Eine neue Untersuchungsmethode

Niemand sieht und findet etwas, alle Untersuchungen sind unauffällig und der Patient hat weiter Schmerzen – Eine neue Untersuchungsmethode bringt Licht in die Nervenstrukturen

Die hochauflösende Nervensonographie ist eine zwar neuartige, aber inzwischen in der Hand erfahrener Untersucher bewährte Methode zur Feststellung peripherer Nervenerkrankungen. Einzigartig ist neben der kompletten Darstellung gesamter Nervenverläufe bis in den Bereich der einzelnen Neurofaszikel auch die Darstellung des umgebenden Gewebes sowie als Besonderheit die bewegungsanatomische Analyse Tätigkeits- und Bewegungsinduzierter Nervenirritationen ( „bewegtes Bild“). So kann zum Beispiel die Ausprägung eines nach distal verlängerten Muskelbauches des musculus flexor digitorum superfizialis (FDS) ein, durch bestimmte Arbeitshaltungen ausgelöstes, rein funktionelles Karpaltunnelsyndrom erzeugen. Diese Diagnose ist einzig und allein nervensonographisch zu stellen. Weitere Anwendungsbeispiele ergeben sich im folgenden Zitat.

„Zitat“

Die klinische Bedeutung des Ultraschalls von Nerven und Muskeln

Wolfgang Grisold und Vera Nussgruber, Wien

Mit verbesserter Auflösung im Vormarsch

Die Ultraschalluntersuchungen von peripheren Nerven und Muskeln gewinnen bei der Diagnose von neuromuskulären Krankheiten zunehmende Bedeutung. Sie haben gegenüber CT- und MR-Untersuchungen den Vorteil der einfachen und raschen Verfügbarkeit und liefern neben dem „statischen“ Bild bei Bewegung auch dynamische Eindrücke, welche auf mögliche Interaktionen mit der Umgebung der untersuchten Struktur Rückschlüsse erlauben. Die Ultraschalluntersuchung ist daher eine sehr gute Ergänzung der Elektroneurodiagnostik. Als Beispiel ist eine Kontinuitätsdurchtrennung eines peripheren Nervs zu nennen. Elektroneurodiagnostisch wird man nur den Ausfall der Funktion feststellen können, während die US-Untersuchung die morphologische Ursache, insbesondere die Kontinuität nachweisen kann.

Technische Ausstattung

Die technische Ausstattung sind moderne High End-Ultraschallgeräte mit moderner Softwareausstattung (Panoramabild, Cine loops) und mit Ultraschallsonden wie möglichst hochfrequente 10–12 Mhz Linearschallköpfe (bis zu 18 Mhz). Je höher die Frequenz, desto besser ist die Bildauflösung und umso geringer ist die Eindringtiefe; z. B. 7,5 Mhz-Linear Scan hat etwa 80 mm Eindringtiefe. Als Vorteil der Ultraschallmethode gelten Belastungs- und Strahlungsfreiheit, leichte Wiederholbarkeit, einfacher Möglichkeit zum Seitenvergleich und auch die Möglichkeit, dynamische Veränderungen zu sehen. Neben dem hohen technisch apparativen Aufwand ist als Nachteil die starke Untersucher-Abhängigkeit zu berücksichtigen. Aus der Sicht des Patienten können die Schlagwörter: „Painless“, und „non invasive“ als sehr positiv angeführt werden. Der Ultraschall gilt seit mehr als 10 Jahren als Standarduntersuchung bei invasiven anästhesiologischen Verfahren, insbesondere bei tief liegenden Nerven- oder Muskelstrukturen. Obwohl auch Nervenwurzeln mit Ultraschall dargestellt werden können, ist diese Untersuchung noch nicht weit eingeführt. Anhand der untersuchten Strukturen wird in Mononeuropathien, Plexopathien, Polyneuropathien und Untersuchungen der Muskulatur unterschieden.

Mononeuropathien

Die derzeitige Domäne des Nervenultraschalles sind die Mononeuropathien, einerseits im Sinne der Engpass-(„Entrapment“)-Syndrome, andererseits in der Traumatologie. Neben der auflösungsabhängigen statischen Darstellung der Nerven können bewegungsabhängige Phänomene wie das sogenannte „Gliding“ und die Beziehung zu den umgebenden Strukturen dargestellt werden. Unmittelbar kann auch die Elektroneurodiagnostik eingesetzt werden und beide Verfahren praktisch gleichzeitig angewandt werden. Es liegen Untersuchungen von vielen Einzelnerven vor, wobei bei Engpassyndromen der N. medianus und N. ulnaris am besten untersucht sind (Abb. 2 und 3). Neben dem Nervendurchmesser wird auch der Längsschnitt mit möglichen Auftreibungen und fokale Engstellen berücksichtigt. Dabei ist die Unterscheidung von umliegenden Sehnen wichtig, aber auch Blutgefäße können farbkodiert dargestellt werden. Der N. ulnaris ist im Vergleich zum N. medianus etwas dünner und kann vom Sulcus N. ulnaris, auch im distalen Abschnitt, dargestellt werden. Auch beim Kompressionssyndrom des N. ulnaris im Sulcus ist der Nerv proximal der Engstelle aufgetrieben. Untersuchungen an anderen „großen“ Nerven wie N. radialis, N. peroneus, N. tibialis und „kleinen“ Nerven wie Digitalnerven, dem N. cutaneus fem. lat. u. a. liegen vor, sind aber wahrscheinlich noch sehr untersucherabhängig. Weiters wird die Darstellung kaliberarmer Nerven erst durch Hochfrequenzsonden (14–18 Mhz Linearsonden) vereinfacht bzw. erst ermöglicht.

Traumatologie

In der Traumatologie ist es klinisch zunächst unklar, in welchem Ausmaß der Nerv geschädigt ist bzw. ob die Kontinuität noch erhalten ist. Dabei kann der US den Nerven in seiner Kontinuität bestätigen, aber auch lokale Hindernisse wie Hämatome, Knochenfragmente, eventuelle Fremdkörper etc. erkennen lassen. Im Vergleich zur Elektroneurodiagnostik, die ein traditionelles und lange entwickeltes System der Untersuchungstechniken ist, fehlt es bei der US-Diagnostik der peripheren Nerven noch an „Gold Standards“. Nervenverdickungen bei Formen der Neurofibromatose, posttraumatische Neurome und Nerventumoren können mit dem Nervenultraschall entdeckt werden und eine wichtige Voraussetzung für plastisch chirurgische Interventionen sein. Eine Unterscheidung in unterschiedliche Entitäten von Nerventumoren ist jedoch mittels Ultraschalls nicht möglich. Weiters kann der Ultraschall zur gezielten Infiltration bei neuralgischen Schmerzsyndromen, wie bei einer Meralgia parästhetica, eingesetzt werden.

Plexopathien

Beim Plexus brachialis ist die Darstellung der oberflächlichen Regionen wie zwischen den Scaleni, supraclavikulär und axillär gut möglich, während die infraklavikulären und proximalen Abschnitte schwerer zu beurteilen sind. Während der Plexus lumbalis bereits seit längerer Zeit in der Anästhesie für Nervenblockaden gezielt mit US erfasst wird, ist die Darstellung des Plexus sakralis aufgrund der Anatomie wesentlich schwieriger.

Polyneuropathien

Bisher war über die Beschaffenheit von peripheren Nerven bei Polyneuropathien wenig bekannt. Die Ultraschalltechnik macht es möglich, in kurzer Zeit lange Abschnitte peripherer Nerven zu beurteilen. Bei einigen Polyneuropathien wie dem GBS, der CIDP, der MMN und manchen hereditären Neuropathien sind Verdickungen bereits aus anderen Bildgebungstechniken bekannt. Auch vergleichende Untersuchungen bei Patienten mit axonalen Neuropathien wurden bereits durchgeführt. Der Vergleich der Nervendurchmesser an definierten Punkten wird angewandt. Bei demyeliniserenden Neuropathien sind die Nervendurchmesser größer als bei Normalpersonen oder bei axonalen Neuropathien. Die Korrelation zum „Standard“ der Neurographie ist nicht klar, und Beobachtungen bei Patienten mit GBS lassen vermuten, dass die Verdickung den elektrophysiologischen Veränderungen vorausgehen kann. Bei fokalen Neuropathien bei der MMN sind die Befunde fokal verteilt. Bei multiplexen Neuropathien und bei der Vaskulitis können im US Hinweise für die Vaskulitis gefunden werden.

Muskulatur

Die Muskulatur kann sowohl im Quer- als auch im Längsschnitt beurteilt werden. Die sonographische Darstellung der Muskulatur ist abhängig vom Alter des Patienten sowie vom individuellen Trainingszustand. Bei der statischen Darstellung zeigen sich in beiden Ansichten charakteristische Strukturen. M. quadriceps femoris und M. Tibialis anterior sind gute Referenzmuskeln für generalisierte Prozesse, während beispielsweise die Unterarmmuskel weniger gut von einander differenziert werden können. Veränderungen der Struktur lassen sich bei Entzündung, Fibrose und besonders bei fettiger Infiltration erkennen. Auch Muskelhämatome lassen sich zuverlässig erkennen. Aussagen, ob myopathische oder neurogene Veränderungen vorliegen, sind, ebenso wie die Frage der Denervation und Reinnervation, weiterhin dem Gebiet der Elektroneurodiagnostik zuzuschreiben. Aufgrund der einfachen und raschen Anwendung können mehrere Muskeln untersucht werden und Rückschüsse über die Verteilung des Krankheitsbildes gefunden werden (z. B. distale/proximale Muskelgruppen, Verschonung einzelner Muskel). Bei chronischen Prozessen (z. B. Muskeldystrophien) kann mit dem US das Ausmaß der Muskelläsion im Krankheitsverlauf bestimmt werden.

Dynamische Darstellung der Muskulatur

Die dynamische Darstellung der Muskulatur lässt langsame Muskelrelaxationen bei Hypothyreose und Bewegungen wie Faszikulationen erkennen. Damit lassen sich Faszikulationen rasch und nicht invasiv an zahlreichen Muskelgruppen und insbesondere schmerzlos in der Zunge demonstrieren (Abb. 1). Bei der Beurteilung des Zwerchfelles lässt sich neben der Dicke des Zwerchfelles auch dessen atemabhängige Verschieblichkeit am Bildschirm verfolgen (Abb. 4). Dabei wird auch die Nadelelektromyographie unterstützt, welche im US die Nadelposition erkennen lässt. Bei ausgedehnten myopathischen Prozessen ist es günstig, die Biopsie mit US-Orientierung durchzuführen, um eine möglichst zielführende Entnahmestelle zu ermöglichen. Bei der verbreiteten Anwendung von Botulinustoxin wird US ebenfalls eingesetzt. Eine nicht veröffentlichte Studie bewies, dass auch bei erfahrenen Botox-Anwendern bei anschließender US-Kontrolle der Zielmuskel oft nicht exakt erreicht wurde.

Radikulopathie

Bei Radikulopathien, besonders bei schmerzhaften Wurzelreizsyndromen, wird Ultraschall zur Lokalisation der Nervenwurzel als Zielort für die Intervention verwendet. Die Nervenwurzeln können im Zervikal- und Lumbalbereich identifiziert werden. Die Entwicklung des Ultraschalls von Nerven und Muskeln ist eine wichtige diagnostische und in manchen Bereichen auch therapeutische Unterstützung. Die ständige Verbesserung der apparativen Ausstattung wird in den nächsten Jahren den US zu einem wichtigen Instrument in der peripheren Neurologie machen.

Literatur

1 Peer S, Bodner G (Hrsg) (2008) High resolution sonography of the peripheral nervous system. Springer, Berlin, Heidelberg

2 Caress JB, Walker FO (2009) Muscle and ultrasound of peripheral nerves. AANEM-Workshop, San Diego

3 Zaidman GM, et al (2009) Peripheral nerve size in normals and patients with polyneuropathy: an ultrasound study. Muscle Nerve 40: 960-966

4 Konermann W, Gruber G (2006) Ultraschalldiagnostik der Bewegungsorgane. Kursbuch nach den Richtlinien der DEGUM und der DGOOC. Thieme, Frankfurt

Zur Person

Univ.-Prof. Dr. Wolfgang Grisold Neurologische Abteilung Ludwig-Boltzmann-Institut für Neuroonkologie Sozialmedizinisches Zentrum Süd Kaiser-Franz-Josef-Spital Kundratstraße 3 1100 Wien Fax: ++43/1/601 91-2009

 

Zur Person

Dr. Vera Nussgruber Neurologische Abteilung Ludwig-Boltzmann-Institut für Neuroonkologie Sozialmedizinisches Zentrum Süd Kaiser-Franz-Josef-Spital Kundratstraße 3 1100 Wien Fax: ++43/1/601 91-2009

Wiener Medizinische Wochenschrift Skriptum 1/2010

© 2010 Springer-Verlag GmbH, Impressum

 

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