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Manske RC, Voight M, Page P, Wolfe C. Utilizing Diagnostic Musculoskeletal Ultrasound in the Evaluation of Cubital Tunnel Syndrome and Ulnar Nerve Pathology. Int J Sports Phys Ther 2024; 19:502-506. [PMID: 38576834 PMCID: PMC10987310 DOI: 10.26603/001c.115363] [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] [Indexed: 04/06/2024] Open
Abstract
Cubital Tunnel Syndrome (CTS), is a frequently encountered condition in clinical settings, typically arising from static or dynamic compression of the ulnar nerve. CTS is characterized by the irritation of the ulnar nerve within the cubital tunnel and is a common neuropathic condition that can significantly impact functional abilities and quality of life. This article explores the utility of diagnostic musculoskeletal ultrasound (MSK-US) in the evaluation of the cubital tunnel and the ulnar nerve. The cubital tunnel syndrome, a common entrapment neuropathy of the ulnar nerve, often presents diagnostic challenges. Traditionally, nerve conduction studies and electromyography have been the primary diagnostic tools used to diagnose CTS. Given the superficial nature of the ulnar groove and its adjacent structures, MSK-US imaging known for its non-invasive nature and high-resolution imaging capabilities, has become an increasingly valuable tool in the assessment and management of various musculoskeletal conditions. This article reviews the technical aspects of MSK-US, its advantages in visualizing the ulnar nerve and related structures, and its implications in clinical practice for rehabilitation providers. By integrating MSK-US in the evaluation of CTS, rehabilitation professionals can enhance diagnostic accuracy, tailor interventions, and improve patient outcomes.
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Rubin DI, Lamb CJ. The role of electrodiagnosis in focal neuropathies. HANDBOOK OF CLINICAL NEUROLOGY 2024; 201:43-59. [PMID: 38697746 DOI: 10.1016/b978-0-323-90108-6.00010-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2024]
Abstract
Electrodiagnostic (EDX) testing plays an important role in confirming a mononeuropathy, localizing the site of nerve injury, defining the pathophysiology, and assessing the severity and prognosis. The combination of nerve conduction studies (NCS) and needle electromyography findings provides the necessary information to fully assess a nerve. The pattern of NCS abnormalities reflects the underlying pathophysiology, with focal slowing or conduction block in neuropraxic injuries and reduced amplitudes in axonotmetic injuries. Needle electromyography findings, including spontaneous activity and voluntary motor unit potential changes, complement the NCS findings and further characterize chronicity and degree of axon loss and reinnervation. EDX is used as an objective marker to follow the progression of a mononeuropathy over time.
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Affiliation(s)
- Devon I Rubin
- Department of Neurology, Mayo Clinic, Jacksonville, FL, United States.
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Beecher G, Dyck PJB, Zochodne DW. Axillary and musculocutaneous neuropathies. HANDBOOK OF CLINICAL NEUROLOGY 2024; 201:135-148. [PMID: 38697736 DOI: 10.1016/b978-0-323-90108-6.00004-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2024]
Abstract
This chapter covers axillary and musculocutaneous neuropathies, with a focus on clinically relevant anatomy, electrodiagnostic approaches, etiologic considerations, and management principles. Disorders of the lateral antebrachial cutaneous nerve, a derivative of the musculocutaneous nerve, are also reviewed. We emphasize the importance of objective findings, including the physical examination and electrodiagnostic evaluation in confirming the isolated involvement of each nerve which, along with the clinical history, informs etiologic considerations. Axillary and musculocutaneous neuropathies are both rare in isolation and most frequently occur in the setting of trauma. Less commonly encountered etiologies include external compression or entrapment, neoplastic involvement, or immune-mediated disorders including neuralgic amyotrophy, postsurgical inflammatory neuropathy, multifocal motor neuropathy, vasculitic neuropathy, and multifocal chronic inflammatory demyelinating polyradiculoneuropathy.
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Affiliation(s)
- Grayson Beecher
- Division of Neuromuscular Medicine, Department of Neurology, Mayo Clinic, Rochester, MN, United States; Neuroscience and Mental Health Institute and Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - P James B Dyck
- Division of Neuromuscular Medicine, Department of Neurology, Mayo Clinic, Rochester, MN, United States; Peripheral Neuropathy Research Laboratory, Mayo Clinic, Rochester, MN, United States
| | - Douglas W Zochodne
- Neuroscience and Mental Health Institute and Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada.
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Classifying the Severity of Cubital Tunnel Syndrome: A Preoperative Grading System Incorporating Electrodiagnostic Parameters. Plast Reconstr Surg 2022; 150:115e-126e. [PMID: 35544306 DOI: 10.1097/prs.0000000000009255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Current classifications for cubital tunnel syndrome have not been shown to reliably predict postoperative outcomes. In this article, the authors introduce a new classification that incorporates clinical and electrodiagnostic parameters, including compound muscle action potential amplitude, to classify the preoperative severity of cubital tunnel syndrome. The authors compare this to established classifications and evaluate its association with patient-rated improvement. METHODS The authors reviewed 44 patients who were treated surgically for cubital tunnel syndrome. Patients were retrospectively classified using their proposed classification and the Akahori, McGowan-Goldberg, Dellon, and Gu classifications. Correlation of grades was assessed by Spearman coefficients and agreement was assessed by weighted kappa coefficients. Patient-reported impairment was assessed using the Disabilities of the Arm, Shoulder, and Hand questionnaire before and after surgery. RESULTS The classifications tended to grade patients in a similar way, with Spearman coefficients of 0.60 to 0.85 ( p < 0.0001) and weighted kappa coefficients of 0.46 to 0.71 ( p < 0.0001). Preoperative Disabilities of the Arm, Shoulder, and Hand scores increased with severity grade for most classifications. In multivariable analysis, the authors' classification predicted postoperative Disabilities of the Arm, Shoulder, and Hand score improvement, whereas established classifications did not. CONCLUSIONS Established classifications are imperfect indicators of preoperative severity. The authors introduce a preoperative classification for cubital tunnel syndrome that incorporates electrodiagnostic findings in addition to classic signs and symptoms. CLINICAL QUESTION/LEVEL OF EVIDENCE Diagnostic, III.
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Jardim M, Vital RT, Illarramendi X, Hacker M, Junqueira B, Pitta IJR, Pinheiro RO, Sarno EN. The red flags of ulnar neuropathy in leprosy. PLoS One 2021; 16:e0259804. [PMID: 34797866 PMCID: PMC8604365 DOI: 10.1371/journal.pone.0259804] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 10/26/2021] [Indexed: 11/26/2022] Open
Abstract
The diagnosis of pure neural leprosy is more challenging because patients share characteristics with other common pathologies, such as ulnar compression, which should be taken into consideration for differential diagnosis. In this study, we identify ulnar nerve conduction characteristics to aid in the differential diagnosis of ulnar neuropathy (UN) in leprosy and that of non-leprosy etiology. In addition, we include putative markers to better understand the inflammatory process that may occur in the nerve. Data were extracted from a database of people affected by leprosy (leprosy group) diagnosed with UN at leprosy diagnosis. A non-leprosy group of patients diagnosed with mechanical neuropathy (compressive, traumatic) was also included. Both groups were submitted to clinical, neurological, neurophysiological and immunological studies. Nerve enlargement and sensory impairment were significantly higher in leprosy patients than in patients with compressive UN. Bilateral impairment was significantly higher in the leprosy group than in the non-leprosy group. Leprosy reactions were associated to focal demyelinating lesions at the elbow and to temporal dispersion (TD). Clinical signs such as sensory impairment, nerve enlargement and bilateral ulnar nerve injury associated with eletrodiagnostic criteria such as demyelinating finds, specifically temporal dispersion, could be tools to help us decided on the best conduct in patients with elbow ulnar neuropathy and specifically decide if we should perform a nerve biopsy for diagnosis of pure neural leprosy.
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Affiliation(s)
- Márcia Jardim
- Oswaldo Cruz Institute, Fiocruz, Rio de Janeiro, Brazil
- Department of Neurology, Pedro Ernesto University Hospital/Rio de Janeiro State University, Rio de Janeiro, Brazil
- Federal University of the State of Rio de Janeiro, Rio de Janeiro, Brazil
- * E-mail:
| | - Robson T. Vital
- Department of Neurology, Pedro Ernesto University Hospital/Rio de Janeiro State University, Rio de Janeiro, Brazil
| | | | | | | | - Izabela J. R. Pitta
- Oswaldo Cruz Institute, Fiocruz, Rio de Janeiro, Brazil
- Department of Neurology, Pedro Ernesto University Hospital/Rio de Janeiro State University, Rio de Janeiro, Brazil
- Federal University of the State of Rio de Janeiro, Rio de Janeiro, Brazil
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Patel K, Horak HA. Electrodiagnosis of Common Mononeuropathies: Median, Ulnar, and Fibular (Peroneal) Neuropathies. Neurol Clin 2021; 39:939-955. [PMID: 34602220 DOI: 10.1016/j.ncl.2021.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
This article addresses common mononeuropathies seen in the electrodiagnostic laboratory. The most common mononeuropathies-median neuropathy at the wrist (carpal tunnel syndrome), ulnar neuropathy at the elbow, and fibular (peroneal) neuropathy at the fibular head-are reviewed. The causes, clinical presentations, approached to the electrodiagnostic studies (including nerve conduction studies and needle electromyography), and the typical findings are discussed.
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Affiliation(s)
- Kamakshi Patel
- University of Texas Medical Branch (UTMB), 301 University Boulevard, JSA 9.128, Galveston, TX 77555, USA
| | - Holli A Horak
- University of Arizona College of Medicine- Tucson, 1501 North Campbell Avenue, Room 6212a, Tucson, AZ 87524, USA.
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Mezian K, Jačisko J, Kaiser R, Machač S, Steyerová P, Sobotová K, Angerová Y, Naňka O. Ulnar Neuropathy at the Elbow: From Ultrasound Scanning to Treatment. Front Neurol 2021; 12:661441. [PMID: 34054704 PMCID: PMC8160369 DOI: 10.3389/fneur.2021.661441] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 03/23/2021] [Indexed: 01/01/2023] Open
Abstract
Ulnar neuropathy at the elbow (UNE) is commonly encountered in clinical practice. It results from either static or dynamic compression of the ulnar nerve. While the retroepicondylar groove and its surrounding structures are quite superficial, the use of ultrasound (US) imaging is associated with the following advantages: (1) an excellent spatial resolution allows a detailed morphological assessment of the ulnar nerve and adjacent structures, (2) dynamic imaging represents the gold standard for assessing the ulnar nerve stability in the retroepicondylar groove during flexion/extension, and (3) US guidance bears the capability of increasing the accuracy and safety of injections. This review aims to illustrate the ulnar nerve's detailed anatomy at the elbow using cadaveric images to understand better both static and dynamic imaging of the ulnar nerve around the elbow. Pathologies covering ulnar nerve instability, idiopathic cubital tunnel syndrome, space-occupying lesions (e.g., ganglion, heterotopic ossification, aberrant veins, and anconeus epitrochlearis muscle) are presented. Additionally, the authors also exemplify the scientific evidence from the literature supporting the proposition that US guidance is beneficial in injection therapy of UNE. The non-surgical management description covers activity modifications, splinting, neuromobilization/gliding exercise, and physical agents. In the operative treatment description, an emphasis is put on two commonly used approaches-in situ decompression and anterior transpositions.
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Affiliation(s)
- Kamal Mezian
- Department of Rehabilitation Medicine, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czechia
| | - Jakub Jačisko
- Department of Rehabilitation and Sports Medicine, Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czechia
| | - Radek Kaiser
- Department of Neurosurgery and Neurooncology, First Faculty of Medicine, Charles University and Military University Hospital Prague, Prague, Czechia
| | - Stanislav Machač
- Department of Rehabilitation and Sports Medicine, Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czechia
| | - Petra Steyerová
- Department of Radiology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czechia
| | - Karolína Sobotová
- Department of Rehabilitation and Sports Medicine, Second Faculty of Medicine, Charles University and University Hospital Motol, Prague, Czechia
| | - Yvona Angerová
- Department of Rehabilitation Medicine, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czechia
| | - Ondřej Naňka
- Institute of Anatomy, First Faculty of Medicine, Charles University, Prague, Czechia
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Ultrasound: A Useful Tool in the Diagnosis and Localization of Ulnar Neuropathy at the Elbow. Ochsner J 2021; 21:3-5. [PMID: 33828418 PMCID: PMC7993428 DOI: 10.31486/toj.21.0002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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Short-term cane use in subacute stroke patients affects the nonparetic upper extremity nerves. Int J Rehabil Res 2020; 43:148-153. [DOI: 10.1097/mrr.0000000000000397] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Raeissadat SA, Youseffam P, Bagherzadeh L, Rayegani SM, Bahrami MH, Eliaspour D. Electrodiagnostic Findings in 441 Patients with Ulnar Neuropathy - a Retrospective Study. Orthop Res Rev 2019; 11:191-198. [PMID: 31819676 PMCID: PMC6897064 DOI: 10.2147/orr.s230116] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 11/11/2019] [Indexed: 11/23/2022] Open
Abstract
Purpose Ulnar neuropathy (UN) is the second most common focal neuropathy in the upper extremities. Electrodiagnostic studies (EDx), including nerve conduction study (NCS) and electromyography (EMG), are reliable tools for the diagnosis of ulnar neuropathy. We aimed to retrospectively analyze the medical records of patients diagnosed with ulnar neuropathy in a seven-year period and report our findings. Patients and methods In this retrospective study, documents of the patients whose ulnar nerve injury was confirmed through electrodiagnostic study in two departments of Physical Medicine and Rehabilitation were collected and demographic data, subjective complaints of the patient, the cause, and electrodiagnostic findings were extracted from each patient’s file. The following points were specifically evaluated in the electrodiagnostic records; type of injury, location, accompanying injuries, sensory nerve action potentials (SNAP) of the fifth finger, SNAP of dorsal ulnar cutaneous nerve (DUCN), compound muscle action potential (CMAP) of abductor digiti minimi (ADM) muscle, nerve conduction velocity (NCV) across elbow, patterns of muscle involvement, and the severity of insult. Results Out of 441 records, 305 (69.2%) were male and 68.1% were non-traumatic. Based on our clinical criteria, the intensity of the injury was mild in most cases. The elbow and forearm were the most involved regions in non-traumatic and traumatic cases respectively. Across elbow nerve conduction velocity showed decreased velocity in 71% of records. In non-traumatic cases, the most affected muscle was ADM (97%) and then FDI (85%). Conclusion In focal entrapments such as ulnar neuropathy, electrodiagnostic findings are very helpful in assessing location, severity, and type of injury. If a consensus is achieved for the diagnosis of UN, even retrospective studies can become valuable sources for studying UN.
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Affiliation(s)
- Seyed Ahmad Raeissadat
- Clinical Development Research Center of Shahid Modarres Hospital, Physical Medicine and Rehabilitation Department and Research Center, Shahid Beheshti University of Medical Sciences, School of Medicine, Tehran, Iran
| | - Parisa Youseffam
- Clinical Development Research Center of Shahid Modarres Hospital, Physical Medicine and Rehabilitation Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Leila Bagherzadeh
- Department of Orthopedics, Faculty of Medicine, Zabol University of Medical Sciences, Zabol, Iran
| | - Seyed Mansoor Rayegani
- Physical Medicine and Rehabilitation Research Center, Shohada-E-Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Hasan Bahrami
- Physical Medicine and Rehabilitation Research Center, Shohada-E-Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Dariush Eliaspour
- Physical Medicine and Rehabilitation Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Abuzinadah AR, Addas BMJ. Ulnar Neuropathy at the Elbow Associated With Focal Demyelination in the Proximal Forearm and Intraoperative Imaging Correlation. Front Neurol 2019; 10:292. [PMID: 30972017 PMCID: PMC6445876 DOI: 10.3389/fneur.2019.00292] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 03/06/2019] [Indexed: 11/13/2022] Open
Abstract
Ulnar nerve focal demyelination (FD) in the forearm [defined as conduction block (CB) and or temporal dispersion (TD)] has been described with immune-mediated neuropathy and with compression affecting the forearm segment of the nerve. The association of FD in the forearm with entrapment ulnar neuropathy at the elbow, as well as the intraoperative imaging of the abnormal ulnar nerve at the flexor carpi ulnaris muscle level (FCU), has not been reported before. We report a 33-years-old woman presented with only sensory symptoms of the right hand suggestive of right ulnar neuropathy for the last 10 years. On clinical examination, she had reduced pinprick sensation on the little and ring fingers with no motor deficit. Nerve-conduction study showed slowing of conduction velocity across the elbow on the right when recording at the abductor digiti minimi (ADM) and first dorsal interossei (FDI). There was 63% amplitude drop when stimulating below the elbow compared to distal stimulation at the wrist. Increment inching study localized the block at 5 cm distal to the medial epicondyle. During surgical transposition, the ulnar nerve was swollen, and edematous in the segment where the nerve enters the FCU muscle, which provides a physiological explanation for the electrophysiological findings. After the surgery, the patient reported complete resolution of the symptoms. This case demonstrate that ulnar nerve motor potential FD at the proximal forearm could be recorded and it is still compatible with ulnar-nerve entrapment at the elbow.
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Affiliation(s)
- Ahmad R Abuzinadah
- Neurology Division, Internal Medicine Department, College of Medicine and King Abdulaziz University Hospital, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Bassam M J Addas
- Neurosurgery Division, Surgery Department, King Abdul-Aziz University Hospital, Jeddah, Saudi Arabia
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Abstract
Electrodiagnostic studies are powerful tools used to objectively examine the physiologic status of a nerve. These consist of nerve conduction studies, which directly examine motor and sensory function of the nerve, and electromyography, which examines spontaneous and voluntary motor unit action potentials in the muscle. Together these studies enable characterization, localization, and duration of nerve pathology. Appropriate timing and use of electrodiagnostic studies assist medical providers in treating nerve pathology.
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Affiliation(s)
- Erik R Bergquist
- Department of Orthopaedic Surgery, University of Rochester Medical Center, 601 Elmwood Avenue, Box 665, Rochester, NY 14642, USA
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Williams FH, Kumiga B. Less Common Upper Limb Mononeuropathies. PM R 2013; 5:S22-30. [DOI: 10.1016/j.pmrj.2013.03.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2013] [Accepted: 03/15/2013] [Indexed: 11/26/2022]
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