Citations

Abstract Background Ultrasound (US)‐guided hydrodissection is a minimally invasive treatment for cubital tunnel syndrome (CuTS) with promising early results. However, data on patient‐perceived outcomes, durability of relief, and impact on surgical need remain limited. Objective To assess the effectiveness of US‐guided cubital tunnel hydrodissection in improving CuTS symptoms via patient‐centered outcomes. Design Retrospective chart review with cross‐sectional telephone follow‐up. Setting Quaternary medical center multidisciplinary outpatient hand clinic. Participants Seventeen patients (19 arms) with clinical CuTS who received US‐guided hydrodissection from one physician. Interventions Patients were contacted by telephone for cross‐sectional outcome assessment. Main Outcome Measures Patient‐reported improvements in weakness, paresthesias, and/or pain, percent pain relief, symptom improvement duration, adverse events, and Patient Global Impression of Change (PGIC) scores. Results At mean 7 ± 5 month follow‐up, improvement in weakness, paresthesia, and pain was reported in 12 (63%) extremities (95% confidence interval [CI] 41%–85%; p < .001) . Pain relief ≥50% occurred in 12 (63%) and ≥75% in 8 (42%) extremities, with mean duration 4 months. PGIC scores showed 14 (74%; 95% CI 54%–94%; p < .001) at least “minimally improved” and 8 (42%) (95% CI 20%–64%; p < .001) “much improved.” No adverse events occurred. Two patients without improvement underwent surgical decompression with anterior transposition at 1 and 3 months after hydrodissection, achieving 90%–100% pain relief and “much or very much improved” PGIC scores. Of 19 extremities, 7 (37%) were McGowan Grade I and 12 (63%) Grade II; none were Grade III. Grade II extremities showed significantly greater overall symptom relief ( p = .004) and pain relief ≥50% ( p = .004). PGIC scores did not differ significantly between grades (both p > .062). Conclusion US‐guided cubital tunnel hydrodissection was associated with meaningful symptom improvement and no adverse events. Limitations include small sample size, no control group, single operator, and potentially time‐limited relief. The procedure appears safe and a potential nonoperative treatment option.

ABSTRACT Introduction/Aims Ultrasound (US) guidance may be essential for accurate electromyography (EMG) needle placement in less‐commonly evaluated muscles, such as the extensor carpi radialis longus (ECRL) and brevis (ECRB), and particularly for identifying suitable donor muscles prior to tendon transfers to restore upper extremity function. Our primary aim was to compare the accuracy of trainee palpation‐guided versus first‐attempt US‐guided needle placement. Our secondary aim was to describe the locations of inaccurate needle placement. Methods Seven subjects each performed four needle placements (ECRL and ECRB, both palpation‐guided and US‐guided), totaling 28 placements into a cadaveric specimen. US‐guided needle placement was performed with one attempt after one live demonstration. Results No palpation‐guided ECRL attempts were accurate while only two of the palpation‐guided ECRB attempts were accurate. First‐attempt US‐guided needle placement was significantly more accurate overall (64.3% vs. 14.2%, p = 0.020), and specifically for ECRL (71.4% vs. 0%, p = 0.025). Combining palpation‐guided ECRL and ECRB attempts, the needle was inadvertently placed in the extensor digitorum communis (50%), extensor carpi ulnaris (16.7%), and brachioradialis (16.7%). Both US‐guided ECRL‐intended errors involved placing the needle into the adjacent ECRB. Discussion This study suggests that EMG needle placement into ECRL and ECRB by trainees may be more accurate with US guidance. Accurate preoperative individual needle assessments of both wrist extensors are essential for patients with tetraplegia considering reconstructive surgery to restore functional grasp and should be performed with US guidance.

ABSTRACT Introduction/Aims Patients with cervical spinal cord injury (SCI) prioritize recovery of upper extremity function. Upper extremity reconstruction can restore function in carefully selected individuals. Infralesional cord damage, observed below the neurological level of injury (NLI), may affect postoperative outcomes. We characterized the extent of infralesional lower motor neuron (LMN) injury in patients with traumatic cervical SCI. Methods Each patient underwent electromyography (EMG) of potential donor and recipient muscles based on preoperative clinical evaluation and specific candidacy for nerve and/or tendon transfers. The presence of infralesional pathologic insertional activity (IA), reduced motor unit potential (MUP) recruitment and/or neurogenic MUPs was assessed. The caudal‐most segment with infralesional LMN injury was determined. Inclusion criteria were patients with (1) traumatic cervical SCI; (2) injury ≥ 3 months duration; (3) preoperative planning EMG for nerve and/or tendon transfers. Results Forty‐eight upper extremity EMGs in 25 patients (68% male; mean age 39.5 years at injury) with traumatic cervical SCI were included. The NLI was at C7 or above in each patient, and 64% of SCIs were motor complete. Infralesional EMG abnormalities (median time from injury to EMG 466 days) were found a median of 3.0 (IQR 3.0–4.0) segments below the NLI. Three patients with an NLI as rostral as C1–C2 exhibited LMN injury seven segments below the NLI. Discussion In persons with traumatic cervical SCI, evidence of LMN injury may be observed several segments below the NLI. Defining the true extent of LMN involvement directly informs timing and selection of reconstructive procedures to maximize functional recovery.

» Thorough patient presurgical counseling should emphasize individual patient goals, which may include improving ambulation, reducing reliance on orthoses, alleviating pain, or facilitating caregiver support. » Careful physical examination is essential to differentiate whether the primary cause of dysfunction is weakness, spasticity, or both. » Diagnostic adjuncts including botulinum toxin, short-acting blocks, instrumented gait analysis, and dynamic electromyography provide valuable insight and guide operative decisions. » Surgical treatment must be individualized, with nerve-based procedures indicated for pure spasticity and tendon lengthening, tenotomy, or joint procedures being required to treat soft tissue and joint contractures.

ABSTRACT Introduction/Aims In severe ulnar neuropathy at the elbow (UNE), occasionally surgeons will employ an end‐to‐side (ETS) nerve transfer of the anterior interosseous nerve (AIN) motor branch of pronator quadratus (PQ) to the ulnar motor component distally (AIN ETS). We used an ultrasound (US)‐guided near‐nerve monopolar needle stimulation of the AIN to determine the specific contribution of the transferred PQ motor branch to the ulnar‐innervated hand intrinsic muscles following AIN ETS in patients with UNE. Methods After inserting the monopolar needle under US guidance, direct stimulation of the AIN was performed while recording from the abductor digiti minimi (ADM), first dorsal interosseous (FDI), and flexor pollicis longus (FPL). The presence or absence of a compound muscle action potential (CMAP) was noted from each muscle. Results The technique was used in two patients with chronic UNE, one with a cubital tunnel decompression and AIN ETS and the other with a decompression alone. In the patient with decompression and AIN ETS, direct stimulation of the AIN revealed a low amplitude CMAP recorded from the FDI and FPL, suggesting AIN axonal contribution to FDI in the setting of prior AIN ETS. In the patient with decompression alone, near‐nerve stimulation generated an expected CMAP in the FPL but no response in the hand intrinsics. Discussion This study may demonstrate the utility of US‐guided near‐nerve monopolar needle AIN stimulation and suggests that it is a reliable technique to isolate the AIN contribution to hand intrinsic reinnervation following AIN ETS.

The extent to which eGFR varies across populations, in the absence of risk factors and comorbidities associated with kidney disease, remains uncertain. We aimed to develop eGFR reference values in healthy American adults and to compare them with previously described European eGFR reference values. This cross-sectional study compared newly described age-specific and sex-specific creatinine-based eGFR reference values from over 9000 healthy Americans from National Health and Nutrition Examination Survey with previously described eGFR reference values from over 1.5 million healthy individuals in the European CKD Burden Consortium. Health status was based on 14 criteria related to comorbidities, lifestyle factors, and medication use. eGFR was calculated using the European Kidney Function Consortium equation and modeled over the age span and by sex using a generalized additive model. The median eGFR in both 20-year-old American and European men was 98 ml/min per 1.73 m 2 . In both 20-year-old American and European women, the median eGFR was 101 ml/min per 1.73 m 2 . eGFR started to decrease at age 40 years, a result of the structure of the European Kidney Function Consortium equation. By age 79 years, the median eGFR in American and European men was 68 and 67 ml/min per 1.73 m 2 , respectively. The median eGFR in 79-year-old American and European women was 63 and 64 ml/min per 1.73 m 2 , respectively. When removing the effect of comorbidities, lifestyle factors and medication use associated with kidney function, achieved by restricting the analyses to individuals who did not have a presence or history of certain criteria, the distribution of eGFR was similar between healthy Americans and Europeans. This supports the notion that eGFR reference values may be generalizable to populations they were not derived from.

ABSTRACT Introduction/Aims Ultrasound (US) guidance may ensure proper needle placement during electromyography (EMG) when assessing for suitable donor muscles for upper limb reconstruction. A distinct intermuscular fascial border aids in delineating the separation between the brachioradialis (BR) and extensor carpi radialis longus (ECRL) muscles. However, this border may be absent, making correct needle placement complex and assessment more difficult. The purpose of this study was to describe the presence and absence of this fascial border in healthy individuals to help with accurate EMG needle placement. Methods Twenty healthy patients underwent sonographic examination by a single sonographer physician of the ECRL and BR to identify the presence or absence of the intermuscular fascial border. Results The fascial border that routinely separates the ECRL and BR was absent in at least one arm in 20% of subjects (12.5% of upper limbs). One subject had an absent fascial border in both upper limbs. Discussion US can assess for the presence or absence of intermuscular fascial borders. This assessment is important for accurate EMG needle placement and localization. While the clinical significance of an absent ECRL‐BR fascial border is currently unknown, future studies should examine the effect of absent ECRL‐BR fascial borders on wrist extension.

Purpose Lower extremity spasticity can cause pain and limit function. This study examined the safety and efficacy of hyperselective neurectomy (HSN) of the gastrocnemius-soleus complex (GSC) in addressing spastic equinus deformities in pediatric patients. Methods Pediatric patients that underwent HSN of the GSC by a single surgeon were retrospectively reviewed. Preoperative and postoperative Modified Ashworth Score and passive ankle dorsiflexion (°) were compared using Wilcoxon signed-rank test and Student's paired two-tailed t-test, respectively. Results Ten lower extremities in seven patients with a mean age of 10 years were reviewed. Mean follow-up was 15 months. All extremities demonstrated improvement in spasticity. All exhibited improved passive ankle dorsiflexion range of motion with the knee in extension (mean change +17°, SD = 8°, p = 0.000). Five patients demonstrated improved passive dorsiflexion with the knee in flexion while two remained unchanged from preoperative assessment (mean change +13°, SD = 9°, p = 0.002). One complication, wound dehiscence, was noted and managed conservatively. No patients reported loss of strength or sensation. Four patients underwent subsequent staged surgery on the ipsilateral extremity for concomitant contractures. Conclusion HSN of the GSC is safe in pediatric patients and effectively reduces spastic equinus deformity and improves ankle passive dorsiflexion in short-term follow-up.