Peripheral Nerve Imaging Can Aid Decision-Making For Post-COVID-19 Neuromuscular Symptoms

In patients with neuromuscular symptoms after recovering from COVID-19, peripheral nerve imaging can help pinpoint the cause and aid in management, researchers say.

"A key message is that clinicians should have a high index of suspicion in COVID patients who are left with chronic pain and weakness, particularly since early diagnosis and appropriate treatment is crucial to prevent irreversible damage," Dr. Swati Deshmukh of Northwestern University in Evanston, Illinois told Reuters Health by email. "As COVID numbers are currently surging, clinicians should also have a high index of suspicion for patients with unexplained new-onset nerve and muscle symptoms and should consider obtaining COVID testing for these patients, along with imaging."

"Clinicians should be aware that there is a differential - i.e., there are multiple different potential causes of nerve and muscle symptoms in COVID19 patients," she added.

In what they believe is the first publication to summarize how advanced imaging techniques can help clinicians identify and treat nerve damage in COVID-19, Dr. Deshmukh and colleagues review specific types of advanced imaging - notably, magnetic resonance (MR) neurography and ultra-high-resolution ultrasound - that can help localize the problem and reveal the extent of nerve damage, as well as some of the conditions that might be uncovered.

"While many patients who sustain peripheral nerve injury during their COVID-19 illness will present to imaging centers in a delayed fashion after COVID-19 test results become negative, some patients with a positive result on their most recent COVID-19 test may require urgent imaging," the authors note in Radiology.

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Dr. Deshmukh said advanced ultrasound technology is portable and can sometimes be better at detecting nerve damage than MRI. It can also be performed on patients who are unable to tolerate MRI.

The paper highlights specific types of conditions that advanced imaging might reveal in recovered COVID-19 patients with peripheral nerve pain. These include injuries that can occur as a manifestation of SARS-CoV-2 infection (e.g., post-infectious inflammatory neuropathy), as a sequela of hospitalization (positioning-related neuropathy, distal symmetric polyneuropathy), or as a result of a treatment complication (nerve entrapment secondary to hematoma in the setting of anticoagulation).

While advanced imaging can help identify the cause of post-COVID-19 symptoms such as pain, numbness or weakness in the hands, feet, arms or legs, the equipment "is generally only available at academic medical centers and large healthcare networks," Dr. Deshmukh said. "Therefore, appropriate referrals may be necessary, particularly for patients in rural communities."

Currently, according to the authors, the American College of Radiology recommends that practitioners minimize use of MRI in patients with known COVID-19 or under investigation for COVID-19 unless absolutely necessary. Imaging of peripheral neuropathy in patients who test positive should be performed only if the results might impact imminent clinical management.

Dr. Jan Fritz, Associate Professor and Section Chief of Musculoskeletal Radiology at NYU Langone Health in New York City, commented in an email to Reuters Health, "With evolving knowledge, it becomes clearer that COVID19, among more central systems such as the lungs, also affects peripheral nerves. Dedicated peripheral nerve imaging can be an important tool in the evaluation of COVID19 patients with developing peripheral nerve symptoms that show clinical overlap and may therefore be difficult to differentiate."

"Peripheral nerve imaging can display patterns and underlying reasons, aiding in defining the type of peripheral injury and potentially aid in finding the most suitable treatment option," he said.

The technologies are "available at the majority of imaging centers with modern scanner technology," he added. "The techniques utilize the same technology as regular MRI and ultrasonography, but with a particular emphasis on display of fine nerve detail."

—Marilynn Larkin

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