Neurilemmoma of median nerve

Neurilemmomas constitute one of the most common tumors of peripheral nerves. Rarer amongst them is their occurrence in median nerve in the region of arm. A sixteen-year-old female presented with painless mass in right arm which was non-tender on palpation with positive Tinel''s sign and no motor or sensory deficit in the affected arm. Ultrasound examination revealed an eccentrically arising mass of size 19 × 11 mm along median nerve. MRI study revealed a mass homogenously isointense on T1 weighted images and hyperintense in T2 weighted images placed eccentrically in relation to median nerve in arm. Excisional biopsy under loupe magnification was carried out which revealed the mass to be neurilemmoma. This slowly growing benign tumor of peripheral nerves with an incidence of 5% with 14% involvement of Median nerve can be enucleated from the nerve with little or no damage. In spite of advanced imaging studies the mass cannot be differentiated preoperatively from another peripheral nerve sheath tumor neurofibroma. Both these tumors although bearing some clinical and imaging resemblance carry different intraoperative findings, histopathological features and post-operative results.     

正中神经、尺神经部分束支移位术重建屈肘功能

目的 观察正中神经、尺神经部分束支移位术的临床疗效及手术前后供体神经功能的变化,分析影响手术疗效的因素。方法 应用正中神经、尺神经部分束支移接给肱二头肌肌支治疗臂丛神经上千型根性撕脱伤,重建屈肘功能。对施行手术的36例患者进行6个月至5年多的随访,根据肱二头肌肌力和肘关节主动活动范围,将患者术后恢复情况分为三级：优：肱二头肌肌力达4级以上,肘关节屈曲达90度以上;可：肱二头肌肌力达3级,肘关节屈曲达60～90度;差：肱二头肌肌力2级以下,肘关节屈曲60度以下。分析影响疗效的几种因素。结果 手术疗效显著,有效率(肱二头肌肌力3级以上)达94．4％,优良率(肱二头肌肌力4级以上)达63．9％。手术前后供体神经功能没有明显变化。影响手术疗效的主要因素有：损伤类型、损伤原因、手术距损伤的间隔时间、患者年龄、供体神经的选择及术后功能锻炼。准确判断患者的损伤类型,严格掌握手术适应证是手术成功的关键。结论 正中神经、尺神经部分束支移位术是治疗臂丛神经上千型根性撕脱伤的一种安全、可靠、有效的手术方法。     

Reconstruction of high ulnar nerve lesions by distal double median to ulnar nerve transfer

Ulnar nerve lesions around the elbow often carry an unfavorable prognosis due to insufficient sensory and intrinsic muscle recovery. We present a series of 7 cases in which restoration of ulnar innervated intrinsic muscles of the hand and of skin sensibility was achieved. This was accomplished by a distal connection of the anterior interosseous nerve and the superficial sensory palmar branch of the median nerve to the motor and sensory components of the ulnar nerve at Guyon's canal. The length of the follow-up period ranged from 1 to 3.5 years. Results were graded by the Highet-Zachary scale. Good motor and sensory recovery was obtained in 6 cases; only return of protective sensation occurred in the remaining case.     

正中神经与肌皮神经的交通支及其临床意义

目的观察正中神经与肌皮神经之间的交通支，探讨其临床意义。方法对72侧防腐固定尸体解剖，对正中神经、肌皮神经之间的交通支进行测量与观察，并对不同类型交通支的结果进行比较。结果13人，16侧肢体存在18支交通支，出现率22．2％，男性与女性相比出现率高且差异显著，左右肢体的出现率无显著差异。其中肌皮神经从正中神经低位发出的有2支，正中神经-肌皮神经的交通支（Ⅰ型）与肌皮神经-正中神经的交通支（Ⅱ型）相比起、止点低，交通支较长，但直径细（Ⅰ型14．2～23．0cm，止点为11．0～21．5cm，长度为2．5～10．7cm，直径为0．55～2．15mm；Ⅱ型起点为0～17．ocm，止点为12．0～24．0cm，长度为1．9～8．4cm，直径为0．76～2．60mm）但两者差异无统计学意义（P〉0．05）。结论正中神经与肌皮神经之间存在着交通支，并起着一定的功能，手术时应注意加以保护，避免损伤。     

正中神经指浅屈肌肌支移位修复尺神经运动支的应用解剖

目的 通过对正中神经指浅屈肌肌支和尺神经运动支的解剖学研究,为正中神经指浅屈肌肌支移位修复尺神经运动支,恢复手内在肌功能的临床应用提供解剖学基础.方法 选用20例40侧近期经福尔马林浸泡固定的成人上肢标本,暴露正中神经、尺神经,测量正中神经指浅屈肌肌支各项解剖学数据;应用图像分析系统对组织切片做定量分析,测算该肌支有髓神经纤维数目.临床模拟操作正中神经指浅屈肌肌支移位修复尺神经运动支.结果 正中神经第4肌支发出部位距离桡骨茎突和尺骨茎突连线(48.4±2.4)mm,入肌部位距离桡骨茎突和尺骨茎突连线(21.4±1.8)mm,可分离长度(27.1±1.2)mm,横径(1.2±0.2)mm,前后径(0.7±0.1)mm;尺神经的运动支和感觉支之间自然分束无损伤分离.长度为(7.1±0.70)cm;组织切片及图片系统测得正中神经指浅屈肌第4肌支有髓神经纤维数目为(1378.9±107.9)条.结论 正中神经指浅屈肌第4肌支可修复尺神经运动支,以期恢复手内在肌的功能.     

Comparison of assessment tools to score recovery of function after repair of traumatic lesions of the median nerve

In this paper the recovery after repair of the median nerve has been used to compare different assessment tools for evaluation of peripheral nerve function: touch (moving 2-point discrimination (2PD); Semmes-Weinstein (SW) monofilament, motor (Medical Research Council (MRC) scale), combined motor and sensory (Dellon modification of the Moberg pick up test; Moberg Recognition test), and pain (visual analogue scale; pinprick-test). The mean (SD) age of our 28 patients was 28 (12) years. The mean (SD) follow-up period was 5 years, 2 months (2 years, 8 months). On the operated side three patients (11%) had a moving 2PD of less than 4 mm. The results of the moving 2PD were compared with those of the SW monofilaments, but with a poor correlation. The MRC score correlated well with opposition movement of the thumb and muscle wasting (p<0.01). We recommend a number of tests to evaluate (the chronological return of) peripheral nerve function.     

外伤性前臂正中神经损伤的治疗

目的　总结外伤性前臂正中神经损伤的治疗经验。方法　对 63例正中神经损伤 ,采用神经端端缝合术 (外膜、束膜缝合 )、神经内外松解术、神经移植术三种方法修复。结果　 63例术后随访 1～ 4年 ,平均 1年 8个月。按中华医学会手外科学会上肢部分功能评定试用标准评定 ,优良率为 66.7%。结论　提高疗效的经验是对不同的伤情采取不同的处理及系统的康复训练。     

Cadaveric study of anatomical variations of the median nerve and persistent median artery at wrist

Background:

Awareness of anatomical variations of the median nerve at wrist is important in repair of traumatic injuries and treatments of compression syndrome because in these situations precise dissection of the nerve is mandatory and such variations are not infrequent.

Materials and Methods:

In this study, 52 hands of 52 fresh cadavers were dissected and median nerve anatomy along with the presence of persistent median artery (PMA) was noted.

Results:

A total of 26 hands (50%) had the deviation from the standard text book anatomy of the median nerve. There was early division of the median nerve into the medial and lateral branches in 11.53% hands. There was early branching of the 2^nd common digital nerve in 9.6% hands. The transligamentous motor branch to the thenar muscle was most prevalent (42.3% hands). The single motor branch to the thenar muscles was found in the majority of hands (84.6%). The PMA was present in 11.53% hands and it was associated with variations in the median nerve anatomy in all cases.

Conclusions:

This study shows a high percentage of deviation from standard anatomy as well as a high percentage of transligamentous thenar muscle motor branch. The presence of PMA was associated with variations in the median nerve anatomy in all cases. Therefore if PMA is present there are very high chances of associated median nerve anomalies.KEY WORDS: Anatomical variations, cadaveric study, median nerve, persistent median artery, wrist     

Ulnar to median nerve anastomosis in the palm (Riches-Cannieu anastomosis)

This report describes an unusual case of pure bilateral ulnar innervation of the thenar and hypothenar muscles of the hands. The patient was a healthy 36-year-old woman who presented with neck pain. Examination and routine laboratory investigation findings were normal, but on electroneuromyography ulnar to median nerve anastomosis of the motor fibers in the palm was detected bilaterally. However, there was no anastomosis between the sensory fibers. On investigation of focal neuropathy the anomaly known as Riches-Cannieu anastomosis may surprise the electroneuromyographer and change the clinical signs and symptoms. It should be suspected when the hand muscles are clinically intact in the presence of a severe median nerve lesion in the forearm. In this case, a complete lesion of the median nerve at the forearm might erroneously be interpreted as a partial lesion of the median nerve. In every surgical intervention to the hand, this anomaly should be kept in mind and should be investigated electrophysiologically. Received: 25 June 1998 / Accepted: 19 August 1998     

Neurothekeoma of the median nerve: case report

We report the case of a large intraneural neurothekeoma of the median nerve at the wrist. Neurothekeomas are rare; they are small, superficial, and typically asymptomatic benign tumors of undetermined cellular origin. Complete excision is usually curative. This case is interesting owing to the tumor's large size and location within the median nerve, which made it highly symptomatic, mimicking carpal tunnel syndrome.     

Meaningful power grip recovery after salvage reconstruction of a median nerve avulsion injury with a pedicled vascularized ulnar nerve

In cases of median nerve injury alongside an unsalvageable ulnar nerve, a vascularized ulnar nerve graft to reconstruct the median nerve is a viable option. While restoration of median nerve sensation is consistently reported, recovery of significant motor function is less frequently observed. The authors report a case involving a previously healthy man who sustained upper arm segmental median and ulnar nerve injuries and, after failure of sural nerve grafts, was treated with a pedicled vascularized ulnar nerve graft to restore median nerve function. Long-term follow-up showed near full fist, with 12 kg of grip strength, key pinch with 1.5 kg of strength and protective sensation in the median nerve distribution. The present case demonstrates that pedicled ulnar vascularized nerve grafts can provide significant improvements to median nerve sensory and motor function in a heavily scarred environment.     

Longitudinal excursion and strain in the median nerve during novel nerve gliding exercises for carpal tunnel syndrome.

Nerve and tendon gliding exercises are advocated in the conservative and postoperative management of carpal tunnel syndrome (CTS). However, traditionally advocated exercises elongate the nerve bedding substantially, which may induce a potentially deleterious strain in the median nerve with the risk of symptom exacerbation in some patients and reduced benefits from nerve gliding. This study aimed to evaluate various nerve gliding exercises, including novel techniques that aim to slide the nerve through the carpal tunnel while minimizing strain ("sliding techniques"). With these sliding techniques, it is assumed that an increase in nerve strain due to nerve bed elongation at one joint (e.g., wrist extension) is simultaneously counterbalanced by a decrease in nerve bed length at an adjacent joint (e.g., elbow flexion). Excursion and strain in the median nerve at the wrist were measured with a digital calliper and miniature strain gauge in six human cadavers during six mobilization techniques. The sliding technique resulted in an excursion of 12.4 mm, which was 30% larger than any other technique (p相似文献   

Extra-adrenal paraganglioma of the median nerve

Abstract

An extra-adrenal paraganglioma is an uncommon tumour that arises from the paraganglia associated with the autonomous nervous system. A paraganglioma arising in the sensory-somatic nervous system is extremely rare and clinically is easily confused with other neurogenic tumours. We describe a paraganglioma that arose in the median nerve of a 22-year-old woman.     

108例腕管综合征正中神经传导测定结果分析

分析１０８例腕管综合征正中神经传导测定结果，以求最敏感的电诊断指标。比较１０８例正中神经复合肌肉动作电位，肘至腕的运动传导速度测定及指至腕部的感觉神经动作电位三项。指标异常检测率，表明拇指至腕段的感觉传导速度减慢是最敏感的电诊断参量。１０８例中伴有前臂段运动传导速度减慢的占１０．５％。同组病例无症状上肢出现电生理异常者为２０％，指示有亚临床的腕管部神经卡压存在的可能。     

Effects of 830 nm continuous wave laser diode irradiation on median nerve function in normal subjects

The presence, magnitude, and nature of the effect that low intensity laser irradiation has on nerve function, growth, and repair constitute a contentious area of research. We have addressed one aspect of this controversy by systematically examining the influence of 830 nm laser radiation on median nerve function. In particular, we investigated median nerve motor and sensory distal latencies, action potential amplitudes, action potential areas, and conduction velocities as well as dorsal hand skin temperatures in 33 normal subjects in a double-blinded, randomized controlled study. All subjects received identical treatment: 30 seconds of “irradiation” at 10 points over the course of the right median nerve (five sites on the forearm and five sites distal to the wrist crease) with either an active (1.2 J/point) or inactive (0 J/point) 40 mW 830 nm continuous wave IR laser diode. Latencies, conduction velocities, amplitudes, areas, and skin temperatures were collected bilaterally at a baseline immediately prior to irradiation and at intervals of 1, 5, 10, 15, 20, and 30 minutes following treatment. Analysis of the results reveals that motor and sensory distal latencies were decreased in the treated limbs of the lasertreated group relative to the control group by 3–4% (P <.016 and.046, respectively, rank sum test). No significant differences in these quantities were found between the limbs within either group. Similarly, no alterations of action potential amplitudes, action potential areas, forearm conduction velocities, or skin temperatures were detected within or between the groups. Thus on the basis of this experiment, percutaneous 830 nm continuous wave laser irradiation can affect median nerve function, but the effects are quite limited and appear to be limited to the distal portion of the nerve. © 1993 Wiley-Liss, Inc.     

Radial nerve repair using an autologous denatured muscle graft: comparison with outcomes of nerve graft repair

Summary Background. The efficiency of denatured muscle grafting in nerve repair has been confirmed in experimental models and animals. The first clinical trials to repair digital nerves and mixed sensory-motor nerves were encouraging regarding sensory recovery but motor recovery was poor, probably because of delayed repair. We present the functional outcome of repair of motor nerves using denatured muscle graft and compare the results with those using standard nerve graft techniques. Methods. This prospective study included 9 radial nerve defects repaired with denatured muscle grafts and 23 radial nerve defects repaired using nerve grafts. Missile induced nerve injury, mid-arm level of lesion, a nerve gap smaller than 6 cm, and a preoperative interval of less than 5 months were characteristics shared by all patients. None of the patients had concomitant vascular injury, severe scarring, or significant soft tissue damage in the region of nerve repair. Motor recovery was estimated with 0–5 points, at least 4.7 years after surgery, according to the BMRC scale. Results. A successful outcome (≥M3) was achieved in 7 out of the 9 patients treated using a muscle graft and in 21 out of the 23 patients treated using nerve grafts (P > 0.05). Excellent recovery and the clinically significant re-establishment of thumb extension (M5 grade) were never achieved in the patients treated using muscle grafts. The average motor score was significantly better in patients treated with nerve grafts than in those who received muscle grafts (3.8 ± 0.9 and 3.2 ± 0.8; P = 0.035). With the patients who received muscle grafts, an inverse correlation existed between motor recovery and the length of the nerve gap (P = 0.017). Conclusions. Denatured muscle grafts can be useful for bridging short radial nerve defects, but the quality of recovery is significantly worse than after nerve graft repair. Even if relatively short nerve defects are bridged with denatured muscle grafts, the outcomes correlate inversely with the length of the gap.     

正中神经、尺神经部分束支移位术重建屈肘功能的远期疗效分析

目的 观察正中神经、尺神经部分束支移位重建屈肘功能的远期疗效,总结其手术适应证的影响疗效的因素。方法 对36例患者进行平均为29．2个月的长期随访,按结果评定手术疗效并分析影响疗效的主要因素。结果 手术有效率达94．4％,优良率达63．9％。影响手术疗效的6个主要因素为：损伤类型、受伤原因、手术距受伤时间、患者年龄、供体神经的选择及术后功能锻炼。准确判断患者的损伤类型,严格掌握手术适应证是手术成功的关键。结论 正中神经、尺神经部分束支移位术是治疗臂丛神经上干型根性撕脱伤的一种安全、可靠而有效的手术方法。     

Radial sensory neurotization of the thumb and index finger for prehension after proximal median and ulnar nerve injuries

Proximal median nerve injuries are functionally disabling, secondary to both motor and sensory deficits. Reestablishment of sensation relies on slow axonal regeneration originating from the site of injury after either primary nerve repair or the use of autogenous nerve grafts. This regeneration can take 2 or more years to restore sensation to the hand, depending on injury location. Distal sensory nerve transfers shorten the recovery time by decreasing the required regeneration distance. The authors present two case reports of patients with proximal median nerve injury, who underwent radial sensory nerve transfers to the ulnar digital nerve of the thumb and the radial digital nerve of the index finger. Protective sensation returned to the index and thumb fingertips at 3 months. By 6 months, both patients attained sufficient sensation to permit active lateral key pinch. At 9 months, each patient had moving sensation; and by 14 months, each patient attained proper localization. Successful digital nerve transfers of the dorsal radial sensory nerves in patients with high proximal median nerve injuries return sensation faster than traditional median nerve repairs. Use of this technique will significantly reduce the insensate time in patients with this unfortunate injury.     

Long-term results of transplantations to repair median, ulnar, and radial nerve lesions by a microsurgical interfascicular autogenous cable graft technique

A comprehensive analysis of 187 patients (78 median, 86 ulnar, and 23 radial nerve lesions) treated by an interfascicular autogenous nerve grafting technique is presented. After a follow-up of at least 18 months good motor recovery was achieved in 72% of median nerve lesions, 77% of ulnar nerve lesions, and 57% of radial nerve lesions. Good functional sensory recovery was found in 36% of median, 45% of ulnar, and 48% of radial nerve lesions. It appears by multivariate analysis that the results obtained generally were better in younger patients, in patients with a shorter preoperative delay, and in cases with a shorter transplant.     

Intraneural lipofibroma of the median nerve

A case of an intraneural lipofibroma of the median nerve is described. The patient was first seen with an enlarging mass on the flexor side of the wrist and in the palm. After interfascicular dissection of the tumor there was a permanent loss in sensibility and motor function. In most cases decompression of the nerve will suffice; resection by means of interfascicular dissection is rarely justified.