Assessment of the utility of ultrasonography with high-frequency transducers in the diagnosis of postoperative neuropathies.

The primary aim of this paper was to assess the relevance of high-frequency ultrasound examination in qualifying patients for either surgical or conservative treatment of postoperative peripheral neuropathies. The study was conducted in a group of 71 patients who in 2009-2011 were referred to ultrasound examinations due to a clinical suspicion of peripheral neuropathies. For the purposes of this analysis, the suspected postoperative neuropathies were divided into three groups: after surgical treatment of the median nerve (1), after surgical treatment of the ulnar nerve (2) and other postoperative neuropathies (3). All patients underwent the interview, physical examination and ultrasound examination. The ultrasound examinations were performed with Esaote MyLab 50 and MyLab 60 systems. Based on the clinical and US examinations, the patients were qualified for either surgical (51 cases) or conservative treatment (20 cases). An EMG examination was also performed in certain patients (60 cases). Mean values of cross-sectional areas and diameters of the nerve trunks were calculated in individual pathology groups. The ultrasound features of the peripheral nerves analyzed in the study, such as echostructure, notch sign, hyperemia and continuity of the transverse ligament, were divided into subgroups. Moreover, the frequency of adhesions between the nerve trunks and adjacent tissues, occurrence of pain on compression with a transducer and instability of the ulnar nerve as well as angulation of the posterior interosseous nerve in a dynamic examination was calculated. The analyses of the collected material were performed by means of descriptive statistics. The results of clinical and surgical verification were consistent with ultrasound findings in 100% of cases. The results indicate that high-frequency ultrasonography is a valuable method in qualifying patients for various types of treatment of peripheral postoperative neuropathies.

Assessment of the utility of ultrasonography with high-frequency transducers in the diagnosis of posttraumatic neuropathies.

The primary aim of this paper was to assess the relevance of high-frequency ultrasound examination in qualifying patients for either surgical or conservative treatment of posttraumatic peripheral neuropathies. The study was conducted in a group of 47 patients aged 16-65 (mean age 33) who in 2009-2011 were referred to ultrasound examinations due to a clinical suspicion of posttraumatic peripheral neuropathies. The group included 30 females and 17 males. The patients examined presented with neuropathies of the following peripheral nerves: median, ulnar, common peroneal, digital, cutaneous in the deltoid area, mental, PIN and RSNR. In 21 patients, nerve injuries were partial, and in 24 - complete. In 2 cases, the nerve was entrapped between bony fragments. 17 of 21 patients with partial nerve injuries (80.95%) underwent an EMG examination. No functional tests were conducted in the cases of complete injuries when ultrasound imaging had confirmed the result of the clinical examination. All patients underwent the interview, physical examination and ultrasound examination. Ultrasound examinations were performed with Esaote MyLab 50 and MyLab 60 systems using high-frequency broadband linear transducers: 6-18 MHz. The nerves were evaluated in the gray-scale and in the power Doppler mode in longitudinal and transverse sections for localization, morphology and the grade of injury as well as for possible anatomic variants of the nerve trunk and pathologies of the adjacent tissues. Moreover, a dynamic examination was performed, and it was attempted to induce pain or paresthesia by palpation at the site of the visualized pathology. Additionally, the motor and sensory-motor nerves were assessed indirectly based on the images of the skeletal muscles innervated by these nerves. The analyses of the collected material were performed by means of descriptive statistics. The results of clinical and surgical verification were consistent with ultrasound findings in 100% of cases. The results obtained indicate that high-frequency ultrasonography is a valuable method in qualifying patients for various types of treatment of peripheral neuropathies resulting from trauma.

Ultrasound-guided joint and soft tissue interventions.

Minor procedures with an injection needle are frequently performed in orthopedic clinics. They may be of a diagnostic, diagnostic and therapeutic or purely therapeutic nature. Ultrasound guidance while inserting the needle allows for a safe medicine administration and evacuation of fluid contents. It improves the efficacy of such procedures by ensuring accurate needle insertion in the target site. Ultrasound-guided procedures reduce the duration of treatment (e.g. medicines reach the target site directly; all fluid collections are removed, even multilocular ones) and minimize pain (by the selection of optimal access sites omitting tendons, vessels and peripheral nerves). This paper presents the principles of performing ultrasound-guided interventions. A detailed description of such a technique is provided and the most commonly injected medicines as well as their adverse reactions and contraindications are discussed. Attention is also paid to image optimization and the role of procedure site selection with the exclusion of other pathologies in the puncture site (such as tumors, foreign bodies and vascular or nerve pathologies). What is more, the author also discusses the principles of needle length and thickness selection as well as the manners of its insertion in relation to the transducer. Moreover, the principles of aseptics that are mandatory during such interventions are also presented and the way to protect transducers from the effects of chemical disinfectants is discussed. Furthermore, the paper contains numerous photographs of performed interventions. It is addressed to clinical practitioners and its aim is to facilitate and improve the efficacy of the procedures which are commonly performed in orthopedics. Ultrasound guidance of joint and soft tissue interventions should become a gold standard in all orthopedic clinics.

Assessment of the utility of ultrasonography with high-frequency transducers in the diagnosis of entrapment neuropathies.

The primary aim of this paper was to assess the relevance of high-frequency ultra-sound examination in qualifying patients for either surgical or conservative treatment of peripheral entrapment neuropathies. The study was conducted in a group of 55 patients aged 7-83 (mean age 43.6), including 28 males and 27 females, who in 2009-2011 were referred to an ultrasound examination due to a clinical suspicion of entrapment neuropathies. For the purposes of the analysis, the patients were divided into four groups: carpal tunnel syndrome (1), ulnar nerve entrapment (2) (cubital tunnel syndrome and Guyon's canal syndrome), posterior interosseous nerve syndrome (3) and other entrapment neuropathies (4). The cases of isolated idiopathic carpal tunnel syndrome were excluded from the analysis. All patients underwent the interview, physical examination and ultrasound examination. Ultrasound examinations were performed with Esaote MyLab 50 and MyLab 60 systems using high-frequency broadband linear transducers: 6-18 MHz. Sixty-seven percent of patients (37 persons) underwent a neurophysiological test. Nerve echostructure, its hyperemia as well as nerve cross-sectional area or, in the case of small nerves, diameter were assessed in all patients. Furthermore, the following were assessed in individual groups: notch sign in group 1, nerve instability in a dynamic ultrasound examination in group 2, nerve angulation in a dynamic ultrasound examination and tenderness on nerve compression at the site of the visualized pathology in group 3. The analyses of the collected material were performed by means of descriptive statistics. The results of clinical and surgical verification were consistent with ultrasound findings in 96.4%. The results indicate that high-frequency ultrasonography is a valuable method in qualifying patients for various types of treatment of peripheral neuropathies resulting from compression.

Ultrasound assessment of selected peripheral nerve pathologies. Part III: Injuries and postoperative evaluation.

The previous articles of the series devoted to ultrasound diagnostics of peripheral nerves concerned the most common nerve pathologies, i.e. entrapment neuropathies. The aim of the last part of the series is to present ultrasound possibilities in the postoperative control of the peripheral nerves as well as in the diagnostics of the second most common neuropathies of peripheral nerves, i.e. posttraumatic lesions. Early diagnostics of posttraumatic changes is of fundamental importance for the course of treatment and its long-term effects. It aids surgeons in making treatment decisions (whether surgical or conservative). When surgical treatment is necessary, the surgeon, based on US findings, is able to plan a given type of operative method. In certain cases, may even abandon the corrective or reconstructive surgery of the nerve trunk (when there are extensive defects of the nerve trunks) and instead, proceed with muscle transfers. Medical literature proposes a range of divisions of the kinds of peripheral nerve injuries depending on, among others, the mechanism or degree of damage. However, the most important issue in the surgeon-diagnostician communication is a detailed description of stumps of the nerve trunks, their distance and location. In the postoperative period, ultrasound is used for monitoring the operative or conservative treatment effects including the determination of the causes of a persistent or recurrent neuropathy. It facilitates decision-making concerning a repeated surgical procedure or assuming a wait-and-see attitude. It is a difficult task for a diagnostician and it requires experience, close cooperation with a clinician and knowledge concerning surgical techniques. Apart from a static assessment, a dynamic assessment of possible adhesions constitutes a crucial element of postoperative examination. This feature distinguishes ultrasound scanning from other methods used in the diagnostics of peripheral neuropathies.

Normal and sonographic anatomy of selected peripheral nerves. Part I: Sonohistology and general principles of examination, following the example of the median nerve.

Ultrasonography is an established method for imaging peripheral nerves. It serves to supplement the physical examination, electromyography, and magnetic resonance imaging. It enables the identification of post-traumatic changes of nerves, neuropathies secondary to compression syndromes, inflammatory or neoplastic nerve lesions as well as the evaluation of postoperative complications. In certain situations, this technique is the imaging method of choice. It is increasingly used in anesthesiology for regional anesthesia. As in the case of other ultrasound imaging studies, the examination of peripheral nerves is non-invasive, well-tolerated by patients, and relatively inexpensive. This article presents the histological structure of peripheral nerves and their appearance in ultrasonography. It also presents the examination technique, following the example of the median nerve, and includes a series of diagrams and ultrasound images. The interpretation of the shape, echogenicity, thickness and vascularity of nerves is described, as well as their relation to the surrounding tissues. The "elevator technique", which consists of locating a set nerve at a characteristic anatomic point, and following it proximally or distally, has been explained. The undisputed benefits of the ultrasound examination have been presented, including its advantages over other diagnostic methods. These advantages include the dynamic component of the ultrasound examination and the possibility of correlating the patient's symptoms with the ultrasound images. As an example, the proper anatomy and the ultrasonographic appearance of the median nerve were described. This nerve's course is presented, its divisions, and characteristic reference points, so as to facilitate its location and identification, and enable subsequent use of the aforementioned "elevator technique". This article opens a series of publications concerning anatomy, technique of examination and pathologies of peripheral nerves.

Ultrasound assessment of selected peripheral nerves pathologies. Part II: Entrapment neuropathies of the lower limb.

Similarly to entrapment neuropathies of upper extremities, the ultrasound constitutes a valuable supplementation of diagnostic examinations performed in patients with suspicions of nerve entrapment syndromes of the lower limb. For many years, it was claimed that such pathologies were rare. This probably resulted from the lack of proper diagnostic tools (including high frequency ultrasound transducers) as well as the lack of sufficient knowledge in this area. In relation to the above, the symptoms of compression neuropathies were frequently interpreted as a manifestation of pathologies of the lumbar part of the spine or a other orthopedic disease (degenerative or overuse one). Consequently, many patients were treated ineffectively for many months and even, years which led to irreparable neurological changes and changes in the motor organ. Apart from a clinical examination, the diagnostics of entrapment neuropathies of lower limb is currently based on imaging tests (ultrasound, magnetic resonance) as well as functional assessments (electromyography). Magnetic resonance imaging is characterized by a relatively low resolution (as compared to ultrasound) which results in limited possibilities of morphological evaluation of the visualized pathology. Electromyography allows for the assessment of nerve function, but does not precisely determine the type and degree of change. This article presents examples of the most common entrapment neuropathies of the lower limb concerning the following nerves: sciatic, femoral, lateral femoral cutaneous, obturator, fibular and its branches, tibial and its branches as well as sural. The pathomorphological basis of the neuropathies as well as corresponding ultrasound images are presented in this paper. Attention has been drawn to echogenicity, degree of vascularization and bundle presentation of the trunk of a pathological peripheral nerve.

Normal and sonographic anatomy of selected peripheral nerves. Part II: Peripheral nerves of the upper limb.

The ultrasonographic examination is frequently used for imaging peripheral nerves. It serves to supplement the physical examination, electromyography, and magnetic resonance imaging. As in the case of other USG imaging studies, the examination of peripheral nerves is non-invasive, well-tolerated by patients, and relatively inexpensive. Part I of this article series described in detail the characteristic USG picture of peripheral nerves and the proper examination technique, following the example of the median nerve. This nerve is among the most often examined peripheral nerves of the upper limb. This part presents describes the normal anatomy and ultrasound picture of the remaining large nerve branches in the upper extremity and neck - the spinal accessory nerve, the brachial plexus, the suprascapular, axillary, musculocutaneous, radial and ulnar nerves. Their normal anatomy and ultrasonographic appearance have been described, including the division into individual branches. For each of them, specific reference points have been presented, to facilitate the location of the set trunk and its further monitoring. Sites for the application of the ultrasonographic probe at each reference point have been indicated. In the case of the ulnar nerve, the dynamic component of the examination was emphasized. The text is illustrated with images of probe positioning, diagrams of the normal course of the nerves as well as a series of ultrasonographic pictures of normal nerves of the upper limb. This article aims to serve as a guide in the ultrasound examination of the peripheral nerves of the upper extremity. It should be remembered that a thorough knowledge of the area's topographic anatomy is required for this type of examination.

Ultrasound assessment on selected peripheral nerve pathologies. Part I: Entrapment neuropathies of the upper limb - excluding carpal tunnel syndrome.

Ultrasound (US) is one of the methods for imaging entrapment neuropathies, post-traumatic changes to nerves, nerve tumors and postoperative complications to nerves. This type of examination is becoming more and more popular, not only for economic reasons, but also due to its value in making accurate diagnosis. It provides a very precise assessment of peripheral nerve trunk pathology - both in terms of morphology and localization. During examination there are several options available to the specialist: the making of a dynamic assessment, observation of pain radiation through the application of precise palpation and the comparison of resultant images with the contra lateral limb. Entrapment neuropathies of the upper limb are discussed in this study, with the omission of median nerve neuropathy at the level of the carpal canal, as extensive literature on this subject exists. The following pathologies are presented: pronator teres muscle syndrome, anterior interosseus nerve neuropathy, ulnar nerve groove syndrome and cubital tunnel syndrome, Guyon's canal syndrome, radial nerve neuropathy, posterior interosseous nerve neuropathy, Wartenberg's disease, suprascapular nerve neuropathy and thoracic outlet syndrome. Peripheral nerve examination technique has been presented in previous articles presenting information about peripheral nerve anatomy [Journal of Ultrasonography 2012; 12 (49): 120-163 - Normal and sonographic anatomy of selected peripheral nerves. Part I: Sonohistology and general principles of examination, following the example of the median nerve; Part II: Peripheral nerves of the upper limb; Part III: Peripheral nerves of the lower limb]. In this article potential compression sites of particular nerves are discussed, taking into account pathomechanisms of damage, including predisposing anatomical variants (accessory muscles). The parameters of ultrasound assessment have been established - echogenicity and echostructure, thickness (edema and related increase in the cross sectional area of the nerve trunk), vascularization and the reciprocal relationship with adjacent tissue.

Normal and sonographic anatomy of selected peripheral nerves. Part III: Peripheral nerves of the lower limb.

The ultrasonographic examination is currently increasingly used in imaging peripheral nerves, serving to supplement the physical examination, electromyography and magnetic resonance imaging. As in the case of other USG imaging studies, the examination of peripheral nerves is non-invasive and well-tolerated by patients. The typical ultrasonographic picture of peripheral nerves as well as the examination technique have been discussed in part I of this article series, following the example of the median nerve. Part II of the series presented the normal anatomy and the technique for examining the peripheral nerves of the upper limb. This part of the article series focuses on the anatomy and technique for examining twelve normal peripheral nerves of the lower extremity: the iliohypogastric and ilioinguinal nerves, the lateral cutaneous nerve of the thigh, the pudendal, sciatic, tibial, sural, medial plantar, lateral plantar, common peroneal, deep peroneal and superficial peroneal nerves. It includes diagrams showing the proper positioning of the sonographic probe, plus USG images of the successively discussed nerves and their surrounding structures. The ultrasonographic appearance of the peripheral nerves in the lower limb is identical to the nerves in the upper limb. However, when imaging the lower extremity, convex probes are more often utilized, to capture deeply-seated nerves. The examination technique, similarly to that used in visualizing the nerves of upper extremity, consists of locating the nerve at a characteristic anatomic reference point and tracking it using the "elevator technique". All 3 parts of the article series should serve as an introduction to a discussion of peripheral nerve pathologies, which will be presented in subsequent issues of the "Journal of Ultrasonography".