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19 90 B ritish E d itor ial S ocie ty ofB on e and Join t S urg ery

03 0l-620 X /90/308 7 $ 2.0 0

JB on eJo in t Surg fB r]

19 90 ; 72 -B : 51 6-8 .

51 6

T H E JO U R N A L O F B O N E A N D JO IN T S U R G E R Y

PRESSURES IN THE CARPAL TUNNEL

A COM PAR ISO N BETW EEN PAT IENTS W ITH

CARPAL TUNNEL SYNDROM E AND NORM AL SUBJECTS

S . RO JV IRO J, W . S IR ICHATIVA PEE , W . KOW SUW ON , J . W ONGW IW ATTANANON ,

N . T A M N A N T H O N G , P . JE E R A V IPO O L V A R N

From K hon K aen U nive rsity T ha ila nd

W e stud ied p ressu re in th e carpa l tunn e l in pa tien ts w ith carpa l tunn e l synd rom e and in no rm a l con tro l

sub jec ts , u sin g a slit ca th e ter and reco rd in g in th e n eu tra l p osit ion , 90 {1 76}orsif iex ion , and 90 {1 76}a lm arfiex io n of

th e w rist.

F or ea ch posit ion th e m ean pressu re in th e pa tien ts w a s very sig n ifican tly h igh er th an in th e contro ls , th e

h igh est p ressu re b ein g in 9 0 {17 6}orsif iex ion , and th e low est in th e n eu tra l p o sitio n . U sin g an upper lim it o f

n orm al p ressu re of 5. 5 mmHg in th e n eu tra l po sit io n gav e a d iagno stic sen s itiv ity o f 78 .7 , a sp ecif ic ity o f

7 8 . 1 % , an a ccu racy of 78.5 and a posit ive p red ic tive v a lu e of 87 .3 .

T here a re sev era l p ossib le cause s o f ca rpa l tun ne l

synd ro m e bu t m o st ca se s are id io pa th ic . In creased

pre ssu re d ue to flu id o r th e p re sen ce o f ano m a lou s

stru ctu re s m ay be asso cia ted (B u tle r and B ig ley 19 71 ;

E rik sen 197 3) and a redu c tion in th e c ross-sectio na l a rea

o fthe tunn el m ay be fou nd in pa tien ts w ith th e sy nd rom e

(D ek e l e t a l 198 0 ; L ian g 1 987 ).

T h e p re ssu re in th e ca rpa l tun ne l has been m easu red

by w ick ca th ete r in pa tien ts and no rm a l sub jec ts by

G e lbe rm an et a l (1 981 ), bu t nea rly o ne -th ird o f the ir

pa tien ts d id no t have th e id io pa th ic sy ndrom e and re su lts

w e re n o t g iv en in term s of sensitiv ity , specif ic ity o r

p red ic tive va lue . W e have com pared pressu re s in fu lly -

do cu m en ted no rm al sub jec ts and in pa tien ts w ith

id iopa th ic ca rpa l tu nne l syn drom e , then ca lcu lated the ir

d iagn ostic v alu e.

S . R ojv iro j, M D , A ssistan t P ro fes sor

W . S iricha tiv ap ee, M D , Instru ctor

W . K ow suwon , M D , A ssis tan t Profe sso r

J

W o ng w iw attana no n, M D , Ins tru cto r

N . T am n an th on g, MD , A ssista n t Profe sso r

P . J eeravipo olv arn , M D , A ssoc iate P ro fessor

D e pa rtm ent o fO rtho pae dic s and R e hab ilita tio n M edic ine , S rin ag arin d

H o spital, Fac ulty of M edicin e, K h on K a en U niversity , K ho n K a en

4 000 2, T hailan d.

C o rre spo nd enc e sh ou ld b e sent to D r S . R o jviro j .

P A T IE N T S A N D M E T H O D S

W e stud ied 3 3 pa tien ts , 25 fem a le and 8 m ale , in w h om

61 hands w ere a ffec ted b y ca rp al tu nn el sy ndrom e. T he ir

ag es rang ed fro m 1 9 to 67 y ea rs (m ean 46 .5 ) and th e

du ra tion o f sy m pto m s w as o ne m on th to 1 0 yea rs , (m ean

19 m o nths) . A ll pa tien ts had pa rae sth esia o r num bn ess

in the d is tribu tion ofthe m ed ian n erve , and the d iagn osis

o f ca rp ab tu nne l syn drom e w as m ade on the p hysica l

s ign s, the w rist f lex ion tes t (P ha len 19 72) , and th e m ed ian

n erve pe rcu ssion test (T in el 191 5 ; M ossm an and B b au

198 7), then con firm ed by elec tro d iagno stic stud ie s . T hese

sho w ed the a ffec ted m ed ian ne rv e to have a p ro long ed

d ista l senso ry la ten cy (m ore than 3 .5 m sec ) , o r a d ista l

m o to r la ten cy o f m ore than 4 .5 m sec, o r b o th (K im ura

198 3). E lec trom y ogram s of the ab duc to r p o llic is b rev is

w ere abno rm a l in 1 1 h ands, and th ree had w as ting of the

thena r m uscle s .

T he 1 2 m ale an d fou r fem ale co n tro l su b jec ts had 32

norm a l h ands w ith no h isto ry o f trau m a or abno rm a lity

ab ou t the w rist an d no rm a l resu lts on eb ec trod iagn ostic

tes ting o f the ir m ed ian ne rves.

P ressu re te sts . T h e slit ca th e ter

is a 2 0 cm leng th o f

p o lye thy lene tu b ing 1 .2 m m in d iam e te r, w ith f ive

sym m etrica l s lits each ex ten d ing 3 m m from its end . T h is

ca th ete r is con nected by tu b ing to a transdu ce r dom e, to

w hich is a lso a ttached a sto pcock w ith a 20 m l sy ring e

filled w ith ster ile w a te r. A ir b ubb les a re ex clu ded from

th e sy stem , and th e tip o f the conn ec ting tu be , th e

transd ucer an d the ca rpa l tu nne l a re p laced a t the sam e

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P R E SS U R E S IN T H E C A R P A L T U N N E L

51 7

V OL . 72-B ,

N o. 3 , M A Y 199 0

horizo n ta l beve l w h ile th e system is ad justed u n til the

m on ito r reco rds zero p ressu re. T h e co nnec ting tube is

then eleva ted to 5 4 cm an d the ran ge co n tro l ad jus ted to

40 m m H g. T h e sy stem is th en ca lib ra ted an d ready fo r

use (F ig . 1 ) .

U n de r lo ca l anaesthe sia , a 14 gaug e n eed le w ith a

p la stic sh eath is in ser ted a t 45 {1 76 } cm prox im al to the

d ista l w rist crease , on the u bna r sid e o f th e pabm aris

long us tendo n , and pu shed in to th e ca rpa l tu nne l. T he

need le is w ith d raw n leav in g the p la stic shea th w ith in the

tunn el. T h e slit ca th ete r is th en in se rted th roug h th e

p la stic shea th un til re sis tance is fe lt, w hen the p la stic

shea th is w ithd raw n . T he respon se o f the system is

ch eck ed by pre ssing a fin ge rtip ov e r th e ca rpa l tunn e l

an d ob se rv in g th e re sp onse on the m o n ito r . In tw o

clin ical ca se s reg iona l anaesthe sia w as u sed , the ca the ters

w ere lef t in p lace d uring the op era tio n , and the co rrec t

locatio n of the tip s w ith in th e ca rp al tu nn el w as p rov ed .

M easu rem en ts o fca rp ab tunn el p res su res w ere m ade

w ith the w rist p laced passive ly in neu tra l positio n , in 90 {1 76}

p alm ar f lex ion , and in 90 {1 76}o rsif lex ion . M ean pre ssu re s,

s tand ard d ev iatio ns an d stand a rd e rro rs w ere ca lcu lated ,

and an aly sed b y S tud en ts t- te st. T he d iagno stic v alu e o f

th e te st w as calcu lated in term s of sensitiv ity , spec ific ity ,

accu racy and p red ic tive v a lue .

RESULTS

T he ca rp a l tunn el p res su res a re show n in T ab le I. In b o th

p atien ts an d con tro ls the m ean p re ssu re w as low es t in the

n eu tra l po sition and h ig hest in 90 {1 76}o rsif lex ion . In all

th ree po sition s the re w ere ve ry h ig h ly sig n if ican t d iffe r-

ences b etw een the m ean pressu re s in th e pa tien ts

com pared w ith th e con tro l su b jects . F o r the neu tra l

p osition p

0 .4 )

bu t ag a in th e p re ssu re w as v ery sign ific an tly h igh e r in

d ors iflex io n th an in pabm arflex io n , and in pabm arf lex ion

than in the neu tra l positio n .

W e ch ose 5 .5 m m H g as the upp er lim it fo r no rm al

ca rp al tunn el p re ssu re in the neu tra l p osition . T h is gave

a sens itiv ity o f 78 .7 % , a specif ic ity o f 7 8 .1% , and a

d iag nostic accu racy o f 7 8 .5% . T h e po sitive p red ic tive

va lue o f th e te st w as 87 .3% .

DISCUSSION

P ressu re in the ca rpab tunn el h as been m easu red in

seve ra l w ays. T an ze r (195 9) in trodu ced a m ercu ry b ag

and show ed tha t p re ssu re w as inc rea sed by flex ion or

ex tensio n o f the w ris t. O ur stu dy sho w ed th at the m ean

pressu re is g reate st at 90 {1 76}orsiflex io n . B rain , W righ t and

W ilk inso n (194 7) , s tu dy in g cadave rs , a lso fo und tha t

w rist d o rsiflex io n cau sed a grea te r in crease than pabm ar-

f lex ion .

G eb be rm an e t a l (198 1 ), u sing a w ick ca the te r, foun d

th at the m ean p re ssu re in th e ca rpa l tunn e l w as e leva ted

in p atien ts w ith ca rpa l tunn el syn dro m e . W e u sed a slit

ca the te r sy stem ; th is h as b een sho w n to be as accu ra te a s

a w ick ca the te r (R orabeck e t ab 19 81) . O u r resu lts d iffer

fro m those o f G elb erm an e t al, in tha t o u r m ean ca rpa l

tu nne l p re ssu re s w ere low er, especia lly in our pa tien t

g roup (T ab le II): o n ly one ofo u r pa tien ts had a pres su re

T ab le I . M ean

ca rpa l tunn el pressure s.e .m . in

vario us pos ition s

o f th e w rist

Po sition of w ris t

M ean p re ssu re in

mmH g

C arp al tu nn el

syndrome

(n =

61 )

No rma l

(n = 32 )

N eu tral 1 1 .8 7 I .53

3 .48 0 .43

90- palmar f iex ion

26 .6 0 2 .5 3 9 .32 1 .06

90 dors if lex ion

3 2.7 6 3.21

1 2.6 8 1 .16

T ab le II .

M ea n ca rpa l tu nn el pressure s.e .m . (rang e) in va riou s

w rist p osit ion s in tw o serie s of p atie n ts w ith ca rpa l tun ne l

syndrome

P os itio n o fw ri st

M ean pre ssu re in m mH g

G elb erm an et a l 198 1

(n

= 15

Ro jviroj et a l 1990

(n = 61 )

N e utral 32 0 .9 8(2 to5 0)

1 1.8 7 l.5 3(I .5 to 62 .2 )

9 0 p al ma rf ie xi on

9 4 5 .1 8(2 0to 25 0)

26 .60 2 .56(5to 8I.8)

90 dors if lex io n 11 0 5 .68(15 to25 0)

32 .7 8 3 .21 (4 to 1 11 .2 )

F ig . 1

D iagram o f a pp ara tus.

54 m

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51 8

S . R O JV IR O J, W . SIR IC H A T IV A PE E , W . K O W SU W O N , E T A L

T H E JO U R N A L O F B O N E A N D JO IN T SU R G E R Y

T ab le II I. M ean carpa l tun nel p res sure s .e .m . (ran ge)

i n v ario us

w rist po sitions in tw o ser ies o f n orm al sub jec ts

Pos it ionofwris t

M e a n

p ressure in

m m H g

Ge l b e r m a n

e t a l 19 81

(n

= 12 )

R o jv lroj et a l

1990

(n = 32 )

Neutral

2 .5 0 . 1 7 (0 to 7)

3 .4 8 0.4 3 (0 to 8 .6)

90 p alm arflex ion 31 .0 0 .86 (15 to7 5) 9 .54 l.0 6(2to 28.5)

90 d ors ifle x io n 30 .0 l.24(4to 50) 12 .46 1.1 6(3 .2 to 2 7.4 )

o f m ore th an 10 0 m m /H g . T h is m ay b e because a ll ou r

ca se s w ere id io pa th ic in o rig in . In our con tro l sub jec ts ,

a ll co n firm ed by n orm a l eb ec trod iagn ostic stu d ie s , w e

a lso fo und bo w er m ean p re ssu re s (T ab le III).

T he w rist f lex ion or P h aben te st ha s been c laim ed to

b e th e m os t sensitiv e d iag no stic tes t (G eb m an et ab 1 986 ).

O u r f ind in g tha t the m ean pres su re w as h ig hest in 9 0 { 176 }f

d orsifiex io n , im p lie s tha t p rov ocativ e te sting fo r ca rpab

tu nne l syn drom e b y w rist ex tensio n m ay be at le a st a s

sen sitive as w ris t f lex ion .

C onc lu sio n s. T h e p ressu re in the ca rpa l tunn e l o f p a tien ts

w ith an id io pa th ic carpa l tunn el syn drom e , w as v ery

s ign if ic an tly h ig he r than n orm al. In b o th pa tien ts an d

con tro l sub jec ts , the m ean pre ssu re w as h ig hest in 9 0 { 176 }f

w rist do rsif lex ion , an d low est in the n eu tra l pos itio n .

U sing o ur slit ca the te r m e thod , a p re ssu re o f m ore than

5 .5 m mH g in th e n eu tra l p o sitio n had a pos itive p red ic -

tive v alu e o f 87 .3% fo r carpab tun ne l sy ndrom e .

N o ben efi ts in any form h av e bee n re ceived or w ill b e rece ive d fro m a

co m m erc ial p arty re lated direc tly o r in directly to the su bje ct of th is

ar t icle .

REFERENCES

Brain

W R,

W r i g h t

AD , W ilk inson M . Spontaneous com pre ssio n of

bo th

m edian n erv es in the c arp al tun ne l : s ix cases tre ate d su rgically .

Lan c e t

1 94 7; i: 27 7-8 2.

B utler B Jr, B igley E C Jr. A b errant ind ex (first) lum brica l ten din ous

o rig in associate d w ith c arp al-tunn el synd rom e : a c ase rep ort.

J

B one Jo in t Surg [A m ]

1971

;

5 3-A :160 -2 .

D ek el 5 ,

Papaioannou T , R ushw orth G , C oate s R . Id iopa th ic ca rpa l

tunn el sy nd rom e c aused b y c arp al s teno sis .

Br M ed J

1 9 8 0 ;

280:1297-9 .

Enksen

J. A

c ase o f carp al tu nne l sy ndrom e on the bas is o f an

a bno rm ally lo ng lum brical m u scle.

A cta O rthop Sca nd

1 9 7 3 ;

44 :275-7 .

Ge l b e r m a n

RH , H ergenro ed er PT , H argen s A R , L undbo rg G N , A keson

W H . Th e carpal tun nel synd rom e : a s tud y ofcarp al can al pre ssu re.

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1 98 1

;

63 -A :38 0-3 .

G el m an

H,Ge l b e n n a n

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JBo n e Jo i n t S u rg [Am]

1 986 ; 68 -A :73 5-7 .

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J. E /ec tro d ia gno sis in d is eases o fnerve an d m usc/e : princ ip /e s an d

pract ice .

P hila delph ia, FA D avis C o m p an y, 19 83 .

Liang

C -L . C T-sca nn in g

stu dy o f cro ss -sec tio nal are a o f th e c arp al

tun ne l in cases of c arp al tun ne l sy ndrom e.

N ip po n Se ike igek a

GakkaiZasshi 1 98 7; 6 1 : 10 33 4 4

M ossm a n 58, B lau JN . T ine ls sign an d the ca rpal tunn el syn dro m e .

Br

MedJ 1987; 294 :680

Phalen GS . T he

ca rpa l tu nne l sy ndrom e : clin ica l e valuation of 59 8

hands .

C /in O rth op

197 2; 83 :2 9-4 0.

R o rab eck C H , C a stle G SP , H ardie R , L o gan J. C o m p artm en tal pressu re

m e asu rem en ts : an e xpe rim en tal inv est iga tion usin g the S li t

catheter .

J T rau ma

1981

;

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RC . Th e ca rp al-tun nel syn drom e : a cl in ic a l and

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s tudy.

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195 9; 41 -A :6 26 -34 .

Tinel

J L e signe d u foum illem ent dans

le sio ns d es n erfs p { 23 3} rip h { 23 3} ri qu es.

PresseM { 35}dPar 1 91 5; 2 3 : 38 5 9