Intraoperative high-resolution ultrasound: a new technique in the management of peripheral nerve disorders

Clinical article

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Object

Surgical treatment of nerve lesions in continuity remains difficult, even in the most experienced hands. The regenerative potential of those injuries can be evaluated by intraoperative electrophysiological studies and/or intraneural dissection. The present study examines the value of intraoperative high-frequency ultrasound as an imaging tool for decision making in the management of traumatic nerve lesions in continuity.

Methods

Intraoperative high-frequency ultrasound was applied to 19 traumatic or iatrogenic nerve lesions of differing extents. The information obtained was correlated with intraoperative electrophysiological, microsurgical intraneural dissection, and histopathological findings in resected nerve segments.

Results

The intraoperative application of high-resolution, high-frequency ultrasound enabled morphological examination of nerve lesions in continuity, with good image quality. The assessment of the severity of the underlying nerve injury matched perfectly with the judgment obtained from intraoperative electrophysiological studies. Both intraneural nerve dissection and neuropathological examination of the resected nerve segments confirmed the sonographic findings. In addition, intraoperative ultrasound proved to be very time efficient.

Conclusions

With intraoperative ultrasound, the extent of traumatic peripheral nerve lesions can be examined morphologically for the first time. It is a promising, noninvasive method that seems capable of assessing the type (intraneural/perineural) and grade of nerve fibrosis. Therefore, in combination with intraoperative neurophysiological studies, intraoperative high-resolution ultrasound may represent a major tool for noninvasive assessment of the regenerative potential of a nerve lesion.

Abbreviation used in this paper:CNAP = compound nerve action potential.

Article Information

Address correspondence to: Ralph W. Koenig, M.D., Department of Neurosurgery, University of Ulm, District Hospital of Guenzburg, Ludwig-Heilmeyer-Strasse 2, 89312 Guenzburg, Germany. email: ralph.koenig@uni-ulm.de.

Please include this information when citing this paper: published online November 5, 2010; DOI: 10.3171/2010.9.JNS10464.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Photographs illustrating the “sandwich” technique, with the nerve lesion embedded in a special, sterile hydrogel (SonarAid, Geistlich Pharma).

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    Photograph showing intraoperative ultrasound scanning with a sterilely draped, small-footprint 15–7 MHz linear array ultrasound transducer.

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    Case 16. Normal: radiograph (lower left) obtained after osteosynthesis of supra- and diacondylar humerus fracture. Intraoperative photograph (lower right) showing the ulnar nerve exposed at the level of the elbow (star denotes the medial epicondyle). Lines indicate the level of corresponding cross-sectional ultrasonographic images (upper left and right: star denotes the medial epicondyle). Intraoperative CNAP recording (upper center) obtained with low stimulation (2.5 mA).

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    Case 12. Epineural fibrosis: intraoperative photograph (center) showing the ulnar nerve exposed at the level of the proximal forearm. Lines indicate the level of corresponding cross-sectional ultrasonographic images (upper). Intraoperative CNAP recording (lower) showing low amplitude at high stimulation (13.4 mA).

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    Case 2. Intraneural fibrosis: photograph of the right hand (center left) showing ulnar claw. Intraoperative photograph (center right) showing formerly subcutaneously transposed ulnar nerve at the elbow level. Arrows indicate the level of corresponding cross-sectional ultrasonographic images (upper). Dotted line in the intraoperative photograph indicates the length of the fibrotic nerve segment. Intraoperative CNAP recording (lower) showing negative results at maximum stimulation (> 20.0 mA).

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    Case 4. Complete/partial neuroma: intraoperative photograph (center) showing exposure of the ulnar and median nerve at the distal forearm. An arrow (solid line; upper) indicates neuroma of the median nerve and the level of corresponding cross-sectional ultrasound images (lower). An arrow (dotted line) indicates ulnar nerve neuroma and the level of corresponding cross-sectional ultrasound images, and another arrow (dashed line) indicates the area of preserved fascicles corresponding to the dorsal cutaneous branch (star).

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    Case 5. Transection: intraoperative photograph (lower) showing the right median nerve exposed at the distal forearm. Lines show the corresponding areas in the longitudinal-section ultrasound image (upper).

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