A nt erior Int ero s s eou s N erv e Sy n drom e - Obs erv ation s f or T hree Surg ical Ca s e s -

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1 3 2 Vol. 3, No 2, November , * * =A bs trac t = A nt erior Int ero s s eou s N erv e Sy n drom e - Obs erv ation s f or T hree Surg ical Ca s e s - Min Jong P ark, M.D., Jong Yoon Lee, M.D., Byoung Joon Kim, M.D.* D epartm ent of Orthop edic S urgery and N eurology*, S ung K y un K wan University College of M edicine, Samsung M edical Center, Seoul, K orea The anterior interosseous nerve syndrome of nontraumatic origin is an uncommon neurologic condition manifested by weakness or paralysis of the flexor pollicis longus,the flexor digitorum profundus of the index,and the pronator quadratus. Since the first report by Kiloh and Nevin in 1952, many cases of anterior interosseous nerve syndrome have been reported suggesting various causes and treatment protocols. The purpose of this report is to consider the cause and treatement about this syndrome upon the findings of three patients who were treated surgically and to review the literatures. Through the findings after the neurolysis, there was no clear evidence of external compression. One patient began to show signs of recovery at one month and the other patient at four months; one patient did not show recovery at thirty- two months from the time of surgery. We could not confirm the pathologic findings suggesting compression neuropathy through the three surgical cases, and the etiology and treatment is still inconclusive. Key Words : Anterior interosseous nerve, Anterior interosseous nerve syndrome :

2 (pronator quadratus), (flexor pollicis longus) (flexor digitorum profundus)., 1952 Kiloh Nevin 6) (neuritis).. (neuritis) 1-3, 6, 7, 12) 2, 5, 10, 11, (compression neuropathy) 14, 15, 18) (epineurium) (fascicle) (constriction) 4, 8) Grade 0 (Fig. 1), Grade 4..,, 23 47, 2, Fig. 1. Characteristic feature of patients hand with anterior interosseous syndrome manifested by inability of active distal finger joints flexion of thumb and index

3 (fibrillation):1+, (positive sharp wave):1+ (denervation), cm. (lacertus fibrosus) (pronator teres) (superficial head) (deep head). 2 mm (venae communicantes) (Fig. 2) Fig. 2-A. Photograph of operative finding during median nerve release. Retracting the superficial head of pronator teres, tendinous arch of flexor digitorum superficialis origin(arrow) can be seen over the median nerve and its anterior interosseous branch.. Grade 0, Grade 4., (fibrillation) : 3+ (positive sharp wave) : 4+ (axon)

4 (nerve fascicle) 7 cm. 4, 1 4 Grade 4 -, Grade 4 +, Grade 4+. Fig. 2-B. After the release of flexor digitorum superficialis arch, anterior interosseous nerve(a) can be distinguished from median nerve(m). Note the aberrant vessel over the anterior interosseous and median nerve(arrow). (Fig. 3).. (pronator quadratus) inching technique. Fig. 3. Photograph of operative finding after the completion of neurolysis. The median nerve(m) and anterior interosseous nerve(arrow) look normal without any gross finding suggesting external compression

5 , (sensory-motor polyneuropathy) Guillain-Barre.. 12, 5, (sural nerve) (biceps), (abductor pollicis brevis), (adductor pollicis) (sensory- motor polyneuropathy). Grade 0, Grade ,. 1 Grade 2, 3. 6 Grade Grade4-, Grade4+.. Kiloh Nevin 6) 1952 (neuritis) Personage Turner 9) (neuralgic amyotrophy) (brachial neuritis)

6 1, 11, 17)... 16). Goulding Schady 3) Miller-Breslow 7) Fearn Goodfellow 2) (fibrous band) 5, 10, 11, 14, 15, 18). Spinner 14), (accessory head), (accessory tendon), (collateral vessel). (tendinous band), 11, 18).. Werner 19) Rask 10) 7 (arcuate ligamnet) Stern 15)

7 Hill 5) Sood 13) 6,. Nagano 8) Haussmann 4). (fascicle) (constriction). Nagano 9 8 (fascicular constriction) (medial epicondyle) cm (interfascicular neurolysis). 2 7cm....,. 8,, ) England JD and Sumner AJ : Neuralgic amyotrophy- An increasing diverse entity. M uscle N erve 10 : 60-68, ) Fearn CB and Goodfellow JW : Anterior interosseous nerve pasly.j B one Joint Surg 47B : 91-93, ) Goulding PJ and Schady W : Favourable outcome in non- traumatic anterior interosseous nerve lesions.j N eurology 240 : 83-86,

8 4) Haussmann P and Patel MR : Intraepineurial constriction of nerve fascicles in pronator syndrome and anterior interosseous nerve syndrome. Orthop Clin N orth A merica.,27 : , ) Hill NA, How ard FM and Huffer BR : The incomplete anterior interosseous nerve syndrome. J Hand Surg 10A : 4-15, ) Kiloh LG and Nevin S : Isolated neuritis of the anterior interosseous nerve.british M idical Journal 19 : , ) Miller- Breslow A, T errono A and Millender LH : Nonoperative treatment of anterior interosseous nerve paralysis. J Hand Surg 15A: , ) Nagano A, Shibata K, T okimura H, Yamamoto S and T ajiri Y : Spontaneous anterior interosseous nerve palsy with hourglass- like fascicular constriction within the main trunk of the median nerve. J Hand Surg 21A : , ) Personage MJ and Turner JWA : Neuralgic amyotrophy- the shoulder girdle syndrome. Lancet 1 : , ) Rask MR : Anterior interosseous nerve entrapment: Kiloh- Nevin sydrome. Report of seven cases..clin orthop 142 : , ) Sharrard WJW : Anterior introsseous neuritis. Report of a case.j B one Joint Surg 50B : , ) Smith BH and Berbst BA : Anterior interosseous nerve palsy. A rch N eurol 30 : , ) Sood MK and Burke FD : Anterior interosseous nerve palsy. J Hand Surg 22B : 64-68, ) Spinner M : The anterior interosseous nerve syndrome. With special attention to its variations. J B one Joint Surg 52A : 84-94, ) Stern MB : The anterior interosseous nerve syndrome:the Kiloh- Nevin syndrome. Report and follow- up study of three cases. Clin Orthop 187 : , ) Sunderland S : The innervation of the flexor digitorum profundus and lumbrical muscles. Anat R ec 93 : , ) T sairis P, Dyck PJ and Mulder DW : Natural histoy of brachial plexus neuropathy. A rch N euro 27 : , ) Vichare NA : Paralysis of the anterior interosseous nerve.j B one Joint Surg 50B : , ) Werner CO : The anterior interosseous nerve syndrome.int Orthop 13 : ,