Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Dr Mohan Z Mani

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Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2021 | Month : August | Volume : 15 | Issue : 8 | Page : TC10 - TC14 Full Version

Ultrasound Assessment of Carpal Tunnel Syndrome in Comparison with Nerve Conduction Study: A Case-control Study


Published: August 1, 2021 | DOI: https://doi.org/10.7860/JCDR/2021/50317.15265
Raja Kollu, Sindhu Vasireddy, Sreekanta Swamy, Nataraju Boraiah, H Ramprakash, Seema Uligada, Anees Dudekua

1. Associate Professor, Department of Radiodiagnosis and Imaging, Mallareddy Medical College for Women, Hyderabad, Telangana, India. 2. Consultant Neurologist, Department of Neurology, Aster Prime Hospital, Hyderabad, Telangana, India. 3. Professor, Department of Neurology, Vydehi Institute of Medical Sciences and Research Centre, Bengaluru, Karnataka, India. 4. Professor and Head, Department of Neurology, Vydehi Institute of Medical Sciences and Research Centre, Bengaluru, Karnataka, India. 5. Professor, Department of Radiodiagnosis and Imaging, Vydehi Institute of Medical Sciences and Research Centre, Bengaluru, Karnataka, India. 6. Assistant Professor, Department of Radiodiagnosis and Imaging, Vydehi Institute of Medical Sciences and Research Centre, Bengaluru, Karnataka, India. 7. Assistant Professor, Department of Radiodiagnosis and Imaging, East Point College of Medical Sciences, Bengaluru, Karnataka, India.

Correspondence Address :
Dr. Raja Kollu,
C/O Krishna Rao Kollu, Royal Gold 8-3-658/6, Flat No. 101, Jaya Prakash Nagar, Yellareddy Guda, Jeedimetla, Suraram X Road, Hyderabad, Telangana, India.
E-mail: raja.kollu@gmail.com

Abstract

Introduction: Carpal Tunnel Syndrome (CTS) is the entrapment neuropathy which is diagnosed based on the clinical history, examinations and the electrophysiological findings. The Cross-sectional Area (CSA) measurement of the median nerve has emerged as an alternative to Nerve Conduction Studies (NCS) for diagnosis of CTS. This study was done to correlate NCS and Ultrasonography (USG) in clinically diagnosed CTS patients.

Aim: To evaluate the diagnostic value of Cross-sectional Area (CSA) of median nerve at carpal tunnel inlet in patients with clinically and NCS confirmed Carpal Tunnel Syndrome (CTS) and to assess severity of the syndrome by NCS and its correlation with USG results.

Materials and Methods: This was a hospital based, case-control study done on a total of 109 patients of CTS and analysed during the period from June 2017 to June 2019. Total 203 hands of the patients with abnormal NCS formed case group while 101 hands from healthy volunteers constituted the control group. All the patients underwent neurological evaluation by Boston Carpal Tunnel Questionnaire (BCTQ) and were divided into mild, moderate and severe according to the score. An electromyography machine was used to perform electrophysiological studies of both the limbs in all subjects. CTS was diagnosed electro-diagnostically based on the American Association of Neuromuscular and Electrodiagnostic Medicine (AANEM) guidelines and were classified as mild (Grades 1 and 2), moderate (Grades 3 and 4), and severe (Grades 5 and 6) grades using Bland’s electrophysiological grading scale. USG was performed for all the subjects and all the data of various investigations was analysed using Statistical Package for Social Sciences (SPSS) version 22.0 software. Chi-square test and Mann Whitney U-test were used as test of significance for qualitative data.

Results: The mean age of subjects was 44.38±9.561 years. Strongly significant association was observed in BCTQ symptom, functional and total scores with NCS severity grading (p-value <0.001). Moderately significant association was found between BCTQ symptom and total scores with USG severity grading (p-value<0.02). Tunnel grade and NCS grade were found significantly correlated (p-value <0.001). The mean CSA cut-off value of 8.5 mm² at the inlet of carpal tunnel had a good sensitivity 86.21%, specificity 83.17%, Positive Predictive Value (PPV) 91.1% and Negative Predictive Value (NPV) 75%.

Conclusion: The diagnostic accuracy of USG assessment and NCS was found to be correlated comparably and complement each other in all grades of CTS. USG, can be considered a preferable screening tool by the patients of CTS due to its painless nature and easy accessibility. It requires minimal time and many a times detects those structural abnormalities which have great therapeutic implications. In mild CTS cases, USG should always be combined with NCS for proper diagnosis as USG might give negative result.

Keywords

American association of neuromuscular and electrodiagnostic medicine, Boston carpal tunnel questionnaire, Cross-sectional area, Electrodiagnosis, Ultrasonogram

Carpal Tunnel Syndrome (CTS) is the most common neuropathy leading to entrapment (1),(2) and the most common occupation related ailment which affects the peripheral nerves (3). CTS has been associated with many causes including chronic diseases like obesity, diabetes, arthritis, gout, hypothyroidism or occupational conditions like clerical, office or data entry or industrial construction or mining, kitchen or supermarket dealing etc. which are associated with rigid, forceful, and repetitive hand movements, uncomfortable postures, mechanical stress at the base of the palm and vibration (4),(5).

Currently, the diagnosis of CTS is typically based on history, physical examination and electrophysiological findings (6),(7),(8). The diagnosis of this condition are largely based on clinical history, examination and Electro-diagnostics (EDx), which is a combination of NCS and electromyography studies. Although NCS is useful for locating the pathology site and also to determine the severity of the condition, but still technique has limitations: it is painful, it does not allow for the visualisation of intrinsic nerve abnormalities and no information is provided about structures surrounding the nerve (9). NCS is a technique with false negative rate with sensitivity ranging from 49-86% (10). Previous studies (6),(11),(12),(13) have shown that musculoskeletal USG, might offer diagnostic accuracy in a similar manner (14). If the median nerve within the carpal tunnel gets compressed, it leads to nerve swelling proximally and distally to the site of compression. For a long time, USG has been considered a good diagnostic modality for proper evaluation and assessment in CTS patients.

Buchberger W et al., first showed USG comparable accuracy to Magnetic Resonance Imaging (MRI) for the diagnosis of CTS (11). Their work was further confirmed by Altinok T et al., (15), using NCS as the reference standard. Duncan I et al., (16) showed that CSA as a diagnostic parameter is a real good criteria as compared to other USG parameters for CTS detection. Supporting this, many other previous studies established that the measurement of carpal tunnel inlet at the level of pisiform to be considered as standard (7),(17),(18),(19),(20). Baiee RH et al., performed study on patients who had signs and symptoms of CTS as well as a positive NCS (21). There was a significant correlation between age and severity of disease determined by NCS. Their study also observed positive correlations between the USG findings and all the other measures in NCS technique for severity of disease in Carpal Tunnel patients. Kwon HK et al., amongst the analysed mild, moderate, and severe CTS subjects observed that the CSA of the median nerve varied significantly between the severe and moderate CTS groups and this factor was also found to correlate with EDx parameters in both severe and mild CTS wrists (22). Kasundra GM et al., used to evaluate and compare patients with clinical and electro-diagnostic proof of CTS and healthy volunteers in the case-control design (23).

The median nerve’s CSA was determined at the inlet and outlet of the carpal tunnel, and the Inlet Outlet Ratio (IOR) was estimated for each wrist. Using the IOR rather than the inlet CSA had a diagnostic benefit (p-value <0.01), according to Receiver Operating Characteristic (ROC) analysis. Optimum sensitivity and specificity in the diagnosis of CTS were obtained at IOR>1.3. They also conducted a comparative research for CTS, diagnostic modalities in cases and controls. The sensitivity of the USG was low, but the specificity was high, and the sensitivity of the MRI was moderate. BCTQ-S and NCS, as well as BCTQ-S and USG, showed a significant correlation. Kanikannan MA et al., (12) carried the study with average CSA at the carpal tunnel inlet was 0.11± 0.0275 cm², 76.43%, 72.72%, 89.47%, and 68%, respectively, for sensitivity, accuracy, positive predictive value, and negative predictive value (p-value-0.0001). Billakota S and Hobson-Webb LD performed the study with median nerve CSA greater than 9 mm² and/or a wrist-to-forearm ratio of greater than 1.4 were used to make a USG diagnosis of CTS (24). For diagnosis, EDx studies were the gold standard. In 97.6% of EDx-confirmed CTS, USG was positive. Roghani RS et al., evaluated that 203 of the clinically diseased patients, EDx supported the best diagnostic accuracy for CTS at the CSA of tunnel inlet as 8.5 mm2 and an inlet-to-antecubital CSA ratio of 0.65. The objective of the present study was to evaluate the diagnostic value of the CSA of median nerve at carpal tunnel inlet in patients with clinically and NCS confirmed CTS and to assess the correlation of its severity with NCS and USG assessment.

Material and Methods

This prospective case-control study was conducted in the Department of Neurology and Radiology, Vydehi Institute of Medical Sciences and Research Centre, Bengaluru, Karnataka, India, with clinically diagnosed cases of CTS included in the study, over a period of two years from June 2017 to June 2019. The study was approved by the Institutional Ethics Committee (Approval no.ECR/747/Inst/KA/2015).

Inclusion criteria: All patients who came to the Department of the Institute during the time period of the study and were diagnosed with CTS based on clinical and NCS according to American Association of Neuromuscular and Electro-diagnostic Medicine (AANEM) diagnostic criteria (25),(26),(27),(29) were included in the study.

Age and sex matched healthy hospital staff and volunteers who had been screened for history and examination were included as control group subjects. All cases and control subjects were included after obtaining proper written informed consent.

Exclusion criteria: Patients with history of wrist surgery or fracture, any accompanying condition other than CTS, like proximal median neuropathy, cervical radiculopathy or polyneuropathy and underlying disorders associated with CTS such as, pregnancy and acromegaly were excluded from the study.

Universal sampling was followed in the study, making the total sample to 109 patients. Total 203 abnormal NCS hands formed the case group while 101 normal NCS hands formed the control group.

Neurological Evaluation

Detailed clinical history and examination with CTS provocative tests like tinels and phalens test were done. BCTQ (23) was applied to all patients, hence the assessment was done on basis of symptoms and functional status. Scores were assigned from 1 (normal) to 5 (most severe). No response to a certain question was given 0 points. Each score was calculated as the mean of the responses of the individual items. Patients were divided into three groups according to their mean score:

I. Mild (0.1-2 points),
II. Moderate (2.1-3 points),
III. Severe (3.1-5 points).

No patients showed negative results on the self-administered questionnaire. The patients who had bilateral symptoms were asked to answer two questionnaires, one for each hand separately.

Nerve Conduction Studies

The electro-physiological studies were performed on both upper limbs in all patients and control subjects utilising an electromyography machine (Neuropack X1-MEB-2300) in a shielded room. NCS were performed according to the American Association of Electro-diagnostic Medicine criteria (25),(26),(27),(29). The abnormal values of various NCS parameters (28) used in this study are depicted in (Table/Fig 1).

CTS was diagnosed electro-diagnostically based on the American Association of Neuromuscular and Electro-diagnostic Medicine (AANEM) guidelines (25),(26),(27),(29) and were classified into mild (Grades 1 and 2), moderate (Grades 3 and 4), and severe (Grades 5 and 6) (Table/Fig 2) using Bland’s electrophysiological grading scale (30).

USG

High resolution USG was performed by the single radiologist, within one-week period of EDx study after blinding the operator to other tests results. A real-time scanner (Philips affinity 50) with a 8-14 MHz linear array transducer was used and transverse USG of the median nerve was performed from the distal forearm to the outlet of the carpal tunnel. The CSA measurements were performed at the inner border of the thin hyperechoic rim of the nerve (perineurium) using the manual tracing technique. The authors in the present study considered CSA values, by logistic regression model of the control group (101 hands) CSA greater than 8.5 mm2 to be abnormal. These abnormal values of CSA measurements of the nerve were classified as: Mild- 8.5 mm2-10.5 mm2, Moderate- 10.5 mm2, 13 mm2 and Severe >13 mm2.

Statistical Analysis

Data was entered into Microsoft Excel data sheet and was analysed using Statistical Package for Social Sciences (SPSS) version 22.0 (IBM SPSS Statistics, Somers NY, USA) software. Categorical data was represented in the form of frequencies (n) and proportions. Chi-square test was used as test of significance for qualitative data. Continuous data was represented as mean±Standard Deviation (SD). Independent t-test or Mann Whitney U-test was used as test of significance for quantitative variables.

Results

Total of 109 patients attended to Department of Neurology during the study time period fulfilling the inclusion criteria were considered for the study. Mean age was 44.38±9.561 years and age range was 16-68 years with maximum (48%) patients in 41-50 years age group. Females were 78 (71.6%) and males were 31 (28.4%). Among the 109 subjects of abnormal NCS, 94 subjects had bilateral involvement, 4.4% had right side involvement and 3% had left side involvement. Hence, a total of 203 hands were considered in analysis of abnormal group while 101 hands of normal NCS were included as controls making a total of 304 hands in this study (Table/Fig 3).

In the present study, all NCS positive were considered cases 203 (66.8%) and controls were 101 (33.2%). Amongst the case group sample, the categorisation was observed as mild grade in 41 (20.2%), moderate grade in 110 (54.2%) and severe grade in 52 (25.6%). In this study, there was a significant association between BCTQ symptoms, functional and total grades with NCS grade (p-value <0.001) as is well evident in (Table/Fig 4).

In this study, 162 (79.8%) had abnormal tunnel findings and 41 (20.2%) had normal tunnel findings. The grading according to tunnel USG findings was observed as mild in 85 (41.9%), moderate in 42 (20.7%) and severe in 35 (17.2%). In the present study, there was significant positive correlation between BCTQ total with tunnel values i.e., with increase in BCTQ score, there was increase in tunnel values and vice versa (Table/Fig 5), (Table/Fig 6).

On clinically analysing the data, most common symptom amongst the subjects of present study was tingling and numbness in 97% subjects and the most common sign was Phalen’s test in 85.20%. Tingling and numbness did not correlate with NCS and USG severity grading. Pain was noted in 31.5% population, correlated with NCS grading (p<0.001) and USG grading (p-value=0.039). Weakness was noted in 19.2% population correlated with NCS grading (p<0.001) and USG grading (p-value=0.04). Sensory disturbances were noted in 33.5% population correlated with NCS grading (p<0.001) but not with USG grading (p-value=0.076). Wasting was noted in 6.9% population correlated with NCS grading (p<0.001) but not with USG grading (p-value=0.678). Tinels sign was noted in 59.6% population which did not correlate significantly with NCS and USG grading. Phalens sign was noted in 85.2% population which correlated with NCS grading (p<0.001) and USG grading (p-value=0.557).

The severity of CTS by NCS comparing with severity by USG, that most of mild cases by NCS are mostly mild (48.8%), moderate (12.2%) and even negative (36.6%) by USG. In moderate cases by NCS most of cases are between mild (49.1%) and moderate (19.1%) by USG and in severe cases by NCS most of cases are between mild (21.2%) and moderate (30.8%) by USG. In the present study, there was strongly significant association between NCS grade and tunnel grade (p-value <0.001) (Table/Fig 7).

Sensitivity, Specificity, PPV and NPV of USG for the diagnosis of CTS. From the statistical point of view the sensitivity and specificity were calculated for mean values of CSA at the carpal tunnel inlet and at 8.5 mm² as cut-off value. The sensitivity of 86.21%, a specificity of 83.17%, a PPV of 91.1%, a NPV of 75.0% and an accuracy of 87.32%. Cut-off CSA at inlet >8.5 mm² had highest sensitivity and specificity.

Discussion

In the present study, 109 total subjects had abnormal NCS. There are numerous studies in the literature on comparison of NCS with tunnel USG in CTS. However, very few studies (12),(23) were available with data on Indian population. Hence, the present study was conducted to evaluate NCS and USG and compared them. The authors compared BCTQ scores with both diagnostic modalities, NCS and USG since many previous studies had led to conflicting results in their association (12),(31),(32).

USG has emerged as a viable, convenient, low-cost, fast and reliable method for evaluating CTS patients. Based on CTS grading, it was possible to compare USG and NCS findings in the current research. USG had comparable accuracy to NCS in all grades of CTS in patients with a clinical diagnosis of CTS.

After reviewing the literature (12) authors found that the most reliable sonography parameter for CTS was an increase in the CSA at the inlet. Hence, this parameter was used in the present study. Authors observed a good diagnostic accuracy with median nerve CSA at the tunnel inlet, in patients with CTS and a good correlation between USG and NCS. This correlation was consistent in all grades of CTS. Other sonographic parameters include, bowing of the flexor retinaculum, change in CSA of median nerve and flattening ratio. Various ranges for abnormal cut-off USG parameters have been reported with CSA ranging from 9 mm2 to 15 mm2. However, a lack of a consensus leads to difficulties in using USG as a diagnostic modality. Also the ideal site of CSA measurement is of debate. Based on the cut-off values considered in the study, sensitivity of CSA in diagnosing CTS ranges from 48% to 89% and specificity from 47% to 100% (19),(20),(21),(33). The sensitivity and specificity of the mean CSA cut-off value of 8.5 mm² at the inlet of the carpal tunnel in present study was comparable to previous studies (7),(16),(20),(21),(34).

The mean age and sex ratio in the present study were comparable to the subjects of previous studies (12),(23),(24),(33). Out of 109 patients, 94 had bilateral hand involvement, and 15 had unilateral involvement. In unilateral hands, right hand was involved in 9 and left hand in 6 cases. Right hand was involved more than left, which was similar with other studies(12),(23), (24),(33).

Tinels sign was noted in 59.6% population which did not correlate significantly with NCS and USG grading and Phalens sign was noted in 85.2% population which correlated with NCS grading (p<0.001) and USG grading (p=0.557). Phalens and tinels sign correlated with NCS grading in Kasundra GM et al., study (23).

In the present study, strong association was found between BCTQ total grading and NCS grading (p-value <0.001). Similarly, strong association was established between BCTQ symptom, functional and total scores and NCS severity grading (p-value <0.001) and significant positive correlation with USG grading (p-value <0.001). BCTQ symptom scores showed significant association with USG severity grading (p-value <0.02) while BCTQ function grading did not show significant association with USG grading. Few studies showed correlation between BCTQ and NCS or USG (12),(32) whereas few showed no correlation between these scores and diagnostic modalities (31). Kasundra GM et al., (23) also showed correlation between BCTQ symptom, function and total score to NCS grading. In the present study there was significant positive correlation between BCTQ total with tunnel values i.e., with increase in BCTQ score there was increase in tunnel values and vice versa.

In present study, the mean CSA cut-off value of 8.5 mm² at the inlet of carpal tunnel, the sensitivity, specificity, positive predictive value, negative predictive value and accuracy were found comparable to other previous studies (7),(16),(19),(20),(21),(34). In the severe CTS group, USG had high sensitivity and specificity. In mild CTS, USG was found to be less sensitive. Thus, it can be inferred that in mild CTS patients, USG despite being negative should mandatorily accompany electrophysiological assessments for confirmatory diagnosis. There was a small group (n=11) of patients with normal NCS and abnormal USG that had clinical symptoms and signs of CTS. Billakota S and Hobson-Webb LD described that despite having some inflammation in the median nerve, the NCS was not affected, yielding an abnormal USG with a normal NCS results (24). Roghani RS et al., (13) highlighted that USG complements NCS in diagnosis, as it was shown to be 73% sensitive in patients with CTS but giving negative NCS, hence the diagnostic sensitivity for clinically suspected CTS is commendably increased. Hence, the study supported the idea of using USG, especially for patients with clinical findings suggestive of CTS but representing normal NCS.

Limitation(s)

In the present study, inclusion of symptomatic hand as a control, led to a subgroup of patients, NCS negative USG positive CTS patients. This subgroup patients could not be statistically analysed due to the inclusion and exclusion criteria of the study. There is a need to study this subgroup of patients, as false negative rates of NCS can be as high as 10-46%. Secondly, in this study, population of mild cases were very less, contributing to better USG sensitivity.

Conclusion

The diagnostic accuracy of USG assessment and NCS was found to be correlated comparably and complement each other in all grades of CTS. USG being a painless and easily accessible technique also requires minimal time and detects structural abnormalities that may have therapeutic implications. Hence, it can be used as a good screening technique preferred by the patients. However, electro-diagnosis should be the preferred diagnostic modality for mild CTS.

References

1.
Thatte MR, Mansukhani KA. Compressive neuropathy in the upper limb. Indian J Plast Surg. 2011;44(2):283-97. [crossref] [PubMed]
2.
Dawson DM, Hallett M, Millender LH. Entrapment neuropathies. Boston: Little Brown; 1990. [crossref]
3.
Kao SY. Carpel tunnel syndrome as an occupational disease. J Am Board Fam Pract. 2003;16(6):533-42. [crossref] [PubMed]
4.
Atcheson SG, Ward JR, Lowe W. Concurrent medical disease in work related carpal tunnel syndrome. Arch Intern Med. 1998;158(14):1506-12. [crossref] [PubMed]
5.
Feldman RG, Travers PH, Chirico-Post J, Keyserling WM. Risk assessment in electronic assembly workers: Carpal tunnel syndrome. J Hand Surg Am. 1987;12(5):849-55. [crossref]
6.
Fu T, Cao M, Liu F, Zhu J, Ye D, Feng X, et al. Carpal tunnel syndrome assessment with ultrasonography: Value of inlet-to-outlet median nerve area ratio in patients versus healthy volunteers. 2015;10(1):e0116777; Doi: 10.1371/journal.pone.0116777.eCollection 2015. [crossref] [PubMed]
7.
Wong SM, Griffth JF, Hui ACF, Lo SK, Fu M, Wong KS. Carpal tunnel syndrome: Diagnostic usefulness of sonography. Radiology. 2004;232(1):93-99. Doi: 10.1148/radiol.2321030071 PMID: 15155897. [crossref] [PubMed]
8.
Cartwright MS, Hobson-Webb LD, Boon AJ, Alter KE, Hunt CH, Victor HF, et al. Evidence-based guideline: Neuromuscular ultrasound for the diagnosis of carpal tunnel syndrome. Muscle Nerve. 2012;46:287-93. Doi: 10.1002/mus.23389 PMID: 22806381. [crossref] [PubMed]
9.
Cartwright MS, Passmore LV, Yoon JS, Brown ME, Caress JB, Walker FO. Cross-sectional area reference values for nerve ultrasonography. Muscle Nerve. 2008;37(5):566-71. Doi: 10.1002/mus.21009 PMID: 18351581. [crossref] [PubMed]
10.
Jablecki CK, Andary MT, Flocter MK, Miller RG, Quartly CA, Vennix MJ, et al. Practice parameter: Electro-diagnostic studies in carpal tunnel syndrome. Report of the American Association of Electrodiagnostic Medicine, American Academy of Neurology, and the American Academy of Physical Medicine and Rehabilitation. Neurology. 2002;58(11):589-92. [crossref] [PubMed]
11.
Buchberger W, Judmaier W, Birbamer G, Lener M, Schmidauer C. Carpal tunnel syndrome: Diagnosis with high-resolution sonography. AJR Am J Roentgenol. 1992;159(4):793-98. [crossref] [PubMed]
12.
Kanikannan MA, Boddu DB, Umamahesh, Sarva S, Durga P, Borgohain R. Comparison of high-resolution sonography and electrophysiology in the diagnosis of carpal tunnel syndrome. Ann Indian Acad Neurol. 2015;18(2):219-25. [crossref] [PubMed]
13.
Roghani RS, Holisaz MT, Norouzi AS, Delbari A, Gohari F, Lokk J, et al. Sensitivity of high-resolution ultrasonography in clinically diagnosed carpal tunnel syndrome patients with hand pain and normal nerve conduction studies. J Pain Res. 2018;11:1319-25. PMID: 30022850. [crossref] [PubMed]
14.
Fowler JR, Cipolli W, Hanson T. A comparison of three diagnostic tests for carpal tunnel syndrome using latent class analysis. J Bone Joint Surg Am. 2015;97(23):1958-61. [crossref] [PubMed]
15.
Altinok T, Baysal O, Karakas HM, Sigirci A, Alkan A, Kayhan A, et al. Ultrasonographic assessment of mild and moderate idiopathic carpal tunnel syndrome. Clin Radiol. 2004;59(10):916-25. [crossref] [PubMed]
16.
Duncan I, Sullivan P, Lomas F. Sonography in the diagnosis of carpal tunnel syndrome. AJR Am J Roentgenol. 1999;173(3):681-84. [crossref] [PubMed]
17.
Lee D, van Holsbeeck MT, Janevski PK, Ganos DL, Ditmars DM, Darian VB. Diagnosis of carpal tunnel syndrome: Ultrasound versus electromyography. Radiol Clin North Am. 1999;37(4):859-72, x. [crossref]
18.
El Miedany YM, Aty SA, Ashour S. Ultrasonography versus nerve conduction study in patients with carpal tunnel syndrome: Substantive or complementary tests? Rheumatology (Oxford). 2004;43(7):887-95. [crossref] [PubMed]
19.
Keles¸ I, Karagülle Kendi AT, Aydin G, Zög? SG, Orkun S. Diagnostic precision of ultrasonography in patients with carpal tunnel syndrome. Am J Phys Med Rehabil. 2005;84:443-50. [crossref] [PubMed]
20.
Swen WA, Jacobs JW, Bussemaker FE, de Waard JW, Bijlsma JW. Carpal tunnel sonography by the rheumatologist versus nerve conduction study by the neurologist. J Rheumatol. 2001;28(1):62-69.
21.
Baiee RH, Almukhtar N, Al-Rubaie SJ, Hammoodi ZH. Neurophysiological findings in patients with carpal tunnel syndrome by nerve conduction study in comparing with ultrasound study. Journal of Natural Sciences Research. 2015;5(16):111-28.
22.
Kwon HK, Kang HJ, Byun CW, Yoon JS, Kang CH, Pyun SB. Correlation between ultrasonography findings and electrodiagnostic severity in carpal tunnel syndrome: 3D ultrasonography. J Clin Neurol. 2014;10(4):348-53. [crossref] [PubMed]
23.
Kasundra GM, Sood I, Bhargava AN, Bhushan B, Rana K, Jangid H, et al. Carpal tunnel syndrome: Analyzing efficacy and utility of clinical tests and various diagnostic modalities. J Neurosci Rural Pract. 2015;6(4):504-10. [crossref] [PubMed]
24.
Billakota S, Hobson-Webb LD. Standard median nerve ultrasound in carpal tunnel syndrome: A retrospective review of 1,021 cases. Clin Neurophysiol Pract. 2017;15(2):188-91. [crossref] [PubMed]
25.
Werner RA, Andary M. Electrodiagnostic evaluation of carpal tunnel syndrome. Muscle Nerve. 2011;44(4):597-607. [crossref] [PubMed]
26.
Kimura J. Electrodiagnosis in diseases of nerve and muscle: Principles and Practice. 3rd ed. New York: Oxford University Press; 2001.
27.
Cranford CS, Ho JY, Kalainov DM, Hartigan BJ. Carpal tunnel syndrome. J Am Acad Orthop Surg. 2007;15(9):537-48. [crossref] [PubMed]
28.
Jablecki CK, Andary MT, Floeter MK, Miller RG, Quartly CA, Vennix MJ, et al. Practice parameter: Electrodiagnostic studies in carpal tunnel syndrome. Report of the American Association of Electrodiagnostic Medicine, American Academy of Neurology, and the American Academy of Physical Medicine and Rehabilitation. Neurology. 2002;58(11):1589 92. [crossref] [PubMed]
29.
Bland JD. A neurophysiological grading scale for carpal tunnel syndrome. Muscle Nerve 2000;23(8);1280-83. 3.0.CO;2-Y>[crossref]
30.
Mondelli M, Filippou G, Gallo A, Frediani B. Diagnostic utility of ultrasonography versus nerve conduction studies in mild carpal tunnel syndrome. Arthritis Rheum 2008;59(3):357-66. [crossref] [PubMed]
31.
Lee CH, Kim TK, Yoon ES, Dhong ES. Correlation of high-resolution ultrasonographic findings with the clinical symptoms and electrodiagnostic data in carpal tunnel syndrome. Ann Plast Surg. 2005;54(1):20-23. [crossref] [PubMed]
32.
Mohammadi A, Ghasemi R M, Mladkova SN, Ansari S. Correlation between the severity of carpal tunnel syndrome and color Doppler sonography findings. AJR Am J Roentgenol. 2012;198(2):W181-84. [crossref] [PubMed]
33.
Nakamichi KI, Tachibana S. Ultrasonographic measurement of median nerve cross-sectional area in idiopathic carpal tunnel syndrome: diagnostic accuracy. Muscle Nerve. 2002;26(6):798-803. [crossref] [PubMed]
34.
Mohammadi A, Afshar A,Etemadi A, Masoudi S, Baghizadeh A. Diagnostic value of cross-sectional area of median nerve in grading severity of carpal tunnel syndrome. Arch Iran Med. 2010;13(6):516-21.

DOI and Others

10.7860/JCDR/2021/50317.15265

Date of Submission: May 12, 2021
Date of Peer Review: Jun 24, 2021
Date of Acceptance: Jul 24, 2021
Date of Publishing: Aug 01, 2021

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

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