Carpal tunnel syndrome is the most common compressive neuropathy of the upper limb. Various methods are used to diagnose this condition including clinical examination and neurophysiologic tests. The DASH (Disability of Arm, Shoulder and Hand) score is also commonly used to quantify the symptoms from the patients’ perspective. The aim of this study was to determine any correlation between the neurophysiology and the various questions in the DASH score. To the best of our knowledge this potential association has not been studied previously. Methods: We reviewed 55 patients who underwent carpal tunnel surgery under the care of the senior author. Case notes were reviewed to extract the DASH score, clinical signs and neurophysiology results. DASH questionnaires are routinely given to all our new patients in the hand clinic and we used these questionnaires for the study (pre operative scores). All the patients were examined clinically by the senior author. The clinical signs used included direct compression, Tinel’s and Phalen’s test. Neurophysiologic testing was conducted by two specialists using a standard format which allowed us to extract the data consistently. Analysis: The data was analysed using linear and logistical regression methods. Results: Of 55 patients, 9 had bilateral surgery, resulting in 64 sets of data. There were 44 females and 11 males, with a mean age of 62 (range 36 – 86) years. The mean DASH score was 38.0 (range 0.8 – 85.0). The relationship between the component scores of the DASH questionnaire and neurophysiology tests will be presented in further detail. Conclusion: The results of this study may facilitate an abbreviation of the DASH questionnaire, making it more focused to patients with carpal tunnel syndrome

Limb lengthening is used to correct leg length discrepancy and to increase stature. The reported frequency of peripheral nerve complications varies from 5% to 30%, but is probably underestimated. Damage may be direct or be caused by overstretching of the nerves. We have used electrophysiological tests to evaluate five patients during bilateral tibial lengthening by the Ilizarov method. Results after 24 to 107 days of lengthening showed electromyographic evidence of partial muscle denervation in all 10 limbs, with reduced motor conduction velocities in two tibial nerves and three common peroneal nerves. The sensory conduction velocity in the sural nerve was always unchanged. A clear relationship was shown between the amount of tibial lengthening and the degree of electrophysiological abnormality. Our results suggest that subclinical nerve damage is a very frequent complication of tibial lengthening.

We investigated the predictive value of intra-operative neurophysiological investigations in obstetric brachial plexus injuries. Between January 2005 and June 2011 a total of 32 infants of 206 referred to our unit underwent exploration of the plexus, including neurolysis. The findings from intra-operative electromyography, sensory evoked potentials across the lesion and gross muscular response to stimulation were evaluated. A total of 22 infants underwent neurolysis alone and ten had microsurgical reconstruction. Of the former, one was lost to follow-up, one had glenoplasty and three had subsequent nerve reconstructions. Of the remaining 17 infants with neurolysis, 13 (76%) achieved a modified Mallet score > 13 at a mean age of 3.5 years (0.75 to 6.25). Subluxation or dislocation of the shoulder is a major confounding factor. The positive predictive value and sensitivity of the intra-operative EMG for C5 were 100% and 85.7%, respectively, in infants without concurrent shoulder pathology. The positive and negative predictive values, sensitivity and specificity of the three investigations combined were 77%, 100%, 100% and 57%, respectively.

In all, 20 infants underwent neurolysis alone for C6 and three had reconstruction. All of the former and one of the latter achieved biceps function of Raimondi grade 5. The positive and negative predictive values, sensitivity and specificity of electromyography for C6 were 65%, 71%, 87% and 42%, respectively.

Our method is effective in evaluating the prognosis of C5 lesion. Neurolysis is preferred for C6 lesions.

Cite this article: Bone Joint J 2013;95-B:699–705.

Neurological complications in oncological and degenerative spine surgery represent one of the most feared risks of these procedures. Multimodal intraoperative neurophysiological monitoring (IONM) mainly uses methods to detect changes in the patient's neurological status in a timely manner, thus allowing actions that can reverse neurological deficits before they become irreversible. The utopian goal of spinal surgery is the absence of neurological complications while the realistic goal is to optimize the responses to changes in neuromonitoring such that permanent deficits occur less frequently as possible. In 2014, an algorithm was proposed in response to changes in neuromonitoring for deformity corrections in spinal surgery. There are several studies that confirm the positive impact that a checklist has on care. The proposed checklist has been specifically designed for interventions on stable columns which is significantly different from oncological and degenerative surgery. The goal of this project is to provide a checklist for oncological and degenerative spine surgery to improve the quality of care and minimize the risk of neurological deficit through the optimization of clinical decision-making during periods of intraoperative stress or uncertainty. After a literature review on risk factors and recommendations for responding to IONM changes, 3 surveys were administered to 8 surgeons with experience in oncological and degenerative spine surgery from 5 hospitals in Italy. In addition, anesthesiologists, intraoperative neuro-monitoring teams, operating room nurses participated. The members participated in the optimization and final drafting of the checklist. The authors reassessed and modified the checklist during 3 meetings over 9 months, including a clinical validation period using a modified Delphi process. A checklist containing 28 items to be considered in responding to the changes of the IONM was created. The checklist was submitted for inclusion in the new recommendations of the Italian Society of Clinical Neurophysiology (SINC) for intraoperative neurophysiological monitoring. The final checklist represents the consensus of a group of experienced spine surgeons. The checklist includes the most important and high-performance items to consider when responding to IONM changes in patients with an unstable spine. The implementation of this checklist has the potential to improve surgical outcomes and patient safety in the field of spinal surgery

A prospective assessment of the cause and results of surgery for recurrent carpal tunnel syndrome. All patients undergoing revision carpal tunnel surgery over a five year period in a specialist hand surgery unit were reviewed. The physical signs, symptoms, ENIG, operative findings and operative outcome were recorded prospectively. The selection criteria for surgery included an appropriate history, positive neurophysiology and one or more positive physical signs (Tinel’s, Phalen’s or pressure signs). Patients with normal neurophysiology results only underwent open release if the signs and symptoms were clear-cut, typically with at least 2 out of 3 positive signs. Twenty-two patients (twenty-four wrists, mean age 55, range 33 to 91) underwent revision surgery. The mean time to re-operation was 7 years. 20 wrists had a positive Tinel’s test, 18 had a positive Phalen’s test, 19 had a positive pressure test and 18 had positive neurophysiology. At operation, 20 wrists were noted to have compression proximally, 3 mid-retinacular and 3 distally. The proximal end of the primary wound scar was 1 cm or more from the distal wrist crease in 9 patients. All patients reported some benefit. Significant or complete relief of symptoms were reported in 19 wrists. Better results were achieved in patients who had noted some improvement after primary surgery that had lasted for at least 4 months before relapse. Most papers report inadequate distal release as the most common cause of re-operation but this study found inadequate proximal release to be more common. Less experienced surgeons may be apprehensive about performing an adequate closed proximal release but should be encouraged to take the scar to the distal wrist crease and if in doubt, incise across it in a standard manner. Our results compare with the best reported in the literature and may be attributable to the selection criteria used

Introduction. Somatosensory evoked potential (SSEP) monitoring allows for assessment of the spinal cord and susceptible structures during complex spinal surgery. It is well validated for the detection of potential neurological injury but little is known of surgeon's responses to an abnormal trace and its effect on neurological outcome. We aimed to investigate this in spinal deformity patients who are particularly vulnerable during their corrective surgery. Methods. Our institutional neurophysiology database was analysed between 1. st. October 2005 and 31. st. March 2010. Monitoring was performed by a team of trained neurophysiology technicians who were separate from the surgical team. A significant trace was defined as a 50% reduction in trace amplitude or a 10% increase in signal latency. Patients suffering a significant trace event were examined post-operatively by a Consultant Neurologist who was separate from the surgical team. Results. 2386 consecutive operations (F:1719, M:667 median age 16 yrs) were performed in the time period and 72 operations reported a significant trace event (‘red alert’). From these cases 47 (65%) had a clearly documented intervention by the surgeon and 7 patients overall suffered a lasting neurological deficit (0.3%). The most common timing events were during instrumentation (50%) and during correction/distraction (16%). Most common responses were optimisation of patient/monitoring set-up (23%) and adjustment of metalwork (22%). There were 18 wake-up tests performed. We found SSEP monitoring to have a sensitivity of 100%, specificity 97.4%, positive predictive value 14% and negative predictive value 100%. A Chi-square test (p=0.016) was significant suggesting intervention had a beneficial effect on neurological outcome. Conclusion. We would advocate the use of SSEP monitoring in all patients undergoing spinal deformity surgery. These patients tend to be young, neurologically intact pre-operatively and are particularly vulnerable to the large corrective forces their surgery requires

Introduction. Evidence suggests that intra-operative spinal cord monitoring is sensitive and specific for detecting potential neurological injury. However, little is known about surgeons' responses to trace changes and the resultant neurological outcome. Objective. To examine the role of intra-operative somatosensory evoked potential (SSEP) monitoring in the prevention of neurological injury, specifically sensitivity and specificity, and whether the abnormalities were reversible. Methods. 2953 consecutive complex spine operations (male 36% female 64%, median age 25yrs) prospectively performed using spinal cord monitoring at a single institution (2005–2009). All traces and neurophysiological events were prospectively recorded by the neurophysiology technician. All patients with a significant neurophysiology event were examined clinically by a neurologist, separate from the spinal surgery team. Significant trace abnormality was defined as a decrease in signal amplitude of 50% or a 10% increase in latency. Timing of trace abnormality, surgeon's response and prospective neurological outcome were recorded. Sensitivity, specificity, positive/negative predictive value were calculated. A Chi-squared test was performed to assess the impact of intervention on neurological outcome (p < 0.05). Results. 2953 operations involving SSEP monitoring were performed and 106 recorded a significant trace abnormality. This most often occurred during instrumentation and the most common reaction was adjustment of metalwork. SSEP monitoring had a sensitivity of 100%, specificity 97.3%, PPV 24%, NPV 100%. There were 79 false positives and no false negatives in this series. Chi-squared test was not significant (p=0.18) suggesting that intervention might not affect neurological outcome in this cohort. Conclusions. Triggering events are uncommon and the development of a persistent neurological deficit is rare with an incidence of 0.85% in this series of 2953 operations. In the majority of cases detection of a monitoring abnormality prompts a corrective reaction by the surgeon. Of those with an abnormal trace 76% were neurologically normal at follow up

A statement of the purposes of the study and background. Lower back pain (LBP) is one of the ten leading causes of disease burden globally, producing significant detrimental effects on physical and emotional wellbeing whilst having a substantial economic burden for society. There is an inverse relationship between socio-economic status and pain prevalence. The effectiveness of a locally run ‘Back to Fitness Programme’ (6-week education and exercise programme) in the most deprived local authority area in England was evaluated. A summary of the methods used and the results. Patients at Blackpool Hospitals NHS Trust over a 6-month timeframe were included. Initial data were collected from 49 patients (mean age 53.4 years, 67% female). The amount of final data collected varied per outcome measure due to a range of factors. Participants reported the programme had helped with their understanding of pain (n=16, 100%), ability to move around and function (n=15, 94%), and level of pain (n=14, 88%). Looking at Roland Morris Disability Questionnaire scores (n=17), 88% (n=15) of patients indicated a reduction (n=12, 71%) or no change (n=3, 18%) in perceived disability. The Pain Self Efficacy Questionnaire (n=18) showed that 78% (n=14) of participants perceived an increase in their average level of confidence to move despite pain. There was an overall improvement in understanding of pain reflected by Revised Neurophysiology of Pain Questionnaire scores (n=44): 89% (n=39) improved (n=36, 82%) or did not change (n=3, 7%). Regarding lumbar flexion post-programme (n=17), 77% (n=13) of participants demonstrated an improvement (n=9, 53%) or no change (n=4, 24%). Conclusion. The majority of clinical outcomes improved following participation, predominantly in relation to understanding of pain. Conflicts of interest: No conflicts of interest. Sources of funding: This study is supported by The University of Central Lancashire in partnership with The Blackpool Teaching Hospitals NHS Foundation Trust

There is an inherent risk of iatrogenic new neurological deficit (NND) arising at the spinal cord, cauda equina and nerve root during spinal surgery. Intraoperative neurophysiological monitoring (IONM) can be employed to preserve spinal cord function during spinal surgery. IONM techniques include somatosensory and motor evoked potentials, amongst others. A Canadian survey of 95 spinal surgeons showed that 62.1% used IONM and a similar survey in France of 117 spinal surgeons showed that only 36% used IONM. Unavailability was a common reason for its disuse. Current literature by the British Society of Clinical Neurophysiology has outlined the importance of IONM in preventing NND and the need for the implementation of guidelines for IONM. The lack of an established guideline has resulted in a varied approach in the use of IONM in England. There has been no previous attempt to ascertain the current use of IONM in England. Our study is aimed at assessing the variability of the use of IONM in England as well as identifying the rationale amongst surgeons that dictate their use of IONM. We are in the process of investigating the indications of use of IONM for cervical and lumbar spine procedures in 252 spinal surgeons from 33 hospitals with spinal services. Our survey will illustrate the current use of IONM in spinal surgery in England. It will highlight some of the reasons for the variability of use of IONM and identify factors that can contribute to a more standardised use of IONM in spinal surgery

57 year old healthy woman, with a non-symptomatic aortic aneurysma after a traffic accident 30 years ago and a 70:ty degree thoracolumbar kyfo-scoliosis, was referred for treatment because of severe postural back-pain. The anticipated treatment was correction of spinal balance with an apical osteotomy, a long instrumentation and maximal number of atachments. A careful preoperative investigation, including DEXA, bending films, internal medical judgement and vascular surgery consultaion, was performed. The latter ended up in an aortic stent, because of the risks of rupture of the aneurysma, due to elongation of the spine and aorta. Correction was performed with an oblique 1,5 segment reduction osteotomy in L1 and L2. Blood loss 2 700 ml. Normal neurophysiology during and after the surgery. The patient could return back home after two weeks, protected by a soft brace. Six weeks after index surgery she became unconscious, got heart arrest and was acute transported to the regional hospital, after resuscitation. Great amounts of blood were found in the lungs and a CT scan demonstrated a severe elongation of aorta as well as a possible rift at the junction between normal and stented vessel. Two weeks later the patient died, still unconscious. Autopsy confirmed aortic rupture. CONCLUSION. What are the risks with aneurysma at spinal correction? Should the correction have been performed without the aortic stent?

Aim:. Recent guidelines have been published by the Association of Neurophysiological Scientists / British Society for Clinical Neurophysiology (ANS/BSCN) regarding the use of intra-operative neurophysiological monitoring (IOM) during spinal deformity procedures. We present our unit's experience with IOM and the compliance with national guidelines. Method:. All patients undergoing intra-operative spinal cord monitoring during adult and paediatric spinal deformity surgery between Jan 2009 and Dec 2012 were prospectively followed. The use of somatosensory-evoked potentials (SSEPs) and motor-evoked potentials (MEPs) was recorded and monitoring outcomes were compared to post-operative clinical neurological outcomes. Compliance with the national ANS/BSCN guidelines was assessed. Results:. 333 patients were included in this study. IOM was successful in 312 patients (94%), with both MEPs and SSEPs obtained in 282 patients (85%). SEPs were achieved in 91% and MEPs in 87%. Aetiology was idiopathic in 199 cases, 53 neuromuscular, 28 degenerative, 16 congenital, 16 other. Nine patients had changes in IOM related to surgical activity; six had MEP changes only, three had MEPs and SSEPs changes. All but one of these changes returned to baseline following surgical action; the one remaining patient had a temporary postoperative neurological deficit. One patient had a post-operative single radiculopathy requiring surgical exploration, without change in initial IOM. Final IOM findings demonstrated a positive predictive value (PPV) of 1 and a negative predictive value (NPV) of 0.996. Discussion:. IOM is essential during spinal deformity surgery and, using MEPs, has a high PPV and NPV. Our unit meets guidelines for MEP use and frequently meets guidelines for SSEP use. Conflict Of Interest Statement: No conflict of interest

Background: Median nerve motor branch compression in patients with Carpal Tunnel Syndrome is usually characterised by reduced finger grip and pinch strength, loss of thumb abduction and opposition strength and thenar atrophy. Surgical decompression is usually necessary in these patients but may result in poor outcomes due to irreversible intraneural changes. Hypothesis: The aim of this study was to investigate patient-reported symptoms which may enable a clinical diagnosis of median nerve motor branch compression to be made irrespective of the presence of advanced signs. Methods: One-hundred-and-twelve patients (166 hands) with a clinical diagnosis of Carpal Tunnel Syndrome were referred to the neurophysiology department and completed symptom severity questionnaires with subsequent neurophysiological testing. Results: An increasing frequency of pain experienced by patients was significantly associated with an increased severity of median nerve motor branch compression with prolonged motor latencies measured in patients that described pain as a predominant symptom. An increasing frequency of paraesthesia and numbness and weakness associated with dropping objects was significantly associated with both motor and sensory involvement but not able to distinguish between them. Conclusion: This study suggests that patients presenting with a clinical diagnosis of carpal tunnel syndrome with pain as a frequently experienced and predominant symptom require consideration for urgent investigation and surgical treatment to prevent chronic motor branch compression with permanent functional deficits. Level of evidence: Prognostic study level 2

The aim of the study was to assess the validity of the new device [BREVIO] [AEND] [Level 2 evidence] in diagnosing carpal tunnel syndrome in the outpatient setting when used by personnel not trained previously in neurophysiologic methods. We prospectively compared the results from a portable handheld automated electroneurodiagnostic devices (AEND) the BREVIO with those from conventional nerve conduction studies. We calculated specificity and sensitivity. We also studied the limits of agreement and correlation between measured latencies. Patient satisfaction with new device was recorded. Twenty-seven participants (42 hands) were tested. The average age was 56.43 years (38-79). There were 16 females and 11 males. The sensitivity and specificity of the BREVIO as compared to conventional methods were 80% and 75% using distal motor latencies; using distal sensory latencies the sensitivity and specificity were 90% and 60% respectively. The limits of agreement between the sensory and motor latencies using Bland Altman plots were good. Similarly there was good correlation between values measured with the Pearson's correlation coefficient. The position of the baseline cursor was questionable in 19 hands. Repositioning the cursor reduced the number of false positive results which would increase the specificity of the device. The average pain score, VAS on a scale of 1-10, with the BREVIO was 1.69 (1-4) and 3.11(1-5) with conventional testing. The average satisfaction rating on a scale of 1-5 was 1.39 with the BREVIO and 2.73 with the conventional nerve conduction testing. The BREVIO is an interesting device. We recommend its use by untrained persons only under the supervision of someone trained in neurophysiology who is aware of potential pitfalls

Carpal tunnel syndrome is a common condition with a prevalence of 2.7% based on symptoms, clinical signs, and neurophysiology. The procedure to cure these patients, whether it is open or endoscopic, is usually successful in returning sensation, abolishing numbness and paraesthesiae, and improving manual dexterity. However, as many as 14%–32% of patients may have persistent symptoms. The general treatment of patients with recurrent carpal tunnel syndrome is re-exploration of the median nerve and neurolysis. Various procedures have been described to cover the median nerve with muscle or fat tissue. These include–external neurolysis, local muscle flaps, fat grafts and flaps, vein wrapping and synovial flaps. The outcome of secondary carpal tunnel surgery is only fair and many procedures are possible. In 19 patients presenting with recurrent carpal tunnel syndrome over a period of five years, silicone sheath was used to cover the median nerve following neurolysis. All of these 19 cases were performed by the senior author (ASR). We audited the results of this procedure using the carpal tunnel outcome instrument (Levine et al., 1993) for subjective assessment and grip strength, thumb key pinch force and two point discrimination sensation for Objective assessment. 17 patients were followed up for the purpose of this study. 2 were lost to follow up. Twelve patients were satisfied with their outcomes and were prepared to undergo the surgery again or recommend it to others (more than 70%). However, two were dissatisfied and three were uncertain of their feelings

Purpose. Tarsal Tunnel Syndrome (TTS) was first reported by Keck and Lam separately in 1962. It has been regarded as the lower limb equivalent to Carpal Tunnel Syndrome (CTS). The gold standard of diagnosis proposed over the years is nerve conduction study (NCS). In reality, TTS is much harder to diagnose and treat compared to CTS. Signs and symptoms can be mimicked by other foot and ankle conditions. Our unit had not seen a single positive nerve conduction result of TTS in clinically suspicious cases. We have therefore audited our 10 year experience. Methods and Results. This is a retrospective audit. Patient list retrieved from neurophysiology. 42 patients were identified. All were referred with a clinical suspicion of TTS. There was no single positive nerve conduction result showing tarsal tunnel compression. Of these, 27 case notes were retrieved (64%). The demographics are: A) age (23 to 78), B) 12 males, 15 females, and C) 12 involving left side, 4 right side and 11 bilateral. These studies were conducted according to national guidelines. There were 8 abnormal studies: 4 showing spinal radiculopathy, 3 showing higher peripheral neuropathy and 1 showing tibial nerve irritation following previous decompression. 4 cases were operated on. These are: 2 for removal of lumps, 1 for partial plantar fascia release, and 1 for redo-decompression. As for the rest: 16 had no change in the symptoms and were discharged, 6 were referred to other disciplines, 2 resolved spontaneously, 2 lost to follow up and 1 resolved after a total knee replacement. Conclusion. Our result does not reflect the findings reported in the literature in the past. Our neurophysiologist also agreed it is very rare to see one positive test. We feel that our understanding of TTS is not complete. The routine NCS done at resting position may not be able to replicate the clinical situations which bring on the symptoms in the first place. Changing lifestyle and improved footwear designs may also have contributed to a change in disease presentation. Further studies are required to clarify the situation

Introduction. One of the most complicated problems of orthopaedics is the treatment of scoliosis. More than 90% of cases are attributable to idiopathic deformation, the cause of which is unknown. We investigated the cause and pathogenesis of this disorder. Methods. At our institution, more than 6900 patients aged 1–89 years have undergone inpatient and outpatient treatment in connection with spinal pain syndrome and different neurological disorders associated with idiopathic scoliosis. This study was undertaken between February, 1996, and February, 2010. All patients had had clinical, radiographic, and laboratory examinations. Results. 29·6% of patients were aged 31–50 years; 60% were men and 40% women. While examining patients with scoliosis deformation we noted symptoms of body asymmetry–ie, different volumes of right and left halves of face, body, and limbs. These features were typical for all patients irrespective of sex, age, and ethnic origin. 83·2% of patients had underdevelopment of left part of the body, and only 16·8% the right side. Analysis of published work in anatomy, physiology, neurophysiology, and vertebrology, done simultaneously with analysis of clinical material, allowed us to make some conclusions. Conclusions. First, asymmetrical structure of human body is based on laws of nature and is linked with difference of sizes and activity of brain's hemispheres, particularly of right or left gyrus centralis anterior, which control the muscle's function and our movements. Second, asymmetrical tension of Erector spinae muscles leads to inclination of the pelvis on a side of weak muscles; thus initiating development of lateral spine curves. Since such a situation is typical for all people, this deformation is known as functional scoliosis. Third, further development of bodies of vertebrae, their arches, processes, intervertebral discs, ligaments, and other anatomical elements in position of deviation leads to one-sided underdevelopment of these structures. As a result, areas of instability appear in each segment of spine (neck, chest, lumbar, and sacral areas). Fourth, the muscles in a growing body misbalance and on the ground of rotating movement start rotatory dislocation of vertebrae in zones of instability in all parts of the spine. As a result, torsion of deformed wedge-shaped vertebrae leads to formation of structural scoliosis. Rotation of vertebrae, described above, does not depend on sex, age, and ethnic origin of a patient and has a character of natural development. Thus, from our point of view, the term idiopathic scoliosis must be changed to spinal muscle asymmetrical deformation of a reflex origin. Understanding of this rotation allowed us to establish an effective non-surgical method of treatment of scoliosis and spinal pain syndrome in patients of all ages

Aims

We aimed to identify the pattern of nerve injury associated with paediatric supracondylar fractures of the humerus.