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 »  Abstract
 »  Introduction
 »  Material and method
 »  Results
 »  Discussion
 »  References

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Year : 1999  |  Volume : 47  |  Issue : 4  |  Page : 272-5

Carpal tunnel syndrome - electrodiagnostic aspects of fifty seven symptomatic hands.


Departments of Neurology, Nizam's Institute of Medical Sciences, Panjagutta, Hyderabad, 500082, India.

Correspondence Address:
Departments of Neurology, Nizam's Institute of Medical Sciences, Panjagutta, Hyderabad, 500082, India.

  »  Abstract

Electrodiagnostic data of fifty seven symptomatic extremities with carpal tunnel syndrome (CTS) are described. Practice recommendations made by American Academy of Neurology, American Association of Electrodiagnostic Medicine and American Academy of Physical Medicine and Rehabilitation regarding electrodiagnostic studies were considered while confirming CTS diagnosis by electrodiagnostic studies. Median sensory nerve conduction studies were the commonest abnormalities noted. The median orthodromic sensory latencies were prolonged in 86% and sensory nerve action potential amplitude abnormalities were seen in 82%. Prolongation of the conduction in the short segment across the wrist in the median nerve was seen in 96.5% and the difference in the conduction between median and ulnar nerve across the wrist was significant in all the 57 extremities. The median motor latencies were prolonged in 67% of hands. Higher incidence of electrodiagnostic abnormalities observed in this study might be due to inclusion of patients with severe disease.

How to cite this article:
Murthy J M, Meena A K. Carpal tunnel syndrome - electrodiagnostic aspects of fifty seven symptomatic hands. Neurol India 1999;47:272


How to cite this URL:
Murthy J M, Meena A K. Carpal tunnel syndrome - electrodiagnostic aspects of fifty seven symptomatic hands. Neurol India [serial online] 1999 [cited 2019 Nov 17];47:272. Available from: http://www.neurologyindia.com/text.asp?1999/47/4/272/1591




   »   Introduction Top


Carpal tunnel syndrome (CTS) is the commonest entrapment neuropathy reported from the western countries. In Rochester, Minnesota, the prevalence of CTS was estimated at 125 per 100,000 in 1976-80.[1] Earlier hospital based studies from India reported CTS rarely.[2],[3] In a recent study from South India, CTS accounted for 7% of patients with peripheral nerve disorders and 84% of entrapment neuropathies referred for electrodiagnostic evaluation.[4] The results of electrodiagnostic studies have been found to be highly sensitive and specific.[5],[6],[7],[8],[9],[10] Recently, American Academy of Neurology (AAN), American Academy of Electrodiagnostic Medicine (AAEM), and American Academy of Physical Medicine and Rehabilitation (AAPMR) have defined the standards, guidelines, and options for electrodiagnostic studies of CTS based on a formal literature review and meta-analysis.[11] In this paper we present the electrodiagnostic features in forty one patients using these practice recommendations.


   »   Material and method Top


The subjects of the study include 84 patients who were referred for electrodiagnostic evaluation for acral paraesthesiae. The electrodiagnostic studies included motor and sensory conduction studies by conventional methods. The practice recommendations made by AAN, AAEM and AAPMR were considered while confirming CTS diagnosis by electrodiagnostic studies.[11] The para- meters studied included :

1. Motor Conduction Studi es: a) Motor distal latencies of median and ulnar, b) Amplitude of the negative component of compound action potential (CMAP), c) Median and ulnar conduction velocities
2. Sensory Conduction Studies: a) Sensory onset latencies of median and ulnar nerves by orthodromic stimulation, b) Peak to peak amplitude of sensory nerve action potential (SNAP).
3. Palm-wrist conduction studies : The median and ulnar nerves were stimulated in the palm between 2nd and 3rd and 4th and 5th metacarpal bones respectively at a point, 8 cm distal to the recording electrodes. The onset latencies were measured both for median and ulnar nerves. Median and ulnar nerve palmar latency differences were also calculated.
4. EMG of abductor pollices brevis and first dorsal interossious was done.

The control values were obtained from a previous study of the reference population of 37 healthy individuals. The Figures given in the brackets are mean values plus or minus 2SD accordingly. The criteria for electrodiagnosis of CTS included.[10],[11]

1. Abnormal sensory conduction studies across the wrist of the median nerve in the symptomatic limb (sensory latency > 2SD mean of control, and amplitude <2SD mean of control and/or
2. Abnormal median sensory nerve conduction across the wrist over a short (8cm) conduction distance or abnormal median sensory conduction across the wrist when compared to ulnar nerve conduction (>2SD of control).
3. Abnormal median motor latency in the symptomatic hand (>2SD of control) was also considered, if the patient fulfilled any one of the above two criteria.


   »   Results Top


Of the 84 patients with acral paraesthesiae, electrodiagnostic evidence of CTS was present in 41 patients. 16 patients had evidence on both the sides. All the 41 patients had other signs suggestive of CTS.

1. Median Motor Conduction Studies : Median distal motor latencies were prolonged (control : mean+2SD=4.33 msec) in 67% of symptomatic hands. The amplitudes of CMAPs recorded from the symptomatic hands were abnormal (control: mean-2SD=<3.95 mv) in 33% [Figure - 1]. Slowing of median nerve conduction velocity in the forearm segment was observed in 9 (15.8%) patients. The slowing in the motor conduction velocity was associated with prolongation of motor latency in all the patients. None of the patients had any underlying neuropathy or evidence of forearm median-ulnar nerve communication. Needle examination showed evidence of significant spontaneous activity in 40% of the symptomatic hands. Reduced recruitment and/or polyphasic potentials were seen in 47% of these hands.

2. Median Sensory Conduction Studies : Median orthodromic sensory nerve onset latencies were prolonged (control: mean+2SD=>3.2 msec) in 86% of the hands and sensory amplitude was reduced (control: mean-2SD= <5.3 mu) in 82%. The conduction time in the median nerve across the wrist on palmar stimulation was abnormal in 96.5% of the hands. The difference between the median and ulnar nerve latencies across the wrist on palmar stimulation was more than 2SD in 100% of patients [Figure. 1]. These two were the most sensitive electrodiagnostic parameters [Table I].

   »   Discussion Top


Acral paraesthesiae are seen in many disorders including lesions in the cortex. Electrodiagnostic studies confirm the diagnosis of CTS with high degree of sensitivity.[10] The first usefulness of the median motor nerve conduction studies in the diagnosis of CTS was by Simpson in 1956.[12] Gilliatt and Sears[13] later recognised the value of sensory conduction studies. The median nerve conduction abnormalities in CTS are focal and localised to the segment of the median nerve in the carpal tunnel. This has been confirmed by Brown[14] by intraoperative conduction studies. Median sensory nerve conduction across the wrist over a short conduction distance has been shown to be more sensitive than antidromic or orthodromic sensory conduction studies.[5],[9] The difference between the median and ulnar nerve latency measurements with palmar stimulation in patients with CTS is another parameter of diagnostic value.[5],[9],[15] Comparison of the sensitivity evaluation of the several different median nerve conduction studies (NCSs) demonstrated that: (1) median sensory NCSs confirm the clinical diagnosis of CTS more often than the median motor NCSs, (2) the median sensory or mixed nerve conduction from wrist to digit is less sensitive for confirmation of the clinical diagnosis of CTS, compared to techniques which evaluate median sensory or mixed nerve conduction over a short conduction distance across the carpal tunnel, or techniques which compare sensory or mixed nerve conduction of the median nerve through the carpal tunnel to sensory or mixed nerve conduction of the ulnar nerve or radial nerve in the same hand.[10] The five studies, which met all the six literature classification criteria, reported sensitivities of electrodiagnostic studies ranging from 49% to 84%.[11] In this study the incidence of electrodiagnostic abnormalities was greater when compared to average Figures published.[10] The median nerve sensory conduction over a short distance across the carpal tunnel was abnormal in 96.5% patients and the median and ulnar latency difference with palmar stimulation was 100%. Such findings suggest that the patient population was biased and included patients with advanced CTS.[16],[17],[18],[19] It is likely that patients with severe disease were referred for electrodiagnostic evaluation. Motor conduction studies were abnormal in upto 67% of patients which also supports such supposition. Jackson and Clifford[9] showed that the incidence of electrodiagnostic abnormalities increased according to the severity of the median compression.

 

  »   References Top

1.Stevens JC, Sun S, Beard CM et al : Carpal tunnel syndrome in Rochester, Minnesota, 1961 to 1980. Neurology 1988; 38 : 134-138.   Back to cited text no. 1    
2.Kaur U, Chopra JS, Prabhakar S et al : Clinical spectrum of peripheral neuropathies. Indian J Med Res 1982; 76 : 728-735.   Back to cited text no. 2    
3.Gourie Devi M : Molecular mechanisms underlying nerve damage - Some aspects of leprous neuropathy. In : Molecular mechanisms underlying neuronal damage. Rao BSS, Bondy SC (Eds) NIMHANS Publications, Bangalore, 1990; 267-276.   Back to cited text no. 3    
4.Murthy JMK, Meena AK : Carpal tunnel syndrome - Is it really uncommon in India? Neurol India 1995; 43 : 26-28.  Back to cited text no. 4    
5.Kimura J : The carpal tunnel syndrome : Localisation of conduction abnormalities within the distal segments of the median nerve. Brain 1979; 102 : 619-635.  Back to cited text no. 5    
6.Carroll G : Comparison of median and radial nerve sensory latencies in the electrophysiological diagnosis of carpal tunnel syndrome. Electroencephalogr Clin Neurophysiol 1987; 68 : 101-106.   Back to cited text no. 6    
7.DeLean J : Transcarpal median sensory conduction: detection of latent abnormalities in mild carpal tunnel syndrome. Can J Neurol Sci 1988; 15 : 388-393.   Back to cited text no. 7    
8.Nathan PA, Meadowa KD, Doyle LS : Sensory segmental latency values of the median nerve for a population of normal individuals. Arch Phys Med Rehabil 1988; 69 : 499-501.   Back to cited text no. 8    
9.Jackson D, Clifford JC : Electrodiagnosis of mild carpal tunnel syndrome. Arch Phys Med Rehabil 1989; 70 : 199-204.   Back to cited text no. 9    
10.Jablecki CK, Andary MT, So YT et al : Literature review of the usefulness of nerve conduction studies and electromyography for the evaluation of patients with carpal tunnel syndrome. Muscle Nerve 1993; 16 : 1392-1414.  Back to cited text no. 10    
11.Practice parameters for electrodiagnostic studies in carpal tunnel syndrome: Summary statement. Neurology 1993; 43 : 2404-2405.   Back to cited text no. 11    
12.Simpson JA : Electrical signs in the diagnosis of carpal tunnel and related syndromes. J Neurol Neurosurg Psychiatry 1956; 19 : 275-280.   Back to cited text no. 12    
13.Gilliat RW, Sears TA : Sensory nerve action potentials in patients with peripheral nerve lesions. J Neurol Neurosurg Psychiatry 1958; 21 : 109-118.  Back to cited text no. 13    
14.Brown WF, Furguson GG, Joses MW et al : The location of conduction abnormalities in human entrapment neuropathies. Can J Neurol Sci 1976; 3 : 111-122.   Back to cited text no. 14    
15.Mills KR : Orthrodromic sensory action potentials from palmar stimulation in the diagnosis of carpal tunnel syndrome. J Neurol Neurosurg Psychiatry 1985; 48 : 250-255.   Back to cited text no. 15    
16.Buchthal F, Rosenflack A, Trojaborg W : Electrophysiological findings in entrapment of the median nerve at wrist and elbow. J Neurol Neurosurg Psychiatry 1974; 37 : 340-360.   Back to cited text no. 16    
17.Buchthal F, Rosenfaick A : Sensory conduction from [digit] to palm and from palm to wrist in the carpal tunnel syndrome. J Neurol Neurosurg Psychiatry 1971; 34 : 243-252.  Back to cited text no. 17    
18.Casey EB, LeQuesne PM : Digital nerve potentials in healthy subjects, and in carpal tunnel and diabetic patients. J Neurol Neurosurg Psychiatry 1972; 35 : 612- 623.  Back to cited text no. 18    
19.Cioni R, Passero S, Paradiso C et al : Diagnostic specificity of sensory and motor nerve conduction variables in early detection of carpal tunnel syndrome. J Neurol 1989; 236 : 208-213.   Back to cited text no. 19    
21.   Back to cited text no. 21    
22.   Back to cited text no. 22    
23.   Back to cited text no. 23    
24.   Back to cited text no. 24    
25.   Back to cited text no. 25    

 

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