Nerve Stretch Research Articles

Treatment of cubital tunnel syndrome with ulnar nerve anterior submuscular transposition and medial epicondyle muscle group in situ reconstruction via a bone tunnel

Objective To investigate the clinical effectiveness of treating moderate to severe cubital tunnel syndrome with ulnar nerve decompression,anterior submuscular transposition and medial epicondyle muscle group in situ reconstruction via a bone tunnel.Methods The clinical data of 45 cases of moderate to severe cubital tunnel syndrome diagnosed between January 2005 and October 2012 were analyzed.The ulnar nerve was decompressed and its perfnsion by the superior ulnar collateral artery was observed under the surgical microscope intraoperatively.After ulnar nerve was transposed anteriorly,the detached medial epicondyle muscle group was reconstructed in situ through a bone tuunel under direct view.The size of the new ulnar nerve tunnel and mobility of the ulnar nerve were observed.Postoperative recovery was follow-up including pain,sensation,muscular atrophy recovery,claw hand,grip strength,wrist flexion and forearm pronation.Results All 45 cases were follow-up for 6 to 18 months.Intraoperative microscopic observation showed good ulnar nerve perfusion by the superior ulnar collateral artery.Reattachment of the medial epicondyle muscle group was secure.The newly formed cubital tunnel could allow an 8 mm dilator without tension in elbow full extension position.Ulnar nerve could glide freely upon elbow flexion and extension.According to the cubital tunnel syndrome function evaluation standard suggested by Gu Yudong,the results were graded as excellent in 20 cases,good in 17 cases,and fair in 8 cases.The overall excellent and good rate was 82.22％.Wrist flexion and forearm pronation force recovered to preoperative level in all the patients 3 months after the operation.Conclusion Including superior ulnar collateral artery in the anterior transposition of the ulnar nerve provides good blood supply to the nerve and benefits nerve recovery.In situ reconstruction of the medial epicondyle muscle group through a bone tunnel puts the ulnar nerve anderneath flexor carpi ulnaris and pronator teres.The new tunnel is big enough to avoid compression of the nerve.The surrounding tissues are loose so there will be neither ulnar nerve compression around the elbow nor nerve stretch upon elbow flexion.Muscle reattachment via a bone tunnel is secure.No postoperative elbow immobilization with a cast is needed.This allows early protected movement and early return to normal life and work. Key words: Cubital tunnel syndrome; Humerus; Anterior submuscular transposition; Bone tunnel; Reconstruction in situ

Periodic thigh pain from radicular endometriosis

A 38-year-old woman gave a 2-year history of periodic left anterior thigh pain (figure 1), described as deep and excruciating. It would begin 2–3 days before menstruation. Its numerical rating...

Positioning patients for spine surgery: Avoiding uncommon position-related complications.

Positioning patients for spine surgery is pivotal for optimal operating conditions and operative-site exposure. During spine surgery, patients are placed in positions that are not physiologic and may lead to complications. Perioperative peripheral nerve injury (PPNI) and postoperative visual loss (POVL) are rare complications related to patient positioning during spine surgery that result in significant patient disability and functional loss. PPNI is usually due to stretch or compression of the peripheral nerve. PPNI may present as a brachial plexus injury or as an isolated injury of single nerve, most commonly the ulnar nerve. Understanding the etiology, mechanism and pattern of injury with each type of nerve injury is important for the prevention of PPNI. Intraoperative neuromonitoring has been used to detect peripheral nerve conduction abnormalities indicating peripheral nerve stress under general anesthesia and to guide modification of the upper extremity position to prevent PPNI. POVL usually results in permanent visual loss. Most cases are associated with prolonged spine procedures in the prone position under general anesthesia. The most common causes of POVL after spine surgery are ischemic optic neuropathy and central retinal artery occlusion. Posterior ischemic optic neuropathy is the most common cause of POVL after spine surgery. It is important for spine surgeons to be aware of POVL and to participate in safe, collaborative perioperative care of spine patients. Proper education of perioperative staff, combined with clear communication and collaboration while positioning patients in the operating room is the best and safest approach. The prevention of uncommon complications of spine surgery depends primarily on identifying high-risk patients, proper positioning and optimal intraoperative management of physiological parameters. Modification of risk factors extrinsic to the patient may help reduce the incidence of PPNI and POVL.

Treatment of Myofascial Pain

SUMMARYThe objective of this article was to perform a narrative review regarding the treatment of myofascial pain syndrome and to provide clinicians with treatment recommendations. This paper reviews the efficacy of various myofascial pain syndrome treatment modalities, including pharmacological therapy, injection-based therapies and physical therapy interventions. Outcomes evaluated included pain (visual analog scale), pain pressure threshold and range of motion. The evidence found significant benefit with multiple treatments, including diclofenac patch, thiocolchicoside and lidocaine patches. Trigger point injections, ischemic compression therapy, transcutaneous electrical nerve stimulation, spray and stretch, and myofascial release were also efficacious. The authors recommend focusing on treating underlying pathologies, including spinal conditions, postural abnormalities and underlying behavioral issues. To achieve maximum pain reduction and improve function, we recommend physicians approach myofascial pain syndrome with a multimodal plan, which includes a combination of pharmacologic therapies, various physical therapeutic modalities and injection therapies.

Brachial plexopathy in laparoscopic-assisted rectal surgery: a case series

Brachial plexopathy may be caused by malpositioning during surgery when the body's protective mechanism is lost under general anaesthesia. It is the second commonest nerve injury reported in the anaesthetized patient. The exact incidence in colorectal surgery is unclear but there have been numerous cases reported of brachial plexopathy as an adverse event following colorectal surgery. Although it is widely believed that these injuries are preventable by paying special attention to vulnerable areas during patient positioning and by careful intraoperative monitoring, it appears that nerve injury may still occur. Patients with post-operative brachial plexopathy in our prospectively kept database were identified. The patient notes were reviewed and documented. In our series, five cases of brachial plexopathy were still observed despite careful precautions taken to prevent nerve injury. The proposed mechanism of nerve injury in our series is most likely due to nerve stretch. All symptoms resolved with the longest taking 7 months before resolution. During this period from 2005 to 2010 our unit performed 548 laparoscopic colorectal resections. The relative incidence of brachial plexopathy in our series is approximately 1 %. We recommend certain precautionary steps to follow, as well as predisposing and perioperative factors to be aware of when anticipating a laparoscopic colorectal procedure. These may all contribute to minimising brachial plexopathy which most likely is under-reported in laparoscopic colorectal surgery but is a preventable morbidity to the patient.

Calpastatin Overexpression Protects Axonal Transport in anIn VivoModel of Traumatic Axonal Injury

Traumatic brain injury (TBI) causes substantial morbidity and mortality worldwide. A key component of both mild and severe TBI is diffuse axonal injury. Except in cases of extreme mechanical strain, when axons are torn at the moment of trauma, axonal stretch injury is characterized by early cytoskeletal proteolysis, transport disruption, and secondary axotomy. Calpains, a family of Ca(2+)-dependent proteases, have been implicated in this pathologic cascade, but direct in vivo evidence is lacking. To test the hypothesis that calpains play a causal role in axonal stretch injury in vivo, we used our rat optic nerve stretch model following adeno-associated viral (AAV) vector-mediated overexpression of the endogenous calpain inhibitor calpastatin in optic nerve axons. AAV vectors were designed for optimal expression of human calpastatin (hCAST) in retinal ganglion cells (RGCs). Calpain inhibition by the expressed protein was then confirmed in primary cortical cultures. Finally, we performed bilateral intravitreal injections of AAV vectors expressing hCAST or the reporter protein ZsGreen 3 weeks prior to unilateral optic nerve stretch. Immediately after stretch injury, Fluoro-Gold was injected into the superior colliculi for assessment of retrograde axonal transport. Rats were euthanized 4 days after stretch injury. Both hCAST and ZsGreen were detected in axons throughout the optic nerve to the chiasm. Calpastatin overexpression partially preserved axonal transport after stretch injury (58.3±15.6% reduction in Fluoro-Gold labeling relative to uninjured contralateral controls in ZsGreen-expressing RGCs, versus 33.8±23.9% in hCAST-expressing RGCs; p=0.038). These results provide direct evidence that axonal calpains play a causal role in transport disruption after in vivo stretch injury.

Pudendal Nerve Stretch Reduces External Urethral Sphincter Activity in Rats

Most animal models of stress urinary incontinence simulate maternal injuries of childbirth since delivery is a major risk factor but they do not reproduce the nerve stretch known to occur during human childbirth. We hypothesized that pudendal nerve stretch produces reversible dysfunction of the external urethral sphincter. Female virgin Sprague-Dawley® rats were anesthetized with urethane. Bilateral pudendal nerve stretch or sham injury was performed for 5 minutes. External urethral sphincter electromyography and leak point pressure were recorded immediately before and after, and 10, 30, 60 and 120 minutes after pudendal nerve stretch. Post-pudendal nerve stretch results were compared to prestretch values and to values in sham injured animals. The pudendal nerves underwent qualitative histological assessment. The nucleus of Onuf was evaluated by immunohistochemistry and polymerase chain reaction for β-APP and c-Fos expression as markers of neuronal activity and injury. A total of 14 rats underwent bilateral pudendal nerve stretch (9) or sham injury (5). Each nerve was stretched a mean ± SEM of 74% ± 18% on the left side and 63% ± 13% on the right side. Electromyography amplitude decreased significantly immediately after stretch compared to before stretch and after sham injury (p = 0.003) but it recovered by 30 minutes after stretch. There was no significant change in leak point pressure at any time. Two hours after injury histology showed occasional neuronal degeneration. β-APP and c-Fos expression was similar in the 2 groups. Acute pudendal nerve stretch produces reversible electrophysiological dysfunction but without leak point pressure impairment. Pudendal nerve stretch shows promise in modeling injury. It should be tested as part of a multi-injury, chronic, physiological model of human childbirth injury.

Short-Duration Treatment with the Calpain Inhibitor MDL-28170 Does Not Protect Axonal Transport in anin VivoModel of Traumatic Axonal Injury

Traumatic axonal injury is characterized by early cytoskeletal proteolysis and disruption of axonal transport. Calpain inhibition has been shown to protect axons in rodent models of traumatic brain injury. However, in these models, both white and gray matter are injured, making it difficult to determine if calpain inhibitors are directly protecting injured axons. To address this issue, we used our rat optic nerve stretch model to test the hypothesis that early calpain inhibition directly protects central nervous system (CNS) axons following stretch injury. Rats were given an intravenous bolus of the calpain inhibitor MDL-28170 (30 mg/kg) 30 min prior to unilateral optic nerve stretch, followed by a 15 mg/kg/h intravenous infusion over the next 2.5 h. Immunohistochemical analysis of optic nerves 30 min after stretch injury revealed variable increases of calpain-cleaved α-spectrin that appeared less evident in stretched nerves from drug-treated rats, although this difference was not statistically significant. Retrograde axonal transport measured by Fluorogold® labeling of retinal ganglion cells was significantly impaired after stretch injury. However, there was no difference in the number of Fluorogold-labeled cells in the vehicle vs. drug treatment groups. These results suggest that early short-duration calpain inhibitor therapy with MDL-28170 is not an effective strategy to prevent disruption of axonal transport following isolated axonal stretch injury in the CNS.

Postsurgical Inflammatory Neuropathy

Perioperative nerve injuries are devastating complications that are commonly attributed to a variety of patient, surgical, or anesthetic factors. Well-documented causes of postsurgical neuropathy include nerve compression, stretch, contusion, or transection, which can occur following surgical trauma or patient positioning. Potential anesthetic causes of perioperative nerve injury include mechanical trauma, local anesthetic toxicity, and ischemic injury. We present a case of a diffuse, bilateral neurologic deficit of unclear etiology in a patient who underwent a combined neuraxial-general anesthetic for bilateral total hip arthroplasty. A 17-year old boy with end-stage Legg-Perthes disease presented with severe lower-extremity neuropathy of both legs following bilateral total hip arthroplasty under combined epidural-general anesthesia. A thorough workup excluded potentially devastating and treatable causes, including epidural hematoma or abscess and surgical bleeding or trauma. A neurology consultation and further testing (electromyography, nerve biopsy) resulted in a diagnosis of postsurgical inflammatory neuropathy. Treatment with prolonged, high-dose corticosteroids was undertaken, and although the patient's symptoms improved, he continues to have significant neurologic deficits 8 months after surgery. Perioperative nerve deficits not readily explained by direct surgical or anesthesia-related causes should prompt early neurologic consultation to seek alternative etiologies such as postsurgical inflammatory neuropathy. Although this condition is poorly understood, it is believed to be an idiopathic immune-mediated response to a physiologic stress (eg, surgery, regional block) and is treated with prolonged, high-dose corticosteroids. Because suppression of the immune system with high-dose steroids may result in improved neurologic outcome, it is essential that surgeons and anesthesiologists are aware of this condition so that treatment is not delayed.

Recurrent choking as a presenting feature of aortic arch aneurysm

Aortic arch aneurysm occurs more commonly in the aging population. Rapid expansion and symptomatic patients should undergo aneurysm resection regardless of size. An 87-year-old man was brought to our emergency department because of choking on food during his dinner. The patient did not have hoarseness, dysarthria, dysphagia, as well as other neurologic symptoms. He was finally found to have an aortic arch aneurysm. Swallowing is complex neuromuscular activity consisting essentially of 3 phases: oral, pharyngeal, and esophageal. The pharyngeal phase was mainly mediated by the pharyngeal plexuses of both the glossopharyngeal and vagus nerves. Uncoordinated movement of the pharyngeal muscles because of a stretch of the left vagus nerve or its plexus by an enlarging aneurysm may be the possible mechanism of choking in this patient.

The application of pelvic osteotomy in adult female patients with exstrophy: applications and outcomes

• To apply the technique of pelvic osteotomy to a select group of adult female patients with exstrophy, in view of the low complication rate and acceptable success rate of the technique. • We applied this technique as an adjunct to uterovaginal suspension and abdominal wall repair after our prior success in treating patients with extreme pelvic diastasis. • Bilateral innominate (transverse) and vertical iliac osteotomies were done from an anterior approach and an external fixator was placed. The fixator and pelvic bones were gradually cranked together over a period of 2-3 weeks until the diastasis was less than 4 cm. • Then sacrocolpopexy was performed with revision of the abdominal wall and revision genitoplasty along with the placement of an intrasymphyseal titanium plate. • Six patients presented with uterine/vaginal prolapse and concerns about the appearance of their abdominal wall and genitalia. Three patients had undergone uterine suspension before and one patient had had five prior attempts at suspension, which failed. The mean (range) age was 22.3 (18-26) years. • All the patients underwent staged reduction of pubic diastasis and sacrocolpopexy along with revision of the abdominal wall and in four cases revision genitoplasty was also performed. The mean (range) diastasis was 12.8 (8-18) cm and 2.8 (3-4) cm before and after staged reduction respectively. • Complications included transient femoral nerve palsy (two) and foot drop secondary to sciatic nerve stretch (one), which resolved with time. The symphyseal plate needed to be removed in three patients: secondary to persistent pain at the site (one), persistent discharge from the lower abdominal wound (one) and erosion into the anterior wall of the vagina (one). • At a mean (range) follow-up of 60.7 (2-137) months the cosmetic and functional outcome of the abdominal wall reconstruction and genitoplasty was good with all the patients being satisfied. Five patients are currently sexually active and none has had a recurrence of their prolapse. None has become pregnant yet. • Although the morbidity of this procedure in the adult is not insignificant, it is a valuable adjunct to pelvic floor reconstruction in young women of childbearing age even in those who have had prior suspension procedures. • In addition, it allows the movement of lateral previously unoperated skin into the midline, allowing scar and skin replacement with healthier more vascularized tissue.

Effect of Clinician-Applied Maneuvers on Brachial Plexus Stretch During a Shoulder Dystocia Event: Investigation Using a Computer Simulation Model

Objective The objective of the study was to determine how standard shoulder dystocia maneuvers affect delivery force and brachial plexus stretch. Study Design A 3-dimensional computer model of shoulder dystocia was developed, including both a fetus and a maternal pelvis. Application of suprapubic pressure, rotation of the infant's shoulders, and delivery of the posterior arm following shoulder dystocia were each modeled, and delivery force and brachial plexus stretch were predicted. Results Compared with lithotomy alone, all maneuvers reduced both the required delivery force and brachial plexus stretch. The greatest effect was seen with delivery of the posterior arm, which showed a 71% decrease in anterior nerve stretch (3.9% vs 13.5%) and an 80% decrease in delivery force. Conclusion The standard maneuvers met the objective of reducing the necessary delivery force compared with the lithotomy position alone. Brachial plexus stretch is also reduced when these maneuvers are used rather than continuing the delivery in lithotomy position.

Spondylolisthesis mimicking the progression of dissection in a case of chronic Stanford type B aortic dissection

Aortic dissection is an acute lethal cardiovascular condition. A 67-year-old hypertensive woman was admitted to our Emergency Department with an abrupt onset of tearing pain in the interscapular area. A thoracic computed tomography scan with contrast showed chronic type B aortic dissection. The patient was transferred to intensive care and medical therapy was initiated. Upon spread of the pain to the lumbar area, the dissection was thought to have progressed. The patient, being hemodynamically stable, was examined using ultrasonography, and the dissection did not show any progression. In the neurological examination for the lumbar pain, the lumbar processus spinosus was found to be sensitive, and the sciatic nerve stretch test was positive at 30 degrees. Magnetic resonance imaging revealed spondylolisthesis and a centrally located disc herniation at the L3-4 level. No operation for the dissection was planned, but discectomy and fusion surgery was scheduled. Since the patient refused surgery, she was discharged with medical therapy. Our aim in this report was to emphasize the importance of spondylolisthesis mimicking the progression of dissection in the differential diagnosis of a chronic type B aortic dissection case.

Clonidine for an unusual isolated femoral nerve stretch injury

Clonidine for an unusual isolated femoral nerve stretch injury

Effect of clinician-applied maneuvers on brachial plexus stretch during a shoulder dystocia event: investigation using a computer simulation model

The objective of the study was to determine how standard shoulder dystocia maneuvers affect delivery force and brachial plexus stretch. A 3-dimensional computer model of shoulder dystocia was developed, including both a fetus and a maternal pelvis. Application of suprapubic pressure, rotation of the infant's shoulders, and delivery of the posterior arm following shoulder dystocia were each modeled, and delivery force and brachial plexus stretch were predicted. Compared with lithotomy alone, all maneuvers reduced both the required delivery force and brachial plexus stretch. The greatest effect was seen with delivery of the posterior arm, which showed a 71% decrease in anterior nerve stretch (3.9% vs 13.5%) and an 80% decrease in delivery force. The standard maneuvers met the objective of reducing the necessary delivery force compared with the lithotomy position alone. Brachial plexus stretch is also reduced when these maneuvers are used rather than continuing the delivery in lithotomy position.

Functional and Mechanical Evaluation of Nerve Stretch Injury

Peripheral nerves undergo tensile loading in common physiological conditions, but stretch can also induce nerve pathology, impairing electrophysiological conduction. The level of strain nerves can tolerate and the functional deficits which result from exceeding this threshold are not thoroughly understood. To examine these phenomena, a novel system for tensile electrophysiology was created using a grease gap-recording chamber paired with a computerized micromanipulator and load cell. Guinea pig sciatic nerves were stretched beyond their maximum physiologic length to examine the effects of tension on signal conduction. Mechanical and electrophysiological data such as load, position, compound action potential amplitude, and signal latency were recorded in real-time. While 5% strain did not affect conduction, further elongation decreased amplitude approximately linearly with strain. These experiments verify the findings of prior studies into nerve stretch, and demonstrate the utility of this apparatus for investigating the mechanical and electrophysiological properties of nerves undergoing strain.

A Case of Hypoglossal Nerve Palsy after Tonsillectomy

Tonsillectomy is a common procedure in the ENT department but unusual complications related to nerve injury might be associated with the surgery. We report a case of permanent hypoglossal nerve palsy following tonsillectomy in a 33-year-old female patient. The findings from the neu-rologic examination were unremarkable except for tongue deviation to the left, hemiatrophy of the tongue and associated dysarthria. Forceful pressure and stretch of hypoglossal nerve during surgery can explain the cause of injury. To avoid nerve compression, intermittent release of the mouth gag and avoidance of neck hyperextension are suggested especially when long operation time would be expected. Although rare, having knowledge of the existence of hypoglossal nerve injury complicating tonsillectomy is important when counseling patients.

PATHOANATOMIC BASIS FOR STRETCH-INDUCED LUMBAR NERVE ROOT INJURY WITH A REVIEW OF THE LITERATURE

Persistent pain originating from a dysfunctional lumbar motion segment poses significant challenges in the clinical arena. Although the predominance of the existing spine literature has addressed nerve root compression as the principal cause of pain, it is equally likely that a stretch mechanism may be responsible for all or part of the pathology. The literature supporting the role of stretch damage as a primary cause of nerve root injury and pain was systematically reviewed. Pathoanatomic considerations between nerve roots and juxtaposed environment are described and correlated with the available literature. Potential anatomic relationships that may lead to stretch-induced injury are delineated. A dynamic lumbar functional spinal unit that encloses a tethered nerve root can create significant stretch and/or compression. This phenomenon may be present in a variety of pathological conditions. These include anterior, posterior, and rotatory olisthesis as well as degenerative conditions such as the loss of disc interspace height and frank multisegment spinal deformity. Although numerous studies have demonstrated that stretch can result in nerve damage, the pathophysiology that may associate nerve stretch with chronic pain has yet to be determined. The current literature concerning stretch-related injury to nerve roots is reviewed, and a conceptual framework for its diagnosis and treatment is proposed and graphically illustrated using cadaveric specimens. The dynamic biomechanical and functional interrelationships between neural structures and adjacent connective tissue elements are particularly important in the face of spinal deformity.

Ocular Advancement in Monobloc Distraction

Monobloc distraction has been demonstrated to be an efficacious, safe, and stable method of providing functional and aesthetic improvement in children with syndromic craniosynostosis. Although the movement of bony structures following monobloc distraction has been quantitatively assessed before, objective analysis of the movement of soft tissues, such as the globe, has not been published previously. The authors present a method that assesses globe movement following monobloc distraction, using computed tomographic scan data. The preoperative and postoperative computed tomographic scans of 10 patients with Pfeiffer's and Crouzon's syndromes, undergoing monobloc distraction, were assessed. Scan data were loaded into voxel image-rendering software that produced a three-dimensional reconstruction. Direct measurements between preoperative and postoperative images were taken. An average upper face osseous distraction distance of 12.94 mm, with an average lower face distraction of 14.19 mm, was achieved in all 10 children. The authors measured average globe movements on three planes and calculated an average left eye forward movement of 5.28 mm and average right eye forward movement of 6.33 mm. In all, globe advancement was approximately two fifths of the distance advanced by the surrounding bone. Forward movement of the globe following monobloc distraction has not previously been described. Although there is no current evidence for optic nerve stretch and compromise in monobloc surgery, the functional implications of these findings should be formally assessed.

Reversible Femoral Distraction-Induced Sciatic Neuropraxia in an Achondroplasia Patient

Abstract Limb lengthening for short stature has become a standardized procedure with a good prognosis. External fixation is commonly used for those procedures. Gradual bone lengthening at a rate of 0.25 millimeter four times daily is commonly performed. Irreversible nerve traction injury was associated with acute limb lengthening rather than gradual distraction of bones. This reported case was unusual. The patient developed sciatic nerve stretch injury during the phase of gradual femoral distraction. Compression of the distraction site made the injury reversible.