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NEM AA ULN P HO RKS WO , MD h c s t Wer J MD e , n i d l l e a u Osw D Jaq A a s M a There . Kincaid, C John, AMERICAN ASSOCIATION OF NEUROMUSCULAR & ELECTRODIAGNOSTIC MEDICINE 2621 Superior Drive NW Rochester, MN 55901 (507) 288-0100 [email protected] www.aanem.org AMERICAN ASSOCIATION OF NEUROMUSCULAR & ELECTRODIAGNOSTIC MEDICINE S E U Q I N H C E T AR Workshop handouts are prepared as background didactic material to complement a hands-on workshop session. This workshop handout was originally prepared in September 1994 and was revised in September 2000. The idea and opinions in this publication are solely those of the author(s) and do not necessarily represent those of the AANEM. Copyright © September 2000 AMERICAN ASSOCIATION OF NEUROMUSCULAR & ELECTRODIAGNOSTIC MEDICINE 2621 Superior Drive NW Rochester, MN 55901 Ulnar Techniques Jacqueline J. Wertsch, MD Department of Physical Medicine and Rehabilitation Medical College of Wisconsin Theresa A. Oswald, MD Prevea Clinic John C. Kincaid, MD Department of Neurology Indiana University INTRODUCTION A “tardy” paralysis of the ulnar nerve was described as early as 1878 by Panas. He noted the relationship between a fracture of the elbow and a slowly progressive ulnar nerve palsy. In 1958 Feindel and Stratford recognized the occurrence of ulnar neuropathies at the elbow in patients without elbow deformities and introduced the cubital tunnel syndrome.1 Many other etiologies of proximal ulnar neuropathies are now recognized (Table 1). Distal ulnar nerve compromise at the wrist or within the palm has been reported as early as 1908 when occupational neuritis of the deep ulnar nerve was described. The Shea classification of Guyon canal ulnar entrapments defines type I as occurring when there is both hypothenar and deep ulnar motor involvement and sensory involvement.4 Type II is with only deep motor branch involvement and type III with only superficial ulnar sensory involvement. Since initial ulnar motor conduction studies by Hodes in 1948, the role of electrophysiologic data in the evaluation of suspected ulnar neuropathies has been the subject of many publications.42 Parameters which have been utilized have included motor, mixed nerve, and sensory conduction velocity of the elbow segment,11,23,39,41,44,48,56,57,63,64 comparison of the elbow segment velocity to that of an adjacent nerve segment,23,39,56 latency from the elbow to wrist,39 latency from the elbow to the flexor carpi ulnaris (FCU) or flexor digitorum profundus (FDP),23,53,56 change in the size or configuration of the compound muscle action potential (CMAP) or sensory nerve action potentials (SNAP), evoked proximal and distal to the elbow,23,36,48,56,57,63 and the pattern of needle examination abnormalities in ulnar supplied muscles.23,39 For evaluation of distal ulnar neuropathy, two additional electrodiagnostic studies may be helpful: evaluation of the dorsal ulnar cutaneous branch and ulnar motor studies to the first dorsal interosseous muscle.3 Interpretation of conduction studies should take into account that cadaver studies show slack and wrinkling of the ulnar nerve at the elbow with the elbow in an extended position.65,66 Thus, it is more difficult to measure accurately the actual length of the ulnar nerve segment across the elbow in the extended position. In normals, conduction studies across the elbow frequently show velocity slowing if an extended elbow position is used; 23,36,39,43,44,65,67,68,69 this is not noted with a flexed position.45,57,65-67 2 Ulnar Techniques TABLE 1. Proximal Ulnar Neuropathy Etiologies Anatomic Sites of Possible Compression Arcade of Struthers Medial epicondylar groove Cubital tunnel (between the two heads of the flexor carpi ulnaris muscle) Muscle anomalies (anconeus epitrochlearis) Snapping triceps tendon Other Mechanical Causes Acute trauma fracture/dislocation soft tissue injury Old fractures medial epicondyle supracondylar humeral shaft Bony deformities rheumatoid arthritis osteoarthritis Paget’s disease cubitis valgus sesamoid bone Ganglia Recurrent dislocation or subluxation of the ulnar nerve at the elbow External pressure single episode multiple episodes related to anesthesia related to prolonged bedrest related to unconsciousness related to casting Postinoculation (tetanus) Vascular Ischemia or venous engorgement Related to AV-fistula placement Metabolic or Toxic Diabetes Alcoholism Hereditary Neuropathies Tumors Infection Leprosy AANEM Workshop At the elbow, the ulnar travels between the medial epicondyle and the olecranon in the retrocondylar groove. Continuing distally, the nerve passes between the two heads of the FCU. The tendinous arch between the heads of the FCU, along with the underlying bone and ligaments, form the cubital tunnel. Motor branches to the FCU most commonly arise distal to the medial epicondyle, but may arise at or above the epicondyle.5 The motor branch to the FDP comes off the ulnar nerve in the proximal forearm. The ulnar nerve continues in the forearm, resting on the FDP and covered by the FCU. At the wrist, the ulnar nerve courses across the flexor retinaculum into Guyon’s canal, which is bound medially by the pisiform and laterally by the hook of the hamate. The superficial volar carpal ligament and palmaris brevis comprise the floor of the canal. In the hand, the ulnar nerve divides into superficial and deep branches. The superficial branch innervates the palmaris brevis and divides into the palmar digital branches which supply the ulnar side of the little finger and the fourth interspace. The deep branch supplies all other ulnar innervated hand muscles. The dorsal ulnar cutaneous nerve branch is off the main ulnar nerve 5 to 10 cm proximal to the wrist but can be identified as an independent bundle for some distance proximal. It passes under the FCU tendon to reach the dorsum of the hand. The palmar cutaneous branch arises at a variable point in the distal half of the forearm and travels with the ulnar artery to innervate the skin of the hypothenar eminence.5 ANATOMY The ulnar nerve is composed of C-8, T-1 fibers and is the distal continuation of the medial cord of the brachial plexus. The ulnar nerve travels with the brachial artery, median nerve, medial cutaneous nerves of the arm, and forearm until mid-arm at the level of the attachment of the coracobrachialis muscle. Generally no branches arise from the ulnar nerve in the arm. The deep fascia which overlies the nerve from the surface of the medial triceps to the medial intermuscular septum is called the arcade of Struthers. Proximal to the arcade of Struthers the nerve is freely mobile. In the area of the arcade, as the nerve travels from the anterior to posterior compartments of the arm, it is firmly bound to the triceps. Figure 1. Sites of Ulnar Nerve Entrapment Reprinted with permission from: Wertsch JJ, Park TA. Electrodiagnostic medicine. In: Moore JS, Garg A, editors. Ergonomics: low-back pain, carpal tunnel syndrome, and upper extremity disorders in the workplace. Occupational medicine: state of the art reviews. Philadelphia: Hanley & Belfus; 1992. AANEM Workshop 3 Ulnar Techniques EMG EXAMINATION ULNAR MOTOR STUDIES - TO HYPOTHENAR Muscles frequently examined in evaluating an ulnar neuropathy include the flexor carpi ulnaris, flexor digitorum profundus, and ulnar hand intrinsic muscles. The first dorsal interossei manus and hypothenar muscles are often studied although the adductor pollicis, other dorsal interossei, the volar interossei, and the ulnar lumbricals can also be examined. EMG examination may help localize the site of an ulnar lesion. Abnormalities in the FCU or medial half of the FDP can help localize the lesion to near or proximal to the elbow. Abnormalities in the interossei with sparing of the hypothenar muscles localize the lesion at or distal to Guyon’s canal. The internal topography of the ulnar nerve may be useful to consider in interpreting EMG findings (Figure 2). The relatively protected lateral position in the retrocondylar groove of the fascicles forming the branch to the flexor carpi ulnaris has been suggested as an explanation for reported sparing of the flexor carpi ulnaris in some proximal ulnar lesions.6,7 Differential fascicular vulnerability has also been postulated to explain the observation that ulnar abnormalities are more frequently detected in the first dorsal interossei manus than the hypothenar muscles.7 Hypothenar recording site: The G1 electrode is placed over the belly of the hypothenar eminence and the G2 electrode over the distal interphalangeal (DIP) joint of the fifth digit. Various G1 sites may be evaluated to determine the point which will yield the maximum amplitude. Stimulation site is at the wrist 6 or 8 cm proximal. The ground is placed over the dorsum of the hand. In the evaluation of the ulnar nerve, the conduction velocity of the elbow segment is often compared to the conduction velocity of an adjacent nerve segment. Velocities may be calculated for the forearm, the elbow segment, and the upper arm.2 In normals, conduction studies across the elbow frequently show velocity slowing if an extended elbow position is used; this is not noted with a flexed position.11,23,36,43-45,57,65-69 Recording from the first dorsal interosseous in addition to the hypothenar muscles has also been advocated, since these may be differentially affected.23,56 REFERENCE VALUES: Hypothenar Recording (DeLisa 1987)37 Onset latency 3.2+ 0.5 msec Amplitude 6.1 + 1.9 mV ULNAR INCHING ACROSS THE ELBOW Figure 2. Diagram of a transverse section of an ulnar nerve at the elbow. TCH=terminal cutaneous of the hand, TMH=terminal motor of the hand, DCH=dorsal cutaneous fibers of the hand, FCU=flexor carpi ulnaris, FDP=flexor digitorum profundus. Reprinted with permission from: Sunderland S: Nerves and Nerve Injuries. Edinburgh, Churchill Livingston, 1978 p 755. Inching allows comparison of superimposed waveforms obtained by stimulating across short, precisely measured intervals. Inching can help define focal ulnar entrapment in the 4 AANEM Workshop Ulnar Techniques retrocondylar groove or more proximally in the arm. Caution is needed in interpreting an amplitude drop distal to the retrocondylar groove as this may simply reflect submaximal stimulation when there is a very proximal cubital tunnel entrance. The patient is supine with shoulder abducted 40 to 45 degrees and externally rotated, the elbow flexed 70 to 90 degrees and the forearm supinated. The flexed elbow position is recommended to provide the greatest correlation between surface measurements and actual nerve length.68-70 Recording can be done from the hypothenar muscles or the first dorsal interosseous manus (FDIM). The ulnar nerve is stimulated distally at the wrist and waveform saved for comparison to proximal responses. The ulnar nerve is then palpated to confirm its location in the retrocondylar groove. Successive stimulations in 2 cm intervals are done distally as far as possible and proximally even into the axilla to assure inclusion of the arcade of Struthers site. Successive responses are evaluated for abrupt concomitant changes in morphology, amplitude, and latency. Inching should be repeated to confirm any focal changes noted. (Original techniques use a supramaximal stimulus intensity. However, Campbell58 discusses a subthreshold stimulus technique and notes care is needed to avoid excessively supramaximal stimuli causing distal migration of the effective cathode, erroneous latency determinations appearing as abnormal inching.) The AAEM Ulnar Practice Parameter suggests that the following may be significant (listed in ascending order by strength of evidence): a) absolute NCV AE-to-BE of less than 50 m/sec, b) an AE-to-BE segment greater than 10 m/s slower than the BE-towrist segment, c) a decrease in CMAP negative peak amplitude from BE to AE greater than 20%, and d) a significant change in CMAP configuration at the AE site compared to BE site.70 ULNAR MOTOR STUDIES - TO FDIM initial positivity which is usually seen when the G2 is placed on the index finger.52 Wrist stimulation is done at the same site used for the hypothenar study. REFERENCE VALUES: FDIM (Olney 1985)49 Onset latency 2.3-4.5 msec Amplitude 6-24 mV ULNAR MOTOR STUDIES - TO FCU The G1 electrode is placed over the motor point of the FCU at the junction of the proximal third and middle third of the forearm. G2 is placed adjacent to G1 over the ulna shaft, with 3 cm separation. The ground is placed between the stimulating and recording electrodes on the volar aspect of the forearm. The ulnar nerve is stimulated 10 cm proximally in the medial arm. REFERENCE VALUES: FCU (Felsenthal 1986)54 Onset latency 2.6 + 0.3 msec Amplitude 5.2 + 1.8 mV ULNAR DIGITAL SENSORY NERVE CONDUCTION First Dorsal Interosseous Manus recording site: The G1 electrode is placed between the first and second metacarpals over the belly of the first dorsal interosseous muscle. The G2 is placed distally over the thumb interphalangeal joint, to avoid the For antidromic digital studies the G1 ring electrode is placed around the proximal phalanx of the little or ring finger with the G2 ring electrode around the distal phalanx. Care is needed to AANEM Workshop 5 Ulnar Techniques maintain adequate interelectrode distance. If the interelectrode distance is less than 4 cm, this needs to be noted and considered in the interpretation. Stimulation is performed at the distal wrist, 10 to 14 cm proximal to the G1 electrode. At the wrist, the ulnar nerve is frequently best stimulated lateral to the FCU tendon. However, in some individuals the ulnar nerve may be easier to stimulate medial to the FCU tendon. REFERENCE VALUES: DUC (Park 1994)33 Peak latency 1.8 + 0.20 msec Amplitude 32 + 13 µV MEDIAL ANTEBRACHIAL CUTANEOUS NERVE The orthodromic ulnar digital technique uses the same set-up except that stimulation is delivered through the ring electrodes and recorded at the wrist. Often a bar electrode is used for recording at the wrist, but again the interelectrode distance of the recording electrodes must be controlled and recording may need to be tried both lateral and medial to the FCU tendon. REFERENCE VALUES: Ulnar Digital Sensory Technique at 14 cm (Melvin 1966)19 Antidromic Peak latency 3.2 + 0.20 msec (4 cm interelectrode) Orthodromic Peak latency 3.0 + 0.20 msec (2 cm interelectrode) DORSAL ULNAR CUTANEOUS BRANCH The medial antebrachial cutaneous (MAC) nerve study can help distinguish between proximal ulnar lesions (MAC preserved) and medial cord plexopathy (MAC involved). Antidromic stimulation is performed 5 cm proximal to the medial epicondyle. The MAC is found medial to the median nerve. A point midway between the bicipital tendon and the medial epicondyle is connected by a line to the pisiform bone or ulnar styloid. A recording bar electrode (usually 3 cm interelectrode distance) is placed 14 cm distal to the stimulation site along this line. The ground is placed between the stimulating and recording electrodes. REFERENCE VALUES: MAC (Izzo 1985)25 Peak latency 2.7 + 0.20 msec Amplitude 11.4 + 5.2 µV TRANSCARPAL ULNAR TECHNIQUE The dorsal ulnar cutaneous (DUC) nerve of the forearm can help distinguish a Guyon canal ulnar entrapment (DUC preserved) from more proximal lesions. A 3 cm bar electrode over the dorsal 4th metacarpal interspace is used for recording. The DUC nerve can be stimulated distally as it wraps around the ulnar styloid. The DUC can be stimulated separately from the entire ulnar nerve in this location. With this technique, the distances between the recording G1 and the cathode are in the range of 4 to 7 cm. With such short distances, the ground electrode needs to be placed carefully between the cathode and recording electrodes. Transcarpal ulnar conduction can be evaluated by stimulation of the ulnar nerve within the palm and recording from the ulnar nerve at the wrist. A bar electrode at the wrist may be used. The 6 Ulnar Techniques ulnar nerve is stimulated at the distal palm crease between the 4th and 5th metacarpals. Although it is recognized that there may be some lumbrical motor fiber contributions, sensory bandpass filtering is usually used. REFERENCE VALUES: Ulnar Transcarpal Technique (Mills 1985)10 Peak latency 1.9 + 0.20 msec Amplitude 28.7 + 11 µV Recording Interelectrode Distance 3 cm Distance Between G1 and Cathode 8.5 to 11 cm Filters 3.2KHz - 32 Hz CONCLUSION The AAEM Practice Parameter for Electrodiagnostic Studies in Ulnar Neuropathy at the Elbow has defined practice standards to include monitoring and controlling limb temperature, to rule out diffuse processes and to specify and control elbow position with 70 to 90 degrees from the horizontal recommended. The articles which formed the basis of the Practice Parameter reported sensitivities of electrodiagnostic studies ranging from 37% to 86% and specificities of 95% or greater.70 REFERENCES Anatomy 1. 2. 3. 4. 5. 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Arch Phys Med Rehabil 1994; 75:259-264. 19. Melvin JL, Harris DH, Johnson EW. Sensory and motor conduction studies in the ulnar and median nerves. Arch Phys Med Rehabil 1966; 47:511-519. 20. Kimura J. Electrodiagnosis in Diseases of Nerve and Muscle: Principles and Practice. Philadelphia: FA Davis; 1989. 21. Kincaid JC, Phillips II, LH, Daube JR. The evaluation of suspected ulnar neuropathy at the elbow: normal conduction study values. Arch Neurol 1986; 43:44-47. 22. Ma DM, Liveson JA. Nerve Conduction Handbook. Philadelphia: FA Davis; 1983. 23. Payan J. Electrophysiological localization of ulnar nerve lesions. J Neurol Neurosurg Psychiatry 1969; 32:208-220. 24. Steton DS, Albers JW, Silverstein BA, Wolfe RA. Effects of age sex and anthrometric factors on nerve conduction measures. Muscle and Nerve 1992; 15:1095-1104. Medial Antebrachial Cutaneous Nerve 25. Izzo KL, Aravabhumi S, Jafri A, Sobel E, Demopoulos JT. 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Arch Phys Med Rehabil 1968; 49:460-466. 36. Carpendale MT. The localization of ulnar nerve compression in the hand and arm: an improved method of electroneuromyography. Arch Phys Med Rehabil 1966; 47:325-330. 37. DeLisa JA, Mackenzie K, Baran EM. Manual of Nerve Conduction Velocity and Somatosensory Evoked Potentials. New York: Ravens Press; 1987. 38. Ebeling P, Gilliatt RW, Thomas PK. A clinical and electrical study of ulnar nerve lesions in the hand. J Neurol Neurosurg Psychiatry 1960; 23:1-9. 39. Eisen A. Early diagnosis of ulnar palsy. Neurology 1974; 24:256-262. 40. Eisen A, Danon J. The mild cubital tunnel syndrome. Neurology 1974; 24:608-613. 41. Gilliatt RW, Thomas PK. Changes in nerve conduction with ulnar lesions at the elbow. J Neurol Neurosurg Psychiatry 1960; 23:312330. 42. Hodes R, Larrabee MG, German W. The human electromyogram in response to nerve stimulation and the conduction velocity of motor axons. Arch Neurol Psychiat 1948; 60:340-365. 43. Jebsen RH. Motor conduction velocities in the median and ulnar nerves. Arch Phys Med 1967; 48:185-194. 44. Krogness K. The cubital ratio method. Electromyogr Clin Neurophysiol 1978; 18:213-216. 45. Kaeser HE. Erregungsleitungsstorungen bei ulnarlsparesen. Dtsch Z Nervenheilkd 1963; 185:231-243. 46. Ma DM, Liveson JA. Nerve Conduction Handbook. Philadelphia: FA Davis; 1983. 47. Melvin JL, Harris DH, Johnson EW. Sensory and motor conduction studies in the ulnar and median nerves. Arch Phys Med Rehabil 1966; 47:511-519. 48. Odusote K, Eisen A. An electrophysiological quantification of the cubital tunnel syndrome. Canad J Neurol Sci 1979; 6:403-410. 49. Olney RK, Wilbourn AJ. Ulnar nerve conduction study of the first dorsal interosseous muscle. Arch Phys Med Rehabil 1985; 66;16-18. 50. Schubert HA. Conduction velocities along the course of the ulnar nerve. J Appl physiol 1964; 19:423-426. 51. Simpson JA. Electrical signs in the diagnosis of carpal tunnel and related syndromes. J Neurol Neurosurg Psychiatry 1956; 19:275-280. 52. Wertsch JJ, Park TA, Lomas JN, Melvin JL. Effect of reference electrode position on deep ulnar nerve conduction studies. Muscle & Nerve 1990; 13:862-863. 7 54. Felsenthal G, Brockman PS, Mondell DL, Hilton EB. Proximal forearm ulnar nerve conduction techniques. Arch Phys Med Rehabil 1986; 67:440-444. 55. Payan J. Electrophysiological localization of ulnar nerve lesions. J Neurol Neurosurg Psychiatry 1969; 32:208-220. 56. Tackman W, Vogel P, Kaeser HE, Ettlin TH. Sensitivity and localizing significance of motor and sensory electroneurographic parameters in the diagnosis of ulnar nerve lesions at the elbow. J Neurol 1984; 231:204-211. Ulnar Inching About the Elbow 57. Brown WF, Yates SK. Percutaneous localization of conduction abnormalities in human entrapment neuropathies. Canad J Neurol Sci 1982; 9:391-400. 58. Campbell WW, Pridgeon RM, Sahni KS. Short segment incremental studies in the evaluation of ulnar neuropathy at the elbow. Muscle Nerve 1992; 15:1050-1054. 59. Esocobar PL. Short segment stimulation in ulnar nerve lesions around the elbow. Ortho Rev 1983; 10:65-69 60. Ioppolo A, Granger CV. A technique for demonstrating nerve entrapment in the ulnar groove. Electromyogr Clin Neurophysiol 1972; 12:273-279. 61. Kanakamedala RV, Simons DG, Porter RW, Zucker RS. Ulnar nerve entrapments at the elbow localized by short segment stimulation. Arch Phys Med Rehabil 1988; 69:959-963. 62. Ma DM, Liveson JA. Nerve Conduction Handbook. Philadelphia: FA Davis; 1983. 63. Miller RG. The cubital tunnel syndrome: diagnosis and precise location. Ann Neurol 1979; 6:56-59. Effect of Elbow Position 64. Bielawski MA, Hallett M. Motor conduction of ulnar in flexion and extension of elbow in normals and in patients with lesions at the elbow. Muscle Nerve 1989; 12:803-809. 65. Checkles NS, Russakov AD, Piero DL. Ulnar nerve conduction velocity-effect of the elbow position on measurement. Arch Phys Med Rehabil 1971; 53:362-365. 66. Harding C, Halar E: Motor and sensory ulnar nerve conduction velocities: effect of elbow position. Arch Phys Med Rehabil 1983; 64:227-232. 67. Kincaid JC, Phillips LH, Daube JR. The evaluation of suspected ulnar neuropathy at the elbow. Arch Neurol 1986; 43:44-47. 68. Kothari MJ, Preston DC. Comparison of the flexed and extended elbow positions in localizing ulnar neuropathy at the elbow. Muscle Nerve 1995; 18:336-340. 69. Nelson RM. Effects of elbow position on motor conduction velocity of the ulnar nerve. Phys Therapy 1980; 69:780-783. Practice Parameter Ulnar Motor Studies - FCU 53. Benecke R, Conrad B. The value of electrophysiological examination of the flexor carpi ulnaris muscle in the diagnosis of ulnar nerve lesions at the elbow. J Neurol 1980; 223:207-217. 70. Practice parameter for electrodiagnostic studies in ulnar neuropathy at the elbow: Summary Statement. Muscle Nerve 1999; 22:408-411. NEM AA ULN P HO RKS WO , MD h c s t Wer J MD e , n i d l l e a u Osw D Jaq A a s M a There . Kincaid, C John, AMERICAN ASSOCIATION OF NEUROMUSCULAR & ELECTRODIAGNOSTIC MEDICINE 2621 Superior Drive NW Rochester, MN 55901 (507) 288-0100 [email protected] www.aanem.org AMERICAN ASSOCIATION OF NEUROMUSCULAR & ELECTRODIAGNOSTIC MEDICINE S E U Q I N H C E T AR