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Chaudhary RK, Karkala N, Nepal P, Gupta E, Kaur N, Batchala P, Sapire J, Alam SI. Multimodality imaging review of ulnar nerve pathologies. Neuroradiol J 2024; 37:137-151. [PMID: 36961518 PMCID: PMC10973834 DOI: 10.1177/19714009231166087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/25/2023] Open
Abstract
The ulnar nerve is the second most commonly entrapped nerve after the median nerve. Although clinical evaluation and electrodiagnostic studies remain widely used for the evaluation of ulnar neuropathy, advancements in imaging have led to increased utilization of these newer / better imaging techniques in the overall management of ulnar neuropathy. Specifically, high-resolution ultrasonography of peripheral nerves as well as MRI has become quite useful in evaluating the ulnar nerve in order to better guide treatment. The caliber and fascicular pattern identified in the normal ulnar nerves are important distinguishing features from ulnar nerve pathology. The cubital tunnel within the elbow and Guyon's canal within the wrist are important sites to evaluate with respect to ulnar nerve compression. Both acute and chronic conditions resulting in deformity, trauma as well as inflammatory conditions may predispose certain patients to ulnar neuropathy. Granulomatous diseases as well as both neurogenic and non-neurogenic tumors can also potentially result in ulnar neuropathy. Tumors around the ulnar nerve can also lead to mass effect on the nerve, particularly in tight spaces like the aforementioned canals. Although high-resolution ultrasonography is a useful modality initially, particularly as it can be helpful for dynamic evaluation, MRI remains most reliable due to its higher resolution. Newer imaging techniques like sonoelastography and microneurography, as well as nerve-specific contrast agents, are currently being investigated for their usefulness and are not routinely being used currently.
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Affiliation(s)
| | - Nikitha Karkala
- Department of Radiology, Northwell North Shore University Hospital, Long Island Jewish Medical Center, Queens, NY, USA
| | - Pankaj Nepal
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Elina Gupta
- Department of Radiology, St. Vincent’s Medical Center, Bridgeport, CT, USA
| | - Neeraj Kaur
- Department of Radiology, University Hospital of Northern British Columbia, Prince George, BC, Canada
| | - Prem Batchala
- Department of Radiology, University of Virginia, Charlottesville, VA, USA
| | - Joshua Sapire
- Department of Radiology, St. Vincent’s Medical Center, Bridgeport, CT, USA
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Cuesta JP, Rodríguez LC, Perdomo L, Bastidas N. Ulnar nerve mononeuropathy in a patient with Hansen's disease: Clinical and radiological features. Neuroradiol J 2023:19714009231224449. [PMID: 38149833 DOI: 10.1177/19714009231224449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2023] Open
Abstract
Leprosy is a chronic infection caused by bacteria called Mycobacterium leprae. This is a prevalent disease in low-income countries, and it has not been completely eradicated. We present the case of a 29-year-old man with a previous diagnosis of Hansen's disease, who consulted for pain in the left elbow and wrist, associated with fever with preserved mobility and pain on palpation. Diagnosis of mononeuropathy of the ulnar nerve was made by MRI of the elbow and forearm. This entity corresponds to an infrequent complication of this infection with few cases reported in the literature. Our added value with this case is to show and explain the clinical imaging correlation, which is vital to understand the presentation of symptoms and to carry out a comprehensive and rapid approach to establish adequate and timely treatment.
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Affiliation(s)
- Juan P Cuesta
- Radiologist at Hospital Universitario de la Samaritana, Bogotá, Colombia
| | | | - Laura Perdomo
- Medical Doctor, Universidad de la Sabana, Chía, Colombia
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Henrique Morais de Souza F, Euripedes Almondes Santana Lemos L, Rafael Sousa Rosado B, Rafaela Borges De Oliveira R, Gomes Ferreira de Araújo M, Silva RPDS, Sena Almeida N, Rocha Cirne Azevedo‐Filho H. Surgery for ulnar nerve decompression and drainage of a caseous granuloma in a neural form of leprosy in children. Clin Case Rep 2023; 11:e7963. [PMID: 37808577 PMCID: PMC10555977 DOI: 10.1002/ccr3.7963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 08/16/2023] [Accepted: 09/14/2023] [Indexed: 10/10/2023] Open
Abstract
Key Clinical Message The findings in the literature, as well as those described in this study, emphasize the need for systematic and longitudinal care for patients with neglected diseases during and after treatment, mainly in low-middle income countries. Abstract Leprosy is a chronic, granulomatous, mycobacterial infection caused by mycobacterium leprae, affecting the skin and peripheral nervous system. We present a case of a 13-year-old child with leprosy for more than a year, indicating decompression of the ulnar nerve. During surgery, an intraneural large caseous granule was evidenced.
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Voltan G, Filho FB, Leite MN, De Paula NA, Santana JM, Silva CML, Barreto JG, Da Silva MB, Conde G, Salgado CG, Frade MAC. Point-of-care ultrasound of peripheral nerves in the diagnosis of Hansen's disease neuropathy. Front Med (Lausanne) 2022; 9:985252. [PMID: 36160126 PMCID: PMC9504868 DOI: 10.3389/fmed.2022.985252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Accepted: 08/05/2022] [Indexed: 11/16/2022] Open
Abstract
Introduction Hansen's disease (HD) is the most common cause of treatable peripheral neuropathy in the world that may or may not involve skin manifestations, and physical examination based on simplified neurologic evaluation is a subjective and inaccurate procedure. High-resolution ultrasound (HRUS) can be used to evaluate peripheral nerves and is a validated technique of good reproducibility, permitting a detailed and precise examination. Objectives We proposed to establish objective criteria for absolute values of the measurement of the CSA of peripheral nerves and their indices of the ΔCSA and ΔTpT in the diagnosis of Hansen's disease neuropathy as compared with healthy voluntaries. Materials and methods In municipalities from different regions of Brazil, we randomly selected 234 volunteer Brazilian patients diagnosed with leprosy to be submitted to peripheral nerve echography and compared with 49 healthy Brazilian volunteers. Results Hansen Disease assessed by high resolution ultrasound is a primarily neural disease that leads to multiple hypertrophic mononeuropathy characterized by CSA values exceeding normal limits (Med CT = 10.2 mm2; UT = 9.8 mm2; UPT = 9.3 mm2; CFFH = 18.3 mm2; T = 9.6 mm2), and the pattern of asymmetry (ΔCSA>2.5 mm2 with RR 13) and focality (ΔTPT > 2.5 mm2 with RR 6.4) of this thickening has higher sensitivity (76,1%) and specificity (87,8 %) for its early diagnosis that laboratory tests. Analyzing each subject, the percentage of thickened nerves detected among the total number of nerves assessed was higher among patients with HD than among healthy individuals (p < 0.0001). Individuals with two or more thickened nerves were at 24.1 times higher relative risk (95% CI: 6.74–88.98) of HD.
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Affiliation(s)
- Glauber Voltan
- Department of Interne Medicine - Dermatology, Faculty of Medicine of Ribeirão Preto, University of São Paulo, São Paulo, Brazil
- *Correspondence: Glauber Voltan
| | - Fred Bernards Filho
- Department of Interne Medicine - Dermatology, Faculty of Medicine of Ribeirão Preto, University of São Paulo, São Paulo, Brazil
| | - Marcel Nani Leite
- Faculty of Medicine of Ribeirão Preto, University of São Paulo, São Paulo, Brazil
| | | | - Jaci Maria Santana
- Faculty of Medicine of Ribeirão Preto, University of São Paulo, São Paulo, Brazil
| | | | | | | | | | | | - Marco Andrey Cipriani Frade
- Department of Interne Medicine - Dermatology, Faculty of Medicine of Ribeirão Preto, University of São Paulo, São Paulo, Brazil
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Gunawan H, Kamilia A, Menaldi SL, Marissa M, Prakoeswa CRS, Alinda MD, Widasmara D, Basuki S, Anum Q, Ariani T, Mamuaja EH, Mas Rusyati LM. Characteristics of Grade 2 Disability in Indonesian Children with Leprosy: A Five-Year Multicenter Retrospective Study. Clin Cosmet Investig Dermatol 2021; 14:1149-1153. [PMID: 34511959 PMCID: PMC8420076 DOI: 10.2147/ccid.s325858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 08/18/2021] [Indexed: 11/23/2022]
Abstract
Background One of the indicators of achieved leprosy control is lower new cases of leprosy with grade 2 disability (G2D), while zero new pediatric case with G2D is one of the targets of The Global Leprosy Strategy. This study aimed to describe the characteristics of leprosy in children with G2D from seven provincial hospitals in Indonesia, spanning a period of five years. Methods This was a descriptive and retrospective study with cross-sectional design. Data were obtained from the medical records of leprosy-affected children in seven provincial hospitals in Indonesia between January 2014 and December 2019 using a total sampling method. Data obtained include characteristics of patients, clinical manifestations, and profile of leprosy in children with G2D. Results From the 132 data of childhood leprosy retrieved, male (58.33%), age group of 13-14 years (47.73%), and borderline tuberculoid leprosy (34.09%) comprised the majority of patients. Most of the patients had anesthetic macules as the initial manifestation. The results showed 20 (15.15%) children had G2D. Hands were the most common site affected (50.00%), manifested as claw hands, contractures, atrophy of thenar and hypothenar muscles, and pseudomutilation. Foot drop was seen in five (62.50%) children, and lagophthalmos was seen in one child with leprosy. Conclusion This study shows that G2D is observed in 15.15% Indonesian children with leprosy at the time of diagnosis, which mostly occurs on the hands in the form of claw hands. Foot disabilities were also observed, most commonly as foot drop, while lagophthalmos was present with disabilities in the eyes. Disability due to leprosy in children really exists. The commitment of all health care services and related institutions is needed in order to reduce the incidence of disability due to leprosy in children.
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Affiliation(s)
- Hendra Gunawan
- Department of Dermatology and Venereology, Faculty of Medicine, Universitas Padjadjaran, Hasan Sadikin Hospital, Bandung, Indonesia.,Indonesian Leprosy Study Group - Indonesian Society of Dermatology and Venereology, Jakarta, Indonesia.,Indonesian College of Dermatology and Venereology, Jakarta, Indonesia
| | - Atika Kamilia
- Department of Dermatology and Venereology, Faculty of Medicine, Universitas Padjadjaran, Hasan Sadikin Hospital, Bandung, Indonesia.,Indonesian Leprosy Study Group - Indonesian Society of Dermatology and Venereology, Jakarta, Indonesia
| | - Sri Linuwih Menaldi
- Indonesian Leprosy Study Group - Indonesian Society of Dermatology and Venereology, Jakarta, Indonesia.,Indonesian College of Dermatology and Venereology, Jakarta, Indonesia.,Department of Dermatology and Venereology, Faculty of Medicine, Universitas Indonesia, Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Melani Marissa
- Indonesian Leprosy Study Group - Indonesian Society of Dermatology and Venereology, Jakarta, Indonesia.,Department of Dermatology and Venereology, Faculty of Medicine, Universitas Indonesia, Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Cita Rosita Sigit Prakoeswa
- Indonesian Leprosy Study Group - Indonesian Society of Dermatology and Venereology, Jakarta, Indonesia.,Indonesian College of Dermatology and Venereology, Jakarta, Indonesia.,Department of Dermatology and Venereology, Faculty of Medicine, Universitas Airlangga, Soetomo Hospital, Surabaya, Indonesia
| | - Medhi Denisa Alinda
- Indonesian Leprosy Study Group - Indonesian Society of Dermatology and Venereology, Jakarta, Indonesia.,Department of Dermatology and Venereology, Faculty of Medicine, Universitas Airlangga, Soetomo Hospital, Surabaya, Indonesia
| | - Dhelya Widasmara
- Indonesian Leprosy Study Group - Indonesian Society of Dermatology and Venereology, Jakarta, Indonesia.,Department of Dermatology and Venereology, Faculty of Medicine, Universitas Brawijaya, Malang, Indonesia
| | - Santosa Basuki
- Indonesian Leprosy Study Group - Indonesian Society of Dermatology and Venereology, Jakarta, Indonesia.,Department of Dermatology and Venereology, Faculty of Medicine, Universitas Brawijaya, Malang, Indonesia
| | - Qaira Anum
- Indonesian Leprosy Study Group - Indonesian Society of Dermatology and Venereology, Jakarta, Indonesia.,Department of Dermatology and Venereology, Faculty of Medicine, Universitas Andalas, Padang, Indonesia
| | - Tutty Ariani
- Indonesian Leprosy Study Group - Indonesian Society of Dermatology and Venereology, Jakarta, Indonesia.,Department of Dermatology and Venereology, Faculty of Medicine, Universitas Andalas, Padang, Indonesia
| | - Enricco H Mamuaja
- Indonesian Leprosy Study Group - Indonesian Society of Dermatology and Venereology, Jakarta, Indonesia.,Department of Dermatology and Venereology, Faculty of Medicine, Universitas Sam Ratulangi, Prof. R. D. Kandou Hospital, Manado, Indonesia
| | - Luh Made Mas Rusyati
- Indonesian Leprosy Study Group - Indonesian Society of Dermatology and Venereology, Jakarta, Indonesia.,Department of Dermatology and Venereology, Faculty of Medicine, Universitas Udayana, Bali, Indonesia
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Nagappa M, Pujar GS, Keshavan AH, Bathala L, Jain RD, Das A, Mehndiratta MM, Visser LH, Kumar HM. Sonographic pattern of median nerve enlargement in Hansen's neuropathy. Acta Neurol Scand 2021; 144:155-160. [PMID: 33899225 DOI: 10.1111/ane.13432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 03/10/2021] [Accepted: 03/30/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES Median nerve enlargement in leprosy seems to be more proximal than in carpal tunnel syndrome (CTS), but this feature has not been studied systematically. The aim of the study was to compare the sites of median nerve enlargement in patients with leprosy with that of patients with CTS. MATERIALS AND METHODS Transverse sections of the median nerve were recorded from wrist to the mid-forearm (at distal wrist crease and at 2-cm: M1, 4-cm: M2, 6-cm: M3, 8-cm: M4 and 10-cm: M5, proximal to the distal wrist crease in the forearm) in patients with leprosy, CTS and healthy subjects using high-resolution ultrasound. RESULTS Twenty-six patients each with leprosy and CTS were compared with healthy controls. Patients with leprosy included 6 (23.1%), 7 (26.9%), 7 (26.9%) and 6 (23.1%) patients with borderline tuberculoid, borderline-borderline, borderline lepromatous and lepromatous leprosy, respectively. Cross-sectional area (CSA) of median nerve was increased in all patients with leprosy as compared to healthy controls at all points of measurement. CSA was higher among patients with leprosy as compared to CTS at all points except at the wrist. In patients with leprosy, the maximal enlargement was noted 2-cm (M1) proximal to the wrist crease with gradual tapering of the CSA proximally (p < .05). In contrast, in patients with CTS the median nerve was maximally enlarged at the distal wrist crease (p<.05). CONCLUSIONS Median nerve enlargement 2-cm proximal to the distal wrist crease distinguishes leprosy from CTS. This important discriminating sign can be used at point-of-care to identify patients with leprosy.
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Affiliation(s)
- Madhu Nagappa
- Department of Neurology National Institute of Mental Health and Neurosciences (NIMHANS) Bangalore India
| | | | | | - Lokesh Bathala
- Department of Neurology Aster CMI Hospital Bangalore India
| | - Richa D. Jain
- Department of Radiology Aster CMI Hospital Bangalore India
| | - Abhijit Das
- Department of Pathology Janakpuri Super Speciality Hospital New Delhi India
| | | | - Leo H. Visser
- Departments of Neurology and Clinical Neurophysiology ETZ, St. Elisabeth Hospital Tilburg Netherlands
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Abstract
Peripheral nerve imaging is a helpful and sometimes essential adjunct to clinical history, physical examination, and electrodiagnostic studies. Advances in imaging technology have allowed the visualization of nerve structures and their surrounding tissues. The clinical applications of ultrasound and magnetic resonance imaging (MRI) in the evaluation of peripheral nerve disorders are growing exponentially. This article reviews basics of ultrasound and MRI as they relate to nerve imaging, reviews advantages and limitations of each imaging modality, reviews the applications of ultrasound and MRI in disorders of peripheral nerve, and discusses emerging advances in the field.
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Affiliation(s)
- Natalia L Gonzalez
- Department of Neurology, Neuromuscular Division, Duke University, Duke University Hospital, 3403 DUMC, Duke South Clinic 1L, Durham, NC 27710, USA.
| | - Lisa D Hobson-Webb
- Department of Neurology, Neuromuscular Division, Duke University, Duke University Hospital, 3403 DUMC, Duke South Clinic 1L, Durham, NC 27710, USA
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BALESTRINO A, RICCARDI N, FIASCHI P, ANANIA P, MARTINOLI C, GENNARO S. Endoneural abscess of common popliteal nerve as first clinical manifestation of leprosy: the first reported case in history in a low-incidence country. JOURNAL OF PREVENTIVE MEDICINE AND HYGIENE 2020; 61:E148-E151. [PMID: 32802998 PMCID: PMC7419112 DOI: 10.15167/2421-4248/jpmh2020.61.2.1492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 04/20/2020] [Indexed: 11/18/2022]
Abstract
A migrant from Palestine came to our attention for weakness of dorsiflexion of the left foot and hypoesthesia of the homolateral common peroneal nerve territory. Skin biopsies from skin lesions in the hypoesthetic area were not diagnostic. Radiological investigation showed focal nerve enlargement with a possible focal lesion. At this time, and given the uncertainty of the diagnosis, we had to choose between medical therapy with steroid and a surgical exploration of the nerve. We decided for the latter option. Intraoperatively, we found a focal round enlargement of the nerve. Epineurotomy was performed at that level, revealing a round caseous granulomatous mass that was excised. Microbiological examination revealed presence of Mycobacterium Leprae allowing diagnosis of leprosy. Medical therapy was then started, leading to resolution of clinical symptoms. Endoneural lepromatous abscesses are uncommon lesions that should be suspected in patients presenting with peripheral nerve dysfunction with anamnesis of travel in leprosy endemic regions or contacts with people from endemic regions with or even without skin lesions. Detection of endoneural abscesses is of critical importance because prompt surgical excision in conjunction with medical therapy leads to improvement of symptoms and permits correct diagnosis. In times of large human migrations from leprosy endemic areas, knowledge of this uncommon presentation of leprosy and its management will help lead to the best management of these patients.
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Affiliation(s)
- A. BALESTRINO
- Division of Neurosurgery, Department of Neuroscience, Ospedale Policlinico San Martino-IST, University of Genoa, Genoa, Italy
- Correspondence: Alberto Balestrino, Division of Neurosurgery, Department of Neuroscience, Ospedale Policlinico San Martino-IST, University of Genoa, largo Rosanna Benzi 10, 16132 Genoa, Italy - Tel.: +39 3405836354 - E-mail:
| | - N. RICCARDI
- Department of Infectious-Tropical Diseases and Microbiology, IRCCS Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, Verona, Italy
- Stop TB Italia Onlus, Milan, Italy
| | - P. FIASCHI
- Division of Neurosurgery, Department of Neuroscience, Ospedale Policlinico San Martino-IST, University of Genoa, Genoa, Italy
- Dipartimento di Neuroscienze, Riabilitazione, Oftalmologia, Genetica e Scienze materno infantili (DINOGMI), IRCCS Ospedale Policlinico San Martino, Università di Genova, Genoa, Italy
| | - P. ANANIA
- Division of Neurosurgery, Department of Neuroscience, Ospedale Policlinico San Martino-IST, University of Genoa, Genoa, Italy
| | - C. MARTINOLI
- Dipartimento di Neuroscienze, Riabilitazione, Oftalmologia, Genetica e Scienze materno infantili (DINOGMI), IRCCS Ospedale Policlinico San Martino, Università di Genova, Genoa, Italy
- Department of Radiology, Department of Health Sciences, Ospedale Policlinico San Martino-IST, University of Genoa, Genoa, Italy
| | - S. GENNARO
- Division of Neurosurgery, Department of Neuroscience, Ospedale Policlinico San Martino-IST, University of Genoa, Genoa, Italy
- Dipartimento di Neuroscienze, Riabilitazione, Oftalmologia, Genetica e Scienze materno infantili (DINOGMI), IRCCS Ospedale Policlinico San Martino, Università di Genova, Genoa, Italy
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Gonzalez NL, Hobson-Webb LD. Neuromuscular ultrasound in clinical practice: A review. Clin Neurophysiol Pract 2019; 4:148-163. [PMID: 31886438 PMCID: PMC6921231 DOI: 10.1016/j.cnp.2019.04.006] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 04/18/2019] [Accepted: 04/29/2019] [Indexed: 12/11/2022] Open
Abstract
Neuromuscular ultrasound (NMUS) is becoming a standard element in the evaluation of peripheral nerve and muscle disease. When obtained simultaneously to electrodiagnostic studies, it provides dynamic, structural information that can refine a diagnosis or identify a structural etiology. NMUS can improve patient care for those with mononeuropathies, polyneuropathy, motor neuron disease and muscle disorders. In this article, we present a practical guide to the basics of NMUS and its clinical application. Basic ultrasound physics, scanning techniques and clinical applications are reviewed, along with current challenges.
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Affiliation(s)
- Natalia L. Gonzalez
- Department of Neurology/Neuromuscular Division, Duke University Hospital, DUMC 3403, Durham, NC 27710, USA
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