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Seror P. Conduction blocks of the median nerve at the wrist in pregnancy and postpartum carpal tunnel syndromes. Muscle Nerve 2023; 68:380-387. [PMID: 37449670 DOI: 10.1002/mus.27929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 06/15/2023] [Accepted: 06/17/2023] [Indexed: 07/18/2023]
Abstract
INTRODUCTION/AIMS The aim in this study is to describe the clinical and electrophysiological patterns of pregnancy-related carpal tunnel syndrome (PRCTS) occurring during pregnancy or after delivery. METHODS Clinical, epidemiological, and electrodiagnostic (EDx) data were studied in 130 women with PRCTS onset during pregnancy (n = 80) or after delivery (n = 50). Twenty-six women with PRCTS underwent EDx analysis during pregnancy and 104 after delivery (83 within 6 months of delivery and 21 up to 24 months after pregnancy onset). PRCTS was compared with idiopathic CTS in a control group consisting of 57 age-matched women with 98 cases of CTS. Twenty-four women with PRCTS had clinical and electrophysiological follow-up after corticosteroid injection (CSI) at the wrist. RESULTS Clinical analysis showed a higher rate of bilateral and diurnal/permanent paraesthesia and more severe symptoms in PRCTS compared with idiopathic CTS. EDx analysis showed more severe abnormalities in classical tests and a higher rate of conduction block (CB) in PRCTS. Statistical analysis showed a strong negative correlation between the incidence and importance of CB and the time interval at which PRCTS women underwent EDx examination, between pregnancy onset and 24 months later. CSI resulted in significant clinical and EDx improvement in 22 of 24 PRCTS women, with disappearance of all motor and most sensory CBs. DISCUSSION The EDx pattern of PRCTS is an acute/subacute median nerve lesion at the wrist identified by many CBs. This occurs concurrently with hormonal changes, is responsible for more severe clinical symptoms and EDx data, and it explains why CSI is so effective.
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Affiliation(s)
- Paul Seror
- Laboratoire d'Electroneuromyographie, Paris, France
- Laboratoire d'Electroneuromyographie, Hôpital de l'Est Parisien, Ramsay GS, Aulnay/s Bois, France
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Grönfors H, Himanen SL, Martikkala L, Kallio M, Mäkelä K. Median nerve ultrasound cross sectional area and wrist-to-forearm ratio in relation to carpal tunnel syndrome related axonal damage and patient age. Clin Neurophysiol Pract 2023; 8:81-87. [PMID: 37215684 PMCID: PMC10196766 DOI: 10.1016/j.cnp.2023.02.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 02/15/2023] [Accepted: 02/21/2023] [Indexed: 05/24/2023] Open
Abstract
Objective Primary objective was to retrospectively examine the effects of patient age and carpal tunnel syndrome (CTS) related axon loss on median nerve (MN) high resolution ultrasound (HRUS) in younger and older patients. HRUS parameters evaluated in this study were MN cross sectional area at the wrist (CSA) and wrist-to-forearm ratio (WFR). Methods The material comprised 467 wrists of 329 patients. The patients were categorized into younger (<65 years) and older (≥65 years) groups. Patients with moderate to extreme CTS were included in the study. Axon loss of the MN was assessed by needle EMG and graded by the interference pattern (IP) density. The association between axon loss and CSA and WFR was studied. Results The older patients had smaller mean CSA and WFR values compared to the younger patients. CSA correlated positively to the CTS severity only in the younger group. However, WFR correlated positively to CTS severity in both groups. In both age groups, CSA and WFR correlated positively with IP reduction. Conclusions Our study complemented recent findings on the effects of patient age on the CSA of the MN. However, although the MN CSA did not correlate with the CTS severity in older patients, the CSA increased in respect to the amount of axon loss. Also, as a new result, we presented the positive association of WFR with CTS severity among older patients. Significance Our study supports the recently speculated need for different MN CSA and WFR cut-off values for younger and older patients in assessing the severity of CTS. With older patients, WFR may be a more reliable parameter to assess the CTS severity than the CSA. CTS related axonal damage of the MN is associated to additional nerve enlargement at the carpal tunnel intel site.
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Affiliation(s)
- Henri Grönfors
- Faculty of Medicine and Health Technology, Tampere University, Arvo Ylpön katu 34, 33520 Tampere, Finland
| | - Sari-Leena Himanen
- Faculty of Medicine and Health Technology, Tampere University, Arvo Ylpön katu 34, 33520 Tampere, Finland
- Department of Clinical Neurophysiology, Tampere University Hospital, Medical Imaging Centre and Hospital Pharmacy, Elämänaukio 2, 33520 Tampere, Finland
| | - Lauri Martikkala
- Faculty of Medicine and Health Technology, Tampere University, Arvo Ylpön katu 34, 33520 Tampere, Finland
| | - Mika Kallio
- Department of Clinical Neurophysiology, Oulu University Hospital, Kajaanintie 50, 90220, PL 10, 90029 OYS, Finland
- Research Unit of Medical Imaging, Physics and Technology; University of Oulu, Kajaanintie 50, 90220; PL 10, 90029 OYS, Finland
| | - Katri Mäkelä
- Department of Clinical Neurophysiology, Tampere University Hospital, Medical Imaging Centre and Hospital Pharmacy, Elämänaukio 2, 33520 Tampere, Finland
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Falsetti P, Conticini E, Baldi C, D’Ignazio E, Al Khayyat SG, Bardelli M, Gentileschi S, D’Alessandro R, D’Alessandro M, Acciai C, Ginanneschi F, Cantarini L, Frediani B. A Novel Ultrasonographic Anthropometric-Independent Measurement of Median Nerve Swelling in Carpal Tunnel Syndrome: The "Nerve/Tendon Ratio" (NTR). Diagnostics (Basel) 2022; 12:diagnostics12112621. [PMID: 36359465 PMCID: PMC9689936 DOI: 10.3390/diagnostics12112621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 10/18/2022] [Accepted: 10/25/2022] [Indexed: 11/30/2022] Open
Abstract
Background: There is little consensus on ultrasound (US) normative values of cross-sectional area of median nerve (MN-CSA) in carpal tunnel syndrome (CTS) because of its dependency on anthropometric parameters. We aim to propose a novel anthropometric-independent US parameter: MN-CSA/flexor radialis carpi CSA (FCR-CSA) ratio (“Nerve Tendon Ratio”, NTR), in the diagnosis of clinically and electrodiagnostic (EDS)-defined CTS. Methods: 74 wrists of 49 patients with clinically defined CTS underwent EDS (scored by the 1−5 Padua Scale of electrophysiological severity, PS) and US of carpal tunnel with measurement of MN-CSA (at the carpal tunnel inlet), FCR-CSA (over scaphoid tubercle) and its ratio (NTR, expressed as a percentage). US normality values and intra-operator agreement were assessed in 33 healthy volunteers. Results: In controls, the mean MN-CSA was 5.81 mm2, NTR 64.2%. In 74 clinical CTS, the mean MN-CSA was 12.1 mm2, NTR 117%. In severe CTS (PS > 3), the mean MN-CSA was 15.9 mm2, NTR 148%. In CTS, both MN-CSA and NTR correlated with sensitive conduction velocity (SCV) (p < 0.001), distal motor latency (DML) (p < 0.001) and PS (p < 0.001), with a slight superiority of NTR vs. MN-CSA when controlled for height, wrist circumference and weight. In CTS filtered for anthropometric extremes, only NTR maintained a correlation with SCV (p = 0.023), DML (p = 0.016) and PS (p = 0.009). Diagnostic cut-offs were obtained with a binomial regression analysis. In those patients with a clinical diagnosis of CTS, the cut-off of MN-CSA (AUROC: 0.983) was 8 mm2 (9 mm2 with highest positive predictive value, PPV), while for NTR (AUROC: 0.987), the cut-off was 83% (100% with highest PPV). In patients with EDS findings of severe CTS (PS > 3), the MN-CSA (AUROC: 0.876) cut-off was 12.3 mm2 (15.3 mm2 with highest PPV), while for NTR (AUROC: 0.858) it was 116.2% (146.0% with highest PPV). Conclusions: NTR can be simply and quickly calculated, and it can be used in anthropometric extremes.
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Affiliation(s)
- Paolo Falsetti
- Rheumatology Unit, Department of Medical, Surgical Sciences and Neurosciences, University Hospital of Siena, 53100 Siena, Italy
- Correspondence:
| | - Edoardo Conticini
- Rheumatology Unit, Department of Medical, Surgical Sciences and Neurosciences, University Hospital of Siena, 53100 Siena, Italy
| | - Caterina Baldi
- Rheumatology Unit, Department of Medical, Surgical Sciences and Neurosciences, University Hospital of Siena, 53100 Siena, Italy
| | - Emilio D’Ignazio
- Rheumatology Unit, Department of Medical, Surgical Sciences and Neurosciences, University Hospital of Siena, 53100 Siena, Italy
| | - Suhel Gabriele Al Khayyat
- Rheumatology Unit, Department of Medical, Surgical Sciences and Neurosciences, University Hospital of Siena, 53100 Siena, Italy
| | - Marco Bardelli
- Rheumatology Unit, Department of Medical, Surgical Sciences and Neurosciences, University Hospital of Siena, 53100 Siena, Italy
| | - Stefano Gentileschi
- Rheumatology Unit, Department of Medical, Surgical Sciences and Neurosciences, University Hospital of Siena, 53100 Siena, Italy
| | - Roberto D’Alessandro
- Rheumatology Unit, Department of Medical, Surgical Sciences and Neurosciences, University Hospital of Siena, 53100 Siena, Italy
| | - Miriana D’Alessandro
- Unit of Respiratory Diseases and Lung Transplantation, Department of Medical, Surgical Sciences and Neurosciences, University Hospital of Siena, 53100 Siena, Italy
| | - Caterina Acciai
- Neurorehabilitation Unit, San Donato Hospital, 52100 Arezzo, Italy
| | - Federica Ginanneschi
- Neurology Unit, Department of Medical, Surgical Sciences and Neurosciences, University Hospital of Siena, 53100 Siena, Italy
| | - Luca Cantarini
- Rheumatology Unit, Department of Medical, Surgical Sciences and Neurosciences, University Hospital of Siena, 53100 Siena, Italy
| | - Bruno Frediani
- Rheumatology Unit, Department of Medical, Surgical Sciences and Neurosciences, University Hospital of Siena, 53100 Siena, Italy
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Expert consensus on the combined investigation of carpal tunnel syndrome with electrodiagnostic tests and neuromuscular ultrasound. Clin Neurophysiol 2022; 135:107-116. [DOI: 10.1016/j.clinph.2021.12.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 12/18/2021] [Accepted: 12/29/2021] [Indexed: 12/13/2022]
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Martikkala L, Mäkelä K, Himanen SL. Reduction in median nerve cross-sectional area at the forearm correlates with axon loss in carpal tunnel syndrome. Clin Neurophysiol Pract 2021; 6:209-214. [PMID: 34377874 PMCID: PMC8327490 DOI: 10.1016/j.cnp.2021.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 04/22/2021] [Accepted: 06/03/2021] [Indexed: 12/30/2022] Open
Abstract
The median nerve CSA at the forearm is smaller when CTS is involved with axon loss. WFR of the median nerve is highest when CTS causes slight axon loss. Axon loss of the median nerve in CTS hampers the diagnostic value of wCSA and WFR.
Objective To explore the relationship between axon loss and measured cross-sectional areas of the median nerve (MN) in severe carpal tunnel syndrome (CTS). Methods In this retrospective study of 158 examined wrists, we compared axon loss to the ultrasound parameters MN cross-sectional area at the wrist (wCSA), MN cross-sectional area at the forearm (fCSA) and wrist-to-forearm ratio (WFR), in patients with moderate to extreme CTS. Axon loss was evaluated by needle electromyography (EMG) of the abductor pollicis brevis muscle (spontaneous activity and reduction of interference pattern). Results Both the spontaneous activity and interference pattern reduction correlated negatively to fCSA (r = −0.189, p = 0.035; r = −0.210, p = 0.019; respectively). In moderate CTS, both the spontaneous activity and interference pattern reduction correlated positively to WFR (r = 0.231, p = 0.048; r = 0.232, p = 0.047; respectively). The WFR was highest when slight spontaneous activity was detected. Neither wCSA nor WFR correlated with axon loss in severe and extreme CTS. Conclusions The fCSA is smaller when axon loss in CTS is more prominent. The WFR is highest when CTS is associated with slight axon loss of the MN. Significance CTS might cause retrograde axonal atrophy detected as small fCSA. Prominent axon loss in CTS may reduce the diagnostic value of WFR.
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Key Words
- APB, abductor pollicis brevis
- CTS, carpal tunnel syndrome
- Carpal tunnel syndrome
- EDX, electrodiagnostic studies
- EMG, needle electromyography
- HRUS, high-resolution ultrasound
- IP, interference pattern
- MN, median nerve
- NCS, nerve conduction studies
- Needle electromyography
- RAA, retrograde axonal atrophy
- Retrograde axonal atrophy
- Ultrasound
- WFR, wrist-to-forearm ratio
- fCSA, median nerve cross-sectional area at the forearm
- wCSA, median nerve cross-sectional area at the wrist
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Affiliation(s)
- Lauri Martikkala
- Department of Clinical Neurophysiology, Pirkanmaa Hospital District, Medical Imaging Centre and Hospital Pharmacy, Tampere University Hospital, Tampere, Finland
| | - Katri Mäkelä
- Department of Clinical Neurophysiology, Pirkanmaa Hospital District, Medical Imaging Centre and Hospital Pharmacy, Tampere University Hospital, Tampere, Finland
| | - Sari-Leena Himanen
- Department of Clinical Neurophysiology, Pirkanmaa Hospital District, Medical Imaging Centre and Hospital Pharmacy, Tampere University Hospital, Tampere, Finland.,Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
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Abstract
PURPOSE Electrodiagnostic studies do not differentiate severe lesions of the median nerve in the distal forearm from those within the carpal tunnel when compound muscle action potential over the abductor pollicis brevis and sensory nerve action potential are absent; needle electromyography showing denervation confined to the abductor pollicis brevis is presumed to suggest localization to the carpal tunnel, although the lesion may be in the forearm. Under these circumstances, the patient may undergo carpal tunnel release without benefit. This retrospective study looked at patients with clinical picture of severe carpal tunnel syndrome who had no compound muscle action potential or sensory nerve action potential on median nerve stimulation; the goal was to determine how often ultrasonic imaging pointed to a location other than the carpal tunnel. METHODS Patients with clinical picture of severe carpal tunnel syndrome with no sensory nerve action potential and no compound muscle action potential over the abductor pollicis brevis and second lumbrical underwent ultrasonic imaging; criteria for localization to the carpal tunnel included significant increase in the cross-sectional area of the median nerve at the carpal tunnel inlet and increase in the wrist/forearm cross-sectional area ratio. RESULTS In 42 of 46 cases, entrapment at the carpal tunnel was confirmed by ultrasonography; in four patients, other causes were located proximal to the carpal tunnel. CONCLUSIONS Ultrasonic imaging is useful not only for confirming entrapment of the median nerve at the carpal tunnel in patients with nonlocalizing electrodiagnostic studies but also in detecting pathology in the forearm, which may mimic severe carpal tunnel syndrome.
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Kerasnoudis A, Barmpalios G, Ntasiou P, Lakkos T, Venouziou A. Ultrasound, Clinical, and Electrophysiological Findings in Persistent Carpal Tunnel Syndrome. J Neuroimaging 2018; 29:218-222. [DOI: 10.1111/jon.12585] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2018] [Revised: 11/10/2018] [Accepted: 11/14/2018] [Indexed: 12/15/2022] Open
Affiliation(s)
- Antonios Kerasnoudis
- Department of Neurology; St. Luke's Hospital; Thessaloniki Greece
- Department of Neurology; St. Josef Hospital; Bochum Germany
| | | | | | - Thomas Lakkos
- Department of Orthopedic Surgery; St. Luke's Hospital; Thessaloniki Greece
| | - Aaron Venouziou
- Department of Orthopedic Surgery; St. Luke's Hospital; Thessaloniki Greece
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Ažman D, Hrabač P, Demarin V. Use of Multiple Ultrasonographic Parameters in Confirmation of Carpal Tunnel Syndrome. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2018; 37:879-889. [PMID: 28960430 DOI: 10.1002/jum.14417] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/05/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVES Ultrasonography (US) of the median nerve has been increasingly studied and used for confirmation of carpal tunnel syndrome (CTS). However, a consensus on the choice of parameters to be evaluated is still not established. The aim of this diagnostic accuracy study was to assess the diagnostic value of multiple parameters individually, as well as in different combinations of variable complexity, and to find an optimal approach for US-based confirmation of a CTS diagnosis. METHODS All participants completed clinical and electrophysiologic evaluations, and their hands were scanned with a 5-13-MHz linear US transducer. Eighty-six patients with CTS (135 symptomatic hands) and 50 control participants (93 asymptomatic hands) were analyzed. The median nerve was recorded transversely at the forearm, at the carpal tunnel inlet, in the mid tunnel, and at the carpal tunnel outlet. For determining the parameters' diagnostic value, sensitivities, specificities, and area under the curve (AUC) values were calculated. RESULTS The inlet cross-sectional area, inlet circumference, and outlet cross-sectional area of the median nerve had the highest AUCs (0.962, 0.920, and 0.913, respectively), sensitivities (87.4%, 80.0%, and 74.1%), and specificities (94.6%, 91.4%, and 92.5%) among single-measurement parameters. An analysis of 2-level parameters (wrist-to-forearm-ratio, inlet-to-outlet-ratio, outlet-to-forearm-ratio, and inlet-outlet mean) yielded the highest AUC (0.974) for the mean cross-sectional area of the median nerve [(inlet + outlet cross-sectional area)/2], with high sensitivity (93.5%) and specificity (91.1%). A compound regression-based index yielded a marginally higher AUC (0.989) than the previously mentioned parameters. CONCLUSIONS Results of the study show that the mean cross-sectional area and inlet cross-sectional area may be valid and easy-to-acquire parameters for routine clinical use in confirming CTS.
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Affiliation(s)
- Dražen Ažman
- Department of Neurology, Dr J. Benčević General Hospital, Medical School of University of Osijek Education Base, Slavonski Brod, Croatia
| | - Pero Hrabač
- Department of Croatian Institute for Brain Research, Medical School of University of Zagreb, Zagreb, Croatia
| | - Vida Demarin
- Department of International Institute for Brain Health, Medical School of University of Zagreb, Zagreb, Croatia
- Department of Croatian Academy of Sciences and Arts, Medical School of University of Zagreb, Zagreb, Croatia
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Kostopoulos D. The use of Neuro-Ultrasound to identify and treat nerve pathology. J Bodyw Mov Ther 2017; 21:692-693. [PMID: 28750985 DOI: 10.1016/j.jbmt.2017.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Dimitrios Kostopoulos
- Charles E. Schmidt College of Medicine at Florida Atlantic University, 66 Mineola Ave, #1342, Roslyn Heights, NY 11577, USA.
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