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Boers N, Martin E, Mazur M, Krijgh DD, Vlak MHM, de Ruiter GCW, Goedee HS, Coert JH. Sonographic normal values for the cross-sectional area of the ulnar nerve: a systematic review and meta-analysis. J Ultrasound 2022; 26:81-88. [PMID: 35182316 PMCID: PMC10063700 DOI: 10.1007/s40477-022-00661-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 01/14/2022] [Indexed: 11/26/2022] Open
Abstract
PURPOSE Nerve size is a commonly used sonographic parameter when assessing suspected entrapment of the ulnar nerve. We aimed to create a robust set of normal values, based on a critical review of published normal values. METHODS We performed a systematic evaluation of studies on normal ulnar nerve sizes, identified in PubMed, Embase, and Cochrane databases. Using meta-analyses, we determined pooled mean cross-sectional area (CSA) values for different anatomical locations of the ulnar nerve throughout the arm. Subgroup analyses were performed for gender, probe frequency, in- or exclusion of diabetic patients, position of the elbow and Asian versus other populations. RESULTS We identified 90 studies of which 77 studies were included for further analyses after quality review, resulting in data from 5772 arms of 3472 participants. Subgroup analyses show lower CSA values at at the wrist crease and proximal to the wrist crease when using low frequency probes (< 15 MHz) and at the wrist crease, proximal to the wrist crease, proximal forearm and the distal upper arm in Asians. CSA values were lower when in flexed position compared to extended position for the cubital tunnel inlet only. No difference was found for gender. CONCLUSIONS Our systematic review provides a comprehensive set of normal values at sites along the entire length of the ulnar nerve. This provides a foundation for clinical practise and upon which future studies could be more systematically compared.
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Affiliation(s)
- Nadine Boers
- Department of Plastic Surgery, Utrecht Medical Center, Utrecht, The Netherlands.
- Department of Plastic, Reconstructive, and Hand Surgery, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - Enrico Martin
- Department of Plastic Surgery, Utrecht Medical Center, Utrecht, The Netherlands
| | - Marc Mazur
- Department of Plastic Surgery, Utrecht Medical Center, Utrecht, The Netherlands
| | - David D Krijgh
- Department of Plastic Surgery, Utrecht Medical Center, Utrecht, The Netherlands
| | - Monique H M Vlak
- Department of Neurology, Haaglanden Medical Center, The Hague, The Netherlands
| | - Godard C W de Ruiter
- Department of Neurosurgery, Haaglanden Medical Center, The Hague, The Netherlands
| | - H Stephan Goedee
- Department of Neurology, Utrecht Medical Center, Utrecht, The Netherlands
| | - J Henk Coert
- Department of Plastic Surgery, Utrecht Medical Center, Utrecht, The Netherlands
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Rowan CC, Graudejus O, Otchy TM. A Microclip Peripheral Nerve Interface (μcPNI) for Bioelectronic Interfacing with Small Nerves. Adv Sci (Weinh) 2022; 9:e2102945. [PMID: 34837353 PMCID: PMC8787429 DOI: 10.1002/advs.202102945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 08/31/2021] [Indexed: 06/13/2023]
Abstract
Peripheral nerves carry sensory (afferent) and motor (efferent) signals between the central nervous system and other parts of the body. The peripheral nervous system (PNS) is therefore rich in targets for therapeutic neuromodulation, bioelectronic medicine, and neuroprosthetics. Peripheral nerve interfaces (PNIs) generally suffer from a tradeoff between selectivity and invasiveness. This work describes the fabrication, evaluation, and chronic implantation in zebra finches of a novel PNI that breaks this tradeoff by interfacing with small nerves. This PNI integrates a soft, stretchable microelectrode array with a 2-photon 3D printed microclip (μcPNI). The advantages of this μcPNI compared to other designs are: a) increased spatial resolution due to bi-layer wiring of the electrode leads, b) reduced mismatch in biomechanical properties with the nerve, c) reduced disturbance to the host tissue due to the small size, d) elimination of sutures or adhesives, e) high circumferential contact with small nerves, f) functionality under considerable strain, and g) graded neuromodulation in a low-threshold stimulation regime. Results demonstrate that the μcPNIs are electromechanically robust, and are capable of reliably recording and stimulating neural activity in vivo in small nerves. The μcPNI may also inform the development of new optical, thermal, ultrasonic, or chemical PNIs as well.
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Affiliation(s)
| | - Oliver Graudejus
- BMSEED LLCPhoenixAZ85034USA
- School of Molecular SciencesArizona State UniversityTempeAZ85281USA
| | - Timothy M. Otchy
- Department of BiologyBoston UniversityBostonMA02215USA
- Neurophotonics CenterBoston UniversityBostonMA02215USA
- Center for Systems NeuroscienceBoston UniversityBostonMA02215USA
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Kolarcik CL, Castro CA, Lesniak A, Demetris AJ, Fisher LE, Gaunt RA, Weber DJ, Cui XT. Host tissue response to floating microelectrode arrays chronically implanted in the feline spinal nerve. J Neural Eng 2020; 17:046012. [PMID: 32434161 DOI: 10.1088/1741-2552/ab94d7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Neural interfacing technologies could significantly improve quality of life for people living with the loss of a limb. Both motor commands and sensory feedback must be considered; these complementary systems are segregated from one another in the spinal nerve. APPROACH The dorsal root ganglion-ventral root (DRG-VR) complex was targeted chronically with floating microelectrode arrays designed to record from motor neuron axons in the VR or stimulate sensory neurons in the DRG. Hematoxylin and eosin and Nissl/Luxol fast blue staining were performed. Characterization of the tissue response in regions of interest and pixel-based image analyses were used to quantify MAC387 (monocytes/macrophages), NF200 (axons), S100 (Schwann cells), vimentin (fibroblasts, endothelial cells, astrocytes), and GLUT1 (glucose transport proteins) reactivity. Implanted roots were compared to non-implanted roots and differences between the VR and DRG examined. MAIN RESULTS The tissue response associated with chronic array implantation in this peripheral location is similar to that observed in central nervous system locations. Markers of inflammation were increased in implanted roots relative to control roots with MAC387 positive cells distributed throughout the region corresponding to the device footprint. Significant decreases in neuronal density and myelination were observed in both the VR, which contains only neuronal axons, and the DRG, which contains both neuronal axons and cell bodies. Notably, decreases in NF200 in the VR were observed only at implant times less than ten weeks. Observations related to the blood-nerve barrier and tissue integrity suggest that tissue remodeling occurs, particularly in the VR. SIGNIFICANCE This study was designed to assess the viability of the DRG-VR complex as a site for neural interfacing applications and suggests that continued efforts to mitigate the tissue response will be critical to achieve the overall goal of a long-term, reliable neural interface.
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Affiliation(s)
- Christi L Kolarcik
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, United States of America. Center for the Neural Basis of Cognition, University of Pittsburgh and Carnegic Mellon University, Pittsburgh, PA, United States of America. McGowan Institute for Regenerative Medicine, Pittsburgh, PA, United States of America. Systems Neuroscience Center, Pittsburgh, PA, United States of America. Live Like Lou Center for ALS Research, Department of Neurobiology, University of Pittsburgh, Pittsburgh, PA, United States of America
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Mirza A, Mirza JB, Thomas TL. Classification and Treatment of Ulnar Nerve Subluxation Following Endoscopic Cubital Tunnel Release. Journal of Hand Surgery Global Online 2020; 2:232-239. [PMID: 35415505 PMCID: PMC8991866 DOI: 10.1016/j.jhsg.2020.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 05/06/2020] [Indexed: 11/09/2022] Open
Abstract
Purpose Endoscopic cubital tunnel release (ECuTR) is an effective procedure to alleviate cubital tunnel syndrome. To improve patient outcomes and lessen concerns regarding ulnar nerve subluxation (UNS) after ECuTR, the current study proposes an intraoperative UNS classification system and subsequent treatment protocol. We present a preliminary report of patients treated under these guidelines. Methods We retrospectively reviewed 87 patients (100 ECuTRs). Nerve mobility was classified during surgery, in which grade 1 = no movement or partial subluxation; deep retrocondylar groove and/or no generalized hypermobility (no further intervention); grade 2 = partial subluxation; shallow retrocondylar groove and/or inherent generalized hypermobility (required medial epicondylectomy); and grade 3 = complete anterior dislocation (required medial epicondylectomy or anterior transposition). Clinical outcomes at final follow-up (mean ± SD, 34 ± 20.3 weeks; range, 5–89 weeks) were collected and included Disabilities of the Arm, Shoulder, and Hand questionnaires, visual analog scale pain score, grip and pinch strength, 2-point discrimination, and range of motion. Results We report 37 patients (42 cases), grade 1 (n = 30), grade 2 (n = 1), and grade 3 (n = 11). Gross grip strength, lateral, 3-jaw chuck, and precision pinch strength recovered 87%, 90%, 105%, and 87%, respectively. Wrist and elbow range of motion returned to normal limits, 2-point discrimination improved to normal scores at final follow-up, Disabilities of the Arm, Shoulder, and Hand scores were reduced from 59.8 before to 29.9 after surgery, and visual analog scale pain score improved from 7.2 before to 2.5 after surgery (P < .001). Conclusions To our knowledge, this is the first study to classify UNS after ECuTR and describe a guideline for ensuing treatment. Our preliminary report of patients shows satisfactory outcomes, which suggests that our intraoperative UNS classification system has promise in preventing adverse complications of ulnar nerve hypermobility after ECuTR. Type of study/level of evidence Therapeutic IV.
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Nanivadekar AC, Ayers CA, Gaunt RA, Weber DJ, Fisher LE. Selectivity of afferent microstimulation at the DRG using epineural and penetrating electrode arrays. J Neural Eng 2019; 17:016011. [PMID: 31577993 PMCID: PMC9131467 DOI: 10.1088/1741-2552/ab4a24] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE We have shown previously that microstimulation of the lumbar dorsal root ganglia (L5-L7 DRG) using penetrating microelectrodes, selectively recruits distal branches of the sciatic and femoral nerves in an acute preparation. However, a variety of challenges limit the clinical translatability of DRG microstimulation via penetrating electrodes. For clinical translation of a DRG somatosensory neural interface, electrodes placed on the epineural surface of the DRG may be a viable path forward. The goal of this study was to evaluate the recruitment properties of epineural electrodes and compare their performance with that of penetrating electrodes. Here, we compare the number of selectively recruited distal nerve branches and the threshold stimulus intensities between penetrating and epineural electrode arrays. APPROACH Antidromically propagating action potentials were recorded from multiple distal branches of the femoral and sciatic nerves in response to epineural stimulation on 11 ganglia in four cats to quantify the selectivity of DRG stimulation. Compound action potentials (CAPs) were recorded using nerve cuff electrodes implanted around up to nine distal branches of the femoral and sciatic nerve trunks. We also tested stimulation selectivity with penetrating microelectrode arrays implanted into ten ganglia in four cats. A binary search was carried out to identify the minimum stimulus intensity that evoked a response at any of the distal cuffs, as well as whether the threshold response selectively occurred in only a single distal nerve branch. MAIN RESULTS Stimulation evoked activity in just a single peripheral nerve through 67% of epineural electrodes (35/52) and through 79% of the penetrating microelectrodes (240/308). The recruitment threshold (median = 9.67 nC/phase) and dynamic range of epineural stimulation (median = 1.01 nC/phase) were significantly higher than penetrating stimulation (0.90 nC/phase and 0.36 nC/phase, respectively). However, the pattern of peripheral nerves recruited for each DRG were similar for stimulation through epineural and penetrating electrodes. SIGNIFICANCE Despite higher recruitment thresholds, epineural stimulation provides comparable selectivity and superior dynamic range to penetrating electrodes. These results suggest that it may be possible to achieve a highly selective neural interface with the DRG without penetrating the epineurium.
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Affiliation(s)
- Ameya C Nanivadekar
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA 15213, United States of America. Rehabilitation Neural Engineering Laboratories, 3520 Fifth Avenue, Suite 300, Pittsburgh, PA 15213, United States of America. Center for Neural Basis of Cognition, Pittsburgh, PA 15213, United States of America
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Michell AW, Sesath HGR. Feasibility Trial of Treatment of Ulnar Neuropathy at the Elbow Using a Specifically Designed Splint. J Clin Rheumatol 2020; 26:37-9. [PMID: 29912777 DOI: 10.1097/RHU.0000000000000828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Liu XH, Gong MQ, Wang Y, Liu C, Li SL, Jiang XY. Anterior Subcutaneous Transposition of the Ulnar Nerve Affects Elbow Range of Motion: A Mean 13.5 Years of Follow-up. Chin Med J (Engl) 2018; 131:282-288. [PMID: 29363642 PMCID: PMC5798048 DOI: 10.4103/0366-6999.223851] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Surgical decompression of the ulnar nerve is effective for cubital tunnel syndrome. However, deep approaches may result in iatrogenic elbow stiffness. This long-term study was to evaluate the range of motion (ROM) of the elbow and functional outcomes after anterior subcutaneous transposition. METHODS A total of 115 patients (78 male and 37 female; mean age: 46.6 years) who underwent anterior subcutaneous transposition of the ulnar nerve between 2001 and 2005 were evaluated retrospectively; mean follow-up was 13.5 years. Elbow ROM was measured as flexion arc, flexion, and extension preoperatively and at the final follow-up, and compared via a mixed analysis of variance adjusting for age. Neuropathy was assessed preoperatively using a modified McGowan neuropathy grade and postoperatively using modified Wilson-Krout criteria. An ordinal logistic regression analysis used postoperative modified Wilson-Krout criteria as the outcome and preoperative factors as predictors. RESULTS Preoperative McGowan grades were Grade 1 in 14 patients (12.2%), Grade 2A in 28 (24.3%), Grade 2B in 53 (46.1%), and Grade 3 in 20 (17.4%) patients. Postoperatively, 66 patients (57.4%) had excellent results, 26 (22.6%) had good results, 16 (13.9%) had fair results, and 7 (6.1%) had poor results at the final follow-up, as per the Wilson-Krout criteria. There were no complications. Pre- and postoperative elbow ROM was significantly decreased in patients with previous trauma or surgery of the elbow compared with those without (P < 0.05). Anterior subcutaneous transposition of the ulnar nerve did not significantly affect elbow ROM regardless of previous trauma or surgical history nor preoperative ROM (P > 0.05), after adjusting for age. Patients with prolonged symptoms prior to surgery and worse neuropathy tended to have less satisfactory functional outcomes (P < 0.05), after adjusting for covariates. CONCLUSIONS Anterior subcutaneous transposition of the ulnar nerve is an effective and reliable treatment of cubital tunnel syndrome with satisfactory outcomes and minimal effect on elbow ROM.
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Affiliation(s)
- Xing-Hua Liu
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, Beijing 100035, China
| | - Mao-Qi Gong
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, Beijing 100035, China
| | - Yang Wang
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, Beijing 100035, China
| | - Chang Liu
- Department of Hand Surgery, Beijing Jishuitan Hospital, Beijing 100035, China
| | - Shao-Liang Li
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, Beijing 100035, China
| | - Xie-Yuan Jiang
- Department of Orthopedic Trauma, Beijing Jishuitan Hospital, Beijing 100035, China
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Michelin P, Leleup G, Ould-Slimane M, Merlet MC, Dubourg B, Duparc F. Ultrasound biomechanical anatomy of the soft structures in relation to the ulnar nerve in the cubital tunnel of the elbow. Surg Radiol Anat 2017; 39:1215-21. [PMID: 28555250 DOI: 10.1007/s00276-017-1879-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 05/24/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Chronic ulnar nerve entrapment worsened by elbow flexion is the most common injury, but rare painful conditions may also be related to ulnar nerve instability. The posterior bundle of the medial collateral ligament (pMCL) and the retinaculum, respectively form a soft floor and a ceiling for the cubital tunnel. The aim of our study was to dynamically assess these soft structures of the cubital tunnel focusing on those involved in the biomechanics of the ulnar nerve. METHODS Forty healthy volunteers had a bilateral ultrasonography of the cubital tunnel. Elbows were scanned in full extension, 45° and 90°, and maximal passive flexion. Morphological changes of the nerve and related structures were dynamically assessed on transverse views. RESULTS Both the pMCL and the retinaculum tightened with flexion. During elbow flexion, the tightening of the pMCL superficially moved the ulnar nerve remote from the osseous floor of the retroepicondylar groove. A retinaculum was visible in all 69 tunnels with stable nerves (86.3%), tightened in flexion, but absent in 11 tunnels with unstable nerves (13.7%). The retinaculum was fibrous in 60 elbows and muscular in nine, the nine muscular variants did not significantly influence the biomechanics of stable nerves. Stable nerves flattened in late flexion between the tightened pMCL and retinaculum, whereas unstable nerves transiently flattened when translating against the anterior osseous edge of the groove. CONCLUSION The retinaculum and the pMCL are key structures in the biomechanics of the ulnar nerve in the cubital tunnel of the elbow.
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Abstract
A systematic review was performed to identify studies reporting summary data (mean, standard deviation) of sonographic cross-sectional measurements of the ulnar nerve at the elbow. Comparisons of measurements were performed to determine whether statistical differences existed between groups of individuals symptomatic and asymptomatic of ulnar nerve entrapment at the elbow (UNE). Across the four studies meeting the selection criteria of the search, five sample groups were identified and compared: three asymptomatic of UNE and two symptomatic of UNE. There were significant differences between measurements of people with and without UNE ( P < .0001—.041). Significant differences also existed between the two symptomatic populations ( P < .0001—.0062) and between the three asymptomatic populations ( P < .0001—.41). This systematic review demonstrates that significant differences exist between sonographic measurements of ulnar nerve dimension between people with and without UNE, confirming that these measurements are potential discriminators of UNE. The demonstration of significant differences between measurements of ulnar nerve size within sample populations with similar symptomatic status suggests that further studies are required to confirm the effect of ulnar nerve pathologies, measurement protocols, and anthropometric factors.
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Affiliation(s)
- Kerry Thoirs
- School of Health Sciences (City East Campus), University of South Australia, Adelaide, South Australia,
| | - Marie A. Williams
- School of Health Sciences (City East Campus), University of South Australia, Adelaide, South Australia
| | - Maureen Phillips
- School of Health Sciences (City East Campus), University of South Australia, Adelaide, South Australia
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Won HS, Liu HF, Kim JH, Kwak DS, Chung IH, Kim IB. Intermuscular aponeuroses between the flexor muscles of the forearm and their relationships with the ulnar nerve. Surg Radiol Anat 2016; 38:1183-9. [PMID: 27172919 DOI: 10.1007/s00276-016-1695-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Accepted: 05/09/2016] [Indexed: 10/21/2022]
Abstract
INTRODUCTION The aim of this study was to clarify the morphological characteristics of the intermuscular aponeurosis between the flexor carpi ulnaris (FCU) and flexor digitorum superficialis (FDS; IMAS), and that between the FCU and flexor digitorum profundus (FDP; IMAP), and their topographic relationships with the ulnar nerve. MATERIALS AND METHODS Fifty limbs of 38 adult cadavers were studied. RESULTS The IMAS extended along the deep surface of the FCU adjoining the FDS, having the appearance of a ladder, giving off "steps" that decreased in width from superficial to deep around the middle of the forearm. Its proximal part divided into two bands connected by a thin membrane, and was attached to the medial epicondyle and the tubercle (the most medial prominent part of the coronoid process of the ulna), respectively. The IMAP extended deep between the FCU and FDP from the antebrachial fascia, and its distal end was located on the posterior border of the FCU. The IMAP became broader toward its proximal part, and its proximal end was attached anterior and posterior to the tubercle and the olecranon, respectively. The ulnar nerve passed posterior to the medial epicondyle and then medial to the tubercle, and was crossed by the deep border of the IMAS at 58.3 ± 14.1 mm below the medial epicondyle. CONCLUSION The deep border of the IMAS and aberrant tendinous structure passing across the ulnar nerve, or the parts of the IMAS and IMAP passing posterior to the ulnar nerve are potential causes of ulnar nerve compression.
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Kamel I, Zhao H, Koch SA, Brister N, Barnette RE. The Use of Somatosensory Evoked Potentials to Determine the Relationship Between Intraoperative Arterial Blood Pressure and Intraoperative Upper Extremity Position–Related Neurapraxia in the Prone Surrender Position During Spine Surgery. Anesth Analg 2016; 122:1423-33. [DOI: 10.1213/ane.0000000000001121] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Kawahara Y, Yamaguchi T, Honda Y, Tomita Y, Uetani M. The Ulnar Nerve at Elbow Extension and Flexion: Assessment of Position and Signal Intensity on MR Images. Radiology 2016; 280:483-92. [PMID: 26894443 DOI: 10.1148/radiol.2016150173] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Purpose To assess the position and signal intensity of the ulnar nerve at elbow extension and flexion by using magnetic resonance imaging. Materials and Methods Institutional review board approval and written informed consent were obtained. Transverse T2-weighted images were obtained perpendicular to the upper arm in 100 healthy elbows of 50 volunteers (23 men, 27 women; age range, 21-57 years) and nine elbows with ulnar neuropathy (five men, four women; age range, 24-59 years) with extension and 130° of flexion. Ulnar nerve position was classified into three types: no dislocation, subluxation, or dislocation. One-way analysis of variance, paired t tests, Student t tests, and multiple regression analysis were used to analyze correlations between ulnar nerve movement angle during flexion and age, sex, presence of the anconeus epitrochlearis muscle, and ulnar neuropathy and to compare the contrast-to-noise ratio of nerve to muscle between extension and flexion. Results Nerve positions in healthy elbows were as follows: All had no dislocation at extension, and at flexion, 51 of 100 elbows (51.0%) had no dislocation, 30 of 100 elbows (30.0%) had subluxation, and 19 of 100 elbows (19.0%) had dislocation. Nerve movement angle was smaller in elbows with the anconeus epitrochlearis muscle than in those without the muscle (P = .045, .015). Presence of the muscle was the only significant factor associated with nerve movement angle (P = .047, .013). Only dominant elbows with nerve movement angle of less than 15° and nondominant elbows with nerve movement angle of less than 10° showed contrast-to-noise ratio increase at flexion (P = .021-.030). Conclusion Ulnar nerve movement during flexion was apparent in approximately half of healthy elbows and was similar between healthy elbows and elbows with ulnar neuropathy. Nerve signal intensity increased during flexion only in elbows without apparent nerve movement. (©) RSNA, 2016 Online supplemental material is available for this article.
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Affiliation(s)
- Yasuhiro Kawahara
- From the Departments of Radiology (Y.K., Y.T.) and Orthopedic Surgery (Y.H.), Nagasaki Rosai Hospital, 2-12-5 Setogoshi, Sasebo 857-0134, Japan; Department of Radiology, Nagasaki University Hospital, Nagasaki, Japan (T.Y.); and Department of Radiological Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan (M.U.)
| | - Tetsuji Yamaguchi
- From the Departments of Radiology (Y.K., Y.T.) and Orthopedic Surgery (Y.H.), Nagasaki Rosai Hospital, 2-12-5 Setogoshi, Sasebo 857-0134, Japan; Department of Radiology, Nagasaki University Hospital, Nagasaki, Japan (T.Y.); and Department of Radiological Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan (M.U.)
| | - Yuzo Honda
- From the Departments of Radiology (Y.K., Y.T.) and Orthopedic Surgery (Y.H.), Nagasaki Rosai Hospital, 2-12-5 Setogoshi, Sasebo 857-0134, Japan; Department of Radiology, Nagasaki University Hospital, Nagasaki, Japan (T.Y.); and Department of Radiological Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan (M.U.)
| | - Yumiko Tomita
- From the Departments of Radiology (Y.K., Y.T.) and Orthopedic Surgery (Y.H.), Nagasaki Rosai Hospital, 2-12-5 Setogoshi, Sasebo 857-0134, Japan; Department of Radiology, Nagasaki University Hospital, Nagasaki, Japan (T.Y.); and Department of Radiological Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan (M.U.)
| | - Masataka Uetani
- From the Departments of Radiology (Y.K., Y.T.) and Orthopedic Surgery (Y.H.), Nagasaki Rosai Hospital, 2-12-5 Setogoshi, Sasebo 857-0134, Japan; Department of Radiology, Nagasaki University Hospital, Nagasaki, Japan (T.Y.); and Department of Radiological Sciences, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan (M.U.)
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Dachs RP, Vrettos BC, Chivers DA, Du Plessis JP, Roche SJ. Outcomes After Ulnar Nerve In Situ Release During Total Elbow Arthroplasty. J Hand Surg Am 2015; 40:1832-7. [PMID: 26254945 DOI: 10.1016/j.jhsa.2015.06.107] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Revised: 06/19/2015] [Accepted: 06/19/2015] [Indexed: 02/02/2023]
Abstract
PURPOSE Ulnar nerve (UN) lesions are a significant complication after total elbow arthroplasty (TEA), with potentially debilitating consequences. Outcomes from a center, which routinely performs an in situ release of the nerve without transposition, were investigated. METHODS Eighty-three primary TEAs were retrospectively reviewed for the intraoperative management of the UN and presence of postoperative UN symptoms. RESULTS Three patients had documented preoperative UN symptoms. One patient had a prior UN transposition. The nerve was transposed at the time of TEA in 4 of the remaining 82 elbows (5%). The indication for transposition in all cases was abnormal tracking or increased tension on the nerve after insertion of the prosthesis. Of the 4 patients who underwent UN transposition, 2 had postoperative UN symptoms. Both were neuropraxias, which resolved in the early postoperative period. The remaining 78 TEAs received an in situ release of the nerve. The incidence of postoperative UN symptoms in the in situ release group was 5% (4 of 78). Two patients had resolution of symptoms, whereas 2 continued to experience significant UN symptoms requiring subsequent transposition. Seven patients had preoperative flexion of less than 100°. Of these, 2 had a UN transposition at the time of TEA. Of the remaining 5 elbows with preoperative flexion less than 100°, 2 had postoperative UN symptoms after in situ release, with 1 requiring subsequent UN transposition. CONCLUSIONS A 3% incidence of significant UN complications after TEA compares favorably with systematic reviews. We do not believe that transposition, which adds to the handling of the nerve and increases surgical time, is routinely indicated and should rather be reserved for cases with marked limitation of preoperative elbow flexion or when intraoperative assessment by the surgeon deems it necessary. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Robert P Dachs
- Department of Orthopaedic Surgery, University of Cape Town, Groote Schuur Hospital, Cape Town, South Africa.
| | - Basil C Vrettos
- Department of Orthopaedic Surgery, University of Cape Town, Groote Schuur Hospital, Cape Town, South Africa
| | - David A Chivers
- Department of Orthopaedic Surgery, University of Cape Town, Groote Schuur Hospital, Cape Town, South Africa
| | - Jean-Pierre Du Plessis
- Department of Orthopaedic Surgery, University of Cape Town, Groote Schuur Hospital, Cape Town, South Africa
| | - Stephen J Roche
- Department of Orthopaedic Surgery, University of Cape Town, Groote Schuur Hospital, Cape Town, South Africa
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Sousa M, Aido R, Trigueiros M, Lemos R, Silva C. Cubital compressive neuropathy in the elbow: in situ neurolysis versus anterior transposition - comparative study. Rev Bras Ortop 2015; 49:647-52. [PMID: 26229876 PMCID: PMC4487434 DOI: 10.1016/j.rboe.2014.10.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Accepted: 10/21/2013] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE To compare the results from two of the most commonly used surgical techniques: in situ decompression and subcutaneous transposition. The processes of patients treated surgically in a public university hospital between January 2004 and December 2011 were reviewed. Cases of proximal compression of the nerve, angular deformity of the elbow and systemic diseases associated with non-compressive neuropathy were excluded. METHODS Ninety-seven cases were included (96 patients). According to the modified McGowan score, 14.4% of the patients presented grade Ia, 27.8% grade II, 26.8% grade IIb and 30.9% grade III. In situ neurolysis of the cubital was performed in 64 cases and subcutaneous anterior transposition in 33. RESULTS According to the modified Wilson and Knout score, the results were excellent in 49.5%, good in 18.6%, only satisfactory in 17.5% and poor in 14.4%. In comparing the two techniques, we observed similar numbers of excellent and good results. Grades IIb and III were associated with more results that were less satisfactory or poor, independent of the surgical technique. CONCLUSION Both techniques were shown to be efficient and safe for treating cubital tunnel syndrome.
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Affiliation(s)
- Marco Sousa
- Departamento de Ortopedia e Traumatologia, Centro Hospitalar do Porto, Porto, Portugal
| | - Ricardo Aido
- Departamento de Ortopedia e Traumatologia, Centro Hospitalar do Porto, Porto, Portugal
| | - Miguel Trigueiros
- Departamento de Ortopedia e Traumatologia, Centro Hospitalar do Porto, Porto, Portugal
| | - Rui Lemos
- Departamento de Ortopedia e Traumatologia, Centro Hospitalar do Porto, Porto, Portugal
| | - César Silva
- Departamento de Ortopedia e Traumatologia, Centro Hospitalar do Porto, Porto, Portugal
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Abstract
Abstract
BACKGROUND:
Ulnar nerve entrapment at the elbow is more than a compressive lesion of the nerve. The tensile biomechanical consequences of entrapment are currently marginally understood.
OBJECTIVE:
To evaluate the effects of tethering on the kinematics of the ulnar nerve as a model of entrapment neuropathy.
METHODS:
The ulnar nerve was exposed in 7 fresh cadaver arms, and markers were placed at 1-cm increments along the nerve, centered on the retrocondylar region. Baseline translation (pure sliding) and strain (stretch) were measured in response to progressively increasing tension produced by varying configurations of elbow flexion and wrist extension. Then the nerves were tethered by suturing to the cubital tunnel retinaculum and again exposed to progressively increasing tension from joint positioning.
RESULTS:
In the native condition, for all joint configurations, the articular segment of the ulnar nerve exhibited greater strain than segments proximal and distal to the elbow, with a maximum strain of 28 ± 1% and translation of 11.6 ± 1.8 mm distally. Tethering the ulnar nerve suppressed translation, and the distal segment experienced strains that were more than 50% greater than its maximum strain in an untethered state.
CONCLUSION:
This work provides a framework for evaluating regional nerve kinematics. Suppressed translation due to tethering shifted the location of high strain from articular to more distal regions of the ulnar nerve. The authors hypothesize that deformation is thus shifted to a region of the nerve less accustomed to high strains, thereby contributing to the development of ulnar neuropathy.
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Affiliation(s)
- Mark A. Mahan
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
- Division of Neurosurgery, University of California, San Diego, La Jolla, California
| | - Kenneth M. Vaz
- Department of Orthopaedic Surgery, University of California, San Diego, La Jolla, California
| | - David Weingarten
- Division of Neurosurgery, University of California, San Diego, La Jolla, California
| | - Justin M. Brown
- Division of Neurosurgery, University of California, San Diego, La Jolla, California
| | - Sameer B. Shah
- Departments of Orthopaedic Surgery and Bioengineering, University of California, San Diego, La Jolla, California
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Sousa M, Aido R, Trigueiros M, Lemos R, Silva C. Neuropatia compressiva cubital no cotovelo: neurólise in situ versus transposição anterior–Estudo comparativo. Rev Bras Ortop 2014; 49:647-52. [DOI: 10.1016/j.rbo.2013.10.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
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Chang Y, Wang T, Wu C. Sonographic Detection of Ulnar Nerve Compression During Elbow Extension. Am J Phys Med Rehabil 2014; 93:636-637. [DOI: 10.1097/phm.0000000000000156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Fisher LE, Ayers CA, Ciollaro M, Ventura V, Weber DJ, Gaunt RA. Chronic recruitment of primary afferent neurons by microstimulation in the feline dorsal root ganglia. J Neural Eng 2014; 11:036007. [DOI: 10.1088/1741-2560/11/3/036007] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Tai TW, Kuo LC, Chen WC, Wang LH, Chao SY, Huang CNH, Jou IM. Anterior translation and morphologic changes of the ulnar nerve at the elbow in adolescent baseball players. Ultrasound Med Biol 2014; 40:45-52. [PMID: 24139913 DOI: 10.1016/j.ultrasmedbio.2013.07.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2013] [Revised: 07/28/2013] [Accepted: 07/29/2013] [Indexed: 06/02/2023]
Abstract
The effect of repetitive throwing on the ulnar nerve is not clear. There are no published imaging studies regarding this issue in adolescent baseball players. The purpose of this cross-sectional ultrasonographic study was to use 5- to 10-MHz frequency ultrasonography to define the anterior translation and flattening of the ulnar nerve in different elbow positions. We divided 39 adolescent baseball players into two groups, 19 pitchers and 20 fielders, according to the amount of throwing. Twenty-four non-athlete junior high school students were also included as controls. We ultrasonographically examined each participant's ulnar nerve in the cubital tunnel with the elbow extended and at 45°, 90° and 120° of flexion. Anterior translation and flattening of the ulnar nerve occurred in all groups. Pitchers had larger-scale anterior translation than did controls. In pitchers, the ulnar nerve exhibited more anterior movement on the dominant side than on the non-dominant side. The anterior subluxation of the ulnar nerve occurred in players without ulnar nerve palsy and was not correlated with elbow pain. In addition to the known musculoskeletal adaptations of pitchers' elbows, ultrasonography revealed new changes in the ulnar nerve, anterior translation and subluxation, after repetitive throwing. These changes might also be physiologic adaptations of throwing elbows.
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Affiliation(s)
- Ta-Wei Tai
- Department of Orthopaedics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Department of Orthopaedics, Tainan Hospital Sinhua Branch, Tainan, Taiwan
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Abstract
This article discusses an alternative approach to general anesthesia with the use of local anesthesia in minor operating procedure suites when performing in situ decompression of cubital tunnel syndrome for those patients who have mild to moderately severe symptoms and for those who fail to respond to conservative measures. Anterior transposition can easily be performed in the same setting if indicated all with local anesthesia.
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Abstract
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.
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Affiliation(s)
- Lisa D Hobson-Webb
- Duke University Medical Center, Department of Neurology , Durham, NC 27710 , USA +1 919 668 2277 ; +1 919 660 3853 ;
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Abstract
INTRODUCTION Ultrasonography of the ulnar nerve has been recommended as a useful additional test in ulnar neuropathy at the elbow (UNE). METHODS We searched the literature and systemically reviewed all clinical trials in UNE. We also looked for articles about the normal sonoanatomy and specific causes of UNE. RESULTS Seven of 14 clinical trials in UNE were suitable for further analysis. Ultrasonographic ulnar nerve size measurement appears to be a test with good diagnostic accuracy. The most frequently reported abnormality was an increased cross-sectional area of the ulnar nerve at the elbow. However, several studies had methodological flaws. In addition, the ultrasonographic techniques and study designs differed among the studies. There were a few other uncontrolled studies about the underlying causes of UNE. DISCUSSION The role of ultrasonography in UNE seems promising but could not be firmly established. More prospective studies are needed, and we make several recommendations for further research.
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Affiliation(s)
- Roy Beekman
- Department of Neurology, Atrium Medical Centre, PO Box 4446, 6401 CX, Heerlen, The Netherlands.
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Abstract
BACKGROUND Operative contracture release may improve motion of a posttraumatic stiff elbow. In this study, we tested the hypothesis that improvement in ulnohumeral motion after elbow contracture release leads to improvement in general health status and decreases upper-extremity-specific disability. METHODS Twenty-three patients with posttraumatic loss of ≥30° of elbow flexion or extension who elected to have an open elbow capsulectomy completed the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH) and the Short Form-36 (SF-36) preoperatively and at least one year postoperatively. Pain was measured with use of the American Shoulder and Elbow Surgeons (ASES) Elbow Evaluation instrument. Four patients underwent additional, subsequent procedures to address residual elbow stiffness. RESULTS One patient who needed several additional procedures, including a total elbow arthroplasty, was considered to have had a failure of the operative contracture release and was excluded from the analysis; this left twenty-two patients in the study. On the average, the arc of flexion and extension improved from 51° preoperatively to 106° postoperatively; the DASH score, from 38 points to 18 points; the SF-36 Physical Component Summary (PCS) score, from 39 points to 49 points (all p < 0.05); and the SF-36 Mental Component Summary (MCS) score, from 49 points to 54 points (p < 0.05). There was no significant correlation between the improvement in the arc of flexion and extension and the improvement in the DASH (p = 0.53), PCS (p = 0.73), or MCS (p = 0.41) score. There also was no correlation between the final arc of flexion and extension and the final DASH score (p = 0.39 for the total score, p = 0.52 for the PCS score, and p = 0.42 for the MCS score). CONCLUSIONS Health status and disability scores improve after open elbow contracture release, but the improvements do not correlate with the improvement in elbow motion. Among multiple objective and subjective factors, pain was a strong predictor of the final general health status and arm-specific disability.
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Affiliation(s)
- Anneluuk L C Lindenhovius
- Orthopaedic Hand and Upper Extremity Service, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
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Husarik DB, Saupe N, Pfirrmann CWA, Jost B, Hodler J, Zanetti M. Elbow Nerves: MR Findings in 60 Asymptomatic Subjects—Normal Anatomy, Variants, and Pitfalls. Radiology 2009; 252:148-56. [PMID: 19451541 DOI: 10.1148/radiol.2521081614] [Citation(s) in RCA: 155] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Daniela B Husarik
- Department of Radiology, University Hospital Balgrist, Zurich, Switzerland.
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Abstract
Anterior, subcutaneous ulnar nerve transposition decompresses the ulnar nerve and, by transposing anterior to the medial epicondyle, eliminates longitudinal traction forces applied to the nerve during elbow flexion. This article reviews the indications and contraindications of the technique and describes the surgical technique in detail.
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Affiliation(s)
- Louis W Catalano
- C.V. Starr Hand Surgery Center, St. Lukes-Roosevelt Hospital, New York, NY 10019, USA.
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28
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Dilley A, Summerhayes C, Lynn B. An in vivo investigation of ulnar nerve sliding during upper limb movements. Clin Biomech (Bristol, Avon) 2007; 22:774-9. [PMID: 17531363 DOI: 10.1016/j.clinbiomech.2007.04.004] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2006] [Revised: 03/30/2007] [Accepted: 04/02/2007] [Indexed: 02/07/2023]
Abstract
BACKGROUND Peripheral nerves straighten and stretch in order to accommodate increases in bed length during joint movements. The ulnar nerve is predicted to show large bed length changes, particularly on elbow flexion. The present study examines sliding of the ulnar nerve during limb movements, to determine how far these changes are accommodated by straightening and stretch. METHODS Ultrasound imaging was used to measure longitudinal nerve sliding in the forearm and upper arm during 40 degrees wrist extension, 90 degrees elbow flexion and 50 degrees shoulder abduction. Nerve trunk folding in the upper arm was measured from still ultrasound images taken in a series of limb positions from 40 degrees shoulder abduction, elbow extended and wrist neutral to full elbow flexion, 90 degrees shoulder abduction and wrist extension, a position designed to stretch the ulnar nerve. FINDINGS Wrist extension led to clear nerve sliding in the forearm with movements of up to 4 mm. However, shoulder abduction and elbow flexion caused remarkably little nerve movement. Images of the ulnar nerve showed considerable curvature with 40 degrees shoulder abduction and elbow extension but a much straighter path with the elbow flexed. INTERPRETATION The ulnar nerve appears unloaded and follows a wavy path in most functional upper limb positions. During elbow and shoulder movements, changes in bed length appear to be accommodated largely by straightening of the nerve path, with only modest stretch of the nerve itself when the elbow flexes. The ulnar nerve is thus well adapted for the large changes in bed length that occur during limb movements.
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Affiliation(s)
- Andrew Dilley
- Department of Physiology, University College London, Gower Street, London WC1E 6BT, UK.
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Abstract
Successful treatment of cubital tunnel syndrome requires obtaining a history of the physical and environmental factors involved for each patient, conducting a thorough physical examination, and staging and implementing an individually tailored treatment plan. Rest and avoiding pressure on the nerve by activity modification might be sufficient. If symptoms persist, splint immobilization of the elbow is warranted. Keep in mind that the natural history of untreated cubital tunnel syndrome includes spontaneous improvement in approximately half of patients.
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Affiliation(s)
- Robert M Szabo
- Department of Orthopaedic Surgery, University of California, Davis School of Medicine, 4860 Y Street, Suite 3800, Sacramento, CA 95817, USA.
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Affiliation(s)
- Robert Shin
- Massachusetts General Hospital, Yawkey Center, Suite 2100, 55 Fruit Street, Boston, MA 02114, USA
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32
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Abstract
MRI is a useful diagnostic method for evaluating nerve disease at the shoulder and elbow. MRI can depict the normal anatomy of the nerves, confirm and identify the cause of the neuropathy, identify the site of entrapment based on muscle denervation patterns, and detect unsuspected space-occupying lesions. MRI can also narrow down the differential diagnosis of nerve disease, such as in the case of suprascapular nerve syndrome versus Parsonage-Turner syndrome, or radial tunnel syndrome versus lateral epicondylitis. Large prospective studies with surgical correlation, however, are still necessary to better elucidate MRI's exact role in the assessment of entrapment neuropathies of the upper extremity.
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Affiliation(s)
- Jenny T Bencardino
- Department of Radiology, Huntington Hospital, North Shore Long Island Jewish Health System, 5 Twelvepence Court, Melville, NY 11747, USA.
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Thoirs K, Williams M, Wilkinson M. Sonographic measurements of the ulnar nerve and the cubital tunnel at the elbow: Interobserver reproducibility. Radiography (Lond) 2005. [DOI: 10.1016/j.radi.2005.01.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Kim BJ, Date ES, Lee SH, Yoon JS, Hur SY, Kim SJ. Distance measure error induced by displacement of the ulnar nerve when the elbow is flexed. Arch Phys Med Rehabil 2005; 86:809-12. [PMID: 15827936 DOI: 10.1016/j.apmr.2004.08.006] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To determine the presence of ulnar nerve displacement at the elbow when it is flexed and to determine its effect on distance measurements using the conventional measurement method for nerve conduction studies (NCSs). DESIGN Comparing the ultrasonography-assisted distance measurement method with the conventional measurement method. SETTING An electrodiagnostic laboratory at a university hospital. PARTICIPANTS Seventy-eight elbows of 39 healthy volunteers. INTERVENTIONS We used high-resolution ultrasonography in real time. Based on sonographic searching, we marked 3 points on the skin through the course of the displaced ulnar nerve when the elbow is flexed: (1) point A, 7 cm above the elbow (from the midpoint between the medial epicondyle tip and olecranon in the postcondylar groove [point M]); (2) point B, 3 cm below the elbow; and (3) point C, the point closest to the medial epicondyle tip. MAIN OUTCOME MEASURES Distance measurements between points A, B, and C were taken. These values were compared with measurements obtained through conventional measurement methods. RESULTS Ulnar nerve displacement occurred in 24.3% (19/78) of the elbows; approximately 20.5% (16/78) were subluxation, and 3.8% (3/78) were dislocation. In the ulnar nerve displacement group, the distance between points A and C was 5.84+/-0.33 cm (range, 5.10-6.30 cm), and the distance between points B and C in the flexed position was 3.35+/-0.19 cm (range, 3.10-3.70 cm). When the conventional distance measurement was used, the ulnar nerve conduction velocity across the elbow was overestimated by approximately 5.33+/-2.29 m/s in the ulnar nerve displacement group. CONCLUSIONS This distance measurement error may be responsible for the decreased sensitivity found in NCSs that test for ulnar neuropathy at the elbow. If the NCS results are normal in patients who have clear symptoms of ulnar neuropathy, the possibility of ulnar nerve displacement at the elbow should be considered, and further investigation with ultrasonography would be beneficial.
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Affiliation(s)
- Byung-Jo Kim
- Division of Physical Medicine & Rehabilitation, Stanford University School of Medicine, CA, USA
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Abstract
MR imaging has a valuable role in the evaluation of compressive neuropathies at the elbow. Specific MR signs in association with clinical findings can supply an accurate diagnosis. A review of normal anatomy, clinical features, and MR assessment of nerve entrapment syndromes at the elbow is presented.
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Abstract
The nerve anatomy of the upper extremity is studied constantly through surgical findings, electrodiagnostic studies, and cadaveric dissections. Although it is recognized that the anatomy is not changing rapidly, knowledge of the anatomic relationships and their significance is increasing. The purpose of the current study is to provide a comprehensive analysis of the nerve anatomy of the upper extremity to include innervation patterns, critical landmarks, and clinical applications, with particular focus on recent contributions in the literature.
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Affiliation(s)
- M T Mazurek
- Department of Orthopaedic Surgery, Naval Medical Center San Diego, CA 92134-5000, USA
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