The Ulnar Nerve After Surgical Transposition: Can Sonography Define the Reason of Persisting Neuropathy?

Abstract

Purpose: Ulnar nerve neuropathy is mainly caused by compression at the level of the cubital tunnel. Two main approaches are currently known for the surgical treatment of this condition: decompression of the nerve in its usual position or transposition to the ulnar flexor side. This study was performed to define the usefulness of ultrasound in patients with persisting symptoms after ulnar nerve transposition.

Materials and Methods: We present the data of 8 subjects with persisting symptoms after nerve transposition due to compressive neuropathy. The cross-section areas (CSA) and texture changes were recorded. Each ulnar nerve was divided into 6 segments – 3 segments at the proximal pass and 3 segments at the distal pass through the subcutaneous fascia.

Results: Texture changes were recorded in 4.6 (76.7 %) ± 1.2 and outer nerve sheath blurring in mean 4.1 (68.3 %) ± 1.1 of the segments. Caliber changes were found in the course of the nerve based on the 6 segments: A mean CSA of 7.45 mm² ± 2.24 was found proximal to the upper fascial passage (PUF), a mean CSA of 11.96 mm² ± 3.61 at the upper fascial passage (UF), a mean CSA of 11.49 mm² ± 8.16 distal to the upper fascial passage (DUF), a mean CSA of 10.84 mm² ± 4.73 proximal to the lower fascial passage (PLF), a mean CSA of 12.12 mm² ± 5 at the lower fascial passage (LF), and a mean CSA of 7.89 mm² ± 3.42 distal to the lower fascial passage (DLF). All transposed nerves presented relevant kinks at the UF, 6 nerves presented relevant kinks at the LF.

Conclusion: In cases of secondary ulnar neuropathy after nerve transposition, ultrasound can reliably assess the actual “situation” of the nerve and thus at least ease the decision for secondary surgery.

Key points

• Sonography can reliably define pathology of the ulnar nerve.

• Blood flow restriction after nerve transposition can be the cause of secondary neuropathy.

• Secondary neuropathy after ulnar nerve transposition can be assessed by sonography.

Citation Format:

• Gruber H., Baur E. M., Plaikner M. et al. The Ulnar Nerve After Surgical Transposition: Can Sonography Define the Reason of Persisting Neuropathy?. Fortschr Röntgenstr 2015; 187: 998 – 1002

Zusammenfassung

Ziel: Die Ulnarisneuropathie wird durch eine Einengung auf Höhe des Kubitaltunnels verursacht. Derzeit sind zwei chirurgische Hauptschulen für die Behandlung einer Ulnarisneuropathie bekannt: Dekompression des Nervens in seiner üblichen Lage oder Nerventransposition auf die ulnare Beugeseite. Diese Arbeit wurde durchgeführt, um den Nutzen der Sonografie bei Patienten mit persistierender Symptomatik nach Ulnaris-Transposition zu definieren.

Material und Methoden: Wir präsentieren die Daten von 8 Patienten mit persistierender Symptomatik nach Transposition der Nervi ulnares. Querschnittsflächen (CSA) sowie Texturänderungen wurden dokumentiert. Jeder Nerv wurde in 6 Segmente – 3 Segmente am proximalen Durchtritt und 3 Segmente am distalen Durchtritt durch die subkutane Faszie segmentiert.

Ergebnisse: Textur-Veränderungen konnten in 4,6 (76,7 %) ± 1,2 nachgewiesen werden, Veränderungen der äußeren Nervenscheide in 4,1 (68,3 %) ± 1,1 der Segmente. Kaliber-Veränderungen basierend auf die 6 Segmente konnten nachgewiesen werden: eine CSA von 7,45 mm² ± 2,24 wurde proximal des oberen Faszien-Durchtritts (PUF) gefunden, am oberen Faszien-Durchtritt (UF) eine mittlere CSA von 11,96 mm² ± 3,61, distal des oberen Faszien-Durchtritts (DUF) eine mittlere CSA von 11,49 mm² ± 8,16, proximal des unteren Faszien-Durchtritts (PLF) eine mittlere CSA von 10,84 mm² ± 4,73, am unteren Faszien-Durchtritt (LF) eine mittlere CSA von 12,12 mm² ± 5 und distal des unteren Faszien-Durchtritts (DLF) eine mittlere CSA von 7,89 mm² ± 3,42. Alle verlagerten Nerven zeigten relevanten Knickstellen an der UF, 6 Nerven präsentierten relevanten Knickstellen an der LF.

Schlussfolgerungen: Die Sonografie kann in Fällen von sekundärer Ulnarisneuropathie nach Transposition des Nervs zuverlässig die tatsächliche „Situation“ des Nervs beurteilen und somit die Entscheidung einer Sekundär-Operation erleichtern.

Kernaussagen

• Die Sonografie kann zuverlässig eine Pathologie des Nervus ulnaris definieren.

• Blutflussrestriktion nach Nerv-Transposition kann eine mögliche Ursache einer sekundären Neuropathie sein.

• Die Sonographie kann eine sekundäre Neuropathie nach Ulnaris-Transposition definieren.

Key words

elbow - nervous-peripheral - ultrasound

• References

• 1 Palmer BA, Hughes TB. Cubital tunnel syndrome. J Hand Surg Am 2010; 35: 153-163 PubMed PMID: 20117320. Epub 2010/02/02. eng.
• 2 Messina A, Messina JC. Transposition of the ulnar nerve and its vascular bundle for the entrapment syndrome at the elbow. Journal of hand surgery 1995; 20: 638-648 PubMed PMID: 8543871.
• 3 Osborne G. Compression neuritis of the ulnar nerve at the elbow. The Hand 1970; 2: 10-13 PubMed PMID: 4328789
• 4 Chan RC, Paine KW, Varughese G. Ulnar neuropathy at the elbow: comparison of simple decompression and anterior transposition. Neurosurgery 1980; 7: 545-550 PubMed PMID: 7207750
• 5 Foster RJ, Edshage S. Factors related to the outcome of surgically managed compressive ulnar neuropathy at the elbow level. J Hand Surg Am 1981; 6: 181-192 PubMed PMID: 7229295
• 6 Mackinnon SE, Novak CB, Myckatyn TM et al. Results of reinnervation of the biceps and brachialis muscles with a double fascicular transfer for elbow flexion. J Hand Surg Am 2005; 30: 978-985 PubMed PMID: 16182054
• 7 Ogata K, Manske PR, Lesker PA. The effect of surgical dissection on regional blood flow to the ulnar nerve in the cubital tunnel. Clinical orthopaedics and related research 1985; 193: 195-198 PubMed PMID: 3971623
• 8 Ogata K, Shimon S, Owen J et al. Effects of compression and devascularisation on ulnar nerve function. A quantitative study of regional blood flow and nerve conduction in monkeys. Journal of hand surgery 1991; 16: 104-108 PubMed PMID: 2007800
• 9 Sugawara M. Experimental and clinical studies of the vascularized anterior transposition of the ulnar nerve for cubital tunnel syndrome. Nihon Seikeigeka Gakkai zasshi 1988; 62: 755-766 PubMed PMID: 3235894
• 10 Dai Z, Liu Y, Liu R. Anatomical changes and dynamic analysis after anterior submuscular transposition in treating cubital tunnel syndrome. Zhongguo xiu fu chong jian wai ke za zhi = Zhongguo xiufu chongjian waike zazhi = Chinese journal of reparative and reconstructive surgery 2004; 18: 254-256 PubMed PMID: 15323433
• 11 Bodner G, Buchberger W, Schocke M et al. Radial nerve palsy associated with humeral shaft fracture: evaluation with US--initial experience. Radiology 2001; 219: 811-816 PubMed PMID: 11376275
• 12 Gassner EM, Schocke M, Peer S et al. Persistent median artery in the carpal tunnel: color Doppler ultrasonographic findings. Journal of ultrasound in medicine: official journal of the American Institute of Ultrasound in Medicine 2002; 21: 455-461 PubMed PMID: 11934102
• 13 Peer S, Kovacs P, Harpf C et al. High-resolution sonography of lower extremity peripheral nerves: anatomic correlation and spectrum of disease. Journal of ultrasound in medicine: official journal of the American Institute of Ultrasound in Medicine 2002; 21: 315-322 PubMed PMID: 11883543
• 14 Kopf H, Mostbeck GH, Loizides A et al. Ultrasound-guided interventions at peripheral nerves: diagnostic and therapeutic indications. Ultraschall in der Medizin 2011; 32: 440-456 ; quiz 57–9. PubMed PMID: 21986925
• 15 Kopf H, Loizides A, Mostbeck GH et al. Diagnostic sonography of peripheral nerves: indications, examination techniques and pathological findings. Ultraschall in der Medizin 2011; 32: 242-263 ; quiz 64–6. PubMed PMID: 21667406
• 16 Mondelli M, Filippou G, Aretini A et al. Ultrasonography before and after surgery in carpal tunnel syndrome and relationship with clinical and electrophysiological findings. A new outcome predictor?. Scandinavian journal of rheumatology 2008; 37: 219-224 PubMed PMID: 18465458
• 17 Mondelli M, Ginanneschi F, Rossi A. Evidence of improvement in distal conduction of ulnar nerve sensory fibers after carpal tunnel release. Neurosurgery 2009; 65: 696-700 ; discussion 1. PubMed PMID: 19834374
• 18 Assmus H, Antoniadis G, Bischoff C et al. Cubital tunnel syndrome – a review and management guidelines. Central European neurosurgery 2011; 72: 90-98 PubMed PMID: 21547883