J Neurol (2017) 264:2394–2400
DOI 10.1007/s00415-017-8637-2
ORIGINAL COMMUNICATION
Treatment outcome in patients with clinically defined carpal
tunnel syndrome but normal electrodiagnostic test results:
a randomized controlled trial
Floriaan G. C. M. De Kleermaeker1 · Jan Meulstee1 · Franka Claes2 ·
Kristel M. Kasius3 · Wim I. M. Verhagen1 
Received: 25 June 2017 / Revised: 1 September 2017 / Accepted: 2 October 2017 / Published online: 9 October 2017
© Springer-Verlag GmbH Germany 2017
Abstract  Little is known about treatment effect of car-
pal tunnel release in patients with clinically defined car-
pal tunnel syndrome (CTS), but normal electrodiagnostic
test results (EDX). The aim of this study was to determine
whether this category of patients will benefit from surgical
treatment. 57 patients with clinically defined CTS and nor-
mal EDX were randomized for surgical treatment (n = 39)
or non-surgical treatment (n = 18). A six-point scale for
perceived improvement as well as the Boston Carpal Tunnel
Questionnaire was completed at baseline and at follow-up
after 6 months. A significant improvement of complaints
was reported by 70.0% of the surgically treated patients
and 39.4% reported full recovery 6 months after surgery.
Furthermore, both Functional Status Score and Symptom
Severity Score improved significantly more in the surgically
treated group (p = 0.036 and p < 0.001, respectively). This
study demonstrates that most patients with clinically defined
CTS and normal EDX results will benefit from carpal tun-
nel release. Therefore, this group of CTS patients must not
a priori be refrained from surgery.
Keywords  Carpal tunnel syndrome · Treatment ·
Outcome · Negative · Electrodiagnostic tests ·
Electroneurography
* Floriaan G. C. M. De Kleermaeker
florisdekleermaeker@gmail.com
1
Department of Neurology, Canisius Wilhelmina
Hospital, Weg door Jonkerbos 100, 6532 SZ Nijmegen,
The Netherlands
2
Department of Neurology, Franciscus Vlietland,
Vlietlandplein 2, 3118 JH Schiedam, The Netherlands
3
Department of Neurology, Onze Lieve Vrouwe Gasthuis, Jan
Tooropstraat 164, 1061 AE Amsterdam, The Netherlands
13
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Introduction
Carpal tunnel syndrome (CTS) is the most common entrap-
ment neuropathy [1]. In clinical practice the diagnosis of
CTS is based on typical symptoms such as nocturnal pain,
burning sensations, paresthesias and numbness in the terri-
tory innervated by the median nerve [2]. Surgical decom-
pression of the median nerve is the most robust treatment for
CTS, with a success rate between 75 and 90% [3]. Improve-
ment after a corticosteroid injection in the carpal tunnel, is
reported in 77% of the patients at 1 month follow-up, but in
50% [4] of them a second treatment is needed after 1 year.
There are no differences in treatment effect between a local
corticosteroid injection and a nocturnal splint [5].
Electrodiagnostic tests (EDX) are often performed to
confirm the clinical diagnosis and to determine the extent
of EDX abnormalities. In clinically defined CTS a sensitiv-
ity of approximately 85–90% and a specificity of 85% have
been reported. This means that, 15% of these patients show
normal EDX results [6]; one study reported even 25% [7].
Surprisingly, few robust data are published about the treat-
ment effect in these patients. Some studies demonstrated
clinical improvement in this group of patients after decom-
pressive surgery and it has therefore been suggested that
these patients should not be refrained from decompressive
surgery [8–10]. In contrast, however, Bland et al. empha-
sized the necessity for NCS, as they found statistically signif-
icant better results of decompressive surgery in CTS patients
with abnormal EDX, compared to patients with normal EDX
results [11].
The aim of this study was to determine whether patients
with clinically defined CTS but normal EDX, benefit from
surgical treatment.
J Neurol (2017) 264:2394–2400 2395
Methods
Patients
Patients with complaints suggestive of CTS were referred to
our outpatient clinic by their general practitioners. Patients
were prospectively enrolled into the study if they com-
plained about pain and/or paresthesias in and restricted to
the territory innervated by the median nerve and if they ful-
filled two or more of the following clinical CTS criteria: (1)
nocturnal paresthesias, (2) aggravation of paresthesias by
activities such as driving a car, riding a bike, holding a book
or holding a telephone, (3) paresthesias relieved by shak-
ing the hand (positive Flick sign). These criteria have been
adopted from a previously performed study [7].
Exclusion criteria were defined as: age under 18, signifi-
cant language barrier, history or clinical signs of polyneu-
ropathy or known HNLPP (hereditary neuropathy with lia-
bility to pressure palsies), previous trauma or surgery to the
wrist, history of rheumatoid arthritis, diabetes mellitus, thy-
roid disease, alcoholism, arthrosis of the wrist, pregnancy, or
severe atrophy of the abductor pollicis brevis muscle.
Patients with normal EDX (i.e. no or only one abnormal
test result) were selected for this study. Informed consent
was obtained from each individual. Permission from the
local Medical Ethics Committee was obtained.
Clinical examination
A complete neurological clinical examination was per-
formed by an experienced examiner (wv). Sensory testing
was performed with a monofilament (10 g) and two-point
discrimination. Strength of the abductor pollicis brevis
(APB) and opponens pollicis muscles was assessed using
the MRC (Medical Research Council) scale. Besides, grip
strength was determined using a Martin Vigorimeter and
classified as normal or abnormal [12]. Thenar atrophy was
classified as absent, mild or severe.
Questionnaires
At 6 months follow-up patients rated their perceived treat-
ment effect on a six-point scale (1 = completely asympto-
matic; 6 = aggravation of symptoms). Besides, they com-
pleted the widely used and validated Boston Carpal Tunnel
Questionnaire (BCTQ), consisting of the Symptom Severity
Score (SSS) and Functional Status Score (FSS) at baseline
and approximately 6 months after treatment.
Electrodiagnostic testing
All patients underwent standardized motor and sensory NCS
in the symptomatic hand as described in previous studies,
performed by an experienced neurophysiologist who was
blinded for clinical data [13, 14]. These tests were performed
with a Viking myograph type IV (Nicolet Biomedical, Mad-
ison, WI, USA). Skin temperature was maintained above
31 °C by applying hot packs [15]. To consider EDX consist-
ent with CTS, a minimum of two tests had to be abnormal.
In summary, three different types of sensory tests were
performed. The first test (DIG-4 test) compares the distal
sensory latency (DSL) of the median nerve and the ulnar
nerve over the same conduction distance, recording from
digit 4 by ring electrodes. Difference in DSL of more than
0.4 ms [according to our laboratory’s reference values the
upper limit of normal (ULN)] or absence of a median SNAP
was considered to be abnormal and supporting CTS.
In the second test (DIG-1 test), the difference in DSL is
determined between median nerve and radial nerve over an
identical distance, recorded from the thumb. A DSL dif-
ference of more than 0.6 ms (according to our laboratory’s
reference values the ULN) or absence of median SNAP was
considered to be abnormal and supporting CTS.
The third sensory test (PALM-test [13]), is performed by
stimulation of the palm, wrist and the elbow while recording
SNAPS by ring electrodes from digits 2 and 3. Differences
in sensory nerve conduction were calculated for the digit-
to-palm, palm-to-wrist and wrist-to-elbow segment. A delay
in conduction velocity in the palm-to-wrist segment relative
to the distal segment greater than 10 m/s or to the proximal
segment greater than 16 m/s was considered to be abnormal
and consistent with CTS.
The median distal motor latency (DML) was recorded
from the APB muscle after stimulation at a standardized
distance of 60 mm. A DML exceeding 4.0 ms (according to
our laboratory’s reference values the ULN) was considered
to be abnormal and consistent with CTS.
Reference values of ULN for these tests were derived
from a control group of 47 healthy, asymptomatic volunteers
tested in our department [16].
Treatment
Patients were assigned by chance using opaque sealed enve-
lopes to surgical decompression or non-surgical treatment, in
a ratio of 2:1. Patients randomized for non-surgical treatment
were offered a nocturnal wrist splint or a local corticoid
injection. Surgery was performed by well-experienced neu-
rosurgeons under local anaesthesia with an open procedure.
Statistics
All statistical analyses were performed using SPSS Statis-
tics 24.0. Differences in SSS and FSS after follow-up were
performed with a paired t test in case of nominal distribu-
tion, and the Wilcoxon signed rank test for non-nominal
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2396 J Neurol (2017) 264:2394–2400

distribution. Comparison in baseline characteristics and
outcome between the surgically treated patients and non-
surgically treated patients were performed with a Chi-square
test for categorial variables. For continuous variables, the
unpaired t test was applied in case of nominal distribution
and the Mann–Whitney test in case of non-nominal distribu-
tion. p < 0.05 was considered as statistically significant. Cal-
culation of sample size was performed using G*Power 3.1.
In previous studies, improvement of symptoms after surgery
is reported to be about 80% and after no treatment at all 22%
[16, 17]. The latter will be an underestimation, because in
our study some patients will be treated by a nocturnal wrist
splint or corticosteroid injection. Therefore, for this power
calculation we used an estimate of 35%. To have a level of
statistical significance 5% and a power of 80%, 26 patients
are needed in the surgically treated group and 13 patients in
the non-surgically treated group.
before inclusion was 12 months. There were no significant
differences at baseline in sex, age, BMI, duration of symp-
toms, included wrist, atrophy or weakness of abductor pol-
licis brevis muscle, weakness of opponens pollicis muscle,
disturbed sensibility tests or occurrence of Tinel or Phalen
sign between the surgically treated group and conservatively
treated group.
Electrodiagnostic tests
None of the included patients fulfilled EDX results consist-
ent with CTS. 21.1% (12/57) of the patients had one abnor-
mal test, most often the PALM-test (Table 2).
Treatment
39 out of 57 (68.4%) patients were treated surgically.
18 (31.6%) patients were treated non-surgically. Of the

Results
Table 2  Electrodiagnostic test results
Patients Electrodiagnostic test N Abnormal test

DIG1-test 57 2 (3.5%)
A total of 57 patients who met the criteria for clinically
DIG4-test 57 4 (7.0%)
defined CTS with normal EDX were included in this study.
PALM-test 57 5 (8.8%)
The clinical characteristics of these patients are shown in
DML 57 1 (1.8%)
Table 1. Of the studied population, 84% were women. Mean
age was 42.67 ± 11.11 years. Median duration of symptoms DML distal motor latency

Table 1  Baseline Characteristic Surgery Non-surgery p

characteristics
Na N

Sex (female) 39 32 (82.1%) 18 16 (88.9%) 0.51

Age (years) 39 43.6 ± 11.8 18 40.56 ± 9.33 0.34
Range 19–67 Range 22–60
BMI 39 27.0 ± 5.2 18 24.99 ± 3.31 0.24
Median duration of symptoms (months) 39 12 18 8
Mean duration of symptoms (months) 39 33.6 ± 48.72 18 13.11 ± 11.91 0.19
Range 3–192 Range 2–36
Wrist included (right) 39 19 (48.7%) 18 13 (72.2%) 0.23
Atrophy of abductor pollicis brevis muscle 38 1 (2.6%) 18 0 (0.0%) 0.49
Weakness
 Abductor pollicis brevis muscle 37 4 (10.8%) 18 2 (11.1%) 0.97
 Opponens pollicis muscle 37 2 (5.4%) 18 1 (5.2%) 0.98
Disturbed sensibility
 Two-point discrimination 37 31 (83.8%) 18 13 (72.2%) 0.32
 Monofilament 37 17 (45.90%) 18 8 (44.4%) 0.92
 Tinel positive 38 24 (63.2%) 18 13 (72.2%) 0.50
 Phalen positive 38 28 (73.7%) 18 13 (72.2%) 0.91

Surgery patients with clinically defined CTS who underwent surgical treatment, Non-surgery patients with
clinically defined CTS who underwent non-surgical treatment, BMI body mass index
a
 Number of patients may vary due to missing values

13
J Neurol (2017) 264:2394–2400 2397

non-surgically treated patients, 4 (22.2%) were given a local Table 3  Subjective outcome after surgical treatment versus non-sur-
corticosteroid injection and 6 (33.3%) received a nocturnal gical treatment
splint. Outcome Surgery Non-surgery p
N Percentage N Percentage
Outcome
Important improve- 23/33 70.0 6/17 35.3 0.020*
43 out of 57 patients (75.4%) completed a follow-up. ment
27 (62.8%) were in the surgically treated group and 16 Completely asymp- 13/33 39.4 0/17 0 0.003*
tomatic
(37.2%) in the non-surgically treated group. At follow-up
Deterioration 2/33 6.1 3/17 17.6 0.152
after 6 months, an important improvement of complaints
as experienced by the patients (defined as “I still occasion- Surgery patients with clinically defined CTS who underwent surgi-
ally have complaints”, “I still rarely have complaints” or cal treatment, Non-surgery patients with clinically defined CTS who
underwent non-surgical treatment
“I am completely asymptomatic”) was reported by 70.0%
of the surgically treated group on a six-point scale (Fig. 1; * Statistically significant difference
Table 3). Besides, 39.4% reported full recovery (defined
as “I am completely asymptomatic”) after 6 months. The deterioration of complaints at follow-up versus 3 (17.6%) in
conservatively treated patients reported statistically signifi- the conservatively treated group (p = 0.152). Deterioration
cant worse outcomes. None of the conservatively treated was caused by complex regional pain syndrome (CRPS) in
patients reported a full recovery and only 35.3% reported one of the operated patients.
a significant improvement (p = 0.003 and p = 0.02). Of The surgically treated patients reported a statistical sig-
the surgically treated patients, two patients (6.1%) noticed nificant improvement in SSS and a marginally non-statistical

100

*
90
*
80

70

60

n.s.
Percent

50

40

30

20

10

0
Surgical treatment Non-surgical treatment

Full recovery Important improvement Deterioraon

* statistically significant difference

n.s. non significant

Fig. 1  Subjective outcome after surgical treatment versus non-surgical treatment

13

2398
significant improvement in FSS (Table 4). The conserva-
tively treated group did not report statistical significant dif-
ferences in SSS and FSS. In comparison to the conserva-
tively treated patients, the surgically treated patients had a
significant improvement in both SSS and FSS (p = 0.001
and p = 0.036).
Discussion
In a previous study, we reported, that, in the Netherlands, the
majority of neurosurgeons and orthopaedic surgeons rarely
operate clinically defined CTS patients without a prior elec-
trodiagnostic confirmation [18]. In addition, other studies
suggest that EDX results may predict the outcome of surgi-
cal decompression and also, that EDX results may prove
to be useful in case patients need treatment if they do not
improve after surgery [11].
In the current study, we demonstrated a significant reduc-
tion of complaints after carpal tunnel release in patients with
clinically defined CTS but normal EDX results. A total of
70% perceived an important reduction in complaints and
almost 40% reported a full recovery after surgery, which was
significantly more than in the non-surgically treated group.
In the latter, none of the patients reported to be completely
asymptomatic and only 35% reported a reduction of com-
plaints. Moreover, there was a statistically significant reduc-
tion in SSS 6 months after surgery, and a non-significant
reduction in FSS. This was significantly better than in the
non-surgically treated patients, in which there was no sta-
tistically significant reduction in FSS and SSS at follow-up.
Previously reported studies showed similar results. Finsen
et al. mentioned a favourable outcome in 88% of the surgi-
cally treated patients. In their study, 68 patients underwent
an open carpal tunnel release. Preoperatively they all under-
went EDX, but these results were not assessed until the end
of the study. In 16 (23%) patients, EDX results appeared to
Table 4  Outcome SSS and FSS SSS
N Mean ± SD
Surgery
 At inclusion 27
 At follow-up 27
 Difference 27
Non-surgery
 At inclusion 16
 At follow-up 16
 Difference 16
p 0.001*
SSS Symptom Severity Score, FSS Functional Status Score
* Statistically significant difference
13
J Neurol (2017) 264:2394–2400
be normal. Out of these patients, 14 (88%) reported improve-
ment after surgery. Complaints were evaluated by applying
visual analogue scale (VAS). The postoperative values did
not differ statistically in the group with normal EDX results
compared to patients with abnormal EDX results [10]. Even
better results were reported by Lama. Eight patients (total of
10 hands) with normal EDX results underwent carpal tunnel
release. All of them believed to perceive improvement of
complaints. Treatment effect was evaluated using the BCTQ.
No differences were found between patients with or without
abnormal EDX results [19]. Unfortunately, exact differences
in BCTQ before and after treatment are not reported.
Similar results were found by Grundberg et al., Louis
et al. and Concannon et al. These studies, however, were
conducted retrospectively lacking valid and reliable out-
come measures [8, 9, 20]. Zyluk et al. studied 93 patients
with clinically defined CTS who underwent carpal tunnel
release. About half of the patients (n = 45) had positive
EDX preoperatively. The other half was operated without
having undergone any electrodiagnostic tests at all. Both
groups reported improvement of SSS and FSS, as well as
VAS and some other parameters [21]. However, baseline
FSS and SSS were significantly lower in the electrodiag-
nostically confirmed group. Unknown is to what extent the
group without EDX actually had no abnormalities in nerve
conduction of the median nerve.
Compared to the outcome of patients with abnormal
EDX, CTS patients without EDX abnormalities seem to have
a less favourable outcome in this regard. Claes et al. stud-
ied 89 patients with clinically defined CTS and abnormal
EDX. They demonstrated a mean improvement in SSS of
1.36 ± 0.82 and FSS of 0.68 ± 0.84. Baseline SSS and FSS
were comparable to our patients. Moreover, in this group
60.6% reported full recovery after 7–9 months [16]. In other
studies, improvement in FSS and SSS was found to the same
extent or even more [22, 23]. A possible reason for the less
favourable results in surgically treated patients with normal
p FSS p
N Mean ± SD
2.95 ± 0.64 27 2.19 ± 0.72
1.86 ± 0.95 27 1.80 ± 0.89
− 1.09 ± 1.11 < 0.001* 27 − 0.39 ± 1.02 0.055
2.88 ± 0.66 16 2.08 ± 0.50
2.69 ± 0.84 16 2.31 ± 0.94
− 0.19 ± 0.48 0.130 16 0.23 ± 0.70 0.380
0.036*
J Neurol (2017) 264:2394–2400 2399
EDX results may be the presence of patients with CTS mim-
ics as cause of their complaints. Obviously, these patients
are less likely to respond to surgical treatment. Lama et al.
found other causes of symptoms in 5 of the 25 studied cases.
These included cervical root compression, thoracic outlet
syndrome and rheumatoid arthritis [19]. In our study, we
selected only those patients who strictly fulfilled the clini-
cal criteria for CTS. If there was any suspicion of another
underlying cause by clinical history or neurological exami-
nation, patients were not included in this study. Therefore,
in our opinion, additional diagnostics have no added value
in this study.
In general, open carpal tunnel release has a very low com-
plication risk. Different studies report about a complication
risk of 0.5%, consisting of nerve injury, postoperative pain
and infection. In this study, one patient developed CRPS
after surgery. Other complications are not reported, since
this was not the aim of the study.
The surgically treated patients in this study reported an
improvement of 1.09 in SSS and 0.39 in FSS, both statisti-
cally significant. The clinical importance of improvement in
BCTQ is still being discussed. In the past, some studies were
performed to determine the minimal clinically important dif-
ference (MCID) of the BCTQ. MCID is the smallest differ-
ence in score of an outcome instrument that patients perceive
as important. Cut-off values for SSS have been published
in a wide range of 0.8–1.45 and 0.5–1.6 for FSS [24–26].
Therefore, in our opinion, the clinical applicability of the
MCID is currently insufficient.
Ultrasonography (US) in carpal tunnel syndrome with-
out abnormal EDX is controversial. One study published
by Rahmani et al. suggests that US is a contributive tool in
suspected carpal tunnel syndrome without abnormal EDX
results. They found that high cross-sectional area (CSA),
hypervascularity and hypoechogenicity of the median nerve
at the carpal tunnel predict clinical evidence of CTS [27]. In
a previously reported study, however, we demonstrated that
in patients with clinically defined CTS and normal EDX
results, additional US is not contributory as the CSA of the
median nerve at the carpal tunnel inlet is seldom abnor-
mal in these cases [14]. Different normal values for CSA
are applied in these studies, which may explain a part of
the difference. Therefore, in our opinion there is currently
insufficient evidence for the role of solely the CSA in these
patients, but in combination with other modalities (hyper-
vascularity and hypoechogenicity), US can be of additional
value.
Our study has some limitations. First of all, the patients
included in this study were suspected to have CTS and had
been referred by their general practitioners. This reflects
daily clinical practice in the Netherlands, but selection bias
is possible. Besides, patients were not blinded for therapy,
as this is impossible in practice. The results therefore, may
be influenced by a placebo effect. The extent of placebo
effect in carpal tunnel release is unknown. Sham surgery
can be considered in future trials to eliminate this factor,
but this seems unethical. Moreover, response rate was not
maximal. 75% of the patients completed all questionnaires.
Response rates of the six-point scale were higher, because
this questionnaire was taken by telephone interviews in
patients who did not respond initially. Additionally, the
number of patients is not very high; however, power
was enough to investigate reliable differences in treat-
ment effect. Moreover, to our knowledge, this is the first
and largest randomized controlled trial (RCT) in which
patients without abnormal EDX results underwent carpal
tunnel release. Furthermore, our results are in accordance
with previously reported results.
In conclusion, this study demonstrates that most patients
with clinically defined CTS and normal EDX results will
benefit from carpal tunnel release. Therefore, this group of
CTS patients must not a priori be refrained from surgery.
Acknowledgements  This research received no funding.
Compliance with ethical standards 
Conflicts of interest  On behalf of all authors, the corresponding au-
thor states that there is no conflict of interest.
Ethical standards  The study was approved by the local ethics com-
mittee and was performed in accordance with the ethical standards
laid down in the 1964 Declaration of Helsinki. Informed consent was
obtained from each individual prior to their inclusion in this study.
References
1. de Krom MC, Knipschild PG, Kester AD, Thijs CT, Boekkooi
PF, Spaans F (1992) Carpal tunnel syndrome: prevalence in the
general population. J Clin Epidemiol 45(4):373–376
2. Katz JN, Simmons BP (2002) Clinical practice. Carpal tunnel
syndrome. N Engl J Med 346(23):1807–1812. doi:10.1056/
NEJMcp013018
3. Louie D, Earp B, Blazar P (2012) Long-term outcomes of car-
pal tunnel release: a critical review of the literature. Hand (N Y)
7(3):242–246. doi:10.1007/s11552-012-9429-x
4. Dammers JW, Veering MM, Vermeulen M (1999) Injection with
methylprednisolone proximal to the carpal tunnel: randomised
double blind trial. BMJ 319(7214):884–886
5. Marshall S, Tardif G, Ashworth N (2007) Local corticosteroid
injection for carpal tunnel syndrome. Cochrane Database Syst Rev
2:CD001554. doi:10.1002/14651858.CD001554.pub2
6. Werner RA, Andary M (2011) Electrodiagnostic evaluation of car-
pal tunnel syndrome. Muscle Nerve 44(4):597–607. doi:10.1002/
mus.22208
7. Witt JC, Hentz JG, Stevens JC (2004) Carpal tunnel syndrome
with normal nerve conduction studies. Muscle Nerve 29(4):515–
522. doi:10.1002/mus.20019
8. Grundberg AB (1983) Carpal tunnel decompression in spite of
normal electromyography. J Hand Surg Am 8(3):348–349
13

2400
9. Louis DS, Hankin FM (1987) Symptomatic relief following carpal
tunnel decompression with normal electroneuromyographic stud-
ies. Orthopedics 10(3):434–436
10. Finsen V, Russwurm H (2001) Neurophysiology not required
before surgery for typical carpal tunnel syndrome. J Hand Surg
Br 26(1):61–64. doi:10.1054/jhsb.2000.0496
11. Bland JD (2001) Do nerve conduction studies predict the outcome
of carpal tunnel decompression? Muscle Nerve 24(7):935–940
12. Desrosiers J, Hebert R, Bravo G, Dutil E (1995) Comparison
of the Jamar dynamometer and the Martin vigorimeter for grip
strength measurements in a healthy elderly population. Scand J
Rehabil Med 27(3):137–143
13. Kasius KM, Claes F, Verhagen WI, Meulstee J (2012) The seg-
mental palmar test in diagnosing carpal tunnel syndrome reas-
sessed. Clin Neurophysiol 123(11):2291–2295. doi:10.1016/j.
clinph.2012.04.003
14. Claes F, Kasius KM, Meulstee J, Verhagen WI (2013) Compar-
ing a new ultrasound approach with electrodiagnostic studies to
confirm clinically defined carpal tunnel syndrome: a prospec-
tive, blinded study. Am J Phys Med Rehabil 92(11):1005–1011.
doi:10.1097/PHM.0b013e31829b4bd8
15. Kasius KM, Riphagen JH, Verhagen WI, Meulstee J (2014) An
easily applicable alternative method for warming cold limbs in
nerve conduction studies. Neurophysiol Clin 44(2):219–226.
doi:10.1016/j.neucli.2014.03.001
16. Claes F, Kasius KM, Meulstee J, Grotenhuis JA, Verhagen WI
(2014) Treatment outcome in carpal tunnel syndrome: does distri-
bution of sensory symptoms matter? J Neurol Sci 344(1–2):143–
148. doi:10.1016/j.jns.2014.06.044
17. Padua L, Padua R, Aprile I, Pasqualetti P, Tonali P, Italian CTSS-
GCts (2001) Multiperspective follow-up of untreated carpal tunnel
syndrome: a multicenter study. Neurology 56(11):1459–1466
18. Claes F, Verhagen WI, Meulstee J (2007) Current practice in the
use of nerve conduction studies in carpal tunnel syndrome by
surgeons in the Netherlands. J Hand Surg Eur 32(6):663–667.
doi:10.1016/J.JHSE.2007.09.007
13
J Neurol (2017) 264:2394–2400
19. Lama M (2009) Carpal tunnel release in patients with negative
neurophysiological examinations: clinical and surgical find-
ings. Neurosurgery 65(4 Suppl):A171–173. doi:10.1227/01.
NEU.0000343546.21265.88
20. Concannon MJ, Gainor B, Petroski GF, Puckett CL (1997) The
predictive value of electrodiagnostic studies in carpal tunnel syn-
drome. Plast Reconstr Surg 100(6):1452–1458
21. Zyluk A, Szlosser Z (2013) The results of carpal tunnel release
for carpal tunnel syndrome diagnosed on clinical grounds, with or
without electrophysiological investigations: a randomized study.
J Hand Surg Eur 38(1):44–49. doi:10.1177/1753193412445162
22. Galasso O, Mariconda M, Donato G, Di Mizio G, Padua L,
Brando A, Conforti F, Valentino P, Gasparini G (2011) Histo-
pathological, clinical, and electrophysiological features influenc-
ing postoperative outcomes in carpal tunnel syndrome. J Orthop
Res 29(8):1298–1304. doi:10.1002/jor.21356
23. Conzen C, Conzen M, Rubsamen N, Mikolajczyk R (2016) Pre-
dictors of the patient-centered outcomes of surgical carpal tunnel
release—a prospective cohort study. BMC Musculoskelet Disord
17:190. doi:10.1186/s12891-016-1046-3
24. Atroshi I, Johnsson R, Sprinchorn A (1998) Self-administered out-
come instrument in carpal tunnel syndrome. Reliability, validity
and responsiveness evaluated in 102 patients. Acta Orthop Scand
69(1):82–88
25. Ozer K, Malay S, Toker S, Chung KC (2013) Minimal clini-
cally important difference of carpal tunnel release in diabetic
and nondiabetic patients. Plast Reconstr Surg 131(6):1279–1285.
doi:10.1097/PRS.0b013e31828bd6ec
26. Kim JK, Jeon SH (2013) Minimal clinically important differences
in the Carpal Tunnel Questionnaire after carpal tunnel release. J
Hand Surg Eur 38(1):75–79. doi:10.1177/1753193412442137
27. Rahmani M, Ghasemi Esfe AR, Vaziri-Bozorg SM, Mazloumi M,
Khalilzadeh O, Kahnouji H (2011) The ultrasonographic corre-
lates of carpal tunnel syndrome in patients with normal electrodi-
agnostic tests. Radiol Med 116(3):489–496. doi:10.1007/s11547-