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NeuroQuantology | January 2022 | Volume 20 | Issue 1 | Page 34-40 | doi: 10.14704/nq.2022.20.1.NQ22005
Mohammed Kadhom Awajel et al / Assessment of Carpal Tunnel Syndrome Severity by Ultrasound and Electrodiagnosis Study
eISSN 1303-5150 www.neuroquantology.com
34
Assessment of Carpal Tunnel Syndrome Severity
by Ultrasound and Electrodiagnosis Study
Mohammed Kadhom Awajel1*, Abdullnasir Hussin2, Mohammed Ab-Khudhur3
Abstract
Carpal tunnel syndrome (CTS) is the upper limb neuropathic entrapment. Electrodiagnostic study (EDX) is the gold
standard for diagnosis. However, EDX is not always abnormal in CTS beside its relatively high cost which requires
the search for alternative modalities.
Objectives: To investigate ultrasound (US) has a function in the evalution of CTS as well as determination disease
severity.
Subjects and Methods: A case-control experiment which involve 50 CTS patients (65 wrists) and 30 healthy
subjects (30 wrists). Electrodiagnostic study involve nerve coduction test (NCS) were performed for all included
wrists, with ultrasound measure the cross-sectional area (CSA) of the median nerve.
Results: The result of 65 affected wrists with CTS is classified for 40 (61.15%) wrist mild disease, 19 wrists
(29.23%) demonstrated a moderate disease and 6 wrists (9.23%) had severe disease. The mean in mild, moderate,
and severe cases, median nerve CSA was determined 11.21±1.22 mm2, 15.09±0.1.14 mm2 and 17.88±0.2.1 mm2,
respectively with highly significant differences between the three categories. Furthermore, all three categories had
higher CSA than control (8.73±0.45 mm2) with highly significant differences. In patients, CSA demonstrated a
significant linked with median distal sensory latency (r = 0.71 8, p <0.001), median motor distal latency (r = 0.818,
p < 0.001) and age (r = 0.316, p = 0.0 1) and a negative significant with median nerve conduction velocity (r= -0.837,
p < 0.001). US demonstrated excellent diagnostic values. The sensitivity and specificity of US in the context of
discriminate patients and controls at cut off value of CSA = 10 mm2 were 92% and 100%, respectively. Furthermore,
US can effectively discriminate between mild, moderate and severe cases CTS with sensitivity levels ranging from
83%- 100% and 94%-100% specificity. The optimal cut off values ranges between 13.2-16.2 mm2.
Conclusions: The CSA of the median nerve is increased and the degree of enlargement significantly correlates with
the parameters of disease severity. However, the CSA of the nerve does not associate with the gender of patients or
the side of the affected wrist. Ultrasound of CST of median nerve has an excellent diagnostic value in the disinguish
between patients and controls, with 92 percent sensitivity and 99 percent specificity, respectively. The optimum cut
off value is 10 mm2. Also, US can effectively distinguish mild, moderate and severe cases CTS with Sensitivity levels
ranging from 83%- 100% and 94%-100% Specificity. The optimal values cut off ranges between 13.2-16.2 mm2.
Key Words: Carpal Tunnel Syndrome, Ultrasound, Median Cross–sectional Area, Nerve Conduction Study,
Electrodiagnostic Study.
DOI Number: 10.14704/nq.2022.20.1.NQ22005 NeuroQuantology 2022; 20(1):34-40
Introduction
Is the neuropathic lesion of the nerve at the region
of wrist that travels during canal along with nine
flexor tendons. It is also is known as the most
prevalent neuropathy of entrapment affecting
upper extremities described by numbness and
tingling, and discomfort or pain in the hand.
Corresponding author: Mohammed Kadhom Awajel
Address: 1*,2,3College of Medicine, University of Baghdad, Iraq.
1*E-mail: awjel_87@yahoo.com
Relevant conflicts of interest/financial disclosures: The authors declare that the research was conducted in the absence of
any commercial or financial relationships that could be construed as a potential conflict of interest.
Received: 02 November 2021 Accepted: 05 December 2021

35
It is consider and is remembered as one of the most
significant causes of morbidity in the workplace
(Coraci., 2014). Trauma, pressure increase in the
canal, ischemia lesion to median nerve in the carpal
tunnel are all factors lead to CTS, the normal
pressure ranged from 2 and 10 mm Hg. Carpal
tunnel pressure changes during wrist extension
and flexion leading to an increase 8 to 10 folds.
Therefore, recurrent hand movement is the main
risk factor of carpal tunnel syndrome (Ibrahim et al,
2012). It can be detected by taking a medical
history and performing physical examinations
depend on American Academy of Neurology
practice.
1. Discomfort, pain, paresthesia, espicialy at
night.
2. Sensory fiber involvement.
3. Motor involvement, weakness of the thumb
abduction and hypotrophy of abductor pollicis
brevis.
4. Positive Phalen’s maneuver and/or Tinel’s
sign (Chen 2011).
Electrodiagnosis is the most useful tool for
diagnosing CTS and determining its severity,
however it is considered intrusive, another
diagnostic noninvasive, feasible, simple like high
resolution ultrasonography. (Kang 2012) The
etiology of carpal tunnel is demyelination and
accompanied by axonal loss due to severity In a
nerve electrodiagnosis, a demyelination lesion in
the median nerve reflected in a slowing of the
sensory median nerve's distal latency, If very tiny
discrepancies between the median and ulnar
latencies (usually 0.4–0.5 ms) are discovered in
these sensitive median-versus-ulnar comparison
investigations, they are regarded abnormal.
(Preston, D., C. & Shapiro, B., E. 2021).
Over the last few years, neuromuscular
ultrasonography has become more widely
employed in conjunction with EDX in the
evaluation of patients with neuromuscular
illnesses. (Preston, D., C. & Shapiro, B., E. (2021).
used of ultrasound growing for many factors
simple, accurate, rapid, non-invasive method low
cost, fesible, (coraci 2014). The prevalent criterion
in CTS is increase diameter of nerve
(cross–sectional area >10 mm2 which has a high
sensitivity as 97.9%. (Cara McDonagh, 2015).
When examining nerve, there are a number of
factors to consider. The cross-sectional area (CSA)
above 10mm is significant, and it is the most
important and well-validated parameter. The
ultrasound image of median compression at the
wrist is an enlarged and hypoechoic nerve next to
the entrapment site with loss of the usual fascicular
architecture, which is evaluated using a tracing
method immediately inside the hyperechoic
epineurium. (Descatha, A., L. Huard 2012).
Materials and Methods
A case - control experiment which conducted in
Al-Shaheed Ghazi Al-Hariri teaching hospital, Iraq,
Baghdad in from 2021/1/20 to 2021/7/23 Which
included a total of 50 patients with carpal tunnel
syndrome and 30 normal subjects As control, they
referred from neurosurgery department,
orthopaedic department, electrodiagnosis study
cover NCS (nerve conduction test) perform for all
hands and ultrasound measure median cross-
sectional area, Data were collected via direct
interface with the patients and examination using a
data collecting sheet including; age, gender, date of
examination, RT or LT hand affected or Both.
Exclusion Criteria Were
Patient with diabetic mellitus, Patient with wrist
trauma, Patient with cervical radiculopathy, Patient
connective tissue diseases, Patient with rheumatoid
arthritis, Thyroid disease Natus
electroneuromyography was used, which involved
assessing bilateral motor with sensory fibers of the
ulnar and median nerves and recording abnormal
parameters in the median nerve. The results
classified into mild (sensory fibers affected),
moderate (sensory and motor fibers affected) and
sever (sever motor fiber affected) according to the
neurophysiological reference values' local severity
scale (J.D. Bland, 2000). During examination during
the test procedures, the room temperature was
kept between (25C°-28C°) and the skin
temperature was kept between (36C°-37C°) with a
mean of 36.7C° using a skin thermometer.
The following parameters were studied in sensory
nerve: Amplitude, conduction velocity, distal
latency. When stimulating sensory fiber the current
of Supramaximal stimulation was used to elicit the
maximum potential of the sensory nerve. The
following parameters were studied in motor nerve:
Amplitude, velocity, latency, duration the motor
nerve is stimulated at two sites along its path
(proximal and distal), and the muscle supplied by
the same nerve is recorded. The stimulus intensity
must be high enough to activate all motor nerve
fibers (Preston and Shapiro, 2013). The HD11XE
Philips 2009 was used for the US evaluation, and

36
the US model was equipped with linear probe of
(7.5 MHz frequency) at the same time with nerve
conduction study, the setting position is apply to
examine the patient, with his hand open and flat on
the coach, examination done with transverse
direction. We used the upper normal CS area limit
for the median nerve (<10 mm²) (Preston, D., C. &
Shapiro, B., E. (2021) (Cara McDonagh, M ichael
Alexander, David Kane, 2015).
Statistic analyse conducted by S P S S software (S P
S S, Chicago). Data were offered as mean and root
mean square deviation, and analysed with unpaired
Student t - test. Relative operating characteristic
curve (ROC) estimated value diagnostic of cross -
sectional area (CSA) of the median nerve in the
context of discrimination between patients and
controls. Pearson’s r to explore possible correlation
CSA with other variable in patients and controls. P -
value < 0. 0 5 significant difference.
Result
Demographic data of population study, mean
patients age 46.1±11.27 years significantly
different from that of controls group (35.35±8.49
years), no significant distinction in gender
distribution between the two groups. Likewise,
patient group and control group had comparable
weight, height and BMI with no significant
differences There were 65 affected wrists in
patients, of which 38 (58.46%) were right wrist
and 27(41.54%) were left wrists. On the other
wrist, there were 13 right wrists (56.52%) and 10
left wrists (43.4 8 %) in control group with no
significant distinction (Table 1).
Table 1. Demographic data of population study
variables Patients (N= 50) Controls (N=30) P value
Age, years
Mean±SD
Range
46.1±11.27
21-64
35.35±8.49
20-52
<0.001
Gender
Male
Female
20(40%)
30(60%)
12(52.17%)
11(47.83%)
0.330
Height, cm
Mean±SD
Range
75.82±10.17
57-110
75.39±8.13
59-90
0.860
Weight, kg
Mean±SD
Range
164.97±9.23
150-179
167.35±7.44
157-180
0.281
BMI, kg/m2
Mean±SD
Range
27.85±2.88
20.76-38.06
26.89±2.05
23.89-23.25
0.156
Side
Right
Left
38(58.46%)
27(41.54%)
13(56.52%)
10(43.48%)
0.871
Electrophysiological Parameters and
Ultrasonography
The mean time for median sensory latency, median
motor latency and conduction velocity in CTS
patients was 4.18±0.63 ms, 4.0±1.41 ms and
49.62±9.79 m/s, respectively compared with
2.8±0.3 ms, 2.92±0.34 ms and 61.32±4.75 m/s,
respectively in controls with highly significant
differences. However, there was no significant
differentiation between them patients group and
controls group in ulnar nerve sensory distal latency
(2.61±0.29 ms versus 2.57±3.66 ms). According to
the result of ultrasound, mean median CSA in CTS
patients 13.11±2.57 mm2 (range= 8.5-19.9 mm2)
which was much higher than that of controls (mean
= 8.73±0.45 mm2, range= 7.5-9.0 mm2) as shown in
table 2.
Table 2. Electrophysiological parameters and sonography
Variables
CTS (65
wrists)
Controls
(30 wrists)
P-
value
Median N. sensory
distal latency, ms
Mean±SD
Range
4.18±0.63
3.5-6.0
2.8±0.3
2.3-3.3
<0.00
Median N. motor distal
latency, ms
Mean±SD
Range
4.0±1.41
2.0-8.09
2.92±0.34
2.2-3.5
0.001
Median N. conduction
velocity, m/s
Mean±SD
Range
49.62±9.79
25.0-60.0
61.32±4.75
52.0-68.0
<0.001
Ulna N. sensory distal
latency, ms
Mean±SD
Range
2.61±0.29
2.06-3.34
2.57±3.66
2.1-3.32
0.644
Median N. cross
sectional area, mm2
Mean±SD
Range
13.11±2.57
8.5-19.9
8.73±0.45
7.5-9.0
<0.001
Disease Severity
The result of 65 affected wrists with CTS is
classified for, 40 (61.15%) had mild disease, 19
wrists (29.23%) demonstrated a moderate disease
and 6 wrist (9.23%) had severe disease (Figure 1).

37
Figure 1. CTS disease severity
Association of MN CSA (median nerve
cross-sectional area) with Disease Severity: The
mean CSA of median nerve in mild, moderate,
severe cases was 11.21±1.22 mm2, 15.09±0.1.14
mm2 and 17.88±0.2.1 mm2, respectively with highly
significant differences between the three
categories. Furthermore, all three categories had
higher CSA than control (8.73±0.45 mm2) with
highly significant differences (Figure 2).
Figure 2. Association of CSA of median Nerve with Disease Severity
**Highly significant difference. Analysis of test
variance was to analyse data
Diagnostic Performance of Ultrasound
Value diagnostic investigated by a Relative
Operating Characteristic (ROC) curve median CSA
(calculated through US) in detection and
differentiation of CTS. Generally, US demonstrated
excellent diagnostic values. In the context
distinguish between CTS patients groub and control
group, area under the curve (AUC) was 0.950 and
95% CI = 0.903 - 0.996, p < 0.001. Sensitivity,
Specificity of US at value cut off of CSA = 10 mm2
were 92% and 100 %, respectively (Figure 3).
Figure 3. Relative operating characteristic curve for Ultrasound
context of discriminate between CTS patients and controls
In the context of discriminate between mild and
moderate CTS, the AUC was 0 .9 74, 95 % CI = 0.
925-1.00, < 0.00 1. Sensitivity, Specificity of the
Ultrasound at value cut-off of CSA = 13.1 mm2 were
95% and 97.5%, respectively (Figure 4).
Figure 4. Relative operating characteristic curve for US in context of
discrimination between mild and moderate CTS
In the context of discrimination mild and severe
CTS, AUC was 1 .0 0, 95 % CI = 1 .0 0 - 1 .0 0,
 < 0 .001. Sensitivity and Specificity of US at cut off
value of CSA = 14.0 mm2 100% for both (Figure 5).

38
discriminate between mild and severe CTS
In the context of discriminate between moderate
and severe CTS, AUC 0. 8 68, 95 % CI = 0. 645-1.00,
p = 0.008. Sensitivity, Specificity of US at cut off
value of CSA = 16.2 mm2 83% and 94%,
respectively (Figure 6).
discriminate between moderate and severe CTS
Discussion
In the present study, patients were older than
controls with a significant difference. This result
corroborates with many previous studies. In A
Turkish study including 547 patients with CTS,
wrists were categorized into four groups normal,
mild, moderate, sever.
After adjusting for BMI, the CTS development risk
raised by a factor of 1.86 for ages thirty–sixty years
and by 4.17 for ages sixty when the age group
eighteen–thirty-five years was used as the control
group. Almost similar result regarding the risk of
older age in development of CTS were reported by
two other studies (Kouyoumdjian, 2002;
Kouyoumdjian, 1999). The precise reasons beyond
this association are not precisely known. However,
it was assumed axon loss, development of nerve
conduction, vessels abnormalities increase with age
(Kommalage, 2011). In the present study, motor
and sensory latency of the median nerve increased
significantly in CTS, while the conduction velocity
of this nerve significantly decreased compared with
the controls. These electrophysiological changes
are the basic for gold standard diagnosis of CTS.
The median nerve is always affected with different
degree of damage. Several mechanisms have been
proposed that results in median nerve injury with
an eventual increase sensory and motor latency
and decrease conduction velocity (Arrori and
Spence, 2008). An interesting finding in this study
was median cross-sectional area was significantly
different on CTS patients than controls, and the CSA
of median was significantly linked with severity
disease. Such results were frequently reported by a
plethora of previous studies (Mohammadi 2012;
Ajeena, 2013; El-Shintenawy 2019). (Tsai 2013)
and (Chan 2011) identified a strong link between
median nerve conduction anomalies detected by
electro diagnostic testing and CSA measured by
ultrasound. In the same context, there was
correlating between CSA medain at the tunnel inlet,
median motor distal latency (DML). As prolonged
median DML is a marker of focal nerve
demyelination across the carpal tunnel, this
provides a biological basis for the US finding in CTS
(Chan 2011). The most important finding in the
present study were that the US had excellent
diagnostic values either discrimination between
control and patients with CTS in the context of CTS
or in the context of discrimination between
different severities of the CTS. In accordance with
these results are many studies worldwide. In many
of these studies the CSA of the median nerve
yielded sensitivities range from sixty-seven to
ninety four percent, and from fifty-seven to ninety
seven percent to specificities, with value cut off 8 .5
to 9.5 percent 15mm2 (Wang 2008; Mondelli 2008;
Padua 2008; Polykandriotis, 2007; Hobson-Webb,
2008). Also, in agreement with the present result is
the result by (Karadag 2010) who claimed that

39
ultrasound was helpful in determining the severity
of CTS They came to the conclusion that ultrasound
measurements of CSA could provide information
regarding the severity of median involvement, it
established value cutoff in the US to differentiate
between different levels of CTS severity as follows:
>thirteen mm2 for mild, thirteen to fifteen mm2 for
moderate, and < fifteen mm2 for severe symptoms.
In a Turkish study, (Kaymak 2008) conducted a
cross-sectional study to clarification whether US or
electrophysiologic testing is a preferable foreteller
of grading severity and to estimated value
diagnostic US in CTS patients. The median CSA at
the tunnel entrance and proximal tunnel were 12. 5
± 2.6 and 10.6 ±2.6, respectively in patients versus
15.6 ±4.2 and 11.5 ±3.2, respectively in control
group, with highly significant differences. The
optimum value cut off for median CSA was
11.2mm2 at the entrance tunnel and 11.9mm2 at the
proximal carpal tunnel. Sensitivity and specificity at
the proximal tunnel (eighty-eight%, sixty-six%,
respectively) were higher than those at the carpal
tunnel entrance (sixty-eight% and sixty-two%,
respectively).
The differences cut off value is mainly related to the
severity of disease. However, these values are
variable and not universally applicable as there are
differences in study population, demographic
differences and the “gold standard” used in the
diagnosis of CTS.
NCS is not always abnormal in CTS (Chan 2011),
and in two studies, US revealed abnormal findings
in CTS patients who had normal NCS (Altinok 2004;
Koyuncuoglu 2005). On the other hand, US appear
to be relatively quite specific for CTS (Pastare
2009). Furthermore, US may be useful in severe
CTS, where NCS may be unrecordable (Chan 2011).
Lower cost, non-invasive - test and shorter time for
test are additional advantages of sonography over
Electrodiagnostic for appraisal of CTS (Mohammadi
2013).
Conclusions
1. The majority of CTS patients in the study had
a mild to moderate disease.
2. The CSA median is largest in patients with CTS
and degree of enlargement significantly
correlates with the parameters of disease
severity. However, the CSA of the nerve not
associated with the gender of patients or the
side of the affected wrist.
3. Ultrasound of CST of median nerve has an
excellent diagnostic value in the
discrimination between patients and controls,
with Sensitivity, Specificity of 92%, 99%. The
optimum value cut off is ten mm2.
4. Also, US can effectively discriminate between
mild, moderate and severe cases of CTS with
sensitivity ranges 83%- 100% and 94%-100%
specificity. The optimal cut off values ranges
between 13.2-16.2 mm2.
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