carpal tunnel syndrome

The electrodiagnostic techniques described in these books are of established values in the diagnosis of the median nerve entrapment neuropathies as the carpal tunnel syndrome (CTS) or anterior interosseous nerve syndrome (AIN), and they can be a valuable aid in the electrophysiological assessment of the polyneuropathies. The CTS is the most common entrapment neuropathy caused by the compression of the median nerve as it passes through the carpal tunnel at the wrist (1) and, consequently, it is one of the most frequent reasons for referral to electromyography laboratories for an electrodiagnostic (EDX) study (2). It is a clinical syndrome of numbness which usually involves the lateral four digits (or sensory loss may be confined to one digit), tingling, burning, and/or pain (3), and the hand pain may be perceived more proximally in the forearm (at the arm or at the shoulder level), mimicking cervical radiculopathy. Pain and paresthesia are aggravated by the repetitive use of the hand, and symptoms usually involve the dominant hand especially in persons who use their hands occupationally. Patients characteristically awaken at night with nocturnal paresthesia, and the onset is insidious in most cases. Weakness and atrophy of the thenar muscles is commonly observed in severe cases.

Recommendations and practice guidelines

The diagnosis is usually based on typical symptoms and signs in conjunction with electrodiagnostic findings (4). Many electrodiagnostic techniques have been developed to assist the electromyographer in the diagnosis of carpal tunnel syndrome (5), in order to verify the compression of the median nerve at the wrist and to assess its severity (6, 7).

AANEMIn 1993, the American Academy of Electrodiagnostic Medicine’s (AAEM) Quality Assurance Committee performed a critical analysis of the CTS electrodiagnostic literature and concluded that the median sensory nerve conduction studies are more sensitive than the median motor nerve conduction studies, the short segment (wrist-palm segment) median sensory or mixed nerve conduction studies are more sensitive than the long segment (wrist-digit) sensory or mixed nerve conduction studies (8). The AAEM formed a second CTS task force in 2000 to update the 1993 report and to provide a single reference for EDX studies in CTS (9). In patients suspected of positive CTS, the following standard electrodiagnostic studies (practice standards) are recommended to confirm a clinical diagnosis of CTS:

1.

The median sensory nerve conduction studies (orthodromic or antidromic studies) across the wrist with a conduction distance of 13 to 14 cm (one test between S4, S5, S26, S27 and S39), as follows:

S4
S4 (Melvin et al., 1966 – ORTHODROMIC) BUY CHAPTER
S5
S5 (Melvin et al., 1966 – ANTIDROMIC) FREE CHAPTER
S26
S26 (Di Benedetto et al., 1986 – ORTHODROMIC) BUY CHAPTER
S27
S27 (Di Benedetto et al., 1986 – ANTIDROMIC) BUY CHAPTER
S39
S39 (Kothari et al., 1995 – ANTIDROMIC) BUY CHAPTER
2.

If  the result is abnormal, comparison of the result of the median sensory nerve conduction studies to the result of a sensory nerve conduction study of one other adjacent nerve (radial or ulnar nerve) in the symptomatic limb.

3.

If the result is normal, one of the following additional studies is recommended:

  • Comparison of the median sensory or mixed nerve conduction across the wrist (palm-wrist segment) over a short (7-8 cm) conduction distance with the ulnar sensory or mixed nerve conduction across the wrist over the same short (7-8 cm) conduction distance (S18 or S24), as follows:
S18
S18 (Felsenthal and Spindler, 1979 – ANTIDROMIC) BUY CHAPTER
S24
S24 (MIlls, 1985 – ORTHODROMIC) BUY CHAPTER
  • Comparison of the median sensory conduction across the wrist with the radial or ulnar sensory nerve conduction across the wrist in the symptomatic limb (one test between S19, S21, S30 and S33), as follows: 
S19
S19 (Brenninkmeyer, 1979 – ANTIDROMIC) BUY CHAPTER
S21
S21 (Johnson et al., 1981 – ANTIDROMIC) BUY CHAPTER
S30
S30 (Johnson et al., 1987 – ANTIDROMIC) FREE CHAPTER
S33
S33 (Uncini et al., 1989 – ORTHODROMIC) BUY CHAPTER
  • Comparison of the median sensory or mixed conduction through the carpal tunnel (palm-wrist segment) to the sensory or mixed nerve conduction studies of proximal (wrist-elbow segment) or distal (digit-palm segment) segments of the median nerve in the symptomatic limb (one test between S16, S23 and S48), as follows:
S16
S16 (Kimura, 1978 – ANTIDROMIC) BUY CHAPTER
S23
S23 (Wongsam et al., 1983 – ANTIDROMIC) BUY CHAPTER
S48
S48 (Chang et al., 2002 – ORTHODROMIC) BUY CHAPTER

The practice standards are generally accepted principles for patient management that reflects a high degree of clinical certainty. AAEM also provides practice guidelines, which are recommendations for patient management that reflect moderate clinical certainty: 

4.

Motor conduction study of the median nerve recording from the thenar muscle (abductor pollicis brevis – APB muscle) and one other nerve in the symptomatic limb to include measurement of distal latency as the motor conduction study of the ulnar nerve recording from the hypothenar muscle (abductor digiti minimi, ADM muscle), as follows:

M8
M8 (Melvin et al., 1966) FREE CHAPTER

The practice options are other strategies for patient management for which the clinical utility is still uncertain (supplementary nerve conduction studies, and needle electromyography):

5.

The median motor nerve conduction between wrist and palm (M16 or M22), comparison of the median motor nerve distal latency recording from the second lumbrical to the ulnar motor nerve distal latency (2L-INT) recording from the second interossei muscle (M27), median motor nerve CMAP wrist to palm amplitude ratio to detect a conduction block (M28), the median motor terminal latency (TLI) index (M29), short segment (1 cm) incremental median sensory nerve conduction across the carpal tunnel (S17 or S46), median SNAP wrist to the palm amplitude ratio to detect conduction block (S38), as follows:

M16
M16 (Kimura, 1978) BUY CHAPTER
M22
M22 (Pease et al., 1988) BUY CHAPTER
M27
M27 (Preston and Logigian, 1992) FREE CHAPTER
M28
M28 (Lesser et al., 1995) BUY CHAPTER
M29
M29 (Simovic and Weinberg, 1997) BUY CHAPTER
S17
S17 (Kimura, 1979 – ANTIDROMIC) BUY CHAPTER
S38
S38 (Lesser et al., 1995 – ANTIDROMIC) BUY CHAPTER
S46
S46 (Seror, 2000 – ORTHODROMIC) BUY CHAPTER
6.

Needle electromyography of a sample of muscles innervated by the C5 to T1 spinal roots, including a thenar muscle (abductor pollicis brevis – APB muscle) innervated by the median nerve of the symptomatic limb.

 

REFERENCES

1) Preston DC, Shapiro BE. Electromyography and neuromuscular disorders. Clinical-electrophysiologic correlations. Elsevier Science 2012; 3rd edition.

2) Löscher WN, Auer-Grumbach M, Trinka E, et al. Comparison of second lumbrical and interosseous latencies with standard measures of median nerve function across the carpal tunnel: a prospective study of 450 hands. J Neurol 2000; 247:530-534

3) Werner RA, Andary M. Electrodiagnostic evaluation of carpal tunnel syndrome. Muscle Nerve 2011; 44:597-607

4) Gazioglu S, Boz C, Altunayoglu Cakmak A. Electrodiagnosis of carpal tunnel syndrome in patients with diabetic polyneuropathy. Clin Neurophysiol 2011; 122:1463-1469

5) Lew HL, Date ES, Pan SS, et al. Sensitivity, specificity, and variability of nerve conduction velocity measurements in carpal tunnel syndrome. Arch Phys Med Rehabil 2005; 86:12-16

6) Lee HJ, Kwon HK, Kim DH, et al. Nerve conduction studies of median motor nerve and median sensory branches according to the severity of carpal tunnel syndrome. Ann Rehabil Med 2013; 37:254-262

7) Chang MH, Liu LH, Lee YC, et al. Comparison of sensitivity of transcarpal median motor conduction velocity and conventional conduction techniques in electrodiagnosis of carpal tunnel syndrome. Clin Neurophysiol 2006; 117:984-991

8) American Association of Electrodiagnostic Medicine (AAEM) Quality Assurance Committee. 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

9) American Association of Electrodiagnostic Medicine, American Academy of Neurology, American Academy of Physical Medicine and Rehabilitation. Practice parameter for electrodiagnostic studies in carpal tunnel syndrome: summary statement. Muscle Nerve 2002; 25:918-922