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Peripheral Nerve Lesions: Role of High-Resolution US¹

¹ From the Department of Radiology, No. 201, Sec 2, Shih-Pai Rd, Taipei-Veterans General Hospital and School of Medicine, National Yang Ming University, Taipei, Taiwan (H.J.C., Y.H.C., S.Y.C., C.Y.C.); and the Institute of Ultrasound, Thomas Jefferson University Hospital, Philadelphia, Pa (J.B.L.). Presented as an educational exhibit at the 2002 RSNA scientific assembly. Received April 29, 2003, revision requested July 2, revision received and accepted July 7. Address correspondence to H.J.C. (e-mail: hjchiou@vghtpe.gov.tw).

View larger version (59K): [in a new window]   Figure 1.  Photograph (lower right) shows a short segment specimen of the median nerve. US scans show parallel echogenic lines (arrows) in the longitudinal section (Sag) and a reticular pattern (arrows) in the transverse section (Tr).

View larger version (77K): [in a new window]   Figure 2.  Photograph (middle) shows the location of the median nerve. US scans show parallel echogenic lines (arrows) in the longitudinal section (Sag) and a reticular pattern (arrows) in the transverse section (Tr).

View larger version (69K): [in a new window]   Figure 3.  Photograph (right) shows the location of the sciatic nerve. US scan shows normal sciatic nerve (arrows) in the upper popliteal fossa region. BF = biceps femoris muscle, ST = semitendinosus muscle, SM = semimembranous muscle.

View larger version (61K): [in a new window]   Figure 4.  Photograph (right) shows the location of the posterior tibial and peroneal nerves. US scan shows the normal posterior tibial nerve (arrows) and common peroneal nerve (arrowheads) in the popliteal fossa. BF = biceps femoris, ST = semitendinous muscle. A = popliteal artery.

View larger version (78K): [in a new window]   Figure 5.  Drawing (right) shows the normal brachial plexus in the neck region. Transverse US scan of the right side of the neck shows the C5-C8 nerve roots behind the anterior scalene muscle (AS). MS = middle scalene muscle, c = common carotid artery, v = vertebral artery.

View larger version (71K): [in a new window]   Figure 6.  Drawing (bottom) shows the normal median nerve. US scans show the normal median nerve as parallel echoic lines (arrows) in the sagittal section (left) and as a reticular pattern (arrowheads) in the transverse section (right).

View larger version (70K): [in a new window]   Figure 7.  Drawing (right) shows the normal radial nerve. Transverse US scan shows the normal radial nerve (arrows) in the spiral groove region. TRI = triceps muscle, H = humeral bone, BR = brachioradialis muscle.

View larger version (91K): [in a new window]   Figure 8.  Traumatic neuroma. A 73-year-old woman underwent a forearm operation because of a median nerve schwannoma (open arrows, lower right image). One month later, she complained of persistent discomfort over the scar region, with a positive Tinel sign. Photograph (upper right) shows location of trauma. US scans (left images) show a hypoechoic structure with irregular margins (arrowheads) surrounding the median nerve (arrows), demonstrating scar tissue infiltration of the median nerve. Sag = sagittal, Tr = transverse.

View larger version (85K): [in a new window]   Figure 9.  Traumatic neuroma. A 48-year-old man underwent surgery after trauma to left forearm (location shown in photograph). Photograph (lower right) obtained 6 months later shows atrophy of left first web muscle (arrow). Transverse (Tr) US scans show enlarged ulnar nerve (arrowheads). Sagittal (Sag) scan shows enlarged distal ulnar nerve. U = ulnar artery.

View larger version (95K): [in a new window]   Figure 10.  Traumatic neuroma. A 56-year-old man had traumatic injuries due to a car accident, including a large laceration over the left thigh that was treated with primary sutures only. Photograph (lower right) shows location of injury. One year later, he complained of a sharply painful sensation over the scar area, with a positive Tinel sign. US scans show a hypoechoic nodule with irregular margins (arrowheads) beside the femoral artery (A) and femoral nerve (arrows). Sag = sagittal, Tr = transverse.

View larger version (83K): [in a new window]   Figure 11.  A 73-year-old man underwent brachial artery catheterization for cerebral angiography. The patient complained of a painful sensation over the elbow and right hand after the procedure. Photograph (middle) shows the location of injury. US scans of the elbow show an echo-free hematoma (arrowheads) in close contact with the median nerve (arrows) in the sagittal (Sag) view. In the transverse (Tr) view, the hematoma was found within the epineurium of the median nerve (arrows). Color Doppler image (lower left) shows the brachial artery beneath the hematoma.

View larger version (81K): [in a new window]   Figure 12.  Ulnar nerve neuritis. Photograph (bottom) shows location of the affected area. Transverse US scans of the ulnar nerve show swelling of the ulnar nerve (arrowheads) in the right arm (RT) compared with a normal ulnar nerve (arrows) in the left arm (LT) in a 35-year-old woman complaining of numbness of the fourth and fifth fingers of the right hand.

View larger version (80K): [in a new window]   Figure 13.  Lower arm abscess. Photograph (middle) shows location of the affected area. Transverse US scans show an ill-defined hypoechoic abscess (thick arrows) compressing the ulnar (UN) (thin arrows) and median (MN) (thin arrows) nerves in a 41-year-old woman with painful swelling in the lower arm.

View larger version (80K): [in a new window]   Figure 14.  Median nerve compressed by lymphadenitis. Photograph (middle) shows location of the affected area. Transverse US scans show two enlarged lymph nodes (arrows) compressing the median nerve (arrowheads) in a 30-year-old man with carpal tunnel syndrome who complained of a painful sensation over the ventral aspect of the arm. A = brachial artery, V = brachial vein.

View larger version (54K): [in a new window]   Figure 15.  Photograph shows the scanning technique for the ulnar nerve.

View larger version (73K): [in a new window]   Figure 16.  Normal ulnar nerve. Photograph (right) shows the area scanned. A 60-year-old man volunteered to undergo a US examination during a routine physical health check-up. Transverse US scan of his right dorsal medial arm at a level 5 cm above the medial epicondyle shows a round-to-ovoid hypoechoic ulnar nerve with a reticular pattern (arrows). T = medial head of triceps muscle, B = biceps muscle.

View larger version (60K): [in a new window]   Figure 17.  Normal ulnar nerve (epicondyle level) in the same volunteer as in Figure 16. Photograph (right) shows the area scanned. Transverse US scan at the right medial epicondyle level shows a 0.13 x 0.51 cm ovoid hypoechoic ulnar nerve (arrows). E = medial epicondyle.

View larger version (72K): [in a new window]   Figure 18.  Normal ulnar nerve (forearm level) in the same volunteer as in Figure 16. Photograph (right) shows the area scanned. Transverse US scan of the right medial forearm at a level 5 cm below distal to the medial epicondyle shows an ovoid heterogeneously echoic ulnar nerve (arrows) with a reticular pattern, lying between the flexor carpi ulnaris (C) and the flexor digitorum profundus (D) muscles.

View larger version (79K): [in a new window]   Figure 19.  Cubital tunnel syndrome. Photograph (right) shows the area scanned. Transverse US scan of the right elbow (RT) shows swelling of the ulnar nerve (arrowheads) at the medial epicondyle level, compared with the normal left arm (LT) (arrows). This 55-year-old woman complained of numbness of the fourth and fifth fingers of the right hand. Cubital tunnel syndrome was diagnosed by means of nerve conduction velocities and electromyography.

View larger version (67K): [in a new window]   Figure 20.  Cubital tunnel syndrome. Transverse US scan in a 45-year-old woman shows swelling of the ulnar nerve (arrows) in the left arm (LT) at the medial epicondyle level, compared with a normal ulnar nerve (arrows) in the right arm (RT).

View larger version (90K): [in a new window]   Figure 21.  Cubital tunnel syndrome: ganglion. Photograph (lower right) shows the area scanned. US scans show a hypoechoic ganglion (arrowheads) compressed to the ulnar nerve (arrows) in the transverse (Tr) and sagittal (Sag) views in a 50-year-old man. Color Doppler US shows no vascularity in the ganglion.

View larger version (70K): [in a new window]   Figure 22.  Ulnar nerve dislocation. Photographs (bottom) show the area scanned in extension and flexion. Transverse US scans of the elbow in extension and flexion in a 25-year-old man complaining of occasional numbness of the fourth and fifth fingers show an unusual location of the ulnar nerve (arrowheads), lateral to the medial epicondyle in extension but medial to the medial epicondyle during flexion E = medial epicondyle.

View larger version (80K): [in a new window]   Figure 23.  Guyon tunnel syndrome: ganglion. Photograph (bottom) shows the area scanned. A 30-year-old woman complained of a palpable nodule in the ulnar aspect of the wrist, with numbness of the fifth finger. Transverse US scans of the wrist show an anechoic ganglion (G) compressing the ulnar nerve (arrowheads) at wrist level. The ulnar nerve is located between the ulnar artery and ganglion.

View larger version (86K): [in a new window]   Figure 24.  Guyon tunnel syndrome. Photograph (bottom right) shows the area scanned. Transverse (left) and sagittal (top right) US scans show a well-defined hypoechoic nodule (arrowheads) in the wrist, compressing the ulnar nerve (arrows) in a 48-year-old man in whom leiomyoma was diagnosed. Color Doppler image (bottom left) shows the ulnar nerve (A) located between the tumor and ulnar artery.

View larger version (93K): [in a new window]   Figure 25.  Pronator syndrome. Photograph (bottom right) shows the area scanned. Sagittal (top left) and transverse (bottom left) US scans show a small anechoic ganglion (arrowheads) compressing the median nerve (arrows) in a 33-year-old woman with numbness of the right palm during compression of the anterior cubital fossa. Compare the right arm (RT) and the normal left arm (LT) (toop right) pronator tunnel regions. Large A = brachial artery. Small A and B are measurements of the size of the median nerve.

View larger version (81K): [in a new window]   Figure 26.  Carpal tunnel syndrome. Photograph (bottom right) shows the area scanned. Sagittal US scans show swelling of the proximal portion of the median nerve (arrows) in the right wrist (RT) in a 45-year-old woman. Color Doppler US shows increased vascularity in the swollen part of the nerve. Compare with the normal median nerve (arrowheads) in the left wrist (LT).

View larger version (67K): [in a new window]   Figure 27.  Carpal tunnel syndrome: ganglion. Photograph (right) shows the area scanned. Transverse US scan of median nerve at wrist level shows a hypoechoic ganglion (arrows) compressing the median nerve (arrowheads) in a 30-year-old woman who complained of numbness of the left hand.

View larger version (74K): [in a new window]   Figure 28.  Palm ganglion with median nerve compression. Photograph (right) shows the area scanned. Transverse US scan of the median nerve at wrist level shows an anechoic ganglion (arrows) compressing the median nerve (arrowheads) in a 60-year-old man.

View larger version (73K): [in a new window]   Figure 29.  Tarsal tunnel syndrome: ganglion. Photograph (bottom) shows the area scanned. A 28-year-old woman complained of a painful sensation with radiation to the foot during compression of the medial aspect of the right ankle. US of the medial malleolus in transverse (Tr) and sagittal (Sag) views shows an anechoic ganglion (arrowheads) with compression of the posterior tibial nerve (arrows). A = posterior tibial artery.

View larger version (75K): [in a new window]   Figure 30.  Tarsal tunnel syndrome: ganglion. Photograph (bottom) shows the area scanned. A 38-year-old woman complained of a palpable nodule over the medial aspect of the left ankle. US in transverse (Tr) and sagittal (Sag) views shows an anechoic ganglion (G) with compression of the posterior tibial nerve (arrowheads).

View larger version (71K): [in a new window]   Figure 31.  Ulnar nerve compressed by hemangioma. Photograph (bottom) shows the area scanned. Transverse (Tr) US scan shows intramuscular hemangioma (arrows) with compression of the ulnar nerve (arrowheads) in a 32-year-old woman complaining of a palpable soft mass in the dorsal aspect of the arm. Sagittal (Sag) color Doppler scan shows hypervascularity in the hemangioma (arrows).

View larger version (78K): [in a new window]   Figure 32.  Ulnar nerve compressed by tumor. Photograph (bottom) shows the area scanned. A 50-year-old man had cubital tunnel syndrome caused by tumor (arrowheads) compression of the ulnar nerve (arrows). Sagittal (Sag) US and color Doppler scans show hypervascularity in the tumor, which was identified as a sarcomatous metastasis.

View larger version (84K): [in a new window]   Figure 33.  Radial nerve compression by ganglion. Photograph (bottom) shows the area scanned. US scans in transverse (Tr) and sagittal (Sag) views show an anechoic ganglion (G) compressing the radial nerve (arrowheads) in a 45-year-old woman complaining of a palpable nodule in the anterior cubital fossa, with a positive Tinel sign.

View larger version (65K): [in a new window]   Figure 34.  Compression of the common peroneal nerve. An 18-year-old man complained of numbness in the lateral aspect of the left lower leg after primary suture for injuries sustained in a car accident. Sagittal US scan shows focal swelling of the common peroneal nerve (arrows). The patient underwent surgery (photograph), during which fibrotic band compression of the common peroneal nerve, resulting in proximal edema (arrows), was found.

View larger version (88K): [in a new window]   Figure 35.  Neurofibromatosis: diffuse type. Photograph (right) shows the discolored skin regions in an 8-year-old girl and the areas scanned. US scan of the discolored skin region (top left) shows infiltrative hypoechoic nodules (arrowheads) within the dermis to the subcutaneous layer. Compare with the scans of the normal skin region (middle). Color Doppler scan (bottom left) shows increased vascularity within the tumor.

View larger version (62K): [in a new window]   Figure 36.  Glomus tumor. Photograph (right) shows the area scanned. A 47-year-old woman complained of sharp pain during compression and a temperature change in her right index fingertip. Sagittal (Sag) US scan shows a well-defined hypoechoic nodule (G) with bone erosion (arrows). Color Doppler scan shows hypervascularity in the nodule. A glomus tumor was identified.

View larger version (70K): [in a new window]   Figure 37.  Ulnar nerve encased by fibromatosis. Photograph (bottom) shows the area scanned. A 22-year-old woman complained of a painful nodule in the hypothenar region of the palm. US scans in transverse (Tr) and sagittal (Sag) views show a lobulated hypoechoic nodule (arrows) encasing the ulnar nerve (arrowheads). The nodule proved to be fibromatosis.

View larger version (88K): [in a new window]   Figure 38.  Sarcoma invasion of the posterior tibial nerve. Photograph (bottom right) shows the area scanned. A 57-year-old woman complained of a painful mass in the popliteal fossa. US scans in transverse (Tr) and sagittal (Sag) views show an ill-defined hypoechoic mass (arrows) with invasion of the posterior tibial nerve (arrowheads). The mass was identified as high-grade sarcoma.

View larger version (86K): [in a new window]   Figure 39.  Radial nerve compressed by metastasis. Drawing (middle) shows the area scanned. A 70-year-old woman complained of a painful mass in the right arm. US scans in transverse (Tr) and sagittal (Sag) views show humeral bone destruction, with a surrounding soft-tissue mass (T) compressing the radial nerve (arrowheads). Hypervascularity within the tumor is noted on the color Doppler scan. Metastatic carcinoma was diagnosed.

View larger version (78K): [in a new window]   Figure 40.  Schwannoma. Photograph (bottom) shows the area scanned. US scans show a lobulated mass (arrows) along the posterior tibial nerve in a 48-year-old woman complaining of a painful mass in the calf, identified as schwannoma.

View larger version (96K): [in a new window]   Figure 41.  Radial nerve schwannoma. Photograph (right) shows the area scanned. US scans show a heterogeneously hypoechoic nodule (arrows) with cystic and solid components along the radial nerve (arrowheads) in a 86-year-old man complaining of a painful nodule in the arm, identified as schwannoma.

View larger version (90K): [in a new window]   Figure 42.  Common peroneal nerve schwannoma. Photograph (bottom right) shows the area scanned. A 30-year-old woman complained of a painful nodule in the lateral popliteal region. Sagittal US scan shows a hypoechoic nodule (arrows) along the common peroneal nerve (arrowheads). Color Doppler scan shows a hypervascular tumor.

View larger version (87K): [in a new window]   Figure 43.  Hand schwannoma. Photograph (right) shows the area scanned. A 27-year-old woman complained of painful nodules in the third finger. US scans in transverse (Tr) and sagittal (Sag) views show a lobulated hypoechoic lesion (arrows) within the digital nerve. Compare with the transverse view of the fourth finger (4th) with a normal digital nerve (arrowheads). t = flexor tendon.

View larger version (78K): [in a new window]   Figure 44.  Posterior tibial nerve neurofibroma. Photograph (bottom) shows the area scanned. Sagittal US scans show a heterogeneously echoic nodule with a target pattern and well-defined margin (arrowheads) in the posterior tibial nerve (arrows) in a 55-year-old woman complaining of a painful nodule in the left calf. Color Doppler scan shows hypervascular tumor, later identified as a neurofibroma.

View larger version (74K): [in a new window]   Figure 45.  Medial tarsal nerve neurofibroma. Photograph (middle) shows the area scanned. US scan shows a hypoechoic nodule (arrowheads) with a well-defined margin in close contact with the medial tarsal nerve (arrows) in a 38-year-old man complaining of foot pain and with a positive Tinel sign in the medial aspect of the foot. Hypervascularity in the tumor, identified as neurofibroma, is noted on the color Doppler scan.

View larger version (77K): [in a new window]   Figure 46.  Median nerve neurofibroma. Photograph (middle) shows the area scanned. A 45-year-old man complained of a painful nodule in the palmar aspect of the forearm. US scans in transverse (Tr) and sagittal (Sag) views show a well-defined hypoechoic nodule (arrows) in close contact with the median nerve (arrowheads). Color Doppler scan shows hypervascularity within the tumor, which was identified as a neurofibroma.

View larger version (73K): [in a new window]   Figure 47.  Neurofibroma. Photograph (middle) shows the area scanned. A 71-year-old man complained of a painful mass in the medial aspect of his right thigh. US scans show a well-defined hypoechoic mass (arrowheads) with cystic and solid component in the medial thigh. Color Doppler scan shows hypervascularity within the tumor, which was identified as a neurofibroma.

View larger version (73K): [in a new window]   Figure 48.  Congenital neurofibromatosis (plexiform type). Photograph and drawings show the areas scanned. A 71-year-old man complained of multiple palpable nodules in all four limbs. US scans show several well-defined hypoechoic nodules along the tracts of peripheral nerves (median [MN}, radial [RN], and ulnar [UN]) in the arm. Color Doppler scan shows that the tumor has poor vascularity. High-resolution US of the diffuse type of NF1 usually shows diffuse, tiny hypoechoic nodules infiltrating the subcutaneous and dermis layers (Fig 35).