mersin univ saglık bilim derg Mersin Üniversitesi Sağlık Bilimleri Dergisi 1308-0830 Mersin University Surgery (Other) Cerrahi (Diğer) The place of B-mode ultrasonography, shear-wave elastography and superb microvascular imaging in the diagnosis of Carpal Tunnel Syndrome Karpal Tünel Sendromu tanısında B-mod ultrasonografi, Shear-wave elastografi ve superb mikrovasküler görüntülemenin yeri https://orcid.org/0000-0001-6536-2780 Ten Barış MERSİN ÜNİVERSİTESİ RADYOLOJİ ABD https://orcid.org/0000-0003-1606-6728 Çevik Kadir SAĞLIK BİLİMLERİ ÜNİVERSİTESİ, ANKARA ETLİK ZÜBEYDE HANIM KADIN HASTALIKLARI SAĞLIK UYGULAMA VE ARAŞTIRMA MERKEZİ, CERRAHİ TIP BİLİMLERİ BÖLÜMÜ, ORTOPEDİ VE TRAVMATOLOJİ ANABİLİM DALI https://orcid.org/0000-0001-6945-0681 Eskandari Metin Manouchehr MERSİN ÜNİVERSİTESİ, TIP FAKÜLTESİ, CERRAHİ TIP BİLİMLERİ BÖLÜMÜ, ORTOPEDİ VE TRAVMATOLOJİ ANABİLİM DALI https://orcid.org/0000-0002-2835-6979 Temel Gülhan MERSİN ÜNİVERSİTESİ, TIP FAKÜLTESİ, TEMEL TIP BİLİMLERİ BÖLÜMÜ, BİYOİSTATİSTİK VE TIBBİ BİLİŞİM ANABİLİM DALI https://orcid.org/0000-0002-8404-7484 Esen Kaan MERSİN ÜNİVERSİTESİ, TIP FAKÜLTESİ, DAHİLİ TIP BİLİMLERİ BÖLÜMÜ, RADYOLOJİ ANABİLİM DALI https://orcid.org/0000-0003-2709-3051 Kaleağası Hakan MERSİN ÜNİVERSİTESİ, TIP FAKÜLTESİ, DAHİLİ TIP BİLİMLERİ BÖLÜMÜ, NÖROLOJİ ANABİLİM DALI https://orcid.org/0000-0003-1758-9600 Balcı Yüksel MERSİN ÜNİVERSİTESİ, TIP FAKÜLTESİ, DAHİLİ TIP BİLİMLERİ BÖLÜMÜ, RADYOLOJİ ANABİLİM DALI https://orcid.org/0000-0002-4022-0222 Yüksek Hasan Hüsnü MERSİN ÜNİVERSİTESİ, TIP FAKÜLTESİ, DAHİLİ TIP BİLİMLERİ BÖLÜMÜ, RADYOLOJİ ANABİLİM DALI 08 16 2024 17 2 219 230 09 22 2023 01 08 2024 Copyright © 2008, Mersin Üniversitesi Sağlık Bilimleri Dergisi 2008 Mersin Üniversitesi Sağlık Bilimleri Dergisi

Aim: Carpal Tunnel Syndrome is the most common neuropathy of the upper extremity. Electrodiagnostic tests are used to determine the indication for surgery by assessing the severity of neuropathy. However, these evaluations have a margin of error of 10-25% for early cases. The aim of our study is to investigate whether the degree of median nerve neuropathy can be detected with higher sensitivity and specificity with relatively new ultrasonographic parameters that evaluate tissue stiffness and vascularity. Method: The patients' median nerve at both wrist levels, the thickness of the transverse carpal ligament, the distance between the transverse carpal ligament and the adjacent bone, and tissue stiffness (shear wave elastography) and vascularity (superb microvascular imaging) of these structures by ultrasonography. The consistency between ultrasonographically measured tissue thicknesses and surgically measured tissue thicknesses using a caliper was also examined. Results: SWE m/s and kPa values of the median nerve in wrists with Carpal Tunnel Syndrome were significantly higher than in wrists without Carpal Tunnel Syndrome (p=0.0003, p=0.01, respectively). There was an increase in microvascularity in superb microvascular imaging of the median nerve in wrists with Carpal Tunnel Syndrome (p=0.003).Conclusion: Our results showed that median nerve stiffness and microvascularity increased in cases with Carpal Tunnel Syndrome. These findings suggest that, in addition to electrodiagnostic tests in the diagnosis of Carpal Tunnel Syndrome, B-mode ultrasonography, Shear wave elastography and superb microvascular imaging examinations may help clinicians in the treatment decision-making process.

Amaç: Karpal Tünel Sendromu üst ekstremitenin en çok karşılaşılan nöropatisidir. Elektrodiagnostik testler nöropatinin şiddetini değerlendirerek cerrahi endikasyonu belirlemeye yarayan tanısal bir araçtır. Elektrodiagnostik değerlendirmeler tanı ve tedavi kararını belirlemede yaygın olarak kullanılsa da erken dönem vakalar için %10-25 oranında hata payına sahiptir. Bu sebeple çalışmamızın amacı doku sertliği ve doku vaskülariteyi değerlendiren nispeten yeni kabul edilen ultrasonografik parametreler ile median sinir nöropatisinin derecesini daha yüksek sensivite ve spesifite ile tespit edilip edilemeyeceğini araştırmaktır. Yöntem: Dokuz tek taraflı Karpal Tünel Sendromu tanısı olan (8 kadın, 1 erkek, 56.55±8.86 yaş) hasta çalışmaya dahil edildi. Hastaların sağlıklı taraf el bilekleri kontrol grubu olarak kabul edildi. Hastaların her iki el bileği düzeyinde median sinir, transvers karpal ligaman kalınlıkları, transvers karpal ligaman ile komşu kemik arasındaki mesafe ve bu yapıların doku sertliği (shear wave elastografi) ve vaskülaritesi (superb mikrovasküler görüntüleme) ultrasonografi ile iki farklı radyolog tarafından değerlendirildi. Radyologlar arasındaki uyumun yanı sıra ultrasonografik olarak ölçülen doku kalınlıkları ile cerrahi olarak kaliper ile ölçülen doku kalınlıkları arasındaki uyum da incelendi. Bulgular: Karpal Tünel Sendromu kliniği olan el bileklerinde Median sinirin SWE m/s ve kPa değerleri, kliniği olmayanlara göre belirgin derece yüksekti (sırasıyla 0.0003, 0.01). Karpal Tünel Sendromu kliniği olan el bileklerinde Median sinirin Superb mikrovasküler görüntülemesinde mikrovaskülaritede artış vardı (p:0.003). Sonuç: Sonuçlarımız Karpal Tünel Sendromlu olgularda Median sinirde sertliğin ve mikrovaskülaritenin arttığını gösterdi. Bu bulgular Karpal Tünel Sendromu tanısında Elektrodiagnostik testlere ek olarak B mode ultrasonografi, Shear wave elastografi ve Superb mikrovasküler görüntüleme incelemelerinin klinisyenlere tedaviye karar verme sürecinde yardımcı olabileceğini düşündürmektedir.

 Karpal tünel sendromu Shear wave elastografi Superb mikrovasküler görüntüleme Elektrodiagnostik testler Carpal tunnel syndrome Shear wave elastography Superb microvascular imaging Electrodiagnostic testing Bu çalışma Mersin Üniversitesi Bilimsel Akademik Proje (2020-1-AP7-4083) tarafından desteklenmiştir. Mersin Üniversitesi Bilimsel Akademik Proje (2020-1-AP7-4083) Phalen GS. The birth of a syndrome, or carpal tunnel revisited. J Hand Surg Am. 1981; 6:109–110. D’Arcy CA, McGee S. Does this patient have carpal tunnel syndrome? JAMA. 2000; 283:3110–3117. Ibrahim I, Khan WS, Goddard N, Smitham P. Carpal tunnel syndrome: a review of the recent literature. Open Orthop J. 2012;6:69-76. Graham B. The value added by electrodiagnostic testing in the diagnosis of carpal tunnel syndrome. J Bone Joint Surg. 2008; 90:2587–2593. Fowler JR, Cipolli W, Hanson T. A comparison of three diagnostic tests for carpal tunnel syndrome using latent class analysis. J Bone Joint Surg. 2015;97:1958–1961. Roll SC, Case-Smith J, Evans KD. Diagnostic accuracy of ultrasonography vs. electromyography in carpal tunnel syndrome: a systematic review of literature. Ultrasound Med Biol. 2011;37:1539–1553. 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;58:1589–1592. Ozcakar L, Kara M, Chang KV, et al. Nineteen reasons why physiatrists should do musculoskeletal ultrasound: EURO-MUSCULUS/ USPRM recommendations. Am J Phys Med Rehabil. 2015;94:45–94. Kara M, Ozcakar L, De Muynck M, Tok F, Vanderstraeten G. Musculoskeletal ultrasound for peripheral nerve lesions. Eur J Phys Rehabil Med. 2012;48:665–674; quiz 708. Descatha A, Huard L, Aubert F, et al. Meta-analysis on the performance of sonography for the diagnosis of carpal tunnel syndrome. Semin Arthritis Rheum. 2012;41:914–922. Mohammadi A, Afshar A, Etemadi A, et al. Diagnostic value of crosssectional area of median nerve in grading severity of carpal tunnel syndrome. Arch Iran Med. 2010;13:516–521. Klauser AS, Halpern EJ, De Zordo T, et al. Carpal tunnel syndrome assessment with US: value of additional cross-sectional area measurements of the median nerve in patients versus healthy volunteers. Radiology. 2009;250:171–177. Karahan AY, Arslan S, Ordahan B, Bakdik S, Ekiz T. Superb Microvascular Imaging of the Median Nerve in Carpal Tunnel Syndrome: An Electrodiagnostic and Ultrasonographic Study. J Ultrasound Med. 2018;37(12):2855-2861. Yuan-cheng Fung. Biomechanics: Mechanical Properties of Living Tissues, Springer Science & Business Media, 2013. A. Nowicki, K. Dobruch-Sobczak. Introduction to ultrasound elastography, J. Ultrason. 2016;16(65):113–124. J.L. Gennisson, T. Deffieux, M. Fink, et al. Ultrasound elastography: principles and techniques, DIR. 2013;94(5):487–495. R.J. De Wall. Ultrasound elastography: principles, techniques, and clinical applications, Crit. Rev. Biomed. Eng. 2013;41.1:1–19. Kantarci F, Ustabasioglu FE, Delil S, et al. Median nerve stiffness measurement by shear wave elastography: a potential sonographic method in the diagnosis of carpal tunnel syndrome. Eur Radiol. 2014;24(2):434-440. Chen J, Chen L, Wu L, et al. Value of superb microvascular imaging ultrasonography in the diagnosis of carpal tunnel syndrome: Compared with color Doppler and power Doppler. Medicine (Baltimore). 2017;96(21):6862. Endo T, Matsui Y, Kawamura D, et al. Diagnostic Utility of Superb Microvascular Imaging and Power Doppler Ultrasonography for Visualizing Enriched Microvascular Flow in Patients With Carpal Tunnel Syndrome. Front Neurol. 2022;13:832569. Nam K, Peterson SM, Wessner CE, Machado P, Forsberg F. Diagnosis of Carpal Tunnel Syndrome using Shear Wave Elastography and High-frequency Ultrasound Imaging. Acad Radiol. 2021;28(9):278-287. Wee TC, Simon NG. Shearwave Elastography in the Differentiation of Carpal Tunnel Syndrome Severity. PM R. 2020;12(11):1134-1139. Cingoz M, Kandemirli SG, Alis DC, Samanci C, Kandemirli GC, Adatepe NU. Evaluation of median nerve by shear wave elastography and diffusion tensor imaging in carpal tunnel syndrome. Eur J Radiol. 2018;101:59-64. 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. 1993;16:1390–91. Padua L, Lo Monaco M, Gregori B, Valente EM, Padua R, Tonali P. Neurophysiological classification and sensitivity in 500 carpal tunnel syndrome hands. Acta Neurol Scand.1997;96:211–217. Gregoris N, Bland J. Is carpal tunnel syndrome in the elderly a separate entity? Evidence from median nerve ultrasound. Muscle Nerve. 2019;60:217–218. Mulroy E, Pelosi L. Carpal tunnel syndrome in advanced age: a sonographic and electrodiagnostic study. Muscle Nerve. 2019;60:236-241. Bartolome´ -Villar A, Pastor-Valero T, Fuentes-Sanz A, Varillas-Delgado D, Garcı´a-de Lucas F. Influence of the thickness of the transverse carpal ligament in carpal tunnel syndrome. Rev Esp Cir Ortop Traumatol (Engl Ed). 2018;62:100–104. Lin R, Lin E, Engel J, Bubis JJ. Histo-mechanical aspects of carpal tunnel syndrome. Hand. 1983;15:305–309. Arı B, Akçiçek M, Taşcı I, Altunkılıç T, Deniz S. Correlations between transverse carpal ligament thickness measured on ultrasound and severity of carpal tunnel syndrome on electromyography and disease duration. Hand Surg Rehabil. 2022;41(3):377-383.