1. Three cases of fatty infiltration of the median nerve are reported. 2. One patient had symptoms of median nerve compression. 3. The intimate association of fibro-fatty tissue within the nerve precludes enucleation of the swelling

INTRODUCTION: Median Nerve has small vessel on the volar aspect of the nerve which is filled with blood and results in so called ‘ BLUSHING’ of the nerve once it has been decompressed. It was thought that the nerve which didnot blush meant an inadequate decompression was carried out. PURPOSE: To evaluate whether ‘Blushing’ of the Median Nerve is correlated with adequate decompression and level of recovery in Carpal Tunnel Syndrome through Mini Palmar Incision. METHODS & MATERIALS: Retrospective analysis of a Single Surgeon practise where it was documented in operation notes whether the nerve was seen to ‘Blushed’ at the time of surgery.They were assessed postoperatively from notes for complete resolution of symptoms and whether there was any recurrence of symptoms. RESULTS: n=330 Carpal Tunnel Decompressions were reviewed. It was noted that those who had complete resolution of symptoms had ‘Blushing’ noted at the time of surgery compared to those who had partial or incomplete resolution of symptoms wher ‘No BUSHING’ was noticed. Average time of follow up = 6 weeks. Blushing Noted at the time of decompression 192, Recovery/ improvement of symptoms 189, Blushing not noted at the time of surgery 38, NO documentation about Blushing in 100. CONCLUSION: Blushing of Median Nerve intraoperatively is a reliable sign for complete decompression of the nerve and is correalted with good final outcome

The anatomical integrity of the epi- and para-nevrium is the most relevant factor for the correct gliding of the median nerve, and when they are surrounded by scar tissue, the result is a chronic neuropathy. This recurrent compressive neuropathy represents a very challenging clinical and surgical problem. Neurolysis can not always improve the recovery of nerve function, and the soft tissue coverage is necessary to prevent recurrent scar and to achieve a useful mobilization of the median nerve. The autogenous vein graft wrapping technique has shown great promise for the treatment of chronic compressive neuropathy after other procedures have failed. The author present their experience using the Basilic vein grafting as a valid alternative to the Saphenous one. All our patients presented symptoms in the median nerve distribution, including pain, swelling and numbness, and grip strength reduction. Four of these patients presented a CRPS and have been evaluated before treatment in a multidisciplinary dedicated equipe to plan the surgical procedure. The vein graft wrapping represents a simple technique without problem in donor area. In the authors’ casuistry it presented also as a very useful technique in the treatment of median neuropathy in CRPS

1. Two cases are reported in which there was diffuse fibro-fatty overgrowth or tumour formation involving the adipose tissue of the median nerve. In each the diagnosis was confirmed by operation and histological examination. 2. The first case is an example of the developmental abnormality usually referred to as "macrodystrophia lipomatosa." The second case should be termed fibrolipoma. 3. The literature is reviewed; no case of fibrolipoma has been recorded

Purpose : We report two cases of bifid median nerve in the carpal tunnel because of the exceptional rarity of this event. This does not abolish the possibility of the existence of the second branch and the inspection of the carpal tunnel’s content should be done with special care. Materials and methods : 530 patients with carpal tunnel syndrome were operated in our clinic in the time period 1994 to 2002 with the open and endoscopic method. 351 of them were women and 179 men. Among these patients two had a bifid median nerve in the carpal tunnel. These two patients were married women whose children had dysplasia of different organs. Results : In both cases the patients were relieved from the symptoms of pressure after the release of the transverse carpal ligament and the epineurium. Conclusions : It is not known if the existence of a bifid median nerve is a reason of carpal tunnel syndrome. However it is an exceptional rare event and we must take special care to recognize the second branch so as to have the same handling as the first one. Finally, we must examine the children of these parents for the existence of organs dysplasia

Purpose: The aim of this study was to redefine the localization of the thenar motor branch (TMB) of the median nerve in relation to the surface landmarks which are in routine use. Methods: The study was performed in 37 hands of 34 patients who underwent carpal tunnel release. All of the patients were women and the mean age was 50 (35–67). A radiological marking technique was used to determine the localization of the TMB, the middle finger radial side line and the Kaplan’s cardinal line. For marking TMB a circumscribing soft radioopaque yarn was used while the surface landmark lines were demonstrated by taping one K-wire for each. An image intensifier print image was obtained for each case and the distances between the markers of the TMB and the wires were measured. Results: The TMB had a mean ulnar offset of 12.6 mm (4.0–19.7) from the middle finger radial side line and located 4.4 (0–9.5) mm proximal to the cardinal line. Conclusion: During the carpal tunnel release operations one must pay more attention to the localization of the TMB of the median nerve because it was found to be 12.6 mm ulnar than that was described in classic literature

The postoperative course of median nerve decompression in the carpal tunnel syndrome may sometimes be complicated by postoperative pain, paresthesias, and other unpleasant symptoms, or be characterized by a slow recovery of nerve function due to prolonged preoperative injury causing extensive nerve damage. The aim of this study is to explore any possible effects of alpha lipoic acid (ALA) in the postoperative period after surgical decompression of the median nerve at the wrist. Patients were enrolled with proven carpal tunnel syndrome and randomly assigned into one of two groups: Group A: surgical decompression of the median nerve followed by ALA for 40 days. Group P: surgical decompression followed by placebo. The primary endpoint of the study was nerve conduction velocity at 3 months post surgery, Other endpoints were static 2 point discrimination, the Boston score for hand function, pillar pain and use of pain killers beyond the second postoperative day. ALA did not show to significantly improve nerve conduction velocity or Boston score. However, a statistically significant reduction in the postoperative incidence of pillar pain was noted in Group A. In addition, static 2 point discrimination showed to be significantly improved by ALA. Administration of ALA following decompression of the median nerve for carpal tunnel release is effective on nerve recovery, although this is not detectable through nerve conduction studies but in terms of accelerated and improved static two-point discrimination. The use of ALA as a supplementation for nerve recovery after surgical decompression may be extended to all types of compression syndromes or conditions where a nerve is freed from a mechanical insult. Furthermore, ALA limits post-decompression pain, including late pericicatricial pain at the base of the palm, the so called pillar pain, which seems to be associated with a reversible damage to the superfical sensitive small nerve fibers. In conclusion postoperative administration of ALA for 40 days post-median nerve decompression was positively associated with nerve recovery, induced a lower incidence of postoperative pillar pain and was associated with a more rapid improvement of static two-point discrimination. This treatment is well tolerated and associated with high levels of satisfaction and compliance, supporting its value as a standard postoperative supplementation after carpal tunnel decompression

Purpose of the study: We report the results of a prospective series of 104 cases of carpal tunnel decompression using a minimally invasive technique performed by one operator. Material and methods: The 92 patients (28 men) were treated in an outpatient clinic between February 1999 and July 2002. Mean age was 50 years and 86% of the cases involved the dominant side. Twenty-one patients were manual laborers. There was a notion of repeated motion (occupational disease) in nine cases and eight patients were diabetics. Nocturnal paresthesia predominated the clinical presentation in all patients. Anesthesia of the median nerve territory was noted in five patients. There was no motor deficit. The technique consisted in decompression of the carpal tunnel under local anesthesia via an incision in the flexion fold of the wrist and introduction of a pre-moulded canulated probe into the carpal tunnel then section of the anterior retinacular ligament using a n°15 lancet guided by the probe. Patients were reviewed at 15 days, then one, three and six months. Results: Outcome was excellent or good in 97.2%. One patient was partially relieved: this diabetic patient retained decreased sensitivity in the median nerve territory but the nocturnal paresthesia resolved completely. Two patients underwent decompression on both sides (same technique) and continued to complain about pain on one side. There were no neurological, tendinous, or infectious complications and no conversion to open surgery was required. Mean duration of sick leave was 22.3 days and daily activities were resumed without pain at the base of the hand on average 15 days after surgery. Conclusion: The results obtained with this minimally invasive non-endoscopic technique are comparable with endoscopic techniques but at a lesser cost

To evaluate the functional outcome after complete median nerve transaction and repair, and sensory reeducation. We studied 40 patients, aged 20 to 32 years, with median nerve neurotmesis at the wrist. Primary epineural microsurgical repair using 8-0 single strand sutures was done in all patients, and a hand and wrist cast was applied for 4 weeks. After cast removal all patients went through physical therapy for 1 month to restore motion and reduce stiffness of the injured hand. After reinnervation was completed, the patients were randomly allocated into 2 equal groups: Group A patients were instructed to a sensory re-education program; Group B patients had no further treatment. Clinical evaluation was done at 18 months postoperatively including the localization test (locognosia), the static and the moving 2 point discrimination tests, the Moberg’s pick-up test (stereognosia), and the hand grip and the opposition strength tests. All patients were included in the postoperative evaluation. Hand grip and opposition strength, static and moving two point discrimination were not statistically significant between the two groups (p= 0.622, p= 0.112 and p= 0.340, respectively). The localization test was statistically significant in group A (p= 0.007), and a trend to statistical significance was observed regarding the Moberg’s pick up test in group A (90% statistical significance, p= 0.063). Sensory reeducation is essential for patients with median nerve neurotmesis and repair, as it significantly re-educates localization and stereognosia in the shortest time following peripheral nerve injury and repair

A variation of the motor branch of the median nerve is described in which this branch arose more proximally and pierced the flexor retinaculum. Its significance during a carpal tunnel decompression is pointed out

1. A lesion of the median nerve after reduction of a dislocated elbow in a boy of nine is recorded. 2. The nerve lesion was progressive, and at operation on the seventh day after injury the nerve was found to be trapped in the joint between the humerus and the ulna. 3. The nerve was freed and gradual recovery occurred

1 . The clinical results in forty cases of repair of the median nerve at the wrist have been examined. Almost half were unsatisfactory. 2. The factors that may have predisposed to failure of adequate re-innervation are discussed. 3. The results might be improved by the use of radio-opaque markers for early detection of separation at the suture line, and by the use of frozen sections to determine the adequacy of resection

Whiplash remains a challenging condition because the pathology is undefined. The purpose of this study was to evaluate the response of chronic neck, shoulder and arm pain to decompression of the median nerve at the wrist and pronator teres level. In a prospective study of 150 cases following whiplash injury (108 carpal tunnel and 42 pronator teres syndrome) clinical symptoms were assessed by clinical, neurological, radiological and visual analogue scale. The pathophysiology of pain and effects of surgery have also been assessed by neuropeptide studies. Clinical and neurological examination revealed signs and symptoms of carpal tunnel and pronator teres syndrome along with severe neck, shoulder and arm pain. Local anesthetic infiltration around the median nerve at the wrist and forearm abolished the chronic neck and shoulder pain within 10mins of injection. This demonstrated the site of pathology and temporarily relieved upper limb symptoms and trapezius muscle spasm as well. Neurophysiological studies were always normal. Surgical intervention in successful cases cured chronic neck shoulder and arm pain with sensory and motor recovery. Also activities of daily life normalised permanently. The main neurotransmitter peptides Substance P and Calcitonin gene related peptide levels returned to control levels six weeks after surgery in successful cases (p< 0. 005 and p< 0. 05 respectively). This is the biochemical evidence of effect of surgery in relieving pain and neuroinflammatory process. Our study suggests that neck shoulder and arm pain following whiplash injury is caused by entrapment of the median nerve due to stretching. Surgical decompression of the carpal tunnel and pronator teres muscle yielded 93% and 80% good results respectively with the disappearance of chronic neck shoulder and arm pain. Consequently normalisation of daily activities were observed. Although mild hand symptoms caused by carpal tunnel syndrome have also been cured the primary aim of surgical intervention is to cure chronic neck shoulder and arm pain

Two cases of delayed median nerve division after laceration of the wrist by glass are described. In both there was no neurological damage at the time of the original injury. However, retained fragments of glass were subsequently responsible for division of the median nerve in both cases and of the surrounding tendons in one. Radiographs were an important diagnostic aid in treating the delayed injury

Two boys with entrapment of the median nerve in the elbow joint after closed reduction of a posterior dislocation with fracture of the medial epicondyle showed a characteristic radiological sign in the anteroposterior radiograph after two to three months. The sign was a depression in the cortex on the ulnar side of the distal humeral metaphysis, with interruption of the local periosteal reaction. At operation in both patients the depression was found to correspond with the place where the median nerve reached the posterior surface of the humerus. Radiographs taken after transverse section of the nerve above and below the joint capsule and end-to-end suture showed gradual disappearance of the cortical depression

1. A case, believed to be the fifth on record, of supracondylar fracture with rupture of the brachial artery is described. 2. The relative immunity of the median nerve in these injuries is discussed, with brief reference to a recent case of complete rupture. Only a single previous report of this complication could be found. 3. It is suggested that these injuries are less uncommon than the number reported would indicate. 4. The anatomy of severe displacement is discussed, with special reference to the role of the brachialis. 5. The danger of closed reduction when the relationship of the upper fragment to the neurovascular bundle is in doubt is stressed. 6. The indications for open reduction are given

Aims: The combination of microsurgical techniques with engineering of pseudo-nerves has recently seen an increased employment for the repair of peripheral nerve defects. Over the last ten years, we have investigated a particular type of bio-engineered nerve guide, the muscle-vein-combined tube, which is made by filling a vein with skeletal muscle. However, the basic mechanism underlying the effectiveness of this surgical technique are still unclear and yet an experimental study on its efficacy on functional recovery compared to traditional nerve autografts is still lacking in the literature. The aim of the present study was thus to fill this gap. Methods: In rats, 10-mm-long median nerve defects were repaired using either traditional autografts or fresh muscle-vein-combined bioengineered scaffolds. Posttraumatic nerve recovery was assessed by grasping test. The samples were collected at different times after surgery: 5, 15, 30 days and 6 months. Analysis was carried out by light and electron microscopy. In addition, reverse transcription polymerase chain reaction (RT-PCR) was used to investigate the expression of mRNAs coding for glial markers as well as glial growth factor (NRG1) and its receptors (erbB2 and erbB3). Results: Results showed that both types of nerve repair techniques led to successful axonal regeneration along the severed nerve trunk as well as to a partial recovery of the lost function as assessed by grasping test. Rats operated on by traditional nerve autografts performed better in the grasping test. Biomolecular analysis by RT-PCR demonstrated early overexpression during nerve regeneration of the gliotrophic factor NRG1 and two of its receptors: erbB2 and erbB3. Conclusions: Our results confirmed that use of muscle-vein-combined tissue-engineered conduits is a good approach for bridging peripheral nerve defects in selected cases when traditional autografts are not employable and disclosed one of the basic biological mechanism that support the effectiveness of this surgical technique. Our experience also suggested that the rat forelimb experimental model is particularly appropriate for the study of microsurgical reconstruction of major mixed nerve trunks. Furthermore, since the forelimb model is less compromising for the animal, it should be preferred to the hindlimb model for many research purposes

Introduction. The flexor carpi radialis (FCR) approach is widely used for volar plate fixation of distal radius fractures. However, patients sometimes complain of postoperative numbness at the thenar eminence. We propose this is derived from injury to the palmar cutaneous branch of the median nerve (PCBm). Materials and methods. From March 2010 to March 2012, we performed 10 operations of volar plate fixation for distal radius fractures using the FCR approach. We detected the PCBm intraoperatively and investigated the anatomy. Results. On average, the PCBm arises from the median nerve 44 mm proximal to the distal wrist crease. It arose from the radial side of the median nerve in nine cases and the ulnar side in one case. In all cases, it ran between the FCR and the palmaris longus tendon under the antebrachial fascia. Nerve supply to the FCR sheath was not observed in the field of operation. Discussion. Numerous studies report the necessity to preserve the PCBm during carpal tunnel release surgery, but the relationship between the FCR approach and the PCBm has not been emphasized. Our results generally agree with past reports on PCBm anatomy. In our experience, the FCR tendon should be retracted to the ulnar side to prevent PCBm injury. If the FCR tendon is retracted radially, the PCBm should be detected and retracted gently. Some studies report that the PCBm joins the FCR sheath at the level of the distal wrist crease. Thus, the distal sheath incision should not be extended blindly

Median nerve release is one of the most common procedures performed in hand surgery (classical incision or endoscopic methods), with a low complication rate, but not free of morbidity conditioning work reincorporation. We present a comparative study between the classical technique and double-incision approach of median nerve preserving the intereminencial space. Material and methods. A review of 155 hands in 133 patients (all operated by the same surgeon), divided in two separate groups:. – 72 hands (61 patients) operated by classical technique. – 83 hands (72 patients) operated by double-incision approach. Excluding criteria: patients under 30 years-old, antecedents or symptoms of associated local pathology, trophic troubles of thenar or hypothenar eminences and recurrent carpal tunnel syndrome. We reviewed: per-operatory neurovascular complications, difficulties in hand activity related to pillar pain at 10 and 21 days and 3 and 12 months after surgery, discomfort in the thenar-hypothenar areas (intereminencial pruritus), remaining discomfort in the area of the surgical scar at 3 and 12 months after surgery, and recurrences at 24 months. Results: Nerve compression symptoms disappeared in all 155 hands and neither complications nor recurrences were observed at 24 months. Pillar pain conditioning hand activity:. 21 days: A-group 32 cases (44 %) %, B-group 0%. 3 months: A-group 18 cases (25 %), B-group 0%. 12 months: A-group 5 cases (7 %), B-group 0%. Discomfort in the thenar-hypothenar areas (inter-eminencial pruritus):. 21 days: A-group 0%, B-group 15 cases (18 %). 3 months: A-group 0%, B-group 6 cases (7 %) Remaining discomfort in surgical scars areas:. 3 months: A-group 18 cases (25%) palm area, B-group 4 cases (5 %) wrist area. 12 months: A-group 5 cases (7 %) palm area, B-group 0%. Conclusion: Absence of pillar pain in double-incision approach and free hand activity 3-4 weeks post-operatively were obtained, only a discrete intereminencial pruritus was observed (unusual at 3 months). We therefore consider this technique as a first choice in suitable patients as it avoids discomfort or disability. Furthermore this technique is of low risk and low cost

Introduction: Conventional nerve conduction studies localize the lesion of a nerve and can disclose the degree of focal conduction block or pinpoint the region of focal slowing, giving complementary information about the character of the lesion. In a group of active population transient disturbances during physical efforts are commonly observed. Aim: To precise the evolution with time of EMG recordings of the median nerve in common sport-specific positions. Material and methods: 20 healthy volunteers and 12 symptomatic patients (persons with a conduction block were excluded from the study). Conventional EMG of median nerve was performed, than a “reversed Phalen” position kept for 30 min, and consequent measurements in 5 min periods were performed. Results: In 20% of asymptomatic patients a significant decrease of sensory nerve action potential was recorded after 20 min of observation, while 100% of symptomatic in daily living and negative in conventional EMG studies developed a severe decrease of conduction and blocks after 15 min. These symptoms recuperated after 5 min in functional wrist position. We proposed to these patients a neuromobilisation physiotherapy program, that clinically diminished their complaints. Conclusions: EMG shows a 97–100% diagnostic specificity and sensitivity. It might be a functional test helping to distinguish a group of risk of development of carpal tunnel syndrome with exercises. This method is useful among patients with functional disturbances due to joint instability or repetitive motions in sports