Update on the Use of Ultrasound in the Diagnosis of Carpal Tunnel Syndrome Renato A. Sernik, MD,...

37
Update on the Use of Ultrasound in the Diagnosis of Carpal Tunnel Syndrome Renato A. Sernik, MD, PhD

Transcript of Update on the Use of Ultrasound in the Diagnosis of Carpal Tunnel Syndrome Renato A. Sernik, MD,...

Page 1: Update on the Use of Ultrasound in the Diagnosis of Carpal Tunnel Syndrome Renato A. Sernik, MD, PhD.

Update on the Use of Ultrasound in the Diagnosis of Carpal Tunnel

Syndrome

Renato A. Sernik, MD, PhD

Page 2: Update on the Use of Ultrasound in the Diagnosis of Carpal Tunnel Syndrome Renato A. Sernik, MD, PhD.

t

Flexor retinaculum

median nerve

median nerve

carpal tunnel

• Common compressive neuropathy.• Initially, pain and sensitivity changes in the median nerve territory.• Advanced stages – weakness and atrophy of the thenar muscles.

Carpal Tunnel Syndrome

Page 3: Update on the Use of Ultrasound in the Diagnosis of Carpal Tunnel Syndrome Renato A. Sernik, MD, PhD.

Carpal Tunnel Syndrome

Renato Sernik
Page 4: Update on the Use of Ultrasound in the Diagnosis of Carpal Tunnel Syndrome Renato A. Sernik, MD, PhD.

- useful as a screening test, reducing the cost of diagnosis of carpal tunnel syndrome.

Fowler JR, Maltenfort MG, Ilyas AM. Ultrasound as a first-line test in the diagnosis of carpal tunnel syndrome: a cost-effectiveness analysis. Clin Orthop Relat Res. 2013 Mar;471(3):932-7.

Ultrasonography

Page 5: Update on the Use of Ultrasound in the Diagnosis of Carpal Tunnel Syndrome Renato A. Sernik, MD, PhD.

Linear transducers:-12 –18 MHz.-High resolution.

Page 6: Update on the Use of Ultrasound in the Diagnosis of Carpal Tunnel Syndrome Renato A. Sernik, MD, PhD.

PERIPHERAL NERVE ANATOMY

Page 7: Update on the Use of Ultrasound in the Diagnosis of Carpal Tunnel Syndrome Renato A. Sernik, MD, PhD.

fiber

fasciclenerve

perineurium

Page 8: Update on the Use of Ultrasound in the Diagnosis of Carpal Tunnel Syndrome Renato A. Sernik, MD, PhD.
Page 9: Update on the Use of Ultrasound in the Diagnosis of Carpal Tunnel Syndrome Renato A. Sernik, MD, PhD.

scaphoid pisiform

trapeziumhamate

flexor retinaculum

Carpal Tunnel

Page 10: Update on the Use of Ultrasound in the Diagnosis of Carpal Tunnel Syndrome Renato A. Sernik, MD, PhD.

PIS

CARPAL TUNNEL

* a

n

scaphoidpisiform

a u fu

* PIS

scaphoid pisiform

Page 11: Update on the Use of Ultrasound in the Diagnosis of Carpal Tunnel Syndrome Renato A. Sernik, MD, PhD.

trapezium

hamatetrapezium

hamate

Page 12: Update on the Use of Ultrasound in the Diagnosis of Carpal Tunnel Syndrome Renato A. Sernik, MD, PhD.

ULTRASONOGRAPHY

Median Nerve Evaluation

• Qualitative• Quantitative

Page 13: Update on the Use of Ultrasound in the Diagnosis of Carpal Tunnel Syndrome Renato A. Sernik, MD, PhD.

Qualitative Evaluation

- shape-echogenicity-structure

Page 14: Update on the Use of Ultrasound in the Diagnosis of Carpal Tunnel Syndrome Renato A. Sernik, MD, PhD.

Echogenicity / structures

Page 15: Update on the Use of Ultrasound in the Diagnosis of Carpal Tunnel Syndrome Renato A. Sernik, MD, PhD.
Page 16: Update on the Use of Ultrasound in the Diagnosis of Carpal Tunnel Syndrome Renato A. Sernik, MD, PhD.

Shape

• COMPRESSION• EDEMA HOURGLASS SHAPE

carpal tunnel

median nerve

Page 17: Update on the Use of Ultrasound in the Diagnosis of Carpal Tunnel Syndrome Renato A. Sernik, MD, PhD.

proximal distal

Page 18: Update on the Use of Ultrasound in the Diagnosis of Carpal Tunnel Syndrome Renato A. Sernik, MD, PhD.

Quantitative Evaluation

Page 19: Update on the Use of Ultrasound in the Diagnosis of Carpal Tunnel Syndrome Renato A. Sernik, MD, PhD.

In 1991, Buchberger et al. proposed 3 criteria for sonographic diagnosis of the carpal tunnel syndrome:

- increase in cross-sectional area of the median nerve, proximal to the compression.- thinning of the median nerve at the site of the compression, measured by the ratio of two diameters of the nerve.- bulging of the flexor retinaculum.

Carpal Tunnel Syndrome

Page 20: Update on the Use of Ultrasound in the Diagnosis of Carpal Tunnel Syndrome Renato A. Sernik, MD, PhD.

In 1991, Buchberger et al. proposed 3 criteria for sonographic diagnosis of the carpal tunnel syndrome:

- increase in cross-sectional area of the median nerve, proximal to the compression.- thinning of the median nerve at the site of the compression, measured by the ratio of two diameters of the nerve.- bulging of the flexor retinaculum.

Carpal Tunnel Syndrome

Page 21: Update on the Use of Ultrasound in the Diagnosis of Carpal Tunnel Syndrome Renato A. Sernik, MD, PhD.

Quantitative Evaluation

 The measurement of the area must be made where it is greater

At the entrance carpal tunnel or in the proximal carpal tunnel

Median Nerve Área

Page 22: Update on the Use of Ultrasound in the Diagnosis of Carpal Tunnel Syndrome Renato A. Sernik, MD, PhD.

Fowler JR, Gaughan JP, Ilyas AM. The sensitivity and specificity of ultrasound for the diagnosis of carpal tunnel syndrome: a meta-analysis. Clin Orthop Relat Res. 2011 Apr;469(4):1089-94.

Tai TW, Wu CY, Su FC, Chern TC, Jou IM. Ultrasonography for diagnosing carpal tunnel syndrome: a meta-analysis of diagnostic test accuracy. Ultrasound Med Biol. 2012 Jul;38(7):1121-8.

Page 23: Update on the Use of Ultrasound in the Diagnosis of Carpal Tunnel Syndrome Renato A. Sernik, MD, PhD.

Fowler JR, Gaughan JP, Ilyas AM. The sensitivity and specificity of ultrasound for the diagnosis of carpal tunnel syndrome: a meta-analysis. Clin Orthop Relat Res. 2011 Apr;469(4):1089-94.

- increase the area of the median nerve used as diagnostic criteria. - Cutoff 9 -11mm².- sensitivity 77.6% and specificity 86.8%.

Tai TW, Wu CY, Su FC, Chern TC, Jou IM. Ultrasonography for diagnosing carpal tunnel syndrome: a meta-analysis of diagnostic test accuracy. Ultrasound Med Biol. 2012 Jul;38(7):1121-8.

Mhoon JT, Juel VC, Hobson-Webb LD. Median nerve ultrasound as a screening tool in carpal tunnel syndrome: correlation of cross-sectional area measures with electrodiagnostic abnormality. Muscle Nerve. 2012 Dec;46(6):871-8.

Ultrasonography in Carpal Tunnel Syndrome

Fowler JR, Maltenfort MG, Ilyas AM. Ultrasound as a first-line test in the diagnosis of carpal tunnel syndrome: a cost-effectiveness analysis. Clin Orthop Relat Res. 2013 Mar;471(3):932-7.

Page 24: Update on the Use of Ultrasound in the Diagnosis of Carpal Tunnel Syndrome Renato A. Sernik, MD, PhD.

Cutoff- 10 mm2 sensitivity – 85.0%

specificity – 92.1%

accuracy – 89.3%

Tai TW, Wu CY, Su FC, Chern TC, Jou IM. Ultrasonography for diagnosing carpal tunnel syndrome: a meta-analysis of diagnostic test accuracy. Ultrasound Med Biol. 2012 Jul;38(7):1121-8.

Page 25: Update on the Use of Ultrasound in the Diagnosis of Carpal Tunnel Syndrome Renato A. Sernik, MD, PhD.

pronador quadratus

Comparative Evaluation

carpal tunnel

A1

A2

Normal Nerve:A1- A2 ≤ 2mm²

Thickened Nerve:A1- A2 ≥ 2mm²

Page 26: Update on the Use of Ultrasound in the Diagnosis of Carpal Tunnel Syndrome Renato A. Sernik, MD, PhD.

pronador quadratus

A1

A2

carpal tunnel

Page 27: Update on the Use of Ultrasound in the Diagnosis of Carpal Tunnel Syndrome Renato A. Sernik, MD, PhD.

Palmar Cutaneus Branch(PCB) of the Median Nerve

Page 28: Update on the Use of Ultrasound in the Diagnosis of Carpal Tunnel Syndrome Renato A. Sernik, MD, PhD.

antebrachial fascia

flexor retinaculum

median nerve median nerve

FCRT

palmaris longus t

Page 29: Update on the Use of Ultrasound in the Diagnosis of Carpal Tunnel Syndrome Renato A. Sernik, MD, PhD.

Palmar Cutaneus Branch of the Median Nerve

• Compression in the tunnel.• Stretching as a consequence to reduced mobility of the

median nerve.

Page 30: Update on the Use of Ultrasound in the Diagnosis of Carpal Tunnel Syndrome Renato A. Sernik, MD, PhD.

FCRT

median nerve

PCB

median nerve FCRT

palmaris longus t

Page 31: Update on the Use of Ultrasound in the Diagnosis of Carpal Tunnel Syndrome Renato A. Sernik, MD, PhD.

Median nerve

Page 32: Update on the Use of Ultrasound in the Diagnosis of Carpal Tunnel Syndrome Renato A. Sernik, MD, PhD.

median nerve

median nerve

Page 33: Update on the Use of Ultrasound in the Diagnosis of Carpal Tunnel Syndrome Renato A. Sernik, MD, PhD.

Post-Operative - Carpal Tunnel Syndrome

Page 34: Update on the Use of Ultrasound in the Diagnosis of Carpal Tunnel Syndrome Renato A. Sernik, MD, PhD.

Post-Operative - Carpal Tunnel Syndrome

Page 35: Update on the Use of Ultrasound in the Diagnosis of Carpal Tunnel Syndrome Renato A. Sernik, MD, PhD.

median nerve

median nerve

Page 36: Update on the Use of Ultrasound in the Diagnosis of Carpal Tunnel Syndrome Renato A. Sernik, MD, PhD.

CONCLUSION

Ultrasound in Carpal Tunnel Syndrome

• The method doesn’t predict severity.• useful as a screening test, reducing the cost of diagnosis

of carpal tunnel syndrome.• post-operative evaluation.