Carpal Tunnel Syndrome

Diagnosis

1. History Taking

The patient's history often is more important than the physical examination in making the diagnosis of
carpal tunnel syndrome (CTS).

 Numbness and tingling

o loss of grip, dropping things
o Symptoms are usually intermittent and are associated with certain activities (eg, driving,
reading the newspaper, crocheting, painting).
o Nighttime symptoms that wake the individual are more specific to CTS, especially if the
patient relieves symptoms by shaking the hand/wrist.
o Bilateral CTS is common, although the dominant hand is usually affected first and more
severely than the other hand.
o Complaints should be localized to the palmar aspect of the first to the fourth fingers and
the distal palm (ie, the sensory distribution of the median nerve at the wrist). Numbness
existing predominantly in the fifth finger or extending to the thenar eminence or
dorsum of the hand should suggest other diagnoses. A surprising number of CTS
patients are unable to localize their symptoms further (eg, whole hand/arm feeling
dead). This generalized numbness may indicate autonomic fiber involvement and does
not exclude CTS from the diagnosis.
 Pain
o Aching sensation over the ventral aspect of the wrist. This pain can radiate distally to
the palm and fingers or, more commonly, extend proximally along the ventral forearm.
o Pain in the epicondylar region of the elbow, upper arm, shoulder, or neck is more likely
to be due to other musculoskeletal diagnoses (eg, epicondylitis) with which CTS
commonly is associated. This more proximal pain also should prompt a careful search
for other neurologic diagnoses (eg, cervical radiculopathy).
 Autonomic symptoms
o Tight or swollen feeling in the hands and/or temperature changes (eg, hands being
cold/hot all the time).
o Many patients also report sensitivity to changes in temperature (particularly cold) and a
difference in skin color. In rare cases, there are complaints of changes in sweating. In all
likelihood, these symptoms are due to autonomic nerve fiber involvement (the median
nerve carries most of the autonomic fibers to the hand).
 Weakness/clumsiness - Loss of power in the hand (particularly for precision grips involving the
thumb) does occur; in practice, however, loss of sensory feedback and pain is often a more
important cause of weakness and clumsiness than is loss of motor power per se.

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 2. Physical Exam

Clinical examination is important to rule out other neurologic and musculoskeletal diagnoses; however,
the examination often contributes little to the confirmation of the diagnosis of carpal tunnel syndrome
(CTS).

 Sensory examination
o Abnormalities in sensory modalities may be present on the palmar aspect of the first 3
digits and radial one half of the fourth digit. Semmes-Weinstein monofilament testing or
2-point discrimination may be more sensitive in picking this up; however, in the author's
experience, pinprick sensation is as good as any test.
o Sensory examination is most useful in confirming that areas outside the distal median
nerve territory are normal (eg, thenar eminence, hypothenar eminence, dorsum of first
web space).
 Motor examination - Wasting and weakness of the median-innervated hand muscles (LOAF
muscles) may be detectable.
o L - First and second lumbricals
o O - Opponens pollicis
o A - Abductor pollicis brevis
o F - Flexor pollicis brevis
 Special tests - No good clinical test exists to support the diagnosis of CTS.
o Hoffmann-Tinel sign
o Gentle tapping over the median nerve in the carpal tunnel
region elicits tingling in the nerve's distribution.
o This sign still is commonly looked for, despite the low
sensitivity and specificity.
o Phalen sign
o Tingling in the median nerve distribution is induced by full
flexion (or full extension for reverse Phalen) of the wrists
for up to 60 seconds
o This test has 80% specificity but lower sensitivity.
o Prayer Test
o The carpal compression test
o This test involves applying firm pressure directly over the
carpal tunnel, usually with the thumbs, for up to 30 seconds
to reproduce symptoms.
o Reports indicate that this test has a sensitivity of up to 89%
and a specificity of 96%.
o Palpatory diagnosis
o This test involves examining the soft tissues directly overlying
the median nerve at the wrist for mechanical restriction.
o This palpatory test has been noted to have a sensitivity of
over 90% and a specificity of 75% or greater.
o The square wrist sign
o The ratio of the wrist thickness to the wrist width is greater than 0.7.
o This test has a modest sensitivity/specificity of 70%.

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  Several other tests have been advocated, but they rarely provide additional information beyond
that which the Phalen and square wrist signs provide.

3. Laboratory Studies
No blood tests exist for the diagnosis of carpal tunnel syndrome; however, laboratory testing for
associated conditions (eg, diabetes) may be performed when clinically indicated.

4. Imaging Studies
No imaging studies are considered routine in the diagnosis of carpal tunnel syndrome (CTS).
Magnetic resonance imaging (MRI) of the carpal tunnel is particularly useful preoperatively if a
space-occupying lesion in the carpal tunnel is suggested. Signal abnormality can be detected in
the median nerve in some cases of CTS, but how these abnormalities correlate to diagnosis and
physiologic severity is not clear. MRI does not rule out the multitude of other differential
diagnoses and is time consuming and resource intensive. [10]

Many clinical neurophysiology laboratories are now using ultrasonography as an adjunct to

electrodiagnostic studies. Ultrasound potentially can identify space-occupying lesions in and
around the median nerve, confirm abnormalities in the median nerve (eg increased cross
sectional area) that can be diagnostic of CTS, and help guide steroid injections into the carpal
tunnel

5. Electromyogram and Nerve conduction velocity study

Electrophysiologic studies, including electromyography (EMG) and nerve conductions studies
(NCS), are the first-line investigations in suggested carpal tunnel syndrome (CTS). Abnormalities
on electrophysiologic testing, in association with specific symptoms and signs, are considered
the criterion standard for CTS diagnosis.

Electrophysiologic testing also can provide an accurate assessment of how severe the damage to
the nerve is, thereby directing management and providing objective criteria for the
determination of prognosis. CTS is usually divided into mild, moderate, and severe; however,
criteria for this assessment usually vary from lab to lab. In general, patients with mild CTS have
sensory abnormalities alone on electrophysiologic testing, and patients with sensory plus motor
abnormalities have moderate CTS. However, any evidence of axonal loss (eg, decreased or
absent sensory or motor responses distal to the carpal tunnel or neuropathic abnormalities on
needle EMG) is classified as severe CTS.

Changes in electrophysiologic results over time can be used to assess the success of various
treatment modalities.

The American Association of Electrodiagnostic Medicine has published standards and guidelines
that govern the minimum number of studies that should be performed to diagnose CTS.

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Differential Diagnosis

 Cervical Disc Disease

Cervical disc disorders encountered in physiatric practice include herniated nucleus pulposus
(HNP), degenerative disc disease (DDD), and internal disc disruption (IDD). HNP (seen in the
image below) is defined as localized displacement of nucleus, cartilage, fragmented apophyseal
bone, or fragmented anular tissue beyond the intervertebral disc space. Most of the herniation
is made up of the annulus fibrosus. DDD involves degenerative annular tears, loss of disc height,
and nuclear degradation. IDD describes annular fissuring of the disc without external disc
deformation. Cervical radiculopathy can result from nerve root injury in the presence of disc
herniation or stenosis, most commonly foraminal stenosis, leading to sensory, motor, or reflex
abnormalities in the affected nerve root distribution.

 Cervical Myofascial Pain

Pain attributed to muscle and its surrounding fascia is termed myofascial pain, with cervical
myofascial pain thought to occur following either overuse or trauma to the muscles that support
the shoulders and neck. In the cervical spine, the muscles most often implicated in myofascial
pain are the trapezius, levator scapulae, rhomboids, supraspinatus, and infraspinatus.

 Compartment Syndrome

Acute compartment syndrome occurs when the tissue pressure within a closed muscle
compartment exceeds the perfusion pressure and results in muscle and nerve ischemia. It
typically occurs subsequent to a traumatic event, most commonly a fracture.

 Diabetic Neuropathy

In people with diabetes, the body's nerves can be damaged by decreased blood flow and a
high blood sugar level. This condition is more likely when blood sugar level is not well
controlled.

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 About half of people with diabetes develop nerve damage. Symptoms often do not begin
until many years after diabetes has been diagnosed. Some persons who have diabetes that
develops slowly already have nerve damage when they are first diagnosed.

 Leprosy

Leprosy is a chronic infection caused by the acid-fast, rod-shaped bacillus Mycobacterium

leprae. Leprosy can be considered 2 connected diseases that primarily affect superficial tissues,
especially the skin and peripheral nerves. Initially, a mycobacterial infection causes a wide array
of cellular immune responses. These immunologic events then elicit the second part of the
disease, a peripheral neuropathy with potentially long-term consequences.

- Painless skin patch accompanied by loss of sensation but not

itchiness
- Loss of sensation or paresthesias where the affected peripheral
nerves are distributed
- Wasting and muscle weakness
- Foot drop or clawed hands
- Ulcerations on hands or feet

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