Ultrasonography of Peripheral Nerve -upper extremity Department of Physical Medicine and Rehabilitation Korea University Guro Hospital Korea University College of Medicine Yoon Joon Shik
Normal median nerve Normal nerve Flattened ovoid structure on top of superficial and deep flexor tendons
Normal nerve Bright linear interface in tendon than in nerve
General course of median nerve Entire course in upp.ext. Course in forearm, wrist
Normal median nerve(transverse)-wrist Medial nerve, carpal tunnel Bony structure Tendon Radial carpal ligament Radial artery median nerve (N) may be confused with the adjacent palmaris longus and flexor carpi radialis. The median nerve lies superficial to tendons of the flexor digitorum. The radiocarpal ligament lies deep to flexor digitorum tendons and superficial to the ulna and radius.
Sonography of median nerve Carpal and Guyon tunnels. (a, b) Drawing (a) and corresponding transverse 5 12-MHz US scan (b) show the proximal level of the carpal tunnel delimited by the pisiform (P) and the scaphoid (S). (c, d) Drawing (c) and corresponding transverse 5 12-MHz US scan (d) show the distal level of the carpal tunnel delimited by the hook of the hamate (H) and the tubercle of the trapezium (T). The flexor retinaculum (medium gray region in a and c; open arrowheads in b and d) forms the roof of the carpal tunnel and the floor of the Guyon tunnel. The palmar carpal ligament (dark gray region in a) forms the volar boundary of the Guyon tunnel. The flexor tendons and median nerve (MN) extend through the carpal tunnel, with the nerve lying palmar and radial. At the level of the pisiform, the ulnar nerve (U) courses medial to the ulnar artery (solid arrowhead) within the Guyon tunnel. At the level of the hamate, the ulnar nerve divides into two terminal branches, a deep motor branch (curved arrow) and a superficial sensory branch (straight arrow). = flexor pollicis longus tendon, = flexor carpi radialis tendon. RadioGraphics 2000; 20:S199 S217
Normal median nerve(transverse) Normal median nerve -wrist Flattened ovoid structure on top of superficial and deep flexor tendons
Sonography of median nerve(transverse) Median nerve foream level -distal forearm Corresponding to the middle level (B) in Figure, the median nerve (N) courses around the radial aspect of the flexor digitorum superficialis (S) lying between the flexor digitorum superficialis and the flexor digitorum profundus (p). The pronator quadratus (Q) lies deep to flexor muscles. J Ultrasound Med 20:1011 1014, 2001 Med Nerve, ant interosseous nerve
Sonography of median nerve(transverse)-mid forearm Corresponding to the proximal level (C) in Figure, the median nerve (N) now appears relatively hyperechoic, contrasting with adjacent hypoechoic muscle, and lies between the flexor digitorum superficialis (S) and the flexor digitorum profundus (P). J Ultrasound Med 20:1011 1014, 2001
Sonography of median nerve( transverse)-upper forearm Upper 1/3 D s D s Median nerve, Muscle (superficial and deep) Ulnar artery, radius, ulnar bone
Median nerve 에서다른구조물과구분하는 point - differentiating the nerve from the nearby tendons, palmaris longus * superficial to flexor tendon, tendons are hyperechoic with fined packed echoes - nerve has oval or slightly dumbbell shaped in axial view * circular shape of tendon - much less movement of nerve * finger wiggling cause prominent to and fro movement of tendon
Dynamics of normal median nerve
Carpal tunnel syndrome
Carpal tunnel syndrome( cut off)
Swelling ratio of median nerve (A) normal median nerve cross-section at the distal wrist crease 11 mm 2. (B) normal median nerve in the forearm measuring 9 mm 2. This control had a WFR of 1.2. (C) CTS at the distal wrist crease measuring 17 mm 2 (D) median nerve in the forearm 7 mm 2 The WFR was 2.4.
The WFR in patients with CTS is elevated as compared to asymptomatic controls. A WFR of P1.4 gave 100% sensitivity for detecting patients with CTS while using only median nerve area at the wrist resulted in a sensitivity of 45 93%, depending on the cutoff value used.
Ulnar nerve: Humero ulnar joint
Ulnar nerve Med to brachial artery Ant to triceps med
Guyon s canal Ulnar nerve is visible(arrow, Rt.)
Lower 1/3 of forearm Ulnar nerve is visualized by arrow
Mid portion of forearm Ulnar nerve is about to split from artery(arrow)
Prox. 1/3 of forearm
Cubital tunnel Hemeroulnar arcade lies about 1 cm distal to epicondyle olecranone line Roof aponeurotic arch and muscle fiber of FCU Floor med. ligament of elbow
Cubital tunnel(ulnar nerve) Transverse sections of US images show normal anatomy of proximal inlet level (,B) and distal outlet level (D) of cubital tunnel. (ME: medial epicondyle, O: olecranon, arrows: arcuate ligament of Osborne, : 2 heads of flexor carpi ulnaris muscle) M E O B D
Dynamics of normal ulnar nerve
Characteristics of Pathologic Ulnar Nerve
A) Anconeous epitrochlearis muscle (arrows) is replacing the arcuate ligament ( : ulnar nerve). B) Ulnar nerve shows fusiform swelling(arrows) with decreased echogenecity in longitudinal scan. A B
A B
Neuroma
Subluxation of ulnar nerve
Radial nerve Hypoechoic nerve fasciculi, surrounded hyperechoic sheath Diameter: 2 mm Rounded at prox, 1/3 of humerus, oval at middle third Rounded again at distal third thickening ( 3 mm) of the radial nerve hourglass-shaped appearance: we noted first a thickening of the nerve ( 3 mm), then a stricture abnormal hypoechogenicity and loss of neuronal fascicle distinction. J Ultrasound Med 2004; 23:1003 1007
Normal radial- contralateral side
Traumatic injury of radial nerve
Traumatic injury-radial nerve
Suprascapular Nerve 10 ml 0.5% bupivacaine 40 mg methylprednisolone needle was directed over the spine in the plane of the scapula
subcutaneous tissue(sct) trapezius (trm) supraspinatus muscles (ssm) suprascapular notch (n) superior transverse scapular ligament (arrows) - echogenic linear corocoid process (cp) shadow is just lateral to the suprascapular notch
Suprascapular nerve - round hyperechoic structure at 4 cm depth
Brachial plexus
Brachial plexus
Brachial plexus : C6 root
Brachial plexus : trunk level Scale ne Scale ne
Cervical root injection
NERVE LOCALIZATION Musculo cutaneous nerve
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