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Savage NJ, McKell JS. Median Nerve Cross-Sectional Area and Carpal Tunnel Syndrome in Specific Populations: Sonographic Analysis of Patients with Type 2 Diabetes or Bifid Anatomy. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2024. [PMID: 38813705 DOI: 10.1002/jum.16491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Revised: 04/01/2024] [Accepted: 05/12/2024] [Indexed: 05/31/2024]
Abstract
OBJECTIVES Evaluate diagnostic accuracy of median nerve cross-sectional area (CSA) to determine severity versus presence of carpal tunnel syndrome (CTS) across existing electrodiagnostic-based (EDX) classification systems in patients with type 2 diabetes or bifid anatomy. METHODS Retrospective analysis of cross-sectional patient data. Receiver operating characteristic analysis used to determine median nerve CSA cutoff values and associated diagnostic likelihood ratios for all consolidated and binary EDX-based classifications of CTS in patients with type 2 diabetes or bifid anatomy. Determine shifts in diagnostic probability based on established cutoff values and associated likelihood ratios. Distal CSA measured at or near carpal tunnel inlet, proximal CSA at level of pronator quadratus muscle, and delta CSA by subtracting proximal from distal. RESULTS Binary categorizations of CTS were statistically superior to consolidated categorizations of CTS severity in patients with type 2 diabetes or bifid anatomy. Binary categorizations established reasonably consistent median nerve CSA cutoff values across all EDX-based classifications examined resulting in the following for distal CSA or delta CSA: ≤10 or ≤4 mm2 to rule out and ≥11 or ≥5 mm2 to rule in CTS, respectively. These cutoff values resulted in small shifts in diagnostic probability in patients with type 2 diabetes and small to conclusive shifts in diagnostic probability in patients with bifid anatomy. CONCLUSIONS Binary categorizations to rule out or rule in CTS based on the proposed cutoff values provide the most meaningful information about shifts in diagnostic probability across all EDX-based classifications examined. The use of median nerve CSA to categorize severity of CTS is not recommended in patients with type 2 diabetes or bifid anatomy.
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Affiliation(s)
- Nathan J Savage
- Department of Physical Therapy, Winston-Salem State University, Winston-Salem, North Carolina, USA
| | - John S McKell
- Department of Physical Therapy, McKell Therapy Group, LLC, Provo, Utah, USA
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Savage NJ, McKell JS. Sonographic Measurement of Median Nerve Cross-Sectional Area to Determine Severity of Carpal Tunnel Syndrome: A Cautionary Tale. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2024. [PMID: 38778784 DOI: 10.1002/jum.16486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 05/02/2024] [Accepted: 05/08/2024] [Indexed: 05/25/2024]
Abstract
OBJECTIVES Evaluate the diagnostic accuracy of median nerve cross-sectional area (CSA) to determine the severity of carpal tunnel syndrome (CTS) vs the presence of CTS across existing electrodiagnostic-based (EDX) classification systems. METHODS Retrospective analysis of cross-sectional patient data. Receiver operating characteristic (ROC) analysis was used to determine CSA cutoff values and associated diagnostic likelihood ratios for all consolidated and binary EDX-based classifications of CTS severity. Identification of CSA cutoff values associated with likelihood ratios capable of achieving conclusive (but at least moderate) shifts in diagnostic probability. RESULTS Binary categorizations of CTS (ie, "Normal" vs "Absent") were statistically superior to consolidated categorizations of CTS severity (ie, "Normal," "Mild," "Moderate," or "Severe"). Binary categorizations established consistent CSA cutoff values across all EDX-based classifications examined and achieved conclusive shifts in diagnostic probability based on the following values of distal CSA or delta CSA: <7 or <1 mm2 to rule out and >13 or >7 mm2 to rule in CTS, respectively. Additionally, the following values of distal CSA and delta CSA may be used in certain circumstances because they produce only small shifts in diagnostic probability: ≤10 or ≤3 mm2 to rule out and ≥11 or ≥4 mm2 to rule in CTS, respectively. CONCLUSIONS Using median nerve CSA to categorize the severity of CTS is not recommended based on lack of consistent and meaningful shifts in diagnostic probability. Rather, binary categorizations to rule out or rule in CTS based on the proposed CSA cutoff values consistently provided conclusive shifts in diagnostic probability across all EDX-based classifications examined.
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Affiliation(s)
- Nathan J Savage
- Department of Physical Therapy, Winston-Salem State University, Winston-Salem, North Carolina, USA
| | - John S McKell
- Department of Physical Therapy, McKell Therapy Group, LLC, Orem, Utah, USA
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Hartinger S, Hammersen J, Leistner NA, Lawson McLean A, Risse C, Senft C, Schütze S, Heiling B, Schwab M, Mäurer I. The role of neuromuscular ultrasound in diagnostics of peripheral neuropathies induced by cytostatic agents or immunotherapies. Acta Neuropathol Commun 2023; 11:187. [PMID: 38012771 PMCID: PMC10683078 DOI: 10.1186/s40478-023-01685-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 11/07/2023] [Indexed: 11/29/2023] Open
Abstract
A relevant number of cancer patients who receive potentially neurotoxic cytostatic agents develop a chemotherapy-induced peripheral neuropathy over time. Moreover, the increasing use of immunotherapies and targeted agents leads to a raising awareness of treatment-associated peripheral neurotoxicity, e.g., axonal and demyelinating neuropathies such as Guillain-Barré-like syndromes. To date, the differentiation of these phenomena from concurrent neurological co-morbidities or (para-)neoplastic nerve affection as well as their longitudinal monitoring remain challenging. Neuromuscular ultrasound (NMUS) is an established diagnostic tool for peripheral neuropathies. Performed by specialized neurologists, it completes clinical and neurophysiological diagnostics especially in differentiation of axonal and demyelinating neuropathies. No generally approved biomarkers of treatment-induced peripheral neurotoxicity have been established so far. NMUS might significantly extend the repertoire of diagnostic and neuromonitoring methods in this growing patient group in short term. In this article, we present enlargements of the dorsal roots both in cytostatic and in immunotherapy-induced neurotoxicity for the first time. We discuss related literature regarding new integrative applications of NMUS for cancer patients by reference to two representative case studies. Moreover, we demonstrate the integration of NMUS in a diagnostic algorithm for suspected peripheral neurotoxicity independently of a certain cancer treatment regimen emphasizing the emerging potential of NMUS for clinical routine in this interdisciplinary field and prospective clinical trials.
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Affiliation(s)
- Stefanie Hartinger
- Department of Neurology, Jena University Hospital, Friedrich Schiller University Jena, Am Klinikum 1, 07747, Jena, Germany.
- Neurooncological Center, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany.
| | - Jakob Hammersen
- Klinik für Innere Medizin II, Hämatologie, Internistische Onkologie und Palliativmedizin, Universitätsklinikum Jena, Friedrich-Schiller-Universität Jena, Jena, Deutschland
| | - Niklas A Leistner
- Department of Neurology, Jena University Hospital, Friedrich Schiller University Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Anna Lawson McLean
- Neurooncological Center, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
- Department of Neurosurgery, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
| | - Clemens Risse
- Department of Neurology, Jena University Hospital, Friedrich Schiller University Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Christian Senft
- Neurooncological Center, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
- Department of Neurosurgery, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
| | - Stefanie Schütze
- Department of Gynecology and Reproductive Medicine, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
| | - Bianka Heiling
- Department of Neurology, Jena University Hospital, Friedrich Schiller University Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Matthias Schwab
- Department of Neurology, Jena University Hospital, Friedrich Schiller University Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Irina Mäurer
- Department of Neurology, Jena University Hospital, Friedrich Schiller University Jena, Am Klinikum 1, 07747, Jena, Germany
- Neurooncological Center, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
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Park D, Lee SE, Cho JM, Yang JW, Kim M, Kwon HD. Characteristics of diabetic and non-diabetic carpal tunnel syndrome in terms of clinical, electrophysiological, and Sonographic features: a cross-sectional study. BMC Musculoskelet Disord 2023; 24:739. [PMID: 37716949 PMCID: PMC10504773 DOI: 10.1186/s12891-023-06881-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 09/13/2023] [Indexed: 09/18/2023] Open
Abstract
BACKGROUND Although diabetes is considered a major risk factor for carpal tunnel syndrome (CTS), the characteristics of diabetic CTS have not been fully understood. OBJECTIVE This study is aimed at evaluation of the clinical, electrophysiological, and ultrasonographic findings of non-diabetic and diabetic CTS. METHODS This retrospective, cross-sectional study included patients diagnosed with CTS. Patient age, sex, involved side, body mass index, clinical and electrophysiological findings, and median nerve cross-sectional area (CSA) were identified. Diabetes was identified through patient or guardian interviews, medical records, and medication history. Linear and binary logistic regression models were established to confirm the associations between the electrophysiological findings, median nerve CSA, and clinical outcomes. Covariates, such as age, sex, body mass index, diabetes, symptom duration, and thenar muscle weakness were adjusted. RESULTS Out of the 920 hands, 126 and 794 belonged to the diabetic and non-diabetic CTS groups, respectively. The patients were significantly older in the diabetic CTS group (P < 0.001). The rate of thenar weakness in the diabetic CTS group was also significantly higher than that in the non-diabetic CTS group (P = 0.009). The diabetic CTS group had a more severe electrodiagnostic grade (P = 0.001). The prolonged onset latency of the compound motor nerve action potential (CMAP) and median nerve CSA were well associated with the degree of clinical symptoms. Increased median nerve CSA was significantly associated with prolonged CMAP onset latency (β = 0.64; P = 0.012), prolonged transcarpal latency (β = 0.95; P = 0.044), and decreased CMAP amplitude (β = -0.17; P = 0.002) in the non-diabetic CTS group. CONCLUSION Diabetic CTS had more profound electrophysiological abnormalities. Distal motor latency and median nerve CSA were not only associated with each other, but also with clinical symptoms. Further studies are needed to investigate the pathophysiological mechanisms underlying diabetic CTS.
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Affiliation(s)
- Dougho Park
- Department of Medical Science and Engineering, School of Convergence Science and Technology, Pohang University of Science and Technology, Pohang, Republic of Korea.
- Department of Rehabilitation Medicine, Pohang Stroke and Spine Hospital, 352, Huimang-daero, Pohang, 37659, Republic of Korea.
| | - Sang-Eok Lee
- Department of Rehabilitation Medicine, Pohang Stroke and Spine Hospital, 352, Huimang-daero, Pohang, 37659, Republic of Korea
| | - Jae Man Cho
- Department of Neurosurgery, Pohang Stroke and Spine Hospital, Pohang, Republic of Korea
| | - Joong Won Yang
- Department of Neurosurgery, Pohang Stroke and Spine Hospital, Pohang, Republic of Korea
| | - ManSu Kim
- Department of Neurosurgery, Pohang Stroke and Spine Hospital, Pohang, Republic of Korea
| | - Heum Dai Kwon
- Department of Neurosurgery, Pohang Stroke and Spine Hospital, Pohang, Republic of Korea
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Heiling B, Karl A, Fedtke N, Müller N, Kloos C, Grimm A, Axer H. Evaluating Diagnostic Ultrasound of the Vagus Nerve as a Surrogate Marker for Autonomic Neuropathy in Diabetic Patients. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59030525. [PMID: 36984526 PMCID: PMC10058247 DOI: 10.3390/medicina59030525] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/01/2023] [Accepted: 03/07/2023] [Indexed: 03/30/2023]
Abstract
Background and Objectives: Diagnostic ultrasound of the vagus nerve has been used to examine different polyneuropathies, and it has been suggested to be useful as a marker of autonomic dysfunction in diabetic patients. Materials and Methods: We analyzed the cross-sectional area (CSA) of the right vagus nerve of 111 patients with type 2 diabetes in comparison to 104 healthy adults and 41 patients with CIDP (chronic inflammatory demyelinating polyneuropathy). In the diabetes group, sympathetic skin response (SSR) was measured as an indicator for autonomic neuropathy. Carotid intima-media thickness (CIMT) was measured as a surrogate for atherosclerosis. Clinical symptoms of polyneuropathy were assessed using the Neuropathy Symptom Score and the Neuropathy Disability Score. Results: In total, 61.3% of the diabetes patients had clinical signs of polyneuropathy; 23.4% had no SSR at the feet as an indicator of autonomic neuropathy. Mean vagus nerve CSA did not differ in patients with and without diabetic polyneuropathy or in diabetic patients with and without SSR at the feet. No significant correlation was found between vagus nerve CSA and CIMT or SSR parameters in diabetic patients. Mean CSA of the right vagus nerve was slightly larger in diabetic patients (p = 0.028) and in patients with CIDP (p = 0.015) than in healthy controls. Conclusions: Effect sizes and mean differences were rather small so that a reliable diagnosis cannot be performed based on the vagus nerve measurement of a single person alone. Vagus nerve CSA seems not suitable as an indicator of autonomic dysfunction or cardiovascular risk in diabetic patients.
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Affiliation(s)
- Bianka Heiling
- Department of Neurology, Jena University Hospital, Friedrich Schiller University, 07747 Jena, Germany
- Clinician Scientist Program OrganAge, Jena University Hospital, 07747 Jena, Germany
| | - Adriana Karl
- Department of Neurology, Jena University Hospital, Friedrich Schiller University, 07747 Jena, Germany
| | - Nadin Fedtke
- Department of Neurology, Jena University Hospital, Friedrich Schiller University, 07747 Jena, Germany
| | - Nicolle Müller
- Department of Internal Medicine III, Jena University Hospital, Friedrich Schiller University, 07747 Jena, Germany
| | - Christof Kloos
- Department of Internal Medicine III, Jena University Hospital, Friedrich Schiller University, 07747 Jena, Germany
| | - Alexander Grimm
- Department of Neurology, Tübingen University Hospital, 72076 Tübingen, Germany
| | - Hubertus Axer
- Department of Neurology, Jena University Hospital, Friedrich Schiller University, 07747 Jena, Germany
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Dong D, Liu H. Prevalence of carpal tunnel syndrome in patients with long-term type 2 diabetes mellitus. Heliyon 2022; 8:e12615. [PMID: 36593820 PMCID: PMC9803777 DOI: 10.1016/j.heliyon.2022.e12615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 11/11/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022] Open
Abstract
Generally, Carpal tunnel syndrome (CTS) is more common in diabetes mellitus (DM), especially in subjects with coexisting diabetic polyneuropathy (DPN) and/or long-term DM. Based on the analysis of nerve conduction velocity (NCV), the prevalence of CTS and the features of nerve injury were retrospectively explored in type 2 diabetes mellitus (T2DM) patients. In this cohort, there were 353 T2DM patients who were hospitalized in Taiyuan Central Hospitalbetween January 2018 and January 2019. The pathological rates of NCVs between the left and right median nerves were compared, including the gender effect. The examinations were mainly directed to analyze the median nerve injury features. Among 353 patients, 139 patients (39.3%) presented with CTS. These 139 T2DM patients with CTS were then divided into groups based on the nerve injury location and injured nerve type. The prevalence of sensory nerve injury (SNI) was higher than that of motor nerve injury (MNI). The CTS patients had a significantly higher occurrence rate of SNI than MNI (P < 0.05). The abnormal rate of sensory nerve conduction velocity (SCV, P = 0.01) and motor nerve conduction velocity (MCV, P < 0.05) were higher in the right median nerve. No significant differences were detected for other nerves on either side. Significant differences in abnormal rates of SCV of the left (P = 0.04) and the right (P = 0.03) median nerves between the two genders were found. There were no significant abnormalities for other nerves on either side and either gender. Early screening of NCV is needed for T2DM patients to detect CTS with a high prevalence rate. This study suggests that early detection of NCV can identify CTS in the absence of clinical conditions and SNI may occur earlier in long-term T2DM patients with CTS.
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Affiliation(s)
- Defu Dong
- Department of General Surgery, Shanxi Bethune Hospital, Third Hospital of Shanxi Medical University, Taiyuan, 030000, China
| | - Hongwei Liu
- Department of General Surgery, Shanxi Bethune Hospital, Third Hospital of Shanxi Medical University, Taiyuan, 030000, China,Department of Neurology, Tai yuan Central Hospital, Shanxi Medical University, Taiyuan, China,Corresponding author.
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Clinical Utility of Boston-CTS and Six-Item CTS Questionnaires in Carpal Tunnel Syndrome Associated with Diabetic Polyneuropathy. Diagnostics (Basel) 2022; 13:diagnostics13010004. [PMID: 36611296 PMCID: PMC9818529 DOI: 10.3390/diagnostics13010004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 12/09/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022] Open
Abstract
Diabetic polyneuropathy (DPN) is the most frequent complication of diabetes. Carpal tunnel syndrome (CTS), one of the most common neuropathies, is a chronic compression of the median nerve at the wrist. In our prospective cross-sectional study, we enrolled patients with type 2 diabetes presenting with signs and symptoms suggestive of DPN (n = 53). We aimed to compare two clinical scales: the Boston Carpal Tunnel Syndrome Questionnaire (BCTQ) and the six-item CTS symptoms scale (CTS-6), with nerve conduction studies (NCS) for detecting CTS in patients with DPN. Carpal tunnel syndrome and DPN were clinically evaluated, and the diagnosis was confirmed by NCS. Depending on the NCS parameters, the study group was divided into patients with and without DPN. For each group, we selected patients with CTS confirmed through NCS, and the results were compared with the BCTQ and CTS-6 scales. The clinical evaluation of CTS performed through BCTQ and CTS-6 was statistically significantly different between patients with and without CTS. When comparing the BCTQ questionnaire with the NCS tests, we found area under the curve (AUC) = 0.76 (95% CI 0.65-0.86) in patients with neuropathy and AUC = 0.72 (95% CI 0.55-0.88) in patients without neuropathy. At the same time, the AUC values of the CTS-6 scale were 0.76 (95% CI 0.61-0.88) in patients with neuropathy and 0.70 (95% CI 0.51-0.86) in patients without neuropathy. Using multiple logistic regression, we demonstrated that DPN increased the chances of detecting CTS using the two questionnaires. The Boston Carpal Tunnel Syndrome and CTS-6 questionnaires can be used in the diagnosis of CTS in diabetic patients with and without DPN but with moderate AUC. The presence of DPN increased the chances of detecting CTS using the BCTQ questionnaire and the CTS-6 scale.
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Recent Research Provides Significant New Information about Predisposing Factors, Diagnostic Practices, and Treatment of Carpal Tunnel Syndrome. J Clin Med 2022; 11:jcm11185382. [PMID: 36143029 PMCID: PMC9501205 DOI: 10.3390/jcm11185382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 09/08/2022] [Indexed: 11/17/2022] Open
Abstract
This current Special Issue of JCM will highlight some of the latest studies on carpal tunnel syndrome (CTS) [...]
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