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Podnar S. Length of affected nerve segment in ulnar neuropathies at the elbow. Clin Neurophysiol 2021; 133:104-110. [PMID: 34826645 DOI: 10.1016/j.clinph.2021.10.010] [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: 08/02/2021] [Revised: 10/06/2021] [Accepted: 10/12/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To establish length of the affected nerve segment (LANS) in ulnar neuropathy at the elbow (UNE). METHODS In a group of our previously reported UNE patients we identified 2-cm segments with reduced motor nerve conduction velocity (MNCV) on electrodiagnostic (EDx) studies and increased nerve cross-sectional areas (CSA) on ultrasonographic (US) studies. LANS was obtained by summation of these abnormal 2-cm segments separately for each approach. We also studied effect of selected independent parameters on LANS. RESULTS Altogether we studied 189 patients (194 arms). Mean (SD) LANS determined in 171 arms with reduced ulnar MNCV was 4.15 (1.89) cm, and was similar (p = 0. 21) to LANS obtained in 147 arms with increased CSA 4.46 (2.29) cm. Longer LANS were found in right arms, clinically severe UNE, axonal UNE and UNE due to entrapment. The most commonly affected 6 cm segment included 89% of abnormal 2-cm segments, with 50% of included 2-cm segments being normal. By contrast, the whole 10 cm segment included all abnormal 2-cm segments, with 66% of included segments being normal. CONCLUSIONS In UNE both EDx and US studies revealed average LANS of around 4 cm. LANS was longer in more severe UNE. SIGNIFICANCE LANS needs to be taken into account in discussion of the mechanisms of UNE and approach to EDx diagnosis of UNE, particularly length of the segment used in nerve conduction studies across the elbow.
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Affiliation(s)
- Simon Podnar
- Institute of Clinical Neurophysiology, Division of Neurology, University Medical Centre Ljubljana, Slovenia.
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Kurver A, Smolders J, Verhagen WIM, Meulstee J, Nijhuis FAP. The Diagnostic Sensitivity for Ulnar Neuropathy at the Elbow Is Not Increased by Addition of Needle EMG of ADM and FDI When Nerve Conduction Studies Are Normal. Front Neurol 2019; 10:196. [PMID: 30915020 PMCID: PMC6421266 DOI: 10.3389/fneur.2019.00196] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 02/15/2019] [Indexed: 11/13/2022] Open
Abstract
Introduction: The main objective of this study was to investigate whether electromyography (EMG) has additional value in the confirmation of the clinical diagnosis of ulnar nerve entrapment at the elbow (UNE) if nerve conduction studies (NCS) are normal. Methods: A prospective cross-sectional cohort observational study was conducted among patients with the clinical suspicion of UNE. A total of 199 arms were included, who were examined according to a standard neurophysiological protocol, i.e., NCS and EMG relevant to the ulnar nerve. Results: NCS were normal in 76 (38.2%) arms. No abnormal spontaneous muscle fiber activity was found with EMG in any of these cases. In 9 arms with normal NCS (11.8%), isolated abnormal MUAP configurations were found with EMG. Of these nine arms one UNE was diagnosed clinically, in which additional ultrasound and repeated NCS/EMG were negative. One had already been diagnosed with neuralgic amyotrophy and one with CTS. The other 6 arms had additional diagnostics which did not reveal an UNE. Conclusion: EMG as part of the standard neurophysiological protocol exclusively in the confirmation of the clinical diagnosis of UNE has limited added value if NCS are normal in a high prior-odds setting. However, removing EMG may prevent detecting concomitant and/or additional differential diagnoses.
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Affiliation(s)
- Anne Kurver
- Department of Neurology, Canisius Wilhelmina Hospital, Nijmegen, Netherlands
| | - Joost Smolders
- Department of Neurology, Canisius Wilhelmina Hospital, Nijmegen, Netherlands
| | - Wim I M Verhagen
- Department of Neurology, Canisius Wilhelmina Hospital, Nijmegen, Netherlands
| | - Jan Meulstee
- Department of Clinical Neurophysiology, Canisius Wilhelmina Hospital, Nijmegen, Netherlands
| | - Frouke A P Nijhuis
- Department of Neurology, Canisius Wilhelmina Hospital, Nijmegen, Netherlands.,Department of Clinical Neurophysiology, Canisius Wilhelmina Hospital, Nijmegen, Netherlands
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Terlemez R, Yilmaz F, Dogu B, Kuran B. Comparison of Ultrasonography and Short-Segment Nerve Conduction Study in Ulnar Neuropathy at the Elbow. Arch Phys Med Rehabil 2018; 99:116-120. [DOI: 10.1016/j.apmr.2017.09.111] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Revised: 09/12/2017] [Accepted: 09/13/2017] [Indexed: 11/25/2022]
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Carroll CG, Landau ME, Rouhanian M, Campbell WW. Inter-rater reliability determination for two tests of ulnar nerve conduction across the elbow. Muscle Nerve 2016; 55:664-668. [PMID: 27571443 DOI: 10.1002/mus.25390] [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: 08/07/2015] [Revised: 08/10/2016] [Accepted: 08/23/2016] [Indexed: 11/11/2022]
Abstract
INTRODUCTION The inter-rater variability in determination of ulnar nerve conduction across the elbow compromises test accuracy. The extent of this variability is unknown. The objective of this study was to determine and compare inter-rater reliability of variables derived from 2 different ulnar nerve conduction studies (NCSs) across the elbow. METHODS Two investigators performed a standard ulnar NCS and a 6-cm conduction time (Six-Centimeter Conduction Time test, SCCT) on 60 extremities of asymptomatic subjects. In the standard test, below-elbow (BE) and above-elbow (AE) stimulation points were ≥ 10 cm apart, measured along a curved path, to calculate across-elbow NCV. In SCCT, BE and AE were precisely 6 cm apart measured linearly to calculate CTE (conduction time elbow). Inter-rater reliability was assessed by means of intraclass correlation coefficients (ICC). RESULTS ICC for across-elbow NCV and CTE were 0.726 and 0.801, respectively. CONCLUSIONS Reliability of CTE and across-elbow NCV are similar. Shorter distances, if measured linearly, can be used to determine across-elbow ulnar nerve conduction. Muscle Nerve 55: 664-668, 2017.
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Affiliation(s)
- Craig G Carroll
- Department of Neurology, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, Maryland, 20815
| | - Mark E Landau
- Department of Neurology, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, Maryland, 20815
| | - Minoo Rouhanian
- Department of Research Programs, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - William W Campbell
- Department of Neurology, Uniformed Services University of the Health Sciences, Bethesda, Maryland
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5
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Abstract
Ulnar neuropathy at the elbow (UNE) is the second most frequent compression neuropathy. While other diagnostic imaging tools are emerging to assist in the diagnosis of UNE, electrodiagnosis remains the gold standard. However, the electrodiagnostic approach to UNE presents unique challenges limiting its diagnostic accuracy. We review advances in 5 areas relevant to the diagnosis of UNE: technologic advancements with modern EMG machines have allowed for reconsideration of the question of experimental error and lesion detection; how temperature effects can lead to misdiagnosis; the effect of body mass index on the electrodiagnosis of UNE; the validation of short segment studies; and the emerging role of high-resolution sonography as a diagnostic tool.
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Affiliation(s)
- William W Campbell
- Department of Neurology (WWC), Uniformed Services University of Health Sciences; and Department of Neurology (CC, MEL), Walter Reed National Military Medical Center, Bethesda, MD
| | - Craig Carroll
- Department of Neurology (WWC), Uniformed Services University of Health Sciences; and Department of Neurology (CC, MEL), Walter Reed National Military Medical Center, Bethesda, MD
| | - Mark E Landau
- Department of Neurology (WWC), Uniformed Services University of Health Sciences; and Department of Neurology (CC, MEL), Walter Reed National Military Medical Center, Bethesda, MD
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Abstract
Entrapment of the ulnar nerve at the elbow is the second most common focal peripheral neuropathy. Recent advances have facilitated the electrodiagnosis of this common nerve entrapment. The goals of electrodiagnosis are to localize ulnar nerve dysfunction, confirm that the disturbance is confined to the ulnar nerve, and assess the severity of ulnar nerve dysfunction. The goal of this review is to highlight the important advances in anatomy, neurophysiology and methodology that impact upon the electrodiagnosis of entrapment of the ulnar nerve at the elbow, illustrate the limits of electrodiagnosis, and discuss methodological issues that may be the subject of further study. Careful attention to elbow position, temperature, and conservative estimates of conduction block should be part of common practice. Awareness of anatomical variations in structural anatomy, anomalous innervation and fascicular arrangement of ulnar nerve fibers are required to interpret electrodiagnostic studies accurately. The most reliable finding is slowing of the ulnar across-elbow motor nerve conduction velocity to less than 50 m/sec while recording from the abductor digiti minimi muscle, and should be carefully interpreted in the presence of a polyneuropathy or other neurogenic process. Alternative techniques such as relative ulnar slowing in different ulnar nerve segments, use of alternative muscles, sensory and mixed nerve techniques provide complementary information, and like all nerve conduction studies are highly operator-dependent and should be used on a case by case basis. Recent studies have focused the electromyographer's attention on the use of shorter across-elbow segments (2-5 cm). This may offer a reasonable trade-off between sensitivity and measurement error and may result in improved electrodiagnosis.
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Affiliation(s)
- Ralph Z Kern
- Mount Sinai Hospital, University Health Network, Toronto, Ontario, Canada
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Logigian EL, Villanueva R, Twydell PT, Myers B, Downs M, Preston DC, Kothari MJ, Herrmann DN. Electrodiagnosis of ulnar neuropathy at the elbow (Une): A bayesian approach. Muscle Nerve 2013; 49:337-44. [DOI: 10.1002/mus.23913] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/15/2013] [Indexed: 12/14/2022]
Affiliation(s)
- Eric L. Logigian
- Department of Neurology; Box 673, 601 Elmwood Avenue, University of Rochester Medical Center Rochester New York 14642 USA
| | - Raissa Villanueva
- Department of Neurology; Box 673, 601 Elmwood Avenue, University of Rochester Medical Center Rochester New York 14642 USA
| | - Paul T. Twydell
- Department of Neurology; Box 673, 601 Elmwood Avenue, University of Rochester Medical Center Rochester New York 14642 USA
| | - Bennett Myers
- Department of Neurology; Box 673, 601 Elmwood Avenue, University of Rochester Medical Center Rochester New York 14642 USA
| | - Marlene Downs
- Department of Neurology; Box 673, 601 Elmwood Avenue, University of Rochester Medical Center Rochester New York 14642 USA
| | - David C. Preston
- Department of Neurology; Case Western Reserve University, University Hospitals Cleveland; Cleveland Ohio USA
| | - Milind J. Kothari
- Department of Neurology; Penn State Hershey Medical Center; Hershey Pennsylvania USA
| | - David N. Herrmann
- Department of Neurology; Box 673, 601 Elmwood Avenue, University of Rochester Medical Center Rochester New York 14642 USA
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Landau ME, Campbell WW. Clinical Features and Electrodiagnosis of Ulnar Neuropathies. Phys Med Rehabil Clin N Am 2013. [DOI: 10.1016/j.pmr.2012.08.019] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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Abstract
Peripheral nerve entrapments are frequent. They usually appear in anatomical tunnels such as the carpal tunnel. Nerve compressions may be due to external pressure such as the fibular nerve at the fibular head. Malignant or benign tumors may also damage the nerve. For each nerve from the upper and lower limbs, detailed clinical, electrophysiological, imaging, and therapeutic aspects are described. In the upper limbs, carpal tunnel syndrome and ulnar neuropathy at the elbow are the most frequent manifestations; the radial nerve is less frequently involved. Other nerves may occasionally be damaged and these are described also. In the lower limbs, the fibular nerve is most frequently involved, usually at the fibular head by external compression. Other nerves may also be involved and are therefore described. The clinical and electrophysiological examination are very important for the diagnosis, but imaging is also of great use. Treatments available for each nerve disease are discussed.
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Affiliation(s)
- P Bouche
- Department of Clinical Neurophysiology Salpêtrière Hospital, Paris, France.
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Kasius KM, Claes F, Verhagen WIM, Meulstee J. The segmental palmar test in diagnosing carpal tunnel syndrome reassessed. Clin Neurophysiol 2012; 123:2291-5. [PMID: 22608474 DOI: 10.1016/j.clinph.2012.04.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2011] [Revised: 02/16/2012] [Accepted: 04/01/2012] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To test our hypothesis that comparing the sensory nerve conduction velocity of the median nerve across the wrist with that of the forearm is more sensitive than comparing it with that of the palm in the electrodiagnostic confirmation of carpal tunnel syndrome (CTS). METHODS One hundred and fifty seven consecutive patients with clinically defined CTS were prospectively included and electrophysiologically examined. Antidromic nerve conduction velocities were measured in 3 segments of the median nerve: forearm, wrist, and palm. Differences and ratios in nerve conduction velocities were computed between the forearm and wrist and between the palm and wrist segments. RESULTS Comparing the median nerve conduction velocities of the forearm with the wrist segment provides a greater sensitivity (79.6% and 82.8% for the second and third digit, respectively) than comparing the palm with the wrist segment (65.6% and 65.0%). Applying the ratio leads to slightly higher sensitivities for both comparisons. CONCLUSIONS The modified segmental palmar test is a sensitive, robust and easily applicable method in diagnosing CTS. SIGNIFICANCE We recommend to use the median nerve sensory conduction velocity in the forearm as a reference in the segmental palmar test instead of that in the palm.
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Affiliation(s)
- Kristel M Kasius
- Department of Neurology and Clinical Neurophysiology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands.
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Korkmaz M, On AY, Çaliş FA. Reference data for ulnar nerve short segment conduction studies at the elbow. Muscle Nerve 2011; 44:783-8. [DOI: 10.1002/mus.22193] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2011] [Indexed: 11/08/2022]
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Conduction time for a 6-cm segment of the ulnar nerve across the elbow: reference values for the 6-cm conduction time test. J Clin Neurophysiol 2009; 26:198-200. [PMID: 19417686 DOI: 10.1097/wnp.0b013e3181a765fc] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Current electrodiagnostic studies for Ulnar nerve mononeuropathy at the elbow have substandard sensitivity and specificity. Reference values for a novel, screening electrodiagnostic test for ulnar nerve mononeuropathy at the elbow were obtained bilaterally from 72 subjects without any upper extremity signs or symptoms. The test used two, 3-cm straight line distances, one proximal, and one distal to the medial epicondyle to avoid a curvilinear measurement. The mean conduction times (CTE) were 1.16 +/- 0.16 milliseconds, 1.23 +/- 0.18 milliseconds, 1.33 +/- 0.24 milliseconds, for subjects 20 to 40, 40 to 60, and >60 years old, respectively. A CTE >1.50 milliseconds, >1.60 milliseconds, and >1.80 milliseconds for each age group would be considered abnormal conferring 98% specificity. The median side-to-side difference of CTE (CTE-diff) was 0.10 milliseconds with a range of 0.00 to 0.55 milliseconds. A CTE-diff >0.45 milliseconds has a specificity of 97%. Potential advantages to this method include straight-line measurement distances to reduce experimental error, and a distance less than 10 cm to improve lesion detection.
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Lo YL, Leoh TH, Xu LQ, Nurjannah S, Dan YF. Short-segment nerve conduction studies in the localization of ulnar neuropathy of the elbow: Use of flexor carpi ulnaris recordings. Muscle Nerve 2005; 31:633-6. [PMID: 15645413 DOI: 10.1002/mus.20250] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Short-segment nerve conduction studies were performed in 17 limbs with clinical features suggestive of ulnar neuropathy at the elbow. Recording from flexor carpi ulnaris yielded 93% sensitivity, compared with 71.4% when recording from abductor digiti minimi. The rationale underlying the technique is discussed. This approach should be of value as a diagnostic adjunct in technically challenging cases of ulnar neuropathy at the elbow.
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Affiliation(s)
- Y L Lo
- Department of Neurology, National Neuroscience Institute, Singapore General Hospital, Outram Road, 169608, Singapore.
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Chapter 13 Neurography – motor and sensory nerve conduction studies. ACTA ACUST UNITED AC 2003. [DOI: 10.1016/s1567-4231(09)70123-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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Padua L, Aprile I, Caliandro P, Foschini M, Mazza S, Tonali P. Natural history of ulnar entrapment at elbow. Clin Neurophysiol 2002; 113:1980-4. [PMID: 12464337 DOI: 10.1016/s1388-2457(02)00295-x] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE No clinical-neurophysiological data on natural history of ulnar neuropathy at elbow (UNE) are reported. The aim of the current study is to assess the course of untreated UNE. METHODS We performed a follow-up at 1 year of 30 neurophysiologically positive UNE, 24 were untreated and 6 were operated on. The evaluation was based on a phone interview and sometimes on neurophysiological investigation. With regard to management of UNE, at initial evaluation we explained to the patients what UNE is and how to avoid posture that can worsen nerve compression. RESULTS Around half of the untreated patients reported improvement of symptoms at follow-up. Comparison between baseline and follow-up neurophysiological measurements showed a significant spontaneous improvement. Most patients reported changing of arm posture after UNE diagnosis. CONCLUSIONS Some UNE cases improve spontaneously without surgical treatment. A part of the improvements could be due to the changing of arm postures. We hypothesize that a good diagnosis that includes an explanation of the anatomical condition of the nerve during postures and movements represents the first therapy for the entrapments.
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Affiliation(s)
- L Padua
- Institute of Neurology, Università Cattolica, L.go F. Vito, Rome, Italy.
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