Where is an ultrasound of the ulnar nerve performed? Ultrasound examination of peripheral nerves, joints, ligaments

To date this procedure is included in the list of mandatory manipulations that are performed if compression or damage to one of the nerve trunks.

Previous methods for studying peripheral nervous system, such as electromyography, provide information only about functional activity nerve trunk, which is not enough to resolve the issue of effective treatment diseases nerve endings. Ultrasound of the nerves makes it possible to study their anatomy, which is an undeniable advantage of this diagnostic procedure.

Peripheral nerves studied

The separation ability of even the most modern ultrasound devices allows for an informative examination of only medium and large nerve trunks. Among the nerves that are subject to ultrasound diagnostics, it is necessary to highlight:

• Ulnar nerve.
• Radial nerve.
• Median nerve.
• Common peroneal nerve.
• Common tibial nerve.
• Sciatic nerve.

Ultrasonography everyone else peripheral nerves can be informative only in the case of a clearly expressed pathological process.

Parameters determined by ultrasound of nerves

To make a conclusion about the condition of the nerve trunk, during its ultrasound examination the following parameters are assessed:

• Thickness of the nerve trunk.
• Cross section shape.
• Contours of the nerve in longitudinal and transverse sections.
• Nerve fiber structure.
• Availability pathological formations.

Besides, most Ultrasound examination of nerves involves a comparative analysis of their indicators at different segments. This makes it possible to identify pathological changes with maximum consideration individual characteristics each person.

Indications for ultrasound of nerves

Ultrasound examination has no restrictions or contraindications. That is why it can be prescribed to absolutely all patients who have symptoms indicating nerve damage:

• Pain in the projection of the nerve trunks, which, as a rule, has the character of lumbago.
• Impaired sensitivity in the area of ​​innervation of certain nerves.
• Paresthesia: tingling, tingling, crawling sensation in the upper or lower extremities.
• Violation motor activity in one of the body parts.
• Palpation of pathological formations in the projection of large nerves.
• Traumatic injuries bodies in the place of nerve trunks.

Preparation and methodology

Ultrasound examination of the peripheral nervous system is carried out without special preliminary preparation. The procedure is usually performed while the patient is in hospital. lying down bodies. To visualize some anatomical structures the patient may be asked to change the position of the limb.

Diseases diagnosed during nerve ultrasound

Ultrasound examination of the peripheral nervous system allows us to draw a conclusion about possible availability one of the following diseases or pathological conditions:

• Neoplasms nerve fibers. IN clinical practice There are two types of nerve tumors, neurofibroma and schwannoma, which can be distinguished by ultrasound. The first comes from the central part of the nerve, and the second from its sheaths.
• Acute and chronic injuries of nerve trunks: sprains, tears, ruptures.
• Compression of the nerve by adjacent muscle or bone structures. The so-called tunnel syndrome.
• Morton's neuroma is a false tumor that is a growth of nerves in the spaces between the fingers.
• Neuritis is inflammation of the nerves of various origins.

Ultrasound examination of nerves is new method diagnostics, which arose as a result of the advent of improved ultrasound equipment equipped with high-frequency sensors. The sensitivity of the device allows you to create a clear picture of the nerves of the upper and lower extremities and the bundles of fibers that form them, and evaluate characteristics such as structure, contours, thickness and blood supply. The ultrasound technique of peripheral nerves has long been successfully used in European countries.

Ultrasound of nerves upper limbs allows you to see as much as possible full description fibers, including their size and structure

Diagnostic ultrasound procedure

Typically, the diagnostic procedure is preceded by special tests and tests, and a thorough study of neurological symptoms. Only then to establish accurate diagnosis procedure is being carried out ultrasound diagnostics. Before starting the ultrasound skin lubricated with a special gel that improves contact with the sensor. The study of the sciatic nerve is carried out by emitting a wave whose frequency ranges from 3 to 5 MHz, peripheral trunks are studied at wave frequencies from 7 to 15 MHz. At the beginning of the procedure, a topographic search for the nerve is performed. This is necessary to reduce scanning time. So, knowing the location of the nerve, during scanning, in case of loss of the visual image, it is possible to return to the beginning. Diagnostics consists of scanning the fiber in longitudinal and cross sections. Then the obtained sections are studied and the data decrypted.

Doppler mapping is used to determine the vascularization of a sciatic nerve tumor, to search for small nerve branches, accompanied by arteries. Dynamic functional testing is often the only way to identify certain diseases.

So, medial displacement ulnar nerve may occur exclusively during elbow flexion. A decrease in its displacement in the frontal projection of the carpal tunnel occurs when the fist is clenched. The appearance of such a symptom indicates carpal carpal tunnel syndrome. Functional test allows us to detect the development of osteophyte, which damages the nerve fiber during joint movement.

Parameters determined during diagnostics

Using ultrasound diagnostics, it is possible to visualize the median, ulnar, radial, femoral, sciatic, tibial and peroneal nerves, as well as the brachial plexus. In the case of the development of pathological conditions accompanied by an increase in the thickness of the nerve trunk and a decrease in its density, the possibility of mapping increases significantly. Due to this property it becomes possible analysis smaller endings that are inaccessible for research in normal healthy condition.

The study allows you to visualize individual areas of the peripheral nervous system and identify disturbances in their functioning.

During an ultrasound examination, the location of compression of the nerve trunk is determined based on several parameters:

1. The amount of flattening at the point of compression. Usually the flattening coefficient is calculated using the formula: the maximum width is divided by its thickness. A coefficient exceeding 3.3 is considered pathological.
2. Thickening area. A cross-sectional area exceeding the generally accepted standard value is regarded as a sign of a pathological process.
3. Structural change, decreased echogenicity, increased thickness of some nerve bundles, fibrous structure.

Using ultrasound examination of the extremities, it is possible to visualize the causes of compression of the sciatic nerve, followed by determination of its size, structure, and vascularization. The rupture of the nerve trunk, the size of the diastasis, and the condition of the ends are also determined.

Pathological conditions determined by ultrasound

• The formation of schwannomas and neurofibromas of tumors that can develop on nerve sheaths.
• Post-traumatic conditions. Acute trauma, which occurs when a nerve is stretched or ruptured during a bone fracture. A rupture is characterized by a violation of an integral structure. At the ends of the torn nerve fiber, the formation of neuromas occurs - thickenings, which are a consequence of the regenerative process of cells. The cause of changes in the nerve structure may be the dissection of the nerve fiber during cut wounds, infringement as a result of fractures.
• Compression of nerve fibers. Typically, the development is caused by the presence of abnormal muscles and blood vessels in the tunnels. A sign of compression is the manifestation of severe deformation, the development of neuroma, and atrophy of the deformed nerve fiber. Nerve thickening is visualized. The development of carpal tunnel syndrome is characteristic.
• Morton's neuroma. As the pathology develops, the interdigital nerves thicken. Diagnosis of Morton's neuroma occurs only in connection with the occurrence of pain symptoms. This is usually a round-shaped neoplasm, so it is often confused with inflammatory process in the metatarsal bursa.
• Pathologies that cause the development of acute or chronic compression of the sciatic and other nerves. This may be a tumor or cyst, synovitis, thrombosis, aneurysm, osteophyte, edema, hematoma, bone fracture or joint dislocation, the development of thickening of the ligaments, the occurrence of infiltration or compaction of the soft tissues that surround the nerve bundle.

Ultrasound of the nerves is necessarily prescribed for post-traumatic damage to the nervous system. This may be due to bone fractures or soft tissue tears

Functional tests allow analysis of the displacement of the sciatic nerve and the tissues that surround it. Based on the test results, it is possible to diagnose a dislocation of the sciatic nerve, accompanied by constant trauma to the bone formation.

Advantages and disadvantages of the survey

TO positive aspects method of ultrasound diagnostics of nerves of the upper and lower extremities can be attributed to the ease of examination and low cost examinations. Due to the absence of harmful radiation, as with radiography, and contraindications, repeated procedures are allowed without negative consequences for the body even in children and pregnant women. The technique allows you to study the dynamic indicators of organs and visualize them in real time. The use of Dopplerography makes it possible to assess blood flow indicators.

Some disadvantages of the technique include limited visualization in subosseous areas. Low quality studies of nerve trunks located deep in tissues. Often this problem interferes with overweight patients. Thus, it is problematic to examine the sciatic and tibial nerves.

Research costs: -joints (for one joint) - doctor - 3500 rubles, professor - 6000 rubles - nerves (for one nerve) - doctor - 3500 rubles, professor - 6000 rubles

Brief information. Nerves are bundles of nerve fibers (processes nerve cells), through which nerve impulses are carried from the center to the periphery and vice versa. Nerves can suffer as a result of injury, external compression, tumor growth, and sometimes they are affected due to lack of blood supply. Among all the causes, vertebrogenic lesions of the roots are leading spinal cord. Often there are primary processes that lead to disturbances in nerve conduction, in particular those of inflammatory origin.

Joints provide mobility to various segments of the body and limbs and overall mobility of a person by connecting bones to each other. Joints are quite complex: the contacting surfaces of the bones are covered with cartilage, and between them there is renewable joint fluid. The framework of the joints and the direction of movement in them are supported by numerous ligaments. Over time separate structures(primarily cartilage) undergo degenerative changes and can ossify (osteoarthrosis). In addition, there are numerous inflammatory diseases joints - arthritis. Articular syndrome is part of a syndrome complex of various general somatic diseases, for example, systemic rheumatoid diseases. Pathological changes associated with injuries are common. Other diseases, including neoplastic ones, also occur.

The ligamentous apparatus helps maintain position, as well as provide directed movements (stabilization of joints, etc.). Ligaments can suffer due to inflammatory changes, injuries and other causes (tumors, etc.).

The role of ultrasound in the diagnosis of diseases of peripheral nerves, joints, and ligaments.

Ultrasound examination is the method of choice, as well as an auxiliary technique for certain types of lesions of joints, ligaments and peripheral nerves. Despite the enthusiasm for these studies in last years, their resolution is not enough in many diagnostic situations.

Titles of studies: Ultrasound examination (US), duplex scanning (DS) of joints, ligaments, peripheral nerves.

Scope of research*:

Ultrasound examination of the joint:

• two-dimensional gray scale echography of the joint and ligaments
• duplex scanning of the joint and ligaments

Ultrasound examination of the peripheral nerve:

• two-dimensional greyscale echography of the peripheral nerve
• duplex scanning of the peripheral nerve

________________

* In the Multidisciplinary Professorial medical center « Vascular clinic At Patriarch's, isolated ultrasound examinations in mono modes are not practiced. In the interests of the patient, Doppler scanning modes are used for all types of studies.

Purpose of the study:

For the joint and ligaments:

• determining the condition of the articular surface, assessing the amount and nature of the joint fluid, determining the presence and properties of additional formations, studying the echographic characteristics of the soft tissues surrounding the joint
• in the presence of additional formations - determination of their size, shape, location, structure, as well as the nature of the distribution of color cartograms of flows and linear characteristics blood flow in their vessels

For peripheral nerves:

• study of the contour, diameter, structure, continuity, echogenicity of the nerve, the state of the surrounding tissues, in the presence of additional formations - their properties, as well as the nature of the distribution of color cartograms of flows and linear characteristics of blood flow in their vessels

Indications for ultrasound (US) of peripheral nerves, joints, ligaments:

The most common conditions and diseases of the joints for which ultrasound examination is performed:

• exclusion (confirmation) of dysplasia hip joint in children (up to 3 - 4 months)
• joint pain
• restrictions on joint movement
• joint deformity
• swelling of the joints
• additional education
• joint injury

The most common conditions and diseases of the nerves for which it is performedultrasonography:

• nerve injury
• suspected nerve compression
• the need to exclude a tumor
• nerve inflammation

Preparing for the study.

Ultrasound of joints, ligaments and nerves using modern diagnostic equipment, available in our center “Vascular Clinic on Patriarch’s”, in most cases does not require special training.

Ultrasound modes and technologies used when conducting ultrasound examination of peripheral nerves, joints and ligaments at the Vascular Clinic on Patriarch's Center:

• two-dimensional gray scale echography (B-mode);
• color Doppler coding - by speed, intensity or energy, convergent or directed energy (CD - mode);
• spectral Doppler analysis (PW - mode);
• duplex scanning;
• triplex duplex scanning mode - triplex scanning.

Based on the research results, the following are issued:

• conclusion (hard copy) - included in the base price
• conclusion in in electronic format (additional service)
• Ultrasound images - static black and white (hard copy), printed on a video printer (additional service)
• ultrasound images - static color (hard copy) (additional service),
• ultrasound images- static or dynamic on the client’s magnetic media (additional service),
• on magnetic media provided by the center (additional service)

For the diagnosis of peripheral pathologies nerve structures The “gold standard” remains electrophysiological methods, which include neuromyography and electromyography. However, ultrasound of the nerves remains popular, since the listed methods have a number of disadvantages:

• do not provide the opportunity to assess the condition of adjacent tissues;
• will not indicate the cause of damage to the nerve structures;
• not informative in determining the nature of damage;
• do not accurately reflect the location of pathological processes.

But this is the information without which it is impossible to competently plan tactics, both operational and conservative treatment. Until recently, diagnosis of the condition of peripheral nerves was incomplete and not very accurate. However, the introduction of ultrasound examination of nerve structures into clinical practice has successfully filled the existing gaps.

At the beginning of a pathological process occurring in the peripheral nervous system, studies are not always effective.

Reference! Some disorders do not reveal themselves for a long time and appear only during examination medical equipment high precision.

Other pathologies, for example, shooting of the ulnar or sciatic nerve, are rarely taken seriously by the patient until the pain becomes unbearable and regular.

What symptoms are determining for a doctor who prescribes an ultrasound of peripheral nerves? There is a whole list of them:

• feeling of numbness in the limbs, disruption of their function;
• shooting pains;
• detected neoplasms in the projection of the trunks;
• foot paresis;
• burning sensation;
• any injuries that negatively affect the sensitivity of individual parts of the body or general motor activity;
• for visual assessment of the degree of dissection of the suspensory ligament of the carpal tunnel, if there is no improvement for a long time after decompression surgery;
• with benign fibrous tissue growths, for example, with Morton's neuroma;
• experiencing any extremely traumatic situations, including accidents;
• suspicion of tumors of any etiology.

What are they watching?

Ultrasound examination allows you to examine in detail the peripheral structures, and, first of all, the key nerves of the upper extremities:

• trunk and fibers of the radial nerve;
• median and brachial nerve bundles;
• carpal, musculocutaneous and axillary nerves;
• finger flexors.

In addition, with great difficulty, one can obtain information about the nerves of the lower extremities. For example, determine the structure and localization of the following nerve endings:

• ischial and femoral;
• lower and upper gluteal;
• obturator and genital;
• iliogastric and inguinal;
• greater and fibula;
• plantar and medial cutaneous nerve feet.

Reference! Difficulty in examining individual nerve structures (eg, femoral, sacral, and lumbar nerves) consists in their deep occurrence.

These groups of nerves are deepened into soft fabrics and hidden by bone elements. Therefore, an ultrasound sensor cannot always provide high-quality visualization.

Preparation

When preparing for sonography of the peripheral nervous system, there are no specific preparatory measures. However, before the procedure, you should discuss your symptoms in detail with your doctor. .

Important! Based on the patient's complaints, the doctor may prescribe additional examinations, including laboratory tests, for example, neurological tests or tests.

If there are skin lesions at the site of the proposed examination, the procedure should be postponed until they are completely healed.

How do they do it?

In order to obtain a clear and accurate image, the sonologist applies a gel to the skin that enhances the conductivity of the sensor. To examine the sciatic nerve, the doctor sets the frequency to 3-5 MHz. For the radial, ulnar plexuses and other peripheral nerve structures, the frequency changes and becomes equal to 7 - 15 MHz.

Ultrasound of peripheral nerve fibers takes place in several stages:

1. First, the exact location of the object under study is determined.
2. Secondly, the desired nerve is examined in the transverse and longitudinal planes. Moreover, assessing large nerve trunks is much simpler than searching and examining small branches. The fact is that during motor functional tests, small nerves may not be visible to the doctor.

Decoding

During the examination, the condition of the nerve trunk, its integrity and structure, the condition of the adjacent tissues and the clarity of the contours are determined.

All these parameters must be reflected in the study protocol.

If negative changes are detected in the structure of nerve fibers, the doctor indicates:

• what type of damage;
• compression zone and its degree;
• cause of stenosis and reduction in nerve diameter.

If a neoplasm is found, the doctor supplements the protocol with its description, which indicates the contours, structure, blood flow (or lack thereof), and interaction with adjacent tissues.

It is better to start the examination peripheral endings from the point of greatest identification of the nerve trunk. Then, moving in the near and far directions, assess the condition and functional features nerve along its entire length.

Characteristic signs of nerves

There are a few characteristic features, which distinguish the image of a nerve from images of other anatomical structures:

1. The transverse projection presents the nerve as a round or oval structure with a smooth contour, increased echogenicity and a heterogeneous internal component.
2. The longitudinal projection demonstrates it as a linear formation with a smooth echogenic contour and regular alternation of stripes of different echogenicity. The thickness of the peripheral nerve structures can vary from 1 to 8 mm.

Inspection healthy nerve allows you to see a homogeneous formation with high echogenicity. Therefore, normal nerve tissue is not clearly visible on ultrasound. But pathological changes in the nerves are accompanied by a decrease in echogenicity and thickening of the trunk. As a result, the changed area is identified by measuring basic parameters and detailed examination of the fibers.

Also dynamic tests are evaluated– studies of nerves under load. Such procedures are often performed in conjunction with Doppler studies of blood flow in the area under study.

This is necessary to obtain a detailed picture of the work of the nerves and the participation of blood vessels in this work.

During these tests, movements should be unimpeded and free.

This is necessary so that if certain pathologies are detected, it does not cause pinched nerves (for example, with osteophyte).

Determining the location of compression

One of the tasks of ultrasound of peripheral nerves is to determine the location of nerve compression. To do this, several basic parameters are used:

1. The degree of thickening in the place where compression is recorded. This parameter is calculated by dividing the maximum width of the nerve by its thickness. Normal value equal to 3.3 - everything that exceeds this indicator is considered pathological.
2. The area of ​​the site with increased thickness. If it exceeds the accepted standard value, then this also indicates a pathological process.
3. Reduced echogenicity and fibrousness of the nervous structure.
4. Changes in the structure of the nerve, an increase in the thickness of its individual bundles.

Pathologies

During an ultrasound examination, the doctor examines the structure of the nerve bundles and can detect deviations from the norm, which may be a sign of a pathological process. For example:

1. Inflammation– Ultrasound can reveal inflamed areas of nerves that cause pain, numbness, decreased sensitivity and other unpleasant symptoms.
2. Nerve injuries– when dislocated or sprained, there is a risk of injuring the fibers. You can find out about the presence of an injury of this kind only with an ultrasound examination of the problem area.
3. Post-traumatic conditions– are diagnosed during the treatment of injury associated with a bone fracture. Often a fracture is accompanied by a rupture (stretch) of the nerve. If we are talking about a rupture, then neuromas appear at the ends of the torn fiber - thickenings formed due to cell regeneration. Changes in the nerve structure can also appear due to the cutting of fibers during incised wounds or pinched nerves during a fracture.
4. Pinching– unsuccessful movements, diseases of the musculoskeletal system or injuries of any kind can cause the formation of a compression area. Over time, the bone tissue in such an area is deformed, which is fraught with the formation of osteophytes - pathological growths on bone tissue. Pinching can also occur due to the development of a tumor - soft tissues can pinch the nerve structure.
5. Tumors of various etiologies – predominantly affect the sheath of the nerve bundle, in this case they speak of the formation of a schwannoma or neurofibroma.
6. Morton's neuroma– characterized by thickening of the interdigital endings due to the activity of the tumor process.
7. Compression of nerve fibers– the cause is often the placement of abnormally located vessels and muscles in the tunnels. It manifests itself as severe deformation of the nerve, the development of neuromas, and atrophy of altered fibers. On an ultrasound, the doctor observes thickening of the nerve structure and the development of carpal tunnel syndrome.
8. Tunnel type neuropathy– it is characterized by compression of nerve endings by tendons and bones. Typically found in people whose work involves computers.
9. Diseases that cause pathologies of the nervous system. This includes a wide group of pathologies, from cysts and hematomas to injuries and thrombosis. Provocateurs are any conditions that can lead to compression of peripheral endings.

For any pathology of the peripheral nerves, it will be prescribed additional examination, to clarify the final diagnosis. In addition to ultrasound, Doppler scanning and neuromyelography are often used.

Conducting functional tests is an important part of diagnosing neural structures.

For example, they make it possible to analyze the displacement of the sciatic nerve and surrounding tissues.

Based on similar tests, dislocation of the sciatic nerve is determined.

It is important to understand that this nerve can be constantly injured by nearby bones.

Contraindications

No contraindications were found for ultrasound of peripheral nerves.

pros

Ultrasound of peripheral nervous structures is a diagnostic method that is widely in demand in modern medical institutions. This method of examination has a number of positive aspects:

• financial inclusion;
• no radiation exposure;
• safety for all categories of patients;
• absence of contraindications and preparatory measures;
• the possibility of dynamic assessment of the condition of the problem area;
• opportunity complex diagnostics in combination with other examination methods;
• good visualization of nerve fibers and endings;
• the ability to conduct examinations as many times as necessary and as often as the patient needs.

Minuses

Despite the fact that the diagnostic method of ultrasound has a lot of advantages, it is not without its disadvantages.

Undesirable aspects of ultrasound examination include insufficient passage of nerve impulses with an inconvenient location of the nerve for examination.

Therefore, it is not always possible to qualitatively examine the area of ​​the peripheral nervous system that interests the doctor.

Thus, examination of the radial nerve trunk will be much more informative than examination of the tibial trunk. Inspection may be difficult:

• heavy weight of the patient;
• deep location of the nerve;
• the location of the bone structures covering the object of study.

Besides Ultrasound is a rather subjective method and this is its main drawback. The interpretation of the data obtained depends too much on the experience and qualifications of the personnel, as well as on the quality of the equipment.

Price and where to make it?

Pass the ultrasound examination peripheral nerves can be done at any budget clinic in the city. In addition, high-quality, but paid medical services can be obtained from private clinics. The price of an ultrasound scan in Moscow of nerve endings can vary from 900 to 1500 rubles.

Conclusion

In clinical practice, ultrasound examinations of individual organs and systems are becoming increasingly important and in demand. Sonography has undeniable advantages over others diagnostic methods. Mainly, they consist in the safety, low cost and informativeness of the procedure.

MILITARY-MEDICAL ACADEMY
DEPARTMENT OF RADIOLOGY AND RADIOLOGY
WITH ULTRASONIC DIAGNOSTICS COURSE
ULTRASONOGRAPHY
PERIPHERAL NERVES
Dean Vyacheslav Stanislavovich, associate professor, Ph.D.

Relevance

In structure neurological diseases pathology
peripheral nervous system is about
50%, while ranking first in degree
loss of ability to work.
According to WHO, neurotraumatism is increasing in
on average by 2% per year.
Most nerve damage occurs
young age, with diagnostic errors of 60%
cases.
The share of iatrogenic nerve injuries is about 4-20% of all
nerve damage.
Odinak M.M., 2010; Peer S., 2008; Mumenthaler M., 2013.

Clinical neurological examination and
Electroneuromyography (ENMG)
They are the main methods for diagnosing diseases and
nerve damage.
Based on the results of these methods, one can only judge
functional state of peripheral nerves.
Does not provide information about the extent of anatomical damage
nerve trunk, condition of surrounding tissues, character and
cause of injury.
They don’t always allow you to decide on further tactics
treatment.
+
=?

MRI in the diagnosis of pathology
peripheral nerves
MRI results complement data from clinical neurological examination and ENMG.
MRI is not common in widespread clinical practice
due to its limitations.
MRI specialists do not know imaging techniques
peripheral nerves.
Limited
nerve imaging
Difficulty of installation
Restrictions
MRI
Big
labor intensity
Significant
time costs
High price
research

Benefits of Ultrasound
The highest in comparison with all existing
using visualization methods, the level of differentiation of the nervous system
trunk and assessment of its anatomical and morphological state.
Ease of execution
price.
And
interpretations
data.
Low
Possibility of conducting multiple studies.
Ability to evaluate in real time
dynamic characteristics of moving structures.
time
No ionizing radiation.
Absence
restrictions
related
With
metal structures, pacemakers, etc.
availability
Usage Doppler techniques to assess blood flow.

Limitations of Ultrasound
Unable to obtain images of nerve trunks in
where they pass under bone structures
(subclavian brachial plexus).
Complex visualization of nerves in cases of severe cicatricial adhesions.
Decline
quality
visualization
at
deep
location of the nerve trunk, especially in patients with
large body mass (tibial nerve in the middle
third of the leg, sciatic nerve in the gluteal region).
Ultrasound diagnostic specialists do not know
peripheral nerve imaging technique.
High operator dependence.

Back in 1988, Fornage B.D. presented the first report on
the possibility of performing ultrasound of peripheral nerves. IN
This work was the first to demonstrate that nerves
have a tubular structure with mottling inside.
Although the results of the first study in which
echographic and surgical data were compared
findings showed high accuracy (92-94%) of the method,
uncertainty about the reliability of ultrasound data and
the complexity of the study contributed to
that this method was practically not used.

History of peripheral nerve ultrasound

Abroad, ultrasound of nerves began to be actively used only in
second half of the 90s. In Vienna there is
International Society for Peripheral Imaging
nervous system (ISPNI). A forum was held in May 2014,
dedicated to ultrasound of the neuromuscular system.
In Russia, the first publications appeared in 2002.
The main engine in this direction is the Central Research Institute
traumatology and orthopedics named after. N.N. Priorov in Moscow.
Department
radiology
And
radiology
(With
course
ultrasound diagnostics) VMedA deals with ultrasound of nerves
since 2007, working closely with the departments of neurosurgery,
neurology, traumatology and orthopedics.

equipment requirements
Ultrasound devices of various classes with linear sensors 4-9, 512 MHz (the higher the frequency of the sensor, the better the visualization
surface structures).
The ideal option is an expert-class general ultrasound machine
appointments
And
broadband
high resolution
multi-frequency linear sensor with operating frequencies
from 5 to 19 MHz.
For deep nerves (or in obese patients)
It is possible to use 2-5 MHz convex sensors.

Patient position during examination:
Basic position for the nerves of the upper limb
is sitting on the couch, for lower limb- lying down.
Convenient access to the nerve for the doctor and at the same time
comfortable for the patient.
Peculiarities:
Ultrasound of the nerve consists of transverse and longitudinal
scanning in B-mode.
Collateral
successful
carrying out
ultrasonic
examinations
serves
good
knowledge
anatomy
research area!
It is necessary to conduct a bilateral study.

Ultrasound technique of peripheral nerves

Ultrasound of peripheral nerves is advisable to begin with
transverse projection at the point where the nerve trunk is easiest
identify, then moving proximally and
distal directions, assessing the structure of the nerve on
throughout.

Normal peripheral anatomy
nerves
1 – axon, 2 – myelin sheath, 3 – endoneurium, 4 –
vessels, 5 – epineurium, 6 – fiber, 7 – bundle, 8 –
perineurium.

Peripheral nerve thickness

Thickness
peripheral
nerves
variable
And
ranges from 1 mm for digital nerves to 8 mm for
sciatic nerve.
In pathology due to thickening of the nerve trunk and
decreasing its density, the level of visualization increases,
which allows you to analyze smaller, inaccessible
nerves are normal.

at
transverse scanning
In transverse projection, the nerve looks like an oval or
round formation with a clear hyperechoic contour and
internal heterogeneous ordered structure (“salt –
pepper", "honeycomb").

Along the perimeter of the nerve trunk a thin
fuzzy hyperechoic contour – epineurium.
The bundles and groups of bundles are hypoechoic.
Perineurium surrounding nerve bundles
identified as thin hyperechoic stripes.
Endoneurium surrounding individual nerve fibers
is beyond the capabilities of echography, because
is a very thin membrane.

Normal ultrasound picture of the nerve trunk during transverse scanning

1
3
2
Epineurium – 1.
Perineurium – 2.
Groups of nerve bundles – 3.

In the longitudinal projection, the nerve is located in the form of a linear
structures with a clear echogenic contour, which includes
Hypo- and hyperechoic stripes alternate correctly –
"electrical cable".

Normal ultrasound picture of the nerve trunk during longitudinal scanning

1
3
2
Epineurium – 1.
Perineurium – 2.
Groups of nerve bundles – 3.

Nerve assessment is carried out according to the following scheme:
contours
dimensions
form
echostructure
echogenicity
Additionally for
finding the nerve
modes apply
Doppler
mapping.

Available for visualization:

Upper limb, trunk and
head:
Cervical plexus
(phrenic nerve)
Brachial plexus
Median nerve
Radial nerve
Ulnar nerve
Musculocutaneous nerve
Nerves of the hand and fingers
Suprascapular nerve
Axillary nerve
Accessory nerve*
Facial nerve*
Nervus vagus *
Lower limb:
* – refer to cranial nerves.
Common femoral nerve
Saphenous nerve
Sciatic nerve
Tibial nerve
Peroneal nerve
Nerves of the foot and toes

Normal ultrasound picture nervous
trunk

Typical ultrasound picture
intact sciatic nerve

Echogram median nerve

Echogram of the C5-C8 roots of the humerus
plexuses
C5
C6
C7
C8

Comparison of nerve trunk ultrasound with histological sections

Longitudinal
histological section
Longitudinal
echogram
2
Transverse
histological section
Transverse
echogram

Comparison of anatomical and histological preparations with ultrasound
brachial plexus
SA – anterior scalene muscle; SM – middle staircase; ST –
sternocleidomastoid m.; V.A. vertebral artery; PN –
phrenic nerve.

Normal ultrasound picture of the nerve trunk

However, it should be noted that the total number of beams,
visualized by ultrasound does not always correspond to
accuracy to the actual number of fascicles in the nerve, which is probably
associated with the merging of adjacent bundles into
single image and with some twisting
nerve bundles.

Normal ultrasound picture of the nerve trunk

At
passing
through
osteofibrous canals nerves
accept more uniform
hypoechoic
view,
can
change shape and size
nerve trunk.
Ulnar nerve in the cubital canal.

MRI of peripheral nerves at the level of the knee joint
On the axial T1-weighted tomogram between the lateral (LG) and
medial heads (MG) calf muscle white short arrow
The tibial nerve is shown. The short black arrow indicates the general
peroneal nerve between the lateral head of the gastrocnemius muscle and the biceps muscle
thigh muscles (B). Lateral to the sartorius muscle (black arrow)
the branch of the saphenous nerve is located (white arrow).
The tomogram in the sagittal plane shows the common fibular
nerve (indicated by arrows) in the place where it goes around the neck fibula(F).

MRI of peripheral nerves of the foot
On the T1 tomogram in the sagittal plane the arrow indicates
medial branch of the deep peroneal nerve.

Transverse ultrasound of nerve trunks

1 1
22
3
3
ahh
b b
a – sensor position; b – echogram of the neurovascular bundle. 1 – median nerve; 2 – shoulder
artery; 3 – brachial veins.

Longitudinal ultrasound of nerve trunks
2
1
A
A
A
b
b
a – sensor position; b –
sciatic nerve (1). 2 – muscle.
echogram

Ultrasound of nerve trunks in Doppler mode

1
Normally, blood flow is not detected in nerve tissue!
1 – median nerve.

Echogram of the median nerve (white ellipse) in
carpal tunnel. Yellow ellipses are tendons.

Differential diagnosis of the echographic picture of nerves and tendons

According to the literature and according to
from our own observations, it is known that
nerves are less anisotropic than tendons,
therefore the angle of inclination of the ultrasonic
sensor
slightly
influences
on
echographic image of the nerve.

Echogram of tibial artery (1) and nerve
(arrows) in longitudinal scanning.
A – sensor position (photo).
B – longitudinal echogram in B-mode.

The median nerve is formed
from lateral and medial
bundles of the brachial plexus.
Located on the shoulder
medial groove
biceps muscle anterior to
brachial artery.
In area elbow joint
the median nerve is located
more medial to
more deeply located
brachial artery and vein.

Topographic anatomy of the median nerve

In the proximal part
the forearm nerve usually passes
between two round heads
pronator
In the area of ​​the wrist joint
the median nerve passes under
flexor retinaculum on
brush through the so-called
carpal tunnel.
Common palmar digits
nerves are formed by
branches of the main trunk
median nerve at the level
distal end of the retinaculum
flexors.

The ulnar nerve is the main branch
medial fascicle of the brachial
plexus. It does not produce branches on the shoulder.
Nerve in the elbow joint
passes through the cubital canal
formed medial
epicondyle of the shoulder and ulna
process. Here is the ulnar nerve
adheres directly to the bone and
the top is covered only by fascia and skin.
Ultrasound of the elbow joint
attention should be paid to
the patient's hand was positioned freely
and was not bent. It is important,
because when flexing the elbow
joint, the thickness of the nerve decreases over
due to its stretching.

Topographic anatomy of the ulnar nerve

Usually located on the forearm
between the two heads of the ulna
flexor carpi, and in the distal
section of the forearm, the nerve lies between
ulnar flexor tendon
wrists medial and lateral from
ulnar artery and vein.
The ulnar nerve enters the hand through
the ulnar nerve canal, called
Guyon canal. In the distal section
Guyon's canal nerve is divided into
deep motor branch and
superficial sensitive, and
namely the superficial branch
continues to accompany the elbow
artery, which makes it easier
navigate with ultrasound.

The radial nerve is
largest branch of the posterior portion
brachial plexus. Visualization
nerve is carried out on the back and
lateral surfaces of the shoulder, where
it accompanies the brachial artery.
IN middle third shoulder radial nerve
goes around humerus And
directly adjacent to it
spiral channel. It is with
a spiral channel is more appropriate
just start the process
radial nerve scan.

Topographic anatomy of the radial nerve

Anterior to the lateral epicondyle
shoulder, n. radialis is divided into
sensitive (or superficial) and
motor (deep) branches and
posterior interosseous nerve.
The superficial branch passes along
medial border of the brachioradialis
muscles and is accompanied by radial
artery and vein. This is where the nerve is
Ultrasound is the most accessible, but only with
condition of using sensors
high frequency (over 15 MHz), so
as the diameter of this branch is very small.
Deep branch of the radial nerve
passes directly into the instep support,
here the nerve is also available for visualization
due to differences in sonographic
structures between it and the surrounding
his muscle.

Topographic anatomy of the radial nerve

In the distal part
extensor surface
forearms n. radialis (his
superficial branch) ends
division into 5 dorsal
digital nerves.
Ultrasound of the digital nerves
implement only with
using high sensors
frequencies, but even in this case
get a clear
sonographic image of these
structures are rarely achieved.

Pathology of peripheral nerves

1. Damage.
2. Tumors and pseudotumor diseases.
3. Compression-ischemic neuropathies
(tunnel syndromes).

Classification of peripheral nerve injuries

I. According to the nature of the nerve damage:
1. Closed.
2. Open:
a) firearms (bullets, shrapnel and
etc.);
b) non-gunshot (chopped, cut,
bruised, etc.).
II. According to the shape and degree of damage
nerve:
1. Concussion.
2. Bruise.
3. Compression.
4. Traction.
5. Partial nerve break.
6. Complete nerve break.
III. By location of damage:
1. Cervical plexus.
2. Brachial plexus.
3. Nerves of the upper limbs.
4. Lumbar plexus.
5. Nerves of the lower extremities.
IV. Combined and
combined damage:
1. Combinations with vascular damage,
bones, tendons, muscles.
2. Combination with burns, frostbite
chemical, radiation damage and etc.
V. Iatrogenic damage.

International classification of the degree of post-traumatic
nerve damage (Mackinnon, Dellon; 1988)
I
Neuropraxia
+/-
Full, fast
(up to 3 months)
Saved
II
Axonotmesis
+
+
Full but slow
(up to 1 mm per day)
Saved
Incomplete, slow
(up to 1 mm per day)
Saved
No recovery
Saved
III
+
+
+
IV
+
+
+
+
+
+
+
+
V
VI
Neurotmesis
There are different degrees
damage
epineurium
Seddon
perineurium
External
continuity
nerve
endoneurium
Recovery
functions without
operations
axon
Sunderland
Pathohistological
peculiarities
nerve damage
myelin
Degree
nerve damage
+
No recovery
Varies in different
bunches
Violated
Saved/
broken

Forms of nerve damage (Grigorovich K.A., 1981)
a – complete interruption of the nerve trunk with the formation of a neuroma of the central end;
b – partial break (tear) of the nerve trunk, formation of a marginal neuroma;
c – rough partial anatomical break of the nerve with the formation of an intra-trunk
neuromas;
d – subepineural intra-trunk nerve damage, accompanied by
separation of axons, fibers, bundles by hematoma or foreign bodies, scar
changes in the nerve at the site of injury without the formation of a neuroma.

Complete damage

2
1
1
Ultrasound picture of a complete break of the ulnar nerve (1 – diastasis
2.7 cm) with the presence of post-traumatic terminal
neuromas in the proximal stump. 2 – true diastasis
equals 4 cm.

Complete damage
Patient K. stab wound forearms.
Longitudinal echogram of the ulnar nerve (arrowheads) with
a complete break. On the proximal (long arrow) and
distal (short arrow) nerve stumps are identified
terminal neuromas. Scar-altered wound channel –
double headed arrow.

Complete damage
Complete break (curly bracket) of the nerve (arrows).
B-mode. Longitudinal panoramic scanning.

Terminal post-traumatic neuroma
central end of the nerve

Partial damage
Patient M., condition after removal
foreign bodies of the forearm.
Echogram of partial damage to the median
nerve with marginal discontinuity and preserved
outer sheath of the nerve before and after the place
traumatic impact.

Partial damage
Partial damage to the sciatic nerve after
mine blast wound.

Post-injection damage
Longitudinal echogram of the sciatic nerve (white
arrows) when it comes out from under the gluteal muscles after
intramuscular injection. Slightly hypoechoic
area with a fuzzy tuft texture (green arrow)
inside the nerve (most likely a hematoma). Asterisk –
ischial tuberosity.

Internal damage -
traction
Traction damage to the radial nerve due to fracture
humerus.

Internal damage -
traction
Traction nerve injury (arrows) with
formation of intrastem neuroma. B-mode.
Longitudinal panoramic scanning.

Ultrasonic options for radial rupture
nerve fragments of the humerus

Traction damage and rupture
Echogram of traction injury of the fibula
nerve (arrows) with rupture and formation of neuroma
on the proximal stump (asterisks) at the level
popliteal fossa.

Internal damage -
traction
2
1
Ultrasound picture of intra-trunk damage (traction)
peroneal nerve (1) with partial rupture fibers
with the outer sheath of the nerve intact. 2 – unchanged
nerve on the opposite limb.

Internal damage -
compression
3
5
1
3
2
4
4
Patient K., improperly healed fracture of the radius.
Ultrasound picture of compression of the median nerve (1) by osteophyte (2) in
carpal tunnel. 3 – wrist flexor retinaculum. 4 -
radius. 5 – unchanged median nerve on
opposite limb.

A sign of nerve damage is swelling
Patient K., Ultrasound picture of diffuse edema
peroneal nerve from the level of bifurcation
sciatic nerve extending to
deep branch to the middle third of the leg.

Iatrogenic nerve damage

In a review article by D. Hak (2009),
it is reported that the frequency
iatrogenic radiation injuries
nerve during treatment
diaphyseal fractures of the humerus
is 10-20%.
Radial nerve damage
could happen in a moment
the injury itself, and at stages
treatment: closed
reduction and external fixation
or when performing
osteosynthesis.

Iatrogenic damage radial nerve
1
1
1
2
2
2
3
1
Patient N., Ultrasound picture of damage to the radial nerve (1) due to
compression by a plate (2) installed for a fracture
humerus. 3 – radial nerve on a healthy limb.

Iatrogenic nerve damage
Multiple ligatures on the superficial fibula
nerve after PSO.

Iatrogenic nerve damage
Compression of the ulnar nerve with a screw during osteosynthesis of the humerus
bone plate.

Iatrogenic nerve damage
Ligature (arrow) on tibial nerve with the formation
terminal neuroma after phlebectomy of the small saphenous
veins in the popliteal fossa.

Preoperative ultrasound of complete injury
median nerve with markings on the skin of the ends
nerve trunk

Progress of the operation to restore the integrity of the nerve
?
?

Postoperative control using
ultrasonography (1 day)
Postoperative ultrasound of the median nerve in longitudinal
(rectangle) and transverse (ellipse) scanning.
Nerve suture (arrows) and surrounding tissues in
satisfactory condition.

Today, ultrasound is a complementary method

Clinical and neurological examination
Nerve damage
(partial or complete)
No nerve damage
Neurophysiological studies (ENMG)
Partial or complete
conduction disturbance
Severity
nerve damage
Supposed
level of damage
Ultrasound
Damage level
Diastasis,
true
diastasis
Nature of damage to the nerve trunk
(break, defect, narrowing, compression)
Presence of traumatic
neuromas (“club-shaped” with a cystic cavity inside
Echogram of the transition site
tumors to unchanged
nerve trunk. Longitudinal
scanning, B-mode.
Echogram of the transition site
tumors to unchanged
nerve trunk. Longitudinal
scanning, color transfer mode.

Ultrasound of median nerve schwannoma
with a cystic cavity inside
Heavily vascularized
median nerve tumor.
Color flow mode, longitudinal
scanning.
Energy mode
mapping, longitudinal
scanning.

Ultrasound of median nerve schwannoma
with a cystic cavity inside
Arterial blood flow in an intratumoral vessel.

MRI of median nerve schwannoma
T2-VI.
STIR mode with MIP
reconstruction.

nerve
Color flow mode. Intensive
vascularization.

Ultrasound of radial neurofibrosarcoma
nerve
Color flow mode.

Ultrasound of radial neurofibrosarcoma
nerve
Elastography.
The neoplasm is “hard-elastic”.