Ganglion-associated ulnar tunnel syndrome treated by ultrasonographically assisted aspiration and splinting

Ulnar tunnel syndrome: pathoanatomy, clinical features and management

Ulnar tunnel syndrome is compression of the ulnar nerve at the level of the wrist within Guyon's canal. It is most commonly caused by a ganglion cyst but may also be secondary to fractures, inflammatory conditions, neoplasm, vascular anomalies, aberrant musculature or a combination of these. Assessment should include a detailed history focusing on duration, site and progression of symptoms. The level of compression can be estimated clinically on examination by assessing motor and sensory changes in the hand. Investigations are used to confirm diagnosis or to clarify the underlying cause. X-rays and computed tomography can be used to exclude fractures. Ultrasound is used to diagnose ganglion cysts and vascular anomalies, and can localise the level of compression. Nerve conduction studies can be used to support the diagnosis and look for proximal compression. Mild symptoms can be managed non-operatively. Surgical exploration and decompression is the gold standard treatment for neuro-compressive causes with largely good outcomes.

Differentiation of ulnar neuropathy at the wrist due to ganglion cyst from ulnar neuropathy at the elbow

OBJECTIVE

Here, we aimed to describe the clinical, electrodiagnostic (EDx) and ultrasonographic (US) findings in a series of patients with ulnar neuropathy at the wrist (UNW) due to compression by a ganglion cyst. We also sought features that differentiate UNW from ulnar neuropathy at the elbow (UNE).

METHODS

We reviewed electronic medical records of consecutive patients with UNW caused by ganglion cysts. We compared their clinical, EDx and US findings to findings in our previously reported prospective series of UNE patients.

RESULTS

We identified 10 patients with UNW caused by ganglion cyst compression, who all presented with intrinsic hand muscle weakness and atrophy. Compared to 175 UNE patients they less often complained of paresthesia (60% vs. 98%) and presented less sensory loss in the palm (30% vs. 96%) and little finger (50% vs. 95%). They more often had distal ulnar motor latency recorded from the abductor digiti minimi (ADM)>3.6ms (80% vs. 30%), and denervation activity on needle EMG in the first dorsal interosseous (FDI) compared to ADM (100% vs. 60%). Only 20% of our UNW patients had ulnar nerve swelling at the site of compression on US.

CONCLUSION

UNW potentially caused by ganglion cyst should be suspected in patients presenting with intrinsic hand muscle atrophy and weakness, particularly in cases with normal sensation, increased distal ulnar motor latency recorded from ADM and more severe neuropathic changes in FDI compared to ADM muscle.

Compressive radial neuropathy by a synovial cyst during pregnancy: A clinical case report

RATIONALE

Compressive radial neuropathy by a synovial cyst in the radial tunnel during pregnancy is a rare occurrence. The management of radial nerve compression caused by a synovial cyst in a pregnant patient is a surgical dilemma owing to the fetal and maternal risks of treatment.

PATIENT CONCERNS AND DIAGNOSIS

A 37-year-old pregnant woman presented with progressive forearm pain at the gestational age of 12 weeks. A cyst was identified via musculoskeletal ultrasound and magnetic resonance imaging examinations in the radiocapitellar joint causing radial compressive neuropathy.

INTERVENTIONS

After regional nerve block and surgical removal of the cyst, the patient's forearm pain was alleviated without neurological deficits.

OUTCOME

symptoms from nerve compression were improved after surgical treatment LESSONS:: This report illustrates the case of a pregnant woman presenting a compressive neuropathy by an enlarged cyst possibly due to the unbalance of growth factors during pregnancy. With proper diagnosis and timely surgical intervention, such patients can achieve good neurologic recovery without maternal or fetal complications.

Ultrasound-Guided Perineural Injection at Guyon's Tunnel: An Anatomic Feasibility Study

Compression of the ulnar nerve (UN) at the wrist causes neuropathy in the ulnar tunnel (UT), or Guyon's tunnel. In the absence of trauma and motor syndromes, primarily conservative treatment is considered. As in carpal tunnel syndrome, a perineural injection of corticosteroids may be beneficial. The aim of this study was to investigate the feasibility of ultrasound-guided injections at the UT. We performed ultrasound-guided injections of ink at the UN within the UT in 21 limbs from 11 non-embalmed cadavers. In all cases, we stained the perineural sheath of the superficial branch of the ulnar nerve within the UT. No ink was found inside the nerve or in adjacent structures such as blood vessels and tendons. In conclusion, perineural injection of the UN in the UT seems to be a technically feasible procedure. On the basis of these anatomic data, clinical trials are needed to prove the concept for routine use.

Entrapment neuropathy of the wrist, forearm, and elbow

This review discusses key diagnostic points and treatment guidelines for compression neuropathies of the wrist, forearm, and elbow. Recent treatment progress is reviewed, controversies are highlighted, and consensus is summarized. Limited or mini-open releases and endoscopic carpal tunnel releases are considered equally safe and efficient. Both methods are currently mainstays of surgical treatment.

Ulnar tunnel syndrome

Ulnar neuropathy at or distal to the wrist, the so-called ulnar tunnel syndrome, is an uncommon but well-described condition. However, diagnosis of ulnar tunnel syndrome can be difficult. Paresthesias may be nonspecific or related to coexisting pathologies, such as carpal tunnel syndrome, cubital tunnel syndrome, thoracic outlet syndrome, C8-T1 radiculopathy, or peripheral neuropathy, which makes accurate diagnosis challenging. The advances in electrodiagnosis, ultrasonography, computed tomography, and magnetic resonance imaging have improved the diagnostic accuracy. This article offers an updated view of ulnar tunnel syndrome as well as its etiologies, diagnoses, and treatments.

Ultrasound-guided aspiration and injection of an intraneural ganglion cyst of the common peroneal nerve

BACKGROUND

Intraneural ganglion cysts are rare, benign, mucinous lesions that occur within neural sheaths and are thought to involve cystic fluid exiting from nearby synovial joints. They often present as tender masses causing paresthesias in the distribution of the involved nerve, muscle weakness or cramping, or localized or referred pain.

CASE DESCRIPTION

We present a case of a patient who initially presented with foot drop due to an intraneural ganglion cyst of the common peroneal nerve. This cyst was successfully treated using ultrasound guidance to aspirate the cyst and inject corticosteroid to prevent further inflammation.

LITERATURE REVIEW

Standard of care has previously involved surgical resection, but this has been associated with a high frequency of recurrence. Due to the risks of nerve and vessel damage, there have been efforts to find alternative ways of resolving these cysts.

PURPOSES AND CLINICAL RELEVANCE

Aspiration and injection of corticosteroid is a useful and minimally invasive alternative to surgery for managing intraneural ganglion cysts.

Ulnar tunnel syndrome

Ulnar tunnel syndrome could be broadly defined as a compressive neuropathy of the ulnar nerve at the level of the wrist. The ulnar tunnel, or Guyon's canal, has a complex and variable anatomy. Various factors may precipitate the onset of ulnar tunnel syndrome. Patient presentation depends on the anatomic zone of ulnar nerve compression: zone I compression, motor and sensory signs and symptoms; zone II compression, isolated motor deficits; and zone III compression; purely sensory deficits. Conservative treatment such as activity modification may be helpful, but often, surgical exploration of the ulnar tunnel with subsequent ulnar nerve decompression is indicated.

Ultrasound-assisted musculoskeletal procedures: A practical overview of current literature

Traditionally performed by a small group of highly trained specialists, bedside sonographic procedures involving the musculoskeletal system are often delayed despite the critical need for timely diagnosis and treatment. Due to this limitation, a need evolved for more portability and accessibility to allow performance of emergent musculoskeletal procedures by adequately trained non-radiology personnel. The emergence of ultrasound-assisted bedside techniques and increased availability of portable sonography provided such an opportunity in select clinical scenarios. This review summarizes the current literature describing common ultrasound-based musculoskeletal procedures. In-depth discussion of each ultrasound procedure including pertinent technical details, indications and contraindications is provided. Despite the limited amount of prospective, randomized data in this area, a substantial body of observational and retrospective evidence suggests potential benefits from the use of musculoskeletal bedside sonography.

Sonography-guided arthroscopy for wrist ganglion

PURPOSE

To describe how to combine the complementary features of sonography and arthroscopy to make the arthroscopic resection of wrist ganglions a safer and more reliable surgery.

METHODS

A total of 22 patients with wrist ganglions had sonography-assisted arthroscopic resection. Sonographic visualization of ganglions, adjacent structures (ie, vessels, nerves, and tendons), and the cycling tip of the arthroscopic shaver was assessed. Arthroscopic visualization of the ganglions or ganglion stalk was also assessed. Clinical outcome measures included wrist range of motion, grip strength, and our patient-rated Hand 20 questionnaire.

RESULTS

Sonographic visualization of the ganglion stalk, adjacent structures, and the cycling tip of the arthroscopic shaver was possible in all 22 cases. However, ganglion stalks were visualized by arthroscopy in only 4 cases. The mean range of motion and grip strength were not significantly changed following surgery. However, the mean Hand 20 score was significantly improved from 17 to 6 at final follow-up. Ganglion recurrence was seen in 2 cases at 6 and 8 months after surgery.

CONCLUSIONS

Sonography-guided wrist arthroscopy provides several advantages for surgeons, including visualization of the ganglions and ganglion stalk, as well as of the arthroscopic shaver and adjacent structures such as nerves, vessels, and tendons to perform surgery safely.

Sonography-assisted arthroscopic resection of volar wrist Ganglia: a new technique

Although satisfactory arthroscopic resection of volar wrist ganglia has been reported recently, the risk of damage to arteries, nerves, and tendons remains. Furthermore, ganglia and their stalks cannot be visualized arthroscopically in many cases, and surgeons must perform a blind resection of the joint capsule until ganglion cysts or their stalks appear. Sonography has limited resolution, but recent improvements in hardware and software have made it an excellent noninvasive and dynamic imaging technique for assessing the musculoskeletal system. Ganglia, tendons, nerves, and vessels around the lesion can be clearly observed by sonography. Furthermore, the cyclic motion of the arthroscopic shaver tip makes identification by sonography easy and assists in guiding the surgeon to the lesion.

Ultrasound-assisted musculoskeletal procedures: A practical overview of current literature

Traditionally performed by a small group of highly trained specialists, bedside sonographic procedures involving the musculoskeletal system are often delayed despite the critical need for timely diagnosis and treatment. Due to this limitation, a need evolved for more portability and accessibility to allow performance of emergent musculoskeletal procedures by adequately trained non-radiology personnel. The emergence of ultrasound-assisted bedside techniques and increased availability of portable sonography provided such an opportunity in select clinical scenarios. This review summarizes the current literature describing common ultrasound-based musculoskeletal procedures. In-depth discussion of each ultrasound procedure including pertinent technical details, indications and contraindications is provided. Despite the limited amount of prospective, randomized data in this area, a substantial body of observational and retrospective evidence suggests potential benefits from the use of musculoskeletal bedside sonography.

Ultrasound-assisted musculoskeletal procedures: A practical overview of current literature

Traditionally performed by a small group of highly trained specialists, bedside sonographic procedures involving the musculoskeletal system are often delayed despite the critical need for timely diagnosis and treatment. Due to this limitation, a need evolved for more portability and accessibility to allow performance of emergent musculoskeletal procedures by adequately trained non-radiology personnel. The emergence of ultrasound-assisted bedside techniques and increased availability of portable sonography provided such an opportunity in select clinical scenarios. This review summarizes the current literature describing common ultrasound-based musculoskeletal procedures. In-depth discussion of each ultrasound procedure including pertinent technical details, indications and contraindications is provided. Despite the limited amount of prospective, randomized data in this area, a substantial body of observational and retrospective evidence suggests potential benefits from the use of musculoskeletal bedside sonography.

Peripheral Neuropathies of the Median, Radial, and Ulnar Nerves: MR Imaging Features

The median, radial, and ulnar nerves of the upper limbs may be affected by various peripheral neuropathies, each of which may be categorized according to its cause, as either an entrapment or a nonentrapment neuropathy. Entrapment neuropathies, also referred to as nerve compression syndromes, include the supracondylar process syndrome, pronator syndrome, anterior interosseous nerve syndrome, carpal tunnel syndrome, posterior interosseous nerve syndrome, cubital tunnel syndrome, and Guyon canal syndrome. Nonentrapment neuropathies include traumatic nerve injuries, infectious and inflammatory conditions, polyneuropathies, and mass lesions at anatomic locations where entrapment syndromes typically do not occur. Although clinical examination and electrophysiologic testing are the cornerstone of the diagnostic work-up, in certain cases magnetic resonance (MR) imaging may provide key information about the exact anatomic location of a lesion or may help narrow the differential diagnosis. In patients with a diagnosis of peripheral neuropathy, MR imaging may help establish the cause of the condition and provide information crucial for conservative management or surgical planning. In addition, knowledge of the normal anatomy and of the possible causes, typical clinical findings, and MR imaging features of peripheral neuropathies that affect the median, radial, and ulnar nerves allows greater confidence in the diagnosis.

Acute ulnar neuropathy at the wrist: a case report and review of the literature

Acute ulnar neuropathy at the wrist is an extremely uncommon condition, at times requiring a high index of suspicion for the diagnosis. Clinical presentations of ulnar nerve lesions at the wrist and hand show variations due to the complex anatomic course of the nerve in distal sites. We report a case of acute ulnar neuropathy at the wrist caused by a ganglion in Guyon's canal, being initially misinterpreted as flexor tenosynovitis. The accurate diagnosis of selective distal motor neuropathy of ulnar nerve was made electrophysiologically. Magnetic resonance imaging revealed a well defined soft tissue mass consistent with a ganglion, compressing the ulnar nerve in Guyon's canal. Entrapment neuropathies are one of the common conditions handled by physiatrists. Ulnar nerve lesions at the wrist should be kept in mind in the differential diagnosis of patients with wrist or hand pain. Magnetic resonance imaging is a useful method in the anatomical evaluation of acute focal neuropathies.

Ulnar tunnel syndrome due to anatomical variant of the ulnar artery

We report a case of ulnar tunnel syndrome due to an anatomical variant branch of the ulnar artery. Anatomical variants can cause compression not visible on imaging and need to be considered for successful surgical decompression.

Ganglion cysts and other tumor related conditions of the hand and wrist

Most regard ganglion, giant cell tumor of tendon sheath and epidermal inclusion cysts as tumor-like conditions as opposed to true neoplasms. Ganglion cysts are the most common lesion of the hand and wrist, accounting for 50% to 70% of all masses identified. The majority of ganglion cysts can be treated nonoperatively but when surgery is performed a low recurrence rate can be anticipated. Giant cell tumor of the tendon sheath hand epidermoid cysts are also common hand lesions that require surgical excision in most instances. Of the three, giant cell tumor of tendon sheath have the most notable recurrence rates. This article reviews the clinical presentations of these lesions as well as their proposed pathophysiology.