Advertisement

Ulnar Nerve Cross-Sectional Area for the Diagnosis of Cubital Tunnel Syndrome: A Meta-Analysis of Ultrasonographic Measurements

  • Ke-Vin Chang
    Correspondence
    Corresponding author Ke-Vin Chang, MD, PhD, Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Bei-Hu Branch and National Taiwan University College of Medicine, Taipei 10845, Taiwan.
    Affiliations
    Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Bei-Hu Branch, Taipei, Taiwan

    Department of Physical and Rehabilitation Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
    Search for articles by this author
  • Wei-Ting Wu
    Affiliations
    Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Bei-Hu Branch, Taipei, Taiwan
    Search for articles by this author
  • Der-Sheng Han
    Affiliations
    Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Bei-Hu Branch, Taipei, Taiwan

    Department of Physical and Rehabilitation Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
    Search for articles by this author
  • Levent Özçakar
    Affiliations
    Department of Physical and Rehabilitation Medicine, Hacettepe University Medical School, Ankara, Turkey
    Search for articles by this author
Published:September 06, 2017DOI:https://doi.org/10.1016/j.apmr.2017.08.467

      Abstract

      Objective

      To examine the performance of sonographic cross-sectional area (CSA) measurements in the diagnosis of cubital tunnel syndrome (CuTS).

      Data Sources

      Electronic databases, comprising PubMed and EMBASE, were searched for the pertinent literature before July 1, 2017.

      Study Selection

      Fourteen trials comparing the ulnar nerve CSA measurements between participants with and without CuTS were included.

      Data Extraction

      Study design, participants' demographic characteristics, diagnostic reference of CuTS, and methods of CSA measurement.

      Data Synthesis

      Among different elbow levels, the between-group difference in CSA was the largest at the medial epicondyle (6.0mm2; 95% confidence interval [CI], 4.5–7.4mm2). The pooled mean CSA in participants without CuTS was 5.5mm2 (95% CI, 4.4–6.6mm2) at the arm level, 7.4mm2 (95% CI, 6.7–8.1mm2) at the cubital tunnel inlet, 6.6mm2 (95% CI, 5.9–7.2mm2) at the medial epicondyle, 7.3mm2 (95% CI, 5.6–9.0mm2) at the cubital tunnel outlet, and 5.5mm2 (95% CI, 4.7–6.3mm2) at the forearm level. The sensitivities, specificities, and diagnostic odds ratios pooled from 5 studies, using 10mm2 as the cutoff point, were .85 (95% CI, .78–.90), .91 (95% CI, .86–.94), and 53.96 (95% CI, 14.84–196.14), respectively.

      Conclusions

      The ulnar nerve CSA measured by ultrasound imaging is useful for the diagnosis of CuTS and is most significantly different between patients and participants without CuTS at the medial epicondyle. Because the ulnar nerve CSA in healthy participants, at various locations, rarely exceeds 10mm2, this value can be considered as a cutoff point for diagnosing ulnar nerve entrapment at the elbow region.

      Keywords

      List of abbreviations:

      CI (confidence interval), CSA (cross-sectional area), CuTS (cubital tunnel syndrome), QUADAS (Quality Assessment of Diagnostic Accuracy Studies)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Kroonen L.T.
        Cubital tunnel syndrome.
        Orthop Clin North Am. 2012; 43: 475-486
        • An T.W.
        • Evanoff B.A.
        • Boyer M.I.
        • Osei D.A.
        The prevalence of cubital tunnel syndrome: a cross-sectional study in a U.S. metropolitan cohort.
        J Bone Joint Surg Am. 2017; 99: 408-416
        • Tai T.W.
        • Wu C.Y.
        • Su F.C.
        • Chern T.C.
        • Jou I.M.
        Ultrasonography for diagnosing carpal tunnel syndrome: a meta-analysis of diagnostic test accuracy.
        Ultrasound Med Biol. 2012; 38: 1121-1128
        • Wu C.H.
        • Chang K.V.
        • Ozcakar L.
        • et al.
        Sonographic tracking of the upper limb peripheral nerves: a pictorial essay and video demonstration.
        Am J Phys Med Rehabil. 2015; 94: 740-747
        • Kerasnoudis A.
        • Tsivgoulis G.
        Nerve ultrasound in peripheral neuropathies: a review.
        J Neuroimaging. 2015; 25: 528-538
        • Kara M.
        • Ozcakar L.
        • De Muynck M.
        • Tok F.
        • Vanderstraeten G.
        Musculoskeletal ultrasound for peripheral nerve lesions.
        Eur J Phys Rehabil Med. 2012; 48: 665-674
        • Beekman R.
        • Visser L.H.
        • Verhagen W.I.
        Ultrasonography in ulnar neuropathy at the elbow: a critical review.
        Muscle Nerve. 2011; 43: 627-635
        • Whiting P.F.
        • Rutjes A.W.
        • Westwood M.E.
        • et al.
        QUADAS-2: a revised tool for the Quality Assessment of Diagnostic Accuracy Studies.
        Ann Intern Med. 2011; 155: 529-536
        • Jacob D.
        • Creteur V.
        • Courthaliac C.
        • et al.
        Sonoanatomy of the ulnar nerve in the cubital tunnel: a multicentre study by the GEL.
        Eur Radiol. 2004; 14: 1770-1773
        • Lin Y.C.
        • Wu W.T.
        • Hsu Y.C.
        • Han D.S.
        • Chang K.V.
        Comparative effectiveness of botulinum toxin versus non-surgical treatments for treating lateral epicondylitis: a systematic review and meta-analysis.
        Clin Rehabil. 2017 March 1; ([E-pub ahead of print.])
        • Hung C.Y.
        • Hsiao M.Y.
        • Chang K.V.
        • Han D.S.
        • Wang T.G.
        Comparative effectiveness of dextrose prolotherapy versus control injections and exercise in the management of osteoarthritis pain: a systematic review and meta-analysis.
        J Pain Res. 2016; 9: 847-857
        • Chang K.V.
        • Wu W.T.
        • Hung C.Y.
        • et al.
        Comparative effectiveness of suprascapular nerve block in the relief of acute post-operative shoulder pain: a systematic review and meta-analysis.
        Pain Physician. 2016; 19: 445-456
        • Zamora J.
        • Abraira V.
        • Muriel A.
        • Khan K.
        • Coomarasamy A.
        Meta-DiSc: a software for meta-analysis of test accuracy data.
        BMC Med Res Methodol. 2006; 6: 31
        • Okamoto M.
        • Abe M.
        • Shirai H.
        • Ueda N.
        Diagnostic ultrasonography of the ulnar nerve in cubital tunnel syndrome.
        J Hand Surg. 2000; 25: 499-502
        • Beekman R.
        • Van Der Plas J.P.
        • Uitdehaag B.M.
        • Schellens R.L.
        • Visser L.H.
        Clinical, electrodiagnostic, and sonographic studies in ulnar neuropathy at the elbow.
        Muscle Nerve. 2004; 30: 202-208
        • Park G.Y.
        • Kim J.M.
        • Lee S.M.
        The ultrasonographic and electrodiagnostic findings of ulnar neuropathy at the elbow.
        Arch Phys Med Rehabil. 2004; 85: 1000-1005
        • Van Den Berg P.J.
        • Pompe S.M.
        • Beekman R.
        • Visser L.H.
        Sonographic incidence of ulnar nerve (sub)luxation and its associated clinical and electrodiagnostic characteristics.
        Muscle Nerve. 2013; 47: 849-855
        • Babusiaux D.
        • Laulan J.
        • Bouilleau L.
        • et al.
        Contribution of static and dynamic ultrasound in cubital tunnel syndrome.
        Orthop Traumatol Surg Res. 2014; 100: S209-S212
        • Beekman R.
        • Zijlstra W.
        • Visser L.H.
        A novel points system to predict the prognosis of ulnar neuropathy at the elbow.
        Muscle Nerve. 2017; 55: 698-705
        • Podnar S.
        • Omejec G.
        • Bodor M.
        Nerve conduction velocity and cross-sectional area in ulnar neuropathy at the elbow.
        Muscle Nerve. 2017 March 27; ([E-pub ahead of print.])
        • Caress J.B.
        • Becker C.E.
        • Cartwright M.S.
        • Walker F.O.
        Ultrasound in the diagnosis of ulnar neuropathy at the elbow.
        J Clin Neuromusc Dis. 2003; 4: 161-162
        • Beekman R.
        • Schoemaker M.C.
        • Van Der Plas J.P.
        • et al.
        Diagnostic value of high-resolution sonography in ulnar neuropathy at the elbow.
        Neurology. 2004; 62: 767-773
        • Omejec G.
        • Podnar S.
        Normative values for short-segment nerve conduction studies and ultrasonography of the ulnar nerve at the elbow.
        Muscle Nerve. 2015; 51: 370-377
        • Sivak W.N.
        • Hagerty S.E.
        • Huyhn L.
        • Jordan A.C.
        • Munin M.C.
        • Spiess A.M.
        Diagnosis of ulnar nerve entrapment at the arcade of Struthers with electromyography and ultrasound.
        Plast Reconstr Surg Glob Open. 2016; 4: e648
        • Kim B.J.
        • Date E.S.
        • Lee S.H.
        • Yoon J.S.
        • Hur S.Y.
        • Kim S.J.
        Distance measure error induced by displacement of the ulnar nerve when the elbow is flexed.
        Arch Phys Med Rehabil. 2005; 86: 809-812
        • Yalcin E.
        • Onder B.
        • Akyuz M.
        Ulnar nerve measurements in healthy individuals to obtain reference values.
        Rheumatol Int. 2013; 33: 1143-1147
        • Yoon J.S.
        • Hong S.J.
        • Kim B.J.
        • et al.
        Ulnar nerve and cubital tunnel ultrasound in ulnar neuropathy at the elbow.
        Arch Phys Med Rehabil. 2008; 89: 887-889
        • Radhika S.
        • Lee Y.L.
        • Low S.F.
        • et al.
        Role of high resolution ultrasound in ulnar nerve neuropathy.
        Med J Malaysia. 2015; 70: 158-161
        • Yalcin E.
        • Unlu E.
        • Akyuz M.
        • Karaahmet O.Z.
        Ultrasound diagnosis of ulnar neuropathy: comparison of symptomatic and asymptomatic nerve thickness.
        J Hand Surg Eur Vol. 2014; 39: 167-171
        • Ellegaard H.R.
        • Fuglsang-Frederiksen A.
        • Hess A.
        • Johnsen B.
        • Qerama E.
        High-resolution ultrasound in ulnar neuropathy at the elbow: a prospective study.
        Muscle Nerve. 2015; 52: 759-766
        • Bathala L.
        • Kumar K.
        • Pathapati R.
        • Jain S.
        • Visser L.H.
        Ulnar neuropathy in Hansen disease: clinical, high-resolution ultrasound and electrophysiologic correlations.
        J Clin Neurophysiol. 2012; 29: 190-193
        • Ayromlou H.
        • Tarzamni M.K.
        • Daghighi M.H.
        • et al.
        Diagnostic value of ultrasonography and magnetic resonance imaging in ulnar neuropathy at the elbow.
        ISRN Neurol. 2012; 2012: 491892
        • Bayrak A.O.
        • Bayrak I.K.
        • Turker H.
        • Elmali M.
        • Nural M.S.
        Ultrasonography in patients with ulnar neuropathy at the elbow: comparison of cross-sectional area and swelling ratio with electrophysiological severity.
        Muscle Nerve. 2010; 41: 661-666
        • Chiou H.J.
        • Chou Y.H.
        • Cheng S.P.
        • et al.
        Cubital tunnel syndrome: diagnosis by high-resolution ultrasonography.
        J Ultrasound Med. 1998; 17: 643-648
        • Ghanei M.E.
        • Karami M.
        • Zarezadeh A.
        • Sarrami A.H.
        Usefulness of combination of grey-scale and color Doppler ultrasound findings in the diagnosis of ulnar nerve entrapment syndrome.
        J Res Med Sci. 2015; 20: 342-345
        • Gruber H.
        • Glodny B.
        • Peer S.
        The validity of ultrasonographic assessment in cubital tunnel syndrome: the value of a cubital-to-humeral nerve area ratio (CHR) combined with morphologic features.
        Ultrasound Med Biol. 2010; 36: 376-382
        • Kim J.H.
        • Won S.J.
        • Rhee W.I.
        • Park H.J.
        • Hong H.M.
        Diagnostic cutoff value for ultrasonography in the ulnar neuropathy at the elbow.
        Ann Rehabil Med. 2015; 39: 170-175
        • Kutlay M.
        • Colak A.
        • Simsek H.
        • et al.
        Use of ultrasonography in ulnar nerve entrapment surgery—a prospective study.
        Neurosurg Rev. 2009; 32: 225-232
        • Mondelli M.
        • Filippou G.
        • Frediani B.
        • Aretini A.
        Ultrasonography in ulnar neuropathy at the elbow: relationships to clinical and electrophysiological findings.
        Clin Neurophysiol. 2008; 38: 217-226
        • Simon N.G.
        • Ralph J.W.
        • Poncelet A.N.
        • Engstrom J.W.
        • Chin C.
        • Kliot M.
        A comparison of ultrasonographic and electrophysiologic ‘inching’ in ulnar neuropathy at the elbow.
        Clin Neurophysiol. 2015; 126: 391-398
        • Volpe A.
        • Rossato G.
        • Bottanelli M.
        • et al.
        Ultrasound evaluation of ulnar neuropathy at the elbow: correlation with electrophysiological studies.
        Rheumatology. 2009; 48: 1098-1101
        • Wiesler E.R.
        • Chloros G.D.
        • Cartwright M.S.
        • Shin H.W.
        • Walker F.O.
        Ultrasound in the diagnosis of ulnar neuropathy at the cubital tunnel.
        J Hand Surg. 2006; 31: 1088-1093
        • Yoon J.S.
        • Walker F.O.
        • Cartwright M.S.
        Ultrasonographic swelling ratio in the diagnosis of ulnar neuropathy at the elbow.
        Muscle Nerve. 2008; 38: 1231-1235
        • Zhong W.
        • Zhang W.
        • Zheng X.
        • Li S.
        • Shi J.
        The high-resolution ultrasonography and electrophysiological studies in nerve decompression for ulnar nerve entrapment at the elbow.
        J Reconstr Microsurg. 2012; 28: 345-348
        • Thoirs K.
        • Williams M.A.
        • Phillips M.
        Ultrasonographic measurements of the ulnar nerve at the elbow: role of confounders.
        J Ultrasound Med. 2008; 27: 737-743
        • Chang K.V.
        • Hung C.Y.
        • Ozcakar L.
        Ultrasound imaging facilitated the detection of a double crush radial nerve injury.
        Am J Phys Med Rehabil. 2015; 94: e89
        • Glas A.S.
        • Lijmer J.G.
        • Prins M.H.
        • Bonsel G.J.
        • Bossuyt P.M.
        The diagnostic odds ratio: a single indicator of test performance.
        J Clin Epidemiol. 2003; 56: 1129-1135