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尺骨神経管(ギオン管)症候群

著者: 信田進吾 東北労災病院 整形外科

監修: 落合直之 キッコーマン総合病院外科系センター

著者校正/監修レビュー済:2021/05/12
患者向け説明資料
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
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尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
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(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
信田進吾 : 特に申告事項無し[2021年]
監修:落合直之 : 特に申告事項無し[2021年]

改訂のポイント:
  1. 定期レビューを行った(変更なし)。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 尺骨神経管(Guyon管)症候群は、尺骨神経が手関節部の豆状骨と有鉤骨鉤の間にある骨線維性トンネルで障害されて生じる尺骨神経の絞扼性神経障害である。
 
尺骨神経管の解剖

a:左尺骨神経管を掌側よりみた図 
b:横断面
※M-Tアーチ:短小指屈筋腱の中枢縁で豆状骨と有鉤骨の間に張る腱性アーチ:musculo-tendinous archを示す。

出典

img1:  著者提供
 
 
 
  1. Guyon[2]が1861年にこのトンネル構造を報告し、Huntはこの部位での尺骨神経障害を報告、Dupontらは1965年にulnar tunnel syndromeと命名した[3][4]
  1. 尺骨神経は手関節の近位で手背尺側へ感覚枝を分岐してから尺骨動静脈とともに尺骨神経管に入るので、本疾患では原則として手背尺側の感覚障害がないことが肘部管症候群との鑑別点となる。Grossらは尺骨神経管を解剖学的に3つに分類し、Zone1が尺骨神経分岐部よりも中枢部、Zone2が尺骨神経深枝部、Zone3が浅枝部としている[5]
  1. 発症原因は占拠性病変としてガングリオン、神経鞘腫、脂肪腫など、外傷では直接外傷のほか、ハンマーの多用など慢性的なストレスや繰り返す外傷によるもの、破格筋や尺骨動静脈の怒張も原因となる[6][7]
  1. 麻痺型はわが国では津下・山河分類が用いられ、1型:尺骨神経管中枢側での障害、2型:感覚枝のみの障害、3型:深枝のみの障害、4型:小指外転筋以外の深枝麻痺、と分類される[8]
問診・診察のポイント  
問診:
  1. 発症時期を確認する。

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文献 

著者: Shingo Nobuta, Hiroshi Okuno, Taku Hatta, Ryo Sato, Eiji Itoi
雑誌名: Prog Rehabil Med. 2021;6:20210010. doi: 10.2490/prm.20210010. Epub 2021 Feb 13.
Abstract/Text Objectives: The purposes of this study were to assess the clinical features of ulnar tunnel syndrome (UTS) and to investigate the diagnostic value of nerve conduction measurements for UTS.
Methods: Eighteen patients with UTS were reviewed retrospectively. Fifteen patients had intrinsic muscle atrophy and motor weakness, and 15 had numbness with hypesthesia. The compound muscle action potentials (CMAPs) from the first dorsal interosseous (FDI) muscle and the abductor digiti minimi (ADM) muscle and the sensory nerve action potential (SNAP) from the little finger were recorded and analyzed. All patients underwent ulnar tunnel release surgery and neurolysis. Static two-point discrimination test results and pinch strengths were assessed before and after surgery.
Results: Before surgery, FDI-CMAP was recorded in 17 patients, and ADM-CMAP in 16, and all showed delayed latency and/or low amplitude. SNAP was recorded in eight patients and two showed delayed latency. The causes of ulnar nerve lesions were ganglion in five patients, traumatic adhesion in four, ulnar artery aberrancy in four, pisohamate arch in three, anomalous muscle in one, and ulnar vein varix in one. The sites of the lesions were in zone 1 of the ulnar tunnel anatomy in 12 patients, in zone 2 in 2, and in zones 1 and 2 in 4. After surgery, all patients obtained recovery of motor function and sensation; however, postoperative FDI-CMAP and ADM-CMAP did not improve to the normal range.
Conclusions: The causes of UTS were ganglion, traumatic adhesion, ulnar artery aberrancy, and pisohamate arch. Both FDI-CMAP and ADM-CMAP were valuable for electrophysiological diagnosis of UTS.

©2021 The Japanese Association of Rehabilitation Medicine.
PMID 33598584  Prog Rehabil Med. 2021;6:20210010. doi: 10.2490/prm.202・・・
著者: C DUPONT, G E CLOUTIER, Y PREVOST, M A DION
雑誌名: J Bone Joint Surg Am. 1965 Jun;47:757-61.
Abstract/Text
PMID 14299666  J Bone Joint Surg Am. 1965 Jun;47:757-61.
著者: M S Gross, R H Gelberman
雑誌名: Clin Orthop Relat Res. 1985 Jun;(196):238-47.
Abstract/Text The distal ulnar tunnel is a region of the wrist 4-4.5 cm in length in which the ulnar nerve is particularly vulnerable to external compression. The relation of the internal topography of the nerve to the structures comprising the tunnel provides a basis for dividing the tunnel into three zones. Zone 1 is that portion of the tunnel proximal to the bifurcation of the ulnar nerve. Zone 2 encompasses the deep motor branch of the nerve, and Zone 3 surrounds the superficial branch. A review of the literature of ulnar nerve compression lesions confirmed expectations based on the regional anatomy. Zone 1 lesions included all (39) cases of combined motor and sensory deficits, one case of pure motor paralysis, and seven cases of sensory deficits. All Zone 2 lesions (36 cases) resulted in paralysis of the intrinsic muscles. Whether or not the hypothenar muscles were affected was dependent upon the location of the lesions within Zone 2. Zone 3 lesions caused sensory deficits only. Combined motor and sensory loss was most often caused by compression from deep to the nerve, while pure sensory deficits were a result of compression lesions lying superficial to the nerve.

PMID 3995823  Clin Orthop Relat Res. 1985 Jun;(196):238-47.
著者: J D Shea, E J McClain
雑誌名: J Bone Joint Surg Am. 1969 Sep;51(6):1095-103.
Abstract/Text
PMID 5805411  J Bone Joint Surg Am. 1969 Sep;51(6):1095-103.
著者: I J Uriburu, F J Morchio, J C Marin
雑誌名: J Bone Joint Surg Am. 1976 Jan;58(1):145-7.
Abstract/Text
PMID 1249106  J Bone Joint Surg Am. 1976 Jan;58(1):145-7.
著者: Keiichi Murata, Jui-Tien Shih, Tsu-Min Tsai
雑誌名: J Hand Surg Am. 2003 Jul;28(4):647-51.
Abstract/Text PURPOSE: The purposes of this study were to determine the distribution of causes and sites of nerve compression in the ulnar tunnel (Guyon's canal), and investigate the relationship between ulnar tunnel syndrome (UTS) and other conditions associated with it.
METHODS: We performed a retrospective review of 31 patients diagnosed with and treated for UTS to determine the most common cause of compression and the sites of compression, systemic illnesses associated with UTS, and postoperative results.
RESULTS: The cause of ulnar nerve compression was idiopathic in 14, trauma in 8, a thrombosis in 2, proliferation of synovium in 2, a prominent hook of the hamate in 1, a schwannoma in 1, postoperative swelling in 1, an aberrant fibrous band in 1, and a ganglion in 1. The sites of compression were classified into 3 zones. Twenty-eight cases had compression in zone 1, 6 in zone 2, and 19 in zone 3. Seventeen cases (55%) had compression in more than 1 zone. Twenty-two cases (71%) were associated with carpal tunnel syndrome (CTS). Twelve (86%) of the 14 idiopathic UTS cases were associated with CTS. The relationship between idiopathic UTS and CTS was not statistically significant. Six cases were associated with diabetes mellitus.
CONCLUSIONS: The most common cause of UTS in our series was idiopathic. Most idiopathic UTS cases were associated with CTS. The clinical symptoms of UTS improved after surgery in all cases. Therefore because of the presence of multiple compression sites of the ulnar nerve in the hand, for UTS patients we believe that the release of Guyon's canal and/or the pisohamate tunnel is an effective way not only to relieve symptoms but also to determine the real cause of compression.

PMID 12877855  J Hand Surg Am. 2003 Jul;28(4):647-51.
著者: J Zeiss, E Jakab, T Khimji, J Imbriglia
雑誌名: AJR Am J Roentgenol. 1992 May;158(5):1081-5. doi: 10.2214/ajr.158.5.1566671.
Abstract/Text The ulnar tunnel (Guyon's canal) is a fibroosseous tunnel along the anteromedial portion of the wrist that contains the ulnar nerve and artery. As with the adjacent carpal tunnel, its main clinical significance is that it may cause nerve compression. The purpose of this study was to determine whether the anatomy of this area could be depicted in sufficient detail by MR imaging for MR to be useful in the evaluation of patients with ulnar neuropathy. MR studies of 36 wrists of volunteers were reviewed with attention to the size and shape of the canal, its anatomic boundaries, the presence of anomalous muscles, the size and bifurcation of the ulnar nerve, and the presence of a fibrous or muscular arch overlying the deep motor branch of the ulnar nerve. T1-weighted transverse MR images of 3-mm-thick sections were obtained by using either an extremity coil or dedicated wrist coil. Excellent anatomic delineation was achieved. The boundaries and shape of the canal varied from proximal to distal, but no statistical differences were present in the mean cross-sectional area of the canal. Anomalous muscles were present in the canal in nine (25%) of 36 wrists; six (67%) of the nine were bilateral. The ulnar nerve had a mean diameter of 3 mm and bifurcated an average distance of 12 mm from the proximal margin of the pisiform bone. Delineation of the fibromuscular arch at the origin of the flexor digiti minimi brevis muscle was limited by imager resolution, but 50% were judged to be fibrous and 50% to be muscular. Our results show that MR images depict the ulnar tunnel in excellent detail. Since those structures associated with ulnar neuropathy are clearly delineated by MR, the procedure should be useful in the evaluation of patients suspected of having ulnar nerve compression within the tunnel.

PMID 1566671  AJR Am J Roentgenol. 1992 May;158(5):1081-5. doi: 10.22・・・
著者: Susan R Cowdery, David C Preston, David N Herrmann, Eric L Logigian
雑誌名: Neurology. 2002 Aug 13;59(3):420-7.
Abstract/Text BACKGROUND: Compared to ulnar neuropathy at the elbow (UNE), ulnar neuropathy at the wrist (UNW) is rarer and more difficult to localize with routine electrophysiologic studies.
METHODS: By stimulating the ulnar nerve at the wrist and palm, and recording from first dorsal interosseous (FDI), the sensitivity and specificity of conduction block (CB) and slow conduction velocity (CV) of FDI fibers across the wrist was compared to traditional electrodiagnostic techniques for localization of UNW. Twenty patients with clinically defined UNW (due mainly to wrist trauma), 30 normal controls, and 20 disease controls with severe (n = 10) and mild (n = 10) UNE were evaluated prospectively. The upper (mean +2.5 SD) and lower (mean -2.5 SD) limits for all measurements were derived from the normal controls.
RESULTS: The UNW patients showed: slow wrist-palm FDI CV (<37 m/s) in 16 (80%); definite or probable CB in 14 (70%); prolonged distal latency (DL) to FDI (>4.5 milliseconds) in 12 (60%), to ulnar-innervated palmar interosseous (PI) versus median-innervated lumbrical (L) in 12 (60%), and to abductor digiti minimi (ADM) in 11 (55%). However, only CB and slow wrist-palm FDI CV (<37 m/s) were specific for UNW; prolonged DL to FDI was found in 4 patients (40%), to ADM in 4 patients (40%), and to PI in 1 patient (10%) with severe UNE. Overall, CB or slow wrist-palm FDI CV was present in 19 patients with UNW (95%). EMG failed to differentiate UNW from UNE, because forearm ulnar-innervated muscles were typically normal in UNW, but also often normal in mild UNE.
CONCLUSIONS: In UNW, an additional palmar stimulation site improves electrodiagnostic yield, and demonstrates that CB is an important cause of muscle weakness.

PMID 12177377  Neurology. 2002 Aug 13;59(3):420-7.

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