Surgical management and outcomes in patients with median nerve lesions

OBJECT: One hundred sixty-seven of 250 patients with median nerve (MN) lesions, excluding carpal tunnel syndrome and nerve sheath tumors, at the levels of the arm, elbow, forearm, and wrist, underwent surgical treatment at Louisiana State University Health Sciences over a 30-year period. The most common causes of MN injuries were laceration, fracture-associated stretch and contusion, gunshot wound, compression, and injection injuries. In this study, surgically treated patients were followed and evaluated retrospectively for favorable functional outcomes. METHODS: Lesions not in continuity required primary or secondary end-to-end suture or graft repairs. With the aid of direct intraoperative recording of nerve action potentials (NAPs), MN injuries in which the lesion was in continuity underwent external or internal neurolysis, or resection of the lesion, followed by end-to-end suture or graft repair. A minimum of 12 months follow-up review (mean 18 months) was available in 85% of the surgically treated patients. For lesions in continuity, a functional recovery of Grade 3 or better was seen in 72 (95%) of 76 patients who underwent neurolysis, 18 (86%) of 21 who received suture repair, and 21 (75%) of 28 who received graft repair. In lesions not in continuity, favorable results (Grade > or = 3) were seen in 10 (91%) of 11 patients who received primary suture repair, seven (78%) of nine who received secondary suture repair, and 15 (68%) of 22 who received graft repair. CONCLUSIONS: Surgical intervention for MN injuries with complete or severe deficits achieved favorable outcomes.     

Surgical outcomes of 654 ulnar nerve lesions

OBJECT: In this article the authors present a retrospective analysis of 654 surgical outcomes in patients with ulnar nerve entrapments, injuries, and tumors during a 30-year period. METHODS: Data were gathered between 1968 and 1998 at Louisiana State University Health Sciences Center. Mechanisms of injuries or lesions included 460 entrapments at the elbow level (70%), 76 lacerations (12%), 52 stretches/contusions (8%), 34 fractures/dislocations (5%), 12 gunshot wounds (2%), two injection-induced injuries (0.3%), and 13 nerve sheath tumors (2%). In cases of entrapment, direct operative recordings uniformly demonstrated a slowing of conduction at the elbow, even in cases in which preoperative noninvasive studies had been nondiagnostic. Intraoperative electrical "inching" studies also demonstrated significant conduction abnormalities that lie just proximal to and through the olecranon notch rather than distal, beneath the flexor carpi ulnaris muscle. There were only eight exceptions to this. Lesions not in continuity due to the injury required primary or secondary end-to-end sutures or graft repair. Aided by intraoperative nerve action potential recording, lesions in continuity received either external or internal neurolysis and split repair or resection followed by end-to-end suture or graft repair. Functional recoveries of Grade 3 or better were seen in 81 (92%) of 88 patients who underwent neurolysis, 42 (72%) of 58 patients who received suture repair, and 24 (67%) of 36 patients who received graft repair. Nevertheless, fewer Grade 4 or 5 recoveries were reached than those seen in patients with radial or median nerve injuries. Nerve sheath tumors were resected with preservation of preoperative function in five of seven patients. CONCLUSIONS: Although difficult to obtain, useful functional recovery can be achieved with proper surgical management of ulnar nerve entrapments and injuries.     

Surgical management and outcome in patients with radial nerve lesions

OBJECT: The goal of this paper was to review surgical management and outcomes in patients treated for radial nerve (RN) lesions at Louisiana State University Health Sciences over a period of 30 years. METHODS: Two hundred sixty patients with RN injuries were evaluated. The most common mechanisms of injuries involving the RN included fracture of the humerus, laceration, blunt contusions, and gunshot wounds. One hundred and eighty patients (69%) underwent surgery. Lesions not in continuity required primary or secondary end-to-end suture repairs or graft repairs. With the use of direct intraoperative nerve action potential recording, RN injuries in which the lesion was in continuity required external or internal neurolysis or resection of the lesion followed by end-to-end suture or graft repair. A minimum of 1.5 years follow-up review was available in 90% of the patients who underwent surgery. Motor function recovery to Grade 3 or better was observed in 10 (91%) of 11 patients who underwent primary suture repair, 25 (83%) of 30 who underwent secondary suture repair, 43 (80%) of 54 who received graft repair, and 63 (98%) of 64 in whom neurolysis was performed. Sixteen (71%) of 21 patients with superficial sensory RN injury achieved satisfactory pain relief after complete resection of a neuroma or neurolysis. CONCLUSIONS: This study clearly demonstrates that excellent functional recovery can be achieved with proper surgical management of RN injuries.     

Posterior interosseous nerve palsies

One hundred seventy patients with radial nerve disorders were reviewed at the Louisiana State University Medical Center over a 15-year period. Of these, 32 had involvement of the posterior interosseous nerve exclusively. Findings included weak wrist extension with a radial drift, inability to extend the fingers, paralysis of thumb extension, and weak thumb abduction. Causes included entrapment at the arcade of Froshe (14 patients), laceration (6 patients), fracture (6 patients), compression or contusion (3 patients), and loss associated with tumor (3 patients). The ratio of men to women was 2:1, and the right arm was involved twice as often as the left. Preoperative evaluation included physical examination, electrophysiological testing (electromyogram/nerve conduction velocity), and roentgenograms of the elbow and forearm. Of the 30 patients (2 patients had bilateral lesions), 26 underwent operation. In the operative series, all 28 nerves had a function of Grade 3 or more of a possible 5 after 4 years of follow-up. Seventeen had achieved Grade 4/5, and 7 had obtained Grade 5/5. At operation, 23 nerves were found to be in continuity. Fourteen lesions of nerves in continuity were associated with entrapment and, not unexpectedly, transmitted a nerve action potential with slowed conduction and low amplitude across the lesion. Four nerves in continuity that had lesions caused by injury had nerve action potentials and were treated by neurolysis, and another 4 had no nerve action potentials and were treated by graft or suture repair. Five injured nerves were not in continuity. Two could be repaired by end-to-end suture, and 3 required graft repair. A large ganglion cyst involving the posterior interosseous nerve was also resected.     

Management and outcomes in 318 operative common peroneal nerve lesions at the Louisiana State University Health Sciences Center

OBJECTIVE: This study analyzes 318 operative knee-level common peroneal nerve lesions managed at the Louisiana State University Health Sciences Center between 1967 and 1999. METHODS: Each patient was retrospectively evaluated for injury mechanism, preoperative neurological status, electrophysiological studies, lesion type, and operative technique, i.e., neurolysis, suture, or graft repair. All lesions in continuity had intraoperative nerve action potential recordings. RESULTS: There were 141 stretch/contusions without fracture/dislocations (44%), 39 lacerations (12%), 40 tumors (13%), 30 entrapments (9%), 22 stretch/contusions with fracture/dislocations (7%), 21 compressions (7%), 13 iatrogenic injuries (4%), and 12 gunshot wounds (4%). After neurolysis, 107 (88%) of 121 knee-level common peroneal nerve lesions with recordable intraoperative nerve action potentials recovered useful function. Nineteen patients underwent end-to-end suture repair, and 16 (84%) of these achieved good recovery by 24 months. Graft repair was performed in 138 peroneal injuries. Thirty-six patients (26%) had grafts less than 6 cm long, of which 27 (75%) achieved Grade 3 or greater peroneal function. Twenty-four (38%) of 64 patients with 6- to 12-cm grafts, and only 6 (16%) of 38 patients with 13- to 24-cm grafts, attained good peroneal function. Longer grafts correlated with more severe injuries and thus poorer outcomes. Thirty-two (80%) of 40 tumors were resected with preservation of preoperative clinical function. CONCLUSION: Surgical exploration and repair of peroneal nerve lesions achieved good results with timely operations and thorough intraoperative evaluations. Useful function was achieved in 27 (75%) of 36 patients with grafts less than 6 cm in length and in only 88 (44%) of 202 patients with grafts greater than 6 cm in length.     

Surgical outcomes of 111 spinal accessory nerve injuries

OBJECTIVE: Iatrogenic injury to the spinal accessory nerve is not uncommon during neck surgery involving the posterior cervical triangle, because its superficial course here makes it susceptible. We review injury mechanisms, operative techniques, and surgical outcomes of 111 surgical repairs of the spinal accessory nerve. METHODS: This retrospective study examines clinical and surgical experience with spinal accessory nerve injuries at the Louisiana State University Health Sciences Center during a period of 23 years (1978-2000). Surgery was performed on the basis of anatomic and electrophysiological findings at the time of operation. Patients were followed up for an average of 25.6 months. RESULTS: The most frequent injury mechanism was iatrogenic (103 patients, 93%), and 82 (80%) of these injuries involved lymph node biopsies. Eight injuries were caused by stretch (five patients) and laceration (three patients). The most common procedures were graft repairs in 58 patients. End-to-end repair was used in 26 patients and neurolysis in 19 patients if the nerve was found in continuity with intraoperative electrical evidence of regeneration. Five neurotizations, two burials into muscle, and one removal of ligature material were also performed. More than 95% of patients treated by neurolysis supported by positive nerve action potential recordings improved to Grade 4 or higher. Of 84 patients with lesions repaired by graft or suture, 65 patients (77%) recovered to Grade 3 or higher. The average graft length was 1.5 inches. CONCLUSION: Surgical exploration and repair of spinal accessory nerve injuries is difficult. With perseverance, however, these patients with complete or severe deficits achieved favorable functional outcomes through operative exploration and repair.     

Surgical treatment and outcomes in 15 patients with anterior interosseous nerve entrapments and injuries

OBJECT: The authors present data obtained in 15 surgically treated patients with anterior interosseous nerve (AIN) entrapments and injuries. METHODS: Fifteen patients with AIN entrapments and injuries underwent surgery between 1967 and 1997 at Louisiana State University Health Sciences Center (LSUHSC) or Stanford University Medical Center. Patient charts were reviewed retrospectively. The LSUHSC grading system was used to evaluate the function of muscles supplied by the AIN. Nontraumatic injuries included seven AIN compressions by bone or soft tissue. Traumatic injury mechanisms consisted of stretch or contusion (six patients), injection (one patient), and burn scar (one patient). Presentations included weakness in the flexor digitorum profundus (FDP) muscle to the index finger, FDP muscle to the middle finger, pronator quadratus muscle, and flexion of the distal phalanx of the thumb. Preoperative evaluations included electromyography and nerve conduction studies as well as elbow and forearm plain radiographs. On surgery, lesions in continuity involved seven compressions, four stretch or contusion injuries, and one injection injury, all of which demonstrated nerve action potentials (NAPs) and were treated with neurolysis. Among the seven compression and four stretch or contusion injury cases, six and three patients, respectively, had LSUHSC Grade 3 or better functional recoveries postoperatively. Two stretch or contusion injuries involved lesions in continuity but demonstrated negative NAPs at surgery. Thus, each was treated using a graft repair after resection of a neuroma. There was one burn scar injury, which was treated via an end-to-end suture anastomosis, leading to a functional recovery better than Grade 3. CONCLUSIONS: Fifteen AIN entrapments or injuries responded favorably to nerve release and/or repair.     

Surgical treatment and outcomes in 45 cases of posterior interosseous nerve entrapments and injuries

OBJECT: The authors report data in 45 surgically treated posterior interosseous nerve (PIN) entrapments or injuries. METHODS: Forty-five PIN entrapments or injuries were managed surgically between 1967 and 2004 at Louisiana State University Health Sciences Center (LSUHSC) or Stanford University Medical Center. Patient charts were reviewed retrospectively. The LSUHSC grading system was used to assess PIN-innervated muscle function. Injuries were caused by nontraumatic (21 PIN entrapments and four tumors) and traumatic (nine lacerations, eight fractures, and three contusions) mechanisms. Presentations included weakness in the extensor carpi ulnaris muscle, causing compromised wrist extension and radial drift; extensor digitorum, indicis, and digiti minimi muscles with paretic finger extension; extensor pollicis brevis and longus muscles with weak thumb extension; and abductor pollicis longus muscle with rare decreased thumb abduction due to substitutions of the median nerve-innervated abductor pollicis brevis muscle and, at 90 degrees, the extensor pollicis brevis and longus muscles. Preoperative evaluations consisted of electromyography and nerve conduction studies, elbow and forearm plain x-ray films, and magnetic resonance imaging for tumor detection. At surgery, in continuity lesions were found in 21 entrapments and three fracture-related and three contusion injuries; all transmitted nerve action potentials (NAPs) and were treated with neurolysis. Five fracture-related PIN injuries, one of which was a lacerating injury, were in continuity and transmitted no NAPs; graft repairs were performed in all of these cases. Among nine lacerations, three PINs appeared in continuity, although intraoperative NAPs were absent. Two of these nerves were treated with secondary end-to-end suture anastomosis repair and one with secondary graft repair. There were six transected lacerations: three were treated with primary suture anastomosis repair, two with secondary suture anastomosis, and one with graft repair. Four tumors involving the PIN were resected. Most muscles innervated by 45 PINs had LSUHSC Grade 3 or better functional outcomes. CONCLUSIONS: Forty-five PIN entrapments or injuries responded well to PIN release and/or repair.     

Management and outcomes in 353 surgically treated sciatic nerve lesions

OBJECT: This is a retrospective analysis of 353 surgically treated sciatic nerve lesions in which injury mechanisms, location, time to surgical repair, surgical techniques, and functional outcomes are reported. Results are presented to provide guidelines for management of these injuries. METHODS: One hundred seventy-five patients with buttock-level and 178 with thigh-level sciatic nerve injury were surgically treated at the Louisiana State University Health Sciences Center between 1968 and 1999. Buttock-level injury mechanisms included injection in 64 patients, hip fracture/dislocation in 26, contusion in 22, compression in 19, gunshot wound (GSW) in 17, hip arthroplasty in 15, and laceration in 12; at the thigh level, GSW was the cause in 62 patients, femoral fracture in 34, laceration in 32, contusion in 28, compression in 12, and iatrogenic injury in 10. Patients with sciatic nerve divisions in which positive intraoperative nerve action potentials (NAPs) were found underwent neurolysis and attained at least Grade 3 functional outcomes in 108 (87%) of 124 and in 91 (96%) of 95 buttock- and thigh-level tibial divisions, respectively, compared with 84 (71%) of 119 and 75 (79%) of 95, respectively, in the peroneal divisions. For suture repair, recovery to at least Grade 3 occurred in eight (73%) of 11 buttock-level and in 27 (93%) of 29 thigh-level tibial division injuries, and in three (30%) of 10 buttock-level and 20 (69%) of 29 thigh-level peroneal division lesions. For graft repair, good recovery occurred in 21 (62%) of 34 and in 43 (80%) of 54 buttock- and thigh-level tibial divisions, respectively, even in proximal repairs requiring long grafts, and in only nine (24%) of 37 and 22 (45%) of 49 buttock- and thigh-level peroneal division lesions, respectively. CONCLUSIONS: Surgical exploration and neurolysis after positive NAP readings, or repair with sutures or grafts after negative NAP results are worthwhile in selected cases.     

Lacerations to the brachial plexus: surgical techniques and outcomes

The charts of patients with 201 brachial plexus elements sustaining operative lacerations and managed at Louisiana State University Health Sciences Center (LSUHSC) were reviewed retrospectively. Results for elements injured by sharp transections and undergoing suture repairs performed within 72 hr, as well as secondary suture and secondary graft repairs are documented. Similarly, results for secondary end-to-end suture anastomosis and secondary graft repairs for elements sustaining blunt transections are reviewed. Results for neurolysis, end-to-end suture anastomosis, and graft repairs for plexus elements in continuity despite the laceration injury are reviewed. Outcomes for the LSUHSC series of brachial plexus lacerations are one of the best of all LSUHSC plexus injuries, even for elements generally viewed as unfavorable for repair. Lesions in continuity with positive nerve action potentials (NAPs) had the best outcomes.     

Outcome of neurolysis for failed tarsal tunnel surgery

Revision tarsal tunnel surgery was performed on 44 patients (two bilaterally). The surgical procedure included a neurolysis of the tibial nerve in the tarsal tunnel, the medial plantar, lateral plantar, and calcaneal nerves in their respective tunnels, excision of the intertunnel septum, and neuroma resection as indicated. A painful tarsal tunnel scar or painful heel was treated, respectively, by resection of the distal saphenous nerve or a calcaneal nerve branch. Postoperative, immediate ambulation was permitted. Outcomes were assessed with a numerical grading scale that included neurosensory measurements. Outcomes were also assessed by patient satisfaction and their own estimate of residual pain and/or numbness. Mean follow-up time was 2.2 years. Outcomes in terms of patient satisfaction were 54% excellent, 24% good, 13% fair, and 9% poor results. The mean preoperative numerical score was 6.0 and the mean postoperative score was 2.7. There was a significant improvement seen, based on the median difference between scores (P<0.001). Prognostic indicators of poor results in our patient group were coexisting lumbosacral disc disease and/or neuropathy. An approach related to resecting painful cutaneous nerves and neurolysis of all tibial nerve branches at the ankle offers hope for relief of pain and recovery of sensation for the majority of patients with failed previous tarsal tunnel surgery.     

Outcomes of Tibial Nerve Repair and Transfer: A Structured Evidence-Based Systematic Review and Meta-Analysis

Although nerve transfer and repair are well-established for treatment of nerve injury in the upper extremity, there are no established parameters for when or which treatment modalities to utilize for tibial nerve injuries. The objective of our study is to conduct a systematic review of the effectiveness of end-to-end repair, neurolysis, nerve grafting, and nerve transfer in improving motor function after tibial nerve injury. PubMed, Cochrane, Medline, and Embase libraries were queried according to the PRISMA guidelines for articles that present functional outcomes after tibial nerve injury in humans treated with nerve transfer or repair. The final selection included Nineteen studies with 677 patients treated with neurolysis (373), grafting (178), end-to-end repair (90), and nerve transfer (30), from 1985 to 2018. The mean age of all patients was 27.0 ± 10.8 years, with a mean preoperative interval of 7.4 ± 10.5 months, and follow-up period of 82.9 ± 25.4 months. The mean graft repair length for nerve transfer and grafting patients was 10.0 ± 5.8 cm, and the most common donor nerve was the sural nerve. The most common mechanism of injury was gunshot wound, and the mean MRC of all patients was 3.7 ± 0.6. Good outcomes were defined as MRC ≥ 3. End-to-end repair treatment had the greatest number of good outcomes, followed by neurolysis. Patients with preoperative intervals less than 7 months were more likely to have good outcomes than those greater than 7 months. Patients with sport injuries had the highest percentage of good outcomes in contrast to patients with transections and who were in MVAs. We found no statistically significant difference in good outcomes between the use of sural and peroneal donor nerve grafts, nor between age, graft length, and MRC score.     

A positive Tinel sign as predictor of pain relief or sensory recovery after decompression of chronic tibial nerve compression in patients with diabetic neuropathy

Predictive ability of a positive Tinel sign over the tibial nerve in the tarsal was evaluated as a prognostic sign in determining sensory outcomes after distal tibial neurolysis in diabetics with chronic nerve compression at this location. Outcomes were evaluated with a visual analog score (VAS) for pain and measurements of the cutaneous pressure threshold/two-point discrimination. A multicenter prospective study enrolled 628 patients who had a positive Tinel sign. Of these patients, 465 (74%) had VAS >5. Each patient had a release of the tarsal tunnel and a neurolysis of the medial and lateral plantar and calcaneal tunnels. Subsequent, contralateral, identical surgery was done in 211 of the patients (152 of which had a VAS >5). Mean VAS score decreased from 8.5 to 2.0 (p <0.001) at 6 months, and remained at this level for 3.5 years. Sensibility improved from a loss of protective sensation to recovery of some two-point discrimination during this same time period. It is concluded that a positive Tinel sign over the tibial nerve at the tarsal tunnel in a diabetic patient with chronic nerve compression at this location predicts significant relief of pain and improvement in plantar sensibility.     

Results of decompression of four medial ankle tunnels in the treatment of tarsal tunnels syndrome

Controversy surrounds the surgical approach and efficacy for tibial nerve compression at the ankle. The hypotheses tested are that the poor published results are due to failure to recognize that the tarsal tunnel is analogous to the forearm, not the carpal tunnel, and that postoperative ankle immobilization contributes to poor results by permitting fibrosis of the tibial nerve branches. From January of 1987 through December of 1994, a consecutive series of 77 patients with tarsal tunnel syndrome was accrued, 10 of whom had the condition bilaterally. The surgical approach included a neurolysis of the tibial nerve in the tarsal tunnel and the medial, lateral plantar, calcaneal nerves in their own tunnels. Postoperatively, immediate weight bearing and ambulation were permitted in a bulky cotton dressing. The dressing was removed at 1 week. For the 87 legs, mean follow-up after surgery was 3.6 years. Utilizing the traditional postoperative assessment, there were 82% excellent, 11% good, 5% fair, and 2% poor results. Utilizing a numerical grading scale, there was a statistically significant improvement at the P<0.001 level for sensory and also for motor impairment. Recognition that decompression of four medial ankle tunnels and immediate postoperative mobilization of the tibial nerve through ambulation is necessary results in a high level of success for patients with tarsal tunnels syndrome.     

Axillary nerve repair in 99 patients with 101 stretch injuries

OBJECT: The purpose of this paper was to analyze outcomes in patients at the Louisiana State University Health Sciences Center (LSUHSC) who presented with contusion-stretch injuries to the axillary nerve. These injuries resulted from shoulder injury either with or without fracture/dislocation. Although recovery of deltoid function can occur spontaneously, this was not always the case. METHODS: Severe deficits persisting for several months led the patients to undergo surgery. Operative categories included isolated axillary palsy (56 procedures), combined axillary and suprascapular palsies (11 procedures), axillary and radial palsies (14 procedures), and axillary palsy with another deficit, usually infraclavicular plexus loss (20 procedures). Deltoid function was evaluated pre- and postoperatively by applying the LSUHSC grading system. An anterior infraclavicular approach was usually followed during surgery, but in three patients an additional posterior approach was used. Axillary lesions usually began in the proximal portion of the posterior cord. Although several patients had distraction of the nerve, lesions in continuity were found in more than 90% of cases. Intraoperative nerve action potential (NAP) recordings were performed to determine the need for resection. Most repairs were made using grafts, although in three patients with relatively focal lesions suture was used. When an NAP was recorded across the lesion and neurolysis was performed, recovery was judged to be a mean Grade 4 according to the LSUHSC in 30 cases. Recovery following suture repairs was a mean Grade 3.8, whereas recovery after 66 graft repairs was a mean Grade 3.7. In cases in which suprascapular palsies were associated with axillary injuries, the former recovered but the latter did not necessarily do so without surgery. If the radial nerve was also injured, recovery of the triceps and brachioradialis muscles and wrist extension was usually obtained, but it was far more difficult to reverse the loss of finger and thumb extension. Although few in number, complications did occur and they are important. CONCLUSIONS: Operative exploration of axillary contusion-stretch lesions is worthwhile in carefully selected cases. If indicated by inspection and intraoperative electrical studies, nerve repair can lead to useful function.     

Tarsal tunnel syndrome: a compression neuropathy involving four distinct tunnels

Tarsal tunnel syndrome is a complex and often under-diagnosed or misdiagnosed condition that affects the foot and ankle. It is a compression neuropathy of the posterior tibial nerve as it passes in the anatomic tarsal tunnel in the medial ankle under flexor retinaculum. This article reviews diagnosis, conservative treatment, and surgical outcomes, which have dramatically improved with more comprehensive release of the foot nerves in addition to the tibial nerve. Internal neurolysis facilitates a second level of nerve decompression in needed cases. Physical therapy protocols have made it possible for patients to return to ambulation with limited long-term down time.     

Effect of foot and ankle position on tarsal tunnel compartment volume

BACKGROUND: Tarsal tunnel pressure is increased when the foot and ankle are positioned in eversion or inversion from neutral, aggravating symptoms of tarsal tunnel syndrome in some patients. Space-occupying lesions may cause tarsal tunnel syndrome. We hypothesized that positional change of the foot and ankle from neutral to eversion or inversion causes decreased tarsal tunnel compartment volume that may aggravate symptoms of posterior tibial nerve entrapment. METHODS: MRI of 13 ankles in nine healthy subjects in three positions (neutral, eversion, inversion) were obtained with respect to the malleolar-calcaneal plane; this plane was defined by the distal tip of the anterior colliculus of the medial malleolus, the medial tubercle of the posterior calcaneal tuberosity, and the lateral tubercle of the posterior calcaneal tuberosity. The borders of the tarsal tunnel noted on the MRI were traced with a computer digitizing apparatus to determine the cross-sectional area of the tarsal tunnel on each image, and the slice thickness and interspace distance for the seven central images were used to calculate tarsal tunnel volume. RESULTS: The mean tarsal tunnel volume was significantly greater when the foot and ankle were in neutral position (21.5 +/- 0.9 cm(3)) than in either full eversion (18.0 +/- 0.9 cm(3); p = or < 0.001) or inversion (20.3 +/- 1.0 cm(3); p = or < 0.001). CONCLUSIONS: The results support the hypothesis that eversion and inversion of the foot and ankle cause decreased compartment volume of the tarsal tunnel and increased tarsal tunnel pressure that may contribute to symptoms of posterior tibial nerve entrapment in tarsal tunnel syndrome. CLINICAL RELEVANCE: Neutral immobilization of the foot and ankle may relieve symptoms of posterior tibial nerve entrapment in tarsal tunnel syndrome by minimizing pressure on the nerve and maximizing tarsal tunnel compartment volume available for the nerve.     

The clinical, electrophysiologic, and surgical characteristics of peripheral nerve injuries caused by gunshot wounds in adults: a 40-year experience

BACKGROUND: There are few large-volume studies on the repair of peripheral nerve lesions caused by gunshot wounds. In this study, the results of peripheral nerve repair are analyzed, and the factors influencing the outcome are investigated. METHODS: During a 40-year period, 2210 peripheral nerve lesions in 2106 patients who sustained gunshot injury were treated surgically in the Department of Neurosurgery. One thousand thirty-four patients had shrapnel injury, and 1072 patients had missile injury. Twelve peripheral nerves were included in this study, and all of them were repaired by direct suture, using nerve graft, or neurolysis. All patients underwent neurologic and electrophysiologic evaluations in the preoperative period and postoperatively at the end of the follow-up period. The mean time of follow-up was 2.6 years. Final outcome was based on the motor, sensory, and electrophysiologic recoveries, and a patient judgment scale. RESULTS: Using the muscle grading scale, sensory grading scale, EMNG, and patient judgments, the maximal recovery was achieved in the subscapular nerve, but there were only 4 subscapular nerve lesions, which is not sufficient for a statistically significant outcome. Furthermore, the tibial, median, and femoral nerve lesions showed the best recovery rate, whereas the peroneal nerve, ulnar nerve, and brachial plexus lesions had the worst. CONCLUSION: Type of the peripheral nerve, injury (repair) level, associated injuries, electrophysiologic findings, operation time, intraoperative findings, surgical techniques, and postoperative physical rehabilitation are the prognostic factors for peripheral nerve lesions due to gunshot wounds.     

Surgical management of neural injuries associated with elbow fractures in children.

Twenty-two patients with 25 neural injuries at the elbow joint were reviewed. Follow-up lasted 2 years after surgery. Mean age was 9.4 years. Findings at surgery revealed discontinuity of the affected nerve trunk in eight cases; 17 cases showed a constrictive lesion with the nerve trunk in continuity. Surgical technique involved repair by interfascicular grafting in six lesions, two by epineural suture, and 17 by neurolysis. The mean interval between injury and surgery was 10.1 months (range, 1-40). Motor and sensory function assessment was according to the Nerve Injuries Committee of the British Medical Research Council (preoperatively and at the final follow-up). Excellent results were found in nearly 80% of the continuous lesions treated by neurolysis. In discontinuous lesions, we found 66% with excellent results with grafting. The prognosis after neurolysis in continuous lesions is excellent. In discontinuous lesions after surgery, the rate of recovery is high. There is a poor prognosis for surgery performed > or = 1 year after the injury.     

Prevention of ulceration, amputation, and reduction of hospitalization: outcomes of a prospective multicenter trial of tibial neurolysis in patients with diabetic neuropathy

This is the first multicenter prospective study of outcomes of tibial neurolysis in diabetics with neuropathy and chronic compression of the tibial nerve in the tarsal tunnels. A total of 38 surgeons enrolled 628 patients using the same technique for diagnosis of compression, neurolysis of four medial ankle tunnels, and objective outcomes: ulceration, amputation, and hospitalization for foot infection. Contralateral limb tibial neurolysis occurred in 211 patients for a total of 839 operated limbs. Kaplan-Meier proportional hazards were used for analysis. New ulcerations occurred in 2 (0.2%) of 782 patients with no previous ulceration history, recurrent ulcerations in 2 (3.8%) of 57 patients with a previous ulcer history, and amputations in 1 (0.2%) of 839 at risk limbs. Admission to the hospital for foot infections was 0.6%. In patients with diabetic neuropathy and chronic tibial nerve compression, neurolysis can result in prevention of ulceration and amputation, and decrease in hospitalization for foot infection.