An ultrasound-guided percutaneous electrical nerve stimulation regimen devised using finite element modeling promotes functional recovery after median nerve transection

Percutaneous electrical nerve stimulation of an injured nerve can promote and accelerate peripheral nerve regeneration and improve function.When performing acupuncture and moxibustion,locating the injured nerve using ultrasound before percutaneous nerve stimulation can help prevent further injury to an already injured nerve.However,stimulation parameters have not been standardized.In this study,we constructed a multi-layer human forearm model using finite element modeling.Taking current density and activated function as optimization indicators,the optimal percutaneous nerve stimulation parameters were established.The optimal parameters were parallel placement located 3 cm apart with the injury site at the midpoint between the needles.To validate the efficacy of this regimen,we performed a randomized controlled trial in 23 patients with median nerve transection who underwent neurorrhaphy.Patients who received conventional rehabilitation combined with percutaneous electrical nerve stimulation experienced greater improvement in sensory function,motor function,and grip strength than those who received conventional rehabilitation combined with transcutaneous electrical nerve stimulation.These findings suggest that the percutaneous electrical nerve stimulation regimen established in this study can improve global median nerve function in patients with median nerve transection.

Resuscitation therapy for traumatic brain injuryinduced coma in rats:mechanisms of median nerve electrical stimulation

In this study, rats were put into traumatic brain injury-induced coma and treated with median nerve electrical stimulation. We explored the wake-promoting effect, and possible mechanisms, of median nerve electrical stimulation. Electrical stimulation upregulated the expression levels of orexin-A and its receptor OX1R in the rat prefrontal cortex. Orexin-A expression gradually in-creased with increasing stimulation, while OX1R expression reached a peak at 12 hours and then decreased. In addition, after the OX1R antagonist, SB334867, was injected into the brain of rats after traumatic brain injury, fewer rats were restored to consciousness, and orexin-A and OXIR expression in the prefrontal cortex was downregulated. Our ifndings indicate that median nerve electrical stimulation induced an up-regulation of orexin-A and OX1R expression in the pre-frontal cortex of traumatic brain injury-induced coma rats, which may be a potential mechanism involved in the wake-promoting effects of median nerve electrical stimulation.

Relationship between sonographically measured median nerve cross-sectional area and presence of peripheral neuropathy in diabetic subjects

BACKGROUND Neuropathy is a common complication of diabetes mellitus resulting from direct damage by hyperglycemia to the nerves and/or ischemia by microvascular injury to the endoneurial vessels which supply the nerves. Median nerve is one of the peripheral nerves commonly affected in diabetic neuropathy. The median nerve size has been studied in non-Nigerian diabetic populations. In attempt to contribute to existing literature, a study in a Nigerian population is needed.AIM To evaluate the cross-sectional area(CSA) of the median nerve using B-mode ultrasonography(USS) and the presence of peripheral neuropathy(PN) in a cohort of adult diabetic Nigerians.METHODS Demographic and anthropometric data of 85 adult diabetes mellitus(DM) and 85 age-and sex-matched apparently healthy control(HC) subjects were taken. A complete physical examination was performed on all study subjects to determine the presence of PN and modified Michigan Neuropathy Screening Instrument(MNSI) was used to grade its severity. Venous blood was taken from the study subjects for fasting lipid profile(FLP), fasting blood glucose(FBG) and glycated haemoglobin(HbA1 c) while their MN CSA was evaluated at a point 5 cm proximal to(5 cmCATL) and at the carpal tunnel(CATL) by high-resolution Bmode USS. Data was analysed using SPSS version 22.RESULTS The mean MN CSA was significantly thicker in DM subjects compared to the HC at 5 cmCATL(P < 0.01) and at the CATL(P < 0.01) on both sides. The presence of diabetic peripheral neuropathy(DPN) further increased the MN CSA at the CATL(P < 0.05) but not at 5 cmCATL(P > 0.05). However, the severity of DPN had no additional effect on MN CSA 5 cm proximal to and at the CATL. There was no significant association between MN CSA and duration of DM and glycemic control.CONCLUSION Thickening of the MN CSA at 5 cmCATL and CATL is seen in DM. Presence of DPN is associated with worse thickening of the MN CSA at the CATL but not at5 cmCATL. Severity of DPN, duration of DM, and glycemic control had no additional effect on the MN CSA.

Total brachial plexus injury： contralateral C7 root transfer to the lower trunk versus the median nerve

Contralateral C7（cC7） root transfer to the healthy side is the main method for the treatment of brachial plexus root injury. A relatively new modification of this method involves cC7 root transfer to the lower trunk via the prespinal route. In the current study, we examined the effectiveness of this method using electrophysiological and histological analyses. To this end, we used a rat model of total brachial plexus injury, and cC7 root transfer was performed to either the lower trunk via the prespinal route or the median nerve via a subcutaneous tunnel to repair the injury. At 4, 8 and 12 weeks, the grasping test was used to measure the changes in grasp strength of the injured forepaw. Electrophysiological changes were examined in the flexor digitorum superficialis muscle. The change in the wet weight of the forearm flexor was also measured. Atrophy of the flexor digitorum superficialis muscle was assessed by hematoxylin-eosin staining. Toluidine blue staining was used to count the number of myelinated nerve fibers in the injured nerves. Compared with the traditional method, cC7 root transfer to the lower trunk via the prespinal route increased grasp strength of the injured forepaw, increased the compound muscle action potential maximum amplitude, shortened latency, substantially restored tetanic contraction of the forearm flexor muscles, increased the wet weight of the muscle, reduced atrophy of the flexor digitorum superficialis muscle, and increased the number of myelinated nerve fibers. These findings demonstrate that for finger flexion functional recovery in rats with total brachial plexus injury, transfer of the cC7 root to the lower trunk via the prespinal route is more effective than transfer to the median nerve via subcutaneous tunnel.

Is it necessary to use the entire root as a donor when transferring contralateral C7 nerve to repair median nerve？

If a partial contralateral C7 nerve is transferred to a recipient injured nerve, results are not satisfactory. However, if an entire contralateral C7 nerve is used to repair two nerves, both recipient nerves show good recovery. These findings seem contradictory, as the above two methods use the same donor nerve, only the cutting method of the contralateral C7 nerve is different. To verify whether this can actually result in different repair effects, we divided rats with right total brachial plexus injury into three groups. In the entire root group, the entire contralateral C7 root was transected and transferred to the median nerve of the affected limb. In the posterior division group, only the posterior division of the contralateral C7 root was transected and transferred to the median nerve. In the entire root ＋ posterior division group, the entire contralateral C7 root was transected but only the posterior division was transferred to the median nerve. After neurectomy,the median nerve was repaired on the affected side in the three groups. At 8, 12, and 16 weeks postoperatively, electrophysiological examination showed that maximum amplitude, latency, muscle tetanic contraction force, and muscle fiber cross-sectional area of the flexor digitorum superficialis muscle were significantly better in the entire root and entire root ＋ posterior division groups than in the posterior division group. No significant difference was found between the entire root and entire root ＋ posterior division groups. Counts of myelinated axons in the median nerve were greater in the entire root group than in the entire root ＋ posterior division group, which were greater than the posterior division group. We conclude that for the same recipient nerve, harvesting of the entire contralateral C7 root achieved significantly better recovery than partial harvesting, even if only part of the entire root was used for transfer. This result indicates that the entire root should be used as a donor when transferring contralateral C7 nerve.

Ultrasonographic measurement of median nerve cross-sectional area reference values in a healthy Han population from Guiyang,China

High-resolution ultrasonography was used to analyze the nerve cross-sectional area （CSA） of the median nerve at 7 sites： the wrist crease, pisiform bone, hamate bone, 6 cm proximal to the tip of the wrist crease, proximal forearm （where the nerve enters the pronator teres muscle）, 4 cm proximal to the tip of the medial epicondyle, and mid-humerus （mid-point between elbow crease and axilla） in 200 healthy volunteers from Guiyang, China. Results showed similar CSA values between the left and right sides, but the CSA 6 cm proximal to the tip of the wrist crease, proximal forearm, 4 cm proximal to tip of the medial epicondyle, and mid-humerus in males was greater than that of females. Moreover, CSA values at the wrist crease, pisiform bone, and hamate bone were greater in the middle-aged and old groups when compared to the young group, and correlated with body mass and height. Thus, reference values of median nerve CSA of the upper limbs can facilitate the analysis of abnormal nerve conditions.

Reinnervation of spinal cord anterior horn cells after median nerve repair using transposition with other nerves

Our previous studies have confirmed that during nerve transposition repair to injured peripheral nerves, the regenerated nerve fibers of motor neurons in the anterior horn of the spinal cord can effectively repair distal nerve and target muscle tissue and restore muscle motor function. To observe the effect of nerve regeneration and motor function recovery after several types of nerve transposition for median nerve defect(2 mm), 30 Sprague-Dawley rats were randomly divided into sham operation group, epineurial neurorrhaphy group, musculocutaneous nerve transposition group, medial pectoral nerve transposition group, and radial nerve muscular branch transposition group. Three months after nerve repair, the wrist flexion test was used to evaluate the recovery of wrist flexion after regeneration of median nerve in the affected limbs of rats. The number of myelinated nerve fibers, the thickness of myelin sheath, the diameter of axons and the cross-sectional area of axons in the proximal and distal segments of the repaired nerves were measured by osmic acid staining. The ratio of newly produced distal myelinated nerve fibers to the number of proximal myelinated nerve fibers was calculated. Wet weights of the flexor digitorum superficialis muscles were measured. Muscle fiber morphology was detected using hematoxylin-eosin staining. The cross-sectional area of muscle fibers was calculated to assess the recovery of muscles. Results showed that wrist flexion function was restored, and the nerve grew into the distal effector in all three nerve transposition groups and the epineurial neurorrhaphy group. There were differences in the number of myelinated nerve fibers in each group. The magnification of proximal to distal nerves was 1.80, 3.00, 2.50, and 3.12 in epineurial neurorrhaphy group, musculocutaneous nerve transposition group, medial pectoral nerve transposition group, and radial nerve muscular branch transposition group, respectively. Nevertheless, axon diameters of new nerve fibers, cross-sectional areas of axons, thicknesses of myelin sheath, wet weights of flexor digitorum superficialis muscle and cross-sectional areas of muscle fibers of all three groups of donor nerves from different anterior horn motor neurons after nerve transposition were similar to those in the epineurial neurorrhaphy group. Our findings indicate that donor nerve translocation from different anterior horn motor neurons can effectively repair the target organs innervated by the median nerve. The corresponding spinal anterior horn motor neurons obtain functional reinnervation and achieve some degree of motor function in the affected limbs.

Microsurgical decompression of the median nerves for treating diabetic peripheral neuropathy in the upper limbs: A 21-month follow-up

BACKGROUND： Peripheral nerve injured by abnormal glucose metabolism is compressed, which is an important etiological factor of diabetic peripheral neuropathy （DPN）. Microsurgical decompression of peripheral nerve maybe effectively releases the symptoms of DPN. OBJECTIVE： To investigate the curative effects of microsurgical decompression of median nerves for treatment of DPN in upper limbs. DESIGN： Case-follow up observation. SETTING： Department of Orthopaedics, Department of Neurosurgery, China-Japan Friendship Hospital, Ministry of Health. PARTICIPANTS： Twelve patients with DPN in upper limbs （19 hands） who received treatment in the Department of Orthopaedics, Department of Neurosurgery, China-Japan Friendship Hospital, Ministry of Public Health between March 2004 and July 2006 were involved in this experiment. The involved patients, 5 male and 7 female, were aged 44 to 77 years, with DPN course of 6 months to 16 years. They all met 1999 WHO diabetic diagnosis criteria. Both two hands had symptom in 7 patients, and only one hand had symptom in 5 patients. Informed consents of detected items were obtained from all the patients, who also received 21 months of follow-up treatment. METHODS： （1）Operation was carried out under the anesthetic status of brachial plexus. Under an operating microscope, transverse carpal ligament was exposed. Subsequently, transverse carpal ligament, forearm superficial fascia and palmar aponeurosis were fully liberated, and then part of them was cut off. Connective tissue around median nerve, superficial flexor muscle of fingers, radial flexor, palmaris longus and other flexor tendons were completely loosened. Finally, epineurium was opened with microinstrument for neurolysis. After tourniquet was loosened, and bipolar coagulator was used to stop bleeding, and the incision was closed. （2） In postoperative 21 months, the subjective symptom, two-point discrimination （The smallest distance of two normal points was 3 to 6 mm）, nerve conduction velocity and action potential amplitude （short abductor muscle of thumb end Lat 〈 4.5 ms; Motor nerve conduction velocity of forearm 〉 50 m/s）, etc. of all the patients were followed up. MAIN OUTCOME MEASURES＂ The objective evaluation and long-term follow up of curative effect of microsurgical decompression of median nerves for treatment of DPN in upper limbs. RESULTS： Twelve patients with DPN in upper limbs participated in the final analysis. （1） After operation, numbness and pain symptom releasing 100% were found in 19 hands of 12 patients with DPN. During follow up, numbness and recrudescent pain symptom were found in one hand （5%, 1/19）. （2）Postoperatively, index finger two point discrimination in 15 （94%, 15/16） hands recovered to normal. （3） nerve conduction velocity and action potential amplitude improved completely. （4） Two hands （2/19, 10% ）had poor healing at incision, and they late healed at postoperative 1 and 1.5 months, respectively. CONCLUSION： Long-term follow-up results show that microsurgical decompression is an effective method to treat DPN in upper limbs.

Nerve function restoration following targeted muscle reinnervation after varying delayed periods

Targeted muscle reinnervation has been proposed for reconstruction of neuromuscular function in amputees.However,it is unknown whether performing delayed targeted muscle reinnervation after nerve injury will affect restoration of function.In this rat nerve injury study,the median and musculocutaneous nerves of the forelimb were transected.The proximal median nerve stump was sutured to the distal musculocutaneous nerve stump immediately and 2 and 4 weeks after surgery to reinnervate the biceps brachii.After targeted muscle reinnervation,intramuscular myoelectric signals from the biceps brachii were recorded.Signal amplitude gradually increased with time.Biceps brachii myoelectric signals and muscle fiber morphology and grooming behavior did not significantly differ among rats subjected to delayed target muscle innervation for different periods.Targeted muscle reinnervation delayed for 4 weeks can acquire the same nerve function restoration effect as that of immediate reinnervation.

Does the ratio of the carpal tunnel inlet and outlet cross-sectional areas in the median nerve reflect carpal tunnel syndrome severity?

Although ultrasound measurements have been used in previous studies on carpal tunnel syndrome to visualize injury to the median nerve, whether such ultrasound data can indicate the severity of carpal tunnel syndrome remains controversial. The cross-sectional areas of the median nerve at the tunnel inlet and outlet can show swelling and compression of the nerve at the carpal. We hypothesized that the ratio of the cross-sectional areas of the median nerve at the carpal tunnel inlet to outlet accurately reflects the severity of carpal tunnel syndrome. To test this, high-resolution ultrasound with a linear array transducer at 5–17 MHz was used to assess 77 patients with carpal tunnel syndrome. The results showed that the cut-off point for the inlet-to-outlet ratio was 1.14. Significant differences in the inlet-to-outlet ratio were found among patients with mild, moderate, and severe carpal tunnel syndrome. The cut-off point in the ratio of cross-sectional areas of the median nerve was 1.29 between mild and more severe（moderate and severe） carpal tunnel syndrome patients with 64.7% sensitivity and 72.7% specificity. The cut-off point in the ratio of cross-sectional areas of the median nerve was 1.52 between the moderate and severe carpal tunnel syndrome patients with 80.0% sensitivity and 64.7% specificity. These results suggest that the inlet-to-outlet ratio reflected the severity of carpal tunnel syndrome.

MR neurography in intraosseous median nerve entrapment

Intraosseous entrapment of the median nerve is an uncommon complication of elbow dislocation and fractures.The condition is seen to occur in adolescent age group with a remote history of trauma.We report two rare cases of type 2 intraosseous median nerve entrapment.Though the diagnosis of median neuropathy is made with clinical tests and neurophysiological studies,however exact site of entrapment and presurgical mapping of nerve is done accurately with MR neurography.Imaging thus plays a pivotal role in management of this condition.

Targeted Ultrasound-Guided Double Catheters (Infraclavicular-Brachial Plexus, Median Nerve) Facilitate Hand Rehabilitation with Superb Analgesia and Motor Function Retention

A 44-year-old male who suffered a crush-degloving hand injury complicated by Complex Regional Pain Syndrome (CRPS) type I was scheduled for operative hand manipulation and inpatient physiotherapy. Preoperative placement of an ultrasound-guided infraclavicular catheter provided incomplete analgesia requiring supplemental morphine during physiotherapy sessions despite continuous infusion of 0.1% bupivacaine at 20 mL/hour. Due to the patient’s adamant refusal of replacement of the infraclavicular catheter, a second ultrasound-guided median nerve catheter was placed distally at the mid-forearm level and elicited complete sensory blockade of the hand. Dual infusions were maintained with 0.25% bupivacaine at 5 mL/hour through the median nerve catheter and 0.1% bupivacaine at 20 mL/hour through the infraclavicular catheter, and subsequent daily physiotherapy progressed productively. Continuous perineural catheter use to facilitate rehabilitation is an emerging practice that may improve overall recovery. Combination catheters, infusing local anesthetics at separate locations, can be used synergistically to preserve motor function and reach a superior analgesic endpoint.

Effects of mechanical tension on intraneural blood circulation of the median nerve in rabbits

Simple stretching was applied to the median nerve of rabbits in vivo to study the relationship of different tension with the change of intraneural blood vessels. It was found that when the tension on the nerve was 42 g, the intraneural blood backflow was blocked, while the arterioles entering the nerve trunk remained open; when the tension was increased to 93 g, the intraneural blood volume was decreased along with the increase of vascular permeability; and when the tension was further increased to 137 g, the intraneural blood supply was completely interrupted.The main injurious factors resulting in acute stretching injury of the peripheral nerves and the clinical significance of the changes of intraneural blood circulation were discussed.

Entrapment of the Median Nerve by a Muscular Branch of the Brachial Artery: A Case Report

Variations in the arterial pattern of the upper limbs are commonly encountered in routine dissection. In-depth information of the vascular structure of the upper extremities is not only important for diagnostic interventions and surgical approaches, but has medico-legal implications. We report the unusual variation of an additional muscular branch of the brachial artery entrapping the median nerve in the middle of the arm. This anomaly was present in both upper extremities of an adult male Indo-Malaysian cadaver. The abnormality reported here might result in neurovascular compression symptoms in the upper limbs. Knowledge of the vascular dissimilarity of the brachial artery and its division, and possible neurovascular entrapment is important to surgeons and medical practitioners for anticipating nerve compression and for confirmation via motor and sensory examination.

The Palmar Cutaneous Branch of the Median Nerve: A Detailed Morphometric Study

Damage to the palmar cutaneous branch of the median nerve (PCBMN) is a potential complication of surgery at the volar aspect of the wrist. The aim of this study was to determine the relationships of the PCBMN to both surface and bony landmarks using reliable methods. Ten pairs of forearms from cadavers aged 73 to 98 years were dissected. The PCBMN was identified and its course and relationships documented. The situation of the PCBMN was quantified relative to the distal wrist crease, bistyloid line, scaphoid tubercle, radial styloid process and flexor carpi radialis tendon. A PCBMN was identified on 90% of sides. The PCBMN arose from the radial aspect of the median nerve 52.4 (SD 31.0) mm from the bistyloid line and entered the transverse carpal ligament 10.9 (SD 9.5) mm proximal to the bistyloid line. At the level of the distal wrist crease the PCBMN was located 0.6 to 7.5 mm (mean 4.5;SD 1.9 mm) from the ulnar aspect of the flexor carpi radialis tendon. The inter- and intra-observer reliability of the measurement methods ranged from ICC 0.96 to 1.00. Detailed morphometric data of the PCBMN relative to bony landmarks contribute to knowledge of the spatial relationships of the PCBMN to inform the precision of surgical incisions.

Neurolysis of the Median Nerve to the Carpal Canal by the Way Mini-Open: Review of 68 Files at Brazzaville University Hospital

Objective: To evaluate the results of neurolysis of the median nerve to the carpal tunnel in patients operated by the mini-open technique. Methods: The prospective study included 68 patients (16 men and 52 women) aged 43 to 80 years (mean age: 64 years). Patients were evaluated in pre- and post-operative by a questionnaire. The mini open technique with cutaneous approach to the heel of the hand following the 4th ray was performed in all patients under local, locoregional or general anesthesia. Results: The results were evaluated in 3 consultations, in the 1st, 3rd and 6th month. We obtained very good results in 54.4% of the cases (n = 37) and 30.9% (n = 21) of good results and 14.70% (n = 10) of poor results. No vascular, tendinous or neurological complications were noted. Two patients were reoperated for incomplete resection of the carpal ring ligament. The mini-open technique has achieved good results in all neurolysis despite the delay in surgical management. Conclusion: The results of the surgical treatment of the carpal tunnel syndrome depend on the precocity of the diagnosis and the surgical indication.

Pseudoaneurysm with Median Nerve Injury Caused by Right Radial Artery Puncture:A Case Report

Background:Pseudoaneurysm with median nerve injury is a serious complication of radial artery puncture.It is very important to summarize the prevention and treatment experience of this complication through case discussion.Case report:A 66-year-old woman was admitted to the hospital because of‘‘paroxysmal chest tightness and suffocation for 5 days.”Coronary angiography was performed.During insertion of the arterial sheath,the patient experienced severe pain in the right forearm,which radiated to the palm.The puncture sheath did not return blood after the sheath core was withdrawn.The sheath was removed and local compression was used to stop bleeding.There was no obvious bleeding at the puncture point,and the compression was removed 6 hours after the procedure.Local swelling and increased tension were seen in the right forearm.At the 1-week follow-up she exhibited swelling,high local tension,small blisters,and bluish-purple skin of the right forearm,with an acceptable right radial artery pulsation.She had severe pain in the affected limb,which radiated to the thumb,index fi nger,and middle fi nger.Case discussion:We discuss the causes of and treatment measures for pseudoaneurysm with median nerve injury caused by radial artery puncture.

Transfer of the extensor indicis proprius branch of posterior interosseous nerve to reconstruct ulnar nerve and median nerve injured proximally:an anatomical study

Proximal or middle lesions of the ulnar or median nerves are responsible for extensive loss of hand motor function.This occurs even when the most meticulous microsurgical techniques or nerve grafts are used.Previous studies had proposed that nerve transfer was more effective than nerve grafting for nerve repair.Our hypothesis is that transfer of the posterior interosseous nerve,which contains mainly motor fibers,to the ulnar or median nerve can innervate the intrinsic muscles of hands.The present study sought to investigate the feasibility of reconstruction of the deep branch of the ulnar nerve and the thenar branch of median nerve by transferring the extensor indicis proprius branch of the posterior interosseous nerve obtained from adult cadavers.The results suggested that the extensor indicis proprius branch of the posterior interosseous nerve had approximately similar diameters and number of fascicles and myelinated nerve fibers to those of the deep branch of ulnar nerve and the thenar branch of the median nerve.These confirm the feasibility of extensor indicis proprius branch of posterior interosseous nerve transfer for reconstruction of the deep branch of the ulnar nerve and the thenar branch of median nerve.This procedure could be a novel and effective method for the functional recovery of the intrinsic muscles of hands after ulnar nerve or median nerve injury.

Anatomical peculiarities of sensory tracts of the wrist median nerve pedicled with nutrient vessels transferring to bridge wrist ulnar nerve defect

BACKGROUND： Translocation or transplantation of nerve stem has good effect; however, nervous function of donator is completely lost. If some nerve stem is damaged, sensory tracts are intercepted from the near nerve stem by nutrient vessels to regard as neural graft for transferring and bridging which may repair injured nerve and decrease neural functional loss of donator. OBJECTIVE： To observe anatomical peculiarities on sensory tracts of wrist median nerve pedicled with nutrient vessels transferring to bridge wrist ulnar nerve defect, and to investigate its feasibility. DESIGN：Duplicated and measured design.SETTING ： Anatomy Department of Medical College affiliated to Nanhua University.MATERIALS： A total of 14 samples of upper limbs were selected from adult unnamed corpse and volunteers.METHODS： The experiment was completed at the Clinical Application Anatomy Laboratory of Medical College affiliated to Nanhua University from September to November 2005. Samples were perfused with red emulsion through artery to observe length, fibrous bands and blood supply of median nerve and ulnar nerve at wrist. Boundary of median nerve at wrist ranged from superficial site between flexor carpi radialis and palmaris Iongus to branch of common palmar digital nerves. Ulnar nerve at wrist ranged from branch of back of the hand to site of common palmar digital nerves. Proximal boundary of the two nerves was crossed from 1/8 to 2/8 region of forearm. Samples of upper limbs from 1 case were selected to simulate operation on sensory tracts of wrist median nerve pedicled with nutrient vessels transferring to bridge wrist ulnar nerve. MAIN OUTCOME MEASURES： Anatomical peculiarities on sensory tracts of wrist median nerve pedicled with nutrient vessels transferring to bridge wrist ulnar nerve defect. RESULTS： ① The length of wrist median nerves was 7.8 （7.5-8.1） cm. There were 19 to 27 nerve tracts in it and the majority belonged to sensory tracts on the ulnar side, in which non-damaged separated length was about 10.0 cm to 14.0 cm. The third, second and first tracts of cutaneous branches at digital interspace and radialis of thumb arrayed from ulnaris to radialis by turns, and numbers of bands were 6.9, 7.4 and 7.2, respectively. The bands in total were 21.6. Cutaneous branches of palm entered from lateral margin of radialis and were completely separated at wrist. Two-thirds of ulnaris at nerve stem, i.e. the third, second and first tracts of cutaneous branches at digital interspace, were separated, which had little effect on sensation in distribution of median nerve. ② Its nutrient vessels originated from radial arteries about 6.2 （6.1-6.6） cm above radial styloid process were 1.2 （1.1-1.4） mm in outer diameter. The length was 5.7 （5.1-6.1） cm.③ The length of wrist ulnar nerve were 9.4 （8.9-9.7） cm and the number of nervous tract were 14 to 19, in which sensory tracts on the anterior external side were approximately equal to motor and mixed tracts on the posterior internal side in quantity. Sensory tracts were located at radialis of palm and motor tracts were located at ulnaris of back. CONCLUSION ：① Character and position of median nerve fibre bundle are clear, and length of non-damage separation of sensory tracts is coincidence with the request of transferring to bridge. ② Summation of the third, second and first tracts of cutaneous branches at digital interspace may be satisfactory to bridge of ulnar nerve at wrist （14-19 bands）. ③ This technique has little effect on sensation in distribution of median nerve. Nutrient artery of median nerve locates constantly; journey table is superficial and is easily to find out; caliber of arterial canal is thick; blood supply is plentiful; length of pedicel is suitable for translocation. The sensery tracts of wrist median nerve pedicled with nutrient vessels can be applied as nervous grafts to join injured gap in wrist ulnar nerve.

Role of High Resolution Ultrasound in Assessment of Abnormalities of Median Nerve in Carpal Tunnel Syndrome

Background: Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy and consists of the compression of the median nerve as it courses through the carpal tunnel. Carpal tunnel syndrome was diagnosed by history and physical examination, electrodiagnostic studies (EDX) were used to confirm the diagnosis. However, these studies are painful for most of the patients with high incidence of false positive or false negative results. Ultrasound is a low cost, short time and non-invasiveness technique that could be used to assess a number of parameters of the median nerve (MN) in cases of CTS. Objective: To assess the utility of high resolution ultrasound (HRUS) in assessment of median nerve in carpal tunnel syndrome through different ultrasound diagnostic criteria in patients with clinical and electrodiagnostic evidence of CTS. Patients and Methods: This study included a total of 60 participants divided into 2 groups;group A, the patients group included 30 patients with a clinical diagnosis of carpal tunnel syndrome (CTS) and group B, the control group who included 30 sex and age-matched healthy individuals. All the included cases were subjected to full history taking, full general and general examination. Nerve conduction studies were performed using a Caldwell Sierra Wave and the NCS consisted of sensory median nerve conduction tests using standard techniques. High resolution US was performed by using an Aplio 400 Ultrasound System. The following measurement was recorded in each of the included subjects including cross sectional area (CSA) of the median nerve, flattening ratio (FR) of median nerve and palmar bowing (PB) of the flexor retinaculum. Results: There was high statistically significant difference in the mean CSA and mean PB between the cases with CTS and healthy control. No statistically significant difference in the mean FR between the cases with CTS and healthy control. Optimal CSA cut-off value to differentiate between cases with CTS and control was (10.2 mm2) and the optimal PB cut-off value to differentiate between cases with CTS and control was (3.3 mm). Positive correlation was detected between the CSA and PB with increasing the severity of CTS. Conclusion: Electrophysiological studies are the most utilized diagnostic methods for diagnosing nerve entrapment including median nerve in CTS. Hugh resolution ultrasound (HRUS) is non- invasive sensitive diagnostic tool in diagnosing CTS.