Early aggressive constriction resection for hourglass-like constriction of peripheral nerve in the upper extremity: a retrospective study

Objectives

The hourglass like constriction (HGC) of peripheral nerves is a characteristic pathological manifestation of Neuralgic Amyotrophy. Once identified, early surgical intervention is essential. However, the method of surgery is controversial, particularly regarding whether HGC needs to be excised. This study aims to explore the efficacy of early aggressive resection of HGC in the upper limb nerves.

Materials and methods

This retrospective study focuses on 13 nerves of spontaneous upper limb paralysis treated at our hospital from June 2019 to July 2023, in which HGC was identified during surgery. During surgery, epineurectomy and interfascicular neurolysis were performed on the constricted areas. Post-neurolysis, constriction excision was carried out if any of the following conditions were met: (1) A single constriction with constriction ≥75%. (2) Constriction combined with torsion. (3) The presence of ≥2 constrictions. Regular face-to-face follow-ups were conducted postoperatively.

Results

Four cases with a single constriction of less than 75% underwent epineurotomy and interfascicular neurolysis; eight underwent constriction excision, of which four cases with a single constriction and associated torsion had direct end-to-end suturing after excision, and four had more than two constrictions treated with autologous sural nerve grafts. Postoperative follow-ups showed good recovery in all but one case, which had unique pathological features and had underwent only epineurectomy, showing moderate recovery.

Conclusions

For early surgical treatment of HGCs in peripheral nerves of the upper limbs, if severe constriction, constriction combined with torsion, or the presence of more than two constrictions are identified during surgery, aggressive constriction resection may be a better option.