ULTRASOUND EVALUATION FOR CARPAL TUNNEL SYNDROME

ULTRASOUND EVALUATION
FOR
CARPAL TUNNEL SYNDROME
Yin-Ting Chen, MD1
Joseph Scholz, DO, PhD
Dallin Thomas, DO, MPH
Dept. of Physical Medicine and Rehabilitation,
Walter Reed National Military Medical Center, Bethesda, MD.
Objective
Background
2. Literature appraisal
3. US vs EMG
4. Ultrasound protocol
5. Summary
1.
Objective
Background
2. Literature appraisal
3. US vs EMG
4. Ultrasound protocol
5. Summary
1.
Disclosure

Yin-Ting Chen has no conflicting interests to disclose

Joseph Scholz has no conflicting interests to disclose

Dallin Thomas has no conflicting interests to disclose

View points presented are those of the authors and
do not represent the Department of Defense, United
States Army or the United States Government.
Background



CTS is the most common compressive neuropathy
 Accounts for 90% of all compressive
neuropathies
 3.8% of all general population (Ibrahim 2012)
 9.2% in women and 6% in men(Atroshi 1999)
Electrodiagnostic examination (EDX) considered
gold standard
Most common referral to EDX laboratory for
evaluation
Advantages of US for CTS








Patient comfort
Non-invasive
Timely evaluation
Real time, office-based exam
Less time-consuming
Dynamic exam
Relatively inexpensive
High resolution anatomical evaluation (mass
lesions, bifid median nerve, tenosynovitis,
lipoma, ganglion cyst, lumbrical incursion… etc)
Disadvantages of US for CTS



Learning curve
Operator dependent
Not yet universally recognized
…..To be overcome with training, training, training
CTS Sonographic Characteristics
Increased cross sectional area (CSA)
within the carpal tunnel due to swelling
 Flexor retinaculum bowing
 Increased flattening ratio of the median
nerve
 Median nerve notching
 Hypervascularity of the median nerve
 Increased Delta CSA
 (as compared to forearm segments)

Conclusion

CSA is mostly studied and validated
measurement for CTS
Objective
Background
2. Literature appraisal
3. US vs EMG
4. Ultrasound protocol
5. Summary
1.
Author, Year
Buchberger,
1992
Reference Methods
Clinical symptoms + NCS
abnormalities (undefined),
MRI
Duncan,
1999
Keberle,
2000
Median/ulnar SNC, MNC (not
specified)
Median SNC, MNC (< 5 mV
CMAP, DML < 4.6 msec, SNAP
digit II > 0.01 mV, SNAP CV <
42 m/s)
Sarria,
2000
Swen, 2001
Nakamichi,
2002
US
measurement
DRUJ, pisiform,
hamate; flattening
ratio, swelling ratio,
retinaculum bowing
Inlet
Sensitivity
(%)
Specificity
(%)
Accuracy
(%)
CSA
(mm2)
Comment
14.5
(pisiform),
10.5
(hamate)
9
82
97
NA
Wrist, inlet, outlet,
flattening ratio
100
100
NA
Swelling
ratio 1.3
Clinical + median SNC, MNC
(SNAP CV < 50 m/s or a DML
> 4.2 ms.)
Wrist, inlet, outlet,
flattening ratio,
bowing
11 (all
levels)
2.5
(bowing)
Inlet
64.3 (bowing)
57.1 (wrist)
57.1 (inlet)
57.1 (outlet)
78.5 (all signs)
40.4 (one of
signs)
63
NA
(1) The median nerve DSL >
3.6 msec. (2) Ring-diff > 0.4
msec, (3) DML-1 over the
thenar > 4.3 msec. (4) The
median MNC CV < 49 m/s. (5)
The median sensory CV < 49
m/s. (6) The ulnar motor and
sensory nerve CV
Measurements 4, 5, and 6
were performed for the
forearm.
Median ulnar SNC, MNC
Forearm NAP (not specified)
81.3 (bowing)
73.4 (wrist)
73.4 (inlet)
75 (outlet)
53.1 (all signs)
95.3 (one of
signs)
70
68
10
US PPV 85, NPV 42
NCS sensitivity 98, specificity
19, PPV 78, NPV 75, accuracy
78.
Less sensitive than NCS but
more specific.
Wrist, inlet, outlet,
distal 1/3 forearm
67.0
96.4
93.9
12 (mean
area
without
forearm)
NCS coefficient of variation <
5%, US < 10%
Mean CSA at wrist, inlet, and
outlet provides improved
sensitivity without reducing
specificity
US
measurement
Sensitivity
(%)
Specificity
(%)
Accuracy
(%)
CSA
(mm2)
Author, Year
Reference Methods
Leonard,
2003
Clinical (characteristic history of
paresthesia in the median nerve
distribution with a positive
Phalen’s test and no other coexistent neurological disease)
Inlet, outlet, flattening
ratio
72
90
NA
NA
Altinok,
2004
Median SNC, MNC
Median-ulnar midpalm-wrist DL
dif > 0.4ms
Wrist, inlet, outlet
65.0
92.5
78.9
9 (inlet)
Swelling
ratio > 1.3
Kotevoglu,
2004
Median SNC, MNC (not
specified)
Wrist, inlet, out,
flattening ratio, flex ret
bowing
89
100
NA
NA
Abnormal US finding is
correlated with clinical exam
(Phalen, Tinnel)
El Miedany,
2004
(1) Median nerve distal sensory
latency, upper limit of normal
3.6ms. (2) Difference between
the median and ulnar nerve
distal sensory latencies, upper
limit of normal 0.4 ms. (3) Distal
motor latency over the thenar,
upper limit of normal 4.3 ms. (4)
Median motor nerve conduction
velocity, lower limit of normal
49m/s.
Median/ulnar SNC, MNC (8-cm
transcarpal orthodromic median
and ulnar SNAP peak latencies,
median forearm CV, 8-cm
median CMAP, and distal motor
latencies)
1. Median SNAP CV of digits I, II,
and III of palm-to-wrist segments
2. Median nerve DML prolonged.
3. Ulnar SNC, MNC
Median SNC, MNC (not
specified)
Inlet, outlet
97.9
100
NA
10
Algorithm for CTS evaluation
suggested
Wong,
2004
Keles, 2005
Lee, 2005
Comment
CTS severity by US:
Mild: CSA 10-13
Mod: CSA 13-15
Severe: > 15
Wrist, inlet, tunnel,
outlet
94
Combine: 86
92.5
74
NA
Wrist 8.8,
inlet 9.8,
outlet 85
Tunnel CSA, flex ret
bowing, flattening of
median nerve
80 (CSA)
71.4 (Flex ret
bowing)
77.5 (CSA)
55 (Flex ret
bowing)
NA
9.3 (Tunnel
CSA), 8.5
(inlet), 9.5
(oulet)
Wrist, inlet, outlet
Inter-rater reliability coefficient
0.87.
CSA inlet best correlates with
EDX finding and questionnaires
Author, Year
Reference Methods
US
measurement
Sensitivity
(%)
Specificity
(%)
Accuracy
(%)
Median/ulnar SNC, MNC (SNAP
CV > 41–53 m/s, DML > 3.9–4.1
msec, and CMAP > 5 mV)
Wrist, inlet
86 (9 mm2),
82 (10mm2),
54 (11 mm2)
70 (9 mm2),
87 (10 mm2),
96 (11 mm2)
Wiesler,
2006
Median SNC, MNC (DSL > 3.5 ms,
or DML latency > 4.5 ms)
Inlet, tunnel, outlet
91
84
Hammer,
2006
Clincial + median NCS (palm-towrist median SNAP onset latency
>2.0 msec at 7 cm, or absence of
SNAP, and median DML >4.9
msec)
Inlet
Mallouhi,
2006
Clinical + NCS (median DSL> 6.2
msec and DML > 3.9 msec)
Wrist, inlet, outlet, Flex
ret bowing, color
Doppler
Bayrak,
2007
Median/ulnar SNC, MNC
(median–ulnar sensory latency
difference >0.5 ms and a
median–ulnar DML difference
>1.2 ms); MUNE APB
Median DSL digit IV > 3.2 msec,
Median ulnar ring-diff > 0.4
msec, median DML > 3.8 msec,
Wrist, inlet, outlet
Distal 2/3 forearm,
inlet
78
91
10 (inlet)
US CSA of 10 at inlet has
equivalent sensitivity and
specificity of ring-diff
Kaymak,
2008
Median SNC, MNC (cut off
unspecified)
Wrist, inlet
88 (Wrist)
68 (inlet)
66 (wrist)
62 (inlet)
11.2 (wrist),
11.9 (inlet)
Median DSL most predictative of
severity; DML most predictative
of functional status
Klauser,
2008
Clinical + NCS (not specified)
Wrist, inlet, tunnel,
outlet, proximal third
of PQ
99
100
Delta 2 mm
Delta CSA useful in both mild
and severe CTS
NCS (Motor DML ≥ 4.4 at 6.5cm,
mixed latency ≥ 2.2, or > 0.3 ms
compared to ulnar)
Wrist-forearm ratio ≥
1.4
100
Visser, 2008
HobosonWebb, 2008
Mhoon,
2012
47 (CSA)
71 (color Doppler)
10 tunnel
Comment
Ziswiler,
2005
91 (CSA)
95 (color Doppler)
83.4
CSA
(mm2)
CSA < 8mm to rule out CTS, >
12mm to rule in CTS
11 at inlet
91(CSA)
91 (color
Doppler)
11
The CSA was significantly higher
in arthritic patients with CTS
than in healthy controls and in
RA patients without symptoms
of CTS.
Healthy controls and RA patients
without symptoms of CTS had no
significant differences in their
CSA
CSA by continuous tracing better
than ellipsoid calculation
Hypervascularization detected
by color Doppler useful for CTS
evaluation
CSA tunnel correlate with MUNE
and severity of CTS
99 (CSA 9)
97 (WFR 1.4)
10 inlet
Locations of Measurement
Author
Distal
PQ
DRUJ
Radiocarpal
Joint
Prox Flex
Retin.
Wrist
Crease
Pisiform
ScaphoidPisiform
(Navicular)
Scaph.
tubercle
Inlet
(Nonspecific)
Tunnel
TrapeziumDistal Edge
(Non- Hook of Hamate hook of
Flex Retin.
specific)
Hamate
Outlet
(Nonspecific)
X
Duncan, 1999
X
Lee, 1999
Keberle, 2000
X
Sarria, 2000
X
X
X
X
Swen, 2001
Nakamichi, 2002
Data
X
X
Leonard, 2003
X
X
X
X
CSA
(mm^2)
Sens, spec.
9
82, 97
15
88, 96
Swelling Ratio 1.3
100, 100
11
73, 57
10
70, 63
14
43, 96
None, mean 11.6
72, 90
Altinok, 2004
X
X
X
9
65, 93
Kotevoglu, 2004
X
X
X
None, mean 15.3
89, 100
El Miedany, 2004
X
Wong, 2004
Yesildag, 2004
X
Bachmann, 2005
Kovuncuoglu,
2005
X
X
10
98, 100
X
X
prox 9 & outlet 12
94, 65
10.5
90, 95
Largest CSA, None
None
X
X
Keles, 2005
X
X
Lee, 2005
X
X
X
X
Ziswiler, 2005
X
X
Wiesler, 2006
X
Hammer, 2006
X
Mallouhi, 2006
X
Bayrak, 2007
X
X
X
Visser, 2008
X
Kaymak, 2008
X
X
Klauser, 2008
X
X
Mondelli, 2008
X
X
X
Pinilla, 2008
Kwon, 2008
X
Sernik, 2008
X
X
X
X
Moran, 2009
X
X
Mohammadi, 2010
X
Deniz, 2011
X
X
X
Klauser, 2011
Roll, 2011
X
Hunderfund, 2011
X
X
X
X
Mohammadi, 2012
Ulasli, 2012
X
X
X
X
10.5
None
9.3
80, 78
None
None
10
82, 87
11
91, 84
None, Mean 15.7
None
Largest CSA 11
91, 47
None, Mean 13.5
None
10
78, 91
11.9
88, 66
12
94, 95
12.3
57, None
6.5
90, 93
10.7
66, 63
10
85, 92
12.3
62, 95
8.5
97, 98
11
84, 79
11
93, 39
10.3
80, 91
X
11
84, 84
X
None, Mean 11.1
None
9.5
95, 71
X
X
Literature Appraisal

Diagnostic value uncertain
 CSA 6.5 mm2 to 13 mm2 (Pinilla, 2008; Bayrak, 2007)

 Sensitivity 60% - 100%
(Moran, 2009; Keberle, 2000)
 Specificity 22% - 100%
(Mhoon, 2012; El Miedany, 2004)
 Accuracy 68% - 97.2%
(Swen, 2001; Klauser, 2011)
EMG
 Various EDX protocols used, differ across studies
 Standard EDX protocol 80-90% accuracy, up to 20% false-positive
rate (Iyer 1993, Nathan 1993, Duncan 1999, Witt 2004)
 Combined sensory index (CSI) not used in any studies

US
 Various protocols (measurement method, location, study design,
tracing algorithm... etc)
 Technique and technician dependent
Literature Review


”…it
is not evident how it compares to
electrodiagnostic studies” (Beekman 2003)
“Determining the diagnostic utility of sonography
has been confounded by a lack of standardization
among research methodologies/designs and
variability in evaluation and measurement
protocols.” (Roll, 2011)
Systematic Review

Fowler et al 2011
 Reviewed 323 papers; 19 entered analysis
 Heterogenous set of reference standards
 Pooled US sensitivity/specificity using different
reference standards
○ Clinical 77.3 (62.1–84.6) 92.8 (81.3–100)
○ EDX 80.2 (71.3–89.0) 78.7 (66.4–91.1)
○ Composite 77.6 (71.6–83.6) 86.8 (78.9–94.8)
 Compares favorably against EDX (69, 97%)
 Limitation:
○ Variable reference methodologies
○ No clear cut-off value for CSA
○ Consider as first-line screening tool when there is high
pre-test probability
AANEM Evidence-Based
Guideline, 2012 (Cartwright et al 2012)

121 manuscripts reviewed
 Class I: 4 (prospective cohort, blinded,
appropriate reference, include measures of
diagnostic accuracy)
 Class II: 6 (retrospective, blinded, free of
spectrum bias, include measures of diagnostic
accuracy)
 Class II with added value: (draw from a statistical
and non-referral clinic-based sample of patients,
evaluate all CTS patients prior to surgery, and
conduct neuromuscular ultrasound on all study
participants)
AANEM Guideline, cont
Class I finding:
 8.5 to 10 mm2
 Sensitivity 65% - 97%, specificity 72.7% 98%, accuracy 79% - 97%
 Class II finding:
 Sensitivity 67 - 83%, specificity 50 - 97%,
accuracy 71 - 87% at CSA 12 mm2
 Delta CSA ≥ 4 mm2 shows sensitivity
92%, specificity 96%, accuracy 94%

AANEM Guideline, cont

Class I/II Recommendation:
 “If available, neuromuscular ultrasound
measurement of median nerve crosssectional area at the wrist may be offered
as an accurate diagnostic test for CTS
(Level A).”
Delta CSA, WFR, Swelling Ratio
Comparison of forearm (PQ or proximal) to
tunnel, inlet
 Indicative of swelling

 Delta CSA ≥ 2 mm2 (99% sensitivity, 100%
specificity) (Klauser 2008)
 Delta CSA ≥ 4 mm2 for bifid median nerve (92.5%
sensitivity, 94.6% specificity) (Klauser 2011)
 WFR > 1.4 (sensitivity 97-99%) (Hobson-Webb 2008, Mhoon
2012)
AANEM Guideline, cont.

Class II with added value:
 Significant anatomical abnormalities noted
 25% occult ganglion cyst (Nakamichi 1993)
 2 - 25% bifid median nerve (Iannicelli 2000)
 6 - 9% persistent median artery (Bayrak 2007,
Padua 2012)
 9% tenosynovitis
(Padua 2012)
 3% accessory muscles
(Padua 2012)
AANEM Guideline, cont.

Class II with added value
Recommendations:

“If available, neuromuscular ultrasound
should be considered to screen for
structural abnormalities at the wrist in
those with CTS (Level B)”
Literature Review Conclusion








Pisiform is the most commonly measured location
No studies definitively demonstrates correlation to
severity
US has definitive value to CTS evaluation, and may be
helpful in diagnosing atypical CTS
CSA > 14 mm2 rules-in CTS
CSA < 8 mm2 rules-out CTS
Delta CSA
 Non-bifid median nerve: ≥ 2 mm2
 Bifid median nerve: ≥ 4 mm2
WFR ratio > 1.4 as screening test
WFR < 1.4 and CSA < 9 mm2 has 99% sensitivity in
predicting normal EDX (Mondelli 2008)
Literature Review Conclusion, Cont.

US should be considered as first line screening tool
in patients with high pre-test probability; EDX may
not be needed

US should be considered in atypical CTS
(unilateral, sudden onset, in setting of trauma, no
occupational history or risk factors) due to high
prevalence of structural abnormalities
Objective
Background
2. Literature appraisal
3. US vs EMG
4. Ultrasound protocol
5. Summary
1.
Comparing US and EMG



EMG and clinical examination both considered as
competing “gold standards” for CTS diagnosis

Debated amongst different specialties

PE vs EMG: study shows no difference in outcome
EMG, however, offers objective data (El Miendany 2004)

Severity

Prognosis

Rule out co-existing conditions
EMG mostly used as validating standard in US CTS
studies
Literature Overview


Literature correlating severity
 El Mietany 2004
 Pauda 2008
 Karadag 2009
Literature not correlating severity
 Kaymak 2008
 Mondelli 2009
 Mhoon 2012
 Visser 2008
El Miedany et al, 2004





Cross-sectional, age-group-matched case–control study
n=78, control n=78
Boston Carpal Tunnel Questionnaire (BCTQ)
US: flattening ratio, CSA (inlet, mid-tunnel)
EMG severity scale
El Miedany et al, 2004

Result
 Diagnostic CSA 10.03 mm2, flattening ratio 0.3
 Mild: 10 - 13 mm2
 Moderate: 13 - 15 mm2
 Severe: > 15 mm2
 Highly positive correlation between EMG and CSA, as well
as both symptom and functional severity scales

“…In addition to being of high diagnostic accuracy it is able to
define the cause of nerve compression and aids treatment
planning; US also provides a reliable method for following the
response to therapy.”
Pauda et al, 2008

Prospective study examining correlation between CSA,
clinical, neurophysiological, BCTQ, EMG findings, and clinical
findings (n=54)
CSA at inlet (10 mm2)
EMG
Clinical exam

Conclusion




Statistically significant linear correlation between CSA and
clinical scales

“…when neurophysiological tests are negative – US may be
useful because it may show abnormal findings that are not
revealed even using sophisticated neurophysiological tests.”
Karadag et al, 2009
Prospective study examining correlation between CSA, BCTQ,
EMG, and clinical findings
 BCTQ assigned severity scale
 Mild: 1.1 – 2
 Moderate: 2.1 – 3
 Severe: 3.1 – 4
 Extreme: 4.1 – 5
 US CTS severity score based on El Miedany
 Mild: 10 - 13 mm2
 Moderate: 13 - 15 mm2
 Severe: > 15 mm2
 EMG CTS severity based on Pauda

Karadag, cont.


Result:

Substantial agreement for CTS severity (Cohen’s k coefficient
= 0.619) between CSA and NCS

Based on US CTS severity classification, groups were
significantly different in VAS (P = 0.017) and BCTQ (P =
0.021)
Conclusion: “CSA reflects in itself
the degree of nerve damage as
expressed by the clinical picture”
Kaymak et al 2008

EMG vs US as predictor of symptom severity (n=34, control=38)

Symptoms: measured by BCTQ

US: median nerve at level of DRUJ vs pisiform

CSA and flattening ratio

EMG: standard studies

Result:

Symptom BCTQ significantly correlated w/sens peak latency

Function BCTQ significantly correlated w/motor distal latency

No US significant correlation with BCTQ

BUT, US can still help in the yes/no diagnosis of CTS
Mhoon et al 2012




Prospective, blinded study comparing CSA and
WFR to EDX and clinical symptoms (n=100,
n=25 control)
EDX: standard studies
US: Inlet, 12 cm proximal to inlet
 WFR > 1.4 considered positive
Result:
 CSA 9 mm2 sens 99%, WRF 1.4 sens 97%
 US parameters not related to CTS
severity
 Consider EMG if CSA ≤8 mm2
Visser et al, 2008
 n= 168 CTS, 137 control
 NCS: Median DSL digit IV > 3.2 msec, Median ulnar
ring-diff > 0.4 msec, median DML > 3.8 msec
 US: distal forearm vs. inlet
 Patient survey on preference (EMG vs. US)
 Result (vs. clinical symptom severity):
○ US: sens 78 (70–84), spec 91 (86–95)
○ EMG: 82 (75–88) 88 (78–95)
○ CSA inlet differed significantly between control and
subject (P < 0.00001)
○ Patient survey indicates preference for US
Mondelli et al, 2008

Prospective study of US vs NCS (n=85)
 Ability to correlate with abnormal BCTQ
 NCS (AAEM standard)
○ Median SNAP, Ulnar SNAP, Median CMAP, median-ulnar transpalmar

US: CSA at inlet, outlet, mid-tunnel using manual tracing method
 Result:
 NCS (57/85): 67%
 US (55/85): 64.7%
 NCS + US: 76.5%
 NCS & US alone miss more cases than when combined
US vs EDX Conclusion
 US has similar diagnostic value as NCS
 Conflicting data on correlating CTS severity
 Can consider US as the first diagnostic
procedure in patients with typical CTS
 EMG remains essential to detect other
confounding diagnoses
Objective
Background
2. Literature appraisal
3. US vs EMG
4. Ultrasound protocol
5. Summary
1.
Don’t worry about:
Ultrasound terminology
--We will teach it in the small groups
Getting your hands dirty,
--We all do in the beginning
Just don’t drop the probe!
Key Views
1.
2.
3.
4.
5.
6.
Distal forearm transverse axis, for baseline CSA
Wrist inlet, transverse axis, CSA
1.
Delta CSA = inlet – baseline
2.
WFR = inlet / baseline
Tunnel to outlet, transverse axis, for mass lesions
Across carpal tunnel, long axis view
1.
Baseline diameter
2.
Notching
3.
Tethering
Dynamic tests
1.
FDS intrusion test
2.
Lumbrical intrusion test
3.
Thenar digital flexion stress test, LAX and SAX
Accessory structures
1.
PCB MN
Ultrasound Protocol







Patient comfortably seated across from examiner
Wrist on table at comfortable height, in slight
extension (10-20 degrees)
Generous gel, throughout distal arm to wrist
Staying perpendicular to structure by examining
the anisotropy
Video
Maintaining proper echotexture
Areas examined
 Distal forearm (pronator quadratus)
 Carpal tunnel (inlet, tunnel, outlet)
Distal Forearm
Inlet
Inlet





Sc: scaphoid
Ps: pisiform
S: FDS
P: FDP
PL: palmaris longus




i: flexor retinaculum
q: median nerve
s: ulnar nerve
U a/v: ulnar a/v
Palmar Cutaneous Branch
Outlet

Longitudinal View

Dynamic Testing

FDS intrusion
Dynamic Testing

Lumbrical intrusion test (Sucher 2014)
Dynamic Testing

Thenar digital flexion
stress test, LAX (Sucher 2014)
 Detect intracanal, where
most compression occurs
 Improves visualization of
notching, at 3rd CMC
Dynamic Testing

Thenar digital flexion
stress test, SAX
“open mouth view”
(Sucher 2014)
Key Views
1.
2.
3.
4.
5.
6.
Distal forearm transverse axis, for baseline CSA
Wrist inlet, transverse axis, CSA
1.
Delta CSA = inlet – baseline
2.
WRF = inlet / baseline
Tunnel to outlet, transverse axis, for mass lesions
Across carpal tunnel, long axis view
1.
Baseline diameter
2.
Notching
3.
Tethering
Dynamic tests
1.
FDS intrusion test
2.
Lumbrical intrusion test
3.
Thenar digital flexion stress test, LAX and SAX
Accessory structures
1.
PCB MN
Objective
Background
2. Literature appraisal
3. US vs EMG
4. Ultrasound protocol
5. Summary
1.
Future Research Direction

Large, population-based prospective study

Assess prevalence of structural abnormalities to
define the expected benefit for delineating
anatomical detail

Standardized research protocol, with defined
measuring method, location

Evaluate efficacy outcome compared between
EDX, US or clinically defined CTS

Utilize improved reference standard (CSI)
Summary

Limitation of literature; interpret results with
caution

No conclusive diagnostic CSA
 Rule in > 14 mm2, rule out < 8 mm2
 Delta CSA 2 mm2, 4 mm2 (bifid), WFR ratio >
1.4

Conflicting literature on correlating to severity;
data support correlation to subjective symptom
and function.
Summary, cont…

Complementary to EDX

Consider for atypical cases for dynamic lesions,
first-line for classic CTS, combine with EDX for
improved sensitivity and specificity

CTS examination can be performed quickly, and
well-preferred by patients

Prospective research with standardized protocol
Questions?
Thank You!
Reference, Cont.
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•
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