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Hannaford A, Paling E, Silsby M, Vincenten S, van Alfen N, Simon NG. Electrodiagnostic studies and new diagnostic modalities for evaluation of peripheral nerve disorders. Muscle Nerve 2024; 69:653-669. [PMID: 38433118 DOI: 10.1002/mus.28068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 01/31/2024] [Accepted: 02/02/2024] [Indexed: 03/05/2024]
Abstract
Electrodiagnostic studies (EDx) are frequently performed in the diagnostic evaluation of peripheral nerve disorders. There is increasing interest in the use of newer, alternative diagnostic modalities, in particular imaging, either to complement or replace established EDx protocols. However, the evidence to support this approach has not been expansively reviewed. In this paper, diagnostic performance data from studies of EDx and other diagnostic modalities in common peripheral nerve disorders have been analyzed and described, with a focus on radiculopathy, plexopathy, compressive neuropathies, and the important neuropathy subtypes of Guillain-Barré syndrome, chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), vasculitic neuropathy and diabetic neuropathy. Overall EDx retains its place as a primary diagnostic modality in the evaluated peripheral nerve disorders. Magnetic resonance imaging and ultrasound have developed important complementary diagnostic roles in compressive and traumatic neuropathies and atypical CIDP, but their value is more limited in other neuropathy subtypes. Identification of hourglass constriction in nerves of patients with neuralgic amyotrophy may have therapeutic implications. Investigation of radiculopathy is confounded by poor correlation between clinical features and imaging findings and the lack of a diagnostic gold standard. There is a need to enhance the literature on the utility of these newer diagnostic modalities.
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Affiliation(s)
- Andrew Hannaford
- Department of Neurology, Concord Hospital, Sydney, New South Wales, Australia
- Brain and Nerve Research Centre, University of Sydney, Sydney, New South Wales, Australia
- Department of Neurology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Elijah Paling
- School of Medicine, University of Notre Dame, Sydney, New South Wales, Australia
| | - Matthew Silsby
- Department of Neurology, Concord Hospital, Sydney, New South Wales, Australia
- Brain and Nerve Research Centre, University of Sydney, Sydney, New South Wales, Australia
- Department of Neurology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Sanne Vincenten
- Department of Neurology and Clinical Neurophysiology, Radboud University Medical Center, Donders Center for Neuroscience, Nijmegen, the Netherlands
| | - Nens van Alfen
- Department of Neurology and Clinical Neurophysiology, Radboud University Medical Center, Donders Center for Neuroscience, Nijmegen, the Netherlands
| | - Neil G Simon
- Northern Beaches Clinical School, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, New South Wales, Australia
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Hussein M, Hanumanthu MM, Shirodkar K, Papineni VRK, Rahij H, Velicheti S, Iyengar KP, Botchu R. Cubital tunnel syndrome: anatomy, pathology, and imaging. Skeletal Radiol 2024:10.1007/s00256-024-04705-4. [PMID: 38760642 DOI: 10.1007/s00256-024-04705-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Revised: 05/02/2024] [Accepted: 05/03/2024] [Indexed: 05/19/2024]
Abstract
Cubital tunnel syndrome (CuTS) is the second most common peripheral neuropathy in the upper limb. It occurs due to ulnar nerve compression within the fibro-osseous cubital tunnel at the elbow joint. Although CuTS is typically diagnosed clinically and with electrodiagnostic studies, the importance of imaging in evaluating the condition is growing. Knowing the typical imaging findings of ulnar nerve entrapment is necessary for precise diagnosis and proper treatment. In this article, we focus on the clinical features, workup and complex imaging of the "anatomic" cubital tunnel and relevant pathological entities.
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Affiliation(s)
- Mohsin Hussein
- Department of Musculoskeletal Radiology, Royal Orthopaedic Hospital, Birmingham, UK
| | - Manasa Mayukha Hanumanthu
- Department of Radiology, Dr.Pinnamaneni, Siddhartha Institute of Medical Sciences & Research Foundation, Vijayawada, India
| | - Kapil Shirodkar
- Department of Musculoskeletal Radiology, Royal Orthopaedic Hospital, Birmingham, UK
| | | | - Hasan Rahij
- Imperial College School of Medicine, London, UK
| | - Sandeep Velicheti
- Department of Radiology, Dr.Pinnamaneni, Siddhartha Institute of Medical Sciences & Research Foundation, Vijayawada, India
| | - Karthikeyan P Iyengar
- Department of Radiology, Sheikh Shakhbout Medical City, Abu Dhabi, United Arab Emirates
- Department of Trauma & Orthopaedics, Southport and Ormskirk Hospitals, Mersey and West Lancashire NHS Trust, Southport, PR8 6PN, UK
| | - Rajesh Botchu
- Department of Musculoskeletal Radiology, Royal Orthopaedic Hospital, Birmingham, UK.
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Carroll TJ, Chirokikh A, Thon J, Jones CMC, Logigian E, Ketonis C. Diagnosis of Ulnar Neuropathy at the Elbow Using Ultrasound - A Comparison to Electrophysiologic Studies. J Hand Surg Am 2023; 48:1229-1235. [PMID: 37877916 DOI: 10.1016/j.jhsa.2023.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 08/16/2023] [Accepted: 08/30/2023] [Indexed: 10/26/2023]
Abstract
PURPOSE Given the relatively high false negative rate of electrodiagnostic studies (EDX) in patients with clinically diagnosed ulnar neuropathy at the elbow (UNE), we sought to determine whether an alternative objective test could more effectively detect UNE. Additionally, we proposed to determine the relationship between the cross-sectional area (CSA) of the ulnar nerve on ultrasound (US), EDX, and clinical symptoms. METHODS This was a retrospective study of patients presenting with symptomatic UNE. The performance characteristics of EDX versus ultrasound were calculated using the clinical diagnosis of UNE as the reference standard. Standard EDX studies and US of the ulnar nerve were analyzed. Maximal CSA of the ulnar nerve and EDX severity were analyzed for patients with each combination of US-positive/negative and EDX-positive/negative findings. RESULTS Analysis was performed on 89 patients and 115 nerves with signs and symptoms of cubital tunnel syndrome. In total, 56 (49%) nerves were diagnosed as mild UNE, 32 (28%) nerves were diagnosed as moderate UNE, 17 (15%) nerves were diagnosed as severe UNE, and 10 (8%) nerves were negative for UNE by EDX. Maximal-maximal CSA was highly correlated with disease severity as determined by nerve conduction studies/electromyography. Compared with EDX+/US+, patients with EDX-/US+ showed higher rates of ulnar sensory loss and elbow tenderness with similar rates of positive Tinel and intrinsic muscle atrophy. In this sample of patients with clinically diagnosed UNE, 91.3% of the patients demonstrated positive EDX studies, whereas 94.8% had a positive US. CONCLUSIONS Ultrasound is an alternative to EDX that could be incorporated clinically in the diagnosis and management of UNE. Ultrasound was able to consistently detect clinically positive cubital tunnel syndrome demonstrating its utility as a confirmatory or supplemental test to the clinical assessment if one is required. Ultrasound additionally may be able to better identify patients with early stages of UNE with negative EDX findings. TYPE OF STUDY/LEVEL OF EVIDENCE Diagnostic IV.
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Affiliation(s)
- Thomas John Carroll
- University of Rochester Department of Orthopaedic Surgery, University of Rochester School, Rochester, NY.
| | - Alexander Chirokikh
- University of Rochester Department of Orthopaedic Surgery, University of Rochester School, Rochester, NY
| | - Julie Thon
- University of Rochester Department of Orthopaedic Surgery, University of Rochester School, Rochester, NY
| | - Courtney Marie Cora Jones
- University of Rochester Department of Orthopaedic Surgery, University of Rochester School, Rochester, NY
| | - Eric Logigian
- University of Rochester Department of Neurology, University of Rochester School, Rochester, NY
| | - Constantinos Ketonis
- University of Rochester Department of Orthopaedic Surgery, University of Rochester School, Rochester, NY
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Chirokikh AA, Carroll TJ, Hoffman S, Speach D, Jones CMC, Ketonis C. Where Does Ultrasound Fit in the Diagnostic Algorithm for Cubital Tunnel Syndrome? Hand (N Y) 2023:15589447231200645. [PMID: 37746734 DOI: 10.1177/15589447231200645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/26/2023]
Abstract
BACKGROUND Ultrasound (US) has emerged as a promising supplement to electrodiagnostic studies (EDX) in the diagnosis of cubital tunnel syndrome (CuTS) and has potential to be performed by novice operators. Our objective is to understand the discrepancies in assessment between the two modalities and to assess the utility of US in CuTS diagnosis by a novice operator. METHODS Patients who presented to a single tertiary academic medical center and clinically diagnosed with CuTS were prospectively enrolled. Electrodiagnostic studies were performed along with US measurements of the cross-sectional area (CSA) of the ulnar nerve by both a board-certified physiatrist and novice operator. Electrodiagnostic study and US outcomes were compared among four diagnostic impression groups: EDX-/US-, EDX+/US-, EDX-/US+, and EDX+/US+. RESULTS Sixteen patients were classified as abnormal by both EDX and US, 14 were classified abnormal by US only, 3 were classified abnormal by EDX only, and 6 were classified normal by both EDX and US (P = .008, K = 0.14). The EDX+/US+ group had a significantly reduced sensory amplitude compared with the EDX-/US+ (P = .04) group. Diagnostic classifications between a board-certified physiatrist and novice operator were in moderate agreement (K = 0.58, P = .08). CONCLUSIONS Ultrasound detected a greater proportion of patients as abnormal than EDX. A subset of patients with clinical diagnoses of CuTS had normal sensory amplitudes but increased maximum nerve CSAs. Competency in US may be easily acquired with minimal training, suggesting its potential to be extended for use by other members of the health care team.
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Collins DW, Rehak D, Dawes A, Collins DP, Daly C, Wagner ER, Gottschalk MB. Cubital Tunnel Syndrome: Does a Consensus Exist for Diagnosis? J Hand Surg Am 2023:S0363-5023(23)00285-X. [PMID: 37422755 DOI: 10.1016/j.jhsa.2023.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 05/04/2023] [Accepted: 05/18/2023] [Indexed: 07/10/2023]
Abstract
PURPOSE Cubital tunnel syndrome (CuTS) is the second most common compressive neuropathy of the upper extremity. We aimed to determine a consensus among experts using the Delphi method for clinical criteria that could be validated further for the diagnosis of CuTS. METHODS The Delphi method was used for establishing a consensus among a group of expert panelists, comprising 12 hand and upper-extremity surgeons, who ranked the diagnostic clinical importance of 55 items related to CuTS on a scale from 1 (least important) to 10 (most important). The average and SDs of each item were calculated, and Cronbach α was used to assess homogeneity among the panelist-ranked items. RESULTS All panelists answered the 55-item questionnaire. A Cronbach α value of 0.963 was obtained on the first iteration. The top criteria that were considered most clinically relevant to the diagnosis of CuTS among the group were determined based on the most highly ranked and correlated items among the expert panelist group. The criteria based on which there was agreement were as follows: (1) paresthesias in ulnar nerve distribution, (2) symptoms precipitated by increased elbow flexion/positive elbow flexion tests, (3) positive Tinel sign at the medial elbow, (4) atrophy/weakness/ late findings (eg, claw hand of the ring/small finger and Wartenberg or Froment sign) of ulnar nerve-innervated muscles of the hand, (5) loss of two-point discrimination in ulnar nerve distribution, and (6) similar symptoms on the involved side after successful treatment on the contralateral side. CONCLUSIONS Our study demonstrated a consensus among an expert panelist group of hand and upper-extremity surgeons on potential diagnostic criteria for CuTS. This consensus on diagnostic criteria may help clinicians readily diagnose CuTS in a standardized form; however, further weighting and validation are necessary prior to the development of a formal diagnostic scale. CLINICAL RELEVANCE This study is the first step in producing a consensus on how to diagnose CuTS.
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Affiliation(s)
- Devin W Collins
- Hand and Upper Extremity Department, Florida Orthopaedic Institute, Tampa Bay, FL; Hughston Clinic, Columbus, GA.
| | | | - Alex Dawes
- Department of Orthopaedics, Emory University, Atlanta, GA
| | - Dylon P Collins
- Nova Southeastern University College of Osteopathic Medicine, Davie, FL
| | - Charles Daly
- Department of Orthopaedics, Emory University, Atlanta, GA
| | - Eric R Wagner
- Department of Orthopaedics, Emory University, Atlanta, GA
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Eby SF, Teramoto M, Lider J, Lash M, Caragea M, Cushman DM. Sonographic peripheral nerve cross-sectional area in adults, excluding median and ulnar nerves: A systematic review and meta-analysis. Muscle Nerve 2023; 68:20-28. [PMID: 36583383 DOI: 10.1002/mus.27783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 12/20/2022] [Accepted: 12/26/2022] [Indexed: 12/31/2022]
Abstract
INTRODUCTION/AIMS Although electromyography remains the "gold standard" for assessing and diagnosing peripheral nerve disorders, ultrasound has emerged as a useful adjunct, providing valuable anatomic information. The objective of this study was to conduct a systematic review and meta-analysis evaluating the normative sonographic values for adult peripheral nerve cross-sectional area (CSA). METHODS Medline and Cochrane Library databases were systematically searched for healthy adult peripheral nerve CSA, excluding the median and ulnar nerves. Data were meta-analyzed, using a random-effects model, to calculate the mean nerve CSA and its 95% confidence interval (CI) for each nerve at a specific anatomical location (= group). RESULTS Thirty groups were identified and meta-analyzed, which comprised 16 from the upper extremity and 15 from the lower extremity. The tibial nerve (n = 2916 nerves) was reported most commonly, followed by the common fibular nerve (n = 2580 nerves) and the radial nerve (n = 2326 nerves). Means and 95% confidence interval (CIs) of nerve CSA for the largest number of combined nerves were: radial nerve assessed at the spiral groove (n = 1810; mean, 5.14 mm2 ; 95% CI, 4.33 to 5.96); common fibular nerve assessed at the fibular head (n = 1460; mean, 10.18 mm2 ; 95% CI, 8.91 to 11.45); and common fibular nerve assessed at the popliteal fossa (n = 1120; mean, 12.90 mm2 ; 95% CI, 9.12 to 16.68). Publication bias was suspected, but its influence on the results was minimal. DISCUSSION Two hundred thirty mean CSAs from 15 857 adult nerves are included in the meta-analysis. These are further categorized into 30 groups, based on anatomical location, providing a comprehensive reference for the clinician and researcher investigating adult peripheral nerve anatomy.
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Affiliation(s)
- Sarah F Eby
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Masaru Teramoto
- Department of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Joshua Lider
- Department of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Madison Lash
- University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Marc Caragea
- Department of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Daniel M Cushman
- Department of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah, USA
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Pardal-Fernández JM, Diaz-Maroto I, Segura T, de Cabo C. Ulnar nerve thickness at the elbow on longitudinal ultrasound view in control subjects. Neurol Res Pract 2023; 5:4. [PMID: 36698205 PMCID: PMC9878874 DOI: 10.1186/s42466-023-00230-2] [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: 08/25/2022] [Accepted: 01/03/2023] [Indexed: 01/27/2023] Open
Abstract
INTRODUCTION Ulnar mononeuropathy at the elbow is the second most frequent neuropathy in humans. Diagnosis is based on clinical and electrophysiological criteria and, more recently, also on ultrasound. Cross-sectional ultrasound is currently the most valued, although longitudinal ultrasound allows assessment of the entire affected trajectory of the nerve in a single view, but always in a straight line with no changes in direction, as in the extended elbow. The main aim of this work is to propose normative values for longitudinal ultrasound of the ulnar nerve at the elbow. METHODS The neurological exploration of upper extremity, and electrophysiological and ultrasound parameters at the elbow of ulnar nerve were evaluated in 76 limbs from 38 asymptomatic subjects. RESULTS The diameters of the nerve as well as the distal and proximal areas were larger at the proximal region of the ulnar groove, and even more so in older individuals. In most of these elderly subjects, we found a small, non-significant slowdown in motor conduction velocity at the elbow with respect to the forearm (less than 5 m/s). CONCLUSIONS We observed a good correlation between the longitudinal and cross-sectional ultrasounds of the ulnar nerve at the elbow. Longitudinal ultrasound proved to be sensitive, reliable, simple and rapid, but its greatest contribution was allowing the visualization of the entire nerve trajectory in an integrated way, providing an image with good definition of the outline, proportions and intraneural characteristics of the nerve.
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Affiliation(s)
| | - Inmaculada Diaz-Maroto
- Unit of Neuromuscular Disorders, Department of Neurology, University General Hospital, Albacete, Spain
| | - Tomás Segura
- Department of Neurology, University General Hospital, Albacete, Spain
| | - Carlos de Cabo
- Neuropsychopharmacology Unit, University General Hospital of Albacete, Albacete, Spain
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Aravind P, Tiongco RFP, McNichols CH, Williams EH. Ultrasound as a Useful Tool for a Peripheral Nerve Surgeon: Examples in Clinical Practice. J Reconstr Microsurg 2022. [PMID: 36584694 DOI: 10.1055/s-0042-1759526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Peripheral nerve surgeons often require additional imaging for examination, diagnostic testing, and preoperative planning. Point-of-care ultrasound (US) is a cost-effective, accessible, and well-established technique that can assist the surgeon in diagnosing and treating select peripheral nerve pathologies. With this knowledge, the properly trained surgeon may perform US-guided nerve blocks to help accurately diagnose and treat causes of neuropathic pain. We offer this paper, not as an exhaustive review, but as a selection of various peripheral nerve pathologies, which the senior author treats, and their associated US examination findings. Our goal is to encourage other peripheral nerve surgeons to incorporate US into their practices. METHODS We provide various cases from our outpatient peripheral nerve clinic demonstrating relevant US anatomy. We also review techniques for US guided nerve blocks with relevant anatomic landmarks. RESULTS US imaging successfully assisted in identification and injection techniques for various peripheral nerve pathologies in a surgeon's practice. Examples were presented from the neck, trunk, upper extremity, and lower extremity. CONCLUSION Our review highlights the use of US by a peripheral nerve surgeon in an outpatient private practice clinic to diagnose and treat select peripheral nerve pathologies. We encourage reconstructive surgeons to add US to their arsenal of diagnostic tools.
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Affiliation(s)
- Pathik Aravind
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rafael Felix P Tiongco
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Colton H McNichols
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Eric H Williams
- Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.,The Dellon Institutes for Peripheral Nerve Surgery, Towson, Maryland
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Graesser EA, Dy CJ, Brogan DM. Future Considerations in the Diagnosis and Treatment of Compressive Neuropathies of the Upper Extremity. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2022. [PMID: 37521547 PMCID: PMC10382897 DOI: 10.1016/j.jhsg.2022.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Compressive neuropathies of the upper extremity are among the most common conditions seen by hand surgeons. The diagnoses of carpal tunnel syndrome and cubital tunnel syndrome have traditionally been made by a combination of history, physical examination, and electrodiagnostic testing. However, findings can be nonspecific and electrodiagnostic testing is invasive for the patient. The diagnosis of compressive neuropathies continues to evolve as technology advances, and newer diagnostic modalities predominantly focus on preoperative diagnostic imaging with ultrasound and magnetic resonance imaging/neurography. With the advent of cheaper, faster, and less invasive imaging, the future may bring a paradigm shift away from electrophysiology as the gold standard for the preoperative diagnosis of compressive neuropathies. Intraoperative imaging of nerve health is an emerging concept that warrants further investigation, whereas postoperative imaging of nerve recovery with ultrasound and magnetic resonance imaging currently has a limited role because of nonspecific findings and potential for misinterpretation. Advances in surgical treatment of compressive neuropathies appear to center around the use of imaging for less invasive neurolysis techniques and other adjunctive treatments with nerve decompression. The management of failed peripheral nerve decompressions and recurrent compressive neuropathies remains challenging.
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Kang M, Nam YS, Kim IJ, Park HY, Ham JR, Kim JM. A Cadaveric Study of Thread Cubital Tunnel Release with Newly Developed Threads. J Korean Neurosurg Soc 2022; 65:307-314. [PMID: 35168309 PMCID: PMC8918247 DOI: 10.3340/jkns.2021.0135] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 08/04/2021] [Indexed: 12/05/2022] Open
Abstract
Objective The percutaneous thread transection technique is a surgical dissecting method using a dissecting thread inserted through a needle under ultrasound guidance without skin incision. As the new dissecting threads were developed domestically, this cadaver study was conducted to compare the effectiveness and safety between the new threads (ultra V sswire and smartwire-01) and a pre-existing commercial dissecting thread (loop & shear) by demonstrating a modified looped thread cubital tunnel release.
Methods The percutaneous cubital tunnel release procedure was performed on 29 fresh cadaveric upper extremities. The preexisting commercial thread was used in 5 upper extremities. The two newly developed threads were used in 24 upper extremities. Two practitioners performed the procedures separately. After the modified looped thread cubital release, anatomical and histological analyses were performed by a blinded anatomist. The presence of the dissected cubital tunnel and damaged adjacent soft tissue was assessed.
Results Out of the 29 cadaveric upper extremities, 27 specimens showed complete dissection of the Osborne ligament and the proximal fascia of the flexor carpi ulnaris muscle. One specimen was incompletely dissected in each of the ultra V sswire and smartwire-01 groups. There were no injuries of adjacent structures including the ulnar nerve, ulnar artery, medial antebrachial cutaneous nerve, or flexor tendon with either the commercial thread or the newly developed threads. The anatomical analysis revealed clear and sharp incisional margins of the cubital tunnel in the Smartwire-01 and loop & shear groups. All three kinds of threads maintained proper linear elasticity for easy handling during the procedure. The smartwire-01 provided higher visibility in ultrasound than the other threads.
Conclusion The newly developed threads were effective and safe for use in the thread cubital tunnel release procedure.
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Affiliation(s)
- Minsuk Kang
- Department of Rehabilitation Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Yong Seok Nam
- Department of Anatomy, Institute for Applied Anatomy, College of Medicine, The Catholic University of Korea, Seoul, Korea.,Department of Anatomy, College of Korean Medicine, Dongshin University, Naju, Korea
| | - In Jong Kim
- Department of Rehabilitation Medicine, Howareyou Rehabilitation Clinic, Seoul, Korea
| | - Hae-Yeon Park
- Department of Rehabilitation Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jung Ryul Ham
- Department of Research & Development, Ultra V Co. Ltd., Seoul, Korea
| | - Jae Min Kim
- Department of Rehabilitation Medicine, Incheon St. Mary`s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Jaques G, Becce F, Ledoux JB, Durand S. Diagnosis of ulnar nerve entrapment anterior to the medial epicondyle by ultrasound elastography and diffusion tensor imaging with fiber tractography: a case report. Surg Radiol Anat 2022; 44:201-205. [PMID: 35024904 PMCID: PMC8831343 DOI: 10.1007/s00276-021-02881-9] [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: 11/26/2021] [Accepted: 12/28/2021] [Indexed: 11/30/2022]
Abstract
Ulnar/cubital tunnel syndrome is the second most common compressive neuropathy of the upper limb. Permanent location of the ulnar nerve anterior to the medial epicondyle is extremely rare, with only five cases reported in the literature. Using ultrasound elastography and diffusion tensor imaging with fiber tractography, we diagnosed a case in which ulnar nerve entrapment was associated with anterior nerve location. Surgical release confirmed the diagnosis and the patient was symptom free 3 months after surgery.
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Affiliation(s)
- Guillaume Jaques
- Department of Plastic and Hand Surgery, Lausanne University Hospital and University of Lausanne, 1011, Lausanne, Switzerland
| | - Fabio Becce
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital and University of Lausanne, 1011, Lausanne, Switzerland
| | - Jean-Baptiste Ledoux
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital and University of Lausanne, 1011, Lausanne, Switzerland
| | - Sébastien Durand
- Department of Plastic and Hand Surgery, Lausanne University Hospital and University of Lausanne, 1011, Lausanne, Switzerland.
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Reddy YM, K. Murthy J, Suresh L, Jaiswal S, Pidaparthi L, S. Kiran ES. Diagnosis and severity evaluation of ulnar neuropathy at the elbow by ultrasonography: A case-control study. J Med Ultrasound 2022; 30:189-195. [DOI: 10.4103/jmu.jmu_152_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 07/31/2021] [Accepted: 08/09/2021] [Indexed: 11/04/2022] Open
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Shook SJ, Ginsberg M, Narayanaswami P, Beekman R, Dubin AH, Katirji B, Swaminathan B, Werner RA, Cartwright MS. Evidence-based guideline: Neuromuscular ultrasound for the diagnosis of ulnar neuropathy at the elbow. Muscle Nerve 2021; 65:147-153. [PMID: 34921428 DOI: 10.1002/mus.27460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 11/09/2021] [Indexed: 11/08/2022]
Abstract
INTRODUCTION/AIMS The purpose of this literature review is to develop an evidence-based guideline for the use of neuromuscular ultrasound in the diagnosis of ulnar neuropathy at the elbow (UNE). The proposed research question was: "In patients with suspected UNE, does ulnar nerve enlargement as measured with ultrasound accurately identify those patients with UNE?" METHODS A systematic review and meta-analysis was performed, and studies were classified according to American Academy of Neurology criteria for rating articles for diagnostic accuracy. RESULTS Based on Class I evidence in four studies, it is probable that neuromuscular ultrasound measurement of the ulnar nerve at the elbow, either of diameter or cross-sectional area (CSA), is accurate for the diagnosis of UNE. RECOMMENDATION For patients with symptoms and signs suggestive of ulnar neuropathy, clinicians should offer ultrasonographic measurement of ulnar nerve cross-sectional area or diameter to confirm the diagnosis and localize the site of compression (Level B).
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Affiliation(s)
- Steven J Shook
- American Association of Neuromuscular & Electrodiagnostic Medicine, Rochester, Minnesota, USA.,Department of Neurology, Neuromuscular Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Matthew Ginsberg
- Department of Neurology, Akron Children's Hospital, Akron, Ohio, USA
| | - Pushpa Narayanaswami
- Department of Neurology, Neuromuscular Division, Beth Israel Deaconess Medical Center, Boston, Ohio, USA
| | - Roy Beekman
- Department of Neurology, Zuyderland Medisch Centrum, Sittard-Geleen, The Netherlands
| | - Andrew H Dubin
- Department of Physical Medicine & Rehabilitation, University of Florida, Gainesville, Florida, USA
| | - Bashar Katirji
- Neurological Institute, University Hospitals, Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Bharathi Swaminathan
- Department of Physical Medicine and Rehabilitation, Chicago Medical School, North Chicago, Illinois, USA
| | - Robert A Werner
- Michigan Medicine, Ann Arbor VA Health System, Ann Arbor, Michigan, USA
| | - Michael S Cartwright
- Department of Neurology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
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Post-Operative Assessment of Ulnar Nerve Tension Using Shear-Wave Elastography. Neurol Int 2021; 13:469-476. [PMID: 34564291 PMCID: PMC8482121 DOI: 10.3390/neurolint13030046] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 07/21/2021] [Accepted: 07/22/2021] [Indexed: 11/17/2022] Open
Abstract
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 AixplorerTM 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.
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Lee GJ, Park D. Ultrasonographic Findings of the Ulnar Nerve Following Elbow Flexion in Patients with Cubital Tunnel Syndrome. PAIN MEDICINE 2021; 21:2684-2691. [PMID: 32594162 DOI: 10.1093/pm/pnaa169] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To evaluate the ultrasonographic findings obtained following various degrees of elbow flexion in patients with cubital tunnel syndrome (CuTS). DESIGN Retrospective, cross-sectional study. SETTING General teaching hospital, rehabilitation unit. SUBJECTS Electrophysiological and ultrasonographic assessments were performed on 11 elbows of healthy controls and 21 elbows of 17 patients with CuTS. METHODS Dynamic movement of the ulnar nerve during elbow motion was measured. To measure ulnar nerve dynamic movement during elbow motion, the distance from the medial epicondyle (ME) to the nearest surface of the ulnar nerve toward the ME was measured at the cubital tunnel inlet at elbow extension (0°), elbow flexion to 60°, and elbow flexion to 90°. RESULTS The distance between the ME and ulnar nerve was lower in CuTS patients than in healthy patients at all elbow flexion angles. This difference was statistically significant at 0° and 60° elbow flexion (P < 0.05). When calculating the cutoff value, the distance between the ME and ulnar nerve at full elbow extension for CuTS diagnosis was 0.53 cm (sensitivity = 71.4%, specificity = 90.7%). The distance ratio between the ME and ulnar nerve for diagnosis of ulnar neuropathy at the elbow was 24.4% (sensitivity = 76.2%, specificity = 100%). CONCLUSION Measurement of the distance between the ME and ulnar nerve in full elbow extension may facilitate the diagnosis of patients with CuTS. These findings may be important for CuTS diagnosis, as they were also observed in patients with mild-stage CuTS.
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Affiliation(s)
- Goo Joo Lee
- Department of Rehabilitation Medicine, College of Medicine, Seoul National University, Seoul, Republic of Korea.,Department of Rehabilitation Medicine, National Traffic Injury Rehabilitation Hospital, Gyeonggi-do, Republic of Korea
| | - Donghwi Park
- Department of Physical Medicine and Rehabilitation, Ulsan University Hospital, University of Ulsan College of Medicine, Dong-gu, Ulsan, Republic of Korea
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Prasetyo M, Rahardja RR, Yanuar A, Prihartono J, Setiawan SI. Ultrasonography evaluation of the normal ulnar nerve in adult: Comparison of the cross-sectional area at elbow extension and flexion. Eur J Radiol Open 2021; 8:100331. [PMID: 33665233 PMCID: PMC7906893 DOI: 10.1016/j.ejro.2021.100331] [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: 12/01/2020] [Revised: 01/27/2021] [Accepted: 02/11/2021] [Indexed: 10/29/2022] Open
Abstract
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.
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Affiliation(s)
- Marcel Prasetyo
- Department of Radiology, Faculty of Medicine, Universitas Indonesia, Dr. Cipto Mangunkusumo National Central General Hospital, Jakarta, Indonesia
| | - Reiner Reza Rahardja
- Department of Radiology, Faculty of Medicine, Universitas Indonesia, Dr. Cipto Mangunkusumo National Central General Hospital, Jakarta, Indonesia
| | - Ahmad Yanuar
- Department of Neurology, Faculty of Medicine, Universitas Indonesia, Dr. Cipto Mangunkusumo National Central General Hospital, Jakarta, Indonesia
| | - Joedo Prihartono
- Department of Community Medicine, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Stefanus Imanuel Setiawan
- Department of Radiology, Faculty of Medicine, Universitas Indonesia, Dr. Cipto Mangunkusumo National Central General Hospital, Jakarta, Indonesia
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Mamarabadi M, Morren JA, Shook SJ. Enhancing diagnostic accuracy using a side-to-side cross-sectional area ratio for the diagnosis of unilateral ulnar mononeuropathy at the elbow. Muscle Nerve 2021; 63:690-696. [PMID: 33543772 DOI: 10.1002/mus.27178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 01/13/2021] [Accepted: 01/16/2021] [Indexed: 11/12/2022]
Abstract
INTRODUCTION Neuromuscular ultrasonography (NMUS) is a valuable adjunct to electrodiagnostic testing for the diagnosis of entrapment neuropathy. The aim of this study was to determine whether diagnostic accuracy of NMUS could be enhanced in patients with unilateral ulnar mononeuropathy at the elbow (UNE) by utilizing side-to-side ulnar nerve cross-sectional area (CSA) ratios. METHODS Retrospective case-control analysis of unilateral UNE cases identified cutoff values for elbow segment ulnar nerve maximum CSA (MCSA) of the symptomatic/asymptomatic limb (M ratio), as well as side-to-side ratios comparing MCSA with ipsilateral CSA at the Guyon canal (E/G), middle forearm (E/F), and middle humerus (E/H). Diagnostic accuracy values were calculated. RESULTS The optimal M-ratio cut-off was 1.22 (sensitivity, 92.9%; specificity, 97.8%; accuracy, 95.4%). Optimal cutoffs for inter-E/G, -E/F, and -E/H ratios were 1.07 (sensitivity, 98%; specificity, 78%; accuracy, 87.7%), 1.11 (sensitivity, 95%; specificity, 80%; accuracy, 87.2%), and 1.18 (sensitivity, 95%; specificity, 93%; accuracy, 94%), respectively. DISCUSSION The M ratio and inter-E/H ratio exhibited high diagnostic accuracy for unilateral UNE. Prospective studies are needed to compare the accuracy of the new measures with a single MCSA measurement.
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Affiliation(s)
- Mansoureh Mamarabadi
- Department of Neurology, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - John A Morren
- Neuromuscular Center, Neurological Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Steven J Shook
- Neuromuscular Center, Neurological Institute, Cleveland Clinic Foundation, Cleveland, Ohio
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Optimal Choice of Ultrasound-Based Measurements for the Diagnosis of Ulnar Neuropathy at the Elbow: A Meta-Analysis of 1961 Examinations. AJR Am J Roentgenol 2020; 215:1171-1183. [PMID: 32960671 DOI: 10.2214/ajr.19.22457] [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] [Indexed: 12/24/2022]
Abstract
OBJECTIVE. The purpose of this study was to determine the optimal ultrasound (US) measurement technique and cutoff value for the diagnosis of ulnar neuropathy at the elbow. MATERIALS AND METHODS. A systematic literature search was conducted of the PubMed, Embase, Scopus, and Web of Science databases for studies evaluating the diagnostic accuracy of US of patients with ulnar neuropathy at the elbow before April 2019. Random-effects modeling was performed to compare the sensitivity, specificity, and diagnostic odds ratio (DOR) of different US measurements, including diameter and cross-sectional area (CSA) of the nerve at the medial epicondyle or proximal and distal levels, maximal diameter, maximal CSA, and nerve ratios. Sensitivity and metaregression analyses were performed to assess the impact of clinical and imaging-based variables on the DOR of US. RESULTS. Among 820 retrieved studies, 19 studies (1961 examinations) were included. Measuring the CSA of the ulnar nerve at the medial epicondyle with a cutoff value greater than 10-10.5 mm2 had higher sensitivity (80.4%, 95% CI, 75.4-84.7%) than other techniques. Nerve ratios had higher specificity (89.1%, 95% CI, 85.8-91.8%) than other measurements; however, the definition of ratios and cutoff values varied across studies. ROC analysis showed higher diagnostic performance for measuring CSA at the medial epicondyle (AUC, 0.931). The mean CSA value was a significant predictor of the DOR of US (β coefficient, 0.307 ± 0.074; p < 0.001). Every 1-mm2 larger CSA was associated with a 36% increase in DOR. The diagnostic performance of US was the same in any degree of elbow flexion. CONCLUSION. Measuring CSA of the ulnar nerve at the medial epicondyle has sensitivity and diagnostic performance superior to those of other techniques for the diagnosis of ulnar neuropathy at the elbow.
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Kim S, Lee GY. Evaluation of the ulnar nerve with shear-wave elastography: a potential sonographic method for the diagnosis of ulnar neuropathy. Ultrasonography 2020; 40:349-356. [PMID: 33115185 PMCID: PMC8217804 DOI: 10.14366/usg.20101] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 08/23/2020] [Indexed: 11/03/2022] Open
Abstract
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.
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Affiliation(s)
- Sujin Kim
- Department of Radiology, Chung-Ang University Hospital, Seoul, Korea
| | - Guen Young Lee
- Department of Radiology, Chung-Ang University Hospital, Seoul, Korea
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Podnar S, Omejec G. Reply to “Electrophysiology and ultrasonography in the diagnosis of ulnar neuropathy at the elbow”. Clin Neurophysiol 2020; 131:1688-1689. [DOI: 10.1016/j.clinph.2020.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 04/06/2020] [Indexed: 10/24/2022]
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Ultrasound Parameters Other Than the Direct Measurement of Ulnar Nerve Size for Diagnosing Cubital Tunnel Syndrome: A Systemic Review and Meta-analysis. Arch Phys Med Rehabil 2019; 100:1114-1130. [DOI: 10.1016/j.apmr.2018.06.021] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 06/14/2018] [Accepted: 06/18/2018] [Indexed: 12/12/2022]
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Rayegani SM, Raeissadat SA, Kargozar E, Rahimi-Dehgolan S, Loni E. Diagnostic value of ultrasonography versus electrodiagnosis in ulnar neuropathy. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2019; 12:81-88. [PMID: 30863191 PMCID: PMC6390865 DOI: 10.2147/mder.s196106] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Purpose Ulnar neuropathy at elbow is the second-most common compression neuropathy. The main aim of this study was to assess the diagnostic value of ultrasonography (US) as an alternative method to electrodiagnosis (EDX), which had traditionally been used as the method of choice. Methods This diagnostic study was conducted on 66 participants (32 patients` elbows and 34 normal elbows) referred for EDX. Both groups were reassessed by US to evaluate the consistency of the two tests. The quantitative parameters of US, such as cross-sectional area (CSA) of the ulnar nerve at three different levels around the medial epicondyle (ME) were compared between groups. Results Our findings demonstrated that CSA at the ME and 2 cm distal to the ME were significantly larger in the patient group than normal participants. This higher nerve size was more prominent among those who had predominant axonal loss rather than demyelinating lesions (P<0.01). Finally, we evaluated US diagnostic value with the best singular feature (2 cm distal to ME) at a cutoff of 9 mm2, which revealed specificity of 80% and sensitivity 84%. Conclusion Based on these results we can conclude that US is a sensitive and specific method in diagnosing ulnar neuropathy at the elbow and can be used as an acceptable complementary method, in particular when EDX is not available.
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Affiliation(s)
- Seyed Mansoor Rayegani
- Physical Medicine and Rehabilitation Department and Research Center, Shohada-e-Tajrish Hospital, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Seyed Ahmad Raeissadat
- Clinical Development Research Center of Shahid Modarres Hospital, Physical Medicine and Rehabilitation Department and Research Center, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Elham Kargozar
- Physical Medicine and Rehabilitation Department, School of Medicine, Tehran University of Medical Sciences (TUMS), Tehran, Iran
| | - Shahram Rahimi-Dehgolan
- Physical Medicine and Rehabilitation Department, School of Medicine, Tehran University of Medical Sciences (TUMS), Tehran, Iran
| | - Elham Loni
- Physical Medicine and Rehabilitation Department, Rofaydeh Rehabilitation Hospital, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran,
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La Torre D, Raffa G, Pino MA, Fodale V, Rizzo V, Visalli C, Guzzi G, Della Torre A, Lavano A, Germanò A. A Novel Diagnostic and Prognostic Tool for Simple Decompression of Ulnar Nerve in Cubital Tunnel Syndrome. World Neurosurg 2018; 118:e964-e973. [PMID: 30048793 DOI: 10.1016/j.wneu.2018.07.123] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 07/12/2018] [Accepted: 07/13/2018] [Indexed: 01/21/2023]
Abstract
BACKGROUND Surgical decompression of the ulnar nerve (UN) is effective for treating cubital tunnel syndrome (CubTS). Nevertheless, the outcome is not always satisfying. Different surgical, clinical, and imaging findings have been claimed as outcome predictors, but there is no consensus in the literature. We analyzed the outcome-predicting role of ultrasonography (US) of the UN in patients with CubTS and its possible role for diagnosis and follow-up. METHODS Patients with CubTS treated by simple UN decompression underwent US and electrodiagnotic (ED) studies of the UN at the elbow before and after surgery. Outcome was evaluated through the Bishop scale. A correlation analysis between pre- and postoperative clinical, US, and ED findings was performed. RESULTS Thirty-six patients were enrolled. Preoperatively, we observed a negative correlation between the motor conduction velocity (MCV) and the transverse (TD) and anteroposterior diameters and cross-sectional area (CSA) of the UN at the precubital (P = 0.001, P = 0.001, P = 0.005) and cubital level (P = 0.02, P = 0.002, P = 0.001). Preoperative precubital TD and CSA were associated with outcome (P = 0.01, P = 0.006) and postoperative MCV (P = 0.004, P = 0.008). The cut-off values TD >6 mm and CSA >23.91 mm2 were predictors of poor outcome. Finally, postoperative cubital TD and CSA values were inversely correlated with outcome (P = 0.0002, P = 0.0007) and postoperative MCV (P = 0.0002, P = 0.0004). CONCLUSIONS The US examination of the UN is useful for the management of patients with CubTS as an adjunct to clinical and ED evaluations. US measurements are correlated with pre- and postoperative ED findings and thus are useful for diagnosis and follow-up. Interestingly, specific precubital US measurements are good predictors of outcome.
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Affiliation(s)
- Domenico La Torre
- Division of Neurosurgery, University of Messina, A.O.U. Policlinico "G. Martino", Messina, Italy
| | - Giovanni Raffa
- Division of Neurosurgery, University of Messina, A.O.U. Policlinico "G. Martino", Messina, Italy; Department of Clinical and Experimental Medicine, University of Messina, A.O.U. Policlinico "G. Martino", Messina, Italy.
| | - Maria Angela Pino
- Division of Neurosurgery, University of Messina, A.O.U. Policlinico "G. Martino", Messina, Italy
| | - Vincenzo Fodale
- Anesthesiology and Intensive Care Unit, University of Messina, A.O.U. Policlinico "G. Martino", Messina, Italy
| | - Vincenzo Rizzo
- Division of Neurology, University of Messina, A.O.U. Policlinico "G. Martino", Messina, Italy
| | - Carmela Visalli
- Division of Radiological Sciences, University of Messina, A.O.U. Policlinico "G. Martino", Messina, Italy
| | - Giusy Guzzi
- Division of Neurosurgery, Department of Medical and Surgical Sciences, University of Catanzaro, Messina, Italy
| | - Attilio Della Torre
- Division of Neurosurgery, Department of Medical and Surgical Sciences, University of Catanzaro, Messina, Italy
| | - Angelo Lavano
- Division of Neurosurgery, Department of Medical and Surgical Sciences, University of Catanzaro, Messina, Italy
| | - Antonino Germanò
- Division of Neurosurgery, University of Messina, A.O.U. Policlinico "G. Martino", Messina, Italy
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Sconfienza LM, Albano D, Allen G, Bazzocchi A, Bignotti B, Chianca V, Facal de Castro F, Drakonaki EE, Gallardo E, Gielen J, Klauser AS, Martinoli C, Mauri G, McNally E, Messina C, Mirón Mombiela R, Orlandi D, Plagou A, Posadzy M, de la Puente R, Reijnierse M, Rossi F, Rutkauskas S, Snoj Z, Vucetic J, Wilson D, Tagliafico AS. Clinical indications for musculoskeletal ultrasound updated in 2017 by European Society of Musculoskeletal Radiology (ESSR) consensus. Eur Radiol 2018; 28:5338-5351. [DOI: 10.1007/s00330-018-5474-3] [Citation(s) in RCA: 132] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 04/02/2018] [Accepted: 04/11/2018] [Indexed: 12/11/2022]
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Paluch Ł, Noszczyk B, Nitek Ż, Walecki J, Osiak K, Pietruski P. Shear-wave elastography: a new potential method to diagnose ulnar neuropathy at the elbow. Eur Radiol 2018; 28:4932-4939. [PMID: 29858636 PMCID: PMC6223854 DOI: 10.1007/s00330-018-5517-9] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2018] [Revised: 04/19/2018] [Accepted: 04/26/2018] [Indexed: 02/06/2023]
Abstract
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
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Affiliation(s)
- Łukasz Paluch
- Department of Radiology, Medical Centre of Postgraduate Education, Gruca Orthopaedic and Trauma Teaching Hospital, Otwock, Poland
| | - Bartłomiej Noszczyk
- Department of Plastic and Reconstructive Surgery, Medical Centre of Postgraduate Education, Prof. W. Orlowski Memorial Hospital, Czerniakowska 231 Street, 00-416, Warsaw, Mazowieckie, Poland.
| | - Żaneta Nitek
- Department of Radiology, Medical Centre of Postgraduate Education, Gruca Orthopaedic and Trauma Teaching Hospital, Otwock, Poland
| | - Jerzy Walecki
- Department of Radiology, Medical Centre of Postgraduate Education, Gruca Orthopaedic and Trauma Teaching Hospital, Otwock, Poland
| | - Katarzyna Osiak
- Department of Plastic and Reconstructive Surgery, Medical Centre of Postgraduate Education, Prof. W. Orlowski Memorial Hospital, Czerniakowska 231 Street, 00-416, Warsaw, Mazowieckie, Poland
| | - Piotr Pietruski
- Department of Plastic and Reconstructive Surgery, Medical Centre of Postgraduate Education, Prof. W. Orlowski Memorial Hospital, Czerniakowska 231 Street, 00-416, Warsaw, Mazowieckie, Poland.,Department of Applied Pharmacy and Bioengineering, Medical University of Warsaw, Warsaw, Poland
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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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Schertz M, Mutschler C, Masmejean E, Silvera J. High-resolution ultrasound in etiological evaluation of ulnar neuropathy at the elbow. Eur J Radiol 2017; 95:111-117. [DOI: 10.1016/j.ejrad.2017.08.003] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 05/17/2017] [Accepted: 08/04/2017] [Indexed: 12/29/2022]
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Chang KV, Wu WT, Han DS, Özçakar L. Ulnar Nerve Cross-Sectional Area for the Diagnosis of Cubital Tunnel Syndrome: A Meta-Analysis of Ultrasonographic Measurements. Arch Phys Med Rehabil 2017; 99:743-757. [PMID: 28888384 DOI: 10.1016/j.apmr.2017.08.467] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Revised: 08/02/2017] [Accepted: 08/02/2017] [Indexed: 01/27/2023]
Abstract
OBJECTIVE To examine the performance of sonographic cross-sectional area (CSA) measurements in the diagnosis of cubital tunnel syndrome (CuTS). DATA SOURCES Electronic databases, comprising PubMed and EMBASE, were searched for the pertinent literature before July 1, 2017. STUDY SELECTION Fourteen trials comparing the ulnar nerve CSA measurements between participants with and without CuTS were included. DATA EXTRACTION Study design, participants' demographic characteristics, diagnostic reference of CuTS, and methods of CSA measurement. DATA SYNTHESIS Among different elbow levels, the between-group difference in CSA was the largest at the medial epicondyle (6.0mm2; 95% confidence interval [CI], 4.5-7.4mm2). The pooled mean CSA in participants without CuTS was 5.5mm2 (95% CI, 4.4-6.6mm2) at the arm level, 7.4mm2 (95% CI, 6.7-8.1mm2) at the cubital tunnel inlet, 6.6mm2 (95% CI, 5.9-7.2mm2) at the medial epicondyle, 7.3mm2 (95% CI, 5.6-9.0mm2) at the cubital tunnel outlet, and 5.5mm2 (95% CI, 4.7-6.3mm2) at the forearm level. The sensitivities, specificities, and diagnostic odds ratios pooled from 5 studies, using 10mm2 as the cutoff point, were .85 (95% CI, .78-.90), .91 (95% CI, .86-.94), and 53.96 (95% CI, 14.84-196.14), respectively. CONCLUSIONS The ulnar nerve CSA measured by ultrasound imaging is useful for the diagnosis of CuTS and is most significantly different between patients and participants without CuTS at the medial epicondyle. Because the ulnar nerve CSA in healthy participants, at various locations, rarely exceeds 10mm2, this value can be considered as a cutoff point for diagnosing ulnar nerve entrapment at the elbow region.
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Affiliation(s)
- Ke-Vin Chang
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Bei-Hu Branch, Taipei, Taiwan; Department of Physical and Rehabilitation Medicine, National Taiwan University College of Medicine, Taipei, Taiwan.
| | - Wei-Ting Wu
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Bei-Hu Branch, Taipei, Taiwan
| | - Der-Sheng Han
- Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Bei-Hu Branch, Taipei, Taiwan; Department of Physical and Rehabilitation Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Levent Özçakar
- Department of Physical and Rehabilitation Medicine, Hacettepe University Medical School, Ankara, Turkey
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Bedewi MA, Yousef AM, Abd-Elghany AA, el-sharkawy MS, Awad EM. Estimation of ultrasound reference values for the ulnar nerve fascicular number and cross-sectional area in young males: A cross-sectional study. Medicine (Baltimore) 2017; 96:e6204. [PMID: 28272211 PMCID: PMC5348159 DOI: 10.1097/md.0000000000006204] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The objective of this study is to estimate the reference values for the number of fascicles and cross-sectional area (CSA) of the ulnar nerve at a single predetermined site by ultrasound in healthy young adult males.The demographic and physical characteristics of 50 adult male volunteers were evaluated and recorded. The subjects were positioned supine with the elbow flexed at 90° and the palm of the hand placed on a hard surface. The ulnar nerve was scanned bilaterally 1 cm proximal to the medial epicondyle in projection of the cubital tunnel. The number of fascicles and mean CSA of the ulnar nerve were identified. In addition, the side-to-side differences of the estimated reference values and their correlations with the age, weight, height, and body mass index (BMI) were evaluated.The mean fascicular number was 5.66 ± 1.48, the mean ultrasound-estimated CSA of the ulnar nerve was 6.54 ± 1.67 mm and both sides were comparable in the mean CSA and fascicular number (6.43 ± 1.80 mm and 5.88 vs 6.64 ± 1.55 mm and 5.44, for right and left side, respectively). No significant correlations were observed between CSA and fascicles number and age, weight, height, or BMI of study subjects.The reference values for the number of fascicles number and the CSA of the ulnar nerve at a single predetermined site were identified. These values could be used for the sonographic diagnosis and follow-up of the ulnar nerve lesions.
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Affiliation(s)
- Mohamed Abdelmohsen Bedewi
- Department of Diagnostic Radiology, College of Medicine, Prince Sattam bin Abdulaziz University, Al-kharj
| | - Ahmed M.M. Yousef
- College of Applied Medical Sciences, Sattam Bin Abdul-Aziz University
| | | | | | - Ezzat M. Awad
- Department of Vascular Biology and Thrombosis Research, Center for Physiology and Pharmacology, Medical University of Vienna, Vienna, Austria
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30
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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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31
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Chhabra A, Belzberg AJ, Rosson GD, Thawait GK, Chalian M, Farahani SJ, Shores JT, Deune G, Hashemi S, Thawait SK, Subhawong TK, Carrino JA. Impact of high resolution 3 tesla MR neurography (MRN) on diagnostic thinking and therapeutic patient management. Eur Radiol 2015; 26:1235-44. [DOI: 10.1007/s00330-015-3958-y] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Revised: 07/26/2015] [Accepted: 07/30/2015] [Indexed: 01/05/2023]
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