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Practice Parameter: Carpal Tunnel SyndromeTable 12. Median Sensory and Mixed Nerve Conduction Between Wrist and Palm in CTS.AuthorJackson andClifford 110 Kimura 130 Scelsa andcolleagues 221 Kuntzer 140 Di Guglielmo and Padua and Padua andcolleagues 59 colleagues 188 colleagues 189Year 1989 1979 1998 1994 1997 1996 1997*Number of Normal Hands (subjects) 38 (38) 122 (61) 30 (25) 70 (70)† 88 (69) 40 (36)Normal Subject’s Age: Mean (range) 42 (21 to 69) 43 (15 to 50) 42 (23 to 63) 43 (25 to 70) 40 (20 to 86) 44 (19 to 79)Number of CTS Hands (patients) 131 (123) 172 (105)‡ 67 (42) 100 (100)† 294 (198) 50 (43) 500 (379)CTS Subject’s Age: Mean (range) 53 (21 to 85) 48 (20 to 78)‡ 50 (25 to 85) 51 (26 to 85) 46 (13 to 84) 45 (23 to 80) 51 (20 to 88)Technique: Conduction Distance 8 cm 8 cmAnatomical Anatomical land– Anatomicallandmarksmarks (6-8 cm) landmarksAnatomical landmarksStimulation SitePalmWrist crease: 3 cmWrist crease: 1-2 cmPalmPalmproximal, 5 cm distalproximal, 3 cm distalD3Recording Site(s) Wrist D2 Wrist Wrist D2 Palm and wristMinimum Hand Temperature 31°C 34°C 32°C 32°C 32°C 31°CMedian Sensory Onset Latency ± SD 1.54 ± 0.12 ms Not reported Not reported Not reported Not reported Not reportedMedian Sensory Peak Latency ± SD 2.03 ± 0.12 ms Not reported Not reported Not reported Not reported Not reportedDifference Median Sensory Onset Latency ± SD Not reported 1.41 ± 0.18 ms Not reported Not reported Not reported Not reportedMedian Sensory Conduction Velocity ± SD Not reported Not reported 58.5 ± 5.2 m/s§ 54.2 ± 3.1 m/s 58.1 ± 6.4 m/s 58.3 ± 6.4 m/sCriteria for Abnormal Value Mean + 2 SD Mean + 2 SD Mean – 2.5 SD Mean – 2 SD Mean – 2 SD Mean – 2 SDAbnormal ValueOnset >1.78 msPeak >2.27 msDifference>1.8 ms
Practice Parameter: Carpal Tunnel SyndromeRosen 214 (1993), 100%; Rossi and colleagues 216 (1994),100%.In a study that met 4 of the 6 AAEM CTS LIC, Rossi 216reported a variation on the orthodromic median and ulnarpalmar conduction studies with a slightly longerconduction distance (about 10 cm) to enable selectivestimulation of the palmar branches to the adjacentsurfaces of the digits at the metacarpophalangeal joints.Rossi 216 concluded that stimulation of the palmar branchto the adjacent surfaces of the middle and ring fingersdemonstrated a measurable abnormal response when theorthodromic median sensory response with stimulation ofthe fourth digit was absent and when the response withstimulation of the palmar branch of the median nerve tothe adjacent surfaces of the index and middle fingers wasnormal.Median SNAP Amplitude Studies. Kuntzer, 140 in a reportthat met all 6 AAEM CTS LIC, confirmed that themeasurements of median sensory conduction from digit towrist is more often abnormal in CTS patients than themeasurement of median SNAP amplitude, 49% versus30% (Table 13). In a study that met 5 of the 6 AAEMCTS LIC, Sander 220 noted that median sensory conductionfrom digit to wrist is more abnormal in CTS thanmeasurement of median SNAP amplitude, 64% versus48%. In a study that met 4 of the 6 AAEM CTS LIC,Sheean and colleagues 233 (1995) also noted that mediansensory conduction from digit to wrist is more oftenabnormal in CTS patients than measurement of medianSNAP amplitude, 55% versus 41%. Two recent studies(Seror 228 and Nesathurai 184 ) and several earlier studies(Cioni, 47 Felsenthal, 68,70 Jackson and Clifford, 110 Redmondand Rivner 204 ) that compared the diagnostic sensitivity ofmedian sensory conduction from digit to wrist tomeasurements of median SNAP amplitudes reached thesame conclusion with the exception of Loong andSeah, 148 who computed the ratio of the median SNAPamplitude to the ulnar SNAP amplitude in the same hand.Two studies of normal subjects that met 5 of the 6 AAEMCTS LIC noted values slightly greater than the valuesreported by Kuntzer 140 in Table 13 for normal subjects forthe mean and SD of the median SNAP amplitude: 32.7 ±11.4 µV by Stetson 242 (1995) and 41 ± 20 µV byBuschbacher. 33Median Sensory Nerve Wrist to Palm SNAP AmplitudeRatio. The ratio of the amplitude of the median SNAPrecorded from a digit with (1) stimulation of the mediannerve at the wrist and (2) stimulation in the palm makes itpossible to identify median sensory nerve conductionblock across the carpal tunnel.Table 14 presents the results of a study by Di Guglielmo 59that met all 6 AAEM CTS LIC; the incidence of sensoryTable 13. Median SNAP Amplitude in CTS.Author Kuntzer 140Year 1994Number of NormalHands (subjects)70 (70)*Normal Subject’sAge: Mean (range)43 (25 to 70)Number CTS Hands(patients)100 (100)*CTS Subject Age 51 (26 to 85)Stimulation SiteDigit‡Recording Site WristMinimum HandTemperature32°CNormal SNAPAmplitude ± SD12 ± 2.5 µVCriteria forAbnormal ValueMean – 2 SDAbnormal Values
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