SENSITIVITIES OF THE ELECTRODIAGNOSTIC TESTS IN IDIOPATHIC MILD CARPAL TUNNEL SYNDROME

Öz

OBJECTIVE: Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy. The diagnosis is based on the history, clinical signs and symptoms of the patient, but electrodiagnostic studies are done to confirm the diagnosis and to manage the treatment. This study aimed to assess sensitivities of clinical symptoms, provocative tests and electrodiagnostic studies (EDS) in patients with idiopathic mild CTS.
MATERIAL AND METHODS:The study included 90 hands of 75 patients with idiopathic mild CTS and 30 hands of 15 healthy volunteers. The patients were questioned for symptoms in the innervation area of the median nerve such as pain, paresthesia, weakness in the hand and numbness and pain worsening at night, relief from the symptoms by shaking hands. Tinel and Phalen tests were done. The EDS included; motor, mixed and sensorial (digits 1-2-3-4 and palm) nerve conduction studies (NCS) for median nerve; motor, mixed and sensorial (fifth digit) NCS for ulnar nerve, sensorial NCS (first digit) for radial nerve, median and ulnar F waves. The values for distal latency and nerve conduction velocity (NCV) were calculated for all studied nerves. Sensitivities of median sensory distal latency and NCV to digits 1,2,3,4 and palm-wrist segments and sensitivities of the following comparative tests were detected; median-radial sensory distal latency difference (SDLD) to the first digit, median-ulnar SDLD to the fourth digit, median-ulnar SDLD to the digits 2-5, 3-5, 4-5 and median-ulnar F latency difference.
RESULTS: The most common symptoms in patients with idiopathic mild CTS were paresthesia (95.6%) and nocturnal numbness (88.8%). The sensitivity of Phalen’s and Tinel’s tests were 67.8% and 56.7%, respectively. Among the EDS, first digit and palm-wrist sensorial NCV were the most sensitive tests (98.9%). Of the comparative tests, median-ulnar SDLD to digits 4-5 was the most sensitive one (93.3%). Median-ulnar F latency difference had the lowest sensitivity (38.9%).
CONCLUSIONS: The most sensitive EDS were first digit and palm-wrist sensorial NCV. Median-ulnar SDLD to digits 4-5 was more sensitive than the other tests. With use of these tests, the diagnostic sensitivity of EDS may be increased in patients with mild CTS.

Anahtar Kelimeler

• Carpal tunnel syndrome
• electrodiagnostic test
• sensitivity

İDİYOPATİK HAFİF KARPAL TÜNEL SENDROMLU HASTALARDA FARKLI ELEKTRODİAGNOSTİK ÇALIŞMALARIN DUYARLILIĞI

Öz

AMAÇ: Karpal Tünel Sendromu (KTS) en sık görülen tuzak nöropatisidir. Tanısı klinik bulgularla ile konulabilir, ancak tanıyı doğrulamak ve tedaviyi planlamak için elektrodiagnostik çalışmalara ihtiyaç vardır. Bu çalışmada, idiyopatik hafif KTS’li hastalarda klinik semptomlar ve provokatif testler ile elektrodiagnostik testlerin duyarlılığını değerlendirmek amaçlandı.
GEREÇ VE YÖNTEM: Çalışmaya 75 idiyopatik hafif KTS tanılı hasta (90 el) ve 15 sağlıklı gönüllü (30 el) alındı. Hastalarda median sinir innervasyon alanında ağrı, parestezi, elde güçsüzlük, uyku sırasında artan ağrı ve uyuşma ile elleri silkeleme ile şikayetlerde rahatlama semptomları sorgulandı; Tinel ve Phalen testleri yapıldı. Elektrodiagnostik incelemede; median sinir motor, miks, 1-2-3-4. parmak ve avuç içi duyusal iletim çalışmaları, ulnar sinir motor, miks ve 5.parmak duyusal iletim çalışmaları, median ve ulnar F dalgası, radial sinir 1.parmak duyusal iletim çalışması yapıldı. Çalışılan tüm sinirler için distal latans ve sinir iletim hızı değerleri hesaplandı. Parmak (1, 2, 3, 4)ve avuç içi median duyusal distal latansları ve iletimhızlarının; karşılaştırmalı elektrodiagnostik testlerden 1.parmaktan median-radial duyusal distal latans farkının(DDLF), 4. parmaktan median-ulnar DDLF, 2-5, 3-5, 4-5.parmaklar arasında median-ulnar DDLF; median ve ulnarF dalgası latans farklarının duyarlılığı hesaplandı.
BULGULAR: İdiyopatik hafif KTS’li hastalarda en sık rastlanan iki semptom parestezi (%95.6) ve gece uyuşması (%88.8) idi. Phalen testi ve Tinel testlerinin duyarlılığı sırasıyla %67.8 ve %56.7 olarak bulundu. Elektrodiagnostik testlerin sonuçları değerlendirildiğinde, 1.parmak-bilek ve avuç içi-bilek segmenti duyusal iletim hızı çalışmaları %98.9 ile duyarlılığı en yüksek testler olarak bulundu. Uygulanan karşılaştırmalı testlerden 4-5.parmak median-ulnar DDLF %93.3 ile en duyarlı karşılaştırmalı test olarak tespit edildi. Median-ulnar F latans farkı duyarlılığı en düşük test (%38.9) olarak saptandı.
SONUÇ: En duyarlı elektrodiagnostik testler 1. parmak-bilek ve avuç içi-bilek segmenti duyusal iletim hızıydı. 4-5 parmak median-ulnar DDLF diğer karşılaştırmalı sinir iletim çalışmalarından daha duyarlı olarak bulundu. KTS elektrodiagnostik tanısında bu testlerin kullanılması ile duyarlılık arttırılabilir.

Anahtar Kelimeler

• Karpal tünel sendromu
• elektrodiagnostik test
• duyarlılık

Kaynakça

1. 1. Jordan R, Carter T, Cummins C. A systematic review of the utility of electrodiagnostic testing in carpal tunnel syndrome. Br J Gen Pract 2002; 52(481): 670-3.
2. 2. Aroori S, Spence RA. Carpal tunnel syndrome. Ulster Med J 2008; 77(1): 6-17.
3. 3. Demirci S, Sonel B. Comparison of sensory conduction techniques in the diagnosis of mild idiopathic carpal tunnel syndrome: which finger, which test? Rheumatol Int 2004; 24(4): 217-20.
4. 4. 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.
5. 5. Werner RA, Andary M. Electrodiagnostic evaluation of carpal tunnel syndrome. Muscle Nerve 2011;44(4):597-607.
6. 6. Sucher BM, Schreiber AL. Carpal tunnel syndrome diagnosis. Phys Med Rehabil Clin N Am 2014;25(2):229-47.
7. 7. Bland JD. Carpal tunnel syndrome. Curr Opin Neurol 2005; 18(5): 581-5.
8. 8. Ertekin C. Pleksus Brakiyalisten Çıkan Sinirler. In: Ertekin C (Editor) Sentral ve Periferik EMG. Izmir: Meta Basım, 2006: 403-27.

9. 9. MacDermid JC, Wessel J. Clinical diagnosis of carpal tunnel syndrome: a systematic review. J Hand Ther 2004; 17(2): 309-19.
10. 10. Oh SJ. Normal values for common nerve conduction tests. In: Oh SJ (Editor) Clinical Electromyography: Nerve Conduction Studies. Philadelphia: Lippincott Williams&Wilkins, 2003: 86-106.
11. 11. Nora DB, Becker J, Ehlers JA, Gomes I. Clinical features of 1039 patients with neurophysiological diagnosis of carpal tunnel syndrome. Clin Neurol Neurosurg 2004; 107(1): 64-9.
12. 12. Szabo RM, Slater RR, Jr., Farver TB, Stanton DB, Sharman WK. The value of diagnostic testing in carpal tunnel syndrome. J Hand Surg Am 1999; 24(4): 704-14.
13. 13. Gupta SK, Benstead TJ. Symptoms experienced by patients with carpal tunnel syndrome. Can J Neurol Sci 1997; 24(4): 338-42.
14. 14. Kendall WW. Results of treatment of severe carpal tunnel syndrome without internal neurolysis of the median nerve. J Bone Joint Surg Am 1988; 70(1): 151.
15. 15. Buch-Jaeger N, Foucher G. Correlation of clinical signs with nerve conduction tests in the diagnosis of carpal tunnel syndrome. J Hand Surg Br 1994; 19(6): 720-4.
16. 16. Gerr F, Letz R, Harris-Abbott D, Hopkins LC. Sensitivity and specificity of vibrometry for detection of carpal tunnel syndrome. J Occup Environ Med 1995; 37(9): 1108-15.
17. 17. Golding DN, Rose DM, Selvarajah K. Clinical tests for carpal tunnel syndrome: an evaluation. Br J Rheumatol 1986; 25(4): 388-90.
18. 18. De Smet L, Steenwerckx A, Van den Bogaert G, Cnudde P, Fabry G. Value of clinical provocative tests in carpal tunnel syndrome. Acta Orthop Belg 1995; 61(3): 177-82.
19. 19. Kaufman MA. Differential diagnosis and pitfalls in electrodiagnostic studies and special tests for diagnosing compressive neuropathies. Orthop Clin North Am 1996; 27(2): 245-52.
20. 20. Bruske J, Bednarski M, Grzelec H, Zyluk A. The usefulness of the Phalen test and the Hoffmann-Tinel sign in the diagnosis of carpal tunnel syndrome. Acta Orthop Belg 2002; 68(2): 141-5.
21. 21. Kuhlman KA, Hennessey WJ. Sensitivity and specificity of carpal tunnel syndrome signs. Am J Phys Med Rehabil 1997; 76(6): 451-7.
22. 22. Mondelli M, Passero S, Giannini F. Provocative tests in different stages of carpal tunnel syndrome. Clin Neurol Neurosurg 2001; 103(3): 178-83.
23. 23. Kuschner SH, Ebramzadeh E, Johnson D, Brien WW, Sherman R. Tinel's sign and Phalen's test in carpal tunnel syndrome. Orthopedics 1992; 15(11): 1297-302.
24. 24. Padua L, Lo Monaco M, Valente EM, Tonali PA. A useful electrophysiologic parameter for diagnosis of carpal tunnel syndrome. Muscle Nerve 1996; 19(1): 48-53.
25. 25. Chang MH, Liu LH, Lee YC, Wei SJ, Chiang HL, Hsieh PF. Comparison of sensitivity of transcarpal median motor conduction velocity and conventional conduction techniques in electrodiagnosis of carpal tunnel syndrome. Clin Neurophysiol 2006; 117(5): 984-91.
26. 26. Aydin G, Keles I, Ozbudak Demir S, Baysal AI. Sensitivity of median sensory nerve conduction tests in digital branches for the diagnosis of carpal tunnel syndrome. Am J Phys Med Rehabil 2004; 83(1): 17-21.
27. 27. Macdonell RA, Schwartz MS, Swash M. Carpal tunnel syndrome: which finger should be tested? An analysis of sensory conduction in digital branches of the median nerve. Muscle Nerve 1990; 13(7): 601-6.
28. 28. Kothari MJ, Rutkove SB, Caress JB, Hinchey J, Logigian EL, Preston DC. Comparison of digital sensory studies in patients with carpal tunnel syndrome. Muscle Nerve 1995; 18(11): 1272-6.
29. 29. Terzis S, Paschalis C, Metallinos IC, Papapetropoulos T. Early diagnosis of carpal tunnel syndrome: comparison of sensory conduction studies of four fingers. Muscle Nerve 1998; 21(11): 1543-5.
30. 30. Lauritzen M, Liguori R, Trojaborg W. Orthodromic sensory conduction along the ring finger in normal subjects and in patients with a carpal tunnel syndrome. Electroencephalogr Clin Neurophysiol 1991; 81(1): 18-23.
31. 31. Stevens JC. AAEM minimonograph #26: the electrodiagnosis of carpal tunnel syndrome. American Association of Electrodiagnostic Medicine. Muscle Nerve 1997; 20(12): 1477-86.
32. 32. Pease WS, Cannell CD, Johnson EW. Median to radial latency difference test in mild carpal tunnel syndrome. Muscle Nerve 1989; 12(11): 905-9.
33. 33. Oh SJ. Normal values for common nerve conduction tests. In: Oh SJ (Editor) Clinical Electromyography: Nerve Conduction Studies. Philadelphia: Lippincott Williams&Wilkins, 2003: 37-53.
34. 34. Uncini A, Lange DJ, Solomon M, Soliven B, Meer J, Lovelace RE. Ring finger testing in carpal tunnel syndrome: a comparative study of diagnostic utility. Muscle Nerve 1989; 12(9): 735-41.
35. 35. Uncini A, Di Muzio A, Awad J, Manente G, Tafuro M, Gambi D. Sensitivity of three median-to-ulnar comparative tests in diagnosis of mild carpal tunnel syndrome. Muscle Nerve 1993; 16(12): 1366-73.
36. 36. Preston DC, Shapiro BE. Median Neuropathy At The Wrist. In: Preston DC, Shapiro BE (Editor) Electromyography And Neuromuscular Disorders. Third edition Elsevier; 2013: 267-88.
37. 37. Sander HW, Quinto C, Saadeh PB, Chokroverty S. Sensitive median-ulnar motor comparative techniques in carpal tunnel syndrome. Muscle Nerve 1999; 22(1): 88-98.
38. 38. Bland JD. Carpal tunnel syndrome. BMJ 2007; 335(7615): 343-6.
39. 39. Padua L, LoMonaco M, Gregori B, Valente EM, Padua R, Tonali P. Neurophysiological classification and sensitivity in 500 carpal tunnel syndrome hands. Acta Neurol Scand 1997; 96(4): 211-7.
40. 40. Carroll GJ. Comparison of median and radial nerve sensory latencies in the electrophysiological diagnosis of carpal tunnel syndrome. Electroencephalogr Clin Neurophysiol 1987; 68(2): 101-6.
41. 41. Padua L, Pasqualetti P, Rosenbaum R. One patient, two carpal tunnels: statistical and clinical analysis--by hand or by patient? Clin Neurophysiol 2005; 116(2): 241-3.