal was the most precarious, due to the close proximity of PIN and its terminal branches. The 3/4 and MCR portals were also at risk, while the 4/5 portal was relatively safe for the PIN. PMID:27777824

Acellular Nerve Allografts in Peripheral Nerve Regeneration: A Comparative Study

PubMed Central

Moore, Amy M.; MacEwan, Matthew; Santosa, Katherine B.; Chenard, Kristofer E.; Ray, Wilson Z.; Hunter, Daniel A.; Mackinnon, Susan E.; Johnson, Philip J.

2011-01-01

Background Processed nerve allografts offer a promising alternative to nerve autografts in the surgical management of peripheral nerve injuries where short deficits exist. Methods Three established models of acellular nerve allograft (cold-preserved, detergent-processed, and AxoGen® -processed nerve allografts) were compared to nerve isografts and silicone nerve guidance conduits in a 14 mm rat sciatic nerve defect. Results All acellular nerve grafts were superior to silicone nerve conduits in support of nerve regeneration. Detergent-processed allografts were similar to isografts at 6 weeks post-operatively, while AxoGen®-processed and cold-preserved allografts supported significantly fewer regenerating nerve fibers. Measurement of muscle force confirmed that detergent-processed allografts promoted isograft-equivalent levels of motor recovery 16 weeks post-operatively. All acellular allografts promoted greater amounts of motor recovery compared to silicone conduits. Conclusions These findings provide evidence that differential processing for removal of cellular constituents in preparing acellular nerve allografts affects recovery in vivo. PMID:21660979

Modified technique for correction of isolated radial head dislocation without apparent ulnar bowing: a retrospective case study

PubMed Central

Tan, Lei; Li, Yan-Hui; Sun, Da-Hui; Zhu, Dong; Ning, Shu-Yan

2015-01-01

Objective: There is currently no general consensus on the optimal treatment of chronic radial head dislocation. Material and Methods: Considering that the annular ligament is important in maintaining elbow stability, we developed a modified method for annular ligament reconstruction in pediatric cases of radial head dislocation without ulnar bowing. We retrospectively investigated the therapeutic outcomes of this technique in a series of cases. We used our modified technique for the treatment of five patients between January 2006 and January 2012. The average age of the patients at the time of injury was 9 years (range, 6-14 years), and the patients were followed up for 1 to 3 years. Results: The perioperative and follow-up data of the patients were examined. All five surgical procedures were completed uneventfully and had been tolerated well by the patients, with minimal complications. Remarkable improvement was noted in all the cases at the end of the follow-up period. Conclusions: Our modified technique for annular ligament reconstruction was effective in achieving good reduction of the radial head dislocation with minimal complications in pediatric cases of isolated radial head dislocation without apparent ulnar bowing. PMID:26770420

Double nerve intraneural interface implant on a human amputee for robotic hand control.

PubMed

Rossini, Paolo M; Micera, Silvestro; Benvenuto, Antonella; Carpaneto, Jacopo; Cavallo, Giuseppe; Citi, Luca; Cipriani, Christian; Denaro, Luca; Denaro, Vincenzo; Di Pino, Giovanni; Ferreri, Florinda; Guglielmelli, Eugenio; Hoffmann, Klaus-Peter; Raspopovic, Stanisa; Rigosa, Jacopo; Rossini, Luca; Tombini, Mario; Dario, Paolo

2010-05-01

The principle underlying this project is that, despite nervous reorganization following upper limb amputation, original pathways and CNS relays partially maintain their function and can be exploited for interfacing prostheses. Aim of this study is to evaluate a novel peripheral intraneural multielectrode for multi-movement prosthesis control and for sensory feed-back, while assessing cortical reorganization following the re-acquired stream of data. Four intrafascicular longitudinal flexible multielectrodes (tf-LIFE4) were implanted in the median and ulnar nerves of an amputee; they reliably recorded output signals for 4 weeks. Artificial intelligence classifiers were used off-line to analyse LIFE signals recorded during three distinct hand movements under voluntary order. Real-time control of motor output was achieved for the three actions. When applied off-line artificial intelligence reached >85% real-time correct classification of trials. Moreover, different types of current stimulation were determined to allow reproducible and localized hand/fingers sensations. Cortical organization was observed via TMS in parallel with partial resolution of symptoms due to the phantom-limb syndrome (PLS). tf-LIFE4s recorded output signals in human nerves for 4 weeks, though the efficacy of sensory stimulation decayed after 10 days. Recording from a number of fibres permitted a high percentage of distinct actions to be classified correctly. Reversal of plastic changes and alleviation of PLS represent corollary findings of potential therapeutic benefit. This study represents a breakthrough in robotic hand use in amputees. Copyright 2010 International Federation of Clinical Neurophysiology. Published by Elsevier Ireland Ltd. All rights reserved.

Nerve Cross-Bridging to Enhance Nerve Regeneration in a Rat Model of Delayed Nerve Repair

PubMed Central

2015-01-01

There are currently no available options to promote nerve regeneration through chronically denervated distal nerve stumps. Here we used a rat model of delayed nerve repair asking of prior insertion of side-to-side cross-bridges between a donor tibial (TIB) nerve and a recipient denervated common peroneal (CP) nerve stump ameliorates poor nerve regeneration. First, numbers of retrogradely-labelled TIB neurons that grew axons into the nerve stump within three months, increased with the size of the perineurial windows opened in the TIB and CP nerves. Equal numbers of donor TIB axons regenerated into CP stumps either side of the cross-bridges, not being affected by target neurotrophic effects, or by removing the perineurium to insert 5-9 cross-bridges. Second, CP nerve stumps were coapted three months after inserting 0-9 cross-bridges and the number of 1) CP neurons that regenerated their axons within three months or 2) CP motor nerves that reinnervated the extensor digitorum longus (EDL) muscle within five months was determined by counting and motor unit number estimation (MUNE), respectively. We found that three but not more cross-bridges promoted the regeneration of axons and reinnervation of EDL muscle by all the CP motoneurons as compared to only 33% regenerating their axons when no cross-bridges were inserted. The same 3-fold increase in sensory nerve regeneration was found. In conclusion, side-to-side cross-bridges ameliorate poor regeneration after delayed nerve repair possibly by sustaining the growth-permissive state of denervated nerve stumps. Such autografts may be used in human repair surgery to improve outcomes after unavoidable delays. PMID:26016986

The comparison of multiple F-wave variable studies and magnetic resonance imaging examinations in the assessment of cervical radiculopathy.

PubMed

Lin, Chu-Hsu; Tsai, Yuan-Hsiung; Chang, Chia-Hao; Chen, Chien-Min; Hsu, Hung-Chih; Wu, Chun-Yen; Hong, Chang-Zern

2013-09-01

The aims of this study were to investigate the correlation of the findings of multiple median and ulnar F-wave variables and magnetic resonance imaging examinations in the prediction of cervical radiculopathy. The data of 68 patients who underwent both nerve conduction studies of the upper extremities and cervical spine magnetic resonance imaging within 3 mos of the nerve conduction studies were retrospectively reviewed and reinterpreted. The associations between multiple median and ulnar F-wave variables (including persistence, chronodispersion, and minimal, maximal, and mean latencies) and magnetic resonance imaging evidence of lower cervical spondylotic radiculopathy (i.e., C7, C8, and T1 radiculopathy) were investigated. Patients with lower cervical radiculopathy exhibited reduced right median F-wave persistence (P = 0.011), increased right ulnar F-wave chronodispersion (P = 0.041), and a trend toward increased left ulnar F-wave chronodispersion (P = 0.059); however, there were no other consistent significant differences in the F-wave variables between patients with and patients without magnetic resonance imaging evidence of lower cervical radiculopathy. In comparison with normal reference values established previously, the sensitivity and positive predictive value of F-wave variable abnormalities for predicting lower cervical radiculopathy were low. There was a low correlation between F-wave studies and magnetic resonance imaging examinations. The diagnostic utility of multiple F-wave variables in the prediction of cervical radiculopathy was not supported by this study.

Association of iatrogenic hypothyroidism with azotemia and reduced survival time in cats treated for hyperthyroidism.

PubMed

Williams, T L; Elliott, J; Syme, H M

2010-01-01

Iatrogenic hypothyroidism can occur after treatment of hyperthyroidism, and is correlated with a reduced glomerular filtration rate in humans and dogs. Cats with iatrogenic hypothyroidism after treatment for hyperthyroidism will have a greater incidence of azotemia than euthyroid cats. Eighty client owned cats with hyperthyroidism. Two retrospective studies. (1) Longitudinal study of 12 hyperthyroid cats treated with radioiodine (documented as euthyroid after treatment), to assess changes in plasma thyroid stimulating hormone (TSH) concentration over a 6-month follow-up period, (2) Cross-sectional study of 75 hyperthyroid cats (documented as euthyroid) 6 months after commencement of treatment for hyperthyroidism to identify the relationship between thyroid status and the development of azotemia. Kaplan-Meier survival analysis was performed to identify relationships between thyroid and renal status and survival. Plasma TSH concentrations were not suppressed in 7 of 8 cats with hypothyroidism 3 months after radioiodine treatment. The proportion of cats with azotemia was significantly (P= .028) greater in the hypothyroid (16 of 28) than the euthyroid group (14 of 47). Twenty-eight of 41 cats (68%) with plasma TT4 concentration below the laboratory reference range had an increased plasma TSH concentration. Hypothyroid cats that developed azotemia within the follow-up period had significantly (P= .018) shorter survival times (median survival time 456 days, range 231-1589 days) than those that remained nonazotemic (median survival time 905 days, range 316-1869 days). Iatrogenic hypothyroidism appears to contribute to the development of azotemia after treatment of hyperthyroidism, and reduced survival time in azotemic cats. Copyright © 2010 by the American College of Veterinary Internal Medicine.

Effect of distal ulnar collateral ligament tear pattern on contact forces and valgus stability in the posteromedial compartment of the elbow.

PubMed

Hassan, Sheref E; Parks, Brent G; Douoguih, Wiemi A; Osbahr, Daryl C

2015-02-01

It is not known whether the pattern of ulnar collateral ligament (UCL) tear affects elbow biomechanics. There will be a significant change in elbow biomechanics with 50% proximal but not 50% distal simulated rupture of the UCL. Controlled laboratory study. Pressure sensors in the posteromedial elbow joint of 25 male cadaveric elbows (average age, 54.9 years; range, 26-66 years) were used to measure contact area, pressure, and valgus torque at 90° and 30° of elbow flexion. Thirteen specimens were tested with the UCL intact, then with proximal-to-distal detachment of 50%, and then with proximal-to-distal detachment of 100% of the anterior band of the UCL from the ulnar attachment. This method was repeated in the remaining 12 specimens in a distal-to-proximal direction. With 50% proximal-to-distal detachment, contact area decreased significantly versus intact at 90° (91.3 ± 23.6 vs 112.2 ± 26.0 mm(2); P < .001) and 30° (69.3 ± 14.8 vs 83.1 ± 21.6 mm(2); P < .001) of elbow flexion; the center of pressure (COP) moved significantly proximally versus intact at 90° (3.8 ± 2.5 vs 5.4 ± 2.3 mm; P < .001) and 30° (5.9 ± 2.8 vs 7.4±1.9 mm; P < .001). With 50% distal-to-proximal UCL detachment versus intact, no significant change was observed in contact area, movement of the COP, or valgus laxity at either flexion position. With 100% proximal-to-distal and distal-to-proximal detachment, significant change in contact area, movement of the COP, and valgus laxity versus intact was found at 90° and 30° of elbow flexion (P < .05). No significant difference in contact pressure was observed in any test conditions. Significant change in contact area and proximal movement of the COP with 50% proximal UCL detachment and the lack of significant change with 50% distal UCL detachment suggest that the proximal half of the UCL ulnar footprint has a primary role in maintaining posteromedial elbow biomechanics. The findings suggest that surgical reconstruction should aim to

Diagnosis and outcome of a dog with iatrogenic hyperadrenocorticism and secondary pulmonary mineralization.

PubMed

Blois, Shauna L; Caron, Isabelle; Mitchell, Colleen

2009-04-01

A 6-year-old, spayed female dog was evaluated for a history of chronic coughing, excessive panting, and lethargy. Iatrogenic hyperadrenocorticism was diagnosed, and pulmonary mineralization was documented with a 99m Technitium-methylene diphosphonate (99mTc-MDP) scan. Blood gas analysis showed hypoxia. Clinical signs resolved and blood gas values returned to normal when corticosteroid therapy was discontinued.

Diagnosis and outcome of a dog with iatrogenic hyperadrenocorticism and secondary pulmonary mineralization

PubMed Central

Blois, Shauna L.; Caron, Isabelle; Mitchell, Colleen

2009-01-01

A 6-year-old, spayed female dog was evaluated for a history of chronic coughing, excessive panting, and lethargy. Iatrogenic hyperadrenocorticism was diagnosed, and pulmonary mineralization was documented with a 99mTechnitium-methylene diphosphonate (99mTc-MDP) scan. Blood gas analysis showed hypoxia. Clinical signs resolved and blood gas values returned to normal when corticosteroid therapy was discontinued. PMID:19436448

Chitin biological absorbable catheters bridging sural nerve grafts transplanted into sciatic nerve defects promote nerve regeneration.

PubMed

Wang, Zhi-Yong; Wang, Jian-Wei; Qin, Li-Hua; Zhang, Wei-Guang; Zhang, Pei-Xun; Jiang, Bao-Guo

2018-06-01

To investigate the efficacy of chitin biological absorbable catheters in a rat model of autologous nerve transplantation. A segment of sciatic nerve was removed to produce a sciatic nerve defect, and the sural nerve was cut from the ipsilateral leg and used as a graft to bridge the defect, with or without use of a chitin biological absorbable catheter surrounding the graft. The number and morphology of regenerating myelinated fibers, nerve conduction velocity, nerve function index, triceps surae muscle morphology, and sensory function were evaluated at 9 and 12 months after surgery. All of the above parameters were improved in rats in which the nerve graft was bridged with chitin biological absorbable catheters compared with rats without catheters. The results of this study indicate that use of chitin biological absorbable catheters to surround sural nerve grafts bridging sciatic nerve defects promotes recovery of structural, motor, and sensory function and improves muscle fiber morphology. © 2018 John Wiley & Sons Ltd.

External laryngeal nerve in thyroid surgery: is the nerve stimulator necessary?

PubMed

Aina, E N; Hisham, A N

2001-09-01

To find out the incidence and type of external laryngeal nerves during operations on the thyroid, and to assess the role of a nerve stimulator in detecting them. Prospective, non-randomised study. Teaching hospital, Malaysia. 317 patients who had 447 dissections between early January 1998 and late November 1999. Number and type of nerves crossing the cricothyroid space, and the usefulness of the nerve stimulator in finding them. The nerve stimulator was used in 206/447 dissections (46%). 392 external laryngeal nerves were seen (88%), of which 196/206 (95%) were detected with the stimulator. However, without the stimulator 196 nerves were detected out of 241 dissections (81%). The stimulator detected 47 (23%) Type I nerves (nerve > 1 cm from the upper edge of superior pole); 86 (42%) Type IIa nerves (nerve < 1 cm from the upper edge of superior pole); and 63 (31%) Type IIb nerves (nerve below upper edge of superior pole). 10 nerves were not detected. When the stimulator was not used the corresponding figures were 32 (13%), 113 (47%), and 51 (21%), and 45 nerves were not seen. If the nerve cannot be found we recommend dissection of capsule close to the medial border of the upper pole of the thyroid to avoid injury to the nerve. Although the use of the nerve stimulator seems desirable, it confers no added advantage in finding the nerve. In the event of uncertainty about whether a structure is the nerve, the stimulator may help to confirm it. However, exposure of the cricothyroid space is most important for good exposure in searching for the external laryngeal nerve.

Structural parameters of collagen nerve grafts influence peripheral nerve regeneration.

PubMed

Stang, Felix; Fansa, Hisham; Wolf, Gerald; Reppin, Michael; Keilhoff, Gerburg

2005-06-01

Large nerve defects require nerve grafts to allow regeneration. To avoid donor nerve problems the concept of tissue engineering was introduced into nerve surgery. However, non-neuronal grafts support axonal regeneration only to a certain extent. They lack viable Schwann cells which provide neurotrophic and neurotopic factors and guide the sprouting nerve. This experimental study used the rat sciatic nerve to bridge 2 cm nerve gaps with collagen (type I/III) tubes. The tubes were different in their physical structure (hollow versus inner collagen skeleton, different inner diameters). To improve regeneration Schwann cells were implanted. After 8 weeks the regeneration process was monitored clinically, histologically and morphometrically. Autologous nerve grafts and collagen tubes without Schwann cells served as control. In all parameters autologous nerve grafts showed best regeneration. Nerve regeneration in a noteworthy quality was also seen with hollow collagen tubes and tubes with reduced lumen, both filled with Schwann cells. The inner skeleton, however, impaired nerve regeneration independent of whether Schwann cells were added or not. This indicates that not only viable Schwann cells are an imperative prerequisite but also structural parameters determine peripheral nerve regeneration.

Results of neurolysis in established upper limb Volkmann's ischemic contracture

PubMed Central

Meena, Dinesh K; Thalanki, Srikiran; Patni, Poornima; Meena, Ram Khiladi; Bairawa, Dinesh; Bhatia, Chirag

2016-01-01

Background: Treatment of established cases of Volkmann's ischemic contracture (VIC) of upper limb is very tedious. Since the period of Volkmann, various experimental works are being performed for its treatment, but none are effective. Disabilities from nerve palsy and hand muscle paralysis are more problematic than any other deformity in VIC. To solve these problems, we conducted a study to see the result of neurolysis of median and ulnar nerve and their subcutaneous placement in established cases of VIC. Materials and Methods: Twelve cases of established VIC operated between July 2007 and August 2010 with complete records and followup were included in the study. VIC of lower limb and contracture of nonischemic etiology were excluded from the study. Their evaluation was done by the British Medical Research Council grading system for sensory and motor recovery. Followup was done for an average period of 24.3 months (range 15-30 months) (the average age was 8.3 years). Results: To study the results, we divided the cases into two series. One group consisted of cases which were operated within 6 months from onset of VIC. The second group consisted of cases which were operated after 6 months from onset of VIC. Our results revealed that there was no statistically significant difference between the two groups operated, though both had significant improvement in motor and sensory recovery in both median and ulnar nerve distribution. Conclusions: Neurolysis of the nerves definitely improved the outcome for motor and sensory components of median and ulnar nerves but the timing of the surgery did not play a role in the outcome contrary to the clinical assumption. This study can serve as a template and further such studies could help us find the answer to a long standing issue. PMID:27904214

Avulsion of the brachial plexus in a great horned owl (Bubo virginaus)

USGS Publications Warehouse

Moore, M.P.; Stauber, E.; Thomas, N.J.

1989-01-01

Avulsion of the brachial plexus was documented in a Great Horned Owl (Bubo virginianus). A fractured scapula was also present. Cause of these injuries was not known but was thought to be due to trauma. Differentiation of musculoskeletal injury from peripheral nerve damage can be difficult in raptors. Use of electromyography and motor nerve conduction velocity was helpful in demonstrating peripheral nerve involvement. A brachial plexus avulsion was suspected on the basis of clinical signs, presence of electromyographic abnormalities in all muscles supplied by the nerves of the brachial plexus and absence of median-ulnar motor nerve conduction velocities.

Clinical Application of Six Current Classification Systems for Iatrogenic Bile Duct Injuries after Cholecystectomy.

PubMed

Velidedeoglu, Mehmet; Arikan, Akif Enes; Uludag, Sezgin Server; Olgun, Deniz Cebi; Kilic, Fahrettin; Kapan, Metin

2015-05-01

Due to being a severe complication, iatrogenic bile duct injury is still a challenging issue for surgeons in gallbladder surgery. However, a commonly accepted classification describing the type of injury has not been available yet. This study aims to evaluate ability of six current classification systems to discriminate bile duct injury patterns. Twelve patients, who were referred to our clinic because of iatrogenic bile duct injury after laparoscopic cholecystectomy were reviewed retrospectively. We described type of injury for each patient according to current six different classifications. 9 patients underwent definitive biliary reconstruction. Bismuth, Strasberg-Bismuth, Stewart-Way and Neuhaus classifications do not consider vascular involvement, Siewert system does, but only for the tangential lesions without structural loss of duct and lesion with a structural defect of hepatic or common bile duct. Siewert, Neuhaus and Stewart-Way systems do not discriminate between lesions at or above bifurcation of the hepatic duct. The Hannover classification may resolve the missing aspects of other systems by describing additional vascular involvement and location of the lesion at or above bifurcation.

Distal Ulnar Artery Aneurysm Repair by End-to-End Technique: A Case Report.

PubMed

Cotroneo, Attilio; Barillà, David; Armienti, Felice; Martinelli, Gian Luca; Diena, Marco

2018-01-01

We report the case of a 33-year-old man presented with a posttraumatic 20-mm left ulnar artery aneurysm without intraluminal thrombus in the left hypothenar eminence. The patient reported left hand paresthesia. Because of symptoms and the embolic risk, we decide to plan an aneurysm resection and an interposition graft with inverted basilic vein for adequacy diameter (∼2 mm), but an end-to-end anastomosis was performed instead. We think that the posttraumatic distal artery aneurysm could be treated without a bypass but, after a meticulous anatomic dissection, with a microvascular anastomosis between the artery stumps. Copyright © 2017 Elsevier Inc. All rights reserved.

Retrospective study of a TTR FAP cohort to modify NIS+7 for therapeutic trials.

PubMed

Suanprasert, N; Berk, J L; Benson, M D; Dyck, P J B; Klein, C J; Gollob, J A; Bettencourt, B R; Karsten, V; Dyck, P J

2014-09-15

Protein stabilization and oligonucleotide therapies are being tested in transthyretin amyloid polyneuropathy (TTR FAP) trials. From retrospective analysis of 97 untreated TTR FAP patients, we test the adequacy of Neuropathy Impairment Score+7 tests (NIS+7) and modifications to comprehensively score impairments for use in such therapeutic trials. Our data confirms that TTR FAP usually is a sensorimotor polyneuropathy with autonomic features which usually is symmetric, length dependent, lower limb predominant and progressive. NIS+7 adequately assesses weakness and muscle stretch reflexes without ceiling effects but not sensation loss, autonomic dysfunction or nerve conduction abnormalities. Three modifications of NIS+7 are suggested: 1) use of Smart Somatotopic Quantitative Sensation Testing (S ST QSTing); 2) choice of new autonomic assessments, e.g., sudomotor testing of distributed anatomical sites; and 3) use of only compound muscle action potential amplitudes (of ulnar, peroneal and tibial nerves) and sensory nerve action potentials of ulnar and sural nerve - than the previously recommended attributes suggested for the sensitive detection of diabetic sensorimotor polyneuropathy. These modifications of NIS+7 if used in therapeutic trials should improve characterization and quantification of sensation and autonomic impairment in TTR FAP and provide better nerve conduction tests. Copyright © 2014 Elsevier B.V. All rights reserved.

Chitosan conduits combined with nerve growth factor microspheres repair facial nerve defects

PubMed Central

Liu, Huawei; Wen, Weisheng; Hu, Min; Bi, Wenting; Chen, Lijie; Liu, Sanxia; Chen, Peng; Tan, Xinying

2013-01-01

Microspheres containing nerve growth factor for sustained release were prepared by a compound method, and implanted into chitosan conduits to repair 10-mm defects on the right buccal branches of the facial nerve in rabbits. In addition, chitosan conduits combined with nerve growth factor or normal saline, as well as autologous nerve, were used as controls. At 90 days post-surgery, the muscular atrophy on the right upper lip was more evident in the nerve growth factor and normal sa-line groups than in the nerve growth factor-microspheres and autologous nerve groups. physiological analysis revealed that the nerve conduction velocity and amplitude were significantly higher in the nerve growth factor-microspheres and autologous nerve groups than in the nerve growth factor and normal saline groups. Moreover, histological observation illustrated that the di-ameter, number, alignment and myelin sheath thickness of myelinated nerves derived from rabbits were higher in the nerve growth factor-microspheres and autologous nerve groups than in the nerve growth factor and normal saline groups. These findings indicate that chitosan nerve conduits bined with microspheres for sustained release of nerve growth factor can significantly improve facial nerve defect repair in rabbits. PMID:25206635

Epidemic History and Iatrogenic Transmission of Blood-borne Viruses in Mid-20th Century Kinshasa.

PubMed

Hogan, Catherine A; Iles, James; Frost, Eric H; Giroux, Geneviève; Cassar, Olivier; Gessain, Antoine; Dion, Marie-Josée; Ilunga, Vicky; Rambaut, Andrew; Yengo-Ki-Ngimbi, André-Édouard; Behets, Frieda; Pybus, Oliver G; Pépin, Jacques

2016-08-01

The human immunodeficiency virus type 1 (HIV-1) pandemic was ignited in Léopoldville (now known as Kinshasa), in the former Belgian Congo. Factors that jump-started its early expansion remain unclear. Nonlethal hepatitis C virus (HCV) and human T-cell lymphotropic virus (HTLV-1) can be used to investigate past iatrogenic transmission. We undertook a cross-sectional study of elderly inhabitants of Kinshasa, with serological assays, amplification, and sequencing. Risk factors were assessed through logistic regression. Phylogenetic methods reconstructed the genetic history of HCV. A total of 217 of 839 participants (25.9%) were HCV seropositive; 26 (3.1%) were HTLV-1-seropositive. Amplification products were obtained from 118 HCV-seropositive participants; subtypes 4k (in 47 participants) and 4r (in 38) were most common. Independent risk factors for HCV subtype 4r seropositivity were intramuscular tuberculosis therapy, intravenous injections at hospital A, intravenous injections before 1960, and injections at a colonial-era venereology clinic. Intravenous injections at hospital B and antimalarials were associated with HCV subtype 4k seropositivity. Risk factors for HTLV-1 seropositivity included intravenous injections at hospitals C or D and transfusions. Evolutionary analysis of viral sequences revealed independent exponential amplification of HCV subtypes 4r and 4k from the 1950s onward. Iatrogenic transmission of HCV and HTLV-1 occurred in mid-20th century Kinshasa, at the same time and place HIV-1 emerged. Iatrogenic routes may have contributed to the early establishment of the pandemic. © The Author 2016. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail journals.permissions@oup.com.

Peripheral Venous Waveform Analysis for Detecting Hemorrhage and Iatrogenic Volume Overload in a Porcine Model.

PubMed

Hocking, Kyle M; Sileshi, Ban; Baudenbacher, Franz J; Boyer, Richard B; Kohorst, Kelly L; Brophy, Colleen M; Eagle, Susan S

2016-10-01

Unrecognized hemorrhage and unguided resuscitation is associated with increased perioperative morbidity and mortality. The authors investigated peripheral venous waveform analysis (PIVA) as a method for quantitating hemorrhage as well as iatrogenic fluid overload during resuscitation. The authors conducted a prospective study on Yorkshire Pigs (n = 8) undergoing hemorrhage, autologous blood return, and administration of balanced crystalloid solution beyond euvolemia. Intra-arterial blood pressure, electrocardiogram, and pulse oximetry were applied to each subject. Peripheral venous pressure was measured continuously through an upper extremity standard peripheral IV catheter and analyzed with LabChart. The primary outcome was comparison of change in the first fundamental frequency (f1) of PIVA with standard and invasive monitoring and shock index (SI). Hemorrhage, return to euvolemia, and iatrogenic fluid overload resulted in significantly non-zero slopes of f1 amplitude. There were no significant differences in heart rate or mean arterial pressure, and a late change in SI. For the detection of hypovolemia the PIVA f1 amplitude change generated an receiver operator curves (ROC) curve with an area under the curve (AUC) of 0.93; heart rate AUC = 0.61; mean arterial pressure AUC = 0.48, and SI AUC = 0.72. For hypervolemia the f1 amplitude generated an ROC curve with an AUC of 0.85, heart rate AUC = 0.62, mean arterial pressure AUC = 0.63, and SI AUC = 0.65. In this study, PIVA demonstrated a greater sensitivity for detecting acute hemorrhage, return to euvolemia, and iatrogenic fluid overload compared with standard monitoring and SI. PIVA may provide a low-cost, minimally invasive monitoring solution for monitoring and resuscitating patients with perioperative hemorrhage.

Radial Head Prosthesis Removal: a Retrospective Case Series of 14 Patients

PubMed Central

Neuhaus, Valentin; Christoforou, Dimitrios C.; Kachooei, Amir Reza; Jupiter, Jesse B.; Ring, David C.; Mudgal, Chaitanya S.

2015-01-01

Background: The purpose of this study was to report the preoperative complaints and postoperative outcome of patients after removal of the radial head prosthesis. Methods: This is a retrospective review of 14 adult patients (6 females and 8 males) from 2007 to 2011, who underwent radial head prosthesis removal by three surgeons. The average time between implantation and removal was 23 months (range from 2 weeks to 12 years, median 12 months). Results: The leading reported complaints before removal were restricted mobility of the elbow (active range of motion of less than 100 degrees) in 6, pain in 3, and pain together with restricted mobility in 4 patients. The objective findings before removal were restricted mobility of the elbow in 10 (71%), capitellar cartilage wear, loose implants, and heterotopic ossification each in 8 (57%), subluxation of the radio-capitellar joint or malpositioning of the stem in 5 (36%), and chronic infection in 2 (14%) patients. All patients with pain had wear of the capitellar cartilage on radiographs. The ulnar nerve was decompressed in four patients at the time of removal. Four patients underwent a subsequent operation for postoperative ulnar nerve symptoms 5 to 21 months after removal. Four patients were still complaining about persistent pain at the last follow-up visit. Except two patients, the total range of motion improved with a mean of 34 degrees (range 5 to 70) after a mean follow-up of 11 months. Conclusions: Removal of radial head prosthesis improved function and lessened pain in our case series. The reoperation rate was yet nearly 30% due to ulnar neuritis. Selective ulnar nerve decompression at the time of removal must be evaluated, especially in patients with expected large gain in range of motion after removal. PMID:26110173

Clinical outcome of single plastic stent treatment of benign iatrogenic biliary strictures: is the outcome predetermined?

PubMed

Rajab, Murad A; Go, Jorge; Silverman, William B

2014-12-01

Endoscopic retrograde cholangiopancreatography (ERCP) is used for the management of benign iatrogenic biliary strictures after cholecystectomy and liver transplantation. Multiple stents can injure biliary circulation. If resolution of reversible ductal edema and/or ischemia is the mechanism for successful therapy then single stent placement for benign biliary stricture should work. Retrospectively reviewed ERCP records between November 1999 and 2012 provided 25 patients with repeat ERCPs performed at 10-week intervals or if symptoms of stent occlusion were present. If strictures did not improve between stent changes and if removal was not an option, hepaticojejunostomy was used. Strictures resolved in 72% of patients. Seven patients underwent hepaticojejunostomy. Three had ERCP-related complications. No stricture recurrence occurred during the follow-up period. Endoscopic single plastic stent treatment of benign biliary iatrogenic strictures has comparable success to multiple stenting. Many postsurgical strictures may have reversible ischemic/edematous component with stenting to maintain bile drainage.

Nerve ultrasound shows subclinical peripheral nerve involvement in neurofibromatosis type 2.

PubMed

Telleman, Johan A; Stellingwerff, Menno D; Brekelmans, Geert J; Visser, Leo H

2018-02-01

Neurofibromatosis type 2 (NF2) is mainly associated with central nervous system (CNS) tumors. Peripheral nerve involvement is described in symptomatic patients, but evidence of subclinical peripheral nerve involvement is scarce. We conducted a cross-sectional pilot study in 2 asymptomatic and 3 minimally symptomatic patients with NF2 to detect subclinical peripheral nerve involvement. Patients underwent clinical examination, nerve conduction studies (NCS), and high-resolution ultrasonography (HRUS). A total of 30 schwannomas were found, divided over 20 nerve segments (33.9% of all investigated nerve segments). All patients had at least 1 schwannoma. Schwannomas were identified with HRUS in 37% of clinically unaffected nerve segments and 50% of nerve segments with normal NCS findings. HRUS shows frequent subclinical peripheral nerve involvement in NF2. Clinicians should consider peripheral nerve involvement as a cause of weakness and sensory loss in the extremities in patients with this disease. Muscle Nerve 57: 312-316, 2018. © 2017 Wiley Periodicals, Inc.

Malignancy Associated Iatrogenic Iliopsoas Abscess -Venous Access Complication From Ablation Procedure.

PubMed

Iskandar, Sandia; Atoui, Moustapha; Rizwan Afzal, Muhammad; Lavu, Madhav; Reddy, Madhu; Lakkireddy, Dhanunjaya

2016-01-01

Iliopsoas abscess is a rare condition with a high rate of mortality and morbidity if left untreated. It can occur from hematogenous or lymphatic spread from distant structures or as a result of contiguous spread from adjacent structures. The disease typically occurs in patients with immunocompromised status and the symptoms can be non-specific.1,2 Generally, infectious complications from venous access during atrial fibrillation (AF) procedure are uncommon, and an iatrogenic iliopsoas abscess from percutaneous cardiac procedures has never been reported. We present the first case of iliopsoas abscess from an ablation procedure.

Optimisation of composite bone plates for ulnar transverse fractures.

PubMed

Chakladar, N D; Harper, L T; Parsons, A J

2016-04-01

Metallic bone plates are commonly used for arm bone fractures where conservative treatment (casts) cannot provide adequate support and compression at the fracture site. These plates, made of stainless steel or titanium alloys, tend to shield stress transfer at the fracture site and delay the bone healing rate. This study investigates the feasibility of adopting advanced composite materials to overcome stress shielding effects by optimising the geometry and mechanical properties of the plate to match more closely to the bone. An ulnar transverse fracture is characterised and finite element techniques are employed to investigate the feasibility of a composite-plated fractured bone construct over a stainless steel equivalent. Numerical models of intact and fractured bones are analysed and the mechanical behaviour is found to agree with experimental data. The mechanical properties are tailored to produce an optimised composite plate, offering a 25% reduction in length and a 70% reduction in mass. The optimised design may help to reduce stress shielding and increase bone healing rates. Copyright © 2016 Elsevier Ltd. All rights reserved.

Electromechanical Nerve Stimulator

NASA Technical Reports Server (NTRS)

Tcheng, Ping; Supplee, Frank H., Jr.; Prass, Richard L.

1993-01-01

Nerve stimulator applies and/or measures precisely controlled force and/or displacement to nerve so response of nerve measured. Consists of three major components connected in tandem: miniature probe with spherical tip; transducer; and actuator. Probe applies force to nerve, transducer measures force and sends feedback signal to control circuitry, and actuator positions force transducer and probe. Separate box houses control circuits and panel. Operator uses panel to select operating mode and parameters. Stimulator used in research to characterize behavior of nerve under various conditions of temperature, anesthesia, ventilation, and prior damage to nerve. Also used clinically to assess damage to nerve from disease or accident and to monitor response of nerve during surgery.

Recovery of laryngeal nerve function with sugammadex after rocuronium-induced profound neuromuscular block.

PubMed

Pavoni, Vittorio; Gianesello, Lara; Martinelli, Cristiana; Horton, Andrew; Nella, Alessandra; Gori, Gabriele; Simonelli, Martina; De Scisciolo, Giuseppe

2016-09-01

The aim of this study was to evaluate the efficacy of sugammadex in reversing profound rocuronium-induced neuromuscular block at the laryngeal adductor muscles using motor-evoked potentials (mMEPs). A prospective observational study. University surgical center. Twenty patients with American Society of Anesthesiologists physical class I-II status who underwent propofol-remifentanil anesthesia for the surgery of the thyroid gland. Patients were enrolled for reversal of profound neuromuscular block (sugammadex 16 mg/kg, 3 minutes after rocuronium 1.2 mg/kg). To prevent laryngeal nerve injury during the surgical procedures, all patients underwent neurophysiologic monitoring using mMEPs from vocal muscles. At the same time, the registration of TOF-Watch acceleromyograph at the adductor pollicis muscle response to ulnar nerve stimulation was performed; recovery was defined as a train-of-four (TOF) ratio ≥0.9. After injection of 16 mg/kg of sugammadex, the mean time to recovery of the basal mMEPs response at the laryngeal adductor muscles was 70 ± 18.2 seconds. The mean time to recovery of the TOF ratio to 0.9 was 118 ± 80 seconds. In the postoperative period, 12 patients received follow-up evaluation of the vocal cords and no lesions caused by the surface laryngeal electrode during electrophysiological monitoring were noted. Recovery from profound rocuronium-induced block on the larynx is fast and complete with sugammadex. In urgent scenarios, "early" extubation can be performed, even with a TOF ratio ≤0.9. However, all procedures to prevent postoperative residual curarization should still be immediately undertaken. Copyright © 2016 Elsevier Inc. All rights reserved.

Tissue-engineered spiral nerve guidance conduit for peripheral nerve regeneration.

PubMed

Chang, Wei; Shah, Munish B; Lee, Paul; Yu, Xiaojun

2018-06-01

Recently in peripheral nerve regeneration, preclinical studies have shown that the use of nerve guidance conduits (NGCs) with multiple longitudinally channels and intra-luminal topography enhance the functional outcomes when bridging a nerve gap caused by traumatic injury. These features not only provide guidance cues for regenerating nerve, but also become the essential approaches for developing a novel NGC. In this study, a novel spiral NGC with aligned nanofibers and wrapped with an outer nanofibrous tube was first developed and investigated. Using the common rat sciatic 10-mm nerve defect model, the in vivo study showed that a novel spiral NGC (with and without inner nanofibers) increased the successful rate of nerve regeneration after 6 weeks recovery. Substantial improvements in nerve regeneration were achieved by combining the spiral NGC with inner nanofibers and outer nanofibrous tube, based on the results of walking track analysis, electrophysiology, nerve histological assessment, and gastrocnemius muscle measurement. This demonstrated that the novel spiral NGC with inner aligned nanofibers and wrapped with an outer nanofibrous tube provided a better environment for peripheral nerve regeneration than standard tubular NGCs. Results from this study will benefit for future NGC design to optimize tissue-engineering strategies for peripheral nerve regeneration. We developed a novel spiral nerve guidance conduit (NGC) with coated aligned nanofibers. The spiral structure increases surface area by 4.5 fold relative to a tubular NGC. Furthermore, the aligned nanofibers was coated on the spiral walls, providing cues for guiding neurite extension. Finally, the outside of spiral NGC was wrapped with randomly nanofibers to enhance mechanical strength that can stabilize the spiral NGC. Our nerve histological data have shown that the spiral NGC had 50% more myelinated axons than a tubular structure for nerve regeneration across a 10 mm gap in a rat sciatic nerve

The effect of concomitant vascular disruption in patients with iatrogenic biliary injuries.

PubMed

Bilge, Orhan; Bozkiran, Süheyla; Ozden, Ilgin; Tekant, Yaman; Acarli, Koray; Alper, Aydin; Emre, Ali; Arioğul, Orhan

2003-09-01

To evaluate treatment results in iatrogenic biliary injuries with concomitant vascular injuries. Between January 1998 and May 2002 (inclusive), angiography was performed in 45 of the 105 patients treated for iatrogenic biliary tract injury. The charts of these 45 patients and 5 other patients in whom vascular injury was diagnosed at operation were evaluated retrospectively. Twenty-nine patients had concomitant vascular injury, the biliovascular injury group (BVI), and the remaining 21 patients had isolated biliary tract injury (IBTI). The most frequent initial operation was a cholecystectomy. The frequency of high-level (Bismuth III or IV) strictures was 90% in the BVI group and 62% in the IBTI group ( P<0.05). Perioperative mortality was 7% in the BVI group and 5% in the IBTI group ( P>0.05). The morbidity in the BVI group was significantly higher ( P<0.05). Two patients in each group were lost to follow up. During a median (range) follow up of 31 months (5-51 months), a successful functional outcome was achieved in 96% of the BVI group and 100% of the IBTI group with a multimodal approach ( P>0.05). The frequency of high-level biliary injury and morbidity were significantly higher in the BVI group. However, concomitant vascular injury had no significant effect on mortality and medium-term outcome of biliary reconstruction. Thus, routine preoperative angiography is not recommended.

Direct Administration of Nerve-Specific Contrast to Improve Nerve Sparing Radical Prostatectomy

PubMed Central

Barth, Connor W.; Gibbs, Summer L.

2017-01-01

Nerve damage remains a major morbidity following nerve sparing radical prostatectomy, significantly affecting quality of life post-surgery. Nerve-specific fluorescence guided surgery offers a potential solution by enhancing nerve visualization intraoperatively. However, the prostate is highly innervated and only the cavernous nerve structures require preservation to maintain continence and potency. Systemic administration of a nerve-specific fluorophore would lower nerve signal to background ratio (SBR) in vital nerve structures, making them difficult to distinguish from all nervous tissue in the pelvic region. A direct administration methodology to enable selective nerve highlighting for enhanced nerve SBR in a specific nerve structure has been developed herein. The direct administration methodology demonstrated equivalent nerve-specific contrast to systemic administration at optimal exposure times. However, the direct administration methodology provided a brighter fluorescent nerve signal, facilitating nerve-specific fluorescence imaging at video rate, which was not possible following systemic administration. Additionally, the direct administration methodology required a significantly lower fluorophore dose than systemic administration, that when scaled to a human dose falls within the microdosing range. Furthermore, a dual fluorophore tissue staining method was developed that alleviates fluorescence background signal from adipose tissue accumulation using a spectrally distinct adipose tissue specific fluorophore. These results validate the use of the direct administration methodology for specific nerve visualization with fluorescence image-guided surgery, which would improve vital nerve structure identification and visualization during nerve sparing radical prostatectomy. PMID:28255352

Direct Administration of Nerve-Specific Contrast to Improve Nerve Sparing Radical Prostatectomy.

PubMed

Barth, Connor W; Gibbs, Summer L

2017-01-01

Nerve damage remains a major morbidity following nerve sparing radical prostatectomy, significantly affecting quality of life post-surgery. Nerve-specific fluorescence guided surgery offers a potential solution by enhancing nerve visualization intraoperatively. However, the prostate is highly innervated and only the cavernous nerve structures require preservation to maintain continence and potency. Systemic administration of a nerve-specific fluorophore would lower nerve signal to background ratio (SBR) in vital nerve structures, making them difficult to distinguish from all nervous tissue in the pelvic region. A direct administration methodology to enable selective nerve highlighting for enhanced nerve SBR in a specific nerve structure has been developed herein. The direct administration methodology demonstrated equivalent nerve-specific contrast to systemic administration at optimal exposure times. However, the direct administration methodology provided a brighter fluorescent nerve signal, facilitating nerve-specific fluorescence imaging at video rate, which was not possible following systemic administration. Additionally, the direct administration methodology required a significantly lower fluorophore dose than systemic administration, that when scaled to a human dose falls within the microdosing range. Furthermore, a dual fluorophore tissue staining method was developed that alleviates fluorescence background signal from adipose tissue accumulation using a spectrally distinct adipose tissue specific fluorophore. These results validate the use of the direct administration methodology for specific nerve visualization with fluorescence image-guided surgery, which would improve vital nerve structure identification and visualization during nerve sparing radical prostatectomy.

Treatment of late identified iatrogenic injuries of the right and left hepatic duct after laparoscopic cholecystectomy without transhepatic stent and Witzel drainage: Case report.

PubMed

Rifatbegovic, Zijah; Kovacevic, Maja; Nikic, Branka

2018-05-26

Most of the case reports about high type iatrogenic hepatic duct injuries reports how to treat and make Roux-en-Y hepaticojejunostomy below the junction of the liver immediately after this condition is recognised during surgical procedure when the injury was made. Hereby we present a case where we made Roux-en-Y hepaticojejunostomy without transhepatic billiary stent and also without Witzel drainage one month after the iatrogenic injury. A 21-year-old woman suffered from iatrogenic high transectional lesion of both hepatic ducts during laparoscopic cholecystectomy in a local hospital. Iatrogenic injury was not immediately recognized. Ten days later due to patient complaints and large amount of bile in abdominal drain sac, second surgery was performed to evacuate biloma. Symptoms reappeared again, together with bile in abdominal sac, and then patient was sent to our Clinical Center. After performing additional diagnostics, high type (Class E) of iatrogenic hepatic duct injury was diagnosed. A revision surgical procedure was performed. During the exploration we found high transection lesion of right and left hepatic duct, and we decided to do Roux-en-Y hepaticojejunostomy. We created a part of anastomosis between the jejunum and liver capsule with polydioxanone suture (PDS) 4-0 because of poor quality of the remaining parts of the hepatic ducts. We made two separate hepaticojejunal anastomoses (left and right) that we partly connected to the liver capsule, where we had a defect of hepatic ducts, without Witzel enterostomy and transhepatic biliary stent. There were no significant postoperative complications. Magnetic resonance cholangiopancreatography (MRCP) was made one year after the surgical procedure, which showed the proper width of the intrahepatic bile ducts, with no signs of stenosis of anastomoses. In most cases, treatment iatrogenic BDI is based on primary repair of the duct, ductal repair with a stent or creating duct-enteric anastomosis, often used and

Nerve regeneration in nerve grafts conditioned by vibration exposure.

PubMed

Bergman, S; Widerberg, A; Danielsen, N; Lundborg, G; Dahlin, L B

1995-01-01

Regeneration distances were studied in nerves from vibration-exposed limbs. One hind limb of anaesthetized rats was attached to a vibration exciter and exposed to vibration (80 Hz/32 m/s2) for 5 h/day for 2 or 5 days. Seven days after the latest vibration period a 10-mm long nerve graft was taken from the vibrated sciatic nerve and sutured into a corresponding defect in the con-tralateral sciatic nerve and vice versa, thereby creating two different models within the same animal: (i) regeneration from a freshly transected unvibrated nerve into a vibrated graft and (ii) regeneration from a vibrated nerve into a fresh nerve graft (vibrated recipient side). Four, 6 or 8 days postoperatively (p.o.) the distances achieved by the regenerating axons were determined using the pinch reflex test. Two days of vibration did not influence the regeneration, but 5 days of vibration reduced the initial delay period and a slight reduction of regeneration rate was observed. After 5 days of vibration an increased regeneration distance was observed in both models at day 4 p.o. and at day 6 p.o. in vibrated grafts. This study demonstrates that vibration can condition peripheral nerves and this may be caused by local changes in the peripheral nerve trunk and in the neuron itself.

The role of great auricular-facial nerve neurorrhaphy in facial nerve damage.

PubMed

Sun, Yan; Liu, Limei; Han, Yuechen; Xu, Lei; Zhang, Daogong; Wang, Haibo

2015-01-01

Facial nerve is easy to be damaged, and there are many reconstructive methods for facial nerve reconstructive, such as facial nerve end to end anastomosis, the great auricular nerve graft, the sural nerve graft, or hypoglossal-facial nerve anastomosis. However, there is still little study about great auricular-facial nerve neurorrhaphy. The aim of the present study was to identify the role of great auricular-facial nerve neurorrhaphy and the mechanism. Rat models of facial nerve cut (FC), facial nerve end to end anastomosis (FF), facial-great auricular neurorrhaphy (FG), and control (Ctrl) were established. Apex nasi amesiality observation, electrophysiology and immunofluorescence assays were employed to investigate the function and mechanism. In apex nasi amesiality observation, it was found apex nasi amesiality of FG group was partly recovered. Additionally, electrophysiology and immunofluorescence assays revealed that facial-great auricular neurorrhaphy could transfer nerve impulse and express AChR which was better than facial nerve cut and worse than facial nerve end to end anastomosis. The present study indicated that great auricular-facial nerve neurorrhaphy is a substantial solution for facial lesion repair, as it is efficiently preventing facial muscles atrophy by generating neurotransmitter like ACh.

The ulnar collateral ligament of the human elbow joint. Anatomy, function and biomechanics.

PubMed Central

Fuss, F K

1991-01-01

The posterior portion of the ulnar collateral ligament, which arises from the posterior surface of the medial epicondyle, is taut in maximal flexion. The anterior portion, which takes its origin from the anterior and inferior surfaces of the epicondyle, contains three functional fibre bundles. One of these is taut in maximal extension, another in intermediate positions between middle position and full flexion while the third bundle is always taut and serves as a guiding bundle. Movements of the elbow joint are checked by the ligaments well before the bony processes forming the jaws of the trochlear notch lock into the corresponding fossae on the humerus. Images Fig. 1 Fig. 2 Fig. 3 Fig. 4 PMID:2050566

Assessment of nerve regeneration across nerve allografts treated with tacrolimus.

PubMed

Haisheng, Han; Songjie, Zuo; Xin, Li

2008-01-01

Although regeneration of nerve allotransplant is a major concern in the clinic, there have been few papers quantitatively assessing functional recovery of animals' nerve allografts in the long term. In this study, functional recovery, histopathological study, and immunohistochemistry changes of rat nerve allograft with FK506 were investigated up to 12 weeks without slaughtering. C57 and SD rats were used for transplantation. The donor's nerve was sliced and transplanted into the recipient. The sciatic nerve was epineurally sutured with 10-0 nylon. In total, 30 models of transplantation were performed and divided into 3 groups that were either treated with FK506 or not. Functional recovery of the grafted nerve was serially assessed by the pin click test, walking track analysis and electrophysiological evaluations. A histopathological study and immunohistochemistry study were done in the all of the models. Nerve allografts treated with FK506 have no immune rejection through 12 weeks. Sensibility had similarly improved in both isografts and allografts. There has been no difference in each graft. Walk track analysis demonstrates significant recovery of motor function of the nerve graft. No histological results of difference were found up to 12 weeks in each graft. In the rodent nerve graft model, FK506 prevented nerve allograft rejection across a major histocompatibility barrier. Sensory recovery seems to be superior to motor function. Nerve isograft and allograft treated with FK506 have no significant difference in function recovery, histopathological result, and immunohistochemistry changes.

Iatrogenic deep musculocutaneous radiation injury following percutaneous coronary intervention.

PubMed

Monaco, JoAn L; Bowen, Kanika; Tadros, Peter N; Witt, Peter D

2003-08-01

Radiation-induced skin injury has been reported for multiple fluoroscopic procedures. Previous studies have indicated that prolonged fluoroscopic exposure during even a single percutaneous coronary intervention (PCI) may lead to cutaneous radiation injury. We document a novel case of deep muscle damage requiring wide local debridement and muscle flap reconstruction in a 59-year-old man with a large radiation-induced wound to the lower thoracic region following 1 prolonged PCI procedure. The deep muscular iatrogenic injury described in this report may be the source of significant morbidity. Recommendations to reduce radiation-induced damage include careful examination of the skin site before each procedure, minimized fluoroscopy time, utilization of pulse fluoroscopy, employment of radiation filters, and collimator s and rotation of the location of the image intensifier.

Nanofiber Nerve Guide for Peripheral Nerve Repair and Regeneration

DTIC Science & Technology

2016-04-01

faster regeneration and functional recovery. Peripheral nerve injury is a common complication of complex tissue trauma and often results in significant...having poor regeneration overall, the areas of regenerating nerve tissue could often be found in sections of the nerve guide where luminal spaces of...conducted in this Aim also provided important insight into the NGC design parameters necessary to allow for maximum nerve tissue ingrowth and regeneration

The role of great auricular-facial nerve neurorrhaphy in facial nerve damage

PubMed Central

Sun, Yan; Liu, Limei; Han, Yuechen; Xu, Lei; Zhang, Daogong; Wang, Haibo

2015-01-01

Background: Facial nerve is easy to be damaged, and there are many reconstructive methods for facial nerve reconstructive, such as facial nerve end to end anastomosis, the great auricular nerve graft, the sural nerve graft, or hypoglossal-facial nerve anastomosis. However, there is still little study about great auricular-facial nerve neurorrhaphy. The aim of the present study was to identify the role of great auricular-facial nerve neurorrhaphy and the mechanism. Methods: Rat models of facial nerve cut (FC), facial nerve end to end anastomosis (FF), facial-great auricular neurorrhaphy (FG), and control (Ctrl) were established. Apex nasi amesiality observation, electrophysiology and immunofluorescence assays were employed to investigate the function and mechanism. Results: In apex nasi amesiality observation, it was found apex nasi amesiality of FG group was partly recovered. Additionally, electrophysiology and immunofluorescence assays revealed that facial-great auricular neurorrhaphy could transfer nerve impulse and express AChR which was better than facial nerve cut and worse than facial nerve end to end anastomosis. Conclusions: The present study indicated that great auricular-facial nerve neurorrhaphy is a substantial solution for facial lesion repair, as it is efficiently preventing facial muscles atrophy by generating neurotransmitter like ACh. PMID:26550216

Nerve Blocks

MedlinePlus

... turn off" a pain signal along a specific distribution of nerve. Imaging guidance may be used to place the needle in the most appropriate location for maximum benefit. A nerve block may allow a damaged nerve time to heal, provide temporary pain relief and help ...

Strategies for prevention of iatrogenic inferior vena cava filter entrapment and dislodgement during central venous catheter placement.

PubMed

Wu, Alex; Helo, Naseem; Moon, Eunice; Tam, Matthew; Kapoor, Baljendra; Wang, Weiping

2014-01-01

Iatrogenic migration of inferior vena cava (IVC) filters is a potentially life-threatening complication that can arise during blind insertion of central venous catheters when the guide wire becomes entangled with the filter. In this study, we reviewed the occurrence of iatrogenic migration of IVC filters in the literature and assessed methods for preventing this complication. A literature search was conducted to identify reports of filter/wire entrapment and subsequent IVC filter migration. Clinical outcomes and complications were identified. A total of 38 cases of filter/wire entrapment were identified. All of these cases involved J-tip guide wires. Filters included 23 Greenfield filters, 14 VenaTech filters, and one TrapEase filter. In 18 cases of filter/wire entrapment, there was migration of the filter to the heart and other central venous structures. Retrieval of the migrated filter was successful in only four of the 18 cases, and all of these cases were complicated by strut fracture and distant embolization of fragments. One patient required resuscitation during retrieval. Successful disengagement was possible in 20 cases without filter migration. Iatrogenic migration of an IVC filter is an uncommon complication related to wire/filter entrapment. This complication can be prevented with knowledge of the patient's history, use of proper techniques when placing a central venous catheter, identification of wire entrapment at an early stage, and use of an appropriate technique to disengage an entrapped wire. Copyright © 2014 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.

Fibrolipomatous hamartoma of the inferior calcaneal nerve (Baxter nerve).

PubMed

Zeng, Rong; Frederick-Dyer, Katherine; Ferguson, N Lynn; Lewis, James; Fu, Yitong

2012-09-01

Fibrolipomatous hamartoma (FLH) is a rare, benign lesion of the peripheral nerves most frequently involving the median nerve and its digital branches (80 %). Pathognomonic MR features of FLH such as coaxial-cable-like appearance on axial planes and a spaghetti-like appearance on coronal planes have been described by Marom and Helms, obviating the need for diagnostic biopsy. We present a case of fibrolipomatous hamartoma of the inferior calcaneal nerve (Baxter nerve) with associated subcutaneous fat proliferation.

Ophthalmic profile and systemic features of pediatric facial nerve palsy.

PubMed

Patil-Chhablani, Preeti; Murthy, Sowmya; Swaminathan, Meenakshi

2015-12-01

Facial nerve palsy (FNP) occurs less frequently in children as compared to adults but most cases are secondary to an identifiable cause. These children may have a variety of ocular and systemic features associated with the palsy and need detailed ophthalmic and systemic evaluation. This was a retrospective chart review of all the cases of FNP below the age of 16 years, presenting to a tertiary ophthalmic hospital over the period of 9 years, from January 2000 to December 2008. A total of 22 patients were included in the study. The average age at presentation was 6.08 years (range, 4 months to 16 years). Only one patient (4.54%) had bilateral FNP and 21 cases (95.45%) had unilateral FNP. Seventeen patients (77.27%) had congenital palsy and of these, five patients had a syndromic association, three had birth trauma and nine patients had idiopathic palsy. Five patients (22.72%) had an acquired palsy, of these, two had a traumatic cause and one patient each had neoplastic origin of the palsy, iatrogenic palsy after surgery for hemangioma and idiopathic palsy. Three patients had ipsilateral sixth nerve palsy, two children were diagnosed to have Moebius syndrome, one child had an ipsilateral Duane's syndrome with ipsilateral hearing loss. Corneal involvement was seen in eight patients (36.36%). Amblyopia was seen in ten patients (45.45%). Neuroimaging studies showed evidence of trauma, posterior fossa cysts, pontine gliosis and neoplasms such as a chloroma. Systemic associations included hemifacial macrosomia, oculovertebral malformations, Dandy Walker syndrome, Moebius syndrome and cerebral palsy FNP in children can have a number of underlying causes, some of which may be life threatening. It can also result in serious ocular complications including corneal perforation and severe amblyopia. These children require a multifaceted approach to their care.

Anatomic Considerations for Plating of the Distal Ulna

PubMed Central

Hazel, Antony; Nemeth, Nicole; Bindra, Randy

2015-01-01

Purpose The purpose of our study was to examine the anatomy of the distal ulna and identify an interval that would be amenable to plating and would not cause impingement during wrist rotation nor irritation to the extensor carpi ulnaris (ECU) tendon. Methods Six cadaveric forearms were dissected and the arc of the articular surface of the distal ulna was measured. The distal ulna was divided up as a clock face, with the ulnar styloid being assigned the 12 o'clock position, and the location of the ECU was identified accordingly. The distance from the ulnar styloid to where the dorsal sensory ulnar nerve crosses from volar to dorsal was also measured. Based on these measurements a safe zone was defined. Results A safe zone was identified between the 12 and 2 o'clock position on the right wrist, and between the 10 and 12 o'clock on the left wrist. The dorsal sensory branch of the ulnar nerve crossed from volar to dorsal position at a variable location near the ulnar styloid. Two commercially available plates were utilized and could be placed in our designated interval and did not cause impingement when the forearm was rotated fully. Conclusion Our study demonstrates a location for plating of the distal ulna that avoids impingement during forearm rotation and that is outside of the footprint of the ECU subsheath. Clinical Relevance Plating of the distal ulna may be necessary with distal ulna fracture, and although plate placement may be dictated by the fracture pattern, it is important to understand the implications of plate placement. Although the ideal plate may not be possible because of comminution, the patient can be educated in regards to potential for tendon irritation, loss of motion, or need for hardware removal. PMID:26261745

Antero-medial approach to the wrist: anatomic basis and new application in cases of fracture of the lunate facet.

PubMed

Uzel, A-P; Bulla, A; Laurent-Joye, M; Caix, P

2011-08-01

The Henry approach is the classical anterolateral surgical exposure of the volar aspect of the distal radius. This approach does not allow good access to the medial side of the volar distal radius (lunate facet) and the distal radio-ulnar joint, unless it is extended proximally, retracting the tendons and the median nerve medially, which can cause some trauma. The purpose of our study was to investigate the anatomic basis and to outline the advantages of the unusual anteromedial approach, reporting our experience in the treatment of 4 distal radius fractures, with a 90° or 180° twist of the lunate facet, and 10 wrist dissections on cadavers. The average follow-up was 68.8 months (range 18 to 115 months). In our series, this approach did not cause any nerve injuries or any sensory loss of the distal forearm and the palm. All the fractures of the lunate facet and of the radial styloid process healed. One patient with an ulnar styloid process fracture associated showed pseudarthrosis, but with no instability of the distal radio-ulnar joint or pain on the ulnar side. Using the criteria of Green and O'Brien, modified by Cooney, the results were: excellent in two cases, good in one case, and average in another. The evaluation of arthritis according to Knirk and Jupiter's classification showed grade 0 in three cases and grade 3 in one case with osteochondral sclerosis. We showed that the anteromedial approach is reliable and convenient in the case of fractures situated in the antero-medial portion of the radius, for the double objective of reducing the fracture under direct control and checking the congruence of the distal radio-ulnar joint.

Overlapping Mechanisms of Peripheral Nerve Regeneration and Angiogenesis Following Sciatic Nerve Transection

PubMed Central

Wang, Hongkui; Zhu, Hui; Guo, Qi; Qian, Tianmei; Zhang, Ping; Li, Shiying; Xue, Chengbin; Gu, Xiaosong

2017-01-01

Peripheral nervous system owns the ability of self-regeneration, mainly in its regenerative microenvironment including vascular network reconstruction. More recently, more attentions have been given to the close relationship between tissue regeneration and angiogenesis. To explore the overlap of molecular mechanisms and key regulation molecules between peripheral nerve regeneration and angiogenesis post peripheral nerve injury, integrative and bioinformatic analysis was carried out for microarray data of proximal stumps after sciatic nerve transection in SD rats. Nerve regeneration and angiogenesis were activated at 1 day immediately after sciatic nerve transection simultaneously. The more obvious changes of transcription regulators and canonical pathways suggested a phase transition between 1 and 4 days of both nerve regeneration and angiogenesis after sciatic nerve transection. Furthermore, 16 differentially expressed genes participated in significant biological processes of both nerve regeneration and angiogenesis, a few of which were validated by qPCR and immunofluorescent staining. It was demonstrated that STAT3, EPHB3, and Cdc42 co-expressed in Schwann cells and vascular endothelial cells to play a key role in regulation of nerve regeneration and angiogenesis simultaneously response to sciatic nerve transection. We provide a framework for understanding biological processes and precise molecular correlations between peripheral nerve regeneration and angiogenesis after peripheral nerve transection. Our work serves as an experimental basis and a valuable resource to further understand molecular mechanisms that define nerve injury-induced micro-environmental variation for achieving desired peripheral nerve regeneration. PMID:29085283

Overlapping Mechanisms of Peripheral Nerve Regeneration and Angiogenesis Following Sciatic Nerve Transection.

PubMed

Wang, Hongkui; Zhu, Hui; Guo, Qi; Qian, Tianmei; Zhang, Ping; Li, Shiying; Xue, Chengbin; Gu, Xiaosong

2017-01-01

Peripheral nervous system owns the ability of self-regeneration, mainly in its regenerative microenvironment including vascular network reconstruction. More recently, more attentions have been given to the close relationship between tissue regeneration and angiogenesis. To explore the overlap of molecular mechanisms and key regulation molecules between peripheral nerve regeneration and angiogenesis post peripheral nerve injury, integrative and bioinformatic analysis was carried out for microarray data of proximal stumps after sciatic nerve transection in SD rats. Nerve regeneration and angiogenesis were activated at 1 day immediately after sciatic nerve transection simultaneously. The more obvious changes of transcription regulators and canonical pathways suggested a phase transition between 1 and 4 days of both nerve regeneration and angiogenesis after sciatic nerve transection. Furthermore, 16 differentially expressed genes participated in significant biological processes of both nerve regeneration and angiogenesis, a few of which were validated by qPCR and immunofluorescent staining. It was demonstrated that STAT3, EPHB3, and Cdc42 co-expressed in Schwann cells and vascular endothelial cells to play a key role in regulation of nerve regeneration and angiogenesis simultaneously response to sciatic nerve transection. We provide a framework for understanding biological processes and precise molecular correlations between peripheral nerve regeneration and angiogenesis after peripheral nerve transection. Our work serves as an experimental basis and a valuable resource to further understand molecular mechanisms that define nerve injury-induced micro-environmental variation for achieving desired peripheral nerve regeneration.

Electrophysiology of Cranial Nerve Testing: Spinal Accessory and Hypoglossal Nerves.

PubMed

Stino, Amro M; Smith, Benn E

2018-01-01

Multiple techniques have been developed for the electrodiagnostic evaluation of cranial nerves XI and XII. Each of these carries both benefits and limitations, with more techniques and data being available in the literature for spinal accessory than hypoglossal nerve evaluation. Spinal accessory and hypoglossal neuropathy are relatively uncommon cranial mononeuropathies that may be evaluated in the outpatient electrodiagnostic laboratory setting. A review of available literature using PubMed was conducted regarding electrodiagnostic technique in the evaluation of spinal accessory and hypoglossal nerves searching for both routine nerve conduction studies and repetitive nerve conduction studies. The review provided herein provides a resource by which clinical neurophysiologists may develop and implement clinical and research protocols for the evaluation of both of these lower cranial nerves in the outpatient setting.

Routine exposure of recurrent laryngeal nerve in thyroid surgery can prevent nerve injury.

PubMed

Shen, Chenling; Xiang, Mingliang; Wu, Hao; Ma, Yan; Chen, Li; Cheng, Lan

2013-06-15

To determine the value of dissecting the recurrent laryngeal nerve during thyroid surgery with respect to preventing recurrent laryngeal nerve injury, we retrospectively analyzed clinical data from 5 344 patients undergoing thyroidectomy. Among these cases, 548 underwent dissection of the recurrent laryngeal nerve, while 4 796 did not. There were 12 cases of recurrent laryngeal nerve injury following recurrent laryngeal nerve dissection (injury rate of 2.2%) and 512 cases of recurrent laryngeal nerve injury in those not undergoing nerve dissection (injury rate of 10.7%). This difference remained statistically significant between the two groups in terms of type of thyroid disease, type of surgery, and number of surgeries. Among the 548 cases undergoing recurrent laryngeal nerve dissection, 128 developed anatomical variations of the recurrent laryngeal nerve (incidence rate of 23.4%), but no recurrent laryngeal nerve injury was found. In addition, the incidence of recurrent laryngeal nerve injury was significantly lower in patients with the inferior parathyroid gland and middle thyroid veins used as landmarks for locating the recurrent laryngeal nerve compared with those with the entry of the recurrent laryngeal nerve into the larynx as a landmark. These findings indicate that anatomical variations of the recurrent laryngeal nerve are common, and that dissecting the recurrent laryngeal nerve during thyroid surgery is an effective means of preventing nerve injury.

Routine exposure of recurrent laryngeal nerve in thyroid surgery can prevent nerve injury★

PubMed Central

Shen, Chenling; Xiang, Mingliang; Wu, Hao; Ma, Yan; Chen, Li; Cheng, Lan

2013-01-01

To determine the value of dissecting the recurrent laryngeal nerve during thyroid surgery with respect to preventing recurrent laryngeal nerve injury, we retrospectively analyzed clinical data from 5 344 patients undergoing thyroidectomy. Among these cases, 548 underwent dissection of the recurrent laryngeal nerve, while 4 796 did not. There were 12 cases of recurrent laryngeal nerve injury following recurrent laryngeal nerve dissection (injury rate of 2.2%) and 512 cases of recurrent laryngeal nerve injury in those not undergoing nerve dissection (injury rate of 10.7%). This difference remained statistically significant between the two groups in terms of type of thyroid disease, type of surgery, and number of surgeries. Among the 548 cases undergoing recurrent laryngeal nerve dissection, 128 developed anatomical variations of the recurrent laryngeal nerve (incidence rate of 23.4%), but no recurrent laryngeal nerve injury was found. In addition, the incidence of recurrent laryngeal nerve injury was significantly lower in patients with the inferior parathyroid gland and middle thyroid veins used as landmarks for locating the recurrent laryngeal nerve compared with those with the entry of the recurrent laryngeal nerve into the larynx as a landmark. These findings indicate that anatomical variations of the recurrent laryngeal nerve are common, and that dissecting the recurrent laryngeal nerve during thyroid surgery is an effective means of preventing nerve injury. PMID:25206452

Neurovascular Structures at Risk With Curved Retrograde TTC Fusion Nails.

PubMed

de Cesar Netto, Cesar; Johannesmeyer, David; Cone, Brent; Araoye, Ibukunoluwa; Hudson, Parke William; Sahranavard, Bahman; Johnson, Michael; Shah, Ashish

2017-10-01

The purpose of this study was to assess the risk of iatrogenic injury to plantar neurovascular structures of the foot during insertion of a curved retrograde tibiotalocalcaneal (TTC) fusion nail. Ten below-knee thawed fresh-frozen cadaveric specimens underwent curved retrograde nailing of the ankle. The shortest distance between the nail and the main plantar neurovascular branches and injured structures were recorded during dissection. We also evaluated the relative position of these structures along 2 lines (AB, connecting the calcaneus to the first metatarsal, and BC, connecting the first and fifth metatarsal). The lateral plantar artery was found to be in direct contact with the nail 70% of the time, with a macroscopic laceration 30% of the time. The Baxter nerve was injured 20% of the time, as was the lateral plantar nerve. The medial plantar artery and nerve were never injured. The most proximal structure to cross line AB was the Baxter nerve followed by the lateral plantar artery, the nail, the lateral plantar nerve, and the medial plantar nerve. Our cadaveric anatomic study found that the most common structures at risk for iatrogenic injury by lateral curved retrograde TTC fusion nails were the lateral plantar artery and nerve, and the Baxter nerve. Determination of a true neurovascular safe zone is challenging and therefore warrants careful operative dissection to minimize neurovascular injuries.

[Clinical and electrophysiological findings in carpal tunnel syndrome].