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Aims: Injection therapies play an increasingly decisive role in the treatment of lower back pain. Cumulative studies could show the benefits of ultrasound-guided instillation procedures in the cervical and lumbar spine. We conducted this study to provide a new simple sonographic approach for pararadicular injections of the sacral spinal nerves and to prove the feasibility and accuracy by means of CT and anatomic dissection.Material and Methods: Eight ultrasound-guided injections at four different levels of the sacral spine on a human ethanol-glycerol-embalmed cadaver (S1-S4) were performed. By means of sonography the sacral foramina were identified and the spinal needles were advanced in "in-plane technique" to the medial margin of the respective sacral foramen. Subsequently a solution of blue dye and contrast agent were injected. Then CT scans and anatomic dissection of the cadaver were performed to verify the correct placement of the needle tips and to visualize the dispersion of the injected solution in the respective compartment.Results: Altogether a 100% success rate for a correct injection could be achieved. CT examination confirmed the correct placement of every needle tip within the intended compartment. Also, the anatomic dissections affirmed the appropriate needle positioning. Moreover, the blue dye dispersion was seen in the correct compartments and around the targeted spinal nerves.Conclusions: Although this study was only performed on cadaveric models, this new sonographic approach for pararadicular injections in the sacral spine allows an easy, precise and unerring needle placement within the dorsal sacral foramen. [ABSTRACT FROM AUTHOR]

Objective: To quantify the diagnostic utility of imaging features in soft tissue masses (STMs) and to provide a ranked list of predictors for malignancy.Subjects and Methods: Imaging features in 260 cases of STMs with verified histology were assessed. Diagnostic properties including sensitivity, specificity, positive and negative predictive values, likelihood/odds ratios (OR) and normalized variance (NV) via random forest analysis were calculated. The diagnostic utility of an 8-item checklist consisting of the highest-ranked features was evaluated through a receiver-operating-characteristics (ROC) curve.Results: The most predictive features (NV/OR in parentheses) were heterogeneous contrast-enhancement in ultrasound (297.9/15.1) and MRI (197.3/11.9), lesion roundness (209.8/5.5), diffusion restriction (175.8/9.3), cystic/necrotic intralesional areas (167.1/8.3), higher patient age (159.0/2.6), surrounding oedema (155.4/6.5) and intralesional Doppler hypervascularity (134.4/5.1). A simple 8-item checklist was highly predictive of malignancy in cases with at least 75% positive features (0.90 area under the ROC curve, 87.0% sensitivity, 84.5% specificity, 59.5% positive and 96.1% negative predictive value, 36.5 odds ratio) even in cases with only partial feature availability.Conclusion: Features vary widely in their diagnostic value in STMs; an 8-item checklist based on the eight most decisive features can be a simple tool to assess the likelihood for malignancy in unknown soft tissue masses, even though a stratified approach is certainly still advisable when first confronted with an STM. [ABSTRACT FROM AUTHOR]

Anatomical variants of peripheral nerves of the lower limb are relatively frequent and vulnerable to injury if not considered by the surgeon. Surgical procedures or percutaneous injections are often performed without knowing the anatomical situation. In a patient with normal anatomy, these procedures are mostly performed smoothly without major nerve complications. But in the case of anatomical variants, surgery may be challenging as "new" anatomical prerequisites complicate the procedure. In this context, high-resolution ultrasonography as the first-line imaging modality to depict peripheral nerves, has become a helpful adjunct in the preoperative setting. It is crucial, on the one hand, to gain knowledge of anatomical nerve variants and, on the other hand, to depict the anatomical situation preoperatively, to minimize the risk of surgical trauma to a nerve and make surgeries safer. [ABSTRACT FROM AUTHOR]

Aim: To compare ultrasound (US)-guided versus computed tomography (CT)-controlled periradicular injections of the first sacral spinal (S1) nerve in a prospective randomized clinical trial. Materials and methods: Thirty-nine patients with S1-radiculopathy were consecutively enrolled for 40 periradicular injections and assigned to an US or CT guided group. Needle position after US-assisted placement was controlled by a low-dose CT-scan. Accessibility, accuracy, and intervention time were compared. The overall effect on pain was matched evaluating the visual analog scale (VAS) decrease before and one month after the intervention. Results: The mean intervention time was lower in the US-group compared to the CT-group: 4.4±3.46 min (1.3-13.2) vs. 6.5±3.03 min (2.4-12.5). Using CT-controlled infiltration the mean number of needle passes was with 1.15 higher than utilizing US-guidance. The therapeutic effect (mean difference between pre- and post-intervention, VAS scores) for the CT-group was 4.85±2.52 and for the US-group 4.55±2.74 with no significant difference between the two groups (p=0.7). Conclusion: US-controlled infiltrations of the first sacral nerve show a similar therapeutic effect to the time consuming, and ionizing CT-controlled injections and result in a significant reduction of procedure expenditure and avoidance of radiation. [ABSTRACT FROM AUTHOR]

Introduction: Peripheral compression neuropathy of the ulnar nerve is a frequent condition, most likely encountered at the ulnar sulcus or the Guyon's canal. High-resolution ultrasound (HRUS) can often identify the site of injury. Primarily idiopathic, compression neuropathy can stem from a punched nerve syndrome, in which direct contact between an arterial branch and the nerve leads to compression. Materials and methods: A 42-year-old male patient was examined by means of HRUS using a 17-5 MHz linear transducer on a Philips iU22 (Philips, Bothell, Washington, USA). Results: After reporting a punched nerve syndrome of the deep motor branch of the ulnar nerve distal to the Guyon's canal, the patient underwent surgery and showed electrophysiological and clinical improvement 6 months after decompression. Conclusion: HRUS is a viable method to demonstrate a punched nerve syndrome. In conjunction with clinical presentation, even unlikely sites of compression such as the deep motor branch of the ulnar nerve can be identified. [ABSTRACT FROM AUTHOR]

Objectives: Changes in the microvascular environment are considered crucial in the pathogenesis of compression neuropathies. Several studies have demonstrated elevated intraneural vascularity in severe neuropathy compared with healthy subjects, where intraneural vascularity is considered predominantly undetectable. The aim of this study was to assess and quantify intraneural vasculature by superb microvascular imaging (SMI) in healthy volunteers in the median, ulnar and common peroneal nerve. Methods: Intraneural vascularity was quantified in 26 healthy volunteers (312 segments overall) by SMI sonography using a 22‐MHz linear transducer. Individual nerve segment vascularity was compared with the mean vascularity using one‐way ANOVA and Kruskal–Wallis tests, respectively. Vendor‐provided quantification and manual vessel count were compared by linear regression analysis. Results: Intraneural vascularity was detectable in all nerve segments (100.0%). Vessel density was highest in the median nerve at the wrist (1.54 ± 0.44/mm2, P < 0.0001) and lowest in the sulcal ulnar nerve (0.90 ± 0.34/mm2, P < 0.0001). Vendor‐provided automated quantification severely overestimated vascular content compared with manual quantification. Conclusion: Superb microvascular imaging can facilitate the visualisation of nerve vascularity and even detect local variations in vessel density. The pathophysiological implications for peripheral neuropathies, especially compression neuropathies, warrant further investigation, but the absence of visible intraneural vasculature as a negative finding in the diagnostic of compression neuropathies should be interpreted with caution, as the intraneural vascularity may lie beyond the 18 MHz resolution power of a transducer. [ABSTRACT FROM AUTHOR]

Repetitive vibratory trauma in cyclists is one of the most common causes of ulnar nerve compression at the wrist. This study describes five cases of clinically suspected compression syndrome of the deep terminal branch of the ulnar nerve (DBUN) defined by high-resolution ultrasound (HRUS) with a 18-MHz linear transducer. Reliable HRUS visualization of the DBUN was feasible in all patients. The affected nerves had focally swollen and hypo-echoic changed segments. HRUS is a good imaging tool for the evaluation of a suspicious DBUN neuropathy if no electrodiagnostic testing is available or in patients with mild to moderate clinical symptoms with inconclusive electrodiagnostic results. [ABSTRACT FROM AUTHOR]

Introduction: Arterial pseudoaneurysms (PSAs) are the most common access site complication following transarterial catheter intervention. Ultrasound-guided injection of thrombogenic substances into perfused arterial PSAs followed by compression therapy is a well-established and less invasive treatment option than surgical repair. Different agents are available to induce thrombosis including thrombin and a fibrin-based tissue glue, which is used as first-line treatment at our institution. This paper deals with our experience using ultrasound-guided fibrin glue injection (UGFI). Materials and Methods: Retrospective data analysis: all patients (55) treated for iatrogenic femoral PSA following digital subtraction angiography of the lower extremities between January 1, 2010, and December 31, 2018, were included. Data on epidemiology, PSA location and size, vascular risk factors, fibrin glue injection (fibrin glue volume), primary success rate of UFGI, and complications related to the treatment were analyzed. Results: A total of 55 consecutive femoral iatrogenic PSAs were treated during the defined period and 32 (58.2%) of the patients were female. Imaging was performed using ultrasound in all cases. The most common PSA location (80.0%) was the common femoral artery, mean PSA size (± SD) was 2.7 ± 1.2 cm, and neck length was 1.6 ± 1.0 cm. The dose (mean ± SD) of fibrin glue was 2.6 mL (± 1.0; maximum: 6 mL). Primary UGFI success rate was 87.3% and conversion rate to open surgery was 12.7%. Two (4%) patients required embolectomy for peripheral embolization after UGFI. Conclusion: Early results achieved with UGFI for treatment of iatrogenic femoral PSA are promising. In our cohort, UGFI was a safe and effective first-line alternative to traditional open surgery, which then was unnecessary in the vast majority of PSA cases. Further prospective studies for comparison of ultrasound-guided techniques should be encouraged. [ABSTRACT FROM AUTHOR]

Objectives To define the diagnostic value of high-resolution ultrasound (HRUS) of the suprascapular nerve (SSN) in the diagnosis of neuralgic amyotrophy (NA). Methods The cross-section areas (CSA) of the SSN at the C5 root (CSA1) and the omohyoid muscle in the midclavicular line (CSA2) were assessed bilaterally in 15 healthy volunteers and 14 patients with clinically and electrophysiologically verified NA. Receiver-operator-characteristics (ROC) curves were generated and cut-off values, sensitivity, specificity, positive (PPV) and negative predictive values (NPV), likelihood (LR) and odds ratios (OR) were calculated. Results Patients with NA had significantly higher CSA2-values than controls (6.36 ± 2.75 vs. 2.79 ± 0.83 mm 2 , p < 0.0001) and significantly higher ratios of SSN CSA2-values of the affected vs. contralateral side (224.6 ± 78.5% vs. 127.7 ± 51.1%, p < 0.0001). The ratios of SSN CSA2-values vs. CSA1-values (146.7 ± 74.5% vs. 99.9 ± 28.3%, p = 0.008) and CSA1-values were also significantly higher (4.70 ± 2.00 vs. 2.90 ± 0.90 mm 2 , p = 0.0028) than in controls. Beyond a CSA2 cut-off value of 4.2 mm 2 , the ROC-AUC was 0.939 [0.861–1.00] when compared against healthy volunteers and 0.971 [0.901–1.00] when compared to patients with degenerative shoulder pain. Sensitivity was 85.7% [57.2–98.2%], specificity 96.7% [82.8–99.9%], PPV 92.3% [64.0–99.8%], NPV 93.5% [78.6–99.2%], OR 174.0 [14.4–2106.0] and LR 25.7 (95% confidence intervals in brackets). Conclusion SSN swelling in the lateral cervical region could be a supportive finding to identify NA patients. Significance This method allows for the rapid sonographic identification of NA. [ABSTRACT FROM AUTHOR]

Purpose: In this retrospective study we examined whether size is a viable marker of tumour malignancy in soft tissue masses (STM) and if the ratio of width and length (RALD) of an STM reflects tumour biology more accurately.Methods: Measurements of maximal lesion size and perpendicular diameter were performed in available MRI and ultrasonography studies of 212 patients (mean age 54.4 ± 17.2 years, male:female 1:1.12) with a histologically verified diagnosis.Results: Overall, 28.2 % of lesions were malignant, 11.1 % intermediate, and 58.8 % benign. Size alone was a weak predictor of malignancy in STMs (sensitivity 68.8 %, specificity 50.3 %, positive predictive value [PPV] 44.0 %, negative predictive value [NPV] 80.4 %). RALD showed better discriminatory power with greater separation between benign and malignant entities and higher values for sensitivity (83.6 %), specificity (53.6 %), and NPV (89.0 %). A weighted combination of size, age and RALD improved diagnostic power, demonstrating higher values for sensitivity (77.0 %), specificity (80.1 %), PPV (61.0 %), and NPV (89.6 %).Conclusions: Size should not be used alone to estimate an STM's malignancy. RALD better reflects a lesion's growth pattern and a combination of age, size, and RALD helps to discriminate more accurately between benign, intermediate, and malignant entities. These findings should help to estimate easily whether a newly found STM is benign or malignant prior to further workup.Key Points: •Size does not reliably differentiate between benign, intermediate, and malignant tumours •The R ALD (ratio of lateral to axial diameter) improves diagnostic confidence •When combined with age and size, STM differentiation was further enhanced •These measurements can aid in earlier detection of sarcomas. [ABSTRACT FROM AUTHOR]

Peliosis hepatis is a rare benign disorder of the liver, histologically characterized by blood-filled cystic cavities of various sizes and irregular shapes, communicating with the hepatic sinusoids. Only a few cases of peliosis hepatis have been described using contrast enhanced ultrasound showing admittedly various dynamic enhancement patterns. We present a case of peliosis hepatis with a typical target-sign enhancement depicted by means of contrast enhanced ultrasound. [ABSTRACT FROM AUTHOR]

Immunologic reactions in transplanted organs are in more or less all allograft patients detectable: clear parameters exist as e.g. in renal transplants where the clearance power reduces by rejection. On the contrary, in composite tissue allografts clear and objective indicators stating a rejection episode lack. We present the case of a hand-transplanted subject with signs of acute transplant rejection diagnosed by means of Duplex Ultrasound and confirmed by biopsy. [ABSTRACT FROM AUTHOR]

Supinator syndrome or posterior interosseous nerve (PIN) syndrome is a compression neuropathy of the deep branch of the radial nerve in the region of the Arcade of Frohse. An extremely rare cause of an acute onset supinator syndrome is the hourglass-like fascicular constriction of the posterior interosseous nerve due to torsion. To our knowledge, only a limited number of cases which describe the sonographic appearance of fascicular torsions are known in the literature. We present a rare case of a supinator syndrome associated with hourglass-like constrictions of the PIN diagnosed by means of sonography. [ABSTRACT FROM AUTHOR]