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J Emerg Trauma Shock. 2017 Apr-Jun; 10(2): 83–84.
PMCID: PMC5357876

Ultrasound application in peripheral nerve localization: Obstacles and learning curve

Dear Editor,

The advancement of peripheral nerve visualization with the use of ultrasonography has been enormous during the last decade.[1] Currently, ultrasonography is used for the localization of peripheral nerves and for the treatment of several peripheral nerve pathologies.[1,2] It has been established as a significant tool for nerve blocks during surgical procedures, pain management, and guidance during resection of peripheral nerve lesions.[1,2] Ultrasound has the significant advantage of zero radiation exposure, and it is an affordable solution for nerve localization as well as for pain management by reducing the associated costs for additional imaging studies and by restricting visits at the doctor's office.[2]

To obtain image acquisitions of the desirable nerve or nerves, physicians are guided through specific anatomical landmarks.[3] This process allows the users to focus on the area of interest and finally recognize the nerve. The ultrasonographic recognition of the nerve structures demands experience on the sonographic anatomy.[3,4] Furthermore, anatomical variations of the used landmarks concerning the size, origin, course and dominance of the closely related vessels, as well as the anatomical alternations of the nearby located tendons, such as the palmaris longus makes things harder for the ultrasound operators. This process is demanding because it needs time and significant efforts from the users to correlate specific image patterns to anatomical structures and their variations.[3,4] These deviations from the normally observed anatomy in the forearm, for example, are noted in 3%–15% of the human population.[3] In addition, the ultrasound operators should be able of distinguishing the pathological from the normal neuronal structures. An ideal way to succeed on this discrimination is to compare the pathological side to the contralateral normal side.[3,4,5]

The ultrasonographic guidance for a nerve block demands significant experience not only for the recognition of the important anatomical structures but also for the guidance of the required instrumentation (i.e., needle) toward the nerve as it is advanced through several layers of human tissue (skin, subcutaneous tissue, and muscles).[2,3,4] The operator should be capable of working with the ultrasound probe in several angles that can give him the perception of depth.[3,5]

The training opportunities on ultrasound are limited in daily clinical practice to several short term in duration courses that comprise the knowledge of the ultrasound basics in 2–3 days.[2] The learning curve is still questionable. The accreditation is not existed as there are no specific requirements for the trainers as well as for the trainees.[2]

In conclusion, ultrasonography is very useful for nerve imaging and nerve recognition as well as for guidance in several procedures. It is a demanding imaging modality that requires knowledge of anatomy and sonographic experience. The role of the several medical specialties that are taking advantage of ultrasound capabilities such as radiologists, orthopedics, neurosurgeons, and anesthesiologists should be more vigorous in defining the education and training on this undoubtedly valuable imaging modality.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

REFERENCES

1. Jackson SA, Derr C, De Lucia A, Harris M, Closser Z, Miladinovic B, et al. Sonographic identification of peripheral nerves in the forearm. J Emerg Trauma Shock. 2016;9:146–50. [PMC free article] [PubMed]
2. Wilson DJ, Scully WF, Rawlings JM. Evolving role of ultrasound in therapeutic injections of the upper extremity. Orthopedics. 2015;38:e1017–24. [PubMed]
3. Soeding P, Eizenberg N. Review article: Anatomical considerations for ultrasound guidance for regional anesthesia of the neck and upper limb. Can J Anaesth. 2009;56:518–33. [PubMed]
4. De Maeseneer M, Brigido MK, Antic M, Lenchik L, Milants A, Vereecke E, et al. Ultrasound of the elbow with emphasis on detailed assessment of ligaments, tendons, and nerves. Eur J Radiol. 2015;84:671–81. [PubMed]
5. Kuo TT, Lee MR, Liao YY, Chen JP, Hsu YW, Yeh CK, et al. Assessment of median nerve mobility by ultrasound dynamic imaging for diagnosing carpal tunnel syndrome. PLoS One. 2016;11:e0147051. [PMC free article] [PubMed]

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