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Abstract posters will be displayed in the Exhibit Hall beginning on Wednesday 9/4 at 10:30am

P-074 - Evaluating Carpal Tunnel Syndrome Severity Using Handheld Point-of-Care Ultrasound (POCUS): A Case Study

POSTER ABSTRACT

Location: Exhibit Hall

Author/Presenter(s)

CE

Charles J. Enfield, M.S.

Medical Student, 4th year
Touro University California College of Osteopathic Medicine
Kensington, California
KL

Kyaw Lin, D.O.

Interventional Pain Physician
Touro University California - College of Osteopathic Medicine
Vallejo, California

Abstract Title: Evaluating Carpal Tunnel Syndrome Severity Using Handheld Point-of-Care Ultrasound (POCUS): A Case Study

Background: Carpal tunnel syndrome (CTS) is the most prevalent focal mononeuropathy. Differentiating the severity of CTS is crucial for determining the need for surgical intervention and may affect workers’ compensation; however, relying on electrodiagnostic (EDX) studies alone can be inconclusive.

This case study involves a 54-year-old right-hand-dominant female with a history of bilateral breast cancer, status post-chemotherapy, presenting with four years of right greater than left hand pain, numbness, and tingling in the first and third digits. A cervical spine MRI on 10/31/2023 showed no significant abnormalities. Physical examination revealed decreased sensation to light touch and pinprick on the right volar aspect of the third digit, bilateral upper extremity muscle strength of 4/5 on manual muscle testing (MMT), a positive right carpal compression test, and a positive right Phalen's test. No significant atrophy was noted.

EDX studies indicated likely right median sensorimotor neuropathy consistent with moderate to severe CTS, with axonal loss. Point-of-care ultrasound (POCUS) showed a median nerve cross-sectional area (CSA) of 22.6 mm² at the carpal tunnel, supporting a diagnosis of severe CTS.

The patient was issued braces, advised on activity modification and a home exercise program, and referred to plastic surgery for carpal tunnel release.

Purpose/Objectives: The purpose of this case study is to:

Evaluate the clinical utility of handheld ultrasound in diagnosing the severity of carpal tunnel syndrome (CTS) when used in conjunction with electrodiagnostic (EDX) studies.

Highlight the improved image quality and affordability of handheld ultrasound devices, which can be used quickly and cost-effectively at the point of care.

Methods: Using a GE Vscan Air handheld ultrasound probe and an iPad, point-of-care ultrasound (POCUS) was employed to measure the median nerve cross-sectional area (CSA) at the carpal tunnel. The linear, high-frequency (3-12 MHz) side of the GE Vscan Air device was utilized, set to the musculoskeletal (MSK) setting through the GE Vscan software application. An iPad controlled the device settings and visualized the image. Ultrasound gel was applied to the palmar aspect of the distal forearm. The median nerve was identified in the sagittal plane and followed distally to the carpal tunnel at the level of the pisiform bone, where its CSA was measured and calculated using the GE Vscan software application.

The criteria for median nerve CSA are a simplification based on the meta-analysis by Roomizadeh, P., et al: absence of CTS: less than 11 mm²; mild CTS: 11-13 mm²; moderate CTS: 13-17 mm²; severe CTS: greater than 17 mm².

Electrodiagnostic (EDX) studies were conducted independently to assess the severity of CTS.

Results: Electrodiagnostic (EDX) studies indicated a likely right median sensorimotor neuropathy consistent with moderate to severe carpal tunnel syndrome, with axonal loss noted. Point-of-care ultrasound (POCUS) demonstrated a median nerve cross-sectional area (CSA) of 22.6 mm at the carpal tunnel, supporting a diagnosis of severe carpal tunnel syndrome (CTS).

Conclusions/Implications for future research and/or clinical care: This case study demonstrates the effectiveness of the GE Vscan Air handheld ultrasound probe for point-of-care ultrasound (POCUS) in conjunction with electrodiagnostic (EDX) studies to diagnose severe carpal tunnel syndrome (CTS). This comprehensive approach enabled timely management, including a referral for surgical intervention. Handheld ultrasound probes provide a quick, cost-effective tool for assessing CTS severity and enhancing patient care.

EDX studies are a cornerstone for CTS diagnosis due to their high sensitivity and specificity. However, ultrasound serves as a valuable adjunct, especially when EDX results are inconclusive or a less invasive method is preferred. Ultrasound is particularly useful for delineating the extent of median nerve swelling and structural changes within the carpal tunnel. In moderate to severe CTS cases, ultrasound can offer a more specific severity assessment informing surgical intervention decisions. As handheld ultrasound technology improves and becomes more affordable, POCUS is becoming a practical adjunct for CTS assessment.

References:

Ahmed A, Malik G, Imtiaz H, Riaz R, Badshah M, Zameer S. (2022). Assessment Of Carpal Tunnel Syndrome With Ultrasonography. J Ayub Med Coll Abbottabad, 34(2):295-299. doi: 10.55519/JAMC-02-9892.

Chen, J., Fowler, JR. (2023). Comparison of Diagnostic Accuracy of Electrodiagnostic Testing and Ultrasonography for Carpal Tunnel Syndrome. Hand (N Y), 18(3):407-412. doi: 10.1177/15589447211038701.

Fowler, JR., Cipolli, W., Hanson, T. (2015) A Comparison of Three Diagnostic Tests for Carpal Tunnel Syndrome Using Latent Class Analysis. The Journal of Bone and Joint Surgery. American Volume, 97(23):1958-61. doi:10.2106/JBJS.O.00476.

Graham B. (2006). The diagnosis and treatment of carpal tunnel syndrome. BMJ. Volume, 24(7556):1463-4. doi: 10.1136/bmj.332.7556.1463.

Karadağ, YS., Karadağ, O., Ciçekli, E., Oztürk, S., Kiraz, S., Ozbakir, S., Filippucci, E., Grassi, W. (2010) Severity of Carpal tunnel syndrome assessed with high frequency ultrasonography. Rheumatol Int., 30(6):761-5. doi: 10.1007/s00296-009-1061-x.

McDonagh, C., Alexander, M., Kane, D. (2015) The Role of Ultrasound in the Diagnosis and Management of Carpal Tunnel Syndrome: A New Paradigm. Rheumatology (Oxford, England), 54(1):9-19. doi:10.1093/rheumatology/keu275.

Roomizadeh, P., Eftekharsadat, B., Abedini, A., Ranjbar-Kiyakalayeh, S., Yousefi, N., Ebadi, S., Babaei-Ghazani, A. (2019). Ultrasonographic Assessment of Carpal Tunnel Syndrome Severity: A Systematic Review and Meta-Analysis Am J Phys Med Rehabilitation, 98(5):373-381. doi: 10.1097/PHM.0000000000001104.

Wang, WL., Buterbaugh, K., Kadow, TR., Goitz, RJ., Fowler, JR. (2018). A Prospective Comparison of Diagnostic Tools for the Diagnosis of Carpal Tunnel Syndrome. The Journal of Hand Surgery, 43(9):833-836.e2. doi:10.1016/j.jhsa.2018.05.022.