同期手术治疗胸廓出口综合征合并远端神经卡压的疗效

目的探讨远近端同期手术治疗胸廓出口综合征合并远端神经卡压的疗效。方法对8例胸廓出口综合征合并远端神经卡压者,一期同时手术松解臂丛神经及远端神经卡压,并消除了全部卡压因素。结果按成效敏等的评定标准评价优3例,良4例,差1例。结论对晚期已出现肌萎缩的胸廓出口综合征合并远端神经卡压患者,应选择一期远近端神经同时松解术,以改善疗效、提高治愈率。     

Carpal tunnel syndrome: Neurographical parameters in different stages of median nerve compression

In a series of 47 cases and 55 hands operated upon for carpal tunnel syndrome, the pre-operative electrodiagnostic findings have been compared retrospectively with the morphological findings within the carpal tunnel during operation. As a main result there was no significant correlation between the degree of electrophysiological changes and the degree of median nerve compression. Only the lack of any motor or sensory response seems to indicate a more severe median nerve compression. In about 20% of cases with operatively proven marked median nerve compression, both distal motor latency and motor nerve conduction velocity were well within normal limits and would not have led to the diagnosis of a carpal tunnel syndrome in these cases. The diagnosis, therefore, cannot be made on the basis of electrodiagnostic pathological values only of distal motor latency and motor nerve conduction velocity, but has to take into account as well the sensory nerve conduction velocity as well as the clinical picture and neurological findings.     

Magnetic resonance neurography studies of the median nerve before and after carpal tunnel decompression

OBJECT: Recently developed novel MR protocols called MR neurography, which feature conspicuity for nerve, have been shown to demonstrate signal change and altered median nerve configuration in patients with median nerve compression. The postoperative course following median nerve decompression can be problematic, with persistent symptoms and abnormal results on electrophysiological studies for some months, despite successful surgical decompression. The authors undertook a prospective study in patients with carpal tunnel syndrome, correlating the clinical, electrophysiological, and MR neurography findings before and 3 months after surgery. METHODS: Thirty patients and eight control volunteers were recruited to the study. The MR neurography consisted of axial and sagittal images (TR = 2000 msec, TE = 60 msec) obtained using a temporomandibular surface coil, fat saturation, and flow suppression. Maximum intensity projection images were used to follow the median nerve through the carpal tunnel in the sagittal plane. Magnetic resonance neurography in patients with carpal tunnel syndrome demonstrated proximal swelling (p < 0.001) and high signal change in the nerve, together with increased flattening ratios (p < 0.001) and loss of nerve signal in the distal carpal tunnel (p < 0.05). Sagittal images were very effective in precisely demonstrating the site and severity of nerve compression. After surgery, division of the flexor retinaculum could be demonstrated in all cases. Changes in nerve configuration, including increased cross-sectional area, and reduced flattening ratios (p < 0.001) were seen in all patients. In many cases restoration of the T. signal intensity toward that of controls was seen in the median nerve in the distal carpal tunnel. Sagittal images were excellent in demonstrating expansion of the nerve at the site of surgical decompression. CONCLUSIONS: In this study the authors suggest that MR neurography is an effective means of both confirming compression of the median nerve and its successful surgical decompression in patients with carpal tunnel syndrome. This modality may prove useful in the assessment of unconfirmed or complex cases of carpal tunnel syndrome both before and after surgery.     

Post-traumatic distal nerve entrapment syndrome

Eleven patients with paralysis of muscle groups in the upper or lower extremity were clinically diagnosed after previous proximal direct trauma to the corresponding peripheral nerves, without complete nerve disruption. Patients were seen within an average of 8 months after trauma (minimum 3 months and maximum 2 years after). Nerve lesions were caused either by gunshot, motor-vehicle accident, and other direct trauma or, in one case, after tumor excision. All patients presented with complete sensory and motor loss distal to the trauma site, but demonstrated a positive Tinel sign and pain on testing over the "classic" (distal) anatomic nerve entrapment sites only. After surgical release through decompression of the nerve compression site distal to the trauma, a recovery of sensory function was achieved after surgery in all cases. Good-to-excellent restoration of motor function (M4/M5) was achieved in 63 percent of all cases. Twenty-five percent had no or only poor improvement in motor function, despite a good sensory recovery. Those patients in whom nerve compression sites were surgically released before 6 months after trauma had an improvement in almost all neural functions, compared to those patients who underwent surgery later than 9 months post trauma. A possible explanation of traumatically caused neurogenic paralysis with subsequent distal nerve compressions is provided, using the "double crush syndrome" hypothesis.     

颈神经根受压伴远端神经卡压的诊治

目的 探讨近端颈神经根受压合并远端神经卡压(双卡综合征)的诊断和治疗。方法 1997年以来共收治双卡综合征29例。5例神经根无明确受压者采用颈椎手法调整及颈椎硬膜外神经阻滞术。24例作受压节段髓核摘除、椎间植骨融合术及远端受压神经松解术。结果 术后平均随访12个月。根据症状、体征的恢复程度评定疗效，分为优、良、可、差4级。评定结果25例为优良占86％。结论 双卡综合征并非罕见，正确的诊断和合理的治疗方案，对预后有重要的意义。     

Two cases of endoscopic management of carpal tunnel syndrome in macrodactyly patients.

Some cases of carpal tunnel syndrome in macrodactyly patients have been reported. We performed endoscopic carpal canal release on two unilateral macrodactyly patients suffering from bilateral carpal tunnel syndrome. We measured carpal canal pressure before performing endoscopic surgery using the Universal Subcutaneous Endoscope system to confirm median nerve compression. We diagnosed median nerve compression in each patient due to the high preoperative carpal canal pressure. Carpal canal pressure immediately decreased to within normal range following release of both the flexor retinaculum and the distal holdfast fibres of the flexor retinaculum. One patient recovered to within normal in terms of sensory disturbances and abductor pollicis brevis muscle strength. The other patient showed improvement in terms of sensory disturbance, however, muscle power did not recover because this patient had suffered from carpal tunnel syndrome for ten years. Endoscopic carpal canal release and decompression surgery was effective for carpal tunnel syndrome in both macrodactyly patients.     

双神经卡压综合征

目的：研究双神经卡压征的病因及手术治疗方法。方法：分析了自１９８８年以来同时诊断为腕管综合征和肘管综合征２６例３４侧的临床资料。全部患者均作两处神经松解术，平均随访１７个月。疗效评定标准，根据术后症状、体征的改善程度分优、良、可和无效四级。结果：２５侧术后疗效优良，占７３．６％（２５／３４）。结论：双神经卡压征手术治疗效果较好。当双神经卡压同时合并颈部神经卡压时，建议优先考虑远端的神经减压。当远端神经减压后未能改善近端神经卡压症状时，才考虑近端神经减压     

The acute carpal tunnel syndrome: nine case reports.

Nine cases of acute carpal tunnel syndrome are reported. Etiologies include: bleeding secondary to chronic lymphatic leukemia; Colles' fracture of the wrist (2 cases); Epiphyseal fracture (Salter II) of the distal radius; Bleeding secondary to giant cell tumor of the tendon sheath; Unstable distal radio-ulnar joint; Displaced intra-articular fracture of the distal radius; Rheumatoid synovitis and vasculitis; Trans-scaphoid, perilunar fracture dislocation of the wrist. Early recognition of median nerve compression in the carpal tunnel is vital. The signs of median nerve compression should be looked for in all cases of wrist trauma. In our opinion, immediate surgical decompression is frequently indicated.     

Neurovascular compression findings in hemifacial spasm

OBJECT: It is generally accepted that hemifacial spasm (HFS) is caused by pulsatile vascular compression upon the facial nerve root exit zone. This 2-3 mm area, considered synonymous with the Obersteiner-Redlich zone, is a transition zone (TZ) between central and peripheral axonal myelination that is situated at the nerve's detachment from the pons. Further proximally, however, the facial nerve is exposed on the pontine surface and emerges from the pontomedullary sulcus. The incidence and significance of neurovascular compression upon these different segments of the facial nerve in patients with HFS has not been previously reported. METHODS: The nature of neurovascular compression was determined in 115 consecutive patients undergoing their first microvascular decompression (MVD) for HFS. The location of neurovascular compression was categorized to 1 of 4 anatomical portions of the facial nerve: RExP = root exit point; AS = attached segment; RDP = root detachment point that corresponds to the TZ; and CP = distal cisternal portion. The severity of compression was defined as follows: mild = contact without indentation of nerve; moderate = indentation; and severe = deviation of the nerve course. Success in alleviating HFS was documented by telephone interview conducted at least 24 months following MVD surgery. RESULTS: Neurovascular compression was found in all patients, and the main culprit was the anterior inferior cerebellar artery (in 43%), posterior inferior cerebellar artery (in 31%), vertebral artery (in 23%), or a large vein (in 3%). Multiple compressing vessels were found in 38% of cases. The primary culprit location was at RExP in 10%, AS in 64%, RDP in 22%, and CP in 3%. The severity of compression was mild in 27%, moderate in 61%, and severe in 12%. Failure to alleviate HFS occurred in 9 cases, and was not related to compression location, severity, or vessel type. CONCLUSIONS: The authors observed that culprit neurovascular compression was present in all cases of HFS, but situated at the RDP or Obersteiner-Redlich zone in only one-quarter of cases and rarely on the more distal facial nerve root. Since the majority of culprit compression was found more proximally on the pontine surface or even pontomedullary sulcus origin of the facial nerve, these areas must be effectively visualized to achieve consistent success in performing MVD for HFS.     

Etiology, diagnosis and therapy of tarsal tunnel syndrome--results of a retrospective study]

Tarsal tunnel syndrome is a rare entrapment neuropathy of the posterior tibial nerve. The compression of the nerve behind the medial ankle should be distinguished from that of the more distal compression syndrome of the plantar nerves, because of different anatomic conditions and pathogenesis. The patient's history is of special diagnostic value. The most impressive clinical finding is tenderness of the nerve. Neurological deficits must be searched for. Decompression by cutting the flexor retinaculum and neurolysis is advised. 77% of the 30 patients having undergone this operation were satisfied with the results.     

Cubital tunnel syndrome — Review of current literature on causes, diagnosis and treatment

Cubital tunnel syndrome is common, but not fully understood. Fortunately, most cases of ulnar nerve compression improve with nonsurgical treatment and large majority get better with surgical decompression. The fact that most people get better with and without surgical treatment is likely the reason that multiple studies have failed to show improved results with different types of decompressions for mild cubital tunnel syndrome. Transposition surgeries have been shown to yield better results with more severe cases and patients who failed previous simple releases, likely secondary to release of other compression sites that were missed by the initial surgery. Knowing more about pathology of the cutbital tunnel syndrome such as compression versus traction injury and having better modalities for evaluation of the nerve should help us to better tailor treatment for the patients in the future.     

Subluxation-related ulnar neuropathy (SUN) syndrome related to distal radioulnar joint instability

Ulnar neuropathy coexistent with distal radioulnar joint (DRUJ) instability has previously been observed in our practice. The aim of this study was to define this phenomenon and investigate the hypothesis that the cause of this intermittent, positional ulnar neuropathy is related to kinking of the ulnar nerve about the DRUJ. Ulna neuropathy was present in 10/51 (19.6%) of a historical cohort of patients who presented with DRUJ instability. Nine subsequent patients with DRUJ instability and coexistent ulnar neuropathy underwent 3-T magnetic resonance imaging to better understand the mechanism of the observed syndrome. Both 3D qualitative and quantitative analyses were used to assess the presence of nerve 'kinking', displacing the nerve from its normal course and causing nerve compression/distraction in the distal forearm and Guyon's canal. Results of the quantitative analysis were statistically significant (p < 0.05). The clinical features of the condition have been delineated and termed subluxation-related ulnar neuropathy or SUN syndrome. The imaging study was a level II diagnostic study.     

A prospective plan to minimise median nerve related complications associated with operatively treated distal radius fractures.

Loss of median nerve function or a neuropathic pain syndrome may occur in around 20% of distal radius fractures if post-traumatic oedema in the carpal canal generates excessive pressure on the median nerve. No method currently exists to reliably distinguish which patients may benefit from a concomitant carpal tunnel release. This case series details the results of following a prospective plan designed to minimise median nerve related complications associated with distal radius fractures by measuring Semmes-Weinstein monofilament scores in 374 radius fracture patients who underwent surgical stabilisation. One hundred and sixty-nine patients with the clinical symptoms of median nerve compression, a decrement in monofilament score of grade 1 (out of 5) compared to the contralateral side or at least 4.31 g underwent concomitant carpal tunnel release. The remaining 205 patients did not have carpal tunnel release. There were no cases of neuropathic pain or loss of median nerve function.     

Clinical and neurophysiologic characteristics of the pronator syndrome

Nine patients were clinically diagnosed as having a pronator syndrome, i.e., high median nerve compression. The main symptom was pain at the proximal volar aspect of the forearm increasing for several hours after exercise. All patients showed local tenderness over the median nerve 4-5 cm distal to the elbow and pain on active forearm pronation against resistance. Two patients had been previously operated upon for carpal tunnel syndrome. Preoperative routine neurographic-electromyographic studies were normal. In the differential diagnosis, the exclusion of carpal tunnel syndrome and anterior interosseous nerve entrapment is most important. On active isometric forearm pronation, interference with median nerve motor conduction occurred in three patients preoperation. This phenomenon had disappeared following median nerve decompression at the level of the pronator muscle. Fibrous bands from the pronator muscle, encircling the nerve, seemed to be an etiological factor. Eight of nine patients were either improved or recovered completely by surgical treatment.     

Hemifacial spasm due to vascular compression of the distal portion of root exit zone of the facial nerve: report of two cases

It has been generally assumed that only vascular contact at the root exit zone (REZ) of the facial nerve can cause hemifacial spasm. We treated two cases of hemifacial spasm in which compression of the distal site of the REZ of the facial nerve produced symptoms. The microvascular decompression for the patients showed excellent results. Extreme care must be taken not to stretch the internal auditory artery during surgical manipulation. The ABR monitoring is useful to prevent the postoperative hearing loss. It must be kept in mind that the compression of distal portions of the facial nerve may be responsible for hemifacial spasm in cases in which neurovascular compression at the REZ is not confirmed intraoperatively.     

旋后肌综合征诱发加重试验的解剖与临床研究

目的从解剖学及临床角度对旋后肌综合征诱发加重试验的机制及可行性进行探讨。方法旋后肌综合征25例,男18例,女7例,均呈垂指变形,旋后肌综合征诱发加重试验均为阳性。8例手术、17例保守治疗;同时对92只成尸上肢旋后肌管进行了解剖、测量,而且在动态下观察其与骨间背侧神经的关系。结果22例得到0．6-1年的随访,16例伸指肌力完全恢复、其余6例部分恢复;解剖提示旋后肌腱弓主要为胶原纤维组成,被动旋前前臂,旋后肌腱弓紧张、压迫骨间背侧神经者80只(87．9％),旋后肌下缘紧张,压迫骨间背侧神经者67只(72．8％)。结论旋后肌综合征诱发加重试验是建立在旋后肌腱弓局部病理变化的情况下,快速、完全旋前旋后前臂,诱发旋后肌综合征一时加重的一种新的试验方法,有助于旋后肌综合征的明确诊断。     

Microneurovascular decompression in patients with hemifacial spasm caused by vascular compression of facial nerve at cisternal portion

Background  

Hemifacial spasm is commonly caused by arterial compression of the facial nerve. Although vascular compression usually occurs at the facial nerve exit zone, in some cases, the facial nerve is compressed more distally. We analyzed the clinical outcome of microneurovascular decompression in patients with hemifacial spasm caused by either distal or proximal compression.     

Distal rupture of the palmaris longus tendon and fascia as a cause of acute carpal tunnel syndrome

Acute carpal tunnel syndrome is rare compared with its more chronic presentation. Previous reports in the literature have documented the most common causes. Rupture of the distal palmaris longus tendon into the palmaris fascia as a cause of an acute carpal tunnel syndrome has not been reported previous to this case report. Partial rupture of the tendon and hemorrhage around its insertion produced intrinsic compression on the transverse ligament and the underlying nerve.     

微创经皮钢板内固定治疗肱骨中下段C型骨折

目的 探讨应用微创经皮钢板内固定技术(MIPPO)治疗肱骨中下段C型骨折的临床疗效.方法 对28例肱骨中下段C型骨折患者通过闭合牵引复位,经小切口插入锁定钢板(LCP),钢板置于肱骨前侧,一期内固定.术后分别以UCLA和Mayo评估肩、肘关节功能.结果 患者均获得随访,时间16～22个月.骨折均愈合,愈合时间3～5个月.1例出现伤口延迟愈合;1例出现桡神经损害症状;1例因钢板过高产生肩关节撞击症状.参照UCLA肩关节评分:优 12例,良 11例,差 5例;Mayo肘关节评分:优 6例,良 14例,可 6例,差 2例.结论 MIPPO技术治疗肱骨中下段C型骨折,临床效果良好.     

Distal sensory latencies of the ulnar nerve in long distance bicyclists: pilot study*

* This article is adapted from a paper written in partial fulfillment of the requirement for the Master of Science Degree, Duke University, Durham, NC 27710. Ulnar neuropathy, an overuse compression syndrome injury of the ulnar nerve at the wrist, is frequently associated with bicycling. Previous studies have shown that after severe compression injury to the ulnar nerve there is a change in nerve conduction velocity. The purpose of this study was to determine if long distance bicyclists have altered nerve conduction velocities due to repeated sustained compression of the ulnar nerve. This study compares the distal sensory latency period of the ulnar nerve in 15 controls and 10 long distance cyclists. The controls bicycled less than 10 miles per week on the average and the long distance cyclists bicycled an average of more than 100 miles per week. Results showed that there was a statistically significant difference (p < 0.002) in distal sensory latencies between long distance cyclists and the control group. However, there was no significant correlation (p > 0.10) between distance bicycled and latency. Results of this study lead to the belief that there may be adaptive changes in long distance cyclists which could account for changes in sensory nerve conduction velocity of the ulnar nerve.J Orthop Sports Phys Ther 1988;9(11):370-374.