Effect of Perineural Dextrose Injection on Ulnar Neuropathy at the Elbow: A Randomized, Controlled, Double-Blind Study.

OBJECTIVE: To compare perineural dextrose injection efficacy in the treatment of ulnar neuropathy at the elbow with a control group. DESIGN: Prospective double-blind randomized control study. SETTING: Training and research hospital. PARTICIPANTS: The study was completed with 40 patients with ulnar neuropathy at the elbow. INTERVENTION: Normal saline (0.9% sodium chloride) was injected in patients in the control group (n=20; mean age=38.1±10.7 years; median duration of symptoms=4.5 months), and 5% dextrose was injected in patients in the dextrose group (n=20; mean age=43.6±13.5 years; median duration of symptoms=5 months), perineurally under ultrasound guidance twice at 2-week intervals. Ultrasound-guided perineural injection of 1 cc each was administered into the ulnar nerve, 2 cm and 4 cm distal to the medial epicondyle, at the level of the medial epicondyle, and 2 cm and 4 cm proximal to the medial epicondyle. The amount of total fluid injected was 5 cc. MAIN OUTCOME MEASURE(S): At baseline and weeks 2, 4, and 12, the patients were evaluated with the Visual Analog Scale for pain and the Disabilities of the Arm Shoulder and Hand questionnaire for disability. Electrophysiological evaluation was performed with ulnar nerve conduction studies, and the ulnar nerve cross-sectional area was measured on ultrasonography. RESULTS: The improvements in pain, disability, ulnar motor nerve velocity, and ulnar nerve cross-sectional area in the dextrose group were superior to those in the control group, especially at weeks 4 and 12 (P<.001, using independent samples t tests). CONCLUSION: Perineural 5% dextrose may be an effective alternative therapy for those with ulnar neuropathy at the elbow for up to the 12th week.

Perineural Dextrose and Corticosteroid Injections for Ulnar Neuropathy at the Elbow: A Randomized Double-blind Trial.

OBJECTIVE: To assess the effects of perineural corticosteroid and 5% dextrose water (D5W) injections in patients with mild to moderate ulnar neuropathy at the elbow (UNE). DESIGN: Prospective, randomized, double-blind, controlled trial (6-month follow-up). SETTING: Outpatients of local medical center settings. PARTICIPANTS: Patients (N=36) with mild to moderate UNE were randomized, and 33 participants were included in the final data analysis. INTERVENTIONS: Patients were administered a single perineural injection with 5 mL D5W and 3 mL corticosteroid (triamcinolone acetonide, 10mg/mL) mixed with 2 mL normal saline under ultrasound guidance in the dextrose and steroid groups, respectively. MAIN OUTCOME MEASURES: The visual analog scale digital pain or paresthesia/dysesthesia score was the primary outcome. The secondary outcomes were the Disabilities of the Arm, Shoulder, and Hand questionnaire, motor nerve conduction velocity, and cross-sectional area (CSA) of the ulnar nerve. The measurement assessment was conducted before and 1, 3, 4, and 6 months after injection. RESULTS: Thirty-three patients completed the study. Both injections were found to be equally effective at most measurement points, although the dextrose group experienced larger reductions in symptom severity and CSA of the ulnar nerve from the third month onward. CONCLUSIONS: We suggest D5W as a more suitable injectate for perineural injection in patients with UNE.

Late-onset ulnar neuritis following treatment of lepromatous leprosy infection.

Neuritis is a frequent complication of Myocobacteria leprae infection and treatment due to the variety of mechanisms through which it can occur. Not only can mycobacterial invasion into peripheral nerves directly cause damage and inflammation, but immune-mediated inflammatory episodes (termed leprosy reactions) can also manifest as neuritis at any point during infection. Treatment of leprosy reactions with thalidomide can also lead to neuritis due to an adverse drug effect. Neuritis can emerge years after initial diagnosis and treatment, although it is most frequently found at time of diagnosis or early into the treatment course. Treatment of neuritis is dependent on high-dose corticosteroid therapy as well as therapy for suspected underlying etiology. Here, we present a case of ulnar neuritis presenting in a patient with lepromatous leprosy four years after treatment of initial infection, with subsequent improvement after corticosteroid burst while maintained on thalidomide therapy.

Incomplete peripheral facial nerve palsy and ulnar neuropathy due to leprosy mistaken as faciobrachial stroke.

A middle-aged woman was referred to our hospital emergency ward in view of acute onset left faciobrachial weakness. An urgent MRI of the brain was performed, which did not reveal any abnormality and hence a neurology consultation was arranged in order to rule out acute stroke. However, examination and retrospective history taking proved to be a valuable aid in this patient's diagnosis. The incomplete lower motor neuron facial nerve palsy and hand weakness due to leprosy in reaction was confused by the general practitioner as a faciobrachial stroke.

Corticosteroid injection in patients with ulnar neuropathy at the elbow: A randomized, double-blind, placebo-controlled trial.

INTRODUCTION: We conducted a randomized, double-blind, placebo-controlled trial to evaluate the effect of ultrasound-guided corticosteroid injection in patients with ulnar neuropathy at the elbow (UNE). METHODS: Fifty-five patients were randomized between an ultrasound-guided injection of 1 ml containing 40 mg methylprednisolone acetate and 10 mg lidocaine hydrochloride or a placebo injection. The primary outcome was the subjective change of symptoms after 3 months. The secondary outcomes were change in electrodiagnostic studies and ultrasonography findings. RESULTS: A success rate of 30% was found in the corticosteroid injection group versus 28% in the placebo injection group. Only the nerve cross-sectional area changed significantly in the intervention group, from a mean of 11.9 mm(2) to 10.9 mm(2) . CONCLUSIONS: We could not demonstrate a positive effect of ultrasound-guided corticosteroid injection in UNE compared with placebo. Favorable outcomes may be attributed to the natural course of UNE or the effect of patient education.

Neurosarcoidosis presenting as mononeuritis multiplex.

Sarcoidosis is a multisystem granulomatous disease of unknown etiology, with prevalence ranging from 1 to 50 per 100,000. Neurologic involvement occurs in up to 5% of patients but can be the initial presentation of sarcoidosis in 50% of those affected by neurosarcoidosis. The authors report a case of mononeuritis multiplex of the ulnar and then the radial nerve that subsequently led to a diagnosis of sarcoidosis in a patient 8 mos after initial presentation. It is important that neurosarcoidosis be in the differential diagnosis of mononeuritis multiplex when other causes cannot be found because early treatment could help prevent progression to other nerves.

Ulnar nerve tuberculoma.

The authors report a very rare case of tuberculoma involving the ulnar nerve. The patient, a 7-year-old girl, presented with swelling over the medial aspect of her right forearm just below the elbow joint, with features of ulnar nerve palsy, including paresthesias along the little and ring fingers and claw hand deformity. There was a history of trauma and contact with a contagious case of tuberculosis. There were no other signs of tuberculosis. At surgical exploration the ulnar nerve was found to be thickened, and on opening the sheath there was evidence of caseous material enclosed in a fibrous capsule compressing and displacing the nerve fibers. The lesion, along with the capsule, was subtotally removed using curettage, and a part of the capsule that was densely adherent to the nerve fibers was left in the patient. Histopathological examination of the specimen was consistent with tuberculoma. The patient received adequate antitubercular treatment and showed significant improvement.

Injection with corticosteroids (ultrasound guided) in patients with an ulnar neuropathy at the elbow, feasibility study.

INTRODUCTION AND PURPOSE: Unlike carpal tunnel syndrome, little is known about injection with corticosteroids in patients with an ulnar neuropathy at the elbow (UNE). The purpose of this feasibility study is to see whether injection with corticosteroids is safe in patients with UNE and whether there are grounds to launch a prospective placebo-controlled study on the effects of corticosteroids. METHODS: Patients with clinical symptoms of UNE and a nerve conduction study compatible with UNE or thickened ulnar nerve at the elbow (> 10 mm(2)) by ultrasonography were included. All included patients received an ultrasound-guided injection of 1 ml containing 40 mg methylprednisoloneacetate and 10 mg lidocainhydrochloride (Depo-Medrol(®)). Complications of the injection were monitored. After 3 months, nerve conduction studies and ultrasonography were repeated and a clinical outcome determined. RESULTS: Eight patients with nine UNE were included. None of the patients mentioned increase in the symptoms directly after the injection nor had an infection on the injection site or haematoma. After 3 months, there was improvement of the symptoms in five patients. One patient deteriorated and three had no change of the symptoms at all. Overall, there was no significant change of the thickness of the ulnar nerve with mean difference -0.056 mm(2) (95% CI -2.56 to 2.45 mm(2)). CONCLUSION: We showed that injection with corticosteroids in patients with UNE is easy and safe, and based on this result, we found enough arguments to launch a prospective, placebo-controlled trial to explore the effectiveness of corticosteroids in patients with UNE.

Ultrasound-guided steroid injection to treat mild ulnar neuropathy at the elbow.

There exists no "gold standard" in the treatment of ulnar neuropathy at the elbow (UNE). We treated 7 patients with mild UNE using a local steroid injection with ultrasonographic monitoring. At clinical follow-up after 6 weeks, 4 patients had improved, 2 were stable, and 1 reported an increase in symptoms. Ultrasound-guided steroid injection in mild UNE is safe and could be effective. Further investigation is needed to prove its efficacy.

Neurophysiological patterns of ulnar nerve neuropathy in leprosy reactions.

BACKGROUND: Leprosy neuropathy, despite being primarily demyelinating, frequently leads to axonal loss. Neurophysiological examination of the nerves during Type 1 (T1R) and Type 2 reactions (T2R) may give some insight into the pathophysiological mechanisms. METHODS: Neurophysiological examinations were performed in 28 ulnar nerves during a clinical trial of steroid treatment effectiveness, 19 patients with T1R and nine with T2R. The nerves were monitored during a period of 6 months; there were eight assessments per nerve, for a total of 224 assessments. Nine neurophysiological parameters were assessed at three sites of the ulnar nerve. The compound motor action potential amplitudes elicited at wrist, elbow and above, as well as the conduction velocity and temporal dispersion across the elbow, were chosen to focus on the changes occurring in the parameters at the elbow tunnel. RESULTS AND CONCLUSION: Neurophysiological changes indicating axonal and demyelinating processes during both T1R and T2R were detected across the elbow. Changes in demyelination, i.e. a Conduction Block, as a primary event present during T2R, occurring as an acute phenomenon, were observed regularly; in T1R Temporal Dispersion, a subacute phenomenon, was seen. During treatment remyelination occurred after both types of reactions.

A randomized clinical trial of oral steroids for ulnar neuropathy in type 1 and type 2 leprosy reactions.

BACKGROUND: Steroids regimens in leprosy neuropathies are still controversial in botth types of reactions. METHOD: For this trial, 21 patients with ulnar neuropathy were selected from 163 leprosy patients, 12 with type 1 reaction (T1R) and nine with type 2 (T2R). One experimental group started with prednisone 2 mg/kg/day and the control group with 1 mg/kg/day. A clinical score based on tests for spontaneous pain, nerve palpation, sensory and muscle function was used. Neurophysiological evaluation consisted on the motor nerve conduction of the ulnar nerve in three segments. Student "t" test for statistical analysis was applied on the results: before treatment, first week, first month and sixth month, between each regimen and types of reaction. CONCLUSION: In both reactions during the first month higher doses of steroids produced better results but, earlier treatment with lower dose was as effective. Short periods of steroid, 1 mg/Kg/day at the beginning and,tapering to 0,5 mg/Kg/day or less in one month turned out to be efficient in T2R.

A randomized clinical trial of oral steroids for ulnar neuropathy in type 1 and type 2 leprosy reactions / Ensaio clínico sobre o tratamento com esteróides via oral da neuropatia ulnar em reação tipo 1 e tipo 2 da hanseníase

BACKGROUND: Steroids regimens in leprosy neuropathies are still controversial in botth types of reactions. METHOD: For this trial, 21 patients with ulnar neuropathy were selected from 163 leprosy patients, 12 with type 1 reaction (T1R) and nine with type 2 (T2R). One experimental group started with prednisone 2 mg/kg/day and the control group with 1 mg/kg/day. A clinical score based on tests for spontaneous pain, nerve palpation, sensory and muscle function was used. Neurophysiological evaluation consisted on the motor nerve conduction of the ulnar nerve in three segments. Student "t" test for statistical analysis was applied on the results: before treatment, first week, first month and sixth month, between each regimen and types of reaction. CONCLUSION: In both reactions during the first month higher doses of steroids produced better results but, earlier treatment with lower dose was as effective. Short periods of steroid, 1 mg/Kg/day at the beginning and,tapering to 0,5 mg/Kg/day or less in one month turned out to be efficient in T2R.

INTRODUÇÃO: O tratamento da neuropatia da hanseníase com esteróides é ainda controverso nos dois tipos de reações. MÉTODO: Neste ensaio, de 163 pacientes foram selecionados 21 com neuropatia ulnar, 12 com reação tipo 1 e 9 com tipo 2. Um grupo experimental iniciou com 2 mg/kg/dia e o grupo controle com 1 mg/kg/dia. Foi composto um escore clínico pela avaliação da sensação dolorosa espontânea, palpação de nervos e funções sensitiva e motora. Realizou-se a condução nervosa motora do nervo ulnar em três segmentos. Aplicaram-se os estudos estatísticos com o teste t de Student nos resultados: antes do tratamento, primeira semana, primeiro mês e sexto mês. CONCLUSÃO: Em ambas as reações dosagens mais elevadas iniciais produziram melhores resultados, mas a dose menor quando administrada precocemente foi igualmente efetiva. Períodos curtos com doses efetivas, 1 mg/Kg/dia no início e reduzindo-se para 0,5 mg/Kg/dia ou menos em um mês foram eficientes na reação tipo 2.