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Jeffrey A. Strakowski, MDClinical Associate Professor, Dept of PM&R
The Ohio State University
Associate Director of Medical Education, PM&R
Riverside Methodist Hospital
Director of Musculoskeletal Research,
The McConnell Spine, Sport & Joint Center
HIGH FREQUENCY ULTRASOUND EVALUATION OF
PERIPHERAL NERVESULTRAEMG 5-11-17
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LEARNING OBJECTIVES
• Review Important Principles of Peripheral Nerve SonographyScanning Techniques
• Review the Anatomy of Sonographic Appearance for Identification of Peripheral Nerves
• Review the Methods of Assessing Normal and Abnormal Peripheral Nerve Appearance
• Discuss Principles and Examples of Assessing Clinical Cases Nerves with Ultrasound.
DISCLOSURES
• Member of Muscle and Nerve Editorial Board
• Textbook Royalties from
Demos Medical Publishing
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MAY 10-13, 2017COLUMBUS, OH
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PROGRESSION OF TECHNOLOGY EDX: 1990
1990
2017
ULTRASOUND
1990
2017
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99
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PRINCIPLES OF IMAGING PERIPHERAL NERVES WITH ULTRASOUND
• Correctly identify the nerve tissue
• Use good technique
• Know the surrounding anatomy
• Use consistent measurement techniques
• Assess in both short and long axis
• Follow the course of the nerve
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NORMAL NERVE
NERVE ECHOTECTURE
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ANOTHER EXAMPLE
HIGH RESOLUTION
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IMAGING STRATEGIES
USE COUPLING GEL LIBERALLY
RN
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PAY ATTENTION TO TRANSDUCER PRESSURE
USE ANATOMIC LANDMARKS TO HELP WITH LOCATION
DS
SS
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LANDMARKS CONTINUED
FOLLOW THE NERVE TO OTHER LOCATIONS WHEN NEEDED
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TOGGLE THE TRANSDUCER
ALTER THE SPEED OF SCANNING
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NORMAL FASCICULAR ARCHITECTURE CAN VARY
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NERVE HISTOLOGY
• Sural Nerve
• Cable model
• Plexiform model
• Appearance
• monofasicular
• oligofascicular
• polyfasicular
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BACK AND FORTH SCANNING
USE SURROUNDING VEINS
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USE SURROUNDING ARTERIES
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USE TISSUE MOVEMENT
USE DOPPLER WHEN NEEDED
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REMEMBER:
• Understanding of basic scanning and imaging techniques is needed for successful use of this modality in assessment of peripheral neves and focal neuropathies.
• Detailed assessment of nerve size, internal architecture and the static and dynamic influence of the surrounding tissue can provide considerable information in the evaluation of focal neuropathies .
ULTRASOUND FOR FOCAL NEUROPATHIES
• Helpful in the context of compression, trauma, post-surgical alteration and tumors.
• Can provide some information about severity.
• Can provide more precise localization than EDX.
• Can be helpful with peripheral nerve blocks.
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MEASUREMENT OF CROSS SECTIONAL AREA
CROSS SECTIONAL AREA
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FOR CSA MEASUREMENT
• Transducer must be placed perpendicular to the nerve for accuracy.
• Measure the inner border of the echogenic epineurium.
• Optimize Focal Zone.
• Optimize Gray Scale Mapping
CSA CALCULATION
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DIRECT VS ELLIPSE
DIRECT VS ELLIPSE
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CONFIRM THAT THE TISSUE BEING MEASURED IS ENTIRELY NERVE
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ALLOW INSPECT IN SHORT AND LONG AXIS
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LONGITUDINAL IS MORE CHALLENGING
LONGITUDINAL MEASURE
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INSPECT FASCICULAR ARCHITECTURE
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PERIPHERAL NERVE VASCULAR SUPPLY
ASSESS FOR ENLARGEMENT
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SIDE-TO-SIDE
SIDE-TO-SIDE LONG AXIS
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INSPECT IN SHORT AND LONG AXIS
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CHANGE IN FASCICULAR SIZE
SIDE-TO-SIDE
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ARCHITECTURAL DISRUPTION
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FOLLOW THE COURSE OF THE NERVE
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ABNORMAL MOVEMENT
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ENCROACHING LUMBRICAL
ENCROACHING FDS
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ENCROACHING FDS
TISSUE COMPRESSION
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ANATOMIC VARIATION
ANATOMIC VARIATION
• Assess normal variation or traumatic or post-surgical variation
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PERSISTENT MEDIAN ARTERY
• Frequently seen in between bifid median n.
• Is a branch from the ulnar artery.
• Is not seen with all bifids
• Can be seen on the ulnar side of typical median nerve
• Seen in up to 20% in cadaveric study
Iannicelli et al. Ultrasound Med 2000, Radiol Med 2001Propeck et al. AJR, 2000Rodriguez-Niedehfuhr, J Anat, 1999.
PMA
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BIFID MEDIAN NERVE
PERSISTENT MEDIAN ARTERY WITHOUT BIFID
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OTHER EXAMPLES
• Anconeus Epitrochlearis
• Ligament of Struthers
• Accessory ADM
• Reverse Palmeris Longus
ANCONEUS EPITROCHLEARIS
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ACCESSORY ADM
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MASSES
MASSES
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TRAUMA
NERVE TRAUMA
• US has good reliability for finding transected nerves (Cartwright 2007) and focal neuromas.
• Neuroma is seen as a well-defined hypoechoic mass along the course of the nerve.
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NERVE INJURY
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NERVE SCAR
POST-SURGICAL
Assess for:-anatomic alteration-scarring-other compressionor injury*get detailed history of complaint
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INSPECT FOR CHANGES IN MUSCLE ECHOTECTURE
ACCURATE MEASUREMENTS
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LCN
S/P THR “FOOT DROP”
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SFN POST-INJECTION
SUPERFICIAL FIBULAR NEUROPATHY AT ANKLE
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CASE: ISOLATED SURAL MONONEUROPATHY
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CASE
• 16 yo f with “foot drop” and numbness. Sat with crossed legs frequently.
• EDX: fibular neuropathy at fibular head
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NORMAL OR ABNORMAL?
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CASE:
• 22 yo college football player with acute injury. “Foot drop.”
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NORMAL OR ABNORMAL?
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DISRUPTED ARCHITECTURE FROM STRETCH?SURGICAL INTERVENTION?
CASE• 21 year old football player with acute injury. “Foot-drop”
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ANOTHER LOOK
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PROGNOSIS? SURGICAL INTERVENTION?
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CONTINUE SCANNING: COMPLETE NEUROTMESIS
CASE: RECURRENT FOOT DROP
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SHORT AXIS
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LONG AXIS
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CASE: LEFT FOOT DROP. R/O “PERONEAL” NEUROPATHY
Normal or abnormal?
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SIDE-TO-SIDE
NORMAL OR ABNORMAL?
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WHAT ELSE CAN WE CHECK?
NORMAL OR ABNORMAL?
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THANK YOU!
