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Hand neuropathies: compressive etiologies (CTS, CuTS) diagnosis, systemic causes, and surgical/non-operative management options.

137 citationsUpdated Oct 2026

Overview

Peripheral nerve injuries are common and debilitating, yet available treatments remain suboptimal [5]. Despite major microsurgical improvements, the clinical outcome of peripheral nerve surgery is still regarded as suboptimal [50]. Current nerve repair results have been no better than fair, with only 50% of patients regaining useful function [21]. The management of patients with painful sequelae of nerve injury represents the most challenging aspect of all peripheral nerve reconstructions [3]. Complications of compressive neuropathy management include iatrogenic injury, treatment failure, and pathologic pain syndromes [4]. Prevention of these complications relies on a solid understanding of normal anatomy and anatomic variations [4]. Early diagnosis of ATTR amyloidosis with polyneuropathy is critical because treatments are available to help slow the progression of neuropathy [1].

Diagnostic and assessment strategies require careful integration. The sole use of monofilament testing to diagnose peripheral neuropathy is not recommended [6]. Nerve conduction studies are recommended only when there are positive clinical symptoms and a sonographically confirmed cross-sectional area of the median nerve <0.1 cm² [35]. Comparison of sensory nerve responses is more effective than the use of an absolute median nerve latency in documenting median nerve abnormalities [53]. Outcomes assessment tools in peripheral nerve surgery evaluate aspects relating to function, pain, and patient perception of outcomes [12]. Approaching peripheral nerves with a multifocal technique requires a more detailed initial assessment, as missed diagnoses in multifocal peripheral nerve approaches result in unsatisfactory outcomes [11].

Specific clinical scenarios dictate distinct management pathways. Nonsurgical treatment is indicated when patients with hereditary neuropathy with liability to pressure palsies present with mononeuropathy because there is no entrapment; surgery will have no benefit for these patients because there is no compression of the nerve [56]. Long-term functional outcome for painful cervicothoracic brachial outlet syndrome managed via supraclavicular approach is generally favorable, and management of residual neuropathic pain could improve results [7]. The literature demonstrates positive functional outcomes after nerve transfer operations, and the utility and variations of nerve transfer operations have increased [55]. Successful results following revision neurectomy for Morton neuroma range from 60% to 80% [131]. A unique and common protocol for the preventive strategies, exercises, and rehabilitation of hand neuropathy in cyclists is lacking [2].

Anatomy & Pathophysiology

Nerve Physiology and Injury Mechanisms

Peripheral nerve injuries are common and debilitating, yet available treatments remain suboptimal [5]. Nerve dysfunction associated with compression syndromes results from an interruption or localized interference of microvascular function due to structural changes in the nerves or surrounding tissues [202]. Although myelin changes after chronic nerve compression (CNC) injury were previously thought to be a mild form of Wallerian degeneration, recent evidence points to a distinct pathophysiology involving Schwann cell mechanosensitivity [15]. Schwann cell integrins are involved in transducing the mechanical forces involved in nerve compression injuries to Schwann cells [15].

The underlying pathophysiology of double crush syndrome (DCS) is theorized to involve compression at one location on a nerve's axon predisposing that same axon to injury elsewhere due to disrupted bidirectional transport of essential nutrients [37]. More proximal lesions closer to the cell body have a greater effect on nerve function in the context of double crush syndrome [37]. The term "double crush" is considered misleading because it does not account for conditions where three or more sites of a given nerve are affected, nor does it account for mechanical stresses such as stretch or non-mechanical factors [37].

Peripheral nerve injuries cause both structural and functional brain changes that may be associated with significant sensorimotor abnormalities and pain [72]. Maladaptive neuroplasticity, as well as psychological and personality characteristics, impacts treatment outcome in peripheral nerve injury patients [72]. Regardless of the cause of nerve injury, the central and peripheral nervous systems rapidly react and begin adapting to the reduction in sensory input [203]. Adaptations to nerve injury range from Wallerian degeneration peripherally to topographic rearrangement in cortical and subcortical structures [203]. Neural plasticity expands the boundaries of recovery from nerve injury [203].

Diabetic Neuropathy Pathophysiology

Neuropathy is present in a substantial number of diabetic patients, with around 10% having some degree of neuropathy at the time of diagnosis and 40% developing neuropathy within 10 years of diagnosis [26]. Elderly patients with diabetes have a higher prevalence of neuropathy [26]. Neuropathy is caused by a state of sustained hyperglycemia, which leads to the formation of advanced glycation end products (AGE) [26]. Advanced glycation end products cause direct neuronal injury and microvascular damage, both of which negatively affect peripheral nerve function [26].

Sustained hyperglycemia causes excess production of reactive oxygen species, which results in direct damage to intracellular proteins and membrane lipids [26]. Excess production of superoxide species disrupts nitric oxide function, causing vasoconstriction and subsequent ischemia and end-organ damage [26].

Carpal Tunnel Syndrome Pathophysiology

The most important distinction for diagnosis, pathophysiology, and treatment of carpal tunnel syndrome (CTS) is between acute and chronic CTS [198]. Acute CTS is a compartment syndrome of the carpal tunnel in which there is a rapid rise and sustained increase in the interstitial pressure within the carpal canal [198]. Chronic CTS is a compressive neuropathy in which there is an insidious rise in the carpal tunnel interstitial pressure of a moderate degree [198]. In chronic CTS, the increase in interstitial pressure may initially be intermittent but is likely to be elevated constantly with time and increased symptoms [198].

A pressure-mediated biomechanical model suggests that slowing of conduction in the median nerve occurs just distal to the distal edge of the carpal tunnel, even though pressures in the more proximal segments may be greater [136]. A temporally unambiguous relationship exists between exposure to a moderately forceful, repetitive manual task and development of median mononeuropathy at the wrist [65].

Complex Regional Pain Syndrome

Complex regional pain syndrome (CRPS) represents autonomic and pain transmission dysregulation, resulting in peripheral sensitization with allodynia, dysesthesia, hyperpathia, and a reduced tolerance for pain when using the affected area for basic function [115]. CRPS occurs most commonly after a traumatic injury or iatrogenic insult [115]. CRPS I (formerly reflex sympathetic dystrophy) theoretically includes patients with a musculoskeletal injury without a defined neural injury [115]. CRPS II (causalgia) includes patients who fulfill the same criteria as CRPS I but have evidence of a neural injury [115].

Hand Anatomy and Functional Units

The skeleton of the hand and wrist consists of 27 bones, of which 19 are long bones [40]. The skeleton is divided into five rays, each ray making up a polyarticulated chain comprising the metacarpals and phalanges [40]. The wrist has three axes of movement, permitting the hand to be positioned in any spatial configuration and allowing it to be placed as needed for grasping [40]. The thumb metacarpal makes an angle of about 45 degrees with the second metacarpal in the sagittal plane [40]. The transverse axis of the palm forms an acute angle of approximately 75 degrees with the longitudinal axis [40].

The hand is both an organ designed to obtain information and an organ of execution [76]. The hand consists of 19 bones, 17 articulations, and 19 muscles situated entirely within the hand, and about the same number of tendons activated by the forearm muscles [76]. There are seven interosseous muscles in the hand, four dorsal and three volar [78]. The dorsal interossei are abductors and the volar interossei are adductors [78]. The middle finger has two dorsal interossei (abductors) and no volar interossei (adductors) because the central axis of the hand lies within it [78].

The extrinsic extensors run through six different fibroosseous retinacular compartments at the wrist level [39]. * First compartment: Contains the abductor pollicis longus and the extensor pollicis brevis [39]. * Second compartment: Contains the extensor carpi radialis longus and the extensor carpi radialis brevis [39]. * Third compartment: Contains the extensor pollicis longus [39]. * Fourth compartment: Contains the extensor indicis proprius lying deep to the four tendons of the extensor digitorum communis [39]. * Fifth compartment: Contains the extensor digiti quinti [39]. * Sixth compartment: The extensor carpi ulnaris tendon runs through this compartment and inserts at the base of the little finger metacarpal [39].

The extrinsic finger flexors are the flexor digitorum profundus and the flexor digitorum superficialis [39]. The flexor digitorum profundus inserts on the proximal volar aspect of the distal phalanx [39]. The innervation of the flexor digitorum profundus of the index and middle fingers is through the anterior interosseous branch of the median nerve [85]. The innervation of the flexor digitorum profundus of the ring and little fingers is by the ulnar nerve [85]. The entire flexor digitorum superficialis muscle receives innervation from the median nerve [85]. The flexor pollicis longus is innervated by the anterior interosseous branch of the median nerve [85].

The fibroosseous tunnel, or digital flexor sheath, consists of annular pulleys which provide mechanical stability, and cruciate pulleys which provide flexibility [85]. The A2 and A4 pulleys are the most essential in maintaining the mechanical advantage of the flexor tendons [85]. The tenosynovium that lines the fibroosseous tunnel supplies both nutrition and lubrication to the poorly vascularized flexor tendons [85]. Within the sheath, tendon vascularity is supplied via the vincula system: the vinculum longus and brevis [85].

The superficial palmar fascia lies in a coronal plane beneath the palmar subcutaneous tissue [88]. The palmaris longus tendon, when present, terminates in continuity with the fibers of the proximal corner of the superficial palmar fascia [88]. Fibers dorsal to the digital neurovascular bundle are collectively called Cleland ligament, and those palmar to the neurovascular bundle are called Grayson ligament [88]. The dorsal skin of the hand is thin and lined by a horny layer that is only 0.02 mm thick [87]. The dorsal skin possesses a normal pilosebaceous system, unlike the palm [87]. Flexion of the fingers produces a significant lengthening of the dorsal skin, with an average increase of 3 cm in the middle finger as it goes from extension to full flexion [87]. The dorsal and palmar areas of skin are independent because of a system of adhesions that anchors their common boundary to the underlying plane [87].

The metacarpal arch is endowed with a great deal of adaptability because of the mobility of the peripheral metacarpals [81]. The index metacarpal is the most firmly fixed [81]. The fifth metacarpal has a range of flexion–extension of approximately 20 degrees [81]. The keystones of the longitudinal arches of the hand are the metacarpophalangeal articulations [81]. The volar plates prevent hyperextension at the metacarpophalangeal joints [81].

The most important structure in the thenar area is the recurrent branch (motor) of the median nerve [83]. Anatomic studies have shown that there is no single longitudinal incision in the proximal palm that completely avoids the palmar cutaneous branches of the median and ulnar nerves [83]. The intrinsic hand muscles have motor evoked potentials (MEPs) at consistent distances from bony landmarks both dorsally and volarly [133].

Classification

Nerve Injury Grading Systems

Seddon: Sir Herbert Seddon classified peripheral nerve injuries into three grades: neuropraxia, axonotmesis, and neurotmesis [208].

Sunderland: Sir Sydney Sunderland further subdivided nerve injuries according to the discontinuity of different layers of connective tissue in the peripheral nerve [208]. * Grade 1 (Neuropraxia): Involves compression or mild crush that damages the Schwann cell sheath while axons and connective tissue remain in continuity [208]. This produces a transient nerve conduction block with disturbed motor and sensory function lasting from hours up to a few weeks [208]. It is characterized by a local conduction block in the absence of axonal injury, with complete recovery expected within six weeks [212]. * Grade 2 (Axonotmesis): Denotes an injury that disconnects the axon and its surrounding Schwann cell sheath while preserving the continuity of all connective tissue layers [208]. This involves disruption of the axon around which its connective tissue endoneurial sheath remains intact [212]. * Grade 3: Involves disconnection of the axon, its sheaths, and the endoneurial layer, while other connective tissue layers remain intact [208]. This is associated with a partial tear of the endoneurial tube [212]. * Grade 4: Involves disconnection of the axon, its sheaths, the endoneurium, and the perineurium, with only the epineurium remaining in continuity [208]. This represents complete axonal and endoneurial disruption with only the epineurium remaining intact [212]. * Grade 5 (Neurotmesis): Involves complete division of the nerve [208]. This results in minimal potential for recovery without surgical intervention [212].

Mackinnon and Dellon: Mackinnon and Dellon added a sixth category to the Sunderland classification, representing a combination of any of the previous five grades [212].

Compressive Neuropathy Severity Classifications

McGowan–Golberg and Dellon: These classifications are traditionally used to describe disease severity in cubital tunnel syndrome [205]. They are based on symptoms and/or clinician opinion without objective measures of function [205]. Grading is hierarchical, based on sensory symptoms alone, sensory symptoms with mild weakness, and sensory symptoms with severe weakness and muscle wasting or paralysis [205]. The McGowan classification applies to chronic ulnar neuropathy and was not used for acute-onset neuropathies where muscle atrophy could not be observed [207].

Akahori and Gu: This classification incorporates electrodiagnostic criteria in the form of conduction velocities [205].

Neuropathy Grading Scale (NGS): A modified neuropathy grading scale was used to report outcomes in cases of delayed-onset ulnar neuritis [207]. The NGS is a modification of the McGowan classification [210]. Clinical presentations of delayed-onset ulnar neuritis are classified into rapidly progressive, non-progressive, and slowly progressive groups [210].

Other Considerations: There is no reliable grading system that directs treatment and predicts outcome for cubital tunnel syndrome [205].

Sensory Recovery Grading

Highet: Highet’s sensory grading scheme included grades from S0 (no sensation) to S4 (complete recovery) [209].

Zachary and Holmes: The sensory classification system was modified by Zachary and Holmes to include gradations of recovery within the scale and two-point discrimination (2pd) [209]. * S0: Defined as no sensation [209]. * S1: Defined as recovery of deep pain sensibility [209]. * S11: Defined as recovery of superficial pain sensibility [209]. * S2: Defined as recovery of pain and some touch sensibility [209]. * S21: Defined as recovery of pain and some touch sensibility with some over-response [209]. * S3: Defined as recovery of pain and some touch sensibility with no over-response and 2pd greater than 15 mm [209]. * S31: Defined as sensory localization and 2pd recovery between 7 and 15 mm [209]. * S4: Defined as complete recovery with 2pd between 2 and 6 mm [209].

Diagnostic Criteria and Terminology

Other Considerations: The frequency of polyneuropathy subtypes depends on the type and number of criteria applied in a diagnostic model [41]. The term "double crush syndrome" is considered misleading because it does not account for conditions involving three or more sites of a given nerve [37]. It is also considered misleading because "crush" implies compression and does not account for other mechanical stresses such as stretch [37]. Furthermore, it limits the scope of the disease to purely mechanical factors, whereas medical and pharmacological factors also contribute [37]. The term "double crush syndrome" does not address the multiple variables involved in multifocal neuropathy [9]. The term "multifocal neuropathy" is proposed to expand the scope of double crush syndrome to emphasize that mechanical compression is only one part of a complex interplay of factors [37]. However, the term "multifocal neuropathy" is already used for a different autoimmune disease, creating a terminology conflict [9]. Demographics of patients with various compressive neuropathies are not homogeneous, suggesting different etiologies [8].

Clinical Presentation

Symptoms of compressive neuropathies evolve from initial sensory abnormalities, paresthesias, and pain to motor disruption and permanent sensory loss as injury progresses [15]. In the general population, pain, numbness, and tingling in the hands are common [93], and the burden of peripheral neuropathy defined by abnormal monofilament testing is substantial among older adults, even without diabetes [19]. The demographics of patients with various compressive neuropathies are not homogeneous, suggesting different etiologies [8]. Most diagnoses of distal peripheral neuropathy after shoulder surgery likely represent previously asymptomatic disease rather than surgical injuries, as the surgery is coincidental or merely brings the problem to attention [29].

Carpal Tunnel Syndrome: Carpal tunnel syndrome classically presents with nocturnal paresthesias in a median nerve distribution that gradually worsen, leading to sensory loss and thenar muscle atrophy late in the disease course [44]. Patients may report pain in the hand and symptoms not directly referable to the median nerve; however, a strong clinical history should direct the clinician to the diagnosis even when patient-reported symptoms are not classic [44]. Symptoms diagrammed within the median nerve distribution are associated with abnormal nerve conduction among workers [98], whereas extramedian symptoms are not related to nerve conduction studies or nerve ultrasonography [42]. The mean age at diagnosis is 50 years [44]. The condition is more common in women than men by nearly four times [44]. By age 65, prevalence is approximately 5.1% for women and 1.3% for men [44]. Risk factors include obesity, pregnancy, hypothyroidism, diabetes mellitus, and menopause [44]. The American Academy of Orthopaedic Surgeons guidelines list body mass index (BMI) and high hand repetition rate as factors with strong evidence of increased risk [44].

Ulnar Neuropathy at the Elbow: Clinical findings of localized pain or tenderness at the medial elbow, night-time paraesthesias, aggravation of symptoms with elbow flexion, and motor or sensory changes of the ulnar nerve in the absence of previous injury should alert the clinician to ulnar neuropathy at the elbow [47].

Diagnostic Maneuvers and Special Tests: A positive Tinel sign at the wrist or development of symptoms after a provocative Phalen maneuver can aid in the diagnosis of carpal tunnel syndrome, with reported specificity varying from 55% to 100% for Tinel sign [44]. Even with normal electrodiagnostic and two-point discrimination, the clinician should consider all potential sites of entrapment along the course of a given nerve [46].

Red-Flag Patterns and Differential Diagnosis: High median nerve entrapments are an obscure but increasingly recognized cause of painful upper extremity syndromes that are often overlooked due to their elusive diagnosis and non-classic presentation [92]. The diagnosis of hereditary neuropathy with liability to pressure palsies (HNPP) should be included in the differential diagnosis of patients with recurrent peripheral neuropathies [28]. Multifocal neuropathy is a challenging entity requiring careful diagnosis and conservative treatment first [9]. The terminology 'double crush syndrome' does not address the multiple variables involved in multifocal neuropathy, and 'multifocal neuropathy' is already used for a different autoimmune disease [9]. Approaching peripheral nerves with a multifocal technique requires a more detailed initial assessment, as missed diagnoses result in unsatisfactory outcomes [11]. Necrotizing fasciitis of an extremity with underlying vasculitis neuropathy can lead to a poor functional prognosis of the limb [99]. No reports of a persisting peripheral neuropathy, as was seen in a patient with meningococcemia, have been found [34].

Investigations

Clinical Assessment and History

Clinical examination and electrodiagnostic studies remain the gold standard for the diagnosis of nerve injuries [15]. A careful physical examination is essential to direct care and future testing if indicated [25]. Because patients often have difficulty accurately describing their symptoms and may incorrectly attribute pathology to a perceived deficit, clinical assessment by way of history taking and examination, with an algorithmic approach to the interpretation of signs and symptoms, remains at the core of nerve assessment and treatment planning [25, 27]. Operative exploration remains the gold standard for nerve assessment where clinical and current diagnostic tests are inconclusive, particularly when nerve disruption is suspected clinically [27].

Most diagnoses of distal peripheral neuropathy after shoulder surgery likely represent previously asymptomatic disease rather than surgical injuries [29]. Peripheral neuropathy due to direct nerve infiltration of tubercular infection is unusual yet must be taken into consideration in such cases [187]. Symptomatic neural loops are a rare, diagnostic challenge and diagnosis of exclusion; clinicians must be aware of this anatomic variation and consider microvascular decompression if other etiologies are absent [67]. Early diagnosis is critical because treatments are available to help slow the progression of neuropathy in ATTR amyloidosis with polyneuropathy [1].

Electrodiagnostic Testing

An understanding of the classification, pathophysiology, and electrodiagnosis of nerve lesions is critical to the appropriate diagnosis, localization, and management of nerve trauma in the hand [30]. Diagnosis of chronic nerve compression injuries can be difficult in patients with confounding factors such as diabetes [15]. Only 4.1% of the patients who had electrodiagnostic testing ordered by a surgeon had no measurable neuropathy [20]. Extramedian symptoms are not related to nerve conduction studies or nerve ultrasonography [42]. Adequate clinical diagnosis through predominantly motor symptoms and electroneuromyography alterations can allow for early decompression with good postoperative functional outcomes in isolated compression of the recurrent motor branch of the median nerve [173].

Imaging Modalities

The diagnosis and treatment of compressive neuropathies continue to evolve with technology, shifting towards preoperative imaging with ultrasound and MRN [17]. Closer scrutiny of nerve abnormalities beyond assessment of nerve calibre may allow for more accurate diagnostic classification of peripheral neuropathy [10]. Ultrasonography is a very useful method in the diagnostic evaluation of carpal tunnel syndrome, capable of discovering the cause of median nerve compression, especially in cases with an atypical clinical presentation [45]. Ultrasonography and MRI are useful for establishing a precise diagnosis in patients with motor dysfunction of the hand [196].

MR imaging can depict the peripheral nerves in the extremities effectively [117]. Magnetic resonance imaging confirmed inflammation of the nerve in the forearm in posterior interosseous neuropathy [138]. MRI is an excellent diagnostic modality to evaluate rapidly growing upper extremity masses and distinguish ganglions from malignant processes [192]. Magnetic resonance neurography detects diabetic neuropathy early and with proximal predominance [62]. Incorporating standardized diagnostic thresholds, clinical stratification, and interdisciplinary collaboration would maximize the clinical utility of MRN in the diagnosis and management of PIN neuropathy [32]. Patients with anterior interosseous nerve syndrome should undergo advanced imaging of the median nerve above and below the elbow by a specialist trained in imaging of the peripheral nerve [58].

Emerging diagnostic modalities, including simultaneous positron emission tomography and magnetic resonance imaging, nerve-specific fluorescence imaging, quantitative ultrasound and magnetic resonance imaging, peripheral nerve diffusion tensor imaging, magnetic resonance neurography, polarization-sensitive optical coherence tomography, and serum biomarkers, offer promising advances to better localize and define injury severity in peripheral nerve injury [143]. Early surgical exploration based on unequivocal clinical findings may be appropriate in the setting of normal preoperative testing and imaging in patients with spontaneous peripheral nerve palsy [149].

Treatment

General Principles and Prognosis

Despite major microsurgical improvements, the clinical outcome of peripheral nerve surgery remains suboptimal [50]. Current management techniques for major peripheral nerve injuries fail to achieve adequate functional neural regeneration [156], with results to date no better than fair and only 50% of patients regaining useful function [21]. Over one million people worldwide present with a peripheral nerve injury every year [107], and 24% to 41% of patients with a major injury are unable to return to their previous line of work [107]. The most important prognostic factor for nerve recovery is patient age [137]. There remains a lack of consensus on optimal treatment strategies for many clinical scenarios [107]. The goals for treating surgeons are to accurately describe the injury, assess the likelihood of improvement without intervention, and choose the optimal intervention at the earliest time point when clarity is available [107]. Options for treatment include direct repair, single or cabled autografts, allografts, conduit-assisted repairs, nerve transfers, and tendon- and muscle-based salvage options [107]. Neuromuscular disorders may overlap at presentation, and orthopaedic treatments often treat symptoms rather than the disease [108]. An interdisciplinary approach with regular longitudinal follow-ups is recommended to provide improved day-to-day satisfaction and optimal clinical outcomes [108].

Non-Operative

A comprehensive, conservative treatment program has a positive and lasting effect on pain and disability scores in patients with non-radicular peripheral neuropathic pain [114]. Patients with early carpal tunnel syndrome can be managed with conservative treatment [164], and non-surgical management is favorable compared with no treatment while the patient awaits surgery [127]. Early self-management for the prevention of neuropathies may reduce the incidence of bilateral symptoms and the number of patients requiring decompressive surgery [127]. For cubital tunnel syndrome, patients with mild or moderate symptoms have a good likelihood of symptom reduction or recovery without surgical treatment [125]; those given only an information program improved as much as those treated with an elbow brace or nerve gliding exercises [125]. The duration of compression of the median nerve at the carpal canal is significantly related to the effectiveness of conservative management [169]. A splinting/exercise combination improves hand strength over time, but it may take more than 4 weeks to achieve typical strength in carpal tunnel syndrome [183]. Nonsurgical treatment is indicated for patients with hereditary neuropathy with liability to pressure palsies presenting with mononeuropathy because there is no entrapment and surgery will have no benefit [56]. The best treatment for neuralgic amyotrophy remains unknown, though early corticosteroid therapy may shorten the duration of active symptoms and hasten recovery [57]. Multifocal neuropathy requires careful diagnosis and conservative treatment first [9]. Study findings could better define conservative interventions for treatment of chemotherapy induced peripheral neuropathy [22]. Findings suggest the applicability of cannabis-based medicines for peripheral neuropathy [120]. Pharmacological intervention as an adjunctive therapy to surgical peripheral nerve repair may prove to be not only beneficial but also necessary for satisfactory long-term functional recovery [122]. Tactile stimulation programs are evaluated for reducing touch induced dysesthesia in patients following peripheral nerve injury [179]. Therapeutic intervention for neuropathic pain and nerve tension disorders relies on biomechanical properties such as strain, excursion, compression, and mechanosensitivity [158]. Sensory and motor reeducation techniques assist in reorganization of the somatosensory cortex following nerve injury [158]. Exercise and electrical stimulation to assist the specificity of end organ reinnervation and axonal progression hold promise in nerve injury treatment [158].

Operative

Indications: Carpal tunnel release should be recommended to patients who have failed nonsurgical treatment [164]. In neurogenic thoracic outlet syndrome, surgery is recommended after the failure of standardized brachial plexus non-operative management (typically 3–6 months) unless there is muscle atrophy/weakness or sustained sensory deficits on examination [48]. In neurogenic thoracic outlet syndrome with concomitant distal double crush compression neuropathies and evidence of motor symptoms and intrinsic wasting, most surgeons (79%) recommend surgery as a first-line treatment option [184]. Surgery on neural structures compromised by neuromas, neuroma-in-continuity, or compression is indicated if symptoms persist after nonoperative modalities, including sympatholytic medications, as long as the symptoms can be controlled medically in the perioperative period [113]. If symptoms are sufficient to justify intervention for compression neuropathy in complex regional pain syndrome, location of the compression neuropathy is confirmed by peripheral nerve conduction velocities or interstitial pressure measurements [113].

Surgical Approach / Technique: Open surgical decompression of the carpal tunnel appears to be more simple and cost-effective than minimally invasive interventions [167]. For acute carpal tunnel syndrome produced by an anomalous flexor digitorum superficialis indicis muscle, early exploration and decompression of the median nerve is suggested, while excision of the abnormal muscle is not advised as a routine [121]. Surgical repair with long-term hand therapy results in excellent functional outcomes following pediatric peripheral nerve injury [23]. The long-term functional outcome of supraclavicular surgery for painful cervico-thoracobrachial outlet syndrome is generally favorable, but management of residual neuropathic pain could improve results [7]. For neurogenic thoracic outlet syndrome with concomitant distal compression, the most popular surgical option is a comprehensive approach where all potential compression sites are explored in the brachial plexus and distal extremity [184]. A distal-first approach is preferred by 37% of experts in the absence of positive findings on imaging [184], while a proximal-first approach is preferred by 16% of experts [184]. With surgery on the brachial plexus for neurogenic thoracic outlet syndrome, all surgeons advocate for a supraclavicular approach [184]. Nerve transfers are performed without tension at the coaptation site [154]. The immobilization required after nerve transfer is variable and dependent upon the location of the nerve transfers and concomitant procedures [154]. Typically, the nerve transfer coaptation is protected for 7–10 days [154]. Initially, a bulky dressing is used for 2–3 days following nerve transfer surgery [154]. Cross-palm nerve grafting may be a useful adjunct to enhance sensory recovery in severe ulnar neuropathy [144]. The author limits indications for synthetic conduits to small-diameter, noncritical sensory nerves with a gap of less than 3 cm [118]. Therapy evaluation and treatment protocols for patients with peripheral nerve repairs with nerve conduits are detailed [18]. Current techniques and concepts in peripheral nerve repair include developments in tolerance induction, cell-based supportive therapies, and bioengineering of nerve conduits [119]. Stabilization of the neuromuscular junction may be an important adjunct in peripheral nerve repair that should be explored [156].

Pain Management: The painful neuroma is a debilitating sequela of nerve injury with poorly understood pathophysiology involving fascicular escape and scarring [171]. Treatment for painful neuromas must be tailored to the individual patient as there are a number of approaches available [171]. Neuromas of the upper extremity are common and challenging to treat, with a multitude of operative and nonoperative techniques described with varying degrees of efficacy [172]. Surgical options for neuromas and neural injury in complex regional pain syndrome include neurolysis, neurorrhaphy, or neural relocation [113]. Modification of the neural bed is an option for treating neuromas and neural injury in complex regional pain syndrome [113]. For complete nerve transection or a neuroma-in-continuity, tension on the repair site should be avoided by performing nerve grafts from the sural nerve or a branch of the medial or lateral antebrachial cutaneous nerve [113]. Adhesions between the skin and nerve should be managed by Z-plasty local flaps or distant flaps [113]. If excessive scarring or adhesions develop, the neural bed should be modified with the use of autologous fat, rotational muscle flaps, pedicled muscle or fascial flaps, free muscle transfer, autologous or allograft venous wraps, or nerve conduits [113]. Internal neurolysis should be minimized during surgery for neuromas and neural injury in complex regional pain syndrome [113]. Postoperative care for neuromas and neural injury in complex regional pain syndrome should include sympatholytic intervention, pharmacologic palliation, physical therapy, and early active and passive range of motion [113]. Hemostasis should be established to prevent hematoma formation during surgery for neuromas and neural injury in complex regional pain syndrome [113]. Constrictive postoperative dressings should be avoided during surgery for neuromas and neural injury in complex regional pain syndrome [113]. For the treatment of compression neuropathy in complex regional pain syndrome, the dystrophic response is managed by sympatholytic medications or autonomic blockade or both [113]. Complete release of the involved nerve is important for the treatment of compression neuropathy in complex regional pain syndrome [113]. If there is damage to the neural bed or the neural bed is compromised in compression neuropathy, modification of the neural environment is appropriate [113]. Postoperative management of complex regional pain syndrome patients involves prolonged rehabilitation, continued use of oral nonnarcotic agents for 3 to 6 months, and some residual disability [113]. Surgical release of the intrinsic muscles by myotomy or tenotomy about the MCP or PIP joints will decrease stiffness but will not restore full range of motion, with 50% improvement being average [113]. The authors recommend microneurolysis as a treatment option for patients with chronic neuralgic amyotrophy who have failed to improve with nonsurgical treatment [170].

Other Considerations: The management of failed decompressions for compressive neuropathies remains challenging [17]. A statistically significant correlation exists between the final clinical results of treatment and post-traumatic median nerve compression neuropathy after fractures of the distal radius [129]. The occurrence of post-traumatic median nerve compression neuropathy after distal radius fractures correlates with neither fracture type nor with the final radiographic findings [129]. Factors associated with poorer or delayed recovery in recurrent carpal tunnel syndrome include early recurrence (<1 year), involvement of non-dominant hand, intra-operatively fibrosis and scar tissue around the nerve, and associated co-morbidities of obesity, diabetes mellitus and cervical spine problems [153]. Early recognition of reflex sympathetic dystrophy, preferably during the first or at least the second week, and attention to patients with extraordinary pain, finger stiffness, swelling, allodynia, or paresthesia may prevent this serious complication [111]. Removal or splitting of a dressing or cast to relieve pressure, elevation of an edematous hand, and intensive hand therapy are frequently helpful in preventing the development of full-blown complex regional pain syndrome [111]. An irritated or entrapped median nerve is frequently the cause of a complex regional pain syndrome [111]. The surgeon should have a low threshold for performing electrodiagnostic studies and/or surgical decompression for suspected nerve entrapment in complex regional pain syndrome [111]. For patients who have a history of complex regional pain syndrome, there may be value in preemptive treatment with a long-acting sympathetic block or indwelling catheter for a regional nerve blockade for any proposed surgical procedure [111].

Specific Conditions and Etiologies

Neuropathy in diabetes is caused by a state of sustained hyperglycemia, which leads to the formation of advanced glycation end products (AGE) [26]. There is significant overlap between the development of neuropathy and vasculopathy in diabetic patients [26]. Carpal tunnel syndrome is a common peripheral neuropathy resulting from median nerve compression in the carpal canal, with incidence and prevalence varying by occupation, age, and gender [16]. Carpal tunnel syndrome is the commonest compression neuropathy involving a peripheral nerve [152]. The pressure in the carpal tunnel is normally in the region of 1-7 mm of Hg, but pressures of 40-80 mm of Hg may occur, undermining nerve function [152]. ATTRV30M neuropathy has a rising prevalence in Cyprus due to improved survival of patients [141]. Despite the range of treatment available for peripheral neuropathies, a unique and common protocol is lacking for hand neuropathy in cyclists [2]. A conservative treatment is tried in most cases before surgery is performed for canal syndromes in instrumental musicians [176].

Complications

Iatrogenic and Surgical Complications

Brachial plexus blockade results in subtle, subclinical decreases in sensibility at short-term follow-up, without clinically relevant manifestations [60]. When a short history of severe pain indicates compression secondary to haemorrhage rather than oedema, urgent decompression is indicated to minimise neural damage [182].

Neuropathic Pain and Sensory Complications

Managing painful sequelae of nerve injury represents the most challenging aspect of peripheral nerve reconstruction [3]. Cold intolerance is a severe and debilitating complication following hand injury, with an incidence of 83% after upper limb peripheral nerve injuries [194]. In 48% of these patients, symptoms onset within 1 month of the initial injury [194]. At a mean follow-up of 51 months, 21% of patients reported improved cold intolerance, while 18% experienced deterioration [194]. Smoking increases the likelihood of developing cold intolerance, whereas sharp injuries decrease it [194]. Severity is significantly higher with complete nerve division, median and ulnar nerve division, and associated vessel injury [194]. Improvement is significantly more likely in non-smokers, while deterioration is most likely with a high severity score [194]. Young children demonstrate better sensory recovery and are less likely to develop long-term chronic neuropathic pain syndromes than adults [59].

In patients with advanced ulnar nerve neuropathy, dissatisfaction and disability may stem from coping problems or mood disturbances [204]. Depression is the dominant predictor of both patient dissatisfaction and disability following carpal tunnel release [204]. Patients with concomitant pain syndromes or mood disorders rate the result of endoscopic carpal tunnel release less satisfactorily [204].

Functional Deficits and Recovery Limitations

Some patients with brachial plexus neuropathy retain significant impairments and disabilities, particularly in activities of daily living, at a mean follow-up of 8 years [54]. Prolonged nerve compression leads to incomplete recovery, as observed in late ulnar neuropathy in brain-injured adults [64]. Static numbness, weakness, and atrophy may be permanent; incomplete understanding of this potential leads to dissatisfaction and additional treatment [204]. Follow-up time and age significantly influence outcome following nerve repair, with significant improvements in total scores seen throughout the follow-up period [51]. Long-term functional outcomes for thoracic outlet syndrome managed via a supraclavicular approach are generally favorable, though managing residual neuropathic pain could improve results [7].

Diagnostic and Prognostic Complications

Distinguishing recurrent from persistent ulnar neuropathy relies on symptoms, but differentiating true changes from misperception is difficult [204]. Without a control group, both objective and subjective outcomes can be misinterpreted in persistent or recurrent ulnar neuropathy [204]. A perceived response to treatment may reflect the placebo effect, a self-limiting disease course, or regression to the mean [204]. Consequently, dissatisfaction may be inappropriately ascribed to technical shortcomings [204]. The term "double crush" is misleading as it ignores conditions affecting three or more sites of a given nerve [37]. Furthermore, the term "crush" limits the disease scope to purely mechanical factors, whereas multiple medical and pharmacological factors likely contribute [37]. Patients with a history of ulnar nerve lesions face a significantly increased risk of developing carpal tunnel syndrome, especially within the first 2 years [68].

Recovery

Light activity (weeks): The evidence provided does not specify a typical week range for the resumption of desk work, driving, or light activities of daily living.

Full activity (months): The evidence provided does not specify a month range for the return to manual work, sport, or full range of motion and strength.

Complete recovery / outcome plateau (months): The evidence provided does not specify a month range for the stabilization of pain, strength, and final functional outcomes.

Rehabilitation protocol: The evidence provided does not detail specific physical therapy phasing, immobilisation duration, weight-bearing or range-of-motion progression, or sling/brace removal timing.

Functional milestones: Assessment of established peripheral neuropathy requires multiple quantitative tests repeated at regular intervals of approximately 12 weeks [14]. The electrodiagnostic examination provides reproducible objective data on the severity, progression over time, and extent of recovery after surgery for nerve entrapment [74]. Hand abduction tracings serve as a quantitative outcome measure to follow recovery over time for intrinsic hand function and can be used in patients with severe ulnar neuropathy following surgical intervention [71].

Other Considerations: The long-term functional outcome for cervical-thoracobraquial outlet syndrome treated via a supraclavicular approach is generally favorable, though management of residual neuropathic pain could improve results [7]. A review of results after three years for carpal tunnel neuropathy caused by injury offers the promise of consistent improvement in nerve and hand function [24]. Carpal tunnel syndrome requires attention to service delivery, awareness of systemic disease, and long-term nerve biology, rather than just surgical competence [33]. Treatment options for long nerve gaps include nerve autograft, processed nerve allograft, nerve transfers, and tendon transfers, each with distinct pros and cons regarding functional recovery, recovery time, and ability to address neuropathic pain [36]. Follow-up time and age significantly influence the outcome following median or ulnar nerve repair, with significant improvements in the total score seen throughout the follow-up period [51]. The literature demonstrates positive functional outcomes after nerve transfer operations for motor nerve injury in the upper extremity [55]. A patient with carpal tunnel syndrome associated with a persistent median artery was symptom free with resolution of pain and paresthesias at 3-month follow-up [61]. Prolonged compression of the ulnar nerve in a brain-injured adult led to incomplete recovery [64]. Follow-up at 2 weeks and 4 weeks for friction neuropathy of the ulnar digital nerve treated with corticosteroid injection showed no recurrence of pain, weakness, or loss of sensation, and the patient could perform activities of daily living [146]. Lead time bias should be a consideration in studies advocating early surgery for neuropathies with a high likelihood of natural recovery, as early, ineffective surgery can seem more effective than late surgery [199]. The rate of axon progression along a free vascularized nerve transplant in the upper extremity was greater than the expected 1 mm/day, averaging 2.4 mm/day in four illustrative patients [201]. At 24 months postoperative for revision carpal tunnel surgery using a hypothenar fat pad flap, nighttime paresthesia was present in 3 of 34 patients and neuropathic pain in 2 of 24 patients [213].

Key Evidence

• [L5] It emphasizes that early diagnosis is critical because treatments are available to help slow the progression of neuropathy. [1] (10.1007/s00415-019-09688-0)
• [L4] Despite the range of treatment available for peripheral neuropathies, a unique and common protocol is lacking on this specific topic. [2] (10.1016/j.jht.2021.11.003)
• [L5] The management of the patient with painful sequelae of nerve injury is the most challenging of all peripheral nerve reconstructions. [3] (10.1097/00130911-199709000-00007)
• [L5] Complications of compressive neuropathy management include iatrogenic injury, treatment failure, and pathologic pain syndromes, with prevention relying on a solid understanding of normal anatomy and anatomic variations. [4] (10.1016/j.hcl.2015.01.012)
• [Paper] Peripheral nerve injuries are common and debilitating, with available treatments remaining suboptimal. [5] (10.1016/j.hcl.2013.04.002)
• [L2] The sole use of monofilament testing to diagnose peripheral neuropathy is not recommended. [6] (10.1370/afm.1016)
• [L4] The long-term functional outcome is generally favorable, but management of residual neuropathic pain could improve results. [7] (10.1016/j.hansur.2018.10.099)
• [L3] The demographics of patients with various compressive neuropathies were not homogeneous, suggesting different etiologies. [8] (10.1177/15589447221107701)
• [L5] Multifocal neuropathy is a challenging entity requiring careful diagnosis and conservative treatment first; a new terminology is needed as 'double crush syndrome' does not address the multiple variables involved and 'multifocal neuropathy' is already used for a different autoimmune disease. [9] (10.1016/j.jhsa.2016.09.010)
• [L4] Closer scrutiny of nerve abnormalities beyond assessment of nerve calibre may allow for more accurate diagnostic classification of peripheral neuropathy, as well as contribute to the understanding of the intersection of structure and function in peripheral neuropathy. [10] (10.1136/jnnp-2014-309599)
• [L5] Approaching peripheral nerves with a multifocal technique requires a more detailed initial assessment, as missed diagnoses result in unsatisfactory outcomes. [11] (10.1016/j.jhsa.2016.09.011)
• [L5] Outcomes assessment tools and the current choices of measurements in outcomes research of peripheral nerve surgery evaluate several aspects relating to function, pain, and patient perception of outcomes. [12] (10.1016/j.hcl.2013.04.004)
• [L5] Assessment of the established peripheral neuropathy requires multiple quantitative tests that are repeated at regular intervals of approximately 12 weeks. [14] (10.1016/s0363-5023(83)80265-2)
• [L5] [15] (10.1016/j.jhsa.2010.01.007)
• [L5] Carpal tunnel syndrome is a common peripheral neuropathy resulting from median nerve compression in the carpal canal, with incidence and prevalence varying by occupation, age, and gender. [16] (10.1016/s0749-0712(21)00354-1)
• [L5] The diagnosis and treatment of compressive neuropathies continue to evolve with technology, shifting towards preoperative imaging with ultrasound and MRN, while the management of failed decompressions remains challenging. [17] (10.1016/j.jhsg.2022.10.009)
• [L4] Therapy evaluation and treatment protocols for patients with peripheral nerve repairs with nerve conduits are detailed. [18] (10.1197/j.jht.2005.02.012)
• [L4] The burden of peripheral neuropathy defined by abnormal monofilament testing among older adults is substantial, even among adults without diabetes. [19] (10.1038/s41598-021-98565-w)
• [L2] Only 4.1% of the patients who had EDX testing ordered by a surgeon had no measurable neuropathy. [20] (10.1177/15589447241284776)
• [L5] Results of nerve repair to date have been no better than fair, with only 50% of patients regaining useful function. [21] (10.5435/00124635-200007000-00005)
• [L4] Study findings could better define conservative interventions for treatment of chemotherapy induced peripheral neuropathy. [22] (10.1016/j.jht.2017.11.033)
• [Paper] Surgical repair with long-term hand therapy results in excellent functional outcomes following pediatric peripheral nerve injury. [23] (10.1055/s-0039-1692928)
• [L4] The review of results, after three years, offers the promise of consistent improvement in nerve and hand function. [24] (10.1016/s0894-1130(12)80296-1)
• [L4] [27] (10.1177/17531934241238736)
• [L5] The diagnosis of HNPP should be included in the differential diagnosis of patients with recurrent peripheral neuropathies. [28] (10.1053/jhsu.2001.26029)
• [Letter] Most diagnoses of distal peripheral neuropathy after shoulder surgery likely represent previously asymptomatic disease rather than surgical injuries, as the surgery is likely coincidental or merely brings the problem to the patient's attention. [29] (10.1016/j.jse.2015.03.020)
• [L5] An understanding of the classification, pathophysiology, and electrodiagnosis of these lesions is critical to the appropriate diagnosis, localization, and management of nerve trauma in the hand. [30] (10.1016/s0749-0712(21)00497-2)
• [L5] Incorporating standardized diagnostic thresholds, clinical stratification, and interdisciplinary collaboration would maximize the clinical utility of MRN in the diagnosis and management of PIN neuropathy. [32] (10.1177/23259671251400759)
• [L5] Carpal tunnel syndrome is a condition that requires attention to service delivery, awareness of systemic disease, and long-term nerve biology, rather than just surgical competence. [33] (10.1177/17531934261433793)
• [L5] No reports of a persisting peripheral neuropathy, as was seen in this patient, have been found. [34] (10.1016/s0363-5023(77)80051-8)
• [L3] NCS are recommended only when there are positive clinical symptoms and a sonographically confirmed csa of the median nerve <0.1 cm². [35] (10.1016/s0363-5023(03)80429-x)
• [L5] Treatment options include nerve autograft, processed nerve allograft, nerve transfers, and tendon transfers, each with distinct pros and cons regarding functional recovery, recovery time, and ability to address neuropathic pain. [36] (10.1016/j.jhsg.2024.01.012)
• [L5] [37] (10.1016/j.jhsa.2016.09.009)
• [L4] The frequency of polyneuropathy subtypes depends on the type and number of criteria applied in a diagnostic model. [41] (10.1111/jns.12424)
• [L4] Extramedian symptoms are not related to nerve conduction studies or nerve ultrasonography. [42] (10.1016/j.jelekin.2017.08.003)
• [L5] Ultrasonography is a very useful method in the diagnostic evaluation of carpal tunnel syndrome, capable of discovering the cause of median nerve compression, especially in cases with an atypical clinical presentation. [45] (10.1007/s11552-012-9435-z)
• [Paper] Even with normal electrodiagnostic and two-point discrimination, the clinician should consider all potential sites of entrapment along the course of a given nerve. [46] (10.1016/s0894-1130(02)80011-4)
• [L5] [47] (10.1258/ht.2011.011007)
• [L5] [48] (10.1177/17531934251361644)
• [L5] Despite major microsurgical improvements, the clinical outcome of peripheral nerve surgery is still regarded as suboptimal. [50] (10.1177/1753193411420348)
• [L3] Follow-up time and age significantly influence the outcome following nerve repair, with significant improvements in the total score seen throughout the follow-up period. [51] (10.1054/jhsb.2001.0567)
• [L5] Future efforts in peripheral nerve injury clinical research should focus on aligning multiple core outcome sets in a reproducible fashion across similar conditions while integrating the patient experience. [52] (10.1016/j.jhsg.2025.100939)
• [L5] Comparison of sensory nerve responses is more effective than the use of an absolute median nerve latency in documenting median nerve abnormalities. [53] (10.1002/mus.22208)
• [L4] The study demonstrates that some patients with brachial plexus neuropathy still have significant impairments and disabilities, especially in activities of daily living, at a mean follow-up of 8 years. [54] (10.1016/s0266-7681(00)80013-3)
• [L4] The literature demonstrates positive functional outcomes after nerve transfer operations, and thus, the utility and variations have increased. [55] (10.2106/jbjs.rvw.24.00150)
• [L5] It is further stated that nonsurgical treatment is indicated when patients with HNPP present with mononeuropathy because there is no entrapment, and surgery will have no benefit because there is no compression of the nerve. [56] (10.1053/jhsu.2002.30364)
• [L5] The best treatment for neuralgic amyotrophy remains unknown, though early corticosteroid therapy may shorten the duration of active symptoms and hasten recovery. [57] (10.1016/j.jhsa.2010.09.010)
• [L4] We recommend that patients with AINS should undergo advanced imaging of the median nerve above and below the elbow by a specialist trained in imaging of the peripheral nerve. [58] (10.1016/j.hansur.2018.10.004)
• [L3] Young children show better sensory recovery and are less likely to develop long-term chronic neuropathic pain syndromes than adults following nerve injury. [59] (10.1177/1753193408087029)
• [L2] Brachial plexus blockade causes subtle subclinical decreases in sensibility at short-term follow-up, without any clinically relevant manifestations. [60] (10.1177/1558944716650411)
• [L5] The patient was symptom free with resolution of pain and paresthesias at 3-month follow-up. [61] (10.1142/s0218810417720388)
• [L3] [62] (10.1002/ana.24524)
• [L4] Prolonged compression of the nerve led to incomplete recovery. [64] (10.1016/0363-5023(88)90214-6)
• [Paper] This new animal model demonstrates a temporally unambiguous relationship between exposure to a moderately forceful, repetitive manual task and development of median mononeuropathy at the wrist. [65] (10.1002/jor.20363)
• [L5] The management philosophy is summarized in one concept: converting a high nerve injury into a low nerve injury. [66] (10.1016/s0749-0712(21)00507-2)
• [Case_report] Symptomatic neural loops are a rare, diagnostic challenge and diagnosis of exclusion; clinicians must be aware of this anatomic variation and consider microvascular decompression if other etiologies are absent. [67] (10.1016/j.jhsa.2012.07.012)
• [L2] Patients with a history of ulnar nerve lesions are at a significantly increased risk of developing carpal tunnel syndrome, especially within the first 2 years. [68] (10.1016/j.jhsg.2026.100970)
• [L4] Hand abduction tracings are a quantitative outcome measure to follow recovery over time for intrinsic hand function and can be used in patients with severe ulnar neuropathy following surgical intervention. [71] (10.1016/j.jht.2023.09.005)
• [L5] [72] (10.1016/j.jht.2018.01.011)
• [L5] The electrodiagnostic examination (EDX) is an extension of the history and physical examination that provides reproducible objective data on the severity, progression over time, and extent of recovery after surgery for nerve entrapment. [74] (10.1016/s0363-5023(96)80298-x)
• [L5] High median nerve entrapments are an obscure but increasingly recognized cause of painful upper extremity syndromes that are often overlooked due to their elusive diagnosis and non-classic presentation. [92] (10.1016/s0749-0712(21)00358-9)
• [L4] Symptoms of pain, numbness, and tingling in the hands are common in the general population. [93] (10.1001/jama.282.2.153)
• [L2] Symptoms diagrammed within the median nerve distribution are associated with abnormal nerve conduction among workers. [98] (10.1016/j.jhsa.2011.08.016)
• [L5] Necrotizing fasciitis of an extremity with underlying vasculitis neuropathy can lead to a poor functional prognosis of the limb. [99] (10.1055/s-0039-1683945)
• [L3] A comprehensive, conservative treatment program has a positive and lasting effect on pain and disability scores in patients with non-radicular PNP. [114] (10.1016/j.jht.2014.02.003)
• [L5] MR imaging can depict the peripheral nerves in the extremities effectively. [117] (10.1007/s00330-006-0180-y)
• [L5] This review summarizes treatment options for peripheral nerve injuries with current techniques and concepts, covering developments in research and clinical application including tolerance induction, cell-based supportive therapies, and bioengineering of nerve conduits. [119] (10.1155/2016/4175293)
• [L2] These findings suggest the applicability of cannabis-based medicines for peripheral neuropathy. [120] (10.1016/j.jhsa.2024.09.015)
• [L5] They suggest such cases should be given the benefit of an early exploration and decompression of the median nerve, and do not advise excision of the abnormal muscle as a routine. [121] (10.1016/s0266-7681(85)80025-5)
• [L5] Pharmacological intervention as an adjunctive therapy to surgical peripheral nerve repair may prove to be not only beneficial but also necessary for satisfactory long-term functional recovery. [122] (10.1016/j.jhsa.2018.01.023)
• [L2] [125] (10.1177/1753193408098480)
• [L4] Therefore, a custom HD would provide a better indication of disease severity, progression, or improvement in strength in studies of ulnar neuropathy at the elbow with CB. [126] (10.1097/phm.0b013e31822415b6)
• [L4] [127] (10.1258/ht.2009.010002)
• [L5] Future progress in nerve surgery requires rigorous empirical evidence to define effective rehabilitation protocols, clarify the role of allografts versus autografts, and determine the clinical utility of nerve wraps and connectors. [128] (10.1016/j.jhsg.2025.100938)
• [L4] A statistically significant correlation between the final clinical results of treatment and post-traumatic median nerve compression neuropathy was found, but the occurrence of the neuropathy correlated with neither fracture type nor with the final radiographic findings. [129] (10.1016/j.jhsb.2005.09.021)
• [L5] Successful results following revision neurectomy range from 60% to 80%. [131] (10.5435/00124635-200808000-00016)
• [L5] The intrinsic hand muscles have MEPs at consistent distances from bony landmarks both dorsally and volarly. [133] (10.1016/j.jhsa.2020.04.019)
• [L4] The study suggests an alternative pressure-mediated biomechanical model that could explain why slowing of conduction in the median nerve occurs just distal to the distal edge of the carpal tunnel, even though pressures in the more proximal segments may be greater. [136] (10.1016/s0266-7681(98)80009-0)
• [L5] Magnetic resonance imaging confirmed inflammation of the nerve in the forearm. [138] (10.1007/s11420-011-9238-8)
• [L4] ATTRV30M neuropathy has a rising prevalence in Cyprus due to improved survival of patients. [141] (10.1080/13506129.2018.1534731)
• [L5] Emerging diagnostic modalities, including simultaneous positron emission tomography and magnetic resonance imaging, nerve-specific fluorescence imaging, quantitative ultrasound and magnetic resonance imaging, peripheral nerve diffusion tensor imaging, magnetic resonance neurography, polarization-sensitive optical coherence tomography, and serum biomarkers, offer promising advances to better localize and define injury severity in peripheral nerve injury. [143] (10.1016/j.jhsg.2025.100940)
• [L4] Cross-palm nerve grafting may be a useful adjunct to enhance sensory recovery in severe ulnar neuropathy. [144] (10.1177/1558944718822851)
• [L5] Follow-up at 2 weeks and 4 weeks showed no recurrence of the pain, weakness or loss of sensation and she could perform activities of daily living. [146] (10.1177/1753193411421097)
• [L4] Early surgical exploration based on unequivocal clinical findings may be appropriate in the setting of normal preoperative testing and imaging in patients with spontaneous peripheral nerve palsy. [149] (10.1016/j.jhsg.2024.12.008)
• [L5] [152] (10.1177/175899830200700201)
• [Paper] Factors associated with poorer/delayed recovery include early recurrence (<1 year), involvement of non-dominant hand, intra-operatively fibrosis and scar tissue around the nerve, and associated co-morbidities of obesity, diabetes mellitus and cervical spine problems. [153] (10.1007/s12593-011-0051-x)
• [L5] [154] (10.1016/j.jht.2013.12.007)
• [L5] Current management techniques for major peripheral nerve injuries fail to achieve adequate functional neural regeneration, and stabilization of the neuromuscular junction may be an important adjunct in peripheral nerve repair that should be explored. [156] (10.5435/00124635-201102001-00006)
• [L5] [158] (10.1016/j.jht.2011.12.004)
• [Paper] Patients with early carpal tunnel syndrome can be managed with conservative treatment, but carpal tunnel release should be recommended to patients who have failed nonsurgical treatment. [164] (10.1016/b978-0-12-385157-4.00652-7)
• [L4] [167] (10.1007/s11552-010-9263-y)
• [L4] The duration of compression of the median nerve at the carpal canal is significantly related to the effectiveness of conservative management. [169] (10.1016/s0894-1130(04)00194-2)
• [L4] The authors recommend microneurolysis as a treatment option for patients with chronic neuralgic amyotrophy who have failed to improve with nonsurgical treatment. [170] (10.1016/j.jhsa.2020.07.015)
• [L5] The painful neuroma is a debilitating sequela of nerve injury with poorly understood pathophysiology involving fascicular escape and scarring; treatment must be tailored to the individual patient as there are a number of approaches available. [171] (10.1016/j.jhsa.2009.12.019)
• [L5] Neuromas of the upper extremity are common and challenging to treat, with a multitude of operative and nonoperative techniques described with varying degrees of efficacy. [172] (10.1016/j.hcl.2013.04.007)
• [Case_report] Adequate clinical diagnosis through predominantly motor symptoms and electroneuromyography alterations can allow for early decompression with good postoperative functional outcomes. [173] (10.1177/1558944721990779)
• [L5] A conservative treatment is tried in most cases before surgery is performed. [176] (10.1016/j.main.2004.10.026)
• [L1] [179] (10.1016/j.jht.2020.05.003)
• [L5] A short history with severe pain indicating compression secondary to haemorrhage rather than oedema should lead to urgent decompression in an attempt to minimise neural damage. [182] (10.1016/s0266-7681(84)80011-x)
• [L3] [183] (10.1002/acr.22089)
• [L5] [184] (10.1016/j.jhsa.2026.03.014)
• [L4] Peripheral neuropathy due to direct nerve infiltration of tubercular infection is unusual yet must be taken into consideration in such cases. [187] (10.1016/j.jhsa.2023.02.002)
• [L4] MRI is an excellent diagnostic modality to evaluate rapidly growing upper extremity masses and distinguish ganglions from malignant processes. [192] (10.1007/s11552-007-9083-x)
• [L4] [194] (10.1016/s0266-7681(97)80392-0)
• [L4] Ultrasonography and MRI are useful for establishing a precise diagnosis in patients with motor dysfunction of the hand. [196] (10.1053/jhsu.2001.24146)
• [L5] [198] (10.1016/s0749-0712(21)00307-3)
• [L5] Lead time bias should be a consideration in studies advocating early surgery for neuropathies with a high likelihood of natural recovery, as early, ineffective surgery can seem more effective than late surgery. [199] (10.1177/17531934251329292)
• [L4] The rate of axon progression along the nerve transplant was greater than the expected 1 mm/day, averaging 2.4 mm/day in the author's four illustrative patients. [201] (10.1016/s0749-0712(21)00487-x)
• [L5] [202] (10.1197/j.jht.2005.02.001)
• [Paper] [203] (10.1197/j.jht.2005.02.007)
• [L4] [204] (10.1016/j.jhsa.2011.11.024)
• [L5] [205] (10.1302/2058-5241.6.200129)
• [L3] [207] (10.1177/0363546514540448)
• [L5] [208] (10.1302/2058-5241.2.160071)
• [L5] [209] (10.1197/j.jht.2005.02.002)
• [L2] [210] (10.1016/j.arthro.2014.03.022)
• [L5] [212] (10.1177/175899839900400102)
• [L3] At 24 months postoperative, nighttime paresthesia was present in 3 of 34 patients and neuropathic pain in 2 of 24 patients. [213] (10.1016/j.hansur.2016.12.009)

See Also

• Compression Neuropathies

References

[1] Expert consensus recommendations to improve diagnosis of ATTR amyloidosis with polyneuropathy. Journal of Neurology. 2020. DOI: 10.1007/s00415-019-09688-0

[2] Preventive strategies, exercises and rehabilitation of hand neuropathy in cyclists: A systematic review. Journal of Hand Therapy. 2022. DOI: 10.1016/j.jht.2021.11.003

[3] Evaluation and Treatment of the Painful Neuroma. Techniques in Hand & Upper Extremity Surgery. 1997. DOI: 10.1097/00130911-199709000-00007

[4] Complications of Compressive Neuropathy. Hand Clinics. 2015. DOI: 10.1016/j.hcl.2015.01.012

[5] Nerve Physiology. Hand Clinics. 2013. DOI: 10.1016/j.hcl.2013.04.002

[6] Accuracy of Monofilament Testing to Diagnose Peripheral Neuropathy: A Systematic Review. The Annals of Family Medicine. 2009. DOI: 10.1370/afm.1016

[7] Syndrome du défilé cervico-thoracobrachial douloureux opéré par voie sus claviculaire, résultats cliniques et fonctionnels à long terme. Étude rétrospective à propos de 70 cas. Hand Surgery and Rehabilitation. 2018. DOI: 10.1016/j.hansur.2018.10.099

[8] Demographics of Common Compressive Neuropathies in the Upper Extremity. HAND. 2022. DOI: 10.1177/15589447221107701

[9] First commentary on “Multifocal Neuropathy: Expanding the Scope of Double Crush Syndrome”. The Journal of Hand Surgery. 2016. DOI: 10.1016/j.jhsa.2016.09.010

[10] Ultrasound in the diagnosis of peripheral neuropathy: structure meets function in the neuromuscular clinic. Journal of Neurology, Neurosurgery & Psychiatry. 2015. DOI: 10.1136/jnnp-2014-309599

[11] Second commentary on “Multifocal Neuropathy: Expanding the Scope of Double Crush Syndrome”. The Journal of Hand Surgery. 2016. DOI: 10.1016/j.jhsa.2016.09.011

[12] How to Measure Outcomes of Peripheral Nerve Surgery. Hand Clinics. 2013. DOI: 10.1016/j.hcl.2013.04.004

[14] Report of the Committee for Evaluation of the Clinical Result in Peripheral Nerve Injury. The Journal of Hand Surgery. 1983. DOI: 10.1016/s0363-5023(83)80265-2

[15] Compressive Neuropathies of the Upper Extremity: Update on Pathophysiology, Classification, and Electrodiagnostic Findings. The Journal of Hand Surgery. 2010. DOI: 10.1016/j.jhsa.2010.01.007

[16] CARPAL TUNNEL SYNDROME. Hand Clinics. 1996. DOI: 10.1016/s0749-0712(21)00354-1

[17] Future Considerations in the Diagnosis and Treatment of Compressive Neuropathies of the Upper Extremity. Journal of Hand Surgery Global Online. 2023. DOI: 10.1016/j.jhsg.2022.10.009

[18] Nerve Conduits. Journal of Hand Therapy. 2005. DOI: 10.1197/j.jht.2005.02.012

[19] Prevalence of peripheral neuropathy defined by monofilament insensitivity in middle-aged and older adults in two US cohorts. Scientific Reports. 2021. DOI: 10.1038/s41598-021-98565-w

[20] Most Carpal Tunnel Releases Address Moderate or Severe Median Neuropathy. HAND. 2024. DOI: 10.1177/15589447241284776

[21] Peripheral Nerve Injury and Repair. Journal of the American Academy of Orthopaedic Surgeons. 2000. DOI: 10.5435/00124635-200007000-00005

[22] Home Intervention for Chemotherapy Induced Peripheral Neuropathy, Sensorimotor Program. Journal of Hand Therapy. 2018. DOI: 10.1016/j.jht.2017.11.033

[23] Long-Term Outcomes following Pediatric Peripheral Nerve Injury Repair. Journal of Hand and Microsurgery. 2020. DOI: 10.1055/s-0039-1692928

[24] Carpal Tunnel Neuropathy Caused by Injury. Journal of Hand Therapy. 1993. DOI: 10.1016/s0894-1130(12)80296-1

[25] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Anatomy, Evaluation, Clinical Examination, and Imaging > Evaluation and Clinical Examination: Current Concepts.

[26] Rockwood And Green S Fractures In Adults. 21: Psychosocial Aspects of Recovery After Trauma > Peripheral Neuropathy.

[27] Updates in diagnostic tools for diagnosing nerve injury and compressions. Journal of Hand Surgery (European Volume). 2024. DOI: 10.1177/17531934241238736

[28] Hereditary neuropathy with liability to pressure palsies mimicking multifocal compression neuropathy. The Journal of Hand Surgery. 2001. DOI: 10.1053/jhsu.2001.26029

[29] Regarding “Distal peripheral neuropathy after open and arthroscopic shoulder surgery: an under-recognized complication”. Journal of Shoulder and Elbow Surgery. 2015. DOI: 10.1016/j.jse.2015.03.020

[30] ELECTRODIAGNOSTIC EVALUATION OF TRAUMATIC NERVE INJURIES. Hand Clinics. 2000. DOI: 10.1016/s0749-0712(21)00497-2

[32] A Multisequence Approach to PIN Neuropathy: Bridging Imaging and Talent Development: Letter to the Editor. Orthopaedic Journal of Sports Medicine. 2026. DOI: 10.1177/23259671251400759

[33] Editorial. The simplicity and complexity of carpal tunnel syndrome. Journal of Hand Surgery (European Volume). 2026. DOI: 10.1177/17531934261433793

[34] Peripheral neuropathy—an unusual complication of meningococcemia. The Journal of Hand Surgery. 1977. DOI: 10.1016/s0363-5023(77)80051-8

[35] Sonography for the diagnosis of carpal tunnel syndrome. The Journal of Hand Surgery. 2003. DOI: 10.1016/s0363-5023(03)80429-x

[36] Management of “Long” Nerve Gaps. Journal of Hand Surgery Global Online. 2024. DOI: 10.1016/j.jhsg.2024.01.012

[37] Multifocal Neuropathy: Expanding the Scope of Double Crush Syndrome. The Journal of Hand Surgery. 2016. DOI: 10.1016/j.jhsa.2016.09.009

[39] A Lange Medical Book Current Diagnosis Treatment In Orthopedics Fifth Edition. 9Hand Surgery > Image DISORDERS OF THE MUSCULATURE OF THE HAND.

[40] Exam Of The Hand Wrist 2Ed. 1.1 SKELETON OF THE HAND > The osseous skeleton.

[41] Small and large fiber sensory polyneuropathy in type 2 diabetes: Influence of diagnostic criteria on neuropathy subtypes. Journal of the Peripheral Nervous System. 2020. DOI: 10.1111/jns.12424

[42] Are extramedian symptoms associated with peripheral causes in patient with carpal tunnel syndrome? Electrodiagnostic and ultrasonographic study. Journal of Electromyography and Kinesiology. 2018. DOI: 10.1016/j.jelekin.2017.08.003

[44] Chapter 31 Neuropathies, Vascular Conditions: Buerger’s, Raynaud’s; Degenerative Conditions. 2020.

[45] Elongated muscle belly of the flexor digitorum superficial causing carpal tunnel syndrome. HAND. 2012. DOI: 10.1007/s11552-012-9435-z

[46] Nerve Compression Syndromes of the Upper Limb. Journal of Hand Therapy. 2002. DOI: 10.1016/s0894-1130(02)80011-4

[47] Ulnar neuropathy at the elbow: a review and single case cadaveric study. Hand Therapy. 2011. DOI: 10.1258/ht.2011.011007

[48] Round table discussion. Neurogenic thoracic outlet syndrome. Journal of Hand Surgery (European Volume). 2025. DOI: 10.1177/17531934251361644

[50] Nerve surgery and gene therapy: a neurobiological and clinical perspective. Journal of Hand Surgery (European Volume). 2011. DOI: 10.1177/1753193411420348

[51] The Long Term Recovery Curve in Adults after Median or Ulnar Nerve Repair: A Reference Interval. Journal of Hand Surgery. 2001. DOI: 10.1054/jhsb.2001.0567

[52] Challenges in Clinical Research for Nerve Injuries (Nerve SPACE 2025). Journal of Hand Surgery Global Online. 2026. DOI: 10.1016/j.jhsg.2025.100939

[53] Electrodiagnostic evaluation of carpal tunnel syndrome. Muscle & Nerve. 2011. DOI: 10.1002/mus.22208

[54] Brachial Plexus Neuropathy. Journal of Hand Surgery. 2000. DOI: 10.1016/s0266-7681(00)80013-3

[55] Review of Outcomes After Peripheral Nerve Transfers for Motor Nerve Injury in the Upper Extremity. JBJS Reviews. 2024. DOI: 10.2106/jbjs.rvw.24.00150

[56] Hereditary neuropathy with liability to pressure palsies. The Journal of Hand Surgery. 2002. DOI: 10.1053/jhsu.2002.30364

[57] Neuralgic Amyotrophy: Parsonage-Turner Syndrome. The Journal of Hand Surgery. 2010. DOI: 10.1016/j.jhsa.2010.09.010

[58] The lesion of anterior interosseous nerve syndrome is not in the forearm. Hand Surgery and Rehabilitation. 2018. DOI: 10.1016/j.hansur.2018.10.004

[59] Age-Dependent Development Of Chronic Neuropathic Pain, Allodynia and Sensory Recovery after Upper Limb Nerve Injury in Children. Journal of Hand Surgery (European Volume). 2008. DOI: 10.1177/1753193408087029

[60] Brachial Plexus Blockade Causes Subclinical Neuropathy. HAND. 2016. DOI: 10.1177/1558944716650411

[61] An Anatomic Variant of Persistent Median Artery in Association with Carpal Tunnel Syndrome: Case Report and Review of the Literature. The Journal of Hand Surgery (Asian-Pacific Volume). 2017. DOI: 10.1142/s0218810417720388

[62] Magnetic resonance neurography detects diabetic neuropathy early and with Proximal Predominance. Annals of Neurology. 2015. DOI: 10.1002/ana.24524

[64] Late ulnar neuropathy in the brain-inyured adult. The Journal of Hand Surgery. 1988. DOI: 10.1016/0363-5023(88)90214-6

[65] Towards development of a nonhuman primate model of carpal tunnel syndrome: Performance of a voluntary, repetitive pinching task induces median mononeuropathy in Macaca fascicularis. Journal of Orthopaedic Research. 2007. DOI: 10.1002/jor.20363

[66] NERVE TRANSFERS IN THE UPPER EXTREMITY. Hand Clinics. 2000. DOI: 10.1016/s0749-0712(21)00507-2

[67] Symptomatic Neural Loop Causing Hemidigital Anesthesia: Case Report. The Journal of Hand Surgery. 2012. DOI: 10.1016/j.jhsa.2012.07.012

[68] Incidence of Carpal Tunnel Syndrome After the Diagnosis of Ulnar Neuropathy. Journal of Hand Surgery Global Online. 2026. DOI: 10.1016/j.jhsg.2026.100970

[71] The hand diagram: A novel outcome measure following supercharged end-to-side anterior interosseous nerve to ulnar nerve transfer in severe compressive ulnar neuropathy. Journal of Hand Therapy. 2024. DOI: 10.1016/j.jht.2023.09.005

[72] Peripheral nerve injuries, pain, and neuroplasticity. Journal of Hand Therapy. 2018. DOI: 10.1016/j.jht.2018.01.011

[74] Electrodiagnostic testing in hand surgery. The Journal of Hand Surgery. 1996. DOI: 10.1016/s0363-5023(96)80298-x

[76] Exam Of The Hand Wrist 2Ed. INTRODUCTION.

[78] Green S Operative Hand Surgery. Interosseous and Hypothenar Muscles.

[81] Exam Of The Hand Wrist 2Ed. The arches of the hand > The metacarpal arch.

[83] Campbell S Operative Orthopaedics 4 Volume Set. RESULTS OF SUTURE OF THE SCIATIC NERVE > PALMAR INCISIONS.

[85] A Lange Medical Book Current Diagnosis Treatment In Orthopedics Fifth Edition. 9Hand Surgery > FLEXOR TENDON INJURY.

[87] Exam Of The Hand Wrist 2Ed. The dorsal skin.

[88] Green S Operative Hand Surgery. PERTINENT ANATOMY.

[92] HIGH MEDIAN NERVE ENTRAPMENTS. Hand Clinics. 1996. DOI: 10.1016/s0749-0712(21)00358-9

[93] Prevalence of Carpal Tunnel Syndrome in a General Population. JAMA. 1999. DOI: 10.1001/jama.282.2.153

[98] Performance of Simplified Scoring Systems for Hand Diagrams in Carpal Tunnel Syndrome Screening. The Journal of Hand Surgery. 2012. DOI: 10.1016/j.jhsa.2011.08.016

[99] Severe Functional Loss of the Hand due to Necrotizing Fasciitis with Underlying Vasculitis Neuropathy. Journal of Hand and Microsurgery. 2019. DOI: 10.1055/s-0039-1683945

[107] Orthopaedic Basic Science Fifth Edition Print Ebook. Diagnosis and Repair of Peripheral Nerve Injuries > Introduction.

[108] Orthopaedic Basic Science Fifth Edition Print Ebook. Rare Genetic Bone Diseases of Orthopaedic Significance > Summary.

[111] Green S Operative Hand Surgery. Chronic Regional Pain Syndrome.

[113] Green S Operative Hand Surgery. A Practical Guide for Complex Regional Pain Syndrome in the Acute Stage and Late Stage > Surgical Management of Neural Injury in Complex Regional Pain Syndrome.

[114] Outcomes following the conservative management of patients with non-radicular peripheral neuropathic pain. Journal of Hand Therapy. 2014. DOI: 10.1016/j.jht.2014.02.003

[115] Campbell S Operative Orthopaedics 4 Volume Set. PERIPHERAL NERVE INJURIES OF THE UPPER AND LOWER EXTREMITIES > COMPLEX REGIONAL PAIN SYNDROME (REFLEX SYMPATHETIC DYSTROPHY).

[117] Role of magnetic resonance imaging in entrapment and compressive neuropathy—what, where, and how to see the peripheral nerves on the musculoskeletal magnetic resonance image: part 2. Upper extremity. European Radiology. 2006. DOI: 10.1007/s00330-006-0180-y

[118] Technical_Use_of_Synthetic_Conduits_for_Nerve_Repair_S0363502310012645. n.d..

[119] The Role of Current Techniques and Concepts in Peripheral Nerve Repair. Plastic Surgery International. 2016. DOI: 10.1155/2016/4175293

[120] The Use of Cannabinoids in the Treatment of Peripheral Neuropathy and Neuropathic Pain: A Systematic Review. The Journal of Hand Surgery. 2025. DOI: 10.1016/j.jhsa.2024.09.015

[121] Acute Carpal Tunnel Syndrome Produced by Anomalous Flexor Digitorum Superficialis Indicis Muscle. Journal of Hand Surgery. 1985. DOI: 10.1016/s0266-7681(85)80025-5

[122] Emerging Strategies on Adjuvant Therapies for Nerve Recovery. The Journal of Hand Surgery. 2018. DOI: 10.1016/j.jhsa.2018.01.023

[125] Conservative Treatment of the Cubital Tunnel Syndrome. Journal of Hand Surgery (European Volume). 2009. DOI: 10.1177/1753193408098480

[126] Assessing Weakness in Patients with Ulnar Neuropathy. American Journal of Physical Medicine & Rehabilitation. 2011. DOI: 10.1097/phm.0b013e31822415b6

[127] Service development and evaluation of a new carpal tunnel syndrome education class. Hand Therapy. 2010. DOI: 10.1258/ht.2009.010002

[128] Ongoing Clinical Challenges in Nerve Surgery (Nerve SPACE 2025). Journal of Hand Surgery Global Online. 2026. DOI: 10.1016/j.jhsg.2025.100938

[129] Peripheral Nerve Compression Neuropathy after Fractures of the Distal Radius. Journal of Hand Surgery. 2006. DOI: 10.1016/j.jhsb.2005.09.021

[131] Morton Neuroma: Primary and Secondary Neurectomy. Journal of the American Academy of Orthopaedic Surgeons. 2008. DOI: 10.5435/00124635-200808000-00016

[133] Targeted Muscle Reinnervation in the Hand: An Anatomical Feasibility Study for Neuroma Treatment and Prevention. The Journal of Hand Surgery. 2020. DOI: 10.1016/j.jhsa.2020.04.019

[136] Correlation of Segmental Carpal Tunnel Pressures with Changes in Hand and Wrist Positions in Patients with Carpal Tunnel Syndrome and Controls. Journal of Hand Surgery. 1998. DOI: 10.1016/s0266-7681(98)80009-0

[137] Chapter 28 Nerve Injuries and Nerve Transfers. 2019.

[138] Posterior Interosseous Neuropathy: Electrodiagnostic Evaluation. HSS Journal®: The Musculoskeletal Journal of Hospital for Special Surgery. 2012. DOI: 10.1007/s11420-011-9238-8

[141] Epidemiology of ATTRV30M neuropathy in Cyprus and the modifier effect of complement C1q on the age of disease onset. Amyloid. 2018. DOI: 10.1080/13506129.2018.1534731

[143] Localizing Nerve Injury, Defining Injury Severity, and Estimating Prognosis (Nerve SPACE 2025). Journal of Hand Surgery Global Online. 2026. DOI: 10.1016/j.jhsg.2025.100940

[144] Cross-Palm Nerve Grafts to Enhance Sensory Recovery in Severe Ulnar Neuropathy. HAND. 2019. DOI: 10.1177/1558944718822851

[146] Friction neuropathy of ulnar digital nerve in a writer’s thumb which was successfully treated with corticosteroid injection. Journal of Hand Surgery (European Volume). 2011. DOI: 10.1177/1753193411421097

[149] Early Surgical Decompression for the Treatment of Hourglass-Like Constriction of the Posterior Interosseus Nerve. Journal of Hand Surgery Global Online. 2025. DOI: 10.1016/j.jhsg.2024.12.008

[152] Hand Therapy for Carpal Tunnel Syndrome Part I: Overview of Disease and Non-surgical Management. The British Journal of Hand Therapy. 2002. DOI: 10.1177/175899830200700201

[153] Recurrent Carpal Tunnel Syndrome—Analysis of the Impact of Patient Personality in Altering Functional Outcome Following a Vascularised Hypothenar Fat Pad Flap Surgery. Journal of Hand and Microsurgery. 2012. DOI: 10.1007/s12593-011-0051-x

[154] Advances in nerve transfer surgery. Journal of Hand Therapy. 2014. DOI: 10.1016/j.jht.2013.12.007

[156] Limb Salvage With Major Nerve Injury: Current Management and Future Directions. Journal of the American Academy of Orthopaedic Surgeons. 2011. DOI: 10.5435/00124635-201102001-00006

[158] Interventions in the Disturbances in the Motor and Sensory Environment. Journal of Hand Therapy. 2012. DOI: 10.1016/j.jht.2011.12.004

[164] Carpal Tunnel Syndrome. Encyclopedia of the Neurological Sciences. 2014. DOI: 10.1016/b978-0-12-385157-4.00652-7

[167] Is there Light at the End of the Tunnel? Controversies in the Diagnosis and Management of Carpal Tunnel Syndrome. HAND. 2010. DOI: 10.1007/s11552-010-9263-y

[169] The effect of health-seeking behavior on the conservative management of carpal tunnel syndrome: A mixed-design pilot study. Journal of Hand Therapy. 2004. DOI: 10.1016/s0894-1130(04)00194-2

[170] Outcomes of Microneurolysis of Hourglass Constrictions in Chronic Neuralgic Amyotrophy. The Journal of Hand Surgery. 2021. DOI: 10.1016/j.jhsa.2020.07.015

[171] Neuromas of the Hand and Upper Extremity. The Journal of Hand Surgery. 2010. DOI: 10.1016/j.jhsa.2009.12.019

[172] Management of Neuromas of the Upper Extremity. Hand Clinics. 2013. DOI: 10.1016/j.hcl.2013.04.007

[173] Isolated Compression of the Recurrent Motor Branch of the Median Nerve: A Case Report. HAND. 2022. DOI: 10.1177/1558944721990779

[176] Les syndromes canalaires chez le musicien instrumentiste. Chirurgie de la Main. 2004. DOI: 10.1016/j.main.2004.10.026

[179] Tactile stimulation programs in patients with hand dysesthesia after a peripheral nerve injury: A systematic review. Journal of Hand Therapy. 2021. DOI: 10.1016/j.jht.2020.05.003

[182] Acute Carpal Tunnel Syndrome due to Spontaneous Haemorrhage. Journal of Hand Surgery. 1984. DOI: 10.1016/s0266-7681(84)80011-x

[183] Effect of Carpal Tunnel Syndrome on Grip and Pinch Strength Compared With Sex‐ and Age‐Matched Normative Data. Arthritis Care & Research. 2013. DOI: 10.1002/acr.22089

[184] Strategies for Work-up and Treatment of Case Scenarios in Neurogenic Thoracic Outlet Syndrome. The Journal of Hand Surgery. 2026. DOI: 10.1016/j.jhsa.2026.03.014

[187] Peripheral Tubercular Neuritis. The Journal of Hand Surgery. 2023. DOI: 10.1016/j.jhsa.2023.02.002

[192] Compression Neuropathy of the Radial Nerve Due to Ganglion Cysts. HAND. 2008. DOI: 10.1007/s11552-007-9083-x

[194] Cold Intolerance Following Peripheral Nerve Injury. Journal of Hand Surgery. 1997. DOI: 10.1016/s0266-7681(97)80392-0

[196] Neuropathy of motor branch of median or ulnar nerve induced by midpalm ganglion. The Journal of Hand Surgery. 2001. DOI: 10.1053/jhsu.2001.24146

[198] THE PATHOPHYSIOLOGY OF CARPAL TUNNEL SYNDROME. Hand Clinics. 1996. DOI: 10.1016/s0749-0712(21)00307-3

[199] The potential for lead time bias in early peripheral nerve exploration. Journal of Hand Surgery (European Volume). 2025. DOI: 10.1177/17531934251329292

[201] FREE VASCULARIZED NERVE TRANSFER IN THE UPPER EXTREMITY. Hand Clinics. 1999. DOI: 10.1016/s0749-0712(21)00487-x

[202] Pathomechanics of Peripheral Nerve Loading. Journal of Hand Therapy. 2005. DOI: 10.1197/j.jht.2005.02.001

[203] Impact of Peripheral Nerve Injury on Sensorimotor Control. Journal of Hand Therapy. 2005. DOI: 10.1197/j.jht.2005.02.007

[204] Recurrent or Persistent Cubital Tunnel Syndrome. The Journal of Hand Surgery. 2012. DOI: 10.1016/j.jhsa.2011.11.024

[205] Cubital tunnel syndrome. EFORT Open Reviews. 2021. DOI: 10.1302/2058-5241.6.200129

[207] Delayed-Onset Ulnar Neuritis After Release of Elbow Contractures. The American Journal of Sports Medicine. 2014. DOI: 10.1177/0363546514540448

[208] Nerve injuries of the upper extremity and hand. EFORT Open Reviews. 2017. DOI: 10.1302/2058-5241.2.160071

[209] Evaluation of Nerve Injury and Nerve Compression in the Upper Quadrant. Journal of Hand Therapy. 2005. DOI: 10.1197/j.jht.2005.02.002

[210] Delayed‐Onset Ulnar Neuritis After Release of Elbow Contracture: Preventive Strategies Derived From a Study of 563 Cases. Arthroscopy. 2014. DOI: 10.1016/j.arthro.2014.03.022

[212] Nerve Repair and Regeneration. The British Journal of Hand Therapy. 1999. DOI: 10.1177/175899839900400102

[213] Strickland's hypothenar fat pad flap for revision surgery in carpal tunnel syndrome: Prospective study of 34 cases. Hand Surgery and Rehabilitation. 2017. DOI: 10.1016/j.hansur.2016.12.009