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Natroshvili T, van de Warenburg MS, Heine EP, Slater NJ, Walbeehm ET, Bartels RHMA. Conservative Treatment of Ulnar Nerve Compression at the Elbow: A Systematic Review and Meta-Analysis. Arch Plast Surg 2023; 50:70-81. [PMID: 36755648 PMCID: PMC9902076 DOI: 10.1055/s-0042-1757571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 05/26/2022] [Indexed: 02/08/2023] Open
Abstract
Background The clinical results of conservative treatment options for ulnar compression at the elbow have not been clearly determined. The aim of this review was to evaluate available conservative treatment options and their effectiveness for ulnar nerve compression at the elbow. Methods In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations, a systematic review and meta-analysis of studies was performed. Literature search was performed using Ovid MEDLINE, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL). Results Of the 1,079 retrieved studies, 20 were eligible for analysis and included 687 cases of ulnar neuropathy at the elbow. Improvement of symptoms was reported in 54% of the cases receiving a steroid/lidocaine injection (95% confidence interval [CI], 41-67) and in 89% of the cases using a splint device (95% CI, 69-99). Conclusions Conservative management seems to be effective. Both lidocaine/steroid injections and splint devices gave a statistically significant improvement of symptoms and are suitable options for patients who refuse an operative procedure or need a bridge to their surgery. Splinting is preferred over injections, as it shows a higher rate of improvement.
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Affiliation(s)
- Tinatin Natroshvili
- Department of Plastic and Reconstructive Surgery, CWZ, Nijmegen, The Netherlands,Department of Plastic and Reconstructive Surgery, Radboud University Medical Center, Nijmegen, The Netherlands,Department of Plastic and Reconstructive Surgery, Martini Hospital, Groningen, The Netherlands,Address for correspondence Tinatin Natroshvili, MD Department of Plastic Surgery, Canisius Wilhelmina ZiekenhuisBurgemeester Daleslaan 27, 6532 CL, NijmegenThe Netherlands
| | - Milly S. van de Warenburg
- Department of Plastic and Reconstructive Surgery, CWZ, Nijmegen, The Netherlands,Department of Plastic and Reconstructive Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Erwin P. Heine
- Department of Plastic and Reconstructive Surgery, CWZ, Nijmegen, The Netherlands
| | - Nicholas J. Slater
- Department of Plastic and Reconstructive Surgery, CWZ, Nijmegen, The Netherlands,Department of Plastic and Reconstructive Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Erik T. Walbeehm
- Department of Plastic and Reconstructive Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
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Mansour J, Ghanimeh J, Ghersi A, Moutinot B, Coulomb R, Kouyoumdjian P, Mares O. Percutaneous ultrasound-guided ulnar nerve release technique compared to open technique: A cadaveric study. SICOT J 2022; 8:40. [PMID: 36155647 PMCID: PMC9511962 DOI: 10.1051/sicotj/2022041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 09/08/2022] [Indexed: 11/29/2022] Open
Abstract
Objectives: To evaluate the outcomes of a novel percutaneous ultrasound-guided technique for release of ulnar nerve entrapment at the elbow when compared to standard open release Methods: One single surgeon performed an ultrasound-guided percutaneous release of the cubital tunnel on a group of five cadaveric elbows and open release on five others. All procedures were timed, and incision lengths were recorded. Meticulous anatomic dissection was then performed to assess the complete release of the carpal tunnel and iatrogenic injuries. Results: No significant difference was found between the two groups in terms of complete release and iatrogenic injury, whereas Operative time was significantly shorter for the US-guided technique. Incomplete releases of the nerve were found only during the first two trials in each group, while the third, fourth, and fifth trials showed a complete ulnar nerve release in both series, highlighting a fast learning curve for both techniques. All of this through a significantly smaller incision in the US-guided technique. Conclusions: This study highlights the similar effects of these two techniques in terms of complete release of the ulnar nerve, with no clear superiority of one over the other in terms of morbidity rate. Both have a fast learning curve for an ultrasound-trained surgeon, with the US-guided technique being a less traumatic and quicker alternative procedure.
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Affiliation(s)
- Jad Mansour
- Centre Hospitalier Universitaire Nîmes-Caremeau, place du professeur Robert-Debré, 30029 Nîmes, France
| | - Joe Ghanimeh
- Department of Orthopedic Surgery, Lebanese American University-Rizk Hospital, Lebanese American University, School of Medicine, Beirut, Lebanon
| | - Abdelhamid Ghersi
- Centre Hospitalier Universitaire Nîmes-Caremeau, place du professeur Robert-Debré, 30029 Nîmes, France
| | - Berenice Moutinot
- Centre Hospitalier Universitaire Nîmes-Caremeau, place du professeur Robert-Debré, 30029 Nîmes, France
| | - Remy Coulomb
- Centre Hospitalier Universitaire Nîmes-Caremeau, place du professeur Robert-Debré, 30029 Nîmes, France
| | - Pascal Kouyoumdjian
- Centre Hospitalier Universitaire Nîmes-Caremeau, place du professeur Robert-Debré, 30029 Nîmes, France
| | - Olivier Mares
- Centre Hospitalier Universitaire Nîmes-Caremeau, place du professeur Robert-Debré, 30029 Nîmes, France
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Poenaru D, Ojoga F, Sandulescu M, Cinteza D. Conservative therapy in ulnar neuropathy at the elbow (Review). Exp Ther Med 2022; 24:517. [PMID: 35837045 PMCID: PMC9257949 DOI: 10.3892/etm.2022.11444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 04/19/2022] [Indexed: 11/13/2022] Open
Abstract
Ulnar neuropathy at the elbow (UNE) is the second most frequent entrapment syndrome in the upper limb after carpal tunnel syndrome. Clinical features are validated through electromyographic and sonographic examination. Although the two aforementioned entrapment syndromes share common pathophysiological traits, the conservative treatment approach for mild and moderate cases of UNE differs from that for median nerve entrapment. The present study identified 23 different types of scientific articles aimed to address this issue. The research stressed the importance of patient education and activity modification. Night splinting offers clinical and functional improvement. Although corticosteroid injections play a role in selected cases, their utility remains to be validated. Physiotherapy trials evaluated ultrasound, low-level laser therapy, diathermy, extracorporeal shock wave therapy and dry cupping. Neurodynamic mobilization may add value to therapeutic approaches and should be a part of it.
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Affiliation(s)
- Daniela Poenaru
- Department of Rehabilitation, ‘Carol Davila’ University of Medicine and Pharmacy, Bucharest 052785, Romania
| | - Florina Ojoga
- Department of Rehabilitation, ‘Carol Davila’ University of Medicine and Pharmacy, Bucharest 052785, Romania
| | - Miruna Sandulescu
- Department of Rehabilitation, ‘Carol Davila’ University of Medicine and Pharmacy, Bucharest 052785, Romania
| | - Delia Cinteza
- Department of Rehabilitation, ‘Carol Davila’ University of Medicine and Pharmacy, Bucharest 052785, Romania
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4
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Dejaco C, Machado PM, Carubbi F, Bosch P, Terslev L, Tamborrini G, Sconfienza LM, Scirè CA, Ruetten S, van Rompay J, Proft F, Pitzalis C, Obradov M, Moe RH, Mascarenhas VV, Malattia C, Klauser AS, Kent A, Jans L, Hartung W, Hammer HB, Duftner C, Balint PV, Alunno A, Baraliakos X. EULAR points to consider for the use of imaging to guide interventional procedures in patients with rheumatic and musculoskeletal diseases (RMDs). Ann Rheum Dis 2022; 81:760-767. [PMID: 34893469 DOI: 10.1136/annrheumdis-2021-221261] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 11/23/2021] [Indexed: 12/25/2022]
Abstract
OBJECTIVES To develop evidence-based Points to Consider (PtC) for the use of imaging modalities to guide interventional procedures in patients with rheumatic and musculoskeletal diseases (RMDs). METHODS European Alliance of Associations for Rheumatology (EULAR) standardised operating procedures were followed. A systematic literature review was conducted to retrieve data on the role of imaging modalities including ultrasound (US), fluoroscopy, MRI, CT and fusion imaging to guide interventional procedures. Based on evidence and expert opinion, the task force (25 participants consisting of physicians, healthcare professionals and patients from 11 countries) developed PtC, with consensus obtained through voting. The final level of agreement was provided anonymously. RESULTS A total of three overarching principles and six specific PtC were formulated. The task force recommends preference of imaging over palpation to guide targeted interventional procedures at peripheral joints, periarticular musculoskeletal structures, nerves and the spine. While US is the favoured imaging technique for peripheral joints and nerves, the choice of the imaging method for the spine and sacroiliac joints has to be individualised according to the target, procedure, expertise, availability and radiation exposure. All imaging guided interventions should be performed by a trained specialist using appropriate operational procedures, settings and assistance by technical personnel. CONCLUSION These are the first EULAR PtC to provide guidance on the role of imaging to guide interventional procedures in patients with RMDs.
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Affiliation(s)
- Christian Dejaco
- Department of Rheumatology, Medical University of Graz, Graz, Austria
- Department of Rheumatology (ASAA-SABES), Brunico Hospital, Brunico, Italy
| | - Pedro M Machado
- Centre for Rheumatology & Department of Neuromuscular Diseases, University College London, London, UK
- National Institute for Health Research (NIHR) University College London Hospitals Biomedical Research Centre, University College London Hospitals NHS Foundation Trust, London, UK
| | - Francesco Carubbi
- Internal Medicine and Nephrology Unit, University of L'Aquila Department of Clinical Medicine Life Health and Environmental Sciences, L'Aquila, Italy
- Department of Medicine, ASL 1 Avezzano-Sulmona-L'Aquila, San Salvatore Hospital, L'Aquila, Italy
| | - Philipp Bosch
- Department of Rheumatology, Medical University of Graz, Graz, Austria
| | - Lene Terslev
- Center for Rheumatology and Spine Diseases, Rigshospitalet, Kobenhavn, Denmark
| | - Giorgio Tamborrini
- UZR, Ultraschallzentrum und Institut für Rheumatologie, Basel, Switzerland
| | - Luca Maria Sconfienza
- Dipartimento di Scienze Biomediche per la Salute, Universita degli Studi di Milano, Milano, Italy
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Galeazzi, Milano, Italy
| | - Carlo Alberto Scirè
- Rheumatology Unit, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
- Epidemiology Research Unit, Italian Society of Rheumatology, Milano, Italy
| | - Sebastian Ruetten
- Center for Spine Surgery and Pain Therapy, Center for Orthopedics and Traumatology, St. Anna Hospital, Herne, Germany
| | - Jef van Rompay
- Patient Research Partners, Patient Research, Antwerpen, Belgium
| | - Fabian Proft
- Department of Gastroenterology, Infectiology and Rheumatology, Charite Universitatsmedizin Berlin Campus Benjamin Franklin, Berlin, Germany
| | - Costantino Pitzalis
- Experimental Medicine and Rheumatology, William Harvey Research Institute, London, UK
| | - Marina Obradov
- Radiology, Sint Maartenskliniek, Nijmegen, The Netherlands
| | - Rikke Helene Moe
- Division of Rheumatology and Research, Diakonhjemmet Hospital, Oslo, Norway
| | - Vasco V Mascarenhas
- UIME (Unidade de Imagem Musculo-esquelética), Hospital da Luz Imaging Center, Lisbon, Portugal
- Rheumatic Diseases Lab, CEDOC, Universidade Nova de Lisboa, Lisboa, Portugal
| | - Clara Malattia
- UOC Clinica Pediatrica e Reumatologia, Istituto Giannina Gaslini, Genova, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetic and Maternal Infantile Sciences (DINOGMI), University of Genoa, Genova, Italy
| | - Andrea Sabine Klauser
- Radiology II, Medical University Innsbruck Department of Radiology, Innsbruck, Austria
| | - Alison Kent
- Salisbury Hospital NHS Foundation Trust, Salisbury, UK
| | - Lennart Jans
- Radiology, Ghent University Hospital Radiology Department, Gent, Belgium
| | - Wolfgang Hartung
- Department of Rheumatology and Clinical Immunology, Asklepios Medical Center, Bad Abbach, Germany
| | - Hilde Berner Hammer
- Rheumatology, Diakonhjemmet Hospital, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Christina Duftner
- Department of Internal Medicine, Clinical Division of Internal Medicine II, Medical University Innsbruck, Innsbruck, Austria
| | - Peter V Balint
- 3rd Department of Rheumatology, National Institute for Rheumatology and Physiotherapy, Budapest, Hungary
| | - Alessia Alunno
- Internal Medicine and Nephrology Unit, University of L'Aquila Department of Clinical Medicine Life Health and Environmental Sciences, L'Aquila, Italy
| | - Xenofon Baraliakos
- Rheumatology, Ruhr-University Bochum, Rheumazentrum Ruhrgebiet Herne, Herne, Germany
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Mezian K, Jačisko J, Kaiser R, Machač S, Steyerová P, Sobotová K, Angerová Y, Naňka O. Ulnar Neuropathy at the Elbow: From Ultrasound Scanning to Treatment. Front Neurol 2021; 12:661441. [PMID: 34054704 PMCID: PMC8160369 DOI: 10.3389/fneur.2021.661441] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 03/23/2021] [Indexed: 01/01/2023] Open
Abstract
Ulnar neuropathy at the elbow (UNE) is commonly encountered in clinical practice. It results from either static or dynamic compression of the ulnar nerve. While the retroepicondylar groove and its surrounding structures are quite superficial, the use of ultrasound (US) imaging is associated with the following advantages: (1) an excellent spatial resolution allows a detailed morphological assessment of the ulnar nerve and adjacent structures, (2) dynamic imaging represents the gold standard for assessing the ulnar nerve stability in the retroepicondylar groove during flexion/extension, and (3) US guidance bears the capability of increasing the accuracy and safety of injections. This review aims to illustrate the ulnar nerve's detailed anatomy at the elbow using cadaveric images to understand better both static and dynamic imaging of the ulnar nerve around the elbow. Pathologies covering ulnar nerve instability, idiopathic cubital tunnel syndrome, space-occupying lesions (e.g., ganglion, heterotopic ossification, aberrant veins, and anconeus epitrochlearis muscle) are presented. Additionally, the authors also exemplify the scientific evidence from the literature supporting the proposition that US guidance is beneficial in injection therapy of UNE. The non-surgical management description covers activity modifications, splinting, neuromobilization/gliding exercise, and physical agents. In the operative treatment description, an emphasis is put on two commonly used approaches-in situ decompression and anterior transpositions.
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Affiliation(s)
- Kamal Mezian
- Department of Rehabilitation Medicine, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czechia
| | - Jakub Jačisko
- Department of Rehabilitation and Sports Medicine, Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czechia
| | - Radek Kaiser
- Department of Neurosurgery and Neurooncology, First Faculty of Medicine, Charles University and Military University Hospital Prague, Prague, Czechia
| | - Stanislav Machač
- Department of Rehabilitation and Sports Medicine, Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czechia
| | - Petra Steyerová
- Department of Radiology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czechia
| | - Karolína Sobotová
- Department of Rehabilitation and Sports Medicine, Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czechia
| | - Yvona Angerová
- Department of Rehabilitation Medicine, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czechia
| | - Ondřej Naňka
- Institute of Anatomy, First Faculty of Medicine, Charles University, Prague, Czechia
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Kortlever JTP, Dekker AB, Ring D, Vagner GA, Reichel LM, Schuurman AH, Coert JH. Radiographs and Corticosteroid Injections at a New Patient Visit for Care of Carpal Tunnel Syndrome and Ulnar Neuropathy at the Elbow. J Hand Microsurg 2020; 14:170-176. [DOI: 10.1055/s-0040-1718968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Abstract
Introduction The benefit of radiographs or steroid injection for idiopathic carpal tunnel syndrome (CTS) or ulnar neuropathy at the elbow (UNE) is open to debate. We assessed: (1) Radiographs ordered and injections performed at a new patient visit for patients presenting with either idiopathic CTS or UNE; (2) The estimated payment reduction if we omit these interventions; and (3) Patient age, sex, geographic region, and work status associated with radiographs or injections at a new patient visit for patients presenting with either idiopathic CTS or UNE.
Materials and Methods Using a large database of commercial insurance claims, we identified patients with a new visit for either CTS (N = 9,522), UNE (N = 2,507), or both (N = 962; 8.7%). We identified injections and radiographs, and estimated total payments for these interventions. We created three multivariable logistic regression models for each diagnosis to identify factors associated with the interventions.
Results Nearly one third of patients had radiographs at a new patient visit (30% and 32% for idiopathic CTS and UNE, respectively). Nearly 10% of patients with CTS and 2.6% with UNE received an injection. Both radiographs and injections representing annual minimum payments of over $345,000 and $294,000, respectively. Among people with CTS, radiographs were independently more common in the South and less common in the West. Injection for CTS was associated with younger age; North, Central, and South regions; and retired employment status. For people with UNE, radiographs were independently associated with younger age; South or West region; and retired or working employment status. Injection for UNE was associated with retired employment status.
Conclusion The prevalence of radiographs and injections suggests opportunities for savings, which might benefit clinicians with bundled or capitated payments and patients with large copayments or deductibles. The observed variation may reflect debate about whether these interventions are worthwhile.
Level of Evidence Diagnostic; Retrospective Database Level III study.
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Affiliation(s)
- Joost T. P. Kortlever
- Department of Surgery and Perioperative Care, Dell Medical School–The University of Texas at Austin, Austin, Texas, United States
| | - Anne-Britt Dekker
- Department of Surgery and Perioperative Care, Dell Medical School–The University of Texas at Austin, Austin, Texas, United States
| | - David Ring
- Department of Surgery and Perioperative Care, Dell Medical School–The University of Texas at Austin, Austin, Texas, United States
| | - Gregg A. Vagner
- Department of Surgery and Perioperative Care, Dell Medical School–The University of Texas at Austin, Austin, Texas, United States
| | - Lee M. Reichel
- Department of Surgery and Perioperative Care, Dell Medical School–The University of Texas at Austin, Austin, Texas, United States
| | - Arnold H. Schuurman
- Department of Plastic Surgery and Hand Surgery, University Medical Center Utrecht–Utrecht University, Utrecht, The Netherlands
| | - J. Henk Coert
- Department of Plastic Surgery and Hand Surgery, University Medical Center Utrecht–Utrecht University, Utrecht, The Netherlands
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Chen LC, Ho TY, Shen YP, Su YC, Li TY, Tsai CK, Wu YT. Perineural Dextrose and Corticosteroid Injections for Ulnar Neuropathy at the Elbow: A Randomized Double-blind Trial. Arch Phys Med Rehabil 2020; 101:1296-1303. [PMID: 32325164 DOI: 10.1016/j.apmr.2020.03.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2019] [Revised: 03/17/2020] [Accepted: 03/19/2020] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To assess the effects of perineural corticosteroid and 5% dextrose water (D5W) injections in patients with mild to moderate ulnar neuropathy at the elbow (UNE). DESIGN Prospective, randomized, double-blind, controlled trial (6-month follow-up). SETTING Outpatients of local medical center settings. PARTICIPANTS Patients (N=36) with mild to moderate UNE were randomized, and 33 participants were included in the final data analysis. INTERVENTIONS Patients were administered a single perineural injection with 5 mL D5W and 3 mL corticosteroid (triamcinolone acetonide, 10mg/mL) mixed with 2 mL normal saline under ultrasound guidance in the dextrose and steroid groups, respectively. MAIN OUTCOME MEASURES The visual analog scale digital pain or paresthesia/dysesthesia score was the primary outcome. The secondary outcomes were the Disabilities of the Arm, Shoulder, and Hand questionnaire, motor nerve conduction velocity, and cross-sectional area (CSA) of the ulnar nerve. The measurement assessment was conducted before and 1, 3, 4, and 6 months after injection. RESULTS Thirty-three patients completed the study. Both injections were found to be equally effective at most measurement points, although the dextrose group experienced larger reductions in symptom severity and CSA of the ulnar nerve from the third month onward. CONCLUSIONS We suggest D5W as a more suitable injectate for perineural injection in patients with UNE.
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Affiliation(s)
- Liang-Cheng Chen
- Department of Physical Medicine and Rehabilitation, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Tsung-Yen Ho
- Department of Physical Medicine and Rehabilitation, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan, Republic of China; Department of Physical Medicine and Rehabilitation, Taichung Armed Forces General Hospital, Taichung City, Taiwan, Republic of China
| | - Yu-Ping Shen
- Department of Physical Medicine and Rehabilitation, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Yu-Chi Su
- Department of Physical Medicine and Rehabilitation, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Tsung-Ying Li
- Department of Physical Medicine and Rehabilitation, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan, Republic of China; Integrated Pain Management Center, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Chia-Kuang Tsai
- Department of Neurology, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan, Republic of China; Graduate Institute of Medical Science, School of Medicine, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Yung-Tsan Wu
- Department of Physical Medicine and Rehabilitation, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan, Republic of China; Integrated Pain Management Center, Tri-Service General Hospital, School of Medicine, National Defense Medical Center, Taipei, Taiwan, Republic of China.
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8
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Sconfienza LM, Adriaensen M, Albano D, Allen G, Aparisi Gómez MP, Bazzocchi A, Beggs I, Bignotti B, Chianca V, Corazza A, Dalili D, De Dea M, Del Cura JL, Di Pietto F, Drakonaki E, Facal de Castro F, Filippiadis D, Gielen J, Gitto S, Gupta H, Klauser AS, Lalam R, Martin S, Martinoli C, Mauri G, McCarthy C, McNally E, Melaki K, Messina C, Mirón Mombiela R, Neubauer B, Obradov M, Olchowy C, Orlandi D, Gonzalez RP, Rutkauskas S, Snoj Z, Tagliafico AS, Talaska A, Vasilevska-Nikodinovska V, Vucetic J, Wilson D, Zaottini F, Zappia M, Plagou A. Clinical indications for image guided interventional procedures in the musculoskeletal system: a Delphi-based consensus paper from the European Society of Musculoskeletal Radiology (ESSR)-part III, nerves of the upper limb. Eur Radiol 2019; 30:1498-1506. [PMID: 31712960 DOI: 10.1007/s00330-019-06479-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 08/30/2019] [Accepted: 09/27/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Image-guided interventional procedures of the nerves are commonly performed by physicians from different medical specialties, although there is a lack of clinical indications for these types of procedures. This Delphi-based consensus provided a list of indications on image-guided interventional procedures for nerves of the upper limb based on updated published evidence. METHODS An expert panel of 45 members of the Ultrasound and Interventional Subcommittees of the ESSR participated in this Delphi-based consensus study. After revision of the published papers on image-guided interventional procedures for nerves of the upper limb updated to September 2018, the experts drafted a list of statements according to the Oxford Centre for evidence-based medicine levels of evidence. Consensus on statements regarding clinical indications was considered as strong when more than 95% of experts agreed, and broad if more than 80% agreed. RESULTS Ten statements were drafted on procedures for nerves of the upper limb. Only two statements reached the highest level of evidence (ultrasound guidance is a safe and effective method for brachial plexus block; ultrasound-guided non-surgical approaches are safe and effective methods to treat carpal tunnel syndrome in the short term, but there is sparse evidence on the mid- and long-term effectiveness of these interventions). Strong consensus was obtained on 6/10 statements (60%), while 4/10 statements reached broad consensus (40%). CONCLUSIONS This Delphi-based consensus study reported poor evidence on image-guided interventional procedures for nerves of the upper limb. Sixty percent of statements on clinical indications provided by the expert board reached a strong consensus. KEY POINTS • An expert panel of the ESSR provided 10 evidence-based statements on clinical indications for image-guided interventional procedures for nerves of the upper limb • Two statements reached the highest level of evidence • Strong consensus was obtained on 6/10 statements (60%), while 4/10 statements reached broad consensus (40%).
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Affiliation(s)
- Luca Maria Sconfienza
- IRCCS Istituto Ortopedico Galeazzi, 20161, Milano, Italy.
- Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Milano, Italy.
| | - Miraude Adriaensen
- Department of Medical Imaging, Zuyderland Medical Center, Sittard-Geleen, Heerlen, Brunssum, Kerkrade, The Netherlands
| | - Domenico Albano
- IRCCS Istituto Ortopedico Galeazzi, 20161, Milano, Italy
- Sezione di Scienze Radiologiche, Dipartimento di Biomedicina, Neuroscienze e Diagnostica Avanzata, Università degli Studi di Palermo, 90127, Palermo, Italy
| | - Georgina Allen
- St Luke's Radiology Oxford Ltd, Oxford, UK
- University of Oxford, Oxford, UK
| | - Maria Pilar Aparisi Gómez
- Department of Radiology, Auckland City Hospital, Auckland, 1023, New Zealand
- Department of Radiology, Hospital Vithas Nueve de Octubre, 46015, Valencia, Spain
| | - Alberto Bazzocchi
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, 40136, Bologna, Italy
| | - Ian Beggs
- Department of Radiology, Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, UK
| | | | - Vito Chianca
- IRCCS Istituto Ortopedico Galeazzi, 20161, Milano, Italy
| | - Angelo Corazza
- IRCCS Istituto Ortopedico Galeazzi, 20161, Milano, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genoa, Italy
| | - Danoob Dalili
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- The Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, UK
| | - Miriam De Dea
- UOC Radiologia, Ospedale di Feltre, AULSS1 Dolomiti, Veneto, Italy
| | - Jose Luis Del Cura
- Department of Radiology, Donostia University Hospital, 20014, Donostia/San Sebastian, Spain
- University of the Basque Country (UPV/EHU), Leioa, Spain
| | - Francesco Di Pietto
- Dipartimento di Diagnostica per Immagini, Pineta Grande Hospital, Castel Volturno, (CE), Italy
| | - Eleni Drakonaki
- Private Institution of Ultrasonography and MSK Radiology, Heraklion, Greece
- Department of Anatomy, Medical School of the European University of Cyprus, Engomi, Cyprus
| | - Fernando Facal de Castro
- IBERORAD 1895 S.L., 08021, Barcelona, Spain
- Department of Radiology, General University Hospital of Valencia, Valencia, Spain
| | - Dimitrios Filippiadis
- 2nd Department of Radiology, University General Hospital "ATTIKON" Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Jan Gielen
- University of Antwerp, Antwerp, Belgium
- University of Antwerp Hospital (UZA), Edegem, Belgium
| | | | | | - Andrea S Klauser
- Medical University Innsbruck, Innsbruck, Austria
- Department of Radiology, Innsbruck, Austria
| | - Radhesh Lalam
- The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust, Gobowen, Oswestry, UK
| | - Silvia Martin
- Hospital Son Llatzer, Palma de Mallorca, Spain
- Universidad de las Islas Baleares Medicine, Palma, Balearic Islands, Spain
| | - Carlo Martinoli
- Ospedale Policlinico San Martino, 16132, Genoa, Italy
- University of Genoa - DISSAL Department of Health Sciences, Genoa, Italy
| | - Giovanni Mauri
- Division of Interventional Radiology, European Institute of Oncology, IRCCS, Milan, Italy
| | - Catherine McCarthy
- The Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, UK
- Oxford Musculoskeletal Radiology, Oxford, UK
| | | | - Kalliopi Melaki
- Department of Radiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Carmelo Messina
- IRCCS Istituto Ortopedico Galeazzi, 20161, Milano, Italy
- Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Milano, Italy
| | - Rebeca Mirón Mombiela
- Department of Physiology, Universidad de Valencia/INCLIVA, 46010, Valencia, Spain
- Herlev og Gentofte Hospital Radiologisk Afdeling, Herlev Ringvej 75, opgang 51, Herlev, Denmark
| | - Benedikt Neubauer
- Radiology, Medical University of Vienna, Vienna, Austria
- Ordensklinikum Linz, Linz, Austria
| | - Marina Obradov
- Sint Maartenskliniek, 9011, Nijmegen, 6500GM, The Netherlands
| | - Cyprian Olchowy
- Department of Oral Surgery, Wroclaw Medical University, Wrocław, Poland
| | | | | | - Saulius Rutkauskas
- Radiology Department, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Ziga Snoj
- Department of Radiology, University Medical Centre Ljubljana, Zaloška 7, Ljubljana, 1000, Slovenia
| | - Alberto Stefano Tagliafico
- Ospedale Policlinico San Martino, 16132, Genoa, Italy
- Department of Health Sciences, University of Genoa, 16132, Genoa, Italy
| | | | - Violeta Vasilevska-Nikodinovska
- Medical Faculty, University "Ss.Cyril and Methodius", Skopje, North Macedonia
- University Surgical Clinic "St.Naum Ohridski", Skopje, North Macedonia
| | - Jelena Vucetic
- Department of Radiology, General University Hospital of Valencia, Valencia, Spain
- Department of Physiology, Universidad de Valencia/INCLIVA, 46010, Valencia, Spain
| | - David Wilson
- St Luke's Radiology Oxford Ltd, Oxford, UK
- University of Oxford, Oxford, UK
| | - Federico Zaottini
- University of Genoa - DISSAL Department of Health Sciences, Genoa, Italy
| | - Marcello Zappia
- Department of Medicine and Health Sciences, University of Molise, Campobasso, Italy
- Varelli Institute, Naples, Italy
| | - Athena Plagou
- Department of Radiology, Private Institution of Ultrasonography, Athens, Greece
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Kooner S, Cinats D, Kwong C, Matthewson G, Dhaliwal G. Conservative treatment of cubital tunnel syndrome: A systematic review. Orthop Rev (Pavia) 2019; 11:7955. [PMID: 31281598 PMCID: PMC6589621 DOI: 10.4081/or.2019.7955] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Indexed: 12/13/2022] Open
Abstract
Cubital tunnel syndrome (CuTS) is one of the most common compression neuropathies of the upper extremity. Conservative management of cubital tunnel syndrome is often considered first line therapy for mild or moderate symptoms; however, there is little evidence-based literature to guide physicians in this regard. As such, the objective of this study is to complete a comprehensive literature search of the conservative therapies available for treatment of CuTS. Additionally, we hope to assess the evidence for each therapy so that we can make evidence- based recommendations regarding the type and duration of optimal treatment. The databases MEDLINE, EMBASE, and CINAHL were search using a sensitive search strategy. Eligibility for studies included any studies or conference abstracts in which patients were treated conservatively for primary CuTS. Any form of non-operative treatment was acceptable. A data extraction form was developed to collect all information and outcomes of interest, including study design, level of evidence, number of patients, treatment modalities, follow- up time, patient reported outcomes, and electrophysiological markers. Qualitative and quantitative analysis was then completed based on the data extraction form. Given the heterogeneity of the included studies, results were summarized as best evidence available. Our sensitive literature search produced 6484 studies. Initial screening based on title and abstract resulted in the selection of 40 studies that underwent full text review. From these 19 studies were included for analysis in our systematic review. There were 3 level I studies, 4 level II studies, 3 level III studies, and 9 level IV studies. In total this included 844 patients. The most commonly reported outcomes included subjective patient reported outcomes and nerve conduction studies. The most common treatment modalities, from most to least common, included education and activity modification, splinting, steroid/lidocaine injection, nerve mobilization/gliding, pulsed ultrasound, laser therapy, non-steroidal antiinflammatory drugs, and physiotherapy. The most common duration of therapy was 3 months with a median follow-up time of 3 months. There was moderate strength evidence to recommend the use of education/activity modification or splinting in mild or moderate CuTS. There is a paucity of literature and highquality studies regarding the conservative management of CuTS. Regardless, there appears to be a role for non-operative management in CuTS, although further studies are needed to delineate this role further. In the cases of mild or moderate CuTS it is reasonable to trial education/activity modification or splinting as both appear to be equally effective.
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Affiliation(s)
- Sahil Kooner
- Department of Orthopedic Surgery, University of Calgary
| | - David Cinats
- Department of Orthopedic Surgery, University of Calgary
| | - Cory Kwong
- Department of Orthopedic Surgery, University of Calgary
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10
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Norbury JW, Nazarian LN. Ultrasound‐guided treatment of peripheral entrapment mononeuropathies. Muscle Nerve 2019; 60:222-231. [DOI: 10.1002/mus.26517] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/13/2019] [Indexed: 01/13/2023]
Affiliation(s)
- John W. Norbury
- Department of Physical Medicine and RehabilitationThe Brody School of Medicine at East Carolina University 600 Moye Boulevard, Greenville North Carolina 27834 USA
| | - Levon N. Nazarian
- Department of RadiologySidney Kimmel Medical College at Thomas Jefferson University Philadelphia Pennsylvania USA
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11
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Percutaneous Ultrasound-Guided Intervention for Upper Extremity Neural and Perineural Abnormalities: A Retrospective Review of 242 Cases. AJR Am J Roentgenol 2019; 212:W73-W82. [DOI: 10.2214/ajr.18.20047] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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12
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Hamscha UM, Tinhofer I, Heber S, Grisold W, Weninger WJ, Meng S. A reliable technique for ultrasound-guided perineural injection in ulnar neuropathy at the elbow. Muscle Nerve 2016; 56:237-241. [PMID: 27875620 DOI: 10.1002/mus.25490] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Revised: 11/14/2016] [Accepted: 11/21/2016] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Ulnar neuropathy at the elbow (UNE) is a common peripheral compression neuropathy and, in most cases, occurs at 2 sites, the retroepicondylar groove or the cubital tunnel. With regard to a potential therapeutic approach with perineural corticosteroid injection, the aim of this study was to evaluate the distribution of injection fluid applied at a standard site. METHODS We performed ultrasound-guided (US-guided) perineural injections to the ulnar nerve halfway between the olecranon and the medial epicondyle in 21 upper limbs from 11 non-embalmed cadavers. In anatomic dissection we investigated the spread of injected ink. RESULTS Ink was successfully injected into the perineural sheath of the ulnar nerve in all 21 cases (cubital tunnel: 21 of 21; retroepicondylar groove: 19 of 21). CONCLUSION US-guided injection between the olecranon and the medial epicondyle is a feasible and safe method to reach the most common sites of ulnar nerve entrapment. Muscle Nerve 56: 237-241, 2017.
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Affiliation(s)
- Ulrike M Hamscha
- Center for Anatomy and Cell Biology & Medical Imaging Cluster, Medical University Vienna, Austria
| | - Ines Tinhofer
- Center for Anatomy and Cell Biology & Medical Imaging Cluster, Medical University Vienna, Austria.,Department of Plastic and Reconstructive Surgery, Medical University Vienna, Austria
| | - Stefan Heber
- Center for Physiology and Pharmacology, Medical University Vienna, Austria
| | | | - Wolfgang J Weninger
- Center for Anatomy and Cell Biology & Medical Imaging Cluster, Medical University Vienna, Austria
| | - Stefan Meng
- Center for Anatomy and Cell Biology & Medical Imaging Cluster, Medical University Vienna, Austria.,Department of Radiology, KFJ Hospital, Vienna, Austria
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Abstract
OBJECTIVE Peripheral nerves are well seen using ultrasound (US) imaging, making US an ideal modality for image-guided nerve injections. This article provides a technical guide for common upper and lower extremity peripheral nerve injections, including the median, ulnar, and radial nerves in the upper extremity and the lateral femoral cutaneous, sciatic, common peroneal, tibial, and sural nerves in the lower extremity. CONCLUSION US is an effective modality for use in common upper and lower extremity peripheral nerve injections. With correct technique, peripheral nerve injections can be performed safely and are useful for both diagnostic evaluation of and therapy for peripheral neuropathy.
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14
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Bodor M, Rojo-Manaute JM, Podnar S. Reply. Muscle Nerve 2016; 54:344-5. [PMID: 27144365 DOI: 10.1002/mus.25170] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Revised: 04/27/2016] [Accepted: 04/29/2016] [Indexed: 11/11/2022]
Affiliation(s)
- Marko Bodor
- Department of Neurological Surgery, University of California San Francisco, California.,Department of Physical Medicine and Rehabilitation, University of California Davis, California
| | - Jose Manuel Rojo-Manaute
- Unit of Hand Surgery, Department of Orthopedics, MedCare Orthopedics and Spine Hospital, Dubai, United Arab Emirates
| | - Simon Podnar
- Institute of Clinical Neurophysiology, Division of Neurology, University Medical Center, Ljubljana, Slovenia
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15
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Abstract
Ultrasound (US) is a cost-effective, noninvasive, and accessible imaging modality that clinicians use at the point of care to assess disease activity and therapeutic efficacy in different rheumatic conditions. It can play a relevant role in invasive procedures performed by the rheumatologist, potentially ensuring a higher degree of accuracy. However, US-guided injections are still underused, and the conventional blind injection the most commonly adopted approach. In this article, we analyze the current evidence supporting the use of US-guided procedures, emphasizing comparative studies between conventional and US-guided procedures and their benefits in the daily rheumatological practice.
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16
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vanVeen KE, Alblas KCL, Alons IM, Kerklaan JP, Siegersma MC, Wesstein M, Visser LH, vankasteel V, Jellema K. Corticosteroid injection in patients with ulnar neuropathy at the elbow: A randomized, double-blind, placebo-controlled trial. Muscle Nerve 2015; 52:380-5. [DOI: 10.1002/mus.24551] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Revised: 12/10/2014] [Accepted: 12/15/2014] [Indexed: 11/08/2022]
Affiliation(s)
- Kiril E.B. vanVeen
- Department of Neurology; Medical Center Haaglanden; Postbus 432 2501 CK The Hague The Netherlands
| | - Kees C L. Alblas
- Department of Neurology; Medical Center Haaglanden; Postbus 432 2501 CK The Hague The Netherlands
| | - Imanda M.E. Alons
- Department of Neurology; Medical Center Haaglanden; Postbus 432 2501 CK The Hague The Netherlands
| | - Joost P. Kerklaan
- Department of Neurology; Medical Center Haaglanden; Postbus 432 2501 CK The Hague The Netherlands
| | - Marry C. Siegersma
- Department of Neurology; Medical Center Haaglanden; Postbus 432 2501 CK The Hague The Netherlands
| | - Michel Wesstein
- Department of Clinical Neurophysiology; Medical Center Haaglanden; The Hague The Netherlands
| | - Leo H. Visser
- Department of Neurology; St. Elisabeth Hospital; Tilburg The Netherlands
- Department of Clinical Neurophysiology; St. Elisabeth Hospital; Tilburg The Netherlands
| | - Viviane vankasteel
- Department of Clinical Neurophysiology; Medical Center Haaglanden; The Hague The Netherlands
| | - Korné Jellema
- Department of Neurology; Medical Center Haaglanden; Postbus 432 2501 CK The Hague The Netherlands
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17
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Choi CK, Lee HS, Kwon JY, Lee WJ. Clinical implications of real-time visualized ultrasound-guided injection for the treatment of ulnar neuropathy at the elbow: a pilot study. Ann Rehabil Med 2015; 39:176-82. [PMID: 25932413 PMCID: PMC4414963 DOI: 10.5535/arm.2015.39.2.176] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2014] [Accepted: 09/15/2014] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To investigate the feasibility of ultrasound (US)-guided steroid injection by in-plane approach for cubital tunnel syndrome (CuTS), based on symptomatic, morphologic and electrophysiological outcomes. METHODS A total of 10 patients, who were clinically diagnosed as CuTS and confirmed by an electrodiagnostic study, participated in this study. US-guided injection into the cubital tunnel was performed with 40 mg triamcinolone and 2 mL of 1% lidocaine. Outcomes of the injections were evaluated at pre-injection, 1st week and 4th week after injection. Visual analog scale, self-administered questionnaire of the ulnar neuropathy at the elbow (SQUNE), and McGowan classification were used for clinical evaluation. Cross-sectional area of the ulnar nerve by US and the electrophysiological severity scale through a nerve conduction study were utilized in the evaluation of morphologic and electrophysiological changes. The cross-sectional area of the ulnar nerve was measured at 3 points of condylar, proximal, and distal level of the cubital tunnel. RESULTS No side effects were reported during the study period. The visual analog scale and cross-sectional area showed a significant decrease at 1st week and 4th week, as compared to baseline (p<0.05). The electrophysiological severity scale was significantly decreased at the 4th week, as compared with baseline and 1st week (p<0.05). Among the quantitative components of the scale, there were statistically significant improvements with respect to the conduction velocity and block. CONCLUSION The new approach of US-guided injection may be a safe tool for the treatment of CuTS. Symptomatic and morphologic recoveries preceded the electrophysiological improvement.
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Affiliation(s)
- Chang Kweon Choi
- Department of Physical Medicine and Rehabilitation, Veterans Health Service Medical Center, Seoul, Korea
| | - Hyun Seok Lee
- Department of Physical Medicine and Rehabilitation, Veterans Health Service Medical Center, Seoul, Korea
| | - Jae Yeoun Kwon
- Department of Physical Medicine and Rehabilitation, Veterans Health Service Medical Center, Seoul, Korea
| | - Won-Jae Lee
- Department of Physical Medicine and Rehabilitation, Veterans Health Service Medical Center, Seoul, Korea
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18
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Stoll G, Wilder-Smith E, Bendszus M. Imaging of the peripheral nervous system. HANDBOOK OF CLINICAL NEUROLOGY 2013; 115:137-153. [PMID: 23931778 DOI: 10.1016/b978-0-444-52902-2.00008-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
This chapter summarizes progress in the evaluation of peripheral nerve (PN) lesions and disorders by imaging techniques encompassing magnetic resonance imaging (MRI) and nerve ultrasound (US). Due to the radiation exposure and limited sensitivity in soft tissue contrast, computed-tomography (CT) plays no significant role in the diagnostic work-up of PN disorders. MRI and US are complementary techniques for the evaluation of peripheral nerves, each having particular advantages and disadvantages. Nerve injury induces intrinsic MRI signal alterations on T2-weighted sequences in degenerating or demyelinating nerve segments as well as in corresponding muscle groups exhibiting denervation which can be exploited diagnostically. Nerve US is based on changes in the nerve echotexture due to tumor formation or focal enlargement caused by entrapment or inflammation. Both MRI and US provide morphological information on the precise site and extent of nerve injury. While US has the advantage of easy accessibility, providing images with superior spatial resolution at low cost, MRI shows better soft tissue contrast and better image quality for deep-lying nerve structures since imaging is not hindered by bone. Recent advances have remarkably increased spatial resolution of both MRI and US making imaging indispensible for the elucidation of causes of nerve compression, peripheral nerve tumors, and focal inflammatory conditions. Both MRI and US further guide neurosurgical exploration and can simplify treatment. Importantly, imaging can reveal treatable conditions even in the absence of gross electrophysiological alterations, illustrating its increasing role in clinical practice. In experimental settings, novel molecular and cellular MRI contrast agents allow in-vivo assessment of nerve regeneration as well as monitoring of neuroinflammation. Depending on further clinical development, contrast-enhanced MRI has the potential to follow cellular responses over time in vivo and to overcome the current limitations of histological assessment of nerve afflictions. Further advances in contrast-enhanced US has the potential for developing into a tool for the assessment of nerve blood perfusion, paving the way for better assessments of ischemic neuropathies.
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Affiliation(s)
- Guido Stoll
- Department of Neurology, University of Würzburg, Würzburg, Germany.
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19
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Kim JM, Oh HM, Kim MW. Real-time visualization of ultrasonography guided cubital tunnel injection: a cadaveric study. Ann Rehabil Med 2012; 36:496-500. [PMID: 22977775 PMCID: PMC3438416 DOI: 10.5535/arm.2012.36.4.496] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2012] [Accepted: 06/13/2012] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To describe an ultrasonography-guided technique for cubital tunnel injection. METHOD The ulnar nerves from 12 elbows of 6 adult cadavers were scanned, and the cross-sectional areas of the ulnar nerves, cubital tunnel inlets and outlets were measured by using ultrasonography. All elbows were dissected after an ultrasonography-guided dye injection at the inlet of the cubital tunnel. The dissectors evaluated the spread of dye and the coloration of the nerve and remeasured the cross-sectional areas of the cubital tunnel inlets and outlets. RESULTS After a real-time visualization of an ultrasonography-guided injection, the ulnar nerves were seperated from the medial groove for the ulnar nerve. All the ulnar nerves of the cadavers were successfully colored with the dye, from the inlet to oulet of the cubital tunnel. The post-injection cross-sectional areas were significantly larger than the pre-injection cross-sectional areas. No significant differences were detected in the post-injection cross-sectional areas of the cubital tunnel outlet and the ulnar nerve as compared with the pre-injection areas. CONCLUSION Clinicians should consider real-time visualization of ultrasonography for guided injection around the ulnar nerve at the inlet of the cubital tunnel.
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Affiliation(s)
- Jae Min Kim
- Department of Rehabilitation Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Incheon 403-720, Korea
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20
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Vuillemin V, Guerini H, Morvan G. Musculoskeletal interventional ultrasonography: the upper limb. Diagn Interv Imaging 2012; 93:665-73. [PMID: 22921692 DOI: 10.1016/j.diii.2012.07.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Forty percent of the 823 ultrasound-guided injections performed in our centre over a year and a half concerned the upper limb, injections involving the shoulder, for subacromial bursitis and the treatment of calcific tendinitis, being the prime indications (24%). The wrist represented 8% of the prescriptions, for treatment of tendinopathy, ganglion cysts, carpal tunnel syndrome and rhizarthrosis. Trigger finger, tenosynovitis and pulley ganglia made up 6% of the indications and the elbow 2.5%. Ultrasound improves the accuracy of the procedure by helping guide the path of the needle and allowing the distribution of the substance injected to be visualised. We shall give details of the technique used for each indication, with advice and hints and post-procedure recommendations.
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Affiliation(s)
- V Vuillemin
- Imagerie médicale Léonard de Vinci, Paris, France.
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21
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Alblas CL, van Kasteel V, Jellema K. Injection with corticosteroids (ultrasound guided) in patients with an ulnar neuropathy at the elbow, feasibility study. Eur J Neurol 2012; 19:1582-4. [PMID: 22339768 DOI: 10.1111/j.1468-1331.2012.03676.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION AND PURPOSE Unlike carpal tunnel syndrome, little is known about injection with corticosteroids in patients with an ulnar neuropathy at the elbow (UNE). The purpose of this feasibility study is to see whether injection with corticosteroids is safe in patients with UNE and whether there are grounds to launch a prospective placebo-controlled study on the effects of corticosteroids. METHODS Patients with clinical symptoms of UNE and a nerve conduction study compatible with UNE or thickened ulnar nerve at the elbow (> 10 mm(2)) by ultrasonography were included. All included patients received an ultrasound-guided injection of 1 ml containing 40 mg methylprednisoloneacetate and 10 mg lidocainhydrochloride (Depo-Medrol(®)). Complications of the injection were monitored. After 3 months, nerve conduction studies and ultrasonography were repeated and a clinical outcome determined. RESULTS Eight patients with nine UNE were included. None of the patients mentioned increase in the symptoms directly after the injection nor had an infection on the injection site or haematoma. After 3 months, there was improvement of the symptoms in five patients. One patient deteriorated and three had no change of the symptoms at all. Overall, there was no significant change of the thickness of the ulnar nerve with mean difference -0.056 mm(2) (95% CI -2.56 to 2.45 mm(2)). CONCLUSION We showed that injection with corticosteroids in patients with UNE is easy and safe, and based on this result, we found enough arguments to launch a prospective, placebo-controlled trial to explore the effectiveness of corticosteroids in patients with UNE.
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Affiliation(s)
- C L Alblas
- Department of Neurology, Medical Center Haaglanden, The Hague, The Netherlands.
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