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Lee JH, Gong HS. Volumetric assessment of ulnar nerves in cubital tunnel syndrome with 3D modeling of the MRI and its relationship with electrodiagnostic findings. J Plast Reconstr Aesthet Surg 2024; 92:244-251. [PMID: 38574571 DOI: 10.1016/j.bjps.2024.03.014] [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] [Received: 01/08/2023] [Revised: 09/06/2023] [Accepted: 03/18/2024] [Indexed: 04/06/2024]
Abstract
BACKGROUND Thickened nerve cross-sectional areas (CSA) have been investigated in compressive neuropathy, but the longitudinal extent of nerve swelling has yet to be evaluated. We did a volumetric assessment of the ulnar nerve in cubital tunnel syndrome (CuTS) with three-dimensional (3D) magnetic resonance imaging (MRI) modeling and investigated this relationship with clinical and electrodiagnostic parameters. METHODS We compared 40 CuTS patient elbow MRIs to 46 patient elbow MRIs with lateral elbow epicondylitis as controls. The ulnar nerve was modeled with Mimics software and was assessed qualitatively and quantitatively. The CSA and ulnar nerve volumes were recorded, and the area under the receiver operating characteristic (ROC) curve was calculated for diagnostic performance. We analyzed clinical and electrodiagnostic parameters to investigate their relationship with the 3D ulnar nerve parameters. RESULTS For the diagnosis of CuTS, the area under the curve value was 0.915 for the largest CSA and 0.910 for the volume in the ROC curve. The optimal cut-off was 14.53 mm2 and 529 mm3 respectively. When electrodiagnostic parameters were investigated, the 3D ulnar nerve volume was significantly inversely associated with motor conduction velocity, although there was no association between the largest CSA and any of the electrodiagnostic parameters. CONCLUSIONS The 3D ulnar nerve volume, which is an integration or multilevel measurement of CSAs, showed diagnostic usefulness similar to CSA, but it correlated better with conduction velocity, indicating demyelination or early-to-moderate nerve damage in CuTS.
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Affiliation(s)
- Jeong Hyun Lee
- Department of Orthopedic Surgery, Armed Forces Capital Hospital, Seongnam, South Korea
| | - Hyun Sik Gong
- Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seongnam, South Korea.
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2
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Robinson LR, Broadhurst P, Wasserman A. Comparison of electrodiagnostic findings in acute traumatic versus chronic non-traumatic ulnar neuropathy at the elbow. Muscle Nerve 2024; 69:218-221. [PMID: 38009374 DOI: 10.1002/mus.28008] [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] [Received: 03/09/2023] [Revised: 11/09/2023] [Accepted: 11/11/2023] [Indexed: 11/28/2023]
Abstract
INTRODUCTION/AIMS A common concept is that traumatic nerve injuries are more likely axonal, and that compressive neuropathies are more likely demyelinating. The purpose of this study was to compare traumatic versus non-traumatic ulnar neuropathy at the elbow (UNE) to look for electrodiagnostic differences between the two groups. METHODS A retrospective 3 year review of UNE patients at two academic health science centers was conducted. Patients were grouped into acute traumatic UNE versus chronic non-traumatic UNE based on clinical history. Electrodiagnostic measurements were compared between the two groups. RESULTS There were 50 subjects with acute traumatic UNE and 41 with chronic non-traumatic UNE. Mean age and sex distribution were similar but those with traumatic UNE had a 7 month duration of symptoms, while those with chronic UNE had 29 month duration (p < .001). All electrodiagnostic measurements were similar between the two groups including compound muscle action potential amplitudes, motor conduction velocities, frequency of conduction block, sensory nerve studies, and needle electromyography. DISCUSSION We did not find a difference between the two groups. One should not make inferences regarding acuity or etiology based on electrodiagnostic features alone.
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Affiliation(s)
- Lawrence R Robinson
- Department of Medicine, Division of Physical Medicine & Rehabilitation, University of Toronto, Toronto, Ontario, Canada
| | - Peter Broadhurst
- Department of Medicine, Division of Physical Medicine & Rehabilitation, University of Toronto, Toronto, Ontario, Canada
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Kurver A, Scherf SM, Meulstee J, Verhagen WIM. The necessity of electrodiagnostic studies and ultrasound in ulnar nerve entrapment according to surgeons in the Netherlands. Clin Neurol Neurosurg 2024; 236:108078. [PMID: 38103390 DOI: 10.1016/j.clineuro.2023.108078] [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] [Received: 08/19/2023] [Revised: 11/30/2023] [Accepted: 12/02/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND Ulnar nerve entrapment at the elbow (UNE) is the second most prevalent entrapment neuropathy after carpal tunnel syndrome. The objective of this study was to evaluate the expert opinion of different surgical disciplines regarding the need for electrodiagnostic or ultrasound confirmation of UNE and, if so, which test was preferred for confirmation. METHODS A questionnaire was sent to all neurosurgeons and plastic or hand surgeons in the Netherlands to evaluate the current practice in planning surgical treatment of UNE. RESULTS The response rate was 36.4 % (134 out of 368). 94 % of surgeons reported that > 95 % of their patients had EDX or ultrasound studies before surgery. 80.6 % of all surgeons who responded reported that they seldom operated on UNE without electrodiagnostic confirmation. Hand surgeons (25.9 %) were more willing to operate on clinically diagnosed UNE without EDX than neurosurgeons (9.4 %) CONCLUSIONS: Dutch surgeons prefer diagnostic confirmation of UNE either by ultrasound or EDX, with a preference for EDX and the vast majority of operated patients do have either EDX or ultrasound or both before surgery. Compared to neurosurgeons, hand surgeons are more willing to operate on patients with clinically defined UNE but normal electrodiagnostic studies.
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Affiliation(s)
- Anne Kurver
- Department of Neurology, Canisius Wilhelmina Hospital, Weg door Jonkerbos 100, 6532 SZ Nijmegen, the Netherlands; Department of Neurology, Haga Hospital, Els Borst-Eilersplein 275, 2545 AA The Hague, the Netherlands.
| | - Suzanne M Scherf
- Department of Neurology, Canisius Wilhelmina Hospital, Weg door Jonkerbos 100, 6532 SZ Nijmegen, the Netherlands; Department of Neurology, Deventer ziekenhuis, Nico Bolkesteinlaan 75, 7416 SE Deventer, the Netherlands
| | - Jan Meulstee
- Department of Clinical Neurophysiology, Canisius Wilhelmina Hospital, Weg door Jonkerbos 100, 6532 SZ Nijmegen, the Netherlands
| | - Wim I M Verhagen
- Department of Neurology, Canisius Wilhelmina Hospital, Weg door Jonkerbos 100, 6532 SZ Nijmegen, the Netherlands
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4
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Hannaford A, Simon NG. Ulnar neuropathy. HANDBOOK OF CLINICAL NEUROLOGY 2024; 201:103-126. [PMID: 38697734 DOI: 10.1016/b978-0-323-90108-6.00006-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2024]
Abstract
Ulnar neuropathy at the elbow is the second most common compressive neuropathy. Less common, although similarly disabling, are ulnar neuropathies above the elbow, at the forearm, and the wrist, which can present with different combinations of intrinsic hand muscle weakness and sensory loss. Electrodiagnostic studies are moderately sensitive in diagnosing ulnar neuropathy, although their ability to localize the site of nerve injury is often limited. Nerve imaging with ultrasound can provide greater localization of ulnar injury and identification of specific anatomical pathology causing nerve entrapment. Specifically, imaging can now reliably distinguish ulnar nerve entrapment under the humero-ulnar arcade (cubital tunnel) from nerve injury at the retro-epicondylar groove. Both these pathologies have historically been diagnosed as either "ulnar neuropathy at the elbow," which is non-specific, or "cubital tunnel syndrome," which is often erroneous. Natural history studies are few and limited, although many cases of mild-moderate ulnar neuropathy at the elbow appear to remit spontaneously. Conservative management, perineural steroid injections, and surgical release have all been studied in treating ulnar neuropathy at the elbow. Despite this, questions remain about the most appropriate management for many patients, which is reflected in the absence of management guidelines.
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Affiliation(s)
- Andrew Hannaford
- Westmead Clinical School, Westmead Hospital, University of Sydney, Westmead, NSW, Australia
| | - Neil G Simon
- Northern Beaches Clinical School, Macquarie University, Sydney, NSW, Australia.
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5
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Telleman JA, Sneag DB, Visser LH. The role of imaging in focal neuropathies. HANDBOOK OF CLINICAL NEUROLOGY 2024; 201:19-42. [PMID: 38697740 DOI: 10.1016/b978-0-323-90108-6.00001-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2024]
Abstract
Electrodiagnostic testing (EDX) has been the diagnostic tool of choice in peripheral nerve disease for many years, but in recent years, peripheral nerve imaging has been used ever more frequently in daily clinical practice. Nerve ultrasound and magnetic resonance (MR) neurography are able to visualize nerve structures reliably. These techniques can aid in localizing nerve pathology and can reveal significant anatomical abnormalities underlying nerve pathology that may have been otherwise undetected by EDX. As such, nerve ultrasound and MR neurography can significantly improve diagnostic accuracy and can have a significant effect on treatment strategy. In this chapter, the basic principles and recent developments of these techniques will be discussed, as well as their potential application in several types of peripheral nerve disease, such as carpal tunnel syndrome (CTS), ulnar neuropathy at the elbow (UNE), radial neuropathy, brachial and lumbosacral plexopathy, neuralgic amyotrophy (NA), fibular, tibial, sciatic, femoral neuropathy, meralgia paresthetica, peripheral nerve trauma, tumors, and inflammatory neuropathies.
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Affiliation(s)
- Johan A Telleman
- Department of Neurology and Clinical Neurophysiology, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | - Darryl B Sneag
- Department of Radiology and Imaging, Hospital for Special Surgery, New York, NY, United States
| | - Leo H Visser
- Department of Neurology and Clinical Neurophysiology, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands.
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Podnar S, Omejec G. Clinical and neurophysiological recovery of ulnar nerve conduction block at the elbow. Muscle Nerve 2023; 68:722-728. [PMID: 37421240 DOI: 10.1002/mus.27928] [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] [Received: 11/25/2022] [Revised: 06/01/2023] [Accepted: 06/18/2023] [Indexed: 07/10/2023]
Abstract
INTRODUCTION/AIMS An important mechanism of peripheral nerve motor and sensory dysfunction is conduction block (CB). However, recovery from mechanically induced CB has been rarely studied in humans. The aim of this study was to describe clinical, electrodiagnostic (EDx), and ultrasonographic (US) characteristics of CB recovery in ulnar neuropathy at the elbow (UNE). METHODS We recruited a group of consecutive patients presenting to our EDx laboratory with UNE and >50% motor CB. Patients' histories were obtained and neurologic, EDx, and US examinations were repeated every 1-3 mo for at least 12 mo. RESULTS We studied 10 patients (5 men), with a mean age of 63 y (range, 51-81 y). In all affected arms CB was localized to the retrocondylar groove. Following conservative management, myometrically measured index finger abduction improved from a median of 49% to 100% relative to the contralateral index finger, and ulnar nerve CB decreased from a median of 74% to 6%. Most of the improvement took place within 8 mo of symptom onset, and 6 mo after receiving treatment instructions. Mean motor nerve conduction velocity improved from 15 to 27 m/s in the most affected 2-cm ulnar nerve segment. DISCUSSION The resolution of CB after typical chronic compression may take longer than after acute compression. This should be considered by clinicians when estimating prognosis for discussions with patients.
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Affiliation(s)
- Simon Podnar
- Division of Neurology, Institute of Clinical Neurophysiology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Gregor Omejec
- Division of Neurology, Institute of Clinical Neurophysiology, University Medical Centre Ljubljana, Ljubljana, Slovenia
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Hearn SL, Jorgensen SP, Robinson LR. Unblocking the ulnar nerve: It takes time. Muscle Nerve 2023; 68:693-695. [PMID: 37632343 DOI: 10.1002/mus.27958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 08/01/2023] [Accepted: 08/04/2023] [Indexed: 08/28/2023]
Affiliation(s)
- Sandra L Hearn
- Department of Physical Medicine and Rehabilitation, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Shawn P Jorgensen
- Department of Physical Medicine and Rehabilitation, Albany Medical College, Albany, New York, USA
- Department of Family Medicine, Larner Medical College at the University of Vermont, Burlington, Vermont, USA
- Adirondack Rehabilitation Medicine, PLLC, Queensbury, New York, USA
| | - Lawrence R Robinson
- Division of Physical Medicine and Rehabilitation, University of Toronto, Toronto, Ontario, Canada
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McGurk K, Tracey JA, Daley DN, Daly CA. Diagnostic Considerations in Compressive Neuropathies. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2023; 5:525-535. [PMID: 37521550 PMCID: PMC10382896 DOI: 10.1016/j.jhsg.2022.10.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 10/14/2022] [Indexed: 12/23/2022] Open
Abstract
Peripheral nerve compression of the upper extremity is a common pathology often necessitating surgical intervention, much is known, but much more is left to understand. For the more common pathologies, carpal tunnel syndrome, cubital tunnel syndrome, and ulnar tunnel syndrome, research and clinical efforts directed toward standardization and reduction of resource use have been attempted with varied success. Diagnosis of many of these syndromes is largely based on a proper history and physical examination. Electrodiagnostic studies continue to have value, but proportionally less than previous decades. In addition, emerging technologies, including magnetic resonance neurography, novel ultrasound evaluation techniques, and ultrasound-guided diagnostic injections, are beginning to demonstrate their ability to add value to the diagnostic algorithm, particularly when less common compressive neuropathies are present and/or the diagnosis is in question.
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Affiliation(s)
- Katherine McGurk
- Department of Orthopedic Surgery, Medical University of South Carolina Charleston, SC
| | - Joseph Anthony Tracey
- Department of Orthopedic Surgery, Medical University of South Carolina Charleston, SC
| | - Dane N. Daley
- Department of Orthopedic Surgery, Medical University of South Carolina Charleston, SC
| | - Charles Andrew Daly
- Department of Orthopedic Surgery, Medical University of South Carolina Charleston, SC
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Giöstad A, Zimmerman M, Anker I, Dahlin E, Dahlin LB, Nyman E. Factors influencing return to work after surgery for ulnar nerve compression at the elbow. Sci Rep 2022; 12:22229. [PMID: 36564424 PMCID: PMC9789024 DOI: 10.1038/s41598-022-26363-z] [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: 10/25/2022] [Accepted: 12/13/2022] [Indexed: 12/24/2022] Open
Abstract
Ulnar nerve compression at the elbow (UNE) frequently affects people of working age. Surgically treated patients may not immediately return to work (RTW) postoperatively. In 2008, the Swedish Social Insurance Agency reformed the national insurance policy. We aimed to examine RTW postoperatively for UNE, variations among surgical methods, and potential risk factors for prolonged RTW (sick leave > 6 weeks). Surgically treated cases of UNE (n = 635) from two time periods (2004-2008 and 2009-2014) and two healthcare regions (Southern and South-eastern) were studied retrospectively regarding age, sex, comorbidities, occupation, type of surgery and time to RTW. A sub-analysis of the exact number of weeks before RTW (n = 201) revealed longer RTW for unemployed cases compared to employed cases. Prolonged RTW was seen among younger, manual workers and after transposition or revision surgery. Prolonged RTW was approximately four times more likely after transposition than after simple decompression. Comparisons before and after 2008 showed occupational differences and differences in RTW, where cases operated before 2008 more often had permanent sickness benefit, but the reform of the social insurance system did not seem to influence RTW. In conclusion, unemployment, younger age at surgery, manual labour, transposition, and revision surgery were related to prolonged RTW.
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Affiliation(s)
- Alice Giöstad
- grid.5640.70000 0001 2162 9922Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Malin Zimmerman
- grid.4514.40000 0001 0930 2361Department of Translational Medicine-Hand Surgery, Skåne University Hospital, Lund University, 205 02 Malmö, Sweden ,grid.413823.f0000 0004 0624 046XDepartment of Orthopaedics, Helsingborg Hospital, Helsingborg, Sweden
| | - Ilka Anker
- grid.4514.40000 0001 0930 2361Department of Translational Medicine-Hand Surgery, Skåne University Hospital, Lund University, 205 02 Malmö, Sweden
| | - Erik Dahlin
- grid.4514.40000 0001 0930 2361Department of Translational Medicine-Hand Surgery, Skåne University Hospital, Lund University, 205 02 Malmö, Sweden
| | - Lars B. Dahlin
- grid.5640.70000 0001 2162 9922Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden ,grid.4514.40000 0001 0930 2361Department of Translational Medicine-Hand Surgery, Skåne University Hospital, Lund University, 205 02 Malmö, Sweden ,grid.411843.b0000 0004 0623 9987Department of Hand Surgery, Skåne University Hospital, Malmö, Sweden
| | - Erika Nyman
- grid.5640.70000 0001 2162 9922Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden ,grid.411384.b0000 0000 9309 6304Department of Hand Surgery, Plastic Surgery and Burns, Linköping University Hospital, Linköping, Sweden
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Nyman E, Giöstad A, Abul-Kasim K, Dahlin L. Patients having surgery for ulnar nerve compression at the elbow rarely have affection of the spinal nerve root at C8-Th1 levels. Front Surg 2022; 9:1049081. [PMID: 36578969 PMCID: PMC9790900 DOI: 10.3389/fsurg.2022.1049081] [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: 09/21/2022] [Accepted: 11/16/2022] [Indexed: 12/14/2022] Open
Abstract
Cervical pathology may contribute to residual problems after surgery for ulnar nerve compression. We aimed to evaluate the presence of pathological conditions in spinal cord and cervical spinal nerve roots in patients surgically treated for ulnar nerve compression at elbow. In a cohort of patients, surgically treated for ulnar nerve compression at elbow, magnetic resonance images (MRI; performed 3 years pre/postoperatively) were evaluated by a neuroradiologist blinded to patient characteristics and outcome of surgery. Cervical conditions were assessed and related to patient characteristics, preoperative McGowan grade, and outcome. Among 62 patients (45 unilaterally and 17 bilaterally), only one had spinal nerve root affection of nerve roots contributing to the ulnar nerve (C8-Th1). About half of the patients, mainly those at higher age, had alterations affecting C3-C7 spinal nerve roots at both surgically treated and contralateral, non-surgically treated, sides. Only few other changes were observed at cervical levels. A high McGowan grading was related to a high frequency of spinal nerve root affection. Smokers were more frequently observed among those with spinal nerve root affection at C3-C7 levels at surgically treated side. Residual problems, expressed as patient dissatisfaction and DASH score ≥40, were common. Spinal nerve roots, contributing to the ulnar nerve, are rarely affected in surgically treated patients with ulnar nerve compression at elbow even though pathology is often observed at other cervical levels. Pathology is often detected at other cervical spinal nerve root levels at surgically treated and contralateral sides, particularly among older patients, smokers, and in conjunction with worse preoperative McGowan grade. No relation between cervical pathology and outcome of ulnar nerve surgery is seen.
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Affiliation(s)
- Erika Nyman
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden,Department of Hand Surgery, Plastic Surgery and Burns, Linköping University Hospital, Linköping, Sweden
| | - Alice Giöstad
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden,Primary Health Care Center Kolmården, Kolmården, Sweden
| | - Kasim Abul-Kasim
- Department of Radiology, Skåne University Hospital, Malmö, Sweden
| | - Lars B. Dahlin
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden,Department of Hand Surgery, Skåne University Hospital, Malmö, Sweden,Department of Translational Medicine – Hand Surgery, Lund University, Malmö, Sweden,Correspondence: Lars B. Dahlin
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Hashimoto T, Imajo Y, Funaba M, Fujii K, Yamagata H, Sakai T. Continuous Scanning and Inching in Ultrasonographic Localisation of Ulnar Neuropathy: A Comparative Study of Sensitivity. J Hand Surg Asian Pac Vol 2022; 27:1026-1034. [PMID: 36606349 DOI: 10.1142/s2424835522500928] [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: 01/07/2023]
Abstract
Background: This study compares the sensitivity of continuous ultrasonographic scanning and ultrasonographic inching in the localisation of ulnar neuropathy at the elbow to diagnose the two common entrapment sites: retroepicondylar groove and cubital tunnel. Methods: The charts of 30 patients who were diagnosed with ulnar neuropathy of the elbow and underwent ultrasonographic examinations using the inching and the continuous technique between April 2015 and September 2019 were reviewed. Sensitivities of ultrasonographic inching and continuous scanning were compared. Results: A total of 34 elbows from 30 patients were examined. The sensitivities of continuous ultrasonographic scanning method and ultrasonographic inching were 85% and 71%, respectively, but this was not significant (p = 0.06). The maximum cross-sectional areas (CSAs) in continuous scanning were mainly found within the area from the medial epicondyle to the 2-cm distal point in the cubital tunnel entrapment, while a majority of the largest CSAs in ultrasonographic inching was observed at the medial epicondyle level in both entrapment sites. The mean of the maximum CSAs in continuous scanning (17.04 ± 6.75 mm2) was higher than that in ultrasonographic inching (14.13 ± 6.63 mm2), although this difference remained non-significant (p = 0.08). However, continuous scanning differed more significantly (p < 0.0001) from the cut-off value than the ultrasonographic inching (p < 0.0066). Conclusions: Continuous scanning might be more suitable than ultrasonographic inching to localise ulnar neuropathy, which inherently has variations in the cubital tunnel anatomy and its entrapment points, when selecting optimal treatment based on the entrapment site. Level of Evidence: Level III (Diagnostic).
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Affiliation(s)
- Takahiro Hashimoto
- Department of Orthopaedic Surgery, Ube-kohsan Central Hospital, Ube, Yamaguchi, Japan
| | - Yasuaki Imajo
- Department of Orthopaedic Surgery, Yamaguchi University Graduate School Medicine, Ube, Yamaguchi, Japan
| | - Masahiro Funaba
- Department of Orthopaedic Surgery, Yamaguchi University Graduate School Medicine, Ube, Yamaguchi, Japan
| | - Kenzo Fujii
- Department of Orthopaedic Surgery, Yamaguchi University Graduate School Medicine, Ube, Yamaguchi, Japan
| | - Hiroki Yamagata
- Department of Orthopaedic Surgery, Yamaguchi University Graduate School Medicine, Ube, Yamaguchi, Japan
| | - Takashi Sakai
- Department of Orthopaedic Surgery, Yamaguchi University Graduate School Medicine, Ube, Yamaguchi, Japan
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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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Anker I, Nyman E, Zimmerman M, Svensson AM, Andersson G, Dahlin LB. Preoperative Electrophysiology in Patients With Ulnar Nerve Entrapment at the Elbow-Prediction of Surgical Outcome and Influence of Age, Sex and Diabetes. FRONTIERS IN CLINICAL DIABETES AND HEALTHCARE 2022; 3:756022. [PMID: 36992728 PMCID: PMC10012145 DOI: 10.3389/fcdhc.2022.756022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 02/04/2022] [Indexed: 11/13/2022]
Abstract
The impact of preoperative electrophysiology on outcome of surgical treatment in ulnar nerve entrapment at the elbow (UNE) is not clarified. Our aim was to evaluate influence of preoperative electrophysiologic grading on outcome and analyse how age, sex, and in particular diabetes affect such grading. Electrophysiologic protocols for 406 UNE cases, surgically treated at two hand surgery units reporting to the Swedish National Quality Register for Hand Surgery (HAKIR; 2010-2016), were retrospectively assessed, and graded as normal, reduced conduction velocity, conduction block or axonal degeneration. Outcome of surgery after primary and revision surgery was evaluated using QuickDASH and a doctor reported outcome measure (DROM) grading. No differences in QuickDASH or DROM were found between the four groups with different electrophysiologic grading preoperatively, or at three and 12 months or at follow up, respectively. When dichotomizing the electrophysiologic grading into normal and pathologic electrophysiology, cases with normal electrophysiology had worse QuickDASH than cases with pathologic electrophysiology preoperatively (p=0.046). Presence of a conduction block or axonal degeneration indicated a worse outcome by DROM grading (p=0.011). Primary surgeries had electrophysiologic more pronounced nerve pathology compared to revision surgeries (p=0.017). Cases of older age, men, and those with diabetes had more severe electrophysiologic nerve affection (p<0.0001). In the linear regression analysis, increasing age (unstandardized B=0.03, 95% CI 0.02-0.04; p<0.0001) and presence of diabetes (unstandardized B=0.60, 95% CI 0.25-0.95; p=0.001) were associated with a higher risk of a worse electrophysiologic classification. Female sex was associated with a better electrophysiologic grading (unstandardized B=-0.51, 95% CI -0.75- -0.27; p<0.0001). We conclude that older age, male sex, and concomitant diabetes are associated with more severe preoperative electrophysiologic nerve affection. Preoperative electrophysiologic grade of ulnar nerve affection may influence surgical outcome.
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Affiliation(s)
- Ilka Anker
- Department of Translational Medicine – Hand Surgery, Skåne University Hospital, Lund University, Malmö, Sweden
- Department of Hand Surgery, Skåne University Hospital, Malmö, Sweden
| | - Erika Nyman
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
- Department of Hand Surgery, Plastic Surgery and Burns, Linköping University Hospital, Linköping, Sweden
| | - Malin Zimmerman
- Department of Translational Medicine – Hand Surgery, Skåne University Hospital, Lund University, Malmö, Sweden
- Department of Hand Surgery, Skåne University Hospital, Malmö, Sweden
| | - Ann-Marie Svensson
- National Diabetes Register, Centre of Registers, Gothenburg, Sweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Gert S. Andersson
- Department of Neurophysiology, Skåne University Hospital, Lund University, Lund, Sweden
| | - Lars B. Dahlin
- Department of Translational Medicine – Hand Surgery, Skåne University Hospital, Lund University, Malmö, Sweden
- Department of Hand Surgery, Skåne University Hospital, Malmö, Sweden
- Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
- *Correspondence: Lars B. Dahlin,
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Campbell WW, Landau M. Treatment and Management of Segmental Neuromuscular Disorders. Neuromuscul Disord 2022. [DOI: 10.1016/b978-0-323-71317-7.00017-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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15
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Risk factors of asymptomatic reduction of motor conduction velocity of the ulnar nerve across the elbow. Neurol Sci 2021; 43:2065-2072. [PMID: 34499243 DOI: 10.1007/s10072-021-05584-6] [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: 06/23/2021] [Accepted: 08/26/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION The aim of the study was to check the risk factors for subjects with motor conduction velocity (MCV) reduction of the ulnar nerve across the elbow without symptoms/signs of ulnar neuropathy at the elbow (UNE) using a database of a previous multicenter case-control study on UNE patients. METHODS From the previous database, we extracted all asymptomatic UNE (A-UNE) and matched for age and sex with a control and UNE groups with a ratio of 1:2. Anthropometric factors were measured and all participants filled in a questionnaire on demographic, lifestyle factors, and medical history. One-sample proportion test and univariate and multivariate logistic regression analyses were performed. RESULTS We enrolled 64 A-UNE, 124 UNE, and 124 controls (mean age 53 years). There were more males with A-UNE than females (74.2%). The predominantly or exclusively concerned side of A-UNE was the right. Logistic regression showed that A-UNE was associated with diabetes (OR = 2.99, 95% CI = 1.21-7.39) and width of cubital groove (CGW) (OR = 0.89, 95% CI = 0.81-0.97). DISCUSSION Risk factors for A-UNE are different from UNE. The prevalence of right side in A-UNE was not due to particular elbow postures. Diabetes is a risk factor, probably because MCV reduction of the ulnar nerve across the elbow was an early manifestation of asymptomatic polyneuropathy in diabetes. A-UNE is associated with narrow CGW as already demonstrated in UNE, even if the OR was higher in UNE than in A-UNE. Only future longitudinal studies will be able to check whether the A-UNE subjects develop symptoms and signs of true mononeuropathy with time.
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Rossmann T, Heber UM, Heber S, Reissig LF, Grisold W, Weninger WJ, Meng S. Cubital tunnel perfusion in different postures-An anatomical investigation. Muscle Nerve 2021; 64:749-754. [PMID: 34453352 PMCID: PMC9292220 DOI: 10.1002/mus.27408] [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: 01/23/2021] [Revised: 08/16/2021] [Accepted: 08/24/2021] [Indexed: 11/21/2022]
Abstract
Introduction/Aims For cubital tunnel syndrome, the avoidance of predisposing arm positions and the use of elbow splints are common conservative treatment options. The rationale is to prevent excessive stretching and compression of the nerve in the cubital tunnel, as this mechanical stress impedes intraneural perfusion. Data regarding those upper extremity postures to avoid, or whether elbow flexion alone is detrimental, are inconsistent. This study aimed to assess perfusion and size changes of the cubital tunnel during different postures in an experimental cadaver setup. Methods Axillary arteries in 30 upper extremities of fresh cadavers were injected with ultrasound contrast agent. High‐resolution ultrasound of the cubital tunnel was performed during five different arm postures that gradually increased tension on the ulnar nerve and caused cubital tunnel narrowing. Contrast enhancement within the tunnel was measured to quantify perfusion. Cubital tunnel cross‐sectional area was measured to detect compression. Results Increasing tension significantly reduced perfusion. When isolated, neither shoulder elevation, elbow flexion, pronation, nor extension of wrist and fingers impaired perfusion. However, combining two or more of these postures led to significant decreases. Significant narrowing of the cubital tunnel was seen in full elbow flexion and shoulder elevation. Discussion Combinations of some upper extremity joint positions reduce nerve perfusion, but isolated elbow flexion does not have a significant impact. We hypothesize that elbow splints alone may not influence cubital tunnel perfusion but may only prevent direct compression of the ulnar nerve. Advising patients about upper extremity postures that should be avoided may be more effective.
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Affiliation(s)
- Tobias Rossmann
- Division of Anatomy, Medical University of Vienna, Vienna, Austria.,Department of Neurosurgery, Neuromed Campus, Kepler University Hospital, Linz, Austria
| | - Ulrike M Heber
- Division of Anatomy, Medical University of Vienna, Vienna, Austria
| | - Stefan Heber
- Center for Physiology and Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Lukas F Reissig
- Division of Anatomy, Medical University of Vienna, Vienna, Austria
| | - Wolfgang Grisold
- Neurology Consultancy Unit, Division of Anatomy, Medical University of Vienna, Vienna, Austria
| | | | - Stefan Meng
- Division of Anatomy, Medical University of Vienna, Vienna, Austria.,Department of Radiology, Hanusch Hospital, Vienna, Austria
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17
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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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18
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Prasetyo M, Rahardja RR, Yanuar A, Prihartono J, Setiawan SI. Ultrasonography evaluation of the normal ulnar nerve in adult: Comparison of the cross-sectional area at elbow extension and flexion. Eur J Radiol Open 2021; 8:100331. [PMID: 33665233 PMCID: PMC7906893 DOI: 10.1016/j.ejro.2021.100331] [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: 12/01/2020] [Revised: 01/27/2021] [Accepted: 02/11/2021] [Indexed: 10/29/2022] Open
Abstract
Background Cross-sectional area (CSA) measurement of the ulnar nerve in the adult population by using ultrasonography (US) at elbow extension and flexion has previously been reported, but not much evidence showed a significant difference between elbow extension and flexion position. Purpose To compare the ulnar nerve CSA between elbow extension and flexion position. Methods A comparative cross-sectional study was conducted by involving 36 healthy adults with normally functioning ulnar nerve proven by Nerve Conduction Study (NCS) or Electroneurography. The ulnar nerve CSA was measured on each elbow by using US at the level of the medial epicondyle, 2 cm distal and 2 cm proximal from the medial epicondyle. Results The average ulnar nerve CSA at the medial epicondyle, 2 cm distal and proximal to the medial epicondyle at elbow extension respectively were 5.95 ± 0.74 mm2, 6.27 ± 0.92 mm2, and 5.92 ± 0.73 mm2. At elbow flexion, the average ulnar nerve CSA at the positions was 5.70 ± 0.83 mm2, 5.23 ± 0.87 mm2, dan 5.73 ± 0.71 mm2 respectively. The CSA of the ulnar nerve at elbow extension was significantly larger compared to the flexion position in the three areas observed in this study (p < 0.001). Conclusion The CSA of the ulnar nerve at elbow extension position was larger compared to the flexion position. Elbow position should be considered in measuring CSA of the ulnar nerve.
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Affiliation(s)
- Marcel Prasetyo
- Department of Radiology, Faculty of Medicine, Universitas Indonesia, Dr. Cipto Mangunkusumo National Central General Hospital, Jakarta, Indonesia
| | - Reiner Reza Rahardja
- Department of Radiology, Faculty of Medicine, Universitas Indonesia, Dr. Cipto Mangunkusumo National Central General Hospital, Jakarta, Indonesia
| | - Ahmad Yanuar
- Department of Neurology, Faculty of Medicine, Universitas Indonesia, Dr. Cipto Mangunkusumo National Central General Hospital, Jakarta, Indonesia
| | - Joedo Prihartono
- Department of Community Medicine, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Stefanus Imanuel Setiawan
- Department of Radiology, Faculty of Medicine, Universitas Indonesia, Dr. Cipto Mangunkusumo National Central General Hospital, Jakarta, Indonesia
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19
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Kuijer PPFM, van der Pas J, van der Molen HF. Work Disabling Nerve Injury at Both Elbows Due to Laptop Use at Flexible Workplaces inside an Office: Case-Report of a Bilateral Ulnar Neuropathy. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17249529. [PMID: 33352652 PMCID: PMC7766745 DOI: 10.3390/ijerph17249529] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Revised: 12/12/2020] [Accepted: 12/15/2020] [Indexed: 11/16/2022]
Abstract
Background: This case report describes whether a female civil servant who developed bilateral ulnar neuropathy can be classified as having an occupational disease. Methods: The Dutch six-step protocol for the assessment and prevention of occupational diseases is used. Results: Based on the six-step protocol, we propose that pressure on the ulnar nerve in the elbow region precipitated the neuropathy for this employee while working prolonged periods in elbow flexion with a laptop. Conclusion: Despite the low incidence laptop use might be a risk factor for the occurrence of ulnar neuropathy due to prolonged pressure on the elbow. Employers and workers need to be educated about this disabling occupational injury due to laptop use and about protective work practices such as support for the upper arm and elbow. This seems especially relevant given the trend of more flexible workspaces inside and outside offices, and given the seemingly safe appearance of laptop use.
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Affiliation(s)
- P. Paul F. M. Kuijer
- Department of Public and Occupational Health, Netherlands Centre for Occupational Diseases, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, 1105 Amsterdam, The Netherlands;
- Correspondence: ; Tel.: +31-20-566-5339
| | - Joris van der Pas
- Self-Employed Occupational Physician, 5221 Den Bosch, The Netherlands;
| | - Henk F. van der Molen
- Department of Public and Occupational Health, Netherlands Centre for Occupational Diseases, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, 1105 Amsterdam, The Netherlands;
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20
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The prevalence of ulnar neuropathy at the elbow and ulnar nerve dislocation in recreational wheelchair marathon athletes. PLoS One 2020; 15:e0243324. [PMID: 33315922 PMCID: PMC7735619 DOI: 10.1371/journal.pone.0243324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 11/18/2020] [Indexed: 11/25/2022] Open
Abstract
Background Ulnar neuropathy at the elbow is an entrapment neuropathy, while ulnar nerve dislocation might also be involved in its incidence and severity. Wheelchair marathon athletes may be at an increased risk for Ulnar Neuropathy. However, there is a paucity of research into the prevalence of Ulnar Neuropathy and ulnar nerve dislocation in this population. Objective To investigate the prevalence of ulnar neuropathy at the elbow and ulnar nerve dislocation in wheelchair marathon athletes. Participants Wheelchair marathon athletes (N = 38) who participated in the 2017, 2018, and 2019 Oita International Wheelchair Marathon. 2 athletes participated only one time, 36 athletes repeatedly. Data from athletes`latest assessment were used. Methods The day before the race, questionnaires, physical examinations, and ultrasonography were conducted to screen for Ulnar Neuropathy in both upper limbs. Ulnar nerve dislocation was confirmed by physical examination and ultrasonography. Results 11 (29%) athletes were diagnosed with Ulnar Neuropathy. There were no significant differences in age, height, weight, Body Mass Index, or history of primary illness between athletes with and without Ulnar Neuropathy. In the group without Ulnar Neuropathy, 44% of athletes reported to have been engaging in other wheelchair sports, compared to 9% in the group with Ulnar Neuropathy (p = 0.037). Ulnar nerve dislocation was diagnosed in 15 (39%) athletes by ultrasonography. Out of the 14 elbows of 11 athletes diagnosed with Ulnar Neuropathy, 9 (64%) elbows had ulnar nerve dislocation. Conclusion The prevalence of Ulnar Neuropathy in wheelchair marathon athletes was higher than previously reported in able-bodied, non-athlete individuals and lower than in non-athletes with lower limb dysfunction. Therefore, while wheelchair sports may provide some protection against Ulnar Neuropathy, this study further supports the importance of screening for Ulnar Neuropathy, as well as for ulnar nerve dislocation as a potential risk factor for the development of Ulnar Neuropathy.
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21
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Podnar S. Patterns and parameters describing nerve thickening in compression and entrapment ulnar neuropathies at the elbow. Clin Neurophysiol 2020; 132:530-535. [PMID: 33450574 DOI: 10.1016/j.clinph.2020.10.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 10/16/2020] [Accepted: 10/19/2020] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To compare pattern and parameters describing nerve thickening in ulnar neuropathy at the elbow (UNE) due to external compression in the retrocondylar groove (RTC), and entrapment under the humeroulnar aponeurosis (HUA). METHODS In a group of our previously reported UNE patients we ultrasonographically (US) measured ulnar nerve cross-sectional areas (CSA) on 6-8 standard locations in the elbow segment. We compared CSA patterns in both groups, and determined diagnostic utility of selected CSA based parameters. RESULTS We studied 79 patients (81 arms) with UNE due to external compression, and 53 patients (55 arms) due to entrapment. Maximal ulnar nerve CSA (>16 mm2), maximal CSA change (>7 mm2/1-2 cm) and maximal/minimal CSA ratio (>2.6) were significantly larger in UNE due to entrapment. They also differentiated these arms from arms with compression with sensitivities of 78%, 87% and 80%, and specificities of 90%, 94%, and 85%, respectively. CONCLUSION Maximal difference in CSA between points separated by 1-2 cm (>7 mm2/1-2 cm) very efficiently differentiated between UNE due to external compression and entrapment. SIGNIFICANCE The proposed parameter will hopefully complement precise localization in determining underlying mechanism of UNE. This may help physicians to determine the most appropriate treatment for UNE and possibly other focal neuropathies of unknown cause; i.e., conservative treatment for external compression and surgery for entrapment.
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Affiliation(s)
- Simon Podnar
- Institute of Clinical Neurophysiology, Division of Neurology, University Medical Centre Ljubljana, Slovenia.
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22
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Mondelli M, Mattioli S, Vinciguerra C, Ciaramitaro P, Aretini A, Greco G, Sicurelli F, Giorgi S, Curti S. Comorbidities, anthropometric, demographic, and lifestyle risk factors for ulnar neuropathy at the elbow: A case control study. J Peripher Nerv Syst 2020; 25:401-412. [PMID: 33140525 DOI: 10.1111/jns.12420] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 10/22/2020] [Accepted: 10/26/2020] [Indexed: 01/21/2023]
Abstract
We performed a prospective multicenter case-control study to explore the association between ulnar neuropathy at elbow (UNE) and body and elbow anthropometric measures, demographic and lifestyle factors, and comorbidities. Cases and controls were consecutively enrolled among subjects admitted to four electromyography labs. UNE diagnosis was made on clinical and neurographic findings. The control group included all other subjects without signs/symptoms of ulnar neuropathy and with normal ulnar nerve neurography. Anthropometric measurements included weight, height, waist, hip circumferences, and external measures of elbow using a caliper. The participants filled in a self-administered questionnaire on personal characteristics, lifestyle factors, and medical history. We estimated odds ratios (ORs) and 95% confidence intervals (CIs) by fitting unconditional logistic regression models adjusted by center and education level. We enrolled 220 cases (males 61.8%; mean age 51.7 years) and 460 controls (47.4% males; mean age 47.8 years). At multivariable analysis, UNE was associated to male gender (OR = 2.4, 95%CI = 1.6-3.7), smoking habits (>25 pack-years (OR = 2.3, 95%CI = 1.3-4.1), body mass index (OR = 1.05, 95%CI 1.01-1.10), polyneuropathies (OR = 4.1, 95%CI 1.5-11.5), and leaning with flexed elbow on a table/desk (OR = 1.5, 95%CI 1.0-2.2). Cubital groove width (CGW) turned out to be negatively associated with UNE (OR = 0.80, 95%CI = 0.74-0.85). Our study suggests that some personal factors especially anthropometric measures of the elbow may play a role in UNE pathogenesis as the measures of wrist in CTS. We demonstrated that for each millimeter of smaller CGW the risk of idiopathic UNE increases of 25%.
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Affiliation(s)
- Mauro Mondelli
- EMG Service, Local Health Unit Toscana Sud Est, Siena, Italy
| | - Stefano Mattioli
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Claudia Vinciguerra
- EMG Service, Local Health Unit Toscana Sud Est, Siena, Italy.,Department of Medical, Surgical and Neurosciences, University of Siena, Siena, Italy
| | - Palma Ciaramitaro
- Clinical Neurophysiology, CTO, Department of Neuroscience, AOU "Città della Salute e della Scienza", Torino, Italy
| | | | - Giuseppe Greco
- EMG Service, Local Health Unit Toscana Sud Est, "Nottola" Hospital, Montepulciano, Siena, Italy
| | - Francesco Sicurelli
- Department of Medical, Surgical and Neurosciences, University of Siena, Siena, Italy
| | - Stefano Giorgi
- Clinical Neurophysiology, CTO, Department of Neuroscience, AOU "Città della Salute e della Scienza", Torino, Italy
| | - Stefania Curti
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
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23
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Podnar S. Prospective, randomized trial of treatment for mild ulnar neuropathy at the elbow. Muscle Nerve 2020; 62:E60-E61. [DOI: 10.1002/mus.27005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 06/01/2020] [Accepted: 06/02/2020] [Indexed: 11/10/2022]
Affiliation(s)
- Simon Podnar
- Institute of Clinical Neurophysiology, Division of NeurologyUniversity Medical Center Ljubljana Slovenia
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24
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Omejec G, Podnar S. Utility of nerve conduction studies and ultrasonography in ulnar neuropathies at the elbow of different severity. Clin Neurophysiol 2020; 131:1672-1677. [DOI: 10.1016/j.clinph.2020.02.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 01/30/2020] [Accepted: 02/09/2020] [Indexed: 02/07/2023]
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25
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Carroll AS, Simon NG. Current and future applications of ultrasound imaging in peripheral nerve disorders. World J Radiol 2020; 12:101-129. [PMID: 32742576 PMCID: PMC7364285 DOI: 10.4329/wjr.v12.i6.101] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 05/10/2020] [Accepted: 05/28/2020] [Indexed: 02/06/2023] Open
Abstract
Neuromuscular ultrasound (NMUS) is a rapidly evolving technique used in neuromuscular medicine to provide complimentary information to standard electrodiagnostic studies. NMUS provides a dynamic, real time assessment of anatomy which can alter both diagnostic and management pathways in peripheral nerve disorders. This review describes the current and future techniques used in NMUS and details the applications and developments in the diagnosis and monitoring of compressive, hereditary, immune-mediated and axonal peripheral nerve disorders, and motor neuron diseases. Technological advances have allowed the increased utilisation of ultrasound for management of peripheral nerve disorders; however, several practical considerations need to be taken into account to facilitate the widespread uptake of this technique.
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Affiliation(s)
- Antonia S Carroll
- Brain and Mind Research Centre, University of Sydney, Camperdown 2050, NSW, Australia
- Department of Neurology, Westmead Hospital, University of Sydney, Westmead 2145, NSW, Australia
- Department of Neurology, St Vincent’s Hospital, Sydney, Darlinghurst 2010, NSW, Australia
| | - Neil G Simon
- Northern Clinical School, University of Sydney, Frenchs Forest 2086, NSW, Australia
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26
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Pompe SM, Schreuder T, Teunissen LL, Visser LH, Beekman R. In situ decompression vs conservative treatment for mild ulnar neuropathy at the elbow. Muscle Nerve 2020; 62:247-253. [DOI: 10.1002/mus.26912] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 04/25/2020] [Accepted: 04/29/2020] [Indexed: 11/05/2022]
Affiliation(s)
- Sander M. Pompe
- Department of NeurologyZuyderland Medisch Centrum Sittard‐Geleen The Netherlands
- Department of Clinical NeurophysiologyZuyderland Medisch Centrum Sittard‐Geleen The Netherlands
| | - Tobien Schreuder
- Department of NeurologyZuyderland Medisch Centrum Sittard‐Geleen The Netherlands
- Department of Clinical NeurophysiologyZuyderland Medisch Centrum Sittard‐Geleen The Netherlands
| | - Laurien L. Teunissen
- Department of NeurologySt. Antonius Ziekenhuis Nieuwegein The Netherlands
- Department of Clinical NeurophysiologySt. Antonius Ziekenhuis Nieuwegein The Netherlands
| | - Leo H. Visser
- Department of NeurologyElisabeth TweeSteden Ziekenhuis Tilburg The Netherlands
- Department Clinical NeurophysiologyElisabeth TweeSteden Ziekenhuis Tilburg The Netherlands
| | - Roy Beekman
- Department of NeurologyZuyderland Medisch Centrum Sittard‐Geleen The Netherlands
- Department of Clinical NeurophysiologyZuyderland Medisch Centrum Sittard‐Geleen The Netherlands
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27
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Ulnar nerve subluxation and dislocation: a review of the literature. Neurosurg Rev 2020; 44:793-798. [PMID: 32338326 DOI: 10.1007/s10143-020-01286-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 02/22/2020] [Accepted: 03/09/2020] [Indexed: 12/12/2022]
Abstract
The pathogenesis of ulnar nerve subluxation and dislocation is widely debated. Upon elbow flexion, the ulnar nerve slips out of the groove for the ulnar nerve, relocates medial or anterior to the medial epicondyle, and returns to its correct anatomical position upon extension. This chronic condition can cause neuritis or neuropathy; however, it has also been suggested that it protects against neuropathy by reducing tension along the nerve. This article reviews the extant literature with the aim of bringing knowledge of the topic into perspective and standardizing terminology.
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28
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Ashworth N. Reply. Muscle Nerve 2020; 61:E31-E32. [DOI: 10.1002/mus.26814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Revised: 01/17/2020] [Accepted: 01/21/2020] [Indexed: 11/09/2022]
Affiliation(s)
- Nigel Ashworth
- Department of MedicineUniversity of Alberta Edmonton Alberta Canada
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29
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Podnar S. Laterality of the ulnar neuropathy at the elbow. Muscle Nerve 2020; 61:E30-E31. [DOI: 10.1002/mus.26815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 11/29/2019] [Accepted: 12/03/2019] [Indexed: 11/07/2022]
Affiliation(s)
- Simon Podnar
- Institute of Clinical Neurophysiology, Division of NeurologyUniversity Medical Center Ljubljana Ljubljana, Slovenia
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30
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Mondelli M, Vinciguerra C, Lazzeretti S, Ciaramitaro P, Sicurelli F, Greco G, Giorgi S, Aretini A. The external elbow measure as surrogate of the anatomical width of cubital groove and possible risk factor of ulnar neuropathy at the elbow. Int J Neurosci 2020; 130:884-891. [PMID: 31877065 DOI: 10.1080/00207454.2019.1709839] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Introduction: There are no studies on elbow anthropometry in ulnar neuropathy at the elbow (UNE). We aimed to test the interrater agreement of external elbow measurements with caliper, the matching of external width of cubital groove (WCG) measures with those obtained through conventional radiography (XR) and ultrasonography (US). The final aim was to evaluate the differences of anthropometric elbow and body measures between UNE cases and controls with multicenter prospective study.Materials and methods: After common training of five observers for external elbow and body anthropometric measurements, we assessed the interrater agreement of measures in a single blind measurement session in 16 healthy volunteers. Then we verified if external WCG measures in eight and four of the above 16 subjects matched with those obtained with US and XR. Finally, we enrolled 40 consecutive idiopathic UNE cases in four electromyographic labs matched for sex and age with 40 controls to evaluate the differences of anthropometric measures.Results: There was high interrater agreement of all anthropometric body and elbow measures (Kendal's and interclass correlation coefficients between 0.84 and >0.9). We found high relations between WCG caliper measures and those obtained with US and XR (r > 0.9). WCG was smaller in cases than in controls (13.2 vs.15.7 mm, p < 0.001). There were no differences in body anthropometric measures (BMI and waist-to-hip ratio).Conclusion: The external measurement of WCG is reliable and reproducible and may be risk factor of UNE. Future studies should be performed in lager samples evaluating the relations with lifestyle and occupational factors.
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Affiliation(s)
| | - Claudia Vinciguerra
- Department of Medical, Surgical and Neurosciences, University of Siena, Italy
| | | | - Palma Ciaramitaro
- Clinical Neurophysiology, CTO, Department of Neuroscience, AO "Città Della Salute e Della Scienza," Torino, Italy
| | - Francesco Sicurelli
- Department of Medical, Surgical and Neurosciences, University of Siena, Italy
| | - Giuseppe Greco
- EMG Service, Local Health Unit 7, "Nottola" Hospital, Montepulciano, Siena, Italy
| | - Stefano Giorgi
- Clinical Neurophysiology, CTO, Department of Neuroscience, AO "Città Della Salute e Della Scienza," Torino, Italy
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31
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Martínez-Aparicio C, Jääskeläinen SK, Puksa L, Reche-Lorite F, Torné-Poyatos P, Paniagua Soto J, Falck B. Constitutional risk factors for focal neuropathies in patients referred for electromyography. Eur J Neurol 2019; 27:529-535. [PMID: 31692180 DOI: 10.1111/ene.14118] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Accepted: 11/04/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND PURPOSE It is well established that patient-related constitutional features predispose to focal peripheral neuropathies. Some of these risk factors were investigated in common focal neuropathies encountered in patients referred for electromyography. METHODS Gender, age, height and body mass index (BMI) were analysed retrospectively as risk factors for 11 focal neuropathies. In all, 9686 patients (age range 18-96 years; 58% women) were included from three different centres, with identical methods and equipment. RESULTS High BMI was related to carpal tunnel syndrome (CTS), ulnar neuropathy at the elbow (UNE), combined CTS and UNE, meralgia paraesthetica and lumbar radiculopathy. In women, CTS and Morton's metatarsalgia were more common, whilst long thoracic neuropathies, suprascapular neuropathies and UNE were more common in men. Older age increased the risk for CTS, UNE, Morton's metatarsalgia and radiculopathies. CONCLUSIONS Age, gender and BMI are important risk factors for many common focal neuropathies.
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Affiliation(s)
- C Martínez-Aparicio
- Doctoral Programme of Medicine and Public Health, University of Granada, Granada, Spain.,Department of Clinical Neurophysiology, Vithas Virgen del Mar Hospital, Almeria, Spain
| | - S K Jääskeläinen
- Department of Clinical Neurophysiology, Turku University Hospital and University of Turku, Turku, Finland
| | - L Puksa
- Department of Clinical Neurophysiology, University of Tartu, Tartu, Estonia
| | - F Reche-Lorite
- Department of Mathematics, University of Almeria, Almeria, Spain
| | - P Torné-Poyatos
- Faculty of Medicine, University of Granada, Hospital Universitario Clinico, Granada, Spain
| | - J Paniagua Soto
- Department of Clinical Neurophysiology, University Hospital Virgen de las Nieves, Granada, Spain
| | - B Falck
- Department of Clinical Neurophysiology, University Hospital, Uppsala, Sweden
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Clinical Findings and Electrodiagnostic Testing in Ulnar Neuropathy at the Elbow and Differences According to Site and Type of Nerve Damage. Am J Phys Med Rehabil 2019; 99:116-123. [PMID: 31369403 DOI: 10.1097/phm.0000000000001286] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The aim of the study was to evaluate the clinical and electrodiagnostic testing in ulnar neuropathy at the elbow and differences according to site (humeroulnar arcade vs. retroepicondylar groove) and injury physiopathology (axonal vs. demyelinating), through prospective multicenter case-control study. DESIGN Cases and controls were matched by age and sex. Ulnar neuropathy at the elbow diagnosis was made on symptoms. Statistical analysis was performed using Mann-Whitney, χ, and analysis of variance tests. RESULTS One hundred forty-four cases and 144 controls were enrolled. Sensory loss in the fifth finger had the highest sensitivity (70.8%) compared with clinical findings. Motor conduction velocity across elbow reached the highest sensitivity (84.7%) in localizing ulnar neuropathy at the elbow recording from at least one of the two hand muscles (first dorsal interosseous and abductor digiti minimi). Abnormal sensory action potential amplitude from the fifth finger occurred more frequently in axonal than in demyelinating forms. Differences between retroepicondylar groove and humeroulnar arcade regarded conduction block and job type. CONCLUSIONS Clinical findings have less usefulness than electrodiagnostic testing in ulnar neuropathy at the elbow diagnosis. Motor conduction velocity across elbow recorded from both abductor digiti minimi and first dorsal interosseous increases diagnostic accuracy. Axonal forms have greater clinical and electrodiagnostic testing severity than demyelinating forms, which are more frequent in retroepicondylar groove. Manual workers prevailed in humeroulnar arcade. These findings may be helpful in prognostic and therapeutic approaches.
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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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Kang S, Yoon JS, Yang SN, Choi HS. Retrospective study on the impact of ulnar nerve dislocation on the pathophysiology of ulnar neuropathy at the elbow. PeerJ 2019; 7:e6972. [PMID: 31149408 PMCID: PMC6532616 DOI: 10.7717/peerj.6972] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 04/18/2019] [Indexed: 12/15/2022] Open
Abstract
Introduction High resolution ultrasonography (US) has been used for diagnosis and evaluation of entrapment peripheral neuropathy. Ulnar neuropathy at the elbow (UNE) is the second most common focal entrapment neuropathy. The ulnar nerve tends to move to the anteromedial side and sometimes subluxates or dislocates over the medial epicondyle as the elbow is flexed. Dislocation of the ulnar nerve during elbow flexion may contribute to friction injury. We aimed to investigate the effects which the dislocation of ulnar nerve at the elbow could have on the electrophysiologic pathology of UNE. Materials We retrospectively reviewed 71 arms of UNE. The demographic data, electrodiagnosis findings and US findings of ulnar nerve were analyzed. We classified the electrodiagnosis findings of UNE into three pathologic types; demyelinating, sensory axonal loss, and mixed sensorimotor axonal loss. The arms were grouped into non-dislocation, partial dislocation, and complete dislocation groups according to the findings of nerve dislocation in US examination. We compared the electrodiagnosis findings, ulnar nerve cross sectional areas in US and electrodiagnosis pathology types among the groups. Results A total of 18 (25.3%) arms showed partial dislocation, and 15 (21.1%) arms showed complete dislocation of ulnar nerve in US. In the comparison of electrodiagnosis findings, the partial and complete dislocation groups showed significantly slower conduction velocities and lower amplitudes than non-dislocation group in motor conduction study. In the sensory conduction study, the conduction velocity was significantly slower in partial dislocation group and the amplitude was significantly lower in complete dislocation group than non-dislocation group. In the comparison of US findings, patients in partial and complete dislocation groups showed significantly larger cross sectional areas of the ulnar nerve. The comparison of electrodiagnosis pathologic types among the groups revealed that there were significantly larger proportions of the axonal loss (sensory axonal loss or mixed sensorimotor axonal loss) in partial and complete dislocation groups than non-dislocation group. Conclusion The ulnar nerve dislocation could influence on the more severe damage of the ulnar nerve in patients with UNE. It might be important to evaluate the dislocation of the ulnar nerve using US in diagnosing ulnar neuropathy for predicting the prognosis and determining the treatment direction of UNE.
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Affiliation(s)
- Seok Kang
- Department of Rehabilitation Medicine, Korea University Guro Hospital, Seoul, South Korea
| | - Joon Shik Yoon
- Department of Rehabilitation Medicine, Korea University Guro Hospital, Seoul, South Korea
| | - Seung Nam Yang
- Department of Rehabilitation Medicine, Korea University Guro Hospital, Seoul, South Korea
| | - Hyuk Sung Choi
- Department of Rehabilitation Medicine, Korea University Guro Hospital, Seoul, South Korea
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Walker FO, Cartwright MS, Alter KE, Visser LH, Hobson-Webb LD, Padua L, Strakowski JA, Preston DC, Boon AJ, Axer H, van Alfen N, Tawfik EA, Wilder-Smith E, Yoon JS, Kim BJ, Breiner A, Bland JDP, Grimm A, Zaidman CM. Indications for neuromuscular ultrasound: Expert opinion and review of the literature. Clin Neurophysiol 2018; 129:2658-2679. [PMID: 30309740 DOI: 10.1016/j.clinph.2018.09.013] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Revised: 08/10/2018] [Accepted: 09/02/2018] [Indexed: 12/11/2022]
Abstract
Over the last two decades, dozens of applications have emerged for ultrasonography in neuromuscular disorders. We wanted to measure its impact on practice in laboratories where the technique is in frequent use. After identifying experts in neuromuscular ultrasound and electrodiagnosis, we assessed their use of ultrasonography for different indications and their expectations for its future evolution. We then identified the earliest papers to provide convincing evidence of the utility of ultrasound for particular indications and analyzed the relationship of their date of publication with expert usage. We found that experts use ultrasonography often for inflammatory, hereditary, traumatic, compressive and neoplastic neuropathies, and somewhat less often for neuronopathies and myopathies. Usage significantly correlated with the timing of key publications in the field. We review these findings and the extensive evidence supporting the value of neuromuscular ultrasound. Advancement of the field of clinical neurophysiology depends on widespread translation of these findings.
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Affiliation(s)
- Francis O Walker
- Department of Neurology at Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC, USA.
| | - Michael S Cartwright
- Department of Neurology at Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC, USA.
| | - Katharine E Alter
- Department of Rehabilitation Medicine, National INeurolnstitutes of Health, Bethesda, MD 20892, USA.
| | - Leo H Visser
- Departments of Neurology and Clinical Neurophysiology, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands.
| | - Lisa D Hobson-Webb
- Department of Neurology, Neuromuscular Division, Duke University School of Medicine, Durham, NC, USA.
| | - Luca Padua
- Don Carlo Gnocchi ONLUS Foundation, Piazzale Rodolfo Morandi, 6, 20121 Milan, Italy; Department of Geriatrics, Neurosciences and Orthopaedics, Universita Cattolica del Sacro Cuore, Rome, Italy.
| | - Jeffery A Strakowski
- Department of Physical Medicine and Rehabilitation, The Ohio State University, Columbus, OH, USA; Department of Physical Medicine and Rehabilitation, OhioHealth Riverside Methodist Hospital, Columbus, OH, USA; OhioHealth McConnell Spine, Sport and Joint Center, Columbus, OH, USA.
| | - David C Preston
- Neurological Institute, University Hospitals, Cleveland Medical Center, Case Western Reserve University, Cleveland, OH, USA.
| | - Andrea J Boon
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN, USA.
| | - Hubertus Axer
- Hans Berger Department of Neurology, Jena University Hospital, Jena 07747, Germany.
| | - Nens van Alfen
- Department of Neurology and Clinical Neurophysiology, Donders Institute for Brain, Cognition, and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Eman A Tawfik
- Department of Physical Medicine & Rehabilitation, Faculty of Medicine, Ain Shams University, Cairo, Egypt.
| | - Einar Wilder-Smith
- Department of Neurology, Yong Loo Lin School of Medicine, National University Singapore, Singapore; Department of Neurology, Kantonsspital Lucerne, Switzerland; Department of Neurology, Inselspital Berne, Switzerland.
| | - Joon Shik Yoon
- Department of Physical Medicine and Rehabilitation, Korea University Guro Hospital, Seoul, Republic of Korea.
| | - Byung-Jo Kim
- Department of Neurology, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea.
| | - Ari Breiner
- Division of Neurology, Department of Medicine, The Ottawa Hospital and University of Ottawa, Canada.
| | - Jeremy D P Bland
- Deparment of Clinical Neurophysiology, East Kent Hospitals University NHS Foundation Trust, Canterbury, Kent, UK.
| | - Alexander Grimm
- Department of Neurology, University Hospital Tuebingen, Tuebingen, Germany.
| | - Craig M Zaidman
- Division of Neuromuscular Medicine, Department of Neurology, Washington University in St. Louis, 660 S. Euclid Ave, Box 8111, St. Louis, MO 63110, USA.
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Pelosi L, Tse DMY, Mulroy E, Chancellor AM, Boland MR. Ulnar neuropathy with abnormal non-localizing electrophysiology: Clinical, electrophysiological and ultrasound findings. Clin Neurophysiol 2018; 129:2155-2161. [PMID: 30130723 DOI: 10.1016/j.clinph.2018.07.020] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2018] [Revised: 07/17/2018] [Accepted: 07/23/2018] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To systematically study demographic, clinical, electrophysiological and nerve ultrasound characteristics of ulnar neuropathy with abnormal non-localizing electrophysiology (NL-UN) and further define the utility of ultrasound over and above the conventional electro-diagnostic approach. METHOD NL-UNs were prospectively identified from 113 consecutive referrals with suspected ulnar neuropathy. All received electro-diagnostic tests and ulnar nerve ultrasound. NL-UN severity was graded using clinical and electrophysiological scales. RESULTS In 64 of 113 referrals, an ulnar mono- neuropathy was confirmed by electrophysiology. Sixteen of these 64 (25%) had NL-UN, predominantly males (14 out of 16 patients) with severe or moderate clinical and electrophysiological ratings. Ultrasound showed focal ulnar neuropathy at the elbow in 13 out of 16, and diffuse ulnar nerve abnormality in three, and identified a likely or possible causative mechanism in 11. CONCLUSION A significant proportion (a quarter) of ulnar neuropathies with abnormal electrophysiology were NL-UN, of heterogeneous etiology; the majority were males with significant disability and axonal loss. Ultrasound had a significant role in localization and classification that facilitated management. SIGNIFICANCE To our knowledge, this is the first systematic prospective study that analyzes the demographic, clinical, electrophysiological and ultrasound characteristics of NL-UN in a routine clinical neurophysiology setting.
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Affiliation(s)
- Luciana Pelosi
- Department of Neurology and Clinical Neurophysiology, Bay of Plenty District Health Board, Tauranga Hospital, Tauranga, New Zealand.
| | | | - Eoin Mulroy
- Auckland District Health Board, Auckland Hospital, Auckland, New Zealand
| | - Andrew M Chancellor
- Department of Neurology and Clinical Neurophysiology, Bay of Plenty District Health Board, Tauranga Hospital, Tauranga, New Zealand
| | - Michael R Boland
- Hand Institute Bioengineering Institute, University of Auckland, Auckland, New Zealand
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Long-term outcomes in patients with ulnar neuropathy at the elbow treated according to the presumed aetiology. Clin Neurophysiol 2018; 129:1763-1769. [DOI: 10.1016/j.clinph.2018.04.753] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 04/19/2018] [Accepted: 04/29/2018] [Indexed: 01/15/2023]
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38
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Simon NG. Treatment of ulnar neuropathy at the elbow - An ongoing conundrum. Clin Neurophysiol 2018; 129:1716-1717. [PMID: 29934265 DOI: 10.1016/j.clinph.2018.06.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Accepted: 06/07/2018] [Indexed: 12/20/2022]
Affiliation(s)
- Neil G Simon
- St Vincent's Clinical School, University of New South Wales, Darlinghurst NSW 2010, Australia.
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Loizides A, Gruber L, Peer S, Plaikner M, Gruber H. [Ultrasound-guided interventions on the peripheral nervous system]. Radiologe 2018; 57:166-175. [PMID: 28054138 DOI: 10.1007/s00117-016-0203-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
CLINICAL/METHODICAL ISSUE Up to the advent of high-resolution ultrasound, interventions on the peripheral nervous system, including local anesthesia and pain treatment were performed without visual guidance, which in some cases led to treatment failure or local tissue and nerve damage. METHODICAL INNOVATIONS Progress in the field of ultrasound has enabled the functional visualization, anesthesia and anti-inflammatory or neurolytic treatment of many peripheral nerves, such as the brachial plexus, nerves of the upper and lower extremities and various nerves of the trunk. Contrast medium-guided biopsies have also become feasible. ACHIEVEMENTS This article discusses the general prerequisites for such interventions and details the visualization and the interventional algorithms for interventions on the brachial plexus, on large nerves often affected by compression neuropathies, such as the median, ulnar, sciatic and femoral nerves and small nerves, such as the lateral cutaneous nerves of the thigh. Furthermore, contrast medium-aided biopsies of intraneural and perineural masses are discussed. Finally, the treatment of stump neuromas via phenol instillation is described. PRACTICAL RECOMMENDATIONS Innovations in high-resolution ultrasound allow the reliable and safe diagnosis and treatment of various pathologies of the peripheral nervous system with few side effects. Compared to older methods, which did not use visual guidance ultrasound provides higher success rates and lower adverse event rates in many instances.
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Affiliation(s)
- A Loizides
- Department Radiologie, Medizinische Universität Innsbruck, 6020, Innsbruck, Österreich.
| | - L Gruber
- Department Radiologie, Medizinische Universität Innsbruck, 6020, Innsbruck, Österreich
| | - S Peer
- CTI GesmbH und Roentgeninstitut B7, 6020, Innsbruck, Österreich
| | - M Plaikner
- Department Radiologie, Medizinische Universität Innsbruck, 6020, Innsbruck, Österreich
| | - H Gruber
- Department Radiologie, Medizinische Universität Innsbruck, 6020, Innsbruck, Österreich
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40
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Podnar S. Contribution of ultrasonography to the evaluation of peripheral nerve disorders. Neurophysiol Clin 2018; 48:119-123. [DOI: 10.1016/j.neucli.2018.01.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Revised: 01/11/2018] [Accepted: 01/11/2018] [Indexed: 02/08/2023] Open
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Law TY, Hubbard ZS, Chieng LO, Chim HW. Trends in Open and Endoscopic Cubital Tunnel Release in the Medicare Patient Population. Hand (N Y) 2017. [PMID: 28644930 PMCID: PMC5484454 DOI: 10.1177/1558944716679610] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Cubital tunnel syndrome (CUT) is the second most common peripheral neuropathy with an annual incidence of 24.7 per 100 000, affecting nearly twice as many men as women. With increasing focus on cost-effectiveness and cost-containment in medicine, a critical understanding of utilization of health care resources for open and endoscopic approaches for cubital tunnel release is of value. The purpose of this study was to evaluate the costs and utilization trends of open and endoscopic cubital tunnel release. METHODS We performed a retrospective review of a Medicare database within the PearlDiver Supercomputer (Warsaw, Indiana) for procedures performed from 2005 to 2012. Annual utilization, charges, reimbursement, demographic data, and compound annual growth rate were evaluated. RESULTS Our query returned 262 104 patients with CUT, of which 69 378 (26.5%) and 4636 (1.8%) were surgically managed with open and endoscopic release respectively. Average charges were higher in endoscopic release ($3798) than open release ($3197) while reimbursements were higher in open releases ($1041) than endoscopic release, ($866). Both were performed most commonly in the <65 years age range. CONCLUSIONS Despite the unexpectedly lower reimbursement rate with endoscopic release, endoscopy utilization is growing faster than open releases in the Medicare population. Lower reimbursement is likely related to lack of a dedicated current procedural terminology code for endoscopic cubital tunnel release.
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Affiliation(s)
- Tsun Yee Law
- University of Miami Miller School of Medicine, FL, USA
| | | | | | - Harvey W. Chim
- University of Miami Miller School of Medicine, FL, USA,Harvey W. Chim, Division of Plastic Surgery, University of Miami Miller School of Medicine, Clinical Research Building, 1120 N.W. 14th Street, 4th Floor, Miami, FL 33136, USA.
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Fadel M, Lancigu R, Raimbeau G, Roquelaure Y, Descatha A. Occupational prognosis factors for ulnar nerve entrapment at the elbow: A systematic review. HAND SURGERY & REHABILITATION 2017; 36:244-249. [PMID: 28528878 DOI: 10.1016/j.hansur.2017.03.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Accepted: 03/13/2017] [Indexed: 11/17/2022]
Abstract
Although ulnar nerve entrapment is the second most common entrapment neuropathy, there is a dearth of studies identifying occupational prognosis factors. We carried out a systematic review of the occupational prognosis factors for ulnar nerve entrapment in order to identify professions at risks and allow better follow-up for their workers. Using the key words, "ulnar OR cubital", "neuropathy OR tunnel", and "work OR occupational" without limitations, original prospective studies were selected from four databases (PubMed, Embase, Web of Science, Cochrane Library) after two rounds (valid design, valid prognosis outcome reported, valid work exposure). Associations between prognosis for ulnar neuropathy and occupational factors were extracted and analyzed qualitatively. Dating from 1981 to 2013, three prospective studies were included; 1420 cases of ulnar nerve entrapment were followed for an average of 4 years and occupational exposure was retrieved. The only high-quality study (related to this question) found a significant relationship between occupational exposure and prognosis with an odds ratio for ulnar nerve entrapment of 1.78 (1.10-2.88). The two other studies were less focused on the occupational prognosis factors; one found that work activity requiring effort had worse prognosis after surgery, while the other found no significant relationship between occupational hand exposure and prognosis. Occupations requiring high effort may be associated with more severe ulnar neuropathies, but further studies (exposure as well as associated disorders) are mandatory for clinicians to provide work task information to their patients.
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Affiliation(s)
- M Fadel
- Occupational Health Unit EMS (Samu 92), University hospital of West Suburb of Paris, AP-HP (Paris Hospital "Assistance publique-Hôpitaux de Paris"), Poincaré site, 104, boulevard Poincaréir, 92380 Garches, France; UMS 011/UMR-S 1168, University of Versailles St-Quentin (UVSQ), 2, avenue de la Source-de-la-Bièvre, 78180 Montigny-Le-Bretonneux, France
| | - R Lancigu
- Département de chirurgie osseuse, centre hospitalier universitaire, 4, rue Larrey, 49933 Angers cedex 9, France
| | - G Raimbeau
- Hand Center, 47, rue de la Foucaudière, 49000 Trélazé, France
| | - Y Roquelaure
- University of Angers, Laboratory of ergonomics and epidemiology in occupational health (LEEST), rue Haute-de-Reculée, 49045 Angers, France
| | - A Descatha
- Occupational Health Unit EMS (Samu 92), University hospital of West Suburb of Paris, AP-HP (Paris Hospital "Assistance publique-Hôpitaux de Paris"), Poincaré site, 104, boulevard Poincaréir, 92380 Garches, France; UMS 011/UMR-S 1168, University of Versailles St-Quentin (UVSQ), 2, avenue de la Source-de-la-Bièvre, 78180 Montigny-Le-Bretonneux, France; Inserm, Population-Based Epidemiological Cohorts Unit, UMS011, hôpital Paul-Brousse, 16, avenue Paul-Vaillant-Couturier, 94807 Villejuif cedex, France; Inserm, Aging and chronic diseases, Epidemiological and public health approaches, U1168, hôpital Paul-Brousse, 16, avenue Paul-Vaillant-Couturier, 94807 Villejuif cedex, France.
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Podnar S, Omejec G, Bodor M. Nerve conduction velocity and cross-sectional area in ulnar neuropathy at the elbow. Muscle Nerve 2017; 56:E65-E72. [DOI: 10.1002/mus.25655] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2017] [Indexed: 11/05/2022]
Affiliation(s)
- Simon Podnar
- Institute of Clinical Neurophysiology; University Medical Center Ljubljana; SI-1525 Ljubljana Slovenia
| | - Gregor Omejec
- Institute of Clinical Neurophysiology; University Medical Center Ljubljana; SI-1525 Ljubljana Slovenia
| | - Marko Bodor
- Department of Physical Medicine and Rehabilitation; University of California Davis; Sacramento California USA
- Department of Neurological Surgery; University of California San Francisco; San Francisco California USA
- Interventional Spine and Sports Medicine; Napa California USA
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Bruder M, Dützmann S, Rekkab N, Quick J, Seifert V, Marquardt G. Muscular atrophy in severe cases of cubital tunnel syndrome: prognostic factors and outcome after surgical treatment. Acta Neurochir (Wien) 2017; 159:537-542. [PMID: 28110402 DOI: 10.1007/s00701-017-3086-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 01/11/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND Cubital tunnel syndrome (CuTS) is a frequent neuropathy, leading to sensor-motoric dysfunction. Many patients even present with muscular atrophy as a sign for severe and long-lasting nerve impairment, usually suggesting unfavourable outcome. We analysed if those patients benefit from surgical treatment on a long-term basis. METHODS Between January 2010 and March 2015, 42 consecutive cases of CuTS with atrophy of the intrinsic hand muscles were surgically treated in our department. Clinical data of the treatment course and postoperative results were collected. Follow-up was prospectively assessed according to McGowen grading and Bishop outcome score. Mean follow-up time was 39.8 (±17.0) months. RESULTS All patients were treated with in situ decompression; in 33%, submuscular transposition was performed. Forty-five percent showed improvement of sensory deficits and 57% showed improvement of motor deficits 6 months after the operation. Atrophy improved in 76%. At the time of follow-up, 79% were satisfied with the postoperative result and 77% of patients reached good or excellent outcome according to modified Bishop rating scale. Patients with improvement of atrophy had significantly shorter symptom duration period (7 ± 10 months vs 26 ± 33 months; p < 0.05). In the case of intraoperative pseudoneuroma observation, atrophy improvement was less likely (p < 0.05). CONCLUSIONS In severe cases of CuTS with atrophy of the intrinsic hand muscles, surgical treatment enables improvement of sensory function, motor function and atrophy even in cases with muscular atrophy. Atrophy improvement was more likely in cases of short symptom duration and less likely in cases with pseudoneuroma.
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Affiliation(s)
- Markus Bruder
- Department of Neurosurgery, Goethe University, Frankfurt, Germany.
| | - Stephan Dützmann
- Department of Neurosurgery, Goethe University, Frankfurt, Germany
| | - Nourdin Rekkab
- Department of Neurosurgery, Goethe University, Frankfurt, Germany
| | - Johanna Quick
- Department of Neurosurgery, Goethe University, Frankfurt, Germany
| | - Volker Seifert
- Department of Neurosurgery, Goethe University, Frankfurt, Germany
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45
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Omejec G, Božikov K, Podnar S. Validation of preoperative nerve conduction studies by intraoperative studies in patients with ulnar neuropathy at the elbow. Clin Neurophysiol 2016; 127:3499-3505. [DOI: 10.1016/j.clinph.2016.09.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Revised: 08/31/2016] [Accepted: 09/19/2016] [Indexed: 12/28/2022]
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46
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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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47
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Can neurologic examination predict pathophysiology of ulnar neuropathy at the elbow? Clin Neurophysiol 2016; 127:3259-64. [DOI: 10.1016/j.clinph.2016.08.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Revised: 08/01/2016] [Accepted: 08/02/2016] [Indexed: 01/17/2023]
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48
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Podnar S. Letter to the Editor: Can muscle hypertrophy cause entrapment neuropathy? J Neurosurg 2016; 125:1608-1609. [PMID: 27419828 DOI: 10.3171/2016.3.jns16612] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Simon Podnar
- Institute of Clinical Neurophysiology, University Medical Center, Ljubljana, Slovenia
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49
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Omejec G, Podnar S. Proposal for electrodiagnostic evaluation of patients with suspected ulnar neuropathy at the elbow. Clin Neurophysiol 2016; 127:1961-7. [DOI: 10.1016/j.clinph.2016.01.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2015] [Revised: 01/08/2016] [Accepted: 01/12/2016] [Indexed: 12/22/2022]
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50
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Podnar S, Omejec G. Why do local corticosteroid injections work in carpal tunnel syndrome, but not in ulnar neuropathy at the elbow? Muscle Nerve 2016; 53:662-3. [DOI: 10.1002/mus.24956] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2015] [Revised: 10/22/2015] [Accepted: 10/26/2015] [Indexed: 11/10/2022]
Affiliation(s)
- Simon Podnar
- Institute of Clinical Neurophysiology, Division of Neurology; University Medical Center Ljubljana; Slovenia
| | - Gregor Omejec
- Institute of Clinical Neurophysiology, Division of Neurology; University Medical Center Ljubljana; Slovenia
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