Virginia Research Day 2021

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 1,2 DO, A. Kozar 1 DO, E. Cash 2 PhD ATC, G. Beato 2 DO

Edward Via College of Osteopathic Medicine – Virginia Campus Virginia Polytechnical Institute and State University, Blacksburg, VA

Introduction

Images

Follow Up

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. Common mononeuropathies affecting athletes and general population include carpal tunnel syndrome and cubital tunnel syndrome. Ultrasound-guided hydrodissection has been used to treat common mononeuropathies such as carpal tunnel syndrome and often referred to in peer reviewed text as an efficient method of treatment without the side effects of corticosteroids prior to surgical management. 1 Even after undergoing surgical correction, 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. 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. 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. MRI revealed no significant findings regarding her ulnar nerve. Diagnostic ultrasound revealed significant kinking of the ulnar nerve at the level of the Flexor Carpi Ulnaris on the distal portion of the humerus. The cross- sectional area of the ulnar nerve was found to be 10-14mm 2 in areas of enlargement and was 6mm 2 in its greatest area of compression, normal diameter being 6.4mm 2 . 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. Report

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.

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Conclusions

Reoccurring mononeuropathies even after multiple modalities of treatment can be a debilitating disease that often causes loss of productivity and function of patients. With US guidance, tissue deformities and structural abnormalities that are not well appreciated in other imaging modalities can be visualized in both static and dynamic testing. D5W has been shown to be well tolerated by patients as a solution to perform nerve decompression without adverse side effects that can be common with steroids including fat atrophy and transient hyperglycemia. 1 Using platelet releasate to enhance the healing process after nerve decompression has been shown to provide additional improvements in symptomatic relief compared to using only D5W. 2 Platelet releasate does require more preparation prior to injection and incurs higher costs to patients. The use of US guided hydrodissection can provide patients a non-surgical treatment option to resolve moderate to severe mononeuropathies that is well tolerated. 3 The procedure can be performed with minimal risks from anesthesia and surgical risk/complications. 4 As reflected from this case, nerve hydrodissection is a beneficial method of treating complex mononeuropathies in high level athletics.

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Figure 3

(1) Ulnar nerve near medial epicondyle in transverse view, with signs of enlargement and compression. Hydrodissection under ultrasound guidance above (2) and below (3) the nerve.

References

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1. Wu, Y.T., et al., Randomized double-blinded clinical trial of 5% dextrose versus triamcinolone injection for carpal tunnel syndrome patients. Ann Neurol, 2018. 84(4): p. 601-610. 2. Wu, Y.T., et al., Six-month efficacy of platelet-rich plasma for carpal tunnel syndrome: A prospective randomized, single-blind controlled trial. Sci Rep, 2017. 7(1): p. 94. 3. Maniquis-Smigel, L., et al., Analgesic Effect of Caudal 5% Dextrose in Water in Chronic Low Back Pain. A Randomized Controlled Trial of Epidural Injection. . Anesthesiology and Pain Medicine. 2017 Feb; 7(1): e42550. Published online 2016 Dec 6. doi: 10.5812/aapm.42550 4. Lam, S.K.H., et al., Ultrasound-Guided Nerve Hydrodissection for Pain Management: An Updated Review of Anatomy and Techniques. Preprint., 2020. https://www.researchgate.net/publication/338627920_Ultrasound- Guided_Nerve_Hydrodissection_for_Pain_Management_An_Updated_Review_of_Anatomy_and_Techniques. Date accessed 1/18/21

(4) Introduction of needle to site of nerve compression in transverse view. (5) Nerve appears more normal after hydrodissection.

Acknowledgements

Figure 6 Figure 7 (6/7) Needle was introduced along the superficial aspect of the ulnar nerve in longitudinal view and hydrodissected along the length of the nerve freeing points of restriction

Acknowledgement made to the Virginia Tech Sports Medicine and Athletic Department, Women’s Basketball Team and Trainers, and VCOM Sports and Osteopathic Medicine Clinic

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