Carlo Martinoli

Carpal Tunnel Syndrome Assessment with US: Value of Additional Cross-sectional Area Measurements of the Median Nerve in Patients versus Healthy Volunteers

PURPOSE To improve accuracy in the diagnosis of carpal tunnel syndrome (CTS) by comparing cross-sectional area (CSA) measurements of the median nerve obtained at the level of the carpal tunnel (CSAc) with those obtained more proximally (CSAp), at the level of the pronator quadratus muscle. MATERIALS AND METHODS The study protocol was approved by the institutional review board, and all subjects gave written informed consent. One hundred wrists of 68 consecutive patients with CTS (16 men, 52 women; mean age, 57.9 years; range, 25-85 years) and 93 wrists of 58 healthy volunteers (16 male, 42 female; mean age, 55.1 years; range, 17-85 years) were examined with ultrasonography (US). Electrodiagnostic test results confirmed the diagnosis of CTS in all 68 patients. The US examiner was blinded to these test results. The CSA of the median nerve was measured at the carpal tunnel and proximal levels, and the difference between CSAc and CSAp (Delta CSA) was calculated for each wrist. RESULTS The mean CSAc in healthy volunteers (9.0 mm(2)) was smaller than that in patients (16.8 mm(2), P < .01). The mean Delta CSA was smaller in asymptomatic wrists (0.25 mm(2)) than in CTS-affected wrists (7.4 mm(2), P < .01). Receiver operating characteristic analysis revealed a diagnostic advantage to using the Delta CSA rather than the CSAc (P = .036). Use of a Delta CSA threshold of 2 mm(2) yielded the greatest sensitivity (99%) and specificity (100%) for the diagnosis of CTS. CONCLUSION Receiver operating characteristic analysis revealed improved accuracy in the diagnosis of CTS determined with the Delta CSA compared with the accuracy of the diagnosis determined with the CSAc.

Ultrasound of tendons and nerves

Tendons and nerves represent probably one of the best application of musculoskeletal US due to the high lesion detection rate and accuracy of US combined with its low cost, wide availability, and ease of use. The refinement of high-frequency broadband linear-array transducers, and sensitive color and power Doppler technology, have improved the ability of US to detect fine textural abnormalities of these structures as well as to identify a variety of pathological conditions. Characteristic echotextural patterns, closely resembling the histological ones, are typically depicted in these structures using high US frequencies. In tendon imaging, US can assess dislocations, degenerative changes and tendon tears, including intrasubstance tears, longitudinal splits, partial and complete rupture, inflammatory conditions and tendon tumors, as well as postoperative findings. In nerve imaging, US can support clinical and electrophysiological testing for detection of compressing lesions caused by nerve entrapment in a variety of osteofibrous tunnels of the limbs and extremities. Congenital anomalies, nerve tears, and neurogenic tumors can also be diagnosed. Overall, US is an effective technique for imaging tendons and nerves. In most cases, a focused US examination can be performed more rapidly and efficiently than MR imaging.

High-frequency ultrasound examination of the wrist and hand.

Abstract High-frequency ultrasound (US) is an efficient, rapid and inexpensive altenative to magnetic resonance imaging (MRI) for investigation of diseases in the soft tissues of the wrist and hand. US allows detection of foreign bodies and the reliable identification of a variety of traumatic lesions affecting tendons, annular pulleys, ligaments, vessels and nerves. Inflammatory diseases of tendons, including acute and chronic tenosynovitis and some degenerative conditions in the wrist and hand, can also be diagnosed. In entrapment neuropathies, US is able to identify nerve shape changes and possible extrinsic space-occupying lesions that may cause nerve compression within the tunnels. In patients with localized swelling of the hand or wrist, US is able to assess the presence of an expansile lesion and to characterize its nature in most cases. The objective of this article is to review the main findings and the primary indications of US in the investigation of disorders of the hand and wrist.

Clinical indications for musculoskeletal ultrasound: A Delphi-based consensus paper of the European society of musculoskeletal radiology

AbstractObjectiveTo develop clinical guidelines for musculoskeletal ultrasound (MSKUS) referral in Europe.MethodsSixteen musculoskeletal radiologists from seven European countries participated in a consensus-based interactive process (Delphi method) using consecutive questionnaires and consensus procedure meetings at several European radiology meetings. The evaluation of musculoskeletal diseases was established by literature reviews, followed by consensus on clinical utility in three consensus meetings. This involved a thorough, transparent, iterative approach which including interview, questionnaire, Delphi and standard setting methodologies. European MSK radiologists with a special interest in MSKUS formed two different expert groups who worked on reaching a consensus in the first two meetings. The third meeting resolved questions that did not achieve a consensus level of 67% using the first two questionnaires.ResultsOn expert consensus, the use of MSKUS is indicated to detect joint synovitis, fluid and septic effusion for potential aspiration, and poorly indicated to detect loose bodies. Recommendations for most appropriate use of musculoskeletal ultrasound are reported in six areas relevant to musculoskeletal ultrasound: hand/wrist, elbow, shoulder, hip, knee and ankle/foot.ConclusionA comprehensive evidence-based, expert consensus-defined educational framework on clinical ultrsound is presented. This should facilitate referrals for this important imaging technique throughout Europe.Key Points• Musculoskeletal ultrasound is indicated for detecting joint synovitis, effusions and fluid collections. • Musculoskeletal ultrasound is poor at detecting loose bodies. • Musculoskeletal ultrasound is relevant for most joints.

Sonographic evaluation of tears of the gastrocnemius medial head ("tennis leg")

Rupture of the medial head of the gastrocnemius muscle, or tennis leg, is a common lesion affecting middle‐aged persons. An imaging examination may be needed to rule out other diseases and assess the severity of the tear. We reviewed the sonographic images of 65 patients with clinically suspected tennis leg. Fifty‐one partial and 14 complete tears were diagnosed. Twenty‐five patients had follow‐up examinations (15 days to 24 months; mean, 45 days). The torn muscle fibers, hematoma, and the reparative process were appreciated by ultrasonography. Ultrasonography may be a useful noninvasive, low‐cost modality for diagnosis and follow‐up of tennis leg.

Carpal Tunnel Syndrome: ultrasound, neurophysiology, clinical and patient-oriented assessment

OBJECTIVE The aim of this study is twofold. First, to assess the relationships between the cross-sectional area (CSA) of the median nerve (MN) calculated at ultrasound (US) and: (1) patients perception of his/her symptoms and hand function; (2) clinical severity of CTS; (3) neurophysiological classification; (4) hand distribution of symptoms. Second, to assess the sensitivity of ultrasonography (US) and neurophysiology in the diagnosis of CTS using clinical measures as gold standard. METHODS We performed a prospective study by using multidimensional assessment: clinical (Historic and Objective scale, Hi-Ob), neurophysiological, patient-oriented measures (Boston Carpal Tunnel Questionnaire, BCTQ) and high-resolution US. The dominant hands of 54 consecutive patients who were referred to our neurophysiologic laboratory with clinical signs of CTS (43 females, mean age 53.3, range 30-80, SD: 13.1) were examined. RESULTS A statistically significant correlation was found between the CSA of the MN at wrist and (1) hand function (according to BCTQ, r=0.35, p=0.01), (2) clinical scale (Hi-Ob scale, r=0.51, p<0.00007), (3) neurophysiologic classification (r=0.80, p<0.0000001), and (4) hand distribution of symptoms (p=0.017). Neurophysiology showed higher sensitivity than US but in one of 3 cases with normal neurophysiological results, US showed data suggestive of CTS. CONCLUSIONS A positive correlation exists between US findings and all the conventional measures of CTS severity. The sensitivity of the combination of US and neurophysiology is higher than the sensitivity of neurophysiology or US alone. US is a useful complementary tool for CTS assessment. SIGNIFICANCE Information on the contribution of US in CTS and the interpretation of severity measurements in CTS.

Musculoskeletal ultrasound: technical guidelines.

Edited by The Ultrasound Subcommittee of the European Society of Musculoskeletal Radiology (ESSR)

Microalbuminuria Is an Early Marker of Target Organ Damage in Essential Hypertension

Microalbuminuria has been associated with a cluster of metabolic and nonmetabolic risk factors, suggesting that it might indicate the presence of generalized microvascular damage in patients with essential hypertension. To explore whether microalbuminuria is associated with early target organ damage, two groups of essential hypertensive patients, with (n = 17) (HtAlb+) and without (n = 16) (HtAlb-) microalbuminuria, and a control group (C) of healthy normotensive subjects (n = 20) were studied. The study groups, selected among participants of a large epidemiologic trial, were carefully matched for several potentially confounding variables such as gender, age, duration of hypertension, and body mass index. Albumin excretion rate was evaluated by radioimmunoassay in three nonconsecutive timed overnight collections after 3 weeks of pharmacologic wash-out. Left ventricular mass was assessed by M-B-mode echocardiography, carotid wall thickness by a high resolution ultrasound scan, and renal vascular impedance by Doppler scan. Office as well as 24-h ambulatory pressure monitoring (Takeda TM-2420) were also evaluated. There was no difference between the two hypertensive groups for office and 24-h blood pressure levels except for a lower daytime/nighttime systolic blood pressure ratio in the group with microalbuminuria. Microalbuminuric patients showed signs of early organ damage as compared to normoalbuminuric patients and normal subjects, namely greater left ventricular mass indices (LVMI 167+/-7 g/m2 in HtAlb+; 139+/-9 g/m2 in HtAlb-; 118+/-5 g/m2 in C, P < .001) and increased wall thickness of common carotid arteries (intima plus media thickness 12.5+/-0.2 mm in HtAlb+; 11.7+/-0.3 mm in HtAlb-; 11.2+/-0.2 mm in C, P < .001) as well as higher intrarenal vascular resistance (mean resistive index 0.62+/-0.01 in HtAlb+; 0.59+/-0.01 in HtAlb-; 0.59+/-0.01 in C, P < .05). In conclusion, microalbuminuria is an early marker of diffuse target organ damage in essential hypertension and therefore can be useful to identify patients for whom more aggressive preventive strategies or additional treatment measures are advisable.

Intra- and internerve cross-sectional area variability: new ultrasound measures.

Introduction: Nerve involvement in immune‐related neuropathies is non‐homogeneous, and therefore characterization of ultrasound (US) abnormalities is difficult. We developed two measures to quantify US abnormalities in immune‐related neuropathies. Methods: Intranerve cross‐sectional area (CSA) variability for each nerve was calculated as: maximal CSA/minimal CSA. Internerve CSA variability for each patient was calculated as: maximal intranerve CSA variability/minimal intranerve CSA variability. Six patients underwent US evaluation of the median, ulnar, and fibular nerves, and the abnormalities were scored with our newly developed measures. Results: The new measures were applicable to all nerves and patients. The highest degree of intra‐ and internerve CSA variability was observed in multifocal motor neuropathy, consistent with the asymmetric characteristics of this neuropathy. Conclusions: The application of intra‐ and internerve CSA variability measures allows us to quantify the heterogeneity of nerves and nerve segments and identify different US patterns in diverse immune‐related neuropathies. Muscle Nerve, 2012

US and MR imaging of peripheral nerves in leprosy

Abstract Objective. To analyze peripheral nerves with ultrasonography (US) and magnetic resonance imaging (MR) in leprosy and assess the role of imaging in leprosy patients. Design and patients. Fifty-eight nerves with abnormal clinical features or electromyograms were examined in 23 leprosy patients by means of gray-scale US, Doppler US and MR imaging. Image analysis included: measurement of nerve cross-sectional area; assessment of nerve structure and MR signal intensities; identification of nerve compression within osteofibrous tunnels; detection of endoneural color flow signals and Gd-DTPA enhancement. Correlations were made with clinical findings and a control group of 20 subjects. Fourteen nerves in active reversal reaction were followed up after therapy. Results. Leprosy nerves were classified into three groups based on imaging appearance: group I consisted of 17 normal-appearing nerves; group II, of 30 enlarged nerves with fascicular abnormalities; group III, of 11 nerves with absent fascicular structure. Group II nerves were from patients subjected to reversal reactions; 75% of patients with group III nerves had a history of erythema nodosum leprosum. Nerve compression in osteofibrous tunnels was identified in 33% of group II and 18% of group III nerves. Doppler US and MR imaging were 74% and 92% sensitive in identifying active reactions, based on detection of endoneural color flow signals, long T2 and Gd enhancement. In 64% of cases, follow-up studies showed decreased color flow and Gd uptake after steroids and decompressive surgery. Conclusions. US and MR imaging are able to detect nerves abnormalities in leprosy. Active reversal reactions are indicated by endoneural color flow signals as well as by an increased T2 signal and Gd enhancement. These signs would suggest rapid progression of nerve damage and a poor prognosis unless antireactional treatment is started.