Peripheral nerve and brachial plexus injuries typically cause severe impairment in the affected limb. The incidence of neuropathic pain is high, reaching up to 95% of cases, especially if cervical root avulsion has occurred. Neuropathic pain results from damage to the somatosensory system, and its progression towards chronicity depends upon disruptions affecting both the peripheral and central nervous system. Managing these painful conditions is complex and must be accomplished by a multidisciplinary team, starting with first-line pharmacological therapies like tricyclic antidepressants and calcium channel ligands, combined physical and occupational therapy, transcutaneous electrical stimulation and psychological support. For patients refractory to the initial measures, several neurosurgical options are available, including nerve decompression or reconstruction and ablative/modulatory procedures.

Neurofibromatosis 1 (NF1) is associated with peripheral nerve tumors (PNTs) in about 30% of cases. In comparison with sporadic forms, NF1 PNTs present some peculiarities: (1) A large prevalence of neurofibromas; (2) the presence of pathognomonic tumoral forms (plexiform neurofibromas); and, (3) a higher incidence (lifetime risk is equal to 8–13%) and an earlier age of onset (2–3 versus 3–6 decades) of malignant peripheral nerve sheath tumors (MPNSTs). For fear of inducing neurological complications, surgical removal of PNTs is generally recommended for symptomatic tumors only. Yet, it can be safely performed by surgeons with expertise in the field. A valid preventive strategy is also essential. Based on the evidence that in NF1, one-third of MPNSTs are consequent to malignant transformation of pre-existing benign tumors, a more aggressive surgical attitude should be advocated.

Radiation-induced brachial plexus neuropathy (RIBPN) is an uncommon problem. It is a delayed nontraumatic brachial plexus neuropathy following radiation treatment for carcinomas in the region of neck, axilla, and chest wall. The incidence is more commonly reported following radiation treatment for carcinoma of breast. The neurological features are characterized by severe neurogenic pain with progressive sensory-motor deficits in the affected upper limb. The incidence has increased following improved survival rate of patients with carcinomas of neck, axilla, and chest wall. The diagnosis of RIBPN is often confused with recurrence of the tumor in the neck and axilla. The management options are limited, and external neurolysis of the involved brachial plexus with excision of the perineural scar tissue is recommended in patients with severe clinical manifestations. We review our experience in the management of RIBPN from 2004 to 2017 and highlight the features of the 11 patients with this disorder whom we encountered during this period. The relevant clinical findings, natural history, pathophysiology, radiological characteristics, and various management options are briefly discussed.

Carpal tunnel syndrome (CTS) is a disease caused by compression of the median nerve passing through the wrist. Patients suffer from severe pain and paresthesis in the median nerve. Compression of the median nerve occurs, with prolonged working on keyboards (computer or laptop or music players) being one of the reasons along with others such as diabetes or rheumatoid arthritis. CTS research holds great promise for the patients as well as doctors for better medical treatment. The study has been carried out with an objective to analyze research progress based on the literature published on CTS during the last 35 years. The retrospective study has been carried out from the data indexed in SCOPUS multidisciplinary database from 1983 to 2017 (35 years). The study involves analysis of publication trends in terms of total articles, productive countries, institutions, journals, productive authors, most cited articles along with impact in terms of citation and h-Index. The SCOPUS database yielded 13187 articles during the study period. These articles were analyzed further for interpreting results. In the last 35 years, the number of scientific publications on CTS has been increasing with an annual growth rate of 9.86% per year. USA has been the most productive country. Literature pertaining to females is more than clinical studies involving males.

Aim: To describe the clinical and laboratory findings of patients with biopsy proven vasculitic neuropathy. Introduction: Peripheral neuropathies form one of the most common disorders of the nervous system. However, more than 50% of them are labelled as 'idiopathic' and, therefore, treatment options become less. In this study, we tried to evaluate the phenotypic as well as laboratory characteristics and outcome of patients with biopsy proven vasculitic neuropathy. Patients and Methods: Review of biopsy proven definite or probable vasculitic neuropathy was done. Results: The cohort consisted of 67 subjects. There were 21 patients of systemic vasculitis (SVS) and 46 of non-systemic vasculitic neuropathy (NSVN). The nerve biopsy revealed definite vasculitis in 37 and probable vasculitis in 30 patients. The symptoms at onset were paraesthesia (68.7%), and paraesthesia and weakness (28.4%). Diffuse polyneuropathy occurred in 70.1% patients. The course was chronic in the majority (80.59%) of patients. Electrophysiology revealed mononeuritis multiplex in 32.84%, and polyneuropathy in 67.16% of patients. Pure sensory neuropathy was present in 16.42%. Among the patients who had undergone bilateral nerve conduction studies, the majority (71.05%) of patients had an asymmetric neuropathy. An elevated erythrocyte sedimentation rate (ESR) was observed in 80.59% (mean 71.57 ± 30.81 mm/1hr [in SVS] and 35.24 ± 21.62mm/1 hr in NSVN) of patients. The treatment included steroids, other immunomodulators, and symptomatic medications. The mean follow up was 10.98 ± 9.58 months. The outcome was good in 73.46% (43.8% with SVS and 87.88% with NSVN) patients, with those having a NSVN having a significantly better outcome. Conclusion: Vasculitis is a potentially treatable cause of peripheral neuropathy. The clinical features, electrophysiology, laboratory results and nerve biopsy may help in the diagnosis and categorization of patients into non-systemic and systemic vasculitic neuropathies. The long-term outcome is better in patients with NSVN compared to those with systemic vasculitis.

Purpose: The purpose of the study was to assess the usefulness of high-resolution ultrasonography (HRU) in the evaluation of diabetic peripheral neuropathy (DPN). Methods: Thirty-seven adult diabetic patients with clinically diagnosed DPN and 45 healthy adult volunteers were included in the study. HRU of the right medial, ulnar, common peroneal, and posterior tibial nerves was done. The mean cross-sectional area (CSA) of the involved nerves was measured in the two groups at identical positions. The CSA was compared between the two groups, and Student t-test was applied to assess statistical significance. Results: There was a significant increase in the CSA of the median, ulnar, common peroneal, and posterior tibial nerve in DPN patients as compared to healthy volunteers. Sonographic findings were compared with nerve conduction study (NCS) for all the nerves studied except common peroneal nerve (CPN), as the NCS of CPN is not routinely done. DPN was classified as mild or moderate to severe on the basis of latency and velocity assessed by NCS. The mean CSA in all the examined nerves was higher in moderate to severe DPN than the mild DPN, but this was not statistically significant except for ulnar nerve with a P value of < 0.0001. Conclusion: HRU demonstrates a morphological change in patients with DPN in the form of an increase in CSAs, which was statistically significant. HRU can objectively complement other diagnostic investigations such as NCS. High resolution ultrasonography of peripheral nerves has the potential to become the investigation of first choice for the evaluation of DPN.

Background: Shoulder stability, abduction and external rotation are vital for the performance of usual daily tasks. Aims: To compare the functional outcomes in the shoulder following spinal accessory to suprascapular nerve transfer (SASNT). Patients and Methods: Comparison of the outcome of adult patients with upper traumatic brachial plexus palsy undergoing SASNT with patients with complete palsy submitted to the same procedure. Statistical Analysis: Ranges of motion were compared via the Mann-Whitney U test. The percentages of patients with a favorable outcome were compared by the chi-square test. All tests were two-tailed and P values <0.05 were considered statistically significant. Results: SASNT was performed in 76 patients: 23 cases (30.2%) of upper-plexus injuries and 53 cases (69.7%) of complete brachial plexus palsy. Good shoulder abduction was achieved in 15 patients (65.2%) with upper plexus palsy and a good external rotation in 5 (21.7%). In those patients with a good recovery, the average range of motion (ROM) was 53° for shoulder abduction and 71.2° for external rotation. Thirty-six patients (67.9%) with complete palsy had a good shoulder abduction recovery with 30.7° of average ROM, but only 3 patients (5.6%) recovered a good shoulder external rotation with 68.3° of average ROM. There was no statistical difference for the abduction outcome, but the external rotation outcome was superior in the upper plexus palsy group. Conclusion: SASNT is a consistent procedure to achieve functional recovery of shoulder abduction after a partial or complete plexus injury, but the outcomes of external rotation were quite disappointing in both the groups.

Objective: A retrospective analysis of surgically treated 354 cases of injection-related iatrogenic peripheral nerve injuries was performed. The purpose of this clinical study was to present our experience in the management of various types of injection-related peripheral nerve injuries and discuss various issues that are associated with this subset of peripheral nerve injuries. Methods: Over a 17-year period, 354 cases of injection-related iatrogenic peripheral nerve injuries were managed surgically at the Department of Neurosurgery at P.D. Hinduja Hospital and Seth G S Medical College, Mumbai. In our series, the injection-related iatrogenic nerve injuries were following intramuscular injections, brachial nerves block procedures, subclavian and jugular venous cannulation procedures for central line placements, and routine intravenous injections in the peripheral veins of the limbs. The age of the patients ranged from 5 years to 65 years. Pain, paresthesia, and sensory-motor deficits were the common presenting features in our series. The operative procedures performed in our series were external neurolysis and excision of neuroma/contused portion of the nerve and sural nerve cable grafting. The follow-up ranged from 6 months to 84 months. There were no major intraoperative complications in our series. Results: In our series, functional improvement (power grade 3 or above) was noted in 190 (53.7%) patients following surgical intervention. In 164 (46.3%) patients, there was either a non-functional status or no recovery. Neurological deterioration in the form of motor weakness was noted in 9 (2.5%) patients in our series after the surgery. The best results (90.1%) were noted with radial nerve repair following surgical intervention. Conclusion: Injection-related iatrogenic nerve injuries are not an uncommon problem. Surgery should be the preferred treatment option when the injured nerve fails to recover following the insult. The results are rewarding in a significant percentage of patients following timely intervention. The problem of litigation attached with this type of injury is also highlighted.

Introduction: Sjogren's syndrome (SS) is a systemic autoimmune disease that apart from involving the exocrine glands can affect any organ. Involvement of the peripheral nervous system results in a wide spectrum of neuropathic manifestations. Objective: To evaluate the clinico-electrophysiological patterns as well as pathological characteristics of neuropathy in SS patients presenting to a neuromuscular clinic in a tertiary hospital from South India. Materials and Methods: This is a retrospective study from the Departments of Neurology, Rheumatology, and Pathology from Nizam's Institute of Medical Sciences. Twenty-one patients with the diagnosis of SS and peripheral neuropathy, seen between 2010 and 2016 were analyzed. Clinical records, conventional nerve conduction studies, and lip and nerve biopsy reports were collected. Results: Twenty one patients with SS had associated neuropathy. Female-to-male ratio was 2:1. In 14 (66.7%) patients, neuropathy was the initial manifestation, while in 4 (20%), exocrinopathy preceded neuropathy. The patterns of neuropathy included mononeuropathy multiplex (MNM) in 7 patients (30%), ganglionopathy in 4 (20%), length-dependant trigeminal autonomic neuropathy, and chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) in 2 (10%), and cranial neuropathy in 1 (10%). Eighteen (86%) were seropositive with either anti Ro/SS-A or anti La/SS-B antibodies. Schirmer's test was positive in 13 (61.9%) patients. Nerve biopsy showed vasculitis in 5 patients and demyelinating and axonopathy in 2 patients each. Conclusions: We conclude that neuropathy is frequently the initial presentation of SS. MNM is the most common pattern followed by ganglionopathy. The pattern of neuropathy helps in arriving at the diagnosis of SS. Serology is a useful initial laboratory test. However,confirmation of SS is not by mere serology. Schirmer's test and lip biopsy are equally essential for the diagnosis, especially in seronegative patients when the clinical index of suspicion is high.

Animal models are widely used in research of peripheral nerve injury and regeneration, since there are only minor differences in the anatomy of peripheral nerves and the physiology of nerve regeneration between the humans and animals. Animal models, especially rodents, are widely used for this purpose. This narrative review provides a brief overview of the role of animal models in peripheral nerve surgery and research.

Peripheral nerve injuries are extremely devastating, and their management is exceedingly complex. Microsurgical repair is the mainstay of treatment and this includes direct nerve repair, nerve grafts, nerve tubes and nerve transfers. Today, nerve transfers are being widely performed due to an increased understanding of cortical plasticity, motor re-education and perioperative rehabilitation, and they are now known to produce excellent functional outcomes. This manuscript reviews the current strategies for nerve repair, including comments on outcomes, with special emphasis on existing nerve transfer techniques.

Magnetic resonance neurography (MRN) is recognized as the imaging modality of choice in the evaluation of patients with brachial plexopathy. It adds vital information to the results of the clinical evaluation and electrodiagnostic tests and facilitates patient management. Its indications include both trauma and non-traumatic forms of plexopathy such as inflammatory, neoplastic and compressive. This article will familiarize readers with the routine MRN protocol in clinical practice and discuss the utility of the different sequences. The timing of the scan is important, especially with reference to trauma and this has been discussed. Both the advantages and limitations of MRN have been elaborated upon.

Peripheral neuropathy is defined as any disease or damage to the peripheral nerves. Imaging modalities are emerging as a complementary tool of choice for diagnosis of peripheral neuropathies. This has been made possible by the advent of high-resolution ultrasound, higher field strength magnets, better surface array coils, and superior software. In addition, imaging plays a pivotal role in deciding the management. They help in determining the continuity and course of the nerve, thereby helping in the pre-surgical mapping of nerve. Imaging studies also help in prognosticating the recovery by determining the event to be acute or chronic. This article describes the imaging findings of various neuropathies affecting upper limb peripheral nerves, broadly categorized as traumatic and non-traumatic. The non-traumatic group is further divided as entrapment, infective, inflammatory and tumors.

Iatrogenic peripheral nerve injury is a considerable social and economic concern and the majority of cases are preventable. Complications should be referred to, and dealt with promptly by experienced surgeons, to ensure the best chances for an optimal functional recovery. Their prevention should be emphasized. Their management should include ensuring an early diagnosis, administering an appropriate treatment with rehabilitation, rendering psychological support and providing control of pain. We will address the aetiology, predisposing factors, diagnostic approaches, and management strategies to reduce the incidence of iatrogenic peripheral nerve injuries.