Sonographic short-term follow-up after surgical decompression of the median nerve at the carpal tunnel: a single-center prospective observational study

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OBJECT

Carpal tunnel syndrome causes increased cross-sectional area (CSA) of the median nerve, which can be assessed by high-definition ultrasonography. It is unclear today, however, whether high-definition ultrasonography may play a role in the postoperative period. This prospective study aimed to determine the natural history of the morphology of the median nerve at the carpal tunnel after surgical decompression assessed by high-definition ultrasonography.

METHODS

Between October and December 2014, patients with suspected carpal tunnel syndrome who were referred to the authors’ center for peripheral neurosurgery were prospectively enrolled and underwent pre- and postoperative (3 months) high-definition ultrasonography, electrophysiology, and clinical testing.

RESULTS

Eighty-one patients were enrolled in the study, and 100% were clinically better at the 3-month follow-up. The mean CSA decreased from 14.7 ± 4.9 mm2 to 12.4 ± 3.4 mm2 (mean ± SD, p < 0.0001). The mean distal motor latency decreased from 6.6 ± 2.4 msec to 4.8 ± 1.0 msec (mean ± SD, p < 0.0001). Ninety-eight percent of patients who were available for electrodiagnostic follow-up showed an improvement of the distal motor latency; only 80% had a reduction in the CSA.

CONCLUSIONS

The authors present the second-largest series of patients with sonographic follow-up after surgical decompression of the carpal tunnel reported in the literature so far. This study, which showed a decrease in size of the median nerve after surgical decompression, suggests that the preoperative increase in median nerve CSA at the carpal tunnel may be due to compression and that enlargement of the median nerve is (partially) reversible.

ABBREVIATIONSCSA = cross-sectional area; CTS = carpal tunnel syndrome; dmL = distal motor latency.

OBJECT

Carpal tunnel syndrome causes increased cross-sectional area (CSA) of the median nerve, which can be assessed by high-definition ultrasonography. It is unclear today, however, whether high-definition ultrasonography may play a role in the postoperative period. This prospective study aimed to determine the natural history of the morphology of the median nerve at the carpal tunnel after surgical decompression assessed by high-definition ultrasonography.

METHODS

Between October and December 2014, patients with suspected carpal tunnel syndrome who were referred to the authors’ center for peripheral neurosurgery were prospectively enrolled and underwent pre- and postoperative (3 months) high-definition ultrasonography, electrophysiology, and clinical testing.

RESULTS

Eighty-one patients were enrolled in the study, and 100% were clinically better at the 3-month follow-up. The mean CSA decreased from 14.7 ± 4.9 mm2 to 12.4 ± 3.4 mm2 (mean ± SD, p < 0.0001). The mean distal motor latency decreased from 6.6 ± 2.4 msec to 4.8 ± 1.0 msec (mean ± SD, p < 0.0001). Ninety-eight percent of patients who were available for electrodiagnostic follow-up showed an improvement of the distal motor latency; only 80% had a reduction in the CSA.

CONCLUSIONS

The authors present the second-largest series of patients with sonographic follow-up after surgical decompression of the carpal tunnel reported in the literature so far. This study, which showed a decrease in size of the median nerve after surgical decompression, suggests that the preoperative increase in median nerve CSA at the carpal tunnel may be due to compression and that enlargement of the median nerve is (partially) reversible.

ABBREVIATIONSCSA = cross-sectional area; CTS = carpal tunnel syndrome; dmL = distal motor latency.

Carpal tunnel syndrome (CTS) causes increased cross-sectional area (CSA) of the median nerve, which can be assessed by high-definition ultrasonography.2,3,5,6,12,15 –17 The compression in the carpal tunnel leads to edema and proliferation of fibrous tissue proximal to the compression site, which in turn results in swelling of the nerve and increased CSA in the 2D image.8,10

High-definition ultrasonography can thus be used for diagnosis of CTS with an accuracy that is equal to electrodiagnostic studies, 10,13 it may give further information about an underlying pathological entity such as a ganglion cyst, 14 or it may provide information about muscular atrophy.9

It is unclear today, however, whether high-definition ultrasonography may play a role in the postoperative period.11 Patients who suffer from persistent or recurring symptoms may have a nerve that is still or again compressed and may benefit from a second decompression. If surgical decompression of the median nerve in the carpal tunnel results in normalization of the median nerve’s CSA, this could help select patients who may benefit from a repeat surgery. On the other hand, if the nerve does not change morphologically postoperatively, then high-definition ultrasonography may not be helpful in the postoperative period to distinguish between patients whose nerve is still or again compressed and patients whose nerve is decompressed.

The goal of this prospective study was to determine the natural history of the morphology of the median nerve at the carpal tunnel after surgical decompression, as assessed by high-definition ultrasonography.

Methods

Institutional review board approval was obtained by the regional medical board committee (Landesärztekammer Baden Württemberg; F-2015-004). Between October and December 2014, patients with suspected CTS referred to our center for peripheral neurosurgery were prospectively screened for the study. Patients gave written informed consent and were prospectively enrolled.

The patients then routinely underwent standardized nerve conduction studies and subsequent sonographic evaluation. Clinical, sonographic, and electrophysiological parameters were assessed, as shown in Table 1. Nerve CSA and age were post hoc dichotomized into ≥ 12 mm2 or < 12 mm2 and ≥ 65 years or < 65 years to compare our findings with those of Vögelin et al.,15 who found a statistically significant difference in CSA reduction in these groups. Surgical decompression was then performed either in open fashion or endoscopically.

TABLE 1.

Summary of pre- and postoperatively assessed parameters in patients with CTS

Variable
Clinical parameters assessed preop
 Age
 Sex
 Laterality
 Duration of symptoms (≤1 yr vs >1 yr)
 Paresthesias (yes vs no)
 Numbness (yes vs no)
 Motor deficits (yes vs no)
 Atrophy (yes vs no)
 Typical brachialgia nocturna (yes vs no)
 Tendovaginitis stenosans (yes vs no)
 Diabetes (yes vs no)
Clinical parameters assessed postop
 Scar pain
 Clinical improvement of preop symptoms
 Paresthesias (complete reduction vs partial reduction vs no change)
 Numbness (complete reduction vs partial reduction vs no change)
 Motor deficits (complete reduction vs partial reduction vs no change)

We performed a follow-up clinical, electrophysiological, and sonographic examination at baseline and at 3 months after surgical treatment.

High-Definition Ultrasonography

A real-time scanner (Toshiba Aplio MX with IStyle technology, Toshiba Medical Systems Europe) with a 19-MHz linear array transducer was used. Patients were seated in a chair with their arms extended and hands resting in a horizontal supinated position. The largest CSA of the median nerve was assessed at 2 positions: 1) distal to the carpal tunnel inlet between the pisiform bone and the scaphoid tubercle—i.e., the distal wrist flection crease (rascetta); and 2) in the forearm 5 cm proximal to the mentioned line, using manual tracing in serial transverse scans. We used only transverse scans to localize the median nerve and exclude relevant pathologies other than CTS. The largest CSA was determined by visual inspection during transverse scanning. In case of uncertainty, several transverse measurements were taken until the largest CSA was identified. Assessments of the largest CSA were performed twice and the arithmetic means of the 2 assessments were recorded. Examinations before and after treatment were performed in the same standardized manner.

Statistical Analyses

The means of categorical variables were compared using a nonparametric test such as the Mann-Whitney U-test. Correlation analysis was done as an exploratory analysis, and subsequent factors were then compared with univariate and multivariate ANOVA. Commercially available software was used (SPSS 22.0; IBM, Inc.).

Results

Overall, 81 patients were recruited for the study and a 3-month clinical follow-up was obtained in 100%. Sixtyseven patients were recruited for another sonographic follow-up. Basic demographic variables are shown in Table 2. The majority of patients had open surgery (85%). The main results for the clinical parameters are shown in Table 3. All of the patients improved clinically in the short-term follow-up. Most of the patients, however, had postoperative scar pain.

TABLE 2.

Summary of basic demographic and preoperative variables in the population of patients with CTS

VariableValue (%)
Total no. of patients81 (100%)
Mean age in yrs, ± SD56.9 ±16.4
Male/female ratio1:1.3
Location of surgery
 Lt51 (63%)
 Rt30 (37%)
Duration of symptoms
 ≤1 yr29 (35.8%)
 >1 yr52 (64.2%)
Paresthesias74 (91.3%)
Numbness30 (37.0%)
Weakness2 (2.5%)
Atrophy2 (2.5%)
Typical brachialgia nocturna80 (98.8%)
Concurrent tendovaginitis stenosans12 (14.8%)
Concurrent hemodialysis0
Concurrent diabetes8 (9.9%)
No. w/ electrodiagnostic follow-up79
No. w/ sonographic follow-up67
Open surgery69 (85.2%)
Endoscopic surgery12 (14.8%)
TABLE 3.

Summary of early clinical results in patients with CTS

Results at 3 Mos PostopNo. of Patients (%)
Clinical improvement81 (100%)
No improvement0 (0%)
Postop scar pain
 Yes70 (86.4%)
 No11 (13.6%)
Paresthesias
 Complete resolution67 (82.7%)
 Partial resolution7 (8.6%)
 Persistent0 (0%)
 No paresthesias preop7 (8.6%)
Numbness
 Complete resolution24 (29.6%)
 Partial resolution6 (7.4%)
 Persistent0 (0%)
 No numbness preop51 (63%)
Weakness
 Complete resolution2 (2.5%)
 Partial resolution0 (0%)
 Persistent0 (0%)
 No weakness preop79 (97.5%)

The main results of the sonographic and electrophysiological measurements are summarized in Table 4. Overall we observed a statistically significant reduction of the mean CSA of the median nerve proximally as well as distally 3 months after surgical decompression. Furthermore, distal motor latency (dmL) also improved statistically significantly after surgical decompression. Nevertheless, although all patients improved clinically, we did not see a reduction in the CSA in 20% of the patients. Whereas 98% of patients who were available for electrodiagnostic follow-up showed an improvement of the dmL, only 80% had a reduction in the CSA. An example of a postoperative reduction is shown in Fig. 1. The reduction of CSA was not statistically significantly correlated with the amount of reduction of the dmL (Pearson correlation coefficient = 0.230, p = 0.067).

FIG. 1.
FIG. 1.

Example of a postoperative reduction of a CSA In 1 patient, as assessed by high-definition ultrasonography Upper: Preoperative image Lower: Postoperative image obtained after 3 months. Of note is a significant change in texture of the nerve that highlights the typical change from a dark nerve to the better visibility of the internal fascicular structure.

TABLE 4.

Main results in 81 patients with CTS*

ParameterPreop3 Mos Postopp Value
Mean CSA of median nerve at wrist, in mm214.7 ± 4.912.4 ± 3.4<0.0001
Mean CSA of median nerve at forearm, in mm29.9 ± 2.88.0 ± 1.6<0.0001
Mean dmL, in msec6.6 ± 2.44.8 ± 1.0<0.0001

Values are expressed as the mean ± SD. All parameters showed significant improvement postoperatively. Only 80% of the patients showed an improvement in their CSA.

A paired t-test was used for statistical analysis.

All statistically significant subgroup analyses are shown in Table 5. If the patient had a CSA that was ≥ 12 mm2 preoperatively or if they were < 65 years old, they had a significantly greater reduction of the percentage of their preoperative CSA (p < 0.001). Patients with motor deficits had statistically significantly longer preoperative dmL (10.5 ± 2.8 msec vs 6.5 ± 2.3 msec; p = 0.021 in multivariate analysis), but not a greater CSA (p = 0.124) or circumference (p = 0.252).

TABLE 5.

Statistically significant findings of the subgroup analyses in patients with CTS

SubgroupMean CSA Reduction, in % of Preop Value*p Value
Age
 ≥65 yrs5.6% ± 26%0.046
 <65 yrs17.4% ± 19%
Preop CSA
 ≥12 mm220.2% ± 18%<0.001
 <12 mm2−1.5% ± 22%

Values are expressed as the mean ± SD.

According to multivariate ANOVA.

Of all the other parameters that were assessed, we did not find a significant correlation between the parameters in the exploratory analysis (i.e., age, diabetes). We also did not find any statistically significant difference between patients who underwent open and endoscopic surgery in any pre- and postoperative parameter, especially in the sonographic and electrophysiological results.

Discussion

Here we present the second-largest series of patients with sonographic follow-up after surgical decompression of the carpal tunnel that has been reported in the literature so far. For sonographic diagnosis of CTS, measurement of the CSA is the most reliable and common parameter.7 Further sonographic signs for CTS are palmar bowing and thickening of the flexor retinaculum and distal flattening of the median nerve, as well as loss of fascicular discrimination and reduced echogenicity. In addition to enlargement of the median nerve, distal flattening and especially reduction or even loss of fascicular texture were regularly seen in our patients; however, these parameters are less reliable because they are more difficult to quantify.

Most of our results are in line with the published literature (Table 6).1,11,15 Also, the subgroups of patients who are older (≥ 65 years) and those who have a greater CSA (≥ 12 mm2) are in line with the published results from the Swiss group.14 Variations in the results may be due to patient heterogeneity or different measurement protocols. This is in accordance with our results that patients with a larger preoperative CSA had a larger reduction in their CSA, even when corrected by using percentage of reduction related to preoperative values. Furthermore, those previous studies did not address whether endoscopic versus open surgery can lead to a difference in postoperative CSA. In retrospective analysis, we could not find any difference.

TABLE 6.

Comparison of results of the current study with the data available in the literature

Authors & YearNo. of ParticipantsFollow-UpMean CSA in mm2*
PreopPostop
Vögelin et al., 2010586 mos12.4 ± 3.310.0 ± 2.7
Abicalaf et al., 2007203 mos15.0 ± 2.18.6 ± 1.6
Smidt & Visser, 20087919 mos14.011.5
Present study673 mos14.7 ± 4.912.4 ± 3.4

Values for CSA are expressed as the mean ± SD.

In general, sonographic short-term follow-up seems to be inferior to electrodiagnostic short-term follow-up. Whereas 98% of patients who were available for electrodiagnostic follow-up showed an improvement, only 80% had a reduction in the CSA. This point was not addressed in the previous studies, which did not report the number of patients who did not improve sonographically.1,11,15 The morphological improvement might be lagging behind the electrical improvement, when we hypothesize that the CSA will still decrease, which is unclear.

The large study of Smidt and Visser could not find any correlation between time of follow-up and reduction in CSA size, which could indicate that after 3 months the CSA will not decrease further.11 On the other hand, the study by Abicalaf et al. showed a time-dependent reduction, but only until 3 months postoperatively, when that study was terminated.1

Several authors have studied the value of high-definition ultrasonography for the diagnosis of CTS.5,6,16,17 In addition to contributing to the diagnostic workup of patients with suspected CTS, sonographic examination allows noninvasive detection of aberrations.4,9,10 In our investigation, however, electrodiagnostic studies seemed to be more sensitive in picking up preoperative deficits—our patients with motor deficits had statistically significantly longer preoperative dmL (10.5 ± 2.8 msec vs 6.5 ± 2.3 msec; p = 0.021 in multivariate analysis), but not greater CSA (p = 0.124) or circumference (p = 0.252).

Our stratified analyses provided little evidence that decreases in CSA depend on baseline characteristics other than the actually measured CSA at baseline. Whereas one study found an almost statistically significant correlation between CSA and clinical improvement,15 we could not find any correlation. In our particular study this is due to the high number of patients with clinical improvement. This could change in the longer term, for example if patients develop late recurrences.

We found a 100% improvement rate in the first 3 months after release. This is better than in most of the large published series and might be surprising given the reader’s personal experience. However, release of the carpal tunnel is a worthwhile procedure and if the diagnosis is correct (i.e., a typical clinical presentation and pathological electrophysiological parameters including an increased dmL), a high degree of improvement can be achieved. The 100% improvement found in this study might be related to the relatively small number of patients, participation bias, and a short follow-up. In larger patient series, participants with persistent complaints are likely.

The strengths of our study include a prospective design in unselected consecutive patients, the standardized protocol, experience of the surgeons (F.S. and T.D.), and the large number of patients. The major limitations of our study are its short-term follow-up and the nonrandomized nature, which may have resulted in confounding based on indication. Furthermore, the exceptionally good clinical results hinder the assessment of a relationship between general clinical outcome and sonographic follow-up. We are not able to answer the question whether a good sonographic reduction can go along with a bad clinical outcome.

Conclusions

Our study, which showed a decrease in size of the median nerve after surgical decompression, suggests that the preoperative increase in median nerve CSA at the carpal tunnel may be due to compression and that enlargement of the median nerve is (partially) reversible.

Author Contributions

Conception and design: Duetzmann, Staub. Acquisition of data: Tas, Staub, Dombert. Analysis and interpretation of data: Duetzmann. Drafting the article: Duetzmann. Critically revising the article: Staub, Marquardt, Senft. Statistical analysis: Duetzmann. Administrative/technical/material support: Staub, Dombert, Marquardt, Seifert. Study supervision: Staub, Dombert.

References

  • 1

    Abicalaf CAde Barros NSernik RAPimentel BFBraga-Baiak ABraga L: Ultrasound evaluation of patients with carpal tunnel syndrome before and after endoscopic release of the transverse carpal ligament. Clin Radiol 62:8918962007

    • Search Google Scholar
    • Export Citation
  • 2

    Bianchi SMartinoli CAbdelwahab IF: High-frequency ultrasound examination of the wrist and hand. Skeletal Radiol 28:1211291999

  • 3

    Bianchi SMartinoli CSureda DRizzatto G: Ultrasound of the hand. Eur J Ultrasound 14:29342001

  • 4

    Gofeld MBristow SJChiu SKliot M: Preoperative ultrasound-guided mapping of peripheral nerves. J Neurosurg 119:7097132013

  • 5

    Martinoli CBianchi SCohen MGraif M: Ultrasound of peripheral nerves. J Radiol 86:186918782005. (Fr)

  • 6

    Padua LPazzaglia CCaliandro PGranata GFoschini MBriani C: Carpal tunnel syndrome: ultrasound, neurophysiology, clinical and patient-oriented assessment. Clin Neurophysiol 119:206420692008

    • Search Google Scholar
    • Export Citation
  • 7

    Peer SBodner G: High-Resolution Sonography of the Peripheral Nervous System BerlinSpringer2008

  • 8

    Rempel DDahlin LLundborg G: Pathophysiology of nerve compression syndromes: response of peripheral nerves to loading. J Bone Joint Surg Am 81:160016101999

    • Search Google Scholar
    • Export Citation
  • 9

    Simon NGRalph JWLomen-Hoerth CPoncelet ANVucic SKiernan MC: Quantitative ultrasound of denervated hand muscles. Muscle Nerve [epub ahead of print]2014

    • Search Google Scholar
    • Export Citation
  • 10

    Simon NGRalph JWPoncelet ANEngstrom JWChin CKliot M: A comparison of ultrasonographic and electrophysiologic ‘inching’ in ulnar neuropathy at the elbow. Clin Neurophysiol 126:3913982015

    • Search Google Scholar
    • Export Citation
  • 11

    Smidt MHVisser LH: Carpal tunnel syndrome: clinical and sonographic follow-up after surgery. Muscle Nerve 38:9879912008

  • 12

    Tagliafico AResmini ENizzo RBianchi FMinuto FFerone D: Ultrasound measurement of median and ulnar nerve cross-sectional area in acromegaly. J Clin Endocrinol Metab 93:9059092008

    • Search Google Scholar
    • Export Citation
  • 13

    Visser LHSmidt MHLee ML: High-resolution sonography versus EMG in the diagnosis of carpal tunnel syndrome. J Neurol Neurosurg Psychiatry 79:63672008

    • Search Google Scholar
    • Export Citation
  • 14

    Vögelin EMészàros TSchöni FConstantinescu MA: Sonographic wrist measurements and detection of anatomical features in carpal tunnel syndrome. ScientificWorldJournal 2014:6579062014

    • Search Google Scholar
    • Export Citation
  • 15

    Vögelin ENüesch EJüni PReichenbach SEser PZiswiler HR: Sonographic follow-up of patients with carpal tunnel syndrome undergoing surgical or nonsurgical treatment: prospective cohort study. J Hand Surg Am 35:140114092010

    • Search Google Scholar
    • Export Citation
  • 16

    Wong SMGriffith JFHui ACFTang AWong KS: Discriminatory sonographic criteria for the diagnosis of carpal tunnel syndrome. Arthritis Rheum 46:191419212002

    • Search Google Scholar
    • Export Citation
  • 17

    Ziswiler HRReichenbach SVögelin EBachmann LMVilliger PMJüni P: Diagnostic value of sonography in patients with suspected carpal tunnel syndrome: a prospective study. Arthritis Rheum 52:3043112005

    • Search Google Scholar
    • Export Citation

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Article Information

Contributor Notes

Correspondence Stephan Duetzmann, Department of Neurosurgery, Goethe University Hospital Frankfurt, Schleusenweg 2-16, 60528 Frankfurt, Germany. email: stephan.duetzmann@gmail.com.INCLUDE WHEN CITING DOI: 10.3171/2015.6.FOCUS15216.Disclosure The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.
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    Example of a postoperative reduction of a CSA In 1 patient, as assessed by high-definition ultrasonography Upper: Preoperative image Lower: Postoperative image obtained after 3 months. Of note is a significant change in texture of the nerve that highlights the typical change from a dark nerve to the better visibility of the internal fascicular structure.

References
  • 1

    Abicalaf CAde Barros NSernik RAPimentel BFBraga-Baiak ABraga L: Ultrasound evaluation of patients with carpal tunnel syndrome before and after endoscopic release of the transverse carpal ligament. Clin Radiol 62:8918962007

    • Search Google Scholar
    • Export Citation
  • 2

    Bianchi SMartinoli CAbdelwahab IF: High-frequency ultrasound examination of the wrist and hand. Skeletal Radiol 28:1211291999

  • 3

    Bianchi SMartinoli CSureda DRizzatto G: Ultrasound of the hand. Eur J Ultrasound 14:29342001

  • 4

    Gofeld MBristow SJChiu SKliot M: Preoperative ultrasound-guided mapping of peripheral nerves. J Neurosurg 119:7097132013

  • 5

    Martinoli CBianchi SCohen MGraif M: Ultrasound of peripheral nerves. J Radiol 86:186918782005. (Fr)

  • 6

    Padua LPazzaglia CCaliandro PGranata GFoschini MBriani C: Carpal tunnel syndrome: ultrasound, neurophysiology, clinical and patient-oriented assessment. Clin Neurophysiol 119:206420692008

    • Search Google Scholar
    • Export Citation
  • 7

    Peer SBodner G: High-Resolution Sonography of the Peripheral Nervous System BerlinSpringer2008

  • 8

    Rempel DDahlin LLundborg G: Pathophysiology of nerve compression syndromes: response of peripheral nerves to loading. J Bone Joint Surg Am 81:160016101999

    • Search Google Scholar
    • Export Citation
  • 9

    Simon NGRalph JWLomen-Hoerth CPoncelet ANVucic SKiernan MC: Quantitative ultrasound of denervated hand muscles. Muscle Nerve [epub ahead of print]2014

    • Search Google Scholar
    • Export Citation
  • 10

    Simon NGRalph JWPoncelet ANEngstrom JWChin CKliot M: A comparison of ultrasonographic and electrophysiologic ‘inching’ in ulnar neuropathy at the elbow. Clin Neurophysiol 126:3913982015

    • Search Google Scholar
    • Export Citation
  • 11

    Smidt MHVisser LH: Carpal tunnel syndrome: clinical and sonographic follow-up after surgery. Muscle Nerve 38:9879912008

  • 12

    Tagliafico AResmini ENizzo RBianchi FMinuto FFerone D: Ultrasound measurement of median and ulnar nerve cross-sectional area in acromegaly. J Clin Endocrinol Metab 93:9059092008

    • Search Google Scholar
    • Export Citation
  • 13

    Visser LHSmidt MHLee ML: High-resolution sonography versus EMG in the diagnosis of carpal tunnel syndrome. J Neurol Neurosurg Psychiatry 79:63672008

    • Search Google Scholar
    • Export Citation
  • 14

    Vögelin EMészàros TSchöni FConstantinescu MA: Sonographic wrist measurements and detection of anatomical features in carpal tunnel syndrome. ScientificWorldJournal 2014:6579062014

    • Search Google Scholar
    • Export Citation
  • 15

    Vögelin ENüesch EJüni PReichenbach SEser PZiswiler HR: Sonographic follow-up of patients with carpal tunnel syndrome undergoing surgical or nonsurgical treatment: prospective cohort study. J Hand Surg Am 35:140114092010

    • Search Google Scholar
    • Export Citation
  • 16

    Wong SMGriffith JFHui ACFTang AWong KS: Discriminatory sonographic criteria for the diagnosis of carpal tunnel syndrome. Arthritis Rheum 46:191419212002

    • Search Google Scholar
    • Export Citation
  • 17

    Ziswiler HRReichenbach SVögelin EBachmann LMVilliger PMJüni P: Diagnostic value of sonography in patients with suspected carpal tunnel syndrome: a prospective study. Arthritis Rheum 52:3043112005

    • Search Google Scholar
    • Export Citation
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