High-resolution ultrasonography in carpal tunnel syndrome: role of ancillary criteria in diagnosis and response to steroid injection

Abstract

Objectives

(1) Development and validation of a composite ultrasound score (cUSS) for the diagnosis of carpal tunnel syndrome (CTS). (2) To predict treatment response after local corticosteroid injection.

Methods

Wrists of CTS patients and controls were evaluated with high-resolution ultrasound and cross-sectional area of median nerve at carpal tunnel inlet (CSAp) and outlet (CSAd) and bowing of flexor retinaculum (FRB), flexor tenosynovitis, and intraneural vascularity and echogenicity changes were noted. Patients were prospectively followed after ultrasound-guided corticosteroid injection.

Results

We studied 479 wrists of 141 patients and 99 controls. Optimal cut-offs for diagnosing CTS were 9.5 mm2 and 10.5 mm2, respectively, for CSAp and CSAd. A cUSS consisting of the following parameters was developed: age, CSAp, CSAd, FRB, and flexor tenosynovitis and echogenicity changes. External validation of cUSS yielded sensitivity, specificity, and diagnostic accuracy of 91.7%, 87.1%, and 89.8%, respectively. Treatment responses from 88 injections (median duration of follow-up of 6 months) were available with satisfactory initial responses in 69.32% (61/88) and relapses in 30.86% (25/81). Median time to relapse was 2 months. Initial response was predicted by FRB (odds ratio (OR): 5.43, 95% confidence interval (CI): 1.45–20.3, p = 0.012). Relapse was predicted by age (hazard ratio (HR) 1.168, 95% CI: 1.076–1.268, p = 0.0002), male gender (HR: 8.1.02, 95% CI: 2.394–27.422, p = 0.0007), FRB, (HR: 46.982, 95% CI: 5.048–437.293, p = 0.0008), and higher body mass index (HR: 0.238, 95% CI: 0.064–0.892, p = 0.0332).

Conclusions

The developed cUSS has a diagnostic accuracy of 88% for diagnosing CTS. Ultrasound parameters could predict both initial treatment response and relapse.

Key points

Anatomical ultrasound parameters in addition to nerve cross-sectional area is important for diagnosis of CTS.

• A composite US score for diagnosis of CTS was developed with accuracy 88.6%.

• Bowing of flexor retinaculum predicts short and long term response to local steroid injection.

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Correspondence to Rudra Prosad Goswami.

Ethics declarations

Our study complies with the Declaration of Helsinki and was reviewed by the Institutional Ethics Committee of IPGME&R, Kolkata, and the ethics committee has approved the research protocol (ethics no. IPGME&R/IEC/2018/042), and prior written informed consent has been obtained from all the subjects.

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Figure S1

Panel of images showing median nerve in various points of the carpal tunnel of a single patient. The median nerve is imaged in various parts of the carpal tunnel: in proximal carpal tunnel (A), in distal carpal tunnel (B), panoramic view of proximal tunnel (C) and longitudinal view of the median nerve (D). In the cross-sectional view of the proximal part of the tunnel (Panel A) at the level of the pisiform (white hollow arrowhead), the median nerve is seen to lie just below the flexor retinaculum (multiple solid white arrowheads) and the retinaculum is seen to gain attachment at the ulnar side on the scaphoid tubercle. To measure bowing a horizontal dotted line is drawn from the scaphoid tubercle to the pisiform and a vertical distance measurement line (Green A and B) are drawn from this horizontal line to the top of the retinaculum. In this picture the bowing distance was 5 mm. In the cross-sectional view of the distal part of the tunnel (panel B), the median nerve (solid white star) is seen to lie between the trapezium (black star with white borders). In the panoramic view of the proximal carpal tunnel (panel C), both the radial (gree and yellow flow signals) and ulnar (red flow signals) are seen and the flexor digitorum superficialis tendons (white arrows) are seen lying below the median nerve (dotted green outline). The flexor carpi radialis (solid white star) lies outside the flexor retinaculum. The area of the median nerve was 8 mm2 in this patient. In the longitudinal view of the median nerve (panel D, the median nerve (solid white arrowheads) is seen lying on top of the flexor digitorum tendon (solid black star). There are inhomogeneoous hyperechoic changes within the nerve (hollow arrowhead with white borders). This patient had carpal tunnel syndrome with electrodiagnostic findings with median nerve area less than the cut off but ancillary criteria was positive. (JPG 140 kb)

Figure S2

Panel of images showing median nerve in various points of the carpal tunnel showing different pathologies. In panel A, the median nerve (white solid star) is traced out. Panel B shows an elarged median nerve with a cross-sectional area of 28 mm2. In panel C, the median neve (solid white star) in the proximal carpal tunnel, is seen to lie below the flexor retinauculm (hollow arrowhead with white borders). The flexor digitorum superficialis tendons (solid black stars with white borders) and the flexor digitorum profundus tendons (solid white stars with black borders) are displaced by the presence of flexor tenosynovitis marked by fluid accumulation (solid white arrowheads). In panel D (same picture as Panel A but the median nerve is not traced out) presence of flexor tenosynovitis (solid white arrowheads) is presence in the intervening areas and inbetween the flexor digitorum superficialis tendons (solid black stars with white borders) and the flexor digitorum profundus tendons (solid white stars with black borders). (JPG 121 kb)

Figure S3 Survival curves for the presence and absence of bowing each for male and female, keeping age fixed at median level We have further tested the similarities between them using the Mantel Cox test. The data shows that the odds ratio (OR) of relapse for the male patients in the presence of bowing compared to absence is 1.25 (95% confidece interval: 0.12–13.24). Similarly for the female patients, OR of relapse in the presence of bowing compared to absence is 3.83 (95% CI 0.98–14.99). The results of the Mantel Cox test shows for male patients relapse occurred in 5/9 males with baseline bowing compared to 2/4 in no baseline bowing (p = 0.02). For females, relapse occurred in 14/42 with baseline bowing comapred to 3/26 without bowing at baseline (p = 0.03).

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Goswami, R.P., Sit, H., Chatterjee, M. et al. High-resolution ultrasonography in carpal tunnel syndrome: role of ancillary criteria in diagnosis and response to steroid injection. Clin Rheumatol 40, 1069–1076 (2021). https://doi.org/10.1007/s10067-020-05228-8

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Keywords

  • Bowing of flexor tenosynovitis
  • Carpal tunnel injection
  • Carpal tunnel syndrome
  • Flexor tenosynovitis
  • Intraneural echogenicity changes
  • Intraneural vascularity
  • Median nerve cross-sectional area
  • Musculoskeletal ultrasound