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Diagnostic significance of ultrasonography in carpal tunnel syndrome and comparison with electrodiagnostic tests/ Karpal tunel sendromu'nda ultrasonografi'nin tanisal degeri ve elektronoromyografik testlerle karsilastirilmasi.

Introduction

Carpal tunnel syndrome occurs as a result of chronic compression of the median nerve in the carpal tunnel whose dorsal medial and lateral walls are formed by carpal bones and whose volar surface is formed by deep transverse carpal ligaments (1). Carpal tunnel syndrome is the most common form of peripheral nerve entrapment (2). Carpal tunnel syndrome is observed primarily among people between the ages of 40 and 60 and it is 2 to 5 times more prevalent among women than men (3). About 50-87% of the cases are bilateral. Although several diseases may lead to Carpal tunnel syndrome, over 50% of carpal tunnel syndrome cases are idiopathic (4). Carpal tunnel syndrome is generally diagnosed by means of clinical data. Electrophysiological studies are consulted for confirming the diagnosis as well as for differential diagnosis. However, they provide no information regarding median nerve morphology and possible etiological factors (5). The Ultrasonographical approach may be an alternative in Carpal tunnel syndrome diagnosis. Several investigators have published the results of their studies on utilizing sonography in the diagnosis of carpal tunnel syndrome, particularly after 1999 (6).

This present study aimed to evaluate the carpal tunnel ultrasonographically in healthy volunteers and patients with clinical symptoms and data, to investigate diagnostic consistency and the correlation between ultrasonographical and electrophysiological parameters while comparing their diagnostic sensitivity.

Materials and Methods

A total of 100 symptomatic wrists of 54 women patients (46 patients bilateral, 8 patients unilateral) clinically prediagnosed with carpal tunnel syndrome and 45 wrists of 25 healthy women (23 left and 22 right wrists) were evaluated prospectively. While the age range for the patient group was 42-79 years with a mean age of 55.2 [+ or -] 8.1 years, the age range for the controls was 37-70 years with a mean age of 49.6 [+ or -] 6.7 years. Individuals with another disease involving peripheral nervous system or those on a drug regimen, which can have an impact on it, those with a history of wrist surgery or wrist fracture, were excluded.

The intensity of the symptoms in the patient group was assessed by using "Symptom Severity Scale" while "Functional Status Scale" was utilized for the impact on daily activities (7,8). These two scales when combined together are also called "the Levine questionnaire" composed of 19 questions and used to evaluate symptom severity and functional status in carpal tunnel syndrome patients. There are 11 questions in the symptom severity scale and each question is answered by assigning a value ranging from 1 to 5, eventually reaching a mean score (sum total of the scores/11). It has a maximum score of five. Higher scores indicate more intense symptoms. Functional Status Scale questions the degree of difficulty encountered in carrying out eight different daily activities (7,8). Each question is answered by assigning a value ranging from one to five, eventually reaching a mean score (sum total of the scores/8). It has a maximum score of five. Higher scores indicate higher disability (7,8). All patients were administered with Tinel, Phalen and Buda tests as well, and were established to be positive or negative.

Nerve conduction studies: Electroneuromyographic examinations were performed by a physiatrist? Motor and sensory nerve conduction studies were carried out by using conventional methods both for the patient and the control groups. Median and ulnar nerve motor conduction velocity, distal motor latency, amplitude of compound muscle action potential, median and ulnar nerve antidromic sensory conduction velocity, distal sensory latency and amplitude of sensory action potential, median nerve palm-to-wrist segment mixed orthodromic sensory conduction velocity, radial nerve antidromic sensory conduction velocity and amplitude of sensory action potential were established. Furthermore, median-2nd lumbrical/ulnar-1st palmar, 2nd dorsal interosseal motor latency difference and fourth digit median-ulnar nerve antidromic sensory latency difference were established as well. Electrophysiological parameters were assessed according to the normal values determined by our laboratory. A minimum room temperature of 25[degrees]C and extremity distal skin temperature of >32[degrees]C was maintained for all electrophysiological measurements. A Medelec[R] Synergy Multimedia EMG/EP (Oxford Instruments) was used for performing the measurements.

Wrist ultrasonography: Ultrasonographic examinations were performed by a single radiologist, blinded to the diagnostic and electrophysiologic data, without querying the subject regarding clinical status. An ultrasonography system equipped with linear-array transducer at VFX 13.5 MHz (Siemens-Antares) was used. Patients were examined while the forearm flexor compartment was facing up with their wrists in neutral posture, and the transducer at a right angle to the wrist by exerting minimum compression. Hypoechoic median nerve and hyperechoic tendons were differentiated in the longitudinal (sagittal) imaging plane. Synovial fluid presence, as well as median nerve and tendon echogenity in the carpal tunnel were assessed in this plane. As it was difficult to differentiate the median nerve because of the tendon and/or median nerve echogenity in certain patients, they were asked to flex their fingers to observe the movement of the tendons to differentiate the median nerve. The long axis (transverse diameter) and the short axis (anteroposterior diameter) of the median nerve, were evaluated on axial (transverse) plan evaluated on milimetric measurement of proximal (distal radioulnar joint level, RU), medium (pisiform bone level, P) and distal (level of the hamate hook, H) parts of the carpal tunnel and the flattening ratio was established for each plane (by dividing long axis with short axis). Furthermore, cross-sectional area was calculated as [cm.sup.2] at these levels by manually establishing the borders of the median nerve in the axial plane. Median nerve swelling ratio was calculated by dividing the cross-sectional area of the median nerve at the pisiform level by the cross-sectional area at the distal radioulnar level. The distance of the midpoint of the line drawn from trapezial tubercule to the hamate hook to the flexor retinaculum at the level of the distal carpal tunnel (bowing of the flexor retinaculum) was also calculated. Patients with bifid median nerve were excluded in order to avoid inconsistencies in measurements. The values, which were 2 standard deviations above or below the data obtained from the healthy volunteers, were considered to be pathologic.

This present study was approved by the local ethics committee of the Baskent University Hospital and informed consents were obtained from the subjects.

Statistical Analysis

Mean values, standard deviations, and prevalence were calculated for all the variables investigated. Pearson correlation coefficient was used in investigating the correlation between continuous data. Student-t test was utilized for evaluating inter-group differences. McNemar chi-square test was used for testing the differences between the diagnostic sensitivity of electrophysiological tests and ultrasonographical parameters. Cohen kappa value was calculated by using kappa statistics for assessing consistency between the methods. A value of p<0.05 was considered to indicate a statistically significant difference.

SPSS for Windows 11.0 software was used for conducting the statistical analyses.

Results

The symptom duration was between 2-264 months in the patient group (mean 54.84 [+ or -] 63.99). Tinel, Phalen and Buda tests were positive in 22%, 33%, and 29% of wrists respectively. Furthermore, Symptom Severity Scale scores in the patient group ranged between 1 and 4.45 (mean 2.26 [+ or -] 0.7), while functional status scale scores ranged between 1 and 4.25 (mean 2.14 [+ or -] 0.8).

Symptom duration and age and symptom severity scale scores were not observed to be correlated significantly. However, symptom duration and functional status scale scores were established to have a weak but positive correlation (p=0.012, r=0.25). On the other hand, functional status scale and symptom severity scale scores were observed to have a positive linear correlation (p=0.000, r=0.69).

Nerve conduction studies: In 80 wrists at least one impaired electrophysiological parameter indicating carpal tunnel syndrome was found. Ratios of pathological findings regarding electrophysiological parameters in the patient group are given in Table 1, while electrophysiological parameters for both groups can be observed in Tables 1 and 2.

Functional status scale was observed to be moderately correlated with median nerve distal motor latency (p=0.000, r=0.36), and weakly correlated with median distal sensory latency (p=0.029, r=0.22). Similarly, there was a weak positive correlation between symptom severity scale scores and median distal motor latency (p=0.004, r=0.28). The other electrophysiological parameters were not significantly correlated with functional status scale and symptom severity scale scores.

Results of the ultrasonographical examination: Ultrasonographical examination revealed a cyst in one wrist and synovial fluid elevation in three wrists. The number of wrists with at least one abnormal ultrasonographical parameter in the patient group was 47. Ratios of pathological findings regarding ultrasonographical parameters in the patient group are given in Table 3, while ultrasonographical parameters for both groups can be found in Table 4. Increased median nerve cross-sectional area at radioulnar and pisiform levels for the patient group can be observed in figures 1 and 2.

Except for the weak correlation between certain parameters, electrophysiological and ultrasonographical parameters were not observed to be correlated significantly (Table 5). McNemar chi-square test, used to assess to compare the diagnostic sensitivity of electrophysiological and ultrasonographical parameters, revealed significant differences between the sensitivity of all electrophysiological and ultrasonographical parameters and non-random consistency coefficients of the methods were found to be low (Table 6).

[FIGURE 1 OMITTED]

Discussion

This present study demonstrated that ultrasonographical parameters were significantly less sensitive when compared with electrophysiological parameters in the diagnosis of patients clinically pre-diagnosed with carpal tunnel syndrome and that non-random consistency coefficients between the parameters of the two approaches were low. Furthermore, ultrasonographical parameters were not correlated significantly with functional assessment or with clinical assessment results based on symptom severity.

[FIGURE 2 OMITTED]

Carpal tunnel syndrome patients can be diagnosed based on their clinical symptoms and findings. Electrodiagnostic tests are helpful in confirming the diagnosis and also in evaluating the pathogenetic process and the level of neuropathy (9). The major limitations of electrodiagnostic tests are their inability to provide information regarding median nerve morphology and possible etiological factors and pain during the tests conducted. Therefore, diagnostic ultrasonography, due to its noninvasive and practical administration and ability to provide anatomical and etiological information, has become increasingly common.

Diagnostic ultrasonographical parameters in carpal tunnel syndrome demonstrated in previous studies can be listed as increased bowing of the flexor retinaculum, increased flattening ratio or above normal cross-sectional area of the median nerve in the carpal tunnel proximal (inlet), middle section, and outlet (distal) (10). Different characteristics of study groups, variations in measurement methods (direct-indirect) and instruments used (equipment specifications) have led to differences in normal range definitions, diagnostic sensitivity as well as specificity. While diagnostic sensitivity has been reported to be about 76.5% in methods using indirect measurement, direct approaches have reported diagnostic sensitivity of up to 82.4% (2). However, the median nerve cross-sectional area calculated at different levels has generally been regarded as the most sensitive and specific ultrasonographical parameter in carpal tunnel syndrome diagnosis (2,4,5,11-13).

According to the data obtained in this present study, median nerve cross-sectional area was observed to be increased in only 19% of the patients at the distal radioulnar joint level, in 33% of the patients at the level of the pisiform and in 18% of the patients at the level of the hamate hook. Bowing of the flexor retinaculum was high only in 2% of the patients. The percentages calculated in this present study are significantly lower than those reported in the literature. Several factors may be listed to explain this inconsistency. The first and most important one is the fact that the normal range observed in the control group was above average values. Previous studies have reported the maximum mean median nerve cross-sectional area to be 9-11 [mm.sup.2] and bowing of the flexor retinaculum to be between 2.5 and 4 mm (2,4,11,13-15). Our results revealed mean median nerve cross-sectional area upper limit at the radioulnar, pisiform and hamate hook levels to be 14 mm_ and the bowing of the flexor retinaculum to be 3.5 mm, which were considerably higher than the values reported in the literature. This particular range significantly decreased the number of subjects in the patient group, which could be considered pathological. In fact, if we had taken the upper limits reported in previous studies, the number of ultrasonographical parameters, which could be considered pathological, would have increased significantly. Therefore, this inconsistency may be explained by the characteristics of the individuals forming the control group.

It has been reported that in some cases local ischemia occurring as a result of depressed endoneural blood support due to chronic compression on the median nerve may be responsible for neuropathy. Therefore, typical ultrasonographical findings of edema and increased cross-sectional area may not be observed (4). Consequently, the pathogenetic process, which has an impact on the median nerve, is critical in the carpal tunnel syndrome. Paranodal demyelination, edema in the nerve, is more pronounced in histopathologically early stage patients. This is followed by complete segmental demyelination, which develops into complete degeneration in the chronic and late stages. As a result, the cross-sectional area of the nerve may be smaller in the presence of axonal degeneration in chronic and late-stage patients when compared with that of the earlier stage patients. The duration of illness in this present study was significantly longer than similar patient groups investigated in the literature. In other words, our study population consisted of patients that are more chronic. This may have resulted in lower percentages of pathological data and, thus, diagnostic sensitivity in ultrasonography.

Technical specifications are another issue of importance. Previous studies have utilized 7-13 MHz linear probes (2,5,10,11,12,13,15). An ultrasound probe of 13.5 MHz was used in this present study. The use of indirect measurement methods has been more common in calculating the mean median nerve cross-sectional area in previous studies. A study used the direct method as well as the indirect method and compared the two methods in mean median nerve cross-sectional area calculation (2). It was reported that the direct method was more sensitive than the indirect approach. We also used the direct method to calculate the mean median nerve cross-sectional area in this present study. Therefore, the inconsistencies observed in this present study cannot be attributed to the technical specifications of the ultrasound device and the method used in calculating the cross-sectional area.

Ultrasonographical examination of the carpal tunnel and the median nerve is not a routine procedure for many healthcare centers. In fact, the same was also true for the radiology clinic where this present study was conducted. Sensitive measurements, such as calculating the diameter and cross-sectional area of a peripheral nerve at different levels, require a certain type of experience. Therefore, our lack of experience in doing so may have led to inconsistent results regarding sensitivity.

Electrodiagnostic study data were used as the standard measurement method in our study and diagnostic sensitivity of ultrasonographical parameters were compared with ENMG. It may be suggested that a possible deviation or error in electrophysiological examination methods may have also led to miscalculations regarding the sensitivity of ultrasonography. However, this does not seem very likely, as the electrophysiological data obtained were highly consistent with the extensive data available in this field in medical literature.

Studies comparing the correlation between electrophysiological and ultrasonographical parameters in carpal tunnel syndrome are few. In general, both approaches have been reported to have high diagnostic sensitivity. However, varying levels of correlations have been reported between ultrasonographical data and ENMG results. While certain investigators reported weak or moderate linear correlation between the two approaches, certain investigators failed to establish any correlation at all (4,5,15). In fact, the results obtained in this present study also established no significant correlation between the parameters of these two methods.

Many studies have also reported that clinical parameters and electrophysiological parameters did not correlate very well in carpal tunnel syndrome. The same is also true for ultrasonographical examinations (5). Similarly,the Levine questionnaire and other clinical parameters were not observed to correlate significantly with electrophysiological and ultrasonographical parameters in this present study, either.

In conclusion, the results of this present study demonstrated that the diagnostic sensitivity of ultrasonographical parameters was significantly lower than that of the electrophysiological parameters in Carpal tunnel syndrome. Therefore, it seems highly unlikely for ultrasonographical approaches to replace electrophysiological ones for this particular condition. Increased cumulative data on ultrasonographical examinations in the literature may lead to more objective assessments on the issue. Ultrasonography may b e particularly useful in examining carpal tunnel syndrome patients in the acute or subacute stage. Moreover, it may be used as an alternative non-painful, non-invasive, and cheaper approach in cases where electrophysiological examination cannot be tolerated or when etiological information is also of importance. Conduction of the examination by an experienced radiologist and using an appropriate probe with a high frequency transducer will lead to increased diagnostic sensitivity.

Note: 5th Mediterranean Congress of Physical and Rehabilitation Medicine, Sepember 30-October 04, 2004, Antalya (Oral presentation)

Received:/Gelis Tarihi Eylul/September 2007 Accepted/Kabul Tarihi: August/Agustost 2008

References

(1.) Oh SJ. Nerve conduction in focal neuropathies. In: Retford DC, editor. Clinical electromyography: Nerve conduction studies. 2nd ed. CN: Williams & Wilkins; 1993. p.517-26.

(2.) Duncan I, Sullivan P, Lomas F. Sonography in the diagnosis of carpal tunnel syndrome. Am J Roentgenol 1999;173:681-4.

(3.) Chen P, Maklad N, Redwine M, Zelitt D. Dynamic high-resolution sonography of the carpal tunnel. Am J Roentgenol 1997;168:533-7.

(4.) Sarria L, Cabada T, Cozcolluela R, Martinez-Berganza T, Garcia S. Carpal tunnel syndrome: usefulness of sonography. Eur Radiol 2000;10:1920-5.

(5.) Kele H, Verheggen R, Bittermann HJ, Reimers CD. The potential value of ultrasonography in the evaluation of carpal tunnel syndrome. Neurology 2003; 61:389-91.

(6.) Beekman R, Visser LH. Sonography in the diagnosis of carpal tunnel syndrome: a critical review of the literature. Muscle Nerve 2003;27:26-33.

(7.) Atroshi I, Gummesson C, Johnsson R, McCabe SJ, Ornstein E. Severe carpal tunnel syndrome potentially needing surgical treatment in a general population. J Hand Surg (Am) 2003;28: 639-44.

(8.) Levine DW, Simmons BP, Koris MJ. A self administered questionnaire for the assessment of severity of symptoms and functional status in carpal tunnel syndrome. J Bone Joint Surg Am 1993; 75:1585-92.

(9.) Jablecki CK, Andary MT, Wilkins DE, Williams FH. Literature review of the usefulness of nerve conduction studies and electromyography for the evaluation of patients with carpal tunnel syndrome. AAEM Quality Assurance Committee. Muscle Nerve 1993;16:1392-414.

(10.) Buchberger W, Judmaier W, Birbamer G, Lener M, Schmidauer C. Carpal tunnel syndrome: diagnosis with high-resolution sonography. Am J Roentgenol 1992;159:793-8.

(11.) Wong SM, Griffith JF, Hui ACF, Tang A, Wong KS. Discriminatory sonographic criteria for the diagnosis of carpal tunnel syndrome. Arthritis & Rheumatism 2002;46:1914-21.

(12.) Leonard L, Rangan A, Doyle G, Taylor G. Carpal tunnel syndrome-is high-frequency ultrasound a useful diagnostic tool? J Hand Surg [Br] 2003;28:77-9.

(13.) Wiesler ER, Chloros GD, Cartwright MS, Smith BP, Rushing J, Walker FO. The use of diagnostic ultrasound in carpal tunnel syndrome. J Hand Surg 2006;31:726-32.

(14.) Kaymak B, Ozcakar L, Cetin A, Candan Cetin M, Akinci A, Hascelik Z. A comparison of the benefits of sonography and electrophysiologic measurements as predictors of symptom severity and functional status in patients with carpal tunnel syndrome. Arch Phys Med Rehabil 2008;89:743-8.

(15.) Yesildag A, Kutluhan S, Sengul N, Oyar O, Guler K, Gulsoy UK. The role of ultrasonographic measurements of the median nerve in the diagnosis of carpal tunnel syndrome. Clinical Radiol 2004;59:910-5.

Sacide NUR SARACGIL, Metin KARATAS, Hasan YERLI *, Iclal ISIKLAR *, Elif KARADELI * Baskent Universitesi Tip Fakultesi, Fiziksel Tip ve Rehabilitasyon ve * Radyoloji Anabilim Dali, Ankara, Turkey

Address for Correspondence/Yazisma Adresi: Dr. Sacide Nur Saracgil, Baskent Universitesi Tip Fakultesi, Fiziksel Tip ve Rehabilitasyon Anabilim Dali, Ankara, Turkey Phone: +90 312 212 29 12 Fax: +90 312 215 78 40 E-mail: sacidenurs@tnn.net
Table 1. Number of pathologies observed in peripheral nerve conduction
studies.

 Number of
 hands with Sensitivity
 abnormality (%) Criteria forabnormality

MMDL 53/100 53 >4 msec
MSDL 65/100 65 >3.41 msec
MPWCV 58/100 58 <35.9 mm/sec
amp PWAP 46/100 46 <32.4 [micro]V
IV. SLD 60/100 60 >0.5 msec
LILD 71/100 71 >0.5 msec

MMDL: Median motor distal latency, MSDL: Median sensory distal latency,
MPWCV: Median mixed palm-wrist conduction velocity, amp PWAP:
Amplitude of palm-to-wrist segment mixed nerve action potentials,
IV. SLD: Fourth digit median-ulnar sensory latency difference,
LILD: Lumbrical-interosseal median ulnar motor latency difference

Table 2. Electrophysiological parameters.

 Patient group Control group p

MMDL (msn) 4.14 [+ or -] 1.26 2.99 [+ or -] 0.3 0.000
MSDL (msn) 3.86 [+ or -] 0.86 2.89 [+ or -] 0.2 0.000
MPWCV 34.6 [+ or -] 7.71 45.1 [+ or -] 4.06 0.000
amp PWAP 37.6 [+ or -] 24.5 42.9 [+ or -] 11.8 0.085
LILD (msn) 1.04 [+ or -] 0.9 0.18 [+ or -] 0.1 0.000
IV. SLD (msn) 1.06 [+ or -] 0.9 0.10 [+ or -] 0.2 0.000
amp SNAPS 44.4 [+ or -] 24.9 61.7 [+ or -] 23.1 0.000
 ([micro]V)
amp CMAPs 8.1 [+ or -] 3.0 10.20 [+ or -] 2.0 0.000
 ([micro]V)

MMDL: Median motor distal latency, MSDL: Median sensory distal latency,
MPWCV: Median mixed palm-wrist conduction velocity, amp PWAP: Median
amplitude of palm-to-wrist segment mixed nerve action potentials, LILD:
Lumbrical interosseal median ulnar motor latency difference, IV.
SLD: Fourth digit median ulnar sensory latency difference, amp SNAPS:
Amplitude of antidromic sensory nerve action potential, amp CMAPs:
Amplitude of compound muscle action potentials

Table 3. Number of pathologies observed in the three levels.

 Number of hands Sensitivity Sensitivity
 with abnormality (%) criteria

CARUJ 19/100 19 >14 mm
MNAP 33/100 33 >14 mm
MNAH 18/100 18 >14 mm
FRRU 6/100 6 >4
FRP 2/100 2 >4
FRH 2/100 2 >4
MNSR 6/100 6 >1.5
BFR 2/100 2 >3:5 mm

CARUJ: Median nerve cross-sectional area at the
radioulnar joint level,

MNAP: Median nerve cross-sectional area at the level of
the pisiform,

MNAH: Median nerve cross-sectional area at the level of
the hamate hook,

FRRU: Flattening ratio at the radioulnar joint level,

FRP: Flattening ratio at the level of the pisiform,

FRH: Flattening ratio at the level of the hamate hook,

MNSR: Median nerve swelling ratio, BFR: Bowing of the
flexor retinaculum

Table 4. Ultrasonographical parameters.

 Patient group Control group p

CARUJ 0.15 [+ or -] 0.1 0.09 [+ or -] 0.02 0.000
MNAP 0.16 [+ or -] 0.1 0.10 [+ or -] 0.02 0.000
MNAH 0.14 [+ or -] 0.1 0.09 [+ or -] 0.02 0.005
FRRU 2.7 [+ or -] 0.7 2.7 [+ or -] 0.7 0.911
FRP 2.6 [+ or -] 0.6 2.5 [+ or -] 0.7 0.404
FRH 2.6 [+ or -] 0.6 2.5 [+ or -] 0.7 0.401
MNSR 1.13 [+ or -] 0.2 1.09 [+ or -] 0.2 0.382
BFR 2.03 [+ or -] 0.8 1.6 [+ or -] 0.8 0.007

CARUJ: Median nerve cross-sectional area at the radioulnar joint
level,

MNAP: Median nerve cross-sectional area at the level of the pisiform,

MNAH: Median nerve cross-sectional area at the level of the hamate
hook,

FRRU: Flattening ratio at the radioulnar joint level, FRP: Flattening
ratio at the level of the pisiform, FRH: Flattening ratio at the
level of the hamate hook,

MNSR: Median nerve swelling ratio, BFR: Bowing of the flexor
retinaculum

Table 5. Correlations between ultrasonographical and
electrophysiological parameters.

 CARUJ MNAP MNAH FRRU

MDML r:-0.119 r:0.032 r:0109 r:0.046
MSDL r:-0.128 r:0.018 r:0129 r:0.004
MPWCV r:0.159 r:0.022 r:0119 r:0.051
Amp PWAP * r: 0.369 * r: 0.360 * r: 0.416 r:0.047
IV. SLD r:-0.129 r:-0.060 r:-0.090 r:-0.074
LILD r:-0.174 r:0.092 r:0171 r:0.070

 FRP FRH MNSR BFR

MDML r:0.047 r:0.028 * r:0.240 r:0.130
MSDL r:0.035 r:0.092 * r:0.212 * r:0.240
MPWCV r:0.053 r:0.077 * r:0.226 * r:0.258
Amp PWAP r:-0.075 r:-0.055 * r:-0.235 r:-0.048
IV. SLD r:-0.052 r:-0.096 r:0.063 * r:0.323
LILD r:0.085 r:0.067 r:0.173 r:0.081

*p<0.05

CARUJ: Median nerve cross-sectional area at the radioulnar joint
level, MNAP: Median nerve cross-sectional area at the level of the
pisiform, MNAH: Median nerve cross-sectional area at the
level of the hamate hook, FRRU: Flattening ratio at the radioulnar
joint level, FRP: Flattening ratio at the level of the pisiform, FRH:
Flattening ratio at the level of the hamate hook,

MNSR: Median nerve swelling ratio, BFR: Bowing of the flexor
retinaculum, MMDL: Median motor distal latency, MSDL: Median sensory
distal latency, MPWCV: Median mixed palm-wrist
conduction velocity, amp PWAP: Median amplitude of palm-to-wrist
segment mixed nerve action potentials, LILD: Lumbrical-interosseal
median ulnar motor latency difference,

IV SLID: Fourth digit median-ulnar sensory latency difference

Table 6. The diagnostic sensitivity of electrophysiological
and ultrasonographical parameters.

 McNemar test
 [X.sup.2] p Cohen Kappa p

MMDL-CARUJ 24.8 0.000 0.152 0.045
MSDL-CARUJ 36.2 0.000 0.06 0.38
PWCV-CARUJ 27.3 0.000 0.036 0.613
LILD-CARUJ 39.4 0.000 0.05 0.40
IV. SLD-CARUJ 33 0.000 0.02 0.75
MMDL-MNAP 9 0.002 0.216 0.019
MSDL-MNAP 21.8 0.000 0.201 0.013
MPWCV-MNAP 14.8 0.000 0.260 0.003
LILD-MNAP 25.4 0.000 0.06 0.46
IV. SLD-MNAP 20.9 0.000 0.1 0.22

MMDL CARUJ: Median motor distal latency-Median nerve cross-sectional
area at the radioulnar joint level, MSDL-CARUJ: Median sensory distal
latency-Median nerve cross-sectional area at the radioulnar joint
level, MPWCV-CARUJ: Median mixed palm-wrist conduction velocity-Median
nerve cross-sectional area at the radioulnar joint level,
LILD-CARUJ: Lumbrical-interossei median ulnar motor latency
difference-Median nerve cross-sectional area at the radioulnar joint
level, IV. SLD-CARUJ: Fourth digit median-ulnar sensory latency
difference-Median nerve cross-sectional area at the radioulnar joint
level, MMDLMNAP: Median motor distal latency-Median nerve
cross-sectional area at the level of the pisiform, MSDLMNAP: Median
sensory distal latency-Median nerve cross-sectional area at the level
of the pisiform, MPWCV-MNAP: Median mixed palm-wrist conduction
velocity-Median nerve cross-sectional area at the level of the
pisiform, LILD-MNAP: Lumbrical-interossei median ulnar motor
latency difference-Median nerve cross-sectional area at the level of
the pisiform, IV. SLD-MNAP: Fourth digit median-ulnar sensory latency
difference-Median nerve cross-sectional area at the level of the
pisiform
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Title Annotation:Original Article/Orijinal Makale
Author:Saracgil, Sacide Nur; Karatas, Metin; Yerli, Hasan; Isiklar, Iclal; Karadeli, Elif
Publication:Turkish Journal of Physical Medicine and Rehabilitation
Article Type:Report
Geographic Code:7TURK
Date:Mar 1, 2009
Words:4493
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