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Role of high-resolution ultrasound and magnetic resonance neurography in the evaluation of peripheral nerves in the upper extremity

Ali Serhal
Ali Serhal
, 
Steven Kyungho Lee
Steven Kyungho Lee
, 
Julia Michalek
Julia Michalek
, 
Muhamad Serhal
Muhamad Serhal
 and 
Imran Muhammad Omar
Imran Muhammad Omar
   | Nov 23, 2023
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Article Category: Review Paper
Published Online: Nov 23, 2023
Page range: e313 - e327
Received: Aug 06, 2023
Accepted: Aug 30, 2023
DOI: https://doi.org/10.15557/jou.2023.0037
Keywords
© 2023 Ali Serhal et al., published by Sciendo
This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

Fig. 1.

A. Anterior and B. Posterior diagrams of major upper extremity peripheral nerves with associated clinical conditions
A. Anterior and B. Posterior diagrams of major upper extremity peripheral nerves with associated clinical conditions

Fig. 2.

Diagram illustrating the structural anatomy of a peripheral nerve
Diagram illustrating the structural anatomy of a peripheral nerve

Fig. 3.

46-year-old female with recent right shoulder dislocation and subsequent shoulder weakness and numbness over the deltoid muscle. A. Sagittal and B. coronal T2-weighted (T2W) fat-suppressed (FS) MR images of the right shoulder demonstrate diffuse edema within the deltoid and teres minor muscles consistent with denervation. Additional C. sagittal and D. axial T2W MR images demonstrate fascicular thickening and increase signal of the axillary nerve consistent with axillary neuropathy
46-year-old female with recent right shoulder dislocation and subsequent shoulder weakness and numbness over the deltoid muscle. A. Sagittal and B. coronal T2-weighted (T2W) fat-suppressed (FS) MR images of the right shoulder demonstrate diffuse edema within the deltoid and teres minor muscles consistent with denervation. Additional C. sagittal and D. axial T2W MR images demonstrate fascicular thickening and increase signal of the axillary nerve consistent with axillary neuropathy

Fig. 4.

Imaging of the musculocutaneous nerve using 24 MHz linear transducer. A. Photograph of the right arm demonstrates the probe position for short-axis US imaging of the musculocutaneous nerve in the upper arm. B. Long-axis grayscale ultrasound (US) image of the musculocutaneous nerve demonstrates a uniform nerve caliber with normal nerve echogenicity and fascicular echotexture (arrows). C. Long-axis grayscale US image in a 37-year-old male with palpable abnormality in the arm and occasional pain. There is an ovoid echogenic lesion (arrow) along the expected course of the musculocutaneous nerve splaying the biceps and brachialis muscles. D. Long-axis color Doppler US image of the lesion demonstrates increased Doppler flow (arrow), consistent with a moderately vascular solid lesion. MR neurography images of the same patient through the mass, including E. axial T2W FS and F. coronal T1-weighted (T1W) FS post contrast images confirm the location of the lesion (arrow) along the musculocutaneous nerve course with a proximal tail sign (upper arrow on F). Pathology showed a schwannoma
Imaging of the musculocutaneous nerve using 24 MHz linear transducer. A. Photograph of the right arm demonstrates the probe position for short-axis US imaging of the musculocutaneous nerve in the upper arm. B. Long-axis grayscale ultrasound (US) image of the musculocutaneous nerve demonstrates a uniform nerve caliber with normal nerve echogenicity and fascicular echotexture (arrows). C. Long-axis grayscale US image in a 37-year-old male with palpable abnormality in the arm and occasional pain. There is an ovoid echogenic lesion (arrow) along the expected course of the musculocutaneous nerve splaying the biceps and brachialis muscles. D. Long-axis color Doppler US image of the lesion demonstrates increased Doppler flow (arrow), consistent with a moderately vascular solid lesion. MR neurography images of the same patient through the mass, including E. axial T2W FS and F. coronal T1-weighted (T1W) FS post contrast images confirm the location of the lesion (arrow) along the musculocutaneous nerve course with a proximal tail sign (upper arrow on F). Pathology showed a schwannoma

Fig. 5.

Imaging of the lateral antebrachial cutaneous nerve using 24 MHz linear transducer. A. Photograph of the right hand demonstrates the probe position for short-axis US imaging of the lateral antebrachial cutaneous nerve. B. Short-axis grayscale US image of the lateral antebrachial cutaneous nerve demonstrates a uniform nerve caliber with normal nerve echogenicity (arrow). C. Short-axis grayscale US image in a 42-year-old male with history of dog bite of the lateral elbow and numbness in the distribution of the lateral antebrachial cutaneous nerve demonstrates thickening and hypoechogenicity of the nerve at the site of the penetrating injury (arrow). D. Long-axis grayscale US image demonstrates interruption of the nerve (arrows) at the level of the scar consistent with traumatic nerve transection
Imaging of the lateral antebrachial cutaneous nerve using 24 MHz linear transducer. A. Photograph of the right hand demonstrates the probe position for short-axis US imaging of the lateral antebrachial cutaneous nerve. B. Short-axis grayscale US image of the lateral antebrachial cutaneous nerve demonstrates a uniform nerve caliber with normal nerve echogenicity (arrow). C. Short-axis grayscale US image in a 42-year-old male with history of dog bite of the lateral elbow and numbness in the distribution of the lateral antebrachial cutaneous nerve demonstrates thickening and hypoechogenicity of the nerve at the site of the penetrating injury (arrow). D. Long-axis grayscale US image demonstrates interruption of the nerve (arrows) at the level of the scar consistent with traumatic nerve transection

Fig. 6.

Imaging of the ulnar nerve using 24 MHz linear transducer. A. Demonstrates the probe position for short-axis US imaging the ulnar nerve in the cubital tunnel. B. Transverse grayscale US image of the ulnar nerve in the cubital tunnel demonstrates normal “honeycomb” appearance of the nerve in the short axis (arrow). C. Short-axis and D. Long-axis US images of the ulnar nerve in the cubital tunnel in a 45-year-old male with numbness and tingling in the hand along the ulnar nerve distribution, show fascicular thickening of the nerve (arrows). Dynamic maneuvers with elbow flexion and extension were performed to assess the ulnar nerve position. E. Short-axis US image of the ulnar nerve with the elbow extended shows the nerve in the normal position within the cubital tunnel posterior to the medial humeral epicondyle (arrow). F. Short-axis US image of the ulnar nerve in the same location with the elbow flexed depicts displacement of the ulnar nerve anterior to the medial humeral epicondyle (arrow)
Imaging of the ulnar nerve using 24 MHz linear transducer. A. Demonstrates the probe position for short-axis US imaging the ulnar nerve in the cubital tunnel. B. Transverse grayscale US image of the ulnar nerve in the cubital tunnel demonstrates normal “honeycomb” appearance of the nerve in the short axis (arrow). C. Short-axis and D. Long-axis US images of the ulnar nerve in the cubital tunnel in a 45-year-old male with numbness and tingling in the hand along the ulnar nerve distribution, show fascicular thickening of the nerve (arrows). Dynamic maneuvers with elbow flexion and extension were performed to assess the ulnar nerve position. E. Short-axis US image of the ulnar nerve with the elbow extended shows the nerve in the normal position within the cubital tunnel posterior to the medial humeral epicondyle (arrow). F. Short-axis US image of the ulnar nerve in the same location with the elbow flexed depicts displacement of the ulnar nerve anterior to the medial humeral epicondyle (arrow)

Fig. 7.

Diagram showing the common sites of the radial nerve and posterior interosseous nerve compression
Diagram showing the common sites of the radial nerve and posterior interosseous nerve compression

Fig. 8.

51-year-old male with wrist drop and clinical suspicion for posterior interosseous neuropathy. Transverse US images using 24 MHz linear transducer of the distal radial nerve and posterior interosseous nerve (PIN) from cranial to caudal were obtained. A. Shortaxis grayscale US image of the distal radial nerve shows a normal caliber and fascicular echotexture of the nerve (arrow). B. Short-axis grayscale US image of the PIN (arrow) and the superficial branch of the radial nerve (SUP), just after the radial nerve divides demonstrates a normal caliber and signal of both nerves. C. Short-axis grayscale US image of the PIN at the elbow shows thickening, hypoechogenicity and loss of fascicular pattern of the proximal posterior interosseous nerve (arrow). D. Long-axis grayscale US image of the PIN demonstrates these findings with tapering of the PIN at the level of the arcade of Fröhse. A corresponding MR neurography was performed. E. Axial T2W FS image of the elbow at the level of the radial tuberosity demonstrates increased T2 signal and thickening of the PIN (arrow). F. Sagittal reformatted 3D STIR SPACE post contrast image of the nerve, shows focal thickening and edema of the PIN proximal to the level of the arcade of Fröhse (arrow). G. Axial T1W nonfat-suppressed (NFS) image of the forearm shows severe extensor muscle atrophy (arrow), consistent with posterior interosseous neuropathy
51-year-old male with wrist drop and clinical suspicion for posterior interosseous neuropathy. Transverse US images using 24 MHz linear transducer of the distal radial nerve and posterior interosseous nerve (PIN) from cranial to caudal were obtained. A. Shortaxis grayscale US image of the distal radial nerve shows a normal caliber and fascicular echotexture of the nerve (arrow). B. Short-axis grayscale US image of the PIN (arrow) and the superficial branch of the radial nerve (SUP), just after the radial nerve divides demonstrates a normal caliber and signal of both nerves. C. Short-axis grayscale US image of the PIN at the elbow shows thickening, hypoechogenicity and loss of fascicular pattern of the proximal posterior interosseous nerve (arrow). D. Long-axis grayscale US image of the PIN demonstrates these findings with tapering of the PIN at the level of the arcade of Fröhse. A corresponding MR neurography was performed. E. Axial T2W FS image of the elbow at the level of the radial tuberosity demonstrates increased T2 signal and thickening of the PIN (arrow). F. Sagittal reformatted 3D STIR SPACE post contrast image of the nerve, shows focal thickening and edema of the PIN proximal to the level of the arcade of Fröhse (arrow). G. Axial T1W nonfat-suppressed (NFS) image of the forearm shows severe extensor muscle atrophy (arrow), consistent with posterior interosseous neuropathy

Fig. 9.

Diagram showing the common sites of median nerve compression about the elbow
Diagram showing the common sites of median nerve compression about the elbow

Fig. 10.

37-year-old male with arm pain and weakness with clinical and EMG concern for anterior interosseous neuropathy. Transverse US images of the anterior interosseous nerve (AIN) using 18 MHz linear transducer in the forearm were obtained. A. Short-axis grayscale US image in the mid forearm shows the normal caliber and echotexture of the AIN (between the calipers marked “B”), which has a fine fasciculated appearance (arrow). The median nerve (between calipers marked “A”) is larger at this level but has similar echotexture and echogenicity. B. A more distal forearm grayscale US image of the AIN demonstrates a thickened, hypoechoic appearance of the AIN (arrow). C. MR neurography axial STIR image of the mid forearm before the AIN divides from the median nerve demonstrates increased median nerve fascicular edema involving its fibers that contribute to the AIN. D. More distal forearm axial STIR MR image demonstrates diffuse pronator quadratus muscle edema felt to be related to denervation
37-year-old male with arm pain and weakness with clinical and EMG concern for anterior interosseous neuropathy. Transverse US images of the anterior interosseous nerve (AIN) using 18 MHz linear transducer in the forearm were obtained. A. Short-axis grayscale US image in the mid forearm shows the normal caliber and echotexture of the AIN (between the calipers marked “B”), which has a fine fasciculated appearance (arrow). The median nerve (between calipers marked “A”) is larger at this level but has similar echotexture and echogenicity. B. A more distal forearm grayscale US image of the AIN demonstrates a thickened, hypoechoic appearance of the AIN (arrow). C. MR neurography axial STIR image of the mid forearm before the AIN divides from the median nerve demonstrates increased median nerve fascicular edema involving its fibers that contribute to the AIN. D. More distal forearm axial STIR MR image demonstrates diffuse pronator quadratus muscle edema felt to be related to denervation

Fig. 11.

50-year-old female with palmar hand numbness in the distribution of the median nerve. A. Long-axis grayscale US image of the median nerve in the carpal tunnel using 24 MHz linear transducer demonstrated fascicular hypoechogenicity and thickening of the nerve (between calipers marked “B”), and distal narrowing of the nerve (between calipers marked “A”). B. Short-axis grayscale US image of the median nerve at the distal forearm shows a cross sectional area (CSA) of 0.19 cm2. C. More distal short-axis grayscale US image of the median nerve within the carpal tunnel shows flattening of the median nerve (arrow) with a CSA of 0.14 cm2. There is more than 0.02 cm2 difference between the CSA of the median nerve at the wrist and in the carpal tunnel, suggesting carpal tunnel syndrome
50-year-old female with palmar hand numbness in the distribution of the median nerve. A. Long-axis grayscale US image of the median nerve in the carpal tunnel using 24 MHz linear transducer demonstrated fascicular hypoechogenicity and thickening of the nerve (between calipers marked “B”), and distal narrowing of the nerve (between calipers marked “A”). B. Short-axis grayscale US image of the median nerve at the distal forearm shows a cross sectional area (CSA) of 0.19 cm2. C. More distal short-axis grayscale US image of the median nerve within the carpal tunnel shows flattening of the median nerve (arrow) with a CSA of 0.14 cm2. There is more than 0.02 cm2 difference between the CSA of the median nerve at the wrist and in the carpal tunnel, suggesting carpal tunnel syndrome

Fig. 12.

56-year-old female with brachial plexus injury presented for upper extremity nerve ultrasound evaluation. A. Short-axis grayscale ultrasound of the median nerve using 24 MHz linear transducer at the level of the carpal tunnel demonstrated a bifid median nerve (arrow). B. Short-axis color Doppler US image at more proximal level demonstrated flow within a persistent median artery (arrow)
56-year-old female with brachial plexus injury presented for upper extremity nerve ultrasound evaluation. A. Short-axis grayscale ultrasound of the median nerve using 24 MHz linear transducer at the level of the carpal tunnel demonstrated a bifid median nerve (arrow). B. Short-axis color Doppler US image at more proximal level demonstrated flow within a persistent median artery (arrow)

Fig. 13.

Imaging of the recurrent branch of the median nerve using 24 MHz linear transducer. A. Photograph of the right hand demonstrating the probe position for imaging the recurrent branch of the median nerve. B. Long-axis grayscale US image of the recurrent branch of the median nerve shows the normal sonographic appearance and caliber of the nerve (arrow). C. Long-axis grayscale US image in a 63-year-old female with right thumb pain and weakness who was referred for clinical suspicion of median neuropathy demonstrates thickening of the recurrent branch of the median nerve after its origin (arrow), consistent with neuropathy
Imaging of the recurrent branch of the median nerve using 24 MHz linear transducer. A. Photograph of the right hand demonstrating the probe position for imaging the recurrent branch of the median nerve. B. Long-axis grayscale US image of the recurrent branch of the median nerve shows the normal sonographic appearance and caliber of the nerve (arrow). C. Long-axis grayscale US image in a 63-year-old female with right thumb pain and weakness who was referred for clinical suspicion of median neuropathy demonstrates thickening of the recurrent branch of the median nerve after its origin (arrow), consistent with neuropathy

Fig. 14.

45-year-old female with constant numbness of the right thumb and index finger after endoscopic carpal tunnel release performed 2 years ago. A long-axis grayscale US image using 24 MHz linear transducer of the palmar proper digital nerve of the index finger, along the radial aspect of the digit, demonstrates an oval hypoechoic mass-like lesion in continuity with the nerve consistent with neuroma-in-continuity (arrow)
45-year-old female with constant numbness of the right thumb and index finger after endoscopic carpal tunnel release performed 2 years ago. A long-axis grayscale US image using 24 MHz linear transducer of the palmar proper digital nerve of the index finger, along the radial aspect of the digit, demonstrates an oval hypoechoic mass-like lesion in continuity with the nerve consistent with neuroma-in-continuity (arrow)

MR neurography protocol used for upper extremity evaluation. The field of view is adjusted depending on the indication

Sequence Echo time Repetition time Slice thickness Flip angle Acquisition matrix
Axial T1 10 619 3 mm 140 336\0\0\286
Axial T2 FS 104 4000 3 mm 130 256\0\0\230
Coronal STIR 49 4000 3 mm 130 272\0\0\403
Space 3D STIR post contrast 252 3000 isotropic variable 0\384\252\0
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