Distal 1
Küçük Resim Yok
Tarih
2023
Yazarlar
Dergi Başlığı
Dergi ISSN
Cilt Başlığı
Yayıncı
Ege Üniversitesi
Erişim Hakkı
info:eu-repo/semantics/openAccess
Özet
Ahmet Enes Örnek,Distal 1/3 Önkol Median , Ulnar Sinir Kesilerinin Primer Tamir Sonrası Uzun Dönem Sonuçlarının Elektromyografi ile Karşılaştırılması :Retrospektif Çalışma,Ege Üniversitesi Tıp Fakültesi Ortopedi Anabilim Dalı, Uzmanlık Tezi,2023 Amaç :El bileği seviyesindeki median ve ulnar sinir üst ekstremiteyi innerve eden sinirlerdir. Sinir yaralanmaları uzun süren iyileşme ve rehabilitasyon süreci gerektiren bir yaralanma şeklidir.Cerrahi teknik ve rehabilatasyon süreci başarılı olsa dahi klinik sonuçları tatmin edici olmayabilir.Son yıllarda nöron bilimindeki ve doku mühendisliğindeki gelişmeler hızla ilerleme kaydetse de klinik sonuçlar halen tatmin edici değildir.Median ve ulnar sinirin motor, sensoriyel özelliklerin farklı olması, klinik muayenede farklı sonuçlara neden olabilmektedir..Literaturde median ve ulnar sinir hasarının primer tamir sonrası sonuçlarına yönelik klinik calişmalar yaygın olarak bulunmaktadır .Ancak Cerrahinin etkinliğini nicel bir zemine koyabilecek calışmalar nadirdir.Nöronlarin elektrofizyolojik değerlendirmelerinden olan elektromiyografi (EMG) testleri sinir sıkışmalarında bizlere değerli bilgiler sunmakta olduğu bilinmektedir. EMG ile,cerrahi girişimin etkinliği de değerlendirilebilmektedir.Bu çalışmanın amacı, sinir onarımından sonra fonksiyonel kapasite ve duysal dönüşün geri kazanılmasıyla ilgili olarak motor ve duyu birimlerin yeniden kurulması ve yeniden modellenmesi sürecini takip etmektir.Bu takip sürecinde cerrahi etkinliğin elektrofizyolojik tabanda değerlendirilmesi bu bağlamda fonksiyonel sonuçların düzeltilmesi ve komplikasyonların erken dönemde önlenmesi amaçlanmaktadır. Gereç ve Yöntem : Bu çalıs?maya Ege Üniversitesi Ortopedi ve Travmatoloji Anabilim Dalında Ocak 2021- Aralık 2022 tarihleri arasında deg?is?ik nedenlerle distal 1/3 ön kol düzeyinde median,ulnar sinir kesisi nedeniyle primer tamir uygulanan ve kontrollerinde EMG sini yaptıran olgular retrospektif doğada incelenlenmiştir.Düzenli kontrollere gelen en az 3 aylık takibi olan olgular kendi rızası ile çalışmaya dahil edildi.Dahil edilme ve dışlama kriterlerine uyan en az 3 ay en çok 12 ay takibi olan 38 hasta ile yapılmıştır. Çalışmaya katılmayı kabul eden ve takiplerine gelen ve tedaviden sonra 3 .ay,6.ay ve ya 12 .aya ait kontrol EMG si ile beraber klinik değerlendirmesi yapılmış 38 hasta çalışmaya dahil edilmiştir.Çalışma grubunda elektromyografik testleri ile eş zamanlı klinik değerlendirilmesi yapılmış 3.ay 26 olgu , 6.ay 27 olgu ve 12.ay 27 olgu olmak üzere 3 adet kontrol grubu bulunmaktadır. Bulgular : Çalışma grubunda cinsiyet,sigara ve eşlik eden arteryel yaralanma primer/geç primer onarım VAS skorları ile elektromyografik parametler arasında istatiksel anlamlı bir fark yoktu.RMUP 3.ayda pozitif olanların takiplerde 3.ayda bulgu vermese de 6. ve 12.aydaki kavrama kuvvetleri (p<0.042, p<0.012),palmar pinch kuvetleri (p<0.029,p<0,027) key pinch kuvvetleri.(p<0.024,p<0.029) daha yüksekti.Tip Pinch kuvvetleri ise sadece 12.ay da anlamlı daha yüksekti. (p<0.026) RMUP 3.ay pozitifleşen ulnar sinir kesilerinde takiplerde 12.ayda froment bulgusu ve wartenberg bulgusu ile istatiksel olarak negatif anlamlı bir ilişki bulundu(P<0.047) ve takiplerde daha az pençe el deformitesi gelişti(p<0.012) RMUP 3. ay ve 6.ayda pozitif olanların 3.ay/6.ay ve 12. ay Qdash (p<0.001,p<0.004,p<0.005) ve kapandji skorları (p<0.004,p<0.006,p<0.042)daha iyiydi. .RMUP + olanların yaş ortalaması daha küçüktü (p<0.013) Cam ile düzgün kesilerin delici kesici alet ile yaralanmalara göre daha erken elektromyografik sinyaller verdiği bulundu.(P<0.018) .Erken RMUP pozitifliği erken işe dönüş ile anlamlıydı. (p<0.022). Iki Nokta diskriminasyonu radyal taraf ile Median sinir DSAP ile 3.ayda çok yüksek derece(r=0.905,p<0,001),6.ayda yüksek (r=0.880,p<0.001) ve 12.ayda orta (r=0.628,p<0,001) pozitif korelesyon gösterdiği bulundu.2 nokta diskriminasyonu ulnar taraf ile ulnar sinir DSAP ise 3 .ayda çok yüksek (r=0.897,p<0,001) ,6.ayda yüksek (R=0.764,p<0,001) ve 12.ayda orta (r=0.502,p<0,008) derece bir korelasyon gösterdiği saptandı Ortalama sinir iyileşmesi 12 aylık takipte iki sinir içinde s3 olarak bulunmuştur.3.ay , 6.ay ve 12 ayda iki sinir arasında duysal dönüş açısından anlamlı bir fark bulunmdı.Kombine kesiler hariç hiç birinde kötü sonuca rastlanmadı. BMRC duyu skalasında median ve ulnar sinir açısından istatiksel olarak anlamlı bir fark saptanamamış olsa da EMG de motor ve duysal değerlendirme açışında RMUP erken pozitifleşen olguların 6. ve 12 ay kontrol Emglerinde median sinir için hem DSAP hem BKAP i istatiksel olarak daha iyi bulundu (p<0,015,p< 0,020),(p< 0,021, p<0,018) Ulnar sinir için sadece 12.ay DSAP değerleri daha iyiydi BKAP değerleri ile anlamlı bir ilişki saptannmadı. (P<0,023) Sonuç :Önkol seviyesinde periferik sinir yaralanmalarında 3.ay, 6.ay ve 12.ay EMG değerlendirilmesinde 3.ayda erken RMUP saptanması fonksiyonel geri dönüş için en iyi prognostik göstergelerden biridir.RMUP 3.ayda pozitif olanların takiplerde 6. ve 12.aydaki kavrama kuvvetleri ,palmar pinch kuvetleri key pinch kuvvetler daha yüksekti.Erken RMUP pozitifligi soğuk intoleransı varlığı 12.ayda daha iyi olduğu ve 6.ay ve 12. ayda da Qdash ve kapandji skorları daha iyiydi.Yine bu çalışmadaki veriler ışığında ulnar sinir tuzak nöropatilerinde sıklıkla değerlendirilen froment,wartenberg bulgusunun erken RMUP pozitifliği olanlarda daha azdı. Sinir tamirleri sonrası rejenerasyon ve fonksiyonel kapasitenin geri dönüşü uzun yıllar almaktadır.Tam dönüş yetişkin hastalarda umulmamalıdır.Bu hastaların uzun takiplerinde klinik testler sinir fibrillerinin yenilenmesi ile motor ve duysal fonksiyonların geri kazanılmasını belirlemek için gereklidir.Duyunun değerlendirilmesinde bir çok test bulunmasına rağmen en iyi test hangisidir konusunda bir fikir birliği yoktur.Biz çalışmamızda ortaya koyduğumuz bu veriler ışığında periferik sinir tamiri sonrası takiplerde Elektromyografik testler kullanımı ile fonksiyonel iyileşme beklentimizi önceden tahmin edilebilir nicel bir zemine koyduğumuzu düşünmekteyiz. Anahtar Kelimeler:Median ve ulnar sinir yaralanmaları,EMG,Rejenerasyon motor ünite potansiyeli,RMUP
Ahmet Enes Örnek MD,Comparison of Long-Term Results of Distal 1/3 Forearm Median and Ulnar Nerve Cuts After Primary Repair with Electromyography: Retrospective Study, Ege University Faculty of Medicine Department of Orthopedics, Phd-Thesis, 2023 Objectives: The median and ulnar nerves at the wrist level are the nerves that innervate the upper extremity. Nerve fractures are a form of injury that require a long recovery and recovery process. Even if the surgical technique and rehabilitation process are successful, clinical results cannot be satisfied. Although developments in neuroscience and tissue engineering have advanced rapidly in recent years, clinical results are still not satisfactory. Different sensory properties may cause different results in clinical examination. In the literature, clinical studies are widely available for containment after primary repair of median and ulnar nerve damage. In the working neural cavities, we offer valuable information from each other. With EMG, the performance of the surgical intervention can also be evaluated. The aim of this study is to continue to re-engage and remodel motor and sensory units in relation to functional shutdown and recovery of emotional return after nerve consequences. It is intended to use scrutiny and complexities at an early stage. Materials and Methods: In this study, patients who underwent primary repair due to median and ulnar nerve incision at the distal 1/3 forearm level for different reasons between January 2021 and December 2022 at Ege University Department of Orthopedics and Traumatology and had their EMG done in their controls were examined in a retrospective nature. At least 3 patients who came to regular controls. Cases with monthly follow-up were included in the study with their own consent. It was conducted with 38 patients who met the inclusion and exclusion criteria and had a minimum follow-up of 3 months and a maximum of 12 months. 38 patients who agreed to participate in the study and came to their follow-ups and who underwent clinical evaluation with their control EMG at 3, 6, or 12 months after the treatment were included in the study. In the study group, clinical evaluation was performed simultaneously with electromyographic tests. There are 26 cases at the 3th month, 27 cases at the 6th month and 27 cases at the 12th month. In our study, it is aimed to evaluate the prognostic variables and surgical efficacy on an electrophysiological basis, which will be revealed in the light of the data to be obtained from a retrospective analysis, from this point of view, in this context, it is aimed to improve the functional results and prevent complications in the early period. Results:There was no statistically significant difference between gender, smoking and accompanying arterial injury primary/late primary repair VAS scores and electromyographic parameters in the study group. Although RMUP was positive at 3 months, there was no finding in the 3rd month, but the grip strength was higher at 6th and 12th months (p <0.042, p<0.012), palmar pinch forces (p<0.029, p<0.027) and key pinch forces (p<0.024, p<0.029) were higher. Tip pinch and opposition pinch forces were significantly higher only at 12 months. (p<0.049) (p<0.026) In the ulnar nerve cuts that became positive at the 3rd month of RMUP, a statistically negative and significant correlation was found with the Froment sign and Wartenberg sign at the 12th month in the follow-ups (P<0.047) and less claw hand deformity developed in the follow-ups (p<0.012). Qdash (p<0.001,p<0.004,p<0.005) and Kapandji scores (p<0.004,p<0.006,p<0.042) at 3rd/6th and 12th months of RMUP positive at 3rd and 6th months was better. The mean age of those with RMUP + was lower (p<0.013).It was found that smooth incisions with glass gave early electromyographic signals compared to injuries with a sharp instrument. (P<0.018). Early RMUP positivity was significant with early return to work. (p<0.022).Two-Point discrimination radial side and Median nerve With DSAP very high (r=0.905,p<0.001) at 3 months, high at 6 months (r=0.880,p<0.001), and moderate at 12 months (r=0.628,p) <0.001) was found to be positively correlated. The 2 point discrimination ulnar side and ulnar nerve DSAP was very high at 3 months (r=0.897, p<0.001), high at 6 months (R=0.764,p<0.001), and at 12 months. A moderate (r=0.502,p<0.008) correlation was found. The mean nerve healing was found to be s3 in both nerves at 12-month follow-up. There was no significant difference in sensory return between the two nerves at the 3rd, 6th and 12th months. Combined Except for the incisions, no bad results were found in any of them.Although there was no statistically significant difference in terms of median and ulnar nerves in BMRC sensory scale, both DSAP and CMAP for the median nerve were found to be statistically better in the 6th and 12th month control EMGs of the cases with early positive RMUP in terms of motor and sensory evaluation in EMG (p< 0.015, p< 0.020),(p< 0.021, p<0.018)For the ulnar nerve, only 12th month DSAP values were found to be better, and no significant correlation was found with CMAP values. (P<0.023) Conclusions In peripheral nerve injuries at the forearm level, early detection of RMUP at 3 months in the 3rd, 6th and 12th month EMG evaluation is one of the best prognostic indicators for functional recovery.The grip strengths, palmar pinch forces and key pinch strengths were higher at the 6th and 12th months in the follow-ups of the cases with early positive RMUP. Tip pinch and opposition pinch strengths were better only at 12 months. Early RMUP positivity was better at the 12th month. and Qdash and Kapandji scores were better at 6 and 12 months. Again, in the light of the data in this study, the Froment, Wartenberg sign, which is frequently evaluated in ulnar nerve entrapment neuropathies, was less in those with early RMUP positivity. ). Early RMUP positivity was significant with early return to work.Regeneration and return of functional capacity after nerve repairs take many years. Full recovery should not be expected in adult patients. In the long follow-ups of these patients, clinical tests are required to determine nerve fiber regeneration and recovery of motor and sensory functions. Although there are many tests in the evaluation of the sense, which is the best test? In the light of the data we have revealed in our study, we think that we have put our expectation of functional recovery on a predictable quantitative basis with the use of Electromyographic tests in the follow-ups after peripheral nerve repair Keywords:Median and ulnar nerve injury,EMG,Regeneration motor unit potential,RMUP
Ahmet Enes Örnek MD,Comparison of Long-Term Results of Distal 1/3 Forearm Median and Ulnar Nerve Cuts After Primary Repair with Electromyography: Retrospective Study, Ege University Faculty of Medicine Department of Orthopedics, Phd-Thesis, 2023 Objectives: The median and ulnar nerves at the wrist level are the nerves that innervate the upper extremity. Nerve fractures are a form of injury that require a long recovery and recovery process. Even if the surgical technique and rehabilitation process are successful, clinical results cannot be satisfied. Although developments in neuroscience and tissue engineering have advanced rapidly in recent years, clinical results are still not satisfactory. Different sensory properties may cause different results in clinical examination. In the literature, clinical studies are widely available for containment after primary repair of median and ulnar nerve damage. In the working neural cavities, we offer valuable information from each other. With EMG, the performance of the surgical intervention can also be evaluated. The aim of this study is to continue to re-engage and remodel motor and sensory units in relation to functional shutdown and recovery of emotional return after nerve consequences. It is intended to use scrutiny and complexities at an early stage. Materials and Methods: In this study, patients who underwent primary repair due to median and ulnar nerve incision at the distal 1/3 forearm level for different reasons between January 2021 and December 2022 at Ege University Department of Orthopedics and Traumatology and had their EMG done in their controls were examined in a retrospective nature. At least 3 patients who came to regular controls. Cases with monthly follow-up were included in the study with their own consent. It was conducted with 38 patients who met the inclusion and exclusion criteria and had a minimum follow-up of 3 months and a maximum of 12 months. 38 patients who agreed to participate in the study and came to their follow-ups and who underwent clinical evaluation with their control EMG at 3, 6, or 12 months after the treatment were included in the study. In the study group, clinical evaluation was performed simultaneously with electromyographic tests. There are 26 cases at the 3th month, 27 cases at the 6th month and 27 cases at the 12th month. In our study, it is aimed to evaluate the prognostic variables and surgical efficacy on an electrophysiological basis, which will be revealed in the light of the data to be obtained from a retrospective analysis, from this point of view, in this context, it is aimed to improve the functional results and prevent complications in the early period. Results:There was no statistically significant difference between gender, smoking and accompanying arterial injury primary/late primary repair VAS scores and electromyographic parameters in the study group. Although RMUP was positive at 3 months, there was no finding in the 3rd month, but the grip strength was higher at 6th and 12th months (p <0.042, p<0.012), palmar pinch forces (p<0.029, p<0.027) and key pinch forces (p<0.024, p<0.029) were higher. Tip pinch and opposition pinch forces were significantly higher only at 12 months. (p<0.049) (p<0.026) In the ulnar nerve cuts that became positive at the 3rd month of RMUP, a statistically negative and significant correlation was found with the Froment sign and Wartenberg sign at the 12th month in the follow-ups (P<0.047) and less claw hand deformity developed in the follow-ups (p<0.012). Qdash (p<0.001,p<0.004,p<0.005) and Kapandji scores (p<0.004,p<0.006,p<0.042) at 3rd/6th and 12th months of RMUP positive at 3rd and 6th months was better. The mean age of those with RMUP + was lower (p<0.013).It was found that smooth incisions with glass gave early electromyographic signals compared to injuries with a sharp instrument. (P<0.018). Early RMUP positivity was significant with early return to work. (p<0.022).Two-Point discrimination radial side and Median nerve With DSAP very high (r=0.905,p<0.001) at 3 months, high at 6 months (r=0.880,p<0.001), and moderate at 12 months (r=0.628,p) <0.001) was found to be positively correlated. The 2 point discrimination ulnar side and ulnar nerve DSAP was very high at 3 months (r=0.897, p<0.001), high at 6 months (R=0.764,p<0.001), and at 12 months. A moderate (r=0.502,p<0.008) correlation was found. The mean nerve healing was found to be s3 in both nerves at 12-month follow-up. There was no significant difference in sensory return between the two nerves at the 3rd, 6th and 12th months. Combined Except for the incisions, no bad results were found in any of them.Although there was no statistically significant difference in terms of median and ulnar nerves in BMRC sensory scale, both DSAP and CMAP for the median nerve were found to be statistically better in the 6th and 12th month control EMGs of the cases with early positive RMUP in terms of motor and sensory evaluation in EMG (p< 0.015, p< 0.020),(p< 0.021, p<0.018)For the ulnar nerve, only 12th month DSAP values were found to be better, and no significant correlation was found with CMAP values. (P<0.023) Conclusions In peripheral nerve injuries at the forearm level, early detection of RMUP at 3 months in the 3rd, 6th and 12th month EMG evaluation is one of the best prognostic indicators for functional recovery.The grip strengths, palmar pinch forces and key pinch strengths were higher at the 6th and 12th months in the follow-ups of the cases with early positive RMUP. Tip pinch and opposition pinch strengths were better only at 12 months. Early RMUP positivity was better at the 12th month. and Qdash and Kapandji scores were better at 6 and 12 months. Again, in the light of the data in this study, the Froment, Wartenberg sign, which is frequently evaluated in ulnar nerve entrapment neuropathies, was less in those with early RMUP positivity. ). Early RMUP positivity was significant with early return to work.Regeneration and return of functional capacity after nerve repairs take many years. Full recovery should not be expected in adult patients. In the long follow-ups of these patients, clinical tests are required to determine nerve fiber regeneration and recovery of motor and sensory functions. Although there are many tests in the evaluation of the sense, which is the best test? In the light of the data we have revealed in our study, we think that we have put our expectation of functional recovery on a predictable quantitative basis with the use of Electromyographic tests in the follow-ups after peripheral nerve repair Keywords:Median and ulnar nerve injury,EMG,Regeneration motor unit potential,RMUP
Açıklama
Anahtar Kelimeler
Ortopedi ve Travmatoloji, Orthopedics and Traumatology
