Virginia Research Day 2021

Medical Resident Research Cl inical

05 Ultrasound Guided Hydrodissection Using 5% Dextrose in Sterile Water and Platelet Releasate To Treat Ulnar Nerve Entrapment Post Ulnar Nerve Translocation in D1 Women’s Basketball Student Athlete

L. Shen DO; A. Kozar DO; E. Cash PhD ATC; G. Beato DO Corresponding author: lshen@vcom.edu

Introduction : Mononeuropathy secondary to nerve compression is a common disorder that causes loss of productivity and decreases in quality of life with activities. In athletes, having a severe mononeuropathy can be debilitating and prevent the athlete from being able to train or compete. Treatment options are limited to medications, physical therapy/rehabilitation, bracing, and ultimately surgical correction. Even after undergoing surgical correct, complete resolution is not guaranteed. Nerve entrapment hydrodissection with 5% Dextrose in sterile water (D5W) has been discovered to be an effective method of decompressing and treating mononeuropathies. Case: 23-yo female, collegiate basketball athlete presented with chronic right medial elbow pain with marked hyperalgesia & allodynia. She has history of ulnar decompression with transposition at the cubital tunnel performed in May 2017. Patient felt improvement for 1- year post surgery but later progressed to having worsening discomfort surrounding her medial epicondyle and forearm. Edward Via College of Osteopathic Medicine – Virginia Campus Virginia Tech

Patient had limited relief with physical therapy and corticosteroid injections. The few months prior to the start of the 2020 season, the patient was unable to practice or use her right arm to any significant function secondary to hyperalgesia and discomfort. EMG showed evidence of demyelinating ulnar mononeuropathy at the elbow, consistent with the clinical diagnosis of cubital tunnel syndrome and elicited responses from motor fibers of the right ulnar nerve in both the ulnar groove and anterior to the medial epicondyle. MRI revealed no significant findings regarding her ulnar nerve. Diagnostic ultrasound revealed significant kinking of the ulnar nerve at the level of the FCU on the distal portion of the humerus. The cross-sectional area of the ulnar nerve was found to be 10-14mm sq in areas of enlargement and was 6mm sq in its greatest area of compression. Significant hyperechoic fascial thickening in both areas of enlargement and entrapment with loss of normal nerve fascial pattern in longitudinal viewing. Patient elected to undergo US guided hydrodissection with D5W. She tolerated the initial procedure well with mild improvement in

overall paresthesia, hyperalgesia, allodynia, focal localization of pain and right upper extremity function. A second US guided hydrodissection with platelet releasate (PRP) was performed after 3 weeks from her initial treatment with D5W. Patient tolerated second procedure well. Results: Over the course of 3 months from initial US guided hydrodissection, patient saw substantial improvement in her ulnar sensitivity, discomfort, and function. Towards the start of the 2020 season, patient was able to practice and play at a competitive level with minimal discomfort and soreness, a vast improvement in from her previous status. Discussion: Hydrodissection of nerve entrapment is a proven method of mechanical decompression of mononeuropathies. The use of US guided hydrodissection can provide patients a non-surgical treatment option to resolve moderate to severe mononeuropathies that is well tolerated. The procedure can be performed with minimal risks from anesthesia and surgical risk/complications.

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