Christine B. Novak

Clinical outcome following nerve allograft transplantation.

The clinical outcome of seven patients who underwent reconstruction of long upper‐ and lower‐extremity peripheral nerve gaps with interposition peripheral nerve allografts is reported. Patients were selected for transplantation when the nerve gaps exceeded the length that could be reconstructed with available autograft tissue. Before transplantation, cadaveric allografts were harvested and preserved for 7 days in University of Wisconsin Cold Storage Solution at 5°C. In the interim, patients were started on an immunosuppressive regimen consisting of either cyclosporin A or tacrolimus (FK506), azathioprine, and prednisone. Immunosuppression was discontinued 6 months after regeneration across the allograft(s) was evident. Six patients demonstrated return of motor function and sensation in the affected limb, and one patient experienced rejection of the allograft secondary to subtherapeutic immunosuppression. In addition to providing the ability to restore nerve continuity in severe extremity injuries, successful nerve allografting protocols have direct applicability to composite tissue transplantation. (Plast. Reconstr. Surg. 107: 1419, 2001.)

Provocative testing for cubital tunnel syndrome

This prospective study evaluated the clinical usefulness of provocative testing in 32 subjects with electrodiagnostically proven cubital tunnel syndrome and 33 control subjects. Four provocative tests were included: Tinels sign, elbow flexion, pressure provocation, and combined elbow flexion and pressure provocation. The mean age of the control group was 41 years and 46 years for the group with cubital tunnel syndrome. In the control group, provocative tests were rarely positive. In 44 extremities with cubital tunnel syndrome, 31 had a Tinels sign, 33 had a positive elbow flexion test, 39 had symptoms with pressure only, and 41 had symptoms with a combination of pressure provocation and elbow flexion testing. The sensitivity of the Tinel sign was 0.70, and at 30 seconds, the sensitivities of the other provocative tests were: elbow flexion (0.32), pressure provocation (0.55), and pressure-flexion test (0.91). The most sensitive provocative test in the diagnosis of cubital tunnel syndrome was elbow flexion when combined with pressure on the ulnar nerve.

Prevalence of smoking, obesity, diabetes mellitus, and thyroid disease in patients with carpal tunnel syndrome.

Carpal tunnel syndrome (CTS) has been associated frequently with physical factors and personal factors including smoking, obesity, diabetes mellitus, and hypothyroidism. The purpose of this retrospective case-control study was to evaluate the prevalence of personal factors in patients with CTS compared with a normal control group. The charts of 514 patients who underwent a carpal tunnel release procedure and 100 control subjects were examined for history of smoking, obesity, diabetes, and hypothyroidism. Compared with the control subjects, there were significantly less CTS patients who smoked (p < 0.001; odds ratio, 0.17). However, there were more CTS patients than control subjects who were obese (p = 0.02; odds ratio, 1.77), had diabetes (p = 0.03; odds ratio, 3.02), and had hypothyroidism (p = 0.02; odds ratio, 3.70). These results support previous reports that CTS is multifactorial, with such factors as obesity, hypothyroidism, and diabetes but not smoking to be more prevalent in this group of CTS patients.Karpitskaya Y, Novak CB, Mackinnon SE. Prevalence of smoking, obesity, diabetes mellitus, and thyroid disease in patients with carpal tunnel syndrome.

Internal neurolysis fails to improve the results of primary carpal tunnel decompression

This prospective, randomized study compares two treatment methods in patients with primary carpal tunnel syndrome. Decompression of the transverse carpal ligament was done in thirty-two hands (thirty patients) and decompression of the transverse carpal ligament with the addition of an internal neurolysis of the median nerve was done in thirty-one hands (twenty-nine patients). Relief of symptoms was described in eighty-eight percent of the patients with carpal ligament release and eighty-one percent of patients with carpal ligament release plus internal neurolysis. Improvement in hand sensibility testing, in thenar muscle strength, and atrophy was noted in both treatment groups with no statistical difference between groups. The addition of an internal neurolysis to division of the transverse carpal ligament does not add significant improvement in the sensory or motor outcome of patients with primary carpal tunnel syndrome.

Establishment of reliability in the evaluation of hand sensibility

Evaluation of hand sensibility using measures of threshold and tactile discrimination are standard assessment methods following nerve injury. Many of the available sensory measures for the quantification of hand sensibility lack verification of intertester reliability. Intertester reliability of vibration threshold, cutaneous pressure threshold, two-point discrimination, object identification, and texture identification was established. The intraclass correlation coefficient ranged from 0.96 to 0.99 for all variables except texture identification (r = 0.77). Comparisons were made between the sensory measures and each functional measure. The strongest correlational relationship was between two-point identification and object identification. Based on the results of this study, evaluation of hand sensibility may be attained with measurement of vibration and cutaneous pressure threshold, two-point discrimination, and object identification.

Evaluation of patients with thoracic outlet syndrome

This prospective study evaluated 50 patients with thoracic outlet syndrome. Detailed history and pain scale evaluation preceded physical examination, which included provocative tests (positional and compressive) and sensory evaluation (baseline and postprovocative vibration thresholds and two-point discrimination). Only one patient had a positive nerve conduction study/electromyograph at the brachial plexus level. Thirty-two percent of the patients had a compressive anatomic abnormality as seen on a computed tomography scan. Ninety-four percent had positive provocative position and compression test results. Two-point discrimination was normal in 98%. Clinical assessment of thoracic outlet syndrome is best achieved by reproduction of symptoms with compression and positional provocative testing. Results of the majority of tests (nerve conduction studies/electromyographs, x-ray films, sensory tests) will be normal. Measurements of changes in sensory thresholds during provocation of symptoms may be useful.

Pathogenesis of cumulative trauma disorder

Ramazzini first described work-related neck and upper limb disorder in 17 13. In the last two decades, industrialized countries have witnessed a remarkable increase in what is termed ‘cumulative trauma disorders’ (CTD).le3 CTD has proven to be a frustrating problem for the worker and those involved in its medical management and an enormous economic cost to employers and healthcare insurers. Numerous terms have been used to describe these disorders, using various combinations of the words “repetitive, ” “cumulative,” “overuse,” and “occupational” with “disorder,” “injury,” “strain,” or “trauma.” In spite of the multiplicity of terms used to describe this syndrome, a uniformity in clinical presentation is recognized. Associated with this disorder are a number of problems (ganglion, arthritis, tendinitis) that are easily managed. However, under this same category a nonspecific upper extremity pain syndrome is recognized and presents the major challenge in patient management. Individuals typically complain of pain that involves the entire upper extremity(ies), including the neck, upper back, and shoulder.4v5 Paresthesia or numbness is noted in the hand, although it can also be present in the forearm. Cramping or aching of the muscles in the forearm and hand is reported. Painful limitation of movement of the neck and shoulder is common. Occipital or orbital headaches and subscapular pain are frequent complaints. Occasionally, anterior chest wall pain or facial numbness is described. Superimposed on these gen-

Verification of the Pressure Provocative Test in Carpal Tunnel Syndrome

Three provocative tests (pressure, Phalens test, and Tinels sign) were studied in 30 patients with carpal tunnel syndrome and 30 control subjects. The pressure provocative test had a sensitivity of 100%. In contrast, Phalens test was 88% sensitive and Tinels sign only 67% sensitive. The pressure provocative test is a sensitive indicator of median nerve compression at the wrist with a faster reaction time than Phalens test (mean time of 9 seconds vs 30 seconds). It is an appropriate provocative test in patients with stiff or painful wrists when wrist flexion is restricted.Williams TM, Mackinnon SE, Novak CB, McCabe S, Kelly L: Verification of the pressure provocative test in carpal tunnel syndrome. Ann Plast Surg 1992;29:8–11

Functional outcomes and donor site morbidity following circumferential pharyngoesophageal reconstruction using an anterolateral thigh flap and salivary bypass tube

This study reports our experience with fasciocutaneous reconstruction of circumferential pharyngoesophageal defects using an anterolateral thigh flap wrapped around a salivary bypass tube.

Repetitive Use and Static Postures: A Source of Nerve Compression and Pain

Nerve compression or musculoskeletal diagnoses require consideration of both the repetitive movements and static postures that may be contributing to the problem. Certain postures and positions assumed at home, at work, and during sleep will have three major influences: (1) directly increasing pressure on nerves at entrapment sites; (2) placing muscles in shortened positions so that adaptive muscle shortening may then secondarily compress nerves; and (3) placing some muscles in elongated and weakened positions, resulting in other muscles being over-used, thus creating the cycle of muscle imbalance. Successful management of the patient with upper extremity pain, paresthesia, and numbness should begin with initial identification of all sites that are contributing to the presenting symptoms. Treatment must then be directed toward the sources of nerve compression and musculoskeletal dysfunction. Upper quadrant symptomatology can be alleviated with an appropriate therapy program, even in the patient with chronic symptoms, but only with patient education, compliance with an exercise program, and behavioral modification at home, work, and during sleep.