Detection of cervical nerve root hypertrophy by ultrasonography in chronic inflammatory demyelinating polyradiculoneuropathy

https://doi.org/10.1016/j.jns.2003.11.011Get rights and content

Abstract

Several studies have demonstrated abnormal MRI findings in chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), especially hypertrophy and abnormal enhancement of spinal nerve roots, but there have been few reports on ultrasonographic findings of spinal nerve roots in CIDP. To determine whether ultrasonography (US) enables detection of hypertrophy of the cervical nerve roots, how frequently hypertrophy occurs in CIDP, and whether US findings correlate with any clinical and laboratory features, US of cervical nerve roots was performed using a 7.5-MHz linear-array transducer in 13 CIDP patients and 35 control subjects. A coronal oblique plane with a transducer placed on the lateral side of the neck was used to visualize the cervical nerve roots just after their point of exit from the cervical foramina, and their diameters were measured. US demonstrated hypertrophy of the cervical nerve roots in 9 (69%) of the 13 CIDP patients as compared with findings in control subjects. The degree of hypertrophy was significantly associated with the level of CSF protein (χ2=5.8, p<0.05, logistic simple regression analysis) but not with other clinical features. US is considered to be a useful method for evaluating cervical nerve root hypertrophy, which is frequently seen in patients with CIDP, particularly in patients with elevated level of CSF protein.

Introduction

Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is a demyelinating disease of the peripheral nerves, frequently involving spinal nerve roots and the plexus [1]. Abnormal findings of these lesions have been demonstrated in previous studies using magnetic resonance imaging (MRI), in which hypertrophy and gadolinium (Gd) enhancement of spinal nerve roots were considered to be major findings in MR images [2], [3]. In view of the location of the spinal nerve roots, such abnormalities of cervical nerve roots have been less commonly demonstrated [3], [4], [5], [6], [7], [8] than those of the lumbar spinal roots or the cauda equina [2], [9], [10], [11], [12], [13]. A few studies on the frequency of these findings on MR images have suggested that there is a high frequency of these findings in CIDP patients [2], [3].

High-resolution ultrasonography (US), regarded as a valid method for examining structures close to the surface of the body such as thyroid glands or carotid arteries [14], is also useful for evaluating peripheral nerves [15], [16], including the median, ulnar, sciatic nerves, and the brachial plexus [17], [18] and even vagus nerves [19]. This inspection method has been predominantly used to evaluate peripheral nerve tumors [15], [20], [21] and carpal tunnel syndrome [22]. Attempts have been made in some recent studies to evaluate the peripheral nerves of extremities by US in patients with hereditary motor and sensory neuropathy type 1 [16], [23], in which widespread hypertrophy of peripheral nerves, including nerve roots, can occur as well as CIDP. In contrast to the frequent use of US for evaluating these diseases, however, there has been only one case report on US findings of peripheral nerves and nerve roots in CIDP [24]. The purpose of this study was to determine whether US enables detection of hypertrophy of the cervical nerve roots in CIDP patients, how frequently nerve root hypertrophy occurs in CIDP, and whether US findings correlate with any clinical or laboratory features.

Section snippets

Subjects

The study included 13 patients (aged 19 to 70 years; mean age, 47.3 years; 9 males and 4 females) with CIDP who had been treated on an inpatient or outpatient basis in our hospital during the period from July 3, 2001 to July 29, 2002. The diagnosis of CIDP was made in accordance with the criteria of the Ad Hoc Subcommittee of the American Academy of Neurology [25] on the basis of clinical history and results of neurological and electrophysiological examinations performed by neurologists. Five

Results

All of the fifth cervical (C5), C6, and C7 nerve roots could be visualized by US in all of the CIDP patients and control subjects, but the eighth cervical nerve roots could be visualized only in 5 of the 13 CIDP patients and in 10 of the 33 control subjects. None of the first thoracic nerve roots were observed. As a C7 nerve root was delineated less articulately compared with C5 and C6 nerve roots due to its deeper position from the surface, both the C5 and C6 nerve root diameters were used for

Discussion

In this study, US showed an excellent capability for enabling detection of hypertrophy of cervical nerve roots and revealed a high frequency of this finding (69%) in CIDP patients. We also demonstrated the high reliability of US for measurement of cervical nerve roots diameters by means of showing the high reproducibility analyzed according to the method of Bland and Altman and by calculating the coefficient of variation. To the best of our knowledge, this is the first study in which the

Acknowledgments

This study was supported in part by grants for Neuroimmunological Diseases (TK) from the Ministry of Health, Labor and Welfare of Japan.

We thank Dr. Hideshi Kawakami, Dr. Sadao Katayama, Dr. Hirofumi Maruyama, Dr. Ken Inoue, and Dr. Takeshi Kitamura for patient referral, Dr. Hiroshi Fukuda, Dr. Kazuko Kozuka, and Dr. Hiromitsu Naka for their technical support, and Mayumi Yoshikawa and Hiromi Sumida for their secretarial assistance.

References (36)

  • G. Midroni et al.

    MRI of the cauda equina in CIDP: clinical correlations

    J. Neurol. Sci.

    (1999)
  • O. Heinemeyer et al.

    Ultrasound of radial, ulnar, median and sciatic nerves in healthy subjects and patients with hereditary motor and sensory neuropathies

    Ultrasound Med. Biol.

    (1999)
  • V.A. Knappertz et al.

    Vagus nerve imaging with ultrasound: anatomic and in vivo validation

    Otolaryngol. Head Neck Surg.

    (1998)
  • P.J. Dyck et al.

    Chronic inflammatory demyelinating polyradiculoneuropathy

  • A.J. Duggins et al.

    Spinal root and plexus hypertrophy in chronic inflammatory demyelinating polyneuropathy

    Brain

    (1999)
  • W. Schady et al.

    Massive nerve root enlargement in chronic inflammatory demyelinating polyneuropathy

    J. Neurol. Neurosurg. Psychiatry

    (1996)
  • G. Midroni et al.

    Chronic inflammatory demyelinating polyradiculoneuropathy: unusual clinical features and therapeutic responses

    Neurology

    (1996)
  • J. Duarte et al.

    Hypertrophy of multiple cranial nerves and spinal roots in chronic inflammatory demyelinating neuropathy

    J. Neurol. Neurosurg. Psychiatry

    (1999)
  • M. Niino et al.

    Chronic inflammatory demyelinating polyneuropathy with multiple hypertrophic nerves in intracranial, and intra- and extra-spinal segments

    Intern. Med.

    (1999)
  • M. Eurelings et al.

    MRI of the brachial plexus in polyneuropathy associated with monoclonal gammopathy

    Muscle Nerve

    (2001)
  • P.B. Crino et al.

    Magnetic resonance imaging of the cauda equina in chronic inflammatory demyelinating polyneuropathy

    Ann. Neurol.

    (1993)
  • G.W. Morgan et al.

    Nerve root enhancement with MRI in inflammatory demyelinating polyradiculoneuropathy

    Neurology

    (1993)
  • R.N. De Silva et al.

    Nerve root hypertrophy in chronic inflammatory demyelinating polyneuropathy

    Muscle Nerve

    (1994)
  • L. Ginsberg et al.

    Chronic inflammatory demyelinating polyneuropathy mimicking a lumbar spinal stenosis syndrome

    J. Neurol. Neurosurg. Psychiatry

    (1995)
  • M.M. Kitakule et al.

    Massive nerve root hypertrophy in chronic inflammatory demyelinating polyradiculoneuropathy

    J. Assoc. Acad. Minor Phys.

    (1997)
  • N. Handa et al.

    Ultrasonic evaluation of early carotid atherosclerosis

    Stroke

    (1990)
  • B.D. Fornage

    Peripheral nerves of the extremities: imaging with US

    Radiology

    (1988)
  • D.G. Sheppard et al.

    Brachial plexus: demonstration at US

    Radiology

    (1998)
  • Cited by (92)

    View all citing articles on Scopus
    View full text