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Introduction: Carpal tunnel syndrome is an entrapment neuropathy that affects 3% of adults in the United States. The current techniques used for diagnosis have limited specificity/sensitivity, and the techniques used for treatment have limited efficacy.Case Report: A 34-year-old female presented to the emergency department with two months of worsening painful paresthesias in her right thenar eminence. Ultrasound was performed showing a median nerve area of 20.4 square millimeters within the carpal tunnel. Median nerve block was performed within the carpal tunnel causing complete resolution of her pain.Conclusion: Emergency physicians skilled in point-of-care ultrasound and needle-guided procedures can diagnose and treat carpel tunnel syndrome.

Purpose: The objective of this study was to determine the incidence, necessity for neurosurgical intervention, and overall results of the treatment of pediatric peripheral nerve injuries associated with dislocated supracondylar fractures of the distal humerus. Method: A retrospective analysis of pediatric patients with supracondylar fractures treated from April 2019 to April 2022 with a minimum follow-up of 3 months was conducted. Results: Of 453 included patients, there were 51 recorded peripheral nerve injuries. The ulnar nerve was the most frequently injured nerve. Nine patients required neurosurgical intervention, with the most common procedure being the release of entrapped nerves. The combination of a supracondylar fracture and arterial injury was identified as a significant risk factor for peripheral nerve injury (p < 0.001). Only one patient experienced an unsatisfactory outcome. Conclusion: Although the prognosis for peripheral nerve injuries in children with supracondylar fractures is generally favorable, these injuries must be properly identified. We recommend an active neurosurgical approach in children with persisting neurological deficits to minimize the risk of permanent neurological impairment. [ABSTRACT FROM AUTHOR]

The experience of pain that is induced by extremely cold temperatures can exert a modulatory effect on motor cortex circuitry. Although it is known that immersion of a single limb in very cold water can increase corticomotor excitability it is unknown how afferent input to the cortex shapes excitatory and inhibitory processes. Therefore, the purpose of this study was to examine motor‐evoked potentials (MEP), short‐latency afferent inhibition (SAI) and long‐latency afferent inhibition (LAI) in response to immersion of a single hand in cold water. Transcranial magnetic stimulation (TMS) was used to assess MEPs, and peripheral nerve stimulation of the median nerve paired with TMS was used to measure SAI and LAI in motor circuits of the ipsilateral hemisphere. Measurements were obtained from electromyography (EMG) of the first dorsal interosseous (FDI) at baseline, during cold‐water immersion, and during recovery from cold‐water immersion. The intervention caused unconditioned MEPs to increase during exposure to the cold stimulus (P = 0.008) which then returned to baseline levels once the hand was removed from the cold water. MEP responses were decoupled from SAI responses, where SAI was reduced during exposure to the cold stimulus (P = 0.005) and remained reduced compared to baseline when the hand was removed from the cold water (P = 0.002). The intervention had no effect on LAI. The uncoupling of SAI from MEPs during the recovery period suggests that the mechanisms underlying the modulation of corticospinal excitability by sensory input may be distinct from those affecting intracortical inhibitory circuits. Highlights: What is the central question of this study?Does immersion of a limb in very cold water influence corticospinal excitability and the level of afferent inhibition exerted on motor cortical circuits?What is the main finding and its importance?In additional to perception of temperature, immersion in 6°C water also induced perceptions of pain. Motor evoked potential (MEP) amplitude increased during immersion, and short‐latency afferent inhibition (SAI) of the motor cortex was reduced during immersion; however, these responses differed after the limb was removed from the cold stimulus, as MEPs returned to normal levels while SAI remained suppressed. [ABSTRACT FROM AUTHOR]

Background We explore a minimally invasive method (combined ultrasound detection, electrode placement and electrophysiologic nerve examination) to evaluate the early-stage quality of a nerve suture site. Methods Ten patients with median and/or ulnar nerve injuries who had undergone nerve suture were recruited. Postoperative ultrasound examination found that the nerve injury was sutured. Then, a stimulating electrode and recording electrode were located beside the nerve proximal and distal to the suture site guided by ultrasound. Measurement of nerve action potentials (NAP) were performed with these electrodes, followed by surgical exploration. The pre- and intraoperative electrophysiologic findings were compared, together with amplitude, latency, and wave shape of NAP. Results Of the 10 patients, 3 patients were diagnosed with median nerve injury, 2 with ulnar nerve injury, and 5 with the median nerve and ulnar nerve injury. NAP could not be detected pre- and intraoperatively in three median nerves from three patients and in two ulnar nerves from two patients. NAP was detected in 10 nerves from the remaining 5 patients. The pre- and intraoperative NAP results showed consistent results concerning the status of the nerve suture. Wilcoxon's signed-rank test indicated no significant difference in the amplitude and latency detected via sonographically placed electrodes and during surgical exploration. The number of negative-phase waves were equally distributed. Conclusion Ultrasound-guided electrode placement and NAP detection can substitute surgery and serve as a minimally invasive approach to evaluate the regeneration of a sutured nerve. [ABSTRACT FROM AUTHOR]

Objectives: To correlate the cross-sectional area (CSA) and elasticity of the median nerve (MN) measured at carpal tunnel inlet between healthy controls and various degrees of carpal tunnel syndrome (CTS) graded as per nerve conduction studies (NCS). Materials and methods: A total of 53 patients (with 81 wrists) presenting with clinical symptoms characteristic of CTS, having their diagnosis confirmed and severity graded by NCS, and 48 healthy controls (with 96 wrists) were included in the study. All the study participants underwent wrist ultrasound which included initial Grey-scale USG followed by strain and shear wave elastography. The CSA and elasticity (in terms of strain ratio and shear modulus) of MN were measured at the carpal tunnel inlet. Statistical analysis was performed using the Mann–Whitney U test to compare between the two groups and for subgroup analysis of cases. The diagnostic performance of each variable was evaluated using the receiver operating characteristic curves. Results: The mean CSA was 9.20 ± 1.64, 11.48 ± 1.05, 14.83 ± 1.19 and 19.87 ± 2.68 mm2, the mean shear modulus was 17.93 ± 2.81, 23.59 ± 2.63, 32.99 ± 4.14 and 54.26 ± 9.24 kPa and the mean strain ratio was 5.26 ± 0.68, 5.56 ± 0.70, 7.03 ± 0.47 and 8.81 ± 0.94 in control, mild, moderate and severe grades of CTS, respectively (p < 0.001). Conclusion: The combined utility of Grey-scale USG and Elastography may serve as a painless and cost-effective alternative to NCS in grading the severity of CTS. [ABSTRACT FROM AUTHOR]

Introduction: Carpal tunnel syndrome is the most common compression neuropathy. Grading the severity of carpal tunnel syndrome is an important factor in deciding on the type of treatment. This study aims to determine the relationships between the findings of the electrodiagnosis and ultrasonography methods based on the severity of carpal tunnel syndrome. Methods: In this prospective clinical study, 50 patients (96 wrists) who were referred to the Physical Medicine and Rehabilitation Department of the Shohada Tajrish Hospital, Tehran, Iran (from March 2021 to November 2022) were studied. All patients with a history and clinical examination related to CTS underwent electrodiagnosis studies. Based on the results of electrodiagnosis, patients were divided into three groups: mild, moderate, and severe. All eligible patients underwent ultrasound at the cross-section of the wrist (at the level of the pisiform bone, the entrance of the canal) and the middle of the forearm. Results: In this study, the cross-sectional area of the median nerve was measured in 96 wrists of 50 patients with a mean age of 51.78 ± 9.80 years. The mean CSA of the median nerve in the mild, moderate, and severe groups was reported as 0.12 ± 0.03, 0.14 ± 0.02, and 0.21 ± 0.06, respectively. The mean WFR in different groups of CTS was reported as 1.85 ± 0.56, 1.93 ± 0.56, and 2.45 ± 0.49, respectively. A significant relationship between ultrasound findings, including CSA-inlet and WFR, and electrodiagnosis findings was presented (P value < 0.05). Conclusion: Based on our findings, there is a statistically significant relationship between the sonographic findings, including the mean CSA-inlet and WFR, and the severity of CTS based on the electrodiagnosis study. Our findings revealed that as disease severity increases, sonographic parameters also increase significantly. [ABSTRACT FROM AUTHOR]

Background: Guillain-Barré syndrome (GBS) is a clinically heterogenous disease and encompasses several distinct clinical variants. Overlap between these variants can pose a diagnostic challenge. We report a case of finger drop variant and acute bulbar palsy overlap as an unusual manifestation of GBS. Case presentation: An 81-year-old man presented with dysarthria, dysphagia, and upper limb weakness. Neurological examination revealed impaired tongue protrusion, the finger drop sign, and diminished brachioradial and triceps muscle reflexes. Nerve conduction studies showed reduced amplitudes and decreased velocities in the median and ulnar nerves. Cerebrospinal fluid analysis revealed albuminocytological dissociation and an anti-ganglioside antibody study revealed positivity for GM1, asialo-GM1, GT1a, GD1b, and GQ1b. As GBS was suspected, we initiated intravenous immunoglobulin treatment, resulting in gradual improvement within the next 3 weeks. Conclusion: To the best of our knowledge, this is the first reported case of an overlap between the finger drop variant and acute bulbar palsy in GBS, highlighting the importance of considering GBS when patients present with a combination of atypical symptoms. Anti-ganglioside antibodies can be helpful and add diagnostic value in these complex cases. [ABSTRACT FROM AUTHOR]

Background/Objectives: The accurate quantification of peripheral nerve axonal regeneration after injury is critically important. Current strategies are limited to detecting early reinnervation. DTI is an MRI modality permitting the assessment of fractional anisotropy, which increases with axonal regeneration. The aim of this pilot study is to evaluate DTI as a potential predictive factor of clinical outcome after median nerve section and microsurgical repair. Methods: We included 10 patients with a complete section of the median nerve, who underwent microsurgical repair up to 7 days after injury. The follow-up period was 1 year, including the current strategy with clinical visits, the Rosén–Lundborg score and electroneuromyography. Additionally, DTI MRI of the injured wrist was planned 1, 3 and 12 months post-operatively and once for the contralateral wrist. Results: The interobserver reliability of DTI measures was almost perfect (ICC 0.802). We report an early statistically significant increase in the fractional anisotropy value after median nerve repair, especially in the region located distal to the suture. Meanwhile, Rosén–Lundborg score gradually increased between the third and sixth month, and continued to increase between the sixth and twelfth month. Conclusions: DTI outcomes three months post-operation could offer greater predictability compared to current strategies. This would enable faster decision-making regarding the need for a potential re-operation in cases of inadequate early reinnervation. [ABSTRACT FROM AUTHOR]

The aim of this study is to determine the maximum loss of median and ulnar nerve substances that can be treated by direct suture in elbow flexion and to quantify this elbow flexion. The other objective is to determine the participation of the wrist position in this direct suture in elbow flexion. We performed an experimental study on 6 ulnar nerve lesions and 6 median nerve lesions. For each defect, a direct tensionless suture was performed with elbow flexion and in three different positions of the wrist (wrist extension, neutral position, and wrist flexion). A 90° elbow flexion allowed direct suturing of defects up to 40 mm in the 3 positions of the wrist. A bowstringing effect (i.e., increase of the perpendicular distance of the nerve from the axis of rotation of the elbow) was noted starting from 25 mm of nerve defect. Wrist extension placed tension on the nerve suture for both nerves. The results of this first anatomical study clarified the conditions for direct suturing of ulnar and median nerve defects in the flexed elbow position and flexed wrist position. This is an approach to consider for limited nerve defects to the elbow or when allograft harvesting is to be avoided. [ABSTRACT FROM AUTHOR]

Introduction: In the arms of patients with Amyotrophic lateral sclerosis (ALS) two peculiar patterns of dissociated muscular atrophy have been described: the split-hand sign (with predominant atrophy of the lateral aspect of the hand, compared to hypothenar eminence) and the split-hand-plus sign (SHPS), a predominant abductor pollicis brevis (ABP) atrophy with sparing of flexor pollicis longus (FPL). Aims: In this case–control study, we evaluated the diagnostic utility of a neurophysiological indicator of SHPS and assessed its association with clinical features. Methods: We prospectively studied 59 incident ALS patients, 61 patients with ALS-mimic disorders (OND) and 61 non-neurological controls (NNCs). ABP and FPL compound muscle action potentials (CMAP) amplitudes were obtained by supramaximal stimulation of median nerve at elbow. Split-hand plus index (SHPI) was calculated according to the formula: APB-CMAP/FPL-CMAP. Results: SHPI was significantly lower in ALS compared to OND patients and NNCs (p < 0.0001). SHPI value < 1 was observed in 2% of NNCs and 9% of OND patients and demonstrated an accuracy of 71% in differentiating ALS from OND and an accuracy of 74% in differentiating ALS from NNC. SHPI was associated with higher LMN score, and higher disease severity as quantified by the ALSFRS-r. Conclusion: Our results indicate that SHPI is a reliable indicator to distinguish ALS patients from ONDs and NNCs. SHPI was significantly associated to the degree of lower motor neuron impairment but showed no association with upper motoneuron impairment. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study is to evaluate the functional outcome and quality of life in distal biceps tendon repair with single incision technique and anchor fixation method. Methods: A retrospective cohort study was made of patients with complete distal biceps tendon rupture. The chosen repair method was single incision technique with anchor fixation. The outcome was assessed with functional testing of the elbow with strength and ROM. Additionally Mayo elbow performance index, Oxford elbow score, Disability arm hand shoulder questionnaire and patient rated elbow evaluation scores were used to evaluate quality of life. Results: Of the 28 patients, the average strength in flexion and supination was decreased with 91% and 89% of the strength compared to the non-injured arm. ROM was preserved in flexion, extension, supination and pronation. The mean scores for quality of life evaluation were MEPS = 96 ± 7.8, OES = 46.8 ± 1.9, DASH = 1.0 ± 1.9 and PREE = 2.0 ± 3.6. LABCN injury was the most common temporary complication with 30% followed by pain with 23%. Two patients were identified with HO and 1 patient was identified with median nerve injury. There were no cases of radioulnar synostosis and PIN injury. Conclusion: Overall strength in flexion and supination were slightly decreased with preserved ROM. Patients reported nearly perfect quality of life as demonstrated with the scores. The complications rate was high with mainly minor complications. Distal biceps tendon repair with single incision technique and anchor fixation overall leads to a very satisfying outcome. [ABSTRACT FROM AUTHOR]

• Increased intraneural microvascular could be detected in patients with peripheral neuropathies using sonography. • Intraneural hypervascularization was frequently observed in patients with inflammatory neuropathies. • Superb microvascular imaging is the most sensitive technique for evaluating microvessel flow within peripheral nerves. We assessed microvessel flow within peripheral nerves using nerve sonography in patients with peripheral neuropathy. This study included consecutive patients with peripheral neuropathy who were admitted to our hospital. The patients were divided into two groups: inflammatory neuropathies for immune-mediated neuropathies, such as Guillain − Barré syndrome and chronic inflammatory demyelinating polyneuropathy, and the rest were defined as non-inflammatory neuropathies. We assessed nerve size and intraneural blood flow at four sites on each median and ulnar nerve. Blood flow was evaluated using color Doppler imaging, advanced dynamic flow (ADF), and superb microvascular imaging (SMI) techniques. Thirty-nine patients (median age, 60.0 years; 20 male) were enrolled in this study. An increase in intraneural blood flow was observed in five patients when evaluated by color Doppler, five patients by ADF, and 13 patients by SMI. An overall analysis of the three methods showed that intraneural blood flow was significantly higher in patients with inflammatory neuropathy than in those with non-inflammatory neuropathy (54.2% vs. 0%, p = 0.0005). Intraneural hypervascularization is more frequent in patients with inflammatory neuropathy than in those with non-inflammatory neuropathy. Evaluation of microvessel flow within peripheral nerves may contribute to the diagnosis of peripheral neuropathy. [ABSTRACT FROM AUTHOR]

Background Nerve transfers from one common donor nerve to recipient nerves with multiple target branches can yield slower and unpredictable recovery in the target nerves. Our hypothesis is that steal phenomenon exists when multiple nerve neurotization comes from one donor nerve. Methods In 30 Sprague-Dawley rats, the left ulnar nerve (UN) was selected as the donor nerve, and the musculocutaneous nerve (MCN) and median nerve (MN) as the recipient target nerves. The rats were separated into three groups (10 rats in each): group A, UN-to-MCN (one-target); group B, UN-to-MN (one-target); and group C, UN-to-MCN and MN (two-target). The right upper limbs were nonoperative as the control group. Outcome obtained at 20 weeks after surgery included grooming test, muscle weight, compound muscle action potential, tetanic muscle contraction force, axon counts, and retrograde labeling of the involved donor and target nerves. Results At 20 weeks after surgery, muscles innervated by neurotization resulted in significant worse outcomes than the control side. This was especially true in two-target neurotization in the parameter of muscle weight and forearm flexor muscle contraction force outcome when compared to one-target neurotization. Steal phenomenon does exist because flexor muscle contraction force was significantly worse during two-target neurotization. Conclusion This study proves the existence of steal phenomenon in multiple target neurotization but does not significantly affect the functional results. Postoperative rehabilitative measures (including electrical stimulation, induction exercise) and patient compliance (ambition and persistence) are other crucial factors that hold equivalent importance to long-term successful recovery. [ABSTRACT FROM AUTHOR]

BACKGROUND: According to the literature, the brachial plexus presents a high rate of anatomical variations in the human neural system. The musculocutaneous nerve, a vital component of the brachial plexus, exhibits significant anatomical variations that hold clinical relevance across multiple medical disciplines. This case report, with a comprehensive review, explores the different variations in the course, branching patterns, and clinical implications of the musculocutaneous nerve. Understanding these variations is essential for surgeons, radiologists, and clinicians to enhance surgical precision, improve diagnostic accuracy, and reduce the risk of iatrogenic complications. CASE REPORT: During an anatomical dissection we observed a very rare anatomical variation of the musculocutaneous nerve. Based on this discovery, we performed research in the literature with the aim of finding if this variation has been previously described. Firstly, we identified various classifications of anatomical variations of communicating branches between the musculocutaneous and median nerves, and then we observed that these variations corresponded to various rates of frequency. Our finding is a rare undescribed anatomical variant within the variants classified as Type II according to Le Minor, which is observed in 6.8-10.7% of cases. CONCLUSIONS: The peculiar position of anatomical variations and anastomosis has clinical and functional relevance. Healthcare professionals must be aware of these variations to minimize surgical complications, accurately diagnose neurovascular pathologies, and optimize patient management. Further research into the genetic and embryological underpinnings of these variations may provide additional insights into this intriguing aspect of human anatomy. [ABSTRACT FROM AUTHOR]

Background and Purpose: Enhancing afferent information from the paretic limb can improve post-stroke motor recovery. However, uncertainties exist regarding varied sensory peripheral neuromodulation protocols and their specific impacts. This study outlines the use of repetitive peripheral sensory stimulation (RPSS) and repetitive magnetic stimulation (rPMS) in individuals with stroke. Methods: This scoping review was conducted according to the JBI Evidence Synthesis guidelines. We searched studies published until June 2023 on several databases using a three-step analysis and categorization of the studies: pre-analysis, exploration of the material, and data processing. Results: We identified 916 studies, 52 of which were included (N = 1,125 participants). Approximately 53.84% of the participants were in the chronic phase, displaying moderate-to-severe functional impairment. Thirty-two studies used RPSS often combining it with task-oriented training, while 20 used rPMS as a standalone intervention. The RPSS primarily targeted the median and ulnar nerves, stimulating for an average of 92.78 min at an intensity that induced paresthesia. RPMS targeted the upper and lower limb paretic muscles, employing a 20 Hz frequency in most studies. The mean stimulation time was 12.74 min, with an intensity of 70% of the maximal stimulator output. Among the 114 variables analyzed in the 52 studies, 88 (77.20%) were in the "s,b" domain, with 26 (22.8%) falling under the "d" domain of the ICF. Discussion and Conclusion: Sensory peripheral neuromodulation protocols hold the potential for enhancing post-stroke motor recovery, yet optimal outcomes were obtained when integrated with intensive or task-oriented motor training. [ABSTRACT FROM AUTHOR]

To test the hypothesis that weight loss following bariatric surgery is associated with a reduced risk of developing carpal tunnel syndrome (CTS) compared with obese patients who do not undergo bariatric surgery. We performed a cohort study using data from the Swedish nationwide healthcare registries. Patients aged 18–79 years who underwent bariatric surgery from 2006 to 2019 were propensity score (PS)–matched to up to 2 obese bariatric surgery-free patients ("unexposed patients"). Cox proportional hazard regression was used to calculate hazard ratios (HR) with 95% confidence intervals (CIs) to compare the incidence of CTS among bariatric surgery patients to obese unexposed patients both overall and divided by subgroups of age, sex, bariatric surgery type, and duration of follow-up. In total, 40,619 bariatric surgery patients were PS-matched to 63,540 obese unexposed patients who did not undergo surgery. Bariatric surgery was not associated overall with CTS (HR 0.98, 95% CI 0.91–1.05). There was a 23% decreased risk of CTS incidence observed within >1–3 years after bariatric surgery (HR 0.77, 95% CI 0.68–0.88). Decreased CTS risks were observed among bariatric surgery patients aged 18–34 years (HR 0.87, 95% CI 0.74–1.01) and those who underwent sleeve gastrectomy (HR 0.81, 95% CI 0.63–1.03), but these risks did not reach significance level compared with obese unexposed patients. However, there was a 20% increased CTS risk after 6 years (HR 1.20, 95% CI 1.05–1.36). Our results suggest that marked weight does not have a lasting impact on the reduction of CTS incidence. [ABSTRACT FROM AUTHOR]

Objective: Schwannomas are benign, slow-growing tumors originating from Schwann cells in peripheral nerves, commonly affecting the median and ulnar nerves in the forearm and wrist. Surgical excision is the gold standard treatment. This study presents our treatment strategies and outcomes for large-sized ulnar and median nerve schwannomas at the forearm and wrist level. Methods: From 2012 to 2023, we enrolled 15 patients with schwannomas over 2 cm in size in the median or ulnar nerve at the forearm and wrist. The study included 12 patients with median nerve schwannomas (mean age: 61 years) and 3 with ulnar nerve schwannomas (mean age: 68 years), with a mean follow-up of 26.9 months. Results: After surgery, all patients with median nerve schwannomas experienced mild, transient numbness affecting fewer than two digits, resolving within six months without motor deficits. Ulnar nerve schwannoma excision caused mild numbness in two patients, also resolving within six months, but all three developed ulnar claw hand deformity, which persisted but improved at the last follow-up. Despite this, patients were satisfied with the surgery due to relief from severe tingling pain. Conclusions: Schwannomas of the median, ulnar, and other peripheral nerves should be removed by carefully dissecting the connecting nerve fascicles to avoid injury to healthy ones. Sensory deficits may occur but are unlikely to significantly impact quality of life. However, in motor-dominant nerves like the ulnar nerve, there is a risk of significant motor deficits that could affect hand function, though not completely. Therefore, thorough preoperative discussion and consideration of interfascicular nerve grafting are essential. [ABSTRACT FROM AUTHOR]

The presentation, management and outcomes of brachial plexus injuries are likely to be subject to regional differences across the globe. A comprehensive literature search was performed to identify relevant articles related to spinal accessory to suprascapular, intercostal to musculocutaneous, and ulnar and/or median nerve fascicle to biceps and/or brachialis motor branch nerve transfers for treatment of brachial plexus injuries. A total of 6007 individual brachial plexus injuries were described with a mean follow-up of 38 months. The specific indication for accessory to suprascapular and intercostal to musculocutaneous transfers were considerably different among regions (e.g. upper plexus vs. pan-plexal), while uniform for fascicular transfer for elbow flexion (e.g. upper plexus +/− C7). Similarly, functional recovery was highly variable for accessory to suprascapular and intercostal to musculocutaneous transfers, while British Medical Research Council grade ≥3 strength after fascicular transfer for elbow flexion was frequently obtained. Overall, differences in outcomes seem to be inherent to the specific transfer being utilized. Level of evidence: III [ABSTRACT FROM AUTHOR]

AbstractBackgroundMethodsResultsConclusionsPROSPERO Protocol numberTinel’s test is commonly used in the diagnosis of carpal tunnel syndrome (CTS) despite its questionable diagnostic test accuracy (DTA). This systematic review investigated the DTA of Tinel’s test in CTS using electrodiagnosis as the reference standard and explored the heterogeneity between included studies.Prospective studies evaluating Tinel’s test in adults with CTS were included. The principal measures were sensitivity and specificity. A literature search was conducted for studies published up to 7 June 2024. The methodological quality was assessed using the QUADAS-2 tool. Narrative synthesis of study results and heterogeneity was undertaken. Meta-analysis was not conducted due to the high variability in diagnostic thresholds.Fifteen out of 4099 identified studies met the inclusion criteria. Patient selection scored ‘high’ in risk of bias and applicability concerns. Examiner blinding was poorly reported. Sensitivity varied from 30 to 89%. Specificity varied from 41 to 100%. Heterogeneity was found across all studies in participant selection criteria, Tinel’s test performance, electrodiagnostic criteria, and diagnostic thresholds.Tinel’s test demonstrated variable diagnostic accuracy in CTS. Due to poor methodological quality and high variability among the studies, more DTA studies are necessary.CRD42020218165 dated 27 November 2020. [ABSTRACT FROM AUTHOR]

Introduction: The median and ulnar nerves have been suggested to play a significant role in hand function; however, there are insufficient data to determine the strength of this association. This study aimed to investigate the correlation between hand function as measured with the Grooved pegboard test (GPT) and conduction velocity and latency of the median and ulnar nerves. Methods: We collected convenience samples in the College of Medicine, KSAU-HS. We used GPT to characterize hand function and performed measured nerve conduction velocity (NCV) and latency of the ulnar and median nerves of both hands. We used the Edinburgh handedness inventory (EHI) to determine hand dominance. Results: We recruited 28 healthy medical students aged 20–29 years (mean: 21.46 ± 1.62 years). Most were right-handed (n = 25, 89.3%), with a mean EHI score of 302 ± 210. The mean GPT time was significantly faster in the dominant (65.5 ± 6.4 s) than in the non-dominant (75.0 ± 9.6 s) hand. The NCV for the ulnar nerve of the dominant hand was significantly correlated with GPT (r = -0.52, p = 0.005) while median nerve was not correlated (0.24, p = 0.21). Regression analysis and collinearity test showed that the ulnar NCV explained 20% of the variance in GPT of the dominant hand (R2 = 0.203, p = 0.016). Conclusion: The ulnar nerve conduction velocity, explained 20% of the variance in GPT times of the young men. Performance on this biomarker of neurological health seems to be more influenced by other factors in healthy young individuals. [ABSTRACT FROM AUTHOR]

Background and Purpose Methods Results Conclusions Supracondylar humerus fractures (SCHFs) are the most common elbow fractures in children. Traumatic median nerve injury and isolated lesions of its pure forearm motor branch, anterior interosseus nerve (AIN), have both been independently reported as complications of displaced SCHFs. Our main objectives were to characterize the neurological syndrome to distinguish median nerve from AIN lesions and to determine the prognosis of median nerve lesions after displaced SCHFs.Ten children were prospectively followed for an average of 11.6 months. Patients received a standardized clinical examination and high‐resolution ultrasound of the median nerve every 1–3 months starting 1–2 months after trauma. Electrodiagnostic studies were performed within the first 4 months and after complete clinical recovery.All children shared a clinical syndrome with predominant but not exclusive affection of AIN innervated muscles. High‐resolution ultrasound uniformly excluded persistent nerve entrapment and neurotmesis requiring revision surgery but visualized post‐traumatic median nerve neuroma at the fracture site in all patients. Electrodiagnostic studies showed axonal motor and sensory median nerve neuropathy. All children achieved complete functional recovery under conservative management. Motor recovery required up to 11 months and differed between involved muscles.It was shown that neurological deficits of the median nerve in displaced SCHFs exceeded an isolated AIN lesion. Notably, detailed neurological follow‐up examinations and sonographic exclusion of persistent nerve compression were able to guide conservative therapy in affected children. Under these conditions the prognosis of median nerve lesions was excellent despite severe initial deficits, development of neuroma and axonal injury. [ABSTRACT FROM AUTHOR]

Introduction/Aims: T2 magnetic resonance imaging (MRI) mapping has been applied to carpal tunnel syndrome (CTS) for quantitative assessment of the median nerve. However, quantitative changes in the median nerve before and after surgery using T2 MRI mapping remain unclear. We aimed to investigate whether pathological changes could be identified by pre‐ and postoperative T2 MRI mapping of the median nerve in CTS patients after open carpal tunnel release. Methods: This was a prospective study that measured median nerve T2 and cross‐sectional area (CSA) values at the distal carpal tunnel, hamate bone, proximal carpal tunnel, and forearm levels pre‐ and postoperatively. Associations between T2, CSA, and nerve conduction latency were also evaluated. Results: A total of 36 patients with CTS (mean age, 64.5 ± 11.7 years) who underwent surgery were studied. The mean preoperative T2 values significantly decreased from 56.3 to 46.9 ms at the proximal carpal tunnel levels (p =.001), and from 52.4 to 48.7 ms at the hamate levels postoperatively (p =.04). Although there was a moderate association between preoperative T2 values at the distal carpal tunnel levels and distal motor latency values (r = −.46), other T2 values at all four carpal tunnel levels were not significantly associated with CSA or nerve conduction latency pre‐ or postoperatively. Discussion: T2 MRI mapping of the carpal tunnel suggested a decrease in nerve edema after surgery. T2 MRI mapping provides quantitative information on the median nerve before and after surgery. [ABSTRACT FROM AUTHOR]

This report describes two similar cases in which the distal forearm was compressed between the rib cage and floor for a prolonged period owing to immobility, resulting in severe compartment syndrome and extensive penetrating necrosis in the forearm. The cases were a 59-year-old man with cervical spondylolisthesis and a 65-year-old man suspected of having Parkinson's disease. A distinctive necrotic pattern characterized by necrosis in the volar and dorsal compartments, preservation of the lateral compartment, and retention of the radial artery was commonly observed in both cases. Despite the anticipated nonfunctional outcome of the salvaged limb, a two-lobed free latissimus dorsi musculocutaneous flap transfer with interposition of the thoracodorsal nerve in the median nerve defect was performed in both cases. Although the salvaged limbs were nonfunctional, the patients were able to use it for activities such as getting up and other daily tasks. [ABSTRACT FROM AUTHOR]

During routine dissection of the anterior compartment of the arm region, we encountered several variations in the muscular and neural structures in the right upper extremity of a female cadaver. We observed one superiorly positioned extramuscular head with fibers originating from both the biceps brachii (BB) and coracobrachialis (CB) muscles and one inferiorly positioned extramuscular head with fibers solely from the BB muscle. The musculocutaneous nerve did not penetrate the CB muscle, but instead provided a muscular branch that communicated with the median nerve (MN). Both the MN and brachial artery (BA) flow beneath the extra head. This case suggests that the described variations may contribute to the entrapment of the MN and compression of the BA. Understanding these variations is crucial before surgical intervention. The failure to recognize such anatomical nuances could lead to inadvertent nerve injury or compromised vascular perfusion, emphasizing the need for preoperative planning and intraoperative vigilance. [ABSTRACT FROM AUTHOR]

To investigate the effect of a pulsed Nd:YAG laser on the forearm local skin temperature (LST) and electrophysiology in healthy adults. A total of 30 healthy subjects with a mean age of 21 ± 0.74 years, mass of 63 ± 9.97 kg, and height of 163.7 ± 6.24 cm participated in this study. The anterior surface of the left non-dominant forearm was scanned with a pulsed Nd:YAG laser at 20 Jcm−2 for a total of 2000 J in 15 min. The right forearm was considered as the control and was scanned with a placebo laser for the same time as the active laser. Forearm minimal, average, and maximum LST were measured using a thermographic camera. Electrophysiological assessment of the median nerve [distal motor latency (DML), motor nerve conduction velocity (MNCV), and sensory nerve conduction velocity (SNCV)] was performed on both forearms before and after the application of the pulsed Nd:YAG laser. Paired and unpaired t tests were used to compare within and between groups, respectively. The level of significance was set at p > 0.05. There were significant increases in the minimum, average, and maximum LST, as well as the MNCV and SNCV with a significant decrease in DML after laser application compared to the control. The average increase in LST and nerve conduction velocity post-treatment was 275.55 K and 4.8 ms−1, respectively. The application of a pulsed Nd:YAG laser significantly increased the forearm LST, MNCV, and SNCV and significantly decreased the DML in healthy subjects. The average increase in the LST was 275.55 K with an average increase of 5 ms−1 in the motor and 4 ms−1 in the sensory NCVS. [ABSTRACT FROM AUTHOR]

Background: Musculocutaneous nerve (MCN) is a mixed nerve arising from the lateral cord of brachial plexus having root values C5, 6, and 7. It supplies the muscles of the flexor compartment of the arm namely; coracobrachialis, most part of brachialis and both heads of biceps brachii. It is cutaneous to the lower lateral part of forearm. Variations in the origin, course, branching pattern, termination, and connections of MCN are very common. Knowledge about these variations is important while evaluating unusual presentations of peripheral nerve injuries, during surgical procedures such as arthroscopy of shoulder joint, corrections of fracture humerus, brachial plexus block, and so on. Aims and Objectives: The study was conducted to find out any variations in the origin, course, branching pattern of the MCN. The secondary objective was to understand about the communication of the MCN with any other nerve. Materials and Methods: A descriptive study was conducted in 60 upper limb specimens dissected from 10% formalin embalmed 30 cadavers (adult) in the Department of Anatomy, Government Medical College, Kottayam. All limbs were carefully dissected and studied about the origin, course, termination, and variations of MCN. Results: Out of 60 specimens studied, in 46 specimens MCN Originate from lateral cord, eight from medial cord, and in six from the lateral root of the median nerve (MN). In 52 specimens, MCN supplies coracobrachialis but only in 34 it pierces this muscle. In four specimens, there is a communication between MCN and MN was seen. Conclusion: The MCN has significant variations and knowledge of these variations is clinically important in diagnosis and management of peripheral nerve injuries as well as surgical interventions in the arm. [ABSTRACT FROM AUTHOR]

Background: Increasing evidence indicates a higher prevalence of polyneuropathy (PNP) in Parkinson's disease (PD). However, the involvement of large fiber neuropathy in PD still remains poorly understood. Given the lack of longitudinal data, we investigated the course of PNP associated with PD. Methods: In total, 41 PD patients underwent comprehensive clinical evaluation including motor and non-motor assessments as well as nerve conduction studies at baseline and at 2 years of follow-up. The definition of PNP was based on electrophysiological standard criteria. Common causes of PNP were excluded. Results: At baseline, PNP was diagnosed in 65.85% of PD patients via electroneurography. Patients with PNP presented with higher age (p = 0.019) and PD motor symptom severity (UPDRS III; p < 0.001). Over the course of 2 years, PNP deteriorated in 21.95% of cases, and 26.83% remained without PNP. Deterioration of nerve amplitude was most prevalent in the median sensory nerve affecting 57.58% of all PD cases with an overall reduction of median sensory nerve amplitude of 45.0%. With regard to PD phenotype, PNP progression was observed in 33.33% of the tremor dominant and 23.81% of the postural instability/gait difficulties subtype. Decrease of sural nerve amplitude correlated with lower quality of life (PDQ-39, p = 0.037) and worse cognitive status at baseline (MoCA, p = 0.042). Conclusion: The study confirms the high PNP rate in PD, and demonstrates a significant electrophysiological progression also involving nerves of the upper extremities. Longitudinal studies with larger cohorts are urgently needed and should elucidate the link between PD and PNP with the underlying pathomechanisms. [ABSTRACT FROM AUTHOR]

The distinct and specialized movements performed in different sports disciplines may significantly influence nerve performance, potentially affecting nerve responses and the overall function within the respective athletic activities. The purpose of this study is to find the effect of forearm supination and pronation across the elbow joint on ulnar and median nerve conduction velocity (NCV) in throwers, archers, and non-athletes. A total of 34 participants both male and females were recruited with a body mass index (BMI) between 18.5 and 24.9 kg/m2. Nerve conduction study (NeuroStim NS2 EMG/NCV/EP System) was used for measuring ulnar and median NCV across the elbow joint at different angles with the forearm in supination and pronation. Repeated measure analysis of variance (RMANOVA) revealed that there are statistically significant differences in mean values of forearm positions, angles, nerves and groups (p <.05). This study illuminates distinctive NCV variations across diverse athletic groups during forearm supination and pronation movements. Pronation consistently exhibited faster ulnar NCV compared to the median nerve across throwers, archers, and non-athletes, while in supination specific joint positions revealed notable differences within sports groups and nerve function. [ABSTRACT FROM AUTHOR]

• The interhemispheric connection between primary somatosensory areas can be probed by using bilateral median nerve stimulation. • N20 potentials and the late component of the high-frequency oscillations vary significantly across interstimulus intervals. • Findings suggest interhemispheric interaction between the primary somatosensory cortices, through corpus callosum. This study aimed at investigating the effect of median nerve stimulation on ipsilateral cortical potentials evoked by contralateral median nerve electrical stimulation. We recorded somatosensory-evoked potentials (SEPs) from the left parietal cortex in 15 right-handed, healthy subjects. We administered bilateral median nerve stimulation, with the ipsilateral stimulation preceding the stimulation on the contralateral by intervals of 5, 10, 20, or 40 ms. We adjusted these intervals based on each individual's N20 latency. As a measure of S1 excitability, the amplitude of the N20 and the area of the High Frequency Oscillation (HFO) burst were analyzed for each condition. The results revealed significant inhibition of N20 amplitude by ipsilateral median nerve stimulation at interstimulus intervals (ISIs) between 5 and 40 ms. Late HFO burst was suppressed at short ISIs of 5 and 10 ms, pointing to a transcallosal inhibitory effect on S1 intracortical circuits. Findings suggest interhemispheric interaction between the primary somatosensory areas, supporting the existence of transcallosal transfer of tactile information. This study provides valuable insights into the interhemispheric connections between primary sensory areas and underscore the potential role of interhemispheric interactions in somatosensory processing. [ABSTRACT FROM AUTHOR]

• Both button hole and I-band methods are effective in kinesio taping added to exercise therapy in patients with carpal tunnel syndrome in terms of functionality, symptom severity, grip strength, and electrophysiology. • The button hole technique added to exercises is more effective than the I-band technique for electrophysiological measurements such as median distal sensory latency, sensory nerve conduction velocity, compound muscle action potential amplitude, and median sensory nerve action potential. To compare the effectiveness of I-tape and button hole kinesio taping (KT) techniques added to exercises in the treatment of carpal tunnel syndrome (CTS). Prospective randomized controlled blinded study. Physical Medicine and Rehabilitation Outpatient Clinic. A total of 108 patients (165 wrists) diagnosed with CTS (N=108). Button hole technique (BG), I-band technique (IG), and exercises (EG). Visual analog scale (VAS), Douleur Neuropathique 4 Questions (DN4), Boston carpal tunnel syndrome questionnaire, and Jamar dynamometer were used. Median sensory nerve action potential (SNAP), compound muscle action potential (CMAP), median distal sensory latency (DSL), median distal motor latency (DML), sensory conduction velocity, and motor conduction velocity were recorded. Measurements were made at baseline, week 3, and week 12. Thirty-six patients were in each group. Significant statistical improvements in VAS and DN4 scores were found in the BG and IG compared with EG (P <.05). Statistically significant improvements in hand grip strength were observed in the IG compared with the EG (P <.05). Significant improvements in DML levels and motor conduction velocity were observed in the BG and IG compared with the EG (P <.05). A significant increase in sensory conduction velocity was detected in the BG compared with the other groups (P <.05). Both KT techniques are effective in terms of pain, functionality, symptom severity, grip strength, and electrophysiologically. The button hole technique was more effective in DSL, sensory conduction velocity, CMAP amplitude, and SNAP. [ABSTRACT FROM AUTHOR]

Objectives: Evaluate diagnostic accuracy of median nerve cross‐sectional area (CSA) to determine severity versus presence of carpal tunnel syndrome (CTS) across existing electrodiagnostic‐based (EDX) classification systems in patients with type 2 diabetes or bifid anatomy. Methods: Retrospective analysis of cross‐sectional patient data. Receiver operating characteristic analysis used to determine median nerve CSA cutoff values and associated diagnostic likelihood ratios for all consolidated and binary EDX‐based classifications of CTS in patients with type 2 diabetes or bifid anatomy. Determine shifts in diagnostic probability based on established cutoff values and associated likelihood ratios. Distal CSA measured at or near carpal tunnel inlet, proximal CSA at level of pronator quadratus muscle, and delta CSA by subtracting proximal from distal. Results: Binary categorizations of CTS were statistically superior to consolidated categorizations of CTS severity in patients with type 2 diabetes or bifid anatomy. Binary categorizations established reasonably consistent median nerve CSA cutoff values across all EDX‐based classifications examined resulting in the following for distal CSA or delta CSA: ≤10 or ≤4 mm2 to rule out and ≥11 or ≥5 mm2 to rule in CTS, respectively. These cutoff values resulted in small shifts in diagnostic probability in patients with type 2 diabetes and small to conclusive shifts in diagnostic probability in patients with bifid anatomy. Conclusions: Binary categorizations to rule out or rule in CTS based on the proposed cutoff values provide the most meaningful information about shifts in diagnostic probability across all EDX‐based classifications examined. The use of median nerve CSA to categorize severity of CTS is not recommended in patients with type 2 diabetes or bifid anatomy. [ABSTRACT FROM AUTHOR]

Objectives: Evaluate the diagnostic accuracy of median nerve cross‐sectional area (CSA) to determine the severity of carpal tunnel syndrome (CTS) vs the presence of CTS across existing electrodiagnostic‐based (EDX) classification systems. Methods: Retrospective analysis of cross‐sectional patient data. Receiver operating characteristic (ROC) analysis was used to determine CSA cutoff values and associated diagnostic likelihood ratios for all consolidated and binary EDX‐based classifications of CTS severity. Identification of CSA cutoff values associated with likelihood ratios capable of achieving conclusive (but at least moderate) shifts in diagnostic probability. Results: Binary categorizations of CTS (ie, "Normal" vs "Absent") were statistically superior to consolidated categorizations of CTS severity (ie, "Normal," "Mild," "Moderate," or "Severe"). Binary categorizations established consistent CSA cutoff values across all EDX‐based classifications examined and achieved conclusive shifts in diagnostic probability based on the following values of distal CSA or delta CSA: <7 or <1 mm2 to rule out and >13 or >7 mm2 to rule in CTS, respectively. Additionally, the following values of distal CSA and delta CSA may be used in certain circumstances because they produce only small shifts in diagnostic probability: ≤10 or ≤3 mm2 to rule out and ≥11 or ≥4 mm2 to rule in CTS, respectively. Conclusions: Using median nerve CSA to categorize the severity of CTS is not recommended based on lack of consistent and meaningful shifts in diagnostic probability. Rather, binary categorizations to rule out or rule in CTS based on the proposed CSA cutoff values consistently provided conclusive shifts in diagnostic probability across all EDX‐based classifications examined. [ABSTRACT FROM AUTHOR]

Objective: This systematic review aims to determine the extent, scope, and nature of research using the sonographic measurement of intraneural blood flow within the median nerve and to identify, characterize, and compare image acquisition and analysis protocols that have been reported as potential candidate techniques for standardizing research and clinical applications. Materials and Methods: This systematic review summarizes image acquisition protocols and analysis methodologies from 52 current research studies using Doppler ultrasound to examine median nerve intraneural blood flow. Results: Four types of Doppler technologies were identified: power Doppler, color Doppler, spectral Doppler, and Superb Microvascular Imaging, but there were inconsistencies in how images were acquired and analyzed. Intraneural blood flow measurements were categorized into four types based on a combination of measurement level (e.g., binary, ordinal, continuous) and type of flow indicator (e.g., pixel count, intensity, velocity). Conclusion: Standardized imaging protocols and reporting guidelines are needed to improve consistency. Future studies should evaluate the accuracy and reliability of different image acquisition methods and analysis measurements. [ABSTRACT FROM AUTHOR]

Aims: The sensitivity and specificity of electrodiagnostic parameters in diagnosing carpal tunnel syndrome (CTS) have been reported differently, and this study aims to address this gap. Methods: This case-control study was conducted on 57 cases with CTS and 58 controls without complaints, such as pain or paresthesia on the median nerve. The main assessed electrodiagnostic parameters were terminal latency index (TLI), residual latency (RL), median ulnar F-wave latency difference (FdifMU), and median sensory latency-ulnar motor latency difference (MSUMLD). Results: The mean age in cases and controls were 50.7 years (SD 9.9) and 47.9 years (SD 12.1), respectively. The CTS severity was mild in 20 patients (34.4%), moderate in 19 patients (32.8%), and severe in 19 patients (32.8%). The sensitivity and specificity of the electrodiagnostic parameters in diagnosing CTS were as follows: TLI 75.4% and 87.8%; RL 85.9% and 82.5%; FdifMU 87.9% and 82.9%; and MSUMLD 94.8% and 60.0%, respectively. Conclusion: Our findings indicated that electrodiagnostic parameters are significantly associated with the clinical manifestation of CTS, and are associated with high diagnostic accuracy in CTS diagnosis. However, further studies are required to highlight the role of electrodiagnostic parameters and their combination in CTS detection. Cite this article: Bone Jt Open 2024;5(10):898–903.

The objective was to analyze the possible reasons for the failure of surgical treatment of carpal tunnel syndrome.One of the most common forms of compression mononeuropathy of the upper extremity is carpal tunnel syndrome. Despite being widely studied, the topic remains relevant due to the fact that this pathology makes up the majority of occupational diseases and its treatment is associated with significant healthcare costs. Carpal tunnell release is the «gold standard» for surgical treatment of carpal tunnel syndrome, but despite its high level of effectiveness, from 2 to 10 % of patients require revision surgery for recurrent carpal tunnel syndrome.

Abstract Objective Schwannomas are benign, slow-growing tumors originating from Schwann cells in peripheral nerves, commonly affecting the median and ulnar nerves in the forearm and wrist. Surgical excision is the gold standard treatment. This study presents our treatment strategies and outcomes for large-sized ulnar and median nerve schwannomas at the forearm and wrist level. Methods From 2012 to 2023, we enrolled 15 patients with schwannomas over 2 cm in size in the median or ulnar nerve at the forearm and wrist. The study included 12 patients with median nerve schwannomas (mean age: 61 years) and 3 with ulnar nerve schwannomas (mean age: 68 years), with a mean follow-up of 26.9 months. Results After surgery, all patients with median nerve schwannomas experienced mild, transient numbness affecting fewer than two digits, resolving within six months without motor deficits. Ulnar nerve schwannoma excision caused mild numbness in two patients, also resolving within six months, but all three developed ulnar claw hand deformity, which persisted but improved at the last follow-up. Despite this, patients were satisfied with the surgery due to relief from severe tingling pain. Conclusions Schwannomas of the median, ulnar, and other peripheral nerves should be removed by carefully dissecting the connecting nerve fascicles to avoid injury to healthy ones. Sensory deficits may occur but are unlikely to significantly impact quality of life. However, in motor-dominant nerves like the ulnar nerve, there is a risk of significant motor deficits that could affect hand function, though not completely. Therefore, thorough preoperative discussion and consideration of interfascicular nerve grafting are essential.

Background/Objectives: The accurate quantification of peripheral nerve axonal regeneration after injury is critically important. Current strategies are limited to detecting early reinnervation. DTI is an MRI modality permitting the assessment of fractional anisotropy, which increases with axonal regeneration. The aim of this pilot study is to evaluate DTI as a potential predictive factor of clinical outcome after median nerve section and microsurgical repair. Methods: We included 10 patients with a complete section of the median nerve, who underwent microsurgical repair up to 7 days after injury. The follow-up period was 1 year, including the current strategy with clinical visits, the Rosén–Lundborg score and electroneuromyography. Additionally, DTI MRI of the injured wrist was planned 1, 3 and 12 months post-operatively and once for the contralateral wrist. Results: The interobserver reliability of DTI measures was almost perfect (ICC 0.802). We report an early statistically significant increase in the fractional anisotropy value after median nerve repair, especially in the region located distal to the suture. Meanwhile, Rosén–Lundborg score gradually increased between the third and sixth month, and continued to increase between the sixth and twelfth month. Conclusions: DTI outcomes three months post-operation could offer greater predictability compared to current strategies. This would enable faster decision-making regarding the need for a potential re-operation in cases of inadequate early reinnervation.

Background: Musculocutaneous nerve (MCN) is a mixed nerve arising from the lateral cord of brachial plexus having root values C5, 6, and 7. It supplies the muscles of the flexor compartment of the arm namely; coracobrachialis, most part of brachialis and both heads of biceps brachii. It is cutaneous to the lower lateral part of forearm. Variations in the origin, course, branching pattern, termination, and connections of MCN are very common. Knowledge about these variations is important while evaluating unusual presentations of peripheral nerve injuries, during surgical procedures such as arthroscopy of shoulder joint, corrections of fracture humerus, brachial plexus block, and so on. Aims and Objectives: The study was conducted to find out any variations in the origin, course, branching pattern of the MCN. The secondary objective was to understand about the communication of the MCN with any other nerve. Materials and Methods: A descriptive study was conducted in 60 upper limb specimens dissected from 10% formalin embalmed 30 cadavers (adult) in the Department of Anatomy, Government Medical College, Kottayam. All limbs were carefully dissected and studied about the origin, course, termination, and variations of MCN. Results: Out of 60 specimens studied, in 46 specimens MCN Originate from lateral cord, eight from medial cord, and in six from the lateral root of the median nerve (MN). In 52 specimens, MCN supplies coracobrachialis but only in 34 it pierces this muscle. In four specimens, there is a communication between MCN and MN was seen. Conclusion: The MCN has significant variations and knowledge of these variations is clinically important in diagnosis and management of peripheral nerve injuries as well as surgical interventions in the arm.

OBJECTIVE: Establish median nerve CSA reference values and identify patient-level factors impacting diagnostic thresholds. METHODS: Studies were identified through a robust search of multiple databases, and quality assessment was conducted using a modified version of the National Institute of Health Study Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. A meta-analysis was performed to identify normative values stratified by anatomic location. A meta-regression was conducted to examine heterogeneity effects of age, sex, and laterality. RESULTS: The meta-analysis included 73 studies; 41 (56.2%) were high quality. The median nerve CSA [95% CI] was 6.46mm2 [6.09-6.84], 8.68mm2 [8.22-9.13], and 8.60mm2 [8.23-8.97] at the proximal forearm, the carpal tunnel inlet, and the proximal carpal tunnel, respectively. Age was positively associated with CSA at the level of proximal carpal tunnel (β=0.03mm2, p=0.047). Men (9.42mm2, [8.06-10.78]) had statistically larger proximal tunnel CSA (p = 0.03) as compared to women (7.71mm2, [7.01-8.42]). No difference was noted in laterality. CONCLUSION: A reference value for median nerve CSA in the carpal tunnel is 8.60mm2. Adjustments may be required in pediatrics or older adults. The diagnostic threshold of 10.0mm2 for male patients should be cautiously applied as the upper limit of normative averages surpasses this threshold.

Introduction: Intercostal nerve transfer is a surgical technique used to restore function in patients with total brachial plexus injury. Stem cell and secretome therapy has been explored as a potential treatment for brachial plexus injuries. This study aimed to compare the functional and histologic outcome of intercostal nerve transfer to median nerve with local stem cells or secretome injection in total type brachial plexus injuries. Materials and methods: This was a double-blinded, randomized controlled study (RCT). We included patients with neglected total type brachial plexus injury (BPI) who underwent nerve transfer and local injection of either umbilical cord-derived mesenchymal stem cells (UC-MSC) or secretome into median nerve–flexor digitorum superficialis (FDS) neuromuscular junction (NMJ). We measured preoperative and 8-month postoperative FDS muscle strength, SF-36, DASH score, and histologic assessment. We then analyzed the difference outcome between those two groups. Result: A total of 15 patients were included in this study. Our study found that after nerve transfer and implantation with either UC-MSC or secretome, significant postoperative improvements were observed in physical functioning, role limitations, energy/fatigue, emotional well-being, social functioning, pain, general health, and DASH scores, particularly in the overall cohort and the secretome group. When we compared the mean difference of clinical outcome from preoperative to postoperative between UC-MSC and secretome groups, the UC-MSC group showed better improvement of health change in SF-36 subgroup compared to secretome group. From the analysis, there was no significant difference in the histologic outcomes (inflammation, regeneration, and fibrosis) in overall cohort between preoperative and postoperative cohort. There was also no significant difference in mean change of the histologic outcomes (inflammation, regeneration, and fibrosis) preoperative and postoperatively between UC-MSC and secretome groups. Discussion and conclusion: Implantation of either UC-MSC or secretome along with nerve transfer may provide clinical improvement, while to achieve histologic improvement, further conditioning should be performed. [ABSTRACT FROM AUTHOR]

Context: Neuromobilization exercises (NE) could be a useful therapeutic tool to induce analgesia and increase function and range of motion (ROM) in patients with musculoskeletal pathologies with neuropathic components; however, the effectiveness of this intervention in patients with cervical radiculopathy (CR) is unknown. Objective: To determine the effectiveness of NE in CR on pain, function, and ROM. Design: Systematic review and meta-analysis. Evidence acquisition: An electronic search was performed in the MEDLINE, Scopus, PEDro, and EBSCO databases from inception until June 2022. The authors included randomized clinical trials that evaluated the effectiveness of NE against control groups or other interventions that aimed to treat patients with CR. Evidence synthesis: Seven clinical trials met the eligibility criteria, and for the quantitative synthesis, 5 studies were included. For the studies that compared NE with a control group, the standardized mean difference for pain was -1.33/10 (95% confidence interval [CI], -1.80 to -0.86; P < .01; I2 = 0%), for function with the Neck Disability Index was -1.21/50 (95% CI, -1.67 to -0.75; P < .01; I2 = 0%), and for neck flexion and extensions was 0.66 (95% CI, 0.23 to 1.10; P < .01; I2 = 0%) and 0.47 (95% CI, 0.04 to 0.90; P < .01; I2 = 0%), respectively, with evidence of clinical effectiveness. These findings were based on moderate-quality evidence according to the Grading of Recommendation, Assessment, Development, and Evaluation rating. In studies that compared NE with other interventions, the meta-analysis failed to demonstrate the statistical or clinical superiority of NE. Conclusions: Moderate quality of evidence suggests that NE may be superior to no treatment for pain, function, and ROM in patients with CR. In contrast, NE are not superior to other interventions in the same outcomes, based on low- to very low-quality evidence. More high-quality research is needed to assess the consistency of these results. [ABSTRACT FROM AUTHOR]

Objective To establish the reference standard of the median nerve conduction study (NCS) in Korea. Methods A total of 648 median motor and 602 median sensory NCSs from 349 Korean healthy volunteers were tested and analyzed prospectively. Equipment calibration, assessment of intra- and inter-rater reliability, and the NCSs per se were conducted according to a predetermined protocol. A reference standard was established from uncertainty components for the following parameters: the onset and peak latencies; the baseline-to-peak and peak-to-peak amplitudes; the area and duration of the negative wave; and the nerve conduction velocity. The effects of sex, age and stimulation intensity were analyzed. Results Each measured value of 648 median motor and 602 median sensory nerves were obtained and presented with both mean and expanded uncertainties, as well as mean and standard deviations. The cut-off values with expanded uncertainty were determined for different age and sex groups. After adjusting for anthropometric covariates, all parameters except duration were affected by age, and sex appeared to influence both duration and area. While stimulation intensity significantly affected some parameters including latencies, the effect sizes were negligible. Conclusion We propose the median NCS reference standard using the largest Korean dataset ever available. The use of the traceable and reliable reference standard is anticipated to promote more accurate and dependable diagnosis and appropriate management of median neuropathies in Korea.

Introduction: Carpal Tunnel Syndrome (CTS) presents with symptoms like numbness, tingling, and weakness along the median nerve pathway. Risk factors include prolonged wrist positions, repetitive muscle contractions, and exposure to vibrations. Aim: To determine the prevalence of CTS among healthcare practitioners at vaccine facilities in Saudi Arabia. Materials and Methods: A cross-sectional study on a total of 150 healthcare practitioners (aged 25-30 years) working in vaccination centres in Riyadh, Saudi Arabia were recruited. The study was conducted from November 2021 to March 2022. The authors collected demographic data, Body Mass Index (BMI) and work shift information, and administered two validated questionnaires, the Boston Carpal Tunnel Syndrome Questionnaire (BCTSQ) and the Duruoz Hand Index (DHI). CTS symptoms were diagnosed using Phalen’s and Arm Raising Test (ART). Results: Of the 150 practitioners (aged 25-45 years), predominantly in the 25-30 age group, n=65 (44.0%) tested positive on the Phalen’s test, and n=65 (43.5%) on the ART. Females had higher BCTSQ scores, while DHI scores were similar across genders. Spearman's correlation analysis showed positive correlations between BCTSQ and DHI, and a moderate negative correlation between ART and DHI. Logistic regression analysed factors affecting the likelihood of CTS diagnosed by ART and Phalen’s Test. Higher BCTSQ and DHI scores increased the likelihood of CTS (ART: BCTSQ OR=0.843, DHI OR=1.064; Phalen’s Test: BCTSQ OR=0.830, DHI OR=1.069). Conclusion: During the Coronavirus Disease-2019 (COVID-19) pandemic, the prevalence of CTS among healthcare practitioners at vaccine centres in Riyadh, Saudi Arabia reached up to 43-44%. The present study highlights that day shift workers face a higher risk of CTS compared to night shift workers, likely due to heavier daytime workloads. This underscores the need for ergonomic interventions and workload management, especially during high-demand periods like the vaccination campaign, to safeguard healthcare workers’ health and productivity.

Purpose: The purpose of this study was to assess ulnar and median nerve injury after reverse total shoulder arthroplasty (RSA) by measuring the sensory nerve conduction velocity (SCV). The secondary objective was to evaluate the impact of lateralization and/or distalization on SCV changes. Methods: Twenty consecutive cases were prospectively included and retrospectively reviewed. SCV of the ulnar and median nerves as well as humeral lateralization/distalization quantified by plain radiography were evaluated pre-operatively and at 1 week post-operatively. Changes in SCV were tested using the paired t-test, and correlations between humeral lateralization/distalization and SCV changes were tested using Kendall's rank correlation coefficient and maximal information coefficient (MIC). Results: The SCV of the ulnar nerve was delayed from 55.4 ​m/s pre-operatively to 53.0 ​m/s post-operatively (p ​= ​0.021), whereas there was no significant change in the median nerve (p ​= ​0.17). There was a weak to moderate correlation between ulnar nerve SCV delay and lateralization (τ ​= ​−0.38; p ​= ​0.021; MIC ​= ​0.70) but no significant correlation with distalization (p ​= ​0.65; MIC ​= ​0.56). Conclusions: Following RSA, a small but significant delay in SCV of the ulnar nerve was observed. A negative correlation was found between lateralization and SCV delay of the ulnar nerve.

Summary: In this study, a modified version of the endoscopic carpal tunnel release surgery was introduced, which is safe and easy to handle. Moreover, the requirement for surgical instruments is low. Six patients with carpal tunnel syndrome underwent the modified procedure. No neurovascular injuries occurred in these patients. According to the one-year follow-up data, all the patients were satisfied with the outcomes. The modified endoscopic carpal tunnel release technique has been proven to be safe with satisfactory outcomes in six patients in this study.

• SBR was suppressed by fear. • Fear increased SBR when a threat stimulus was present. • No change in SBR was detected in control conditions, and the findings were unrelated to habituation or attention. This study evaluated the isolated and combined effects of fear and PPS paradigms on SBR. The prospective study was conducted with healthy participants. After stimulation of the right median nerve at the wrist, bilateral recordings were randomized under the following conditions: First experiment (with the right hand on the chair armrest): i. baseline recordings, ii. while watching fearful facial expressions from the Karolinska Emotional Faces battery (fear), iii. post-watching (post-fear), iv. while watching neutral facial expressions from the same battery (neutral), v. Immediately after viewing (post-neutral). Second experiment (right hand 2 cm away from the right eye, PPS): i. reference condition (PPS), ii. while watching fearful facial expressions (PPS-fear), iii. while watching neutral facial expressions (PPS-neutral). In each condition, SBR latency, area, duration, and amplitudes were measured and compared between conditions. We included 16 participants. SBR could be recorded in 11 (mean age:30.7 ± 5.2, F/M:5/6). First experiment: SBR amplitude was significantly reduced in fear condition (p = 0.008), and SBR area was reduced considerably in fear and post-fear conditions (p = 0.004) compared to the baseline. Second experiment: The SBR area was higher in the PPS (p = 0.009) compared to the baseline and even higher in the fearPPS compared to the PPS (p = 0.038). In neutral or PPS-neutral conditions, the area of the SBR did not change significantly. Fear suppressed SBR, but fear increased SBR when a threat stimulus was present. The findings were unrelated to habituation or attention, indicating cortical-amygdala-bulbar connections. [ABSTRACT FROM AUTHOR]

Accuracy of a median nerve block is normally assessed by testing skin sensitivity on the medial and dorsal aspects of fetlock and pastern. The present study evaluated subjective and objective analysis of skin surface temperature obtained with two different infrared (IR) thermography cameras (a high-end [FLIR P640] and a smartphone IR thermography device [FLIR One®]) before and after anaesthesia of the median nerve. Thermographic images were obtained at 0, 30, 60 and 90 minutes after performing a median nerve block with 2% mepivacaine hydrochloride. The subjective analysis of thermographic images using the FLIR P640 camera found assessors had >50% agreement for the presence of a nerve block (p<0.01) based on assessment of skin temperature within the expected dermatome of the median nerve. The objective analysis found skin temperature increases in the treated leg using the FLIR One® in the dorsal fetlock, dorsal pastern and medial pastern at 60 minutes, and the lateral pastern at 90 minutes (p<0.05). The treated leg, imaged using the FLIR P640 camera, had increases in skin temperature at the medial aspect of the fetlock at 60 minutes and lateral pastern at 90 minutes (p<0.05). Images obtained with the P640 camera had higher resolution and finer thermal detail. The images obtained with the FLIR One® camera had a wider temperature range with overall higher temperature measurements than the images obtained using the P640 camera (p<0.001). Skin temperatures in horses should be interpreted with caution when using the FLIR One® camera. Furthermore, the FLIR One® device detected an increase in skin surface temperature in both treated and non-treated legs and should not be used for assessment of a median nerve block. Infrared thermography appears to be useful for determining the presence of a high regional nerve block such as the median nerve block by observing increased temperatures of the skin surface after perineural anaesthesia. Further studies with a larger sample size as well as investigating the use of thermography for assessment of other regional nerve blocks are warranted. [ABSTRACT FROM AUTHOR]

Background: The complex anatomy of peripheral nerves has been traditionally investigated through histological microsections, with inherent limitations. We aimed to compare three-dimensional (3D) reconstructions of median and ulnar nerves acquired with tomographic high-resolution ultrasound (HRUS) and magnetic resonance microscopy (MRM) and assess their capacity to depict intraneural anatomy. Methods: Three fresh-frozen human upper extremity specimens were prepared for HRUS imaging by submersion in a water medium. The median and ulnar nerves were pierced with sutures to improve orientation during imaging. Peripheral nerve 3D HRUS scanning was performed on the mid-upper arm using a broadband linear probe (10–22 MHz) equipped with a tomographic 3D HRUS system. Following excision, nerves were cut into 16-mm segments and loaded into the MRM probe of a 9.4-T system (scanning time 27 h). Fascicle and nerve counting was performed to estimate the nerve volume, fascicle volume, fascicle count, and number of interfascicular connections. HRUS reconstructions employed artificial intelligence-based algorithms, while MRM reconstructions were generated using an open-source imaging software 3D slicer. Results: Compared to MRM, 3D HRUS underestimated nerve volume by up to 22% and volume of all fascicles by up to 11%. Additionally, 3D HRUS depicted 6–60% fewer fascicles compared to MRM and visualized approximately half as many interfascicular connections. Conclusion: MRM demonstrated a more detailed fascicular depiction compared to 3D HRUS, with a greater capacity for visualizing smaller fascicles. While 3D HRUS reconstructions can offer supplementary data in peripheral nerve assessment, their limitations in depicting interfascicular connections and small fascicles within clusters necessitate cautious interpretation. Clinical relevance statement: Although 3D HRUS reconstructions can offer supplementary data in peripheral nerve assessment, even in intraoperative settings, their limitations in depicting interfascicular branches and small fascicles within clusters require cautious interpretation. Key Points: 3D HRUS was limited in visualizing nerve interfascicular connections. MRM demonstrated better nerve fascicle depiction than 3D HRUS. MRM depicted more nerve interfascicular connections than 3D HRUS. [ABSTRACT FROM AUTHOR]

Purpose: To investigate the effect of mecobalamin dispersible tablets and surgical treatment on nerve conduction velocity and skin sympathetic reflex in patients with cervical spondylotic radiculopathy (CSR). Methods: 82 patients diagnosed with CSR between February 2019 and January 2022 in Inner Mongolia Medical University School of Basic Medicine, Hohhot City, China were randomized into control and study groups comprising 41 patients each. The control group was treated with anterior cervical diskectomy and fusion, while the study group was treated with mecobalamin dispersible tablets in addition to surgery. Efficacy was assessed 3 months after surgery. Results: Efficacy in the study group was significantly higher than in the control group (p < 0.05). Furthermore, the study group had significantly greater motor and sensory nerve conduction velocity of the median and ulnar nerve as well as reduced initial wave latency (p < 0.05). Scores of subjective symptoms, clinical signs, and life-work-social adaptability were significantly higher in the study group than in the control group (p < 0.05). Range of motion of the neck significantly improved and brainderived neurotrophic factor and glial neurotrophic factor were significantly increased in the study group compared to control group (p < 0.05). Conclusion: Mecobalamin dispersible tablets in combination with surgery improve nerve conduction velocity, skin sympathetic reflex function, neurotrophic factor level, cervical motion, and cervical spine function in patients with CSR. Multicenter long-term controlled studies with larger sample sizes are required in future studies. [ABSTRACT FROM AUTHOR]

Intraoperative mapping of the nervous system is used to identify "eloquent" cortical areas. In this technical report, we describe a novel way of mapping the somatosensory cortex so that injury to those critical pathways can be avoided. An 8-year-old female with drug resistant epilepsy presented for resection of a right posterior parietal focal cortical dysplasia. Left median nerve stimulation was used to record somatosensory evoked potentials (SEPs) directly from the somatosensory cortex with a strip electrode. A handheld monopolar electrode was also used to record both the median and tibial SEP. Total intravenous anesthesia with propofol and remifentanil was used. SEP recordings were obtained from a 4-contact strip electrode placed across the central sulcus. A phase reversal was identified and the most likely post central gyrus was noted. With the strip electrode left in place, a monopolar handheld electrode was used to record the median nerve SEPs from different locations on the postcentral gyrus. The tibial nerve was also stimulated to record where the highest amplitude tibial nerve SEP was present. This map was used delineate functionally "eloquent" areas to avoid during surgery. During resection, the median nerve SEP was recorded from the strip electrode continuously. No significant change in the SEP was noted, and the patient awoke without any sensory deficits. Sensory mapping of the cortex is possible with a handheld monopolar electrode. This technique is easy to perform and can help reduce neurological morbidity. [ABSTRACT FROM AUTHOR]