Open Access

Reference values for the cross sectional area of normal tibial nerve on high-resolution ultrasonography

Kunwar Pal Singh
Kunwar Pal Singh
, 
Sumanjeet Kaur
Sumanjeet Kaur
 and 
Vijinder Arora
Vijinder Arora
   | Sep 01, 2022
Journal of Ultrasonography's Cover Image
About this article
Previous Article
Next Article
Cite
Article Category: research-paper
Published Online: Sep 01, 2022
Page range: e144 - e152
Received: Nov 24, 2021
Accepted: Mar 02, 2022
DOI: https://doi.org/10.15557/jou.2022.0024
Keywords
© 2022 Kunwar Pal Singh et al., published by Sciendo
This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

Fig. 1.

A. Subject lying in prone position, the transducer is kept perpendicular just 1 cm below the bifurcation of the sciatic nerve at the lower aspect of the popliteal fossa (corresponds to level I). B. High-resolution ultrasonography image at the same level showing normal tibial nerve (arrow). C. Transducer is kept 1 cm superior and posterior to the medial malleolus (corresponds to level II). D. High-resolution ultrasonography image at the same level showing the tibial nerve (arrow)
A. Subject lying in prone position, the transducer is kept perpendicular just 1 cm below the bifurcation of the sciatic nerve at the lower aspect of the popliteal fossa (corresponds to level I). B. High-resolution ultrasonography image at the same level showing normal tibial nerve (arrow). C. Transducer is kept 1 cm superior and posterior to the medial malleolus (corresponds to level II). D. High-resolution ultrasonography image at the same level showing the tibial nerve (arrow)

Fig. 2.

High-resolution ultrasonography of normal tibial nerve at level I (A, B) and II (C, D) in bilateral lower limb in 25 years old female weighing 46 kg, having height of 158 cm and body mass index of 19.1. Cross sectional area measured at level I was 0.178 cm2 and 0.170 cm2 and at level II was 0.098 cm2 and 0.097 cm2 in right and left lower limb, respectively (RT – right, LT – left, arrow – tibial nerve)
High-resolution ultrasonography of normal tibial nerve at level I (A, B) and II (C, D) in bilateral lower limb in 25 years old female weighing 46 kg, having height of 158 cm and body mass index of 19.1. Cross sectional area measured at level I was 0.178 cm2 and 0.170 cm2 and at level II was 0.098 cm2 and 0.097 cm2 in right and left lower limb, respectively (RT – right, LT – left, arrow – tibial nerve)

Fig. 3.

High resolution ultrasonography of normal tibial nerve at level I (A, B) and II (images C, D) in left lower limb in 42 years old male weighing 63 kg, having height of 168 cm and body mass index of 22.3. Mean cross sectional area was 0.193 cm2 and 0.190 cm2 at level I and 0.101 cm2 and 0.103 cm2 at level II. (RT – right, LT – left, arrow – tibial nerve)
High resolution ultrasonography of normal tibial nerve at level I (A, B) and II (images C, D) in left lower limb in 42 years old male weighing 63 kg, having height of 168 cm and body mass index of 22.3. Mean cross sectional area was 0.193 cm2 and 0.190 cm2 at level I and 0.101 cm2 and 0.103 cm2 at level II. (RT – right, LT – left, arrow – tibial nerve)

Fig. 4.

High resolution ultrasonography of normal tibial nerve at level I (A, B) and II (C, D) in bilateral lower limb in 61 years old male weighing 79 kg, having height of 177 cm and body mass index of 25.3. Cross sectional area was 0.205 cm2 and 0.207 cm2 at level I and 0.129 cm2 and 0.127 cm2 at level II in right and left lower limb respectively. (RT – right, LT – left, arrow – tibial nerve)
High resolution ultrasonography of normal tibial nerve at level I (A, B) and II (C, D) in bilateral lower limb in 61 years old male weighing 79 kg, having height of 177 cm and body mass index of 25.3. Cross sectional area was 0.205 cm2 and 0.207 cm2 at level I and 0.129 cm2 and 0.127 cm2 at level II in right and left lower limb respectively. (RT – right, LT – left, arrow – tibial nerve)

Fig. 5.

Graph representation of positive correlation of mean cross sectional area (CSA) of both tibial nerves with weight (A), height (B) and BMI (C)
Graph representation of positive correlation of mean cross sectional area (CSA) of both tibial nerves with weight (A), height (B) and BMI (C)

Mean cross-sectional area (CSA) of both tibial nerves at levels I and II and their correlation with weight

Weight (kg) No. of cases Level I mean CSA (cm2)
Right p-value Left p-value
Mean SD Mean SD
≤60 (Group I) 64 0.18116 0.005671 r = 0.908p = 0.001 0.18110 0.005591 r = 0.909p = 0.001
61–70 (Group II) 60 0.19412 0.004268 0.19459 0.004425
>70 (Group III) 76 0.21193 0.007021 0.21213 0.007113

Tabulated list of studies as mentioned in literature along with references

Sr No. Study performed by Result
1 Bedewi et al. did a case control study for determining the CSA of lower limb peripheral nerves to establish some reference values.CSA values were obtained for tibial nerve, common peroneal nerve and sural nerve(15). Normal reference value for the tibial nerve was 19 mm2 ± 6.9 at the popliteal fossa and 12.7 mm2 ± 4.5 at the level of the medial malleolus. The study revealed a positive correlation between CSA and weight, BMI, and age of subjects. No significant relationship was observed between CSA and height or gender.
2. Fisse et al. performed a systematic review and a meta-analysis of published CSA reference values for lower extremity nerves(16). They calculated the mean CSA of the tibial nerve at popliteal fossa and at malleolus, which was 25.9 mm2 and 10.0 mm2, respectively.
3. Qrimli et al. conducted a study in 100 healthy volunteers. Median, ulnar, fibular, tibial, sural and superficial fibular nerves were studied at predetermined sites with high-resolution US(8). Positive correlation was observed between the CSA of nerve and age of the subjects. However, gender and BMI had no significant relationship with the cross sectional area of nerve. CSA tends to be bilaterally symmetrical in both lower limbs.
4. Study conducted by Kerasnoudis et al.(7) CSA reference values for peripheral nerves acquired in their study, showed a positive correlation with age, weight and sex of the subjects. However, no obvious correlation was seen with height.
5. Singh et al. performed study on radial nerve(17). Strong correlation between the CSA of the radial nerve and height, weight, BMI was seen with no statistically significant correlation with age. Males had higher CSA values for the radial nerve than females.
6. Singh et al. performed study on the sciatic nerve(18). Reference CSA values for the sciatic nerve were also studied by Singh et al. and the values were correlated statistically with the demographic parameters. They concluded that a positive correlation of the mean cross-sectional area was established with height, weight, and body mass index. Women had smaller cross-sectional areas of the normal sciatic nerves than men at both measuring sites. No significant relationship was established with the age of the subjects.
7. In a study by Chen et al. on sciatic nerve(5). CSA of sciatic nerves was measured with high resolution US in 200 subjects. The results showed that females had smaller CSA of sciatic nerves than males at the two different sites (p <0.05).
8. Kowalska et al. performed a study on median, ulnar, common peroneal, digital, cutaneous nerve in the deltoid area, mental and posterior interosseous nerve in patients referred for ultrasound due to clinical suspicion of traumatic peripheral neuropathies(14). US findings were consistent with the clinical and surgical verification in almost 100 % of cases.
9. Singh et al. performed a study on thetibial nerve in diabetic patients having diabetic peripheral neuropathy(19). The mean CSA along with maximum thickness of nerve fascicles of the tibial nerve in patients with diabetic peripheral neuropathy was significantly on higher side as compared with controls. Statistically significant correlation was also found with the Toronto Clinical Neuropathy Score (p <0.001).
10. Study conducted by Riazi et al. in diabetic patients on peripheral nerve(20). Mean CSA of the posterior tibial nerve above the medial malleolus was considerably larger in the diabetic sensorineural polyneuropathy subjects compared with controls.
11. Singh et al. performed a study in diabetic patients with clinically diagnosed diabetic polyneuropathy and healthy adult volunteers(3). The mean CSA of the medial, ulnar, common peroneal and posterior tibial nerves was measured in the two groups at identical sites. CSA was significantly higher in diabetic patients as compared to healthy volunteers.
12. Afsal et al. performed a study in five patients with diabetic peripheral neuropathy(21). Diffuse thickening of peripheral nerves along with higher mean CSA of the median nerve and the ulnar nerve was found in patients with diabetic peripheral neuropathy when compared to controls.
13. Study by Lee et al. on peripheral nerves(22). Concluded that ultrasonography plays a vital role in diagnosing a lesion and its location accurately in the 13 cases who were the subjects of their study. In 7 (58%) out of 12 cases, ultrasonography contributed to establishing the correct diagnosis when other imaging and electrophysiological studies were inconclusive or inadequate.

Mean cross-sectional area (CSA) of the tibial nerve at two levels

Levels Cross-sectional area (cm2)
Mean Standard deviation
Level I 0.196 0.014
Level II 0.111 0.011
p-value 0.001

Mean cross sectional area (CSA) of both tibial nerves at levels I and II and their correlation with body mass index (BMI)

Lower limb level I mean CSA (cm2)
Body mass index No. of cases Right p-value Left p-value
Mean SD Mean SD
19.5–22.5 (Group I) 84 0.18540 0.009219 r = 0.768p = 0.001 0.18553 0.009138 r = 0.767p = 0.001
22.6–24.5 (Group II) 80 0.20050 0.008742 0.20073 0.009125
>24.5 (Group III) 36 0.21485 0.009913 0.21516 0.009689

Mean cross sectional area (CSA) of both tibial nerves at levels I and II and their correlation with height

Lower limb level I mean CSA (cm2)
Height (cm) No. of cases Right p-value Left p-value
Mean SD Mean SD
≤165 (Group I) 74 0.18330 0.008366 r = 0.857p = 0.001 0.18339 0.008204 r = 0.850p = 0.001
166–175 (Group II) 63 0.19641 0.005966 0.19691 0.006370
0 >175 (Group III) 63 0.21285 0.007225 0.21288 0.007830

Mean cross-sectional area (CSA) of both tibial nerves at levels I and II and their correlation with age

Age group (years) No. of cases Level I mean CSA (cm2)
Right p-value Left p-value
Mean SD Mean SD
18–30 (Group I) 43 0.19494 0.014106 r = 0.254p = 0.081 0.19424 0.012472 r = 0.244p = 0.092
31–50 (Group II) 81 0.19514 0.012935 0.19545 0.013611
>50 (Group III) 76 0.20116 0.015516 0.20119 0.015043

Mean cross-sectional area (CSA) of both tibial nerves at levels I and II and their correlation with gender

Gender No. of cases Level I mean CSA (cm2)
Right p-value Left p-value
Mean SD Mean SD
Male 101 0.20538 0.012126 r = –0.615p = 0.001 0.20585 0.011966 r = –0.630p = 0.001
Female 99 0.18793 0.010277 0.18785 0.010261
eISSN:
2451-070X
Language:
English
Publication timeframe:
4 times per year
Journal Subjects:
Medicine, Basic Medical Science, other
Journal RSS Feed