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To assess the predictive variables after sonographically guided corticosteroid injection in carpal tunnel syndrome.
A prospective, observational study was carried out on 25 wrists of 20 consecutive patients with carpal tunnel syndrome, confirmed by the American Association of Neuromuscular and Electrodiagnostic Medicine criteria, which includes clinical history, symptoms, and evidence of slowing of distal median nerve conduction. Visual analogue scale (VAS) and Boston Carpal Tunnel Questionnaire (BCTQ) were asked to the patients before and 4 weeks after the procedure. On a basis of VAS difference before and after the procedure, we divided the patients into two groups: more than 50% of VAS improving (good response group) and less than 50% of VAS improving (poor response group). Also, nerve conduction studies and ultrasound evaluations were performed prior to sonographically guided corticosteroid injection and at 4 weeks after the procedure. The cross-sectional area (CSA) of median nerve at maximal swelling point around wrist was measured by manual tracing using ultrasonography. With assessments mentioned above, we tried to assess predictive variables for prognosis after sonographically guided corticosteroid injection in carpal tunnel syndrome.
The CSA of median nerve at wrist measured before the procedure was significantly larger in good response group than in poor response group. Furthermore, the CSA of median nerve at wrist, symptom severity scale of BCTQ, motor/sensory latency and sensory amplitude were correlated with VAS improving.
The CSA of median nerve at wrist is the strongest predictive value for sonographically guided corticosteroid injection in mild-to-moderate carpal tunnel syndrome.
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To investigate the diagnostic value of cross-sectional area (CSA) and wrist to forearm ratio (WFR) in patients with electro-diagnosed carpal tunnel syndrome (CTS) with or without diabetes mellitus (DM).
We retrospectively studied 256 CTS wrists and 77 healthy wrists in a single center between January 1, 2008 and January 1, 2013. The CSA and WFR were calculated for each wrist. Patients were classified into four groups according to the presence of DM and CTS: group 1, non-DM and non-CTS patients; group 2, non-DM and CTS patients; group 3, DM and non-CTS patients; and group 4, DM and CTS patients. To determine the optimal cut-off value, receiver operating characteristic (ROC) curve analysis was performed.
The CSA and WFR were significantly different among the groups (p<0.001). The ROC curve analysis of non-DM patients revealed CSA ≥10.0 mm2 and WFR ≥1.52 as the most powerful diagnostic values of CTS. The ROC curve analysis revealed CSA ≥12.5 mm2 and WFR ≥1.87 as the most powerful diagnostic values of CTS.
Ultrasonographic assessment for the diagnosis of CTS requires a particular cut-off value for diabetic patients. Based on the ROC analysis results, improved accurate diagnosis is possible if WFR can be applied regardless of presence or absence of DM.
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To establish the cutoff value of cross-sectional area (CSA) of the median nerve at the wrist, for determination of electrophysiologically moderate and severe carpal tunnel syndrome (CTS).
The prospective study was conducted among patients suspected of having CTS. A total of 106 patients (185 symptomatic wrists) received nerve conduction study (NCS) and ultrasonography. To establish a cutoff value, various diagnostic properties were calculated across a range of the CSA.
A mean±standard deviation of CSA of the median nerve of normal and mild, moderate and severe CTS was 9.4±2.1, 12.0±2.7, 13.8±4.7, and 15.4±4.1 mm2, respectively. The positive relationship between CTS severities and CSA was observed (rs=0.56). A 14 mm2 CSA had sufficient power to rule in moderate and severe CTS, with a specificity of 91.4% and sensitivity of 42.3%. In addition, it showed a post-test probability (positive predictive value) of 86.3% as against a pre-test probability of 56.2%.
Patients who had ≥14 mm2 of median nerve CSA had very high probability of moderate to severe CTS.
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To determine which ultrasonographic measurement can be used as an indicator reflecting the severity of carpal tunnel syndrome (CTS), by comparing electrodiagnostic results with ultrasonographic measurements in females. Many previous studies have tried to reveal that the ultrasonography (US) can possibility be used for diagnosis and severity of CTS. However, the criteria are different by gender. Thus far, there have been many efforts towards providing patients with a CTS diagnosis and severity prediction using US, but studies' results are still unclear due to lack of data on gender differences.
We collected data from 54 female patients. We classified the severity of CTS according to electrodiagnostic results. Ultrasonographic measurements included proximal and distal cross-sectional areas of the median nerve and carpal tunnel.
The severity by electrodiagnostic results statistically correlated to the proximal cross-sectional area (CSA) of the median nerve and carpal tunnel. However, there was no relationship between the proximal and distal nerve/tunnel indexes and the severity by electrodiagnostic results.
In female patients with CTS, the proximal CSAs of the median nerve and carpal tunnel increase. They correlate with the severity by electrodiagnostic findings. The CSA of the proximal median nerve could be particularly used as a predictor of the severity of CTS in female patients. However, the nerve/tunnel index is constant, irrespective of the severity of CTS.
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To investigate the contributing factors of carpal tunnel syndrome (CTS), electrodiagnostic and ultrasonographic findings of median nerve, and median nerve change after exercise in wheelchair basketball (WCB) players.
Fifteen WCB players with manual wheelchairs were enrolled in the study. Medical history of the subjects was taken. Electrodiagnosis and ultrasonography of both median nerves were performed to assess CTS in WCB players. Ultrasonographic median nerves evaluation was conducted after wheelchair propulsion for 20 minutes.
Average body mass index (BMI) and period of wheelchair use of CTS subjects were greater than those of normal subjects. Electrodiagnosis revealed CTS in 14 of 30 hands (47%). Cross-sectional area (CSA) of median nerve was greater in CTS subjects than in normal subjects at 0.5 cm and 1 cm proximal to distal wrist crease (DWC), DWC, 1 cm, 2 cm, 3 cm, and 3.5 cm distal to DWC. After exercising, median nerve CSAs at 0.5 cm and 1 cm proximal to DWC, DWC, and 3 cm and 3.5 cm distal to DWC were greater than baseline CSAs in CTS subjects; and median nerve CSAs at 1 cm proximal to DWC and DWC were greater than baseline CSAs in normal subjects. The changes in median nerve CSA after exercise in CTS subjects were greater than in normal subjects at 0.5 cm proximal to DWC and 3 cm and 3.5 cm distal to DWC.
BMI and total period of wheelchair use contributed to developing CTS in WCB players. The experimental exercise might be related to the median nerve swelling around the inlet and outlet of carpal tunnel in WCB athletes with CTS.
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To assess the reliability of quantitative muscle ultrasonography (US) in healthy subjects and to evaluate the correlation between quantitative muscle US findings and electrodiagnostic study results in patients with carpal tunnel syndrome (CTS). The clinical significance of quantitative muscle US in CTS was also assessed.
Twenty patients with CTS and 20 age-matched healthy volunteers were recruited. All control and CTS subjects underwent a bilateral median and ulnar nerve conduction study (NCS) and quantitative muscle US. Transverse US images of the abductor pollicis brevis (APB) and abductor digiti minimi (ADM) were obtained to measure muscle cross-sectional area (CSA), thickness, and echo intensity (EI). EI was determined using computer-assisted, grayscale analysis. Inter-rater and intra-rater reliability for quantitative muscle US in control subjects, and differences in muscle thickness, CSA, and EI between the CTS patient and control groups were analyzed. Relationships between quantitative US parameters and electrodiagnostic study results were evaluated.
Quantitative muscle US had high inter-rater and intra-rater reliability in the control group. Muscle thickness and CSA were significantly decreased, and EI was significantly increased in the APB of the CTS group (all p<0.05). EI demonstrated a significant positive correlation with latency of the median motor and sensory NCS in CTS patients (p<0.05).
These findings suggest that quantitative muscle US parameters may be useful for detecting muscle changes in CTS. Further study involving patients with other neuromuscular diseases is needed to evaluate peripheral muscle change using quantitative muscle US.
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To investigate the relationship between electrodiagnosis and various ultrasonographic findings of carpal tunnel syndrome (CTS) and propose the ultrasonographic standard that has closest consistency with the electrodiagnosis.
Ultrasonography was performed on 50 female patients (65 cases) previously diagnosed with CTS and 20 normal female volunteers (40 cases). Ultrasonography parameters were as follows: cross-sectional area (CSA) and flattening ratio (FR) of the median nerve at the levels of hamate bone, pisiform bone, and lunate bone; anteroposterior diameter (AP diameter) of the median nerve in the carpal tunnel; wrist to forearm ratio (WFR) of median nerve area at the distal wrist crease and 12 cm proximal to distal wrist crease; and compression ratio (CR) of the median nerve. Independent t-test was performed to compare the ultrasonographic findings between patient and control groups. Significant ultrasonographic findings were compared with the electrodiagnosis results and a kappa coefficient was used to determine the correlation.
CSA and FR of median nerve at the hamate bone level, CSA of median nerve at pisiform bone level, AP diameter of median nerve within the carpal tunnel, CSA of median nerve at the distal wrist crease and WFR showed significant differences between patient and control groups. WFR showed highest concordance with electrodiagnosis (κ=0.71, p<0.001).
These findings suggested the applicability of ultrasonography, especially WFR, as a useful adjunctive tool for diagnosis of CTS.
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To determine the prevalence and related characteristics of carpal tunnel syndrome (CTS) in orchardists and to investigate the association between electrodiagnostic severity and physical examinations.
Between July 2013 and September 2014, 377 subjects (174 men and 203 women) visited the Gyeongsang National University Hospital's Center for Farmer's Safety and Health. All the subjects underwent electrodiagnostic tests and physical examination, including Phalen's test, Tinel's sign, and Durkan's carpal compression test (CCT). The subjects were classified into 2 groups, the normal group and the CTS group, according to electrodiagnostic test results. To determine the related characteristics of CTS, potential variables, including age, sex, drinking, smoking, body mass index, waist circumference, and total work time, were compared between the 2 groups. The association between electrodiagnostic severity and physical examinations was analyzed.
CTS was diagnosed in 194 subjects based only on electrodiagnostic test results, corresponding to a prevalence of 51.5%. Among the variables, mean age (p=0.001) and total work time (p=0.007) were significantly correlated with CTS. With respect to the physical examinations, low specificities were observed for Tinel's sign, Phalen's test, and Durkan's CCT (38.4%, 36.1%, and 40.9%, respectively) in the subjects aged ≥65 years. In addition, Phalen's test (p=0.003) and Tinel's sign (p=0.032) in men and Durkan's CCT (p=0.047) in women showed statistically significant differences with increasing CTS severity. The odds ratio was 2.066 for Durkan's CCT in women according to the multivariate logistic regression analysis.
CTS prevalence among orchardists was high, and Durkan's CCT result was significantly quantitatively correlated with the electrodiagnostic test results. Therefore, Durkan's CCT is another reliable examination method for CTS.
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To evaluate the clinical differences between patients with diabetes mellitus (DM) who have asymptomatic carpal tunnel syndrome (CTS) and those who have symptomatic CTS.
Sixty-three patients with DM were assessed using the Boston Carpal Tunnel Questionnaire (BCTQ), nerve conduction studies (NCS), and ultrasonographic evaluation of the cross-sectional area (CSA) of the median nerve. According to the BCTQ responses and NCS results, the patients were divided into the following three groups: group 1 (n=16), in which NCS results did not reveal CTS; group 2 (n=19), in which NCS results revealed CTS but the group scored 0 points on the BCTQ (asymptomatic); and group 3 (n=28), in which NCS results revealed CTS and the group scored >1 point on the BCTQ (symptomatic). The clinical findings, NCS results, and CSA of the median nerve were compared among the three groups.
There were no significant differences in age, DM duration, glycated hemoglobin levels, and presence of diabetic polyneuropathy among the three groups. The peak latency of the median sensory nerve action potential was significantly shorter in group 1 than in groups 2 and 3 (p<0.001); however, no difference was observed between groups 2 and 3. CSA of the median nerve at the carpal tunnel in group 2 was significantly larger than that in group 1 and smaller than that in group 3 (p<0.05).
The results of our study suggest that the symptoms of CTS in patients with diabetes are related to CSA of the median nerve, which is consistent with swelling of the nerve.
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To examine the usefulness of the second lumbrical-interosseous (2L-INT) distal motor latency (DML) comparison test in localizing median neuropathy to the wrist in patients with absent median sensory and motor response in routine nerve conduction studies.
Electrodiagnostic results from 1,705 hands of patients with carpal tunnel syndrome (CTS) symptoms were reviewed retrospectively. All subjects were evaluated using routine nerve conduction studies: median sensory conduction recorded from digits 1 to 4, motor conduction from the abductor pollicis brevis muscle, and the 2L-INT DML comparison test.
Four hundred and one hands from a total of 1,705 were classified as having severe CTS. Among the severe CTS group, 56 hands (14.0%) showed absent median sensory and motor response in a routine nerve conduction study, and, of those hands, 42 (75.0%) showed an abnormal 2L-INT response.
The 2L-INT DML comparison test proved to be a valuable electrodiagnostic technique in localizing median mononeuropathy at the wrist, even in the most severe CTS patients.
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Carpal tunnel release is required to treat patients with severe carpal tunnel syndrome. The regional anesthesia of the upper limb by brachial plexus block (BPB) may be a good alternative to general anesthesia for carpal tunnel release surgery, because it results in less complications. However, the regional anesthesia still has various side effects, such as hematoma, infection, and peripheral neuropathy. We hereby report a rare case of median nerve injury caused by BPB for carpal tunnel release.
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To understand the quantitative correlation between the clinical severity and physical examinations along with the electrodiagnostic findings by subjects with carpal tunnel syndrome (CTS) and also the influence of diabetic polyneuropathy (DPN) on physical examinations by subjects with CTS.
Among 200 patients suffering from hand tingling sensations, 68 patients were diagnosed with CTS on at least one hand by nerve conduction tests. Therefore, the Phalen test (PT), hand elevation test (HET), Tinel sign (TS) results were recorded on both hands. The physical examination grades were compared with the electrophysiological CTS grades in 126 hands of 68 patients. Also the comorbidity effect of DPN to CTS was evaluated. For the evaluation of the severity correlations between CTS, PT, HET, and TS, the Spearman analysis was used. An attempt was started to create a formula which could depict the electrophysiological severity of CTS.
Out of the 68 tested subjects, 31 were diagnosed with both DPN and CTS, and 37 with CTS only. Both PT and HET correlated well with the severity of CTS where the correlation of PT was higher than that of HET. The formula were the motor distal latency (MDL)=(72.4-PT)/5.3 and MDL=(76-HET)/7.2. Both PT and HET showed in the presence of DPN a relatively higher relation with CTS without significance.
PT and HET would be useful screening tools for the diagnosis and treatment of CTS as the grade of PT and HET present the severity of CTS well. During this study, a formula was created expecting the severity of nerve conduction study with PT and HET through the time domain value of physical examinations.
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To evaluate each digital branch of the median sensory nerve and motor nerves to abductor pollicis brevis (APB) and 2nd lumbrical (2L) according to the severity of carpal tunnel syndrome (CTS).
A prospective study was performed in 67 hands of 41 patients with CTS consisting of mild, 23; moderate, 27; and severe cases, 17. Compound muscle action potentials (CMAPs) were obtained from APB and 2L, and median sensory nerve action potentials (SNAPs) were recorded from the thumb to the 4th digit. Parameters analyzed were latency of the median CMAP, latency difference of 2L and first palmar interosseous (PI), as well as latency and baseline to peak amplitude of the median SNAPs.
The onset and peak latencies of the median SNAPs revealed significant differences only in the 2nd digit, according to the severity of CTS, and abnormal rates of the latencies were significantly lower in the 2nd digit to a mild degree. The amplitude of SNAP and sensory nerve conduction velocities were more preserved in the 2nd digit in mild CTS and more affected in the 4th digit in severe CTS. CMAPs were not evoked with APB recording in 4 patients with severe CTS, but obtained in all patients with 2L recording. 2L-PI showed statistical significance according to the severity of CTS.
The branch to the 4th digit was mostly involved and the branch to the 2nd digit and 2L were less affected in the progress of CTS. The second digit recorded SNAPs and 2L recorded CMAPs would be valuable in the evaluation of severe CTS.
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Ulnar neuropathy at the wrist is rarely reported as complications of carpal tunnel release. Since it can sometimes be confused with recurrent median neuropathy at the wrist or ulnar neuropathy at the elbow, an electrodiagnostic study is useful for detecting the lesion in detail. We present a case of a 51-year-old woman with a two-week history of right ulnar palm and 5th digit tingling sensation that began 3 months after open carpal tunnel release surgery of the right hand. Electrodiagnostic tests such as segmental nerve conduction studies of the ulnar nerve at the wrist were useful for localization of the lesion, and ultrasonography helped to confirm the presence of the lesion. After conservative management, patient symptoms were progressively relieved. Combined electrodiagnostic studies and ultrasonography may be helpful for diagnosing and detecting ulnar neuropathies of the wrist following carpal tunnel release surgery.
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To investigate the correlation of the ultrasonographic wrist-to-forearm median nerve area ratio (WFR) and cross sectional area of median nerve at the wrist (CSA-W) to the electrophysiologic severity in patients with carpal tunnel syndrome (CTS).
One hundred and ten wrists electrophysiologically graded as mild, moderate, and severe CTS and 38 healthy controls underwent ultrasonography of median nerve at the distal wrist crease and mid-forearm. WFR and CSA-W were analyzed according to the severity of CTS.
WFR was 1.12±0.14, 1.91±0.33, 2.27±0.47 and 3.02±0.97 and the CSAs-W was 7.23±1.67 mm2, 13.51±3.72 mm2, 14.67±2.93 mm2, and 18.74±6.01 mm2 in controls, mild (n=28), moderate (n=46), and severe (n=36) CTS, respectively. CSA-W displayed significant differences between the control and the mild CTS, moderate CTS and severe CTS groups. However, there was no significant difference between mild CTS and moderate CTS groups. WFR revealed significant difference between all groups. The sensitivity and specificity of the WFR in grading the severity of CTS were higher than those of the CSA-W.
Ultrasonography is a useful complementary tool for the evaluation of CTS. Both WFR and CSA-W are highly correlated with severity grade of CTS. However, WFR is superior to CSA-W for diagnosis and grading of the severity of CTS.
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To evaluate the clinical significance of motor unit number estimation (MUNE) and quantitative analysis of motor unit action potential (MUAP) in carpal tunnel syndrome (CTS) according to electrophysiologic severity, ultrasonographic measurement and clinical symptoms.
We evaluated 78 wrists of 45 patients, who had been diagnosed with CTS and 42 wrists of 21 healthy controls. Median nerve conduction studies, amplitude and duration of MUAP, and the MUNE of the abductor pollicis brevis were measured. The cross sectional area (CSA) of the median nerve at the pisiform and distal radioulnar joint level was determined by high resolution ultrasonography. Clinical symptom of CTS was assessed using the Boston Carpal Tunnel Questionnaire (BCTQ).
The MUNE, the amplitude and the duration of MUAP of the CTS group were significantly different from those found in the control group. The area under the ROC curve was 0.944 for MUNE, 0.923 for MUAP amplitude and 0.953 for MUAP duration. MUNE had a negative correlation with electrophysiologic stage of CTS, amplitude and duration of MUAP, CSA at pisiform level, and the score of BCTQ. The amplitude and duration of MUAP had a positive correlation with the score of BCTQ. The electrophysiologic stage was correlated with amplitude but not with the duration of MUAP.
MUNE, amplitude and duration of MUAP are useful tests for diagnosis of CTS. In addition, the MUNE serves as a good indicator of CTS severity.
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To verify the feasibility of initial parameters of ultrasonography or electromyography for the prediction of effect after steroid injection therapy in a carpal tunnel syndrome (CTS) patient.
We recruited individuals with clinical and electrodiagnostic evidence of CTS. Results from the Boston self-assessment questionnaire, median motor and sensory nerve conduction studies, and median nerve ultrasonography were evaluated at baseline, 1 month, and 6 months after injection. Evaluation of median nerve ultrasonography parameters included measurements taken at the maximal swelling point (MS), 2 cm proximal from MS (2MS), and 12 cm proximal from MS (12MS), and its ratio (MS/12MS, 2MS/12MS) was calculated. The correlation between improvement of the symptom score after treatment and baseline parameters was estimated.
Fourteen individuals (14 women, mean age 53.8 years) with 22 affected wrists were enrolled. After steroid injection therapy, clinical and electromyographic parameters showed significant improvements at 1 month or 6 months after injection, and ultrasonographic parameters showed significant changes in maximal area and area ratio (MS/12MS) of the median nerve. Symptom score improvement showed a positive correlation in the initial 2MS and ratio of 2MS/12MS after 6 months (p<0.05).
Most of the improvements occurred during the first month after injection and lasted up to 6 months. The initial median nerve swelling and its ratio may be a useful predictor of response after steroid injection.
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Method Subjects included 50 hands of 33 patients with CTS with electrophysiologic evidence of CTS and 50 hands of 39 adults with no evidence of CTS. CuSP was measured on abductor pollicis brevis (APB) and adductor digiti minimi (ADM) by stimulation of digit 3. All subjects were examined with ultrasonography (US). Using US, the cross-sectional area (CSA) and flattening ratio (FR) of the median nerve were calculated under carpal tunnel. Analysis of differences between the control group and the CTS group was performed using ANOVA.
Results Differences of CSA, FR, latency, and duration of CuSP in both APB, ADM muscles were observed between the two groups. Correlations were observed in the patient group in latency and duration of the APB muscle and only in duration of the ADM (p=0.048, r=0.159; p=0.035, r=−0.315; p=0.039, r=−0.293) muscle. Correlations were found only in duration of ADM (p=0.011, r=0.358) in the control group with respect to CSA. However, there was no correlation with FR.
Conclusion There seems to be a significant correlation between the CSA of the median nerve and the latency and duration of CuSP in patients with CTS. In addition, there seems to be a significant difference of CSA, FR, and latency in both APB and ADM between the two groups. CuSP and CSA might be useful for study that reflects intact small fibers in patients with CTS.
Objective: To compare the latency difference of median and ulnar sensory nerves through the wrist-palm short segment in patients with carpal tunnel syndrome (CTS).
Method: Subjects included 68 hands of 36 carpal tunnel syndrome patients and 97 hands of 53 healthy adults with no electrophysiologic evidence of CTS. The median and the ulnar sensory responses were recorded on the third and the fifth digit using bar recording electrode, respectively. Both nerves were stimulated just proximal to the distal wrist crease and 5 cm distal to the proximal stimulation point. The latency differences between the 2 stimulation points were obtained.
Results: The transcarpal short segment conduction times in the control group were 1.0⁑0.1 msec and 0.9⁑0.1 msec for the median and ulnar nerves, respectively. The transcarpal short segment conduction times in the patients with CTS were 1.9⁑0.5 msec and 1.0⁑0.3 msec for the median and ulnar nerves, respectively. The transcarpal short segment conduction time difference between the median and ulnar nerves were 0.13⁑0.12 msec in the control group and 0.88⁑0.50 msec in the CTS group. The difference of transcarpal conduction of two nerves was statistically significant in comparison with the two groups.
Conclusion: Wrist-palm short segment study of median and ulnar sensory nerve may be used adjunctively in diagnosis of mild CTS. (J Korean Acad Rehab Med 2002; 26: 539-542)
Local steroid injection in carpal tunnel syndrome(CTS) is widely practised for the relief of symptoms such as pain and paresthesias. We evaluated the effects of the injection with electrophysiologic changes and improvement in pain and paresthesias.
27 patients, 40 cases with carpal tunnel syndrome diagnosed clinically and electrophysiologically were injected with 40mg of triamcinolone acetonide. Patients were reevaluated with the visual analogue scale and electrophysiologic parameters after 2 to 4 weeks. Then we split up the patients into "excellent", "good" ,"poor" group by the degree of responses to the injections. In order to predict the injection effect, we analyzed several clinical and electrophysiologic factors: duration of symptoms, Phalen test, prolongation of distal motor latency of the median nerve, denervation evidence of the abductor pollicis brevis muscle.
Symptom relief was noted in the 89% of the cases[excellent(75%), good(14%)], and there was no statistically significant correlation between any of the above four factors and the degree of the symptom responses. Among the electrophysiologic parameters motor distal latency, motor residual latency, sensory onset and peak latency, median to radial sensory onset and peak latency difference reflected the clinical improvements(p＜0.05). But there was some cases that improved clinically but deteriorated electrophysiologically(2 cases in motor distal latency, 5 cases in motor residual latency, 1 case in sensory peak latency, none in sensory onset latency).
In conclusion we find that local steroid injection in CTS is an effective therapeutic modality for the symptom remission and it also showed changes in electrophysiologic parameters. And among these parameters sensory distal latency seems to be the most appropriate electrophysiologic parameter which best reflects the improvement of pain and paresthesias.
Objective: The previously established method of carpal tunnel syndrome (CTS) diagnosis is relatively troublesome and risk of misleading due to uncertainty of exact distance measurement for stimulation. If we use the wrist crease, an anatomical landmark, there might not be error in length measurement for stimulation at any wrist position. This study was performed to evaluate the wrist stimulation method in the diagnosis of CTS for it's convenience and reducing the errors.
Method: Seventy healthy adults and sixty-five patients with clinical and electrophysiologic evidence of CTS were studied. Sensory nerve action potentials (SNAPs) in second and fifth digit were recorded antidromically with stimulation at a distance of 14 cm from recording electrode and stimulation at wrist crease. The ratio and difference of distal latency and ratio of amplitude between median and ulnar SNAPs were assessed.
Results: The ratio and difference of distal latency and ratio of amplitude in the 14 cm stimulation method were 1.52⁑0.28, 1.59⁑0.91 msec, 1.26⁑0.27 in the right, 1.43⁑0.14, 1.29⁑0.42 msec, 1.18⁑0.20 in the left, respectively in the men patients, and those of women patients were 1.48⁑0.35, 1.43⁑1.04 msec, 1.18⁑0.30 in the right, 1.53⁑0.30, 1.46⁑0.80 msec, 0.75⁑0.36 in the left. In wrist crease stimulation, those of men patients were 1.72⁑0.39, 1.74⁑0.98 msec, 1.22⁑0.24 in the right, 1.53⁑0.21, 1.31⁑0.46 msec, 1.25⁑0.29 in the left, and those of women patients were 1.67⁑0.46, 1.56⁑1.01 msec, 0.63⁑0.32 in the right, 1.68⁑0.37, 1.56⁑0.82 msec, 0.68⁑0.30 in the left. These results showed a significant positive correlation between the patients group and the control group in two stimulation methods (p＜0.001).
Conclusion: Based on the result of this study, wrist crease stimulation method is a quick and easy procedure, which would be recommended in the early diagnosis of CTS.
Objective: To compare the degree of change of current perception threshold (CPT) results with the degree of nerve conduction study (NCS) change and evaluate the effectiveness of the CPT in following up patients who went through operation for carpal tunnel syndrome (CTS).
Method: Twenty hands with CTS were examined with CPT and NCS, before, 2 weeks after and 2 months after operation. In the CPT, the threshold of the median nerve was measured, in the NCS, amplitude and latency of the median nerve was measured. Subjects were divided into 3 groups according to the severity by NCS results and into 2 groups according to the subjective perception of improvement.
Results: The subjects mean age was 51.4. Changes of NCS results in amplitude and latency showed no statistical relevance. CPT study result changes demonstrated to be statistically significant. Improvement of CPT results seen in the period of 2 weeks and 2 months and the initial first 2 weeks showed no difference. Change of CPT results showed correlation not in accordance with the severity of the NCS study, but with the symptomatic improvement of the patients.
Conclusion: CPT can be an effective tool in evaluating the improvement of symptoms and may be used as a follow up tool in patients with CTS. (J Korean Acad Rehab Med 2002; 26: 414-419)
Objective: The purpose of this study was to evaluate therapeutic effect of local steroid injection in carpal tunnel syndrome, and to make a comparison between therapeutic effect in patients with and without diabetic neuropathy.
Method: 30 patients (40 hands) with carpal tunnel syndrome diagnosed clinically and electrophysiologically were injected with 40mg of methylprednisone. Patients were evaluated with the visual analogue scale after 4 weeks and 8 weeks. According to the therapeutic responses, the patients were grouped into: excellent; good; poor; failed; recurrent.
Results: After 4 weeks, symptom relief was noted in the 95% of all cases: 100% of the patients without diabetic neuropathy; 82% of the patients with diabetic neuropathy. After 8 weeks, symptom relief was noted in the 82.5% of all cases: 86% of the patients without diabetic neuropathy; 73% of the patients with diabetic neuropathy. There was no statistically significant difference between the patients with and without diabetic neuropathy (p＞0.05).
Conclusion: We concluded that local steroid injection in carpal tunnel syndrome was an effective therapeutic modality for a short term and local steroid injection in the carpal tunnel syndrome with diabetic neuropathy diagnosed by palmar test also had a good effect.
Objective: High body temperature may alter nerve conduction in demyelinated neurons. This study was designed to investigate the changes in nerve conduction parameters in response to the heat applied over the wrist in the patients with carpal tunnel syndrome (CTS).
Method: 16 hands of CTS patients and 16 hands of normal subjects were involved in this study. Motor and sensory nerve responses were measured at 32oC and 42oC in all the subjects. Infrared was applied on the wrist to warm the skin to 42oC. Changes of relative amplitude, duration, and latency of evoked potentials in median sensory and motor nerves of CTS patients were compared with those of the normal subjects. Correlation between the latency measured at 32oC and changes of amplitude of motor and sensory nerve responses after warming to 42oC was evaluated in CTS group.
Results: Relative reduction in duration of motor responses in CTS group was significantly greater than in normal group. Relative reduction of motor and sensory amplitude, and sensory latency were greater in CTS. There was no significant relation between motor and sensory latency at 32oC and relative amplitude reduction in motor and sensory responses at 42oC.
Conclusion: Increase in temperature may increase the number of blocked nerve fibers in patients with CTS than in normal subjects.
Objective: The purpose of this study was to find out diagnostic clue for the carpal tunnel syndrome. So we investigated the postional relationships between the structures, the degree of entrance of the muscle bellies in the carpal tunnel, the location of flexor retinaculum (FR) and the cross sectional area to the tunnel of the tendons, the median nerve and the soft tissues occupied with the wrist.
Method: Seventy-seven wrists of Korean adults's cadavers were dissected. Fifty-three wrists were examined by posteroanterior view of X-ray. The area of each structure was measured by image analyzer (Optimas Co. WA). The upper and lower borders the FR were confirmed at the sagittal plane after sagittal section.
Results: Frequency of the bellies of FDS, FDP and lumbricalis observed in each finger, the length of these bellies entering into the carpal tunnel were obtained. The cases that the third and fourth FDS were located side by side, the second FDS tendon under the third FDS tendon and the fifth tendon under the fourth FDS tendon were most common. The cases that the median nerve was bordered on the third FDS and the second FDS deep inside of the median nerve were most common. Mean length of the FR was 32.1 mm. The cases that the location of the upper margin of the FR was 10 mm and 15 mm from the end of radius were most common (44%). The cases that the margin of FR was 5 mm and 10 mm from the base of the 3rd metacarpal bone were most common (52%). The cross sectional area ratios to the carpal tunnel of the tendon, median nerve and connective tissues were 30%, 4%, 66% at the level of the pisiform bone, 36%, 4%, 60% at the level of the hook of hamate and 28%, 3%, 67% at the level of the lower margin of the FR, respectively.
Conclusion: These results could help to understand the etiology of the carpal tunnel syndrome and would be a helpful information to the diagnostic imaging of the carpal tunnel.
Method: Subjects were 22 patients with AVF in patients with CRF and 10 controls without AVF in patients with CRF. We studied nerve conductions, and compared the findings in the arms with fistula and without fistula, and the arms in controls.
Results: In ulnar motor nerve conduction study, the amplitude in fistula side was lower than non-fistula side, but the conduction velocity in non-fistula side was lower than fistula side. In radial motor nerve conduction study, the distal latency in non-fistula side was more delayed than that in fistula side. There were no statistical significancies between fistula side and non-fistula side in the other nerve conduction study parameters in arms. And there was no statistically different incidences of carpal tunnel syndrome in both sides. Comparing with controls, conduction velocities of ulnar and radial motor nerves and peak latencies of ulnar and radial sensory nerves were more delayed in both sides.
Conclusion: There were no significant local effects of arteriovenous fistula on nerve conductions in patients with chronic renal failure. (J Korean Acad Rehab Med 2003; 27: 912-916)
Method: The sixty eight patients with documented CTS in outpatient clinic from January, 2000 to June, 2001 were included (9 male, 59 female, averaged age 50.0⁑8.8 years). We evaluated the severity of symptom, functional status of ADL with the Levine' questionnaire, and clinical severity with 3 kinds of examination (thenar atrophy, sensory change, and Phalen's test). The electrodiagnostic severity was classified according to Stevens' classification and compared with the severity of symptom, functional status, and clinical severity.
Results: The electrodiagnostic severity was classified into three degrees. Five patients (7.4%) were classified into mild degree, 32 patients (47.1%) moderate degree, 31 patients (45.6%) severe degree. The average of severity of symptom scores were 28.4⁑8.5, 31.8⁑7.4, and 31.8⁑9.1 respectively, and there was no significant difference (p＞0.05) between the groups. Functional status scales were 14.2⁑6.7, 15.6⁑5.4 and 18.9⁑7.0 respectively and no significant difference (p=0.07) but there was a tendency that the severer was electrodiagnostic severity, the more decreased functional status scale. The clinical severity showed a significant correlation with the electrodiagnostic severity (p＜0.05).
Conclusion: The electrodiagnostic severity has a significant correlation with the clinical severity, but not with the severity of symptom, the functional status in CTS. (J Korean Acad Rehab Med 2003; 27: 906-911)
Objective: To assess the median nerve compression with ultrasonography before and after the carpal tunnel release and to assess the correlation between electrophysiologic findings and ultrasonographic findings of the median nerve.
Method: We studied 50 hands of 29 patients diagnosed as carpal tunnel syndrome electrophysiologically and 20 hands of 19 asymptomatic controls. We evaluated the flattening ratio and compression ratio through the short axis and long axis of the median nerve by ultrasonography before carpal tunnel release, 2 weeks and 3 months after release. The correlation of the
improvement between the eletrophysiologic findings and compression ratio was analyzed.
Results: The compression ratio of the median nerve was decreased significantly after carpal tunnel release, compared with that before release. The decrease of the compression ratio correlated with the improvement of the electrophysiologic findings significantly.
Conclusion: The ultrasonography is useful to follow up the median nerve after carpal tunnel release. (J Korean Acad Rehab Med 2002; 26: 172-176)
Objective: To compare current perception threshold with nerve conduction study, we measured current perception threshold (CPT) in healthy control and patients with carpal tunnel syndrome (CTS).
Method: Twenty control subjects and twenty patients with CTS were included. Latency and amplitude of median and ulnar motor and sensory nerves were measured. The sensory current perception threshold was measured at the distal interphalangeal joint of third and fifth fingers and the palm with electrical current of 5 Hz, 250 Hz, and 2,000 Hz in frequency. We compared the results of the nerve conduction study with the data of the CPT.
Results: We found that measuring of the sensory threshold might detect carpal tunnel syndrome, especially with 2,000 Hz and 250 Hz stimulation and that CPT data correlated to sensory latency and amplitude of the median nerve.
Conclusion: The sensory threshold test might be useful for diagnosis and follow up test in carpal tunnel syndrome.
Objective: To investigate the reliability of distoproximal latency ratio of median sensory nerve as a diagnostic criterion of carpal tunnel syndrome (CTS) in patients with diabetic polyneuropathy.
Subject: Electrophysiologic study was performed in 264 hands of 208 patients with diabetes. Forty eight hands (24 subjects) without diabetes mellitus or CTS were included as a normal control group. Another 48 hands having CTS without diabetes mellitus were also included as a CTS control group.
Method: Clinical and electrophysiologic findings were included to detect carpal tunnel syndrome in patients with diabetic neuropathy. Sensitivity and specificity of various electrodiagnostic parameters to confirm clinical CTS were obtained.
Results: Diabetic neuropathy was diagnosed in 66.3%, and median neuropathy was diagnosed in 52.7%. CTS was found in 32.2% as determined by the distoproximal latency ratio. The sensitivity of distoproximal latency ratio as a diagnostic tool for CTS was the highest (95.1%) and the specificity was the second highest (51.3%) among 5 different electrodiagnostic criteria of CTS.
Conclusion: The results suggest that distoproximal latency ratio is an important parameter with high sensitivity in determining CTS in the patients with diabetic polyneuropathy.
Method: Eighteen wheelchair ambulators with spinal cord injury who had neurological level below T2 were studied. Patients with peripheral or central neuropathies were excluded. Patients were assigned to either the electrodiagnostic CTS (group CTS, 7) or electrodiagnostically negative (group non- CTS, 11), and healthy volunteers (15) were classified as control group. The cross sectional area of the median nerve (MN-CSA) at carpal pisiform level was ultrasonographically measured. The degree of painful restriction to execute ADL by hands (TR-ADL), the pain grade (visual analog scale, VAS) of upper extremities and revised version of Korean spinal cord independence measure (KSCIM-R) for functional level were measured and analyzed. Results: Nine hands (14.3%) of 7 patients out of 34 hands had CTS in electrodiagnostic study. There were significant difference among groups in TR-ADL hours (CTS group; 5.0 vs non-CTS group; 10.2, p＜0.05), VAS (4.1 vs 2.0, respectively, p＜0.05), and no statistical difference in KSCIM-R (68.4 vs 52.1, p＞0.05), MN-CSA (12.3 mm2 vs 7.9 mm2 vs control group; 8.0 mm2, p＜0.05). Using the ROC curve, the cut-off value of MN-CSA produced 8.5 mm2 providing a diagnostic sensitivity of 77.8% and specificity of 59.6%. Conclusion: The ultrasonographic measurement of the median nerve may be a useful non-invasive screening test for the diagnosis of CTS in paraplegic patients with wrist pain. (J Korean Acad Rehab Med 2008; 32: 216-221)
Objective: To demonstrate a conduction block of the median nerve at the flexor retinaculum (FR) in carpal tunnel syndrome (CTS), comparison of potentials obtained with stimulation of median nerve at the wrist and the palm may be required.
Method: To determine the severity and incidence of conduction block in patients with CTS, seventy hands of neurologically healthy adults (mean age, 48 years) as control, and seventy hands of patients with CTS (mean age, 51 years) were tested. We performed median motor and middle finger recorded antidromic sensory conduction study with stimulation of the wrist and palm of a distance of 5 cm. The negative peak spike duration and baseline to peak amplitude of the compound muscle action potential (CMAP), and sensory nerve action potential (SNAP) with wrist and palm stimulations were measured. From these values, the wrist to palm duration ratio and amplitude ratio were obtained.
Results: The criteria of median motor nerve conduction block were a wrist to palm amplitude ratio of less than 0.7 and a wrist to palm duration ratio of less than 1.13. The criteria of median sensory conduction block were a wrist to palm amplitude ratio of less than 0.61 and a wrist to palm duration ratio of less than 1.33. In the patient group, 10 hands (14.3%) showed motor conduction block and 12 hands (17.1%) showed sensory conduction block and 3 hands (4.3%) showed both. The wrist to palm amplitude ratios of CMAP and SNAP in the patient showing conduction block were 0.6⁑0.1, and 0.4⁑0.2, respectively. There was no correlation between palm CMAP or SNAP amplitude and respective wrist to palm ratios.
Conclusion: Comparison of the amplitude and duration of CMAP or SNAP obtained with stimulation of both wrist and palm may be able to differentiate between conduction block and axonal degeneration. These values may be useful in planning treatment and predicting outcome.
Method: Thirteen patients (24 hands) with CTS diagnosed clinically and electrophysiologically were included. All subjects were examined by ultrasonography with high-resolution linear array transducer and injected with 40 mg of triamcinolone acetonide. The ultrasonography was evaluated with regard to cross-sectional area and the flattening ratio of the median nerve and cross-sectional area of the flexor pollicis longus tenon at pisiform and hamate bone. After 4 weeks, the patients were re-evaluated with electrophysiologic study and ultrasonography. Results: Most patients (11/13) showed improvement of clinical symptoms and electrophysiologic parameters after the local steroid injection. The cross-sectional area of median nerve at pisiform using ultrasonography significantly decreased after the local steroid injection. However, flexor pollicis longus tendon did not show significant change after the injection. Conclusion: Local steroid injection in the patients with CTS caused improvement in ultrasonographic findings of median nerve. (J Korean Acad Rehab Med 2008; 32: 189-193)
Objective: We investigated the useful electrodiagnostic indicators and the extent of retrograde degeneration (RD) in carpal tunnel syndrome (CTS).
Method: We measured median mixed nerve action potentials (MMNAP) in 26 CTS and 37 normal hands by recording at the elbow and stimulating 0, 3, 6 and 9 cm proximal to the distal wrist crease. The 3 MMNAP parameters such as amplitude, latency and conduction velocity were compared between CTS and control group. The most useful indicator was compared between subgroups of CTS (mild and severe) and control group.
Results: The amplitudes of all MMNAPs in CTS group, except stimulating 9 cm proximal to the wrist (MA9), were significantly smaller than those in control group (p＜0.05). MA9 in severe CTS subgroup, not mild subgroup, was significantly smaller than that in control group (p＜0.05). CTS and control group were not significantly different in the MMNAP latencies, except stimulating 9 cm proximal to the wrist (p＜0.05), and in the MMNAP conduction velocity, except stimulating in 0 cm to 3 cm segment proximal to the wrist.
Conclusion: The amplitude of MMNAP in forearm can be the most useful indicator of RD in CTS, and the conduction velocity, a less useful indicator. We believe that RD progresses as the severity of CTS increases, and dose beyond 9 cm proximal to the distal wrist crease.
This prospective study following American Association of Electrodiagnostic Medicine recommended criteria in the diagnosis of Carpal Tunnel Syndrome(CTS) evaluated the sensitivity of multi-electrodiagnostic parameters and usefulness of residual latency in CTS.
In 45 symptomatic hands of 26 patients with clinical diagnosis of CTS, 8 electrodiagnostic parameters-median motor distal latency, median motor residual latency, median sensory onset latency, median sensory peak latency, median to ulnar sensory onset latency difference(digit 4), median to ulnar sensory peak latency difference(digit 4), median to radial sensory onset latency difference(digit 1), median to radial sensory peak latency difference(digit 1)-were compared to the normative data obtained from the age-matched control group.
In 31 CTS hands without polyneuropathy, median to ulnar sensory latency difference(digit 4), median to radial sensory latency difference(digit 1), median sensory peak latency have same sensitivity(71.0%).
In 8 CTS hands with delayed proximal median motor nerve conduction velocity which were indiscernible from polyneuropathy in routine nerve conduction study, residual latency was more sensitive than median to ulnar sensory latency difference and median to radial sensory latency difference.
Sensitivity difference between sensory onset latency and sensory peak latency was negligible in the electrophysiologic diagnosis of CTS.
We concluded that residual latency measurement was a very useful and convenient method in the diagnosis of CTS, especially in the patients with delayed proximal median motor conduction velocity.
Method: Subjects included 30 hands of 25 carpal tunnel syndrome patients and 20 hands of 17 healthy adults with no electrophysiologic evidence of carpal tunnel syndrome. All subjects were examined with real-time ultrasonography. The ultrasonography was evaluated quantitatively with regard to the cross-sectional area and the flattening ratio of the median nerve and the palmar displacement of the flexor retinaculum. The analysis of difference between normal control group and carpal tunnel syndrome group was done by independent t-test.
Results: The carpal tunnel syndrome patients group had significantly increased cross-sectional area of the median nerve at distal radio-ulnar joint, pisiform and hamate. The carpal tunnel syndrome patients group had significantly increased flattening ratio of median nerve at hamate. The carpal tunnel syndrome patients group had significantly increased palmar displacement of the flexor retinaculum.
Conclusion: Based on the result of this study, the ultrasonography is useful in the diagnosis of the carpal tunnel syndrome.
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