An unusual case of haemorrhagic median neuropathy

The authors describe a rare case of carpal tunnel syndrome secondary to intraneural haemorrhage of the median nerve.     

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.     

Intraneural median nerve pressure in carpal tunnel syndrome

In order to determine whether endoscopic carpal tunnel release decompresses the median nerve, we measured the intraneural median nerve pressure pre- and postoperatively in 55 hands. The median nerve pressure was significantly reduced postoperatively.     

Measurement of carpal canal and median nerve pressure in patients with carpal tunnel syndrome

Carpal tunnel syndrome is a compression neuropathy wherein the median nerve is compressed inside of the carpal canal. Its diagnosis is made clinically, electrophysiologically, and sometimes by carpal canal pressure measurement. The objective of surgical management of this condition is the decompression of the median nerve. We usually measure carpal canal pressure preoperatively and postoperatively using a continuous infusion technique for diagnoses as well as for postoperative evaluation of decompression following our Universal Subcutaneous Endoscope system procedure. To evaluate whether our procedure effectively decompressed the median nerve, we measured intraneural pressure preoperatively and postoperatively in the resting position, with active power grip, and in the Okutsu test position. Correlation between the carpal canal pressure and intraneural median nerve pressure was statistically analyzed using the Kendall rank correlation coefficient (n = 157 hands). A significant correlation was present preoperatively in resting position and postoperatively with active power grip and in the Okutsu test position. Because of this correlation, we conclude that our endoscopic operative procedure effectively decompresses the median nerve and that simple carpal canal pressure measurement is sufficient to confirm diagnoses and to evaluate the status of postoperative decompression.     

Measurement of median nerve blood flow during carpal tunnel release with laser Doppler flowmetry.

Eight consecutive median nerves in eight patients with clinical carpal tunnel syndrome were prospectively examined by non-contact laser Doppler flowmetry before and after undergoing carpal tunnel release. Before performing carpal tunnel release, the difference in the median nerve blood flow between the values at the distal and proximal portions to the transverse carpal ligament was statistically significant (p = 0.021). After carpal tunnel release, the median nerve blood flow both distal and proximal to the transverse carpal ligament increased by 1.5 and 1.3 times, respectively, compared to the flow prior to carpal tunnel release, however, only the difference at the distal portion to the transverse carpal ligament was statistically significant (p = 0.015). In this study, we directly measured the median nerve blood flow using non-contact laser Doppler flowmetry and thus demonstrated a significant difference in the median nerve blood flow between the values at the distal and proximal portions to the transverse carpal ligament before carpal tunnel release and a significant increase in the nerve blood flow only at the distal portion to the transverse carpal ligament after surgery. This technique is thus considered to be an easy and reproducible way to intraoperatively evaluate the nerve blood flow in real time during the release of entrapment neuropathies.     

Intraneural lipomatous tumor of the median nerve: Three case reports with a review of literature

INTRODUCTIONIntraneural lipoma and fibrolipomatous hamartoma of the nerve are rare soft tissue tumors that most commonly occur in the forearm and the wrist, and particularly within the median nerve. When the lesions are large enough, they may cause progressive compression neuropathy. They are distinct entities each other with different clinical and radiological findings and thereby need different surgical treatments.PRESENTATION OF CASEWe report here 3 cases of intraneural lipomatous tumors of the median nerve (1 case of intraneural lipoma and 2 cases of fibrolipomatous hamartoma).DISCUSSIONAll patients were surgically treated successfully with complete excision for intraneural lipoma and with carpal tunnel releases for the both fibrolipomatous hamartomas.CONCLUSIONA careful preoperative planning is necessary for the optimal treatment by distinguishing whether it is a resectable or non-resectable tumor based on the clinical and radiological findings, because they have characteristic findings each other.     

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.     

Acute carpal tunnel syndrome resulting from haemorrhage into the carpal tunnel in a patient on Warfarin

A case of acute compression neuropathy of the median nerve associated with haemorrhage into the carpal tunnel is presented. The condition occurred spontaneously in a patient on Warfarin for previous deep venous thrombosis. The signs and symptoms were those of acute tenosynovitis originating in the common flexor synovial sheath at the wrist with associated paraesthesia in the distribution area of the median nerve in the hand. The patient was afebrile and blood tests were normal.     

Intraneural blood flow analysis during an intraoperative Phalen's test in carpal tunnel syndrome

Phalen's test has been one of the most significant of clinical signs when making a clinical diagnosis of idiopathic carpal tunnel syndrome (CTS). However, it is unknown whether intraneural blood flow changes during Phalen's test in patients with CTS. In this study, an intraoperative Phalen's test was conducted in patients with CTS to observe the changes in intraneural blood flow using a laser Doppler flow meter. During Phalen's test, intraneural blood flow showed a sharp decrease, which lasted for 1 min. Intraneural blood flow decreased by 56.7%–100% (average, 78.0%) in the median nerve relative to the blood flow before the test. At 1 min after completing the test, intraneural blood flow returned to the baseline value. After carpal tunnel release, there was no marked decrease in intraneural blood flow. This study demonstrated that the blood flow in the median nerve is reduced when Phalen's test is performed in vivo. © 2010 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 28:1022–1025, 2010     

Intraoperative assessment of median nerve blood flow during carpal tunnel release with laser Doppler flowmetry

Eleven consecutive median nerves in patients with clinical carpal tunnel syndrome were examined prospectively with laser Doppler flowmetry. All procedures were done without a tourniquet with the patient under local or general anesthesia. Multiple measurements of median nerve blood flow were obtained during carpal tunnel release. Flow characteristics proximal to the transverse carpal ligament did not change after release of the ligament. Beneath the transverse carpal ligament, initial flow was random in 10 of 11 nerves. Within 1 minute after release of the transverse carpal ligament, flow became pulsatile and synchronized with the patient's pulse in nine nerves. Although preliminary, these data suggest that in carpal tunnel syndrome the segment of median nerve beneath the carpal ligament is relatively ischemic and this ischemia may be a factor in the development of symptomatic median nerve entrapment. The rapid return of a pulsatile signal within the nerve after release is positively correlated with relief or improvement of median nerve dysesthesias.     

Fracture of the hamate hook presenting as median nerve palsy

We report a case of fracture of the hamate hook presenting as median nerve palsy and discuss the etiology of this rarely seen complication. We consider that the median nerve palsy in this case was due to direct nerve compression within the carpal tunnel caused by a displaced fractured hook fragment. Received: 13 June 1995     

Anomalous flexor digitorum superficialis muscle transposition for vascular coverage of the median nerve in recurrent carpal tunnel syndrome

Recurrent carpal tunnel syndrome is uncommon yet troublesome. Significant adhesions and scarring around the median nerve can render it relatively ischemic. A number of vascular flaps have been described to provide vascular coverage in attempts to decrease further cicatricial adhesions and to improve local blood supply around the median nerve. A rare case of an anomalous muscle in the distal forearm used as tissue to provide good vascularized coverage of the median nerve that was severely scarred in its bed is reported. The anomalous muscle was distal to the flexor digitorum superficialis tendon and inserted in the palmar fascia on the ulnar aspect of the hand. Referring branches from the ulnar artery provided vascular supply to the anomalous muscle. The muscle on these vascular pedicles was transposed over the median nerve, providing good, stable, unscarred coverage. The patient had an excellent result with resolution of the carpal tunnel symptoms. The redundant anomalous muscle provided a unique vascularized source for coverage of the median nerve in recurrent carpal tunnel syndrome.     

Plexiform neurofibroma of the median nerve

Summary A case of plexiform neurofibroma of the median nerve is presented. This hamartomatous condition presented as a growth in the palm and in the distal third of the forearm, with symptoms of carpal tunnel syndrome. Treatment consisted of division of the volar carpal ligament for relief of pain and a neurolysis of the median nerve with partial resection of the tumour mass.     

Persistent carpal tunnel syndrome after both endoscopic and open release: a rare case of a bifid median nerve in two separate compartments

We present a case of carpal tunnel syndrome in the presence of a bifid median nerve. The symptoms had not been relieved by two previous operations to decompress the median nerve, one endoscopic and one open. At the third operation the second half of the nerve was found in its own tunnel, and released. The literature on variations in the median nerve is reviewed. Open release is indicated in recurrent carpal tunnel syndrome and where anatomical variations are suspected.     

Ulnar subluxation of the median nerve following carpal tunnel release: a case report

Complications of carpal tunnel release, while infrequent, include incomplete release resulting in persistent symptoms or recurrence due to postoperative scarring, as well as iatrogenic damage to nerves and vessels. We present the case of a patient who underwent carpal tunnel release with resolution of symptoms in the immediate postoperative period. At one and a half years post release he started to experience numbness and tingling in a median nerve distribution triggered by repetitive ulnar to radial deviation of the wrist, with no symptoms at rest. Dynamic ultrasound showed a subluxation of the median nerve from one side of the palmaris longus tendon to the other. The patient's symptoms were triggered as the median nerve squeezed in between the palmaris longus and flexor digitorum superficialis tendons.     

Giant median nerve in bilateral carpal tunnel syndrome

We introduce a middle age healthy man with sequential bilateral carpal tunnel syndrome. At the surgery, we encountered a wide median nerve in both wrists. Although enlargement of median nerve in carpal tunnel has been well documented, 25 mm width of the nerve is a rare scene, underscoring that leaving the nerve under the unyielding pressure would lead to a fibrous atrophic median nerve.KEY WORDS: Blood-nerve barrier, carpal tunnel syndrome, compressive neuropathy, median nerve, neural edema     

Free dermal fat graft for coverage of the median nerve following failed carpal tunnel release

ObjectivesWe wished to evaluate the effectiveness of a free dermal fat graft for covering the median nerve in order to improve function after failure of carpal tunnel release.MethodsEight patients with nine failures of carpal tunnel release were reviewed for this retrospective study. They all had significant perineural fibrosis. We performed a free dermal fat graft harvested from the inguinal region on the same side. The mean follow-up was 37 months (range 6 to 112). All patients had a clinical examination, a disability arm and shoulder scoring (DASH) and magnetic resonance imaging (MRI).ResultsFive patients were satisfied or very satisfied with the procedure although only two patients returned to work. Mean grip strength was 13 kg (43% of non-operated hand) and the two-point discrimination test was normal or subnormal six times on the eight wrists tested. The mean DASH score was 43 out of 100. MRI scans on eight wrists showed a fat signal in all patients and enhanced signal with gadolinium contrast in six cases.ConclusionsFree dermal fat graft offers a good covering for the median nerve over the carpal tunnel in cases of failure of carpal tunnel release. MRI showed viability of the graft. Clinical results show improvement but symptoms of median nerve irritation persisted. Permanent intraneural changes may explain these limited results.     

A foregoing thenar muscular branch of the median nerve

We present a 62-year-old female patient who had an anatomic variation in the median nerve of the left hand. During surgery for releasing the left carpal tunnel, an abnormally high level of origin of the thenar muscular branch of the median nerve was detected, at 2.5 cm above the proximal border of transverse carpal ligament. It traveled between the medial side of the flexor carpi radialis tendon and median nerve and entered the carpal tunnel. After exiting the carpal tunnel distally, the nerve, was noted to course towards the thenar area. Such variations in the median nerve should be kept in mind while performing carpal tunnel release.     

Carpal tunnel syndrome associated with extra tunnel vascular compression of the median nerve motor branch

We report a case of carpal tunnel syndrome associated with median nerve motor branch compression by a large superficial palmar branch of the radial artery.     

Hyperostotic macrodactyly and lipofibromatous hamartoma of the median nerve associated with carpal tunnel syndrome

A new case with 14-year follow-up of an extremely rare variety of congenital hand macrodactyly is presented. The disease characteristically presents a diffuse proliferation of fibrofatty tissue, but in this special type, osteocartilaginous deposits around the joints can also be found. The case presented included the troublesome feature of a lipofibromatous hamartoma in the median nerve at the wrist and its branches producing carpal tunnel syndrome. The patient obtained benefit from carpal tunnel release and epineurolysis. The hyperostotic development was managed with conservative resection of the periarticular osteochondromas. The literature reviewed suggests that the hyperostotic cases of macrodactyly do not differ from general cases of this congenital condition, except for the osteochondral deposits. These tumours develop during adulthood or after previous trauma, before epiphyseal closure.