The hyperchoic rim of the normal nerve in ultrasound: how significant is it?
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LETTER TO THE EDITOR
The hyperchoic rim of the normal nerve in ultrasound: how significant is it? Daniele Coraci 1 & Silvia Giovannini 2 & Claudia Loreti 1 & Francesco Ruggeri 3 & Luca Padua 1,4 Received: 9 April 2019 / Accepted: 10 April 2020 # Fondazione Società Italiana di Neurologia 2020
Dear Editor, We have read with pleasure and interest the paper by De Kleermaeker and colleagues about the wrist-dependent upper limit of median nerve dimension for the carpal tunnel syndrome (CTS) diagnosis [1]. The authors tried to increase the diagnostic usefulness of nerve ultrasound (US) in CTS diagnosis. At present, the proposed absolute upper limit values of nerve dimension seem inefficient for this purpose, because of a large inhomogeneity of these values [1]. The paper represents an update of a previous work, where the authors found a solid correlation between median nerve cross sectional area (CSA), measured by US, and the wrist circumference [2]. In their last paper, De Kleermaeker and collaborators enrolled new forty-two healthy subjects (adding them to the previous fifty-four subjects), in order to have a new control group more comparable with the CTS patient group, regarding the age. The age discrepancy between subjects and patients was supposed to be a possible cause of the low diagnostic power of the wrist-dependent cutoff value of the median nerve in CTS. Actually, in the new work, the authors confirmed the high correlation between the dimension of the median nerve and the wrist, but the diagnostic sensitivity remained low. The paper is very important for several reasons. First, the authors showed median nerve CSA in carpal tunnel that is hardly connected with anthropometric features, and this issue should encourage developing personalization of diagnostic cut-off
* Daniele Coraci [email protected] 1
Riabilitazione ad Alta Intensità, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Francesco Vito, 1, 00168 Rome, Italy
2
Rehabilitation Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
3
IRCCS Fondazione Don Carlo Gnocchi, Milan, Italy
4
Department of Geriatrics, Neurosciences and Orthopaedics, Catholic University of Sacred Heart, Rome, Italy
values, as De Kleermaeker and colleagues showed [1, 2]. Second, the results may indicate the high importance of electrophysiological examination for CTS diagnosis. Besides the usefulness of US in showing the morphological features of a nerve and supporting the surgical intervention, electrophysiology remains the approach able to define the nerve function and the impairment degree. Finally, the authors present specific upper limit values different from the others in literature. They justified these dissimilarities with a list of possible causes, including the technique of US measurement, which may influence CSA estimation. This issue should be always taken into account. Really, one of the rules for a proficient nerve CSA measurement is the exclusion of the hyperechoic rim, mainly representing the epineurium. This approach shoul
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