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Is Needle Examination Always Necessary in Evaluation of Carpal Tunnel Syndrome?

Janet M. Balbierz, MD, Ann C. Cottrell, MD, Wayne D. Cottrell, PhD
ABSTRACT. Balbierz JM, Cottrell AC, Cottrell WD. Is needle examination always necessary in evaluation of carpal tunnel syndrome? Arch Phys Med Rehabil 1998;79:514-516. Objective: To investigate whether needle evaluation added any important clinical information to normal nerve conduction studies in the evaluation of carpal tunnel syndromes. Design: Retrospective review of electromyography (EMG) done with the referring diagnosis of possible carpal tunnel syndrome. Setting: Outpatients seen for EMG evaluation at one university hospital by a single electromyographer. Patients: Consecutive sample of possible carpal tunnel syndrome patients. Interventions: None Main Outcome Measure: We determined whether needle examination was abnormal when nerve conduction studies were normal. Results: In patients in whom only carpal tunnel syndrome was suspected, normal nerve conduction studies predicted that EMG would be normal 89.8% of the time (p = .0494). Testing based on a larger sample size might increase the predictive value. Conclusions: There may be a subpopulation of patients referred for carpal tunnel syndrome who may be adequately evaluated by nerve conduction studies alone. Additional studies will help evaluate whether this is so. 0 1998 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation ARPAL TUNNEL SYNDROME is the most common peripheral nerve entrapment syndrome.1-4 It is associated C with repetitive motion jobs,5-* muscle anomalies9 stenosing tenosynovitis, lo distal radius fractures l1 use of ambulatory aids,12persistent median artery,13chronic hemodialysis,14,15 and pregnaw, I6 and is treated with orthoses,12injections,17 vitamin B-6,18-2o job modifications, and, frequently, by surgery.21-26 It is one of the most common reasons for electromyography (EMG) referrals. Studies suggest that EMG and nerve conduction studies are needed only to reinforce the diagnosis of carpal tunnel syndrome,27 or that the entire test is unnecessary if there is a good clinical history.28 One study asserts that electrodiagnostic studies in carpal tunnel syndrome are essential to document median neuropathy within the carpal tunnel and exclude alternative or concomitant disorders.29 Many studies have
From the Division of Physical Medicine and Rehabilitation (Drs. Balbierz, A. Cottrell) and the Department of Civil Engineering (Dr. W. Cottrell), University of Utah, Salt Lake City, UT. Submitted for publication May 29, 1997. Accepted in revised form September 7, 1997. The authors have chosen not to select a disclosure statement. Reprint requests to Janet M. Balbierz, MD, 50 North Medical Drive, Salt Lake City, UT 84132. 0 1998 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation 0003-9993/98/7905-4512$3.00/O

described methods of diagnosing carpal tunnel syndrome.30-36 Recently, Werner and associates37 documented a lack of correlation between nerve conduction study abnormalities and the presence or absence of abnormalities on EMG. Needle examination, especially of the thenar muscles, is usually considered the most uncomfortable part of the electrodiagnostic consultation. Guidelines of the American Association of Electrodiagnostic Medicine (AAEM) recommend that needle EMG of limb muscles innervated by the C5-Tl roots be performed to rule out cervical radiculopathy, brachial plexopathy, or a proximal median neuropathy as the cause of paresthesias in the hand.38 However, the practice parameters suggested by AAEM, the American Academy of Neurology, and the American Academy of Physical Medicine and Rehabilitation include needle evaluation as optional.39 This study is a retrospective review of electrodiagnostic studies on patients referred for evaluation of possible carpal tunnel syndrome. The purpose was to document whether significant needle electrode examination findings were present in a subpopulation of patients in whom carpal tunnel syndrome, but no other neuromuscular problem, was suspected and in whom nerve conduction studies were normal. METHOD Nerve conduction studies and EMG performed by a single electromyographer between 1990 and 1994 were screened for the words carpal tunnel syndrome in the impression of the EMG report. The screening generated reports on 293 hands. In each exam, a brief history included the distribution and type of symptoms, the duration of symptoms, occupation, and medical history, including questions about medical problems (such as diabetes) or medications that could cause a neuropathy. A focused neurologic exam was performed, primarily to look for thenar atrophy, weakness, or decreased sensation in the median nerve distribution. Depending on the clinical history, an additional exam including additional muscle testing, sensory exam, and/or reflexes was also done with significant abnormalities recorded. Nerve conduction studies of the median and ulnar motor and sensory nerves were done with surface and ring electrodes at 8 and 14 cm, respectively. If standard nerve conduction studies of the median and ulnar nerves were normal, median and ulnar midpalmar stimulations were also performed (stimulating in the palm and recording 8cm proximally along the course of the nerve). Each patient had needle electrode examination of the affected upper extremity, usually consisting of the abductor pollicis, first dorsal interosseous manus, pronator teres, biceps brachii, triceps brachii, extensor digitorum communis, and deltoid muscles. The muscles were examined with a monopolar electrode for activity with the muscle at rest, during insertion, and during minimal to full voluntary muscle contraction. The needle examination was performed in every patient, regardless of the results of the nerve conduction studies. The actual muscles studied varied at times because of patient tolerance, but did include the myotomes C5-Tl. Of the 293 hands, 113 had normal nerve conduction study results and 180 had abnormal results. The hands with normal results were used in this study. The histories and physical

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examination findings of the hands with normal nerve conduction study results were reviewed and separated into three groups by a blinded observer who was unaware of the EMG results. The criteria for inclusion in subgroup 3 (carpal tunnel syndrome but no other diagnosis suspected) were, in order of importance, (1) sensory changes in the distribution of the median nerve and/or decreased motor function/wasting in thenar median innervated muscles, and (2) if only partial median nerve distribution was affected (eg, digits 2 and 3 only), then additional criteria were used, such as sensory changes occurring at night or while driving relieved with change of hand position or positive Phalens or Tinels sign, and (3) no other nonmedian nerve pathology was suspected from the history and physical, such as history of cervical stenosis, diabetes, nonmedian nerve distribution of sensory changes. If other pathology was suspected, as in the aforementioned examples, those data were placed in subgroup 1 (diagnosis other than carpal tunnel syndrome suspected). Subgroup 2 consisted of cases that did not fit in either subgroup 1 or subgroup 3.
RESULTS

abnormal. In both of these cases, however, there is poor correlation between Tl and T2. The casein which subgroup 3 is absent cannot be clearly defined in this study. Furthermore, the correlation between abnormal nerve conduction studies and EMG is poor.37
DISCUSSION

After separation into subgroups, the EMG study results were reviewed and scored as either normal or abnormal for each subgroup to determine if there was a correlation between the history and physical exam subgroup and the EMG result. The results are summarized in table 1. There were no abnormal EMGs in subgroup 3 (carpal tunnel syndrome only is suspected). Using binomial proportion testing,40 in this study subgroup 3 is predictive of a normal EMG 89.8% of the time (p = .0494). If subgroups 2 and 3 are added to effectively broaden the carpal tunnel syndrome history and physical exam criteria, only 1 of 52 had an abnormal EMG. The resulting new subgroup is predictive of a normal EMG 91.8% of the time (p = .0495). A hypothesis test on a binomial proportion of successeswas conducted, where a success is a normal EMG given that the nerve conduction study result is normal. The fraction of successesin subgroup 3 was 100%. The fraction of successes when subgroups 2 and 3 are added was 98.1%. Statistical analysis. Sensitivity and specificity analysis is not easily applied in this study because there is no definitive test to prove carpal tunnel syndrome. In this study, we used subgroup 3 plus a normal nerve conduction study result to predict a normal EMG. This corresponds to a true positive. If subgroup 3 and normal nerve conduction study results gave an abnormal EMG result, this would correspond to a false positive. False negative and true negative conditions are not well defined in this study because conditions in subgroups 1 and 2, or abnormal nerve conduction study results, do not correlate well with EMG.37 In this case, a false negative should be the condition in which subgroup 3 is absent and/or the nerve conduction study is abnormal (Tl) when EMG is normal (T2) and a true negative would occur when subgroup 3 is absent and/or the nerve conduction study is abnormal when EMG is
Table 1: Breakdown of MMG With Normal Nerve Indication H&P subgroup H&P subgroup H&P subgroup Total Abbreviation: *Subgroup subgroup suggestive I* 2 3* Findings Conduction EMG in Three Subgroups Studies Abnormal 21 1 0 22 examination. something subgroup other than 3, diagnosis CTS; very EMG

Carpal tunnel syndrome is very common, especially in patients whose jobs involve repetitive activities. In early or mild carpal tunnel syndrome, the primary abnormality seen on nerve conduction studies is prolonged sensorydistal latency,4 indicating a certain degree of demyelination. In more severe cases, there may be involvement of the axons, which may lead to atrophy of the muscle and more significant disability. Nerve conduction studies have been shown to be extremely sensitive in detecting demyelination, although it has been shown that the abnormalities seen on nerve conduction studies do not predict EMG needle examination abnormalities very we11.37 This retrospective study suggests that when a patients history is suggestive of a diagnosis of carpal tunnel syndrome and no other diagnosis is suspected, a normal nerve conduction study implies that the EMG will be normal 89.8% of the time. Testing based on a larger sample size might increase the predictive value. In view of the discomfort for the patient, the cost, and the minimal contribution of the results to the clinical decision-making (regarding treatment of possible carpal tunnel syndrome), it may be acceptable to perform screening nerve conduction studies in a certain group of patients. Patients with no history of diabetes or other systemic diseases that may predispose them to neuropathy and no history of neck or upper extremity trauma or pain who present with complaints of numbness in the hand in the median nerve distribution may be effectively evaluated for carpal tunnel syndrome with nerve conduction studies only, if the latencies and conduction velocities are normal. The physician must exercise sound clinical judgement based on broad-based neuromuscular training and experience. If there is any possibility of another reason for the numbness, then additional needle electrode examinations, other nerve conduction studies, or additional neurological evaluations should be considered. In a carefully selected subpopulation of patients, needle electrode examination failed to identify any underlying serious problem. In the ever-changing health care environment, with the push toward capitated health care contracts, we must be mindful of cost-effective medical practice, including the cost of diagnostic procedures such as EMG and nerve conduction studies. Additional studies of how much is enough will be helpful. As electromyographers, we must be involved in the development of clinical pathways for the diagnosis of carpal tunnel syndrome, and we must be able to explain the rationale for the test and demonstrate its costeffectiveness. 1. Howard FM. Controversies in nerveentrapmentsyndromes in the forearm andwrist. OrthopClin North Am 1986;17:375-81. 2. Heckler FR, JabaleyME. Evolving conceptsof median nerve decompression in the carpaltunnel. Hand Clin 1986;2:723-36. 3. Pfeffer GB, Gelberman RH, BoyesJH, RydevikB. The history of carpaltunnel syndrome.J HandSurg [Br].1988;13:28-34. 4. RommensP.Towfigh H. Carnaltunnel svndrome. Acta Chir Bek
1987;87:142-6.
5.

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