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Objective: To evaluate the clinical efficacy of ultrasound-guided needle knife release with different pathways for carpal tunnel syndrome (CTS)., Methods: Sixty CTS patients were randomly divided into a transverse group and a longitudinal group, with 30 patients in each group. The transverse group received the needle knife release under ultrasound above and below the median nerve along the short axis, while the longitudinal group received the needle knife release under ultrasound above the median nerve along the long axis. The patients' visual analogue scale (VAS) scores, Levine scores, and median nerve cross-section area (CSA) were assessed before treatment, on the 7th, 14th, and 30th days after treatment. The median nerve conduction indexes (motor conduction: latency [Lat], amplitude[Amp], motor conduction velocity [MCV]; sensory conduction: Lat, Amp, sensory conduction velocity [SCV]) were evaluated before treatment and on the 30th day after treatment., Results: Compared before treatment, the VAS scores, Levine scores, and median nerve CSA were reduced in both groups on the 7th, 14th, and 30th days after treatment ( P <0.05); the transverse group showed lower VAS and Levine scores and smaller CSA than those in the longitudinal group ( P <0.05). On the 30th day after treatment, motor and sensory Lat was reduced ( P <0.05), motor and sensory Amp was increased ( P <0.05), and MCV and SCV were faster ( P <0.05) in both groups. The transverse group had shorter Lat, higher Amp, and faster MCV and SCV than those in the longitudinal group ( P <0.05)., Conclusion: The ultrasound-guided needle knife release with transverse and longitudinal pathways could both effectively alleviate pain and improve median nerve conduction in CTS patients, with the transverse pathway showing superior efficacy to longitudinal pathway.

Objective: This study was conducted to ascertain the efficacy of photo acupuncture (PA) on the neurophysiological parameters of the median nerve and hand function in postnatal women. Background: Carpal tunnel syndrome (CTS) has been documented in up to 62% of pregnant females. PA, a noninvasive treatment that utilizes photo therapy on acupoints, could aid in the management of CTS. Material and Methods: Thirty-six postpartum women diagnosed with CTS depending on their medical history, physical examination, and electrodiagnostic study were distributed into two equal-sized groups at random. The PA group ( n = 18) received PA for 12 min on the following acupuncture points: PC4, PC6, PC7, PC8, HT2, HT3, HT7, LI10, LI11, LI4, LU9, and LU10. The treatment was given 3 times weekly for four weeks; in addition, night splints were worn. Women in the control group ( n = 18) just wore night splints. Before and after the 12-session treatment, each woman was assessed using an electrodiagnostic test to measure the motor distal latency (MDL), sensory distal latency (SDL), motor conduction velocity (MCV), sensory conduction velocity (SCV), pinch dynamometer for assessing pinch strength, and the Brief Michigan Hand Questionnaire (BMHQ) for assessing hand function. Results: A statistically significant improvement was observed in both groups after therapy regarding SDL, SCV, MDL, MCV, pinch strength, and BMHQ ( p < 0.05) in favor of the PA group. Conclusion: Adding PA to a night splint should be suggested as an effective conservative therapy for CTS in postpartum women.

Objective: To investigate whether nerve mobilization related to nerve mobility or the removal of edema using lymphatic drainage affects the cross-sectional area of the nerve, hand function, and symptom severity in carpal tunnel syndrome., Design: The study is a prospective randomized controlled trial. Data were analyzed between groups using ANOVA, Chi-squared test, and Kruskal-Wallis test., Setting: Treatment lasted 4 weeks. Splint group wore the splint daily. Splint+manual lymphatic drainage received lymphatic drainage 5 days a week. Splint+nerve mobilization performed neuromobilization exercises as home exercises 5 days a week. Evaluations were conducted before and after 4 weeks of treatment., Participants: The study included 80 patients with mild-to-moderate carpal tunnel syndrome., Interventions: The patients were randomly divided into three groups: splint ( n  = 27), splint+manual lymphatic drainage ( n  = 27), or the splint+nerve mobilization ( n  = 26)., Main Outcome Measures: The main outcome measures were ultrasound assessments and the Boston Carpal Tunnel Questionnaire (Symptom Severity Scale and Boston Functional Status Scale)., Results: Compared to the other groups, the nerve cross-sectional area decreased at both the carpal tunnel ( p  = 0.003) and mid-forearm ( p  = 0.014) levels in the drainage group. Nerve mobilization did not result in a significant change in the nerve cross-sectional area. All groups showed significant improvements in both symptom severity and functional status scores ( p  < 0.001)., Conclusion: The reduction of edema through lymphatic drainage contributes to a decrease in the cross-sectional area of the median nerve. Additionally, all three methods appear to positively impact the functional capacity of the hand and alleviate symptoms., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: Extrapolated reference values (E-Ref) procedure is a new method for determining the cutoff value without collecting the control data. We tried to apply this method to determine the cutoff value for the distal motor latency of the median nerve (median DML). During this process, we found two pitfalls of the E-Ref method. First, the E-Ref procedure did not correctly work when the DML values measured with 0.1 ms accuracy frequently took on tie values. Second, the result was influenced by the proportion of abnormal values. This study investigated these issues., Methods: Data of the median DML were extracted from our laboratory database. To solve the problem of tie values, we tried a wider post-smoothing window in the original E-Ref method. We also devised a modified method conducting pre-smoothing. To see the effect of the proportion of abnormal data, we simulated many datasets having different proportion of abnormal data., Results: In total, 1016 DML values were identified. False deflections due to tie values were often identified as the E-Ref point using the original methods even using a wider window, resulting in unrealistically low values. Modified method was free from this drawback. For all methods, the E-Ref value increased as the proportion of abnormal values increased., Discussion: The problem of tie values, a pitfall of the E-Ref method, might be solved by pre-smoothing the data. The E-Ref value is influenced by the proportion of the normal data, and datasets containing less than 20% abnormal data may achieve appropriate results., (© 2025 Wiley Periodicals LLC.)

Objectives: To compare the out-of-plane (OP) and in-plane (IP) approaches for carpal tunnel syndrome (CTS) in terms of pain during injection and postinjection adverse effects, and to investigate whether these approaches led to any difference in terms of pain/numbness, symptom severity, functionality, and median nerve cross-sectional area and to examine the relationship of these parameters with the pain during injection., Design: Patient/assessor-blinded randomized study., Setting: Hospital outpatient clinic., Participants: Fifty patients with mild-to-moderate CTS., Interventions: The participants were randomized into OP and IP (both n=25) ultrasound-guided injection groups., Main Outcome Measures: Each patient reported the pain felt during the injection at 1 hour thereafter, and also any adverse effects at 4 weeks after injection. Before and 4 weeks after injection, patients used a visual analog scale to indicate pain/numbness; symptom severity and functionality were assessed using the Boston Carpal Tunnel Syndrome Questionnaire. The cross-sectional area of the median nerve was also obtained., Results: The average pain during injection was 2.64±0.82 in the IP group and 1.96±0.86 in the OP group (P=.017). Postinjection adverse effects were similar between the 2 groups (P<.05). After injection, the percentage change in symptom severity was 49.8±11.8 in the IP group and 40.6±11.5 in the OP group (P=.008). In the IP group, day preinjection pain/numbness, night pain/numbness percentage change scores, and symptom severity percentage change scores were moderately correlated with the pain during injection (r=.439, .469, and .429, respectively)., Conclusions: IP injection caused greater pain during injection than OP injection and led to greater reduction in symptom severity at 1 month after injection. In that group, injection pain was associated with the baseline day pain score, change in night pain score, and change in symptom severity score., (Copyright © 2024 American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.)

Introduction: Carpal tunnel syndrome is the most common compression neuropathy. Grading the severity of carpal tunnel syndrome is an important factor in deciding on the type of treatment. This study aims to determine the relationships between the findings of the electrodiagnosis and ultrasonography methods based on the severity of carpal tunnel syndrome., Methods: In this prospective clinical study, 50 patients (96 wrists) who were referred to the Physical Medicine and Rehabilitation Department of the Shohada Tajrish Hospital, Tehran, Iran (from March 2021 to November 2022) were studied. All patients with a history and clinical examination related to CTS underwent electrodiagnosis studies. Based on the results of electrodiagnosis, patients were divided into three groups: mild, moderate, and severe. All eligible patients underwent ultrasound at the cross-section of the wrist (at the level of the pisiform bone, the entrance of the canal) and the middle of the forearm., Results: In this study, the cross-sectional area of the median nerve was measured in 96 wrists of 50 patients with a mean age of 51.78 ± 9.80 years. The mean CSA of the median nerve in the mild, moderate, and severe groups was reported as 0.12 ± 0.03, 0.14 ± 0.02, and 0.21 ± 0.06, respectively. The mean WFR in different groups of CTS was reported as 1.85 ± 0.56, 1.93 ± 0.56, and 2.45 ± 0.49, respectively. A significant relationship between ultrasound findings, including CSA-inlet and WFR, and electrodiagnosis findings was presented (P value < 0.05)., Conclusion: Based on our findings, there is a statistically significant relationship between the sonographic findings, including the mean CSA-inlet and WFR, and the severity of CTS based on the electrodiagnosis study. Our findings revealed that as disease severity increases, sonographic parameters also increase significantly., (© 2024. The Author(s).)

Background: Carpal tunnel syndrome (CTS) is the most common mononeuropathy in the upper limb. It remains uncertain whether adding extracorporeal shockwave therapy (ESWT) or low-level laser therapy (LLLT) to conventional treatment benefits CTS patients., Purpose: This study aimed to compare the effectiveness of ESWT and LLLT in conjunction with conventional treatments (including carpal mobilization, transcutaneous electrical nerve stimulation, and ultrasound) on the cross-sectional area (CSA) of the median nerve and pain in mild-to-moderate CTS patients., Study Design: This was a single-blinded randomized clinical trial with registration number IRCT20220504054734N1., Methods: Thirty-six patients were randomly assigned using block balanced randomization to receive either four sessions of ESWT or 10 sessions of LLLT in addition to 10 sessions of conventional treatments over 2 weeks. Patients received numbered closed envelopes indicating their treatment group. CSA (primary) and pain (secondary) in 18 patients who completed the treatment were assessed at baseline and after 2 weeks by a blinded assessor. Paired and independent sample t-tests were used for analyses due to the normal distribution of data was checked by Kolmogorov-Smirnoff. Cohen's d effect size was used to assess the intervention's magnitude., Results: Both ESWT and LLLT groups showed significant improvements in CSA (p = 0.002) and pain (p < 0.001) from baseline to posttreatment. CSA improvement was moderate for ESWT (mean difference: 1.2, 95% CI 0.51-1.9) and mild for LLLT (mean difference: 0.76, 95% CI 0.4-1.14). Conversely, pain improvement was substantial in both groups (ESWT: mean difference 4.4, 95% CI 3.6-5.3; LLLT: mean difference 4.4, 95% CI 3.7-5.2). No substantial differences between ESWT and LLLT were observed, highlighting their comparable efficacy., Conclusion: The addition of either LLLT or ESWT to conventional treatment effectively reduced pain and median nerve CSA in mild-to-moderate CTS. The absence of significant differences between ESWT and LLLT indicates their comparable efficacy in pain relief and CSA reduction., Competing Interests: Declaration of Competing Interest The authors declare that we have no financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

The aim of this study was to assess the sensitivity and specificity of ultrasonography in the diagnosis of carpal tunnel syndrome. The cross-sectional area of the median nerve at the carpal tunnel for a positive diagnosis had a sensitivity of ∼ 98.6% but a specificity of 60%. The measure of the difference in cross-sectional area of the median nerve at the carpal tunnel and at the level of pronator quadratus had much better sensitivity and specificity of 97.1% and 80%, respectively. Signs of nerve flattening, palmar bowing and increased nerve vascularity were valuable in confirming the diagnosis. A positive predictive value of ultrasonography was found to be > 95% and a negative predictive value was ∼ 66% for a diagnosis of carpal tunnel syndrome. Ultrasonography is, therefore, an effective diagnostic tool in this regard., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: While living in a socially disadvantaged neighborhood is linked with numerous health outcomes, its effect on patient-reported outcome scores and diagnostic measures in carpal tunnel syndrome (CTS) is not fully understood. This study examines the effect of neighborhood socioeconomic deprivation on CTS severity as measured by the Boston Carpal Tunnel Questionnaire (BCTQ), 6-item Carpal Tunnel Symptoms Scale (CTS-6), and diagnostic testing modalities., Methods: This was a retrospective analysis of patients who presented to the hand clinic at a single hospital system with symptoms consistent with CTS. Ultrasound cross-sectional area (CSA) of the median nerve, CTS-6, Symptom Severity Scale (SSS) and Functional Status Scale (FSS) of the BCTQ, and the Area Deprivation Index (ADI) national rank percentile were collected. Patients were grouped into 4 quartiles based on their ADI national percentile. Analyses of variance (ANOVAs) were conducted to test for statistical differences between the 4 quartiles based on the average values of median nerve CSA, CTS-6, SSS, and FSS score. The bottom quartile was compared with the upper 75% of the sample (26th-100th percentile) and to the upper quartile via Student t test. Statistical significance was set at P < .05., Results: Analyses of variance revealed no statistically significant differences between the 4 quartiles for either median nerve CSA, CTS-6, SSS, or FSS. When comparing the bottom quartile with the upper 75% of the sample and the upper quartile, no significant statistical differences were identified., Conclusions: No relationships were found between social deprivation (ADI) and patient-reported outcomes, CTS-6 scores, or median nerve CSA., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: The authors declare that there are no conflicts of interest. J.R.F. is a member of the Integra Life Sciences Nerve Advisory Board; however, this relationship has no conflict with this manuscript.

Hydrodissection is becoming increasingly recognized as a treatment for nerve entrapment syndromes in the orthopedic and rehabilitation world. Carpal Tunnel Syndrome (CTS) is the most prevalent nerve entrapment neuropathy, characterized by compression of the median nerve as it passes through the carpal tunnel. Initial management includes NSAIDs and wrist splints, but surgical intervention is often necessary when these measures fail. Ultrasound-guided hydrodissection of the median nerve is both safe and effective and presents a minimally invasive option when first-line treatments fail to provide adequate symptom relief. This case report demonstrates the potential for an alternative approach to analgesia in the Emergency Department (ED) for patients presenting with pain related to CTS. Here we discuss a case of a 26-year-old female presenting with CTS symptoms and her successful treatment with ultrasound-guided hydrodissection in the ED., Competing Interests: Declaration of competing interest None of the listed authors have any financial conflicts of interest or any other disclosures., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objectives: Evaluate diagnostic accuracy of median nerve cross-sectional area (CSA) to determine severity versus presence of carpal tunnel syndrome (CTS) across existing electrodiagnostic-based (EDX) classification systems in patients with type 2 diabetes or bifid anatomy., Methods: Retrospective analysis of cross-sectional patient data. Receiver operating characteristic analysis used to determine median nerve CSA cutoff values and associated diagnostic likelihood ratios for all consolidated and binary EDX-based classifications of CTS in patients with type 2 diabetes or bifid anatomy. Determine shifts in diagnostic probability based on established cutoff values and associated likelihood ratios. Distal CSA measured at or near carpal tunnel inlet, proximal CSA at level of pronator quadratus muscle, and delta CSA by subtracting proximal from distal., Results: Binary categorizations of CTS were statistically superior to consolidated categorizations of CTS severity in patients with type 2 diabetes or bifid anatomy. Binary categorizations established reasonably consistent median nerve CSA cutoff values across all EDX-based classifications examined resulting in the following for distal CSA or delta CSA: ≤10 or ≤4 mm 2 to rule out and ≥11 or ≥5 mm 2 to rule in CTS, respectively. These cutoff values resulted in small shifts in diagnostic probability in patients with type 2 diabetes and small to conclusive shifts in diagnostic probability in patients with bifid anatomy., Conclusions: Binary categorizations to rule out or rule in CTS based on the proposed cutoff values provide the most meaningful information about shifts in diagnostic probability across all EDX-based classifications examined. The use of median nerve CSA to categorize severity of CTS is not recommended in patients with type 2 diabetes or bifid anatomy., (© 2024 The Author(s). Journal of Ultrasound in Medicine published by Wiley Periodicals LLC on behalf of American Institute of Ultrasound in Medicine.)

Background: Unconscious bias of the clinician favors the diagnosis of carpal tunnel syndrome (CTS) in patients with median paresthesia. We hypothesized that more patients in this cohort would be diagnosed with proximal median nerve entrapment (PMNE) by strengthening our cognitive awareness of this alternative diagnosis. We also hypothesized that patients with PMNE may be successfully treated with surgical release of the lacertus fibrosus (LF)., Methods: In this retrospective study, cases of median nerve decompression at the carpal tunnel and in the proximal forearm for the 2-year periods before and after adopting strategies to mitigate cognitive bias for CTS were enumerated. Patients diagnosed with PMNE and treated by LF release under local anesthesia were evaluated to determine surgical outcome at minimum 2-year follow-up. Primary outcome measures were changes in preoperative median paresthesia and proximal median-innervated muscle strength., Results: There was a statistically significant increase in PMNE cases identified after our heightened surveillance was initiated ( z = 3.433, P < .001). In 10 of 12 cases, the patient had previous ipsilateral open carpal tunnel release (CTR) but experienced recurrent median paresthesia. In 8 cases evaluated an average of 5 years after LF release, there was improvement in median paresthesia and resolution of median-innervated muscle weakness., Conclusions: Owing to cognitive bias, some patients with PMNE may be misdiagnosed with CTS. All patients with median paresthesia, particularly those with persistent or recurrent symptoms after CTR, should be assessed for PMNE. Surgical release limited to the LF may be an effective treatment for PMNE., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objectives: Evaluate the diagnostic accuracy of median nerve cross-sectional area (CSA) to determine the severity of carpal tunnel syndrome (CTS) vs the presence of CTS across existing electrodiagnostic-based (EDX) classification systems., Methods: Retrospective analysis of cross-sectional patient data. Receiver operating characteristic (ROC) analysis was used to determine CSA cutoff values and associated diagnostic likelihood ratios for all consolidated and binary EDX-based classifications of CTS severity. Identification of CSA cutoff values associated with likelihood ratios capable of achieving conclusive (but at least moderate) shifts in diagnostic probability., Results: Binary categorizations of CTS (ie, "Normal" vs "Absent") were statistically superior to consolidated categorizations of CTS severity (ie, "Normal," "Mild," "Moderate," or "Severe"). Binary categorizations established consistent CSA cutoff values across all EDX-based classifications examined and achieved conclusive shifts in diagnostic probability based on the following values of distal CSA or delta CSA: <7 or <1 mm 2 to rule out and >13 or >7 mm 2 to rule in CTS, respectively. Additionally, the following values of distal CSA and delta CSA may be used in certain circumstances because they produce only small shifts in diagnostic probability: ≤10 or ≤3 mm 2 to rule out and ≥11 or ≥4 mm 2 to rule in CTS, respectively., Conclusions: Using median nerve CSA to categorize the severity of CTS is not recommended based on lack of consistent and meaningful shifts in diagnostic probability. Rather, binary categorizations to rule out or rule in CTS based on the proposed CSA cutoff values consistently provided conclusive shifts in diagnostic probability across all EDX-based classifications examined., (© 2024 The Authors. Journal of Ultrasound in Medicine published by Wiley Periodicals LLC on behalf of American Institute of Ultrasound in Medicine.)

Background: Nerve conduction studies (NCS) and ultrasound (US) remain imperfect compared with clinical diagnosis and/or diagnostic tools such as carpal tunnel syndrome-6 (CTS-6) for diagnosis of carpal tunne syndrome (CTS). One potential reason for the discrepancy between clinical diagnosis and testing is "borderline" case inclusion. This study aims to compare clinical outcomes after carpal tunnel release (CTR) between "borderline" and "clear" patients with CTS determined by NCS and US., Methods: This was a retrospective review of patients who underwent CTR. We collected NCS and US measurements of the median nerve cross-sectional area (MNCSA) at the carpal tunnel inlet, and the Boston Carpal Tunnel Questionnaire (BCTQ) scores comprised of the Symptom Severity Scale (SSS) and the Functional Status Scale (FSS). Ultrasound measurements defined patients as having "borderline" (MNCSA < 13 mm 2 ) or "clear" (MNCSA ≥ 13 mm 2 ) CTS., Results: The study included 94 unilateral patients with CTS. "Borderline" CTS was diagnosed in 58 patients (62%), and "clear" CTS was diagnosed in 36 patients (38%). No significant differences in BCTQ scores were found between groups. At greater than 6-month follow-up, the mean FSS was 1.44 and 1.45 for clear and borderline groups, respectively ( P = .97) and the mean SSS was 1.47 and 1.51, respectively ( P = .84). However, a significant difference between groups when comparing distal motor latency (DML) and distal sensory latency (DSL) existed. The mean DSL was 3.71 and 4.44 for the clear and borderline groups, respectively ( P = .02). The mean DML was 4.59 and 5.36 ( P = .048)., Conclusion: Categorizing CTS diagnosis into "borderline" and "clear" based on preoperative US and NCS testing did not correlate with BCTQ changes after CTR. It remains unclear whether the BCTQ is a valid postoperative assessment tool, despite its frequent use in literature., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: J.R.F.J. is an advisor for Integra LifeSciences. R.C.V. has no conflicts of interest.

Introduction/aims: T2 magnetic resonance imaging (MRI) mapping has been applied to carpal tunnel syndrome (CTS) for quantitative assessment of the median nerve. However, quantitative changes in the median nerve before and after surgery using T2 MRI mapping remain unclear. We aimed to investigate whether pathological changes could be identified by pre- and postoperative T2 MRI mapping of the median nerve in CTS patients after open carpal tunnel release., Methods: This was a prospective study that measured median nerve T2 and cross-sectional area (CSA) values at the distal carpal tunnel, hamate bone, proximal carpal tunnel, and forearm levels pre- and postoperatively. Associations between T2, CSA, and nerve conduction latency were also evaluated., Results: A total of 36 patients with CTS (mean age, 64.5 ± 11.7 years) who underwent surgery were studied. The mean preoperative T2 values significantly decreased from 56.3 to 46.9 ms at the proximal carpal tunnel levels (p = .001), and from 52.4 to 48.7 ms at the hamate levels postoperatively (p = .04). Although there was a moderate association between preoperative T2 values at the distal carpal tunnel levels and distal motor latency values (r = -.46), other T2 values at all four carpal tunnel levels were not significantly associated with CSA or nerve conduction latency pre- or postoperatively., Discussion: T2 MRI mapping of the carpal tunnel suggested a decrease in nerve edema after surgery. T2 MRI mapping provides quantitative information on the median nerve before and after surgery., (© 2024 Wiley Periodicals LLC.)

Background: Connective tissue serves a role beyond mere spatial filling. Furthermore, there is increasing evidence that connective tissue plays an important role in the pathogenesis of conditions such as carpal tunnel syndrome (CTS). According to our hypothesis, the median nerve (MN) is surrounded by a system of connective tissue distal to the pronator teres and extending up to, and including, the carpal tunnel., Methods: To visualize the connective tissue surrounding the median nerve, we dissected the forearms of 15 body donors from pronator teres to the carpal tunnel, created plastination slices stained with Periodic Acid-Schiff (PAS), and injected ink into the seen spaces. We verified our findings with a segmentational analysis of radiological data of 10 healthy individuals., Results: We macroscopically describe the median nerve´s system of connective tissue (MC) distal to the pronator teres and up to and including the carpal tunnel. This system creates, connects, and separates spaces. At least from the pronator teres to the carpal tunnel it also creates subspaces from proximal to distal. For the MC, we established a mean cross-sectional area of 153.1 mm 2 (SD=37.15) in the carpal tunnel. The median nerve consistently resides at the center of this MC, which further connects to flexor muscles of the forearm, and to the radius bone. In the carpal tunnel, the MC creates subspaces inside. There, it also acts as the outermost internal layer enveloping flexor tendons, and the MN., Discussion: The term MC does not negate but orders the existence of other "connectives", like subsynovial connective tissue, endo-, epi- or perineuria, epimysia, periostea, or peritendinea, to a hierarchy related to the median nerve. Diseases of the MN are common. Knowing the anatomy of the MC and how it relates to MN function may help clinicians recognize and understand conditions like CTS., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier GmbH.. All rights reserved.)

Background: Physiotherapeutic management is the first-line intervention for patients with entrapment neuropathies such as carpal tunnel syndrome (CTS). As part of physiotherapy, neurodynamic interventions are often used to treat people with peripheral nerve involvement, but their mechanisms of action are yet to be fully understood. The MONET (mechanisms of neurodynamic treatment) study aims to investigate the mechanisms of action of neurodynamic exercise intervention on nerve structure, and function., Methods: This mechanistic, randomised, single-blind, controlled trial will include 78 people with electrodiagnostically confirmed mild or moderate CTS and 30 healthy participants (N = 108). Patients will be randomly assigned into (1) a 6-week progressive home-based neurodynamic exercise intervention (n = 26), (2) a steroid injection (= 26), or (3) advice (n = 26) group. The primary outcome measure is fractional anisotropy of the median nerve at the wrist using advanced magnetic resonance neuroimaging. Secondary outcome measures include neuroimaging markers at the wrist, quantitative sensory testing, electrodiagnostics, and patient reported outcome measures. Exploratory outcomes include neuroimaging markers at the cervical spine, inflammatory and axonal integrity markers in serial blood samples and biopsies of median nerve innervated skin. We will evaluate outcome measures at baseline and at the end of the 6-week intervention period. We will repeat questionnaires at 6-months. Two-way repeated measures ANCOVAs, followed by posthoc testing will be performed to identify differences in outcome measures among groups and over time., Discussion: This study will advance our understanding of the mechanisms of action underpinning neurodynamic exercises, which will ultimately help clinicians to better target these treatments to those patients who may benefit from them. The inclusion of a positive control group (steroid injection) and a negative control group (advice) will strengthen the interpretation of our results., Trial Registration: NCT05859412, 20/4/2023., (© 2024. The Author(s).)

Ultrasound imaging (US) is being increasingly used to aid in the diagnosis of entrapment neuropathies. This study aims to evaluate the shear modulus and cross-sectional area (CSA) of the median nerve in patients with carpal tunnel syndrome (CTS). A total of 35 patients with CTS participated in the study. CSA and shear modulus testing were performed in shear wave elastography (SWE) mode in five positions of the right and left radiocarpal joints (intermediate position 0°, 45° of extension, maximum extension, 45° of flexion, and maximum flexion). There were significant side-to-side differences in the median nerve shear modulus at each wrist position as compared to the asymptomatic side. There were significant side-to-side differences in the median nerve CSA at each wrist position as compared to the asymptomatic side. Shear modulus increases in patients with CTS at different angular positions of flexion and extension of the radiocarpal joint. In individuals with CTS, the CSA of the median nerve is greater on the symptomatic side compared to the asymptomatic side. The CSA decreases in positions of maximum extension and 45° of flexion and in maximum flexion relative to the resting position.

Objectives: This study examines the associations between the median nerve (MN) shear wave elastography (SWE), the MN cross-sectional area (CSA), patient's symptoms, and the neurophysiological severity of carpal tunnel syndrome (CTS). The most appropriate site to perform SWE was also tested., Methods: This prospective study comprised 86 wrists of 47 consecutive patients who volunteered for MN ultrasound after an electrodiagnostic study. The neurophysiological severity of CTS was assessed according to the results of a nerve conduction study (NCS). The MN CSA was measured at the carpal tunnel inlet (wCSA) and the forearm (fCSA). SWE was performed on the MN in a longitudinal orientation at the wrist crease (wSWE), at the forearm (fSWE), and within the carpal tunnel (tSWE)., Results: The wCSA and wSWE correlated positively with the neurophysiological severity of CTS (r = .619, P < .001; r = .582, P < .001, respectively). The optimal cut-off values to discriminate the groups with normal NCS and with findings indicating CTS were 10.5 mm 2 for the wCSA and 4.12 m/s for the wSWE. With these cut-off values, wCSA had a sensitivity of 80% and specificity of 87% and wSWE a sensitivity of 88% and specificity of 76%. Neither tSWE nor fSWE correlated with the neurophysiological severity of CTS or differed between NCS negative and positive groups (P = .429, P = .736, respectively)., Conclusion: Shear wave velocity in the MN at the carpal tunnel inlet increases in CTS and correlates to the neurophysiological CTS severity equivalently to CSA measured at the same site., (© 2024 The Authors. Journal of Ultrasound in Medicine published by Wiley Periodicals LLC on behalf of American Institute of Ultrasound in Medicine.)

This study investigated the reliability of measuring the median nerve cross-sectional area (CSA) at the carpal tunnel inlet using a handheld ultrasound device (HUD) compared to a standard ultrasound system, focusing on intra- and inter-operator reproducibility among novice and expert operators. Employing a prospective cross-sectional design, 37 asymptomatic adults were assessed using both devices, with measurements taken by an expert with over five years of experience and a novice with less than six months. The CSA was determined using manual tracing and ellipse methods, with reproducibility evaluated through intraclass correlation coefficients (ICCs) and agreement assessed via Bland-Altman plots. Results showed a high degree of agreement between the devices, with excellent intra-operator reproducibility (ICC > 0.80) for the expert, and moderate reproducibility for the novice (ICCs ranging from 0.539 to 0.841). Inter-operator reliability was generally moderate, indicating acceptable consistency across different experience levels. The study concludes that HUDs are comparable to standard ultrasound systems for assessing median nerve CSA in asymptomatic subjects, with both devices providing reliable measurements. This supports the use of HUDs in diverse clinical environments, particularly where access to traditional ultrasound is limited. Further research with a larger sample and symptomatic patients is recommended to validate these findings.

Background: Current illustrations of the carpal tunnel vary greatly. The relative positions of the components such as the median nerve and flexor pollicis longus (FPL) tendon seem often arbitrarily chosen. The purpose of this study was to determine the locations of the median nerve and FPL in the carpal tunnel using ultrasound (US) and to determine whether the position of the median nerve changes in carpal tunnel syndrome (CTS)., Method: Patients with and without CTS underwent US examination of the wrist. A 4 × 10 grid was fitted to each saved cross-sectional image. The center points of the median nerve and FPL were identified, and their horizontal and vertical coordinates were recorded., Results: The median nerve was identified in 115 wrists (average x = 0.70, y = 0.82), and FPL was identified in 90 wrists (average x = 0.86, y = 0.59). A scatter plot was created by stacking all US images to demonstrate the average positions of the median nerve and FPL. There were 97 wrists without CTS (No CTS) and 17 wrists with CTS. There was a significant difference in the vertical position of the median nerve between No CTS and CTS wrists ( P = .0006)., Conclusions: The locations of the median nerve and FPL within the carpal tunnel were determined using US of 115 wrists, and a heat map was created to illustrate these locations. The median nerve was found to be more superficial in the setting of CTS., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: We hypothesized that postoperative Boston Carpal Tunnel Questionnaire (BCTQ) scores and ultrasound (US) measurements of the median nerve cross-sectional area (CSA) at the distal wrist crease are significantly decreased at 2-week, 6-week, and ≥ 6 months follow-up appointments, compared with baseline values., Methods: This study was a retrospective chart review of patients who presented to a single hand clinic with evidence of carpal tunnel syndrome over a 6-year period (2014-2020). Patients received baseline US measurements of the median nerve CSA as well as completion of the BCTQ, and for the patients who underwent carpal tunnel release (CTR), postoperative US measurements and questionnaire scores were obtained at 2 weeks, 6 weeks, or ≥ 6 months postoperatively., Results: This study included 224 separate wrists. Median Nerve CSA measurements were 13.2 ± 4.5 mm 2 at baseline, 11.9 ± 3.6 mm 2 at 2 weeks postoperatively, 11.6 ± 4.5 mm 2 at 6 weeks postoperatively, and 11.7 ± 4.3 mm 2 at 6 months or more ( P = .002). The BCTQ Symptom Severity Scale scores were 3.14 ± 0.76 at baseline, 1.76 ± 0.63 at 2 weeks, 1.68 ± 0.70 at 6 weeks, and 1.41 ± 0.64 at 6 months or longer ( P < .001). The BCTQ Functional Status Scale scores were 2.56 ± 0.89 at baseline, 2.03 ± .1.0 at 2 weeks, 1.65 ± 0.77 at 6 weeks, and 1.36 ± 0.61 at 6 months or longer ( P < .001)., Conclusions: These findings demonstrated a sustained decrease in median nerve CSA and patient-reported outcomes following CTR at 2 weeks, 6 weeks, and between 6 and 12 months., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: The authors declare that there are no conflicts of interest. J.R.F. is a member of the Integra Life Sciences Nerve Advisory Board; however, this relationship has no conflict with this manuscript.

Objective: Carpal tunnel syndrome (CTS) is the most common nerve entrapment neuropathy in the USA. In this study, we define anatomical landmarks to assess symptomatic and asymptomatic cohorts with persistent CTS using MRI imaging., Materials and Methods: Distal vs proximal incomplete release was determined using the distal most aspect of the hook of hamate and the distal wrist crease. An incomplete release showed the transverse carpal ligament (TCL) intact at either boundary. Twenty-one patients with persistent CTS were analyzed for incomplete release, median nerve enlargement and T2 signal hyperintensity, and flattening ratio using postoperative wrist MRI. These findings were compared to a ten-patient asymptomatic persistent CTS control group. Fisher's exact and a Student's two-tailed t-tests were used to determine statistical significance., Results: In the symptomatic persistent CTS group, 13 (61.9%) incomplete releases were identified, 5 (38.5%) incomplete distally, and 1 (7.7%) incomplete proximally. There was no statistical significance in the rate of incomplete releases when compared to the asymptomatic group (p = 1.00). T2 signal hyperintensity and enlargement at the site of release showed no statistical significance, (p = 0.319 and p = 0.999, respectively). The mean flattening ratio at the site of release in the symptomatic group (2.45 ± 0.7) was statistically significant compared to the asymptomatic group (1.48 ± 0.46), (p = 0.007)., Conclusion: Utilizing the established landmarks, the full length of the TCL can be assessed via MRI. Additionally, evaluation of the median nerve flattening ratio at the level of the incomplete release may be utilized as an aid to the clinical management of persistent CTS., (© 2023. The Author(s), under exclusive licence to International Skeletal Society (ISS).)

Background: Endoscopic carpal tunnel release (ECTR) is a less invasive procedure but has a higher risk of complications. We analysed ECTR cases dividing them into three periods according to a single surgeon's experience when the ECTR was performed: the initial, midterm and late period. Cases of iatrogenically induced median nerve injuries that occurred after ECTR were then noted and evaluated. Methods: We reviewed 195 ECTRs done with the 2-portal technique and divided the patients into three groups according to periods of when ECTR was done. The indications for ECTR surgery were limited to severe CTS cases. These groups of patients were similar in terms of age, duration of disease, electrophysiological study results and severity of the disease. The patients were evaluated for median neuropathy pre- and postoperatively using Semmes-Weinstein monofilament test (SWT), Disabilities of the arm, shoulder and hand (DASH) Score, Coin-flip test (CFT), postoperative paraesthesias and complications, such as pillar pain, and so on. Electrophysiological evaluation was performed only preoperatively. Results: Postoperative median nerve recovery was overall good. Normal recovery was noted in 181 cases (93%). SWT, DASH and CFT were all significantly improved upon follow-up in all three groups. In terms of iatrogenic neuropathy, median nerve palsy worsened (including those transiently worsened) after ECTR in 11 cases (5.6%), even in the later period. The sensory disturbance was equally worsening from the radial to the ulnar side. Conclusions: The fact that there were neurologically worsened cases even in the later period, when the operator is higher skilled in the technique, suggests that the surgical technique itself may be the one posing higher risk than the level of surgical skill. The most likely causes of aggravated nerve palsy were a direct injury by cannula insertion at the proximal portal, or additional median nerve compression during cannula insertion into the carpal tunnel. Level of Evidence: Level IV (Therapeutic).

Purpose: To investigate the efficacy of sagittal ultrasonography of the median nerve in diagnosing carpal tunnel syndrome (CTS)., Methods: Seventy-six hands with idiopathic CTS and 80 hands of asymptomatic subjects were included. All patients with CTS underwent ultrasonographic examination, electrodiagnostic testing, and CTS-6 assessment. In the sagittal ultrasonographic examination, the maximum and minimum median nerve diameters (MNDs) were measured at the proximal and distal ends of the carpal tunnel, respectively. The median nerve stenosis rate (MNSR) was computed as (1 - minimum MND/maximum MND) × 100 (%). The cross-sectional area (CSA) of the median nerve at the level of the pisiform was measured., Results: In the sagittal ultrasonographic examination, the mean maximum MNDs were 0.252 cm and 0.202 cm, mean minimum MNDs were 0.145 cm and 0.165 cm, and mean MNSRs were 41.83% and 17.35% in the CTS and control groups, respectively; the mean maximum MND and MNSR were considerably larger in the CTS group. The maximum MND and MNSR were correlated with the electrodiagnostic testing results and CTS-6 score. The MNSR with a cut-off value of 34.0% had a higher sensitivity and specificity than the CSA in diagnosing CTS., Conclusions: Sagittal ultrasonographic examination is useful in diagnosing CTS., (© 2023 The Authors. Journal of Clinical Ultrasound published by Wiley Periodicals LLC.)

Purpose: Earlier research has explored carpal tunnel release (CTR) surgery outcomes using electrodiagnostic tests (EDX). However, evaluation of the median nerve before and after CTR by ultrasound (US) is understudied. This study aimed to establish the outcomes of CTR by EDX and US, and examine the correlation between the clinical improvement and US after CTR., Methods: The sample consisted of 172 wrists that underwent CTR. Pain was assessed using the visual analog scale (VAS). The Boston Carpal Tunnel Syndrome Questionnaire (BCTQ), including the symptom severity and function subscales, was applied before and 3 months after CTR. The proximal and distal cross-sectional areas (CSAs) of the median nerve were measured using US, and EDX was performed before and 3 months after CTR., Results: Patients had mean preoperative and postoperative VAS scores of 7.7 ± 1.2 and 1.7 ± 1.2, respectively. The mean preoperative and postoperative proximal CSA measurements were 16.4 ± 4.5 mm 2 and 12.1 ± 3.9 mm 2 , respectively. The mean preoperative and postoperative distal CSA measurements were 13.6 ± 3.7 mm 2 and 11.0 ± 3.1 mm 2 , respectively. A significant improvement was observed in VAS, BCTQ, and EDX 3 months after CTR. A weak, positive correlation was observed between the improvement in the BCTQ symptom severity and function subscales and CSAs following CTR., Conclusions: The results of this study demonstrate that preoperative median nerve CSA values may be used in evaluating CTR outcomes., Type of Study/level of Evidence: Therapeutic IV., (Copyright © 2023. Published by Elsevier Inc.)

Introduction/aims: The aim in this study is to describe the clinical and electrophysiological patterns of pregnancy-related carpal tunnel syndrome (PRCTS) occurring during pregnancy or after delivery., Methods: Clinical, epidemiological, and electrodiagnostic (EDx) data were studied in 130 women with PRCTS onset during pregnancy (n = 80) or after delivery (n = 50). Twenty-six women with PRCTS underwent EDx analysis during pregnancy and 104 after delivery (83 within 6 months of delivery and 21 up to 24 months after pregnancy onset). PRCTS was compared with idiopathic CTS in a control group consisting of 57 age-matched women with 98 cases of CTS. Twenty-four women with PRCTS had clinical and electrophysiological follow-up after corticosteroid injection (CSI) at the wrist., Results: Clinical analysis showed a higher rate of bilateral and diurnal/permanent paraesthesia and more severe symptoms in PRCTS compared with idiopathic CTS. EDx analysis showed more severe abnormalities in classical tests and a higher rate of conduction block (CB) in PRCTS. Statistical analysis showed a strong negative correlation between the incidence and importance of CB and the time interval at which PRCTS women underwent EDx examination, between pregnancy onset and 24 months later. CSI resulted in significant clinical and EDx improvement in 22 of 24 PRCTS women, with disappearance of all motor and most sensory CBs., Discussion: The EDx pattern of PRCTS is an acute/subacute median nerve lesion at the wrist identified by many CBs. This occurs concurrently with hormonal changes, is responsible for more severe clinical symptoms and EDx data, and it explains why CSI is so effective., (© 2023 Wiley Periodicals LLC.)

Purpose: Carpal tunnel (CT) syndrome continues to be a commonly treated hand pathology. We aimed to evaluate several CT injection techniques for (1) spatial accuracy within the CT and (2) risk of median nerve (MN) injury. Our purpose was to evaluate for any significant differences in accuracy of needle placement within the carpal tunnel and final distance between the needle tip and the MN with each technique., Methods: Fifteen fresh frozen cadaveric arms were used for this study. Six different injection techniques for CT injection were performed on each specimen, including palmaris longus, ulnar to flexor carpi radialis, trans-flexor carpi radialis, volar radial, volar ulnar, and direct through the palm techniques. After needle placement, a standard open CT release was performed to assess for accuracy of placement within the CT and measure needle position in relation to the MN and other anatomic structures., Results: Accurate intra-CT needle placement was seen in 91% of injections. While there was no significant difference between injection techniques for distance to nearest tendon (p = 0.1531), the trans-flexor carpi radialis (tFCR), volar radial (VR), and volar ulnar (VU) techniques consistently provided the greatest intra-CT distance from needle tip to median nerve (p = 0.0019). The least incidence of intraneural needle placement was found with the tFCR and VR approaches., Conclusion: All six injection techniques reliably enter the CT space. The lowest risk to the MN was found with tFCR and VR techniques, and we recommend these techniques for safe and effective needle placement to avoid iatrogenic intraneural injection., Level of Evidence: Level V: Cadaveric Study., (© 2023. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Purpose: By constructing a prediction model of carpal tunnel syndrome (CTS) based on ultrasound images, it can automatically and accurately diagnose CTS without measuring the median nerve cross-sectional area (CSA)., Methods: A total of 268 wrists ultrasound images of 101 patients diagnosed with CTS and 76 controls in Ningbo NO.2 Hospital from December 2021 to August 2022 were retrospectively analyzed. The radiomics method was used to construct the Logistic model through the steps of feature extraction, feature screening, reduction, and modeling. The area under the receiver operating characteristic curve was calculated to evaluate the performance of the model, and the diagnostic efficiency of the radiomics model was compared with two radiologists with different experience., Results: The 134 wrists in the CTS group included 65 mild CTS, 42 moderate CTS, and 17 severe CTS. In the CTS group, 28 wrists median nerve CSA were less than the cut-off value, 17 wrists were missed by Dr. A, 26 wrists by Dr. B, and only 6 wrists were missed by radiomics model. A total of 335 radiomics features were extracted from each MN, of which 10 features were significantly different between compressed and normal nerves, and were used to construct the model. The area under curve (AUC) value, sensitivity, specificity, and accuracy of the radiomics model in the training set and testing set were 0.939, 86.17%, 87.10%, 86.63%, and 0.891, 87.50%, 80.49%, and 83.95%, respectively. The AUC value, sensitivity, specificity, and accuracy of the two doctors in the diagnosis of CTS were 0.746, 75.37%, 73.88%, 74.63% and 0.679, 68.66%, 67.16%, and 67.91%, respectively. The radiomics model was superior to the two-radiologist diagnosis, especially when there was no significant change in CSA., Conclusion: Radiomics based on ultrasound images can quantitatively analyze the subtle changes in the median nerve, and can automatically and accurately diagnose CTS without measuring CSA, especially when there was no significant change in CSA, which was better than radiologists., (© 2023 Wiley Periodicals LLC.)

Purpose: This report describes a bilateral persistent median artery (PMA) originating from the ulnar artery and terminating at different levels of the upper limb. The PMA coexisted with a bilateral bifid median nerve (MN) and two bilateral interconnections (ICs characterized with the symbol -) of the MN with the ulnar nerve (UN) (MN-UN) and a unilateral reverse IC (UN-MN). Emphasis was given to the artery's developmental background., Methods: The PMA was identified in an 80-year-old formalin-embalmed donated male cadaver., Results: The right-sided PMA terminated at the wrist, posterior to the palmar aponeurosis. Two neural ICs were identified: the UN joined the MN deep branch (UN-MN), at the forearm's upper third, and the MN deep stem joined the UN palmar branch (MN-UN), at the lower third (9.7 cm distally to the 1st IC). The left-sided PMA ended in the palm giving off the 3rd and 4th proper palmar digital arteries. An incomplete superficial palmar arch was identified by the contribution of the PMA, radial, and ulnar arteries. After the MN bifurcation into superficial and deep branches, the deep branches formed a loop, that was penetrated by the PMA. The MN deep branch communicated with the UN palmar branch (MN-UN)., Conclusions: The PMA should be evaluated as a causative factor of carpal tunnel syndrome. The modified Allen's test and the Doppler ultrasound may detect the arterial flow and the angiography may depict the vessel thrombosis in complex cases. PMA could also be a "salvage" vessel for the hand supply, in radial and ulnar artery trauma., (© 2023. The Author(s).)

Background: Carpal tunnel syndrome (CTS) is the most common nerve entrapment neuropathy and is commonly evaluated using electrodiagnostic studies (EDSs). Ultrasound (US) has emerged as a potentially easier and more comfortable alternative to EDSs. The purpose of this study is to evaluate whether measurements of the cross-sectional area (CSA) of the median nerve via US correlate with the severity rating of CTS based on EDSs. Methods: A retrospective review of patients aged 18 years or older who underwent US and EDSs of the median nerve for CTS was performed. Sensory nerve action potential, distal motor latency, and compound muscle action potential were measured, and severity was graded on American Association of Neuromuscular and Electrodiagnostic Medicine guidelines. Cross-sectional area of the median nerve was measured via US at the wrist crease. Results: There was a significant association between increasing CSA and increasing EDS severity ( P < .0001). The mean CSA for normal, mild, moderate, and severe CTS was 7.48 ± 2.00, 10.36 ± 2.53, 12.01 ± 3.64, and 14.34 ± 4.77 mm 2 , respectively. The area under the curve demonstrated the ability of median nerve CSA to discriminate between normal and abnormal EDSs with an optimal cutoff CSA of ≥10 mm 2 , as well as, the ability to discriminate between mild CTS and moderate to severe CTS at a cutoff CSA of greater than or equal to 12 mm 2 . Conclusions: The results of this study show that US measurements of the median nerve at the distal wrist crease discriminate between normal and abnormal EDSs, and between mild CTS and moderate to severe CTS.

Objective: The aim of the study was to investigate the associations of cross-sectional area (CSA) of the median nerve measured by ultrasonography, the median to ulnar nerve ratio (MUR), the median to ulnar nerve difference (MUD) and the ratio of CSA of the median nerve to height squared (MHS) in relation to electrodiagnostic classification of moderate and severe carpal tunnel syndrome (CTS) and thus to identify patients suitable for surgical treatment., Materials and Methods: A prospective study was conducted in patients aged ≥ 18 years who underwent both median and ulnar nerve ultrasonography and electrodiagnostic studies (EDS). 124 wrists of 62 patients were examined. The patients' characteristics were acquired through a questionnaire. CTS was diagnosed using EDS and classified according to the guidelines of the Czech Republic Association of Electrodiagnostic Medicine. The CSA of the median nerve and of the ulnar nerve were measured at the carpal tunnel inlet., Results: Median nerve CSA at the tunnel inlet ≥ 12 mm 2 correlates with electrodiagnostic classification of moderate to severe carpal tunnel syndrome. At this cut-off value, the sensitivity of ultrasonography is 82.4%, its specificity is 87.7%, the positive predictive value is 82.4%, the negative predictive value is 87.7%. MUD, MUR and MHS perform worse than the median nerve CSA, as shown by their lower area under the receiver operating characteristic curve., Conclusions: Ultrasound could help us indicate surgical treatment for CTS, especially in patients with clinical findings. Our results suggest a cut-off value of CSA at the tunnel inlet of ≥ 12mm 2 ., Competing Interests: The authors report no conflicts of interest in this work.

Objective: To study the ability of image analysis measures to quantify echotexture changes of median nerve in order to provide a complementary diagnostic tool in CTS., Methods: Image analysis measures (gray level co-occurrence matrix (GLCM), brightness, hypoechoic area percentage using max entropy and mean threshold) were calculated in normalized images of 39 (19 younger and 20 older than 65y) healthy controls and 95 CTS patients (37 younger and 58 older than 65y)., Results: Image analysis measures were equivalent or superior (older patients) to subjective visual analysis. In younger patients, GLCM measures showed equivalent diagnostic accuracy with cross sectional area (CSA) (Area Under Curve (AUC for inverse different moment = 0.97). In older patients all image analysis measures showed similar diagnostic accuracy to CSA (AUC for brightness = 0.88). Moreover, they had abnormal values in many older patients with normal CSA values., Conclusions: Image analysis reliably quantifies median nerve echotexture alterations in CTS and offers similar diagnostic accuracy to CSA measurement., Significance: Image analysis may offer added value to existing measures in the evaluation of CTS, especially in older patients. Its clinical implementation would require incorporation of mathematically simple software code for online nerve image analysis in ultrasound machines., Competing Interests: Conflict of interest Christos Moschovos, MD, Georgios Tsivgoulis, MD, Apostolia Ghika, MD, Eleni Bakola, MD, Marianna Papadopoulou, MD, Panagiotis Zis, MD, Vasiliki Zouvelou MD, Stavroula Salakou, MD, Georgia Papagiannopoulou, MD, Vassiliki Kotsali-Peteinelli, MD, Elisabeth Chroni, MD, Andreas Kyrozis, MD report no disclosures., (Copyright © 2023 International Federation of Clinical Neurophysiology. Published by Elsevier B.V. All rights reserved.)

Objectives: This systematic review and meta-analysis investigated the mobility of the median nerve (MN) in carpal tunnel syndrome (CTS) patients compared to healthy people., Methods: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline was followed and the electronic databases including PubMed, Scopus, EMBASE, and Cochrane Library were searched up to April 2022. All published observational studies comparing the excursion of MN between participants with and without CTS were included. The quality of research was assessed by the Newcastle-Ottawa Scale tool. The primary outcome was the excursion of the MN under dynamic examination, representing nerve mobility quantified by the standardized mean difference (SMD) for random effect meta-analysis., Results: Fourteen studies were included in the qualitative review, and twelve entered the meta-analysis involving a total of 375 CTS patients and 296 healthy controls. The forest plot revealed that the mobility of the MN significantly decreased in the CTS group compared to the non-CTS control (SMD = -1.47, 95% CI: -1.91, -1.03, p < 0.001, heterogeneity 82%). In subgroup analysis, both transverse and longitudinal methods for nerve excursion showed less nerve mobility in CTS than in non-CTS., Conclusions: This meta-analysis showed that the patients with CTS exhibited less mobility of the MN than those without CTS, suggesting MN mobility as a potential CTS marker., Key Points: • The patients with CTS revealed less mobility of the median nerve than those without CTS. • The mobility of the median nerve could be regarded as a potential CTS marker., (© 2022. The Author(s), under exclusive licence to European Society of Radiology.)

Background: This study aimed to investigate the relationship between postoperative clinical results and long-term morphological changes in patients with carpal tunnel syndrome (CTS) as observed on magnetic resonance imaging (MRI) before and after open carpal tunnel release (OCTR). Methods: We retrospectively analysed data for 28 hands that had undergone OCTR with at least 24 months of follow-up data. Two-point discrimination (2PD) test results were examined for the first three fingers, as were the distal motor latency (DML) and sensory conduction velocity (SCV) of the median nerve. We also calculated the cross-sectional area (CSA) of the carpal tunnel and the distance from the median nerve to the volar carpal bone at the hamate and the pisiform levels using MRI images. Variables were compared before and 24 months after OCTR. Results: Significant improvements in all variables were observed, including average 2PD scores (Finger I: 13.1 ± 6.2 vs. 7.7 ± 4.3, p < 0.01, Finger II: 11.9 ± 6.6 vs. 7.0 ± 3.5, p < 0.01, Finger III: 13.6 ± 6.1 vs. 7.8 ± 4.5, p < 0.01), average DML (8.3 ± 3.3 vs. 4.3 ± 0.6 m/s, p < 0.01), average SCV (30.8 ± 11.0 vs. 41.3 ± 5.3 m/s, p < 0.01), CSA of the carpal tunnel (hamate level: 194.9 ± 30.6 vs. 254.2 ± 47.6 mm 2 , p < 0.01, pisiform level: 244.2 ± 46.5 vs. 274.7 ± 75.1 mm 2 , p = 0.01) and the distance between the median nerve and volar carpal bone (hamate level: 8.7 ± 1.4 vs. 11.2 ± 1.6 mm, p < 0.01, pisiform level: 11.8 ± 1.7 vs. 13.8 ± 2.5 mm, p < 0.01). Conclusions: Our results demonstrate that OCTR is successful in achieving long-term decompression and recovery of the median nerve in patients with CTS. Level of Evidence: Level III (Therapeutic).

Purpose: Local steroid injection is an effective treatment modality for carpal tunnel syndrome. This study aimed to investigate the success rate of ultrasonography-guided local steroid injection and determine the prognostic value of the cross-sectional area (CSA) of the median nerve for steroid injection., Methods: We retrospectively evaluated 40 patients with carpal tunnel syndrome whose median nerve CSA was >15 mm 2 (large-CSA group; n = 16) or ≤15 mm 2 (small-CSA group; n = 24). The CSA was measured using ultrasonography, and all the patients were treated with ultrasonography-guided corticosteroid injection. Demographic characteristics, symptoms, initial QuickDASH score, Boston Carpal Tunnel Questionnaires, and results of the nerve conduction study were assessed at baseline. Treatment success was defined in this study as the absence of symptom recurrence within the entire follow-up period., Results: The treatment success rate was 45% (n = 18) after an average follow-up of 16 months. Overall, 11 patients (28%) underwent carpal tunnel release on an average of 11 months after steroid injection. The large-CSA group showed a significantly worse grade of electrodiagnostic testing at baseline than did the small-CSA group; however, there was no significant difference in final Boston Carpal Tunnel Questionnaires symptom score (1.7 vs 1.8, respectively) and the rate of continued treatment success at the last follow-up (42% vs 50%, respectively). The proportions of patients who required carpal tunnel decompression were 29% and 25% in the small-CSA and large-CSA groups, respectively., Conclusions: Local steroid injection for carpal tunnel syndrome has an overall success rate of 45% after a mean follow-up of 16 months. Preinjection CSA was not associated with whether the steroid injection was considered successful. This indicates that increased median nerve CSA does not preclude the possibility of symptomatic relief after a local steroid injection., Type of Study/level of Evidence: Therapeutic IV., (Copyright © 2023 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Background: The purpose of this study was to evaluate the relationship between cross sectional area (CSA) of the median nerve on ultrasound (US) with pre- and postoperative Boston Carpal Tunnel Questionnaire (BCTQ) scores. We hypothesize that there is a positive correlation between CSA and the ΔBCTQ after carpal tunnel release (CTR)., Methods: This was a single center study. During a 6-year period (2014-2020), CSA of the median nerve on US and BCTQ scores were collected prospectively for patients presenting with the chief complaint of numbness and tingling in the upper extremity. Patients who underwent CTR and presented for their 6-week follow-up had repeat measurements of the CSA and BCTQ. These patients were included in this study. Patients were then divided into ultrasound positive (CSA ≥ 10) and ultrasound negative (CSA < 10) groups. These groups were compared on the basis of demographics, preoperative BCTQ scores, postoperative BCTQ scores, and 6-week ΔBCTQ score., Results: US-positive and-negative groups did not differ significantly in their preoperative BCTQ, postoperative BCTQ, or ΔBCTQ scores. Both groups did, however, experience significant improvement when comparing preoperative to postoperative BCTQ scores within their respective US group., Conclusion: Regardless of the preoperative CSA of the median nerve, patients who underwent CTR experienced a significant improvement in their BCTQ results. US-positive patients experienced no greater improvement than US-negative patients. These results would suggest that US is not a good predictor of subjective surgical outcome measures such as the BCTQ.

Background: The ultrasound imaging findings and clinical treatment procedure of a case of fibrolipomatous hamartoma of the median nerve are reported in this paper. The disease diagnosis was mainly dependent on magnetic resonance, and rarely described by ultrasound. This paper introduces the imaging manifestations of median neurofibromatoid hamartoma under ultrasound., Case Presentation: This case is a middle-aged female with pituitary adenoma. Fibrolipomatous hamartoma, as a rare benign fibrofatty tumor, is characterized by the slow proliferation of mature adipocytes and fibrous tissue around and inside the peripheral nerves, eventually leading to the fusiform enlargement of nerve fiber bundles., Disscussion: This paper discusses the value and application of color doppler ultrasound in the diagnosis of FLH to provide a reference for the clinical diagnosis and treatment of this disease in the future and reviews the literature on this disease., Conclusion: Because fibrolipomatous hamartoma is very rare, it is very important to improve the understanding and diagnosis of this disease., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.net.)

Background: Our purpose was to describe structural and morphological features of the median nerve and carpal tunnel on magnetic resonance imaging (MRI) studies obtained before, immediately after, 6 weeks after, and 6 years after endoscopic carpal tunnel release (ECTR)., Methods: In this prospective cohort study, 9 patients with a diagnosis of carpal tunnel syndrome (CTS) underwent ECTR. Standardized MRI studies were obtained before ECTR, immediately after ECTR, and 6 weeks and 6 years after surgery. Structural and morphological features of the median nerve and carpal tunnel were measured and assessed for each study with comparisons made between each time point., Results: All 9 patients had complete symptom resolution postoperatively. On the immediate postoperative MRI, there was a discrete gap in the transverse carpal ligament in all patients. There was retinacular regrowth noted at 6 weeks in all cases. The median nerve cross-sectional area and the anterior-posterior dimension of the carpal tunnel at the level of the hamate increased immediately after surgery and these changes were maintained at 6 years., Conclusions: We defined structural and morphological changes on MRI for the median nerve and carpal tunnel in patients with continued symptom resolution 6 years after ECTR. Changes in median nerve and carpal tunnel morphology that occur immediately after surgery remain unchanged at mid-term follow-up in asymptomatic patients. Established imaging criteria for CTS may not apply to postoperative patients. Magnetic resonance imaging appears to be of limited clinical utility in the workup of persistent or recurrent CTS.

Background: The purpose of the present study was to evaluate the usefulness of the median nerve stenosis rate (MNSR) measured on sagittal sonographic images of the median nerve in the diagnosis of carpal tunnel syndrome (CTS)., Methods: The study population consisted of 45 hands from 37 patients with idiopathic CTS (CTS group), and 60 hands from 35 asymptomatic healthy subjects (control group). Carpal tunnel syndrome was diagnosed by clinical findings and positive electrophysiological study results. All patients and control subjects underwent ultrasonographic examination. At the carpal tunnel level, the transducer was placed longitudinally to the median nerve, and an image of the longitudinal median nerve was obtained. The minimum median nerve diameter (MND) was measured at the middle part of the capitate level, while the maximum MND was measured at the distal radioulnar joint level. The MNSR was calculated as (1 - minimum MND/maximum MND) × 100 (%). The cross-sectional area of the median nerve was also measured at the level of the pisiform., Results: On longitudinal sonographic images, the MNSR was significantly larger in the CTS group than the control group. When the cut-off value of the MNSR was 26.73%, the sensitivity and specificity were 91.1% and 80%, respectively. The area under the receiver operating characteristic curve was larger for the MNSR than for the cross-sectional area., Conclusion: The results suggest that the MNSR proposed in the present study may be useful as an auxiliary method for CTS diagnosis on ultrasonographic examination.

The ultrasound study for the diagnosis of carpal tunnel syndrome can reveal different anatomical variants. A rare variant is the presence of a trifid median nerve. The visualization of this anatomical variant may be of importance in the surgical planning of carpal tunnel syndrome. Fifty-two-year-old male, with a clinic compatible with bilateral carpal tunnel syndrome. In the ultrasound examination, a bifid median nerve appears as a finding in the right wrist and a trifid median nerve in the left wrist as anatomical variants. It is important to distinguish a trifid median nerve from a persistent median artery at the level of the carpal tunnel, much more frequent than the first. For this, the ultrasound visualization of the study area using the Doppler function is essential., (Copyright © 2022 Sociedad Española de Rehabilitación y Medicina Física. Publicado por Elsevier España, S.L.U. All rights reserved.)

Background: High-resolution ultrasound (HRU) has demonstrated utility in the diagnosis and treatment of carpal tunnel syndrome (CTS) by measuring the cross-sectional area (CSA) of the median nerve. We investigated whether HRU could be helpful in evaluating outcomes of carpal tunnel release in patients with severe CTS., Methods: Patients greater than 18 years of age with severe CTS on electrodiagnostic (EDX) studies and scheduled to have carpal tunnel release were enrolled. At baseline visit within 6 weeks preoperatively, HRU was used to measure median nerve CSA at the carpal tunnel inlet and forearm, and the wrist/forearm ratio (WFR) was calculated. Patients also completed the Boston Carpal Tunnel Questionnaire (BCTQ). Ultrasound and BCTQ were repeated at 6 weeks and 6 months postoperatively., Results: Twelve patients completed the study (average age, 69 years; range, 52-80 years). The WFR improved significantly at 6 weeks and reached normal levels at 6 months. The CSA at the wrist also improved at 6 months, although this did not reach statistical significance ( P = .059). Boston Carpal Tunnel Questionnaire symptoms and function scores improved significantly at 6 weeks and 6 months., Conclusions: High-resolution ultrasound provides an objective assessment of surgical outcomes in cases of severe CTS, demonstrating normalization of WFR in our series of successful cases. Future study of poor outcomes may help determine whether improvement in WFR and CSA can provide reassurance and support for observation rather than reoperation. Ultrasound also provides anatomical evaluation and may be helpful in cases with medicolegal or psychosocial issues while potentially being less costly and better tolerated than EDX or magnetic resonance imaging.

Purpose: The purpose of this study is to characterize the division of the median nerve by the persistent median artery (PMA) and highlight the associated clinical implications. Penetration of the median nerve by the PMA is believed to cause compression of the median nerve and affect nerve conduction velocity. This paper explored whether the origin and the pattern of PMA dictate its ability to divide the median nerve., Methods: Origin, and relationship of the PMA to the median nerve were documented in 60 cadavers donated to the Human Anatomy Program at UT Health San Antonio. Entire path of this artery was followed in the forearm and the hand., Results: Twenty-five cases of a persistent median artery (PMA) were found in the upper limbs (20.83%; 25/120) of these donated cadavers. Most of the persistent median arteries originated from the ulnar artery (48%; 12/25) and the others originated either from the anterior interosseous artery (36%; 9/25) or from the common interosseous artery (16%; 4/25). Sixty percent (15/25) of the persistent median arteries penetrated and divided the median nerve in the forearm. Interestingly, all the persistent median arteries that originated from the ulnar artery (100%; 12/12) divided the median nerve in the forearm and a palmar type of PMA was found to be more likely to divide the median nerve., Conclusion: Clinicians performing surgeries in the forearm and hand need to be aware of this anomaly and should screen patients for the presence of this artery prior to surgical intervention., (© 2022. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Background: Carpal tunnel syndrome is an entrapment neuropathy at the wrist characterized by compromised median nerve mobility. The purpose of this study was to investigate the effect of wrist position on median nerve longitudinal mobility in healthy subjects and the effect of radioulnar wrist compression on the median nerve mobility under non-neutral wrist positions., Methods: Dynamic B mode ultrasound images captured longitudinal median nerve motion in the carpal tunnel in 10 healthy subjects at wrist neutral position, 30-degree flexion, and 30-degree extension. In each position, RWC of 0, 5, 10, and 15 N were applied. One-way repeated measure analysis of variance (ANOVA), Post-hoc Tukey's tests, and the Friedman Test were used to show the significant differences of median nerve longitudinal mobility at different wrist positions and force conditions., Findings: Median nerve longitudinal mobility was found to be significantly influenced by wrist position (P < 0.05). The mobility under wrist neutral position was 3.02 mm/s, 38% higher than under wrist flexion (2.18 ± 0.60 mm/s), and 32% higher than under wrist extension (2.29 ± 0.43 mm/s). The impaired median nerve mobility was significantly restored under 10 N radioulnar wrist compression (P < 0.05), by 34.4% under wrist flexion (3.03 ± 0.85 mm/s), and 38.9% under wrist extension (3.07 ± 0.79 mm/s)., Interpretation: Non-neutral wrist positions compromise median nerve longitudinal mobility, but moderate radioulnar compressive forces are beneficial in the recovery of median nerve longitudinal mobility, and may help to prevent symptoms associated with carpal tunnel syndrome., Competing Interests: Declaration of Competing Interest The authors have no conflicts of interest to disclose., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

As the median nerve enters the carpal tunnel, it is a single nerve that soon bifurcates into lateral and medial branches into the hand. If the bifurcation is proximal to the carpel tunnel, a bifid median nerve (BMN) results. Carpal tunnel syndrome is often associated with a BMN with or without a persistent median artery. Individual keywords and MeSH phrases were searched in the Google Scholar, SCOPUS, and PubMed databases. Full texts were then collected and assessed for suitability. The prevalence of BMN at the wrist joint in normal and carpal tunnel syndrome wrists (precanal part) and the mean difference between groups were recorded. Only human data were used to test the findings. The pooled odds ratio (with minimal heterogeneity) was 1.50 [1.17-1.93, 95% CI]. The BMN cross-sectional area (CSA) was significantly greater than that of a solitary median nerve in normal wrists. The mean difference in CSA between the two was 1.50 mm 2 [0.56-2.45 mm 2 , 95% CI] without heterogeneity (i 2  = 0). Sex and laterality distributions scarcely differed between the two types of wrists. Owing to the insufficiency of data, the relationships with mean height and weight were not examined. There was a 50% greater incidence of bifid median nerves in carpal tunnel syndrome patients than in normal subjects. A bifid median nerve increases the mean CSA at the wrist joint by 1.5 mm 2 . These findings indicate that the bifid median nerve is an anatomical risk factor for carpal tunnel syndrome., (© 2022 American Association for Clinical Anatomists and the British Association for Clinical Anatomists.)

Objectives. Tendonitis and carpal tunnel syndrome are common cumulative trauma disorders that can occur with repetitive usage of pistol grip power tools. The role of reaction torque resulting in a forceful rotary displacement of the tool handle, as well as the role of applied grip force, is not clear in the development of these disorders. This study aimed to quantify the flexor tendon strains and median nerve pressure during a typical power tool operation securing a threaded fastener. Methods. Six fresh-frozen cadaver arms were made to grip a replica pistol grip power tool using static weights to apply muscle forces. A 5-Nm torque was applied to the replica power tool. The median nerve pressure and strains in the flexor digitorum profundus and superficialis tendons were measured using a catheter and strain gauges, at three wrist flexion angles. Results The peak tendon strains were between 1.5 and 2% and were predominantly due to the grip force more than the transmitted torque. Median nerve pressure significantly increased with the wrist flexed versus extended. . The results indicate that the contribution of the grip force to the tendon strain and median nerve pressure was greater than the contribution from the reaction torque.Conclusion . The results indicate that the contribution of the grip force to the tendon strain and median nerve pressure was greater than the contribution from the reaction torque.

Background: Ultrasonography is often used in the diagnosis of carpal tunnel syndrome (CTS). However, we were unable to find normative data regarding the cross-sectional area (CSA) of the median nerve in the Singapore population as measured by ultrasound. The aims of this study were to establish normative values of the CSA of the median nerve at the carpal tunnel inlet in a healthy population, 5 cm proximal to the carpal tunnel inlet, and to determine if the CSA correlated with side, age, gender or race. Methods: Sixty-nine wrists of 36 healthy subjects with no history of wrist injury or any signs and symptoms of CTS were examined. The CSA of the median nerve at the carpal tunnel inlet and 5 cm proximal to the carpal tunnel inlet was determined using ultrasound by a trained operator. Results: The mean CSA of the median nerve at the carpal tunnel inlet was 6.41 mm 2 (SD 2.18 mm 2 ). These were not significantly different from the values for mean CSA obtained 5 cm proximal to the carpal tunnel inlet. We did not find any correlation between the CSA of the median nerve and age, gender or race. Conclusions: The mean CSA of the median nerve at the carpal tunnel inlet in normal subjects in Singapore was found to be lower than other Asian populations. Wide variations of the median nerve CSA at the carpal tunnel inlet exists in the literature, and this is probably due to the heterogeneity of the study methodology and population. Level of Evidence: Level III (Diagnostic).

Median nerve cross-sectional area (CSA) was used for screening and diagnosis of neuropathy, but few studies have suggested reference range. Hence, this systematic review was performed to evaluate a normative values of median nerve CSA at various landmarks of upper limb based on ultrasonography. PubMed and Web of science were used to search relevant articles from 2000 to 2020. Forty-one eligible articles (2504 nerves) were included to access median nerve CSA at different landmarks (mid-arm, elbow, mid-forearm, carpal tunnel (CT) inlet and CT outlet). Data was also stratified based on age, sex, ethnicity, geographical location, and method of measurement. Random effects model was used to calculate pooled weighted mean (95% confidence interval (CI), [upper bound, lower bound]) at mid-arm, elbow, mid-forearm, CT inlet and outlet which found to be 8.81 mm 2 , CI [8.10, 9.52]; 8.57 mm 2 [8.00, 9.14]; 7.07 mm 2 [6.41, 7.73]; 8.74 mm 2 [8.45, 9.03] and 9.02 mm 2 [8.08, 9.95] respectively. Median nerve CSA varies with age, geographical location, and sex at all landmarks. A low (I 2  < 25%) to considerable heterogeneity (I 2  > 75%) was observed, indicating the variation among the included studies. These findings show that median nerve CSA is varying not only along its course but also in other sub-variables., (© 2022. The Author(s).)

Competing Interests: Competing interests: None declared.