Name: ultrasound-guided needle release combined with corticosteroid injection for the treatment of supinator syndrome
Uploaded: 2023-05-26T14:20:00.000+00:00
Duration: 5 min 18 s
Description: Watch this Scientific Journal Video about Ultrasound-Guided Needle Release Combined with Corticosteroid Injection for the Treatment of Supinator Syndrome at JoVE.com

This work was supported by the General Scientific Research Project of Zhejiang Provincial Education Department, China (Grant No. Y202249231).

This study was approved by the ethical and scientific review board of our hospital. Written informed consent was obtained from the patient. All the treatment procedures were performed by personnel with 10 years of experience in musculoskeletal ultrasound intervention. The operator must have good knowledge of musculoskeletal anatomy. The ultrasound machine used here is mentioned in the Table of Materials and has a high-frequency probe.
1. Instrument setup and patient preparation
<ol>
	<li>Enter the ID number and the patient&#39;s name to save the images.</li>
	<li>Sanitize the ultrasound probe using equipment disinfectant wipes. Perform all the procedures with the probe covered with surgical gloves.</li>
	<li>Set the image with the DBRN in the middle of the screen. To do this, perform cross-sectional scanning along the supinator muscle to find the DBRN. Then, rotate 90&#176; to obtain a long-axis section. Under continuous ultrasound guidance, separate the adhesion between the surrounding tissue of the posterior spin muscles and the DBRN.</li>
	<li>Ask the patient to sit and place their arm in a flexed 20&#176; position on the examination bed. Perform ultrasound to check for DBRN adhesion to the surrounding tissue (Figure 1; Video 1).</li>
</ol>
2. Ultrasound examination and treatment
<ol>
	<li>Use complex iodine to disinfect the patient&#39;s skin three times, and then place a sterile surgical towel on the patient&#39;s arm.</li>
	<li>Provide local anesthesia using a 10 mL aliquot of a mixed solution (5 mL of 2% lidocaine and 5 mL of 0.9% sodium chloride) layer by layer until the DBRN surface is reached (Figure 2). The four layers that are anesthetized include the skin, the subcutaneous soft tissue, the brachioradialis, and the superficial supinator muscle. Confirm the anesthetization of each layer using ultrasound guidance, and check that the tip of the needle passes through each layer.</li>
	<li>Identify the radial nerve by transversely using the probe at the level of the lateral epicondyle of the humerus. The radial nerve is located between the humerus muscle and the brachioradial muscle. Then, move the probe distally to find the deep branch of the radial nerve between the deep and superficial layers of the supinator.</li>
	<li>Use a 5 mL syringe to separate the adhesion between the surrounding tissue of the posterior spin muscles and the DBRN under the continuous ultrasound guidance. Perform needle release from the DBRN distal area to the proximal area. Prick the adhesion tissue back and forth with the tip. Stop when there is resistance between the syringe and the tissues around the DBRN.</li>
	<li>Ensure that the probe and the needle are accurately controlled, keep the tip of the needle visible during the entire operation, and avoid damage to the DBRN.</li>
	<li>After the procedure, inject a mixture of 1 mL of corticosteroid (betamethasone) and 2 mL of 2% lidocaine into the superficial area of the DBRN.</li>
</ol>

Ultrasound-Guided Needle Release Combined with Corticosteroid Injection

<ol>
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T., Ozcakar, L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ultrasound+imaging+for+a+rare+cause+of+postpartum+forearm+pain:+Diffuse+enlargement+rather+than+focal+swelling+of+the+deep+branch+of+the+radial+nerve.">Ultrasound imaging for a rare cause of postpartum forearm pain: Diffuse enlargement rather than focal swelling of the deep branch of the radial nerve.</a> Pain Medicine. 21 (1), 203-205 (2020).</li><li>Dang, A. C., Rodner, C. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Unusual+compression+neuropathies+of+the+forearm,+part+I:+Radial+nerve.">Unusual compression neuropathies of the forearm, part I: Radial nerve.</a> Journal of Hand Surgery. American Volume. 34 (10), 1906-1914 (2009).</li><li>Sarris, I. K., Papadimitriou, N. G., Sotereanos, D. G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Radial+tunnel+syndrome.">Radial tunnel syndrome.</a> Techniques in Hand &amp; Upper Extremity Surgery. 6 (4), 209-212 (2002).</li><li>Ozcakar, L., Kara, M., Gurcay, E., Onat, S. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ultrasound+imaging+for+prompt+clinical+decision+making+before+interventions.">Ultrasound imaging for prompt clinical decision making before interventions.</a> American Journal of Physical Medicine and Rehabilitation. 96 (3), (2017).</li><li>Domkundwar, S., Autkar, G., Khadilkar, S. V., Virarkar, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ultrasound+and+EMG-NCV+study+(electromyography+and+nerve+conduction+velocity)+correlation+in+diagnosis+of+nerve+pathologies.">Ultrasound and EMG-NCV study (electromyography and nerve conduction velocity) correlation in diagnosis of nerve pathologies.</a> Journal of Ultrasound. 20 (2), 111-122 (2017).</li><li>Chang, K. V., Wu, W. T., Han, D. S., Ozcakar, L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Static+and+dynamic+shoulder+imaging+to+predict+initial+effectiveness+and+recurrence+after+ultrasound-guided+subacromial+corticosteroid+injections.">Static and dynamic shoulder imaging to predict initial effectiveness and recurrence after ultrasound-guided subacromial corticosteroid injections.</a> Archives of Physical Medicine and Rehabilitation. 98 (10), 1984-1994 (2017).</li><li>Wu, W. T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Subacromial+motion+metrics+in+painful+shoulder+impingement:+A+dynamic+quantitative+ultrasonography+analysis.">Subacromial motion metrics in painful shoulder impingement: A dynamic quantitative ultrasonography analysis.</a> Archives of Physical Medicine and Rehabilitation. 104 (2), 260-269 (2023).</li><li>Martinoli, C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Sonography+of+entrapment+neuropathies+in+the+upper+limb+(wrist+excluded).">Sonography of entrapment neuropathies in the upper limb (wrist excluded).</a> Journal of Clinical Ultrasound. 32 (9), 438-450 (2004).</li><li>Cartwright, M. S., Walker, F. O. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Neuromuscular+ultrasound+in+common+entrapment+neuropathies.">Neuromuscular ultrasound in common entrapment neuropathies.</a> Muscle and Nerve. 48 (5), 696-704 (2013).</li><li>Rota, E., Morelli, N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Entrapment+neuropathies+in+diabetes+mellitus.">Entrapment neuropathies in diabetes mellitus.</a> World Journal of Diabetes. 7 (17), 342-353 (2016).</li><li>Miller, T. T., Reinus, W. R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Nerve+entrapment+syndromes+of+the+elbow,+forearm,+and+wrist.">Nerve entrapment syndromes of the elbow, forearm, and wrist.</a> American Journal of Roentgenology. 195 (3), 585-594 (2010).</li><li>Zeng, Z., Chen, C. X. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ultrasound-guided+needle+release+plus+corticosteroid+injection+of+superficial+radial+nerve:+A+case+report.">Ultrasound-guided needle release plus corticosteroid injection of superficial radial nerve: A case report.</a> World Journal of Clinical Cases. 10 (4), 1320-1325 (2022).</li><li>Barnum, M., Mastey, R. D., Weiss, A. P., Akelman, E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Radial+tunnel+syndrome.">Radial tunnel syndrome.</a> Hand Clinics. 12 (4), 679-689 (1996).</li><li>Spinner, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+arcade+of+Frohse+and+its+relationship+to+posterior+interosseous+nerve+paralysis.">The arcade of Frohse and its relationship to posterior interosseous nerve paralysis.</a> The Journal of Bone and Joint Surgery. British Volume. 50 (4), 809-812 (1968).</li><li>Dufour, E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Ultrasound-guided+perineural+circumferential+median+nerve+block+with+and+without+prior+dextrose+5%+hydrodissection:+A+prospective+randomized+double-blinded+noninferiority+trial.">Ultrasound-guided perineural circumferential median nerve block with and without prior dextrose 5% hydrodissection: A prospective randomized double-blinded noninferiority trial.</a> Anesthesia and Analgesia. 115 (3), 728-733 (2012).</li><li>Wu, Y. T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Nerve+hydrodissection+for+carpal+tunnel+syndrome:+A+prospective,+randomized,+double-blind,+controlled+trial.">Nerve hydrodissection for carpal tunnel syndrome: A prospective, randomized, double-blind, controlled trial.</a> Muscle and Nerve. 59 (2), 174-180 (2019).</li><li>Lin, C. P., Chang, K. V., Huang, Y. K., Wu, W. T., Ozcakar, L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Regenerative+injections+including+5%+dextrose+and+platelet-rich+plasma+for+the+treatment+of+carpal+tunnel+syndrome:+A+systematic+review+and+network+meta-analysis.">Regenerative injections including 5% dextrose and platelet-rich plasma for the treatment of carpal tunnel syndrome: A systematic review and network meta-analysis.</a> Pharmaceuticals. 13 (3), (2020).</li></ol>

The authors declare no competing financial interests.

In recent years, ultrasound has become a valuable tool for assessing peripheral nerve entrapments. Ultrasound can be used to observe nerves in real-time and provide dynamic visualization12. The obvious sonographic indicator of entrapment is the increased nerve CSA at the site of entrapment13,14. Other findings such as a hypoechoic texture, nerve flattening, and increased vascularity are also reported in entrapment neuropathy15.
RN entrapment syndrome accounts for about 0.7% of nontraumatic upper extremity lesions. RN entrapment syndrome is less common compared with ulnar and median nerve entrapment syndromes. The RN can be stretched or compressed in patients who have undergone surgery16. Radial tunnel syndrome involves forearm pain that is caused by a compressive injury of the DBRN. Home keeping occupations, sport practice, and professional activities can cause these issues17. The most common anatomical part of RN that experiences compression is the proximal edge of the superficial layer of the supinator muscle, which is called the arcade of Frohse (AF). Frohse and Frankel first described this anatomical tendinous structure in 1908. The pronation and supination of the forearm can increase the harm caused by the compression of the DBRN due to a fibrous AF4,18.
In this case, we found that after the first surgery, when the joints of the fingers were fully straightened, the dorsal extension of the ring and little fingers had obvious limitations (ring finger: &#8722;30&#176;, little finger: &#8722;40&#176;). Ultrasound examination showed that the thickened DBRN was deeply adhered to the surrounding tissues at the exit point. Due to the patient's last surgery 1 month ago, he was reluctant to undergo further surgery. Therefore, he twice underwent ultrasound-guided needle release of the DBRN combined with a corticosteroid injection to relieve the adhesion between the DBRN and the surrounding tissue. At 1 month after the second treatment, the patient's dorsal extension of the ring and the little finger was normal when the joints of the fingers were fully straightened (ring finger: 0&#176;, little finger: 0&#176;). 
With the help of real-time ultrasound guidance, we can observe the nerve and its surrounding tissues accurately and safely. A high-frequency linear-array transducer (&gt;10 MHz) is the best choice for visualizing both superficial tissues and peripheral nerve injections. All the nerve injection procedures in this study were performed with sterile techniques; for example, the probe was covered with surgical gloves, and complex iodine was used to disinfect the patient's skin. There are many regimens that can be used for nerve hydro-dissection. For example, low-concentration dextrose was the first one used for hydro-location during regional anesthesia19. Another research study showed that hydro-dissection of the median nerve could be performed precisely by using saline under the guidance of ultrasound20. In our study, we used 5 mL of 2% lidocaine and 5 mL of 0.9% sodium chloride to perform the hydro-dissection. A recent study reported that 5% dextrose and platelet-rich plasma injections were valuable regiments in treating carpal tunnel syndrome, and the results of the treatment, including the symptom relief, were better than with saline and corticosteroid injections21. Although platelet-rich plasma injections are expensive and the preparation process is complex, they need to be further studied due to their potentially better effects.
Swelling and adhesion decrease gradually after trauma, and the length of time this takes depends on the severity of the injury, the location of the injury, and how well the injury is treated. In general, mild swelling from a minor injury typically goes down within a few days to 1 week. However, more severe swelling from a major injury could last several weeks or even a few months. This process can be aided with needle release combined with corticosteroid injection.
There are several points to be learned from this case. First, the operator should know the anatomy of the hand in detail and have excellent technical skills in procedures involving the needle release of peripheral nerves. Second, ultrasound is a useful observation tool in pre-operative, intraoperative, and post-operative studies when performing peripheral nerve treatment. Ultrasound images can provide information on the location of the nerves and their relationship with the surrounding tissues. Third, needle release combined with an injection to the peripheral nerves has great challenges. Nerves adhered to the surrounding tissues may have indistinct borders. Additionally, peripheral nerves are small and move easily when the body moves slightly, so the injection to the targeted nerve requires good operator skills.

The radial nerve (RN) splits into two main branches at the elbow level: the deep branch (DBRN) and the superficial branch (SBRN). The DBRN originates from the main trunk of the RN at the level of the lateral epicondyle of the humerus1. The DBRN curves around the neck of the radius and then goes through under the tendinous arch of the superficial edge of the supinator muscle, which is called the arcade of Frohse2. This anatomical site is the most common entrapment site of the DBRN at the forearm3,4. In some rare cases, the DBRN can be compressed from the entrance to the exit of supinator5. The entrapment of the DBRN can cause pain in the lateral-dorsal proximal forearm and weakness of the wrist extensor muscles6,7,8.
When a nerve is injured, nerve conduction studies (NCS) and electromyography (EMG) sometimes show abnormal results indicating that the nerve is damaged. Although EMG is an established method and provides functional information about nerve disease, it lacks the ability to detect anatomical and morphological information related to the nerve9. Besides that, the sensitivity and specificity of EMG are not very high at early stages of nerve injury. Ultrasound can easily detect peripheral nerves and show them in sonographic imaging. Many studies have reported the value of high-frequency ultrasound in diagnosing the entrapment of peripheral nerves5. It has great potential as a diagnostic method for finding peripheral nerves. Babaei-Ghazani et al. reported ultrasonographic values for the DBRN at the arcade of Frohse, and they concluded that age was associated with the cross-sectional area (CSA) of DBRN, while other features such as height or gender were not1. Some studies have reported that corticosteroid injections are effective in treating musculoskeletal diseases10,11. However, until now, there have been no reports on ultrasound-guided needle release plus a corticosteroid injection in the DBRN for treating adhesion. Here, we report a method that can separate the adhesion without open surgery. A male patient who had a dorsiflexion limitation in his left ring and little fingers was treated using this method. This patient had injured his left forearm 1 month prior to the treatment. Multiple muscles of the forearm (the extensor digitorum, extensor digiti minimi, and extensor carpi ulnaris) were sutured in another hospital. His DBRN had edema and was thickened, and the exit point of DBRN was deeply adhered to the surrounding tissue. After treatment using US-guided needle release and corticosteroid injection of the DBRN, the patient&#39;s dorsal extension of the ring and the little finger was normal when the joints of the fingers were fully straightened.

<table><tbody><tr><td>Betamethasone</td><td>MSD Merck Sharp &amp;amp; Dohme AG</td><td>B7005-100MG</td><td></td></tr><tr><td>Injection syringe</td><td>Hangzhou Minsheng Pharmaceutical Co., LTD</td><td></td><td>5 mL and 10 mL</td></tr><tr><td>Lidocaine</td><td>Shanghai Zhaohui Pharmaceutical Co., LTD</td><td>H41022244</td><td>7 mL</td></tr><tr><td>Sodium chloride</td><td>Hangzhou Minsheng Pharmaceutical Co., LTD</td><td>http://www.mspharm.com/pro_list.asp?PageNumber=3&amp;amp;info_kind=004001&lt;br/&gt; &amp;amp;d_add_date1=&amp;amp;d_add_date2=&amp;amp;&lt;br/&gt; skind=&amp;amp;p_keys=</td><td>5 mL</td></tr><tr><td>Ultrasonic diagnostic system</td><td>SIEMENS</td><td></td><td>Type:ACUSON Sequoia</td></tr></tbody></table>

ultrasound-guided needle release combined with corticosteroid injection for the treatment of supinator syndrome

The two main branches of the radial nerve (RN) are the deep branch (DBRN) and the superficial branch (SBRN). The RN splits into two main branches at the elbow. The DBRN runs between the deep and shallow layers of the supinator. The DBRN can be easily compressed at the arcade of Frohse (AF) due to its anatomical features. This work focuses on a 42-year-old male patient who had injured his left forearm 1 month prior. Multiple muscles of the forearm (extensor digitorum, extensor digiti minimi, and extensor carpi ulnaris) were sutured in another hospital. After that, he had dorsiflexion limitations in his left ring and little fingers. The patient was reluctant to undergo another operation because he had undergone suture surgeries for multiple muscles 1 month prior. Ultrasound revealed that the deep branch of the radial nerve (DBRN) had edema and was thickened. The exit point of the DBRN had deeply adhered to the surrounding tissue. To relieve this, ultrasound-guided needle release plus a corticosteroid injection were performed on the DBRN. Nearly 3 months later, the dorsal extension in the patient's ring and little fingers was significantly improved (ring finger: &#8722;10&#176;, little finger: &#8722;15&#176;). Then, the same treatment was done for the second time. Nearly 1 month after that, the dorsal extension of the ring and the little finger was normal when the joints of the fingers were fully straightened. Ultrasound could evaluate the condition of the DBRN and its relationship with the surrounding tissues. Ultrasound-guided needle release combined with corticosteroid injection is an effective and safe treatment for DBRN adhesion.

At 1 month after the treatment, the joints of the fingers were fully straightened, and the dorsal extension of the ring and little fingers was significantly improved upon fully straightening the fingers (ring finger: &#8722;15&#176;, little finger: &#8722;25&#176;). At 3 months after the treatment, the patient came back for re-examination of the DBRN. The range of DBRN adhesions, as assessed by ultrasound, was significantly reduced compared to before the treatment. The dorsal extension of the ring and little fingers was also improved (ring finger: &#8722;10&#176;, little finger: &#8722;15&#176;; Figure 3; Video 2). At 1 month after the same treatment was performed for the second time, the dorsal extension of the ring and the little fingers was normal when the joints of the fingers were fully straightened (ring finger: 0&#176;, little finger: 0&#176;; Figure 4).
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/65256/65256fig01.jpg" /> 
Figure 1: Physical examination upon admission and ultrasound findings. (A) When the patient&#39;s finger joints were fully straightened, there was obvious restriction of the dorsal extension of the ring and little fingers (ring finger: &#8722;30&#176;, little finger: &#8722;40&#176;, white arrow). (B) Ultrasound of the long-axis view showed that the deep branch of the radial nerve (DBRN) was obviously edematous and thickened (white arrow). The exit point of the DBRN was adhered to the surrounding tissues (white dotted arrow). <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/65256/65256fig01large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/65256/65256fig02.jpg" /> 
Figure 2: Ultrasound image from the first treatment. We separated the adhesion between the surrounding tissue using needle release. A mixture of 1 mL of corticosteroid (betamethasone) and 2 mL of 2% lidocaine was injected into the superficial area of the DBRN. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/65256/65256fig02large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 3" class="xfigimg" src="/files/ftp_upload/65256/65256fig03.jpg" /> 
Figure 3: Ultrasound image from the second treatment. (A) At 1 month after the first treatment, when the joints of the fingers were fully straightened, the patient&#39;s dorsal extension of the ring and little fingers was significantly improved (ring finger: &#8722;15&#176;, little finger: &#8722;25&#176;, white arrow). (B) At 3 months later, the patient&#39;s dorsal extension of the ring and little fingers was further improved (ring finger: &#8722;10&#176;, little finger: &#8722;15&#176;, white arrow). (C) The ultrasound image showed that the DBRN area adhered to the surrounding tissues was significantly reduced 3 months after the first treatment (white dotted arrow). <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/65256/65256fig03large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 4" class="xfigimg" src="/files/ftp_upload/65256/65256fig04.jpg" /> 
Figure 4: The subsequent treatment. At 1 month after the same treatment was done for the second time, the patient&#39;s dorsal extension of the ring and the little fingers was normal when the joints of the fingers were fully straightened (ring finger: 0&#176;, little finger: 0&#176;, white arrow). <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/65256/65256fig04large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
Video 1: Ultrasound video before treatment. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/65256/pre-treatment_Re.zip" target="_blank">Please click here to download this Video.</a>
Video 2: Ultrasound video after treatment. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/65256/post-treatment_RE.zip" target="_blank">Please click here to download this Video.</a>

Watch this Scientific Journal Video about Ultrasound-Guided Needle Release Combined with Corticosteroid Injection for the Treatment of Supinator Syndrome at JoVE.com

Author Spotlight: Ultrasound-Guided Needle Release Combined with Corticosteroid Injection for the Treatment of Supinator Syndrome  

The deep branch of the radial nerve can easily be compressed at the arcade of Frohse due to its anatomical features. Ultrasound-guided needle release combined with corticosteroid injection is an effective and safe treatment for deep branch radial nerve adhesion.

Ultrasound-Guided Needle Release Combined with Corticosteroid Injection for the Treatment of Supinator Syndrome

The two main branches of the radial nerve (RN) are the deep branch (DBRN) and the superficial branch (SBRN). The RN splits into two main branches at the ...

ultrasound-guided-needle-release-combined-with-corticosteroid

Nanyang Technological University

Research

JoVE Journal

Neuroscience

1.3K Views.  Hangzhou Medical College. The deep branch of the radial nerve can easily be compressed at the arcade of Frohse due to its anatomical features. Ultrasound-guided needle release combined with corticosteroid injection is an effective and safe treatment for deep branch radial nerve adhesion.

Video: Author Spotlight: Ultrasound-Guided Needle Release Combined with Corticosteroid Injection for the Treatment of Supinator Syndrome  

Neuro-rehabilitation Approach for Sudden Sensorineural Hearing Loss

Sudden sensorineural hearing loss (SSHL) is characterized by acute, idiopathic hearing loss. The estimated incidence rate is 5-30 cases per 100,000 people per year. The causes of SSHL and the mechanisms underlying SSHL currently remain unknown. Based on several hypotheses such as a circulatory disturbance to the cochlea, viral infection, and autoimmune disease, pharmaco-therapeutic approaches have been applied to treat SSHL patients; however, the efficacy of the standard treatment, corticosteroid therapy, is still under debate. Exposure to intense sounds has been shown to cause permanent damage to the auditory system; however, exposure to a moderate level enriched acoustic environment after noise trauma may reduce hearing impairments. Several neuroimaging studies recently suggested that the onset of SSHL induced maladaptive cortical reorganization in the human auditory cortex, and that the degree of cortical reorganization in the acute SSHL phase negatively correlated with the recovery rate from hearing loss. This article reports the development of a novel neuro-rehabilitation approach for SSHL, &#34;constraint-induced sound therapy (CIST)&#34;. The aim of the CIST protocol is to prevent or reduce maladaptive cortical reorganization by using an enriched acoustic environment. The canal of the intact ear of SSHL patients is plugged in order to motivate them to actively use the affected ear and thereby prevent progress of maladaptive cortical reorganization. The affected ear is also exposed to music via a headphone for 6 hr per day during hospitalization. The CIST protocol appears to be a safe, easy, inexpensive, and effective treatment for SSHL.

This article reports the development of a neuro-rehabilitation approach, "constraint-induced sound therapy (CIST)" for sudden sensorineural hearing loss. The aim of CIST is to prevent maladaptive cortical reorganization by using an enriched acoustic environment. CIST represents a safe, easy, inexpensive, and effective approach to treat sudden sensorineural hearing loss.

Sudden sensorineural hearing loss (SSHL) is characterized by acute, idiopathic hearing loss. The estimated incidence rate is 5-30 cases per 100,000 people ...

Behavior

Analyzing Satellite Cell Function During Skeletal Muscle Regeneration by Cardiotoxin Injury and Injection of Self-delivering siRNA In Vivo

Skeletal muscle possesses an enormous capacity to regenerate after injury. This process is mainly driven by muscle stem cells, also termed satellite cells. Satellite cells are characterized by the expression of the transcription factor Pax7 and their location underneath the basal lamina in the resting skeletal muscle. Upon injury, satellite cells get activated, undergo self-renewal or differentiation to either form new myofibers or to fuse with damaged ones. The functionality of satellite cells in vivo can be investigated using a cardiotoxin based injury model of skeletal muscle. To study the function of one gene during the regeneration of skeletal muscle, transgenic mouse models are mostly used. Here, we present an alternative method to transgenic mice, to investigate the gene function in satellite cells during regeneration, e.g., in cases where transgenic mice are not available. We combine the cardiotoxin mediated injury of a specific skeletal muscle with the injection of a self-delivering siRNA into the regenerating muscle which is then taken up by satellite cells among other cells. Thereby, we provide a method to analyze gene function in satellite cells during regeneration under physiological conditions without the need for transgenic mice.

We describe an in vivo method to investigate the functional loss of a specific gene in satellite cells by using a combination of cardiotoxin mediated injury of skeletal muscle and the injection of a self-delivering siRNA.

Skeletal muscle possesses an enormous capacity to regenerate after injury. This process is mainly driven by muscle stem cells, also termed satellite ...

Genetics

An Ultrasonic Tool for Nerve Conduction Block in Diabetic Rat Models

Nerve conduction block with a high intensity-focused ultrasound (HIFU) transducer has been performed in normal and diabetic animal models recently. HIFU can reversibly block the conduction of peripheral nerves without damaging the nerves while using an appropriate ultrasonic parameter. Temporary and partial block of the action potentials of nerves shows that HIFU has the potential to be a useful clinical treatment for pain relief. This work demonstrates the procedures for suppressing the action potentials of neuropathic nerves in diabetic rats in vivo using an HIFU transducer. The first step is to generate adult male diabetic neuropathic rats by streptozotocin (STZ) injection. The second step is to evaluate the peripheral diabetic neuropathy in STZ-induced diabetic rats by an electronic von Frey probe and a hot plate. The final step is to record in vivo extracellular action potentials of the nerve exposed to HIFU sonication. The method showed here may benefit the study of ultrasound analgesic applications.

This work presents the methodology of applying high intensity-focused ultrasound to block the action potentials of diabetic neuropathic nerves.

Nerve conduction block with a high intensity-focused ultrasound (HIFU) transducer has been performed in normal and diabetic animal models recently. HIFU ...

Bioengineering

Screening of Axonal Degeneration in Carpal Tunnel Syndrome Using Ultrasonography and Nerve Conduction Studies

Axonal degeneration, indicative of surgical decompression, may coexist in carpal tunnel syndrome (CTS) as the disease progresses. However, the current diagnostic and severity gradation system cannot clearly indicate its coexistence, resulting in&#160;confusion of appropriate treatment prescription. There are also constraints in conventional methods for&#160;differentiation as well. This study aims at introducing an innovative, efficient, and quick screening protocol to differentiate axonal degeneration associated with CTS, using ultrasound and nerve conduction studies (NCS). It starts by using NCS to perform orthodromic stimulation at the wrist, to obtain the sensory conduction of the median and the ulnar nerves respectively. Meanwhile, the motor conduction&#160;of the median nerve is collected by stimulating the palm, wrist, and elbow, followed by the stimulation of the ulnar nerve at the wrist,&#160;below and above the elbow. Then, an ultrasound assessment is performed, using a linear array transducer, with cross-sectional area (CSA) and perimeter (P) at the wrist and at the one-third distal forearm calipered. Ratios (R-CSA, R-P) and changes from wrist to one-third distal forearm (&#916;CSA and &#916;P) are calculated according to a standard format. Potential axonal degeneration coexisting in CTS will be screened according to the criteria of NCS and cut-off values of ultrasound measurements established in a previous study. In terms of its noninvasiveness, low cost, convenience, and efficiency, it is easy to apply ultrasound complimentarily in clinical practice to prescreen patients with potential coexisting axonal degeneration. Nevertheless, the ultrasonographic imaging cannot directly reflect axonal degeneration. It still relies on conventional but invasive methods&#160;such as electromyography (EMG) and biopsy&#160;for confirmation if needed.

Here we present a protocol using nerve conduction studies and ultrasound to screen potential axonal degeneration associated with carpal tunnel syndrome. The criteria for differentiation are established. Compared to conventional approaches, this method is noninvasive, convenient, and efficient, with an overall satisfactory accuracy, sensitivity, and specificity.

Axonal degeneration, indicative of surgical decompression, may coexist in carpal tunnel syndrome (CTS) as the disease progresses. However, the current ...

Neuromuscular Ultrasound of the Median Nerve at the Carpal Tunnel

The use of neuromuscular ultrasound greatly enhances the evaluation of carpal tunnel syndrome as an adjunct diagnostic tool as it provides dynamic and structural information about the median nerve and its surrounding anatomy.&#8239;Neuromuscular ultrasound aids in diagnostic accuracy (when used with electrodiagnostic testing) and offers etiologic information as a non-invasive, painless, cost-effective, and radiation-free imaging technology that can be easily carried out at the bedside for immediate interpretation. Neuromuscular ultrasound has the limitation of subjectivity, and the need for training and experience will affect the interpretation of results. This article describes a basic practical guide to visualizing the median nerve using neuromuscular ultrasound in a step-by-step manner to aid in the evaluation of carpal tunnel syndrome. Even though the use of ultrasound in the assessment of median nerve entrapment has been long established, there has been no recognized standard protocol. The present protocol aims to provide clear and concise instructions to describe a standard technique to visualize the median nerve through diagnostic ultrasound.

The present protocol describes a technique for the standardization of median nerve ultrasound in cases of suspected carpal tunnel syndrome.

The use of neuromuscular ultrasound greatly enhances the evaluation of carpal tunnel syndrome as an adjunct diagnostic tool as it provides dynamic and ...

Medicine

Treatment Protocol for Rotator Cuff Calcific Tendinitis Using a Single-Crystal Piezoelectric Focused Shock Wave Source

Focused shock waves have emerged as a highly effective noninvasive therapeutic option for the treatment of calcific tendinitis of the shoulder. There are three types of focused shock wave generators: electrohydraulic, electromagnetic, and piezoelectric. According to our literature search, there are no reports of results with the use of single-crystal piezoelectric generators in calcific tendinitis of the shoulder. In a consecutive retrospective series of 23 patients with G&#228;rtner type I and II calcifications of the rotator cuff, we performed three applications of high-energy piezoelectric focused waves (4,000 pulses per session with a frequency of 6 Hz). At the final follow-up (average of 14 months), 82.6% of the cases showed complete resorption of the calcification in radiographic controls. In 8.7% of the cases, partial disappearance of the calcification was achieved, and in the remaining 8.7% there were no significant changes. Single-crystal piezoelectric generators have a success rate comparable to those already reported with electrohydraulic and electromagnetic devices.

Calcific tendinitis of the shoulder is a relatively common condition with numerous treatment options. Here, we discuss the indications of focused shock waves generated by a single-crystal piezoelectric device, describe a treatment protocol, and present the preliminary results.

Focused shock waves have emerged as a highly effective noninvasive therapeutic option for the treatment of calcific tendinitis of the shoulder. There are ...

Ultrasound Scanning Protocol in the Assessment of Ulnar Neuropathy at the Elbow

Ulnar neuropathy at the elbow is commonly encountered in clinical practice and is the second most common entrapment neuropathy. Left untreated, ulnar neuropathy at the elbow can result in significant disability due to loss of dexterity and grip strength secondary to the weakness of intrinsic hand muscles. Precisely localizing a lesion in ulnar neuropathy can be challenging with electrodiagnostic testing alone. Ultrasound is a relatively quick and useful adjunctive diagnostic modality in overcoming this limitation, as an increase in the cross-sectional area (CSA) of the nerve is a common and validated finding in ulnar neuropathies at the elbow. Sonographic assessment of the nerve's echotexture and vascularity can provide additional diagnostic clues. Ultrasound also offers the unique benefit of detecting ulnar nerve subluxation or dislocation out of the retroepicondylar groove during dynamic assessment, although the clinical significance of this is controversial. Finally, ultrasound can also identify structural abnormalities leading to nerve compressions, such as the presence of bony abnormalities, scar tissue, and space-occupying lesions. These findings may influence management strategies and surgical planning. This protocol aims to illustrate the technique of static and dynamic sonographic imaging of the ulnar nerve around the elbow as a complement to electrodiagnostic testing in the assessment of ulnar neuropathy at the elbow.

This is a standardized protocol for evaluating the ulnar nerve at the elbow using ultrasound.

Ulnar neuropathy at the elbow is commonly encountered in clinical practice and is the second most common entrapment neuropathy. Left untreated, ulnar ...

Therapeutic Efficacy of Small Needle Knife Therapy in Treating Frozen Shoulder

Clinical Efficacy of Small Needle Knife Therapy on Stage I-II Frozen Shoulder

Frozen shoulder is a kind of aseptic inflammatory disease of the shoulder caused by strain, trauma, and other reasons, resulting in shoulder joint pain and limited function. The protocol presented here demonstrates the operation of a small needle knife in treating frozen shoulders, including patient management, material preparation, positioning, operation, and postoperative care. The purpose of this protocol is to relieve the pain and functional limitations and improve the living ability of patients with frozen shoulders. In our study, 76 stage I-II frozen shoulder patients who met the inclusion criteria were randomly divided into a control group and a treatment group (n=38). Patients in the control group received functional exercise, while the treatment group received small needle knife therapy with functional exercise. The visual analogue scores (VAS), the Constant and Murley scores (CMS), and the thickness of the coracohumeral ligament (CHL) under ultrasound were evaluated. After small needle knife therapy, the VAS score was significantly lower in the treatment group (5.11 &plusmn; 0.89) than in the control group (5.49 &plusmn; 0.65; t=-2.065, p&lt;0.05); the CMS score was significantly higher in the treatment group (64.72 &plusmn; 4.78) than in the control group (60.97 &plusmn; 6.00; t=2.947, p&lt;0.05); the CHL thickness was significantly decreased in the treatment group (2.38 &plusmn; 0.36) than in the control group (2.57 &plusmn; 0.42; t=-2.117, p&lt;0.05). These results indicate that the small needle knife significantly relieved the pain symptoms, improved the shoulder function, reduced the CHL thickness, and improved the quality of life and, therefore, had significant therapeutic efficacy in stage I-II frozen shoulder patients.

Author Spotlight: Treating Frozen Shoulder with Small Needle Knife Therapy 

The protocol presented here describes the detailed operation method and proves the effectiveness of a small needle knife in the treatment of frozen shoulders.

Frozen shoulder is a kind of aseptic inflammatory disease of the shoulder caused by strain, trauma, and other reasons, resulting in shoulder joint pain ...

Metacarpal Small Incision for Carpal Tunnel Syndrome

Endoscopic carpal tunnel release (ECTR) techniques have been established as a successful treatment for carpal tunnel syndrome and have proven equally effective as traditional open carpal tunnel release (OCTR) techniques in relieving pain and numbness. However, patients who undergo OCTR are more likely to experience scar tenderness and pillar pain and take longer to return to work.
We present here a method of metacarpal small incision for carpal tunnel release (MSICTR) as a safe, reliable, cost-effective alternative surgical decompression of the median nerve of the wrist. This technique utilizes a metacarpal small incision and direct visualization of the median nerve and carpal tunnel contents, reducing the risk of permanent injury and neurasthenia when compared to traditional OCTR. MSICTR is also suitable for the examination of the median nerve, surrounding tendon sheath, or space-occupying lesions.
MSICTR is associated with shorter operation times, less postoperative pain, faster recovery, and improved cosmetic results when compared to traditional OCTR. Therefore, MSICTR is an effective surgical decompression of the median nerve for the treatment of carpal tunnel syndrome.

Carpal tunnel decompression with transverse carpal ligament transection is a very successful treatment of carpal tunnel syndrome. The standard long-curved incision technique has become the best treatment for median nerve entrapment decompression. Here we introduce the metacarpal small incision carpal tunnel release (MSICTR) in the treatment of carpal tunnel syndrome (CTS).

Endoscopic carpal tunnel release (ECTR) techniques have been established as a successful treatment for carpal tunnel syndrome and have proven equally ...

A1 Pulley Reconstruction for Severe Trigger Finger

The aim of this study was to evaluate the effectiveness of A1 pulley reconstruction in treating severe trigger fingers and to compare its outcomes with those of the traditional A1 pulley release technique. A total of 43 patients participated in the study, divided into two groups: 22 patients underwent A1 pulley reconstruction, while the remaining 21 patients received the standard A1 pulley release procedure. The outcomes were assessed using the Michigan Hand Outcomes Questionnaire (MHQ) 1 month post-surgery. The results demonstrated that patients who received the A1 pulley reconstruction reported significantly better outcomes. These included enhanced hand function and quality of life, reduced levels of pain, improved aesthetic appearances, and higher overall satisfaction when compared to the traditional release group. The findings suggest that A1 pulley reconstruction offers superior benefits over the standard release procedure for individuals suffering from severe trigger fingers, highlighting its potential as a more effective surgical intervention.

Here, we present a protocol to compare A1 pulley reconstruction with traditional release surgery in treating a trigger finger, revealing enhanced outcomes and patient satisfaction through the Michigan Hand Outcomes Questionnaire.

The aim of this study was to evaluate the effectiveness of A1 pulley reconstruction in treating severe trigger fingers and to compare its outcomes with ...