The relationship between electrodiagnostic findings and patient symptoms and function in carpal tunnel syndrome

OBJECTIVE: To examine whether, in patients with carpal tunnel syndrome (CTS), electrodiagnostic study findings were associated with patient symptom severity and functional limitations after controlling for potentially confounding variables including depression, somatization, and pain-related catastrophizing. DESIGN: Cross-sectional design including data from 2 ongoing CTS studies. SETTING: Patients enrolled from hospitals and clinics in Washington State between October 2002 and February 2006. PARTICIPANTS: Adults with CTS (N=215) (based on symptoms and abnormal electrodiagnostic findings) were analyzed. Exclusion criteria were any mass, tumor, severe trauma, or deformity in the hand or wrist, radiculopathy, polyneuropathy, pregnancy, lactation, or severe CTS. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The Carpal Tunnel Syndrome Assessment Questionnaire (CTSAQ) functional status scale assessed the ability to perform 9 common hand-related tasks. The CTSAQ symptom severity scale included 11 items that assess pain, numbness, and weakness. Patients also rated their average hand and wrist pain in the last month. RESULTS: With and without controlling for patient characteristics, including age, sex, body mass index, symptom duration, depression, somatization, and pain-related catastrophizing, there were no statistically significant relationships between the electrodiagnostic findings and patient functional status and symptom severity. CONCLUSIONS: Electrodiagnostic findings and patient CTS-related symptoms and function appear to be independent measures. Clinicians and researchers interested in CTS outcomes need to assess both.     

Single vs. two steroid injections for carpal tunnel syndrome: a randomised clinical trial

We investigated the efficacy of a single vs. double steroid injections in the treatment of carpal tunnel syndrome (CTS) in a randomised double-blind controlled trial. Patients with idiopathic CTS were randomised into (i) one group receiving a baseline methylprednisolone acetate injection plus a saline injection 8 weeks later and (ii) a second group receiving methylprednisolone acetate injection at baseline and at 8 weeks. The primary outcome was the Global Symptom Score (GSS). Forty patients were recruited. By 40 weeks, the mean GSS improved from 25.6 to 14.1 in the single-injection group whereas from 26.7 to 12.6 in the reinjection group, but there was no significant difference in GSS between the two groups (p = 0.26). There were also no significant differences in terms of electrophysiological and functional outcomes. The results suggest that an additional steroid injection confers no added benefit to a single injection in terms of symptom relief.     

Efficacy of a fabricated customized splint and tendon and nerve gliding exercises for the treatment of carpal tunnel syndrome: a randomized controlled trial

Brininger TL, Rogers JC, Holm MB, Baker NA, Li Z-M, Goitz RJ. Efficacy of a fabricated customized splint and tendon and nerve gliding exercises for the treatment of carpal tunnel syndrome: a randomized controlled trial.

Objective

To compare the effects of a neutral wrist and metacarpophalangeal (MCP) splint with a wrist cock-up splint, with and without exercises, for the treatment of carpal tunnel syndrome (CTS).

Design

A 2×2×3 randomized factorial design with 3 main factors: splint (neutral wrist and MCP and wrist cock-up), exercise (exercises, no exercise), and time (baseline, 4wk, 8wk).

Setting

Subjects were evaluated in an outpatient hand therapy clinic.

Participants

Sixty-one subjects with mild to moderate CTS; 51 subjects completed the study.

Interventions

There were 4 groups: the neutral wrist and MCP group and the neutral wrist and MCP-exercise group received fabricated customized splints that supported the wrist and MCP joints; the wrist cock-up group and the wrist cock-up-exercise group received wrist cock-up splints. The neutral wrist and MCP-exercise and wrist cock-up-exercise groups also received tendon and nerve gliding exercises and were instructed to perform exercises 3 times a day. All subjects were instructed to wear the assigned splint every night for 4 weeks.

Main Outcome Measures

We used the CTS Symptom Severity Scale (SSS) and the Functional Status Scale (FSS) to assess CTS symptoms and functional status.

Results

Analysis of variance showed a significant main effect for splint and time on the SSS (P<.001, P=.014) and FSS (P<.001, P=.029), respectively. There were no interaction effects.

Conclusions

Our results validate the use of wrist splints for the treatment of CTS, and suggest that a splint that supports the wrist and MCP joints in neutral may be more effective than a wrist cock-up splint.     

腕管综合征和肘管综合征的超声影像学研究

目的探讨超声在腕管综合征和肘管综合征中的诊断价值。方法80例健康者为对照组,临床疑诊27例腕管综合征和32例肘管综合征患者,超声测量其正中神经、尺神经的前后径、左右径及横截面积,同时测定神经传导速度。结果腕管综合征和肘管综合征组正中神经、尺神经的前后径、左右径及横截面积均大于对照组（P〈0．01）,腕管综合征和肘管综合征组的病变神经横截面积均与运动传导速度呈负相关（r分别为-0．76、-0．80）。结论超声可为腕管综合征和肘管综合征的诊断提供影像学依据,并对其治疗及疗效评价有重要价值。     

Outcome of surgical release among diabetics with carpal tunnel syndrome

OBJECTIVE: To compare the results of surgical decompression of carpal tunnel syndrome (CTS) in patients with diabetes with those of patients with idiopathic CTS. DESIGN: Prospective case series. SETTING: Ambulatory care in Italy. PARTICIPANTS: Twenty-four consecutive patients with diabetes type 1 or 2 and CTS (mean age, 66.7 y) were matched for age and sex with 72 patients (mean age, 66.2 y) with idiopathic CTS. INTERVENTIONS: All patients underwent surgical release of CTS by the mini-incision of palm technique. MAIN OUTCOME MEASURES: Clinical and electrophysiologic evaluation and patient self-administered Boston Questionnaire (BQ) for the assessment of severity of CTS symptoms and hand functional status before and 1 and 6 months after surgery. RESULTS: After surgical release, almost all patients of both groups reported an absence of pain, disappearance or reduction of paresthesia, and improvement in hand function. One month after surgery, there was a significant improvement in clinical status, BQ scores, and distal conduction velocities of the median nerve. A further improvement was evident at 6-month follow-up. There were no differences between the 2 groups in the number of surgical complications, in clinical and electrophysiologic status, or in BQ scores before and after surgery. The improvement in distal conduction velocities of the median nerve, BQ scores, and clinical and electrophysiologic status were similar in the 2 groups after surgery. CONCLUSION: Diabetes is not a risk factor for poor outcome of surgical decompression of CTS. Patients with diabetes have the same probability of positive surgical outcome as patients with idiopathic CTS.     

腕管综合征的超声声像图特征及量化诊断探讨

目的探讨超声检查在腕管综合征(CTS)诊治中的作用。方法60只来自50例CTS患者的手腕,经手术证实。50只无CTS症状的手腕。由同一人进行超声检查,矢状位观察正中神经的形态、回声的改变,计算厚度比(厚度比=最小神经厚度/最大神经厚度)。横断面测量豌豆骨水平的神经面积。结果卡压最常见的部位为钩骨勾水平。卡压两端神经肿胀,肿胀处回声减低。CTS组与对照组在厚度比、豌豆骨水平神经面积这2个量化指标之间差异明显,各自的诊断阈值为≤0.81、>0.11cm2,诊断敏感度为90.2%、80.2%,特异度为88.2%、88.4%。结论超声检查可以从形态、量化指标两个方面鉴别诊断CTS,可以发现局部致病病因及解剖变异,为手术方式选择提供帮助。     

Development of a clinical prediction rule for the diagnosis of carpal tunnel syndrome

OBJECTIVES: To develop a clinical prediction rule (CPR) and to assess the reliability and diagnostic accuracy of individual clinical examination items for the diagnosis of carpal tunnel syndrome (CTS). DESIGN: Prospective diagnostic test study with blind comparison to a reference criterion of a compatible clinical presentation and abnormal electrophysiologic findings. SETTING: Multicenter medical center and community hospital with patient referrals from ambulatory primary care and specialty practice settings. PARTICIPANTS: Eight-two consecutively referred patients (50% men; mean age, 45+/-12 y) with suspected cervical radiculopathy or CTS referred for electrophysiologic examination. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Sensitivity, specificity, and likelihood ratios. RESULTS: The CPR identified in this study consisted of 1 question (shaking hands for symptom relief), wrist-ratio index greater than .67, Symptom Severity Scale score greater than 1.9, reduced median sensory field of digit 1, and age greater than 45 years. The likelihood ratio for the CPR was 18.3 when all 5 tests were positive. Interrater reliability was acceptable for all but 2 clinical examination items. CONCLUSIONS: The CPR identified was more useful for the diagnosis of CTS than any single test item and resulted in posttest probability changes of up to 56%. Further investigation is required both to validate the test-item cluster and to improve point-estimate precision.     

高频超声对ECTR术后神经解剖学参数的动态评估价值

目的 探讨高频超声对关节镜下腕管松解术后神经解剖学参数的动态评估价值。方法 随访31例（44腕）腕管综合症患者术前3天,术后2周、4周、3月、6月、1年正中神经卡压近端水肿范围、腕管入口正中神经直径及横截面积,并根据横截面积绘制高频超声诊断腕管综合征ROC曲线。结果 术后各神经解剖学参数逐步改善,术后1个月至3个月各解剖学参数改善最明显。高频超声对CTS具有较高的诊断效能。结论 高频超声能够对关节镜下腕管松解术后神经解剖学参数进行有效地的动态评估。     

Reduced longitudinal excursion of the median nerve in carpal tunnel syndrome

OBJECTIVE: To determine if longitudinal excursion of the median nerve is reduced in patients with carpal tunnel syndrome (CTS). DESIGN: Case-control study. SETTING: University human movement laboratory. PARTICIPANTS: Nineteen patients with CTS (8 men, 11 women; mean age, 57+/-15 y), and 37 healthy controls (8 men, 29 women; mean age, 48+/-10 y). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Longitudinal excursion of the median nerve, and the ratio of nerve to flexor digitorum superficialis tendon excursion at the carpal tunnel evoked by finger extension. Measurements were taken using a validated Doppler ultrasound technique, and tests were conducted with the elbow positioned in extension and flexion. RESULTS: Mean longitudinal excursion of the median nerve was significantly greater in controls (11.2+/-2.8 mm) than patients (8.3+/-2.6 mm) with the elbow extended (P=.013), but not with the elbow flexed (controls, 12.5+/-2.5 mm; patients, 10.2+/-3.1 mm; P=.089). Mean nerve/tendon excursion ratios were significantly greater in controls (.32+/-.07) than patients (.23+/-.06), with the elbow extended (P<.001), and flexed (controls, .36+/-.06; patients, .28+/-.10; P=.019). Discriminant analysis identified that 11 (58%) of the 19 patients and 3 (8%) of the 37 controls showed a nerve/tendon excursion ratio of .25 or less when tested with the elbow in extension. CONCLUSIONS: Reduced longitudinal excursion of the median nerve at the carpal tunnel was identified in a substantial proportion of patients with CTS. Further studies are merited to determine if reduced median nerve excursion at the carpal tunnel is clinically relevant in CTS, and can be influenced by movement-based interventions.     

Arnold-Chiari malformation with syrinx presenting as carpal tunnel syndrome: a case report

A 26-year-old administrative assistant presented with 3 years of left-hand dysesthesia involving primarily the first 3 digits. Her symptoms increased at night and with keyboard use. Through 12 visits to primary and specialty care physicians over 3 years, she experienced minimal improvement with splints and moderate improvement with gabapentin. On presentation, careful questioning revealed an abrupt onset of symptoms 3 years previously, related to a 2-week episode of gastritis associated with recurrent emesis. Examination revealed a negative Tinel sign over the median nerve at the wrist, decreased left biceps reflex, positive Spurling test, and decreased sensation over the palmar and dorsal surfaces of the left hand in the C5-6 distribution. The atypical onset of symptoms, poor response to therapy, and physical findings suggested the possibility of a radicular or central neurologic etiology for the patient's hand numbness. Magnetic resonance imaging demonstrated a Chiari I malformation with a syrinx extending from C2 to T10, with the greatest diameter at C4. Neurosurgical decompression led to a decrease in symptoms. A meticulous history and physical examination should be performed on patients with presumed carpal tunnel syndrome with an atypical onset of symptoms or response to therapy.     

超声对腕管综合征和肘管综合征的诊断价值

目的探讨超声对腕管综合征、肘管综合征的诊断价值。方法 25例体检健康者为对照组,临床疑诊35例腕管综合征和22例尺神经卡压患者为病变组,超声探查正中神经豌豆骨水平横断面积及其前后径(D1)、钩骨勾水平前后径(D2)、钩骨勾水平远端前后径(D3),肘部尺神经横断面积,计算D1与D2差值(D),D3与D2差值(d),将病变组超声检查结果与术中所见进行比较。结果超声可显示正中神经、尺神经卡压后的形态变化,病变组正中神经横断面积、D、d及尺神经横断面积均大于对照组(P0.03)。与术中所见比较,超声诊断腕管综合征、肘管综合征准确率分别为97.9%、95.4%。结论超声能有效诊断腕管综合征和肘管综合征。     

Sensitivity, specificity, and variability of nerve conduction velocity measurements in carpal tunnel syndrome

OBJECTIVE: To explore the diagnostic values of 8 commonly used electrodiagnostic techniques for measuring median nerve conduction velocity (NCV) in carpal tunnel syndrome (CTS). DESIGN: Sensitivity and specificity analyses. SETTING: A hospital-based electrodiagnostic laboratory. PARTICIPANTS: Forty-four normal hands and 136 symptomatic hands. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: (1) Long-segment studies: antidromic wrist-to-digit sensory NCV without subtraction, (2) short-segment studies: transcarpal palm-to-wrist mixed NCV without subtraction, and (3) 2 segment studies: antidromic transcarpal sensory NCV with subtraction (differential calculation from wrist-to-digit and palm-to-digit segments). Both onset and peak latency values were obtained for calculating the NCV. Sensitivity, specificity, and coefficient of variance were calculated for each NCV study. RESULTS: The short-segment, onset latency-based transcarpal mixed NCV yielded the highest sensitivity (75%). CONCLUSIONS: Results from measurement of a single, short-nerve segment tended to be superior to results obtained by either long-segment studies or differential subtraction between 2 segments of the same nerve in the electrodiagnosis of CTS. Explanations for our results are offered from both electrophysiologic and statistical perspectives.     

A comparison of the benefits of sonography and electrophysiologic measurements as predictors of symptom severity and functional status in patients with carpal tunnel syndrome

Kaymak B, Özçakar L, Çetin A, Candan Çetin M, Ak?nc? A, Hasçelik Z. A comparison of the benefits of sonography and electrophysiologic measurements as predictors of symptom severity and functional status in patients with carpal tunnel syndrome.

Objectives

To clarify whether sonography or electrophysiologic testing is a better predictor of symptom severity and functional status in carpal tunnel syndrome (CTS) and to assess the diagnostic value of sonography in patients with idiopathic CTS.

Design

Cross-sectional.

Setting

University hospital physical medicine and rehabilitation clinic.

Participants

Thirty-four hands with CTS and 38 normative hands were evaluated.

Interventions

Not applicable.

Main Outcome Measures

The Boston Carpal Tunnel Questionnaire, which comprised symptom severity and functional status scale, was applied to CTS patients. Bilateral upper-extremity nerve conduction studies of median and ulnar nerves and sonographic imaging of the median nerve were performed in all participants. Sonographic evaluation was performed by a physician blinded to the physical and electrophysiologic findings of the subjects.

Results

Cross-sectional areas (CSAs) of the median nerve at the carpal tunnel entrance and proximal carpal tunnel were 12.5±2.6 and 10.6±2.6 versus 15.6±4.2 and 11.5±3.2 in CTS patients versus controls, respectively. Increased CSA of the median nerve at the carpal tunnel entrance (P<.002) and at the proximal carpal tunnel (P<.000) were detected in the hands with CTS. Flattening ratios did not differ in a statistically significant manner between the groups (P>.05). The best predictor of symptom severity was median nerve sensory distal latency and that of functional status was median nerve motor distal latency. The optimum cutoff value for median nerve CSA was 11.2mm² at the carpal tunnel entrance and 11.9mm² at the proximal carpal tunnel. Sensitivity, specificity, and positive and negative predictive values at the proximal carpal tunnel (88%, 66%, 71%, 80%, respectively) were higher than those at the carpal tunnel entrance (68%, 62%, 65%, 66%, respectively).

Conclusions

The best predictors of symptom severity and functional status in idiopathic CTS seem to be the electrophysiologic assessments rather than sonographic measurements. On the other hand, sonography may be helpful in the diagnosis of idiopathic CTS.     

腕管综合征神经电生理诊断

目的:探讨神经电生理检测对非典型腕管综合征(CTS)的诊断价值。方法:对16例CTS患者测定双侧正中神经运动传导速度(MCV)和感觉传导速度(SCV),其中14例用微移法(inchingtechnique)检测腕部正中神经,13例行肌电图(EMG)检查。结果:16例CTS患者中,15例正中神经末端运动潜伏期(DML)延长(≥4.5ms);14例SCV减慢(<46m/s);14例微移法检测患者均有腕部正中神经传导阻滞(≥0.5ms/cm);13例肌电图检测患者中8例有神经源性肌电改变。正中神经微移法检测是4项检查中最为敏感的指标。结论:在临床症状不明显时,神经电生理检查是发现和诊断CTS最有效的方法之一。     

Restless hand symptoms in carpal tunnel syndrome

Carpal tunnel syndrome (CTS) is a nerve entrapment disorder, involving the median nerve when it passes the carpal tunnel at the wrist. Using a case-control methodology, 312 electrophysiologically confirmed CTS patients with mean age of 51.3+/-9.4 (27-74) years (81.7% women) and 100 controls with mean age of 50.4+/-9.2 (21-88) years (75% women) were examined utilising a questionnaire similar to the clinical diagnostic criteria of restless legs syndrome (RLS). Forty-four (14.1%) of the CTS patients have symptoms compatible with restless hand syndrome compared with none (0%) in the control group (p < 0.0001). The severity of CTS was not significantly associated with the motor restlessness. Our observations suggest that entrapment syndromes such as CTS can be associated with a form of restlessness in the hands, analogous to RLS.     

Second lumbrical muscle recordings improve localization in severe carpal tunnel syndrome

OBJECTIVE: To determine how often the second lumbrical motor potential is present when the abductor pollicis brevis (APB) motor potential is absent in severe carpal tunnel syndrome (CTS). DESIGN: Prospective study of consecutive patients with severe CTS and an absent motor potential from the APB. SETTING: Single-center public hospital-based electromyography lab. PARTICIPANTS: Patients with a clinical diagnosis of CTS who had an absent median sensory response and an absent median motor response to APB on routine nerve conduction testing. Twenty-two hands of 19 patients were examined. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Presence and distal latency of motor potential to the second lumbrical. RESULTS: The second lumbrical potential was present in 17 hands (77%). The distal motor latency to the second lumbrical was prolonged in all (mean, 9.1ms; normative value, <4.1ms). CONCLUSIONS: Second lumbrical recordings improve localization in many patients with severe CTS when routine median sensory and motor conduction studies produce no potentials.     

腕管综合征46例临床与神经电生理分析

目的：探讨腕管综合征的临床特点和神经电生理检测的诊断价值。方法：回顾性分析46例腕管综合征的临床特征和神经电生理检测结果。结果：46例腕管综合征中76．1％为女性，共有病变71侧，单侧病变21例，双侧病变25例。以桡侧3个半手指为主29侧，5个手指均有症状42侧。临床表现为手指麻木、疼痛，可向肘部和肩部放射。电生理检查正中感觉神经传导速度异常占95．8％，正中运动神经潜伏期延长占67．6％，运动传导速度异常53．5％，拇展短肌呈神经源性损害占31％。结论：腕管综合征以中年女性多见，临床上以手指麻木、疼痛为主要特点，活动和甩手可使症状减轻。神经电生理检测对腕管综合征的诊断与鉴别诊断具有重要价值。     

Compliance with electrodiagnostic guidelines for patients undergoing carpal tunnel release

OBJECTIVE: To describe how clinical practice in those who underwent carpal tunnel release (CTR) matched the American Association of Electrodiagnostic Medicine (AAEM) 1993 practice parameters for electrodiagnostic evaluation of carpal tunnel syndrome (CTS). DESIGN: Cohort study using 1998-1999 Medicare billing data. SETTING: Washington State. PARTICIPANTS: State Medicare beneficiaries who underwent CTR in 1999 (N=1567) Interventions Not applicable. MAIN OUTCOME MEASURES: Compliance with the AAEM practice parameters. RESULTS: Of the 1567 [corrected] receiving surgery, 324 [corrected] (20.7%) did not have any electrodiagnostic testing before surgery. One hundred seventy-one (10.9%) had testing performed that did not lead to the diagnosis of CTS. One thousand seventy-two (68.4%) patients were diagnosed with CTS through electrodiagnostic testing; 155 (9.9%) had less than 2 sensory nerves studied, 114 (7.3%) had less than 2 motor nerves studied, and 65 (4.2%) of the studies met neither the standard (sensory nerve testing) nor guideline (motor nerve testing). In a multivariate analysis, neurologists were more likely than physiatrists not to meet the AAEM standards (adjusted relative risk [adj RR]=1.61; 95% confidence interval [CI], 1.13-2.31) and patients living in rural areas were more likely to have no or inadequate testing (adj RR=1.6; 95% CI, 1.3-1.9). CONCLUSIONS: Over one third of Medicare patients undergoing CTR in Washington State in 1999 may have had an inappropriate electrodiagnostic workup before the surgery. Policymakers should consider mandating an appropriate electrodiagnostic test before approving CTR.