Comparison of Ultrasonic and Electrophysiological Pre and Postoperative Evaluation for Carpal Tunnel Syndrome
Lutz Schreiber1*, Matthias Vorgerd², Dirk Taeger³, Tim Maecken4, Lars Steinstraesser5
1Department of
Neurosurgery, Klinikum Vest, Academic Teaching Hospital, Ruhr University
Bochum, Dorstener Str. 151, 45657 Recklinghausen, Germany
2Department of
Neurology, BG University Hospital Bergmannsheil, Ruhr-Universität Bochum, Bürkle-de-la-camp-Platz
1, 44789 Bochum, Germany
³Institute for Prevention and Occupational Medicine of the German Social
Accident Insurance, Institute of the Ruhr-Universität Bochum (IPA), Bürkle-de-la-camp-Platz
1, 44789 Bochum Germany
4Department of Anesthesiology, Intensive Care,
Palliative Care and Pain Therapy, BG University Hospital Bergmannsheil,
Ruhr-Universität Bochum, Bürkle-de-la-camp-Platz 1, 44789 Bochum, Germany
5Department of Plastic, Reconstructive and Aesthetic Surgery, Handsurgery, Christliches Krankenhaus Quakenbrück / St. Anna-Klinik Löningen, Danziger Str. 2, 49610 Quakenbrück, Germany
*Corresponding author: Lutz Schreiber, Department of Neurosurgery, Klinikum Vest, Academic Teaching Hospital, Ruhr University Bochum, Dorstener Str. 151, 45657 Recklinghausen, Germany. Tel: +49-236156 83621; Fax: +49-2361563697; Email: lutz.schreiber@klinikum-vest.de
Received Date: 13 February, 2019; Accepted Date: 06 March, 2019; Published Date: 11 March, 2019
Citation: Schreiber L, Vorgerd
M, Taeger D, Maecken T, Steinstraesser L (2019) Comparison of Ultrasonic and
Electrophysiological Pre and Postoperative Evaluation for Carpal Tunnel
Syndrome. J Surg 11: 1203. DOI: 10.29011/2575-9760.001203
Abstract
Purpose: The aim of this prospective study was to compare high definition
ultrasonography vs. electrophysiological testing in order to evaluate their
diagnostic value for Carpal Tunnel Syndrome (CTS).
Methods: In this prospective study forty patients with carpal tunnel syndrome
were studied preoperatively and 1, 3, 6 and 12 months postoperatively. The
electrophysiological testing included the distal motor latency and the sensory
conduction velocity. The cross-sectional area of the median nerve at the carpal
tunnel inlet (Level 1) and at the middle of carpal tunnel (Level 2) was
measured with ultrasonography. The intensity of pre- and postoperative pain was
also documented with pain scales and correlated with the electrophysiological
and ultrasonic findings.
Results: A postoperative statistical significant alteration was observed for the
distal motor latency and the sensory conduction velocity. At Level 1 and at
Level 2 no statistical significant change of the cross-sectional area of the
median nerve was observed postoperatively. The cross-sectional area of the
median nerve of the operated and non-operated hand at Level 2 showed
preoperatively a statistic significant difference which was not detectable 12
months postoperatively
Discussion: The electrophysiological testing as a clinically established method for diagnosing CTS also allows a postoperative monitoring of the level of regeneration and function of the median nerve. High definition ultrasound is a versatile method to diagnose CTS, but it is necessary to analyze both hands in order to identify a difference of the cross-sectional area of both median nerves. For the postoperative follow up of median nerve recovery electrophysiological testing has to be preferred.
Keywords: Carpal tunnel syndrome; Cross-sectional
area; Distal motor latency; Electrophysiology; Ultrasound
Introduction
Carpal Tunnel Syndrome (CTS) is the most
common nerve compression syndrome of peripheral nerves in the upper extremity.
The CTS is caused by increasing pressure in the carpal tunnel with consecutive
compression of the median nerve. The cause for the CTS is mainly
idiopathic [1]. There is a prevalence of
CTS in the adult population of 2.5-11% [2-4]. The mean age of patients
with carpal tunnel syndrome is 45 years up to 54 years. The Incidence is
mentioned with 0.125 up to 1% [5-7]. Electrophysiological
testing is one of the most important diagnostic tools for carpal tunnel
syndrome and the current “gold standard” for the diagnosis. The distal motor
latency of the median nerve shows a sensitivity of 63 % and a specificity of
98%. The sensory conduction velocity shows a sensitivity of 65% and a
specificity of 98% [8]. Recently, high
definition ultrasonography has been proposed for the diagnosis of CTS [9-13]. Previous studies have
hypothesized that ultrasonography might be a useful alternative for testing the
median nerve with suspected carpal tunnel syndrome [14-17]. The aim of this
prospective study was to shed light on the informative value of high definition
ultrasound in comparison with electrophysiological testing and to identify the
responsible factors and parameters respectively.
Materials
and Methods
For this prospective study 80 wrists of 40
patients were included (Male: 6, Female: 34). Their mean-age was 56.6 years (32
years - 82 years; standard deviation: 13,4). All persons gave their informed
consent prior to their inclusion in the study. The study protocol conformed to
the ethical guidelines of the 1975 Declaration of Helsinki and an ethical
committee authorized this study. All referred patients were diagnosed with CTS
for the first time and surgical therapy was carried out with limited incision
and decompression of the median nerve in wide awake anesthesia. Functional and
neurological assessment of the hand was carried out preoperative and after 1,
3, 6 and 12 months postoperatively. Each evaluation of the patient was
subdivided in a clinical inspection and clinical testing of the operated and
the non-operated wrist (Phalen-Test/ Hoffmann-/ Tinel-sign). A “Dantec
Neuromatic 2000M” (Dantec, Copenhagen, Denmark) was used for a detailed
electrophysiological testing of both wrists of the patient. The investigator is
neurologist and has 20 years of experience in electrophysiological testing.
Amongst others this electrophysiological
evaluation of the wrists included the distal motor latency and the antidromic
sensory conduction velocity as two relevant parameters for testing the median
nerve in cause of a carpal tunnel syndrome. Furthermore, detailed sonographic
measurements of the median nerve at 4 various levels of the forearm and wrists
of both hands were performed. All measurements were performed by a single
investigator in an objective manner. Two levels proximal of the carpal tunnel,
one level at the carpal-tunnel-inlet and one level at the middle of the carpal
tunnel. The cross-sectional area at the carpal tunnel inlet and at the middle
of carpal tunnel was the preferred side of visualization. The cross-sectional
area of the median nerve was calculated as an ellipsoid by measuring the
anterior-posterior and the medio-lateral parameter.
The ultrasonic device was the
High-Definition-Ultrasonic-device “Micromaxx, Sonosite” (Sonosite, Bothell,
USA) with a “HFL-38 E”-linear-probe (6-13 MHz) (Figure 1).
All results were compared with the initial
evaluation and were compared with the non-operated wrist of the patients. The
operated hand was in 62.5 % the dominant hand of the patient. In this study 38
right-handed and 2 left-handed patients were included. Observed mean values,
standard deviations, medians, minimum and maximum values of the distal motor
latency, the sensory conduction velocity, the cross-sectional area at the
carpal-tunnel-inlet and at the middle of the carpal tunnel, and the pain of the
operated hand were calculated. In order to identify potential influences linear
regression analysis was carried out for age, sex, operated hand (left/right),
guide hand (left/right), duration of discomfort, and time after surgery. These
models provide estimated means adjusted for the influenced variables. The
preoperative values were compared with postoperative values during the
follow-up.
Results
Electrophysiological Testing
Surgery was carried out after a pathological
prolonged Distal Motor Latency (DML) of the operated hand was observed (DML>
4ms was considered pathologic). After surgical decompression of the median
nerve a statistic significant reduction for the distal motor latency was
detected at all time points during the postoperative period of one year. The
Sensory Conduction Velocity (SCV) increased significantly at each time point
during the follow-up of one year and was statistic significant after month 3
for the remaining period of the investigation (Figures 2,3).
Ultrasonography
After open decompression of the median nerve
no statistical difference was observed in regard to the cross-sectional area.
At the follow-up period (12 months) a decreasing and increasing of the
cross-sectional area is shown but it was not statistically significant (Figure
4).
The comparison of the cross-sectional area at
the middle of the carpal tunnel of the operated hand and the no-operated hand
demonstrated that there was a statistic significant difference preoperative (p
= 0.004) and 1 month postoperative (p = 0.005). Later time points revealed no
significant difference anymore (Figure 5).
Clinical Evaluation
The surgical decompression of the median
nerve resulted in a fast and highly significant reduction of the initial pain
of the patients at all time points (Figure 6).
Discussion
The “carpal tunnel syndrome” is diagnosed
clinically. The exact evaluation of the symptoms and the physical examination
of the patients allow usually the diagnosis “carpal tunnel syndrome” [6,18,19]. Furthermore, the
verification of CTS is frequently carried out before planning the surgery.
Currently electrophysiological testing is the clinical “gold-standard” for the
diagnosis for CTS [8,20]. The distal motor
latency and the sensory conduction velocity of the median nerve are the two
most important electrophysiological parameters. The distal motor latency shows
a sensitivity of 63 % and a specificity of 98%. The sensory conduction velocity
shows a sensitivity of 65% and a specificity of 98% [8]. Recently, several
studies demonstrated that high definition ultrasound might be a potential
alternative for the electrophysiological testing [14,9,21-23]. In this study we were
able to demonstrate that electrophysiological testing is a reliable and
reproducible method for the diagnosis of carpal tunnel syndrome. Furthermore,
it could be shown that the regeneration of the median nerve after surgical
decompression in the carpal tunnel could be demonstrated and monitored with the
electrophysiological method. The analysis of the patient’s conception of pain
after surgical decompression of the median nerve is a sufficient method for
assessing the success of the surgical decompression. We observed a good
correlation between the pain-reduction and the electrophysiological improvement
of the median nerve. The high definition ultrasound assessment did not hold the
promises we had at the initiation of this study [14].
Further refinements in the ultrasonic
assessment and resolution are required and both hands need to be investigated
because there was a statistic significant difference between the
cross-sectional area of the operated and the no-operated hand detectable (p =
0.004). In the 3-months postoperative measurement this difference was no longer
detectable.
In the postoperative follow-up of one year the
ultrasound testing was not able to show a statistic significant changing of the
cross-sectional area of the median nerve. In our study we were not able to
repeat previous studies that demonstrated a significant postoperative change of
the cross-sectional area after surgical decompression [1,11,10]. Due to this fact one of
the most important benefits of the high-definition ultrasound is the real-time
visualization of the carpal tunnel and the median nerve. In the preoperative
analyze tumorous lesions, ganglions or an atypical anatomical course of the
median nerve can be visualized and included in the surgical strategy. In the
postoperative ultrasound follow-up possible complications like edema or
post-operative-bleeding could be excluded or detected. In future the high
definition ultrasound will presumably be qualified for standardized
preoperative testing of patients with clinical symptoms of carpal tunnel
syndrome because a first meta-analysis presents new reference parameters for
the cross-sectional area of the median nerve [24]. If postoperative testing
is necessary, the electrophysiological measurement demonstrates the
regeneration of the median nerve reliably and reproducible and has to be
preferred.
Figure 1: Sonographic representation of the carpal tunnel.
(+ = N. medianus; * = tendon of the M. flexor pollicis
longus; ↑ = tendons of the M. flexor digitorum superficialis)
Figure 2: Distal Motor Latency.
Figure 3: Sensory Conduction Velocity.
Figure 4: Cross-Sectional Area.
Figure 5: Comparison Cross-Sectional Area.
Figure 6: Pain Scale.
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