Ultrasonography for nerve compression syndromes of the upper extremity

A positioning approach to upper extremity sonographic evaluation and intervention

Total supported abduction, or TSA, is a position for ultrasound evaluations and guided interventions of the upper extremity. It provides optimal access to the medial arm through the volar wrist and palmar hand for diagnostic evaluations of the median and ulnar nerves as well as procedures including injections for carpal tunnel syndrome, ulnar neuropathy at the elbow, and stenosing tenosynovitis. It enables ease of both ipsilateral and bilateral evaluations/interventions without the need for significant positional changes by the patient or physician. Incorporation of TSA may enhance clinical efficiency by reducing the amount of time, materials, and space required to provide such services.

Ultrasonographic differential diagnosis of medial elbow pain

Medial elbow pain is a common musculoskeletal problem among individuals engaging in repetitive activities. Medial epicondylitis is the predominant cause of this pain. However, other potential causes must be considered as part of the differential diagnosis. This article discusses several etiologies of medial elbow pain, including medial epicondylitis, ulnar neuropathy, snapping triceps syndrome, ulnar collateral ligament injury, medial antebrachial cutaneous neuropathy, and diseases of the elbow joint, with an emphasis on ultrasound (US) findings. Awareness of possible diagnoses and their US features can assist radiologists in establishing a comprehensive diagnosis for medial elbow pain.

Superficial Radial Neuropathy due to Anatomic Variation: A Case Report

Superficial radial neuropathy is a purely sensory neuropathy, usually caused by nerve entrapment in the distal forearm. We report a case of superficial radial neuropathy caused by the anomalous course of the superficial radial nerve, which was found to be spirally encircling the brachioradialis tendon in the distal forearm. To the best of our knowledge, this is the first report of an anatomical variant of the superficial radial nerve that causes neuropathy.

Pronator syndrome and anterior interosseous nerve palsy due to neurolymphomatosis: a case report

Pronator syndrome is a median nerve entrapment neuropathy that can be difficult to diagnose due to its variable presentation and objective findings. Neurolymphomatosis is an uncommon disease in which malignant lymphocytes infiltrate central or peripheral nerve endoneurium and is often missed for prolonged periods prior to diagnosis. We present a rare case of pronator syndrome and anterior interosseous nerve palsy due to neurolymphomatosis that was occult on initial MRI in spite of the presence of a median nerve mass discovered intra-operatively during neurolysis. This case demonstrates the value of ultrasound for the examination of peripheral nerve pathology and illustrates its utility as an adjunct to MRI, in part due to the ability to screen a large region.

Imaging Biomarkers of Peripheral Nerves: Focus on Magnetic Resonance Neurography and Ultrasonography

Peripheral neuropathy is a prevalent and debilitating condition affecting millions of individuals globally. Magnetic resonance neurography (MRN) and ultrasonography (US) are noninvasive methods offering comprehensive visualization of peripheral nerves, using anatomical and functional imaging biomarkers to ensure accurate evaluation. For optimized MRN, superior and high-resolution two-dimensional and three-dimensional imaging protocols are essential. The anatomical MRN and US imaging markers include quantitative measures of nerve and fascicular size and signal, and qualitative markers of course and morphology. Among them, quantitative markers of T2-signal intensity ratio are sensitive to nerve edema-like signal changes, and the T1-mapping technique reveals nerve and muscle tissue fatty and fibrous compositional alterations.The functional markers are derived from physiologic properties of nerves, such as diffusion characteristics or blood flow. They include apparent diffusion coefficient from diffusion-weighted imaging and fractional anisotropy and tractography from diffusion tensor imaging to delve into peripheral nerve microstructure and integrity. Peripheral nerve perfusion using dynamic contrast-enhanced magnetic resonance imaging estimates perfusion parameters, offering insights into nerve health and neuropathies involving edema, inflammation, demyelination, and microvascular alterations in conditions like type 2 diabetes, linking nerve conduction pathophysiology to vascular permeability alterations.Imaging biomarkers thus play a pivotal role in the diagnosis, prognosis, and monitoring of nerve pathologies, thereby ensuring comprehensive assessment and elevating patient care. These biomarkers provide valuable insights into nerve structure, function, and pathophysiology, contributing to the accurate diagnosis and management planning for peripheral neuropathy.

Acroparesthesias: An Overview

Acroparesthesia is a symptom characterized by a subjective sensation, such as numbness, tingling, prickling, and reduced sensation, affecting the extremities (fingers and toes). Despite its frequency, data regarding its diagnostic approach and management are scarce. The etiological diagnosis of acroparesthesia is sometimes challenging since it can be due to abnormality anywhere along the sensory pathway from the peripheral nervous system to the cerebral cortex. Acroparesthesia can reveal several diseases. It can be associated with rheumatic complaints such as arthritis or myalgia. Further cautions are required when paresthesia is acute (within days) in onset, rapidly progressive, severe, asymmetric, proximal, multifocal, or associated with predominant motor signs (limb weakness) or severe dysautonomia. Acroparesthesia may reveal Guillain-Barré syndrome or vasculitis, requiring rapid management. Acroparesthesia is a predominant symptom of polyneuropathy, typically distal and symmetric, often due to diabetes. However, it can occur in other diseases such as vitamin B12 deficiency, monoclonal gammopathy of undetermined significance, or Fabry's disease. Mononeuropathy, mainly carpal tunnel syndrome, remains the most common cause of acroparesthesia. Ultrasonography contributes to the diagnosis of nerve entrapment neuropathy by showing nerve enlargement, hypoechogenic nerve, and intraneural vascularity. Besides, it can reveal its cause, such as space-occupying lesions, anatomical nerve variations, or anomalous muscle. Ultrasonography is also helpful for entrapment neuropathy treatment, such as ultrasound-guided steroid injection or carpal tunnel release. The management of acroparesthesia depends on its causes. This article aimed to review and summarize current knowledge on acroparesthesia and its causes. We also propose an algorithm for the management of acroparesthesia.

Kiloh-Nevin syndrome: an unusual cause of forearm pain

The popularity of weight training, bodybuilding and general physical conditioning has led to an increased rate of musculoskeletal injuries, such as nerve compression caused by muscle hypertrophy and, stretching of nerves peripherally. We present a case of anterior interosseous nerve (AIN) entrapment syndrome/neuropathy otherwise known as Kiloh-Nevin syndrome in a 22-year-old weightlifter. Knowledge of this injury is paramount for practitioners to increase awareness among athletes and bodybuilders.

Ultrasonographic Evaluation of Peripheral Nerves: Technical Considerations

Advances in ultrasonographic (US) technology featuring high-resolution transducers have revolutionized US over recent years as a modality increasingly used in the evaluation of musculoskeletal structures and peripheral nerves. A wide variety of nerve pathologies can be detected, such as neoplastic and tumorlike lesions, entrapment syndromes, posttraumatic injuries, and inflammatory conditions. US can serve as an imaging tool for guiding percutaneous treatments, such as injection therapies or hydrodissection, and assist with perioperative nerve marking and visualization of peripheral nerves in the operating room. This article describes the normal US appearance of peripheral nerves, US imaging techniques, common peripheral nerve pathologies, and interventional applications.

The EFSUMB Guidelines and Recommendations for Musculoskeletal Ultrasound - Part I: Extraarticular Pathologies

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.

A Review of Upper Extremity Peripheral Nerve Injuries in Throwing Athletes

Peripheral nerve injuries in the upper extremities may be common in throwing athletes as the throwing motion places extreme stress on the dominant arm. The combination of extreme stress along with repetitive microtrauma from throwing uniquely places the throwing athlete at elevated risk of upper extremity peripheral nerve injury. However, because symptoms can be non-specific and frequent co-exist with pathology in the upper extremity, the diagnosis of peripheral nerve injury is often delayed. Diagnosis of peripheral nerve injuries may require a combination of history and physical exam, diagnostic imaging, electrodiagnostic testing, and diagnostic ultrasound guided injections. The primary management should include physical therapy focusing on throwing mechanics and kinetic chain evaluation. However, some athletes require surgical intervention if symptoms do not improve with conservative management. The purpose of this focused narrative review is to highlight upper extremity peripheral neuropathies reported in throwing athletes and to provide an overview of the appropriate clinical diagnosis and management of the throwing athlete with a peripheral nerve injury. This article is protected by copyright. All rights reserved.

Cross-Sectional Area Reference Values for Sonography of Peripheral Nerves in Taiwanese Adults

Background: Neuromuscular ultrasound is a complementary technology that aids in the diagnosis of peripheral neuropathy. The interpretation of neuromuscular ultrasound results requires the use of accurate normative cross-sectional area (CSA) reference values. This study aims to provide CSA reference values specific to Taiwanese adults for Sonography of peripheral nerves in the upper and lower extremities.

Methods: The study cohort included 66 healthy subjects (36 women; 30 men). A linear probe was used to measure the CSA of the median, ulnar, radial, tibial, sural, and peroneal nerves at multiple sites. These data were analyzed to determine standard ranges for the CSA at each site (reference range = mean ± 2 × SD) and identify correlations between the CSA and patient characteristics.

Results: Normative CSA ranges were determined for all the assessed nerve sites, revealing that the nerve sizes in this Taiwanese population were smaller than Caucasian populations but comparable to those reported for other Asian cohorts. Men tended to have larger nerves than women, even after adjusting for height and weight. The size of ulnar nerve in the cubital tunnel and the peroneal nerve in the popliteal fossa correlated negatively with increasing age. The nerve size correlated positively with increasing weight and BMI at several sites, correlation of median nerve in the forearm with weight and BMI was significant after multiple testing. Significant correlation was also found between size of ulnar nerve in cubital tunnel and decreasing height.

Conclusion: We provide reference ranges for neuromuscular ultrasound CSA values for the upper and lower extremities that are specific to the Taiwanese population. These reference values may be useful for evaluating peripheral neuropathy in Taiwanese subjects.

MRI Evaluation of Various Elbow, Forearm, and Wrist Neuropathies: A Pictorial Review

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.

Clinical Manifestations, Pathogenesis, Diagnosis and Treatment of Peripheral Neuropathies in Connective Tissue Diseases: More Diverse and Frequent in Different Subtypes than Expected

Purpose of review: To discuss and summarize recent findings in peripheral neuropathy (PN) related to connective tissue diseases (CTD) including its prevalence, clinical manifestations, pathogenesis, diagnosis and treatment. Recent findings: Although PN is a common complication in CTD and has been well studied, recent research has shown that PN is more diverse and frequent in different subtypes of CTD than was expected. The incidence of PN in Sjögren’s syndrome and rheumatoid arthritis (RA) varies according to different disease subtypes, and the pathogenesis of neuropathic pain in different subtypes of eosinophilic granulomatosis with polyangiitis (EGPA) may also differ. Neurogenic inflammation, autoantibody-mediated changes, ischemia of the vascular wall and metabolic mechanisms have been shown to contribute to the pathogenesis of PN in CTD. Moreover, allergic inflammation has been recently identified as a possible new mechanism producing peripheral neuropathic pain associated with MPO-ANCA negative EGPA patients. Glucocorticoids are routinely used to relieve pain caused by PN. However, these steroids may cause hyperalgesia, exacerbate neuropathic pain, and activate the early phase of pain induction and produce hyperalgesia. Recently, neuroactive steroids, such as progesterone, tetrahydroprogesterone and testosterone, have been shown to exert protective effects for several PN symptoms, and in particular neuropathic pain. Neuroactive steroids will be an interesting topic for future research into PN in CTD. Summary: It is essential for the diagnosis and treatment of PN in CTD to be updated. Timely diagnosis, appropriate treatments, and multidisciplinary care are essential to minimize morbidity and decrease the risk of permanent neurologic deficits. Further studies are needed to guide diagnosis and treatment.

A Comparative Study Using Electromyography to Assess Hand Exercises For Rehabilitation After Ulnar Nerve Decompression

Ulnar nerve (UN) entrapment is a common peripheral neuropathy and can lead to dysfunction of both sensory and motor function of the hand. Surgical release is the mainstay of treatment, but post-operative rehabilitation of UN innervated intrinsic muscles is lacking evidence. This cohort study utilized surface electromyography (EMG) and assessed the activation of UN innervated intrinsic and extrinsic hand muscles during four exercises in healthy participants. Exercises included rotating baoding balls, squeezing a stress ball or grip device every second, and repetitive finger abduction against a rubber band. Normalized percent activation of each muscle was calculated for each exercise. It was demonstrated that rubber band resistance (RBR) finger abduction showed significantly increased activation in both intrinsic muscles tested, while minimizing activation of the one tested UN innervated extrinsic muscle. Thus, to best target the intrinsic hand muscles without fatiguing extrinsic muscles, the inexpensive and practical RBR exercise is beneficial in post-UN release rehabilitation.

Hand and Wrist Neuropathies: High-resolution Ultrasonography and MR Neurography

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.

Can Foraminal Stenosis Due to Lumbar Isthmic Spondylolisthesis Cause Axonopathy in the Lower Extremity?

This study aimed to investigate, using electrodiagnosis, whether foraminal stenosis due to isthmic spondylolisthesis (IS) causes peripheral nerve axonopathy. We retrospectively reviewed the medical records of the Yeungnam University Hospital and included 46 patients (mean age = 60.8 ± 13.7 years; male:female = 24:22) with foraminal stenosis due to IS. We classified foraminal stenosis grading based on T2 and T1 sagittal spinal magnetic resonance imaging (MRI). Patients were divided into mild (n = 18) and severe foraminal stenosis (n = 28) groups. To evaluate axonopathy in the lower extremity, results of compound motor action potential (CMAP) of the extensor digitorum brevis muscle (EDB) and abductor hallucis brevis muscle (AHB), and sensory nerve action potential (SNAP) of the sural nerve were retrieved. No statistically significant difference was observed in the amplitude of CMAP of the EDB and AHB and SNAP of the sural nerve with the severity of foraminal stenosis. However, age showed a statistically significant relationship with the amplitude of NCS in the EDB, AHB, and sural nerves (p < 0.001). The severity of foraminal stenosis due to IS showed no relationship with axonopathy beyond age-related degeneration of the lower extremities. Therefore, if there is robust axonopathy in lower extremities, physicians should consider pathologies other than foraminal stenosis due to IS.

Common Compression Neuropathies

Compression neuropathies, also known as entrapment neuropathies, are common neurologic conditions seen in medicine. These often are due to mechanical injury, either compression or stretch of the affected nerve, and initially result in focal demyelinating changes. If left untreated, secondary axonal injury and lasting disability can result. Patients typically present with pain, sensory changes, and potentially weakness in the distribution of the affected nerve; therefore, a basic knowledge of neuromuscular anatomy is necessary to identify these conditions. Initial treatment of mild to moderate cases often is conservative. In severe cases or those refractory to conservative therapy, surgery should be considered.

Ultrasonography evaluation of the normal ulnar nerve in adult: Comparison of the cross-sectional area at elbow extension and flexion

Background

Cross-sectional area (CSA) measurement of the ulnar nerve in the adult population by using ultrasonography (US) at elbow extension and flexion has previously been reported, but not much evidence showed a significant difference between elbow extension and flexion position.

Purpose

To compare the ulnar nerve CSA between elbow extension and flexion position.

Methods

A comparative cross-sectional study was conducted by involving 36 healthy adults with normally functioning ulnar nerve proven by Nerve Conduction Study (NCS) or Electroneurography. The ulnar nerve CSA was measured on each elbow by using US at the level of the medial epicondyle, 2 cm distal and 2 cm proximal from the medial epicondyle.

Results

The average ulnar nerve CSA at the medial epicondyle, 2 cm distal and proximal to the medial epicondyle at elbow extension respectively were 5.95 ± 0.74 mm2, 6.27 ± 0.92 mm2, and 5.92 ± 0.73 mm2. At elbow flexion, the average ulnar nerve CSA at the positions was 5.70 ± 0.83 mm2, 5.23 ± 0.87 mm2, dan 5.73 ± 0.71 mm2 respectively. The CSA of the ulnar nerve at elbow extension was significantly larger compared to the flexion position in the three areas observed in this study (p < 0.001).

Conclusion

The CSA of the ulnar nerve at elbow extension position was larger compared to the flexion position. Elbow position should be considered in measuring CSA of the ulnar nerve.

Surgical intervention for carpal tunnel syndrome in individuals with spinal cord injuries-patient characteristics, diagnostic considerations, and treatment outcomes

STUDY DESIGN

A retrospective chart audit.

OBJECTIVES

To characterize SCI patients with carpal tunnel syndrome (CTS) and evaluate the diagnostic rationale for surgical decision-making.

SETTING

Swiss Paraplegic Centre, Nottwil, Switzerland.

METHODS

Retrospective investigation of medical history, diagnostics, surgeries, and outcomes of surgical treatments of CTS in patients with para- and tetraplegia.

RESULTS

We identified a total of 77 surgeries for CTS in 55 patients: 16 females (25 surgeries) and 39 males (52 surgeries) with spinal cord injury. The majority (47 persons, 68 surgeries) were paraplegic (level of lesion Th2 and below); 8 persons (9 surgeries) were tetraplegic (level of lesion Th1 and above). ASIA scores in the tetraplegic group were A: 0, B: 1, C: 4, D: 3 while complete lesions predominated in the paraplegic group (A: 32, B: 4, C: 5, D: 6). Sixty-six out of 77 patients reported total relief of symptoms. Neither nerve conduction velocity nor motor amplitude correlated well with the severity of CTS. Co-morbidity and specific risk factors were rare.

CONCLUSIONS

SCI patients with CTS respond well to surgical decompression of median nerve regardless of level and type of spinal cord lesion and risk factors. Nerve conduction parameters and clinical findings can provide additional diagnostic support of CTS although nocturnal hand paresthesia, wrist pain at and after loading as well as failed conservative treatment are the main indications for surgical interventions. Based on symptomatology, clinical findings, and nerve conduction studies, we propose a decision-making tree for suggesting surgery or not.

Clinico-radiological review of peripheral entrapment neuropathies - Part 1 upper limb

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.

Evaluation of the ulnar nerve with shear-wave elastography: a potential sonographic method for the diagnosis of ulnar neuropathy

PURPOSE

This study was designed to verify whether shear-wave elastography (SWE) can be used to differentiate ulnar neuropathy at the cubital tunnel from asymptomatic ulnar nerve or medial epicondylitis. An additional aim was to determine a cut-off value to identify patients with ulnar neuropathy.

METHODS

This study included 10 patients with ulnar neuropathy at the cubital tunnel as confirmed with electromyography (three women and seven men; mean age, 51.9 years), 10 patients with medial epicondylitis (nine women and one man; mean age, 56.1 years), and 37 patients with asymptomatic ulnar nerve and lateral epicondylitis (21 women and 16 men; mean age, 54.0 years). Each patient underwent SWE of the ulnar nerve at the cubital tunnel, distal upper arm, and proximal forearm.

RESULTS

Patients with ulnar neuropathy at the cubital tunnel exhibited significantly greater mean ulnar nerve stiffness at the cubital tunnel (66.8 kPa) than controls with medial epicondylitis (21.2 kPa, P=0.015) or lateral epicondylitis (33.9 kPa, P=0.040). No significant differences were observed between patients and controls with regard to ulnar nerve stiffness at the distal upper arm or the proximal forearm. A stiffness of 31.0 kPa provided 100% specificity, 80.0% sensitivity, 100% positive predictive value, and 83.3% negative predictive value for the differentiation between ulnar neuropathy and medial epicondylitis.

CONCLUSION

Cubital tunnel syndrome is associated with a stiffer ulnar nerve than lateral or medial epicondylitis. SWE seems to be a new, reliable, and simple quantitative diagnostic technique to aid in the precise diagnosis of ulnar neuropathy at the cubital tunnel.

Ultrasound imaging and guidance in peripheral nerve entrapment: hydrodissection highlighted

Ultrasound (US) imaging has become one of the most useful modalities to assess peripheral nerve disorders. Nowadays, it is as important as nerve conduction studies and electromyography for peripheral nerve entrapment. Additionally, US is also helpful in guiding a possible intervention. As peripheral nerves are tiny, palpation-guided injections are really challenging for precisely targeting the nerves. By using US, perineural injections have significantly become safe and effective. Recently, US-guided hydrodissection has emerged as the mainstream for nerve entrapment. Accordingly, this review aims to summarize and update the mechanism and evidence regarding this imperative procedure for neuropathic pain management. Furthermore, the pathogenesis, anatomic features, US findings and histological correlations of nerve entrapment syndromes will also be discussed in this article.

Imaging of ulnar-sided wrist pain

Ulnar-sided wrist pain is a complex entity to diagnose clinically and frequently requires imaging to help confirm or determine the diagnosis. This article reviews the imaging and the logical imaging pathway of the common causes of ulnar-sided wrist pain, and illustrates various pathologies. It also discusses appropriate imaging modalities for various conditions. The causes of ulnar-sided wrist pain are stratified according to the affected anatomical structures, such as bony, soft tissue or neurovascular aetiologies. This review provides a handy imaging framework for non-radiologist clinicians of the common conditions producing ulnar-sided wrist pain. A linked article (10.12968/hmed.2019.80.8.456) detailing the diagnosis of ulnar-sided wrist pain is included in this issue.

Imaging of Damaged Nerves

Nerve imaging is an important component in the assessment of patients presenting with suspected peripheral nerve pathology. Although magnetic resonance neurography and ultrasound are the most commonly utilized techniques, several promising new modalities are on the horizon. Nerve imaging is useful in localizing the nerve injury, determining the severity, providing prognostic information, helping establish the diagnosis, and helping guide surgical decision making. The focus of this article is imaging of damaged nerves, focusing on nerve injuries and entrapment neuropathies.

Can ultrasound imaging be used for the diagnosis of carpal tunnel syndrome in diabetic patients? A systemic review and network meta-analysis

BACKGROUND

High-resolution ultrasound (US) becomes a reliable tool for diagnosing carpal tunnel syndrome (CTS), but whether it can be applied to patients with preexisting diabetes mellitus (DM) remains unclear.

METHODS

We searched PubMed and Embase and systemically reviewed studies exploring the median nerve CSAs at the wrist level by US imaging. Nine studies enrolling at least one subgroup comprising patients with both DM and CTS were included for network meta-analysis. The primary outcome was the inter-group difference of the wrist-level median nerve CSA.

RESULTS

The median nerve size at the wrist level was larger in patients with only CTS than in patients with only DM [CSA difference = 3.14 mm², 95% confidence interval (CI) 1.92-4.35]. Patients with DM and CTS had a slightly enlarged median nerve CSA than did patients with only CTS, but the difference was not statistically significant (0.52 mm², 95% CI - 0.54 to 1.59). According to rank probabilities, median nerve CSAs in patients with DM and CTS were likely to be ranked as the largest, followed by patients with only CTS, patients with only DM, and healthy controls. Furthermore, median nerve CSAs seemed smaller in patients with than without diabetic polyneuropathy.

CONCLUSIONS

Although DM causes swelling of the median nerve at the wrist level, patients with CTS have a larger CSA regardless of preexisting DM. The add-on effect of DM on median nerve CSAs in patients with CTS is limited. Diabetic polyneuropathy tends to result in less swollen median nerves in the CTS population.

Sonographic evaluation of uncommonly assessed upper extremity peripheral nerves: anatomy, technique, and clinical syndromes

Targeted ultrasound of the median, ulnar, and radial nerves is a well-established technique for suspected upper extremity peripheral neuropathy. However, sonographic imaging of the brachial plexus and smaller peripheral nerve branches is more technically difficult and the anatomy is less familiar to many radiologists. As imaging techniques improve, many clinicians refer patients for imaging of previously less-familiar structures. In addition, some patients may present with injuries that could involve local neurovascular structures. Finally, patients presenting with isolated peripheral neuropathies may be referred for perineural injections with local anesthetic for diagnostic purposes, or steroid for therapeutic reasons. This requires sonologists to have a firm understanding of the courses of these nerves and the surrounding anatomic landmarks that can be used to accurately identify and characterize them. We discuss clinical syndromes referable to specific peripheral nerve branches in the upper extremity, the relevant anatomy, and sonographic technique.

Shear-wave elastography: a new potential method to diagnose ulnar neuropathy at the elbow

Objectives

The primary aim of this study was to verify if shear-wave elastography (SWE) can be used to diagnose ulnar neuropathy at the elbow (UNE). The secondary objective was to compare the cross-sectional areas (CSA) of the ulnar nerve in the cubital tunnel and to determine a cut-off value for this parameter accurately identifying persons with UNE.

Methods

The study included 34 patients with UNE (mean age, 59.35 years) and 38 healthy controls (mean age, 57.42 years). Each participant was subjected to SWE of the ulnar nerve at three levels: in the cubital tunnel (CT) and at the distal arm (DA) and mid-arm (MA). The CSA of the ulnar nerve in the cubital tunnel was estimated by means of ultrasonographic imaging.

Results

Patients with UNE presented with significantly greater ulnar nerve stiffness in the cubital tunnel than the controls (mean, 96.38 kPa vs. 33.08 kPa, p < 0.001). Ulnar nerve stiffness of 61 kPa, CT to DA stiffness ratio equal 1.68, and CT to MA stiffness ratio of 1.75 provided 100% specificity, sensitivity, positive and negative predictive value in the detection of UNE. Mean CSA of the ulnar nerve in the cubital tunnel turned out to be significantly larger in patients with UNE than in healthy controls (p < 0.001). A weak positive correlation was found in the UNE group between the ulnar nerve CSA and stiffness (R = 0.31, p = 0.008).

Conclusions

SWE seems to be a promising, reliable and simple quantitative adjunct test to support the diagnosis of UNE.

Key Points

• SWE enables reliable detection of cubital tunnel syndrome

• Significant increase of entrapped ulnar nerve stiffness is observed in UNE

• SWE is a perspective screening tool for early detection of compressive neuropathies

Simultaneous Compression of the Median and Ulnar Nerve at the Elbow: A Retrospective Study

BACKGROUND

Simultaneous compression of the median and ulnar nerve at the elbow region has not been sufficiently highlighted in the literature. The purposes of the present study are to report our experience regarding this entity, to elucidate the clinical features, and to describe the operative technique and findings as well as the results of simultaneous decompression performed through the same medial incision.

METHODS

We performed a retrospective study of thirteen elbows in thirteen patients -nine men and four women- with simultaneous compression of the median and ulnar nerve at the elbow region between 2000 and 2011. All were manual workers. Diagnosis was largely based on symptoms, patterns of paresthesia, and specific tests. Surgical decompression of both nerves at the same time was performed through a single anteromedial incision creating large flaps.

RESULTS

Patients were followed for a mean of thirty-eight months (range seven to ninety six). Resting pain in the proximal forearm as well as sudden onset of numbness in the ring and little fingers were reported by all patients. Nerve conduction studies were positive only for cubital tunnel syndrome. In all patients symptoms subsided following surgical decompression. At the time of final follow up there is no evidence of recurrence.

CONCLUSIONS

Proximal median nerve compression can be seen in association with cubital tunnel syndrome. Careful evaluation of the reported symptoms as well as thorough clinical examination are the keystone of the correct diagnosis. Also, on the basis of this study, we believe that concurrent decompression can be performed through a single medial incision, though extensive dissection may be required.

A randomized, controlled trial of magnetic therapy for carpal tunnel syndrome

INTRODUCTION

Magnet therapy has been proposed as a treatment for neurologic conditions. In this this trial we assessed the feasibility and efficacy of a magnet inserted into a wristband for carpal tunnel syndrome (CTS).

METHODS

Twenty-two patients with mild to moderate CTS were randomized to wear a high-dose or low-dose "sham" magnetic wristband for 6 weeks. The primary outcome was the Symptom Severity Scale (SSS) of the Boston Carpal Tunnel Questionnaire. Secondary measures were nerve conduction studies (NCS), median nerve ultrasound, and compliance.

RESULTS

Compliance for both groups was >90%. Improvements in the mean SSS, NCS, and median nerve ultrasound did not reach statistical significance.

DISCUSSION

Magnet therapy via wristband is well-tolerated. Further investigations in larger populations are needed to determine efficacy. Muscle Nerve 58: 310-313, 2018.

Increased stiffness of median nerve in systemic sclerosis

Background

Systemic sclerosis can affect peripheral nerves, but the extent and the nature of this involvement are not well defined. The aim of this study is to compare the sonoelastrographic measurements of median nerves in systemic sclerosis (SSC), idiopathic carpal tunnel syndrome (CTS) and healthy individuals.

Methods

The clinical, electrophysiological and ultrasonographic assessments were done. Patients with SSC and CTS were assessed with nerve conduction studies. The measurements of cross sectional areas (CSA) were performed at psiform and forearm level from axial US images. The elastic ratio is the ratio of strain distribution in two selected region of interests (ROI) done via comparing the median nerve to flexor digitorum superfcialis tendon. The ROIs were fixed to 2 mm.

Results

The study was completed with 47 hands of 24 patients with SSC, 53 hands of 27 patients with CTS and 38 hands of health controls. The CSA of CTS group was significantly higher than systemic sclerosis and control groups. The elastic ratio at psiform level and forearm levels of systemic sclerosis group were significantly higher than the CTS and control groups.

Conclusion

Median nerves lose the elasticity while the CSA’s are in the normal range in patients with SSC. These results suggested that the increased peripheral nerve involvement in SSC is about the increased stiffness of the nerves.

The scratch collapse test in the diagnosis of compression of the median nerve in the proximal forearm

Our purpose was to review the clinical usefulness of the scratch collapse test (SCT) in the diagnosis of proximal entrapment of the median nerve in the forearm. Eighteen consecutive cases were reviewed. The diagnosis was based on the patient's symptoms and signs. The SCT was positive in the affected forearm in all clinical assessments before surgery and it was negative in all after median nerve release. An anatomical reason for nerve compression was identified in all cases at operation. The SCT is a useful tool for the diagnosis of the proximal entrapment of the median nerve.

LEVEL OF EVIDENCE

IV.

Nerve ultrasound identifies abnormalities in the posterior interosseous nerve in patients with proximal radial neuropathies

INTRODUCTION

The radial nerve and posterior interosseous nerve (PIN) are prone to injury at multiple sites. Electrodiagnostic (EDx) studies may only identify the most proximal lesion. Nerve ultrasound could augment EDx by visualizing additional pathology.

METHODS

This investigation was a retrospective examination of ultrasound and EDx from 26 patients evaluated for posterior cord/radial/PIN lesions.

RESULTS

Eighteen of 26 patients had abnormalities on EDx (15 radial, 2 PIN, 1 posterior cord). Ultrasound identified 15 of 18 (83%) of the EDx abnormalities and provided additional diagnostic information. In 6 of 15 (40%) patients with EDx evidence of radial neuropathy, ultrasound identified both radial nerve enlargement and additional, unsuspected PIN enlargement (53% to 339% enlarged vs. unaffected side). Ultrasound also identified: nerve (dis)continuity at the trauma site (n = 8); and nerve tumor (n = 2; 1 with normal EDx).

CONCLUSION

In radial neuropathy, ultrasound often augments EDx studies and identifies a second lesion in the PIN. Further studies are required to determine the etiology and significance of this additional distal pathology.

MR anatomy and pathology of the ulnar nerve involving the cubital tunnel and Guyon's canal

Ulnar neuropathy is a common and frequent reason for referral to hand surgeons. Ulnar neuropathy mostly occurs in the cubital tunnel of the elbow or Guyon's canal of the wrist, and it is important for radiologists to understand the imaging anatomy at these common sites of impingement. We will review the imaging and anatomy of the ulnar nerve at the elbow and wrist, and we will present magnetic resonance imaging examples of different causes of ulnar neuropathy, including trauma, overuse, arthritis, masses and mass-like lesions, and systemic diseases. Treatment options will also be briefly discussed.