Tinel's Sign Research Articles

Symptomatic Neuroma Development following En Bloc Resection of Skeletal and Soft-Tissue Tumors: A Retrospective Analysis of 331 Cases.

Although symptomatic neuroma formation has been described in other patient populations, these data have not been studied in patients undergoing resection of musculoskeletal tumors. This study aimed to characterize the incidence and risk factors of symptomatic neuroma formation following en bloc resection in this population. The authors retrospectively reviewed adults undergoing en bloc resections for musculoskeletal tumors at a high-volume sarcoma center from 2014 to 2019. The authors included en bloc resections for an oncologic indication and excluded non-en bloc resections, primary amputations, and patients with insufficient follow-up. Data are provided as descriptive statistics, and multivariable regression modeling was performed. The authors included 231 patients undergoing 331 en bloc resections (female, 46%; mean age, 52 years). Nerve transection was documented in 87 resections (26%). There were 81 symptomatic neuromas (25%) meeting criteria of Tinel sign or pain on examination and neuropathy in the distribution of suspected nerve injury. Factors associated with symptomatic neuroma formation included age 18 to 39 [adjusted OR (aOR), 3.6; 95% CI, 1.5 to 8.4; P < 0.01] and 40 to 64 (aOR, 2.2; 95% CI, 1.1 to 4.6; P = 0.04), multiple resections (aOR, 3.2; 95% CI, 1.7 to 5.9; P < 0.001), preoperative neuromodulator requirement (aOR, 2.7; 95% CI, 1.2 to 6.0; P = 0.01), and resection of fascia or muscle (aOR, 0.5; 95% CI, 0.3 to 1.0; P = 0.045). The authors' results highlight the importance of adequate preoperative optimization of pain control and intraoperative prophylaxis for neuroma prevention following en bloc resection of tumors, particularly for younger patients with a recurrent tumor burden. Risk, III.

44. Symptomatic Neuroma Formation following Skeletal and Soft Tissue Tumor Resection

PURPOSE: While symptomatic neuroma formation has been described in other patient populations, these data have not been studied in patients undergoing resection of musculoskeletal tumors. This study aims to characterize the incidence and risk factors of symptomatic neuroma formation following en bloc resection in this population. METHODS: We retrospectively reviewed adults undergoing en bloc resections for musculoskeletal tumors at a high-volume sarcoma center from 2014-2019. We included en bloc resections for an oncologic indication and excluded non-en bloc resections, primary amputations, and patients with insufficient follow-up. Data are provided as descriptive statistics and multivariable regression modeling was performed. RESULTS: We included 231 patients undergoing 331 en bloc resections (46% female; mean age 52 years). Nerve transection was documented in 87 resections (26%). There were 81 symptomatic neuromas (25%) meeting criteria of Tinel sign or pain on exam and neuropathy in the distribution of suspected nerve injury. Factors associated with symptomatic neuroma formation included age 18-39 (aOR, 3.6; 95% CI, 1.5-8.4; p < 0.01) and 40-64 (aOR, 2.2; 95% CI, 1.1-4.6; p = 0.04), multiple resections (aOR, 3.2; 95% CI, 1.7-5.9; p < 0.001), preoperative neuromodulator requirement (aOR, 2.7; 95% CI 1.2-6.0; p = 0.01) and resection of fascia or muscle (aOR, 0.5; 95% CI, 0.3-1.0; p = 0.045). CONCLUSION: Our results highlight the importance of adequate preoperative optimization of pain control and intraoperative prophylaxis for neuroma prevention following en bloc resection of tumors, particularly for younger patients with a recurrent tumor burden.

Radius palmar plate removal without carpal tunnel release: Correlation between plate position and median nerve symptoms

We aimed to report the clinical results of volar plate removal without carpal tunnel release in patients with late-onset median neuropathy and to evaluate the relationship between plate position and median nerve symptoms. Part I. Twelve consecutive patients with late-onset median neuropathy treated with volar plate removal without carpal tunnel release were enrolled for analysis. Pre- and post-operative Tinel sign, Phalen and Ten test, subjective rating of tingling sensation, Mayo wrist score and Disabilities of the Arm, Shoulder and Hand (DASH) score were collected. Part II. 232 consecutive patients underwent volar plating for distal radius fracture. The relationships between median nerve symptoms and volar plate prominence on the Soong classification, fracture classification, gender and age were investigated. All cases except one showed complete symptom resolution at final follow-up, with negative Tinel sign and Ten test score of 10/10. Tingling was rated 0 at final follow-up. Mean Mayo wrist and DASH scores improved to 86.7 and 23.1, respectively. The incidence of the median nerve symptoms in our cohort was 5.6%. Even though the odds ratio in Soong grade 2 was 4.0957 (95% CI, 0.93–16.9) compared to the combination of grades 0 and 1, no statistically significant relationship was found between the median nerve symptoms and volar plate prominence (p > 0.05). Plate removal without carpal tunnel release adequately relieved symptoms of late-onset median neuropathy after volar plating in patients with distal radius fracture. Level of EvidenceIV; Therapeutic.

Prevalence and Impact of Cell Phone Elbow among Mobile Users in Different Cities of Punjab, Pakistan

Cell phone elbow is the pinching of ulnar nerve behind the elbow resulting in tingling or numbness within the hand when using a cell phone, sleeping with your elbows bent, or holding your arms bent and by your head for long period of time. Objective: To find out the prevalence of cellphone elbow among mobile phone users and its associated impairments and functional limitations. Methods: A cross-sectional study was conducted during October 2021 to April 2022. Data were collected from different Punjab colleges and universities: NUR International University, Riphah International University, The University of Lahore, University of Faisalabad, Niazi College of Physical Therapy and Fatima Memorial Hospital and College. Participants were recruited through convenience sampling from 17-50 years of age with positive Tinel sign test. Data collection were done by using the Numeric Pain Rating Scale and Boston Carpal Tunnel Syndrome Questionnaires. Results: Out of 250 subjects 33.2% were having noticeable symptoms associated with prolong phone usage. Among them 39.6% experienced numbness and tingling. Hand pain is reported in 32.8% and 27.6% experienced pain on ulna side of elbow. Conclusions: The prevalence of cell phone elbow was 33.2%, higher than the previous studies. This research advice the cell phone users to minimize their mobile usage, avoid prolonged calls, use hands alternately to avoid strain on one hand, use hands-free and ear pods while taking calls

Diagnostic Test Accuracy of Provocative Maneuvers for the Diagnosis of Carpal Tunnel Syndrome: A Systematic Review and Meta-Analysis.

The purpose of this study was to summarize and evaluate the research on the accuracy of provocative maneuvers to diagnose carpal tunnel syndrome (CTS). The MEDLINE, CINAHL, Cochrane, and Embase databases were searched, and studies that assessed the diagnostic accuracy of at least 1 provocative test for CTS were selected. Study characteristics and data about the diagnostic accuracy of the provocative tests for CTS were extracted. A random-effects meta-analysis of the sensitivity (Sn) and specificity (Sp) of the Phalen test and Tinel sign was conducted. The risk of bias (ROB) was rated using the QUADAS-2 tool. Thirty-one studies that assessed 12 provocative maneuvers were included. The Phalen test and the Tinel sign were the 2 most assessed tests (in 22 and 20 studies, respectively). The ROB was unclear or low in 20 studies, and at least 1 item was rated as having high ROB in 11 studies. Based on a meta-analysis of 7 studies (604 patients), the Phalen test had a pooled Sn of 0.57 (95% CI = 0.44-0.68; range = 0.12-0.92) and a pooled Sp of 0.67 (95% CI = 0.52-0.79; range = 0.30-0.95). For the Tinel sign (7 studies, 748 patients), the pooled Sn was 0.45 (95% CI = 0.34-0.57; range = 0.17-0.97) and the pooled Sp was 0.78 (95% CI = 0.60-0.89; range = 0.40-0.92). Other provocative maneuvers were less frequently studied and had conflicting diagnostic accuracies. Meta-analyses are imprecise but suggest that the Phalen test has moderate Sn and Sp, whereas the Tinel test has low Sn and high Sp. Clinicians should combine provocative maneuvers with sensorimotor tests, hand diagrams, and diagnostic questionnaires to achieve better overall diagnostic accuracy rather than relying on individual clinical tests. Evidence of unclear and high ROB do not support the use of any single provocative maneuver for the diagnosis of CTS. Clinicians should consider a combination of noninvasive clinical diagnostic tests as the first choice for the diagnosis of CTS.

Hand Allodynia, Lack of Finger Flexion, and the Need for Carpal Tunnel Release

The clinical features of classic carpal tunnel syndrome are well known. However, some patients who may respond equally well to carpal tunnel release (CTR) display atypical signs and symptoms. The chief differential features are allodynia (painful dysesthesias), lack of finger flexion, and, on examination, pain on passive finger flexion. The goal of the study was to present the clinical features, increase awareness, facilitate accurate diagnosis, and report the outcomes after surgery. Thirty-five hands, from 22 patients with the main features of allodynia and lack of full finger flexion, were gathered in the period 2014-2021. The other common complaints included sleeping disturbances (20 patients), hand swelling (31 hands), and shoulder pain on the same side as the hand problem with limited range of motion (30 sides). The Tinel or Phalen signs were obscured by the pain. However, pain with passive flexion of the fingers was universally present. All the patients were treated with carpal tunnel release through a mini-incision approach: four patients had a trigger finger, which was treated concomitantly in six hands, and one patient underwent contralateral CTR for carpal tunnel syndrome with a more standard presentation. At a minimum of 6 months of follow-up (mean, 22 months; range, 6-60 months), the pain decreased by 7.5 ± 1.9 points on the Numerical Rating Scale, which ranges from 0 to 10. The pulp-to-palm distance improved from 3.7 to 0.3 cm. The mean Disabilities of the Arm, Shoulder, and Hand score decreased from 67 to 20. The mean Single-Assessment Numeric Evaluation score for the whole group was 9.7 ± 0.6. Hand allodynia and lack of finger flexion may be indications of median neuropathy in the carpal canal, which responds to CTR. Awareness of this condition is important because the uncharacteristic clinical presentation may not be considered an indication for surgery that can be beneficial. Therapeutic IV.

Palmar Scapholunate Interosseous Ligament Repair in the Acute Traumatic Wrist Disarticulation

Objective: The volar scapholunate interosseous ligament is an important stabilizer of the wrist. In 2015, Kampen et al. described the technique for reconstruction of an isolated palmar injury using the long radiolunate ligament in the subacute or chronic setting, however its use has not been described in the acute, traumatic setting. Methods: The patient is 22-year-old male who presented with a traumatic right open trans-radial/ulnar wrist disarticulation with underlying bony, tendinous, ligamentous, and neurovascular injuries secondary to a motor vehicle accident. The volar scapholunate ligament was found to be completely disrupted at the time of surgery with appreciable gapping. As described by Kampen, the long radiolunate (LRL) ligament was identified. An L shaped incision was made within the ligament, releasing the radial attachment, and then extending the cut in line with the transverse fibers, dividing the ligament in half. The scapholunate joint was manually reduced under direct visualization. The strip of LRL was rotated distally toward the scaphoid, tensioned, and attached to the proximal pole of the scaphoid with a suture anchor. The remainder of the volar capsule was then repaired. Intra-operative repair also included six-strand repair in a M-tang fashion of flexor pollicis longus (FPL), flexor digitorum superficialis (FDS) to index and middle, flexor carpi radialis (FCR), extensor pollicis brevis (EPB) and abductor pollicis longus (APL). The lacerated median nerve was trimmed back to healthy fascicular architecture, mobilized, primarily repaired without undue tension, and wrapped with a nerve protector. Results: At 3 months post-operatively, the patient had improved range of motion, specifically with wrist flexion and radial deviation. Pronation and supination were near equivalent compared to the uninjured wrist. Currently, the patient reports no pain and has a recovering Tinel sign at the distal palmar crease. On radiographic analysis, patient had normal scapholunate (SL) angle at 59.6° and no SL gap. Patient also reports ability to hold and swing a baseball bat. Conclusion: The volar scapholunate interosseous ligament is an important stabilizer of the wrist. A strip of the long radiolunate ligament can be used to reconstruct the volar scapholunate ligament in the acute, subacute, or chronic setting. This technique is a useful tool for the hand surgeon faced with an isolated palmar scapholunate injury in the acute traumatic hand. Corresponding Author: Olivia Means, 100 Michigan St NE, Suite A601, Grand Rapids, MI 49503, [email protected], (202) 258 - 0130

Tarsal tunnel syndrome – a disease ignored by doctors and totally unknown for the patients

Tarsal tunnel syndrome (TTS), or tibial nerve compression at the internal malleolus level, is a frequently missed disease among clinicians, although it can be found in diabetic pa­tients (almost half of them will develop peripheral neu­ro­pa­thy and related complications) and in non-diabetic pa­tients due to the existence of tumors and anatomical ac­ces­sory elments. The aim of this paper is to increase the le­vel of awareness regarding the TTS diagnostic tools and treat­ments among doctors. The main source of literature re­view was PubMed database and the author’s per­so­nal ex­­pe­­rience. Although it is considered a rare di­sease, for sure underdiagnosed, left without treatment, TTS will lead to foot sensitive and motor deficits with dra­ma­tic ef­fects on patients quality of life and survival. Pa­tient’s his­to­ry, cli­ni­cal examination (positive Tinel sign, ob­jec­tive test­ing of in­creased sensibility threshold) and pa­ra­cli­ni­cal exa­mi­na­tion (soft tissue ultrasonography and ner­vous conduction stu­dies) highlight the diagnostic. The con­ser­va­tive and mi­ni­mally invasive therapeutic methods are effi­cient, but limited in time, the surgical solution – tarsal tun­nel de­com­pre­sion – being still the elective procedure, even in cri­ti­cal peri­pheral neu­ro­pa­thy.

Outcomes of Surgical Treatment of Peripheral Neuromas of the Hand and Forearm.

The choice of a specific technique for surgical treatment of neuromas remains a problem. The purpose of this study is to determine the overall effectiveness of surgery as well as to find out whether certain surgical procedures are more effective than others. Twenty-nine patients operated between 1998 and 2018 and followed for at least 12 months were reviewed. Clinical assessment included the identification of a pre- and postoperative Tinel sign, pain visual analog score, two-point discrimination (2PD), and grip strength. Mechanisms of injury included clean lacerations (11), crush injuries (11), and other trauma or surgery (7). Mean time from presentation to surgery was 9 months. Seven surgical procedures involving excision in 10 patients and excision and nerve repair in 19 patients were performed. Pain score improved from an average of 7.1 ± 2.3 to 1.8 ± 1.7 with 27 patients (93%) reporting mild or no postoperative pain. Nine patients complained of residual scar hypersensitivity and six patients had residual positive Tinel. No patient required an additional surgical procedure. 2PD improved from an average of 9.6 ± 4.0 to 6.8 ± 1.0. The improvement of pain score and 2PD was statistically significant. Nerve repair resulted in marginally better outcomes, in terms of 2PD and grip strength recovery, than excision alone. The mechanism of injury, zone of involvement, time to intervention, or length of follow-up did not have an impact on the outcomes. Although patient numbers in this study are large in comparison to previous studies, larger patient numbers will allow for a multivariate analysis, which can be possible with a prospective multicenter trial.

The effects of tibial nerve mobilization in patients with tarsal tunnel syndrome: A randomized controlled trial

In tarsal tunnel syndrome (TTS), the nerve mobilization, one of the conservative treatment methods, aims to relieve abnormal nerve tension with appropriate movements of the nerve tissue. The aim of this study was to investigate the effect of tibial nerve mobilization in addition to home exercise on the tibial nerve area in patients diagnosed with TTS. The study included 40 participants, including 20 cases in the intervention group (IG) and 20 cases in the control group (CG). IG received tibial nerve mobilization and a home exercise program for and foot-ankle joint. Participants in the control group had only a home exercise program for the foot-ankle joint. Primary outcome measures were tibial nerve diameter and Tinel's sign measurements. Secondary outcome measures were pain intensity, neuropathic pain status (NPQ) and foot functional index (FFI). The positive Tinel's sign incidence was lower in favour of IG (Odds ratio:0.11 95% CI: 0.03 to 0.46). Between-group comparisons revealed a significant difference in pain intensity (Mean difference: 1.45; 95% CI: 0.69 to 2.20), NPQ (Mean difference: 0.70; 95% CI: 0.36 to 1.03), pain subscale (Mean difference: 10.0; 95% CI: 4.33 to 15.66) and total score of FFI (Mean difference: 20.60; 95% CI: 0.53 to 40.66) in favour of IG. There was no reported adverse events. This study showed that the addition of tibial nerve mobilization to home exercise program might improve symptoms, especially pain and functionality in patients with TTS. Further studies with large sample sizes are need to support these results.

Pronator Quadratus: A Preferable Recipient for Targeted Muscle Reinnervation of Neuromas in the Hand.

Targeted muscle reinnervation (TMR) has emerged as a useful solution to the problem of painful neuromas and is increasingly being applied in many clinical circumstances. Relatively little has been written about TMR for painful neuromas of the hand, and what has been written describes use of the intrinsic muscles as recipients for the nerve transfer. Except in cases of amputation, intrinsic muscle sacrifice carries morbidity. Furthermore, TMR to intrinsic muscles will place the nerve coaptation in areas subject to pressure with loading of the palm. For these reasons, the pronator quadratus may be a preferable target muscle when performing TMR for painful neuromas of the hand. In this report, we describe the rationale for its use and demonstrate the surgical technique and outcomes with case examples.

Autoimmune hepatitis complicated with entrapment neuropathy &amp; fibromyalgia: A case report

46. y-old right-handed female with history of controlled autoimmune hepatitis since 2001 with negative liver biopsy on 2017 presented with chronic generalized pain affecting neck, upper back, buttocks, knee and chest associated with paresthesia and tingling of left hand with nocturnal exacerbation. Clinical exam revealed; Neurologically Positive Tinel sign over median nerve at wrist bilaterally, Positive Phalen test bilaterally, Musculoskeletal exam revealed multiple tender points bilaterally with limited neck Rom due to pain. Electrophysiological testing of both upper extremities documented bilateral median sensory neuropathy at wrist, demyelinating pathology and bilateral ulnar nerve entrapment at wrist: Guyon canal syndrome; sensory-motor axonal demyelinating. Normal liver and kidney function tests and glycosylated hemoglobin 5.

Posterior Interosseous Nerve Compression in the Forearm, AKA Radial Tunnel Syndrome: A Clinical Diagnosis.

Posterior interosseous nerve (PIN) compression in the forearm without motor paralysis is a challenging clinical diagnosis. This retrospective study evaluated the clinical assessment, diagnostic studies, and outcomes following surgical decompression of the PIN in the forearm. This study reviewed 182 patients' medical charts following PIN decompression between 2000 and 2020 by a single surgeon. After exclusion of combined nerve entrapments, polyneuropathy, motor palsy, or lateral epicondylitis, the study included 14 patients. Data collected included: clinical presentation and pain drawings, provocative testing, functional outcomes, and Disabilities of the Arm, Shoulder, and Hand (DASH) scores. There were 15 PIN decompressions (14 patients, mean follow-up = 11.9 months). Clinical presentation included pain (n = 14) (proximal dorsal forearm, n = 14; distal forearm over radial sensory nerve, n = 3) and positive clinical tests (sensory collapse test over the radial tunnel, n = 8; pain with forearm pronation and compression over the radial tunnel, n = 10; Tinel sign, n = 5). Postoperatively, there were significant improvements in Visual Analog Scale pain scores (6.7 to 3.3, P = .0006), quality-of-life scores (74.7 to 32.7, P = .0001), and DASH scores (46.3 to 33.6, P = .02). The PIN compression in the forearm without motor paralysis is a clinical diagnosis supported by pain drawings, pain quality, and provocative tests. Patients with persistent, therapy-resistant dorsal forearm pain should be evaluated for PIN compression. Surgical decompression provides statistically significant quantifiable improvement in pain and quality of life.

EFFICACY OF ULTRASOUND GUIDED CORTICOSTEROID INJECTION IN CARPAL TUNNEL SYNDROME

BACKGROUND : Carpal tunnel syndrome is the most common peripheral nerve entrapment syndrome. The etiology can be hereditary, repetitive movements of the wrist in mechanical workers, injury to the wrist, pregnancy, obesity, metabolic disorders, auto immune conditions such as diabetes mellitus, rheumatoid arthritis and in elderly population. Females are affected more than males. A lot of treatment options are available for carpal tunnel syndrome. Corticosteroid injections are very effective in mild to moderate carpal tunnel syndrome on short and in some cases on long term basis.&#x0D; OBJECTIVES:To evaluate the efficacy and clinical outcomes of ultrasound guided corticosteroid injection for treatment of carpal tunnel syndrome.&#x0D; STUDY SETTING: Department of Orthopedic surgery Services Hospital Lahore .&#x0D; STUDY DESIGN: Cross sectional study.&#x0D; STUDY DURATION: From December 2018 to December 2019 &#x0D; METHODOLOGY: This prospective cross sectional study was carried out from Dec 2018 – Dec 2019 on OPD basis. A total number of 80 patients were included in the study. There were 40 males and 40 females in our study. Each patient was injected triamcinolone 40 mg with 2 % xylocaine. After the injection every patient was followed at 6 weeks, 3 months and at 6 months.&#x0D; At each follow up these patients were assessed by Phalen test, Tinel sign, Boston carpal tunnel syndrome severity score, functional assessment scale, electrophysiological studies and nerve conduction study.&#x0D; RESULTS : Our study included 80 patients with 40 males and 40 females. 40 female patients were housewives, 25 male patients were manual workers and remaining 15 patients were computer operator. 30 patients had mild symptoms of carpal tunnel syndrome, 35 had moderate while the remaining 15 patients had severe symptoms of carpal tunnel syndrome. All these patients were having symptoms for the last 6 – 12 weeks which did not improve with the conservative management. These patients were having symptoms of numbness and tingling at the initial presentation. Phalen test was positive in 95 % (76 patients) patients while Tinel test was positive in 80 % patients ( 64 patients ) at the initial presentation . &#x0D; Boston’s severity symptom score was 35.34 +/- 3.59 and functional status scale was 25.43 + 5.82 (At the initial presentation) in all patients. Following corticosteroid injection at 06 weeks the symptoms severity score was 21+/-3.32 ( mean ) and at 03 months 18.80 + 3.41 ( mean ) in 72 patients while 8 patients did not respond to corticosteroid injection while the functional status scale 17.62 +- 5.01 and 13.45 +- 4.2 at 03 months .&#x0D; Electrophysiological study was also improved after 06 weeks and after 03 months&#x0D; CONCLUSION : Corticosteroid injections are very effective regarding the outcomes on short term basis . However , they are effective in small number of patients on long term basis

The Tinel Sign and Myelinated Axons in the Cross-Face Nerve Graft: Predictors of Smile Reanimation Outcome for Free Gracilis Muscle Transfer?

Introduction: During a two-stage free gracilis muscle transfer (FGMT) to restore smile to patients with facial paralysis, some surgeons assess nerve regeneration through the cross-face nerve graft (CFNG) with the Tinel sign and a nerve biopsy. Objective: To test whether ultimate smile reanimation outcomes are correlated with (1) the Tinel sign or (2) myelinated axons of the biopsied CFNG at the time of FGMT. Methods: Retrospective case series was performed at a tertiary care facial nerve center. Dynamic smile outcomes were quantified with Emotrics analysis of pre- and postoperative photographs. Results: Of the 113 FGMT surgeries by CFNG performed since 2002, 92 patients had pre- and postoperative photo-documentation. Most patients (89%, N = 82) had a positive Tinel sign at the time of FGMT; however, 14 patients with positive Tinel signs were deemed failures. Interestingly, 4 patients with a negative Tinel sign went on to have successful dynamic outcomes and 16 patients lacking myelinated axons in their CFNG biopsy ultimately achieved successful smile outcomes. Conclusion: Although the majority of patients had a positive Tinel sign and myelinated axons in the CFNG at the time of FGMT, the presence or absence of either factor did not predict ultimate smile outcome in this series.

Commentary on: "The Tinel Sign and Myelinated Axons in the Cross-Face Nerve Graft: Predictors of Smile Reanimation Outcome for Free Gracilis Muscle Transfer?" by Greene et al.

Facial Plastic Surgery & Aesthetic MedicineVol. 24, No. 4 Invited CommentaryCommentary on: “The Tinel Sign and Myelinated Axons in the Cross-Face Nerve Graft: Predictors of Smile Reanimation Outcome for Free Gracilis Muscle Transfer?” by Greene et alBabak Azizzadeh and Adrian E. HouseBabak Azizzadeh*Address correspondence to: Babak Azizzadeh, MD, Center for Advanced Facial Plastic Surgery, 9401 Wilshire Boulevard, Suite #650, Beverly Hills, CA 90212, USA. E-mail Address: drazizzadeh@gmail.comhttps://orcid.org/0000-0002-5607-1022Center for Advanced Facial Plastic Surgery, Beverly Hills, California, USA.Search for more papers by this author and Adrian E. HouseCenter for Advanced Facial Plastic Surgery, Beverly Hills, California, USA.Search for more papers by this authorPublished Online:29 Jul 2022https://doi.org/10.1089/fpsam.2022.0027AboutSectionsView articleView Full TextPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail View article"Commentary on: “The Tinel Sign and Myelinated Axons in the Cross-Face Nerve Graft: Predictors of Smile Reanimation Outcome for Free Gracilis Muscle Transfer?” by Greene et al." Facial Plastic Surgery & Aesthetic Medicine, 24(4), pp. 260–261FiguresReferencesRelatedDetails Volume 24Issue 4Aug 2022 Information© 2022, American Academy of Facial Plastic and Reconstructive Surgery, Inc.To cite this article:Babak Azizzadeh and Adrian E. House.Commentary on: “The Tinel Sign and Myelinated Axons in the Cross-Face Nerve Graft: Predictors of Smile Reanimation Outcome for Free Gracilis Muscle Transfer?” by Greene et al.Facial Plastic Surgery & Aesthetic Medicine.Aug 2022.260-261.http://doi.org/10.1089/fpsam.2022.0027Published in Volume: 24 Issue 4: July 29, 2022Online Ahead of Print:June 3, 2022PDF download

An Update on Posterior Tarsal Tunnel Syndrome.

Posterior tarsal tunnel syndrome (PTTS) is an entrapment neuropathy due to compression of the tibial nerve or one of its terminal branches within the tarsal tunnel in the medial ankle. The tarsal tunnel is formed by the flexor retinaculum, while the floor is composed of the distal tibia, talus, and calcaneal bones. The tarsal tunnel contains a number of significant structures, including the tendons of 3 muscles as well as the posterior tibial artery, vein, and nerve. Focal compressive neuropathy of PTTS can originate from anything that physically restricts the volume of the tarsal tunnel. The variety of etiologies includes distinct movements of the foot, trauma, vascular disorders, soft tissue inflammation, diabetes mellitus, compression lesions, bony lesions, masses, lower extremity edema, and postoperative injury. Generally, compression of the posterior tibial nerve results in clinical findings consisting of numbness, burning, and painful paresthesia in the heel, medial ankle, and plantar surface of the foot. Diagnosis of PTTS can be made with the presence of a positive Tinel sign in combination with the physical symptoms of pain and numbness along the plantar and medial surfaces of the foot. Initially, patients are treated conservatively unless there are signs of muscle atrophy or motor nerve involvement. Conservative treatment includes activity modification, heat, cryotherapy, non-steroidal anti-inflammatory drugs, corticosteroid injections, opioids, GABA analog medications, tricyclic antidepressants, vitamin B-complex supplements, physical therapy, and custom orthotics. If PTTS is recalcitrant to conservative treatment, standard open surgical decompression of the flexor retinaculum is indicated. In recent years, a number of alternative minimally invasive treatment options have been investigated, but these studies have small sample sizes or were conducted on cadaveric models.

Assessing carpal tunnel syndrome with magnetoneurography

ObjectiveTo measure the neuromagnetic fields of carpal tunnel syndrome patients after electrical digital nerve stimulation and evaluate median nerve function with high spatial resolution. MethodsA superconducting quantum interference device magnetometer system was used to record neuromagnetic fields at the carpal tunnel after electrical stimulation of the middle digital nerve in 10 hands of nine patients with carpal tunnel syndrome. The patients were diagnosed based on symptoms (numbness, tingling, and pain) supported by a positive Phalen or Tinel sign. A novel technique was applied to remove stimulus-induced artifacts, and current distributions were calculated using a spatial filter algorithm and superimposed on X-ray. ResultsIn 6 of the 10 hands, the amplitude of the inward current waveform attenuated to <70% or the nerve conduction velocity was <40 m/s. The results of conventional nerve conduction studies were normal for two of these six hands. All four hands that could not be diagnosed by magnetoneurography had severe carpal tunnel syndrome superimposed on peripheral neuropathy secondary to comorbidities. ConclusionsTechnical improvements enabled magnetoneurography to noninvasively visualize the electrophysiological nerve activity in carpal tunnel syndrome patients. SignificanceMagnetoneurography may have the potential to contribute to the detailed diagnosis of various peripheral nerve disorders.

Tarsal tunnel syndrome secondary to accessory or variant muscles: a clinical and anatomical systematic review.

Many etiologies are known to lead to a tarsal tunnel syndrome (TTS). One rare cause is mass-occupying lesions, and particularly accessory or variant muscles (AVM). This study aimed to systematically collect published clinical cases of TTS caused by AVM. An electronic literature search was conducted from inception to April 2021. The diagnosis of AVM should be reported in one of the following methods: ultrasonography, magnetic resonance imaging (MRI), or per-operatively. Data extraction included types and prevalence of accessory muscles, clinical presentation and diagnosis, and treatment modalities. Twenty-five studies were identified with a total 39 patients (47 ankles). The prevalence of TTS was reported in only two studies (9%). Forty-nine AVM were identified with the accessory flexor digitorum longus being the most common (52%). The most common sign/symptoms were tenderness (78.7%), pain (82.9%), dysesthesia (57.4%), Tinel sign (44.6%), and a swelling (25.5%). Decompression and excision were the most commonly performed procedures. Four accessory/variant muscles in the ankle have the potential to induce a tarsal tunnel syndrome. This review highlights the clinical and imagery specificities of TTS secondary to accessory or variant muscles. Mass-occupying etiology should be included in the list of differential diagnoses whenever a posterior tibial nerve compression is suspected.

Validity of range of motion, muscle strength, sensitivity, and Tinel sign tele-assessment in adults with traumatic brachial plexus injury.

BackgroundThe COVID-19 pandemic and the need for social distancing created challenges for accessing and providing health services. Telemedicine enables prompt evaluation of patients with traumatic brachial plexus injury, even at a distance, without prejudice to the prognosis. The present study aimed to verify the validity of range of motion, muscle strength, sensitivity, and Tinel sign tele-assessment in adults with traumatic brachial plexus injury (TBPI).MethodsA cross-sectional study of twenty-one men and women with TBPI admitted for treatment at a Rehabilitation Hospital Network was conducted. The participants were assessed for range of motion, muscle strength, sensitivity, and Tinel sign at two moments: in-person assessment (IPA) and tele-assessment (TA).ResultsThe TA muscle strength tests presented significant and excellent correlations with the IPA (the intra-rater intraclass correlation coefficient, ICC ranged between 0.79 and 1.00 depending on the muscle tested). The agreement between the TA and IPA range of motion tests ranged from substantial to moderate (weighted kappa coefficient of 0.47–0.76 (p < 0.05) depending on the joint), and the kappa coefficient did not indicate a statistically significant agreement in the range of motion tests of supination, wrist flexors, shoulder flexors, and shoulder external rotators. The agreement between the IPA andTA sensitivity tests of all innervations ranged from substantial to almost perfect (weighted kappa coefficient 0.61–0.83, p < 0.05) except for the C5 innervation, where the kappa coefficient did not indicate a statistically significant agreement. The IPA versus TA Tinel sign test showed a moderate agreement (weighted kappa coefficient of 0.57, p < 0.05).ConclusionsThe present study demonstrated that muscle strength tele-assessment is valid in adults with TBPI and presented a strong agreement for many components of TA range of motion, sensitivity, and Tinel sign tests.