| Part Ⅰ The application of high-resolution ultrasonography in the diagnosis and classification of carpal tunnel syndromeObjectiveTo explore the role of high-resolution ultrasonography in the diagnosis and classification of carpal tunnel syndrome (CTS), and establish the high sensibility and specificity cut-off point to diagnose and classify the severity of CTS.Materials and methodsSeventy-seven patients with CTS in our outpatient department and 22 healthy controls were assessed and underwent ultrasonography of the wrist, from December 2013 to February 2014. Our patient group was 72 females (93.5%) and 5 males (6.5%) with ages ranging between 27 and 72 years, mean age was 51.4 years. Right wrists were 46 (59.7%) and left wrists were 31 (40.3%). The medical history ranged from three months to ten years, mean is four years. Patients were classified as having mild, moderate, and severe CTS according to the method by Gu yudong 2010. Eleven had mild CTS,51 had moderate CTS, and 15 had severe CTS. Exclusion criteria include history of wrist injury and other peripheral nerve disorders. The healthy controls group was 20 females (90.9%) and 2 males(9.1%) with ages ranging between 35 and 55 years, mean age is 41.3 years. Right wrists were 12 (54.5%) and left wrists were 10 (45.5%).In the sagittal plane of wrist, we observed the configurations of median nerve, whether there were compressed site and swelling of median nerve. The anteroposterior diameter of compressed site and swelling site of median nerve and the thickness of transverse carpal ligament thickness (TCL-T) were measured, the thickness ratio (defined as the ratio of the anteroposterior diameter of the compressed site of median nerve to the swelling site) (TR) was calculated. In the transverse plane of wrist, we observed the configurations of median nerve at three different levels (levels of the carpal tunnel inlet, outlet and the forearm), and the cross-sectional area (CSA) of median nerve were measured, include CSA of the median nerve at the carpa tunnel inlet (CSA-I), outlet (CSA-O) and at forearm (CSA-F). The flattening ratio of median nerve in carpal tunnel outlet (defined as the ratio of the major axis of median nerve to its minor axis) (FR), inlet-outlet ratio (defined as the ratio of the CSA-I to CSA-O) (IOR) and wrist-forearm ratio (defined as the ratio of CSA-I to CSA-F) (WFR) were calculated.The data manipulation and analysis were performed using the SPSS Version 16. Statistical analysis was performed using the Kruskal-Wallis H test and Mann-Whitney U to test differences between groups’means. The cut-off point of diagnostic criteria was determined by using a receiver operating characteristic curve (ROC). The Kappa test was used to analysis the consistency of electromyography to ultrasound. In all tests, the P value is less than 0.05 indicates that the difference was statistically significant.ResultsFor all severity of CTS, the compressed site of median nerve and swelling proximal and distal to it, the increased thickness of transverse carpal ligament were observed in the sagittal plane. The swelling of median nerve of carpal tunnel inlet and constriction of median nerve of carpal tunnel outlet were observed in the transverse plane.The CSA-I,IOR,WFR, TCL-T and TR showed significant differences between CTS group and healthy control group (P<0.05). By calculating the area under curve (AUC) of ROC, CSA-I, WFR, IOR and TCL-T can be used to diagnose CTS, the cut-off point is 9.05mm2,1.14,1.41,3.77mm, and its sensibility is 85.7%,81.8%, 77.9%,89.6% and specificity is 55%,68.2%,55.5%,81.8%, respectively. TCL-T has the high sensibility and specificity to diagnose the CTS, and the Youden index is 0.72.The IOR and TR showed significant differences among the different severity of CTS (P<0.05). By calculating the AUC of ROC, we found that IOR can be confident of determining the level of severity of CTS. This study revealed that 1.29 and 1.52 were the best cut-off points to discriminate the severity of CTS, its sensibility is 64.7%、80% and specificity is 72.7%、64.7%, respectively. Statistical analysis showed a consistency the IOR measured by ultrasound with electro diagnostic for classifying the severity of CTS.ConclusionThe high-resolution ultrasonography can be used to observe the change of configurations of median nerve for those patients with CTS. The measurements of ultrasound not only used in diagnosis the CTS, but also classification.Part II The application of intraoperative high-resolution ultrasonography in therapeutic evaluation during the surgeryObjectiveExplore the value of intraoperative high-resolution ultrasonography during the decompression of CTS. Find out the high sensitive and specific index to evaluation of the effect of decompression.Materials and methodsThirty-eight patients with CTS in our outpatient department were included in this study, from December 2013 to February 2014. They underwent the first carpal tunnel decompression. Our patient group was 36 females (94.7%) and 2 males (5.3%) with ages ranging between 38 and 72 years, the mean age is 55.5 years. Right wrists were 20 (52.6%) and left wrists were 18 (47.4%). Patients were classified as having mild, moderate, and severe CTS according to the method by Gu yudong 2010. Two had mild CTS,26 had moderate CTS, and 10 had severe CTS. Exclusion criteria include history of wrist injury and other peripheral nerve disorders.All patients underwent ultrasonography of the wrist pre-and intra-operation. In the sagittal plane of wrist, we observed the change of the configurations of median nerve in compressed site, the maximum and minimum anteroposterior diameter of median nerve were measured. The TR was calculated. In the transverse plane of wrist, the CSA-I and CSA-O were measured. The IOR was calculated.The data manipulation and analysis were performed using the SPSS Version 16. All indexes pre- and intra- operation were performed by Paired T test. The P value is less than 0.05 indicates that the difference was statistically significant.ResultsBy intraoperative high-resolution ultrasonography, we observed that the compressed site of median nerve was relieved after carpal tunnel decompression. For moderate CTS, TR showed significant differences between pre- and intra- operation (P=0.0002). For severe CTS, CSA-O and TR showed significant differences between pre- and intra- operation (P=0.032 and 0.0002, respectively).ConclusionThe intraoperative high- resolution ultrasonography may be considered as a complementary tool to observe the complete or incomplete relieve of the compressed site of median nerve. For moderate and severe carpal tunnel syndrome, TR can be used to evaluate the effect of median nerve intraoperative decompression. |
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