The role of ultrasound in the early diagnosis of sciatic and peroneal nerve injuries in earthquake survivors

Authors

Abstract

Aim The study aimed to evaluate the effectiveness of ultrasonographic measurements in diagnosing sciatic and peroneal nerve injuries among earthquake survivors suffering from unilateral drop foot, focusing on changes in the cross-sectional area (CSA) of these nerves.
Materials and Methods A study enrolled 22 patients with foot drop following traumatic injuries from the February 6, 2023, earthquakes in Türkiye. Data was collected, followed by ultrasonographic assessments of sciatic and peroneal nerves, pain intensity measured using the Visual Analog Scale (VAS), and neuropathic pain assessed using the Neuropathic Pain Questionnaire (NPQ).
Results The patient population, predominantly female (72.7%), had an average age of 29 ± 15.8 years. The CSA of the sciatic and peroneal nerves was significantly larger on the affected side, with changes in peroneal nerve CSA greater in the lower extremities.
Discussion Ultrasonography helps earthquake survivors detect peripheral nerve injuries early. The observed CSA enlargement suggests nerve edema contributes to post-disaster neurological deficits. Early assessment may improve functional outcomes and accelerate intervention.

Keywords

Introduction

Disasters have major effects on society, culture, people, the economy, and the environment, which in turn cause health problems like new disabilities [1]. Public health consequences can sometimes marginalize vulnerable populations; they can lead to disabilities, injuries, operations, and hospital stays. Catastrophic events that often impede aid delivery owing to infrastructure damage, lack of equipment, and hospital destruction are earthquakes, which have claimed many lives and injuries since ancient times [2]. The most tragic earthquake in Turkiye and Syria on February 6, 2023, claimed more than 50,000 lives and left 18 million injured [3]. After the initial panic subsides, disasters can cause disability for many individuals, including those with amputations, central nervous system impairments, spinal cord injuries, nerve root avulsions, peripheral nerve damage, brachial plexopathy, childhood injuries, compartment syndrome complications, and multiple fractures, requiring rehabilitation [4, 5].
Ultrasonography plays a critical role in the early evaluation and diagnosis of musculoskeletal injuries. In this study, the sizes of the sciatic and peroneal nerves were measured by ultrasound to assess their value in detecting peripheral nerve damage in patients with earthquake-related drop foot, compared to their unaffected limbs.

Materials and Methods

The study examined the clinical relevance of ultrasonographic evaluations of sciatic and peroneal nerve diameters in 22 individuals with unilateral drop foot following an earthquake in Kahramanmaraş, Turkiye, and in 22 individuals with sciatic nerve injury. Eligible patients exhibited nerve damage, stable vital signs, no cognitive impairments, and literacy. The data encompassed age, gender, BMI, educational level, duration of entrapment under debris, history of intensive care, length of intensive care admission, and related pathologies. The affected limb was measured at three levels, comparing it to the unaffected limb, and extreme circumferential measurement differences (CMD) were recorded, along with patients with pitting edema (PE). The Visual Analog Scale (VAS) measured pain intensity, and the Neuropathic Pain Questionnaire (NPQ) measured neuropathic pain presence and severity [6].
A standardized ultrasound protocol measures nerve diameters and cross-sectional areas (CSA) at the fibular head and gluteal region of both lower extremities [7, 8, 9, 10]. A study used an ALOKA Prosound Alpha 6 device and a 4-13 MHz linear array transducer to assess the sciatic and peroneal nerves bilaterally at the gluteal region and fibular head. To ensure accuracy, measurements were made three times and averaged by a physical therapist and a radiologist. Electrodiagnostic studies were performed by the same clinician for all eligible patients. Due to regional limitations such as edema, abrasions, or fasciotomy wounds, electromyography (EMG) could not be conducted in eight cases, where diagnosis was based on clinical and ultrasonographic findings.
The data were analyzed using SPSS 25.0, with continuous measurements summarized as means and standard deviations, and categorical measurements as counts and percentages. Chi- square was used for comparing categorical variables, while Shapiro-Wilk and Spearman’s rho were used for continuous measurements comparison, all with 0.05 statistical significance. SPSS 25.0 was used to analyze the data statistically. Continuous measurements were summarized as means and standard deviations (with medians and minimum-maximum values where necessary), while categorical measurements were counts and percentages. Categorical variables were compared using the chi-square. The Shapiro-Wilk test determined whether study parameters were normally distributed. Spearman’s rho was used to compare continuous measurements. All tests used a 0.05 statistical significance.
Ethical Approval
This study was approved by the Ethics Committee of Adana City Training and Research Hospital (Date: 2023-05-25, No: 2598).
Informed Consent
Informed consent was obtained from all participants prior to inclusion in the study.

Results

The study involved 22 patients, with a mean age of 30.4 ± 14.4 years, comprising 72.7% females and 27.3% males. The majority had right-sided involvement, with 54.5%. The median stay was 13 hours. Neuropathy was detected in 59.1% of patients. The demographic characteristics, questionnaire results, laboratory data, and ultrasonographic findings of the patients are summarized in Table 1. The mean values of the sciatic nerve for the affected and healthy sides were 0.48 ± 0.14 and 0.33 ± 0.11 (p < 0.01). The mean values of the peroneal nerve for the affected and healthy sides were 0.24 ± 0.04 and 0.17 ± 0.07 (p < 0.01). In addition, the CSA of both the sciatic and peroneal nerves was significantly larger on the affected side compared to the healthy side (p < 0.01).
There was no statistically significant correlation between the duration of staying under the wreckage and intensive care unit care and ultrasonographic nerve measurement parameters (p > 0.05), and no statistically significant correlation was detected between ultrasonographic measurement parameters and VAS scores (p > 0.05). The Pearson correlation between VAS and NPQ was 0.62 (p = 0.002), indicating a moderate positive and statistically significant relationship.
Although VAS were higher in patients with CMD compared to those without, the difference was not statistically significant (p = 0.083). However, NPQ scores were significantly higher in patients with CMD (p < 0.001).
Patients with pitting edema in the lower extremity or with significant differences in peripheral measurements showed significantly higher peroneal nerve CSA measurements (Table 2).

Discussion

This study assessed the demographic, clinical, and ultrasonographic features of individuals exhibiting unilateral drop foot associated with earthquakes. The results demonstrated significant disparities in the CSA of the sciatic and peroneal nerves between the affected and healthy sides, highlighting the efficacy of ultrasonographic assessments in peripheral nerve injury. Furthermore, there was more noticeable peroneal nerve involvement in patients with lower extremity edema and diameter variations. In the early stages of peripheral nerve injury, ultrasound is especially useful because it offers early insights into nerve damage and is a vital tool for directing treatment.
The research population was mostly comprised of young females. The ratio of females to males in the study population was roughly 3:1. Thirteen hours is the median amount of time spent under the wreckage, emphasizing the extreme challenges that rescuers and survivors confront. This underscores the need to conduct rescue operations as quickly and efficiently as possible [11, 12].
The group of patients with low levels of vitamin D, albumin, and prealbumin indicates serious eating problems caused by being trapped under debris for a long time. Such issues can be worsened by insufficient food and medical assistance in the post-disaster period. The physical and psychological strain from the disaster may lead to metabolic disruptions and increased dietary needs [13]. Early and targeted nutritional therapies, such as vitamin D supplements and high-protein meals, may improve recovery. After a disaster, nutritional evaluations and customized therapies should be included in the first evaluation of victims [14].
Thanks to its real-time imaging capability, non-invasive nature, and ease of repeatability, ultrasonography has become a widely accepted method for evaluating musculoskeletal conditions. In our study, CSA measurements were carried out simultaneously by a radiologist and a specialist in physical medicine and rehabilitation to ensure precision and consistency. This dual- observer approach was designed to strengthen interobserver agreement, in line with previous studies that highlight the importance of reliability and reproducibility in musculoskeletal ultrasound [15, 16]. We observed that the CSA of the sciatic and peroneal nerves was noticeably larger on the affected side, allowing ultrasonography to detect early changes that may result from trauma. These alterations are likely linked to inflammatory processes triggered by injuries to neighboring structures following the earthquake [17, 18]. Such early findings underscore the value of ultrasonography in the prompt identification of peripheral nerve damage. This is particularly relevant in situations where EMG cannot be performed. As demonstrated in our study, ultrasonography served as a critical diagnostic alternative in eight patients who were unable to undergo EMG due to fasciotomy-related scarring in the lower extremities, allowing for the early detection of nerve involvement. An illustrative ultrasonographic image from one of these cases is presented in Figure 1, highlighting the CSA enlargement in both the sciatic and peroneal nerves on the affected side.
In addition, patients who exhibited pitting edema or clear asymmetry in leg circumference showed greater involvement of the peroneal nerve. The marked increase in its CSA may point to the nerve’s particular sensitivity to pressure-related injuries. Given its superficial course around the fibular head, the peroneal nerve is especially prone to compression when swelling is present in the surrounding tissue [19]. The obtained results highlight the importance of ultrasonographic evaluation in identifying these alterations. Prompt detection of nerve damage with ultrasonography might provide rapid therapeutic measures, such as decompression operations, which may enhance long-term functional results [20, 21].
Ultrasonographic nerve parameters showed no notable link in our study with the length of time patients spent in intensive care or trapped under debris. This implies that the severity of the injury, rather than the length of exposure, may be more closely related to the degree of nerve involvement. Though a favorable correlation was found between VAS and NPQ scores, no significant link between VAS or NPQ scores and the ultrasonographic nerve measurements appeared. The multifactorial character of pain and the natural constraints of self-reported subjective scales could explain this. Furthermore, injuries to the musculoskeletal, ischemic, and connective tissue caused by earthquakes could change pain perception in different ways [22]. Cultural and psychological variations in pain perception might also have dulled the noted linkages. Post- disaster psychological disorders, such as anxiety, depression, and post-traumatic stress disorder, may have increased the pain reaction independent of structural nerve damage [23, 24].

Limitations

There are many shortcomings in this work. The findings’ generalizability is limited by the relatively small sample size. Its cross-sectional design, therefore, precludes the formation of causality and restricts the evaluation of long-term results. Thirdly, the research ignored functional outcomes like quality of life or gait patterns, which are vital elements in thorough rehabilitation plans.

Conclusion

Particularly in those with unilateral foot drop, this study emphasizes how earthquake-related trauma may influence peripheral nerves. Among other ultrasonographic results, variations in nerve diameter offer insightful diagnostic information. Enlargement of the affected nerve side implies that the pathophysiology is mostly caused by edema and inflammation. Clinicians should think about nerve damage in those with lower limb asymmetry or edema; regular use of ultrasonography for diagnosis should be promoted. Larger, more varied populations should be the emphasis of future studies, which should also have long-term follow-up to more accurately evaluate treatment effectiveness, functional recovery, and more general clinical relevance.

References

1. Maboloc CR. Natural disasters as a public health issue. J Public Health. 2024;46(3):e534-e535. doi:10.1093/pubmed/fdae039.
   Article PubMed Google Scholar
2. Leppold C, Gibbs L, Block K, Reifels L, Quinn P. Public health implications of multiple disaster exposures. Lancet Public Health. 2022;7(3):e274-e286. doi: 10.1016/S2468-2667(21)00255-3.
   Article PubMed Google Scholar
3. Al Mandhari A. Earthquakes as triggers for public health disasters: WHO and health systems’ response. East Mediterr Health J. 2023;29(3):165-7. doi:10.26719/2023.29.3.165.
   Article PubMed Google Scholar
4. Kocyigit BF. Rehabilitation needs after earthquakes. J Korean Med Sci. 2023;38(17):e153. doi:10.3346/jkms.2023.38.e153.
   Article PubMed Google Scholar
5. Bilir EE, Borman P, Ata AM, et al. Clinical properties and rehabilitation needs of earthquake survivors in a subacute rehabilitation setting. Turk J Trauma Emerg Surg. 2024;30(4):297. doi:10.14744/tjtes.2024.27553.
   Article PubMed Google Scholar
6. Breivik H, Borchgrevink PC, Allen SM, et al. Assessment of pain. Br J Anaesth. 2008;101(1):17-24. doi:10.1093/bja/aen103.
   Article PubMed Google Scholar
7. Cornelson SM, Ruff AN, Wells C, Sclocco R, Kettner NW. Sonographic measures and sensory threshold of the normal sciatic nerve and hamstring muscles. J Ultrasound. 2022;25(1):47-57. doi:10.1007/s40477-020-00552-w.
   Article PubMed Google Scholar
8. Ricci V, Ricci C, Cocco G, et al. Histopathology and high-resolution ultrasound imaging for peripheral nerve (injuries). J Neurol. 2022;269(7):3663-75. doi:10.1007/s00415-022-10988-1.
   Article PubMed Google Scholar
9. Oosterbos C, Weerdt OD, Lembrechts M, et al. Diagnostic accuracy of ultrasound and MR imaging in peroneal neuropathy: a prospective, single‐center study. Muscle Nerve. 2024;70(3):360-70. doi:10.1002/mus.28187 doi:10.1097/ MD.0000000000029842.
   Article PubMed Google Scholar
10. Bae DW, An JY. Cross-sectional area reference values for high-resolution ultrasonography of the lower extremity nerves in healthy Korean adults. Medicine (Baltimore). 2022;101(26):e29842. doi:10.1097/MD.0000000000029842.
    Article PubMed Google Scholar
11. Celikmen MF, Tatliparmak AC, Tunaligil V, Yilmaz S. Challenges and clinical impact of medical search and rescue efforts following the Kahramanmaraş earthquake. Prehosp Disaster Med. 2024;39(4):295-300. doi:10.1017/ S1049023X24000463.
    Article PubMed Google Scholar
12. Çetinkaya Özdemir S, Semerci Çakmak V, Ziyai NY, Çakir E. Experiences of intensive care nurses providing care to the victims of Kahramanmaraş earthquakes. Nurs Crit Care. 2024;29(4):661-71. doi:10.1111/nicc.12992.
    Article PubMed Google Scholar
13. Kheiry M, Farahmandnia H, Zarei M, Sahebi A. Nutritional status among earthquake survivors: a systematic review and meta-analysis. Public Health. 2024;227(1):24-31. doi:10.1016/j.puhe.2023.11.028.
    Article PubMed Google Scholar
14. Tokumaru O, Fujita M, Nagai S, Minamikawa Y, Kumatani J. Medical problems and concerns with temporary evacuation shelters after great earthquake disasters in Japan: a systematic review. Disaster Med Public Health Prep. 2022;16(4):1645- 52. doi:10.1017/dmp.2021.99.
    Article PubMed Google Scholar
15. Chiaramonte R, Bonfiglio M, Castorina EG, Antoci SA. The primacy of ultrasound in the assessment of muscle architecture: precision, accuracy, reliability of ultrasonography. Physiatrist, radiologist, general internist, and family practitioner’s experiences. Rev Assoc Med Bras. 2019;65(2):165-70. doi:10.1590/1806-9282.65.2.165.
    Article PubMed Google Scholar
16. Tang CT, Decker G, Steger‐May K, Middleton W, Teefey S. Method comparison for detection and measurement of rotator cuff tears: Office‐ based bedside ultrasonography by a single physiatrist versus imaging center– based ultrasonography by two expert musculoskeletal radiologists. PM R. 2020;12(6):563-72. doi:10.1002/pmrj.12256.
    Article PubMed Google Scholar
17. Schwabl C, Schmidle G, Kaiser P, Drakonaki E, Taljanovic MS, Klauser AS. Nerve entrapment syndromes: detection by ultrasound. Ultrasonography. 2023;42(3):376-87. doi:10.14366/usg.22186.
    Article PubMed Google Scholar
18. Degrugillier L, Prautsch KM, Schaefer DJ, et al. A new model of chronic peripheral nerve compression for basic research and pharmaceutical drug testing. Regen Med. 2021;16(10):931-47. doi:10.2217/rme-2020-0129.
    Article PubMed Google Scholar
19. Kerns J, Piponov H, Helder C, Amirouche F, Solitro G, Gonzalez M. Mechanical properties of the human tibial and peroneal nerves following stretch with histological correlations. Anat Rec (Hoboken). 2019;302(11):2030-9. doi:10.1002/ ar.24250.
    Article PubMed Google Scholar
20. Toia F, Gagliardo A, D’Arpa S, Gagliardo C, Gagliardo G, Cordova A. Preoperative evaluation of peripheral nerve injuries: what is the place for ultrasound? J Neurosurg. 2016;125(3):603-14. doi:10.3171/2015.6.JNS151001.
    Article PubMed Google Scholar
21. Visalli C, Cavallaro M, Concerto A, et al. Ultrasonography of traumatic injuries to limb peripheral nerves: technical aspects and spectrum of features. Jpn J Radiol. 2018;36(10):592-602. doi:10.1007/s11604-018-0765-9.
    Article PubMed Google Scholar
22. Jinnouchi H, Ohira T, Kakihana H, et al. Lifestyle factors associated with prevalent and exacerbated musculoskeletal pain after the Great East Japan Earthquake: a cross-sectional study from the Fukushima Health Management Survey. BMC Public Health. 2020;20(1):677. doi:10.1186/s12889-020-08764-9.
    Article PubMed Google Scholar
23. Valladares-Garrido MJ, Zapata-Castro LE, Domínguez-Troncos H, et al. Mental health disturbance after a major earthquake in northern Peru: a preliminary, cross-sectional study. Int J Environ Res Public Health. 2022;19(14):8357. doi:10.3390/ijerph19148357.
    Article PubMed Google Scholar
24. Turan N, Hülya KE, Acar Gül GB. Emotions, coping and psychological flexibility in earthquake survivors: a cross-sectional study. Psychol Health Med. 2025;30(4):677-96. doi:10.1080/13548506.2024.2433540.
    Article PubMed Google Scholar

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