Motor Nerve Palsies Research Articles

Functional and Motor Outcomes of Strabismus Surgery for Chronic Isolated Adult Sixth Nerve Palsy

Abducens nerve palsy is the most common acquired ocular motor nerve palsy in adults. Chronic cases of abducens palsy often require surgical intervention to relieve disabling diplopia. The goal of this study was to identify factors associated with surgical outcomes in isolated abducens palsy. Medical records of all adult patients from 1988 to 2012 with abducens palsies who underwent strabismus procedures were retrospectively reviewed. Motor alignment, extraocular motility, and sensory outcomes were recorded. Success was defined as absence of diplopia without prisms or face turn, vertical deviation ≤2 prism dioptres (PD), and horizontal deviation ≤10 PD. Eighty-one patients (age range: 20–86 years) met inclusion criteria. Success was achieved in 58% of patients. Final success rates for abducens palsy were 50% for neoplastic, 59% traumatic, 57% for microvascular/unknown, and 67% for other central nervous system causes (p > 0.05). Patients with an underlying neoplastic or traumatic aetiology required more than one strabismus procedure more often than those with microvascular/idiopathic or other central nervous system causes (48% vs. 24%; p = 0.03). For complete abducens palsies, patients who underwent Hummelsheim-type procedures had a higher success rate than those who underwent a full-tendon vertical rectus muscle transposition. (78% versus 35%; p = 0.049). Success rates for strabismus procedures in patients with abducens palsies are similar across all aetiologies. Frequency of re-operation is higher among those patients with neoplastic or traumatic aetiologies for their abducens palsies. Hummelsheim-type procedures have a higher success rate for complete abducens palsies than full-tendon vertical rectus transpositions.

Do patients with neurologically isolated ocular motor cranial nerve palsies require prompt neuroimaging?

Do patients with neurologically isolated ocular motor cranial nerve palsies require prompt neuroimaging?

Recovery of Motor Nerve Injuries Associated With Displaced, Extension-Type Pediatric Supracondylar Humerus Fractures: Level 4 Evidence

Nerve injuries occur in approximately 13% of pediatric extension-type supracondylar humerus fractures, but no large-scale studies have analyzed recovery of these nerve injuries (Ref 1). We hypothesized that the time to recovery for a motor nerve palsy associated with a supracondylar humerus fracture would vary by which nerve is injured, if more than one nerve is injured, and if immediate decompression of the affected nerve(s) occurred at the time of fracture fixation.

Operative Treatment of Type II Supracondylar Humerus Fractures

Because of the changing referral patterns, operative pediatric supracondylar humerus fractures are increasingly being treated at tertiary referral centers. To expedite patient flow, type II fractures are sometimes pinned in a delayed manner. We sought to determine if delay in surgical treatment of modified Gartland type II supracondylar humerus fractures would affect the rate of complications following closed reduction and percutaneous pinning. We performed a retrospective review of a consecutive series of 399 modified Gartland type II supracondylar fractures treated operatively at a tertiary referral center over 4 years. Mean patient age in the type II group was 5 years (range, 1 to 15 y). A total of 48% were pinned within 24 hours, 52% pinned >24 hours after the injury. No difference was in detected in rates of major complications between the early and delayed treatment group. Four percent of patients sustained a complication (16 patients). There were no compartment syndromes, vascular injuries, or permanent nerve injuries. Complications included nerve injury (3), physical therapy referral for stiffness (3), pin site infection (2 treated with oral antibiotics, 4 treated with debridement), refracture (2), and loss of fixation or broken hardware (2). Of the 3 patients who sustained nerve injuries, all underwent surgery within 24 hours of injury. One patient developed an ulnar motor and sensory nerve palsy after fixation with crossed K-wires. This resolved by 7 weeks postoperatively. Two patients presented with an anterior interosseous nerve palsy-1 resolved 1 week after surgery, the other by 8 weeks postoperatively. Delay in surgery did not result in an increased rate of major complications following closed reduction and percutaneous pinning of type II supracondylar humerus fractures in children. Further prospective work is necessary to determine if there are subtle treatment benefits from emergent treatment of type II supracondylar humerus fractures. Level III-retrospective comparative series.

Curved periacetabular osteotomy for the treatment of dysplastic hips.

Curved periacetabular osteotomy (CPO) was developed for the treatment of dysplastic hips in 1995. In CPO, the exposure of osteotomy sites and osteotomy of the ischium are made in the same manner as Bernese periacetabular osteotomy, and iliac and pubic osteotomies are performed in the same manner as rotational acetabular osteotomy. We studied the dynamic instabilities of 25 dysplastic hips before and after CPO using triaxial accelerometry. Overall magnitude of acceleration was significantly decreased from 2.30 ± 0.57 m/sec2 preoperatively to 1.55 ± 0.31 m/sec2 postoperatively. Pain relief and improvement of acetabular coverage resulting from acetabular reorientation seem to be related with reduction of dynamic instabilities of dysplastic hips. Isokinetic muscle strengths of 24 hips in 22 patients were measured preoperatively and after CPO. At 12 months postoperatively, the mean muscle strength exceeded the preoperative values. These results seem to be obtained due to no dissection of abductor muscles in CPO. The preoperative presence of acetabular cysts did not influence the results of CPO. An adequate rotation of the acetabular fragment induced cyst remodeling. Satisfactory results were obtained clinically and radiographically after CPO in patients aged 50 years or older. CPO alone for the treatment of severe dysplastic hips classified as subluxated hips of Severin group IV-b with preoperative CE angles of up to -20° could restore the acetabular coverage, weight-bearing area and medialization of the hip joint. CPO without any other combined procedure, as a treatment for 17 hips in 16 patients with Perthes-like deformities, produced good mid-term clinical and radiographic results. We have been performing CPO in conjunction with osteochondroplasty for the treatment of acatabular dysplasia associated with femoroacetabular impingement since 2006. The combined procedure has been providing effective correction of both acetabular dysplasia and associated femoral head-neck deformities without any increased complication rate. We have encountered an obturator artery injury in one case and two intraoperative comminuted fractures. Although serious complications such as motor nerve palsy, deep infection, necrosis of the femoral head or acetabulum, and delayed union or nonunion of the ilium were reported, such complications have never occurred in our 700 cases so far.

Tolosa-Hunt Syndrome: A Case Report and Review of the Literature

Tolosa-Hunt Syndrome is a painful ophthalmoplegia which is characterized by periorbital or hemicranial pain, with ipsilateral ocular motor nerve palsies, oculosympathetic paralysis, sensory loss in the distribution of the ophthalmic and occasionally the maxillary division of the trigeminal nerve. Various combinations of these cranial nerve palsies may occur, localising the pathological process to the region of the cavernous sinus/superior orbital fissure. We report the case of a patient presented with severe pain in the right side of face which was periorbital with ipsilateral 3rd,4th, 6th cranial nerve palsies along with ophthalmic and maxillary division of trigeminal nerve involvement. MRI of orbit showed hypo-intense lesion in right cavernous sinus extending to right superior orbital fissure (suggestive of granulomatous infiltration). After taking oral steroid her pain was relieved quickly and cranial nerve palsies reversed within one week. Azathioprin was added and she was completely cured of within next three months.
 Bangladesh Journal of Neuroscience 2013; Vol. 29 (2) : 130-133

Painful ophthalmoplegia: The role of imaging and steroid response in the acute and subacute setting

Background and purposeAlthough reports of single cases of painful ophthalmoplegia (PO) are common, studies considering larger case series are lacking. Here, we aimed to determine the relative frequencies of ocular neuropathies, the causes, the usefulness of diagnostic procedures and the role of steroid treatment in PO. MethodsBetween January 2006 and September 2012, 149 patients' charts who presented with diplopia in our emergency department were studied retrospectively. 34 of them met the inclusion criteria that included recent (≤3days) symptom onset and a minimum of diagnostic work. Results32% of single or combined ocular motor nerve palsies were of diabetic microvascular etiology and most of them were IIIrd or VIth nerve neuropathies. The most useful, in terms of sensitivity and specificity of diagnostic test in the acute setting was ESR, whereas MR-angiography and focused cavernous sinus imaging led to diagnosis in the post-acute phase. Pain response to steroids was non-specific, in contrast to palsy improvement after steroid administration which was indicative of Tolosa–Hunt syndrome or temporal arteritis. ConclusionsAlthough acute and subacute PO might be intuitively associated with Tolosa–Hunt syndrome or sinister pathology such as aneurysmal hemorrhage, our data show that these causes are far less common than diabetic microvascular palsies. Brain CT, MR-imaging of brainstem, cerebellum or hemispheres, CSF analysis and pain response to steroids are nonspecific and hence less helpful in order to arrive at a diagnosis. Instead, improved ocular motility after steroid treatment, as well as MR-angiography and cavernous sinus imaging appear more useful for this purpose.

Isolated Third, Fourth, and Sixth Cranial Nerve Palsies from Presumed Microvascular versus Other Causes: A Prospective Study

To estimate the proportion of patients presenting with isolated third, fourth, or sixth cranial nerve palsy of presumed microvascular origin versus other causes. Prospective, multicenter, observational case series. A total of 109 patients aged 50 years or older with acute isolated ocular motor nerve palsy. Magnetic resonance imaging (MRI) of the brain. Causes of acute isolated ocular motor nerve palsy (presumed microvascular or other) as determined with early MRI and clinical assessment. Among 109 patients enrolled in the study, 22 had cranial nerve III palsy, 25 had cranial nerve IV palsy, and 62 had cranial nerve VI palsy. A cause other than presumed microvascular ischemia was identified in 18 patients (16.5%; 95% confidence interval, 10.7-24.6). The presence of 1 or more vasculopathic risk factors (diabetes, hypertension, hypercholesterolemia, coronary artery disease, myocardial infarction, stroke, and smoking) was significantly associated with a presumed microvascular cause (P = 0.003, Fisher exact test). Vasculopathic risk factors were also present in 61% of patients (11/18) with other causes. In the group of patients who had vasculopathic risk factors only, with no other significant medical condition, 10% of patients (8/80) were found to have other causes, including midbrain infarction, neoplasms, inflammation, pituitary apoplexy, and giant cell arteritis (GCA). By excluding patients with third cranial nerve palsies and those with GCA, the incidence of other causes for isolated fourth and sixth cranial nerve palsies was 4.7% (3/64). In our series of patients with acute isolated ocular motor nerve palsies, a substantial proportion of patients had other causes, including neoplasm, GCA, and brain stem infarction. Brain MRI and laboratory workup have a role in the initial evaluation of older patients with isolated acute ocular motor nerve palsies regardless of whether vascular risk factors are present.

English

Tolosa-Hunt syndrome (THS) is a painful ophthalmoplegia caused by nonspecific inflammation of the cavernous sinus or superior orbital fissure. The syndrome consists of periorbital or hemicranial pain, combined with ipsilateral ocular motor nerve palsies, oculosympathetic paralysis, and sensory loss in the distribution of the ophthalmic and occasionally the maxillary division of the trigeminal nerve. Although they have relapsing and remitting course, they respond promptly to systemic corticosteroid therapy. The diagnostic eponym Tolosa-Hunt syndrome has been applied to these patients and it is this entity which forms the basis of this review. CASE REPORT: A 42 year old man presented with painful diminution of vision since one month and diplopia in the left eye since 7 days. Tingling sensation was noted over left half of upper face. On clinical examination –V/A was 6/12 (B/E) improving to 6/6 with pinhole, IOP and fundus was normal both eyes, extra ocular movement was completely restricted in left eye with painful movements. Left III, IV and VI Cranial nerve palsies were noted with decreased sensation over the area supplied by V Cranial Nerve. The patient was sent for an MR examination. MR imaging was performed on a 1.5 Tesla MR scanner (GE). 10ml Gadolinium was injected in the left antecubital vein to obtain post contrast T1WI.Study revealed moderately enhancing soft tissue in the region of left cavernous sinus and orbital apex. It was isointense to muscle on T1WI and hypo intense to fat on T2WI. MANAGEMENT: On the basis of history and imaging findings, a diagnosis of THS was made and the patient was started on corticosteroid therapy: Injection Methyl-Prednisolone (1gm.I.V for 3 days).Dramatic improvement in diplopia and pain was noted within 48 hours of starting IV steroid therapy. Oral Prednisolone 40mg daily was started after 3 days and continued for 6 weeks. At the end of therapy the patient's ophthalmoplegia also recovered. DISCUSSION: Tolosa–Hunt syndrome (THS) is a rare disorder characterized by severe and unilateral headaches with extra ocular palsies, usually involving the third, fourth, fifth, and sixth cranial nerves, and pain around the sides and back of the eye, along with weakness and paralysis (ophthalmoplegia) of certain eye muscles1. The syndrome of painful ophthalmoplegia consists of periorbital or hemicranial pain, combined with ipsilateral ocular motor nerve palsies, oculosympathetic paralysis, and sensory loss in the distribution of the ophthalmic and occasionally the maxillary division of the

Treatment of tolosa-hunt syndrome with acupuncture: A case report

Tolosa-Hunt syndrome is a rare medical condition with special clinical manifestations, characterized by sharp severe headache as the initial symptom. The pain is usually located around the orbit or deep inside, ocular motor nerve palsy following or together with the pain[1]. We treated a case of Tolosa-Hunt syndrome with acupuncture-moxibustion treatment, and now report it as follows.

Surgical outcomes in adult sixth nerve palsy

Sixth nerve palsy (6NP) is the most common adult ocular motor nerve palsy. Our goal was to identify factors associated with surgical outcomes in 6NP. Medical records of all adult patients from 1988-2012 with 6NP who underwent strabismus surgery or botulinum toxin injections were retrospectively reviewed. Success was defined as absence of diplopia without prisms, vertical deviation ≤2Δ, and horizontal deviation ≤10Δ. 83 patients from four surgeons were included [50 (60%) women; mean age 52 (range, 20-86)]. 66 (80%) had unilateral sixth nerve palsies. Palsies were complete in 34 (41%). 21 (25%) had >1 surgery. Underlying etiology was idiopathic/microvascular in 23 (28%), traumatic in 23 (28%), neoplastic in 19 (23%), and miscellaneous causes in 18 (22%). Success frequency was similar across etiologies. 16/42 patients (38%) with trauma or neoplasm required repeat surgery vs 5/41 (12%) with other etiologies (P < 0.05). Success was more frequent with Hummelsheim-type procedures than vertical rectus transposition (VRT) among patients with complete palsies (7/9 = 78% vs 8/23 = 35%; P < 0.05). Success was more frequent among all surgically-treated 6NP patients who had adjustable vs nonadjustable sutures (21/29 = 73% vs 22/44 = 52%; P = 0.06). Etiology of 6NP does not appear to affect surgical success in adults, but patients with traumatic and neoplastic causes were more likely to require repeat procedures. Despite a small number of patients, success was more frequent using the Hummelshiem-type procedure and with adjustable sutures. Surgical success in adults does not correlate with the etiology of the sixth nerve palsy, but may vary based on the type of procedures in this patient population.

Prevention of Nerve Injury After Periacetabular Osteotomy

The Bernese periacetabular osteotomy (PAO) is the preferred pelvic osteotomy in many centers treating symptomatic acetabular dysplasia in the young adult. Major nerve injury has been reported as a complication that can occur with this complex procedure, but the incidence and circumstances associated with such injury are not well known. We asked: (1) What is the incidence of sciatic and femoral nerve injury after PAO; (2) what are the risk factors associated with such injury; and (3) what are the consequences of such injury including the degree of neurologic recovery? We identified 1760 PAOs that were performed between 1991 and 2008 at five institutions. A major nerve injury was defined as a postoperative motor nerve palsy or sensory deficit present after surgery in the distribution of the femoral or sciatic nerves. Risk factors associated with nerve injury and the treatment and degree of neurologic recovery were reviewed from medical records. Thirty-six of the 1760 patients (2.1%) had a major nerve deficit of the sciatic or femoral nerve develop. We identified no patient or surgical risk factor associated with the occurrence of nerve injury. Seventeen of the 36 patients had complete recovery. The median time to recovery or plateau was 5.5 months (range, 2 days to 24 months). The incidence of sciatic and femoral nerve injury during PAO is less than previously reported. Full recovery can be expected in only ½ of the patients and more commonly with injuries of the femoral nerve. If direct nerve injury is suspected, we believe exploration may be warranted. Level II, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.

Alveolar bone necrosis and spontaneous tooth exfoliation associated with trigeminal herpes zoster: a report of three cases

J Korean Assoc Oral Maxillofac Surg 2012;38:177-83) Herpes zoster is a viral infection caused by the reactivation of the varicella zoster virus, an infection most commonly affecting the thoracolumbar trunk. Herpes Zoster Infection (HZI) may affect the cranial nerves, most frequently the trigeminal. HZI of the trigeminal nerve distribution network manifests as multiple, painful vesicular eruptions of the skin and mucosa which are innervated by the infected nerves. Oral vesicles usually appear after the skin manifestations. The vesicles rupture and coalesce, leaving mucosal erosions without subsequent scarring in most cases. The worst complication of HZI is post-herpetic neuralgia; other complications include facial scarring, motor nerve palsy and optic neuropathy. Osteonecrosis with spontaneous exfoliation of the teeth is an uncommon complication associated with HZI of the trigeminal nerve. We report several cases of osteomyelitis appearing on the mandible, caused by HZI, and triggering osteonecrosis or spontaneous tooth exfoliation.

Isolated Oculomotor Nerve Palsy Caused by Cavernous Sinus Dural Arteriovenous Fistula: Case Report

Isolated oculomotor palsy is a rare symptom seen in patients with many, different neurological disorders (1, 2). It is often the first or even the sole manifestation of a pathology that potentially affects the nervous system. When older patients are presented with isolated ocular motor nerve palsy, without congestive ocular features, this condition is easily misdiagnosed as idiopathic, ischemic mononeuropathy or aneurysm. While isolated ocular motor nerve palsy, presenting as the only manifestation of cavernous dural arteriovenous fistula (DAVF), has occasionally been reported (3-5), we report a case of cavernous DAVF presenting with unusual, isolated oculomotor nerve palsy and treated by transvenous coil embolization.

Oculomotor Nerve Palsy Caused by Posterior Communicating Artery Aneurysm: Evaluation of Symptoms after Endovascular Treatment

We report the outcome of endovascular treatment in a series of patients presenting with posterior communicating artery aneurysm causing ocular motor nerve palsy. A retrospective study was made of ten patients who were treated by coil embolization of posterior communicating artery aneurysm caused by oculomotor nerve palsy. The assessed parameters were as follows: patient's age, presence of subarachnoid hemorrhage, aneurysm size, preoperative severity of symptoms, and timing of treatment after onset of symptoms. Improvement of oculomotor nerve palsy after treatment was noted in eight patients (80.0%). Complete recovery was noted in seven patients (70.0%), partial recovery in one patient (10.0%), and no recovery in two patients (20%). Clinical presentations with early management (≤2 days) were significant in influencing recovery. Complete recovery from ocular motor nerve palsy was significantly higher in patients with initial incomplete palsy compared with initial complete palsy patients (6/6 versus 1/4). Early treatment and initial partial palsy are relevant to improving prognoses. Endovascular treatment is favored method for treating oculomotor palsy.

PITUITARY MACROADENOMAS

Objectives: To describe the demographic profile, patterns of visual disturbance and imaging studies of patients with Macroadenoma. Design: Retrospectively. Reviewed the clinical charts and neuroradiologic imaging of 125 patients who were diagnosed as cases of Macroadenoma. Duration: 2000 to 2009. Subjects and Methods: 100 patients were selected who had visual disturbances along with Macroadenomas. Age, sex, visual symptoms and other associated systemic problems of these patients were reviewed. The Neuroimaging data (Magnetic Resonance Imaging) was correlated with the clinical picture. The data was analysed using Statistical package for social sciences (SPSS). The Descriptive Statistics were calculated for age and MR findings. Results: The age ranged from 9 to 85 years (mean 42.92). Male to female ratio was 1.4: 1. 90% patients had visual disturbances including visual field defects and 10% had ocular motor nerve palsies. Tumour extension on MR studies showed optic chiasma compression in 69% patients, cavernous sinus invasion in 57% and Sphenoidal sinus invasion in 14%. Haemorrhagic foci were seen in 8% and intra tumour necrosis was found in 9% patients. Conclusions: The most common path for the extension of pituitary macroadenomas is towards the optic chiasma. Hence majority of these patients present with visual disturbances. MRI is an excellent aid to see the extent and invasion of Macroadenomas to the surrounding structures.

Peripheral Neuropathy and VIth Nerve Palsy Related to Randall Disease Successfully Treated by High-Dose Melphalan, Autologous Blood Stem Cell Transplantation, and VIth Nerve Decompression Surgery

Randall disease is an unusual cause of extraocular motor nerve (VI) palsy. A 35-year-old woman was hospitalized for sicca syndrome. The physical examination showed general weakness, weight loss, diplopia related to a left VIth nerve palsy, hypertrophy of the submandibular salivary glands, and peripheral neuropathy. The biological screening revealed renal insufficiency, serum monoclonal kappa light chain immunoglobulin, urinary monoclonal kappa light chain immunoglobulin, albuminuria, and Bence-Jones proteinuria. Bone marrow biopsy revealed medullar plasma cell infiltration. Immunofixation associated with electron microscopy analysis of the salivary glands showed deposits of kappa light chains. Randall disease was diagnosed. The patient received high-dose melphalan followed by autostem cell transplantation which led to rapid remission. Indeed, at the 2-month followup assessment, the submandibular salivary gland hypertrophy and renal insufficiency had disappeared, and the peripheral neuropathy, proteinuria, and serum monoclonal light chain had decreased significantly. The persistent diplopia was treated with nerve decompression surgery of the left extraocular motor nerve. Cranial nerve complications of Randall disease deserve to be recognized.

Vasculopathic Cranial Ocular Motor Neuropathy Following Sudden Emotional Stress

We describe three patients who experienced onset of a microvascular ocular motor nerve palsy in the setting of sudden emotional stress. Such emotional states are accompanied by a marked increase in sympathetic tone in some individuals. Mechanisms by which these autonomic changes might produce an ischemic cranial nerve palsy include intra-cranial vasoconstriction and transient systemic hypotension due to alterations in cardiac function.

Apoplexie hypophysaire et baisse d’acuité visuelle bilatérale sévère : à propos d’un cas

Pituitary apoplexy is caused by an infarction or a hemorrhage in a pituitary adenoma manifesting in acute headaches, consciousness impairment, endocrine features, and moderate to severe visual loss, with chiasmal syndrome or oculomotor palsies. We present a case report and a review of the literature. We report the case of a 31-year-old man who neglected bitemporal visual loss (less than 1/10 OD and 2/10 OS). Emergency cerebral tomodensitometry found a pituitary apoplexy. Visual field loss was nearly complete at OD and temporal hemianopia was present at OS. These ocular complications led to a neurosurgical transsphenoidal resection of the necrotic adenoma. Follow-up was satisfactory with complete recovery of visual acuity and visual field. In the literature, headaches are present in 76% of the patients, visual loss in 62%, and ocular motor nerve palsy in 40%. Third cranial nerve palsies are predominant. The clinical picture of pituitary apoplexy is characterized by the sudden onset of oculomotor palsy or blindness with acute headaches and even consciousness impairment. A functional and vital risk is present because of acute hypopituitarism. This emergency diagnosis is confirmed by tomodensitometry or magnetic resonance imaging. The association of hormone substitution and tumor transsphenoidal resection commonly leads to a positive outcome and visual improvement.

Prevention of Nerve Injuries Using a Safety-Driven Step-Wise Technique for Arthroscopic Capsulectomy of the Elbow (SS-23)

The risk of nerve injury is of concern in arthroscopic elbow release, but has not previously been described in a large series. We report a series of 502 arthroscopic capsular releases over 15 years by a single surgeon, using a standardized technique, with specific focus on neurological outcomes. There were no permanent nerve injuries, with 23 patients (4.6%) noted to have transient nerve palsies due to varied factors such as tourniquet time, retraction, or medial skin incisions. In this series, a standardized safety-driven approach and experience of the surgeon decreased the risk of nerve injury. Release of contracture is a common indication for elbow arthroscopy. The major factor limiting use of arthroscopy for contracture release is the concern about nerve injury, but the risk of nerve injury has not been documented in a large series. The purpose of this report is to document the risk of nerve injury in arthroscopic contracture release using a safety-driven step-wise technique. A retrospective review was performed of 502 consecutive cases of arthroscopic contracture release in 464 patients by one surgeon during a 15 year period. The safety-driven step-wise technique evolved during the first 100 cases from detaching to incising to completely excising the capsule. For the next 402 cases arthroscopic capsulectomy was performed in a standardized sequence: (1) Get In and Establish a View, (2) Create a Space in Which to Work, (3) Bone Removal, and (4) Capsulectomy. Retractors were used to maintain space and to protect the nerves. Suction was detached from the shavers and burrs. Cases included complex and revision contracture releases. Transient sensory motor nerve palsies that resolved within three days developed in three cases (0.6%), two from blunt retraction and one from local anesthetic injection. Two medial antebrachial cutaneous nerve injuries from portal sites occurred but resolved completely within 3 and 18 months respectively. Thus, 5 nerve palsies (1%) occurred as a direct result of the arthroscopy itself. Eleven patients (2.2%) experienced transient diffuse sensory motor nerve palsies involving 2 or 3 major nerves that were associated with prolonged tourniquet times; all resolved within 3 days. Two patients (0.4%) had a transient partial sensory motor after ulnar nerve transposition that resolved completely within 1-3 days. Seven patients experienced sensory dysesthesia of the skin innervated by the posterior branch of the medial antebrachial cutaneous nerve due to a posterior medial incision for decompression of the ulnar nerve. These involved the skin in the region of the olecranon and six of seven (1.4%) resolved completely within three months to two years. The final patient was lost to follow-up. Thus, a total of 19 cases (3.8%) experienced nerve palsies indirectly related to the arthroscopy (due to other factors such as prolonged tourniquet time, ulnar nerve transposition, or a posteromedial skin incision). Overall, 23 of the 502 cases (4.6%) experienced transient nerve palsies that resolved completely with 1 additional patient (0.2%) having a cutaneous nerve dysesthesia but was lost to follow-up. There were no permanent nerve injuries. Temporary nerve injuries are a definite risk with arthroscopic elbow contracture release. They occur due to tourniquet palsies, compression by instruments and retractors. However, under the conditions in this study, we found permanent nerve injuries to be a minimal risk, with a surgeon highly experienced in open and arthroscopic elbow surgery, the adherence to a safety-driven step-wise technique, the routine use of retractors and avoidance of suction on shavers. The risk of nerve injury is more related to the experience and expertise of the operating team and facility than to the severity of the contracture.