Comparison of high-resolution sonography and electrophysiology in the diagnosis of carpal tunnel syndrome

Diagnostic Accuracy of Neuromuscular Ultrasound vs. Electrodiagnostic Studies for Carpal Tunnel Syndrome: Systematic Review and Meta-analysis of Paired Accuracy Studies

This systematic review with meta-analysis compared the diagnostic accuracy of neuromuscular ultrasound (NMUS) and electrodiagnostic studies (EDX) as confirmatory tests for carpal tunnel syndrome (CTS) diagnosis. We used bivariate random-effects models to estimate pooled sensitivity and specificity and generate hierarchical summary receiver-operating characteristic curves to assess diagnostic test accuracy. Nine paired accuracy studies were included, representing 1751 hands (743 clinically diagnosed CTS; 1008 without CTS) that underwent NMUS and EDX. Compared to the clinical diagnosis reference standard, the pooled sensitivity was 86.4% for NMUS and 91.6% for EDX. Pooled specificity was 79.3% for NMUS and 81.9% for EDX. The positive likelihood ratios were 4.2 and 5.1 for NMUS and EDX, respectively, and the negative likelihood ratios were 0.17 and 0.10, respectively. The diagnostic odds ratio was 24 for NMUS and 49 for EDX. No statistically significant differences were identified between NMUS and EDX for sensitivity, specificity, or overall diagnostic accuracy. Overall, the diagnostic accuracy of NMUS is similar to that of EDX for CTS diagnosis, with high sensitivity and moderate specificity for each. The choice between these confirmatory diagnostic tests should incorporate shared decision-making between patients and providers that weighs diagnostic accuracy as well as factors such as patient preferences, test availability, cost, and tolerability.

Diagnostic meta-analysis of the efficacy of ultrasonography for diagnosing carpal tunnel syndrome: A comparison between Asian and non-Asian populations

BACKGROUND

Ultrasonography is used to diagnose carpal tunnel syndrome (CTS) according to various criteria. This diagnostic meta-analysis aimed to evaluate the efficacy of ultrasonography for diagnosing CTS, focusing on the cross-sectional area (CSA) of the median nerve (MN) at the inlet of the carpal tunnel and regional variations in diagnostic thresholds between Asian and non-Asian populations.

METHODS

A comprehensive literature search was conducted using PubMed, Embase, and the Cochrane Library. The risk of bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2). Patient demographic data, diagnostic "gold standards", CSA cutoff values, and diagnostic results were extracted. Meta-analysis was performed to determine the sensitivity, specificity, and optimal CSA cutoff values.

RESULTS

For the 25 included studies, a combined sensitivity of 88% and specificity of 84% for CSA measurements at the carpal tunnel inlet were obtained. The Asian group had a sensitivity of 84% and specificity of 86%, while the non-Asian group had a sensitivity of 91% and specificity of 82%. The mean CSA in the Asian group was significantly lower than that in the non-Asian group (12.93 mm2 and 14.77 mm2, respectively; p = 0.042). For the Asian group, the summary receiver operating characteristic curve had an area under the curve (AUC) of 0.92 with an optimal cutoff of 10.5 mm2; for the non-Asian group, an AUC of 0.94 was obtained with a cutoff of 11.5 mm2.

CONCLUSION

Ultrasonography is a reliable diagnostic method for CTS, with distinct optimal cutoff values observed between Asian and non-Asian populations. Therefore, population-specific diagnostic criteria for CTS are recommended.

Median nerve ultrasonography in Parkinson's disease: a systematic review and meta-analysis

BACKGROUND

The cross-sectional area (CSA) of the median nerve in Parkinson's disease remains unclear.

OBJECTIVES

This meta-analysis assesses median nerve CSA changes in Parkinson's using ultrasonography.

METHODS

PubMed, Web of Science, Scopus, and EBSCO were selectively searched for literature on Parkinson's disease, Median nerve, and ultrasonography. Following full-text screening, three studies were included in this meta-analysis with 144 Parkinson's disease patients and 127 controls. The primary outcome was the cross-sectional area of the median nerve; other motor parameters were also evaluated.

RESULTS

The cross-sectional area of the median nerve was significantly increased in Parkinson's patients compared to controls (p = 0.007); the standardized mean difference was 0.79 [95% CI (0.21 - 1.37)]. The standardized mean difference of the motor parameters of the median nerve, amplitude, and latency was -0.04 [95% CI (-0.85 to 0.77)] and 0.30 [95% CI (-0.04 to 0.64)], respectively, with statistically insignificant (All p > 0.05).

CONCLUSION

This meta-analysis concluded that the cross-sectional area of the median nerve is increased in Parkinson's disease patients. The increase in the CSA of the median nerve might explain the higher prevalence of carpal tunnel syndrome in Parkinson's disease. Further studies are needed to quantify carpal tunnel syndrome prevalence accurately in Parkinson's.

LIMITATIONS

Heterogeneity exists due to non-standardized CSA calculation methods and varied disease stages. Finger movement during ultrasound may introduce artifacts, compromising CSA measurement accuracy. Establishing a definitive CSA cut-off for carpal tunnel syndrome in Parkinson's requires further investigation.

The Impact of Reference Standard on Diagnostic Testing Characteristics for Carpal Tunnel Syndrome: A Systematic Review

Lack of a reliable reference standard for carpal tunnel syndrome (CTS) diagnosis could impact the diagnostic test characteristics. This systematic review sought to evaluate differences in the accuracy of CTS diagnostic modalities based on the reference standard used.

Methods

A systematic review was performed following PRISMA guidelines to investigate diagnostic modalities used in CTS. A literature search of Embase, PubMed, and Cochrane Reviews was conducted for the years of 2010-2021 for primary data, and 113 studies met final inclusion criteria. Studies were stratified based on the reference standard utilized and diagnostic modality assessed, and the weighted means of the sensitivities and specificities were calculated.

Results

Thirty-five studies used clinical diagnosis alone as a reference standard, and 78 studies used electrodiagnostic study (EDS). The specificity for MRI and ultrasound (US) were substantially lower when EDS was used as the reference standard. MRI was the test most affected by the reference standard used, showing increased sensitivity when using EDS as the reference compared to clinical diagnosis (77.1% versus 60.9%) and decreased specificity (87.6% versus 99.2%). Regardless of the reference standard used, all tests had anticipated false-positive and/or false-negative rates of at least 10%.

Conclusions

Testing characteristics vary greatly based on the choice of reference standard, with the sensitivity of MRI most affected. Regardless of reference standard used, EDS, US, and MRI each had false-positive and/or false-negative rates too great to be appropriate for use as a screening examination.

Comparison efficacy of ultrasound-guided needle release plus corticosteroid injection and mini-open surgery in patients with carpal tunnel syndrome

This retrospective study was to compare clinical outcomes of ultrasound-guided needle release with corticosteroid injection vs. mini-open surgery in patients with carpal tunnel syndrome (CTS). From January 2021 to December 2021, 40 patients (40 wrists) with CTS were analyzed in this study. The diagnosis was based on clinical symptoms, electrophysiological imaging, and ultrasound imaging. A total of 20 wrists were treated with ultrasound-guided needle release plus corticosteroid injection (Group A), and the other 20 wrists were treated with mini-open surgery (Group B). We evaluated the Boston carpal tunnel questionnaire, electrophysiological parameters (distal motor latency, sensory conduction velocity, and sensory nerve action potential of the median nerve), and ultrasound parameters (cross-sectional area, flattening ratio, and the thicknesses of transverse carpal ligament) both before and 3 months after treatment. Total treatment cost, duration of treatment, healing time, and complications were also recorded for the two groups. The Boston carpal tunnel questionnaire and electrophysiological and ultrasound outcomes at preoperatively and 3 months postoperatively had a significant difference for each group (each with P < 0.05). There were no complications such as infection, hemorrhage, vascular, nerve, or tendon injuries in both groups. Ultrasound-guided needle release and mini-open surgery are both effective measures in treating CTS patients. Ultrasound-guided needle release plus corticosteroid injection provides smaller incision, less cost, less time of treatment, and faster recovery compared with mini-open surgery. Ultrasound-guided needle release plus corticosteroid injection is better for clinical application.

Comprehensive Assessment of Ultrasound’s Role in Carpal Tunnel Syndrome in Reference to Electromyography

Carpal tunnel syndrome (CTS) is the most common peripheral mononeuropathy related to entrapment syndrome. An increase in the median nerve cross-sectional area (CSA) is visualized using ultrasound (US) imaging for CTS patients. This study aims to correlate, for the first time in the state of Qatar, the findings of US imaging and electromyography (EMG) in patients with CTS for diagnostic and classification purposes. First, US CSA was numerically obtained from patients' records. Second, EMG findings were gathered as normal, mild, moderate, and severe CTS. After that, we performed a different statistical approach than those used in the literature, using one-way analysis of variance (ANOVA) and post hoc tests for the final analysis. In summary, we found that the US seems unable to differentiate some normal from mild CTS cases; however, it appears to be excellent at differentiating moderate from severe CTS cases.

Diagnosis of Carpal Tunnel Syndrome using Shear Wave Elastography and High-frequency Ultrasound Imaging

OBJECTIVES

The performance of ultrasound features from shear wave elastography (SWE) and high-frequency ultrasound imaging was evaluated independently and in combination to diagnose carpal tunnel syndrome (CTS).

MATERIALS AND METHODS

Twenty-five subjects were imaged in a sitting position with an arm extended and palm facing up. SWE of the medial nerve (MN) was acquired at the wrist level (site 1) and proximal to the pronator quadratus muscle (site 2). Cross-sectional area (CSA) and vascularity of the MN were assessed at the wrist using a 24 MHz probe. Color and power Doppler imaging (CDI and PDI), monochrome and color-coded Superb Microvascular Imaging (SMI) were performed for vascularity assessments. The diagnosis and severity of CTS was determined by clinical and electrodiagnostic tests. Diagnostic performance of the ultrasound features was assessed by t-tests, ANOVAs, and ROC analysis.

RESULTS

The study included 20 control hands and 27 hands with CTS. All ultrasound features except for the stiffness ratio were significantly different between the CTS and control wrists (p<0.04). The stiffness of MN at site 1 showed a higher accuracy than at site 2. The combination of CSA and MN stiffness from site 2 showed an overall accuracy of 95% with a specificity and sensitivity of 100% and 93%, respectively. The CSA, MN stiffness from site 2, and CDI combination improved the accuracy to 96% with specificity and sensitivity of 100% and 93%, respectively. However, no ultrasound features (independently or in combination) differentiated all stages of CTS severity.

CONCLUSIONS

SWE with high-frequency ultrasound imaging showed potential for the diagnosis of CTS.

Clinical Evaluation and Diagnostic Utilities of Different Nerve Conduction Tests in 100 Patients with Carpal Tunnel Syndrome

Background and Purpose:

The purpose of the study is to determine whether the clinical profile of patients with carpal tunnel syndrome (CTS) has been same over the years with the help of routine and comparative electrodiagnostic tests.

Methods:

A prospective study of 100 patients with suspected CTS was conducted without controls. Three provocative maneuvers were performed. Routine and comparison nerve conduction tests were performed, i.e., second lumbrical interossei motor latency difference (2 LIMLD), digit 4 median-ulnar sensory latency difference (D4MUSLD), palm wrist distal sensory latency difference (PWDSLD), and digit 1 median-radial sensory latency difference (D1MRSLD). Data entry, analysis, and statistical evaluation were done using International Business Machines Corporation Statistical Package for the Social Sciences statistics package (IBM, SPSS).

Results:

A total of 195 hands of 100 patients met the criteria for CTS. Forty-three percentage of patients were homemakers. Considering the rapidly changing communication technology, we observed 84% patients had aggravation of symptoms with continuous long-term daily mobile phone use (>30 min per session per day). We noted positive Tinel's sign in only 25%. Phalen's sign was positive in 53 right hands with mean duration of 11.49s (standard deviation [SD] ± 2.54 s) and was positive in 26 left hands with mean being 10.4 s (SD ± 1.91 s). The mean motor distal latency of median was 4.67 ms (SD ± 1.71 ms) and mean sensory distal latency of median was 3.24 ms (SD ± 1 ms). On internal comparison testing, mean difference in 2 LIMLD was 0.7 ± 0.3 ms, in D4MUSLD was 0.81 ± 0.32, in PWDSLD was 0.71 ± 0.20, and in D1MRSLD was 0.76 ± 0.32.

Conclusion:

Further analysis of clinical profile needs to be done, and new risk or provoking factors should be analyzed in patients with CTS.

Risk Factors for Post-treatment Complex Regional Pain Syndrome (CRPS): An Analysis of 647 Cases of CRPS from the Danish Patient Compensation Association

OBJECTIVES

Complex regional pain syndrome is a challenging condition that includes a broad spectrum of sensory, autonomic, and motor features predominantly in extremities recovering from a trauma. Few large-scale studies have addressed occurrence of and factors associated with complex regional pain syndrome (CRPS) following orthopedic treatment. The present study aimed to identify factors associated with post-treatment development of CRPS.

METHODS

Using the Danish Patient Compensation Association's database, we identified 647 patients claiming post-treatment CRPS between 1992 and 2015. Age, gender, initial diagnosis, treatment, and amount of compensation were extracted. Multivariate logistic regressions were performed to identify variables associated with approval of the claim. For carpal tunnel syndrome (CTS) patients, we registered whether symptoms were bilateral or unilateral and if neurophysiology prior to treatment was pathologic.

RESULTS

The following ratios were found: women:men was 4:1, primary diagnosis to the upper limb:lower limb was 2.5:1, and surgical:nonsurgical treatment was 3:1. Mean age was 47.5 ± 13.7 years, and no intergender difference was detected. Antebrachial fracture (23%) and CTS (9%) were the most common primary conditions. Surgical treatment was associated with approval of the claim (odds ratio 3.5, 95% confidence interval 2.3 to 5.3; P < 0.001). Half of CTS patients had normal neurophysiology prior to surgery; among patients with unilateral symptoms, 71.4% had normal neurophysiology.

CONCLUSIONS

Female gender, surgical treatment, and treatment to the upper limb were risk factors. Elective surgery accounted for a large number of post-treatment CRPS patients. In CTS patients developing CRPS, normal neurophysiological examination findings were common, and it could be suspected that these patients were suffering from an pre-clinical stage of CRPS, not CTS.

Comparison of the Clinical Effectiveness of Ultrasound-Guided Corticosteroid Injection with and without Needle Release of the Transverse Carpal Ligament in Carpal Tunnel Syndrome

BACKGROUND

To compare the clinical effectiveness of ultrasound-guided corticosteroid injection with and without needle release of the transverse carpal ligament (TCL) in carpal tunnel syndrome (CTS).

METHODS

Between May 2014 and June 2016, 52 patients (56 wrists) with CTS were included in this study. Among these patients, 28 wrists were treated with ultrasound-guided corticosteroid injection plus needle release of the TCL (group A) and 28 wrists were treated with a single ultrasound-guided corticosteroids injection (group B). The following parameters were assessed and compared including postoperative results of procedure based on relief of symptoms, electrophysiological parameters (distal motor latency, sensory conduction velocity, and sensory nerve action potential of median nerve), and ultrasound parameters (anteroposterior diameter and cross-sectional area of the median nerve at the levels of pisiform and hamate bone, and the thicknesses of TCL on the cross-section at the level of hamate bone).

RESULTS

The overall excellent and good rate regarding the postoperative results of procedure based on the relief of symptoms at 1 month postoperatively was 82.1% in group A and 46.4% in group B (p = 0.004). There was significant difference in the above electrophysiological and ultrasound parameters between the preoperative and postoperative values in both groups (all p < 0.05). Furthermore, a significant difference was also observed in the postoperative values of the above-mentioned electrophysiological and ultrasound parameters in the 2 groups (all p < 0.05).

CONCLUSIONS

Both approaches had treatment benefit in CTS. Ultrasound-guided corticosteroid injection in combination with needle release of the TCL is superior to the single ultrasound-guided corticosteroids injection.

Diagnostic value of median nerve ultrasonography for screening of carpal tunnel syndrome in hypothyroid patients: A cross-sectional study

BACKGROUND

Carpal tunnel syndrome (CTS) is a common peripheral entrapment neuropathy in patients with hypothyroid. The diagnosis of CTS is usually clinical and confirmed by electrodiagnostic (EDX) procedures. This study aimed to describe the diagnostic accuracy of high-resolution ultrasonography (US) as an alternative method to nerve conduction study (NCS) for the diagnosis of subclinical CTS in patients with hypothyroidism.

METHODS

Between April 2013 and November 2014, from the patients with the diagnosis of hypothyroidism referring to the institute of endocrinology and metabolism of Firoozgar Hospital, Tehran, Iran, those who met our inclusion criteria entered this cross-sectional study. The patients divided into two groups of subclinical CTS with the age- and gender-matched control group. US measurements of the median nerve cross-sectional area (CSA) in the CT inlet were compared with the NCS results as the gold standard diagnostic test.

RESULTS

A total number of 152 wrists of 76 hypothyroid patients were examined in this study. The mean of median nerve CSA at the tunnel inlet was 9.96 ± 2.20 mm(2) for the CTS group and 7.08 ± 1.38 mm(2) for the control group (P < 0.05). 31 wrists (20.4%) were diagnosed as CTS using NCS while US diagnosed 19 wrists (12.5%) as CTS. Using receiver-operating-characteristics analysis, the sensitivity and specificity of US at the diagnosis of CTS were 45.0 and 95.8%, respectively, with a median nerve CSA cutoff point of 9.8 mm(2). Positive and negative predictive values of US were 87.2 and 85.5%, respectively, with a test accuracy of 85.5%.

CONCLUSION

According to our findings, US has an acceptable diagnostic value to confirm CTS in hypothyroid patients. However, it may not replace NCS due to low sensitivity.