The ultrasonographic and electrodiagnostic findings of ulnar neuropathy at the elbow

doi:10.1016/j.apmr.2003.09.016

Archives of Physical Medicine and Rehabilitation

Volume 85, Issue 6, June 2004, Pages 1000-1005

https://doi.org/10.1016/j.apmr.2003.09.016 Get rights and content

Abstract

Park G-Y, Kim J-M, Lee S-M. The ultrasonographic and electrodiagnostic findings of ulnar neuropathy at the elbow. 2004;85:1000–5.

Objective

To evaluate and compare the morphologic changes of the ulnar nerve at the elbow, using ultrasonography, between patients with cubital tunnel syndrome and retrocondylar compression syndrome determined with electrodiagnosis.

Design

Prospective study using electrodiagnosis and ultrasonography.

Setting

An outpatient rehabilitation clinic in a tertiary university hospital in South Korea.

Participants

Thirteen patients (8 men, 5 women; mean age, 48.2y).

Interventions

Not applicable.

Main outcome measures

In the electrodiagnostic study, we used the inching technique to localize the ulnar nerve lesion at the elbow. In the ultrasonography study, we measured the length of the swollen ulnar nerve and the ratio of the nerve diameter between the proximal end of the medial epicondyle to the elbow joint level and the tip of medial epicondyle to the elbow joint level.

Results

The mean length of the swollen ulnar nerve segment in retrocondylar compression syndrome (2.58±0.58cm) was significantly longer than that of cubital tunnel syndrome (1.64±0.31cm). The mean ratio of the nerve diameter between the proximal end of medial epicondyle and the elbow joint level was significantly larger in retrocondylar compression syndrome (1.52±0.25) than that of cubital tunnel syndrome (1.06±0.06).

Conclusions

Ultrasonography detected the morphologic changes and the extent of the ulnar nerve lesion at the elbow, and it can become a screening and follow-up imaging modality in patients with ulnar neuropathy at the elbow.

Section snippets

Participants

Thirteen patients (8 men, 5 women; mean age, 48.2y) with ulnar neuropathy at the elbow were diagnosed by using electrodiagnostic study between September 2001 and April 2003. Of the 13 patients, 9 had right-sided lesions and 4 had left-sided lesions. Their lesion site was localized by using the inching technique at the Department of Rehabilitation Medicine, Keimyung University College of Medicine.

Measures

Demographic data and histories were recorded, and physical examinations were conducted to determine

Physical examinations

During physical examination, sensory abnormalities of ulnar nerve innervation territory were seen in 11 patients. Weakness or atrophy was seen in the first dorsal interosseous or abductor digiti minimi of all 13 patients.

Electrodiagnostic findings

In the electrodiagnostic study, both ulnar nerve conduction abnormalities and abnormal spontaneous activities in ulnar nerve-innervated muscles were seen in 12 patients. Only ulnar NCV abnormalities were seen in 1 patient. The mean motor NCV of the ulnar nerve below the elbow

Etiology of ulnar nerve lesion

The ulnar nerve is compressed most commonly at the elbow. In its passage around the medial aspect of the elbow, the ulnar nerve lies in an osteofibrous ring—the cubital tunnel—which is formed by a groove between the olecranon process of the ulna and the medial epicondyle of the humerus and is bridged by a fascial sheet. The roof of the cubital tunnel is formed by the cubital tunnel retinaculum and the flexor carpi ulnaris aponeurosis. The nerve enters the hiatus between the ulnar and humeral

Conclusions

Because high-resolution ultrasonography can detect morphologic changes and the extent of ulnar nerve lesion, if done in conjunction with electrodiagnostic studies, it can provide additional anatomic information of ulnar neuropathy at the elbow and can become a screening and follow-up diagnostic modality for patients with ulnar neuropathy at the elbow. But, patients with electrodiagnostically determined retrocondylar compression syndrome showed variable findings, so further study with more

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Citation Excerpt :
Several previous EDx studies estimated length of the affected nerve segment (LANS) in UNE. However, all of them (Agnew et al., 2012; Brown et al., 1976; Brown and Yates, 1982; Kanakamedala et al., 1988; Park et al., 2004) except one (Visser et al., 2005) included very few (<20) affected arms. Such small samples might not include all variability present in arms with UNE.
To establish length of the affected nerve segment (LANS) in ulnar neuropathy at the elbow (UNE).
In a group of our previously reported UNE patients we identified 2-cm segments with reduced motor nerve conduction velocity (MNCV) on electrodiagnostic (EDx) studies and increased nerve cross-sectional areas (CSA) on ultrasonographic (US) studies. LANS was obtained by summation of these abnormal 2-cm segments separately for each approach. We also studied effect of selected independent parameters on LANS.
Altogether we studied 189 patients (194 arms). Mean (SD) LANS determined in 171 arms with reduced ulnar MNCV was 4.15 (1.89) cm, and was similar (p = 0. 21) to LANS obtained in 147 arms with increased CSA 4.46 (2.29) cm. Longer LANS were found in right arms, clinically severe UNE, axonal UNE and UNE due to entrapment. The most commonly affected 6 cm segment included 89% of abnormal 2-cm segments, with 50% of included 2-cm segments being normal. By contrast, the whole 10 cm segment included all abnormal 2-cm segments, with 66% of included segments being normal.
In UNE both EDx and US studies revealed average LANS of around 4 cm. LANS was longer in more severe UNE.
LANS needs to be taken into account in discussion of the mechanisms of UNE and approach to EDx diagnosis of UNE, particularly length of the segment used in nerve conduction studies across the elbow.
Ultrasound Parameters Other Than the Direct Measurement of Ulnar Nerve Size for Diagnosing Cubital Tunnel Syndrome: A Systemic Review and Meta-analysis
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To investigate the diagnostic performance of available ultrasound (US) parameters, other than the direct measurements of ulnar nerve size, that is, cross-sectional area (CSA) and diameter, for diagnosing cubital tunnel syndrome (CuTS).
Databases, including PubMed and Embase, were searched from the earliest record of CuTS US to April 24, 2018.
Published studies (N=13) comparing US parameters of ulnar nerves between patients with CuTS and patients without CuTS were included.
Study design, participants’ demographics, diagnostic references of CuTS, and US parameters other than the direct measurements of the ulnar nerve size were retrieved from the included studies.
This systematic review comprised 663 CuTS patients and 543 patients without CuTS. The pooled nerve swelling ratio in the CuTS group was significantly larger than that of the controls. The mean between-group differences of CSA_{Max or ME}/CSA_arm, CSA_{Max or ME}/CSA_forearm and CSA_{Max or ME}/CSA_wrist were 1.03 (95% confidence interval [CI], 0.77-1.29), 1.38 (95% CI, 0.93-1.82), and 0.83 (95% CI, 0.56-1.11), respectively. Regarding the swelling ratio of CSA_{Max or ME} /CSA_arm, the pooled sensitivity and specificity available from the 3 included studies were 0.67 (95% CI, 0.59-0.74) and 0.81 (95% CI, 0.75-0.86), respectively. Similarly, for the swelling ratio of CSA_{Max or ME}/CSA_forearm, the pooled sensitivity and specificity were 0.62 (95% CI, 0.54-0.69) and 0.86 (95% CI, 0.81-0.90), respectively. Other US parameters identified in this review included nerve-flattening ratio (maximum diameter/minimum diameter), nerve-to-tunnel ratio (ulnar nerve CSA/cubital tunnel CSA), nerve echogenicity, and intraneural vascularity, all of which were reported in a minority of included articles.
Despite the insufficient number of pertinent studies to prove its superiority to other US measurements, the ulnar nerve-swelling ratio can be a complementary tool for diagnosing CuTS. The presence of intraneural vascularity, increased flattening ratio, and enlarged intraneural hypoechoic fraction also seem to be potential US indicators for CuTS diagnosis, which need to be validated with more prospective studies.
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Preoperative dynamic ultrasound can be used to accurately predict the degree of ulnar nerve instability following in situ decompression.
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Surgical decompression of the ulnar nerve (UN) is effective for treating cubital tunnel syndrome (CubTS). Nevertheless, the outcome is not always satisfying. Different surgical, clinical, and imaging findings have been claimed as outcome predictors, but there is no consensus in the literature. We analyzed the outcome-predicting role of ultrasonography (US) of the UN in patients with CubTS and its possible role for diagnosis and follow-up.
Patients with CubTS treated by simple UN decompression underwent US and electrodiagnotic (ED) studies of the UN at the elbow before and after surgery. Outcome was evaluated through the Bishop scale. A correlation analysis between pre- and postoperative clinical, US, and ED findings was performed.
Thirty-six patients were enrolled. Preoperatively, we observed a negative correlation between the motor conduction velocity (MCV) and the transverse (TD) and anteroposterior diameters and cross-sectional area (CSA) of the UN at the precubital (P = 0.001, P = 0.001, P = 0.005) and cubital level (P = 0.02, P = 0.002, P = 0.001). Preoperative precubital TD and CSA were associated with outcome (P = 0.01, P = 0.006) and postoperative MCV (P = 0.004, P = 0.008). The cut-off values TD >6 mm and CSA >23.91 mm² were predictors of poor outcome. Finally, postoperative cubital TD and CSA values were inversely correlated with outcome (P = 0.0002, P = 0.0007) and postoperative MCV (P = 0.0002, P = 0.0004).
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ArticleThe ultrasonographic and electrodiagnostic findings of ulnar neuropathy at the elbow1

Abstract

Objective

Design

Setting

Participants

Interventions

Main outcome measures

Results

Conclusions

Section snippets

Participants

Measures

Physical examinations

Electrodiagnostic findings

Etiology of ulnar nerve lesion

Conclusions

Semin Ultrasound CT MR

Eur J Ultrasound

J Hand Surg [Br]

Cubital tunnel syndromediagnosis by high-resolution ultrasonography

J Ultrasound Med

Sensory and mixed nerve conduction studies in the evaluation of ulnar neuropathy at the elbow

Muscle Nerve

Echotexture of peripheral nervescorrelation between US and histologic findings and criteria to differentiate tendons

Radiology

Practice parameter for electrodiagnostic studies in ulnar neuropathy at the elbowsummary statement

Muscle Nerve

Clinical features and electrodiagnostic findings of ulnar neuropathy at the elbow

J Korean Acad Rehabil Med

Article
The ultrasonographic and electrodiagnostic findings of ulnar neuropathy at the elbow¹