9

Carpal Tunnel Syndrome

Lyn Weiss

Carpal tunnel syndrome (symptomatic median neuropathy at the wrist) is the most
common focal nerve entrapment, and a frequent reason for electrodiagnostic consultation.
Electrodiagnostic testing is the only available method to assess the physiologic changes
that occur in carpal tunnel syndrome.

! Clinical Presentation
Classic symptoms of carpal tunnel syndrome (CTS) include paresthesias and numbness
in the thumb, index and long fingers, and radial half of the ring finger (Fig. 9.1). Pain in
the hand may also be present, and radiation proximally is not uncommon. The symptoms
are frequently more prominent at night. The patient may complain of an inability to
perform fine motor tasks and/or weakness of the hand. Certain medical and/or physical
conditions predispose patients to CTS. These include diabetes, pregnancy, thyroid
disorders, repetitive strain, rheumatoid arthritis, gout, peripheral neuropathy, and edema.
A good history is therefore important.
On physical examination, there may be a sensory deficit in the radial three and a half
digits. Weakness of pinch strength may also be noted. In severe cases of carpal tunnel
syndrome, wasting of the thenar eminence may be present. Provocative tests may
reproduce the symptoms. These include Tinel’s test (percussion of the median nerve about
the wrist) and Phalen’s test (maximum flexion of the wrist, which is maintained for one to
two minutes). Since CTS can be confused with other disorders, a thorough physical
examination is always important.

! Anatomy
The carpal tunnel is a fixed space that includes nine tendons (four flexor digitorum
superficialis tendons, four flexor digitorum profundus tendons, and the flexor pollicis

Figure 9.1
Median nerve
sensory
distribution (A),
palmar (B).

A B 121
122 Easy EMG

Figure 9.2
Anatomy of the Ulnar nerve Flexor tendons Radial artery
carpal tunnel. Median Flexor
Ulnar artery nerve retinaculum

um
ezi
p
Tra
Ha
ma
te
ezoid
Capitate Trap

Ext
ens
or
ten
don
s

longus tendon), and the median nerve (Fig. 9.2). The carpal tunnel is bound dorsally by
the carpal bones and volarly by the transverse carpal ligament (flexor retinaculum).
When the space in the tunnel becomes restricted, the median nerve can become
compressed.

! Electrodiagnostic Findings
In order to do a complete electrodiagnostic assessment of the median nerve, the affected
extremity must be compared to the unaffected side and to another nerve in the same
hand, usually the ulnar nerve. Sensory and motor studies should be performed, as well as
needle testing. When performing nerve conduction studies, it is imperative that the
distance from the active electrode to the stimulation site be recorded. If a person has a
large hand, and the distance for the distal latency for motor nerve conduction studies is
not the standard 8 cm, an increased latency will have no real meaning (Fig. 9.3).

Sensory Nerve Conduction Studies

Sensory nerve action potentials (SNAPs) are usually the first potentials affected in
carpal tunnel syndrome. A useful technique is to compare SNAPs recorded at mid palm
and across the carpal tunnel. Usually, a distance of 7 cm from the ring electrode on the
second digit to mid palm and then another 7 cm to the carpal tunnel (14 cm total) is used.
However, since it is important to stimulate across the carpal tunnel, a larger distance can
be used and recorded. Although every lab has its own standards of normal, in general a
velocity of less than 44 meters/second across the carpal tunnel indicates slowing.
Normal mid palm SNAPs confirm that the slowing is only across the carpal tunnel,
although in moderate or severe cases, Wallerian degeneration may occur and affect these
distal SNAPs as well. Median SNAPs may also be compared to ulnar SNAPs on the
same finger. A greater than 0.5 milliseconds difference between the two sensory latencies
indicates CTS. Decreased amplitude on the affected side could indicate either an axonal
lesion of the median nerve (not specific as to where along the course of the nerve) or a
conduction block across the carpal tunnel (if proximal amplitude is less than 50% of
 9 Carpal Tunnel Syndrome 123

Figure 9.3
Active electrode Distance from the
situated over Median nerve
stimulation active electrode
abductor pollicis
at wrist to the stimulation
brevis
site for motor
nerve conduction
1 13 studies. Note that
3 5 7 9 11
in a large hand,
0
2 12 the distance from
4 6 8 10 the APB to the
wrist may be
more than 8 cm.
The latency will
be longer if the
distance is
greater.

distal mid palm amplitude). An amplitude difference of more than 50% (as compared to
the median sensory amplitude on the non-affected side) is considered significant.

Motor Nerve Conduction Studies

The distal latency of the compound muscle action potential (CMAP) is an important
parameter in assessing for motor fiber involvement in CTS. As in sensory studies, the
distance from the active electrode to the stimulation site must be standardized. Many
laboratories use a distance of 8 cm. With this distance, a latency of more than
4.2 milliseconds usually indicates CTS. The ulnar nerve must also be assessed to ensure
that there is not a generalized motor neuropathy present. A median to ulnar distal latency
difference of more than 1 millisecond also indicates CTS, as with sensory conduction
studies. Decreased amplitude on the affected side could indicate either an axonal lesion
of the median nerve (not specific as to where along the nerve) or a conduction block
across the carpal tunnel.

Late Responses
Late responses (F-waves and H-reflexes) are generally not helpful in the evaluation of
CTS because they are non-specific and the area of greatest interest is not being assessed
directly. The areas of interest are easily directly assessed by conventional motor and
sensory studies.

EMG
EMG testing should be performed to provide evidence of axonal damage (fibrillation
potentials or positive sharp waves), and/or reinnervation. Testing should include the
abductor pollicis brevis (APB) muscle. If spontaneous activity is present in this muscle,
other muscles should be tested to ensure that the diagnosis is indeed CTS, as CTS can
coexist with other conditions. Specifically, a more proximal median muscle should be
tested to be sure there is not a median neuropathy elsewhere along the nerve’s course. In
addition, a non-median innervated C8 muscle should be tested. Finally, especially if
there is any indication of a neck problem, the cervical paraspinal muscles may be tested
Table 9.1 Median nerve innervated muscles and expected electromyography changes for focal median nerve injuries 124

Muscles innervated by median Nerve Muscles affected in Muscles affected in Muscles affected Muscles affected
nerve from proximal to distal the ligament of pronator teres in anterior in carpal tunnel
Struther’s syndrome syndrome interosseous nerve syndrome
(AIN) syndrome
Easy EMG

Pronator teres (forearm) Median nerve ✓

Flexor carpi radialis Median nerve ✓ ✓
Palmaris longus Median nerve ✓ ✓
Flexor digitorum superficialis Median nerve ✓ ✓
Flexor digitorum profundus AIN ✓ ✓ ✓
(digits 2 and 3)
Flexor pollicis longus AIN ✓ ✓ ✓
Pronator quadratus AIN ✓ ✓ ✓
Abductor pollicis brevis (distal Median nerve ✓ ✓ ✓
to wrist)
Opponens pollicis Median nerve ✓ ✓ ✓
Flexor pollicis brevis Median nerve ✓ ✓ ✓
(superficial head)
1st, 2nd lumbrical Median nerve ✓ ✓ ✓

Clinical sign: Nocturnal paresthesia Yes Yes No Yes

Pain in the palm and thenar eminence Yes Yes, plus pain in No, but pain in Yes
elbow region volar wrist or
forearm
Difficult to form ‘O’ sign Yes Yes Yes No
Weakness of pronation Yes* No No No
Abnormal sennsation in palm Yes† Yes† No No
NCV Conduction block Upper arm to Elbow to wrist No conduction Across wrist
elbow segment segment block

*Weakness of pronation differentiates ligament of Struther’s syndrome from pronator teres syndrome.
†
The palmar cutaneous branch is spared in carpal tunnel syndrome because it passes superficial to the carpal tunnel. Sensory deficits in the palm and thenar
eminence can help to differentiate pronator teres syndrome or ligament of Struther’s syndrome from carpal tunnel syndrome.
 9 Carpal Tunnel Syndrome 125

to rule out a cervical radiculopathy. If there is conduction block in the median nerve,
recruitment may be decreased in the APB without evidence of spontaneous potentials.

! Written Report
The written conclusion should include the following:
1. Whether or not carpal tunnel syndrome is present electrodiagnostically.
2. The severity of the CTS (mild, moderate or severe).1 As a general guideline:
a. Mild – median sensory nerve conduction slowing and/or median sensory
amplitude decreased but more than 50% of reference value (no motor
involvement).
b. Moderate – Median sensory and motor slowing, and/or SNAP amplitude less
than 50% of the reference value.
c. Severe – Absence of median SNAP with motor slowing or median motor
slowing with decreased median motor amplitude or CMAP abnormalities with
evidence of axonal injury on needle testing of the thenar muscles.
3. Whether sensory and/or motor fibers are affected.
4. If spontaneous activity is noted in the abductor pollicis brevis (fibrillation potentials
and/or positive sharp waves).

! Summary
The classic electrodiagnostic findings in carpal tunnel syndrome may include:
1. slowing of median sensory nerve conduction velocity across the carpal tunnel
2. prolonged distal latency of the median motor nerve
3. low amplitude of the median SNAP
4. low amplitude of the median CMAP
5. spontaneous potentials (fibs and/or PSWs) in the abductor pollicis brevis muscle.
For a summary of NCS/EMG findings in median neuropathy, see Table 9.1.

REFERENCE
1. O’Young B, Young M, Stiens S. PM&R Secrets. Philadelphia, PA: Hanley & Belfus,
Inc., 1997, p. 188.