A study the various clinical and electrophysiological parameters of severity of carpal tunnel syndrome, their correlation with post-operative recovery

Objective: We aimed to study the various clinical and electrophysiological parameters of severity of carpal tunnel syndrome (CTS) and to see if the severity of CTS affects recovery after surgery. Patients and Methods: A prospective study of 35 patients suffering from CTS. Clinical severity was assessed using visual analogue scale and standard questionnaires such as Levine and Disabilities of Arm, Shoulder and Hand questionnaires. All the patients underwent electrophysiological evaluation to assess electrophysiological severity of CTS. According to modified Padua classification, they were classified into three groups, namely, minimal to mild, moderate and severe to extreme. All patients underwent Carpal tunnel release in our unit. The clinical assessment was repeated 3 months post-operatively. Results: Out of 33 patients, majority (65.7%) of the patients were suffering from moderately severe CTS. The clinical provocative tests were positive in majority of patients. Clinically and statistically significant (P 0.05). Conclusions: Although pre-operative clinical scores of severity and electrophysiology have a diagnostic role in CTS, they do not correlate with post-operative recovery and in turn fail to predict the extent of post-operative recovery before surgery

Correlation of compound muscle action potential generated by donor nerves with the recovery of elbow flexion in Oberlin transfer in brachial plexus injury

Objective: To study the correlation of compound muscle action potential of donor nerves with the recovery of elbow flexion in Oberlin transfer in brachial plexus injury. Introduction: Distal nerve transfer using motor fascicle of ulnar or median nerve to restore elbow flexion is a part of reconstructive surgery after upper brachial plexus injury, first described by Oberlin et al. However, one of the most critical influences on functional outcome is number of functioning motor axons in donor fascicle which is reflected by its compound muscle action potential. We studied whether nerve transfers with donor nerves showing higher amplitudes will yield better reinnervation of muscle and therefore better function as estimated by clinical examination. Methods: We prospectively studied 30 cases of upper brachial plexus injury, of which were treated with Oberlin transfer using ulnar or median or both nerves. The prerequisites were no elbow flexion and hand and wrist flexors showing the power of more than Medical research Council MRC Grade 4. Donor nerves selected either ulnar or median having CMAP >4 mv in our electrophysiology laboratory during nerve conduction study. Patients were followed up for 1 year and assessed clinically for restoration of elbow flexion, weight tolerance. Results: A total of 30 patients of Oberlin transfer were evaluated for improvement power of biceps and elbow flexion. (MRC) grading was done at 1 year. Twenty-seven patients had a good result (MRC grade ≥3), i.e., 90% of patients. Based on the MRC grades, we categorised the patients into two groups as follows: Group A and Group B. Group A included patients with MRC Grade 4–5 and Group B included Grades 3–3.5. We tried to establish a correlation between CMAP and MRC scores by comparison of MRC grade patients for their pre CMAPs which revealed a statistically significant higher CMAPs between the groups. (Mann–Whitney U-test, P = 0.028). This indicates the association of higher pre-CMAPs with higher MRC grades. Conclusion: We conclude that higher the compound muscle action potential of donor nerves, better the recovery of elbow flexion in Oberlin transfer in brachial plexus injury

Unfavourable results in pollicisation

Pollicisation of the index finger is perhaps one of the most complex and most rewarding operations in hand and plastic surgery. It however has a steep learning curve and demands very high skill levels and experience. There are multiple pitfalls and each can result in an unfavourable result. In essence we need to: Shorten the Index, recreate the carpo metacarpal joint from the metacarpo phalangeal (MP) joint, rotate the digit by about 120° for pulp to pulp pinch, palmarly abduct by 40-50° to get a new first web gap, Shorten and readjust the tension of the extensors, re attach the intrinsics to form a thenar eminence capable of positioning the new thumb in various functional positions and finally close the flaps forming a new skin envelope. The author has performed over 75 pollicisations personally and has personal experience of some of the issues raised there. The steps mentioned therefore are an algorithm for helping the uninitiated into these choppy waters