Diagnostic value of ultrasonography versus electrodiagnosis in ulnar neuropathy

The elastography of distal ulnar nerve branches in cyclists

INTRODUCTION

Forced elbow flexion and pressure during bicycling result in ulnar nerve traction and pressure exerted in Guyon's canal or the nerve's distal branches. The compression of the nerves causes a change in their stiffness related to edema and eventually gradual fibrosis.

PURPOSE

This study aimed to evaluate the elastography of terminal branches of the ulnar nerve in cyclists.

STUDY DESIGN

Cross-sectional study.

METHODS

Thirty cyclists, 32 healthy individuals, and 32 volunteers with ulnar nerve entrapment neuropathies participated in the study. Each participant underwent a nerve examination of the cubital tunnel, Guyon's canal and the deep and superficial branches of the ulnar nerve using shear wave elastography. The cyclist group was tested before and after a 2-hour-long workout.

RESULTS

Before cycling workouts, the ulnar nerve stiffness in the cubital tunnel and Guyon's canal remained below pathological estimates. Cycling workouts altered nerve stiffness in the cubital tunnel only. Notably, the stiffness of the ulnar terminal branches in cyclists was increased even before training. The mean deep branch stiffness was 50.85 ± 7.60 kPa versus 20.43 ± 5.95 kPa (p < 0.001) in the cyclist and healthy groups, respectively, and the mean superficial branch stiffness was 44 ± 12.45 kPa versus 24.55 ± 8.05 kPa (p < 0.001), respectively. Cycling contributed to a further shift in all observed values.

DISCUSSION

These observations indicate the existence of persistent anatomical changes in the distal ulnar branches in resting cyclists that result in increased stiffness of these nerves. The severity of these changes remains, however, to be determined.

CONCLUSIONS

These data show elastography values of the ulnar terminal branches in healthy individuals and cyclists where despite lack of clinical symptoms that they seem to be elevated twice above the healthy range.

Morphological Changes of Medial Epicondyle-Olecranon Ligament and Ulnar Nerve in the Cubital Tunnel Syndrome: An Ultrasonic Study

Objective

Few studies have performed detailed ultrasound measurements of medial epicondyle‐olecranon (MEO) ligament that cause the entrapment of ulnar nerve. This study aims to comprehensively evaluate dynamic ultrasonographic characteristics of MEO ligament and ulnar nerve for clinical diagnosis and accurate treatment of cubital tunnel syndrome (CuTS).

Methods

Thirty CuTS patients (CuTS group) and sixteen healthy volunteers (control group) who underwent ultrasound scanning from October 2016 to October 2020 were retrospectively collected, with 30 elbows in each group. Primary outcomes were thickness at six points, length and width of MEO ligament. Secondary outcomes were thickness of ulnar nerve under MEO ligament at seven parts and the cross‐sectional area (CSA) of ulnar nerve at proximal end of MEO ligament (P_0 mm). The thickness of MEO ligament and ulnar nerve in different points of each group was compared by one‐way ANOVA analysis with Bonferroni post hoc test, other outcomes were compared between two elbow positions or two groups using independent‐samples t test.

Results

Thickness of MEO ligament in CuTS group at epicondyle end, midpoint in transverse view, olecranon end, proximal end, midpoint in axial view, and distal end was 0.67 ± 0.31, 0.37 ± 0.18, 0.89 ± 0.35, 0.39 ± 0.21, 0.51 ± 0.38, 0.36 ± 0.25 at elbow extension, 0.68 ± 0.34, 0.38 ± 0.27, 0.77 ± 0.39, 0.32 ± 0.20, 0.48 ± 0.22, 0.32 ± 0.12 (mm) at elbow flexion, respectively. Compared with control group, they were significantly thickened except for proximal end at elbow flexion. MEO ligament thickness at epicondyle end and olecranon end was significantly larger than midpoint in two groups. No significant difference was found in length and width of MEO ligament among different comparisons. Ulnar nerve thickness at 5 mm proximal to MEO ligament (P_5 mm, 3.25 ± 0.66 mm) was significantly increased than midpoint of MEO ligament (Mid), distal end of MEO ligament (D_0 mm), 5 mm (D_5 mm), 10 mm (D_10 mm) distal to MEO ligament at extension in CuTS group. Compared with control group, ulnar nerve thickness at P_5 mm in CuTS group was significantly increased at extension position, at D_5 mm and D_10 mm was significantly decreased at flexion position. CSA of ulnar nerve at extension position (14.44 ± 4.65 mm²) was significantly larger than flexion position (11.83 ± 3.66 mm²) in CuTS group, and CuTS group was significantly larger than control group at two positions.

Conclusions

MEO ligament in CuTS patients was thickened, which compressed ulnar nerve and caused its proximal end swelling. Ultrasonic image of MEO ligament thickness was a significant indicator for CuTS and can guide surgeons in selecting the appropriate treatment.

Post-Operative Assessment of Ulnar Nerve Tension Using Shear-Wave Elastography

BACKGROUND

Ulnar nerve compression at the elbow level is the second-most common entrapment neuropathy. The aim of this study was to use shear-wave elastography for the quantification of ulnar nerve elasticity in patients after ulnar nerve decompression with anterior transposition and in the contralateral non-operative side.

METHOD

Eleven patients with confirmed diagnosis and ulnar nerve decompression with anterior transposition were included and examinations were performed on an Aixplorer^TM ultrasound system (Supersonic Imagine, Aix-en-Provence, France).

RESULTS

We observed significant differences at 0-degree (p < 0.001), 45-degree (p < 0.05), 90-degree (p < 0.01) and 120-degree (p < 0.001) elbow flexion in the shear elastic modulus of the ulnar nerve in the operative and non-operative sides. There were no statistically significant differences between the elasticity values of the ulnar nerve after transposition at 0-degree elbow flexion and in the non-operative side at 120-degree elbow flexion (p = 0.39), or in the ulnar nerve after transposition at 120-degree elbow flexion and in the non-operative side at 0-degree elbow flexion (p = 0.09).

CONCLUSION

Shear-wave elastography has the potential to be used postoperatively as a method for assessing nerve tension noninvasively by the estimation of mechanical properties, such as the shear elastic modulus.

Interpretation of Electrodiagnostic Studies: How to Apply It to the Practice of Orthopaedic Surgery

Electrodiagnostic studies may help orthopaedic surgeons to identify and confirm nerve pathology, determine severity of disease, localize the lesion, identify concomitant or alternative pathology, and prognosticate potential outcomes with nonoperative or operative treatment. Surgeons should recognize the indications for electrodiagnostic studies, principles of their performance, and how to assess the primary data generated by the examination and how it can inform their treatment plans.

Revision Peripheral Nerve Surgery of the Upper Extremity

Peripheral nerve injuries of the upper extremity can result from a wide array of etiologies, with the two most common being compression neuropathy and traumatic injuries. These types of injuries are common and can be psychologically, functionally, and financially devastating to the patient. A detailed preoperative evaluation is imperative for appropriate management. Traumatic injuries can typically be treated with local burial techniques, targeted muscle reinnervation, and regenerative peripheral nerve interfaces. Median nerve compression is frequently managed with complete release of the antebrachial fascia/transverse carpal ligament and/or use of flap coverage such as the hypothenar fat pad flap and local muscle flaps. Ulnar nerve compression is commonly managed via submuscular transposition, subcutaneous transposition, neurolysis, and nerve wrapping. In this review, we discuss the preoperative evaluation, surgical techniques, and advantages and disadvantages of each treatment modality for patients with compressive and traumatic upper extremity nerve injuries.

Beliefs, attitude, and knowledge of the Iranian physiatrists towards neuromusculoskeletal ultrasound and common barriers in its application

Background

Regarding the increasing application of neuromusculoskeletal sonography among medical specialties, specifically physiatrists, this study aims to assess the knowledge and skill level of these specialists in neuromusculoskeletal sonography in Iran.

Methods

This descriptive, cross-sectional study was performed in 2018. The utilized questionnaire developed based on previous studies in collaboration with 6 university lecturers of Shaheed Beheshti, Iran, and Tabriz medical universities and a physiatrist from Hacettepe University (Turkey); it included questions entailing demographic data, knowledge, and performance levels. Its validity and reliability were evaluated through face validation, pilot study, and the Cronbach α calculated via SPSS. Data extraction and analysis were also performed by SPSS-25.

Results

Of 364 questionnaires distributed, 300 were properly filled and entered into the study, of which, 38% were filled by clinical residents, 10% university lecturers, and 52% other categories (e.g. private sector).

The average number of musculoskeletal patient visits was 140.6 ± 119 and the mean number of musculoskeletal sonographies requested was 8.2 ± 5.2 per month (the three most common indications reported as the shoulder, carpal tunnel syndrome, and tendon injuries).

95% of the participants considered the importance of sonography for physiatrists to be “very high” or “high”; with the most valuable applications “as a guide for procedures (90%), its diagnostic utility (68%), and follow up/evaluating the response to treatment (45%). 86% of physiatrists reported they had participated in musculoskeletal sonography courses, 60% during residency, and the rest through workshops.

Also, the participants mentioned safety (83%), the possibility of performing simultaneous diagnosis and intervention procedures (70%), repeatability (58%), and dynamic imagery (52%) as the major advantages of musculoskeletal ultrasound.

Conclusion

a large number of doctors consider musculoskeletal sonography to be essential for physiatrists, though insufficient education on the subject and the low number of ultrasound devices are some of the obstacles in enhancing the use of this technology in PM&R setting. Presenting certified specific training courses during residency, provision of necessary rotations, using the capacities of the PM&R scientific committee, and the private sector for running workshops and professional training courses are suggested for enhancing the knowledge and skills of neuromusculoskeletal sonography.

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.

Current and future applications of ultrasound imaging in peripheral nerve disorders

Neuromuscular ultrasound (NMUS) is a rapidly evolving technique used in neuromuscular medicine to provide complimentary information to standard electrodiagnostic studies. NMUS provides a dynamic, real time assessment of anatomy which can alter both diagnostic and management pathways in peripheral nerve disorders. This review describes the current and future techniques used in NMUS and details the applications and developments in the diagnosis and monitoring of compressive, hereditary, immune-mediated and axonal peripheral nerve disorders, and motor neuron diseases. Technological advances have allowed the increased utilisation of ultrasound for management of peripheral nerve disorders; however, several practical considerations need to be taken into account to facilitate the widespread uptake of this technique.