Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 


 
 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 35  |  Issue : 1  |  Page : 164-171

Diagnostic accuracy of nerve conduction studies versus ultrasonography in early diagnosis of ulnar nerve entrapment at the elbow


1 Department of Physical Medicine, Rheumatology and Rehabilitation, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Radiodiagnosis, Faculty of Medicine, Menoufia University, Menoufia, Egypt

Date of Submission07-May-2021
Date of Decision09-Jun-2021
Date of Acceptance13-Jun-2021
Date of Web Publication18-Apr-2022

Correspondence Address:
Fatma El-Zahraa M. M. Khattab
Tala, Menoufia 32611
Egypt
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_92_21

Rights and Permissions
  Abstract 


Background
Ulnar nerve entrapment at the elbow (UNE) is a compression of the ulnar nerve at the elbow level that is mainly diagnosed clinically and confirmed by electrodiagnostic testing as well as diagnostic imaging of the ulnar nerve.
Objectives
To evaluate the diagnostic accuracy of nerve conduction studies (NCSs) versus ultrasonography (US) in the early diagnosis of UNE.
Patients and methods
This cross-sectional study included 160 patients: 80 patients with symptoms suggestive of UNE for less than or equal to 6 weeks and a control group of 80 healthy adults. Both groups were clinically examined and assessed using a self-administered questionnaire of UNE. Furthermore, motor and sensory NCS and short-segment nerve conductions of ulnar nerve in both groups with measurement of ulnar nerve cross-sectional area using US in the case group were performed.
Results
A high sensitivity of using NCSs for early diagnosis of UNE measuring conduction velocity and amplitude was exhibited via traditional 10-cm NCSs (95 and 82.5%, respectively) and short-segment nerve conductions (97.5 and 90%, respectively). US has showed a decrease in the sensitivity (40%) in comparison with short-segment amplitude drop, with an accuracy of 91% as well as a specificity of 99%, and there was a high sensitivity of short-segment amplitude drop D2/ME (80%) when compared with US at P2, which exhibited an accuracy of 91% and specificity of 92%.
Conclusion
Herein, electrodiagnostic in addition to the US studies would play a vital role in increasing the accuracy of diagnosis of UNE; additionally, it will help in precise localization of the site of pathology.

Keywords: nerve conduction studies, questionnaire of ulnar neuropathy at the elbow, short-segment nerve conduction studies, ulnar nerve entrapment at the elbow, ultrasonography


How to cite this article:
Soliman SG, Labeeb AA, Fotoh DS, Serag DM, Khattab FE. Diagnostic accuracy of nerve conduction studies versus ultrasonography in early diagnosis of ulnar nerve entrapment at the elbow. Menoufia Med J 2022;35:164-71

How to cite this URL:
Soliman SG, Labeeb AA, Fotoh DS, Serag DM, Khattab FE. Diagnostic accuracy of nerve conduction studies versus ultrasonography in early diagnosis of ulnar nerve entrapment at the elbow. Menoufia Med J [serial online] 2022 [cited 2024 Mar 28];35:164-71. Available from: http://www.mmj.eg.net/text.asp?2022/35/1/164/343142




  Introduction Top


Ulnar nerve entrapment at the elbow (UNE) is a compression of the ulnar nerve at the elbow level. It is the second most common peripheral entrapment neuropathy [1]. UNE has been diagnosed by clinical examination and electrodiagnostic testing, mainly standard 10-cm nerve conduction studies (NCSs) [2]. Another useful electrodiagnostic approach is short-segment nerve conductions (SSNCs) [3]. Ultrasonography (US) is a promising tool for detecting peripheral neuropathy measuring the nerve cross-sectional area (CSA) [4].

The aim of this work was to evaluate the diagnostic accuracy of NCS versus US in early diagnosis of UNE.


  Patients and methods Top


This cross-sectional study included 160 patients, comprising 80 patients with symptoms suggestive of UNE and a control group of 80 healthy adults without neurological symptoms or signs in the arms, who had attended the outpatient clinic of Physical Medicine, Rheumatology, and Rehabilitation Department, Menoufia University Hospitals, from April 2018 to June 2019. This research was approved by the local ethical committee at Faculty of Medicine, Menoufia University. Ethical written consent was obtained from the patients and the controls about the study and procedure.

All patients had at least one of the following presenting symptoms typical for UNE for less than or equal to 6 weeks: (a) continuous numbness or paresthesias in the fifth and the ulnar half of the fourth finger, or (b) sensation of weakness or clumsiness of the ulnar-innervated muscles, or (c) pain on the medial aspect of the elbow radiating to the forearm or hand. Besides, a control group of 80 healthy adults without neurological symptoms or signs in the arms was recruited. In all participants, the symptomatic arm was examined. In controls, the left arms were neurologically examined.

Exclusion criteria included previous elbow fracture or surgery, known polyneuropathy, liability to pressure palsies and multifocal motor neuropathy with conduction block (CB), motor neuron disorders, malignancy, paraneoplastic syndrome, autoimmune, vasculitic diseases, space-occupying lesions within the cubital tunnel, pregnancy, inflammatory conditions, cervical radiculopathy, brachial plexopathy, and thoracic outlet syndrome.

All patients were subjected to demographic data and clinical assessment including medical history, clinical examination, and a self-administered questionnaire of ulnar neuropathy at the elbow (UNEQ) [5]. This questionnaire is a new subjective method for assessment of symptom severity of UNE at the elbow. UNEQ includes nine questions and considers numbness and tingling in the fourth and fifth fingers, elbow pain, and modification of pain and paresthesia with elbow position. A score from 1 (absence of symptom) to 5 (most severe) is assigned for each question. The overall score is calculated as the mean of the nine scores. The questions on symptoms had a forced response (yes or no) and indicate hand or elbow symptoms in the last 2 weeks. Moreover, all patients were subjected to cervical spine radiograph using conventional radiographic unit and laboratory investigation including complete blood count (Sysmex xn 1000, Germany), Kobe (HQ) Japan. Wakihama Park, 5 Chome-1-11 Iwaya Kitamachi, Nada-ku. erythrocyte sedimentation rate, C-reactive protein, thyroid function tests, blood sugar level, coagulation profile, alanine transaminase, aspartate transaminase, serum creatinine using Cobass 6000 (c501 module) (Roche, Germany), and autoimmune panel (ANA, Anti-dsDNA, Anti-RO, Anti-La, C-ANCA, P-ANCA) using indirect immunofluorescence technique, Biorad (1000 Alfred Nobel Drive Hercules, California 94547, USA, for exclusion of secondary causes. All patients were subjected to US measuring ulnar nerve CSA and NCS for ulnar nerve (motor, sensory, and SSNCs).

NCSs using Menoufia University (Nihon Kohden Neuropack M1 Electromyograph Apparatus, Tokyo, Japan) included traditional 10-cm NCS of the ulnar nerve (motor NCS measuring distal motor latency, amplitude of compound muscle action potentials (CMAP), and motor conduction velocity (CV), whereas sensory NCS measuring sensory peak latency, amplitude, and sensory CV [2], and SSNCs where the electrophysiological study was obtained at the following five standardized sites: with the elbow flexed at 90°, markers placed at the medial epicondyle (ME), 2 and 4 cm distal (D2, D4) and 2, 4, and 6 cm proximal (P2, P4, P6) along the course of the ulnar nerve [3]. CMAPs were recorded from the abductor digiti minimi muscle on stimulation at the wrist and at all elbow markers in addition to CV.

US included measuring of ulnar nerve CSA on the symptomatic arm at the wrist, at ME, D2, D4, P2, P4, and P6[6] using Philips HDI 5000 device (967 mi; Philips, HDI 5000 Device, Newark, New Jersey, USA), with 7.5–15-MH linear probe in the Radiology Department of Menoufia University Hospitals.

Statistical analysis

Data were collected, tabulated, and statistically analyzed using an IBM compatible personal computer with Statistical Package for the Social Sciences (SPSS), version 23 (SPSS Inc. Released 2015. IBM SPSS statistics for Windows, version 23.0; IBM Corp., Armonk, New York, USA). Descriptive statistics presented quantitative data in the form of the mean, SD, and range, and qualitative data in the form of numbers and percentages (%). The used tests of significance included χ2 test and Fisher's exact test, Student's t test (P < 0.05 was considered statistically significant), and Z test. Sensitivity is the proportion of patients with disease who test positive = TP/(TP + FN), and specificity is the proportion of patients without disease who test negative = TN/(TN + FP).


  Results Top


There was no statistically significant difference between both the groups regarding sex, age, and occupation, with female predominance in case group and increased incidence in working population. A total of 48 (60%) patients presented with numbness or paresthesia in fifth and ulnar half of fourth finger, and 32 (40%) patients presented with numbness and pain on the medial aspect of the elbow. Twenty (25%) patients had diminished sensation to pinprick and light touch. Right arm was affected in 42 (52.5%) patients. Using UNEQ, patients exhibited mild (27.5%), moderate (62.5%), and severe (10%) symptoms severity [Table 1].
Table 1: Demographic data and clinical assessment of the studied groups

Click here to view


Motor NCS showed statistically significant delayed latency and reduced amplitude below the elbow and above the elbow, and statistically high significant slowing of CV across elbow segment between both groups. Regarding CB, there was a statistically high significant slowing of CV between forearm segment and elbow segment more than 10–11 m/s, statistically significant amplitude drop between wrist and above elbow more than 20%, and amplitude drop between below elbow and above elbow more than 10% between both the groups. In sensory NCS, there was a statistically high significant amplitude reduction of sensory nerve action potential between both groups [Table 2].
Table 2: Traditional 10-cm nerve conduction studies of the studied groups

Click here to view


In SSNCs, there was a statistically highly significant reduction of CV (≤40 m/s) between point D4 and point D2, reduction of CV (≤36 m/s) between point D2 and ME, and reduction of CV (≤31 m/s) between ME and point P2 between both the groups and no statistically significant difference between both the groups regarding CV slowing between point P2 and point P4. Regarding CV slowing (CV drop <10–11 m/s), there was a statistically significant slowing of CV from the ME to point P4 and statistically high significant slowing of CV across all other points between both the groups. Regarding amplitude drop, there was a statistically significant amplitude drop less than 6% between point D4 and point D2 and a statistically highly significant amplitude drop less than 8% between point D2 and ME between both the groups [Table 3].
Table 3: Short-segment nerve conduction studies of studied groups

Click here to view


There was a statistically nonsignificant increment in ulnar nerve CSA between both the groups by US [Table 4].
Table 4: The ultrasound of studied groups regarding the cross-sectional area

Click here to view


Using motor NCSs, there was high sensitivity (95%) of measuring CV across elbow segment with cutoff point less than 87.5 but was specificity 10%, whereas there was high sensitivity (82.5%) of measuring amplitude at forearm segment with a cutoff point of 12.3 but the specificity was 10% in the detection of UNE. However, using SSNCs, there was a high sensitivity (97.5%) of measuring CV between ME and P2 at a cutoff point of less than 62.95 but specificity was 50%, and also there was high sensitivity (90%) of measuring amplitude at point D2, with a cutoff of point less than 7.75, but the specificity was 15% [Table 5].
Table 5: Sensitivity and specificity of traditional 10-cm nerve conduction studies versus short-segment nerve conduction studies in cases versus controls

Click here to view


For early diagnosis of UNE, there was a highly significant relation between increment in the CSA in the US at P2 and amplitude drop (D2/ME) in SSNCs; there was decreased sensitivity of US (40%) in comparison with short-segment amplitude drop with an accuracy of 91% and specificity of 99%; there was a highly significant relation between short-segment amplitude drop (D2/ME) and US at P2; and there was high sensitivity of short-segment amplitude drop D2/ME (80%) in comparison to the US at P2 with an accuracy of 91% and specificity of 92% [Table 6].
Table 6: Relation between US and short-segment nerve conduction studies and accuracy of these studies in early diagnosis of ulnar nerve entrapment at the elbow

Click here to view



  Discussion Top


Our study exhibited female predominance (65%) among the studied case group. Female predominance was also reported by Visser et al. [7], Pompe and Beekman [6], and Terlemez et al. [8], which may be owing to external compression at the elbow causing CB [7]. In contrast to the current study, Omejec and Podnar [9], Yoon et al. [10], and Mondelli et al.[5] reported male predominance, as the ulnar nerve is more mobile in men and therefore more sensitive to gliding impairment at ME [11],[12]. Working population especially farmers were more than the nonworking population in both groups (77.5% working population vs. 22.5% nonworking population in case group and 78% working population vs. 27.5% nonworking population in control group), which may be explained by the nature of their occupation (holding tools in position for long periods) [9],[13],[14],[15].

A total of 48 (60%) patients presented with numbness or paresthesia in fifth and ulnar half of fourth finger and 32 (40%) patients presented with numbness and pain on the medial aspect of the elbow. This goes in line with Beekman et al. [16], Yoon et al. [10], Pompe and Beekman [6], and Omejec and Podnar [9]. The right arm was affected in 42 (52.5%) patients, which may be owing to involvement of the dominant hand. Simon et al. [17], also reported that all patients were right handed. On the contrary, Pompe and Beekman [6], and Omejec and Podnar[9] reported a predominance of UNE in the left arm. A total of 20 (25%) patients had diminished sensation to pinprick and light touch, which goes in line with Beekman et al. [16], Yoon et al. [10], and Simon et al. [17].

In traditional 10-cm motor NCS, there was a significant difference between both groups in latency delay (7.5% in case group and no affection in control group) and amplitude reduction (7.5% drop below elbow and 10% drop above elbow in case group, no affection in control group) and highly significant difference in CV slowing across elbow between both groups (20% in case group, no affection in control group). This goes in line with Beekman et al. [16], Visser et al. [7], Mondelli et al. [5], and Pompe and Beekman [6]. Regarding CB across elbow, there was a highly significant slowing of CV between forearm segment and elbow segment more than 10–11 m/s between both groups (28.7% in case group and no affection in control group), significant amplitude drop between wrist and above elbow more than 20% between cases and control group (10% in case group and no affection in control group), and significant amplitude drop between below elbow and above elbow more than 10% between both groups (7.5% in case group and no affection in control group). This goes in line with Beekman et al. [16], Visser et al. [7], and Pompe and Beekman [6], who reported CB in 71, 50, and 44.1%, respectively.

SSNCs shows a highly significant reduction of amplitude between cases and control group (42.5% in case group and no affection in control group). It comes in accordance with Beekman et al. [16], Visser et al. [7], and Simon et al. [17].

Regarding SSNCs, there was a highly significant reduction of CV (≤40 m/s) between point D4 and point D2 between both the groups (22.5% in case group and no affection in control group), between point D2 and ME between both the groups (35% in case group and no affection in control group), and between the ME and point P2 between both the groups (45% in case group and no affection in control group). Regarding CV drop according to traditional CV drop level (CV drop <10–11 m/s), a highly significant difference between cases and controls was found at all levels [between W/D4 and D4/D2 (27.5%), between D4/D2 and D2/ME (42.5%), between D2/ME and ME/P2 (57.5%), between ME/P2 and P2/P4 (10%), and between P2/P4 and P4/P6, with 12.5% in the case group but no affection in the control group]. Visser et al.[7] found that SSNCs localized the lesion proximal to the ME in 32 (53%), at the level of the ME in 16 (27%), and distal to the ME in 12 (20%) of the 60 arms with abnormal SSNCs. Regarding CB, Omejec and Podnar[9] found that the most affected ulnar nerve segment was ME/P2 for SSNCs, and also postulated that in theory, motor nerve conduction should be similar in every 2-cm segment across the elbow, meaning that slowing in any segment is indicative of subclinical UNE. However, using such criteria, only 11 (22%) of 49 controls would have normal SSNCs, pointing to an extremely high prevalence (78%) of ulnar nerve conduction abnormality at the elbow in asymptomatic individuals. So, measuring amplitude drop using SSNCs should be considered. Regarding amplitude drop, there was a statistically significant amplitude drop less than 6% between point D4 and point D2 between both the groups (10% in case group and no affection in control group) and a highly significant amplitude drop less than 8% between point D2 and ME between both the groups (12.5% in the case group and no affection in the control group). Herrmann et al.[18] also reported amplitude drop in short-segment incremental study [of the 13 patients, short-segment incremental stimulation was localized at the ulnar motor CB (sudden drop in CMAP amplitude and area of >20%) to above the epicondyle in eight (62%), at ME in three (23%) patients, and below ME (1–3 cm) in two (15%)]. Omejec and Podnar[9] reported that using SSNCSs (abnormal Motor Nerve Conduction Velocity (MNCV) slowing or CMAP amplitude drop), the most common localization of UNE at Humeral-Ulnar Angle (HUA) was in the 2-cm segment just distal to ME (D2/ME) in eight (73%) arms and in UNE at Revised Trauma Score (RTC) in the 2-cm segment just proximal to ME (ME/P2) in 41 (82%) arms. Visser et al.[7] also reported that in 35 arms of 70 patients, focal CB (amplitude reduction of >17%) was present.

Regarding the ulnar nerve CSA, there was a nonsignificant increment in the CSA of the ulnar nerve between both the groups at ME, P2, and P4 (2.5, 6.3, and 2.5% in case group and no affection in control group). Beekman et al.[16] found that the ulnar-nerve diameter was abnormally large at one or more of the three levels around the elbow in 91 cases. In accordance with our study, Omejec and Podnar[9] reported point P2 to be the most affected point across the elbow. Simon et al.[17] reported that mean CSA and hypoechoic fraction were greatest at P1 and then D1.

According to the current study, regarding traditional 10-cm motor NCSs, measuring CV and amplitude measurement across elbow were of high sensitivity (95 and 82.5%, respectively) and low specificity (10% each) in cases vs the control group. Regarding SSNCS, measuring CV between ME and P2 was of high sensitivity and average specificity (97.5 and 50%, respectively) in cases versus control group. However, measurement of amplitude at point D2 using SSNCS was of high sensitivity and low specificity (90 and 15%, respectively) in cases versus control group. This goes in line with Beekman et al.[16] (MCV slowing has a sensitivity of 78% using traditional 10-cm motor NCS) and Omejec and Podnar [9], which reported that the sensitivity of SSNCSs, US, and standard 10-cm NCSs was 89, 71, and 83%, respectively. Their specificities were 80, 82, and 82%, respectively. We found a highly significant relation between increment in the CSA in the US at P2 and amplitude drop (D2/ME) in SSNCs in cases versus controls. We found decreased sensitivity of US (40%) in comparison with short-segment amplitude drop with an accuracy of 91% and specificity of 99% in cases versus controls. Pompe and Beekman[6] also reported that measuring CSA using the US was of 60.6% sensitivity and 79.6% specificity, and Omejec and Podnar[9] reported diagnostic accuracy of the US in UNE of about 80%. Decreased sensitivity found in the current study may be explained by a short period of complaint, early course of the disease, and exclusion of traumatic, axonal, and any neuropathic disease affecting the ulnar nerve. This goes in line with the study by Omejec and Podnar [9], as it postulated that in demyelinated nerves, swelling occurs due to endoneurial edema, inflammation, demyelination and remyelination, and thickening of the perineurium and endoneurium. Neary and Eames [19], Rempel et al. [20], morphologic changes that need some time to develop Ochoa et al. [21].

We found a highly significant relation between short-segment amplitude drop (D2/ME) and the US at P2 in cases versus controls. We found high sensitivity of short-segment amplitude drop D2/ME (80%) in comparison with the US at P2 for early diagnosis of UNE, with an accuracy of 91% and specificity of 92%. Omejec and Podnar [9] found that in patients with UNE, NCSs were diagnostically more accurate than in the US. The sensitivity of the US was particularly poor in UNE with CB (55%).


  Conclusions Top


For electro-diagnosis of UNE, although traditional 10-cm NCS of the ulnar nerve measuring CV and amplitude across the elbow has high sensitivity, performing SSNCs improves the outcome of the diagnostic procedure through precise localization of the site of entrapment. In addition, measuring CV slowing between different segments, using other parameters such as amplitude drop, improves the accuracy of diagnosis and avoids overdiagnosis of UNE.

US is a noninvasive, cost-effective, time-wise complementary diagnostic tool especially in case of presence of a primary cause as a space-occupying lesion or in case of the axonal lesion. Measuring CSA of the ulnar nerve across different segments is considered a good parameter for diagnosis of UNE.

Using both electrophysiological studies in addition to the US would increase the accuracy of diagnosis of UNE and would indicate the cause of entrapment, which would help in planning the type of surgical interference and the precise localization of the site of pathology.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Hobson-Webb L, Juel V. Common entrapment neuropathies. Continuum (Minneap Minn) 2017; 23:487–511.  Back to cited text no. 1
    
2.
Mallik A, Weir AINerve conduction studies: essentials and pitfalls in practiceJournal of Neurology, Neurosurgery & Psychiatry 2005;76:ii23-ii31.  Back to cited text no. 2
    
3.
Yüksel Y, Akıncı Ü, Polat H. An introduced effective-field approximation and Monte Carlo study of a spin-1 Blume–Capel model on a square lattice. Phys Scripta 2009; 79:045009.  Back to cited text no. 3
    
4.
Scheid E, Böhm J, Farbaky Z, Simó M, Bereczki D, Arányi Z. Ultrasonography of ulnar neuropathy at the elbow: axonal involvement leads to greater nerve swelling than demyelinating nerve lesion. Clin Neurophysiol 2013; 124:619–625.  Back to cited text no. 4
    
5.
Mondelli M, Padua L, Giannini F, Bibbo G, Aprile I, Rossi S. A self-administered questionnaire of ulnar neuropathy at the elbow. Neurol Sci 2006; 27:402–411.  Back to cited text no. 5
    
6.
Pompe S, Beekman R. Which ultrasonographic measure has the upper hand in ulnar neuropathy at the elbow. Clin Neurophysiol 2013; 124:190–196.  Back to cited text no. 6
    
7.
Visser L, Beekman R, Franssen H. Short-segment nerve conduction studies in ulnar neuropathy at the elbow. Muscle Nerve 2005; 31:331–338.  Back to cited text no. 7
    
8.
Terlemez R, Yilmaz F, Dogu B, Kuran B. Comparison of ultrasonography and short segment nerve conduction study in ulnar neuropathy at the elbow. Arch Phys Med Rehabil 2018; 99:116–120.  Back to cited text no. 8
    
9.
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.  Back to cited text no. 9
    
10.
Yoon J, Walker F, Cartwright M. Ultrasonographic swelling ratio in the diagnosis of ulnar neuropathy at the elbow. Muscle Nerve 2008; 38:1231–1235.  Back to cited text no. 10
    
11.
Richardson J, Green D, Jamieson S, Valentin F. Gender, body mass and age as risk factors for ulnar mononeuropathy at the elbow. Muscle Nerve 2001; 24:551–554.  Back to cited text no. 11
    
12.
Matev B. Cubital tunnel syndrome. Hand Surg 2003; 8:127–131.  Back to cited text no. 12
    
13.
Descatha A, Leclerc A, Chastang J, Roquelaure Y. Incidence of ulnar nerve entrapment at the elbow in repetitive work. Scand J Work Environ Health 2004; 30:234.  Back to cited text no. 13
    
14.
Bartels R, Verbeek A. Risk factors for ulnar nerve compression at the elbow: a case control study. Acta Neurochir (Wien) 2007; 149:669–674.  Back to cited text no. 14
    
15.
Tourinho P, Van Gestel C, Lofts S, Svendsen C, Soares A, Loureiro S. Metal-based nanoparticles in soil: fate, behavior, and effects on soil invertebrates. Environ Toxicol Chem 2012; 31:1679–1692.  Back to cited text no. 15
    
16.
Beekman R, Van Der Plas J, Uitdehaag B, Schellens R, Visser L. Clinical, electrodiagnostic, and sonographic studies in ulnar neuropathy at the elbow. Muscle Nerve 2004; 30:202–208.  Back to cited text no. 16
    
17.
Simon N, Ralph J, Poncelet A, Engstrom J, Chin C, Kliot M. A comparison of ultrasonographic and electrophysiologic 'inching' in ulnar neuropathy at the elbow. Clin Neurophysiol 2015; 126:391–398.  Back to cited text no. 17
    
18.
Herrmann D, Preston D, McIntosh K, Logigian E. Localization of ulnar neuropathy with conduction block across the elbow. Muscle Nerve 2001; 24:698–700.  Back to cited text no. 18
    
19.
Neary, D, Eames R. The pathology of ulnar nerve compression in man. Neuropathol Appl Neurobiol 1975; 1:69–88.  Back to cited text no. 19
    
20.
Rempel D, Dahlin, L, Lundborg G. Pathophysiology of nerve compression syndromes: response of peripheral nerves to loading. J Bone Joint Surg Am 1999; 81:1600–1610.  Back to cited text no. 20
    
21.
Ochoa J, Fowler T, Gilliatt R. Anatomical changes in peripheral nerves compressed by a pneumatic tourniquet. J Anat 1972; 113:433.  Back to cited text no. 21
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Patients and methods
Results
Discussion
Conclusions
References
Article Tables

 Article Access Statistics
    Viewed668    
    Printed16    
    Emailed0    
    PDF Downloaded70    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]