Role of multisegmental nerve ultrasound in the diagnosis of leprosy neuropathy.

INTRODUCTION/AIMS: Leprosy is the most common treatable peripheral neuropathy worldwide. The detection of peripheral nerve impairment is essential for its diagnosis and treatment, in order to prevent stigmatizing deformities and disabilities. This study was performed to identify neural thickening through multisegmental ultrasound (US). METHODS: We assessed US measurements of cross-sectional areas (CSAs) of ulnar, median and tibial nerves at two points (in the osteofibrous tunnel and proximal to the tunnel), and also of the common fibular nerve at the fibular head level in 53 leprosy patients (LP), and compared with those of 53 healthy volunteers (HV), as well as among different clinical forms of leprosy. RESULTS: US evaluation detected neural thickening in 71.1% (38/53) of LP and a mean number of 3.6 enlarged nerves per patient. The ulnar and tibial were the most frequently affected nerves. All nerves showed significantly higher measurements in LP compared with HV, and also greater asymmetry, with significantly higher values for ulnar and tibial nerves. We found significant CSAs differences between tunnel and pre-tunnel points for ulnar and tibial nerves, with maximum values proximal to the tunnel. All clinical forms of leprosy evaluated showed neural enlargement through US. DISCUSSION: Our findings support the role of multisegmental US as a useful method for diagnosing leprosy neuropathy, revealing that asymmetry, regional and non-uniform thickening are characteristics of the disease. Furthermore, we observed that neural involvement is common in different clinical forms of leprosy, reinforcing the importance of including US evaluation of peripheral nerves in the investigation of all leprosy patients.

Ulnar nerve subluxation and dislocation: a review of the literature.

The pathogenesis of ulnar nerve subluxation and dislocation is widely debated. Upon elbow flexion, the ulnar nerve slips out of the groove for the ulnar nerve, relocates medial or anterior to the medial epicondyle, and returns to its correct anatomical position upon extension. This chronic condition can cause neuritis or neuropathy; however, it has also been suggested that it protects against neuropathy by reducing tension along the nerve. This article reviews the extant literature with the aim of bringing knowledge of the topic into perspective and standardizing terminology.

An anatomical study of so-called fibrous bands around the ulnar nerve distal to the cubital tunnel.

BACKGROUND: Fibrous bands (FB) are structures that cross the ulnar nerve (UN), distal to the cubital tunnel (CT). In surgical decompression of the UN in the elbow region, by endoscopy, these FB significantly impact UN visibility. The aim of the current study was to characterize the anatomical characteristics of these FB distal to the CT. METHODOLOGY: Eighteen formalinized upper limbs were dissected, nine right and nine left, within the Department of Anatomy of the Federal University of the State of Rio de Janeiro (UNIRIO). The dissections were performed with micro techniques, under a magnifying glass and a microscope. Classical UN exposure was established in the elbow region. RESULTS: Of the 18 upper limbs studied, 50% lacked any FB. When present, both the number and location of the FB varied, as near to the cubital tunnel as 3 cm past the UN's entrance into the tunnel, and as far away as almost 11 cm distal to it. Overall, there were no FB on either the left or right side in three cadavers (33.3%), FB on both the left and right side in three, and FB only on the left in three, meaning that FB were twice as common in left limbs (n = 6) as on the right (n = 3). CONCLUSIONS: Our study identified FB in 50% of the dissected limbs, all within 3-11 cm of the CT, though their number and location varied. Further studies are necessary to describe FB variations associated with compressive neuropathies of the UN distal to the CT.

Asymmetric Nerve Enlargement: A Characteristic of Leprosy Neuropathy Demonstrated by Ultrasonography.

BACKGROUND: Neurological involvement occurs throughout the leprosy clinical spectrum and is responsible for the most feared consequences of the disease. Ultrasonography (US) provides objective measurements of nerve thickening and asymmetry. We examined leprosy patients before beginning multi-drug therapy aiming to describe differences in US measurements between classification groups and between patients with and without reactions. METHODOLOGY/PRINCIPAL FINDINGS: Eleven paucibacillary (PB) and 85 multibacillary (MB) patients underwent nerve US. Twenty-seven patients had leprosy reactions (type 1, type 2 and/or acute neuritis) prior to US. The ulnar (at the cubital tunnel-Ut-and proximal to the tunnel-Upt), median (M) and common fibular (CF) nerves were scanned to measure cross-sectional areas (CSAs) in mm2 and to calculate the asymmetry indexes ΔCSA (absolute difference between right and left CSAs) and ΔUtpt (absolute difference between Upt and Ut CSAs). MB patients showed greater (p<0.05) CSAs than PB at Ut (13.88±11.4/9.53±6.14) and M (10.41±5.4/6.36±0.84). ΔCSAs and ΔUtpt were similar between PB and MB. The CSAs, ΔCSAs and ΔUtpt were similar between PB patients with reactions compared to PB patients without reactions. MB patients with reactions showed significantly greater CSAs (Upt, Ut and M), ΔCSAs (Upt and Ut) and ΔUtpt compared to MB patients without reactions. PB and MB showed similar frequencies of abnormal US measurements. Patients with reactions had higher frequency of nerve thickening and similar frequency of asymmetry to those without reactions. CONCLUSIONS/SIGNIFICANCE: This is the first study to investigate differences in nerve involvement among leprosy classification groups using US before treatment. The magnitude of thickening was greater in MB and in patients with reactions. Asymmetry indexes were greater in patients with reactions and did not significantly differ between PB and MB, demonstrating that asymmetry is a characteristic of leprosy neuropathy regardless of its classification.

Neural relapse in multibacillary leprosy 6 years after end of treatment.

This article presents a case of relapse, with isolated neural manifestation, in a multibacillary patient previously treated with multidrug therapy for multibacillary leprosy (24 doses). The patient returned to the service six years after the end of treatment, with pain in hands and legs. He was investigated, and the serological monitoring showed an important increase in anti-phenolic glycolipid serum levels. A neural recurrence was suspected, since the patient had no new skin lesions. A new biopsy in the right ulnar nerve showed a bacilloscopy of 2 +, compatible with relapse. This is a literature review of the etiological, clinical, propedeutical and diagnostic aspects of this situation so poorly understood.

Neural relapse in multibacillary leprosy 6 years after end of treatment / Recidiva neural em hanseníase multibacilar após 6 anos de tratamento

This article presents a case of relapse, with isolated neural manifestation, in a multibacillary patient previously treated with multidrug therapy for multibacillary leprosy (24 doses). The patient returned to the service six years after the end of treatment, with pain in hands and legs. He was investigated, and the serological monitoring showed an important increase in anti-phenolic glycolipid serum levels. A neural recurrence was suspected, since the patient had no new skin lesions. A new biopsy in the right ulnar nerve showed a bacilloscopy of 2 +, compatible with relapse. This is a literature review of the etiological, clinical, propedeutical and diagnostic aspects of this situation so poorly understood.

O presente artigo relata um caso de recidiva, com manifestação neural isolada, em paciente multibacilar previamente tratado com poliquimioterapia para multibacilar 24 doses. O paciente retorna ao serviço, seis anos depois do fim do tratamento, com dores em mãos e pernas. Na investigação, o acompanhamento da sorologia anti-glicolipídeo fenólico 1 demonstrou aumento importante dos níveis séricos, e foi aventada a hipótese de recidiva neural, já que o paciente não apresentava lesões cutâneas novas. Uma nova biópsia, em nervo ulnar direito, demonstrou baciloscopia de 2+, compatível com recidiva. Faz-se revisão da literatura sobre aspectos etiológicos, clínicos, propedêuticos e diagnósticos dessa situação tão pouco compreendida.

Contribución proximal del nervio ulnar para la formación del nervio digital palmar propio ulnar del dedo mínimo / Proximal contribution of the ulnar nerve in the formation of the ulnar proper palmar digital nerve of the little finger

La anatomía de la mano presenta padrones generales en la distribución de los nervios responsables de la inervación motora y sensitiva. Sin embargo, se encuentran variaciones que son de interés para la anatomía quirúrgica de la región. En una serie de 20 manos disecadas, en 19 (95 por ciento) observamos que el nervio digital palmar propio del lado ulnar del dedo mínimo correspondía a un ramo directo del nervio ulnar y en el caso restante (5 por ciento), de un cadáver de sexo femenino, se observó un ramo de origen antebraquial que participó en la formación del nervio digital palmar propio ulnar del dedo mínimo. Este ramo se originó desde el tronco del nervio ulnar, distal al origen del ramo dorsal de este nervio y proximal al hueso pisiforme. En su trayecto pasó a través del músculo abductor del dedo mínimo, emergiendo por la cara superficial de éste a una distancia de 11,3 mm del origen del músculo en el hueso pisiforme, uniéndose al nervio digital palmar propio del dedo mínimo, distal al hueso mencionado. A pesar que la literatura muestra diversas variaciones en la formación y distribución de los nervios en la mano, la disposición descrita es inusual y no ha sido mencionada en ella.

The hand anatomy presents general patterns in motor and sensitive nerves distribution. However, is possible to find some variations that are very important for the surgical anatomy of the region. We study 20 hands of 10 cadaver individuals, fixed in 10 percent formaldehyde solution. We found in 19 hands (95 percent) that the ulnar proper palmar digital nerve of the little finger was a direct branch of the ulnar nerve and only one case (5 percent) - of female cadaver ¡ we observed one branch originated from the forearm, which was a part in the formation of the nerve mentioned above. This branch originated from the trunk of the ulnar nerve, distal to the origin of the dorsal branch of this nerve, proximal to the pisiform bone. This nerve passed through of the abductor digiti minimi muscle and then it emerged by the superficial face of this muscle, 11,3 mm distal to its origin in the pisiform bone. Then, it joined to the ulnar proper palmar digital nerve of the little finger, distal to mentioned bone. Although the literature describes innumerous variations in the formation and distribution of the hand nerves, this disposition is rare and has not been mentioned.

Magnetic resonance imaging of idiopathic carpal tunnel syndrome: correlation with clinical findings and electrophysiological investigation.

OBJECTIVE: To compare clinical evaluation, electrophysiological investigation and magnetic resonance findings in assessing the severity of idiopathic carpal tunnel syndrome. PATIENTS AND METHODS: Seventy-four patients with idiopathic carpal tunnel syndrome were prospectively recruited. Clinical evaluation included symptoms severity score and two-point discrimination, sensory and motor nerve conduction velocities were determined by electroneuromyography and imaging parameters were obtained after wrist magnetic resonance. The Wilcoxon test was used to define the differences between measurements of median nerve area. The Pearson and Spearman correlation tests were used to determine the relationships between all the measured parameters. RESULTS: Cross-sectional area of median nerve was smaller at hamate level than at radio-ulnar joint and pisiform levels (p<0.001). With exception of median nerve area at hamate level, there was a lower degree of correlation between MRI parameters and findings obtained by clinical assessments and electrophysiological measurements. The median nerve area at hamate level correlated negatively with duration of symptoms, two-point discrimination, symptoms severity score and positively with sensory nerve conduction velocity (p<0.01). CONCLUSION: In patients with idiopathic carpal tunnel syndrome, median nerve area measured by wrist magnetic resonance at hamate level may be considered as a valuable indicator to grading the severity of disease.

Uso da técnica ulnar-bíceps (oberlin) em paralisias altas do plexo braquial: estudo funcional de 20 casos / The use of ulnar-biceps technique's in high paralyses of plexo brachialfunctional study of 20 cases

O autor apresenta 20 casos de paralisia alta do plexo braquial, acometendo as raízes C5, C6 ± C7, tratadas pela neurotização dos fascículos do nervo musculocutâneo que inervam o músculo bíceps braquial por fascículos do nervo ulnar para recuperação da flexão do cotovelo (Técnica de Oberlin).A neurorrafia pode ser executada sem enxertos nervosos de interposição. Em todos os paciente aferiu-se resultado positivo, com início da recuperação funcional aos 5,5 ± 1,7 meses pós- operatórios e flexão do cotovelo contra resistência aos 14,7 ± 5,5 meses depois da cirurgia.A seqüela provocada pela secção dos fascículos doadores do nervo ulnar foram clinicamente desprezíveis quando comparadas ao beneficio proporcionado. O sucesso alcançado pelo procedimento cirúrgico se deu, principalmente, pelo curto espaço de tempo entre o acidente e a cirurgia. Os resultados descritos estão de acordo com os da literatura e reafirmam que a neurotização "Ulnar-Biceps" e o procedimento de escolha para o tratamento cirúrgico das paralisias altas do plexo braquial.

The author presents 20 cases of upper brachial plexus palsies, concerning C5, C6 ± C7 roots, treated by neurotization of the musculocutaneus nerve fascicles innervating the biceps brachial muscle with ulnar nerve fascicles to recover elbow flexion (Oberlin's Technique). The neurorraphy could be executed without interposition of nerve grafts. All the patients had positive result, with beginning of the functional recovery at 5.5 ± 1.7 of postoperative month sandel bow flexi on again stresistance at 14.7 ± 5.5 months after the surgery. The sequel provoked by the sectioned donor fascicles of the ulnar nerve is clinically worthless when compared with the benefit produced. The success reached by the surgical procedure can be mainly given by short gap of time between accident and surgery. The described results are in accordance with the literature and reaffirm that the Ulnar-Biceps neurotization is the first choice procedure for the surgical treatment of the upper brachial plexus palsies.

[Ulnar nerve palsy in leprosy without skin changes: biopsy of the superficial branch of the ulnar nerve in the hand]. / Paralisia do nervo ulnar na lepra sem alterações cutâneas. Biópsia do ramo superficial do nervo ulnar na mão.

Leprosy is one of the most common diseases of peripheral nerves in the world. In Brazil it is particularly frequent, being a major health problem. In tuberculoid leprosy the ulnar nerve is the most common affected nerve. Sometimes there are no skin changes. In these cases in spite of nerve thickening only the nerve biopsy is capable to make a specific diagnosis. We performed a biopsy in the dorsal sensory branch of the ulnar nerve in the hand in 17 patients with ulnar palsy with thickening of the nerve in the elbow, without skin changes. The pathological findings consisted mainly of: loss of fibers (14 cases), inflammatory infiltration (13), fibrosis (12), demyelination and remyelination (9), presence of granuloma (6) and presence of bacilli (5 cases). We conclude that in case of ulnar nerve palsy in leprosy without skin changes, the biopsy of the dorsal sensory branch of this nerve in the hand is a good procedure for the diagnosis of leprosy.

Paralisia do nervo ulnar na lepra sem alteraçöes cutâneas: biópsia do ramo superficial do nervo ulnar na mäo / Ulnar nerve palsy in leprosy without skin changes: biopsy of the surface branch of the ulnar nerve in hand

A lepra constitui causa frequente de acometimento de nervos periféricos, em nosso meio. O sistema nervoso periférico é acometido por vezes sem que haja alteraçoes cutâneas: é a chamada forma neurítica pura. Nessa variante, o nervo mais afetado é o ulnar. Nos casos de acometimento isolado de nervos periféricos somente a feitura de biópsia de nervo conduzirá ao diagnóstico. Assim, resolvemos realizar biópsia do ramo sensitivo superficial do nervo ulnar na mao em 17 pacientes com paresia ou paralisia desse nervo e espessamento do mesmo na altura do cotovelo. Os pricnipais achados foram: reduçao do número de fibras mielínicas em 14 casos, infiltrado inflamatório em 13, fibrose em 12, desmielinizaçao e remielinizaçao em 9, presença de granuloma em 6 e visualizaçao do Mycobacterium leprae em 5. Concluímos que a biópsia do ramo sensitivo superficial do nervo ulnar na mao é um bom meio diagnóstico de lepra em pacientes com acometimento desse nervo.

Reaçäo hansênica tipo I na hanseníase borderline tuberculóide durante a poliquimioterapia: época de aparecimento e nervos acometidos / Type I reaction in borderline tuberculoid leprosy under multidrug therapy: time of onset and nerves affected

FUNDAMENTOS - A reaçäo tipo I é pouco estudada na literatura. OBJETIVOS - Descrever a época de aparecimento da reaçäo tipo 1 e os nervos acometidos, nos pacientes portadores de hanseníase borderline tuberculóide (BT), durante a poliquimioterapia(PQT). PACIENTES E MÉTODOS - Estudo longitudinal realizado no Ambulatório de Dermatologia da Faculdade de Medicina da UFMG. Setenta e um pacientes com hanseníase BT foram incluídos no estudo de agosto de 1989 a agosto de 1993. RESULTADOS - 89,3 por cento dos pacientes hansenianos BT com reaçäo tipo 1 apresentaram esse surto atá a sexta dose de tratamento. O nervo ulnar foi o mais acometido nas reaçöes tipo 1 (37,0 por cento). CONCLUSÃO - A reaçäo tipo 1 nos pacientes hansenianos BT ocorre mais frequentemente até a sexta dose de PQT. O nervo ulnar foi o mais acometido

Exame palpatório de nervos periféricos (espessados na hansenáse) e suas vias anatômicas / Palpations of peripheral nerves (thickened in leprosy) and their anatomical pathways

Este trabalho demonstra, por meio de dissecçäo, o trajeto superficial dos nervos comprometidos na hanseníase. Nessa doença, as lesöes ocorrem com mais frequência em determinados nervos que, nesses casos, se tornam mais espessos do que o normal. Esses nervos específicos säo superficiais em alguma parte de seus trajetos anatômicos e, aí, mais facilmente palpáveis