L` ecografia per lo studio dei nervi periferici

L’ ecografia per lo
studio dei nervi
periferici
L. Padua
C. Pazzaglia
Università Cattolica
Fondazione Don Gnocchi
Rome – Italy
[email protected]
From
From
To
..No doubt: we cannot keep away from US.
To
L. Padua C. Martinoli
BECAUSE IT PROVIDES CRUCIAL INFORMATION
FOR DIAGNOSIS AND THERAPEUTICAL APPROACH
THAT CANNOT BE PROVIDED BE NEUROPHYSIOLOGY
EMG + US
Functional + anatomical situation
Quantitative Evaluation
Classification of contribution of US
D
D
D
D
US
G
EM
DIAGNOSTIC
modifies
diagnosis or
therapeutical
path
EMG US
EMG
US
EMG
US
CONFIRMING
NON-CONTRIBUTORY
EQUIVOCAL
provides
more
evidences
does not
confirm or
modify
diagnosis and
ther
causes
misdiagnosis
(Normal
(NormalUS)
US)
excluded
excluded
Tumors
Tumors
…..
….. etc
etc
26%
Non-contr
1%
Diagn
Confirm
Provided
Providedmore
moreevidences
evidences
confirming
confirming
etiopahologically
etiopahologically
the
thecause
cause
47%
26%
D
DIAGNOSTIC
US
G
EM
In 20 cases (26%)
– in 6 cases: nerve tumour (2 of median nerve, 2 of sural
nerve, 1 of tibial nerve and 1 of radial nerve),
– in 6 cases: other causes of focal nerve lesion (anomalous
muscles, vascular conflicts, lipoma, bursitis, sinovial cysts
and fibrosis post-fracture)
– in the other cases: entrapment where normal
neurophysiological findings.
In most “diagnostic” cases ultrasound modified
therapeutical approach providing information on
the site and type of surgery
Cosa vediamo?
Neural fiber embedded in endoneurium, because the
endoneurium is too thin to reflect the sound beam, it is
hypoechogenic at high-resolution US.
All together nerves fibers compound the nerve fascicles
The neural fascicle consists of several neural fibers and is embedded
in a capsule called perineurium. This capsule consists of connective
tissue, vessels, and lymphatic ducts and is thick enough to reflect the
sound beam, resulting in hyperechoic lines at high-resolution US.
The trunk of the peripheral nerve consists of several neural fascicles and is embedded
in a thicker membrane called epineurium, which is seen as bold echogenic lines at highresolution US. Therefore, at high-resolution US the peripheral nerve is seen as several
parallel echogenic lines within two bold echogenic lines in longitudinal sections and as a
reticular pattern in transverse sections.
Sonde a 15-18 Hz
COMPRESSIONI
Sindrome Tunnel Carpale
(CSA<9 mm2)
Ulnare al gomito
(CSA<7,5 mm2)
CTS: sites of entrapments
Recidive of CTS at right hand and diagnosis of CTS in the left
WRIST MED
Atypical neurophysiological picture
Minimal impairment of I digit branch
Severe impairment of III digit wrist
Ulnare al gomito – m.accessorio
US: Dynamic – Luxation/ subluxation of ulnar nerve
Video
Lussazione
ulnare.avi
Video 2
LESIONI TRAUMATICHE NERVI
Elbow Fracture – sensory motor Ulnar deficit
Baby girl wrist trauma – sens/motor Ulnar deficit
Arteria ulnare
n.ulnare
aneurismatica post traumatica dell’arteria ulnare con
conseguente conflitto neurovascolare
Baby girl wrist trauma – sens/motor Ulnar deficit
Humeral fracture .
“radial” deficit
more severe in
PIN muscles
Allungamento femore,applicazione di doccia/cosciale: lesione
in due siti nervo sciatico bilateralmente
Tibial nerve CSA 24 mm²
Sciatic nerve CSA 30mm2
Peroneal nerve CSA18 mm²
Cavo popliteo
Deficit acuto della dorsiflessione del piede con reperto
neurofisiologico di danno assonale del n. peroneo destro.
Capitello:
Nervo aumentato
di volume e
dislocato
lateralmente da
formazione
ipoecogena
versosimilmente
cistica con dotto
dalla capsula
articolare
male 35 yrs, after exercise pain and motor deficit
S PERONEO COMUNE
2
1
3
5
1
50ms 5mV 210V
4
2
1
3
5
2
4
50ms 5mV 210V
2
1
3
5
4
3
50ms 5mV 154V
S PERONEO COMUNE
4
1
3
5
2
82V
50ms
50ms1mV
1mV118V
151V
85V
226V
Cyst
1cm
longit
Fib head transv
Lussazione ginocchio in rugbista
Deficit acuto dorsiflessione piede
Aumento della CSA
In sezione longitudinale
Marcato disarray
muscolare del tibiale
anteriore
Sofferenza nervo radiale post mezzi di sintesi
Sofferenza del n. ulnare dopo frattura gomito
Nervo ulnare ipoecogeno, di dimensioni
marcatamente aumentate (csa 12 mm2). A
livello della doccia struttura ipoecogena che
disloca verso l’alto il nervo; ipertrofia della
porzione inferiore dell’epinevrio nella parte
adiacente alla sopradescritta formazione
ipoecogena
TUMORI
•
•
•
•
•
•
•
•
56 years old
Pain and trigger point at
popliteal area
Hypoesthesia in plantar foot
region
Diagnosis S1 root impairment
MRI disk herniation
EMG S1 axonal damage
Operated on without benefit
EMG with nerve conduction
velocity
36m/s
48m/s
S SURALE - Lat Mall
S NERVO TI BIAL E - AH
2
1
3
5
Ank le 1
4
30ms 5m V 263 V
4 Calf 1
10m s 20 µV 84V
25
2
1
3
2
1
4
3
2
1
3
4
2
Kne e 2
30ms 5m V 300 V
3
30ms 5m V 198 V
1
3
Calf
4 2
10ms 20 µV 100 V
8
1 cm
M, 21yrs
Previous diagnoses:
-Broken of tendon
-Interosseus syndrome
-MMN
Neurofibroma radiale
transversal Radial nerve
1cm
longitudinal Radial nerve
1cm
NEURINOMA ULNARE
Da alcuni mesi
sensazione di scossa
elettrica che si irradia al
V dito della mano
sinistra
ENG nella norma
EO: palpazione a livello
della doccia del gomito
di formazione solida
rotondeggiante
Bambino affetto da neurofibramatosi
POLINEUROPATIE
Pz con polineuropatia assonale sensitiva
Pz con CMT demielinizzante
Possibilità di
vedere i blocchi di
conduzione?
PLESSO BRACHIALE
Brachial Plexus – technique
TRANSVERSE PLANE
A
T
*
Vertebra
PT
Body
Pedicle
Transverse Process
Nerve Root
C3
C4
C5
C6
C7
T1
Trauma moto: deficit arto superiore dx + Claude-Bernard-Horner.
In regione sovraclavicolare le strutture nervose
(radici/plesso) sono marcatamente aumentate di
volume, la più grande delle quali (radice C8) presenta
una cross sectional area di 20 mm2. Alla valutazione
longitudinale di tale radice si evidenzia la presenza di
varie aree di ingrossamento focale che sono suggestive
di una sofferenza diffusa.
Alla valutazione longitudinale di
tale radice si evidenzia la
presenza di varie aree di
ingrossamento focale che sono
suggestive di una sofferenza
diffusa.
When in a neurophys lab US should be
performed to assess nerve involvement
8 commandments
•
•
•
•
•
•
•
•
Palpable mass
Atypical clinical neurophysiological picture
Clinical-Neurofisiological dissociation
Meaningful differences between sides
Focal slowing out of entrapment sites
No benefit from surgery
Sensory motor syndrome after trauma
Entrapment *
* When US tool is easily available
Clinical Neurophysiology and US
• Recently someone said neuroimaging
peripheral nerves will substitute
neurophyisiology.
• These tools used in complementary way
performed in the same session may crucially
increase the information that can provide
separately.
Clinical neurophysiology
nerve US