Siegfried Peer

High-resolution sonography of lower extremity peripheral nerves: anatomic correlation and spectrum of disease.

The value of sonography for the diagnosis of diseases of the peripheral nervous system is only little known. This image presentation is intended to raise the awareness of sonographers and clinicians of the potential of sonography by giving an anatomic‐sonographic correlation of lower extremity peripheral nerves and an overview of commonly encountered diseases.

Persistent Median Artery in the Carpal Tunnel Color Doppler Ultrasonographic Findings

To describe the ultrasonographic and color Doppler ultrasonographic findings in 2 patients with carpal tunnel syndrome associated with a persistent median artery and to report the frequency of this anatomic variation in healthy volunteers.

The ultrasonographic appearance of the femoral nerve and cases of iatrogenic impairment.

Objective. To assess the feasibility of ultrasonography of femoral nerves in a cadaveric specimen, healthy volunteers, and patients. Methods. In 1 unembalmed cadaveric specimen (female, 90 years) and 20 healthy volunteers (9 male and 11 female, 18–50 years; n = 40 scans), the topographic features, cross‐sectional shapes (oval or triangular), and cross‐sectional areas of the femoral nerves were evaluated by ultrasonography (5‐ to 12‐MHz broadband linear array). In a subsequent study, 7 consecutive patients with postoperative findings assigned to the femoral nerve were evaluated and assessed by a neurologist. Results. The mean ± SD anteroposterior and mediolateral diameters of the femoral nerves in the volunteers were 3.1 ± 0.8 and 9.8 ± 2.1 mm, respectively, at an average cross‐sectional area of 21.7 ± 5.2 mm2. The cross‐sectional shape was oval in 67.5% superior to the inguinal ligament and in 95% inferior to the ligament. The infrainguinal femoral nerve showed variable distances to the femoral artery. In the subsequent patient study, 5 patients had swelling of the femoral nerve in the affected side. In 1 patient, the nerve had a blurred echo structure due to a hematoma. In 1 patient, major damage of the femoral nerve was ruled out clearly. Conclusions. Ultrasonography allows the depiction and assessment of the femoral nerve from about 10 cm superior to 5 cm inferior to the inguinal ligament. In this region, ultrasonography is helpful in detection of impairments and, therefore, in decisions about planning and even acceleration of further treatment.

Peroneal Nerve Palsy Associated with Knee Luxation: Evaluation by Sonography—Initial Experiences

OBJECTIVE Traumatic knee dislocation needs immediate surgical repair to restore joint function. A concomitant traction injury of the peroneal nerve is reported to exist in up to 25% of cases and is often overlooked initially. In patients with major nerve lesions, immediate surgical nerve repair might be necessary to avoid irreversible loss of neural function. In the present study, we tried to evaluate whether sonography is a valuable tool for identification of nerve pathology that warrants surgical intervention. SUBJECTS AND METHODS In this prospective study, both peroneal nerves in nine patients with one-sided peroneal nerve palsy after closed knee luxation and the peroneal nerves of 11 healthy volunteers were investigated with sonography. Using statistical analysis, we tried to define the comparability and significance of the findings. RESULTS The mean cross-sectional area of healthy peroneal nerves in the genicular region was 0.18 cm2 (SD, 0.07 cm2). Impaired nerves were significantly discerned because of their increased cross-sectional area at the level of the injury (mean cross-sectional area, 0.7 cm2; SD, 0.46 cm2; p < 0.05). Identification of caliber changes and depiction of at least one nerve stump were found to be the most specific criteria for the definition of a major neural lesion. The ability of sonography to provide additional information about surrounding soft-tissue impairment (scar tissue and hematoma formation) proved helpful. CONCLUSION Sonography allows radiologists to visualize neural and extraneural pathology and to define the exact level and extent of lesions. Thus, it may be a valuable adjunct in the decision of whether surgical intervention is necessary.

Ultrasonography of the accessory nerve: normal and pathologic findings in cadavers and patients with iatrogenic accessory nerve palsy.

Objective. To determine feasibility of ultrasonography in detecting the normal accessory nerve as well as pathologic changes in cases of accessory nerve palsy. Methods. Four patients with accessory nerve palsy were investigated by ultrasonography. Three cases of accessory nerve palsy after lymph node biopsy and neck dissection were primarily diagnosed on the basis of ultrasonography using a 5‐ to 12‐MHz linear transducer. In addition, we performed ultrasonography in 3 cadaveric specimens to show the feasibility of detecting the accessory nerve. Results. Nerve transection (n = 2), scar tissue (n = 1), and atrophy of the trapezius muscle (n = 4) were confirmed by electroneurographic testing and surgical nerve inspection. In 1 case in which a patient had a whiplash injury with accessory nerve palsy, ultrasonography showed atrophy of the trapezius muscle with a normal nerve appearance. Conclusions. Ultrasonography allows visualization of the normal accessory nerve as well as changes after accessory nerve palsy.

Practical Experience with Sonographically Guided Phenol Instillation of Stump Neuroma: Predictors of Effects, Success, and Outcome

OBJECTIVE Phantom limb pain and stump pain frequently occur after limb amputation, and stump neuromas play an important role in generation of the pain. The purpose of this study was to evaluate the effects of a previously described optimized procedure for sclerosis of painful stump neuromas under real-time high-resolution sonographic guidance. SUBJECTS AND METHODS In this prospective study, neurosclerosis was performed on 82 patients by means of high-resolution sonographically guided injection of up to 0.8 mL of 80% phenol solution according to a standardized protocol. RESULTS During treatment all patients had marked improvement in terms of reduction of pain measured with a visual analog scale. Twelve (15%) of the subjects were pain free after one to three treatments, nine of the 12 achieving relief with the initial instillation. At 6-month follow-up evaluation, 52 patients assessed their present pain quantity with a simplified three-step score. Twenty (38%) of the 52 patients reported almost unnoticeable pain, and 33 (64%) reported pain equal to the minimum reached during therapy. In 18 (35%) of the 52 patients, the incidence of painful periods had markedly decreased. The neurosclerosis procedure had a low complication rate (5% rate of minor complications, 1.3% rate of major complications). CONCLUSION The high-resolution sonographically guided neurosclerosis procedure had a significantly better outcome than other documented treatments. Sonographically guided neurosclerosis should be included in the management of chronic phantom limb and stump pain.

Radiographic assessment in total knee arthroplasty.

Sixty-five total knee arthroplasties were evaluated by the Knee Society Radiological Evaluation System which was developed to encourage uniform reporting of the results of total knee arthroplasty. All patients were examined by three independent experienced radiologists 8.9 years after surgery (range, 3–16 years) to analyze the interobserver variability. For measurement of angles, high interobserver correlation was calculated for the prosthetic component angles and the femorotibial shaft angle. The comparison of the means indicated no significant differences except for the femorotibial shaft angle. For measurement of radiolucent lines, interobserver correlation was low for all components. The differences of the means were significantly different for all components. The results of interobserver variability of the patellar evaluation revealed high interobserver correlation for the patellar angle and for patellar subluxation and dislocation evaluation. For assessment of patellar mediolateral and superoinferior displacement, a low interobserver correlation was found. For radiographic assessment of total knee arthroplasty, the measurement of angles, including alpha, beta, femorotibial shaft angle, sagittal femoral and tibial component angle, patellar angle, and patellar subluxation and dislocation evaluation are recommended. The method of assessing radiolucent lines should be reconsidered.

Detection and Characterization of Perianal Inflammatory Disease Accuracy of Transperineal Combined Gray Scale and Color Doppler Sonography

Objective. To evaluate the accuracy of transperineal gray scale and color Doppler sonography for the detection and characterization of perianal inflammatory disease with surgical correlation. Methods. Eighty‐seven patients with suspected perianal inflammatory disorders underwent transperineal gray scale and color Doppler sonography with a linear 4‐ to 7‐MHz transducer that was used to scan the entire perianal region for the detection of suspected inflammatory disorders. Each detected inflammatory disorder was evaluated to determine its morphologic characteristics and extent. Color Doppler sonography was applied to assess the presence of increased vascularity in the perianal region. In comparison with surgical findings, the diagnostic performance of transperineal sonography was assessed by means of receiver operating characteristic analysis for lesion detection and the Spearman ρ test for lesion characterization. Logistic regression analysis was used to assess whether increased perineal vascularity was a predictive factor of perianal inflammatory disease. Results. Seventy‐seven perianal inflammatory disorders were confirmed in 62 patients. Gray scale sonography achieved a significantly good performance in the detection (area under the curve = 0.86; P < .001) and characterization (r = 0.65; P < .001) of perianal inflammatory disease. For the detection of perianal fistulas and abscesses, sensitivity was 100% for both, and specificity was 100% and 94%, respectively. With the use of color Doppler sonography, the diagnostic confidence increased slightly (area under the curve = 0.89) but significantly (P = .002). Logistic regression analysis identified hypervascularity at the periphery of a perianal lesion as a significant independent predictor of an inflammatory disease. Conclusions. Combined gray scale and color Doppler sonography enables a high detectability rate and comprehensive characterization of perianal abscesses and fistulas.

High resolution ultrasound in posterior interosseous nerve syndrome

Introduction: Posterior interosseous nerve (PIN) syndrome is a rare compression neuropathy of the PIN in the region of the supinator muscle, most common by the arcade of Frohse. We aimed to specify ultrasonographic findings in patients with PIN syndrome in comparison to healthy volunteers. Methods: Ultrasound images and clinical data of 13 patients with PIN syndrome confirmed by neurological examination and electrophysiological testing were evaluated retrospectively. Anteroposterior nerve diameters measured at the arcade of Frohse were compared with those of 20 healthy volunteers. The echotexture and the presence of a caliber change of the PIN were additionally assessed. Results: Enlargement of the PIN was seen in all patients with PIN syndrome, but not in volunteers (statistically significant difference in mean diameter P < 0.05). Furthermore, edema and caliber change of the PIN were present in all patients. Conclusions: High‐resolution ultrasound allows for differentiation between patients with PIN syndrome and healthy volunteers. Muscle Nerve 49: 35–39, 2014

Nontumorous Vascular Malformations in the Liver Color Doppler Ultrasonographic Findings

Objective. To investigate color Doppler and spectral wave characteristics of nontumorous vascular malformations in the liver. Methods. From September 1995 to January 2001, 32 cases of vascular malformations were identified by means of color Doppler ultrasonography and spectral wave analysis. Computed tomography, angiography, or both were performed in all cases. Results. Five arterioportal and 14 portovenous malformations, 1 arteriovenous malformation, and 4 portoportal and 8 venovenous shunts were detected. Associations with Rendu‐Osler‐Weber syndrome in 6 cases and with cirrhotic liver in 12 cases were found. Fourteen patients were liver disease free. In 3 cases, interventional procedures were necessary to reduce portal hypertension or cardiac dysfunction. The incidence of finding vascular malformations in 12,000 patients was 0.1%. Conclusions. Nontumorous vascular malformations are rare disorders in the liver. They may appear in patients with healthy livers and in patients with portal hypertension. Color Doppler ultrasonography and spectral wave analysis are capable of showing and differentiating different types of hepatic vascular malformations.