CORRESPONDENCE
We agree that it is still unclear whether resection should be recommended for a patient with a severe fascicular constriction. However, similar to Nagano et al and Haussmann et al, we perform interfascicular neurolysis and do not resect severe fascicular constrictions. A representative case of spontaneous AIN palsy is presented in our paper with a photograph of a severe fascicular constriction (Figures 1Eand1G).3 This patient had a complete recovery after interfascicular neurolysis alone (patient 23).4 We hope that our experience along with their study will provide more insights into the pathophysiology and treatment of this type of palsy. Disclosure The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.
Kensuke Ochi, MD*‡ Yukio Horiuchi, MD‡ *Department of Orthopaedic Surgery School of Medicine, Keio University Tokyo, Japan ‡Department of Orthopaedic Surgery Kawasaki Municipal Kawasaki Hospital Kanagawa, Japan
1. Pan Y, Wang S, Zheng D, et al. Hourglass-like constrictions of peripheral nerve in the upper extremity: a clinical review and pathological study. Neurosurgery. 2014;75 (1):10-22. 2. Ochi K, Horiuchi Y, Tazaki K, et al. Surgical treatment of spontaneous posterior interosseous nerve palsy: a retrospective study of 50 cases. J Bone Joint Surg Br. 2011; 93(2):217-222. 3. Ochi K, Horiuchi Y, Tazaki K, Takayama S, Matsumura T. Fascicular constrictions in patients with spontaneous palsy of the anterior interosseous nerve and the posterior interosseous nerve. J Plast Surg Hand Surg. 2012;46(1):19-24. 4. Ochi K, Horiuchi Y, Tazaki K, Takayama S, Matsumura T. Surgical treatment of spontaneous anterior interosseous nerve palsy: a comparison between minimal incision surgery and wide incision surgery. J Plast Surg Hand Surg. 2013;47(3): 213-218. 5. Nakamichi K, Tachibana S. Ultrasonographic findings in isolated neuritis of the posterior interosseous nerve: comparison with normal findings. J Ultrasound Med. 2007;26(5):683-687. 6. Kodama A, Sunagawa T, Ochi M. Early treatment of anterior interosseous nerve palsy with hourglass-like fascicular constrictions by interfascicular neurolysis due to early diagnosis using ultrasonography: a case report. J Hand Surg Eur. 2014 [Epub ahead of print]. 7. Okinaga S. A case of spontaneous posterior interosseous nerve palsy whose lesion was visualized by diffusion weighted magnetic resonance imaging. Jpn J Elbow Soc. 2011;18(1):S71. 8. Nagano A. Spontaneous anterior interosseous nerve palsy. J Bone Joint Surg Br. 2003;85(3):313–318. 9. Haussmann P, Patel MR. Intraepineurial constriction of nerve fascicles in pronator syndrome and anterior interosseous nerve syndrome. Orthop Clin North Am. 1996; 27(2):339–344.
10.1227/NEU.0000000000000546
E738 | VOLUME 75 | NUMBER 6 | DECEMBER 2014
In Reply: Fascicular Constrictions in Spontaneous Anterior Interosseous Nerve Palsy and Spontaneous Posterior Interosseous Nerve Palsy We are honored that Dr Ochi and Dr Horiuchi were willing to share their experience and would like to thank them for adding their view on spontaneous peripheral nerve palsy with accompanying hourglass-like fascicular constrictions to our observations. As we mentioned in our report, an hourglass-like constriction of the nerve is a newly discovered neuropathy, the clinical manifestations have not been well defined, the origin remains unclear, and the treatment strategy has not yet been determined. Ochi et al made astute observations, and we agree with their point of view that there is no correlation between preoperative periods and the severity of fascicular constriction, that means that less severe types of fascicular constriction may not change into severe types of fascicular constriction in a time-dependent manner. However, relapse may occur in a few patients. Because the number of cases was small, we did not compare the relationship between age and immune response. We do not know whether younger patients could have more severe immune responses than older patients, resulting in a severe type of fascicular constriction. Based on our experience, we did not find the age of onset of palsy correlated with the severity of fascicular constriction, or the results of neurolysis. Some of our poor recovery cases had a long preoperative period, so we agree that early surgical intervention may be favorable for nerve recovery. The question is how to avoid unnecessary surgery. Case selection and timing of surgery are particularly important for such patients. As we had pointed out in our report, magnetic resonance neurography and high-resolution ultrasound studies may be useful tools to visualize the neuropathy status of affected nerves. If neurotmetic lesions are detected, an early surgical intervention should be encouraged to ensure full recovery. Otherwise, a conservative treatment should be implemented. As Ochi et al pointed out, the option of treatment for nerve constrictions at surgery is controversial. Since large series studies and controlled trials are still absent, it is difficult to draw any sound conclusions on the basis of retrospective study. Further study is required. Disclosure The author has no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.
Yongwei Pan, MD, PhD Department of Hand Surgery Beijing Jishuitan Hospital Beijing, China 10.1227/NEU.0000000000000548
www.neurosurgery-online.com
Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited
We agree that it is still unclear whether resection should be recommended for a patient with a severe fascicular constriction. However, similar to Nagano et al and Haussmann et al, we perform interfascicular neurolysis and do not resect severe fascicular constrictions. A representative case of spontaneous AIN palsy is presented in our paper with a photograph of a severe fascicular constriction (Figures 1Eand1G).3 This patient had a complete recovery after interfascicular neurolysis alone (patient 23).4 We hope that our experience along with their study will provide more insights into the pathophysiology and treatment of this type of palsy. Disclosure The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.
Kensuke Ochi, MD*‡ Yukio Horiuchi, MD‡ *Department of Orthopaedic Surgery School of Medicine, Keio University Tokyo, Japan ‡Department of Orthopaedic Surgery Kawasaki Municipal Kawasaki Hospital Kanagawa, Japan
1. Pan Y, Wang S, Zheng D, et al. Hourglass-like constrictions of peripheral nerve in the upper extremity: a clinical review and pathological study. Neurosurgery. 2014;75 (1):10-22. 2. Ochi K, Horiuchi Y, Tazaki K, et al. Surgical treatment of spontaneous posterior interosseous nerve palsy: a retrospective study of 50 cases. J Bone Joint Surg Br. 2011; 93(2):217-222. 3. Ochi K, Horiuchi Y, Tazaki K, Takayama S, Matsumura T. Fascicular constrictions in patients with spontaneous palsy of the anterior interosseous nerve and the posterior interosseous nerve. J Plast Surg Hand Surg. 2012;46(1):19-24. 4. Ochi K, Horiuchi Y, Tazaki K, Takayama S, Matsumura T. Surgical treatment of spontaneous anterior interosseous nerve palsy: a comparison between minimal incision surgery and wide incision surgery. J Plast Surg Hand Surg. 2013;47(3): 213-218. 5. Nakamichi K, Tachibana S. Ultrasonographic findings in isolated neuritis of the posterior interosseous nerve: comparison with normal findings. J Ultrasound Med. 2007;26(5):683-687. 6. Kodama A, Sunagawa T, Ochi M. Early treatment of anterior interosseous nerve palsy with hourglass-like fascicular constrictions by interfascicular neurolysis due to early diagnosis using ultrasonography: a case report. J Hand Surg Eur. 2014 [Epub ahead of print]. 7. Okinaga S. A case of spontaneous posterior interosseous nerve palsy whose lesion was visualized by diffusion weighted magnetic resonance imaging. Jpn J Elbow Soc. 2011;18(1):S71. 8. Nagano A. Spontaneous anterior interosseous nerve palsy. J Bone Joint Surg Br. 2003;85(3):313–318. 9. Haussmann P, Patel MR. Intraepineurial constriction of nerve fascicles in pronator syndrome and anterior interosseous nerve syndrome. Orthop Clin North Am. 1996; 27(2):339–344.
10.1227/NEU.0000000000000546
E738 | VOLUME 75 | NUMBER 6 | DECEMBER 2014
In Reply: Fascicular Constrictions in Spontaneous Anterior Interosseous Nerve Palsy and Spontaneous Posterior Interosseous Nerve Palsy We are honored that Dr Ochi and Dr Horiuchi were willing to share their experience and would like to thank them for adding their view on spontaneous peripheral nerve palsy with accompanying hourglass-like fascicular constrictions to our observations. As we mentioned in our report, an hourglass-like constriction of the nerve is a newly discovered neuropathy, the clinical manifestations have not been well defined, the origin remains unclear, and the treatment strategy has not yet been determined. Ochi et al made astute observations, and we agree with their point of view that there is no correlation between preoperative periods and the severity of fascicular constriction, that means that less severe types of fascicular constriction may not change into severe types of fascicular constriction in a time-dependent manner. However, relapse may occur in a few patients. Because the number of cases was small, we did not compare the relationship between age and immune response. We do not know whether younger patients could have more severe immune responses than older patients, resulting in a severe type of fascicular constriction. Based on our experience, we did not find the age of onset of palsy correlated with the severity of fascicular constriction, or the results of neurolysis. Some of our poor recovery cases had a long preoperative period, so we agree that early surgical intervention may be favorable for nerve recovery. The question is how to avoid unnecessary surgery. Case selection and timing of surgery are particularly important for such patients. As we had pointed out in our report, magnetic resonance neurography and high-resolution ultrasound studies may be useful tools to visualize the neuropathy status of affected nerves. If neurotmetic lesions are detected, an early surgical intervention should be encouraged to ensure full recovery. Otherwise, a conservative treatment should be implemented. As Ochi et al pointed out, the option of treatment for nerve constrictions at surgery is controversial. Since large series studies and controlled trials are still absent, it is difficult to draw any sound conclusions on the basis of retrospective study. Further study is required. Disclosure The author has no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.
Yongwei Pan, MD, PhD Department of Hand Surgery Beijing Jishuitan Hospital Beijing, China 10.1227/NEU.0000000000000548
www.neurosurgery-online.com
Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited
