Contribution of ultrasound in a neurophysiological lab in diagnosing nerve impairment: A one-year systematic assessment

The role of preoperative ultrasound in the management of peripheral nerve injuries

BACKGROUND

Peripheral nerve injury refers to any damage or trauma to the nerves located outside the central nervous system. Ultrasonography is a reliable, cheap, and minimally invasive method in clinical practice to give physicians useful information about nerve injury.

OBJECTIVES

to assess the power of ultrasound in determining the presence, localization, and extent of neural damage in patients with clinical evidence of peripheral nerve lesions before surgery.

METHODS

This cross-sectional study was conducted on 78 patients (56 females and 22 males, aged from 9 to 52 years) who had different pathologies including entrapment, tumoral, post-traumatic, and post-surgical nerve injuries at the Neurosurgery and Physical Medicine, Rheumatology, and Rehabilitation Departments, Tanta University Hospitals. All studied patients had preoperative evaluation; neurological examination, electrodiagnostic studies, and sonographic examinations with linear array transducers (frequencies ranging from 7.5 to 16 MHz).

RESULTS

The most common pathological condition was entrapment neuropathy (39 patients) (50%). Ultrasound complemented the electrodiagnostic studies by determining the site of entrapment manifested by increased mean maximum cross-sectional area of the nerve proximal to the site of entrapment and nerve hypoechogenicity. In post-traumatic and iatrogenic neuropathies (35 patients) (44.9%), the ultrasound finding revealed neuroma in continuity in nine cases (11.5%), complete neurotmesis with stump neuroma in eighteen patients (23.1%), and eight cases (10.3%) showed perineural adhesion. In all cases, the nerve was hypoechoic at the site of injury. The presence of hyperechoic fibrous tissue could indicate perineural adhesion and the necessity for neurolysis. This study also included three (3.8%) cases had schwannoma, and one case (1.3%) had neurofibroma. Ultrasound was used to confirm the diagnosis by determining the tumor's size and vascular supply.

CONCLUSIONS

Ultrasonography is a diagnostic and surgical planning tool that is becoming more and more useful for the management of peripheral nerve injuries. Its high resolution and real-time capability provide safe and cost-effective scans that aid in determining the extent of injuries. For patients with peripheral nerve injuries, ultrasound is advised to be added to the routine clinical and neurophysiological evaluation. It is also advised to use ultrasound as a first-line imaging modality for tumors thought to be of nerve origin.

Ulnar nerve thickness at the elbow on longitudinal ultrasound view in control subjects

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.

Evidence-based guideline: Neuromuscular ultrasound for the diagnosis of ulnar neuropathy at the elbow

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).

Peripheral Neuropathies Seen by Ultrasound: A Literature Analysis through Lexical Evaluation, Geographical Assessment and Graph Theory

(1) Background: Ultrasound is a well-known tool used for the diagnosis and management of many diseases, including peripheral neuropathies. The main aim of this study was the lexical analysis of the literature on this topic considering the most cited words and the relationship between the words and the papers. Furthermore, a geographical analysis was performed to evaluate the worldwide prevalence. (2) Methods: We performed a literature search on PubMed, and we calculated the occurrence of the words indicating nerves and the body parts. Furthermore, we calculated the number of papers for each country, considering the affiliation of the first author. Finally, to describe the relationships between the words and the papers, we used the 30 most cited words, and we built a matrix describing in which papers a word was cited. This matrix was used to create a network based on the graph theory using Gephi 0.9.2 software. (3) Results: The most cited nerves were median and ulnar ones, and the most cited body parts were hand, wrist and elbow. The United States of America was the most productive country, with 80 papers. The graph of the network showed the importance of ultrasound as support for therapy. (4) Conclusions: The study represents a lexical analysis of the literature and shows information about subjects, authors and relationships of the papers. This may be helpful for better understanding and evaluation of the situation of the current literature.

Posterior Border Distance: An Effective Diagnostic Measurement for Carpal Tunnel Syndrome Using Ultrasonography

Purpose

The purpose of this study was to define posterior border distance (PBD), which represents an ultrasonographic diagnosing method of carpal tunnel syndrome (CTS), and to determine the reliability of PBD in comparison with electromyography (EMG) results.

Methods

Thirty-three patients (mean age: 51.8 ± 9.5 years; 27 females and six males) with CTS were included in this study. Ultrasonography (US) and EMG were performed under blinded conditions. PBD was evaluated by measuring the length of the perpendicular line between the posterior border of the median nerve and the line between the hook of the hamate and trapezoid tubercle. The cross-sectional area, anteroposterior (AP), and transverse diameter of the median nerve were measured. Control US was performed in 20 patients who were available at the first year postoperative follow-up and the results compared with preoperative US values. Correlation analyzes were performed to determine the relationship between electrodiagnostic results and ultrasonographic measurements.

Results

According to the results of preoperative and postoperative first-year US, there were statistically significant differences in the results of PBD (preoperative: 3.309±1.7472 mm, postoperative: 2.290±0.7867 mm p: 0.013) and AP diameter of the median nerve (preoperative: 3.012±0.7865 mm, postoperative: 2.680±0,5578 mm p: 0.017). There was no statistically significant difference in transverse diameter (preoperative: 6.585±1.9505 mm, postoperative: 6.955±2.2128 mm) and cross-sectional area (preoperative: 14.33±6.513 mm², postoperative: 11.20±5.830 mm²) results (p>0.05).

The cut-off value of PBD was ≥3.6 mm, it yielded 81.48% specificity and 83.33% sensitivity in the diagnosis of CTS. PBD was correlated with motor and sensory latency, anteromedial, and transverse diameter of the median nerve (p<0.05). There was no correlation between EMG values and the results of the cross-sectional area, transverse diameter, and AP diameter of the median nerve (p>0.05).

Conclusion

PBD is suggested as a reliable ultrasonographic measurement method for the diagnosis of CTS.

Ultrasound in the diagnosis and management of fibular mononeuropathy

INTRODUCTION

Ultrasound (US) evaluation of peripheral nerves is a noninvasive, cost-effective approach to diagnosing focal mononeuropathies and guiding surgical management. We used the intranerve ratio to evaluate for possible cut-off values in diagnosis of fibular mononeuropathies (FNs).

METHODS

A retrospective analysis of FN confirmed by electrodiagnosis (EDx) was performed to identify intranerve ratio values between affected and unaffected limbs at the fibular head and popliteal fossa.

RESULTS

The optimal fibular head/popliteal fossa intranerve ratio to discriminate between limbs with and without disease was 1.25 (sensitivity, 51%; specificity, 71%). There was no statistically significant difference between affected vs unaffected limbs (ratio, 1.13; P = .15) nor in subgroup analyses. However, 25% of patients had structural lesions amenable to surgery.

DISCUSSION

The utility of US in diagnosis of FN is limited using intranerve ratio data, but US has a distinct advantage over EDx for identifying treatable structural lesions.

Cost-effectiveness of neuromuscular ultrasound in focal neuropathies

OBJECTIVE

To evaluate the cost-effectiveness of neuromuscular ultrasound (NMUS) for the evaluation of focal neuropathies.

METHODS

A prior prospective, randomized, double-blind controlled trial demonstrated that NMUS, when added to electrodiagnostic testing, resulted in improved clinical outcomes after 6 months of follow-up. From this study, we abstracted quality-adjusted life-years (QALYs) from the 36-item Short Form Health Survey and entered this health-utility estimate into a mixed trial and model-based cost-effectiveness analysis from the societal perspective. Costs of intervention (NMUS) were estimated from Medicare payment rates for Current Procedural Terminology codes. Health care use was otherwise estimated to be equal, but sensitivity analyses further examined this and other key assumptions. Incremental cost-effectiveness ratio (ICER) was used as the primary outcome with a willingness-to-pay threshold of $50,000 per QALY.

RESULTS

The predicted mean health outcome associated with use of NMUS was 0.079 QALY, and the mean cost was $37, resulting in an ICER of $463 per QALY. Results and conclusions remained robust across all sensitivity analyses, including variations in time horizon, initial distribution of health states, costs, and effectiveness.

CONCLUSIONS

From a societal perspective, the addition of NMUS to electrodiagnostic testing when evaluating a focal neuropathy is cost-effective. A study of longer follow-up incorporating total health care use would further quantify the value of NMUS.

CLINICALTRIALSGOV IDENTIFIER

NCT01394822.

Ultrasound-guided decompression surgery of the tarsal tunnel: a novel technique for the proximal tarsal tunnel syndrome-Part II

Background

The aim of this study is to provide a safe ultrasound-guided minimally invasive surgical approach for a proximal tarsal tunnel release concerning nerve entrapments.

Methods and results

The study was carried out on ten fresh-frozen feet. All of them were examined by high resolution ultrasound at the medial ankle region. The surgical approach was marked throughout the course of the flexor retinaculum (laciniate ligament). Once the previous steps were done, the flexor retinaculum release technique was carried out with a 2-mm entry only. As a result, an effective and safe release of the flexor retinaculum was obtained in all fresh-frozen feet.

Conclusion

The results of our anatomic study indicate that our novel ultrasound-guided minimally invasive surgical approach for the release of the flexor retinaculum might be an effective, safe and quick decompression technique treating selected patients with a proximal tarsal tunnel syndrome.

Neuromuscular ultrasound in electrically non-localizable ulnar neuropathy

INTRODUCTION

The aim of this study was to determine the value of high-resolution ultrasound (HRUS) in patients with ulnar neuropathy whose electrophysiology displayed an axonal, non-localizing pattern.

METHODS

A prospective study of patients referred to an electromyography laboratory for ulnar neuropathy was performed. Of the 56 patients with clinical and electrodiagnostic (EDx) evidence of ulnar neuropathy, 12 were identified with non-localizing electrophysiology who subsequently underwent HRUS of the ulnar nerve.

RESULTS

HRUS localized the ulnar neuropathy in all patients. In 2 patients, HRUS demonstrated structural lesions not at the elbow.

DISCUSSION

HRUS often adds complementary information to standard EDx studies, including ulnar neuropathy. Thus, HRUS should be employed in patients with a non-localizing ulnar neuropathy on EDx studies. Muscle Nerve 58: 655-659, 2018.

Use of Multiple Ultrasonographic Parameters in Confirmation of Carpal Tunnel Syndrome

OBJECTIVES

Ultrasonography (US) of the median nerve has been increasingly studied and used for confirmation of carpal tunnel syndrome (CTS). However, a consensus on the choice of parameters to be evaluated is still not established. The aim of this diagnostic accuracy study was to assess the diagnostic value of multiple parameters individually, as well as in different combinations of variable complexity, and to find an optimal approach for US-based confirmation of a CTS diagnosis.

METHODS

All participants completed clinical and electrophysiologic evaluations, and their hands were scanned with a 5-13-MHz linear US transducer. Eighty-six patients with CTS (135 symptomatic hands) and 50 control participants (93 asymptomatic hands) were analyzed. The median nerve was recorded transversely at the forearm, at the carpal tunnel inlet, in the mid tunnel, and at the carpal tunnel outlet. For determining the parameters' diagnostic value, sensitivities, specificities, and area under the curve (AUC) values were calculated.

RESULTS

The inlet cross-sectional area, inlet circumference, and outlet cross-sectional area of the median nerve had the highest AUCs (0.962, 0.920, and 0.913, respectively), sensitivities (87.4%, 80.0%, and 74.1%), and specificities (94.6%, 91.4%, and 92.5%) among single-measurement parameters. An analysis of 2-level parameters (wrist-to-forearm-ratio, inlet-to-outlet-ratio, outlet-to-forearm-ratio, and inlet-outlet mean) yielded the highest AUC (0.974) for the mean cross-sectional area of the median nerve [(inlet + outlet cross-sectional area)/2], with high sensitivity (93.5%) and specificity (91.1%). A compound regression-based index yielded a marginally higher AUC (0.989) than the previously mentioned parameters.

CONCLUSIONS

Results of the study show that the mean cross-sectional area and inlet cross-sectional area may be valid and easy-to-acquire parameters for routine clinical use in confirming CTS.

Krishnam V, Kumar HK, Neladimmanahally V, Nagaraju U, Kumar HM, Telleman JA, Visser LH. Extensive sonographic ulnar nerve enlargement above the medial epicondyle is a characteristic sign in Hansen's neuropathy

Objective

Earlier studies have shown sonographic enlargement of the ulnar nerve in patients with Hansen’s neuropathy. The present study was performed to determine whether sonography or electrophysiological studies can detect the specific site of ulnar nerve pathology in leprosy.

Methods

Eighteen patients (thirty arms) with Hansen’s disease and an ulnar neuropathy of whom 66% had borderline tuberculoid (BT), 27% lepromatous leprosy (LL) and 7% mid-borderline (BB) leprosy were included in the study. Cross-sectional area (CSA) of ulnar nerve was measured every two centimeters from wrist to medial epicondyle and from there to axilla. All patients underwent standard motor and sensory nerve conduction studies of the ulnar nerve. Thirty age and sex matched controls underwent similar ulnar nerve CSA measurements and conduction studies.

Results

Ulnar nerve was clinically palpable in 19 of the 30 arms of patients. Motor and sensory nerve conduction studies of the ulnar nerve showed a reduced compound motor action potential and sensory nerve action potential amplitude in all patients. Motor Conduction Velocity (MCV) in patients were slower in comparison to controls, especially at the elbow and upper arm, but unable to exactly locate the site of the lesion. In comparison to controls the ulnar nerveCSA was larger in the whole arm in patients and quite specific the maximum enlargement was seen between nulnar sulcus and axilla, peaking at four centimeters above the sulcus.

Conclusions

A unique sonographic pattern of nerve enlargement is noted in patients with ulnar neuropathy due to Hansen’s disease, while this was not the case for the technique used until now, the electrodiagnostic testing. The enlargement starts at ulnar sulcus and is maximum four centimeters above the medial epicondyle and starts reducing further along the tract. This characteristic finding can help especially in diagnosing pure neuritic type of Hansen’s disease, in which skin lesions are absent, and alsoto differentiate leprosy from other neuropathies in which nerve enlargement can occur.

Hansen’s neuropathy is caused by Mycobacterium leprae. The diagnosis of Hansen disease is based on typical skin lesions, nerve enlargement and presence of bacilli in the skin smear. One of the types of leprosy is a pure neuritic type which manifests without skin lesions. High resolution ultrasound is new modality by which the morphology of the peripheral nerves can be studied. Earlier studies have shown that peripheral nerves are thickened in Hansen’s disease and ultrasound is superior in identifying nerve enlargement when compared with clinical palpation. Good correlation exits between nerve enlargement and electrophysiological studies. The current research was to look for a specific pattern of nerve enlargement and we studied patients with Hansen’s ulnar neuropathy. We found an unique pattern of nerve enlargement in which the ulnar nerve enlargement starts at the sulcus and the enlargement is maximum four centimetres above the sulcus and then it tapers. This pattern of unique nerve enlargement can help especially in diagnosing pure neuritic type of Hansen’s disease, in which skin lesions are absent, and is also useful to differentiate leprosy from other neuropathies in which nerve enlargement can occur.

Preoperative evaluation of peripheral nerve injuries: What is the place for ultrasound?

OBJECTIVE

The purpose of this study was to evaluate the usefulness of ultrasound in the preoperative workup of peripheral nerve lesions and illustrate how nerve ultrasonography can be integrated in routine clinical and neurophysiological evaluation and in the management of focal peripheral nerve injuries. The diagnostic role and therapeutic implications of ultrasonography for different neuropathies are described.

METHODS

The authors analyzed the use of ultrasound in 119 entrapment, tumoral, posttraumatic, or postsurgical nerve injuries of limbs evaluated in 108 patients during 2013 and 2014. All patients were candidates for surgery, and in all cases the evaluation included clinical examination, electrodiagnostic studies (nerve conduction study and electromyography), and ultrasound nerve study.

Ultrasound was used to explore the nerve fascicular echotexture, continuity, and surrounding tissues. The maximum cross-sectional area (CSA) and the presence of epineurial hyperechogenicity or intraneural hyper- or hypoechogenicity, of anatomical anomalies, dynamic nerve dislocations, or compressions were recorded.

The concordance rate of neurophysiological and ultrasonographic data was analyzed, classifying ultrasound findings as confirming, contributive, or nonconfirming with respect to electrodiagnostic data. The correlation between maximum nerve CSA and neurophysiological severity degree in entrapment syndromes was statistically analyzed.

RESULTS

Ultrasonography confirmed electrodiagnostic findings in 36.1% of cases and showed a contributive role in the diagnosis and surgical planning in 53.8% of all cases; the findings were negative (“nonconfirming”) in only 10.1% of the patients. In 16% of cases, ultrasound was not only contributive, but had a key diagnostic role in the presence of doubtful electrodiagnostic findings. The contributive role differed according to etiology, being higher for tumors (100%) and for posttraumatic or postsurgical neuropathies (72.2%) than for entrapment neuropathies (43.8%).

CONCLUSIONS

Ultrasound is a powerful, noninvasive tool for the examination of peripheral nerve injuries, and can guide diagnosis of and surgical strategy for focal peripheral nerve injuries. It allows direct visualization of the cause and extent of nerve lesions and finds its place between electrodiagnostic tests and exploratory surgery. It can provide invaluable information, such as the presence and extent of a mass, scar compression, or neuromas. The authors recommend it as a complement to routine clinical and neurophysiological evaluation and as the first-line imaging modality for masses of suspected nerve origin.

Advances in the neurological and neurosurgical management of peripheral nerve trauma

Peripheral nerve trauma frequently affects younger people and may result in significant and long-lasting functional disability. Currently, diagnosis and monitoring of peripheral nerve injury relies on clinical and electrodiagnostic information, supplemented by intraoperative electrophysiological studies. However, in a significant proportion of nerve injuries, the likelihood of spontaneous regeneration resulting in good functional outcome remains uncertain and unnecessary delays to treatment may be faced while monitoring for recovery. Advances in non-invasive imaging techniques to diagnose and monitor nerve injury and regeneration are being developed, and have the potential to streamline the decision-making process. In addition, advances in operative and non-operative treatment strategies may provide more effective ways to maximise functional outcomes following severe peripheral nerve trauma. This review discusses these advances in light of the current state of the art of management of peripheral nerve trauma.

Electrosonodiagnosis in Carpal Tunnel Syndrome: A Proposed Diagnostic Algorithm Based on an Analytic Literature Review

BACKGROUND

Suspected carpal tunnel syndrome (CTS) remains the most common clinical scenario prompting referral for electrodiagnostic (EDx) studies to identify objective correlates of reported subjective symptoms and clinical examination findings. Despite much debate and a rapidly expanding literature, identification of an optimal algorithm for diagnosing focal median mononeuropathy at the wrist (FMMW) associated with CTS signs and symptoms remains elusive. The introduction and rapid dissemination of peripheral nerve ultrasound imaging (PN-USI) of the median nerve has raised new questions regarding the relative value of structural information from PN-USI versus physiological information from EDx in the diagnosis of FMMW, as well as the significance of various clinical signs and symptoms suggestive of CTS. The means by which PN-USI and EDx may be optimally deployed and integrated in the process of diagnosing FMMW remains to be clearly delineated.

OBJECTIVE

To complete an analytical literature review to guide the formulation of a clinical diagnostic algorithm (CDA) integrating the use of PN-USI and EDx for the optimal detection of FMMW in the context of making a clinical diagnosis of CTS.

DATA SOURCES

A structured literature review was performed on the MEDLINE medical literature database accessed through PubMed.

ANALYSIS

Papers with particular relevance and connection to the goal of formulating the CDA were selected from the identified studies. Studies specifically examining the correlations between systematically documented clinical symptomatology, EDx findings, and PN-USI findings were reviewed for consistent outcomes that could be incorporated into a CDA to guide the integration of these two complementary technologies in the diagnostic process.

LIMITATIONS

The formulation of the algorithm was limited to measures with established validity that can be readily obtained by means of widely accepted protocols using standard EDx and ultrasound equipment. The formulated algorithm assumes a consistent association between pathophysiology and anatomical deformation of the median nerve, which may not occur in certain situations. It may also not be as accurately applied to patients with CTS with significant comorbid neuromuscular conditions.

CONCLUSIONS

An algorithm has been developed and presented, and illustrated as a flow chart, based on findings reported in the relevant reviewed literature in which PN-USI is proposed as a painless and rapidly performed screening test for FMMW to be completed before subjecting a patient to a systematic EDx testing process.

Peripheral nerve imaging

Disorders of peripheral nerve have been traditionally diagnosed and monitored using clinical and electrodiagnostic approaches. The last two decades have seen rapid development of both magnetic resonance imaging (MRI) and ultrasound imaging of peripheral nerve, such that these imaging modalities are increasingly invaluable to the diagnosis of patients with peripheral nerve disorders. Peripheral nerve imaging provides information which is supplementary to clinical and electrodiagnostic diagnosis. Both MRI and ultrasound have particular benefits in specific clinical circumstances and can be considered as complementary techniques. These technologic developments in peripheral nerve imaging will usher in an era of multimodality assessment of peripheral nerve disorders, with clinical evaluations supported by anatomic information from imaging, and functional information from electrodiagnostic studies. Such a multimodality approach will improve the accuracy and efficiency of patient care.

Charcot-Marie-Tooth 1A: A narrative review with clinical and anatomical perspectives

Charcot-Marie-Tooth 1A (CMT1A) is regarded as the most common hereditary peripheral neurodegenerative disorder. This narrative review highlights perspectives around the historically well-established and characteristic anatomical manifestations of CMT1A seen in the feet, legs and hands, in addition to a clinical diagnosis that may be confirmed by electrophysiology, genetic or molecular markers together with the presence of a typical family history. A less well-known perspective is the potential for systemic manifestations and wider complication. The condition is characterised by a progressive clinical picture with unmistakable anatomical and neurological features that have been described since the late 19th century. There remains no cure although supportive, rehabilitative, and surgical regimes may provide helpful management or amelioration of symptoms. Most recently, the emergence of a pleotherapeutic approach suggests distinct promise. Future research focused on a detailed elucidation of the underlying molecular mechanisms underpinning myelin and axonal function may eventually hold the key to successful treatment of CMT1A. Genetic modification would potentially present a cure. Clin. Anat. 29:547-554, 2016. © 2015 Wiley Periodicals, Inc.

A randomized trial of diagnostic ultrasound to improve outcomes in focal neuropathies

INTRODUCTION

Neuromuscular ultrasound is valid, reliable, and accurate, but it is not known whether combining it with electrodiagnostic studies leads to better outcomes in individuals with focal neuropathies.

METHODS

One hundred twenty individuals with focal neuropathy, based on history, examination, and electrodiagnosis, were enrolled in this study. All patients underwent neuromuscular ultrasound and were randomized to either have their ultrasound results sent to the referring physician or not have them sent. Outcomes were assessed at 6 months by evaluators blinded to group assignment.

RESULTS

The Overall Disability Sum Score and 7 of 8 domains of the Medical Outcomes Study 36-item Short-Form Health Survey (SF-36) showed more improvement in the "report sent" group, although only the general health perception domain was significant (P = 0.005).

CONCLUSIONS

Most 6-month outcomes did not reach statistical significance between the 2 groups. However, the "report sent" group had trends toward better outcomes, with significance being reached in the general health perception domain of the SF-36.

Nerve size in chronic inflammatory demyelinating neuropathy varies with disease activity and therapy response over time: a retrospective ultrasound study

INTRODUCTION

Nerves are often enlarged in chronic inflammatory demyelinating polyneuropathy (CIDP). In this investigation we studied changes with treatment over time.

METHODS

We retrospectively compared serial ultrasound measurements of median and ulnar nerve size with clinical and electrodiagnostic evaluations in 23 CIDP subjects. We defined remission as stable clinical improvement on low or decreasing amounts of medication.

RESULTS

Nerves were normal at last follow-up more often in subjects who achieved remission than in those who did not (10 of 13 vs. 0 of 10, P = 0.0001). Nerves were normal or smaller (>30% reduction) more often in subjects whose grip strength improved or remained strong compared those whose grip strength weakened (12 of 16 vs. 0 of 3, P = 0.04), and in subjects whose demyelinating electrodiagnostic features resolved compared with those whose demyelination persisted (7 of 7 vs. 6 of 12, P = 0.04). Over time, nerve size decreased more in subjects with baseline nerve enlargement who achieved remission than in those who did not (-41% vs. 7%, P = 0.04).

CONCLUSION

In CIDP, enlarged nerves normalized or decreased with remission.

Fascicular ratio: a new parameter to evaluate peripheral nerve pathology on magnetic resonance imaging: a feasibility study on a 3T MRI system

The objective of the study was to define and quantitatively evaluate the fascicular ratio (FR) on magnetic resonance imaging (MRI) in patients with peripheral neuropathies compared with healthy controls. Forty control subjects (20 women, 20 men; age, 44.6 ± 13.4 years) and 40 patients with peripheral neuropathy (22 women, 18 men; age, 50.3 ± 10.2 years) were examined with a standard 3T MRI protocol. With customized software (with semiautomatic and automatic interface), the hypointense and hyperintense areas of the peripheral nerves corresponding to fascicular and nonfascicular tissue were examined on T1-weighted sequences. The ratio of fascicular pixels to total pixels was called FR. Correlation with FR calculated on high-resolution ultrasound was performed. The statistical analysis included the Mann-Whitney U test of controls versus patients, the receiver operating characteristic (ROC) analysis, and the subgroup analysis of patients according to etiologies of neuropathy. Intraobserver and interobserver agreement was calculated based on the evaluation made by 3 readers. Finally, a complete automatic evaluation was performed. On MRI, FRs were significantly increased in patients compared with controls (FR, 76.7 ± 15.1 vs 56 ± 12.3; P < 0.0001 for the semiautomatic interface; and FR 66.3 ± 17.5 vs 47.8 ± 18.4; P < 0.0001 for the automatic interface). The increase in FR was caused mainly by an increase in the hypointense part of the nerve. This observation was valid for all causes of neuropathies. ROC analysis found an area under the curve of 0.75 (95% confidence interval, 0.44-0.81) for FR to discriminate neuropathy from control. The correlation coefficient between MRI and ultrasound was significant (r = 0.49; 95% confidence interval for r, 0.21-0.70; P = 0.012). With the semiautomated evaluation, the mean intraobserver agreement was good (K = 0.86). The interobserver agreements were also good (reader 1 vs reader 2, k = 0.71; reader 2 vs reader 3, k = 0.78; reader 3 vs reader 1, k = 0.71). There were no statistically significant differences between the results obtained using the 2 methods. FR calculation on MRI is feasible, and it may be used in adjunct to standard MRI evaluation in peripheral nerve disorders.

Nerve ultrasound findings in neuropathy associated with anti-myelin-associated glycoprotein antibodies

BACKGROUND AND PURPOSE

No systematic nerve ultrasound (US) studies on patients with neuropathy and anti-myelin-associated glycoprotein (anti-MAG) antibodies are available.

PATIENTS AND METHODS

Twenty-eight patients (18 men, 10 women, mean age 69.2 ± 10.9 years; mean disease duration 6.9 years) with anti-MAG neuropathy underwent nerve US. Echotexture, nerve cross-sectional area (CSA) and intra-nerve and inter-nerve CSA variability were assessed. The frequency (number of nerves with enlarged CSA, 'enlarged nerves sum score') and distribution (proximal versus distal, arms versus legs, symmetry) of US abnormalities were considered. Controls included two groups: four patients with immunoglobulin M (IgM) paraproteinaemic neuropathy without anti-MAG antibodies and five with chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) associated with IgM paraprotein.

RESULTS

In all, 26/28 patients had increased CSA (23 with at least one nerve outside entrapment sites). Intra-nerve CSA variability was abnormal in 21/28 patients (in 14 for increased nerve CSA outside entrapment sites). Inter-nerve CSA variability was abnormal in 16 patients (of whom half for CSA increase out of entrapment sites). The enlarged nerves sum score in anti-MAG neuropathy patients was greater than in MAG-negative paraproteinaemic neuropathies and lower than in CIDP. Intra-nerve variability appeared instead similar in anti-MAG and controls. No correlation was found between US findings and Inflammatory Neuropathy Cause and Treatment Group (INCAT) disability score or disease duration.

DISCUSSION

Amongst the different measures to assess the US pattern (symmetry/asymmetry, proximal/distal distribution and sum score), the enlarged nerves sum score was the most useful for differentiating the three groups of patients with demyelinating neuropathies and may contribute to diagnosis in a typical cases.

Ultrasound evaluation in transthyretin-related amyloid neuropathy

INTRODUCTION

Familial amyloid polyneuropathy is a rare condition caused by mutations of the transthyretin gene (TTR). We assessed the pattern of nerve ultrasound (US) abnormalities in patients with TTR-related neuropathy.

METHODS

Seven patients with TTR-related neuropathy (TTR-N) and 5 asymptomatic TTR-mutation carriers (TTR-C) underwent neurological examination, nerve conduction studies, and US evaluation.

RESULTS

Multifocal US abnormalities were identified in 6 of 7 TTR-N patients. A single patient with only a mild sensory polyneuropathy had normal nerves on US evaluation. In the TTR-C, we only detected an enlarged ulnar nerve at the elbow. Interestingly, disease severity correlated with number of nerves affected on US evaluation.

CONCLUSIONS

No specific pattern of US abnormalities was identified in this cohort. However, in TTR-related amyloid neuropathy, US may be a helpful tool in monitoring disease progression, and/or clinical response to pharmacological treatment.

Contribution of ultrasound in the assessment of patients with suspect idiopathic pudendal nerve disease

OBJECTIVE

To assess if Ultrasound (US) is contributive in patients suspected of having idiopathic pudendal neuralgia.

METHODS

Between July 2012 and April 2013, 10 consecutive female patients with suspected idiopathic pudendal neuralgia (mean age: 47±14 years; mean BMI: 24±3) were included. Two radiologists blinded to the clinical and neurophysiological data performed pudendal nerve evaluation with broadband linear array transducers (12-7 MHZ, and 17-5 MHZ). MRI was added to confirm US data. A third independent clinician, who did not perform electrodiagnosis and US, reviewed the data and scored US as "contributive" or "non-contributive": if US confirmed the clinical and neurophysiological diagnosis or if US findings were not useful.

RESULTS

Ultrasound identified alterations to the pudendal nerve in 7/10 of cases (70%). In seven cases US revealed the presence of a diffusely or focally enlarged pudendal nerve confirmed by MRI. In these cases neurophysiological findings were suspicious for pudendal neuralgia in 5/7 cases, whereas in 2/7 cases they were inconclusive.

CONCLUSION

High-resolution ultrasound (US) may demonstrate alterations to the pudendal nerve in patients with pudendal neuralgia.

SIGNIFICANCE

US is useful in patients with suspected idiopathic pudendal nerve disease.

Ultrasound of inherited vs. acquired demyelinating polyneuropathies

We compared features of nerve enlargement in inherited and acquired demyelinating neuropathies using ultrasound. We measured median and ulnar nerve cross-sectional areas in proximal and distal regions in 128 children and adults with inherited [Charcot-Marie-Tooth-1 (CMT-1) (n = 35)] and acquired [chronic inflammatory demyelinating polyneuropathy (CIDP) (n = 55), Guillaine-Barre syndrome (GBS) (n = 21) and multifocal motor neuropathy (MMN) (n = 17)] demyelinating neuropathies. We classified nerve enlargement by degree and number of regions affected. We defined patterns of nerve enlargement as: none, no enlargement; mild, nerves enlarged but never more than twice normal; regional, nerves normal in at least one region and enlarged more than twice normal in at least one region; diffuse, nerves enlarged at all four regions with at least one region more than twice normal size. Nerve enlargement was commonly diffuse (89 %) and generally more than twice normal size in CMT-1, but not (p < 0.001) in acquired disorders which mostly had either no, mild or regional nerve enlargement [CIDP (64 %), GBS (95 %), and MMN (100 %)]. In CIDP, subjects treated within 3 months of disease onset had less nerve enlargement than those treated later. Ultrasound identified patterns of diffuse nerve enlargement can be used to screen patients suspected of having CMT-1. Normal, mildly, or regionally enlarged nerves in demyelinating polyneuropathy suggests an acquired etiology. Early treatment in CIDP may impede nerve enlargement.

Heterogeneity of root and nerve ultrasound pattern in CIDP patients

OBJECTIVE

The few published ultrasound (US) studies on chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) report diffusely increased cross-sectional area (CSA) of nerves. The data are, however, heterogeneous and correlations with clinical history or disease severity are lacking.

METHODS

Thirty-four patients with CIDP underwent US nerve evaluation by two neurologists blinded to clinical data. US nerve pattern for each patient was defined by a third neurologist blinded to clinical data. Three US classes were identified based on CSA and echogenicity: large nerves with hypoechoic nerves/fascicles (class 1); large nerves with heterogeneous hypo- and hyperechoic fascicles (class 2); normal size nerve but abnormal hyperechoic array (class 3).

RESULTS

In all patients, US nerve changes were observed: in most of the cases, enlarged nerves or nerve segments were observed. The three 'classes' of US nerve changes significantly correlated (R: 0.68, p<0.001) with disease duration, but not with age or Inflammatory Neuropathy Cause and Treatment (INCAT) disability score.

CONCLUSIONS

US may be of adjunctive diagnostic value in CIDP assessment. Nerve morphological changes may mirror the underlying pathophysiological mechanisms and seem to correlate with disease duration.

SIGNIFICANCE

These results offer the possibility of exploring the use of US to assess CIDP disease activity and treatment.

Ultrasound diagnosis of bony nerve entrapment: case series and literature review

INTRODUCTION

Nerve entrapment due to osseous callus formation is a rare complication after bone fracture. Electrodiagnostic studies and routine radiographic imaging often fail to demonstrate the pathology. The diagnosis is difficult and is often made incidentally upon surgical exploration. Nerve ultrasonography has not been used routinely to assess such lesions.

METHODS

We report 5 cases of nerve entrapment in osseous callus after fractures that occurred in 2011 and 2012. The diagnosis was made by ultrasound (US). We then performed a review of the relevant literature.

CONCLUSIONS

US is becoming an invaluable tool for diagnosing peripheral nerve entrapments. The current cases suggest that nerve US should be strongly considered as an adjunctive diagnostic tool for nerve palsies developing after trauma.

Ultrasound assessment of sural nerve in Charcot-Marie-Tooth 1A neuropathy

OBJECTIVE

Nerve ultrasound (US) has been used to study peripheral nerve disease, and increase of the cross-sectional area (CSA) has been described in demyelinating polyneuropathy. The objective of the current study is to characterise the US features of the sural nerve in a sample of Charcot-Marie-Tooth (CMT) 1A patients.

METHODS

A total of 20 CMT1A patients were enrolled. As control group we studied 37 age- and sex-matched subjects. All patients underwent clinical examination, neurophysiology and US evaluation of the bilateral sural nerve and right ulnar nerve. US results were correlated with neurophysiology and clinical data.

RESULTS

Sural nerve CSA was not increased in the majority of patients (70%), whereas an increased ulnar nerve CSA was present in the whole sample. Inverse relations were found between CSA of the ulnar nerve and body mass index (BMI) (p<0.0002, R=-0.8) and CSA of the sural nerve and age (right 0.006, R=-0.6, left 0.002, R=-0.6 and left and right p=0.00003, R=-0.4).

CONCLUSIONS

US showed ulnar CSA enlargement and normal sural nerve CSA.

SIGNIFICANCE

The significance of normal sural nerve CSA in CMT1A patients need to be further investigated, possibly through longitudinal studies.

Soft tissue pathology: regional pain syndromes, nerves and ligaments

Musculoskeletal ultrasonography (MSUS) is a useful imaging technique in the diagnosis of various soft tissue pathologies. High-frequency linear array transducers provide excellent resolution of soft tissue pathology. Pathological changes in subcutaneous tissue, including soft tissue tumours, abscesses, tenosynovitis, ligamentous and tendinous abnormalities, and peripheral nerve lesions, including carpal tunnel syndrome, can be identified. This review addresses the role of US in diagnosing regional pain syndrome, ligament lesions and nerve lesions.

Evidence-based guideline: neuromuscular ultrasound for the diagnosis of carpal tunnel syndrome

INTRODUCTION

The purpose of this study was to develop an evidence-based guideline for the use of neuromuscular ultrasound in the diagnosis of carpal tunnel syndrome (CTS).

METHODS

Two questions were asked: (1) What is the accuracy of median nerve cross-sectional area enlargement as measured with ultrasound for the diagnosis of CTS? (2) What added value, if any, does neuromuscular ultrasound provide over electrodiagnostic studies alone for the diagnosis of CTS? A systematic review was performed, and studies were classified according to American Academy of Neurology criteria for rating articles of diagnostic accuracy (question 1) and for screening articles (question 2).

RESULTS

Neuromuscular ultrasound measurement of median nerve cross-sectional area at the wrist is accurate and may be offered as a diagnostic test for CTS (Level A). Neuromuscular ultrasound probably adds value to electrodiagnostic studies when diagnosing CTS and should be considered in screening for structural abnormalities at the wrist in those with CTS (Level B).

Ultrasonography in the diagnosis of peripheral nerve disease

INTRODUCTION

High-resolution ultrasound (US) of the peripheral nerves is now a standard means of assessing neuromuscular disorders in many centers. Currently used in conjunction with electrodiagnostic (EDX) studies, nerve US is especially effective in the diagnosis of entrapment neuropathies.

AREAS COVERED

This article reviews the basic physics of peripheral nerve US, guidelines for its current use and future directions. Advantages of using nerve US alongside EDX studies are outlined along with current limitations of testing. The role of US in the diagnosis of entrapment neuropathy is emphasized, particularly in carpal tunnel syndrome (CTS). US assisted diagnosis of peripheral nerve tumors, hereditary neuropathy and dysimmune neuropathy and traumatic injuries is also described.

EXPERT OPINION

US is a powerful tool in the assessment of peripheral nerve disease. Nerve US is an evolving, young discipline. There is still much to learn, but current evidence supports US imaging of all patients presenting for evaluation of possible mononeuropathy. With improvements in resolution, the introduction of US contrast agents and objective measures of nerve echogenicity, there is promise for further expanding its role in the diagnosis of all peripheral neuropathies.

Ultrasound evaluation of peripheral neuropathy in POEMS syndrome

INTRODUCTION

Polyneuropathy, organomegaly, endocrinopathy, M protein, skin changes (POEMS) syndrome is a rare multisystem disorder associated with plasma cell dyscrasia whose main neurological feature is a demyelinating polyneuropathy. The aim of our study was to assess the pattern of ultrasound (US) nerve abnormalities in POEMS syndrome patients.

METHODS

Eight POEMS syndrome patients underwent neurological examination and US evaluation of the median, ulnar, fibular, tibial, and sural nerves. Nerve cross-sectional area and echogenicity abnormalities were analyzed.

RESULTS

US abnormalities were mostly localized at entrapment sites. Enlargements outside the entrapment sites were uncommon. No correlation was found between muscle weakness and focal US findings.

CONCLUSIONS

No specific pattern of US abnormalities was identified in this cohort of patients with POEMS syndrome. The lack of correlation between US and clinical findings may be secondary to the chronic nerve damage that is common in POEMS syndrome, where the diagnosis is often delayed.

Quantitative assessment of nerve echogenicity: comparison of methods for evaluating nerve echogenicity in ulnar neuropathy at the elbow

OBJECTIVE

The objective is to evaluate different methods to assess nerve echogenicity in a quantitative way by comparing a group of patients with ulnar neuropathy at the elbow (UNE) and a healthy control group, subsequently selecting the best tests for quantitative assessment of nerve echogenicity.

METHODS

We included 56 patients with UNE and 37 healthy controls. High-resolution ultrasonography images of the ulnar nerve at the level of the medial epicondyle were saved in JPEG, TIFF or DICOM format, with a 19 pixels/mm resolution. Hypoechoic fraction was calculated by using 1 manual and 16 automatic thresholding methods.

RESULTS

A significant difference in mean hypoechoic fraction between patients and controls was found using the following automatic thresholding methods: MaxEntropy 82% versus 74% (p < 0.001), RenyiEntropy 80% versus 69% (p < 0.001), Shanbhag 76% versus 68% (p = 0.002), Triangle 45% versus 58% (p = 0.036) and Yen 79% versus 67% (p < 0.001). Of these five tests a significant correlation between hypoechoic fraction and the cross-sectional area was found for: MaxEntropy 0.542 (p < 0.001), RenyiEntropy 0.558 (p < 0.001), Shanbhag 0.219 (p = 0.035) and Yen 0.513 (p < 0.001). The manual thresholding method did not detect a significant difference in hypoechoic fraction between patients and controls, and inter-rater agreement in hypoechoic fraction for manual thresholding was poor.

CONCLUSION

Quantitative nerve echogenicity assessment can be successfully used to distinguish between a group of patients with UNE and a healthy control group, preferably by using the MaxEntropy, RenyiEntropy or Yen methods.

SIGNIFICANCE

Automatic thresholding techniques using the MaxEntropy, RenyiEntropy or Yen methods are the best quantitative tests, and these quantitative measures can probably be used in further studies evaluating echogenicity in mono- and polyneuropathies.

Contribution of ultrasound in the assessment of nerve diseases

BACKGROUND AND PURPOSE

Recently, ultrasound (US) has been used to assess the peripheral nervous system; however, there is no real study about its possible significant role in routine practice. Our study aims to assess the contribution of US as a routine tool in a neurophysiological laboratory.

METHODS

The study assesses 130 patients who presented clinical suspicion of peripheral nerve diseases, excluding motor neuron disease, radiculopathy, hereditary and acquired polyneuropathy. All patients were clinically, neurophysiologically and sonographically assessed in the same session by the same neurologist/neurophysiologist. To avoid interpretation bias, two independent and blinded clinicians, different than the examiners performing electrodiagnosis and US, reviewed clinical, neurophysiological and US findings (also data about follow-up, when available) and classified the contribution of US as follows: Contributive (US had influence on the diagnostic and therapeutic strategies), Confirming (US confirmed the clinical and neurophysiological diagnosis), Non-Confirming (US findings were normal) and Incorrect (US findings led to incorrect diagnosis).

RESULTS

US impacted, namely modified the diagnostic and therapeutic path in 42.3% of cases (55 patients); US had a confirmatory role in 40% (52 patients); US did not confirm clinical and neurophysiological diagnosis in 17.7% (23 cases); no incorrect US findings were observed.

CONCLUSION

US complements neurophysiological assessment even in routine practice, and this confirms the increasing interest in US for a multidimensional evaluation of peripheral nerve system diseases.

Ultrasound diagnosis of peroneal nerve variant in a child with compressive mononeuropathy

We report on a 6-year-old child presenting with subacute foot drop. Neurophysiologic and radiologic studies revealed a peroneal nerve compression secondary to fibular exostosis. Before undergoing surgical removal of the exostosis, the patient underwent further neurophysiologic and ultrasonographic evaluation that showed the presence of an accessory peroneal nerve branch that caused gastrocnemius involvement. Findings at surgery confirmed the supposed anatomical variant. Both nerve components were carefully preserved during the operative procedure. The association of ultrasonographic and neurophysiologic studies was crucial in identifying the etiopathologic mechanism and anatomical picture and provided clinicians and surgeons with important information in planning the procedure.

Nerve density: a new parameter to evaluate peripheral nerve pathology on ultrasound. Preliminary study

The possibility to realize a quantitative evaluation of nerve density on ultrasound is clinically important to enhance the evaluation of peripheral nerve disorders. We developed software that quantifies the ratio between the hypoechoic and hyperechoic areas of peripheral nerves on ultrasound. Nerve density was defined as (hypoechoic pixels)/(total pixels) and the purpose of our study was to asses if nerve density can be used to differentiate pathologic conditions affecting peripheral nerves. Ultrasound images of peripheral nerves were obtained with a high-frequency probe (17-5 MHz, 288 elements). Sixty-five different patients and (n = 65) controls (age range, 35-81 years; mean 55 years) were prospectively evaluated. Thirty-five patients had carpal tunnel syndrome and 30 patients had neurofibromas. Three radiologists performed a semiautomated evaluation with intra and interobserver agreement. A complete automatic evaluation was performed with no need of intra and interobserver evaluation. With the semiautomated evaluation, mean intraobserver agreement was good (K = 0.85). Interobserver agreements was good as well (reader 1 vs reader 2: k = 0.72; reader 2 vs reader 3: k = 0.80; reader 3 vs reader 1: k = 0.72). Differences among value of nerve density in normal nerves, CTS and neurofibromas were statistically significant (p < 0.0001). There were no statistically significant differences between the results obtained using the automatic or the semiautomatic method. Nerve density is capable of discriminating between normal and pathologic nerves of patients affected by carpal tunnel syndrome or neurofibromas. Moreover, nerve density measure is useful to discriminate between patients with mild and severe CTS.

Intraneural perineurioma of the median nerve: case report and literature review

Intraneural perineurioma is a benign peripheral nerve sheath tumor of perineurial cell origin. We present the case of an intraneural perineurioma of the median nerve in a 23-year-old woman which posed a diagnostic challenge. Ultrasonography was found to be a quick, easy, and effective screening tool for identifying the source of the deficit followed by MRI to further elucidate the lesion. We discuss surgical management options for optimizing functional outcomes when addressing such lesions.

Sonographic follow-up of patients with carpal tunnel syndrome undergoing surgical or nonsurgical treatment: prospective cohort study

PURPOSE

To compare changes in the largest cross-sectional area (CSA) of the median nerve in wrists undergoing surgical decompression with changes in wrists undergoing non-surgical treatment of carpal tunnel syndrome (CTS).

METHODS

This study was a prospective cohort study in 55 consecutive patients with 78 wrists with established CTS, including 60 wrists treated with surgical decompression and 18 wrists with non-surgical treatment. A sonographic examination was scheduled before and 4 months after initiation of treatment. We compared changes in CSA of the median nerve between wrists with surgical treatment and wrists with non-surgical treatment using linear regression models.

RESULTS

Decreases in CSA of the median nerve were more pronounced in wrists with CTS release than in wrists undergoing nonsurgical treatment (difference in means, 1.0 mm(2); 95% confidence interval, 0.3-1.8 mm(2)). Results were robust to the adjustment for age, gender, and neurological severity at baseline. Among wrists with CTS release, those with postoperative CSA of 10 mm(2) or less tended to have better clinical outcomes than those with postoperative CSA of greater than 10 mm(2) (p=.055). Postoperative sonographic workup in the 3 patients with unfavorable outcome or recurrence identified likely causes for treatment failure in 2 patients.

CONCLUSIONS

In this observational study, surgical decompression was associated with a greater decrease in median nerve CSA than was nonsurgical treatment. Smaller postoperative CSAs may be associated with better clinical outcomes. Additional randomized trials are necessary to determine the optimal treatment strategy in different subgroups of patients with CTS.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.