Leo H. Visser

Sonography in the diagnosis of carpal tunnel syndrome: a critical review of the literature.

Advances in ultrasound technology have made it possible to gain higher spatial resolution and even depict nerves with excellent visual quality. In this article, the literature concerning sonography in the diagnosis of carpal tunnel syndrome (CTS) is critically reviewed. We searched Medline for studies on sonography in the diagnosis of CTS and used the reference lists of the articles found. A total of seven studies on the diagnostic capabilities of sonography was found. There were considerable differences in study design. A reliable diagnosis of CTS could be made sonographically, mainly based on an increase in cross‐sectional area of the median nerve at the level of the pisiform or hamate bone. However, most studies could not compare the diagnostic capabilities of sonography to those of electrodiagnostic studies, because the latter was applied as the gold standard. Several other reports on the possible extra value of sonography in CTS are mentioned (mass lesions, anatomical variants, rheumatological diseases, renal dialysis–related amyloidosis, surgery, corticosteroid injection). It is probable that sonography will not replace electrodiagnostic studies, but may serve as an additional investigation. To gain further insight into the possible additional value of sonography, it is necessary to examine subcategories of CTS patients in which electrodiagnostic studies are equivocal.

Clinical, electrodiagnostic, and sonographic studies in ulnar neuropathy at the elbow

The aim of this study was to determine possible correlations between the clinical characteristics, electrophysiological features, and sonographic ulnar‐nerve diameter in patients with ulnar neuropathy at the elbow (UNE). We prospectively performed clinical, electrodiagnostic, and sonographic studies in 102 patients having either purely sensory signs (35%) or sensorimotor signs (65%) of UNE. Nerve conduction studies had a sensitivity of 78%, and the addition of sonography increased this to 98%. The diagnostic value of both tests was not different among cases with and without motor deficit. Motor studies with recording from the abductor digiti minimi and first dorsal interosseous muscles were equally sensitive for the detection of conduction block or velocity slowing across the elbow, but the combination yielded more positive cases than when only one study was performed. There were modest negative correlations between the electrodiagnostic parameters and the sonographic ulnar‐nerve diameter. Electrodiagnostically and sonographically, there were no significant differences between clinically pure sensory and mixed sensorimotor cases of UNE, except for electrodiagnostic findings suggesting loss of motor axons in cases with motor signs. Almost half the patients with only sensory signs had electromyographic evidence of motor axonal loss. We conclude that, although UNE is clinically heterogeneous, the electrophysiological and sonographic findings are fairly consistent despite the clinical manifestations. Muscle Nerve 30: 202–208, 2004

A randomized, double-blind, placebo-controlled pilot study of IV immune globulins in combination with IV methylprednisolone in the treatment of relapses in patients with MS:

Background: Some patients with multiple sclerosis (MS) do not show a clear improvement of acute relapses after treatment with intravenous methylprednisolone (IVMP). We compared the efficacy of the combination of intravenous immunoglobulins (IVIg) and IVMP with the standard treatment of IVMP alone in promoting recovery from moderate to severe acute relapses in MS. Methods: Patients with clinically definite MS having a relapse with at least a one point increase in Kurtzke’s expanded disability status scale (EDSS) in comparison to the preattack EDSS were randomized to IVMP-IVIg or IVMP-placebo treatment. The primary outcome criterion was the EDSS grade at four weeks. A preplanned interim analysis was performed after inclusion of 19 consecutive MS patients to evaluate the sample size necessary for a larger trial. Findings: Both groups had improved one point on the EDSS four weeks after start of treatment (P =0.81) and one of the stopping rules of the interim analysis was fulfilled. There were also no differences in secondary outcomes: EDSS at eight and 12 weeks, time to improve]-1 EDSS points, difference in Scripps score and ambulation index. Five patients in the IVMP-IVIg group and two in the IVMP group had a new relapse in the six month follow-up. Interpretation: O ur study could not show superiority of IVMP-IVIg in the treatment of moderate to severe acute relapses in MS.

Ultrasonography in ulnar neuropathy at the elbow: a critical review.

Ultrasonography of the ulnar nerve has been recommended as a useful additional test in ulnar neuropathy at the elbow (UNE).

Carpal tunnel syndrome: Clinical and sonographic follow-up after surgery

High‐resolution sonography has the same accuracy as electrophysiological studies in confirming the diagnosis in carpal tunnel syndrome (CTS), but the value of sonographic follow‐up after surgery requires prospective examination. The aims of the present study were to assess: (1) change in the size of the median nerve at the proximal carpal tunnel after surgery compared to conservative treatment, and (2) the correlation between sonographic characteristics and clinical outcome after surgery. Seventy‐nine patients undergoing surgery for CTS were assessed at least 6 months after surgery. The patients completed questionnaires and underwent sonography. Postoperative improvement was scored by the patient on a 6‐point ordinal transition scale ranging from “completely recovered” to “much worse.” The median cross‐sectional area of the median nerve at the proximal carpal tunnel decreased after surgery from 14 mm2 [interquartile range (IQR) 12–16 mm2] to 11.5 mm2 (IQR 11–13.5 mm2) (P < 0.0001); no significant changes in the cross‐sectional area occurred in symptomatic hands treated conservatively or in asymptomatic hands. Sonography at the time of diagnosis was not a predictor of postoperative outcome, but in this study only a relatively small number of patients had a poor postoperative outcome. Muscle Nerve, 2008

Diagnostic value of high-resolution sonography in common fibular neuropathy at the fibular head.

In 30% of patients with common fibular (CF) neuropathy at the fibular head, reliable localization of the site of the lesion by means of electrodiagnostic testing is challenging.

Diagnostic value of sonography in treatment-naive chronic inflammatory neuropathies.

Objective: To determine the diagnostic value of high-resolution ultrasound (HRUS) for detection of chronic inflammatory demyelinating polyneuropathy (CIDP), Lewis-Sumner syndrome (LSS), and multifocal motor neuropathy (MMN). Methods: Between January 2013 and January 2015, we enrolled 75 consecutive treatment-naive patients with chronic inflammatory neuropathies and 70 disease controls. We performed extensive nerve conduction and standardized HRUS studies bilaterally of large arm and leg nerves and brachial plexus. We determined optimal sonographic cutoff values of nerve size and used receiver operating characteristic analysis and logistic regression models to identify nerve combinations with optimal diagnostic performance. Results: Enlargement of median nerve at forearm >10 mm2, upper arm >13 mm2, and any trunk of brachial plexus >8 mm2 was 99% specific for chronic inflammatory neuropathies. A shortened HRUS protocol for detecting this abnormal nerve enlargement showed high sensitivity (83%–95%), positive predictive value (100%), and negative predictive value (98%) in discriminating CIDP, LSS, and MMN from clinical mimics. Conclusions: Sonographic enlargement of proximal median nerve segments in the arms and brachial plexus is a key feature of chronic inflammatory neuropathies, which helps to reliably distinguish them from axonal neuropathies and amyotrophic lateral sclerosis. Classification of evidence: This study provides Class II evidence that, in absence of clinical features that suggest a hereditary demyelinating neuropathy, sonographic enlargement of proximal median nerve segments and brachial plexus accurately identifies patients with chronic inflammatory neuropathies.

Sonographic incidence of ulnar nerve (sub)luxation and its associated clinical and electrodiagnostic characteristics

Introduction: The aim of this study was to assess the presence of (sub)luxation of the ulnar nerve in patients with ulnar neuropathy at the elbow (UNE) compared with healthy controls (HC). We assessed its clinical patterns, electrodiagnostic, and sonographic characteristics. Methods: Using high‐resolution sonography, we studied the incidence of (sub)luxation in a cohort of 342 patients and 70 HC. Results: Subluxation occurred in 14% and luxation in 6.7% of the UNE patients versus 5.7% and 5.7%, respectively, in HC (no significant differences). Pain at the elbow occurred more often in patients with (sub)luxation (P = 0.007). Electrodiagnostic and sonographic findings did not differ between patients with or without (sub)luxation. Conclusions: The incidence of ulnar nerve (sub)luxation between patients with UNE and HC does not differ. UNE patients with (sub)luxation do not have specific clinical or electrodiagnostic findings, apart from experiencing pain at the elbow more often. Muscle Nerve 47: 849–855, 2013

Ulnar neuropathy in hansen disease: clinical, high-resolution ultrasound and electrophysiologic correlations.

Objective To assess the relationship between the cross-sectional area (CSA) of the ulnar nerve by ultrasound (US) with clinical and electrophysiologic findings in Hansen ulnar neuropathy. Methods Twenty-one patients (42 arms) with Hansen disease (mean age 30.0 ± 12.97, range 13–61 years, borderline tuberculoid 29%, borderline lepromatous, 19% lepromatous leprosy 42%, and pure neuritic type 10%) were examined clinically for ulnar sensory and motor weakness. The ulnar nerve was ultrasonographically examined from the wrist to the axilla, and CSA was measured at the level of maximum enlargement. Ulnar sensory nerve conduction was recorded orthodromically with ring electrodes placed at the fifth digit and amplitude of sensory nerve action potential (SNAP) recorded 3 cm proximal to the distal wrist crease. Motor conduction velocity (MCV) was recorded at the wrist—below the elbow, below the elbow—above the elbow, and above the elbow—axilla segments. Results Out of the 42 arms with Hansen disease, 76% had clinically motor weakness, and 43% had sensory loss in the upper limbs innervated by the ulnar nerve. As compared with healthy subjects, the patients with Hansen ulnar neuropathy had a statistically significant reduction in SNAP (P ⩽ 0.0001) and MCV (P ⩽ 0.0001). It was observed that the maximum enlargement of the ulnar nerve in all the patients was a few centimeters above the elbow segment. The mean CSA of ulnar nerve above the medial epicondyle was 18 ± 15 mm2 as compared with controls 4.83 ± 1.12 mm2 (P < 0.0001). In addition to nerve thickening, US depicted abnormality in morphology. In 55%, the nerve was hypoechoic, and in 7.1%, the nerve pattern was oligofascicular. Color Doppler (CD) flow signals were observed in all the nerves with loss of fascicular pattern and in 40% of the nerves that were hypoechoic. A statistically significant correlation was found between CSA of ulnar nerve above the medial epicondyle vs. MCV at BE–AE and compound muscle action potentials (CMAP) above the elbow in the patients with clinical motor weakness (r = −0.55, P < 0.001) and (r = −0.57, P < 0.001), respectively. There was no statistical significant correlation between CSA and SNAP in the patients with (r = −0.52, P = 0.23) and without (r = −0.07, P = 0.83) sensory loss. Conclusions In leprosy patients, a positive correlation exits between the presence of motor weaknesses of the ulnar nerve innervated muscles, sonographically thickening of the ulnar nerve, and motor conduction slowing of the ulnar nerve at the BE–AE segment. In addition, US provided information on nerve morphologic alterations regarding the echo texture and location of nerve enlargement.

Increased nerve vascularization detected by color Doppler sonography in patients with ulnar neuropathy at the elbow indicates axonal damage.

Introduction: The aim of this study was to establish the prevalence of increased intraneural vascularization detected by ultrasonography (IVUS) in patients with ulnar neuropathy at the elbow (UNE) and to determine its relationship to clinical, ultrasonographic, and electrodiagnostic findings. Methods: High‐resolution ultrasonography and color Doppler imaging were performed in 137 patients with confirmed UNE, 24 patient controls, and 70 healthy controls (HCs). Results: IVUS was found in 21 (15%) of 137 patients with UNE, in 1 (4%) of 24 patient controls, and in 0 of 70 HCs (P = 0.001). Patients with IVUS were more likely to have severe weakness (P = 0.01), severe atrophy of ulnar‐innervated muscles (P = 0.008), axonal damage (P = 0.001), and more pronounced nerve enlargement (P = 0.03) than those without IVUS. Conclusions: IVUS in the ulnar nerve can be detected in patients with UNE and is associated with nerve enlargement and clinical and electrodiagnostic severity. In addition, IVUS is associated with axonal damage. Muscle Nerve, 2013