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

Restricted access

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.

ABBREVIATIONSCMAP = compound muscle action potential; CSA = cross-sectional area; EMG = electromyography; LSD = least significant difference; MUAP = motor unit action potential; SNAP = sensory nerve action potential.

Article Information

INCLUDE WHEN CITING Published online January 22, 2016; DOI: 10.3171/2015.6.JNS151001.

Drs. Toia and A. Gagliardo contributed equally to this work.

Correspondence Andrea Gagliardo, “Clinical Course” Neurophysiology Unit, via A. De Gasperi, 81, Palermo 90146, Italy. email: andrigl@gmail.com.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Ultrasound axial scan of the median nerve at the wrist, showing 2 anatomical variants associated with carpal tunnel syndrome. Upper: Bifid median nerve in axial scan at the wrist. The nerve is divided by a fibrous hyperechoic septum (asterisk) into 2 compartments (arrows). Lower: A persistent median artery (A) can be found within this septum.

  • View in gallery

    A: Ultrasound axial scan of the Guyon canal at the wrist. The ulnar nerve is generally located between the pisiform bone and the ulnar artery. In this case, ultrasound revealed a ganglion cyst (asterisk) occupying the canal and causing nerve compression. B: Intraoperative photograph obtained after nerve exposure and decompression but before removal of the ganglion cyst. C: Intraoperative photograph showing the cyst. The presence of the cyst was known beforehand and the risk of missing it was avoided. Figure is available in color online only.

  • View in gallery

    Ultrasound scans of the forearm showing the typical shape of a neuroma in longitudinal (upper) and axial (lower) views of the median nerve. The axial scan shows a partial neurotmesis of the nerve with preservation of a significant percentage of nerve fascicles (arrow) in continuity below the neuroma. Figure is available in color online only.

  • View in gallery

    Longitudinal ultrasound scans of the median nerve. Note the interruption of many fascicles (white arrows) for the presence of a neuroma (asterisk). Slightly moving the probe, different planes of the nerve can be explored and a small number of fascicles (black arrows) show their continuity across the lesion. These are the advantages of a dynamic real-time high-resolution ultrasound examination.

  • View in gallery

    Ulnar nerve (arrows) in longitudinal ultrasound scan at the elbow. After a displaced fracture of the elbow, the patient did not recover any motor or sensory ulnar function. Ultrasound showed deposits of bone (asterisk) over the nerve fascicles, as a “fatal embrace” with the ulnar nerve. Note the shadow cone of the ultrasound that does not pass through the bone and obscures the underlying nerve.

  • View in gallery

    Ultrasound axial scan of the posterior interosseus nerve (N) between the superficial and deep heads of the supinator muscle (S) in a patient who had suffered a hunting accident. The nerve has a focal huge increase of its CSA. A small hyperechoic metallic bullet (asterisk), easy to identify because of the prominent ultrasound artifact that it generates (arrows), pushes laterally and compresses the nerve, causing a deficit of the finger extension. The bullet is located on the superficial profile of the cortical bone of the radius (R). With an exact preoperative diagnosis surgery can be targeted without the need for wide exploration and dissection.

  • View in gallery

    Superior trunk brachial plexopathy. Ventral branches of the C-5 (upper arrow), C-6 (middle arrow), and C-7 (lower arrow) spinal nerves in the interscalenic area. Note that the superior trunk shows an inner hyperechogenicity (white asterisk) and is surrounded by a thick hyperechoic fibrous tissue (black asterisk). This pattern suggests a stretching injury of the nerve trunk. Figure is available in color online only.

  • View in gallery

    Upper: Schwannoma of the median nerve at the mid-arm in a longitudinal ultrasound scan. Following the median nerve by ultrasound, from the distal carpal tunnel to the axilla, we clearly show a mass, which originates from within this nerve and which displaces and does not infiltrate most of nerve fascicles. Lower: Intraoperative photograph showing the lesion. The diagnosis of schwannoma was confirmed by surgical exploration and histological examination. This case beautifully illustrates how close the ultrasound image is to reality. In this particular case, already conscious of the diagnosis and knowing that the nerve conduction and continuity are intact, thanks to the unparalleled high-resolution details, ultrasound imaging allowed for improvements in patient information, surgical planning, and decision making. Figure is available in color online only.

  • View in gallery

    A–D: Axial ultrasound images showing the same schwannoma as in Fig. 8. Schwannomas usually displace most axon fibers, which can be spared during tumor enucleation. In axial live scans, the fascicles surrounding the tumor could be followed along the nerve (arrows) (also see Video 1).

  • View in gallery

    Same schwannoma as in Figs. 8 and 9 in an axial and color Doppler ultrasound scan, which shows tumor neovascularization. The feeding artery, the plexiform veins, and eventual hypervascularity can be visualized with this technique. Figure is available in color online only.

  • View in gallery

    Role of ultrasound with respect to neurophysiological examination in diagnosis and surgical planning in the 3 different groups of peripheral neuropathies. post-traum/post-surg = posttraumatic/postsurgical.

References

1

Alaqeel AAlshomer F: High resolution ultrasound in the evaluation and management of traumatic peripheral nerve injuries: review of the literature. Oman Med J 29:3143192014

2

Beekman RVan Der Plas JPUitdehaag BMSchellens RLVisser LH: Clinical, electrodiagnostic, and sonographic studies in ulnar neuropathy at the elbow. Muscle Nerve 30:2022082004

3

Caliandro PFoschini MPazzaglia CLa Torre GAprile IGranata G: IN-RATIO: a new test to increase diagnostic sensitivity in ulnar nerve entrapment at elbow. Clin Neurophysiol 119:160016062008

4

Cartwright MSChloros GDWalker FOWiesler ERCampbell WW: Diagnostic ultrasound for nerve transection. Muscle Nerve 35:7967992007

5

Cesmebasi ASpinner RJSmith JMartinoli C: Dynamic ultrasonography can demonstrate the mechanism of the palmaris profundus in carpal tunnel syndrome. Clin Anat 28:4284302015

6

Daube JR: AAEM minimonograph #11: Needle examination in clinical electromyography. Muscle Nerve 14:6857001991

7

Di Pasquale AMorino SLoreti SBucci EVanacore NAntonini G: Peripheral nerve ultrasound changes in CIDP and correlations with nerve conduction velocity. Neurology 84:8038092015

8

Erra CGranata GLiotta GPodnar SGiannini MKushlaf H: Ultrasound diagnosis of bony nerve entrapment: case series and literature review. Muscle Nerve 48:4454502013

9

Filippou GMondelli MGreco GBertoldi IFrediani BGaleazzi M: Ulnar neuropathy at the elbow: how frequent is the idiopathic form? An ultrasonographic study in a cohort of patients. Clin Exp Rheumatol 28:63672010

10

Filler AGHowe FAHayes CEKliot MWinn HRBell BA: Magnetic resonance neurography. Lancet 341:6596611993

11

Gagliardo AAvarino CGiaimi GDi Matteo DMidiri MGagliardo C: Ultrasound combined with clinical neurophysiology in peripheral nerve pathologies: when it is worth? Preliminary data in 50 outpatients. Clin Neurophysiol 124:e1892013. (Abstract)

12

Gagliardo AAvarino CGiaimi GDi Matteo DMidiri MGagliardo C: Emerging role of Ultrasound imaging associated to Clinical Neurophysiology as an advanced diagnostics of peripheral nerves pathologies. A Sicilian experience. Neuroradiology 55:S1142013. (Abstract)

13

Gagliardo AToia FMaggì FMariolo AVCillino MMoschella F: Clinical neurophysiology and imaging of nerve injuries: preoperative diagnostic work-up and post-operative monitoring. Plast Aesthet Res 2:1491552015

14

Gofeld MBristow SJChiu SKliot M: Preoperative ultrasound-guided mapping of peripheral nerves. J Neurosurg 119:7097132013

15

Grimm AHeiling BSchumacher UWitte OWAxer H: Ultrasound differentiation of axonal and demyelinating neuropathies. Muscle Nerve 50:9769832014

16

Gruber HGlodny BBendix NTzankov APeer S: High-resolution ultrasound of peripheral neurogenic tumors. Eur Radiol 17:288028882007

17

Howe BMSpinner RJFelmlee JPAmrami KK: High-resolution imaging of upper limb neuropathies. Semin Musculoskelet Radiol 19:1601672015

18

Howe FAFiller AGBell BAGriffiths JR: Magnetic resonance neurography. Magn Reson Med 28:3283381992

19

Iannicelli EAlmberger MChianta GASalvini VRossi GMonacelli G: High resolution ultrasonography in the diagnosis of the carpal tunnel syndrome. Radiol Med (Torino) 110:6236292005

20

Jarvik JGComstock BAHeagerty PJHaynor DRFulton-Kehoe DKliot M: Magnetic resonance imaging compared with electrodiagnostic studies in patients with suspected carpal tunnel syndrome: predicting symptoms, function, and surgical benefit at 1 year. J Neurosurg 108:5415502008

21

Kara MEkiz TÖztürk GTOnat ŞŞÖzçakar L: Heterotopic ossification and peripheral nerve entrapment: ultrasound is a must-use imaging modality. Pain Med 16:164316442015. (Letter)

22

Moran LPerez MEsteban ABellon JArranz Bdel Cerro M: Sonographic measurement of cross-sectional area of the median nerve in the diagnosis of carpal tunnel syndrome: correlation with nerve conduction studies. J Clin Ultrasound 37:1251312009

23

Naranjo AOjeda SMendoza DFrancisco FQuevedo JCErausquin C: What is the diagnostic value of ultrasonography compared to physical evaluation in patients with idiopathic carpal tunnel syndrome?. Clin Exp Rheumatol 25:8538592007

24

Padua LAprile IPazzaglia CFrasca GCaliandro PTonali P: Contribution of ultrasound in a neurophysiological lab in diagnosing nerve impairment: A one-year systematic assessment. Clin Neurophysiol 118:141014162007

25

Padua LLiotta GDi Pasquale AGranata GPazzaglia CCaliandro P: Contribution of ultrasound in the assessment of nerve diseases. Eur J Neurol 19:47542012

26

Padua LLoMonaco MGregori BValente EMPadua RTonali P: Neurophysiological classification and sensitivity in 500 carpal tunnel syndrome hands. Acta Neurol Scand 96:2112171997

27

Pardal-Fernandez JM: [Carpal tunnel syndrome. The contribution of ultrasonography.]. Rev Neurol 59:4594692014. (Sp)

28

Simon NGCage TNarvid JNoss RChin CKliot M: High-resolution ultrasonography and diffusion tensor tractography map normal nerve fascicles in relation to schwannoma tissue prior to resection. J Neurosurg 120:111311172014

29

Simon NGRalph JWPoncelet ANEngstrom JWChin CKliot M: A comparison of ultrasonographic and electrophysiologic ‘inching’ in ulnar neuropathy at the elbow. Clin Neurophysiol 126:3913982015

30

Solbiati LDe Pra LIerace TBellotti EDerchi LE: High-resolution sonography of the recurrent laryngeal nerve: anatomic and pathologic considerations. AJR Am J Roentgenol 145:9899931985

31

Stevens JC: AAEM minimonograph #26: the electrodiagnosis of carpal tunnel syndrome. Muscle Nerve 20:147714861997

32

Yoon JSWalker FOCartwright MS: Ulnar neuropathy with normal electrodiagnosis and abnormal nerve ultrasound. Arch Phys Med Rehabil 91:3183202010

33

Zaidman CMSeelig MJBaker JCMackinnon SEPestronk A: Detection of peripheral nerve pathology: comparison of ultrasound and MRI. Neurology 80:163416402013

TrendMD

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 34 34 33
Full Text Views 224 224 29
PDF Downloads 187 187 22
EPUB Downloads 0 0 0

PubMed

Google Scholar