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Dos Santos Silva J, de Barros LFP, de Freitas Souza R, Mendonça SM, Costa FM, Landeiro JA, Lopes FCR, Acioly MA. "Million dollar nerve" magnetic resonance neurography: first normal and pathological findings. Eur Radiol 2021; 32:1154-1162. [PMID: 34363135 DOI: 10.1007/s00330-021-08213-0] [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: 05/16/2021] [Revised: 07/07/2021] [Accepted: 07/12/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To evaluate prospectively the feasibility of magnetic resonance neurography (MRN) in identifying the anatomical characteristics of thenar muscular branch (TMB) of the median nerve, also known as the "million dollar nerve," in patients and controls. METHODS Thirteen patients affected by carpal tunnel syndrome (CTS) and four healthy controls had their hands scanned on a 3-T MR imaging scanner for TMB visualization. Median nerve anatomical variations were classified into four groups according to Poisel's classification system modified by Lanz. TMB signal intensity and diameter were assessed for the diagnosis of neuropathy. RESULTS TMB was successfully identified in all patients and subjects by using MRN. The most suitable pulse sequences to identify and measure nerve diameter were 3D DW-PSIF and T2-FS-TSE. The axial oblique and sagittal oblique planes are complementary in demonstrating its entire course. TMB had mostly an extraligamentous course with radial side origin (93.8%, each). All patients experienced increased T2 signal intensity (p < 0.001) and thickened nerves. Mean TMB diameters were 1.27 ± 0.21 mm (range, 1.02-1.74 mm) and 0.87 ± 0.16 mm (0.73-1.08 mm) (p = 0.008) in the patient and control groups, respectively. CONCLUSION MRN is a reliable imaging technique for identification and anatomical characterization of TMB in patients affected by CTS. This innovative imaging workup may therefore be included in the preoperative evaluation of patients scheduled for carpal tunnel release, especially in CTS with TMB involvement or even in isolated TMB neuropathy. KEY POINTS • Magnetic resonance neurography allows precise visualization of the thenar muscular branch of the median nerve. • Thenar muscular branch anatomical variations can be correctly identified. • Preoperative scanning can contribute to reducing the risk of iatrogenic injuries during carpal tunnel release, especially in carpal tunnel syndrome with thenar muscular branch involvement or even in isolated thenar muscular branch neuropathy.
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Affiliation(s)
| | | | - Renan de Freitas Souza
- Division of Neurosurgery, Fluminense Federal University, Niterói, Rio de Janeiro, Brazil
| | | | | | - José Alberto Landeiro
- Division of Neurosurgery, Fluminense Federal University, Niterói, Rio de Janeiro, Brazil
| | - Fernanda Cristina Rueda Lopes
- Division of Radiology, DASA, Rio de Janeiro, Brazil.,Division of Radiology, Fluminense Federal University, Niterói, Rio de Janeiro, Brazil
| | - Marcus André Acioly
- Division of Neurosurgery, Fluminense Federal University, Niterói, Rio de Janeiro, Brazil. .,Division of Neurosurgery, Federal University of Rio de Janeiro (UFRJ), Rio de Janeiro, Brazil.
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Murase N, Goto M, Kohara N, Kimura J. Sustained atypical myokymia of the abductor pollicis brevis with a focal slowing of the median nerve motor axons at the wrist. Clin Neurophysiol Pract 2020; 6:36-40. [PMID: 33490741 PMCID: PMC7808925 DOI: 10.1016/j.cnp.2020.11.003] [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: 05/17/2020] [Revised: 11/15/2020] [Accepted: 11/26/2020] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE We report a case of sustained atypical myokymia associated with short bursts of neuromyotonic discharges involving the abductor pollicis brevis (APB) muscle and describe a useful way of detecting a focal slowing involving a small number of median nerve motor fibers with a concentric needle using the filter setting for single fiber electromyography (EMG). METHODS AND RESULTS A 62-year-old woman developed right thumb twitches at regular interval of 1.7-3.3 s (0.6-0.3 Hz), which continued for more than four months. Muscle twitches remained the same during altered hand position, psychological stress, or sleep. A concentric needle inserted in the active zone of the APB muscle revealed myokymic bursts with a characteristic of neuromyotonic discharges. Inching study, stimulating at 5 mm increment along the median nerve and recording with a concentric needle using a filter setting for single fiber EMG, revealed a focal slowing of the motor fibers at a point 5-10 mm distal from the distal crease of the wrist, an entrapment site occasionally seen in the carpal tunnel syndrome. One injection of botulinum toxin type A eliminated the myokymia, which then recurred two and a half years later, showing less prominent muscle twitches. CONCLUSIONS Sustained atypical myokymia seen in our case represented bursts of neuromyotonic discharges originated from a focal demyelinating lesion involving a few median nerve motor fibers.
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Affiliation(s)
- Nagako Murase
- Department of Neurology, National Hospital Organization, Kyoto Medical Center, 1-1 Mukoubata-cho, Fukakusa, Fushimi-ku, Kyoto City, Kyoto 612-8555, Japan
| | - Masahiro Goto
- Department of Neurology, National Hospital Organization, Kyoto Medical Center, 1-1 Mukoubata-cho, Fukakusa, Fushimi-ku, Kyoto City, Kyoto 612-8555, Japan
| | - Nobuo Kohara
- Department of Neurology, Kobe City Medical Center General Hospital, 1-1, 2 cho-me, Minamimachi, Minatojima, Chuou-ku, Kobe City, Kobe 650-0047, Japan
| | - Jun Kimura
- Department of Neurology, Division of Clinical Neurophysiology, University of Iowa Health Center, 200 Hawkins Drive, Iowa City, IA 52242, USA
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Mathews H, Middleton A, Boan L, Jacks M, Riddick L, Shepherd J, Patel J, McNeal A, Fritz S. Intrarater and interrater reliability of a hand-held dynamometric technique to quantify palmar thumb abduction strength in individuals with and without carpal tunnel syndrome. J Hand Ther 2019; 31:554-561. [PMID: 28943237 DOI: 10.1016/j.jht.2017.08.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 08/18/2017] [Accepted: 08/24/2017] [Indexed: 02/03/2023]
Abstract
STUDY DESIGN Clinical measurement. INTRODUCTION Individuals with carpal tunnel syndrome (CTS) sometimes exhibit weakness of palmar abduction strength (TAS). Reliable assessment of this strength in both subjects with and without CTS with the commonly available Microfet 2 is not known. PURPOSE OF THE STUDY The purpose of this study was to determine the intrarater and interrater reliabilities of a handheld dynamometric (HHD) method to assess TAS in individuals with and without CTS using the commercially available MicroFET2 and to examine the association between TAS in individuals with CTS and the Carpal Tunnel Symptom Questionnaire (CTSQ) scores. METHODS In 2 different study phases, individuals with and without CTS were assessed for TAS by 2 different examiners. The CTSQ was administered to the individuals with CTS. RESULTS Intrarater and interrater reliability coefficients (0.89-0.93 and 0.82-0.90, respectively) were excellent in individuals with and without CTS. Weak negative correlations were found between TAS and overall CTSQ and symptom severity subscale scores, and a moderate negative correlation was found between TAS and functional Status Subscale score. DISCUSSION This HHD method of reliably assessing TAS better quantifies deficits and progress than traditional manual muscle testing for muscle grades greater than 3/5. CONCLUSION This method of HHD reliably quantifies TAS but is more reliable with the same than different raters.
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Affiliation(s)
- Harvey Mathews
- Department of Exercise Science, Program of Physical Therapy, Arnold School of Public Health, University of South Carolina, Columbia, SC.
| | - Addie Middleton
- Division of Rehabilitation Sciences, University of Texas Medical Branch, Galveston, TX
| | - Lindsey Boan
- Department of Exercise Science, Program of Physical Therapy, Arnold School of Public Health, University of South Carolina, Columbia, SC
| | - Madison Jacks
- Department of Exercise Science, Program of Physical Therapy, Arnold School of Public Health, University of South Carolina, Columbia, SC
| | - Lindsey Riddick
- Department of Exercise Science, Program of Physical Therapy, Arnold School of Public Health, University of South Carolina, Columbia, SC
| | - Jessica Shepherd
- Department of Exercise Science, Program of Physical Therapy, Arnold School of Public Health, University of South Carolina, Columbia, SC
| | - Jay Patel
- Palmetto Health USC Medical Center, Palmetto Health USC Orthopedic Rehabilitation, Columbia, SC
| | - Antonia McNeal
- Palmetto Health USC Medical Center, Palmetto Health USC Orthopedic Rehabilitation, Columbia, SC
| | - Stacy Fritz
- Department of Exercise Science, Program of Physical Therapy, Arnold School of Public Health, University of South Carolina, Columbia, SC
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Neral M, Imbriglia JE, Carlson L, Wollstein R. Motor Examination in the Diagnosis of Carpal Tunnel Syndrome. J Hand Microsurg 2017; 9:67-73. [PMID: 28867905 DOI: 10.1055/s-0037-1603346] [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: 01/23/2017] [Accepted: 04/21/2017] [Indexed: 10/19/2022] Open
Abstract
The relative importance and use of motor evaluation to diagnose carpal tunnel syndrome (CTS) is not clear. Because the ulnar nerve is not affected in CTS, we evaluated comparing the strength of the median-nerve innervated muscles to the ulnar innervated muscles in the same patient, through manual muscle testing (MMT) and a handheld dynamometer. Our purpose was to evaluate whether this method, which takes into account patient-dependent factors that would affect both groups of muscles equally, can provide better assessment of CTS. A retrospective case-control review of MMT and dynamometer-measured strength for CTS was performed. The study was performed retrospectively but prior to surgery or other treatment. There were 28 cases (CTS) and 14 controls (without CTS). Positive nerve conduction tests defined cases. MMT of the thenar musculature was found to be unreliable as a test for CTS. Comparisons to ulnar nerve innervated muscle strength did not improve sensitivity or specificity of the MMT examination. Use of the dynamometer improved sensitivity and specificity of motor testing in CTS over MMT. Motor evaluation is important for the diagnosis of CTS, but further study is warranted, specifically to define the method of motor evaluation and delineate the subgroup of patients (predominantly thenar motor presentation) that would benefit most from motor testing and motor-focused treatment.
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Affiliation(s)
- Mithun Neral
- Department of Plastic and Reconstructive Surgery, University of Pittsburgh Medical School, Pittsburgh, Pennsylvania, United States.,Department of Orthopedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| | - Joseph E Imbriglia
- Department of Orthopedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| | - Lois Carlson
- The Hand Center, University of Connecticut School of Medicine, Glastonbury, Connecticut, United States
| | - Ronit Wollstein
- Department of Plastic and Reconstructive Surgery, University of Pittsburgh Medical School, Pittsburgh, Pennsylvania, United States.,Division of Hand and Upper Extremity Surgery, Department of Orthopedics, Technion School of Medicine, Haifa, Israel
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Riegler G, Pivec C, Platzgummer H, Lieba-Samal D, Brugger P, Jengojan S, Vierhapper M, Bodner G. High-resolution ultrasound visualization of the recurrent motor branch of the median nerve: normal and first pathological findings. Eur Radiol 2016; 27:2941-2949. [PMID: 27957641 PMCID: PMC5486794 DOI: 10.1007/s00330-016-4671-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 09/11/2016] [Accepted: 11/21/2016] [Indexed: 12/31/2022]
Abstract
Purpose To evaluate in a prospective study the possibility of visualization and diagnostic assessment of the recurrent motor branch (RMB) of the median nerve with high-resolution ultrasound (HRUS). Materials and methods HRUS with high-frequency probes (18–22 MhZ) was used to locate the RMB in eight fresh cadaveric hands. To verify correct identification, ink-marking and consecutive dissection were performed. Measurement of the RMB maximum transverse-diameter, an evaluation of the origin from the median nerve and its course in relation to the transverse carpal ligament, was performed in both hands of ten healthy volunteers (n = 20). Cases referred for HRUS examinations for suspected RMB lesions were also assessed. Results The RMB was clearly visible in all anatomical specimens and all volunteers. Dissection confirmed HRUS findings in all anatomical specimens. Mean RMB diameter in volunteers was 0.7 mm ± 0.1 (range, 0.6–1). The RMB originated from the radial aspect in 11 (55%), central aspect in eight (40%) and ulnar aspect in one (5%) hand. Nineteen (95%) extraligamentous courses and one (5%) subligamentous course were detected. Three patients with visible RMB abnormalities on HRUS were identified. Conclusion HRUS is able to reliably visualize the RMB, its variations and pathologies. Key Points • Ultrasound allows visualization of the recurrent motor branch of the median nerve. • Ultrasound may help clinicians to assess patients with recurrent motor branch pathologies. • Patient management may become more appropriate and targeted therapy could be improved. Electronic supplementary material The online version of this article (doi:10.1007/s00330-016-4671-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Georg Riegler
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Währingergürtel 18-20, 1090, Vienna, Austria.
| | - Christopher Pivec
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Währingergürtel 18-20, 1090, Vienna, Austria
| | - Hannes Platzgummer
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Währingergürtel 18-20, 1090, Vienna, Austria
| | - Doris Lieba-Samal
- Department of Neurology, Medical University of Vienna, Währingergürtel 18-20, 1090, Vienna, Austria
| | - Peter Brugger
- Department of Anatomy, Center for Anatomy and Cell Biology, Medical University of Vienna, Währingerstrasse 13, 1090, Vienna, Austria
| | - Suren Jengojan
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Währingergürtel 18-20, 1090, Vienna, Austria
| | - Martin Vierhapper
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Medical University of Vienna, Währingergürtel 18-20, 1090, Vienna, Austria
| | - Gerd Bodner
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Währingergürtel 18-20, 1090, Vienna, Austria
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Alrawashdeh O. Prevalence of Asymptomatic Neurophysiological Carpal Tunnel Syndrome in 130 Healthy Individuals. Neurol Int 2016; 8:6553. [PMID: 27994828 PMCID: PMC5136750 DOI: 10.4081/ni.2016.6553] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Revised: 06/05/2016] [Accepted: 06/05/2016] [Indexed: 11/23/2022] Open
Abstract
Diagnosis of carpal tunnel syndrome (CTS) is frequently confirmed by performing nerve conduction studies. Previous studies demonstrated that abnormal nerve conduction study (NCS) is suggestive of CTS among asymptomatic individuals. However, previous studies included individuals with risk factors for the syndrome. A NCS was performed on the median and ulnar nerves in 130 healthy individuals. About 15% of individuals in this study demonstrated electrodiagnostic evidence of carpal tunnels syndrome. Four cases have shown signs of isolated median neuropathy with normal median sensory component. Results indicated that the most widely used method for confirming diagnosis of CTS may have up to 15% of false positives. However, most of those showed changes of minimal CTS. Isolated prolongation of the median motor latency should be investigated further as they are usually classified as moderate to severe CTS and may undergo unnecessary surgeries.
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Affiliation(s)
- Omar Alrawashdeh
- Clinical Neurology, Faculty of Medicine, Mutah University , Mutah, Jordan
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Funaba M, Kanchiku T, Imajo Y, Yamamoto H, Hiura Y, Fujimoto K, Taguchi T, Kido K. Relation between distal motor latency delay and sensory action potential absence of the median nerve in carpal tunnel syndrome. Clin Neurol Neurosurg 2016; 148:45-8. [PMID: 27391975 DOI: 10.1016/j.clineuro.2016.06.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Revised: 06/12/2016] [Accepted: 06/22/2016] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To elucidate the cutoff value for distal motor latency (DML) at which sensory nerve action potentials (SNAPs) are absent in carpal tunnel syndrome (CTS) patients. METHOD We examined 157 hands in 129 patients with CTS retrospectively. We classified the patients according to whether SNAPs were successfully obtained. Group A consisted of hands with SNAPs, while Group B consisted of hands without SNAPs. The cutoff value for DML was determined by receiver-operating characteristic curve analysis. We enrolled 130 hands with CTS for the analysis, because measurements were successful in 130 hands for compound muscle action potentials and in 82 hands for SNAPs from a total of 157 hands investigated. RESULTS A significant correlation was observed between DML and SCV (P<0.0001, R*2=0.40). The most discriminative cutoff value for DML was 7.7ms, resulting in a sensitivity of 79.6% and specificity of 79.3%. CONCLUSION Cases in which SNAPs are evoked despite a DML longer than 7.7ms should raise suspicion.
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Affiliation(s)
- Masahiro Funaba
- Department of Orthopedic Surgery, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan; Department of Orthopedic Surgery, Yamaguchi Rosai Hospital, Yamaguchi, Japan.
| | - Tsukasa Kanchiku
- Department of Orthopedic Surgery, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan
| | - Yasuaki Imajo
- Department of Orthopedic Surgery, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan
| | - Hisashi Yamamoto
- Department of Orthopedic Surgery, Yamaguchi Rosai Hospital, Yamaguchi, Japan
| | - Yasuhiro Hiura
- Department of Orthopedic Surgery, Ube Kosan Central Hospital, Yamaguchi, Japan
| | - Kazuhiro Fujimoto
- Department of Orthopedic Surgery, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan
| | - Toshihiko Taguchi
- Department of Orthopedic Surgery, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan
| | - Kenji Kido
- Department of Orthopedic Surgery, Yamaguchi Rosai Hospital, Yamaguchi, Japan
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