A. Lee Dellon

Review of treatment results for ulnar nerve entrapment at the elbow

A review of 50 published reports between 1898 and 1988, comprising more than 2000 patients treated for ulnar nerve compression at the elbow, demonstrated that little more than personal bias is available for guidance in selecting treatment. To provide uniform data, the degree of nerve compression of the patients from these articles was staged using a sensory plus motor classification based on contemporary concepts of the pathophysiology of chronic nerve compression. The results of these studies are reinterpreted in light of this staging system. This analysis suggests that for a minimal degree of compression, excellent results can be achieved in 50% of the patients by nonoperative techniques and in almost 100% of patients by any of five surgical techniques. For a moderate degree of compression, the anterior submuscular technique yields the most excellent results with the fewest recurrences. For a severe degree of compression, the anterior intramuscular transposition yielded the fewest excellent and the most recurrent results. This review suggests that an internal neurolysis, combined with an anterior submuscular transposition, may be the best approach when the ulnar nerve is severely compressed.

Surgical management of groin pain of neural origin.

BACKGROUNDnAn approach to surgical management of the patient with groin pain is described based on our experience with 54 patients, six of whom had bilateral symptoms. History and physical examination are sufficient to relate the pain to one or more of the lateral femoral cutaneous (LFC), ilioinguinal (II), iliohypogastric (IH), or genitofemoral (GF) nerves.nnnSTUDY DESIGNnRetrospective analysis of patients with groin pain is reported, with emphasis on cause, involved nerves, and outcomes of operative management. The LFC was decompressed. The II, IH, and GF nerves were resected. Outcomes were graded as excellent, good, and poor in terms of pain relief and functional restoration.nnnRESULTSnFor the entire series of patients with painful groins, excellent relief of pain was achieved in 68% and restoration of function achieved in 72%. Ten percent had a poor result. The best results were for II and IH, which were 78% and 83% excellent for both pain relief and restoration of function, with 11% and 17% having a poor result, respectively. The worst results were for the small group of patients with a GF problem, 50% of whom had an excellent and 25% a poor result. Patients who were likely to get an LFC entrapment were those with a nerve located above or within the inguinal ligament. Complications included bruising and cautery injury to the LFC.nnnCONCLUSIONSnGroin pain of neural origin can be relieved with a high degree of patient satisfaction by considering whether one or more of four different nerves are the source of that pain, by realizing that symptoms can be referred to regions other than the groin, such as the pelvic viscera (IH), the knee (LFC), and the testicle (GF), and by treating the appropriate nerve(s) by either neurolysis (LFC) or resection.

Results of the Musculofascial Lengthening Technique for Submuscular Transposition of the Ulnar Nerve at the Elbow

Background: In the absence of a randomized, prospective study comparing different surgical approaches for decompression of the ulnar nerve at the elbow, the choice of an approach relies on the individual surgeons training and experience. The present report describes the results of a prospective, long-term evaluation of the musculofascial lengthening technique in a large series of patients. In these patients, the degree of ulnar nerve compression was staged with use of a numerical grading system that included measures of both motor and sensory function. Methods: From 1985 through 1991, 121 consecutive patients (161 extremities) in whom the ulnar nerve was entrapped at the elbow were treated with surgical decompression with use of a musculofascial lengthening technique. In addition to the patient history and physical examination, measurements of sensory and motor function were obtained prospectively to permit staging of the severity of the compression by means of a grading scale. The preoperative and postoperative scores on this scale were evaluated. The mean duration of follow-up after surgery was 45.6 months. Results: On the basis of traditional criteria, 105 limbs (65%) had an excellent result; thirty-seven (23%), a good result; six (4%), a fair result; twelve (7.5%), a failure; and one (0.5%), a recurrence. There was significant improvement in ulnar nerve function in terms of both the sensory (p < 0.001) and motor (p < 0.001) components of the grading scale. Comparisons of clinical subgroups revealed significant improvement in patients with diabetes, those with a Workers Compensation claim, and those who had a severe degree of compression rather than a mild degree of compression. Conclusion: Surgical decompression of ulnar nerve entrapment at the elbow by means of a musculofascial lengthening technique was associated with an 88% rate of good to excellent results. The results of the present study demonstrate the feasibility of performing a statistical analysis of surgical results by using a numerical grading system to stage the degree of nerve compression. This method may be used to study different surgical techniques for the treatment of this common nerve compression syndrome. Level of Evidence: Therapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence.

Treatment of Superficial and Deep Peroneal Neuromas by Resection and Translocation of the Nerves into the Anterolateral Compartment

An approach to the treatment of dorsal foot pain of neuroma origin is described based upon principals demonstrated to be effective in the treatment of upper extremity dorsoradial neuromas: translocation of the appropriate nerves into a muscle environment away from the joint. In the lower extremity, this requires identification of the appropriate nerves by anesthetic block, resection of the dorsal foot neuroma(s), and translocation of the nerves into the muscles of the anterolateral compartment. This approach yielded excellent results in 9 of the 11 patients with a mean follow-up of 29 months.

Nerve conduction studies and sensibility testing in carpal tunnel syndrome

This paper compares the results of detailed sensibility testing with nerve conduction studies done in patients with carpal tunnel syndrome. Forty-three patients with 74 symptomatic hands were examined. Median and ulnar distal sensory and motor latencies were obtained bilaterally. Sensibility testing included assessment of perception of vibratory stimuli, classic two-point discrimination, and moving two-point discrimination. Comparison of the results were made in the overall group of patients, and patients were also grouped according to the severity of symptoms. In the 74 hands, nerve conduction studies were abnormal in 81 % and sensory examination was abnormal in 66%, for an overall combined abnormality rate of 92%. In the most severely involved hands, both nerve conduction and sensory testing were abnormal in approximately 80%. However, in the least severely involved group, nerve conduction studies were abnormal in 80%, while sensory examination was abnormal in only 10%.

Reconstruction of a painful post-traumatic medial plantar neuroma with a bioabsorbable nerve conduit: a case report.

Although nerve injuries to feet may be common, primary repair of a damaged nerve in the foot is rare. Secondary digital nerve reconstruction in the foot has not been previously reported. This report describes a patient with post-traumatic neuroma of medial plantar nerve who was treated by neuroma resection; the nerve defect was reconstructed with bioabsorbable nerve conduit. This case illustrates successful, secondary reconstruction of nerve injury in the foot using a new surgical technique. A bioabsorbable polyglycolic acid nerve conduit eliminated the need for a short nerve graft and was effective in relieving the neuroma pain by providing an appropriate distal site for neural regeneration.

Intraneural ulnar nerve pressure changes related to operative techniques for cubital tunnel decompression

To evaluate the effect of critical anatomic structures on the ulnar nerve after cubital tunnel decompression, we determined the intraneural ulnar nerve pressure in 50 fresh cadavers after the following surgical procedures: simple decompression, medial epicondylectomy, subcutaneous transposition, and submuscular transposition by the Learmonth and by the musculofascial lengthening technique. Intraneural pressure was measured in 0 degrees, 30 degrees, 60 degrees, and 90 degrees elbow flexion at locations that were proximal, within, and distal to the cubital tunnel. Statistical analysis compared the mean change in intraneural pressure between the postoperative and the baseline preoperative pressure measurements for the different surgical strategies. While both the simple decompression and the medial epicondylectomy had significantly lower intraneural pressures than the Learmonth or the subcutaneous transposition, each of these four techniques resulted in elevated intraneural pressures. The musculofascial lengthening technique for submuscular transposition was the only surgical strategy that reduced intraneural ulnar pressure at each site of measurement and for all degrees of elbow flexion, this reduction of pressure being significant in comparison with the other surgical techniques.

Neuromas of the calcaneal nerves.

A neuroma of a calcaneal nerve has never been reported. A series of 15 patients with heel pain due to a neuroma of a calcaneal nerve are reviewed. These patients previously had either a plantar fasciotomy (n = 4), calcaneal spur removal (n = 2), ankle fusion (n = 2), or tarsal tunnel decompression (n = 7). Neuromas occurred on calcaneal branches that arose from either the posterior tibial nerve (n = 1), lateral plantar nerve (n = 1), the medial plantar nerve (n = 9), or more than one of these nerves (n = 4). Operative approach was through an extended tarsal tunnel incision to permit identification of all calcaneal nerves. The neuroma was resected and implanted into the flexor hallucis longus muscle. Excellent relief of pain occurred in 60%, and good relief in 33%. One patient (17%) had no improvement and required resection of the lateral plantar nerve. Awareness that the heel may be innervated by multiple calcaneal branches suggests that surgery for heel pain of neural origin employ a surgical approach that permits identification of all possible calcaneal branches.

Neurectomy for Treatment of Intercostal Neuralgia

BACKGROUNDnIntercostal neuralgia due to surgical injury of the intercostal nerve is difficult to treat. No treatment modality has given effective pain relief. Experience with other painful neuromas has demonstrated that neuroma resection and muscle implantation has been effective in the upper and lower extremities. This approach was applied to patients with intercostal neuralgia.nnnMETHODSnA retrospective review was done of 5 consecutive patients who have had neurectomy of one or more intercostal nerves. Preoperative and postoperative pain levels, patient demographics, length of follow-up, and surgical technique were reviewed.nnnRESULTSnAverage patient age was 51.0 years (range, 39.2 to 61.3). Patients presented an average of 42.8 months (range, 10 to 138) after the surgical procedure or trauma that created their painful intercostal neuromas. The mean maximum pain level was 10, and the mean average pain level was 8 (range, 7 to 9). Postoperatively, the mean maximum pain level was 3.4 (range, 0 to 9), and the mean average pain level was 2.2 (range, 0 to 7). The differences were significant: p less than 0.01 for maximum pain level and p less than 0.05 for average pain level. Average follow-up after surgery was 8.8 months (range, 6.5 to 10.9). The most common surgical technique used was intercostal nerve neurectomy proximal to the intercostal nerve neuroma and implantation of the cut nerve into the latissimus dorsi muscle.nnnCONCLUSIONSnIntercostal neurectomy and implantation of the cut nerve into the latissimus dorsi or into the rib for severe intercostal neuralgia was an efficacious treatment in this small consecutive patient series.

A Numerical Grading Scale for Peripheral Nerve Function

A numerical grading scale for median and ulnar function is outlined. This system, based upon the known pathophysiology of chronic nerve compression, creates a hierarchical scale of mutually exclusive categories for motor and sensory function. The scale is responsive to incorporating new technologies for sensorimotor evaluation if these should offer advantages in computer-assisted evaluation, validity, or reliability. The scale is assumed to be nonuniform, and nonparametric statistical analysis, such as use of the Wilcoxon rank-sum test, is appropriate. Where motor function may predominate the peripheral nerve function, such as the ulnar nerve, in contrast to the median nerve, the scale may be uniquely defined to reflect this attribute. Pilot study examples of application of the numerical scoring system are given, and specific areas to better define the scale through research are suggested.