British Journal of Plastic Surgery (2005) 58, 1136–1142

Carpal tunnel syndrome: comparison of intra-

operative structural changes with clinical and
electrodiagnostic severity
D. Tuncali*, A. Yuksel Barutcu, A. Terzioglu, G. Aslan

Department of Plastic-Reconstructive and Aesthetic Surgery, Ankara Education and Research Hospital,
Cebeci, Ankara, Turkey

Received 9 September 2004; accepted 17 May 2005

KEYWORDS Summary The aim of this study is to grade the intraoperative findings seen in
Carpal tunnel carpal tunnel syndrome (CTS) based on severity, and compare it with clinical and
syndrome; electrodiagnostic severity.
Surgery; Thirty-one hands surgically treated for CTS were graded according to the severity
Severity; of clinical signs, and electrodiagnostic tests. Oedema, vascularisation, and fibrosis
Morphology; were graded on a scale of 1–3. Pseudoneuroma or ‘hour-glass’ formation were graded
Internal neurolysis as either 0 or 1. The hands were allocated by an observer into an assumptive severity
group, from grade 1 to 3. Clinical severity and electrodiagnostic severity were
statistically compared with each other, and with each intraoperative severity
criteria.
A high statistical correlation (p!0.01) was found between clinical severity and
vascularisation, fibrosis, and the assumptive intraoperative severity. No correlation
could be demonstrated between electrodiagnostic severity and the intraoperative
criteria.
Intraoperative grading should be regarded as a supportive measure to the clinical
evaluation in order to obtain a sound base for surgical intervention and internal
neurolysis.
q 2005 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All
rights reserved.

Carpal tunnel syndrome (CTS) is a common peripheral
neuropathy, characterised by nocturnal hand dis-
comfort, paraesthesia of the fingers in the
* Corresponding author. Address: Mahatma Gandi cad. Mesa
Ufuk 1 Sitesi, 51/28 Gaziosmanpasa 06700, Ankara, Turkey. Tel.:
C90 312 595 34 40; fax: C90 312 437 69 86.
E-mail address: dogan_tuncali@yahoo.com (D. Tuncali).
S0007-1226/$ - see front matter q 2005 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjps.2005.05.010
distribution of the median nerve, and thenar muscle
weakness or atrophy.1,2 Compression of the median
nerve by an increase in carpal tunnel pressure is the
main cause.3–5 It usually occurs between ages 36 to 60
years and two to five times more common in women.
The diagnosis is confirmed by thorough physical
examination and electrodiagnostic tests.6 However,
correlation of electrodiagnostic severity and clinical
Structural changes in CTS
severity does not always reveal an exact match7
although they are highly correlated for diagnosis.8
The mostly used surgical technique for the
treatment of CTS is the decompression of the
median nerve at the wrist level.9 Based on several
clinical studies9–14 it is now accepted that surgery is
not a contraindication for severe CTS. However, the
benefit and role of internal neurolysis in these
patients are still controversial. In 1973, Curtis and
Eversmann15 have reported good results using
carpal tunnel release combined with internal
neurolysis of the palmar 50% of the median nerve.
They have suggested that neurolysis be considered
in patients with evidence of chronic compression.
Others have questioned the value of this interven-
tion, suggesting that dissection of the median nerve
may lead to an increase in interfascicular fibrosis.16
The argument has continued in subsequent clinical
studies reporting favourable results both with10 and
without9,11,12 internal neurolysis. Nevertheless, it is
apparent from these studies that as far as symptoms
are of concern, patients with severe CTS definitely
benefit from surgery whether internal neurolysis is
added or not. It seems that the main problem in
these studies is the highly subjective criteria
(sensibility, thenar atrophy) used to assess surgical
outcome that hinders the confidence of compari-
son. Therefore, it still remains unclear for which
group of patients the technique should be applied.
Rhoades et al.10 have recommended using some
type of severity criteria to distinguish these
patients in order to avoid unnecessary dissections.
However, these are not usually objective, but
rather call for a degree of surgeon experience.
Literature information relevant to intraoperative
gross structural changes that occur in an affected
median nerve in CTS is generally dispersed,4,17–22
narrative in nature and usually far from being
demonstrative. The only study that provides an
intraoperative classification system is based on the
subjective evaluation of the apparent median nerve
compression and lacks the essential details.8
The aim of this study is to search for the
possibility of an intraoperative grading system for
CTS so that an almost objective criteria can be
obtained that will aid especially in the decision
making phase for internal neurolysis. A visual
demonstration of the specific array of changes will
be presented according to a grading scheme.
Materials and methods
The diagnosis of CTS was based on previously
1137
reported clinical criteria.9 Only subjects with
idiopathic CTS were enrolled in the evaluation.
A form containing separate sections for symptoms
and signs was prepared. Data regarding pain or
paraesthesia in the distribution of the median
nerve, two-point discrimination, thenar atrophy,
Phalen test, Tinel sign, fine touch sensory (cotton
wool was used as standard material) and motor
functional deficits were fastidiously sought and
recorded. Weber two-point discrimination test using
a dull-pointed eye-calliper23 was applied in a
longitudinal axis while not blanching the skin.24 The
classification of two-point discrimination values
advocated by the American Society for Surgery of
the Hand was used: normal (0–6 mm), fair (7–10 mm),
poor (11–15 mm), and protective sensation (more
than 15 mm). Clinical symptoms and signs were
subsequently graded according to severity (Table 1).
Electrodiagnostic test results were combined in a
single severity classification for statistical analysis
(Table 1).
All operations were performed by the senior
author (DT) under general or axillary block anaes-
thesia. Following tourniquet application, the oper-
ation was carried out using an open approach
through a curvilinear incision and 4.0! magnifi-
cation was used throughout the procedure.
Macro digital photographs were obtained at two
specific steps of the operation: immediately after
sectioning the transverse carpal ligament and
following release of the tourniquet. This provided
the opportunity to record any original structural
alterations of the nerve that may be subjected to
change in time.25 The nerves were evaluated using
these digital images blindly by the same author (GA)
being unaware of the preoperative evaluation.
Structural changes such as oedema, vascularisa-
tion, fibrosis, ‘hour-glass’ or ‘pseudoneuroma’
formation were recorded according to a severity
scheme. Oedema, vascularisation, and fibrosis were
graded on a scale of 1–3. Pseudoneuroma or ‘hour-
glass’ deformities were graded as either 0 or 1, the
former being absence of the finding. Subsequently
the affected hands were allocated by the same
observer into an assumptive severity group graded
on a scale of 1–3. This last step has made it possible
to statistically cross-check the reliability of the
classification.
Kappa measure of agreement analysis and Kruskal–
Wallis tests were used for statistical analysis.
Results
Surgically treated 25 consecutive patients (31
1138 D. Tuncali et al.

Table 1 Severity grading criteria for clinical, electrodiagnostic and intraoperative evaluations
Evaluation Grade Symptoms
Clinical 1 Intermittent symptoms of pain and paraesthesia, night pain and
paresthesia in the median nerve distribution, with a normal motor and
sensory examination
2 Constant symptoms, with a decrease in fine touch and pin prick but
normal two-point discrimination in the median nerve distribution and no
weakness of the thenar muscles
3 Marked sensory loss, including decreased two-point discrimination and
weakness of the thenar muscles or atrophy
Nerve conduction delay 0 Normal: normal motor and sensory latenciesa
1 Mildly abnormal: less than 15% prolongation of motor and/or sensory
latencies
2 Moderately abnormal: 15–30% prolongation of motor and/or sensory
latencies
3 Severely abnormal: greater than 30% prolongation of motor and/or
sensory latencies
Electromyography 0 Normal: no fibrillation potentials and positive short waves
1 Mildly abnormal: fibrillation potentials and positive short waves, at least
two locations
2 Moderately abnormal: fibrillation potentials and positive short waves,
many but not all locations
3 Severely abnormal: fibrillation potentials and positive short waves, most
or all locations, of moderate or numerous quantity
Intraoperative 1 Normal-mild: thickening and flattening of the nerve but normal vascular
structures of the epineurium, no fibrosis
2 Moderate: moderate decrease in vascularity, mild to moderate fibrosis in
any part of the nerve, ‘hour-glass’ or ‘pseudoneuroma’ appearance
3 Severe: loss of vascularity, diffuse fibrosis, rounding of the nerve, ‘hour-
glass’ or ‘pseudoneuroma’ appearance
a
Laboratory reference normal values: median sensory latency !3.0 ms; median motor latency !3.8 ms.

hands) were included in the study. The average and electrodiagnostic severity revealed no statisti-
age was 52.4 years with a range of 34–64. cal correlation.
Nineteen were female (76.0%) and six were
males (24.0%). Six patients (24.0%) had bilateral
involvement.
All patients (100%) had symptoms of pain and Discussion
paraesthesia. Positive Phalen and Tinel signs were
found in 84.1 and 72.6% of patients, respectively. The three progressive stages in the pathophysiology
Thenar atrophy was the least confronted (23.0%) of CTS has been described in detail by Sunderland.26
finding. The first stage refers to the early vascular
Oedema severity did not reveal any statistical compromise of the nerve that results in a hyper-
correlation either with clinical or electrodiagnostic excitable state and is responsible for the night
severity. So the grading for oedema was conse-
quently discarded from the intraoperative classifi- Table 2 Distribution of operated hands according to
cation criteria. severity in each evaluation group
A high statistical correlation (p!0.01) was found Severity Number of operated hands
between clinical severity and vascularisation, Clinical Electro- Intraopera-
fibrosis, and the assumptive intraoperative severity evaluation diagnostic tive evalu-
(Table 2). The hour-glass formation was primarily evaluation ation
associated with clinical and intraoperative grade 2 Grade 1 4 (12.9%) 8 (25.8%) 4 (12.9%)
(Fig. 1) and to a lesser degree with grade 3 nerves Grade 2 15 (48.4%) 12 (38.7%) 16 (51.6%)
(Fig. 2). No correlation (pO0.05) was observed Grade 3 12 (38.7%) 11 (35.5%) 11 (35.5%)
between electrodiagnostic tests and intraoperative Total 31 (100%) 31 (100%) 31 (100%)
criteria (Table 2). Similarly, comparison of clinical
Structural changes in CTS
Figure 1 Case 10 (grade 2): a typical ‘hour-glass’
deformity (between arrows) with a minimal proximal
pseudoneuroma seen following transection of the trans-
verse carpal ligament. Note that the operation is still
under tourniquet control so the vascular network cannot
yet be evaluated.
pains, Phalen and Gilliatt signs.21,27,28 The second
stage refers to the oedematous changes that occurs
mainly as a result of protein leakage from the
vascular network. The pseudoneuroma formation
seen dominantly in grade 2 nerves in our series was
interpreted to represent this second stage of
changes (Fig. 1). Stage three represents the most
severe changes that are characterised by fibrosis
formation in the nerve. Fibroblasts start to
proliferate in the protein exudate and the final
phase is reached when nutrient vessels are
obliterated and the affected segment of the nerve
converts into a fibrous chord with a relatively
avascular epineuria (Fig. 2).19,26,29
The intraoperative grading criteria used in this
study are not new.10,27,29 In a series of 34 wrists
explored for recurrent carpal tunnel syndrome,
fibrous proliferation was a contributing cause in 22
and represented the most frequent surgical find-
ing.30 The ‘hour-glass’ formation (pseudoneuroma
or ‘false’ neuroma) (Fig. 1) was first demonstrated
by Marie and Foix in 1913 and later by several
authors.18–20,26,27,29,31–33 The swelling is usually
considered to be due to oedema formation related
to local vascular stasis.26,27,31 Thomas and Full-
erton31 have described the gross pathology as an
enlargement of the nerve with the bulbous portion
lying proximal to the edge of the ligament while the
smaller tapered portion extends into the proximal
third of the carpal canal (Fig. 1). Phalen,27 did not
attribute pseudoneuroma to be a specific factor in
the pathogenesis of CTS but rather a consequence
of the pathology. He also pointed to its rare
occurrence in patients with severe thenar
1139
Figure 2 (A) Case 4 (grade 3): severe fibrosis in the
median nerve. Note the vascular cut-off proximally (black
arrow) as soon as the tourniquet is released. Pseudoneur-
oma formation may also be observed in grade 3. (B) Case 3
(grade 3): extensive fibrosis may eventually result in
conversion of the median nerve into a fibrous chord with a
relatively avascular epineurium. Fibrosis even extends
beyond the borders of the transverse carpal ligament into
the motor branch of the median nerve (white arrow).
atrophy.27 Similarly, pseudoneuroma was more
prevalent in grade 2 (Fig. 1) than grade 3 nerves
(Fig. 2) in our series. The role of vascular
compromise in the pathogenesis of CTS is well
documented in the literature.5,26,27,34,35 The
vessels situated in the perineurium are not as easily
exposed to trauma as epineurial vessels.5,26,35–37
The rapid improvement of the symptoms following
hand shaking or surgery, is constantly attributed to
this pathophysiology.5,26,34 The term ‘ischemia’ is
intentionally and carefully avoided here because
the vascular problem seems to be the result of, or
at least begin with, venous congestion and capillary
stasis (Fig. 3) rather than an arterial insufficiency.26
Phalen27 has clearly described the abrupt disap-
pearance of the vasa nervorum of many median
nerves at the proximal edge of the carpal ligament.
After release of the tourniquet, engorgement of the
nerve would develop but this would stop abruptly at
1140 D. Tuncali et al.

Figure 3 Case 5 (grade 2): the median nerve at the end

of the operation following release of the tourniquet.
Notice the vascular cut-off (small, black arrow) and the
intact ulnar epineurial vasa-nervorum (large, black
arrow). Because of the venous compromise, a localised
congestion is observed (white arrow). Note that the
‘hour-glass’ and pseudoneuroma formation is relieved.

the level of the proximal edge where the major site

of compression was usually found (Figs. 2 and 3).
Fuchs et al.4 and Scelsi et al.,38 have found a high
incidence (98%) of vascular sclerosis in long
standing CTS specimens. With these studies in
mind we have considered that the specific vascular Figure 4 Case 22 (grade 1): (A) mild carpal tunnel
changes should be one of the main criteria for syndrome with very good vascular network (black
arrows). Note the transverse anastomoses are still intact.
grading the intraoperative severity, although they
(B) The intact fascicles of the thenar branch of the
may not be readily observed in grade 1 nerves median nerve can be clearly seen under magnification
(Fig. 4). (white arrow).
Some degree of connective tissue proliferation in
the median nerve is believed to be a protective
phenomenon against intratunnel compressive
forces in normal individuals3,26,33,36 and it should
not be surprising that the degree of fibrosis will be
more extensive under excessive pressures.39 All
funiculi or fibers are not affected to the same
degree in the initial stages and this explains the
variations in the distribution of the symptoms.26
Lundborg35 has clearly demonstrated how each
large epineurial arteriolar vessel feeds at least
five fascicles with blood. Although some authors
have reported that fibrosis is located mainly under
the transverse carpal ligament,10 it is our constant
observation that, the affected fascicles are
observed anywhere along the median nerve and
can even be counted under magnification (Fig. 4).
We believe that this observation may only be
explained by the ‘fascicular vascularisation’ pat-
tern, rather than by direct pressure. In this regard a Figure 5 Case 12 (grade 2): fascicular fibrosis can be
distinction can be made between grade 1 (Fig. 4) observed in various parts of the median nerve (arrows)
and grade 2 (Fig. 5) since fibrosis is almost never under magnification. An ‘hour-glass’ deformity can also
observed in the former. Although Rhoades et al.,10 be observed.
Structural changes in CTS
could not demonstrate a correlation between the
degree of fibrosis and preoperative symptoms, it
was highly correlated in our series. Since pro-
gression of fibrosis is gradual in the course of the
disease, it should be logical to expect some degree
(if not highly) of correlation along with clinical
progression.
Some clinical and intraoperative findings such as
the Phalen and Tinel signs, calibre of the median
nerve and oedema formation were not included in
the classification criteria because of their incon-
sistent patterns observed in our study and previous
reports.4,5,7,18–20,26,27,29,32 The two-point discrimi-
nation test, which constitutes an ‘all or none
function’ rather than an accurate indication of the
number of functioning sensory fibers,34 was
included only as a criterion for the most severe
grade of clinical findings.
Thenar atrophy is universally accepted as an
absolute indication for the surgical release of the
carpal tunnel27 and a strong indication for internal
neurolysis.10,15,40 However, there are also patients
with severe clinical and electrodiagnostic findings
that do not yet have thenar atrophy. For these
patients an intraoperative evaluation of the median
nerve was recommended.10 Although controver-
sial,16,41 there is a common consensus that internal
neurolysis is justified only when there is established
intraneural fibrosis that interferes with nerve
function.10,15,40 Rhoades et al.10 have combined
two-point discrimination, thenar muscle atrophy,
or denervation potentials in the thenar muscles
coupled with evidence of fibrosis of the median
nerve for a sound indication for internal neurolysis.
However, the degree of fibrosis that will justify an
intraneural dissection has never been designated in
any of the previous reports. In this regard, we
believe that the vascularity pattern of the nerve
will be of help in order to make a distinction.
Although criteria for intraoperative grading are
provided in Table 1, a more simplified method can
be used in clinical practice. In order to distinguish
grade 1 from grade 2, the observer should look for
any degree of fibrosis or hour-glass (pseudo-
neuroma) formation. Both findings are never
associated with grade 1 nerves. Similarly, any
degree of vascularity should be verified for the
distinction between grades 2 and 3. Loss of
vascularity is the key finding in grade 3 nerves.
We now perform internal neurolysis only in grade
3 nerves (Fig. 2). We believe it to be an unnecessary
and possibly harmful intervention for grade 2 nerves
that display apparent vascularity (Figs. 1 and 3).
Grade 3, with loss of vascularity, diffuse fibrosis or
rounding of the nerve as its main criteria, harbours
the most advanced or recurrent cases. This
1141
approach surely restricts the use of internal
neurolysis to a more limited number of patients.
Intraoperative grade 3 can be interpreted as
reciprocal to clinical grade 3, which includes signs
such as marked sensory loss, decreased two-point
discrimination and weakness of the thenar muscles
or atrophy. These signs are universally accepted to
define severe CTS and used in studies that question
the value of internal neurolysis.10–12 Since we could
not demonstrate any statistically significant corre-
lation with either clinical or intraoperative sever-
ity, it is not appropriate to recommend a similar
assessment for electrodiagnostic severity. The use
of an intraoperative grading system for deciding
whether or not to perform neurolysis is still
arguable since the value of the technique in CTS
outcome is still debatable. However, we think that
if the surgeon believes in the value of internal
neurolysis, then the classification will aid in
deciding for which nerves it will be used. Further,
prospective clinical outcome studies are needed in
order to prove the value of our intraoperative
classification system and its place in internal
neurolysis.
Some degree of observer experience is still
needed for an intraoperative evaluation, or at
least, the observer should be exposed to the array
of changes beforehand. This was one of the main
aims of this study: in order to provide a visual array
of structural changes for training. Following dem-
onstration, an inexperienced eye can easily partici-
pate in the grading because of the simple criteria
used. However, it should be regarded and used as a
supportive measure to the clinical evaluation of the
patient in order to have a sound base for surgical
intervention and especially for internal neurolysis.
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