In this edition, we meet a young man with a sports injury affecting his right elbow, and learn how MR Neurography helped provide an accurate diagnosis and path to treatment for him. MRN images for this case study follow this article below.
History/background: This is a 15-year-old, right-handed male with a history of recurring right elbow pain for the past three years. The patient reports that initially it began while he was playing baseball and throwing the ball. He is now currently in basketball which has been aggravated while shooting the ball. He notes that the pain is focal to his right elbow with some intermittent tingling into the fingertips of the right hand. He notes that sometimes raising his hand in class will also aggravate his symptoms. The patient has been to physical therapy consistently 3 times a week with stimulation and massage with intermittent relief. He notes that icing the area results in shooting pain into the hand. He has had MRI, X-Ray, with no significant findings. He has had an EMG that demonstrated right cubital tunnel ulnar nerve entrapment. The patient denies any noticeable weakness. He reports his pain at a 3 out of 10 and intermittent on the pain scale.
Physical Exam: His neurologic exam: unremarkable for cranial. Additional examination of upper extremities with his arm at his side, at 90 degrees, and at 180 degrees reveals that on the left side and on the right side there is some slight lumbrical weakness affecting the fourth and fifth digits and there is some reproduction of symptoms with internal and external rotation, particularly internal rotation with the arm at his side and internal rotation at the shoulder.
Additional directed exam with palpation and percussion over the carpal tunnel, Guyon’s canal, mid-forearm, cubital tunnel, mid-upper arm, axilla, infraclavicular and supraclavicular regions revealed that on the right side there is mild Tinel’s over the cubital tunnel and also significant Tinel’s over the middle scalene and anterior scalene with radiation into the fingertips. Neck flexion and extension, turning to the left and right and lateral bending did not significantly affect the symptoms. There was some slight scapular winging appreciable affecting the right scapula.
Treatment plan: Based on this history, exam, data and findings, we believe the hand symptoms may significantly be affected by a mild-to-moderate scalene syndrome. It is also possible that the ulnar nerve sensitivity at the cubital tunnel is secondary to an upstream irritation at the scalene musculature in the neck. He has had a recommendation for an ulnar nerve transposition, but we will advise against that out of concern that it would limit his arm extension. An insight of decompression along the nerve entrapment is equally effective according to numerous extensive literature studies and will need much smaller operation with much more rapid recovery. The overall problem has in the past included some inflammation of the olecranon and the medial epicondyle, but that was an MRI from a year ago.
The question here is difficult and that we are not simply asking whether we can relieve an underlying symptoms, but whether it can be indeed successful as a high-performance athlete in basketball of which he has great skill demonstrated at this time, this will require; however, that this limiting elbow and neck problem be brought under control. We will plan to proceed with the intensive anti-inflammatory trial and complete an MR Neurography study to visualize the nerve in the cubital tunnel to help with the decision making.
MRN Results: These images demonstrate the course and caliber of the median radial and ulnar nerves as they traverse the level of the elbow. Appearance of the median and radial nerves is normal. The ulnar nerve demonstrates a sharp increase in image intensity just proximal to the entry into the cubital tunnel. As it traverses the cubital tunnel there is a second point of abnormality where there is an abrupt broadening or flattening proximally in the mid point of the cubital tunnel. Distal to this point the nerve is normal in caliber, but there is some persistent nerve image intensity increase as it traverses and then exits the cubital tunnel. Distal to the cubital tunnel the nerve is entirely normal in appearance. Note is additionally made of some excess fluid in the humeral-ulnar joint just on the deep surface of the olecranon process.
Impression: Mild joint inflammation at the humeral-ulnar joint. Irritative changes within the ulnar nerve commencing just proximal or at the entry into the cubital tunnel with a second focus of abnormality of broadening and flattening of the ulnar nerve at the mid point of the cubital tunnel. These findings would be consistent with the cubital tunnel syndrome with a nonstandard component of irritation or compression just above or at the entry to the cubital tunnel in addition to a compressive abnormality within the cubital tunnel itself.
3D results: Hyperintensity change commencing just proximal to the cubital tunnel and extending along the course of the ulnar nerve in the cubital tunnel.
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