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Diagnosis and Clinical Presentation of Carpal Tunnel Syndrome

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Abstract

Carpal tunnel syndrome typically presents with paresthesias in the thumb, index, middle, and radial half of ring finger. These symptoms are typically worse at night and may be exacerbated by activities that include wrist flexion. The diagnosis can be confirmed using clinical examination and/or a number of diagnostic tests including electrodiagnostic testing, CTS-6, ultrasound, and other validated diagnostic tools. The sensitivity and specificity of these diagnostic tests vary widely in the literature and are highly susceptible to the population being chosen and the cut-offs used for diagnosis. Electrodiagnostic testing has been traditionally considered the reference standard for diagnosis. However, recent data has found relatively high rates of false positives in asymptomatic individuals. Most studies show little benefit to additional testing in patients with “classic” carpal tunnel syndrome. However, additional testing may be indicated to rule out a more proximal site of nerve compression, systemic disease such as polyneuropathy, or in patients with atypical symptoms. Clinical diagnostic tools may offer cost-savings as screening tools when used in place of electrodiagnostic testing.

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References

  1. Blumenthal S, Herskovitz S, Verghese J. Carpal tunnel syndrome in older adults. Muscle Nerve. 2006;34(1):78–83. https://doi.org/10.1002/mus.20559.

    Article  PubMed  PubMed Central  Google Scholar 

  2. Bland JD. Carpal tunnel syndrome. BMJ. 2007;335(7615):343–6. https://doi.org/10.1136/bmj.39282.623553.AD.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Hakim AJ, Cherkas L, Zayat El S, MacGregor AJ, Spector TD. The genetic contribution to carpal tunnel syndrome in women: a twin study. Arthritis Rheum. 2002;47(3):275–9. https://doi.org/10.1002/art.10395.

    Article  PubMed  Google Scholar 

  4. American Academy of Orthopaedic Surgeons. Management of carpal tunnel syndrome evidence-based clinical practice guideline. Feb 2016. www.aaos.org/ctsguideline.

  5. Graham B. The value added by electrodiagnostic testing in the diagnosis of carpal tunnel syndrome. J Bone Joint Surg Am. 2008;90(12):2587–93. https://doi.org/10.2106/JBJS.G.01362.

    Article  PubMed  Google Scholar 

  6. Glowacki KA, Breen CJ, Sachar K, Weiss AP. Electrodiagnostic testing and carpal tunnel release outcome. J Hand Surg Am. 1996;21(1):117–21. https://doi.org/10.1016/S0363-5023(96)80164-X.

    Article  CAS  PubMed  Google Scholar 

  7. Cranford CS, Ho JY, Kalainov DM, Hartigan BJ. Carpal tunnel syndrome. J Am Acad Orthop Surg. 2007;15(9):537–48.

    Article  PubMed  Google Scholar 

  8. Gelberman RH, Hergenroeder PT, Hargens AR, Lundborg GN, Akeson WH. The carpal tunnel syndrome. A study of carpal canal pressures. J Bone Joint Surg Am. 1981;63(3):380–3.

    Article  CAS  PubMed  Google Scholar 

  9. Michelsen H, Posner MA. Medical history of carpal tunnel syndrome. Hand Clin. 2002;18(2):257–68.

    Article  PubMed  Google Scholar 

  10. Jenkins PJ, Srikantharajah D, Duckworth AD, Watts AC, McEachan JE. Carpal tunnel syndrome: the association with occupation at a population level. J Hand Surg Eur Vol. 2013;38(1):67–72. https://doi.org/10.1177/1753193412455790.

    Article  CAS  PubMed  Google Scholar 

  11. Nathan PA, Keniston RC, Myers LD, Meadows KD. Longitudinal study of median nerve sensory conduction in industry: relationship to age, gender, hand dominance, occupational hand use, and clinical diagnosis. J Hand Surg Am. 1992;17(5):850–7.

    Article  CAS  PubMed  Google Scholar 

  12. Gelberman RH, Szabo RM, Williamson RV, Dimick MP. Sensibility testing in peripheral-nerve compression syndromes. An experimental study in humans. J Bone Joint Surg Am. 1983;65(5):632–8.

    Article  CAS  PubMed  Google Scholar 

  13. Szabo RM, Gelberman RH, Dimick MP. Sensibility testing in patients with carpal tunnel syndrome. J Bone Joint Surg Am. 1984;66(1):60–4.

    Article  CAS  PubMed  Google Scholar 

  14. Cheng CJ, Mackinnon-Patterson B, Beck JL, Mackinnon SE. Scratch collapse test for evaluation of carpal and cubital tunnel syndrome. J Hand Surg Am. 2008;33(9):1518–24. https://doi.org/10.1016/j.jhsa.2008.05.022.

    Article  PubMed  Google Scholar 

  15. Simon J, Lutsky K, Maltenfort M, Beredjiklian PK. The accuracy of the scratch collapse test performed by blinded examiners on patients with suspected carpal tunnel syndrome assessed by electrodiagnostic studies. J Hand Surg Am. 2017;42(5):386.e1–5. https://doi.org/10.1016/j.jhsa.2017.01.031.

    Article  Google Scholar 

  16. Katz JN, Larson MG, Sabra A, et al. The carpal tunnel syndrome: diagnostic utility of the history and physical examination findings. Ann Intern Med. 1990;112(5):321–7.

    Article  CAS  PubMed  Google Scholar 

  17. Levine DW, Simmons BP, Koris MJ, et al. A self-administered questionnaire for the assessment of severity of symptoms and functional status in carpal tunnel syndrome. J Bone Joint Surg Am. 1993;75(11):1585–92.

    Article  CAS  PubMed  Google Scholar 

  18. Fowler JR, Cipolli W, Hanson T. A comparison of three diagnostic tests for carpal tunnel syndrome using latent class analysis. J Bone Joint Surg Am. 2015;97(23):1958–61. https://doi.org/10.2106/JBJS.O.00476.

    Article  PubMed  Google Scholar 

  19. Fowler JR, Munsch M, Tosti R, Hagberg WC, Imbriglia JE. Comparison of ultrasound and electrodiagnostic testing for diagnosis of carpal tunnel syndrome: study using a validated clinical tool as the reference standard. J Bone Joint Surg Am. 2014;96(17):e148. https://doi.org/10.2106/JBJS.M.01250.

    Article  PubMed  Google Scholar 

  20. Lo JK, Finestone HM, Gilbert K. Prospective evaluation of the clinical prediction of electrodiagnostic results in carpal tunnel syndrome. PM R. 2009;1(7):612–9. https://doi.org/10.1016/j.pmrj.2009.05.004.

    Article  PubMed  Google Scholar 

  21. Wainner RS, Fritz JM, Irrgang JJ, Delitto A, Allison S, Boninger ML. Development of a clinical prediction rule for the diagnosis of carpal tunnel syndrome. Arch Phys Med Rehabil. 2005;86(4):609–18. https://doi.org/10.1016/j.apmr.2004.11.008.

    Article  PubMed  Google Scholar 

  22. Kamath V, Stothard J. A clinical questionnaire for the diagnosis of carpal tunnel syndrome. J Hand Surg. 2003;28(5):455–9.

    Article  CAS  Google Scholar 

  23. Slutsky DJ. Use of nerve conduction studies and the pressure-specified sensory device in the diagnosis of carpal tunnel syndrome. J Hand Surg Eur Vol. 2009;34(1):60–5. https://doi.org/10.1177/1753193408094921.

    Article  CAS  PubMed  Google Scholar 

  24. Dahlin LB, Shyu BC, Danielsen N, Andersson SA. Effects of nerve compression or ischaemia on conduction properties of myelinated and non-myelinated nerve fibres. An experimental study in the rabbit common peroneal nerve. Acta Physiol Scand. 1989;136(1):97–105. https://doi.org/10.1111/j.1748-1716.1989.tb08634.x.

    Article  CAS  PubMed  Google Scholar 

  25. Tapadia M, Mozaffar T, Gupta R. Compressive neuropathies of the upper extremity: update on pathophysiology, classification, and electrodiagnostic findings. J Hand Surg Am. 2010;35(4):668–77. https://doi.org/10.1016/j.jhsa.2010.01.007.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Slutsky DJ. Electromyography in hand surgery. J Am Soc Surg Hand. 2004;4(3):176–88. https://doi.org/10.1016/j.jassh.2004.06.008.

    Article  Google Scholar 

  27. Sonoo M, Menkes DL, Bland JDP, Burke D. Nerve conduction studies and EMG in carpal tunnel syndrome: do they add value? Clin Neurophysiol Pract. 2018;3:78–88. https://doi.org/10.1016/j.cnp.2018.02.005.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Jablecki CK, Andary MT, Floeter MK, et al. Practice parameter: electrodiagnostic studies in carpal tunnel syndrome. Report of the American Association of Electrodiagnostic Medicine, American Academy of Neurology, and the American Academy of Physical Medicine and Rehabilitation. Neurology. 2002;58(11):1589–92.

    Article  CAS  PubMed  Google Scholar 

  29. 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(6):918–22. https://doi.org/10.1002/mus.10185.

    Article  Google Scholar 

  30. Lew HL, Wang L, Robinson LR. Test-retest reliability of combined sensory index: implications for diagnosing carpal tunnel syndrome. Muscle Nerve. 2000;23(8):1261–4.

    Article  CAS  PubMed  Google Scholar 

  31. Redmond MD, Rivner MH. False positive electrodiagnostic tests in carpal tunnel syndrome. Muscle Nerve. 1988;11(5):511–8. https://doi.org/10.1002/mus.880110515.

    Article  CAS  PubMed  Google Scholar 

  32. Chen S, Andary M, Buschbacher R, et al. Electrodiagnostic reference values for upper and lower limb nerve conduction studies in adult populations. Muscle Nerve. 2016;54(3):371–7. https://doi.org/10.1002/mus.25203.

    Article  PubMed  Google Scholar 

  33. Szabo RM, Slater RRJ, Farver TB, Stanton DB, Sharman WK. The value of diagnostic testing in carpal tunnel syndrome. J Hand Surg Am. 1999;24(4):704–14.

    Article  CAS  PubMed  Google Scholar 

  34. Wang WL, Buterbaugh K, Kadow TR, Goitz RJ, Fowler JR. A prospective comparison of diagnostic tools for the diagnosis of carpal tunnel syndrome. J Hand Surg Am. 2018;43(9):833–836.e2. https://doi.org/10.1016/j.jhsa.2018.05.022.

    Article  PubMed  Google Scholar 

  35. Fowler JR, Munsch M, Huang Y, Hagberg WC, Imbriglia JE. Pre-operative electrodiagnostic testing predicts time to resolution of symptoms after carpal tunnel release. J Hand Surg Eur Vol. 2016;41(2):137–42. https://doi.org/10.1177/1753193415576248.

    Article  CAS  PubMed  Google Scholar 

  36. Beck JD, Wingert NC, Rutter MR, Irgit KS, Tang X, Klena JC. Clinical outcomes of endoscopic carpal tunnel release in patients 65 and over. J Hand Surg Am. 2013;38(8):1524–9. https://doi.org/10.1016/j.jhsa.2013.05.016.

    Article  PubMed  Google Scholar 

  37. Chang M-H, Wei S-J, Chiang H-L, Wang H-M, Hsieh PF, Huang S-Y. Forearm mixed nerve conduction velocity: questionable role in the evaluation of retrograde axonal atrophy in carpal tunnel syndrome. J Clin Neurophysiol. 2003;20(3):196–200.

    Article  PubMed  Google Scholar 

  38. Bland JD. A neurophysiological grading scale for carpal tunnel syndrome. Muscle Nerve. 2000 Aug;23(8):1280-3.

    Google Scholar 

  39. Bland JD. Do nerve conduction studies predict the outcome of carpal tunnel decompression? Muscle Nerve. 2001;24(7):935–40.

    Article  CAS  PubMed  Google Scholar 

  40. Grundberg AB. Carpal tunnel decompression in spite of normal electromyography. J Hand Surg Am. 1983;8(3):348–9.

    Article  CAS  PubMed  Google Scholar 

  41. Braun RM, Jackson WJ. Electrical studies as a prognostic factor in the surgical treatment of carpal tunnel syndrome. J Hand Surg Am. 1994;19(6):893–900. https://doi.org/10.1016/0363-5023(94)90086-8.

    Article  CAS  PubMed  Google Scholar 

  42. Atroshi I, Gummesson C, Johnsson R, Ornstein E, Ranstam J, Rosen I. Prevalence of carpal tunnel syndrome in a general population. JAMA. 1999;282(2):153–8.

    Article  CAS  PubMed  Google Scholar 

  43. Witt JC, Hentz JG, Stevens JC. Carpal tunnel syndrome with normal nerve conduction studies. Muscle Nerve. 2004;29(4):515–22. https://doi.org/10.1002/mus.20019.

    Article  PubMed  Google Scholar 

  44. Buch-Jaeger N, Foucher G. Correlation of clinical signs with nerve conduction tests in the diagnosis of carpal tunnel syndrome. J Hand Surg. 1994;19(6):720–4.

    Article  CAS  Google Scholar 

  45. Rydevik B, Lundborg G. Permeability of intraneural microvessels and perineurium following acute, graded experimental nerve compression. Scand J Plast Reconstr Surg. 1977;11(3):179–87.

    Article  CAS  PubMed  Google Scholar 

  46. Yoshii Y, Nishiura Y, Terui N, Hara Y, Saijilafu, Ochiai N. The effects of repetitive compression on nerve conduction and blood flow in the rabbit sciatic nerve. J Hand Surg Eur Vol. 2010;35(4):269–78. https://doi.org/10.1177/1753193408090107.

    Article  CAS  PubMed  Google Scholar 

  47. Mackinnon SE, Dellon AL, Hudson AR, Hunter DA. Chronic nerve compression--an experimental model in the rat. Ann Plast Surg. 1984;13(2):112–20.

    Article  CAS  PubMed  Google Scholar 

  48. Buchberger W, Judmaier W, Birbamer G, Lener M, Schmidauer C. Carpal tunnel syndrome: diagnosis with high-resolution sonography. AJR Am J Roentgenol. 1992;159(4):793–8. https://doi.org/10.2214/ajr.159.4.1529845.

    Article  CAS  PubMed  Google Scholar 

  49. Nakamichi K, Tachibana S. Ultrasonographic measurement of median nerve cross-sectional area in idiopathic carpal tunnel syndrome: diagnostic accuracy. Muscle Nerve. 2002;26(6):798–803. https://doi.org/10.1002/mus.10276.

    Article  PubMed  Google Scholar 

  50. Wong SM, Griffith JF, Hui AC, Lo SK, Fu M, Wong KS. Carpal tunnel syndrome: diagnostic usefulness of sonography. Radiology. 2004;232(1):93–9. https://doi.org/10.1148/radiol.2321030071.

    Article  PubMed  Google Scholar 

  51. Kaymak B, Ozcakar L, Cetin A, Candan Cetin M, Akinci A, Hascelik Z. A comparison of the benefits of sonography and electrophysiologic measurements as predictors of symptom severity and functional status in patients with carpal tunnel syndrome. Arch Phys Med Rehabil. 2008;89(4):743–8. https://doi.org/10.1016/j.apmr.2007.09.041.

    Article  PubMed  Google Scholar 

  52. Nakamichi KI, Tachibana S. Enlarged median nerve in idiopathic carpal tunnel syndrome. Muscle Nerve. 2000;23(11):1713–8.

    Article  CAS  PubMed  Google Scholar 

  53. Kele H, Verheggen R, Bittermann HJ, Reimers CD. The potential value of ultrasonography in the evaluation of carpal tunnel syndrome. Neurology. 2003;61(3):389–91.

    Article  PubMed  Google Scholar 

  54. Cartwright MS, Shin HW, Passmore LV, Walker FO. Ultrasonographic reference values for assessing the normal median nerve in adults. J Neuroimaging. 2009;19(1):47–51. https://doi.org/10.1111/j.1552-6569.2008.00256.x.

    Article  PubMed  Google Scholar 

  55. Fowler JR, Gaughan JP, Ilyas AM. The sensitivity and specificity of ultrasound for the diagnosis of carpal tunnel syndrome: a meta-analysis. Clin Orthop Relat Res. 2011;469(4):1089–94. https://doi.org/10.1007/s11999-010-1637-5.

    Article  PubMed  Google Scholar 

  56. Ziswiler HR, Reichenbach S, Vogelin E, Bachmann LM, Villiger PM, Juni P. Diagnostic value of sonography in patients with suspected carpal tunnel syndrome: a prospective study. Arthritis Rheum. 2005;52(1):304–11. https://doi.org/10.1002/art.20723.

    Article  PubMed  Google Scholar 

  57. Cartwright MS, Hobson-Webb LD, Boon AJ, et al. Evidence-based guideline: neuromuscular ultrasound for the diagnosis of carpal tunnel syndrome. Muscle Nerve. 2012;46(2):287–93. https://doi.org/10.1002/mus.23389.

    Article  PubMed  Google Scholar 

  58. Hobson-Webb LD, Massey JM, Juel VC, Sanders DB. The ultrasonographic wrist-to-forearm median nerve area ratio in carpal tunnel syndrome. Clin Neurophysiol. 2008;119(6):1353–7. https://doi.org/10.1016/j.clinph.2008.01.101.

    Article  PubMed  Google Scholar 

  59. Al-Hashel JY, Rashad HM, Nouh MR, et al. Sonography in carpal tunnel syndrome with normal nerve conduction studies. Muscle Nerve. 2015;51(4):592–7. https://doi.org/10.1002/mus.24425.

    Article  PubMed  Google Scholar 

  60. Aseem F, Williams JW, Walker FO, Cartwright MS. Neuromuscular ultrasound in patients with carpal tunnel syndrome and normal nerve conduction studies. Muscle Nerve. 2017;55(6):913–5. https://doi.org/10.1002/mus.25462.

    Article  PubMed  Google Scholar 

  61. Fowler JR, Maltenfort MG, Ilyas AM. Ultrasound as a first-line test in the diagnosis of carpal tunnel syndrome: a cost-effectiveness analysis. Clin Orthop Relat Res. 2013;471(3):932–7. https://doi.org/10.1007/s11999-012-2662-3.

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Orthopaedics, University of Pittsburgh Medical Center, Pittsburgh, PA, USA

    John R. Fowler

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Correspondence to John R. Fowler .

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  1. Orthopaedic Specialists - UPMC, University of Pittsburgh, Pittsburgh, PA, USA

    Dean G. Sotereanos

  2. Orthopaedic Specialists - UPMC, University of Pittsburgh, Pittsburgh, PA, USA

    Loukia K. Papatheodorou

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Fowler, J.R. (2020). Diagnosis and Clinical Presentation of Carpal Tunnel Syndrome. In: Sotereanos, D., Papatheodorou, L. (eds) Compressive Neuropathies of the Upper Extremity. Springer, Cham. https://doi.org/10.1007/978-3-030-37289-7_3

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