Method for carrying out ultrasonic median and ulnar nerve rupture diagnostics at forearm level and controlling their recovery after suturing

FIELD: medicine.

SUBSTANCE: method involves measuring uniform ampoule-like enlargement area of nerve trunk smoothly transforming itself into hypoechogenic formation with smooth distinct outline of no longitudinal striation echo-structure in longitudinal projection and enlarged rounded hypoechogenic region with changed echo-structure without granularity in transverse projection observed in visualizing the nerve trunk enlargement in transverse scanning mode. Area of zone proximally located 3-4 cm far from lesion region. Asymmetry coefficient is determined as ratio of the values. The coefficient value being greater than 2.4, terminal neuroma is diagnosed witnessing complete nerve rupture. When visualizing the single side nerve boundary enlargement in both projections with hypoechogenic zone of disturbed echogenicity structure and retained nerve segment unchanged at this level under asymmetry coefficient value being less than 2.4, lateral neuroma is diagnosed to be the case witnessing partial nerve rupture. When finding zone of linear striation echo-structure in longitudinal scanning mode and showing echo-structure granularity in transverse scanning mode not greater than 1.7 times proximal zone area 2-6 months later after the operation, fascicle nerve structure recovery in suture vicinity is considered to take place. Ampoule-like enlarged, hypoechogenic formation having partially disturbed inhomogeneous heterogeneous structure 1.7 times greater than proximal zone area being found within this period, intensive nerve trunk connective tissue elements proliferation and intratrunk neuroma is proved to be the case.

EFFECT: high accuracy in determining nerve injury degree; enhanced effectiveness in controlling postoperative nerve fiber recovery.

2 cl, 3 dwg

 

The present invention relates to medicine, namely to traumatology and neurosurgery.

There is a method of ultrasound diagnosis of carpal tunnel syndrome, described in the methodological recommendations No. 95/160 “Diagnosis and treatment of compressive neuropathies”, authors: Bersnev VP, Kokin G.S., other, St. Petersburg, 1995, 9 C.; article Bouffard J.I. “Sonography of tendons” in the journal Ultrasound Quarterly, 1993, V.11, No. 4, R-275.

There is also known a method of ultrasonic diagnostics of tumors of the nerve trunk is schwannomas described Simonovsky V. in the article “Peripheral nerve schwannoma preoperatively diagnosed by sonography: report of three cases and discussion” W. Eur. J. Radiol, 1997, Jul 25:1, 47-51.

Ultrasound diagnosis of these pathological conditions reflects only quality sonographically characteristics of neural stem: level echogenicity of the damage zone, the clarity of boundaries nerve, echostructure, not giving information about signs of nerve damage.

Closest to the proposed invention is a method of ultrasonic diagnostics limit newrom at breaks peripheral nerves, described Chhem RK, Cardinal E. Soft-tissue masses: an algorithmic approach. In: Guidelines and gamuts in musculoskeletal ultrosound. Somerset (NJ): Wiley-Liss, 1999, p.311-23. In accordance with this method the end neuroma identified by identifying in the longitudinal projection of uniform ampalavanar extensions of the nerve trunk, smoothly transitioning into hypoechogenic education with smooth, clear contours, with the broken echo tissue in the form of loss characteristic longitudinal iscertainly, as if in a transverse projection on the same level define an enlarged, rounded or oval, hypoechoic education with a modified echo tissue in the absence of grain - diagnose end-neuroma and complete interruption of the nerve.

However, in this method reflects the strict quality criteria of the end neuroma upon interruption of the nerve. The disadvantages of this method are the absence of high-quality ultrasonic characteristics of the side neuroma incomplete interruption of the nerve, quantitative ultrasound characteristics of the side neuroma incomplete interruption of the nerve, quantitative ultrasonographically criteria end neuroma, and the lack of qualitative and quantitative characteristics of regeneration after nerve suture.

The present invention is the determination of the degree of nerve injury and postoperative control of regeneration of nerve fibers.

This problem is solved due to the fact that in the method of the ultrasonic diagnostic break the median and ulnar nerves at the level of the forearm and control their regeneration after seam by ultrasonic scanning nerves in the projection of their injuries, when identifying in case a longitudinal scan of the uniform inuloides the expansion of the nerve trunk, smoothly transitioning into hypoechoic education with smooth, clear contours with echo tissue without the characteristic longitudinal iscertainly, and in the case of transverse scan at the level of the enlarged, rounded, hypoechoic area with a modified echo tissue without the presence of grain size, measure the area of education in the transverse projection and the area located proximal to the damaged area of 3-4 cm, determine the asymmetry factor, equal to the ratio of these values and if the value of the asymmetry factor more 2,4, diagnose the presence of end neuroma, indicating a complete interruption of the nerve, and if visualization in both projections unilateral enlargement of the nerve simultaneously with the presence of hypoechoic areas disturbed echoes and preservation at this level an unmodified section of the nerve, with the value of the asymmetry factor less than 2, 4, diagnosed the side neuroma, which indicates incomplete interruption of the nerve, the detection within two to six months after surgery in the area of the welding seam nerve plot echostructure in the form of a linear iscertainly for longitudinal scan and echo-structure having a grain size in the transverse scan, not exceeding an area of more than 1.7 times the area of the proximal section, state vosstanovlenie the beam structure of the nerve in the area of the seam, and this is evidence of satisfactory progress the regeneration of nerve fibers, and the definition of these terms in the area of the seam ampulove enlarged, hypoechoic with partially broken, heterogeneous echostructure of education, exceeding an area of more than 1.7 times the area of the proximal section, indicative of the intense proliferation of connective tissue elements of the stroma of the nerve trunk and the formation of vnutridvorovyh neuroma.

The method is as follows. Linear transducer with a frequency of 5-10 MHz and a maximum penetration depth of 3 cm mounted on the forearm perpendicular to the projection of the examined nerve 3-4 cm proximal to the intended areas of damage. In the transverse projection define the nerve. Proximally located section of the nerve trunk of the nerve is oval in shape, smooth, clear boundary, moderate echogenicity, echo-structure in the form of fine-grained inclusions. Measure the square - Sp this section of the nerve, setting ultrasonic border along its outline. Further, the sensor include a longitudinal axis of the nerve. The intact proximal section of the median or ulnar nerve is defined as malosmadulu, moderate echogenicity education a linear shape with smooth, sharp edges, echostructure in the form of longitudinal iscertainly.

The sensor is moved along an axis OAD is the t to the damage zone. When identifying uniform ampalavanar extensions of the nerve trunk, smoothly transitioning into hypoechoic education with smooth, clear contours and loss of internal longitudinal iscertainly mark on the skin the maximum projection of the extended area. At this level sensor is transferred to the transverse projection. When rendering the enlarged, rounded, hypoechoic area of the nerve with the broken echo tissue in the absence of graininess measure the area - Sz. Calculate the asymmetry factor k equal to the ratio of the area of the enlarged section of the nerve to the area of the proximal section:

k=Sz/Sp, where

k - coefficient of asymmetry;

Sz - the area of the nerve in the damage zone, as measured transverse scanning;

Sp is the area of the nerve that is located 3-4 cm proximal to the damaged area, measured in the transverse scan.

When k>2,4 (the lower bound of the confidence interval of the ratio of the square newrome to the area of the proximal part of the nerve) diagnose the presence of end neuroma that is interpreted as a complete break of the nerve (see Fig. 1A, 1B). Visualization in both projections of a unilateral breach of the path of the nerve with the presence of hypoechoic zone, a violation of the echoes in the background of unmodified plot shows the lateral neuroma and, consequently, on the under plumage is ive nerve trunk (see Fig. 1B).

Repeated ultrasound examination should take place two to six months after surgery, using the proposed scheme sonography and determining factor.

The detection zone is made of nerve suture site with echostructure in the form of a linear iscertainly for longitudinal scanning and grain size in the transverse scan, not exceeding an area of more than 1.7 times the area of the proximal section, shows the reconstruction beam structure of the nerve in the area of the seam, a neurotic distal segment of the nerve and of satisfactory progress the regeneration of nerve fibers (1.7 to the upper boundary of the confidence interval of the ratio of the area of the seam to the area of the proximal part of the nerve with a positive clinical dynamics of regenerative-reinnervation process) (see Fig. 2A, 2B).

Visualization ampulove enlarged, hypoechoic education with partially broken, heterogeneous echostructure, exceeding an area of more than 1.7 times the area of the proximal section (k>1.7)and are characterized by strong growth of connective tissue elements of the stroma of the nerve trunk and the formation of vnutrishkolnoe neuroma (Fig. 3A, 3b). This indicates poor neurotic distal segment of the nerve.

Clinical example.

Patient C., 52 years old (case history No. 20385, No. 571/02), 11.08.02 household received incised wound, break flexor tendon IV-V fingers, median, ulnar nerve and ulnar artery at the level of the lower third of the left forearm. In the Central district hospital for the initial debridement and primary suture of flexor tendons, median nerve, the ligation of the ulnar artery. Turned in NIETO because of progressive deterioration of function of the left hand (limitation of movements in the joints of the left hand, the lack of sensitivity in the area of II-V fingers in the area of innervation of the median and ulnar nerves), the progression of muscle atrophy and the formation of neurogenic deformation of the brush. System evaluation the Polenov research neurosurgical Institute them. Polenov motor and sensory nerve function assessed as M0S1. Ultrasonography performed 24.10.02. In the lateral projection was visualized rounded hypoechoic education with clear boundaries and violated the echostructure in the absence of grain size (see Fig. 1A). For longitudinal scanning in the damage zone of the ulnar nerve revealed a uniform anolamine expansion of the nerve trunk, fades into hypoechoic education with smooth, clear contours and loss of the characteristic longitudinal iscertainly (see Fig. 1B). When measuring the area of the proximal section in the transverse projection Sp=0.1 cm2the area of the nerve is in the damage zone Sz=0,36 cm 2, k=3,6, testified to the presence of end neuroma and break the ulnar nerve. By ultrasound scanning of the median nerve in the area of primary seam identified ampulove enlarged, hypoechoic education with partially broken, heterogeneous echostructure (see Fig. 3A, 3b). The area of the proximal section Sp=0,12 cm2the area of the nerve in the area of primary seam Sz=0,29 cm2, k=2,41. Such a value of the asymmetry factor testified enhanced proliferation of connective tissue elements of the stroma of the nerve trunk and the formation vnutrishkolnoe neuroma.

30.10.02 in the Department of surgery of a brush made revision of the median and ulnar nerves. Revealed a complete break of the ulnar nerve and ulnar artery, absence of sprouting of nerve fibers through the welded area of the median nerve. Operation performed: microsurgical epidurally seam median and ulnar nerves, endovascular dilatation of the stubs of the ulnar artery, plastic, its defect autovenous grafts, borivali suture of flexor tendon IV-V fingers. The patient received a course of rehabilitation measures (physical therapy, physical therapy, massage, reflexology, medical treatment). Six months after surgery (27.04.03) by ultrasound scanning of the ulnar nerve in the area of the welding seam visualized plot with ehostruktura is in the form of a linear iscertainly for longitudinal scanning and grain size in a cross. The area of the proximal segment of the nerve Sp=0,09 cm2the area of the nerve in the area of the seam Sz=0,16 cm2, k=1.7, which testified to the sprouting of nerve fibers through the zone of the weld and of satisfactory progress of regeneration (see Fig. 2A, 2B).

At ultrasonography of the median nerve in the area of the weld revealed similar sonographic picture, Sp=0,11 cm2, Sz=0,18 cm2, k=1,6. Such a value of the asymmetry factor testified satisfactory progress of regeneration.

When examining the patient six months after the operation defined positive dynamics of clinical manifestations of nerve regeneration: motor and sensory function is evaluated as M3S3 that the evaluation of the Polenov research neurosurgical Institute them. Polenov regarded as a satisfactory result at this time.

1. The method of an ultrasonic diagnostic break the median and ulnar nerves of the forearm and control their regeneration after seam by ultrasonic scanning nerves in the projection of the damage, characterized in that when rendering in the longitudinal projection of uniform ampalavanar extensions of the nerve trunk, smoothly transitioning into hypoechoic education with smooth clear contours, echostructure without longitudinal iscertainly, and a transverse projection on the same level-large, rounded, hypoechoic Uch is STCA with a modified echo tissue without the presence of grit, measure the area under the cross-scan and area located proximal to the damaged area of 3-4 cm, determine the asymmetry factor, equal to the ratio of these values, and, if the coefficient is greater 2,4, diagnose the presence of end neuroma, indicating a complete interruption of the nerve, and when rendering in both projections unilateral enlargement of the nerve simultaneously with the presence of hypoechoic areas disturbed echoes and maintaining this level of constant section of the nerve with the value of the asymmetry factor less than 2,4 diagnose lateral neuroma, which indicates incomplete interruption of the nerve.

2. The method of an ultrasonic diagnostic break the median and ulnar nerves at the level of the forearm and control their regeneration after seam, characterized in that when detecting two to six months after surgery in the area of the welding seam area with echostructure in the form of a linear iscertainly for longitudinal scanning and echostructure with grain, while transverse scanning, not exceeding an area of more than 1.7 times the area of the proximal section, state the restoring beam structure of the nerve in the area of the seam, and the definition of these terms in the area of the seam ampulove-enlarged, hypoechoic with partially broken, heterogeneous echostructure clicks the education, exceeding an area of more than 1.7 times the area of the proximal section is indicative of the intense proliferation of connective tissue elements of the stroma of the nerve trunk and the formation of vnutridvorovyh neuroma.



 

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