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Carpal tunnel syndrome

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Carpal tunnel syndrome results from compression of the median nerve (tunnel syndrome) within the carpal tunnel. It is a cause of significant disability and is one of three common median nerve entrapment syndromes, the other two being anterior interosseous nerve syndrome and pronator teres syndrome.

Epidemiology

The prevalence of carpal tunnel syndrome is estimated to be 2.7-5.8% of the general adult population, with a lifetime incidence of 10-15%, depending on occupational risk ⁴.

Carpal tunnel syndrome usually occurs between ages 36 and 60 and is more common in women, with a female-to-male ratio of 2-5:1.

Clinical presentation

Carpal tunnel syndrome is primarily defined by pain and sensory symptoms:

brachialgia paraesthetica nocturna, or nocturnal ascending pain emanating from the wrist, is typical
sensory symptoms affect the first three digits and, depending on innervation patterns, the radial aspect of the fourth digit
positive Tinel test: paraesthesias elicited by tapping the median nerve at the wrist
positive Phalen test: paraesthesias caused by wrist flexion over 30-60°

Hand weakness, as a rule, is a late and often functionally irrelevant symptom ⁵.

The dominant hand is affected more frequently, and bilateral involvement has been reported to occur in ~30% (range 8-50%) of cases.

The clinical presentation can harbour some pitfalls. Sensory and pain symptoms of the pronator teres syndrome (PTS) and carpal tunnel syndrome can overlap; one can distinguish the two by examining for numbness of the forearm, which does not occur in carpal tunnel syndrome and ask about nocturnal exacerbation, which is atypical in PTS. Provocation tests as detailed above can help further.

Pathology

There is a wide spectrum of causative pathologies, converging on two mechanisms of disease, both of which lead to entrapment ⁵:

a decrease in the size of the carpal tunnel caused by such conditions as:
- mechanical overuse (considered the most common association)
- osteoarthritis
- trauma
- acromegaly
disease states leading to augmentation of carpal tunnel contents:
- masses, e.g. ganglion cysts, primary nerve sheath tumours
- deposition of foreign material, e.g. amyloid
- synovial hypertrophy in rheumatoid arthritis

A useful mnemonic to remember these causes is MEDIAN TRAP.

Radiographic features

Ultrasound and MRI are the two imaging modalities that best lend themselves to investigating entrapment syndromes. Next to directly visualising direct causes and anatomical variants (e.g. a Gantzer muscle), recognising pathological muscle signal patterns on MRI can point to the affected nerve.

Ultrasound

In imaging median nerve syndromes, ultrasound is useful in examining carpal tunnel syndrome, potentially revealing, in fully developed cases, a triad of:

palmar bowing of the flexor retinaculum (>2 mm beyond a line connecting the pisiform and the scaphoid)
distal flattening of the nerve
enlargement of the nerve proximal to the flexor retinaculum

Enlargement of the nerve seems to be the most sensitive and specific criterion, but what cut-off value for pathological size remains debated; the normal cross-sectional area is given at 9-11 mm² (0.09-0.11 cm²), but the range of sizes deemed pathological is wide. If the nerve is bifid some suggest measuring the combined cross-sectional area ^ref.

According to one study, a 2 mm² difference in nerve cross-section between the level of the pronator quadratus and the carpal tunnel has a 99% sensitivity and 100% specificity for carpal tunnel syndrome ⁹.

Some of the other proposed findings include^ref:

a flattening ratio of over x 3
bowing of the flexor retinaculum of >4 mm

MRI

~~In carpal tunnel syndrome,~~ MRI ~~can demonstrate palmar bowing of the flexor retinaculum, enlargement of the median nerve at the level of the pisiform, and flattening of the median nerve at the level of the hook of the~~ ~~~~hamate~~.~~

~~Other signs are oedema or loss of fat within the carpal tunnel, and increased size or oedema of the nerve on fluid-sensitive sequences, and, in some cases, contrast enhancement of the nerve~~ ⁴.

~~Although~~has good-to-excellent sensitivity (84-100%) and specificity ~~of MRI in~~(85-94%) for diagnosing carpal tunnel syndrome ~~are low (23-96% and 39-87%, respectively),~~when using cross-sectional area >15 mm² as a cut-off ^12,13. MRI is especially well-suited for detecting masses, arthritic changes, and normal variants (e.g. bifid median nerve) ⁵.

In carpal tunnel syndrome, MRI can demonstrate ⁴:

palmar bowing of the flexor retinaculum
nerve thickening at the carpal tunnel inlet (level of the pisiform)
nerve flattening at the carpal tunnel outlet (level of the hook of hamate)
increased cross-sectional area
- ultrasound values do not correlate with MRI values ¹¹
- >15 mm² at the carpal tunnel inlet or outlet can be used as a diagnostic criterion or cut-off ^12,13
- >19 mm² has been proposed as a marker for severe carpal tunnel syndrome ¹³
oedema or loss of fat within the carpal tunnel
neural oedema s +/- contrast enhancement

Treatment and prognosis

It is initially often treated conservatively with splinting and non-steroidal anti-inflammatory drugs (NSAIDS). Corticosteroid injections into the carpal tunnel can alleviate symptoms temporarily for about 4 weeks. Median nerve injury is a very rare complication ¹⁰.

Surgical release of the flexor retinaculum is indicated in cases of pronounced nocturnal pain, permanent dysaesthesias and prolonged distal motor latency on electroneurography (>6 ms). Long-term recurrence rates reach 30% ⁴.

Differential diagnosis

Possible differential diagnoses of carpal tunnel syndrome include:

other median nerve entrapment syndromes:
- pronator teres syndrome
- anterior interosseous nerve syndrome

~~-<li>positive <a title="Tinel test" href="/articles/tinel-test">Tinel test</a>: paraesthesias elicited by tapping the median nerve at the wrist</li>~~
~~-<li>positive <a title="Phalen test" href="/articles/phalen-test">Phalen test</a>: paraesthesias caused by wrist flexion over 30-60°</li>~~
+<li>positive <a href="/articles/tinel-test">Tinel test</a>: paraesthesias elicited by tapping the median nerve at the wrist</li>
+<li>positive <a href="/articles/phalen-test">Phalen test</a>: paraesthesias caused by wrist flexion over 30-60°</li>
-</ul>Enlargement of the nerve seems to be the most sensitive and specific criterion, but what cut-off value for pathological size remains debated; the normal cross-sectional area is given at 9-11 mm2 (0.09-0.11 cm2), but the range of sizes deemed pathological is wide. If the nerve is bifid some suggest measuring the combined cross-sectional area ref.According to one study, a 2 mm2 difference in nerve cross-section between the level of the pronator quadratus and the carpal tunnel has a 99% sensitivity and 100% specificity for carpal tunnel syndrome 9.Some of the other proposed findings include:<ul>
+</ul>Enlargement of the nerve seems to be the most sensitive and specific criterion, but what cut-off value for pathological size remains debated; the normal cross-sectional area is given at 9-11 mm2 (0.09-0.11 cm2), but the range of sizes deemed pathological is wide. If the nerve is bifid some suggest measuring the combined cross-sectional area ref.According to one study, a 2 mm2 difference in nerve cross-section between the level of the pronator quadratus and the carpal tunnel has a 99% sensitivity and 100% specificity for carpal tunnel syndrome 9.Some of the other proposed findings include ref:<ul>
-</ul><h5>MRI</h5>In carpal tunnel syndrome, MRI can demonstrate palmar bowing of the flexor retinaculum, enlargement of the median nerve at the level of the pisiform, and flattening of the median nerve at the level of the hook of the <a href="/articles/hamate">hamate</a>.Other signs are oedema or loss of fat within the carpal tunnel, and increased size or oedema of the nerve on fluid-sensitive sequences, and, in some cases, contrast enhancement of the nerve 4.Although sensitivity and specificity of MRI in carpal tunnel syndrome are low (23-96% and 39-87%, respectively), MRI is especially well-suited for detecting masses, arthritic changes, and normal variants 5.<h4>Treatment and prognosis</h4>It is initially often treated conservatively with splinting and <a href="/articles/non-steroidal-anti-inflammatory-drugs">non-steroidal anti-inflammatory drugs (NSAIDS)</a>. Corticosteroid injections into the carpal tunnel can alleviate symptoms temporarily for about 4 weeks. Median nerve injury is a very rare complication 10. Surgical release of the flexor retinaculum is indicated in cases of pronounced nocturnal pain, permanent dysaesthesias and prolonged distal motor latency on electroneurography (>6 ms). Long-term recurrence rates reach 30% 4.<h4>Differential diagnosis</h4>Possible differential diagnoses of carpal tunnel syndrome include:<ul><li>other <a href="/articles/median-nerve-entrapment-syndromes">median nerve entrapment syndromes</a>:<ul>
+</ul><h5>MRI</h5>MRI has good-to-excellent sensitivity (84-100%) and specificity (85-94%) for diagnosing carpal tunnel syndrome when using cross-sectional area >15 mm2 as a cut-off 12,13. MRI is especially well-suited for detecting masses, arthritic changes, and normal variants (e.g. <a title="Bifid median nerve" href="/articles/bifid-median-nerve">bifid median nerve</a>) 5.In carpal tunnel syndrome, MRI can demonstrate 4:<ul>
+<li>palmar bowing of the flexor retinaculum</li>
+<li>nerve thickening at the carpal tunnel inlet (level of the pisiform)</li>
+<li>nerve flattening at the carpal tunnel outlet (level of the hook of hamate)</li>
+<li>increased cross-sectional area<ul>
+<li>ultrasound values do not correlate with MRI values 11
+</li>
+<li>>15 mm2 at the carpal tunnel inlet or outlet can be used as a diagnostic criterion or cut-off 12,13
+</li>
+<li>>19 mm2 has been proposed as a marker for severe carpal tunnel syndrome 13
+</li>
+</ul>
+</li>
+<li>oedema or loss of fat within the carpal tunnel</li>
+<li>neural oedema s +/- contrast enhancement</li>
+</ul><h4>Treatment and prognosis</h4>It is initially often treated conservatively with splinting and <a href="/articles/non-steroidal-anti-inflammatory-drugs">non-steroidal anti-inflammatory drugs (NSAIDS)</a>. Corticosteroid injections into the carpal tunnel can alleviate symptoms temporarily for about 4 weeks. Median nerve injury is a very rare complication 10. Surgical release of the flexor retinaculum is indicated in cases of pronounced nocturnal pain, permanent dysaesthesias and prolonged distal motor latency on electroneurography (>6 ms). Long-term recurrence rates reach 30% 4.<h4>Differential diagnosis</h4>Possible differential diagnoses of carpal tunnel syndrome include:<ul><li>other <a href="/articles/median-nerve-entrapment-syndromes">median nerve entrapment syndromes</a>:<ul>

References changed:

1. Mesgarzadeh M, Schneck C, Bonakdarpour A, Mitra A, Conaway D. Carpal Tunnel: MR Imaging. Part II. Carpal Tunnel Syndrome. Radiology. 1989;171(3):749-54. <a href="https://doi.org/10.1148/radiology.171.3.2541464">doi:10.1148/radiology.171.3.2541464</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/2541464">Pubmed</a>
2. Campagna R, Pessis E, Feydy A et al. MRI Assessment of Recurrent Carpal Tunnel Syndrome After Open Surgical Release of the Median Nerve. AJR Am J Roentgenol. 2009;193(3):644-50. <a href="https://doi.org/10.2214/AJR.08.1433">doi:10.2214/AJR.08.1433</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/19696276">Pubmed</a>
3. Wong S, Griffith J, Hui A, Lo S, Fu M, Wong K. Carpal Tunnel Syndrome: Diagnostic Usefulness of Sonography. Radiology. 2004;232(1):93-9. <a href="https://doi.org/10.1148/radiol.2321030071">doi:10.1148/radiol.2321030071</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/15155897">Pubmed</a>
4. Miller T & Reinus W. Nerve Entrapment Syndromes of the Elbow, Forearm, and Wrist. AJR Am J Roentgenol. 2010;195(3):585-94. <a href="https://doi.org/10.2214/AJR.10.4817">doi:10.2214/AJR.10.4817</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/20729434">Pubmed</a>
5. Dong Q, Jacobson J, Jamadar D et al. Entrapment Neuropathies in the Upper and Lower Limbs: Anatomy and MRI Features. Radiol Res Pract. 2012;2012:230679. <a href="https://doi.org/10.1155/2012/230679">doi:10.1155/2012/230679</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/23125929">Pubmed</a>
6. Tsujii M, Hirata H, Morita A, Uchida A. Palmar Bowing of the Flexor Retinaculum on Wrist MRI Correlates with Subjective Reports of Pain in Carpal Tunnel Syndrome. J Magn Reson Imaging. 2009;29(5):1102-5. <a href="https://doi.org/10.1002/jmri.21459">doi:10.1002/jmri.21459</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/19388125">Pubmed</a>
7. Mesgarzadeh M, Triolo J, Schneck C. Carpal Tunnel Syndrome. MR Imaging Diagnosis. Magn Reson Imaging Clin N Am. 1995;3(2):249-64. - <a href="https://www.ncbi.nlm.nih.gov/pubmed/7553021">Pubmed</a>
8. Buchberger W. Radiologic Imaging of the Carpal Tunnel. Eur J Radiol. 1997;25(2):112-7. <a href="https://doi.org/10.1016/s0720-048x(97)00038-7">doi:10.1016/s0720-048x(97)00038-7</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/9283839">Pubmed</a>
9. Klauser A, Halpern E, De Zordo T et al. Carpal Tunnel Syndrome Assessment with US: Value of Additional Cross-Sectional Area Measurements of the Median Nerve in Patients Versus Healthy Volunteers. Radiology. 2009;250(1):171-7. <a href="https://doi.org/10.1148/radiol.2501080397">doi:10.1148/radiol.2501080397</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/19037017">Pubmed</a>
10. Kim H & Park S. Median Nerve Injuries Caused by Carpal Tunnel Injections. Korean J Pain. 2014;27(2):112-7. <a href="https://doi.org/10.3344/kjp.2014.27.2.112">doi:10.3344/kjp.2014.27.2.112</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/24748938">Pubmed</a>
11. Lee R, Griffith J, Ng A et al. Cross-Sectional Area of the Median Nerve at the Wrist: Comparison of Sonographic, MRI, and Cadaveric Measurements. J Clin Ultrasound. 2019;47(3):122-7. <a href="https://doi.org/10.1002/jcu.22647">doi:10.1002/jcu.22647</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/30597562">Pubmed</a>
12. Park J, Won H, Oh J, Kim D, Hwang S, Yoo J. Value of Cross-Sectional Area of Median Nerve by MRI in Carpal Tunnel Syndrome. Asian Journal of Surgery. 2020;43(6):654-9. <a href="https://doi.org/10.1016/j.asjsur.2019.08.001">doi:10.1016/j.asjsur.2019.08.001</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/31473048">Pubmed</a>
13. Ng A, Griffith J, Tong C et al. MRI Criteria for Diagnosis and Predicting Severity of Carpal Tunnel Syndrome. Skeletal Radiol. 2019;49(3):397-405. <a href="https://doi.org/10.1007/s00256-019-03291-0">doi:10.1007/s00256-019-03291-0</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/31396669">Pubmed</a>
1. Mesgarzadeh M, Schneck CD, Bonakdarpour A et-al. Carpal tunnel: MR imaging. Part II. Carpal tunnel syndrome. Radiology. 1989;171 (3): 749-54. <a href="http://radiology.rsna.org/content/171/3/749.abstract">Radiology (abstract)</a> - <a href="http://www.ncbi.nlm.nih.gov/pubmed/2541464">Pubmed citation</a><div class="ref_v2"></div>
2. Campagna R, Pessis E, Feydy A et-al. MRI assessment of recurrent carpal tunnel syndrome after open surgical release of the median nerve. AJR Am J Roentgenol. 2009;193 (3): 644-50. <a href="http://www.ajronline.org/content/193/3/644.full">AJR Am J Roentgenol (full text)</a> - <a href="http://dx.doi.org/10.2214/AJR.08.1433">doi:10.2214/AJR.08.1433</a> - <a href="http://www.ncbi.nlm.nih.gov/pubmed/19696276">Pubmed citation</a>
3. Wong SM, Griffith JF, Hui AC et-al. Carpal tunnel syndrome: diagnostic usefulness of sonography. Radiology. 2004;232 (1): 93-9. <a href="http://radiology.rsna.org/content/232/1/93.full">Radiology (full text)</a> - <a href="http://dx.doi.org/10.1148/radiol.2321030071">doi:10.1148/radiol.2321030071</a> - <a href="http://www.ncbi.nlm.nih.gov/pubmed/15155897">Pubmed citation</a>
4. Miller TT, Reinus WR. Nerve entrapment syndromes of the elbow, forearm, and wrist. AJR Am J Roentgenol. 2010;195 (3): 585-94. <a href="http://www.ajronline.org/content/195/3/585.full">AJR Am J Roentgenol (full text)</a> - <a href="http://dx.doi.org/10.2214/AJR.10.4817">doi:10.2214/AJR.10.4817</a> - <a href="http://www.ncbi.nlm.nih.gov/pubmed/20729434">Pubmed citation</a>
5. Dong Q, Jacobson JA, Jamadar DA et-al. Entrapment neuropathies in the upper and lower limbs: anatomy and MRI features. Radiol Res Pract. 17;2012: 230679. <a href="http://www.hindawi.com/journals/rrp/2012/230679/abs/">Radiol Res Pract (abstract)</a> - <a href="http://dx.doi.org/10.1155/2012/230679">doi:10.1155/2012/230679</a> - <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3483739">Free text at pubmed</a> - <a href="http://www.ncbi.nlm.nih.gov/pubmed/23125929">Pubmed citation</a>
6. Tsujii M, Hirata H, Morita A et-al. Palmar bowing of the flexor retinaculum on wrist MRI correlates with subjective reports of pain in carpal tunnel syndrome. J Magn Reson Imaging. 2009;29 (5): 1102-5. <a href="http://dx.doi.org/10.1002/jmri.21459">doi:10.1002/jmri.21459</a> - <a href="http://www.ncbi.nlm.nih.gov/pubmed/19388125">Pubmed citation</a>
7. Mesgarzadeh M, Triolo J, Schneck CD. Carpal tunnel syndrome. MR imaging diagnosis. Magn Reson Imaging Clin N Am. 1995;3 (2): 249-64. <a href="http://www.ncbi.nlm.nih.gov/pubmed/7553021">Pubmed citation</a>
8. Buchberger W. Radiologic imaging of the carpal tunnel. Eur J Radiol. 1997;25 (2): 112-7. <a href="http://www.ncbi.nlm.nih.gov/pubmed/9283839">Pubmed citation</a>
9. Klauser AS, Halpern EJ, De Zordo, T, et-al. Carpal tunnel syndrome assessment with US: Value of additional cross-sectional area measurements of the median nerve in patients versus healthy volunteers. Radiology. 2009;250 (1): 171-7. <a href="http://pubs.rsna.org/doi/full/10.1148/radiol.2501080397">Radiology (full text)</a> - <a href="http://dx.doi.org/10.1148/radiol.2501080397">doi:10.1148/radiol.2501080397</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/19037017">Pubmed citation</a>
10. Kim HJ, Park SH. Median nerve injuries caused by carpal tunnel injections. (2014) The Korean journal of pain. 27 (2): 112-7. <a href="https://doi.org/10.3344/kjp.2014.27.2.112">doi:10.3344/kjp.2014.27.2.112</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/24748938">Pubmed</a>

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