High-Resolution Sonography: A New Technique to Detect Nerve Damage in Leprosy

Mycobacterium leprae, which causes leprosy, infects peripheral nerves resulting in functional impairment, ulcer formation and stigmatizing deformities. Early diagnosis of nerve involvement is important to avoid nerve related complications. We used non-invasive, high-resolution sonography (US) and color Doppler (CD) imaging to study the ulnar (UN), median (MN), lateral popliteal (LP) and posterior tibial (PT) nerves in 20 leprosy patients and compared 30 healthy Indian controls. The nerves were significantly thicker in the patients (p<0.0001 for each nerve). One of the key signs of leprosy is the presence of enlarged nerves. The kappa for clinical palpation and nerve enlargement by sonography was 0.30 for all examined nerves. Increased neural vascularity, the sign of inflammation was observed in 26% (39/152) of nerves by CD imaging. Increased CD was observed in multiple nerves in 3 of 4 patients with type 2 reaction. Significant correlation was observed between clinical parameters of grade of thickening, sensory loss and muscle weakness and US abnormalities of nerve echotexture, endoneural flow and cross-sectional area (p<0.001). We conclude that sonography is a better diagnostic tool to predict nerve damage as compared to clinical assessment. Nerve damage was sonographically more extensive and was observed in nerves considered clinically normal

Ultrasonographic median nerve cross-section areas measured by 8-point "inching test" for idiopathic carpal tunnel syndrome: a correlation of nerve conduction study severity and duration of clinical symptoms

<p>Abstract</p> <p>Background</p> <p>Incremental palmar stimulation of the median nerve sensory conduction at the wrist, the "inching test", provides an assessment with reference to segments proximal and distal to the entrapment. This study used high-resolution ultrasonography (US) to measure the median nerve's cross-section areas (CSAs) like the "inching test" and to correlate with the nerve conduction study (NCS) severity and duration of carpal tunnel syndrome (CTS).</p> <p>Methods</p> <p>Two hundred and twelve (212) "CTS-hands" from 135 CTS patients and 50 asymptomatic hands ("A-hands") from 25 control individuals were enrolled. The median nerve CSAs were measured at the 8-point marked as <it>i</it>4, <it>i</it>3, <it>i</it>2, <it>i</it>1, <it>w</it>, <it>o</it>1, <it>o</it>2, and <it>0</it>3 in inching test. The NCS severities were classified into six groups based on motor and sensory responses (i.e., negative, minimal, mild, moderate, severe, and extreme). Results of US studies were compared in terms of NCS severity and duration of clinical CTS symptoms.</p> <p>Results</p> <p>There was significantly larger CSA of the NCS negative group of "CTS-hands" than of "A-hands". The cut-off values of the CSAs of the NCS negative CTS group were 12.5 mm², 11.5 mm²and 10.1 mm²at the inlet, wrist crease, and outlet, respectively. Of the 212 "CTS-hands", 32 were NCS negative while 40 had minimal, 43 mild, 85 moderate, 10 severe, and two extreme NCS severities. The CSAs of "CTS-hands" positively correlated with different NCS severities and with the duration of CTS symptoms. By duration of clinical symptoms, 12 of the 212 "CTS-hands" were in the 1 month group; 82 in >1 month and ≤12 months group, and 118 in >12 months group. In "inching test", segments <it>i</it>4-<it>i</it>3 and <it>i</it>3-<it>i</it>2 were the most common "positive-site". The corresponding CSAs measured at <it>i</it>4 and <it>i</it>3, but not at <it>i</it>2, were significantly larger than those measured at points that were not "positive-site".</p> <p>Conclusions</p> <p>Using the 8-point measurement of the median nerve CSA from inlet to outlet similar to the "inching test" has positive correlations with NCS severity and duration of CTS clinical symptoms, and can provide more information on anatomic changes. Combined NCS and US studies using the 8-point measurement may have a higher positive rate than NCS alone for diagnosing CTS.</p

Ulnar neuropathy at the elbow - Follow-up and prognostic factors determining outcome

Objective: To determine the outcome in patients with ulnar neuropathy at the elbow (UNE) treated surgically or conservatively, and the prognostic value of clinical, sonographic, and electrophysiologic features. Methods: After a median follow-up of 14 months, 69 of 84 patients initially included in a prospective blinded study on the diagnostic value of sonography in UNE were re-evaluated. The patients underwent renewed systematic clinical and sonographic examination. Patients were scored as having a poor ( stable or progressive symptoms) or favorable ( complete remission of symptoms or improvement) outcome. Results: Of the 74 initially affected arms, 12 (16%) had a complete remission, 21 (28%) improved, 25 (34%) remained stable, and 16 (22%) had progression. Surgically treated patients ( 28 arms) had a more favorable outcome than those treated conservatively (p = 0.03). After surgery, the mean ulnar nerve diameter decreased from 3.2 to 2.9 mm (p = 0.03), while this was not seen after conservative treatment. Multiple logistic regression analysis showed that more outspoken nerve enlargement found during sonography at the time of the diagnosis was associated with a poor outcome (OR: 2.9, p = 0.009). Furthermore, the presence of a motor conduction block (OR: 0.2, p = 0.03) and motor velocity slowing across the elbow (OR: 0.1, p = 0.01) were associated with a favorable outcome. Conclusion: More pronounced ulnar nerve thickening at the time of the diagnosis is associated with poor outcome at follow-up, especially in conservatively treated cases, while electrodiagnostic signs of demyelination on testing indicate favorable outcome