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High resolution ultrasound in the evaluation and management of traumatic peripheral nerve injuries: review of the literature.

Introduction

Peripheral nervous system injuries can result in multiple pathologies, with involvement of single or multiple nerve units and subsequent sensory and/or motor impairment. (1) Certain biological mechanisms were involved in injuries recovery such as axonal regeneration and/or re-myelination with resultant re-innervation of the targeted organ. (2) This review aim to discuss the various peripheral neuropathies with a main focus on traumatic peripheral nerve injuries elaborating the different applications of ultrasound imaging in relation to the management and clinical assessment of such injuries.

Peripheral Neuropathies: Types and Classification

Etiologies of peripheral neuropathy ranges from acute, chronic to congenital anomalies; including various systemic illnesses and idiopathic pathologies. (1,3-7) Trauma is one of the most common causes of acute peripheral neuropathy. (1)

In a study involving 5,777 trauma patients, Noble et al. (8) showed a 3% prevalence of traumatic peripheral nerve injuries that involved either upper and/or lower extremities; in which 54% required surgical intervention. (8) Similarly in a retrospective study by Taylor et al, an incidence of 2% for traumatic nerve injuries in either upper or lower extremities was reported with the highest rate of such pathologies associated with crush injuries. (9) A study by Seddon led to clinical identification and classification of such injuries into a three graded system (neurapraxia, axonotmesis and neurotmesis). (10) This was later adapted into a five grade system by Sunderland, (11) and recently has been updated to include a sixth grade; a combination of any of the five degrees of injury can be present together. (12,13)

Findings of High Resolution Ultrasound Imaging In Various Peripheral Neuropathies

The concept of utilizing ultrasonography to evaluate peripheral nerves dates back to Solbiati et al; in which they evaluated this modality to assess the recurrent laryngeal nerve and to diagnose its associated palsy, particularly in cases of infiltrating thyroid or parathyroid pathologies. (14) Focused imaging of the nerves, which is suspected to be involved and subsequent identification of the changes in their structure or lack of continuity, has helped in selecting the most appropriate management strategy and thereby has associated with improved outcome. (15-20)

The study conducted by Fornage et al. had helped in the differentiation between normal versus pathological conditions of peripheral nerves. The normal appearance of the nerves (Fig. 1) was shown to have echogenic fibrillar exterior texture; whereas, the pathological conditions ranged from masses to inflammatory conditions and was linked to a hypo-echoic with distal sound enhancement as well as thickening of the nerve. (21) Silvestri, et al. utilized the same concept and found that in the peripheral nerves examined, hypo-echoic areas were separated by hyper-echoic bands. On histological examination, they showed that the hypo-echoic areas corresponded to the neuronal fascicles. This pattern was essential to differentiate the nerves from the surrounding tendons. (22)

Further analysis of the sonographic imaging has aided better delineation of the peripheral nerves, demonstrating that the echogenic appearance of peripheral nerves lies between that of the corresponding muscle and tendon with muscles having more hypoechoic appearance relative to peripheral nerves. This evolved to the identification of the echogenic exterior texture in longitudinal sections parallel to the axis of the nerve, whereas, cross sections produce a more reticular appearance. (15)

On the other hand, Nerve enlargement has been shown to occur at an early stage of several neuropathies, suggesting a potential application of ultrasound in early diagnosis. (23) A study by Beekman R et al. found that nerve enlargement at multiple sites extended to the median, ulnar, radial and brachial plexus in patients with multifocal motor neuropathy. (24) Furthermore, such findings were not accompanied by any electro-physiological or clinical abnormalities. (25)

High-resolution sonography has been demonstrated to delineate the precise location, type and extent of post-operative complication such as hematoma or collection, in addition to enable assessment of the disease status of adjacent tissues surrounding the nerve. (26)

High-resolution sonography has also been shown to have utility for the evaluation of brachial plexus pathology. (27) In a study of 28 patients by Graif et al, ultrasound was able to detect abnormalities in 20 patients, which the cause of these pathological changes was trauma, benign and malignant primary tumors as well as secondary tumors; or nerve injury following irradiation therapy. (27)

Role of High Resolution Ultrasound Imaging In Traumatic Peripheral Neuropathies

The use of ultrasound as a diagnostic modality has aided the field of surgical intervention directed towards peripheral nerves. In particular, it has demonstrated utility for confirming and/or excluding the presence of such injury when suspected. (28,29) Table 1 summarizes the pertinent literature regarding ultrasound evaluation of traumatic neuropathies.

Ultrasound examination identified a traumatic neuroma just before the ulnar nerve branched into sensory termini and excluded neurotmesis. (30)

The use of high-resolution ultrasound in the operative exploration and surgical identification of nervous tissue was evaluated well. Work of Lee FC, et al. have demonstrated the beneficial role of such modality in the intraoperative detection and localization of various surgical pathologies like neuromas or nerve entrapment following surgical ligation of surrounding nervous structures. (28) Their work showed that the use of ultrasound have aided the exclusion of any presence of nerve injuries when other modalities of diagnosis, for example clinical, electro-physiological and/or radiological diagnoses, have failed to do so (Table. 1). Other efforts showed the essential role of high-resolution ultrasound when used intra-operatively to localize the site (intraneural and/ or perineural), type, and extent of nervous injuries making the operative intervention goal oriented with less invasive and time consuming (Table. 1). (29)

Ultrasound is an effective tool for routine examination of peripheral nerve disorders and complemented neurophysiological assessment. (31-33) This imaging modality has been successfully applied for the diagnosis of the formation of traumatic neuromas, which are non-neoplastic masses of proliferating cells that include fibroblasts, neurons and Schwann cells. Traumatic neuromas may develop because of surgical procedure or trauma (e.g; Motor vehicle accident, fall, etc.). (25,26) The concept, that ultrasound could be the method of choice for diagnosing traumatic neuromas, (34) was illustrated by a case report of a traumatic neuroma in an adult woman who received median nerve and associated tendon repair following a suicide attempt. Although electro-diagnostic testing was normal, ultrasonographic imaging demonstrated a hypo-echoic, focal swelling close to the median nerve that was consistent with the presence of a neuroma. Furthermore, a report of an ultrasound examination of accessory nerve lesions due to trauma in four cases, showed the feasibility of using this technique for the detection of pathological changes in the nerve following surgical procedures. (35)

In addition, Ultrasound was able to diagnose traumatic peripheral neuropathies from penetrating or non-penetrating causes in both the upper and lower limbs. (36,37) Likewise, ultrasound examination for peripheral neuropathy of the upper limb, which caused clinically diagnosed sensory or motor deficiency, showed a number of diagnostic features including loss of nerve continuity, axonal swelling together with a hypo-echoic nerve, presence of a neuronal stump, and partial nerve severance with an absence of the normal fascicular nerve pattern; wherein surgical exploration had confirmed these diagnoses. (38) The power of ultrasound imaging to diagnose traumatic neuromas is high where commonly the ultrasound show that the nerve distal to the neuroma is enlarged. (39,40)

In cases of fine needle aspiration biopsy, ultrasound was able to detect traumatic neuromas in the neck in the absence of any clinical signs of neuromas. It also detected an iso-echoic mass with an internal hyper-echogenic lesion, which had a heterogeneous parallel pattern. (41) A retrospective analysis of 24 pediatric cases with closed upper limb injuries following bone fractures and subsequent development of peripheral nerve motor and sensory palsy, reviewed the application of ultrasound in eight of these patients. Ultrasound revealed a 50% laceration of a radial nerve in one patient and radial nerves, which were constricted and buried in fracture callus, in two other patients. Based on these sonographic findings, these three patients underwent surgery that confirmed the ultrasound diagnoses. On the basis of ultrasound assessment, a conservative management plan was followed in the other five patients. The nerves in these patients were shown to be intact; although nerves were swollen, kinked close to the fracture site, or adjacent to an orthopaedic metal screw or wire, which impaired their function. Recovery of nerve function following surgery or conservative management was observed after around 12 weeks. (42)

In a study by Filippou et al, high-resolution ultrasonography was found to be more useful than nerve conduction studies in localizing ulnar neuropathy, whether localized at the elbow, outside the elbow or due to previous trauma. (43) There was a good correlation between ultrasonic measurement of the cross sectional area of the ulnar nerve at the sulcus and distal nerve conduction study results. (44) A recent review of clinical trials addressing the application of ultrasonography in ulnar neuropathy at the elbow concluded that an increased cross sectional area of the ulnar nerve at the elbow was the most reliable parameter that was diagnostic of an abnormality. (45)

In other literatures, this modality was compared to other imaging techniques, where the benefits of ultrasound over MRI were shown in the diagnosis of entrapment of the radial nerve following fracture of humerus. (46,47)

This led to meticulous evaluation of high-resolution ultrasound together with other modalities, especially magnetic resonance imaging, in the evaluation of peripheral nerves in cases of trauma or any suspected pathology.

Conclusion

This article showed ultrasound as an extremely important tool in the diagnosis, management and monitoring of both acute and chronic peripheral nerve injury. Numerous studies in different indications have now demonstrated high sensitivity and specificity for the detection of specific pathologies and the ability to differentiate between them. Therefore, ultrasound represents a powerful tool in enabling appropriate planning for treatment, preventing unnecessary surgery where conservative management is sufficient and thus improving overall outcomes in patients with peripheral neuropathy.

DOI 10.5001/omj.2014.86

Received: 25 Apr 2014/Accepted: 13 June 2014

Acknowledgements

This study was funded by the College of Medicine Research Center, Deanship of Scientific Research, King Saud University.

References

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(19.) Filippou G, Mondelli M, Greco G, Bertoldi I, Frediani B, Galeazzi M, et al. Ulnar neuropathy at the elbow: how frequent is the idiopathic form? An ultrasonographic study in a cohort of patients. Clin Exp Rheumatol 2010 JanFeb; 28(1):63-67.

(20.) Grechenig W, Mayr J, Peicha G, Boldin C. Subluxation of the ulnar nerve in the elbow region-ultrasonographic evaluation. Acta Radiol 2003 Nov; 44(6):662-664.

(21.) Fornage BD. Peripheral nerves of the extremities: imaging with US. Radiology 1988 Apr; 167(1):179-182.

(22.) Silvestri E, Martinoli C, Derchi LE, Bertolotto M, Chiaramondia M, Rosenberg I. Echo texture of peripheral nerves: correlation between US and histologic findings and criteria to differentiate tendons. Radiology 1995 Oct; 197(1):291-296.

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(40.) Cartwright MS, Yoon JS, Lee KH, Deal N, Walker FO. Diagnostic ultrasound for traumatic radial neuropathy. American journal of physical medicine & rehabilitation / Association of Academic Physiatrists. 2011 Apr; 90(4):342-3. PubMed PMID: 20531154. Pubmed Central PMCID: 2964388.

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(42.) Lee J, Bidwell T, Metcalfe R. Ultrasound in pediatric peripheral nerve injuries: can this affect our surgical decision making? A preliminary report. J Pediatr Orthop 2013 Mar; 33(2):152-158.

(43.) Filippou G, Mondelli M, Greco G, Bertoldi I, Frediani B, Galeazzi M, et al. Ulnar neuropathy at the elbow: how frequent is the idiopathic form? An ultrasonographic study in a cohort of patients. Clin Exp Rheumatol 2010 JanFeb; 28(1):63-67.

(44.) Ng ES, Vijayan J, Therimadasamy AK, Tan TC, Chan YC, Lim A, et al. High resolution ultrasonography in the diagnosis of ulnar nerve lesions with particular reference to post-traumatic lesions and sites outside the elbow. Clinical neurophysiology: official journal of the International Federation of Clinical Neurophysiology. 2011 Jan; 122(1):188-93. PubMed PMID: 20541969.

(45.) Beekman R, Visser LH, Verhagen WI. Ultrasonography in ulnar neuropathy at the elbow: a critical review. Muscle Nerve 2011 May; 43(5):627-635.

(46.) Bodner G, Huber B, Schwabegger A, Lutz M, Waldenberger P. Sonographic detection of radial nerve entrapment within a humerus fracture. Journal of ultrasound in medicine: official journal of the American Institute of Ultrasound in Medicine. 1999 Oct; 18(10):703-6. PubMed PMID: 10511303.

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Ahmed Alaqeel [mail]

Division of Neurosurgery, Department of Clinical Neurosciences, Room 1195, 1403 29th St NW, Calgary, Alberta, Canada T2L 2T9; Division of Neurosurgery, Department of Surgery, Collage of Medicine, King Saud University, Riyadh, Saudi Arabia.

E-mail: ahmedalaqeel@hotmail.com

Feras Alshomer

Division of Plastic Surgery, Department of Surgery, Collage of medicine, King Saud University, Riyadh, Saudi Arabia.

Table 1: Summarizes the relevant literature related to the use of
ultrasound in the evaluation of traumatic peripheral nerve injuries.

Author               Study Type      Population

Chiou et al. [15]    Review

Peer et al.          Prospective     * 18 patients
[26]                 study
                                     * 8 adult men and 10
                                     adult women.

Lee et al. [28]      Retrospective   * 13 patients,
                     study
                                     * Underwent
                                     ultrasonographic
                                     evaluation and surgical
                                     treatment of peripheral
                                     nerve lesions

Koenig et al.        Prospective     * 18 Patients.
[29]                 study
                                     * Aged 17 to 42 years

                                     * History of traumatic
                                     or iatrogenic lesions
                                     of peripheral nerves of
                                     the upper and lower
                                     extremity

Renna et al. [30]    Case report     * Female patient,

                                     * Aged 43 years,

                                     * History of sensory
                                     digital ulnar nerve
                                     injury following
                                     surgery.

Zhu et al.           Prospective     * 202 patients.
[32]                 study
                                     * Aged 17 to 64

                                     * History of traumatic
                                     peripheral nerve injury.

Padua et al. [33]    Prospective     * 98 patients.
                     study
                                     * Aged 8 to 79 years.

                                     * History of traumatic
                                     nerve lesions.

Bodner et al. [35]   Case series     * 4 Adults.

                                     * Aged 28 to 62.

                                     * Having accessory
                                     nerve palsy.

Cokluk et al. [36]   Prospective     * 36 patients.
                     study
                                     * Aged 7 to 57 years.

                                     * 30 adults, 6 children.

Cokluk et al. [37]   Prospective     * 22 patients.
                     study           * Aged 21 to 52 years.

Toros et al. [38]    Prospective     26 patients.
                     study

Huang et al. [39]    Case report     * Male patient.

                                     * Aged 31 years.

                                     * Retroperitoneal femoral
                                     nerve injury.

Cartwright           Case report     * Adult Male,
et al. [40]
                                     * Aged 36 years

                                     * History of shot in the
                                     right arm

Kwak et al.          Retrospective   * 8 patients.
[41]                 study
                                     * Aged 36 to 69 years.

Lee et al. [42]      Retrospective   * 24 paediatric patients
                     study
                                     * Aged 6 to 12 years.

                                     * History of closed
                                     upper limb injuries and
                                     associated peripheral
                                     nerve palsy.

Filippou et al.      Prospective     91 patients.
[43]                 study

Ng et al. [44]       Retrospective   * 42 patients.
                     study
                                     * History of ulnar
                                     neuropathy at the elbow.

Bodner et al.        Case report     * Adult male patient.
[46]
                                     * Fractured humerus.

Bodner et al.        Prospective     * 11 Patients.
[47]                 study
                                     * Aged 10 to 72 years.

                                     * History of radial nerve
                                     palsy following fractured
                                     humerus.

Author               Findings

Chiou et al. [15]    US was successful in showing:

                     * Nerve matter enlargement.

                     * Complete or partial transection.

                     * Nerve laceration.

                     * Epineural hematoma.

                     * Neuroma formation.

Peer et al.          US was successful in showing:
[26]
                     * Nerve axonal swelling.

                     * Scar tissue or surgical implant
                     compromising the nerve.

                     * Neuroma.

                     * Insufficient surgical repair.

Lee et al. [28]      US was successful in showing:

                     * Localize painful postoperative
                     neuromas.

                     * Limit extensive dissections.

                     * Localizing the proximal segment
                     of a radial nerve divided by a
                     humerus fracture.

Koenig et al.        US was successful in showing:
[29]
                     * Intra-neural structure with high
                     resolution.

                     * Fascicles passing through a
                     damaged nerve segment may be
                     differentiated from neuromatous
                     tissue more accurately.

Renna et al. [30]    US was successful in showing:

                     * Very small nerves and their
                     terminal branches.

Zhu et al.           US was successful in showing:
[32]
                     * Evaluate the type of traumatic
                     injuries.

                     * Monitor the morphological
                     changes in injured nerve,
                     particularly the inner part.

Padua et al. [33]    US was successful in showing:

                     * The diagnosis or modify the
                     therapeutic path in 60% of
                     patients.

                     * Nerve injury (neurotmesis/
                     axonotmesis)

                     * The etiology and sites of
                     damage.

                     * The diagnosis where
                     neurophysiological evaluation
                     could not do so.

                     * Useful for surgical planning

                     * Depiction of very small nerves
                     with dynamic imaging.

Bodner et al. [35]   US was successful in showing:

                     * Nerve transection.

                     * Scar tissue.

                     * Atrophy of Trapezius muscle as
                     an indirect indicator of nerven
                     injury.


Cokluk et al. [36]   The patients had various traumatic
                     upper extremity peripheral nerve
                     injuries including:

                     * Ulnar nerve injury.

                     * Radial nerve injury.

                     * Median nerve injury.

                     * Brachial plexus injuries.

Cokluk et al. [37]   The patients with traumatic lower
                     extremity peripheral nerve
                     injuries including:

                     * Femoral nerve injury.

                     * Sciatic nerve injury.

Toros et al. [38]    US was successful in showing:

                     * Hypo-echogenicity.

                     * Swelling of the nerve axons.

                     * Transection.

                     * Partial laceration.

                     * Neuroma formation.
Huang et al. [39]    US was successful in showing:

                     * Femoral nerve lesion at the
                     retroperitonium.

                     * Determination of swelling of
                     the nerve.

                     * Identification of neuroma
                     formation.

Cartwright           * Site of the fracture was over
et al. [40]          the nerve, which was difficult to
                     visualize by US.

                     * Nerve segments proximal and
                     distal to fracture site were
                     aligned.

Kwak et al.          Incidental detection of traumatic
[41]                 neuromas with history of neck
                     dissection or painful Fine needle
                     aspiration.

Lee et al. [42]      US was successful in showing:

                     * Pathomorphologic information.

                     * Reduce the morbidity involved
                     in nerve explorations

Filippou et al.      US was successful in showing:
[43]
                     * Subluxation of the ulnar nerve

                     * Luxation of the ulnar nerve

                     * Presence of osteophytes

                     * Presence of accessory muscle

                     * Articular ganglion

                     * Post-traumatic lesions

                     * Presence of osseous fragments

Ng et al. [44]       US was successful in showing:

                     * Ulnar neuropathy at the elbow.

                     * Localize anatomical details
                     such as nerve continuity.

                     * Diagnose and characterize
                     lesions outside the elbow region

Bodner et al.        * Entrapment of Radial nerve
[46]                 within fracture site.

                     * Abrupt change in the surface of
                     radial nerve was seen.

Bodner et al.        US confirmed radial nerve injury,
[47]                 and showed:

                     * Nerve entrapment
                     between bony fragments.

                     * Complete nerve dissection.

                     * Nerve laceration.

                     * Nerve riding on the edges of
                     bony fragments.
                     * Nerve buried in callus.

Author               Comments

Chiou et al. [15]    * Mechanism of injury ranges from
                     either direct force or transmitted
                     forces applied the nerve matter.

                     * Ultrasound can identifies
                     nerve matter disruption or subsequent
                     neuroma formation of the
                     injured segment.

Peer et al.          The lesions detected with ultrasound
[26]                 were consistent with the surgical
                     findings applied in most of the
                     patients.

Lee et al. [28]      Ultrasound demonstrated correct
                     lesion diagnosis and location.

Koenig et al.        Ultrasound represents useful tool for
[29]                 assessment of the internal extent of
                     a nerve lesion and for noninvasive
                     assessment of regenerative potential.

Renna et al. [30]    * Ultrasonography was applied for
                     examination of digital ulnar branch
                     neuromas.

Zhu et al.           * Ultrasound combined with
[32]                 electrodiagnostic tests provide more
                     data to make a decision about whether
                     or not to precede with surgery.

Padua et al. [33]    * Ultrasound was recommended for
                     evaluation in all traumatic patients
                     in whom nerve lesion is suspected

Bodner et al. [35]   Posttraumatic accessory nerve palsy
                     was successfully diagnosed with
                     ultrasound. This was confirmed with
                     electro-physiologic testing and
                     surgical exploration.

Cokluk et al. [36]   * Sonographic observations were
                     compared with the surgical findings.

                     * Use of ultrasound has a role in
                     detecting the early as well as late
                     phase of injury with excellent
                     results.

Cokluk et al. [37]

Toros et al. [38]    * Trauma and/or entrapment of
                     peripheral nerves with resultant
                     Sensory and/or motor neuropathy were
                     evaluated using ultrasound. * Such
                     findings were correlated with the
                     physiological examination and
                     surgical exploration.

Huang et al. [39]    * Ultrasound proposed to be used to
                     make early decision in clinical
                     treatment for a better recovery.

Cartwright           * Ultrasound proposed the radial
et al. [40]          nerve was anatomically intact and
                     therefore conservative management was
                     used rather than surgical
                     intervention.

Kwak et al.          * Asymptomatic patients were
[41]                 incidentally diagnosed to
                     have neuroma.
                     * Ultrasound showed iso-echoic mass
                     with associated internal parallel
                     heterogeneous hyper-echogenicity.

Lee et al. [42]      * Ultrasound findings correlated with
                     intraoperative findings and clinical
                     recovery

Filippou et al.      * Ulnar neuropathy; can be caused by
[43]                 multiple aetiologies involving
                     posttraumatic changes such as bone
                     fragments.

                     * Ultrasound imaging of
                     the affected joint has a significant
                     role in detecting such changes.

Ng et al. [44]       * Ultrasound can diagnose and
                     characterize lesions outside the
                     elbow region.

Bodner et al.        * The technique involved
[46]                 identification of radial nerve at the
                     distal trauma free part of the
                     humerus in both a transverse and
                     longitudinal scans and followed
                     proximally to the site of injury.

Bodner et al.
[47]
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Author:Alaqeel, Ahmed; Alshomer, Feras
Publication:Oman Medical Journal
Article Type:Report
Geographic Code:7OMAN
Date:Sep 1, 2014
Words:4472
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