正中神经松解术联合屈肌腱滑膜切除治疗腕管综合征的疗效

目的 探讨正中神经松解术联合屈肌腱滑膜切除治疗腕管综合征(CTS)的疗效.方法 选择2017年1月至2018年12月上海德济医院诊治的CTS患者117例为研究对象,按照手术方式不同分为观察组(74例,接受正中神经松解术联合屈肌腱滑膜切除治疗)和对照组(43例,接受正中神经松解术治疗).比较两组疗效,手术前后握力、捏力、...     

超声定量测定正中神经诊断腕管综合征

目的 研究高频超声定量测定正中神经诊断腕管综合征,并探索有价值的诊断指标及其标准.方法 对32例经电生理检查确诊的腕管综合征患者及30例正常人的腕管行高频超声检测,两组间的差异采用t检验,超声诊断标准的确定采用ROC曲线分析.结果 除掌侧位移(PD)和钩骨钩水平膨胀率(SR3)外,腕管综合征患者正中神经的内径(D)、腕管3个水平的横径(a)、前后径(b)、横截面积(CSA)、扁平率(FR)以及SR2均较正常组增大,差异均有统计学意义(t分别=2.45、2.56、3.16、2.51、2.66、2.78、3.05、2.28、4.11、2.89、3.37、2.89、3.06、2.76,P均＜0.05).其中正中神经豌豆骨水平CSA临床诊断价值最大,当其临界值定为＞0.11 cm2时,对应的敏感度、特异度分别为89.60%、95.30%.结论 高频超声测定正中神经是一种能够准确诊断腕管综合征的新方法,其中以豌豆骨水平CSA的诊断价值最大.     

高频超声检测腕管段正中血管神经束解剖变异及其临床意义

目的探讨高频超声对腕管段正中血管神经束解剖变异的检测价值及其在腕管综合征诊治中的临床意义。方法对500例健康志愿者的1000只手腕部腕管结构及前臂行高频超声检查,记录腕管段正中神经分叉、永存正中动、静脉的位置及分布,测量腕管段永存正中动、静脉的直径,于豌豆骨水平测量正中神经的横截面积。结果①共检出正中神经分叉者34例(41处),检出率4.1%,且均分为两支,其桡侧支横截面积均大于尺侧支[(0.075±0.015)cm2vs.(0.023±0.005)cm2],差异有统计学意义(P0.05);27例单侧正中神经分叉者分叉侧两分支横截面积之和与健侧同一位置横截面积比较,差异无统计学意义;②共检出永存正中动脉者15例(20处),检出率2.0%;永存正中动脉直径0.04～0.19 cm,平均(0.11±0.04)cm,其中13例伴有永存正中静脉,检出率1.3%;③在34例正中神经分叉和15例永存正中动脉阳性者中,正中神经分叉合并永存正中动脉者均为16处,占比为39%、80%,差异有统计学意义(χ2=9.050,P=0.003)。结论高频超声可以清晰显示正常成人腕管段正中血管神经束的解剖变异,有助于临床医师准确诊断腕管综合征,具有较好应用价值。     

健康人腕管内正中神经的超声显像

目的 :研究正常健康人腕管内正中神经的超声回声表现。方法 :对 118例正常健康人腕管行高频超声检查 ,观察正中神经的形态、大小、解剖关系及回声表现 ;且在桡骨远端、豌豆骨及钩状骨切面测量正中神经的前后、左右径及截面积 ,并计算正中神经的扁平率和肿胀率。结果 :高频超声能纵、横向显示正中神经。横断面上正中神经呈圆形或类圆形低回声区 ,周围包绕以稍强回声 ;纵断面上 ,正中神经呈条带状弱回声。本组正中神经的前后、左右径及截面积分别为 :桡骨远端平面 4 2 5± 0 5 0mm、 1 92± 0 2 0mm、 6 0 4± 1 0 0mm2 ;豌豆骨平面5 0 8± 0 4 6mm、 1 88± 0 2 0mm、 7 19± 1 2 3mm2 ;钩骨平面 5 6 8± 0 6 2mm、 1 5 8± 0 2 0mm、 6 3± 1 17mm2 。正中神经平均扁平率和腕横韧带的膨隆率分别为 :桡骨远端平面 2 2 4± 0 4 1;豌豆骨平面 2 73± 0 4 5、 1 91±0 77mm ;钩骨平面 3 0 5± 0 4 7、 1 82± 0 5 9mm。正中神经平均肿胀率 :16 2 0± 0 17。结论 :高频超声能清楚显示腕管内正中神经的形态、大小及其关系 ,并能测量正中神经截面积等指标 ,有一定临床应用价值     

正中神经压迫试验对腕管综合征神经传导速度的影响

目的比较正中神经压迫试验对腕管综合征（carpal tunnel syndrome,CTS）患者正中神经传导速度的影响。方法设置CTS组和对照组两个组别,共29例受试者纳入研究。CTS组为14例CTS患者,对照组为15例健康受试者。神经传导速度测定包括正中神经和尺神经的感觉传导末端潜伏期（distal sensory latency,DSL）、感觉神经动作电位（sensory nerve action potential,SNAP）、跨腕关节感觉传导速度（sensory conduction velocity,SCV）、运动传导末端潜伏期（distal motor latency,DML）及复合肌肉动作电位（compound muscle action potential,CMAP）。先测感觉传导,再测运动传导。正中神经压迫试验5min后再次测量上述指标。结果正中神经压迫试验前后电生理检查考虑诊断CTS分别为22侧和24侧。压迫正中神经后,CTS组正中神经DSL较压迫前显著延长（P〈0.05）。CTS组尺神经和对照组正中神经及尺神经的各参数在压迫前后均无显著改变（P〉0.05）。与对照组相比,在压迫试验前后CTS组的正中神经DSL和DML均明显延长（P〈0.05）,尺神经DSL和DML均无显著改变（P〉0.05）。结论正中神经压迫试验5min能使CTS患者正中神经的感觉传导末端潜伏时明显延长,有助于提高神经传导测定对早期CTS的诊断率。     

肌腱滑膜炎致急性腕管综合征超声表现二例

腕管综合征是正中神经在腕管内被卡压而产生正中神经感觉或运动功能障碍的一组症状与体征,分急性与慢性.急性腕管综合征多由创伤和急性炎症造成,慢性腕管综合征病因不明,可能与内分泌等因素有关.现将应用高频超声诊断肌腱滑膜炎所致急性腕管综合征2例,报道如下.     

腕管内正中神经变异的声像图表现及其临床意义

目的 探讨腕管正中神经及伴行结构变异在人群中的发生率、超声表现及其在腕管综合征诊断中的意义.方法 对180位健康志愿者的360只手腕部腕管结构及前臂进行高频超声检查.检查前臂和腕部正中神经走行,先进行腕管结构的横断面扫查,确认正中神经位置后,采用连续横断面扫查法向近端前臂进行动态观察并适当结合纵断面扫查,记录图像资料.结果 腕管正中神经及伴行结构变异:①正中神经高位分叉2例(0.56％);②正中神经裂17例(4.72％);③腕部正中神经区发现永存正中动脉22例(6.11％),并且2例(0.56％)永存正中动脉周有静脉伴存.永存正中动脉出现伴随正中神经走形变异16例(4.44％).结论 腕部高频超声检查能够敏感地发现正中神经变异,认识这些变异,有助于正确诊断腕管综合征.     

高频超声在腕管综合征病因学评价中的应用

目的探讨高频超声在评价腕管综合征病因中的作用。 方法选取2015年3月至2019年12月在解放军总医院经电生理检查诊断或手术证实腕管综合征的患者,首先对腕管进行灰阶超声检查,观察腕管内正中神经的位置、走向,神经受压情况、神经束结构、神经外膜回声以及神经周围结构的异常,横切面扫查腕管及正中神经时观察正中神经横截面情况、测量豌豆骨平面正中神经的横截面积以及观察神经周围结构的异常;应用能量多普勒超声以观察正中神经及腕管内其他结构的血流情况。采用独立样本t检验比较患侧腕和无症状侧腕豌豆骨平面正中神经横截面面积的差异。利用受试者操作特征（ROC）曲线分析豌豆骨平面正中神经的横截面面积的诊断价值并找出最佳的诊断界值。 结果腕管综合征患者63例,共95侧腕。腕管综合征患者高频超声表现为腕管内正中神经的卡压近端肿胀、增粗,神经束结构模糊,神经外膜增厚。能量多普勒超声显示正中神经内血流信号增加。患侧腕与无症状侧腕的豌豆骨平面正中神经横截面面积比较［（15.91±5.95）mm² vs（8.71±1.62）mm²］,差异具有统计学意义（t=-2.51,P＜0.001）,ROC曲线下面积为0.946,截断值为10.5 mm2时,敏感度为89.5%,特异度为83.9%。高频超声诊断为特发性腕管综合征者73侧腕（76.8%,73/95）,可明确诊断病因的共22侧腕（23.2%,22/95）,其中13侧腕（13.7%,13/95）为腕管内屈肌腱腱鞘炎,1侧腕（1.1%,1/95）为腕管内屈肌腱腱鞘积液,2侧腕（2.1%,2/95）为腕管内腱鞘囊肿,1侧腕（1.1%,1/95）为腕管内实性肿块,2侧腕（2.1%,2/95）为腕管内指浅屈肌肌腹过低,2侧腕（2.1%,2/95）为正中神经高位分叉伴永存正中动脉,1侧腕（1.1%,1/95）为桡骨远端术后瘢痕压迫正中神经。 结论高频超声可作为评估腕管综合征病因的一种手段。     

高频超声对上肢正中神经正常值的研究

目的通过高频超声获取正中神经的横截面积(cross-sectional area,CSA)正常值并探讨其与周围组织的关系,为临床诊断不同的外周神经疾病提供依据。方法对200例健康志愿者沿正中神经行程进行高频超声观察,依次测量7个位点的CSA[腕横纹、腕管入口(豌豆骨)、腕管出口(钩骨)、腕横纹上6cm、正中神经穿出旋前圆肌处(前臂近端)、肱骨内髁上4cm、肱骨中点],每个位点重复测量3次取其平均值,并进行CSA与身高、体重的相关性分析。结果高频超声下正常人正中神经呈筛网状低回声图像,横截面在不同部位分别表现为圆形、椭圆形或三角形。正中神经在前述7个位点的CSA依次为(8.67±1.24)mm2、(8.68±1.22)mm2、(8.56±1.25)mm2、(7.11±1.33)mm2、(7.08±1.21)mm2、(9.38±1.28)mm2、(9.48±1.28)mm2;左右上肢之间比较CSA差异无统计学意义;正中神经在腕横纹上6cm、肱骨内髁上4cm、肱骨中点处的CSA同年龄组男女之间差异有统计学意义;正中神经在腕横纹处、腕管出入口、肱骨内髁上4cm处中老年人比青年人增粗;CSA与身高、体重有相关性。结论上肢正中神经基本全程可视,在不同部位的正常值及超声声像图略有差异。神经的CSA在上臂段最粗,腕管处次之,前臂段最细,与身高、体重呈正相关性。     

Comparison of Proximal and Distal Cross-Sectional Areas of the Median Nerve,Carpal Tunnel,and Nerve/Tunnel Index in Subjects With Carpal Tunnel Syndrome

Objectives

To provide a quantitative analysis of ultrasonographic measurements and possible pathophysiology of carpal tunnel syndrome by comparing cross-sectional areas of the median nerve, carpal tunnel, and nerve/tunnel index and the difference in ultrasonographic findings between affected and nonaffected hands and between sexes.

Design

Blinded comparison study.

Setting

Secondary referral and training hospital of institutional practice.

Participants

Patients (N=51; 42 women, 9 men) with suspected carpal tunnel syndrome who underwent sonography within 1 week after the electrodiagnostic study.

Interventions

Not applicable.

Main Outcome Measures

Electrodiagnostic and ultrasonographic studies were conducted on both upper extremities. Cross-sectional areas of the median nerve and carpal tunnel were measured at 2 separate levels; proximal and distal cross-sectional areas of the carpal tunnel were each measured at the scaphoid-pisiform and trapezium-hamate levels, respectively.

Results

Comparison between normative (n=24) and abnormal hands (n=78) revealed the following: the mean proximal cross-sectional areas of the median nerve, carpal tunnel, and nerve/tunnel index of electrodiagnostically normative hands were 10.941mm², 192.43mm², and 5.635%, respectively, whereas those of abnormal hands were 13.74mm², 208.87mm², and 6.693%, respectively, showing statistically significant differences for all (P<.05). Distal measurements of the cross-sectional area of the median nerve, carpal tunnel, and nerve/tunnel index were 10.088mm², 150.4mm², and 6.762%, respectively, in normative hands, and 11.178mm², 149.6mm², and 7.493%, respectively, in abnormal hands, showing no statistically significant differences (P>.05). In women, proximal cross-sectional areas of the median nerve and nerve/tunnel index of abnormal hands showed statistically significant differences, but no ultrasonographic measurement with a statistically significant difference was observed in men.

Conclusions

Compared with nonaffected hands, the proximal cross-sectional areas of the median nerve and carpal tunnel were greater, but the distal ultrasonographic measurements were not in affected hands. Ultrasonographic findings of carpal tunnel syndrome were different according to sex.     

Transverse Ultrasound Assessment of Median Nerve Deformation and Displacement in the Human Carpal Tunnel during Wrist Movements

The symptoms of carpal tunnel syndrome, a compression neuropathy of the median nerve at the wrist, are aggravated by wrist motion, but the effect of these motions on median nerve motion are unknown. To better understand the biomechanics of the abnormal nerve, it is first necessary to understand normal nerve movement. The purpose of this study was to evaluate the deformation and displacement of the normal median nerve at the proximal carpal tunnel level on transverse ultrasound images during different wrist movements, to have a baseline for comparison with abnormal movements. Dynamic ultrasound images of both wrists of 10 asymptomatic volunteers were obtained during wrist maximal flexion, extension and ulnar deviation. To simplify the analysis, the initial and final shape and position of the median nerve were measured and analyzed. The circularity of the median nerve was significantly increased and the aspect ratio and perimeter were significantly decreased in the final image compared with the first image during wrist flexion with finger extension, wrist flexion with finger flexion and wrist ulnar deviation with finger extension (p < 0.01). There were significant differences in median nerve displacement vector between finger flexion, wrist flexion with finger extension and wrist ulnar deviation with finger extension (all p's < 0.001). The mean amplitudes of median nerve motion in wrist flexion with finger extension (2.36 ± 0.79 normalized units [NU]), wrist flexion with finger flexion (2.46 ± 0.84 NU) and wrist ulnar deviation with finger extension (2.86 ± 0.51 NU) were higher than those in finger flexion (0.82 ± 0.33 NU), wrist extension with finger extension (0.77 ± 0.46 NU) and wrist extension with finger flexion (0.81 ± 0.58 NU) (p < 0.0001). In the normal carpal tunnel, wrist flexion and ulnar deviation could induce significant transverse displacement and deformation of the median nerve.     

Measurement of Median Nerve Strain and Applied Pressure for the Diagnosis of Carpal Tunnel Syndrome

The objective of this study was to evaluate the diagnostic utility of strain and applied-pressure measurements of the median nerve in carpal tunnel syndrome (CTS). Thirty-five wrists of 23 idiopathic CTS patients and 30 wrists of 15 normal patients were examined. Median nerve strain, pressure to the skin and the pressure/strain ratio were measured at the proximal carpal tunnel level. Parameters were compared between CTS patients and controls. The areas under the receiver operating characteristic curves (AUCs) were compared for the parameters. Median nerve strain was significantly lower in the patients than in the controls (p < 0.01). Pressure and pressure/strain ratio were significantly higher in the patients than in the controls (p < 0.05: pressure, p < 0.01: ratio). The AUCs were 0.926, 0.681 and 0.937 for strain, pressure and pressure/strain ratio, respectively. Pressure/strain ratio is useful for evaluating the condition of the median nerve with respect to the hardness of the surrounding structures in CTS.     

Predominant Patterns of Median Nerve Displacement and Deformation during Individual Finger Motion in Early Carpal Tunnel Syndrome

Idiopathic carpal tunnel syndrome (CTS) is a common neuropathy, yet the pathologic changes do not explain the fleeting dynamic symptoms. Dynamic nerve-tendon interaction may be a contributing factor. Based on dynamic ultrasonographic examination of the carpal tunnel, we quantified nerve-tendon movement in thumb, index finger and middle finger flexion in normal subjects and those with mild-idiopathic CTS. Predominant motion patterns were identified. The nerve consistently moves volar-ulnarly. In thumb and index finger flexion, the associated tendons move similarly, whereas the tendon moves dorsoradially in middle finger flexion. Nerve displacement and deformation increased from thumb to index finger to middle finger flexion. Predomination motion patterns may be applied in computational simulations to prescribe specific motions to the tendons and to observe resultant nerve pressures. By identification of the greatest pressure-inducing motions, CTS treatment may be better developed. Symptomatic subjects displayed reduced nerve movement and deformation relative to controls, elucidating the physiologic changes that occur during mild CTS.     

Carpal tunnel: Normal anatomy,anatomical variants and ultrasound technique

The carpal tunnel is an osteofibrous canal situated in the volar wrist. The boundaries are the carpal bones and the flexor retinaculum. In addition to the medial nerve, the carpal tunnel contains nine tendons: the flexor pollicis longus, the four flexor digitorum superficialis and the four flexor digitorum profundus. Ultrasound (US) study of the carpal tunnel generally involves short-axis imaging of the tendons, and in the presence of disease, long-axis imaging and dynamic maneuvers are added. There are numerous reports of anatomical variants of the wrist involving vessels, nerves, tendons and muscles, and they can all be studied by US. Some are particularly relevant from a clinical point of view and will therefore be accurately described. The anatomy is complex, and the US operator should therefore be thoroughly familiar with the normal anatomy as well as the anatomical variants that may have a role in the pathogenesis of carpal tunnel syndrome or influence treatment.     

Longitudinal Design for Sonographic Measurement of Median Nerve Swelling with Controlled Exposure to Physical Work Using an Animal Model

In the study described here, we examined the feasibility of a longitudinal design to measure sonographically swelling of the median nerve caused by controlled exposure to a work task and to evaluate the relationship of changes in morphology to diagnostic standards. Fifteen macaques, Macaca fascicularis, pinched a lever in various wrist positions at a self-regulated pace (8 h/d, 5 d/wk, 18–20 wk). Nerve conduction velocity (NCV) and cross-sectional area (CSA) were measured every 2 wk from baseline through working and a 6-wk recovery. Trending across all subjects revealed that NCV slowed and CSA at the carpal tunnel increased in the working arm, whereas no changes were observed in CSA either at the forearm or for any measure in the non-working arm. There was a small negative correlation between NCV and CSA in the working arm. This study provides validation that swelling can be observed using a longitudinal design. Longitudinal human studies are needed to describe the trajectory of nerve swelling for early identification of median nerve pathology.     

曲安奈德腕管内注射治疗轻度腕管综合征的临床研究

目的 观察曲安奈德腕管内注射治疗轻度腕管综合征的临床疗效.方法 选取74例轻度腕管综合征患者随机分为观察组和对照组,观察组37例使用曲安奈德药物腕管内注射治疗;对照组37例使用超短波治疗仪患处局部疗法加用丹参和维生素B1、B6、B12等药物治疗.结果 观察组疗效与对照组的差别有显著性意义(P＜0.05)、观察组复发率与对照组的差别也有显著性意义(P＜0.05).结论 曲安奈德腕管内注射治疗轻度腕管综合征的临床疗效明显,优于其他保守疗法,且见效快,复发率低,临床评价疗效满意.