-
Clinical Anatomy 12/2007; 20(8):968-9. · 1.29 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Chronic inflammatory neuropathies can present with a sensory ataxia due to involvement of dorsal root ganglia (DRG) or sensory nerves. Selective inflammatory involvement of sensory nerve roots proximal to the DRG has been postulated.
The authors identified 15 patients with a sensory syndrome and normal nerve conduction studies. Sensory nerve root involvement was suggested by either somatosensory evoked potential (SSEP) or imaging abnormalities. CNS disease was excluded.
All patients had gait ataxia, large fiber sensory loss, and paresthesias, and nine had frequent falls. The disease course was chronic and progressive (median duration 5 years, range 3 months to 18 years). Sural sensory nerve action potential amplitudes were preserved and SSEP abnormalities were consistent with sensory nerve root involvement. Five patients had enlargement of lumbar nerve roots on MRI with enhancement in three. The CSF protein was elevated in 13 of 14 patients tested. Three patients had lumbar sensory rootlet biopsies that showed thickened rootlets, decreased density of large myelinated fibers, segmental demyelination, onion-bulb formation, and endoneurial inflammation. Six patients who required aids to walk were treated with immune modulating therapy and all had marked improvement with four returning to normal ambulation.
Based on the described clinical features, normal nerve conduction studies, characteristic somatosensory evoked potential (SSEP) abnormality, enlarged nerve roots, elevated CSF protein, and inflammatory hypertrophic changes of sensory nerve rootlet tissue, we suggest the term chronic immune sensory polyradiculopathy (CISP) for this syndrome. This condition preferentially affects large myelinated fibers of the posterior roots, may respond favorably to treatment, and may be a restricted form of chronic inflammatory demyelinating polyradiculoneuropathy.
Neurology 12/2004; 63(9):1662-9. · 8.31 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Because of the poor clinical results in achieving hand function in patients with complete brachial plexus root avulsion with other nerve transfers, we evaluated 111 patients prospectively to evaluate the technique of the hemi-contralateral C7 transfer to the median nerve. The transfer was performed as a primary procedure in 62 patients and as a secondary procedure in additional 49 patients. Twenty-one of the 62 patients in the primary group had sufficient follow-up (at least 3 years) to assess the motor and sensory recovery in the median nerve. The adverse effects of the operation were also analyzed in all 111 patients. Six of the 21 (29%) patients obtained M3 and 4 (19%) experienced M2 recovery of the wrist and finger flexors. Ten (48%) patients obtained S3 and 7 (33%) had S2 recovery in the median nerve area. The rate of the advancing Tinel's sign was markedly different between those achieving M3 function and the remaining patients. Although the age of the patient did not correlate with outcome, patients aged 18 and younger had the best motor recovery (ie, achieving M3 function in 3 of 6 cases). There was no correlation between the timing of the surgery after the initial injury, medical comorbidities, and clinical outcome. After surgery 108 of 111 (97%) patients experienced temporary paresthesia in the median nerve area, which resolved by an average of 2.8 months. Three (3%) patients had motor weakness of the donor limb; this resolved completely in 2 patients and left a mild deficit in wrist extension in 1 patient.
The Journal Of Hand Surgery 12/2001; 26(6):1058-64. · 1.35 Impact Factor
-
S W O'Driscoll, R J Spinner,
M D McKee,
W B Kibler,
H Hastings,
B F Morrey,
H Kato,
S Takayama,
J Imatani,
S Toh,
H K Graham
[show abstract]
[hide abstract]
ABSTRACT: Cubitus varus has long been considered merely a cosmetic deformity. The purpose of this paper is to demonstrate a causal relationship between cubitus varus and instability of the elbow.
In twenty-four patients (twenty-five limbs) with a cubitus varus deformity following a pediatric distal humeral fracture or resulting from a congenital anomaly (three limbs of two patients), tardy posterolateral rotatory instability of the elbow developed approximately two to three decades after the deformity occurred. All patients presented with lateral elbow pain and recurrent instability. The average varus deformity was 15 degrees (range, 0 degrees to 35 degrees ). Surgery was performed in twenty-one patients (twenty-two limbs). Treatment consisted of reconstruction of the lateral collateral ligament and osteotomy in seven limbs, ligament reconstruction alone in ten, osteotomy alone in four, and total elbow arthroplasty in one.
In three patients, the triceps muscle was dynamically stimulated intraoperatively to contract while resisting extension of the elbow. This produced posterolateral rotatory subluxation of the elbow, which was reversed by corrective osteotomy and lateral transposition of a portion of the medial head of the triceps that originally had been attached to the elongated, deformed medial aspect of the olecranon. At an average of three years (minimum, one year) after the operation, the result was good or excellent for nineteen of the twenty-two limbs that had undergone an operation; three limbs had persistent instability.
With cubitus varus, the mechanical axis, the olecranon, and the triceps line of pull are all displaced medially. The repetitive external rotation torque on the ulna permitted by these deformities can stretch the lateral collateral ligament complex and lead to posterolateral rotatory instability. Thus, cubitus varus deformity secondary to supracondylar malunion or congenital deformity of the distal part of the humerus may not always be a benign condition and may have important long-term clinical implications. Operative correction can relieve symptoms of instability. The indications for preventive corrective osteotomy remain to be determined.
The Journal of Bone and Joint Surgery 10/2001; 83-A(9):1358-69. · 3.27 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The practice of neurological surgery at the Mayo Clinic began as early efforts were undertaken by Drs. Charles Mayo and Emil Beckman, and surgical procedures were performed for trauma, infection, tumor, epilepsy, and hemorrhage. In 1919, the Section of Neurologic Surgery was established, with Alfred W. Adson as its first chair. Subsequently, Drs. Winchell McK. Craig, J. Grafton Love, Collin S. MacCarty, Ross H. Miller, and Thoralf M. Sundt, Jr., followed as eminent chairmen. Beginning with a modest number of cases per year, the neurosurgical service at the Mayo Clinic has grown to become one of the largest in North America. Under the current leadership of Dr. David G. Piepgras, approximately 3200 surgical procedures spanning the spectrum of subspecialties are performed each year by a staff of 10 neurosurgeons. This article traces neurosurgery at the Mayo Clinic, including several persons who contributed to its achievements over the past century.
Neurosurgery 09/2001; 49(2):438-46. · 2.79 Impact Factor
-
Acta Orthopaedica Scandinavica 07/2001; 72(3):320.
-
[show abstract]
[hide abstract]
ABSTRACT: We postulate an iatrogenic cause for snapping of the medial head of the triceps. A patient whose ulnar nerve and triceps did not dislocate over the medial epicondyle preoperatively had snapping of a portion of the medial triceps after submuscular transposition of the ulnar nerve. We believe that release of the brachial fascia and excision of the medial intermuscular septum removed the restraint to anterior translation of the medial aspect of the triceps, permitting dislocation of a portion of the medial head of the triceps with elbow flexion in this case. Previous reports of snapping of the triceps resulting after ulnar nerve transposition occurred in patients whose ulnar nerve dislocated preoperatively; in these cases, the triceps was thought to have dislocated preoperatively (along with the ulnar nerve) but was not recognized. Careful intraoperative assessment of the triceps after ulnar nerve transposition should prevent medial triceps instability as a postoperative concern.
Journal of the Southern Orthopaedic Association 02/2001; 10(4):236-40.
-
[show abstract]
[hide abstract]
ABSTRACT: A study was conducted to determine the incidence of ulnar and peripheral neuropathy in patients with rheumatoid arthritis undergoing total elbow arthroplasty and the effect it has on ulnar nerve function after surgery. Preoperative and postoperative clinical and electrodiagnostic examinations were completed in 10 patients. Before surgery 4 patients had clinical and electrophysiologic evidence of a neuropathy (2 each with a peripheral neuropathy and an ulnar neuropathy). One patient had subclinical evidence of a chronic T-1 radiculopathy. After surgery 2 patients showed neurologic improvement (1 had ulnar neuropathy and 1 had diabetic neuropathy). One patient who had normal test results before surgery developed transient ulnar sensory symptoms after surgery. An electrodiagnostic study confirmed an ulnar neuropathy that was not detected on physical examination; the electrodiagnostic findings improved 4 months later. We found that a large percentage of patients (40%) with rheumatoid arthritis had evidence of ulnar or peripheral neuropathy before surgery. The presence of an ulnar or peripheral neuropathy did not predispose patients to develop postoperative ulnar nerve dysfunction either clinically or electrophysiologically. Preoperative and postoperative physical and electrodiagnostic examination results correlated in 9 of the 10 patients.
The Journal Of Hand Surgery 04/2000; 25(2):360-4. · 1.35 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Different theories have evolved to explain the pathogenesis and the cell of origin of intraneural ganglion cysts. Reportedly only three cases of intraneural ganglion of the tibial nerve have been located within the popliteal fossa, and all of these were thought to arise within the nerve. The authors report a case of a recurrent tibial intraneural ganglion in which a connection to the proximal tibiofibular joint was demonstrated on magnetic resonance (MR) images and at surgery. Surgical ligation of the articular branch and evacuation of the cyst led to symptomatic relief, and an MR image obtained 1 year after surgery documented no recurrence. This case reinforces the fact that surgeons need to consider and search for an articular connection in all cases of intraneural ganglia, especially in those that have recurred.
Journal of Neurosurgery 03/2000; 92(2):334-7. · 2.96 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Failed surgical treatment for ulnar neuropathy or neuritis due to dislocation of the ulnar nerve presents diagnostic and therapeutic challenges. The authors of this paper will establish unrecognized dislocation (snapping) of the medial portion of the triceps as a preventable cause of failed ulnar nerve transposition.
Fifteen patients had persistent, painful snapping at the medial elbow after ulnar nerve transposition, which had been performed for documented ulnar nerve dislocation with or without ulnar neuropathy. The snapping was caused by a previously unrecognized dislocation of the medial portion of triceps over the medial epicondyle. Seven of the 15 patients also had persistent ulnar nerve symptoms. The correct diagnosis of snapping triceps was delayed for an average of 22 months after the initial ulnar nerve transposition. An additional surgical procedure was performed in nine of the 15 cases and, in part, consisted of lateral transposition or excision of the offending snapping medial portion of the triceps. Of the four patients in this group who had persistent neurological symptoms, submuscular transposition was performed in the two with more severe symptoms and treatment of the triceps alone was performed in the two with milder neurological symptoms. Excellent results were achieved in all surgically treated patients. Six patients declined additional surgery and experienced persistent snapping and/or ulnar nerve symptoms.
Failure to recognize that dislocation of both the medial portion of the triceps and the ulnar nerve can exist concurrently may result in persistent snapping, elbow pain, and even ulnar nerve symptoms after a technically successful ulnar nerve transposition.
Journal of Neurosurgery 01/2000; 92(1):52-7. · 2.96 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: A patient was evaluated with familial trigeminal neuralgia (TN) and contralateral hemifacial spasm. The mother of the patient, 5 of 10 siblings, and 1 nephew also had TN confirmed by neurologists. The transmission of TN was suggestive of an autosomal dominant inheritance. This family provides additional evidence of a genetic basis for TN in selected cases and also provokes further speculation on a common unifying hypothesis of pathophysiology in cranial rhizopathies.
Neurology 08/1999; 53(1):216-8. · 8.31 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Five patients with cubitus varus deformities from malunited childhood fractures had dislocation (snapping) of both the medial portion of the triceps and the ulnar nerve over the medial epicondyle. In addition to snapping, these patients had medial elbow pain or ulnar nerve symptoms. Cubitus varus shifts the line of pull of the triceps more medial, which can cause anteromedial displacement of the medial portion of the triceps during elbow flexion. The ulnar nerve is concomitantly pushed or pulled anteromedially by the triceps, and ulnar neuropathy may result from friction neuritis or from dynamic compression by the triceps against the epicondyle. Recognition of both the dislocating ulnar nerve and the snapping medial triceps is crucial in the successful treatment of this pathologic finding. In symptomatic individuals, we recommend either corrective valgus osteotomy of the distal humerus or partial excision or lateral transposition of the snapping medial triceps, or a combination of both. Alternatively, medial epicondylectomy can also eliminate the snapping. Transposition of the ulnar nerve can be performed for ulnar nerve symptoms and/or ulnar nerve instability. Using this approach, correction of the snapping and/or ulnar nerve symptoms was achieved in all cases.
The Journal Of Hand Surgery 08/1999; 24(4):718-26. · 1.35 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: We present a patient with translocation (snapping) of a portion of the triceps over the lateral epicondyle with elbow flexion. This condition is in many ways analogous to its counterpart at the medial aspect of the elbow, snapping of the medial head of the triceps, a clinical entity that is being increasingly recognized.
The Journal Of Hand Surgery 04/1999; 24(2):381-5. · 1.35 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: We describe a patient with a preexisting posttraumatic brachial plexopathy who had a complete high median nerve palsy due to rupture of the pectoralis major to biceps transfer near its distal insertion at the elbow region.
Journal of the Southern Orthopaedic Association 02/1999; 8(2):105-7.
-
[show abstract]
[hide abstract]
ABSTRACT: We describe two patients who had episodic elbow snapping and ulnar nerve dysesthesias only after weightlifting. These symptoms would disappear soon afterward. The episodic nature of their complaints and findings led to misdiagnosis. We documented by repeated clinical examinations and magnetic resonance imaging that the presence of these symptoms correlated directly with the finding of intermittent, activity-related snapping of the medial triceps. In both patients, the symptoms disappeared when the medial portion of the triceps migrated medially but did not dislocate over the medial epicondyle with elbow flexion. Thus, a minor change in the configuration of the medial portion of the triceps (fluid accumulation) in the same individual at different times can cause intermittent dislocation of the medial triceps. Previous papers dealing with patients with snapping of the medial triceps describe symptoms exacerbated by athletic activities, but the constant finding of snapping on sequential examinations.
Journal of the Southern Orthopaedic Association 02/1999; 8(4):288-92.
-
[show abstract]
[hide abstract]
ABSTRACT: This 4 1-year-old man presented with a 2-year history of symptoms and signs of sciatic nerve compression. Imaging studies revealed a large ossified fragment within the biceps muscle of the thigh abutting the sciatic nerve at the level of the lesser trochanter. The bony fragment resulted from an unrecognized apophyseal avulsion fracture of the ischial tuberosity, which the patient had sustained while sprinting 27 years earlier. External neurolysis of the sciatic nerve and excision of the mass led to a successful outcome.
Journal of Neurosurgery 12/1998; 89(5):819-21. · 2.96 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: We describe seventeen patients (twenty-two limbs) who had snapping (dislocation) of both the ulnar nerve and the medial head of the triceps over the medial epicondyle. Two patients (two limbs) were seen because of painless snapping, four patients (five limbs) had snapping and pain in the medial aspect of the elbow, three patients (three limbs) had symptoms related to the ulnar nerve only, and six patients (seven limbs) had snapping and symptoms related to the ulnar nerve. In addition, snapping was identified incidentally on routine screening in five asymptomatic limbs in four patients, one of whom was seen because of snapping and symptoms related to the ulnar nerve on the contralateral side. The diagnosis was confirmed with magnetic resonance imaging or computerized tomography, or both, in all but the first three patients, in whom the operative findings were confirmatory. Only six patients (seven limbs) were sufficiently symptomatic to be managed operatively. Of these six patients, five (six limbs) who had symptoms related to the ulnar nerve had lateral transposition or excision of the dislocating medial head of the triceps in addition to decompression and transposition of the ulnar nerve. Two of these patients had had persistent symptoms immediately after a previous transfer of the ulnar nerve performed at another institution for symptoms related to, and well documented dislocation of, the ulnar nerve; we performed the index procedure to correct the postoperative snapping, which was the result of an unrecognized dislocation of the medial head of the triceps in one patient and the result of an accessory triceps tendon in the other. One patient who had pain in the medial part of the elbow, snapping (without symptoms related to the ulnar nerve), and cubitus varus had a valgus osteotomy of the distal aspect of the humerus that corrected the line of pull of the triceps and relieved the snapping. All of the patients who were managed operatively had an excellent result (no snapping, no symptoms related to the ulnar nerve, and a full range of motion), at an average of 4.5 years postoperatively. Non-operative treatment provided control of symptoms related to the ulnar nerve in four limbs and control of pain from the snapping in four limbs. Snapping on the medial side of the elbow, even if it is associated with symptoms related to the ulnar nerve, is not necessarily caused by dislocation of the ulnar nerve alone. Patients who have a transposition of the ulnar nerve, especially those who have dislocation of the ulnar nerve, should be examined intraoperatively with the elbow in flexion and extension so that the surgeon can be certain that the medial head of the triceps does not snap over the medial epicondyle. Failure to recognize concurrent dislocation of the ulnar nerve and the medial head of the triceps can result in persistent, symptomatic snapping after an otherwise successful transposition of the ulnar nerve.
The Journal of Bone and Joint Surgery 03/1998; 80(2):239-47. · 3.27 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Seven patients presented with an isolated extensor digitorum communis (EDC) palsy immediately after undergoing surgery in which the posterior (Thompson) approach to the proximal radius was used. All had normal neurologic examination findings documented prior to surgery. In an attempt to localize this lesion, the authors studied the arborization of the terminal motor branches of the posterior interosseous nerve (PIN) at the distal edge of the supinator. A common innervation pattern to the superficial extensor muscles was observed in 29 of 30 cadaveric limbs. In 10 of 10 specimens, when the EDC was subdivided into its individual bellies, a reproducible pattern emerged: the proximal EDC muscles of the middle and ring fingers were supplied primarily by the recurrent nerve branch(es) and the EDC muscles of the index and little fingers, by separate nerve branches. Consistent with our anatomic findings, perioperative stimulation of the recurrent branch in 1 neurologically intact patient resulted in middle and ring finger extension. Electromyography in 8 normal limbs showed that the middle and ring fingers could be activated together without the index and little fingers in all cases. We believe that these patients with isolated EDC nerve palsy may have sustained an iatrogenic injury to EDC motor branches, distal to the supinator rather than to a PIN fascicle near the proximal supinator.
The Journal Of Hand Surgery 01/1998; 23(1):135-41. · 1.35 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: A partial posterior interosseous nerve (PIN) paralysis developed in a patient more than 2 decades after having childhood osteomyelitis of the metaphysis of the radius. In previous reports of tardy PIN palsy, the radial head was dislocated (frequently in cases of unrecognized Monteggia fracture-dislocations), causing compression at the arcade of Frohse. In the patient whose case is discussed here, the radial head was located; compression of the PIN at the arcade of Frohse, in combination with traction against inflamed periosteum, likely resulted in the late development of clinical symptoms and signs.
The Journal Of Hand Surgery 12/1997; 22(6):1049-51. · 1.35 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Variations in the medial triceps in conjunction with bilateral ulnar neuropathy have been identified in three generations of one family also possessing the phenotype of Waardenburg syndrome (a rare autosomal-dominant disorder with clinical features including cochlear deafness, dystopia canthorum, and pigmentation problems). To our knowledge, no other inherited condition with triceps anomalies has been reported. Study of this family provided insight into the relationship between dislocating medial triceps and ulnar neuropathy and demonstrated that a broad spectrum of clinical presentations exists-from being completely asymptomatic to producing symptomatic snapping and ulnar neuropathy.
The Journal Of Hand Surgery 02/1997; 22(1):132-7. · 1.35 Impact Factor
