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Failure of the post-operative studies to show this improvement in comparison with timely pre-operative studies which showed grade 5 or less CTS is very suggestive of inadequate decompression. Change in neurophysiological grade from before to after surgery in operations vs outcome of surgery. Green bars show the percentage of patients with a given improvement in NCS results reporting that symptoms are completely cured or much improved. Red bars show the percentage of patients with a given change in NCS who report themselves worse after surgery.
The AAOS Guidelines are based on analysis of the strength of evidence in the literature, and this is important in guiding evidence-based practice. We should keep in mind that this could bias published reports in favour of unusual cases and studies of aetiology, such as the literature on workplace injury, designed to establish a role for manual labour and repetitive wrist movement. The Guidelines indicate that there is strong evidence for an association between thenar wasting and carpal tunnel syndrome, and this is not surprising in the context of a patient presenting with symptoms suggestive of carpal tunnel syndrome.
However neurologists should be concerned if there is thenar wasting without those symptoms. In any case the diagnosis of carpal tunnel syndrome should be made long before wasting or fixed sensory loss develop because this suggests a severe compression neuropathy, and the results of decompression are likely to be incomplete. However clinicians rely not on isolated signs and symptoms but on the whole picture, and the lack of strong evidence for a symptom or sign by itself does not negate the value of that feature in context.
There are reports of patients successfully treated by carpal tunnel decompression, who reported pain extending from the neck to the hand Crymble, and with shoulder pain Kummell and Zazanis, It is common for patients to say that their troubles involve the whole of the palmar aspect of the hand and fingers, even the numbness.
Similarly Zanette et al. While patients with symptoms restricted to a median distribution and those with extra-median distribution may respond equally well to surgery Claes et al. With regard to mechanisms and treatment, it is of interest that Zanette et al. Prolonged wrist extension can produce conduction block even in previously healthy subjects, though more readily in patients with CTS.
While exercise should be encouraged, I stress that push-ups, exercising by lifting weights or dumbbells, or sitting, placing the hands flat on the floor and lifting the body from the floor using the hands are exercises that involve two manoeuvres that increase pressure in the carpal tunnel. Given this, practitioners should report nerve conduction studies appropriately. They support the diagnosis of CTS, but cannot make it. Secondly , the defined abnormalities of nerve conduction need not be symptomatic, just as radiological evidence of cervical spondylosis does not mean that symptoms are due to that abnormality.
In this respect, many patients have similar though commonly less severe abnormalities of nerve conduction on their other, asymptomatic side. While nerve conduction abnormalities commonly improve following successful decompression surgery, they often do not normalise, as also noted by Dr. It can therefore be difficult to attribute a nerve conduction abnormality to recurrence of nerve compression in a patient who had previously undergone decompression surgery, particularly if preoperative studies were not performed.
This is one of a number of reasons why NCS should be undertaken in all patients with suspect carpal tunnel syndrome prior to surgery. Before they go under the knife, most patients want to know that the surgeon is indeed operating on a documented abnormality rather than an undocumented clinical diagnosis. Not to undertake nerve conduction studies prior to surgery is bordering on clinical arrogance; all practitioners will have seen patients who underwent decompression for carpal tunnel syndrome but probably never had the condition.
There are patients in whom I think the diagnosis is probably carpal tunnel syndrome but in whom the nerve conduction studies are not diagnostic according to the criteria that I use. At the time of testing, patients are commonly not symptomatic, the numbness and dysaesthesiae having subsided shortly after waking. The yield of NCS in these patients is remarkably high, and is not improved further by studying patients when they have their distressing symptoms.
Readers should keep in mind two issues. First , we do not study axons of small calibre responsible for pain, perhaps the most distressing symptom. Secondly , in those fibres that we can study, large myelinated axons, we look for conduction slowing across the carpal tunnel with or without attenuation of the compound action potential. We artificially synchronise all axons to discharge together and conduction slowing of 0. In terms of function, however, conduction slowing of this degree is immaterial provided that a sufficient number of axons can conduct. With large myelinated cutaneous sensory axons, the delay will have no effect on the perception of touch which requires temporal and spatial summation of the activity of a number of asynchronously discharging axons.
Accordingly that there is a significant correlation between conduction abnormalities and symptomatology Fig. When numbness persists during the day, the sensory potential is always small, and I am then more likely to recommend invasive management. The symptoms of carpal tunnel syndrome can resolve with time, and management should be directed to i alleviating discomfort, and ii preserving nerve function.
I agree with Dr. Menkes and Dr. Bland that the greater the pre-existing nerve damage, the greater the need for decompression, and am happy for conservative approaches to be tried in those with less abnormal nerve conduction findings. If the patient can tolerate the discomfort and the amplitudes of sensory potentials are preserved, I am content to see if the condition will resolve without external interference.
National Center for Biotechnology Information , U. Journal List Clin Neurophysiol Pract v. Clin Neurophysiol Pract. Published online Apr 5. Masahiro Sonoo , a Daniel L. Menkes , b Jeremy D. Daniel L. Jeremy D. Author information Article notes Copyright and License information Disclaimer.
David Burke: ua. Published by Elsevier B. This article has been cited by other articles in PMC. Abstract This paper summarises the views of four experts on the place of neurophysiological testing EDX in patients presenting with possible carpal tunnel syndrome, in guiding their treatment, and in reevaluations.
Keywords: Carpal tunnel syndrome, Median neuropathy at the wrist, Nerve conduction studies, Needle EMG, Surgical decompression, Local injection of corticosteroids, Conservative management. Introduction Carpal tunnel syndrome is perhaps the commonest cause of referral for neurophysiological testing, herein referred to as electrodiagnostic testing or EDX.
Masahiro Sonoo: Review of existing guidelines and diagnostic criteria, and the role of nerve conduction study in CTS evaluation Several neurological disorders to which EDX tests make significant contributions have widely-approved diagnostic criteria, such as amyotrophic lateral sclerosis ALS de Carvalho et al. Existing diagnostic criteria There are very few published diagnostic criteria for CTS. Open in a separate window. Practical use of NCS Most experts will agree that a typical CTS patient can be diagnosed only from clinical symptoms and signs with high certainty.
Daniel Menkes: The role of electrodiagnostic testing in the diagnosis of carpal tunnel syndrome The American Academy of Orthopedic Surgeons published an article that discussed the management of carpal tunnel syndrome CTS based on the evidence published in the medical literature AAOS, Table 1 Suggested Management Principles. Carpal tunnel syndrome is a syndrome Given this, practitioners should report nerve conduction studies appropriately. Why are patients commonly asymptomatic and without deficits when tested? When should we contemplate median nerve decompression?
Follow-up studies at a suitable interval are advised in patients with mild or equivocal findings. Such patients should be treated conservatively. However, these patients should be tested on relapse to ensure that progression is not occurring. Patient factors such as the degree of discomfort and social factors such as the needs of employment are important considerations. Indications for needle EMG also include establishing how acute and complete is the abnormality, or that the abnormality is indeed at the carpal tunnel. The latter might require EMG of muscles outside the thenar eminence depending on the differential diagnosis.
NCS can also document the state of neural function before an invasive procedure allowing for a post-intervention comparison when required. Conflict of interest The authors have no conflicts of interest to declare. References American Academy of Orthopaedic Surgeons, Management of carpal tunnel syndrome: Evidence based clinical practice guideline, www. Alshaikh N. Perception of pain during electromyography in children: A prospective study. Muscle Nerve. Local injection versus surgery in carpal tunnel syndrome: neurophysiologic outcomes of a randomized clinical trial.
Diagnostic properties of nerve conduction tests in population-based carpal tunnel syndrome. BMC Musculoskelet. Prevalence of carpal tunnel syndrome in a general population. Patient satisfaction and return to work after endoscopic carpal tunnel surgery. Hand Surg.
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A neurophysiological grading scale for carpal tunnel syndrome. The value of the history in the diagnosis of carpal tunnel syndrome. Do nerve conduction studies predict the outcome of carpal tunnel decompression? Treatment of carpal tunnel syndrome. Nerve conduction studies for carpal tunnel syndrome: gold standard or unnecessary evil?
New Method Diagnoses Chronic Unexplained Nerve Pain | HuffPost Life
Remodelling during remyelination in the peripheral nervous system. Lumbrical and interossei recording in severe carpal tunnel syndrome. El Escorial revisited: Revised criteria for the diagnosis of amyotrophic lateral sclerosis. Lateral Scler. Other Motor Neuron Disord. Distribution of paresthesias in Carpal Tunnel Syndrome reflects the degree of nerve damage at wrist.
Medicare's reimbursement reduction for nerve conduction studies: effect on use and payments. JAMA Intern. Median nerve changes following steroid injection for carpal tunnel syndrome. Treatment outcome in carpal tunnel syndrome: does distribution of sensory symptoms matter? Often atypical? The distribution of sensory disturbance in carpal tunnel syndrome. The predictive value of electrodiagnostic studies in carpal tunnel syndrome.
Brachial neuralgia and the carpal tunnel syndrome. Does this patient have carpal tunnel syndrome? Entrapment Neuropathies. Electrodiagnostic criteria for diagnosis of ALS. Efficacy of provocative tests for diagnosis of carpal tunnel syndrome. Corticoid injection as a predictive factor of results of carpal tunnel release. Acta Ortop. Predicting the outcome of carpal tunnel release. Corticosteroid injections for carpal tunnel syndrome: long-term follow-up in a population-based cohort.
Factores pronosticos en la cirugia del sindrome del tunel carpiano. Acta Orthop. Clinical Neurology. Splinting vs Surgery in the treatment of carpal tunnel syndrome: a randomised controlled trial. Electrodiagnostic testing and carpal tunnel release outcome. The value added by electrodiagnostic testing in the diagnosis of carpal tunnel syndrome.
Bone Joint Surg. Development and validation of diagnostic criteria for carpal tunnel syndrome. Prevalence of decompression surgery in patients with carpal tunnel syndrome 8 years after initial treatment with a local corticosteroid injection. Clinical utility of the flick maneuver in diagnosing carpal tunnel syndrome.
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Electrodiagnosis of mild carpal tunnel syndrome. Corticosteroid injection for carpal tunnel syndrome: a 5-year survivorship analysis. Diagnosis of carpal tunnel syndrome The gold standard. Safety of corticosteroid injection for carpal tunnel syndrome. The carpal tunnel syndrome: diagnostic utility of the history and physical examination findings.
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Functional Electromyography: Provocative Maneuvers in Electrodiagnosis
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Shoulder pain as the presenting complaint in carpal tunnel syndrome. Carpal tunnel syndrome diagnosis and treatment: a survey of members of the american society for surgery of the hand. The carpal tunnel syndrome: a clinical and electrophysiological study in patients. Surgical decompression versus local steroid injection in carpal tunnel syndrome: a one-year, prospective, randomized, open, controlled clinical trial. Arthritis Rheum. Local corticosteroid injection for carpal tunnel syndrome.
Cochrane Database Syst. Relationship between the self-administered Boston questionnaire and electrophysiological findings in follow-up of surgically-treated carpal tunnel syndrome. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. Slowing of sensory conduction of the median nerve and carpal tunnel syndrome in Japanese and American industrial workers.
Clinical features of patients with neurophysiological diagnosis of carpal tunnel syndrome. Anatomical changes in peripheral nerves compressed by a pneumatic tourniquet. The nature of the nerve lesion caused by chronic entrapment in the guinea-pig. Neurophysiological classification and sensitivity in carpal tunnel syndrome hands. Acta Neurol. Multiperspective follow-up of untreated carpal tunnel syndrome: a multicenter study.
False positive electrodiagnostic tests in carpal tunnel syndrome. Consensus criteria for the classification of carpal tunnel syndrome in epidemiologic studies. Public Health. Carpal tunnel syndrome and the myth of El dorado. The importance of accounting for correlated observations. Diagnostic testing requested before surgical evaluation for carpal tunnel syndrome. Nerve conduction studies after treatment for carpal tunnel syndrome.
Symptoms of thoracic outlet syndrome in women with carpal tunnel syndrome. The electrodiagnosis of carpal tunnel syndrome. Symptoms of patients with electromyographically verified carpal tunnel syndrome. Endoscopic carpal tunnel release: a prospective analysis of factors associated with unsatisfactory results. Referred pain from intraneural stimulation of muscle fascicles in the median nerve.
Independent variables affecting outcome of carpal tunnel surgery Hand N Y. Electrodiagnostic evaluation of carpal tunnel syndrome. Carpal tunnel syndrome with normal nerve conduction studies. Central sensitization in carpal tunnel syndrome with extraterritorial spread of sensory symptoms. Proximal pain in patients with carpal tunnel syndrome: a clinical-neurophysiological study. Nerve Syst. The results of carpal tunnel release for carpal tunnel syndrome diagnosed on clinical grounds, with or without electrophysiological investigations: a randomized study. Articles from Clinical Neurophysiology Practice are provided here courtesy of Elsevier.
Support Center Support Center. External link. Wilkins , Hardcover. Be the first to write a review About this product. About this product Product Information The book introduces the use of provocative maneuvers to widen the scope of application and sharpen the diagnostic acuity of electrodiagnostic studies including nerve conduction velocities NCV and electromyogram EMG. Employing provocative maneuvers in somatosensory, ocular, and brainstem studies is suggested but not detailed. The author suggests the further use of provocative maneuvers in other electrodiagnostics such as somatosensory, visual, and brains stem evoked potential studies.
The electrodiagnostic studies described and suggested here are extensions of the physical examination conducted in many clinical specialties, ranging from internal medicine to neurosurgery to chiropractic and other types of body workers. These studies are central to the work of physiatrists, neurologists, orthopedic surgeons and specialists in pain management. The techniques extend the reach of EMG to conditions that were difficult to diagnose by any means before.
In addition, the book provides direction to adapt its methods to cases beyond those it discusses. The book presents three well-documented examples of functional EMG: the changes in electrophysiological parameters with provocative maneuvers help make diagnosis of piriformis syndrome that is otherwise considered a "diagnosis of exclusion" by many physicians, yet can be proven to occur frequently in respectably large sample populations.
Neurological thoracic outlet syndrome is another diagnosis that is even less accessible. Although its incidence and prevalence are less thoroughly documented, it is important both to identify the entity and to have a definitive means to rule it out, especially in referred or neurological upper extremity pain of non-cervical origin.
Third, the distinction between foraminal narrowing due to disc herniations and spinal stenosis is often difficult in the many cases in which both are present. The clinical question often revolves around which of the two conditions is the major pain generator.
Conversely, while flexion is beneficial for spinal stenosis, it can dangerously extend discal herniations. A safe. The book then goes on to suggest a safe and scientific method for determining other functional maneuvers of value to the electromyographer and suggests means of validating one-time measures that may benefit the electromyographer in diverse clinical situations that are neither common nor predictable. Some of these are as obvious as comparison with the unaffected limb in a carpal tunnel syndrome that only shows up in the flexed wrist; others require the use of standard deviations derived for other purposes, and depend upon the discretion of the clinician as well as the particular case.
Additional Product Features Number of Volumes. From the book reviews: "This is an excellent monograph concerning EMGs of the upper and lower extremities for electrodiagnosis and treatment planning.
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It covers all aspects of diagnosis, surgery, and physical therapy. This is a great text on EMG. I highly recommend it to physiologists, surgeons, students, and fellows of EMGs. Grenier, Amazon. Show More Show Less. Any Condition Any Condition. No ratings or reviews yet.