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Savage NJ, McKell JS. Median Nerve Cross-Sectional Area and Carpal Tunnel Syndrome in Specific Populations: Sonographic Analysis of Patients with Type 2 Diabetes or Bifid Anatomy. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2024. [PMID: 38813705 DOI: 10.1002/jum.16491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Revised: 04/01/2024] [Accepted: 05/12/2024] [Indexed: 05/31/2024]
Abstract
OBJECTIVES Evaluate diagnostic accuracy of median nerve cross-sectional area (CSA) to determine severity versus presence of carpal tunnel syndrome (CTS) across existing electrodiagnostic-based (EDX) classification systems in patients with type 2 diabetes or bifid anatomy. METHODS Retrospective analysis of cross-sectional patient data. Receiver operating characteristic analysis used to determine median nerve CSA cutoff values and associated diagnostic likelihood ratios for all consolidated and binary EDX-based classifications of CTS in patients with type 2 diabetes or bifid anatomy. Determine shifts in diagnostic probability based on established cutoff values and associated likelihood ratios. Distal CSA measured at or near carpal tunnel inlet, proximal CSA at level of pronator quadratus muscle, and delta CSA by subtracting proximal from distal. RESULTS Binary categorizations of CTS were statistically superior to consolidated categorizations of CTS severity in patients with type 2 diabetes or bifid anatomy. Binary categorizations established reasonably consistent median nerve CSA cutoff values across all EDX-based classifications examined resulting in the following for distal CSA or delta CSA: ≤10 or ≤4 mm2 to rule out and ≥11 or ≥5 mm2 to rule in CTS, respectively. These cutoff values resulted in small shifts in diagnostic probability in patients with type 2 diabetes and small to conclusive shifts in diagnostic probability in patients with bifid anatomy. CONCLUSIONS Binary categorizations to rule out or rule in CTS based on the proposed cutoff values provide the most meaningful information about shifts in diagnostic probability across all EDX-based classifications examined. The use of median nerve CSA to categorize severity of CTS is not recommended in patients with type 2 diabetes or bifid anatomy.
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Affiliation(s)
- Nathan J Savage
- Department of Physical Therapy, Winston-Salem State University, Winston-Salem, North Carolina, USA
| | - John S McKell
- Department of Physical Therapy, McKell Therapy Group, LLC, Provo, Utah, USA
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Savage NJ, McKell JS. Sonographic Measurement of Median Nerve Cross-Sectional Area to Determine Severity of Carpal Tunnel Syndrome: A Cautionary Tale. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2024. [PMID: 38778784 DOI: 10.1002/jum.16486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 05/02/2024] [Accepted: 05/08/2024] [Indexed: 05/25/2024]
Abstract
OBJECTIVES Evaluate the diagnostic accuracy of median nerve cross-sectional area (CSA) to determine the severity of carpal tunnel syndrome (CTS) vs the presence of CTS across existing electrodiagnostic-based (EDX) classification systems. METHODS Retrospective analysis of cross-sectional patient data. Receiver operating characteristic (ROC) analysis was used to determine CSA cutoff values and associated diagnostic likelihood ratios for all consolidated and binary EDX-based classifications of CTS severity. Identification of CSA cutoff values associated with likelihood ratios capable of achieving conclusive (but at least moderate) shifts in diagnostic probability. RESULTS Binary categorizations of CTS (ie, "Normal" vs "Absent") were statistically superior to consolidated categorizations of CTS severity (ie, "Normal," "Mild," "Moderate," or "Severe"). Binary categorizations established consistent CSA cutoff values across all EDX-based classifications examined and achieved conclusive shifts in diagnostic probability based on the following values of distal CSA or delta CSA: <7 or <1 mm2 to rule out and >13 or >7 mm2 to rule in CTS, respectively. Additionally, the following values of distal CSA and delta CSA may be used in certain circumstances because they produce only small shifts in diagnostic probability: ≤10 or ≤3 mm2 to rule out and ≥11 or ≥4 mm2 to rule in CTS, respectively. CONCLUSIONS Using median nerve CSA to categorize the severity of CTS is not recommended based on lack of consistent and meaningful shifts in diagnostic probability. Rather, binary categorizations to rule out or rule in CTS based on the proposed CSA cutoff values consistently provided conclusive shifts in diagnostic probability across all EDX-based classifications examined.
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Affiliation(s)
- Nathan J Savage
- Department of Physical Therapy, Winston-Salem State University, Winston-Salem, North Carolina, USA
| | - John S McKell
- Department of Physical Therapy, McKell Therapy Group, LLC, Orem, Utah, USA
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Cano LC, Leiby BM, Shum LC, Ward MG, Joseph AE. Clinical Results of Carpal Tunnel Release Using Ultrasound Guidance in Over 100 Patients at Two to Six Years. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2024; 6:349-354. [PMID: 38817770 PMCID: PMC11133916 DOI: 10.1016/j.jhsg.2024.02.004] [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: 02/16/2024] [Accepted: 02/20/2024] [Indexed: 06/01/2024] Open
Abstract
Purpose The purpose of this study was to determine the clinical results of carpal tunnel release using ultrasound guidance (CTR-US) at a minimum of 2 years postprocedure. Methods The study consisted of 102 patients (162 hands) treated with CTR-US by the same physician between June 2017 and October 2020 for whom minimum 2-year follow-up data were available. Questionnaires were sent to gather long-term information, with additional phone calls for clarification if needed. Outcomes included Boston Carpal Tunnel Questionnaire symptom severity (BCTQ-SSS) and functional status (BCTQ-FSS) scores; Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) scores; global satisfaction scores; and subsequent surgeries. Results The 102 patients included 68 females and 34 males with a mean age of 56.9 years at the time of surgery. Fifty-five (53.9%) patients had simultaneous bilateral procedures, 42 (41.2%) had unilateral procedures, and 5 (4.9%) had staged bilateral procedures. Significant improvements in BCTQ-SSS, BCTQ-FSS, and QuickDASH scores persisted at a mean final follow-up of 46 months (range 2-6 years). At final follow-up, 91.2% of patients reported satisfaction with the procedure. No outcomes were significantly different between those treated with simultaneous bilateral versus unilateral procedures. No revision surgeries were reported. Conclusions CTR-US is a safe and effective procedure that results in significant improvements that persist up to 6 years postprocedure. Long-term results of simultaneous bilateral and unilateral procedures are similar. Type of study/level of evidence Therapeutic IV.
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Affiliation(s)
| | | | | | | | - Anthony E. Joseph
- OrthoIdaho, LLC, Pocatello, ID
- Department of Family Medicine, Idaho State University, Pocatello, ID
- Department of Family Medicine, University of Washington, Seattle, WA
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Alkaphoury MG, Dola EF. Ultrasound and magnetic resonance imaging neurography assessment of diagnostic criteria in patients with carpal tunnel syndrome using electrophysiological tests as gold standard: A prospective study. SAGE Open Med 2023; 12:20503121231218889. [PMID: 38162910 PMCID: PMC10757434 DOI: 10.1177/20503121231218889] [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: 03/26/2023] [Accepted: 11/16/2023] [Indexed: 01/03/2024] Open
Abstract
Objectives Evaluating peripheral neuropathy mainly relies on physical examination, patient history, and electrophysiological studies. High-resolution ultrasound is a fast, noninvasive modality for dynamic nerve assessment that enables the length of the nerve to be examined. Magnetic resonance imaging is preferred for examining deeper nerves with a high contrast resolution; its use shows excellent benefit in patients with atypical presentation, equivocal diagnosis, suspected secondary causes, and postsurgical relapse. We aimed to assess the measurements and criteria for both ultrasound and magnetic resonance neurography for the diagnosis of carpal tunnel syndrome, based mainly on the three measurements assessed by Buchberger et al. Methods This prospective study was conducted to test diagnostic accuracy. Thirty-two patients who presented clinically with, and were diagnosed by electrophysiological tests as having, carpal tunnel syndrome participated. Superficial ultrasound of the wrist joint was performed on all participants, followed by magnetic resonance imaging within 1 week of ultrasonography. Results The three main parameters of cross-sectional area measurement, distal nerve flattening, and flexor retinaculum bowing indices showed positive occurrences of 93.7%, 59.4%, and 59.4%, respectively; 90.6% of patients had decreased nerve echotexture. The diagnostic ability of magnetic resonance imaging was decreased when cross-sectional area measurements were used: positive results were achieved in 81.2% of patients, but the positive results showing the distal tunnel nerve increased flattening and bowed flexor retinaculum slightly decreased to 56.2% for each. A high T2 signal of the median nerve was observed in 90.6% of patients. In an agreement analysis, we found a statistically significant difference that supported the use of ultrasound as a primary diagnostic modality for carpal tunnel syndrome. However, magnetic resonance imaging improved tissue characterization and was a good diagnostic modality, with a statistically significant difference, for cases of secondary carpal tunnel syndrome, detection of the underlying entrapping cause, and early abnormality detection in the innervated muscle. Conclusions Our results demonstrate that ultrasound examination can be used as the first imaging modality after physician evaluation, with results comparable to those of electrophysiological studies for evaluating carpal tunnel syndrome and determining its cause. Magnetic resonance neurography examination is the second step in detecting secondary causes in cases with suspected early muscle denervation changes that cannot be elicited by ultrasound or in cases with equivocal results.
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Affiliation(s)
| | - Eman F Dola
- Faculty of Medicine, Ain Shams University, Cairo, Egypt
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Han D, Xu L, Xu J. Clinical Application of Ultrasound-guided Electrode Placement and Detection of Nerve Action Potential. J Neurol Surg A Cent Eur Neurosurg 2023. [PMID: 35504295 DOI: 10.1055/a-1842-4343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND We explore a minimally invasive method (combined ultrasound detection, electrode placement and electrophysiologic nerve examination) to evaluate the early-stage quality of a nerve suture site. METHODS Ten patients with median and/or ulnar nerve injuries who had undergone nerve suture were recruited. Postoperative ultrasound examination found that the nerve injury was sutured. Then, a stimulating electrode and recording electrode were located beside the nerve proximal and distal to the suture site guided by ultrasound. Measurement of nerve action potentials (NAP) were performed with these electrodes, followed by surgical exploration. The pre- and intraoperative electrophysiologic findings were compared, together with amplitude, latency, and wave shape of NAP. RESULTS Of the 10 patients, 3 patients were diagnosed with median nerve injury, 2 with ulnar nerve injury, and 5 with the median nerve and ulnar nerve injury. NAP could not be detected pre- and intraoperatively in three median nerves from three patients and in two ulnar nerves from two patients. NAP was detected in 10 nerves from the remaining 5 patients. The pre- and intraoperative NAP results showed consistent results concerning the status of the nerve suture. Wilcoxon's signed-rank test indicated no significant difference in the amplitude and latency detected via sonographically placed electrodes and during surgical exploration. The number of negative-phase waves were equally distributed. CONCLUSION Ultrasound-guided electrode placement and NAP detection can substitute surgery and serve as a minimally invasive approach to evaluate the regeneration of a sutured nerve.
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Affiliation(s)
- Dong Han
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, People's Republic of China
- Key Laboratory of Hand Reconstruction, Ministry of Health, Shanghai, People's Republic of China
- Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, People's Republic of China
| | - Le Xu
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, People's Republic of China
- Key Laboratory of Hand Reconstruction, Ministry of Health, Shanghai, People's Republic of China
- Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, People's Republic of China
| | - Jianguang Xu
- Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, People's Republic of China
- Key Laboratory of Hand Reconstruction, Ministry of Health, Shanghai, People's Republic of China
- Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai, People's Republic of China
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Kumar N, Chandan SK, Jalan D, Sinha S, Jaiswal B, Singh DK. Ultrasound-guided interventions in primary carpal tunnel syndrome: perineural injection to thread carpal tunnel release. Br J Radiol 2023; 96:20230552. [PMID: 37660684 PMCID: PMC10546448 DOI: 10.1259/bjr.20230552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 07/12/2023] [Accepted: 08/09/2023] [Indexed: 09/05/2023] Open
Abstract
Carpal tunnel syndrome (CTS), the most common entrapment neuropathy, is compression of the median nerve deep to transverse carpal ligament at wrist. Ultrasonography and electrophysiological study are complementary in the diagnosis and grading of CTS in appropriate clinical settings. The initial management of patients with CTS is conservative with medical therapy and splinting. However, surgical interventions are indicated in patients in whom medical management has failed. With evolution of the concept of safe zone on ultrasonography and identification of the sonoanatomical landmarks of carpal tunnel in greater detail, Ultrasonography-guided interventions are safer and preferred over surgical management in CTS. The primary ultrasonography-guided interventions include perineural injection, perineural hydrodissection and ultrasonography-guided release of transverse carpal ligament. This review article presents the principles of ultrasonography-guided perineural injection, perineural hydrodissection in CTS, the merits and demerits of injectant used in perineural injection/ hydrodissection, and percutaneous ultrasonography-guided thread release of transverse carpal ligament utilizing the concept of safe zone of the ultrasonography-guided interventions for CTS.
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Affiliation(s)
- Nishith Kumar
- Department of Radiodiagnosis, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Shishir Kumar Chandan
- Department of Neurology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Divesh Jalan
- Central Institute of Orthopaedics, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Skand Sinha
- Sports Injury Centre, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Binita Jaiswal
- Department of Anaesthesia and Critical Care, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Dharmendra Kumar Singh
- Department of Radiodiagnosis, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
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Serhal A, Lee SK, Michalek J, Serhal M, Omar IM. Role of high-resolution ultrasound and magnetic resonance neurography in the evaluation of peripheral nerves in the upper extremity. J Ultrason 2023; 23:e313-e327. [PMID: 38020515 PMCID: PMC10668945 DOI: 10.15557/jou.2023.0037] [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: 08/06/2023] [Accepted: 08/30/2023] [Indexed: 12/01/2023] Open
Abstract
Upper extremity entrapment neuropathies are common conditions in which peripheral nerves are prone to injury at specific anatomical locations, particularly superficial regions or within fibro-osseous tunnels, resulting in pain and potential disability. Although neuropathy is primarily diagnosed clinically by physical examination and electrophysiology, imaging evaluation with ultrasound and magnetic resonance neurography are valuable complementary non-invasive and accurate tools for evaluation and can help define the site and cause of nerve dysfunction which ultimately leads to precise and timely treatment. Ultrasound, which has higher spatial resolution, can quickly and comfortably characterize the peripheral nerves in real time and can evaluate for denervation related muscle atrophy. Magnetic resonance imaging on the other hand provides excellent contrast resolution between the nerves and adjacent tissues, also between pathologic and normal segments of peripheral nerves. It can also assess the degree of muscle denervation and atrophy. As a prerequisite for nerve imaging, radiologists and sonographers should have a thorough knowledge of anatomy of the peripheral nerves and their superficial and deep branches, including variant anatomy, and the motor and sensory territories innervated by each nerve. The purpose of this illustrative article is to review the common neuropathy and nerve entrapment syndromes in the upper extremities focusing on ultrasound and magnetic resonance neurography imaging.
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Affiliation(s)
- Ali Serhal
- Department of Radiology, Northwestern University, Chicago, USA
| | | | - Julia Michalek
- Department of Radiology, Northwestern Memorial Hospital, Chicago, USA
| | - Muhamad Serhal
- Department of Radiology, Northwestern University, Chicago, USA
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Flores DV, Murray T, Jacobson JA. Diagnostic and Interventional US of the Wrist and Hand: Quadrant-based Approach. Radiographics 2023; 43:e230046. [PMID: 37498783 DOI: 10.1148/rg.230046] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
Diagnostic and interventional US of the wrist and hand can be challenging due to the small size and superficial location of structures and various disorders that need to be considered. A quadrant-based approach (volar, ulnar, dorsal, and radial) provides a rational method for performing a focused examination and joint positioning during both diagnostic imaging and intervention. Volar wrist disorders primarily involve the median nerve and the digital flexor system comprised of the flexor tendons and pulleys. The ulnar nerve and extensor carpi ulnaris tendon are chiefly responsible for ulnar-sided wrist pain. The differential diagnosis for dorsal-sided symptoms typically involves the extensor tendon compartments and includes distal intersection syndrome, extensor pollicis longus tear, and digital extensor apparatus injury. The soft-tissue ganglion is the most common abnormality in the dorsal wrist, typically associated with wrist ligaments or joint capsule. Radial-sided pain may be secondary to de Quervain tenosynovitis and must be differentiated from the more proximal intersection syndrome. US is an important tool for assessing the ulnar collateral ligament of the first metacarpophalangeal joint of the thumb and differentiating between displaced and nondisplaced tears, thereby influencing management. Despite the complexity of the anatomy and potential pathologic features within the wrist, a focused quadrant-based examination can permit the sonologist to focus on the structures of relevance. In conjunction with a systematic approach, this can aid in precise and efficient diagnostic scanning and intervention of the wrist and hand. ©RSNA, 2023 Supplemental material is available for this article. Quiz questions for this article are available through the Online Learning Center.
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Affiliation(s)
- Dyan V Flores
- From the Department of Radiology, Radiation Oncology and Medical Physics, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada K1H 8L6 (D.V.F.); Department of Medical Imaging, The Ottawa Hospital, Ottawa, Ontario, Canada (D.V.F.); Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (D.V.F.); Department of Radiology, St Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada (T.M.); Lenox Hill Radiology and Medical Imaging, New York, NY (J.A.J.); and Department of Radiology, University of California-San Diego, San Diego, Calif (J.A.J.)
| | - Timothy Murray
- From the Department of Radiology, Radiation Oncology and Medical Physics, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada K1H 8L6 (D.V.F.); Department of Medical Imaging, The Ottawa Hospital, Ottawa, Ontario, Canada (D.V.F.); Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (D.V.F.); Department of Radiology, St Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada (T.M.); Lenox Hill Radiology and Medical Imaging, New York, NY (J.A.J.); and Department of Radiology, University of California-San Diego, San Diego, Calif (J.A.J.)
| | - Jon A Jacobson
- From the Department of Radiology, Radiation Oncology and Medical Physics, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada K1H 8L6 (D.V.F.); Department of Medical Imaging, The Ottawa Hospital, Ottawa, Ontario, Canada (D.V.F.); Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (D.V.F.); Department of Radiology, St Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada (T.M.); Lenox Hill Radiology and Medical Imaging, New York, NY (J.A.J.); and Department of Radiology, University of California-San Diego, San Diego, Calif (J.A.J.)
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Schwabl C, Hörmann R, Strolz CJ, Drakonaki E, Zimmermann R, Klauser AS. Anatomical Variants of the Upper Limb Nerves: Clinical and Preoperative Relevance. Semin Musculoskelet Radiol 2023; 27:129-135. [PMID: 37011614 PMCID: PMC10069954 DOI: 10.1055/s-0043-1761952] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
Abstract
Profound knowledge of nerve variations is essential for clinical practice. It is crucial for interpreting the large variability of a patient's clinical presentation and the different mechanisms of nerve injury. Awareness of nerve variations facilitates surgical safety and efficacy. Clinically significant anatomical variations can be classified into two main groups: variability in the course of the nerve and variability of structures surrounding the nerve. In this review article we focus on the most common nerve variants of the upper extremity and their clinical relevance.
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Affiliation(s)
- Christoph Schwabl
- Radiology Department, Medical University of Innsbruck, Innsbruck, Austria
| | - Romed Hörmann
- Department of Anatomy, Histology and Embryology, Institute of Clinical and Functional Anatomy, Medical University of Innsbruck, Innsbruck, Austria
| | | | - Elena Drakonaki
- Independent MSK Radiology Practice, Heraklion, Crete, Greece
| | - Robert Zimmermann
- Department of Surgery, University Hospital for Plastic, Reconstructive and Aesthetic Surgery, Medical University of Innsbruck, Innsbruck, Austria
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Wang JC, Shu YC, Lin CY, Wu WT, Chen LR, Lo YC, Chiu HC, Özçakar L, Chang KV. Application of deep learning algorithms in automatic sonographic localization and segmentation of the median nerve: A systematic review and meta-analysis. Artif Intell Med 2023; 137:102496. [PMID: 36868687 DOI: 10.1016/j.artmed.2023.102496] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 11/13/2022] [Accepted: 01/18/2023] [Indexed: 01/22/2023]
Abstract
OBJECTIVE High-resolution ultrasound is an emerging tool for diagnosing carpal tunnel syndrome caused by the compression of the median nerve at the wrist. This systematic review and meta-analysis aimed to explore and summarize the performance of deep learning algorithms in the automatic sonographic assessment of the median nerve at the carpal tunnel level. METHODS PubMed, Medline, Embase, and Web of Science were searched from the earliest records to May 2022 for studies investigating the utility of deep neural networks in the evaluation of the median nerve in carpal tunnel syndrome. The quality of the included studies was evaluated using the Quality Assessment Tool for Diagnostic Accuracy Studies. The outcome variables included precision, recall, accuracy, F-score, and Dice coefficient. RESULTS In total, seven articles were included, comprising 373 participants. The deep learning and related algorithms comprised U-Net, phase-based probabilistic active contour, MaskTrack, ConvLSTM, DeepNerve, DeepSL, ResNet, Feature Pyramid Network, DeepLab, Mask R-CNN, region proposal network, and ROI Align. The pooled values of precision and recall were 0.917 (95 % confidence interval [CI], 0.873-0.961) and 0.940 (95 % CI, 0.892-0.988), respectively. The pooled accuracy and Dice coefficient were 0.924 (95 % CI, 0.840-1.008) and 0.898 (95 % CI, 0.872-0.923), respectively, whereas the summarized F-score was 0.904 (95 % CI, 0.871-0.937). CONCLUSION The deep learning algorithm enables automated localization and segmentation of the median nerve at the carpal tunnel level in ultrasound imaging with acceptable accuracy and precision. Future research is expected to validate the performance of deep learning algorithms in detecting and segmenting the median nerve along its entire length as well as across datasets obtained from various ultrasound manufacturers.
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Affiliation(s)
- Jia-Chi Wang
- Department of Physical Medicine and Rehabilitation, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yi-Chung Shu
- Institute of Applied Mechanics, College of Engineering, National Taiwan University, Taipei, Taiwan
| | - Che-Yu Lin
- Institute of Applied Mechanics, College of Engineering, National Taiwan University, Taipei, Taiwan
| | - Wei-Ting Wu
- Department of Physical Medicine and Rehabilitation and Community and Geriatric Research Center, National Taiwan University Hospital, Bei-Hu Branch, Taipei, Taiwan; Department of Physical Medicine and Rehabilitation, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Lan-Rong Chen
- Department of Physical Medicine and Rehabilitation and Community and Geriatric Research Center, National Taiwan University Hospital, Bei-Hu Branch, Taipei, Taiwan
| | - Yu-Cheng Lo
- Institute of Applied Mechanics, College of Engineering, National Taiwan University, Taipei, Taiwan
| | - Hsiao-Chi Chiu
- Institute of Applied Mechanics, College of Engineering, National Taiwan University, Taipei, Taiwan
| | - Levent Özçakar
- Department of Physical and Rehabilitation Medicine, Hacettepe University Medical School, Ankara, Turkey
| | - Ke-Vin Chang
- Department of Physical Medicine and Rehabilitation and Community and Geriatric Research Center, National Taiwan University Hospital, Bei-Hu Branch, Taipei, Taiwan; Department of Physical Medicine and Rehabilitation, National Taiwan University College of Medicine, Taipei, Taiwan; Center for Regional Anesthesia and Pain Medicine, Wang-Fang Hospital, Taipei Medical University, Taipei, Taiwan.
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11
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Wu Y, Barrere V, Han A, Chang EY, Andre MP, Shah SB. Repeatability, Reproducibility and Sources of Variability in the Assessment of Backscatter Coefficient and Texture Parameters from High-Frequency Ultrasound Acquisitions in Human Median Nerve. ULTRASOUND IN MEDICINE & BIOLOGY 2023; 49:122-135. [PMID: 36283940 DOI: 10.1016/j.ultrasmedbio.2022.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 08/01/2022] [Accepted: 08/07/2022] [Indexed: 06/16/2023]
Abstract
Ultrasound (US) is an increasingly prevalent and effective diagnostic modality for neuromuscular imaging. Gray-scale B-mode imaging has been the dominant US approach to evaluating nerves qualitatively or making morphometric measurements of nerves, providing important insights into pathological changes for conditions such as carpal tunnel syndrome. Among more recent ultrasound strategies, high-frequency ultrasound (often defined as >15 MHz for clinical applications), quantitative ultrasound and image textural analysis offer promising enhancements for improved and more objective approaches to nerve imaging. In this study, we evaluated the repeatability and reproducibility of backscatter coefficient (BSC) and imaging texture features extracted by gray-level co-occurrence matrices (GLCMs) in homogeneous tissue-mimicking reference phantoms and in median nerves in the wrists of healthy participants. We also investigated several practical sources of variability in the assessment of quantitative parameters, including influences of operators, and participant-to-participant variability. Overall, BSC- and GLCM-based outcomes are highly repeatable and reproducible after operator training, based on measurement of descriptive statistics, repeatability coefficient (RC) and reproducibility coefficient recommended by Quantitative Imaging Biomarker Alliance (QIBA RDC). GLCM parameters appear more reproducible and repeatable than BSC-based parameters in healthy participants in vivo. However, such variability noted here must be compared with the value ranges and variability of the results in pathological nerves, including median nerves afflicted by trauma, overuse syndromes such as carpal tunnel syndrome and after surgical repair.
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Affiliation(s)
- Yuanshan Wu
- Department of Bioengineering, University of California, San Diego, California, USA; Research Service, VA San Diego Healthcare System, San Diego, California, USA
| | - Victor Barrere
- Research Service, VA San Diego Healthcare System, San Diego, California, USA; Department of Orthopaedic Surgery, University of California, San Diego, California, USA
| | - Aiguo Han
- Department of Electrical and Computer Engineering, University of Illinois at Urbana-Champaign, Urbana, Illinois, USA
| | - Eric Y Chang
- Research Service, VA San Diego Healthcare System, San Diego, California, USA; Department of Radiology, University of California, San Diego, California, USA
| | - Michael P Andre
- Research Service, VA San Diego Healthcare System, San Diego, California, USA; Department of Radiology, University of California, San Diego, California, USA
| | - Sameer B Shah
- Department of Bioengineering, University of California, San Diego, California, USA; Research Service, VA San Diego Healthcare System, San Diego, California, USA; Department of Orthopaedic Surgery, University of California, San Diego, California, USA.
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Abstract
BACKGROUND The purpose of this study was to determine the long-term safety and efficacy of carpal tunnel release (CTR) using ultrasound guidance in a group of patients treated by a single physician. METHODS The study group consisted of 76 consecutive CTRs performed on 47 patients between June 2017 and April 2019 for whom 1-year follow-up was available. All procedures were performed by the same operator using a single CTR technique. Outcomes included complications; Boston Carpal Tunnel Questionnaire symptom severity (BCTQ-SSS) and functional status (BCTQ-FSS) scores; Quick Disabilities of the Arm, Shoulder, and Hand (QDASH) scores; and a 5-point global satisfaction score (4 = satisfied, 5 = very satisfied). RESULTS The 47 patients included 27 females and 20 males (ages 31-91 years). Twenty-five patients (50 hands) had simultaneous bilateral CTRs, 4 patients (8 hands) had staged bilateral CTRs, and 18 patients had unilateral CTRs. No complications occurred. Statistically and clinically significant reductions in BCTQ-SSS, BCTQ-FSS, and QDASH scores occurred by 1 to 2 weeks post-CTR and persisted at 1-year (mean 1-year changes vs. pre-CTR -2.11, -1.70, and -44.99, respectively; P < .001 for all). The mean global satisfaction score at 1-year was 4.63. CONCLUSIONS CTR using ultrasound (US) guidance is a safe and effective procedure that produces statistically and clinically significant improvements within 1 to 2 weeks postprocedure that persist to 1 year. Furthermore, simultaneous bilateral CTRs using US guidance are feasible and may be advantageous for patients who are candidates for bilateral CTR.
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Affiliation(s)
| | | | - Anthony E. Joseph
- OrthoIdaho, Pocatello, ID, USA
- Idaho State University, Pocatello, ID, USA
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13
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Voltan G, Filho FB, Leite MN, De Paula NA, Santana JM, Silva CML, Barreto JG, Da Silva MB, Conde G, Salgado CG, Frade MAC. Point-of-care ultrasound of peripheral nerves in the diagnosis of Hansen's disease neuropathy. Front Med (Lausanne) 2022; 9:985252. [PMID: 36160126 PMCID: PMC9504868 DOI: 10.3389/fmed.2022.985252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Accepted: 08/05/2022] [Indexed: 11/16/2022] Open
Abstract
Introduction Hansen's disease (HD) is the most common cause of treatable peripheral neuropathy in the world that may or may not involve skin manifestations, and physical examination based on simplified neurologic evaluation is a subjective and inaccurate procedure. High-resolution ultrasound (HRUS) can be used to evaluate peripheral nerves and is a validated technique of good reproducibility, permitting a detailed and precise examination. Objectives We proposed to establish objective criteria for absolute values of the measurement of the CSA of peripheral nerves and their indices of the ΔCSA and ΔTpT in the diagnosis of Hansen's disease neuropathy as compared with healthy voluntaries. Materials and methods In municipalities from different regions of Brazil, we randomly selected 234 volunteer Brazilian patients diagnosed with leprosy to be submitted to peripheral nerve echography and compared with 49 healthy Brazilian volunteers. Results Hansen Disease assessed by high resolution ultrasound is a primarily neural disease that leads to multiple hypertrophic mononeuropathy characterized by CSA values exceeding normal limits (Med CT = 10.2 mm2; UT = 9.8 mm2; UPT = 9.3 mm2; CFFH = 18.3 mm2; T = 9.6 mm2), and the pattern of asymmetry (ΔCSA>2.5 mm2 with RR 13) and focality (ΔTPT > 2.5 mm2 with RR 6.4) of this thickening has higher sensitivity (76,1%) and specificity (87,8 %) for its early diagnosis that laboratory tests. Analyzing each subject, the percentage of thickened nerves detected among the total number of nerves assessed was higher among patients with HD than among healthy individuals (p < 0.0001). Individuals with two or more thickened nerves were at 24.1 times higher relative risk (95% CI: 6.74–88.98) of HD.
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Affiliation(s)
- Glauber Voltan
- Department of Interne Medicine - Dermatology, Faculty of Medicine of Ribeirão Preto, University of São Paulo, São Paulo, Brazil
- *Correspondence: Glauber Voltan
| | - Fred Bernards Filho
- Department of Interne Medicine - Dermatology, Faculty of Medicine of Ribeirão Preto, University of São Paulo, São Paulo, Brazil
| | - Marcel Nani Leite
- Faculty of Medicine of Ribeirão Preto, University of São Paulo, São Paulo, Brazil
| | | | - Jaci Maria Santana
- Faculty of Medicine of Ribeirão Preto, University of São Paulo, São Paulo, Brazil
| | | | | | | | | | | | - Marco Andrey Cipriani Frade
- Department of Interne Medicine - Dermatology, Faculty of Medicine of Ribeirão Preto, University of São Paulo, São Paulo, Brazil
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14
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Symanski JS, Ross AB, Davis KW, Brunner MC, Lee KS. US for Traumatic Nerve Injury, Entrapment Neuropathy, and Imaging-guided Perineural Injection. Radiographics 2022; 42:1546-1561. [PMID: 35776677 DOI: 10.1148/rg.210152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
US is commonly performed to help diagnose traumatic peripheral nerve injury and entrapment neuropathy, particularly with superficial nerves, where higher spatial resolution provides an advantage over MRI. Other advantages of US include dynamic evaluation, easy contralateral comparison, fewer implant contraindications, less artifact from ferromagnetic debris, and facile needle guidance for perineural injections. The authors review peripheral nerve US for traumatic peripheral nerve injury with an emphasis on injury grading and entrapment neuropathy and describe best-practice techniques for US-guided perineural injections while highlighting specific techniques and indications. Online supplemental material is available for this article. ©RSNA, 2022.
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Affiliation(s)
- John S Symanski
- From the Department of Radiology, University of Wisconsin Hospital and Clinics, 600 Highland Ave, Madison, WI 53792 (J.S.S., A.B.R., K.W.D., M.C.B., K.S.L.); and Department of Radiology, William S. Middleton Veterans Hospital, Madison, Wis (M.C.B.)
| | - Andrew B Ross
- From the Department of Radiology, University of Wisconsin Hospital and Clinics, 600 Highland Ave, Madison, WI 53792 (J.S.S., A.B.R., K.W.D., M.C.B., K.S.L.); and Department of Radiology, William S. Middleton Veterans Hospital, Madison, Wis (M.C.B.)
| | - Kirkland W Davis
- From the Department of Radiology, University of Wisconsin Hospital and Clinics, 600 Highland Ave, Madison, WI 53792 (J.S.S., A.B.R., K.W.D., M.C.B., K.S.L.); and Department of Radiology, William S. Middleton Veterans Hospital, Madison, Wis (M.C.B.)
| | - Michael C Brunner
- From the Department of Radiology, University of Wisconsin Hospital and Clinics, 600 Highland Ave, Madison, WI 53792 (J.S.S., A.B.R., K.W.D., M.C.B., K.S.L.); and Department of Radiology, William S. Middleton Veterans Hospital, Madison, Wis (M.C.B.)
| | - Kenneth S Lee
- From the Department of Radiology, University of Wisconsin Hospital and Clinics, 600 Highland Ave, Madison, WI 53792 (J.S.S., A.B.R., K.W.D., M.C.B., K.S.L.); and Department of Radiology, William S. Middleton Veterans Hospital, Madison, Wis (M.C.B.)
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15
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Daniels SP, De Tolla JE, Azad A, Petchprapa CN. Nerve Imaging in the Wrist. Semin Musculoskelet Radiol 2022; 26:140-152. [PMID: 35609575 DOI: 10.1055/s-0042-1742393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Neuropathic symptoms involving the wrist are a common clinical presentation that can be due to a variety of causes. Imaging plays a key role in differentiating distal nerve lesions in the wrist from more proximal nerve abnormalities such as a cervical radiculopathy or brachial plexopathy. Imaging complements electrodiagnostic testing by helping define the specific lesion site and by providing anatomical information to guide surgical planning. This article reviews nerve anatomy, normal and abnormal findings on ultrasonography and magnetic resonance imaging, and common and uncommon causes of neuropathy.
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Affiliation(s)
- Steven P Daniels
- Department of Radiology, New York University Grossman School of Medicine, New York University, New York, New York
| | - Jadie E De Tolla
- Department of Orthopedic Surgery, New York University Grossman School of Medicine, New York University, New York, New York
| | - Ali Azad
- Department of Orthopedic Surgery, New York University Grossman School of Medicine, New York University, New York, New York
| | - Catherine N Petchprapa
- Department of Radiology, New York University Grossman School of Medicine, New York University, New York, New York
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16
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Yerasu MR, Ali M, Rao R, Murthy JMK. Bifid median nerve: a notable anomaly in carpal tunnel syndrome. BMJ Case Rep 2022; 15:e249220. [PMID: 35580937 PMCID: PMC9114938 DOI: 10.1136/bcr-2022-249220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2022] [Indexed: 11/03/2022] Open
Affiliation(s)
| | - Mahmood Ali
- Neurology, CARE Hospital, Banjara Hills, Hyderabad, India
| | - Ravichander Rao
- Plastic surgery, CARE Hospital, Banjara Hills, Hyderabad, India
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17
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Asghar A, Patra A, Ravi KS, Tubbs RS, Kumar A, Naaz S. Bifid median nerve as an anatomical risk factor for carpal tunnel syndrome: A meta-analysis. Clin Anat 2022; 35:946-952. [PMID: 35489054 DOI: 10.1002/ca.23900] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 04/22/2022] [Accepted: 04/28/2022] [Indexed: 11/06/2022]
Abstract
As the median nerve enters the carpal tunnel, it is a single nerve that soon bifurcates into lateral and medial branches into the hand. If the bifurcation is proximal to the carpel tunnel, a bifid median nerve results. Carpal tunnel syndrome is often associated with a bifid median nerve with or without a persistent median artery. Individual keywords and MeSH phrases were searched in the Google Scholar, SCOPUS, and PubMed databases. Full texts were then collected and assessed for suitability. The prevalence of bifid median nerve at the wrist joint in normal and carpal tunnel syndrome wrists (pre-canal part) and the mean difference between groups were recorded. Only human data were used to test the findings. The pooled odds ratio (with minimal heterogeneity) was 1.50 [1.17-1.93, 95% CI]. The bifid median nerve cross-sectional area (CSA) was significantly greater than that of a solitary median nerve in normal wrists. The mean difference in CSA between the two was 1.50 mm2 [0.56-2.45 mm2 , 95% CI] without heterogeneity (i2 = 0). Sex and laterality distributions scarcely differed between the two types of wrists. Owing to the insufficiency of data, the relationships with mean height and weight were not examined. There was a 50% greater incidence of bifid median nerves in carpal tunnel syndrome patients than in normal subjects. A bifid median nerve increases the mean CSA at the wrist joint by 1.5 mm2 . These findings indicate that the bifid median nerve is an anatomical risk factor for carpal tunnel syndrome. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Adil Asghar
- Associate Professor, Dept of Anatomy, AIIMS, Patna, India
| | - Apurba Patra
- Assistant Professor, Dept of Anatomy, AIIMS, Bathinda, India
| | | | - R Shane Tubbs
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, Louisiana, USA; Ochsner Neuroscience Institute, Ochsner Health System, New Orleans, Louisiana, USA; Department of Structural & Cellular Biology, Tulane University School of Medicine, New Orleans, Louisiana, USA; Department of Neurology, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, New Orleans, Louisiana, USA; Department of Anatomical Sciences, St. George's University School of Medicine, St. George's, Grenada
| | - Ashutosh Kumar
- Assistant Professor, Dept of Anatomy, AIIMS, Patna, India
| | - Shagufta Naaz
- Associate Professor, Dept of Anaesthesiology, AIIMS, Patna, India
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18
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Abstract
Diagnostic ultrasound in the diagnosis of carpal tunnel syndrome is firmly established. Preoperative evaluation is based on quantitative parameters such as measurement of the pathologically enlarged cross-sectional area of the nerve. The value of postoperative ultrasound lies in the visualization of the anatomy and the conclusions that can be drawn from it. It focuses on the semiquantitative sonographic parameters of nerve compression. Nerve lesions and persistent strictures can be visualized and clearly localized. In recurrent disease, the primary focus is to dynamically exclude postoperative scarring, which results in a reduction of nerve gliding.
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Affiliation(s)
- Sebastian Kluge
- Handchirurgie Seefeld, Seefeldstrasse 27, Zurich 8008, Switzerland; Department of Hand Surgery, Klinik Impuls, Bahnhofstraße 137, Wetzikon 8620, Switzerland.
| | - Martin Langer
- Department of Trauma, Hand and Reconstructive Surgery, University of Munster, Waldeyerstraße 1, Munster 48149, Germany
| | - Thomas Schelle
- Department of Neurology, Klinikum Dessau-Rosslau, Auenweg 38, Dessau-Rosslau 06847, Germany
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19
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Fodor D, Rodriguez-Garcia SC, Cantisani V, Hammer HB, Hartung W, Klauser A, Martinoli C, Terslev L, Alfageme F, Bong D, Bueno A, Collado P, D'Agostino MA, de la Fuente J, Iohom G, Kessler J, Lenghel M, Malattia C, Mandl P, Mendoza-Cembranos D, Micu M, Möller I, Najm A, Özçakar L, Picasso R, Plagou A, Sala-Blanch X, Sconfienza LM, Serban O, Simoni P, Sudoł-Szopińska I, Tesch C, Todorov P, Uson J, Vlad V, Zaottini F, Bilous D, Gutiu R, Pelea M, Marian A, Naredo E. The EFSUMB Guidelines and Recommendations for Musculoskeletal Ultrasound - Part I: Extraarticular Pathologies. ULTRASCHALL IN DER MEDIZIN (STUTTGART, GERMANY : 1980) 2022; 43:34-57. [PMID: 34479372 DOI: 10.1055/a-1562-1455] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
The first part of the guidelines and recommendations for musculoskeletal ultrasound, produced under the auspices of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB), provides information about the use of musculoskeletal ultrasound for assessing extraarticular structures (muscles, tendons, entheses, ligaments, bones, bursae, fasciae, nerves, skin, subcutaneous tissues, and nails) and their pathologies. Clinical applications, practical points, limitations, and artifacts are described and discussed for every structure. After an extensive literature review, the recommendations have been developed according to the Oxford Centre for Evidence-based Medicine and GRADE criteria and the consensus level was established through a Delphi process. The document is intended to guide clinical users in their daily practice.
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Affiliation(s)
- Daniela Fodor
- 2nd Internal Medicine Department, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | | | - Vito Cantisani
- Department of Radiological, Oncological and Anatomo-pathological Sciences, "Sapienza" University, Rome, Italy
| | - Hilde B Hammer
- Department of Rheumatology, Diakonhjemmet Hospital and Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Wolfgang Hartung
- Clinic for Rheumatology and Clinical Immunology, Asklepios Clinic, Bad Abbach, Germany
| | - Andrea Klauser
- Department of Radiology, Medical University Innsbruck, Section Head Rheumatology and Sports Imaging, Innsbruck, Austria
| | - Carlo Martinoli
- Department of Health Science - DISSAL, University of Genova, Italy
- UO Radiologia, IRCCS Policlinico San Martino, Genova, Italy
| | - Lene Terslev
- Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Rigshospitalet, Glostrup, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Fernando Alfageme
- Dermatology Department, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
| | - David Bong
- Instituto Poal de Reumatologia Barcelona, EULAR Working Group Anatomy for the Image, University of Barcelona, International University of Catalunya, Spain
| | - Angel Bueno
- Department of Musculoskeletal Radiology, Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | - Paz Collado
- Rheumatology Department, Transitional Care Clinic, Hospital Universitario Severo Ochoa, Madrid, Spain
| | - Maria Antonietta D'Agostino
- Istituto di Reumatologia Università Cattolica del Sacro Cuore, UOC Reumatologia, Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Rome, Italy
| | | | - Gabriella Iohom
- Department of Anaesthesiology and Intensive Care Medicine, Cork University Hospital and University College Cork, Cork, Ireland
| | - Jens Kessler
- Department of Anaesthesiology, Division of Pain Medicine, University Hospital Heidelberg, Heidelberg, Germany
| | - Manuela Lenghel
- Radiology Department, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Clara Malattia
- UOC Clinica Pediatrica e Reumatologia, IRCCS Istituto Giannina Gaslini, Department of Neurosciences, Rehabilitation, Ophthalmology, Genetic and Maternal Infantile Sciences (DINOGMI) University of Genoa, Genoa, Italy
| | - Peter Mandl
- Division of Rheumatology, Medical University of Vienna, Vienna, Austria
| | | | - Mihaela Micu
- Rheumatology Division, 2nd Rehabilitation Department, Rehabilitation Clinical Hospital Cluj-Napoca, Romania
| | - Ingrid Möller
- Instituto Poal de Reumatologia Barcelona, EULAR Working Group Anatomy for the Image, University of Barcelona, International University of Catalunya, Spain
| | - Aurelie Najm
- Institute of Infection, Immunity and Inflammation, College of Medical Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Levent Özçakar
- Department of Physical and Rehabilitation Medicine, Hacettepe University Medical School, Ankara, Turkey
| | - Riccardo Picasso
- Department of Health Science - DISSAL, University of Genova, Italy
- UO Radiologia, IRCCS Policlinico San Martino, Genova, Italy
| | - Athena Plagou
- Ultrasound Unit, Private Radiological Institution, Athens, Greece
| | - Xavier Sala-Blanch
- Department of Anaesthesiology, Hospital Clinic, Department of Human Anatomy, Faculty of Medicine, University of Barcelona, Spain
| | - Luca Maria Sconfienza
- IRCCS Istituto Ortopedico Galeazzi, Milano Italy
- Department of Biomedical Sciences for Health, University of Milano, Milano, Italy
| | - Oana Serban
- 2nd Internal Medicine Department, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Paolo Simoni
- Paediatric Imaging Department, "Reine Fabiola" Children's University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Iwona Sudoł-Szopińska
- Department of Radiology, National Institute of Geriatrics, Rheumatology and Rehabilitation, Warsaw, Poland
| | | | - Plamen Todorov
- Department of Internal Disease Propaedeutic and Clinical Rheumatology, Medical University of Plovdiv, Plovdiv, Bulgaria
| | - Jacqueline Uson
- Department of Rheumatology Hospital Universitario Móstoles, Universidad Rey Juan Carlos, Madrid, Spain
| | - Violeta Vlad
- Sf. Maria Hospital, Rheumatology Department, Bucharest, Romania
| | - Federico Zaottini
- Department of Health Science - DISSAL, University of Genova, Italy
- UO Radiologia, IRCCS Policlinico San Martino, Genova, Italy
| | - Diana Bilous
- 2nd Internal Medicine Department, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Roxana Gutiu
- 2nd Internal Medicine Department, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Michael Pelea
- 2nd Internal Medicine Department, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Anamaria Marian
- 2nd Internal Medicine Department, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Esperanza Naredo
- Department of Rheumatology, Bone and Joint Research Unit, Hospital Universitario Fundación Jiménez Díaz, IIS Fundación Jiménez Díaz, and Universidad Autónoma de Madrid, Madrid, Spain
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Funahasi T, Suzuki T, Hayakawa K, Nakane T, Maeda A, Kuroiwa T, Kawano Y, Iwamoto T, Fujita N. Visualization of the morphological changes in the median nerve after carpal tunnel release using three-dimensional magnetic resonance imaging. Eur Radiol 2022; 32:3016-3023. [DOI: 10.1007/s00330-021-08447-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 10/16/2021] [Accepted: 10/27/2021] [Indexed: 11/04/2022]
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21
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Husain R, Reddy A, Dayan E, Huang M, Corcuera-Solano I. MRI Evaluation of Various Elbow, Forearm, and Wrist Neuropathies: A Pictorial Review. Semin Musculoskelet Radiol 2021; 25:617-627. [PMID: 34706391 DOI: 10.1055/s-0041-1729961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Upper extremity entrapment neuropathies are common and can cause pain, sensory loss, and muscle weakness leading to functional disability. We conducted a retrospective review from January 2007 until March 2020 of the magnetic resonance imaging (MRI) features of intrinsic and extrinsic causes of wrist, forearm, and elbow neuropathies of 637 patients who received a diagnosis of neuropathy by means of clinical and electrodiagnostic testing. We discuss cases with varying intrinsic and extrinsic nerve pathologies, including postoperative examples, affecting the median, radial, and ulnar nerve.Our collection of cases demonstrates a diversity of intrinsic and extrinsic causative factors. Intrinsic pathologies include neuritis as well as tumors arising from the nerve. Extrinsic causes resulting in nerve entrapment include masses, acute and chronic posttraumatic cases, anatomical variants, inflammatory and crystal deposition, calcium pyrophosphate deposition disease, and dialysis-related amyloidosis. Finally, we review postsurgical cases, such as carpal tunnel release and ulnar nerve transposition.Although upper extremity neuropathies tend to have a typical clinical presentation, imaging, particularly MRI, plays a vital role in evaluating the etiology and severity of each neuropathy and ultimately helps guide clinical management.
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Affiliation(s)
- Rola Husain
- Department of Radiology, Icahn School of Medicine at Mount Sinai Hospital, New York, New York
| | - Arthi Reddy
- Department of Radiology, Icahn School of Medicine at Mount Sinai Hospital, New York, New York
| | - Etan Dayan
- Department of Radiology, Icahn School of Medicine at Mount Sinai Hospital, New York, New York
| | - Mingqian Huang
- Department of Radiology, Icahn School of Medicine at Mount Sinai Hospital, New York, New York
| | - Idoia Corcuera-Solano
- Department of Radiology, Icahn School of Medicine at Mount Sinai Hospital, New York, New York
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22
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Chhabra A, Ratakonda R, Zaottini F, Picasso R, Martinoli C. Hand and Wrist Neuropathies: High-resolution Ultrasonography and MR Neurography. Semin Musculoskelet Radiol 2021; 25:366-378. [PMID: 34450661 DOI: 10.1055/s-0041-1730406] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
High-resolution ultrasonography (US) and magnetic resonance neurography (MRN) have followed parallel paths for peripheral nerve imaging with little comparison of the two modalities. They seem equally effective to study a variety of neuropathies affecting large and small nerves in the wrist and hand. This article outlines the technical considerations of US and MRN and discusses normal and abnormal imaging appearances of hand and wrist nerves from etiologies such as entrapment, injury, tumor, and proximal and diffuse neuropathy, with specific case illustrations.
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Affiliation(s)
- Avneesh Chhabra
- Radiology and Orthopedic Surgery, UT Southwestern Medical Center, Dallas, Texas
| | - Raghu Ratakonda
- Radiology and Orthopedic Surgery, UT Southwestern Medical Center, Dallas, Texas
| | - Federico Zaottini
- Radiology Unit, Department of Health Sciences (DISSAL), Università di Genova, Genova, Italy.,IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Riccardo Picasso
- Radiology Unit, Department of Health Sciences (DISSAL), Università di Genova, Genova, Italy.,IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Carlo Martinoli
- Radiology Unit, Department of Health Sciences (DISSAL), Università di Genova, Genova, Italy.,IRCCS Ospedale Policlinico San Martino, Genova, Italy
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Knarr J, Schmitt R, Mühldorfer-Fodor M. Partial Neuritis of a Bifid Median Nerve. Clin Neuroradiol 2021; 31:1205-1208. [PMID: 34032880 DOI: 10.1007/s00062-021-01022-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 04/15/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Jonas Knarr
- Institut für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Würzburg, Oberdürrbacher Straße 6, 97080, Würzburg, Germany.
| | - Rainer Schmitt
- Klinik für Radiologie, RHÖN-KLINIKUM Campus Bad Neustadt, Von-Guttenberg-Straße 11, 97616, Bad Neustadt a. d. Saale, Germany
| | - Marion Mühldorfer-Fodor
- Klinik für Handchirurgie, RHÖN-KLINIKUM Campus Bad Neustadt, Von-Guttenberg-Straße 11, 97616, Bad Neustadt a. d. Saale, Germany
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24
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Park D, Kim BH, Lee SE, Kim DY, Eom YS, Cho JM, Yang JW, Kim M, Kwon HD. Electrodiagnostic, Sonographic, and Clinical Features of Carpal Tunnel Syndrome with Bifid Median Nerve. J Pain Res 2021; 14:1259-1269. [PMID: 34040430 PMCID: PMC8140939 DOI: 10.2147/jpr.s303142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 04/28/2021] [Indexed: 12/31/2022] Open
Abstract
Purpose A bifid median nerve (BMN) is not a rare variant. This study aimed to investigate the features of carpal tunnel syndrome (CTS) accompanied by BMN. Patients and Methods In this retrospective study, we defined a BMN group as CTS with BMN and a non-bifid median nerve (NMN) group as CTS without BMN. All hands were assigned to four severity grades according to the findings of electrodiagnosis (EDx): very mild, mild, moderate, and severe. The cross-sectional area (CSA) of the median nerve, palmar bowing of the flexor retinaculum, and persistent median artery (PMA) were assessed by ultrasonography. Numerical pain rating scale (NRS) and symptom duration were assessed as clinical variables. Results Sixty-four hands (57 patients) and 442 hands (341 patients) were enrolled in the BMN and the NMN groups, respectively. BMN was prevalent in 12.6% of all CTS hands. The distribution of EDx severity grade was milder in the BMN group than in the NMN group (P<0.001). The CSA of the BMN group was 16.2±4.1 mm2, slightly larger than 15.1±4.2 mm2 in the NMN group (P=0.056). The BMN group showed higher NRS than the NMN group (5.5±1.5 and 4.4±1.7, respectively; P<0.001). In the subgroup analysis, NRS was significantly higher in the BMN group than in the NMN group at all EDx severity grades. In the BMN group, the PMA group showed greater EDx severity (P=0.037) and higher NRS (6.0 and 5.0, respectively; P=0.012) than the non-PMA group. The radial side branch's CSA was larger than that of the ulnar side branch (10.0 mm2 and 6.0 mm2, respectively; P<0.001). Conclusion CTS with BMN presented more severe symptoms and relatively milder EDx severity. When assessing the severity of CTS with BMN, the clinical symptoms should primarily be considered, as well as we should complementarily evaluate the EDx and ultrasonography.
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Affiliation(s)
- Dougho Park
- Department of Rehabilitation Medicine, Spine and Joint Center, Pohang Stroke and Spine Hospital, Pohang, Republic of Korea
| | - Byung Hee Kim
- Department of Rehabilitation Medicine, Spine and Joint Center, Pohang Stroke and Spine Hospital, Pohang, Republic of Korea
| | - Sang-Eok Lee
- Department of Rehabilitation Medicine, Spine and Joint Center, Pohang Stroke and Spine Hospital, Pohang, Republic of Korea
| | - Dong Young Kim
- Department of Orthopedic Surgery, Spine and Joint Center, Pohang Stroke and Spine Hospital, Pohang, Republic of Korea
| | - Yoon Sik Eom
- Department of Orthopedic Surgery, Spine and Joint Center, Pohang Stroke and Spine Hospital, Pohang, Republic of Korea
| | - Jae Man Cho
- Department of Neurosurgery, Spine and Joint Center, Pohang Stroke and Spine Hospital, Pohang, Republic of Korea
| | - Joong Won Yang
- Department of Neurosurgery, Spine and Joint Center, Pohang Stroke and Spine Hospital, Pohang, Republic of Korea
| | - Mansu Kim
- Department of Neurosurgery, Spine and Joint Center, Pohang Stroke and Spine Hospital, Pohang, Republic of Korea
| | - Heum Dai Kwon
- Department of Neurosurgery, Spine and Joint Center, Pohang Stroke and Spine Hospital, Pohang, Republic of Korea
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Colorado BS. Incongruent electrodiagnostic and sonographic evaluations of a trifid median nerve in carpal tunnel syndrome. Muscle Nerve 2021; 63:E44-E46. [PMID: 33533023 DOI: 10.1002/mus.27189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 01/28/2021] [Accepted: 01/31/2021] [Indexed: 11/08/2022]
Affiliation(s)
- Berdale S Colorado
- Departments of Orthopedic Surgery and Neurology, Washington University School of Medicine, St. Louis, Missouri, USA
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Corte EL, Gelmi CAE, Acciarri N. Carpal tunnel syndrome caused by the entrapment of a bifid Lanz IIIA Type anatomical variant of median nerve: A case report and systematic literature review. Surg Neurol Int 2021; 12:37. [PMID: 33598353 PMCID: PMC7881513 DOI: 10.25259/sni_765_2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 12/15/2020] [Indexed: 12/31/2022] Open
Abstract
Background: Carpal tunnel syndrome (CTS) is the most common entrapment peripheral neuropathy. Median nerve may present several anatomical variations such as a high division or bifid median nerve (BMN). A thorough knowledge of the normal anatomy and variations of the median nerve at the wrist are fundamental to reduce complications during carpal tunnel release. Case Description: A 63-year-old man with CTS underwent preoperative ultrasound that showed the entrapment of the median nerve and disclosed a BMN Lanz IIIA Type anatomical variation at the carpal tunnel. During the surgery, the anatomical variant of a BMN at the wrist has been visualized. Both nervous rami entirely occupied the carpal canal and this may have predisposed to the development of the entrapment syndrome. Nor persistent median artery, or other associated abnormalities, have been identified. At the 6 months follow-up control, the patient referred a good surgical recovery with complete resolution of the preoperative symptoms of the median nerve entrapment. Conclusion: A rare case of Lanz IIIA BMN Type at the wrist has been encountered in a patient with a CTS and a systematic review and practical considerations have been presented with the aim of raising awareness to the neurosurgical community of a such rare variant that could be encountered during carpal tunnel release procedures. CTS may be caused by the entrapment of a BMN Lanz IIIA Type anatomical variant of median nerve. Preoperative US would help to identify such patients to reduce risk of iatrogenic injuries.
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Affiliation(s)
- Emanuele La Corte
- Neurosurgery Unit, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy.,Department of Biomedical and Neuromotor Sciences (DIBINEM), Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Clarissa A E Gelmi
- Neurosurgery Unit, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy.,Department of Biomedical and Neuromotor Sciences (DIBINEM), Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Nicola Acciarri
- Neurosurgery Unit, IRCCS Istituto delle Scienze Neurologiche di Bologna, Bologna, Italy
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Chen YT, Miller Olson EK, Lee SH, Sainani K, Fredericson M. Assessing Diagnostic and Severity Grading Accuracy of Ultrasound Measurements for Carpal Tunnel Syndrome Compared to Electrodiagnostics. PM R 2020; 13:852-861. [PMID: 33306874 DOI: 10.1002/pmrj.12533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 11/18/2020] [Accepted: 11/25/2020] [Indexed: 11/08/2022]
Abstract
BACKGROUND The combined sensory index (CSI) is the most sensitive electrodiagnostic criteria for carpal tunnel syndrome (CTS), and the CSI and Bland criteria have been shown to predict surgical treatment outcomes. The proposed ultrasound measurements have not been assessed against the CSI for diagnostic accuracy and grading of CTS severity. OBJECTIVE To investigate the use of ultrasound evaluations for both diagnosis and assessment of severity grading of CTS in comparison to electrodiagnostic assessment. DESIGN All patients underwent an electrodiagnostic evaluation using the CSI and Bland severity grading. Each patient underwent an ultrasound evaluation including cross-sectional area (CSA), the change in CSA from the forearm to the tunnel (∆CSA), and the wrist-forearm ratio (WFR). These measurements were assessed for diagnostic and severity grading accuracy using the CSI as the gold standard. SETTING Tertiary academic center. PARTICIPANTS All patients referred for electrodiagnostic evaluation for CTS were eligible for the study. Only those with idiopathic CTS were included and those with prior CTS treatment were also excluded. Ninety-five patients were included in the study. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES The primary study outcome measure was concordance between CSI diagnosis and severity categories and the ultrasound measurements. Both outcomes were also assessed using Bland criteria. RESULTS Optimal cut-points for diagnosis of CTS were found to be CSA ≥12 mm2 , ∆CSA ≥4 mm2 , WFR ≥1.4. Using these cut-points, C-statistics comparing diagnosis of CTS using ultrasound measurements versus using the CSI ranged from 0.893-0.966. When looking at CSI severity grading compared to ∆CSA, however, the C-statistics were 0.640-0.661 with substantial overlap between severity groups. CONCLUSIONS Although ultrasound measurements had high diagnostic accuracy for CTS based on the CSI criteria, ultrasound measurements were unable to adequately distinguish between CSI severity groups among patients with CTS.
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Affiliation(s)
- Yin-Ting Chen
- Interdisciplinary Pain Management Center, Brooke Army Medical Center, San Antonio, TX, USA
| | - Emily K Miller Olson
- Division of Physical Medicine & Rehabilitation, Department of Orthopaedics, Stanford University, Stanford, CA, USA
| | - Sung-Hoon Lee
- Department of Physical Medicine & Rehabilitation, Kwangju Christian Hospital, Gwangju, South Korea
| | - Kristin Sainani
- Department of Epidemiology and Population Health, Stanford University, Stanford, CA, USA
| | - Michael Fredericson
- Division of Physical Medicine & Rehabilitation, Department of Orthopaedics, Stanford University, Stanford, CA, USA
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Bruns A, Möller I, Martinoli C. Back to the roots of rheumatology - Imaging of regional pain syndromes. Best Pract Res Clin Rheumatol 2020; 34:101630. [PMID: 33272828 DOI: 10.1016/j.berh.2020.101630] [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] [Indexed: 12/24/2022]
Abstract
Musculoskeletal regional pain syndromes (RPS) often lead to patient referrals in general and rheumatological practice. Detailed history taking and clinical examination can, in most cases, reveal the cause for pain and direct the subsequent management of the conditions. Yet, when in doubt, imaging methods, such as ultrasound (US) may support the clinical assessment. This paper reviews the underlying pathologies of some of the most frequently encountered RPS and the role of musculoskeletal US imaging for their diagnosis and treatment. If available, data on diagnostic accuracy and comparisons with gold standards are reported. The article stresses the importance of anatomical and sonoanatomical knowledge for the proper interpretation of the US images, points out the advantages and disadvantages of this imaging tool, and suggests the future research agenda.
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Affiliation(s)
- Alessandra Bruns
- Division of Rheumatology, Sherbrooke University, Sherbrooke, Canada.
| | - Ingrid Möller
- Instituto Poal de Reumatologia, University of Barcelona, Barcelona, Spain
| | - Carlo Martinoli
- Department of Health Sciences (DISSAL), Università di Genova, Genova, Italy; IRCCS Ospedale Policlinico San Martino, Genova, Italy
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Manoharan D, Sudhakaran D, Goyal A, Srivastava DN, Ansari MT. Clinico-radiological review of peripheral entrapment neuropathies - Part 1 upper limb. Eur J Radiol 2020; 131:109234. [PMID: 32949858 DOI: 10.1016/j.ejrad.2020.109234] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 06/21/2020] [Accepted: 08/08/2020] [Indexed: 02/06/2023]
Abstract
PURPOSE This article aims to review the pertinent anatomy, etiopathogenesis, current clinical and radiological concepts and principles of management in case of upper limb entrapment neuropathies. METHODS The review is based on critical analysis of the existing literature as well as our experience in dealing with entrapment neuropathies. RESULTS Entrapment neuropathies of the upper limb peripheral nerves are common conditions that are often misdiagnosed because of their varying clinical presentations and lack of standardized diagnostic methods. Clinical assessment and electrodiagnostic studies have been the mainstay; however, imaging techniques have provided newer insights into the pathophysiology of these entities, leading to a paradigm shift in their diagnosis and management. The current best practice protocols for entrapment syndromes are constantly evolving with increasing emphasis on the role high-resolution ultrasound and magnetic resonance imaging. Many imaging criteria are described and we have tried to present the most validated measurements for diagnosing entrapment neuropathies. CONCLUSION It is imperative for a clinical radiologist to be familiar with the etiopathogenesis and clinical features of these conditions, in addition to being thorough with the anatomy and the latest imaging strategies.
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Affiliation(s)
- Dinesh Manoharan
- Department of Radiology, All India Institute of Medical Sciences, New Delhi, India
| | - Dipin Sudhakaran
- Department of Radiology, All India Institute of Medical Sciences, New Delhi, India
| | - Ankur Goyal
- Department of Radiology, All India Institute of Medical Sciences, New Delhi, India.
| | | | - Mohd Tahir Ansari
- Department of Orthopedics, All India Institute of Medical Sciences, New Delhi, India
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30
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Dhal A, Prakash S, Kalra P, Khan Y. Unusual Triad of Bifid Median Nerve, Persistent Median Artery, and Aberrant Muscle Causing Carpal Tunnel Syndrome: A Case Report. JBJS Case Connect 2020; 10:e1900468. [PMID: 32773698 DOI: 10.2106/jbjs.cc.19.00468] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
CASE A 15-year-old boy presented with intermittent pain, in the left nondominant hand, for the past 3 years. He recently developed numbness in the radial 3 and a half digits. Ultrasonography revealed a bifid median nerve (BMN) with a persistent median artery (PMA). An open carpal tunnel release was performed, which revealed an accessory lumbrical muscle in addition to the BMN and a PMA. CONCLUSION The surgeon should be aware of the possible coexistence of 3 anomalous structures while performing carpal tunnel release in a young patient.
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Affiliation(s)
- Anil Dhal
- 1Department of Orthopaedics, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi, India
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31
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Bhattacharya AK, Awan OA, Fenerty S, Taqi I, Jonnalagadda P, Ling S, Ali S. Repetitive Strain Injuries of the Upper Extremity: Imaging of Tendon Pathology and Compressive Neuropathies. Curr Probl Diagn Radiol 2020; 50:512-522. [PMID: 32826098 DOI: 10.1067/j.cpradiol.2020.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 07/20/2020] [Accepted: 07/23/2020] [Indexed: 11/22/2022]
Abstract
Repetitive strain injuries (RSIs) encompass a broad clinicopathologic spectrum which includes discrete patterns of tissue injury involving tendons, bursae and nerves although an element of subjective symptomatology may be contributory. Upper extremity RSIs include De Quervain's tenosynovitis, intersection syndromes, epicondylitis, ulnar, and median neuritis as well as other compressive neuropathies. It is estimated that RSIs cost the US economy over $60 billion annually and while detailed clinical examination remains the diagnostic mainstay, imaging can aid in diagnosis, guide management and reduce costs.
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Affiliation(s)
| | - Omer A Awan
- Department of Radiology, Temple University Hospital, Philadelphia, PA
| | - Sarah Fenerty
- Department of Radiology, Temple University Hospital, Philadelphia, PA
| | - Irfan Taqi
- Department of Radiology, Temple University Hospital, Philadelphia, PA
| | | | - Stephen Ling
- Department of Radiology, Temple University Hospital, Philadelphia, PA
| | - Sayed Ali
- Department of Radiology, Temple University Hospital, Philadelphia, PA
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32
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Draghi F, Ferrozzi G, Bortolotto C, Ballerini D, Fiorina I, Preda L. Sonography before and after carpal tunnel release: video article. J Ultrasound 2020; 23:363-364. [PMID: 32378166 DOI: 10.1007/s40477-020-00465-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 04/18/2020] [Indexed: 11/25/2022] Open
Abstract
Carpal tunnel release for compression of the median nerve at the wrist is a common procedure, often resulting in good clinical outcomes. There are, however, many anatomical variations in and around the carpal tunnel and it is important to be aware of these during carpal tunnel release. After surgery, recurrent carpal tunnel syndrome is uncommon, but difficult to diagnose and treat. Ultrasonography is often necessary for the evaluation of the anatomical variations before carpal tunnel release and to evaluate the most common complications after carpal tunnel release.
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Affiliation(s)
- Ferdinando Draghi
- Radiology Institute, Fondazione IRCCS Policlinico San Matteo, Piazzale Golgi, Pavia, Italy
| | - Guia Ferrozzi
- Diagnostic Imaging Department, Centro Medico Inacqua, Piacenza, Italy
- Diagnostic Imaging Department, Centro Medico Riabilitativo Rocca, Piacenza, Italy
| | - Chandra Bortolotto
- Radiology Institute, Fondazione IRCCS Policlinico San Matteo, Piazzale Golgi, Pavia, Italy
| | - Daniela Ballerini
- Radiology Institute, Fondazione IRCCS Policlinico San Matteo, Piazzale Golgi, Pavia, Italy.
| | - Ilaria Fiorina
- Unit of Interventional Radiology-Radiology Department, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Lorenzo Preda
- Radiology Institute, Fondazione IRCCS Policlinico San Matteo, Piazzale Golgi, Pavia, Italy
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33
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Gervasio A, Stelitano C, Bollani P, Giardini A, Vanzetti E, Ferrari M. Carpal tunnel sonography. J Ultrasound 2020; 23:337-347. [PMID: 32323256 DOI: 10.1007/s40477-020-00460-z] [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] [Received: 03/31/2020] [Accepted: 04/06/2020] [Indexed: 12/20/2022] Open
Abstract
Carpal tunnel syndrome (CTS) is the most frequent entrapment neuropathy of peripheral nerves, with an incidence of 1-3 patients in 1000. CTS typically occurs between 45 and 60 years of age, and it is more frequent in women than in men. The main cause of CTS is chronic compression of the median nerve and ischemic suffering secondary to increased pressure in the carpal tunnel. There are many possible causes of CTS, which can be differentiated into idiopathic causes, which include most cases, and secondary causes. Classical CTS diagnosis is based on the patient's clinical examination and electrophysiological tests, such as electromyography and nerve conduction studies. The latter are helpful for determining the site of nerve compression, assessing its severity, monitoring the course of the disease after therapy, and excluding other causes of median nerve pain, such as cervical radiculopathies, brachial plexopathies, polyneuropathy, or other forms of mononeuropathies. However, clinical examination and electrophysiological tests are not able to differentiate idiopathic forms from secondary forms of CTS, and discrepancies are possible between clinical examination and electrophysiological tests (false negatives). Ultrasound examination is able to recognize most of the secondary forms of CTS. It can evaluate the morphological alterations of the nerve and correlate them with the severity of nerve suffering in all cases, even idiopathic ones, with a sensitivity and specificity equal to those of electrophysiological tests. It can also highlight some anatomical predisposing variants or conditions that may represent contraindications to minimally invasive treatments. Ultrasound examination also plays a fundamental role in evaluating patients with an unfavorable outcome after surgical treatment.
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Affiliation(s)
- A Gervasio
- Radiology Department, San Donato Hospital Group, Istituto Clinico Città di Brescia, Via Bartolomeo Gualla 15, 25128, Brescia, Italy
| | - C Stelitano
- Radiology Institute, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Viale Camillo Golgi 19, 27100, Pavia, Italy.
| | - P Bollani
- Radiology Department, San Donato Hospital Group, Istituto Clinico Città di Brescia, Via Bartolomeo Gualla 15, 25128, Brescia, Italy
| | - A Giardini
- Radiology Department, San Donato Hospital Group, Istituto Clinico Città di Brescia, Via Bartolomeo Gualla 15, 25128, Brescia, Italy
| | - E Vanzetti
- Radiology Department, San Donato Hospital Group, Istituto Clinico Città di Brescia, Via Bartolomeo Gualla 15, 25128, Brescia, Italy
| | - M Ferrari
- Radiology Department, San Donato Hospital Group, Istituto Clinico Città di Brescia, Via Bartolomeo Gualla 15, 25128, Brescia, Italy
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34
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Joseph AE, Leiby BM, Beckman JP. Clinical Results of Ultrasound-Guided Carpal Tunnel Release Performed by a Primary Care Sports Medicine Physician. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2020; 39:441-452. [PMID: 31449326 DOI: 10.1002/jum.15120] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 06/26/2019] [Accepted: 07/28/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVES The purpose of this study was to determine the safety and efficacy of ultrasound-guided carpal tunnel release (USCTR) in a consecutive group of patients treated by a single primary care sports medicine physician. METHODS The study group consisted of 35 USCTRs performed on 22 consecutive patients for whom clinical outcomes were available before USCTR and at 1 to 2 weeks, 1 month, and 3 months after USCTR. All procedures were performed by the same operator using a single USCTR technique. Outcomes included complications, Quick Disabilities of the Arm, Shoulder, and Hand scores, Boston Carpal Tunnel Questionnaire symptom severity and functional status scores, and a 5-point global satisfaction score. RESULTS The 22 patients included 13 female and 9 male patients (ages 31-82 years). Eleven patients (22 wrists) had bilateral simultaneous USCTRs; 2 patients (4 wrists) had staged bilateral USCTRs; and 9 patients had unilateral USCTRs. No complications occurred in any patient. Statistically and clinically significant reductions in Quick Disabilities of the Arm, Shoulder, and Hand scores and Boston Carpal Tunnel Questionnaire symptom severity and functional status scores occurred by 1 to 2 weeks after USCTR (mean 1- to 2-week changes, -29.23, -1.74, and -1.18, respectively), and further improvements occurred during the 3-month follow-up period (mean 3-month changes, -51.11, -2.29, and -1.91; P < .0001 for all values versus before USCTR). Mean global satisfaction scores at 1 to 2 weeks and 3 months were 4.63 and 4.66. CONCLUSIONS Ultrasound-guided CTR is a safe and effective procedure that can be performed by an experienced primary care sports medicine physician and typically results in significant improvements within the first 2 weeks after the procedure. Furthermore, bilateral simultaneous USCTRs are feasible and may provide significant advantages for patients who are candidates for bilateral CTRs.
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Affiliation(s)
- Anthony E Joseph
- OrthoIdaho, Pocatello, Idaho, USA
- Department of Family Medicine, Idaho State University, Pocatello, Idaho, USA
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Fan CH, Lee YH, Ho YJ, Wang CH, Kang ST, Yeh CK. Macrophages as Drug Delivery Carriers for Acoustic Phase-Change Droplets. ULTRASOUND IN MEDICINE & BIOLOGY 2018; 44:1468-1481. [PMID: 29685589 DOI: 10.1016/j.ultrasmedbio.2018.03.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2017] [Revised: 03/06/2018] [Accepted: 03/14/2018] [Indexed: 05/19/2023]
Abstract
The major challenges in treating malignant tumors are transport of therapeutic agents to hypoxic regions and real-time assessment of successful drug release via medical imaging modalities. In this study, we propose the use of macrophages (RAW 264.7 cells) as carriers of drug-loaded phase-change droplets to penetrate ischemic or hypoxic regions within tumors. The droplets consist of perfluoropentane, lipid and the chemotherapeutic drug doxorubicin (DOX, DOX-droplets). The efficiency of DOX-droplet uptake, migration mobility and viability of DOX-droplet-loaded macrophages (DLMs) were measured using a transmembrane cell migration assay, the alamarBlue assay and flow cytometric analysis, respectively. Our results indicate the feasibility of utilizing macrophages as DOX-droplet carriers (DOX payload of DOX-droplets: 459.3 ± 35.8 µg/mL, efficiency of cell uptake DOX-droplets: 88.8 ± 3.5%). The migration mobility (total number of migrated microphages) of DLMs decreased to 32.3% compared with that of healthy macrophages, but the DLMs provided contrast-enhanced ultrasound imaging (1.7-fold enhancement) and anti-tumor effect (70.9% cell viability) after acoustic droplet vaporization, suggesting the potential theranostic applications of DLMs. Future work will assess the tumor penetration ability of DLMs, mechanical effect of droplet vaporization on in vivo anti-tumor therapy and the release of the carried drug by ultrasound-triggered vaporization.
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Affiliation(s)
- Ching-Hsiang Fan
- Department of Biomedical Engineering and Environmental Sciences, National Tsing Hua University, Hsinchu, Taiwan
| | - Ya-Hsuan Lee
- Department of Biomedical Engineering and Environmental Sciences, National Tsing Hua University, Hsinchu, Taiwan
| | - Yi-Ju Ho
- Department of Biomedical Engineering and Environmental Sciences, National Tsing Hua University, Hsinchu, Taiwan
| | - Chung-Hsin Wang
- Department of Biomedical Engineering and Environmental Sciences, National Tsing Hua University, Hsinchu, Taiwan
| | - Shih-Tsung Kang
- Department of Biomedical Engineering and Environmental Sciences, National Tsing Hua University, Hsinchu, Taiwan
| | - Chih-Kuang Yeh
- Department of Biomedical Engineering and Environmental Sciences, National Tsing Hua University, Hsinchu, Taiwan.
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36
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Sonographic evaluation of peripheral nerve pathology in the emergency setting. Emerg Radiol 2018; 25:521-531. [DOI: 10.1007/s10140-018-1611-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Accepted: 05/01/2018] [Indexed: 12/31/2022]
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Abstract
CLINICAL/METHODICAL ISSUE For the diagnostics of nerve lesions an imaging method is necessary to visualize peripheral nerves and their surrounding structures for an etiological classification. STANDARD RADIOLOGICAL METHODS Clinical neurological and electrophysiological investigations provide functional information about nerve lesions. The information provided by a standard magnetic resonance imaging (MRI) examination is inadequate for peripheral nerve diagnostics; however, MRI neurography is suitable but on the other hand a resource and time-consuming method. METHODICAL INNOVATIONS Using ultrasonography for peripheral nerve diagnostics. PERFORMANCE With ultrasonography reliable diagnostics of entrapment neuropathies and traumatic nerve lesions are possible. The use of ultrasonography for neuropathies shows that a differentiation between different forms is possible. ACHIEVEMENTS Nerve ultrasonography is an established diagnostic tool. In addition to the clinical examination and clinical electrophysiology, structural information can be obtained, which results in a clear improvement in the diagnostics. Ultrasonography has become an integral part of the diagnostic work-up of peripheral nerve lesions in neurophysiological departments. PRACTICAL RECOMMENDATIONS Nerve ultrasonography is recommended for the diagnostic work-up of peripheral nerve lesions in addition to clinical and electrophysiological investigations. It should be used in the clinical work-up of entrapment neuropathies, traumatic nerve lesions and spacy-occupying lesions of nerves.
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Affiliation(s)
- T Bäumer
- Institut für Neurogenetik, Universität zu Lübeck (CBBM; Haus 66), Marie-Curie-Straße, 23562, Lübeck, Deutschland.
| | - A Grimm
- Klinik und Poliklinik für Neurologie, Universitätsklinikum Tübingen, Tübingen, Deutschland
| | - T Schelle
- Neurologische Klinik, Städtisches Klinikum Dessau, Dessau, Deutschland
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Trachani E, Rigopoulou A, Veltsista D, Gavanozi E, Chrysanthopoulou A, Chroni E. Occurrence of bifid median nerve in healthy and carpal tunnel syndrome patients. J Electromyogr Kinesiol 2018; 39:77-80. [PMID: 29413456 DOI: 10.1016/j.jelekin.2018.01.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Accepted: 01/24/2018] [Indexed: 12/31/2022] Open
Abstract
We investigated the possible association between median nerve morphology and carpal tunnel size, hand side and nerve conduction measurements. The study included a patient group (n = 58; 44 women) with idiopathic carpal tunnel syndrome (CTS) in 100 hands and a control group of healthy volunteers (n = 56, 112 hands; 44 women). The following data were recorded: (1) median and ulnar motor and sensory nerve conduction parameters (2) ultrasonographic dimensions of the carpal tunnel inlet area (CTAin) and inlet area of the median nerve. The prevalence of bifid median nerve was 19% in the CTS hands and 13.3% in the control group. Bilateral bifid nerve was detected in 7 subjects and unilateral in 23, with no side or sex preponderance. The median nerve area was larger in the participants with single than those with bifid median nerve. No correlation was found between CTAin and median nerve area for single or bifid nerves in controls or patients. It was concluded that bifid median nerve was not a rare variation. We could not, however, support its etiological relation to CTS. Ultrasonographic examination of the carpal tunnel region supplementing neurophysiology provided a reliable means to detect median nerve size and morphology. CLINICAL TRIAL REGISTRATION NUMBER 84; 5/3/15.
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Affiliation(s)
- Eftychia Trachani
- Department of Neurology, School of Medicine, University of Patras, Patras, Greece
| | - Aspasia Rigopoulou
- Department of Radiology, School of Medicine, University of Patras, Patras, Greece
| | - Dimitra Veltsista
- Department of Neurology, School of Medicine, University of Patras, Patras, Greece
| | - Evangelia Gavanozi
- Department of Neurology, School of Medicine, University of Patras, Patras, Greece
| | | | - Elisabeth Chroni
- Department of Neurology, School of Medicine, University of Patras, Patras, Greece.
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Abstract
The median nerve (MN) may be affected by various peripheral neuropathies, each of which may be categorized according to its cause, as either an extrinsic (due to an entrapment or a nerve compression) or an intrinsic (including neurogenic tumors) neuropathy. Entrapment neuropathies are characterized by alterations of the nerve function that are caused by mechanical or dynamic compression. It occurs because of anatomic constraints at specific locations including sites where the nerve courses through fibro-osseous or fibromuscular tunnels or penetrates a muscle. For the diagnosis of peripheral neuropathies, physicians traditionally relied primarily on clinical findings and electrodiagnostic testing with electromyography. However, if further doubt exists, clinicians may ask for an additional imaging evaluation.
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40
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Deng X, Chau LHP, Chiu SY, Leung KP, Li SW, Ip WY. Exploratory use of ultrasound to determine whether demyelination following carpal tunnel syndrome co-exists with axonal degeneration. Neural Regen Res 2018; 13:317-323. [PMID: 29557383 PMCID: PMC5879905 DOI: 10.4103/1673-5374.226402] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Carpal tunnel syndrome (CTS) accompanied by secondary axonal degeneration cannot be clearly discriminated using the current cross-validated ultrasound severity classification system. This study aimed at exploring cut-off values of ultrasound parameters, including wrist cross-sectional area (W-CSA), wrist perimeter (W-P), ratio of cross-sectional area (R-CSA) and perimeter (R-P), changes of CSA and P from wrist to one third distal forearm (ΔCSA&ΔP) for differentiation. Seventy-three patients (13 male and 60 female) were assigned into group A (demyelination only, n = 40) and group B (demyelination with secondary axonal degeneration, n = 33) based on the outcomes of nerve conduction studies (NCS). Receiver Operative Characteristics (ROC) curves were plotted to obtain sensitivity, specificity, and accuracy of cut-off values for all the ultrasound parameters. The overall identified cut-off values (W-CSA 12.0 mm2, W-P 16.27 mm, R-CSA 1.85, R-P 1.48, ΔCSA 6.98 mm2, ΔP 5.77 mm) had good sensitivity (77.1–88.6%), fair specificity (40–62.2%) and fair-to-good accuracy (0.676–0.758). There were also significant differences in demographics (age and severity gradation, P < 0.001), NCS findings (wrist motor latency and conduction velocity, P < 0.0001; wrist motor amplitude, P < 0.05; distal sensory latency, P < 0.05; sensory amplitude, P < 0.001) and ultrasound measurements (W-CSA, W-P, R-CSA, R-P, ΔCSA&ΔP, P < 0.05) between groups. These findings suggest that ultrasound can be potentially used to differentiate demyelinating CTS with secondary axonal degeneration and provide better treatment guidance.
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Affiliation(s)
- Xue Deng
- Department of Orthopedics & Traumatology, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Lai-Heung Phoebe Chau
- Clinical Electro-diagnostic Unit, Tung Wah Hospital, Hong Kong Special Administrative Region, China
| | - Suk-Yee Chiu
- Clinical Electro-diagnostic Unit, Tung Wah Hospital, Hong Kong Special Administrative Region, China
| | - Kwok-Pui Leung
- Department of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Sheung-Wai Li
- Department of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Wing-Yuk Ip
- Department of Orthopedics & Traumatology, The University of Hong Kong, Hong Kong Special Administrative Region, China
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Chen YT, Williams L, Zak MJ, Fredericson M. Review of Ultrasonography in the Diagnosis of Carpal Tunnel Syndrome and a Proposed Scanning Protocol. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2016; 35:2311-2324. [PMID: 27629754 DOI: 10.7863/ultra.15.12014] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 02/21/2016] [Indexed: 06/06/2023]
Abstract
Carpal tunnel syndrome is the most common peripheral compressive neuropathy. Ultrasonography (US) is an emerging technology that can be used in the diagnosis of carpal tunnel syndrome. Although the cross-sectional area is the most studied and validated measurement for carpal tunnel syndrome, there is no standardized neuromuscular US scanning protocol. We review the most studied neuromuscular US characteristics and protocols in the evaluation of carpal tunnel syndrome and propose a standardized protocol for evaluating carpal tunnel syndrome with neuromuscular US based on current literature.
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Affiliation(s)
- Yin-Ting Chen
- Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, Maryland USA
| | - Lisa Williams
- Division of Physical Medicine and Rehabilitation, Department of Orthopedic Surgery, Stanford University, Stanford, California USA
| | - Matthew J Zak
- Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, Maryland USA
| | - Michael Fredericson
- Division of Physical Medicine and Rehabilitation, Department of Orthopedic Surgery, Stanford University, Stanford, California USA
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Holováčová D, Kužma M, Killinger Z, Payer J. Cross-sectional area of the median nerve is increased in primary autoimmune hypothyroidism and decreases upon treatment with thyroxine. Eur J Endocrinol 2016; 175:265-71. [PMID: 27418060 DOI: 10.1530/eje-16-0397] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2016] [Accepted: 07/14/2016] [Indexed: 11/08/2022]
Abstract
BACKGROUND The purpose of this study was to assess changes in the cross-sectional area (CSA) of nervus medianus by ultrasound in newly diagnosed primary hypothyroid patients after thyroxine replacement treatment. PATIENTS AND METHODS The cohort comprised 30 patients with newly diagnosed primary autoimmune hypothyroidism. These were subsequently compared with 30 controls, matched for sex, BMI and age. Ultrasound evaluation, including measurement of CSA at the level of the pisiform bone or tunnel inlet was performed at baseline and after 3months. A CSA threshold of more than 10mm(2) was considered pathological. RESULTS CSA was increased in patients compared with controls (9.8±0.7mm(2) vs 7.2±1.1mm(2); P<0.001). Thyroxin substitution increased fT4 levels (baseline, 11.0±0.6pmol/L vs 15.5±0.4pmol/L; P<0.001) and decreased TSH (baseline, 23.9±6.0mIU/L vs 2.7±0.2mIU/L; P<0.001). Thyroxine treatment decreased CSA to 8.4mm(2)±0.3mm(2) (P=0.033). Before treatment, four patients experienced distal paresthesia in the median nerve distribution area. Increased CSA pathognomonic for carpal tunnel syndrome found in two symptomatic patients normalized after 3months. No clinical symptoms were observed after 3months. A positive correlation was found between TSH and CSA (R=0.155, P=0.05) before treatment. CONCLUSION Our study demonstrates that increase in median nerve CSA caused by primary autoimmune hypothyroidism can be fully reversible after achieving target levels of TSH and fT4.
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Affiliation(s)
- Dana Holováčová
- Comenius University Faculty of Medicine5th Department of Internal Medicine, University Hospital, Bratislava, Slovakia
| | - Martin Kužma
- Comenius University Faculty of Medicine5th Department of Internal Medicine, University Hospital, Bratislava, Slovakia
| | - Zdenko Killinger
- Comenius University Faculty of Medicine5th Department of Internal Medicine, University Hospital, Bratislava, Slovakia
| | - Juraj Payer
- Comenius University Faculty of Medicine5th Department of Internal Medicine, University Hospital, Bratislava, Slovakia
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Jacobson JA, Wilson TJ, Yang LJS. Sonography of Common Peripheral Nerve Disorders With Clinical Correlation. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2016; 35:683-693. [PMID: 26931790 DOI: 10.7863/ultra.15.05061] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 07/13/2015] [Indexed: 06/05/2023]
Abstract
Sonography is now considered an effective method to evaluate peripheral nerves. Low cost, high resolution, the ability to image an entire limb in a short time, and dynamic assessment are several of the positive attributes of sonography. This article will review the normal appearance of peripheral nerves as shown with sonography. In addition, the most common applications for sonography of the peripheral nerves will be reviewed, which include entrapment neuropathies, intraneural ganglion cyst, nerve trauma, and peripheral nerve sheath tumors. Clinical information related to nerve disorders is also included, as it provides valuable information that can be obtained during sonographic examinations, increasing diagnostic accuracy.
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Affiliation(s)
- Jon A Jacobson
- Departments of Radiology, University of Michigan, Ann Arbor, Michigan USA.
| | - Thomas J Wilson
- Departments of Neurosurgery, University of Michigan, Ann Arbor, Michigan USA
| | - Lynda J-S Yang
- Departments of Neurosurgery, University of Michigan, Ann Arbor, Michigan USA
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Yu G, Chen Q, Wang D, Wang X, Li Z, Zhao J, Song C, Wang H, Wang Z. Diagnosis of carpal tunnel syndrome assessed using high-frequency ultrasonography: cross-section areas of 8-site median nerve. Clin Rheumatol 2016; 35:2557-64. [DOI: 10.1007/s10067-016-3214-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Revised: 01/22/2016] [Accepted: 02/13/2016] [Indexed: 12/23/2022]
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Deniel A, Causeret A, Moser T, Rolland Y, Dréano T, Guillin R. Entrapment and traumatic neuropathies of the elbow and hand: An imaging approach. Diagn Interv Imaging 2015; 96:1261-78. [PMID: 26573067 DOI: 10.1016/j.diii.2015.10.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2015] [Accepted: 10/15/2015] [Indexed: 12/14/2022]
Abstract
Ultrasound and magnetic resonance imaging currently offer a detailed analysis of the peripheral nerves. Compressive and traumatic nerve injuries are the two main indications for imaging investigation of nerves with several publications describing the indications, technique and diagnostic capabilities of imaging signs. Investigation of entrapment neuropathies has three main goals, which are to confirm neuronal distress, search for the cause of nerve compression and exclude a differential diagnosis on the entire nerve. For traumatic nerve injuries, imaging, predominantly ultrasound, occasionally provides essential information for management including the type of nerve lesion, its exact site and local extension.
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Affiliation(s)
- A Deniel
- Department of Medical Imaging, Rennes University Hospitals, Sud Hospital, 16, boulevard de Bulgarie, 35203 Rennes cedex 2, France.
| | - A Causeret
- Department of Medical Imaging, Rennes University Hospitals, Sud Hospital, 16, boulevard de Bulgarie, 35203 Rennes cedex 2, France
| | - T Moser
- Department of Radiology, Montreal University Hospital Centre, 1560, rue Sherbrooke-Est, Montreal, Quebec H2 4M1, Canada
| | - Y Rolland
- Department of Medical Imaging, Eugène Marquis Centre, avenue de la Bataille-Flandres-Dunkerque, 35000 Rennes, France
| | - T Dréano
- Department of Orthopaedics and Traumatology, Rennes University Hospitals, 2, rue Henri-Le-Guilloux, 35000 Rennes, France
| | - R Guillin
- Department of Medical Imaging, Rennes University Hospitals, Sud Hospital, 16, boulevard de Bulgarie, 35203 Rennes cedex 2, France
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Henry BM, Zwinczewska H, Roy J, Vikse J, Ramakrishnan PK, Walocha JA, Tomaszewski KA. The Prevalence of Anatomical Variations of the Median Nerve in the Carpal Tunnel: A Systematic Review and Meta-Analysis. PLoS One 2015; 10:e0136477. [PMID: 26305098 PMCID: PMC4549253 DOI: 10.1371/journal.pone.0136477] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Accepted: 08/04/2015] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND AND OBJECTIVE The course and branches of the median nerve (MN) in the wrist vary widely among the population. Due to significant differences in the reported prevalence of such variations, extensive knowledge on the anatomy of the MN is essential to avoid iatrogenic nerve injury. Our aim was to determine the prevalence rates of anatomical variations of the MN in the carpal tunnel and the most common course patterns and variations in its thenar motor branch (TMB). STUDY DESIGN A systematic search of all major databases was performed to identify articles that studied the prevalence of MN variations in the carpal tunnel and the TMB. No date or language restrictions were set. Extracted data was classified according to Lanz's classification system: variations in the course of the single TMB--extraligamentous, subligamentous, and transligamentous (type 1); accessory branches of the MN at the distal carpal tunnel (type 2); high division of the MN (type 3); and the MN and its accessory branches proximal to the carpal tunnel (type 4). Pooled prevalence rates were calculated using MetaXL 2.0. RESULTS Thirty-one studies (n = 3918 hands) were included in the meta-analysis. The pooled prevalence rates of the extraligamentous, subligamentous, and transligamentous courses were 75.2% (95%CI:55.4%-84.7%), 13.5% (95%CI:3.6%-25.7%), and 11.3% (95%CI:2.4%-23.0%), respectively. The prevalence of Lanz group 2, 3, and 4 were 4.6% (95%CI:1.6%-9.1%), 2.6% (95%CI:0.1%-2.8%), and 2.3% (95%CI:0.3%-5.6%), respectively. Ulnar side of branching of the TMB was found in 2.1% (95%CI:0.9%-3.6%) of hands. The prevalence of hypertrophic thenar muscles over the transverse carpal ligament was 18.2% (95%CI:6.8%-33.0%). A transligamentous course of the TMB was more commonly found in hands with hypertrophic thenar muscles (23.4%, 95%CI:5.0%-43.4%) compared to those without hypertrophic musculature (1.7%, 95%CI:0%-100%). In four studies (n = 423 hands), identical bilateral course of the TMB was found in 72.3% (95%CI:58.4%-84.4%) of patients. CONCLUSIONS Anatomical variations in the course of the TMB and the MN in the carpal tunnel are common in the population. Thus, we recommend an ulnar side approach to carpal tunnel release, with a careful layer by layer dissection, to avoid iatrogenic damage to the TMB.
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Affiliation(s)
- Brandon Michael Henry
- Department of Anatomy, Jagiellonian University Medical College, 12 Kopernika Street, 31–034, Krakow, Poland
| | - Helena Zwinczewska
- Department of Anatomy, Jagiellonian University Medical College, 12 Kopernika Street, 31–034, Krakow, Poland
| | - Joyeeta Roy
- Department of Anatomy, Jagiellonian University Medical College, 12 Kopernika Street, 31–034, Krakow, Poland
| | - Jens Vikse
- Department of Anatomy, Jagiellonian University Medical College, 12 Kopernika Street, 31–034, Krakow, Poland
| | - Piravin Kumar Ramakrishnan
- Department of Anatomy, Jagiellonian University Medical College, 12 Kopernika Street, 31–034, Krakow, Poland
| | - Jerzy A. Walocha
- Department of Anatomy, Jagiellonian University Medical College, 12 Kopernika Street, 31–034, Krakow, Poland
| | - Krzysztof A. Tomaszewski
- Department of Anatomy, Jagiellonian University Medical College, 12 Kopernika Street, 31–034, Krakow, Poland
- * E-mail:
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Klauser AS, Abd Ellah MMH, Halpern EJ, Siedentopf C, Auer T, Eberle G, Bellmann-Weiler R, Kremser C, Sojer M, Löscher WN, Gabl MF, Feuchtner GM, Jaschke WR. Sonographic cross-sectional area measurement in carpal tunnel syndrome patients: can delta and ratio calculations predict severity compared to nerve conduction studies? Eur Radiol 2015; 25:2419-27. [DOI: 10.1007/s00330-015-3649-8] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Revised: 01/23/2015] [Accepted: 02/02/2015] [Indexed: 11/28/2022]
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Melville DM, Del Giudice M, Taljanovic MS. Advances in Upper Extremity Musculoskeletal Ultrasound. CURRENT RADIOLOGY REPORTS 2015. [DOI: 10.1007/s40134-015-0093-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Fu T, Cao M, Liu F, Zhu J, Ye D, Feng X, Xu Y, Wang G, Bai Y. Carpal tunnel syndrome assessment with ultrasonography: value of inlet-to-outlet median nerve area ratio in patients versus healthy volunteers. PLoS One 2015; 10:e0116777. [PMID: 25617835 PMCID: PMC4305299 DOI: 10.1371/journal.pone.0116777] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2014] [Accepted: 12/14/2014] [Indexed: 12/28/2022] Open
Abstract
Objective To evaluate the diagnostic value of the Inlet-to-outlet median nerve area ratio (IOR) in patients with clinically and electrophysiologically confirmed carpal tunnel syndrome (CTS). Methods Forty-six wrists in 46 consecutive patients with clinical and electrodiagnostic evidence of CTS and forty-four wrists in 44 healthy volunteers were examined with ultrasonography. The cross-sectional area (CSA) of the median nerve was measured at the carpal tunnel inlet (the level of scaphoid-pisiform) and outlet (the level of the hook of the hamate), and the IOR was calculated for each wrist. Ultrasonography and electrodiagnostic tests were performed under blinded conditions. Electrodiagnostic testing combined with clinical symptoms were considered to be the gold standard test. Receiver operating characteristic (ROC) curves were used to evaluate the diagnostic value between the inlet CSA and IOR. Results The study population included 16 men and 30 women (mean age, 45.3 years; range, 18–83 years). The control population included 18 men and 26 women (mean age, 50.4 years; range, 18–79 years). The mean inlet CSA was 8.7 mm2 in healthy controls and 14.6mm2 in CTS group (P<0.001). The mean IOR in healthy volunteers (1.0) was smaller than that in patients (1.6, P<0.001). Receiver operating characteristic analysis revealed a diagnostic advantage to using the IOR rather than the inlet CSA (P<0.01). An IOR cutoff value of ≥ 1.3 would yield 93% specificity and 91% sensitivity in the diagnosis of CTS. Conclusion The IOR of median nerve area promises to be an effective means in the diagnosis of CTS. A large-scale, randomized controlled trial is required to determine how and when this parameter will be used.
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Affiliation(s)
- Tengfei Fu
- Department of Rehabilitation Medicine, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Manlin Cao
- Department of Rehabilitation Medicine, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Fang Liu
- Department of Ultrasound, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Jiaan Zhu
- Department of Ultrasound, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Dongmei Ye
- Department of Rehabilitation Medicine, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Xianxuan Feng
- Department of Rehabilitation Medicine, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Yiming Xu
- Department of Rehabilitation Medicine, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Gang Wang
- Department of Rehabilitation Medicine, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Yuehong Bai
- Department of Rehabilitation Medicine, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
- * E-mail:
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