Clinical and epidemiological research

EXTENDED REPORT

Ultrasound for diagnosis of carpal tunnel syndrome:

comparison of different methods to determine
median nerve volume and value of power Doppler
sonography
Christian Dejaco,1 Martin Stradner,1 Dorothea Zauner,1 Werner Seel,2
Nicole Elisabeth Simmet,2 Alexander Klammer,1 Petra Heitzer,2 Kerstin Brickmann,1
Judith Gretler,1 Florentine C Frst-Moazedi,1 Rene Thonhofer,1,3 Rusmir Husic,1
Josef Hermann,1 Winfried B Graninger,1 Stefan Quasthoff2,4
Handling editor Tore K Kvien
Additional supplementary
data are published online only.
To view these les please visit
the journal online (http://dx.
doi.org/10.1136/annrheumdis2012-202328).
1

Department of Rheumatology
and Immunology, Medical
University Graz, Graz, Austria
2
Department of Neurology,
Medical University Graz, Graz,
Austria
3
Department of Internal
Medicine, General hospital
Muerzzuschlag,
Muerzzuschlag, Austria
4
Department of Neurology,
General hospital of the
Barmherzige Brder
Eggenberg, Graz, Austria
Correspondence to
Dr Christian Dejaco,
Department of Rheumatology
and Immunology, Medical
University Graz,
Auenbruggerplatz 15,
Graz A-8036, Austria;
christian.dejaco@gmx.net
Accepted 28 October 2012
Published Online First
4 December 2012

ABSTRACT
Objective To compare ultrasound measurement of
median nerve cross-sectional area (CSA) at different
anatomical landmarks and to assess the value of power
Doppler signals within the median nerve for diagnosis of
carpal tunnel syndrome (CTS).
Methods A prospective study of 135 consecutive
patients with suspected CTS undergoing two visits
within 3 months. A nal diagnosis of CTS was
established by clinical and electrophysiological ndings.
CSA was sonographically measured at ve different levels
at forearm and wrist; and CSA wrist to forearm ratios or
differences were calculated. Intraneural power Doppler
signals were semiquantitatively graded. Diagnostic values
of different ultrasound methods were compared by
receiver operating characteristic curves using SPSS.
Results CTS was diagnosed in 111 (45.5%) wrists;
84 (34.4%) had no CTS and 49 (20.1%) were possible
CTS cases. Diagnostic values were comparable for all
sonographic methods to determine median nerve
swelling, with area under the curves ranging from 0.75
to 0.85. Thresholds of 9.8 and 13.8 mm2 for the largest
CSA of the median nerve yielded a sensitivity of 92%
and a specicity of 92%. A power Doppler score of 2 or
greater had a specicity of 90% for the diagnosis of
CTS. Sonographic median nerve volumetry revealed a
good reliability with an intraclass correlation coefcient
of 0.90 (95% CI 0.79 to 0.95).
Conclusions Sonographic assessment of median nerve
swelling and vascularity allows for a reliable diagnosis of
CTS. Determination of CSA at its maximal shape offers
an easily reproducible tool for CTS classication in daily
clinical practice.

INTRODUCTION

To cite: Dejaco C,
Stradner M, Zauner D, et al.
Ann Rheum Dis
2013;72:19341939.
1934

Ultrasound of the wrists is a means of detecting

abnormalities of median nerve and related structures in patients with (suspected) carpal tunnel syndrome (CTS).1 An increased nerve cross-sectional
area (CSA) and/or the presence of intranerval
power Doppler signals are characteristic ultrasound
signs of CTS.2 The underlying pathophysiology of
these ndings remains elusive; however, compression of median nerve with congestion of epineural

and endoneural veins, nerve oedema and/or impairments of blood supply may play a role.3
One of the most important factors hampering
the routine use of median nerve sonography is the
difculty of determining CSA thresholds (ranging
from 9 to 15 mm2).2 4 5 In addition, there is a lack
of consensus regarding anatomical landmarks for
the measurement of median nerve volume.
Calculating the ratio between the median nerve
CSA at the proximal forearm and the carpal tunnel
improved diagnostic accuracy.68 However, in those
studies reliability testing and adequate control
groups were lacking.68
In this report we present a large prospective
ultrasound study of patients with suspected CTS.
The specic aim of the study was to analyse the
diagnostic value of sonography-determined CSA at
different anatomical landmarks including forearm
to wrist ratios and differences. Moreover, we investigated the value of intranerval power Doppler
signals as an additional diagnostic tool for the diagnosis of CTS.

METHODS
Patients
We performed a prospective study of 135 consecutive patients with suspected CTS undergoing clinical and electrophysiological evaluation between
March 2010 and December 2011. In addition, we
included 23 healthy controls (mean age 50.4
6.7 years, 78.3% women) for ultrasound studies.
The study was approved by the institutional review
board of the Medical University Graz and written
informed consent was obtained from each patient.
Patients presenting with one or more of the following symptoms at one wrist at least were included:
(1) paresthesias, pain and/or sensory decits in the
hand in a median nerve distribution; (2) nocturnal/
early morning worsening of paresthesias with disturbed sleep; (3) paresthesias relieved by hand
movement or shaking; (4) pain and/or paresthesias
in a median nerve distribution provoked by monotone exercises; (5) weakness of ngers supplied by
the median nerve. Patients with previously diagnosed CTS, conditions resulting in an increased
risk of (associated) CTS such as former surgery at

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Clinical and epidemiological research

wrist, recent wrist fracture, known inammatory rheumatic
disease or pregnancy, patients with known polyneuropathy or
contraindications against electrophysiological testing were
excluded.9 Clinical examination consisted of an evaluation of
muscular strength and trophism, sensory function and clinical
provocation tests including Phalens, reverse Phalens and carpal
tunnel compression test.
Nerve conduction studies (NCS) were performed at the symptomatic side(s) according to a routine protocol by two neurologists who were unaware of ultrasound results. In brief, NCS was
done using commercially available nerve conduction equipment
(EMG/NLG/EP-system type Topas; Schwarzer, Munich,
Germany). Skin temperature over the dorsum of the hand was
kept at 34C. The antidromic sensory median nerve conduction
velocity (normal values 50 m/s), distal motor latency (4.2 m)
and median motor compound muscle action potential (5 mV)
were determined.10
Follow-up visits were performed 3 months after baseline
evaluation. Patients were re-evaluated using clinical and electrophysiological tests as described above.
As there are no uniformly accepted diagnostic criteria for
CTS,2 11 the nal diagnosis was established by the evaluating
neurologist based on symptoms, clinical and NCS results. The
neurologist was asked to indicate his condence (0100%) of
the diagnosis at each visit.
The diagnosis according to both visits was used as the reference standard in order to increase the validity of the nal result:
CTS was considered as conrmed with a 90% or greater condence in diagnosis and was excluded if the likelihood of the
diagnosis was 10% or less. Patients with a probable (>10% and
<90%) CTS at visit 1 and denite CTS at visit 2 were considered as conrmed CTS. All other cases were rated as possible
CTS cases. For those patients not attending the follow-up visit
the nal diagnosis from the baseline visit was taken for the
analysis.

Ultrasound protocol
Sonographic evaluations were performed by two rheumatologists
experienced in musculoskeletal sonography (CD 5 years experience, MS 2 years experience) at the days of baseline and follow-up
clinical and electrophysiological testing. Both sonographers were
unaware of clinical and NCS results. Patients were examined in the
sitting position with hands resting in a horizontal supine position
on the examination table with ngers semi-extended.12 We used a
Logiq E9 ultrasound device (GE, Milwaukee, Wisconsin, USA)
with a multifrequence linear transducer (615 MHz). A frequency
of 15.0 MHz was used for B-mode ultrasound, and imaging parameters were adjusted to maximise the contrast between examined
structures. Power Doppler settings were standardised accordingly:
frequency 11.9 MHz, pulse repetition frequency 600 Hz (lowest
possible avoiding motion artefacts most of the time) and medium
persistence. The power Doppler gain was optimised by increasing
gain until noise appeared and then reduced just enough to suppress the noise.13
Transverse imaging of the median nerve was done in the area
between the distal forearm and the outlet of the carpal tunnel.
To minimise sampling errors due to differential loads, a gel pad
(thickness 3.3 mm; Sonar Aid, Gestlich Pharma, Wolhusen,
Switzerland) was used. CSA of the median nerve was determined by tracing a continuous line at the inner hyperechoic rim
with electronic callipers.6 11 Images were magnied in order to
reduce measurement error. CSA was measured at ve different
levels as previously proposed: (1) CSA at the proximal border
of the pronator quadratus muscle (CsP); (b) area of the proximal
third of the pronator quadratus muscle (CsT); (c) level of largest
CSA of the median nerve observed between the area proximal
to the carpal tunnel inlet and the tunnel outlet (CsL); (d) carpal
tunnel inlet dened as the proximal margin of the exor retinaculum (CsR); and (e) in the carpal canal, level of the scaphoid
tubercle and pisiform bone (CsS) (see gure 1 for
illustration).6 11 12

Figure 1 Anatomical levels to

determine median nerve cross-sectional
area (CSA) and power Doppler signals.
Illustration indicates anatomical levels
where median nerve CSA and power
Doppler signals were assessed. In
addition, ultrasound image examples of
the median nerve (including CSA in
mm2) obtained at each level are shown.
CsL, level of largest CSA of the median
nerve observed between the area
proximal to the carpal tunnel inlet and
the tunnel outlet; CsP, proximal border
of the pronator quadratus muscle; CsR,
carpal tunnel inlet dened as the
proximal margin of the exor
retinaculum; CsS, level of the scaphoid
tubercle and pisiform bone; CsT, area of
the proximal third of the pronator
quadratus muscle; FRe, exor
retinaculum; H, hamulus of the hamate
bone; MN, median nerve; M1, M5,
metacarpal bones 1 and 5; P, pisiform
bone; PQMu, pronator quadrates
muscle; R, radius; U, ulna. Access the
article online to view this gure in
colour.

Dejaco C, et al. Ann Rheum Dis 2013;72:19341939. doi:10.1136/annrheumdis-2012-202328

1935

Clinical and epidemiological research

Power Doppler signals were graded from 0 to 3, in which 0
represented no power Doppler signal, 1=one single vessel
within median nerve, 2=two or three single or two conuent
vessels and 3=more than three single or more than two conuent vessels. See supplementary gure S1 (available online only)
for examples.
Each assessment was performed twice and the arithmetic
mean of the two measurements was recorded. The duration of
sonography did not exceed 5 min per examined wrist (ie,
10 min/patient).

Statistical analysis
Statistical analysis was performed using SPSS (V.19.0).
Descriptive statistics were used to summarise the data.
Proportions were analysed by the 2 test and quantitative results
were compared using the MannWhitney U test (due to nonparametric distribution of the data). Correlations were done
with the Spearmans rank correlation test. For nal assessment
of the diagnostic value of sonography we included the data of
the 135 patients with suspected CTS only (excluding healthy
controls). To compare the diagnostic values of different
methods determining median nerve swelling receiver operating
characteristic (ROC) curves were constructed by plotting sensitivity against 1-specicity varying the cut-offs and calculating
the area under the curve (AUC). To correct for the fact that
wrists were clustered within patients we calculated the mean of
AUC 95% CI from left and right sites.
Interobserver variability of B-mode and power Doppler ndings was determined by intraclass correlation coefcient (ICC)
and linear weighted coefcient, respectively, based on data
from 34 patients wrists analysed by two ultrasonographers at
one visit. Intraobserver variability was investigated by ICC using
data from all available patients wrists. To calculate reliability,
CSA of the median nerve at CsP (where the median nerve is
also normal in CTS patients) as determined by one ultrasonographer was compared between baseline and follow-up visits.

RESULTS
A total of 135 patients was included in the study and 111
(82.2%) patients completed baseline and follow-up visits.
Clinical characteristics are detailed in table 1.
Out of the 270 carpal tunnels available for sonography, four
were excluded because of previous surgery and 22 had a bid
median nerve, which was analysed separately. Abnormal ultrasound ndings were present in 11 wrists including effusion
(n=8), tenosynovitis (n=2) or intra-articular calcications
(n=1). In one patient rheumatoid arthritis was diagnosed during
work-up of CTS.
The nal diagnosis of CTS (as outlined in the Methods
section) was made in 111 (45.5%) wrists. CTS was excluded in
59 (24.2%) wrists, 25 were asymptomatic (10.2%) and 49
(20.1%) were considered as possible CTS cases. The prevalences
of abnormal NCS ndings are summarised in supplementary
table S1 (available online only).
Out of the 46 wrists from healthy controls, two (4.3%) were
excluded because of previous fracture and four (8.7%) had bid
median nerve.

Median nerve sonography

CSA of the median nerve at different anatomical levels are
shown in table 2. CSA were larger at wrists with conrmed CTS
compared to wrists without CTS, asymptomatic sites and wrists
of healthy controls. Ultrasound ndings correlated with NCS
1936

Table 1 Clinical characteristics of patients with suspected CTS

(n=135)
Age at inclusion, years*
Female, n (%)
Body mass index, kg/m2*
Symptom duration, months
ESR, mm/1st h (n=102)
CRP, mg/l (n=102)
Associated diseases, n (%)
Diabetes mellitus type 2
Hypothyroidism
Rheumatoid arthritis
Employment (n=133), n (%)
Blue-collar jobs
White-collar jobs
Housewives/charlady
Pensioners
Other
Manual hobbies (n=107)

51.9 (14.5)
99 (73.3)
26.8 (4.3)
12 (1362)
8 (260)
1.3 (0.626.2)
2 (1.5)
9 (6.7)
1 (0.7)
51 (38.3)
49 (36.8)
23 (17.3)
4 (3.1)
6 (4.5)
79 (73.8)

*Mean (SD).
Median (range).
CRP, C-reactive protein (normal values 05 mg/l); CTS, carpal tunnel syndrome; ESR,
erythrocyte sedimentation rate (normal values 110 mm/1st h); n, number.

data as depicted in supplementary table S2 (available online

only).
The CSA of bid median nerves was calculated adding the
area of the two nerve bundles. Median CsL at wrists without
CTS (n=3) was 9.0 mm2 (range 7.013.5), at wrists from
healthy controls (n=4) 10.0 mm2 (8.010.5) and at wrists from
patients with CTS (n=7) 12.0 mm2 (11.015.5, differences not
signicant).

Ultrasound-determined median nerve swelling

for the diagnosis of CTS
To compare the diagnostic value of different methods determining median nerve swelling directly ROC curve analysis was performed. Data from wrists with ruled out CTS and asymptomatic
sites were pooled, whereas data from healthy controls were
excluded for this analysis. The following techniques were compared: (1) determination of CsL, CsR and CsS; (2) ratio CsL/
CsP, CsR/CsP, CsS/CsP and CsL/CsT, CsR/CsT, CsS/CsT; as well
as (3) difference CsLCsP, CsRCsP, CsSCsP and CsLCsT,
CsRCsT, CsSCsT.
Comparable diagnostic values were found for all methods
with AUC ranging from 0.75 to 0.85 (see supplementary gure
S2, available online only, for examples). The numerically highest
AUC was found for CsL (0.85, 95%CI 0.79 to 0.91), difference
CsLCsP (0.84, 95% CI 0.780.89) and CsR (0.84, 95% CI
0.780.90).
Similar results were obtained when only diagnoses from baseline visits were considered (CTS: 115 (46.6%), no CTS: 56
(22.5%), asymptomatic: 36 (14.5%), possible CTS: 41 (16.5%;
eight out of them with <50% probability for the diagnosis and
33 with 50% probability)) or when only patients with conrmed diagnosis at both visits (excluding asymptomatic sites and
patients with a single visit) were analysed (CTS: 61 (30.7%) and
no CTS: 23 (27.4%).
For the bid median nerve no ROC curve analysis was calculated because of the low number of cases and controls available.
As a result of ROC curve analysis numerous cut-offs for the
ultrasound methods tested were generated with varying

Dejaco C, et al. Ann Rheum Dis 2013;72:19341939. doi:10.1136/annrheumdis-2012-202328

Clinical and epidemiological research

Table 2 Cross-sectional areas of median nerve at different anatomical levels
CsP
CTS
No CTS
Assymp
Possible
Healthy

7.0
7.0
7.5
7.0
7.5

(5.011.0)
(5.012.0)
(6.09.5)
(5.512.0)
(6.09.5)

CsT

CsL

CsR

CsS

7.5 (5.012.0)
7.0 (5.012.0)
8.0 (6.010.5)
7.0 (5.511.5)
8.0 (5.510.0)

13.0 (9.028.5)*
9.0 (6.022.0)
9.0 (7.015.0)
11.5 (6.020.5)
8.8 (6.513.5)

12.0 (8.025.5)*
9.0 (6.020.0)
9.0 (6.514.0)
11.0 (6.016.0)
8.3 (6.011.5)

11.5 (7.028.0)*
9.0 (6.021.0)
9.0 (7.513.0)
10.0 (5.523.5)
8.0 (6.013.0)

Data indicate median (range) cross-sectional (mm2) at different levels as indicated.

*p<0.001 compared to wrists with no CTS, to asymptomatic sites and wrists from healthy controls (not corrected for multiple testing)
Assymp, assymptomatic sites; CsL, level of largest cross-sectional area of the median nerve observed between the area proximal to the carpal tunnel inlet and the tunnel outlet; CsP,
proximal border of the pronator quadratus muscle; CsR, carpal tunnel inlet defined as the proximal margin of the flexor retinaculum; CsS, level of the scaphoid tubercle and pisiform
bone; healthy, wrist from healthy controls; CsT, area of the proximal third of the pronator quadratus muscle; CTS, wrists with confirmed carpal tunnel syndrome (as defined in the
Methods section); no CTS, wrists with excluded CTS; possible, wrists with possible CTS.

sensitivities and specicities. Table 3 illustrates selected cut-offs

with a 90% or greater sensitivity or 90% or greater specicity.
Next, we investigated whether the CSA ratio or CSA difference method increases the diagnostic accuracy of sonography in
cases when CsL resulted in a moderate sensitivity and specicity
(ie, CsL between 9.8 and 13.8 mm2). ROC curve analysis
yielded an additional diagnostic value for both CSA ratio and
CSA difference techniques with AUC ranging from 0.60 (0.48
0.72, ns; method: ratio CsS/CsT) to 0.68 (0.570.80, p=0.007;
method: difference CsLCsP). Selected cut-offs with corresponding sensitivities and specicities are detailed in supplementary table S3 (available online only).

Impact of median nerve vascularisation for diagnosis of CTS

The prevalence and median power Doppler scores at CsL, CsR
and CsS are shown in table 4. No vascularisation of the median

Table 3 Sensitivity and specificity of different methods to

determine median nerve swelling for the diagnosis of carpal tunnel
syndrome
Method

Cut-off

Sensitivity (%)

Specificity (%)

CsL

9.8 mm2
13.8 mm2
9.8 mm2
13.8 mm2
8.8 mm2
12.8 mm2
1.30
1.81
1.25
1.68
1.07
1.66
2.5 mm2
6.5 mm2
1.5 mm2
5.5 mm2
0.5 mm2
5.5 mm2

91.8
38.2
90.9
31.8
90.0
35.5
90.9
50.9
90.9
56.4
90.9
46.4
93.6
41.8
96.4
51.8
92.7
36.4

60.0
91.8
61.2
91.8
44.7
91.8
50.6
91.8
44.7
91.8
21.2
91.8
55.3
92.9
31.8
92.9
16.5
95.3

CsR
CsS
CsL/CsP
CsR/CsP
CsS/CsP
CsLCsP
CsRCsP
CsSCsP

Data are presented for those methods with the highest area under the curve in
receiver operating characteristic (ROC) curve analysis. Cut-offs were selected to obtain
either a 90% sensitivity or a 90% specificity for each method.
Data indicate cut-offs for the cross-sectional area (CSA) at CsL, the level of largest
median nerve swelling observed between the area proximal to the carpal tunnel inlet
and the tunnel outlet; the CsR, the level of carpal tunnel inlet defined as the proximal
margin of the flexor retinaculum and the CsS, the level of the scaphoid tubercle and
pisiform bone. In addition, cut-offs for the CSA ratio between CsL, CsR or CsS and
CsP (level of the proximal border of the pronator quadratus muscle) as well as
cut-offs for the CSA difference between CsL, CsR or CsS and CsP are shown.

nerve at the level of the pronator quadratus muscle was

observed.
For calculation of the diagnostic value of power Doppler,
data from healthy controls were excluded. Considering a power
Doppler score of 2 or greater as an abnormal nding resulted in
a high specicity of this method: at area CsL sensitivity 47.4%
and specicity 89.8%, CsR 40.5% and 90.9%, CsS 19.1% and
96.6%, respectively.
In cases when CsL was between 9.8 and 13.8 mm2, a power
Doppler score of 2 or greater led to an additional correct classication of 45.8% of CTS wrists with a specicity of 80%
(p=0.017). When CsL was greater than 13.8 mm2 power
Doppler was of no additional value because 42.7% of wrists
without CTS had a power Doppler score of 2 or greater in this
group.

Reproducibility of ultrasound ndings

The ICC of CsL (0.90; 95% CI 0.79 to 0.95) was higher than
the ICC of ratio CsL/CsP (0.79; 95% CI 0.62 to 0.89), whereas
ICC of difference CsLCsP did not differ from the two other
methods (0.85; 95% CI 0.72 to 0.92). The linear weighted
kappa coefcient for power Doppler assessments at CsL was
0.51 (95%CI 0.32 to 0.71). The ICC for intra-observer variability was 0.65 (95%CI 0.55 to 0.73).

DISCUSSION
Our data indicate a high diagnostic accuracy and reliability of
median nerve sonography for patients with suspected CTS.
Determination of CSA at the level of maximal nerve shape had
comparable performance to measurement at anatomical landmarks. The calculation of CSA ratio or difference between the
site of entrapment and the distal forearm was advantageous
only in cases of moderate nerve swelling. Power Doppler signals
within the median nerve improved correct classication of CTS.
We compared different ultrasound methods to determine
median nerve swelling to resolve the most important uncertainty
resulting from previous studies, namely that the optimal level or
anatomical landmark examining CSA is unknown and that published CSA cut-offs are not directly comparable.2 The majority
of earlier studies investigated the median nerve at the scaphoidpisiform level (CsS), whereas CsL and CsR were less commonly
assessed.2 CSA measurements at the carpal tunnel outlet (level
of the hook of the hamate) resulted in a low diagnostic accuracy
and reliability in previous publications and were thus not
included in our study.2 Recently proposed CSA ratio or difference methods comparing the median nerve at the site of entrapment with sites at the distal forearm intended to compensate for
interindividual variability of median nerve CSA that may range

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Clinical and epidemiological research

Table 4 Prevalence of power Doppler signals within median nerve and median power Doppler score at different anatomical levels
CsL

CTS
No CTS
Assymp
Possible
Healthy

CsR

CsS

n (%)

Power Doppler score

n (%)

Power Doppler score

n (%)

Power Doppler score

89 (80.9)* **
23 (39.0)
8 (32.0)
29 (59.2)
6 (15.0%)

1 (03)
0 (03)
0 (02)
1 (03)
0 (01)

87 (79.1)* **
19 (32.2)
8 (32.0)
27 (55.1)
7 (17.5%)

1 (03)
0 (03)
0 (02)
1 (03)
0 (01)

57 (52.3)* ***
9 (15.3)
6 (24.0)
14 (28.6)
7 (17.5%)

1 (03)
0 (03)
0 (02)
0 (03)
0 (02)

Data indicate the number (percentage) of wrists with intranerval power Doppler signals as well as the median (range) power Doppler score (possible range 03) at different levels as
indicated.
*p<0.001 compared to wrists with no CTS.
**p<0.001 compared to asymptomatic sites and wrists from healthy controls.
***p<0.05 compared to asymptomatic sites and wrists from healthy controls (not corrected for multiple testing).
Assymp, assymptomatic sites; CsL, level of largest cross-sectional area of the median nerve observed between the area proximal to the carpal tunnel inlet and the tunnel outlet; CsR,
carpal tunnel inlet defined as the proximal margin of the flexor retinaculum; CsS, level of the scaphoid tubercle and pisiform bone; CTS, wrists with confirmed carpal tunnel syndrome
(as defined in the Methods section); Healthy, wrists from healthy controls; No CTS, wrists with excluded CTS; Possible, wrists with possible CTS.

from 5.5 to 13.5 mm2 in healthy controls.58 14 According to

our ROC curve analyses none of these methods can be favoured
over the other. Assessment of median nerve CSA at its maximal
shape (CsL) is probably the simplest way to investigate median
nerve swelling in clinical practice and has a high diagnostic
accuracy and good reproducibility. Also a recent systematic
review favoured this technique because the site of maximal
median nerve swelling varies between CTS patients.2 15
The CSA cut-offs presented in table 3 are arbitrary and
depending on the clinical question and pretest probability other
cut-offs may perform better.11 In our setting, we considered
two cut-offs as the most relevant ones: one resulting in a high
(ie, 90%) sensitivity and a second revealing a high specicity.
Explanations for the fact that we were unable to conrm the
superior performance of CSA ratio/difference over CsL or CsR
(as proposed earlier) are the methodological differences
between ours and previous studies as well as the possibility that
the interindividual variability of the median nerve is not relevant if the CSA cut-off is selected above the upper range of
normal.58 Applying the ratio or difference method to cases
with moderate nerve swelling, it was of additional diagnostic
value as outlined in supplementary table S3 (available online
only). Another notable nding is the high interobserver reliability of CsL. A higher reproducibility of the ratio or difference
method could be expected given that examiner-dependent variances of manual tracing are internally corrected.68 On the
other hand, the inner hyperechoic rim of the median nerve is
clearly identiable at wrists, resulting in a high reproducibility
of CSA at this level.16 17
We investigated the presence of power Doppler signals within
the median nerve as an alternative/additional tool for CTS diagnosis. A power Doppler score of 2 or greater had a comparable
sensitivity and specicity to CsL, and in patients with moderate
nerve swelling, a power Doppler score of 2 or greater was associated with a positive likelihood ratio (=sensitivity/1-specicity)
of 2.3 to classify these patients correctly. Only one previous
study investigated the value of power Doppler signals systematically;3 however, that study was retrospective, used ultrasound
equipment with a low power and did not grade power Doppler
signals. Semiquantitative scoring was useful to increase the specicity of power Doppler, whereas the absence of vascularisation
almost excludes CTS.3
The diagnostic value of other ultrasound ndings such as the
median nerve attening ratio or retinacular bulging were not
investigated in this study as a low accuracy of these ndings is
already known.3 18
1938

Our study has several strengths. First, we performed the study

in the target population of median nerve sonography, namely in
patients with suspected CTS. In contrast to previous studies, we
excluded healthy controls from ROC curve analyses and did not
focus on patients with (long) known CTS because a casecontrol
design might have resulted in a false high diagnostic accuracy of
sonography ( partly due to incomplete blinding).68 11 1921 In
our study for example, the specicity of CsL (cut-off 13.8 mm2)
would have increased from 91.8% to 94.5% if healthy controls
were included. Second, the diagnosis was based on clinical and
electrophysiological ndings from two subsequent visits. Patients
with transient symptoms as well as patients with unclear ndings
were considered as possible CTS cases and were analysed separately. This approach is conservative, resulting in a high number of
unclassied cases. Some of them might be considered as mild
CTS cases,12 others have a transient disorder resolving without
specic treatment, and a proportion of patients might develop
full CTS at a later time point.22 23 A long-term follow-up study
investigating this issue is underway.
Many previous studies focused on NCS as the reference
standard excluding those 1634% of patients with clinically
characteristic CTS but normal electrophysiological testing.2 24 25
NCS identies permanent nerve damage, but not intermittent
nerve disturbance in early CTS.26 Others considered the resolution of symptoms after release of the transverse carpal ligament as a sign of denite CTS.27 28 This approach, however,
excludes patients with mild to moderate denite CTS because
surgical intervention is usually performed in cases with persistent sensible decits and/or motor weakness.29 Physicians nal
diagnosis based on clinical and NCS results is therefore the only
adequate reference standard to study the diagnostic accuracy of
sonography for CTS.24
The limitations of our study are the single-centre design and
the tertiary care setting. The reproducibility of ultrasound ndings in multicentre trials and the diagnostic performance of sonography in primary care (where the ratio between patients with
conrmed and excluded CTS might be different) have to be
addressed by future studies.
In conclusion, we demonstrated a high diagnostic value and
good reliability of ultrasound determination of median nerve
CSA in patients with suspected CTS. Measurement of nerve
CSA at its maximal shape is the simplest way to investigate
median nerve swelling and may thus be favoured in clinical
practice. Assessment of intranerval power Doppler signals
improves classication of CTS particularly in cases of moderate
nerve swelling.

Dejaco C, et al. Ann Rheum Dis 2013;72:19341939. doi:10.1136/annrheumdis-2012-202328

Clinical and epidemiological research

Contributors All authors contributed to the conception and design of the study,
acquisition and/or interpretation of data, drafting the article or revising it critically for
important intellectual content and approved the nal version of the manuscript. All
authors had full access to all of the data (including statistical reports and tables) in
the study and can take responsibility for the integrity of the data and the accuracy of
the data analysis.

12

13
14

Funding None.
Competing interests None.
Patient consent Obtained.
Ethics approval This study was approved by the institutional review board of the
Medical University Graz.

15
16
17

Provenance and peer review Not commissioned; externally peer reviewed.

Data sharing statement In case of publication in ARD, dataset is available from
the corresponding author at christian.dejaco@gmx.net. Presented data are
anonymised and risk of identication is low.

18

REFERENCES

19

1
2

3
4

5
6

8
9
10

11

Klauser AS, Faschingbauer R, Bauer T, et al. Entrapment neuropathies II: carpal

tunnel syndrome. Semin Musculoskelet Radiol 2010;14:487500.
Roll SC, Case-Smith J, Evans KD. Diagnostic accuracy of ultrasonography vs.
electromyography in carpal tunnel syndrome: a systematic review of literature.
Ultrasound Med Biol 2011;37:153953.
Mallouhi A, Pulzl P, Trieb T, et al. Predictors of carpal tunnel syndrome: accuracy of
gray-scale and color Doppler sonography. AJR Am J Roentgenol 2006;186:12405.
Fowler JR, Gaughan JP, Ilyas AM. The sensitivity and specicity of ultrasound for
the diagnosis of carpal tunnel syndrome: a meta-analysis. Clin Orthop Relat Res
2011;469:108994.
Seror P. Sonography and electrodiagnosis in carpal tunnel syndrome diagnosis, an
analysis of the literature. Eur J Radiol 2008;67:14652.
Klauser AS, Halpern EJ, De Zordo T, et al. Carpal tunnel syndrome assessment with
US: value of additional cross-sectional area measurements of the median nerve in
patients versus healthy volunteers. Radiology 2009;250:1717.
Hobson-Webb LD, Massey JM, Juel VC, et al. The ultrasonographic wrist-to-forearm
median nerve area ratio in carpal tunnel syndrome. Clin Neurophysiol
2008;119:13537.
Hobson-Webb LD, Padua L. Median nerve ultrasonography in carpal tunnel
syndrome: ndings from two laboratories. Muscle Nerve 2009;40:947.
Ibrahim I, Khan WS, Goddard N, et al. Carpal tunnel syndrome: a review of the
recent literature. Open Orthop J 2012;6:6976.
Sthr M, Schulte-Mattler W, Quasthoff S. Klinische Elektromyographie und
NeurographieLehrbuch und Atlas. 6th edn. Stuttgart, Germany: Kohlhammer,
2010:3979.
Ziswiler HR, Reichenbach S, Vogelin E, et al. Diagnostic value of sonography in
patients with suspected carpal tunnel syndrome: a prospective study. Arthritis
Rheum 2005;52:30411.

20

21
22
23
24
25

26
27

28
29

Dejaco C, et al. Ann Rheum Dis 2013;72:19341939. doi:10.1136/annrheumdis-2012-202328

Mondelli M, Filippou G, Gallo A, et al. Diagnostic utility of ultrasonography versus

nerve conduction studies in mild carpal tunnel syndrome. Arthritis Rheum
2008;59:35766.
Torp-Pedersen ST, Terslev L. Settings and artefacts relevant in colour/power Doppler
ultrasound in rheumatology. Ann Rheum Dis 2008;67:1439.
Gruber H, Glodny B, Peer S. The validity of ultrasonographic assessment in cubital
tunnel syndrome: the value of a cubital-to-humeral nerve area ratio (CHR) combined
with morphologic features. Ultrasound Med Biol 2010;36:37682.
Wong SM, Grifth JF, Hui AC, et al. Carpal tunnel syndrome: diagnostic usefulness
of sonography. Radiology 2004;232:939.
Aleman L, Berna JD, Reus M, et al. Reproducibility of sonographic measurements of
the median nerve. J Ultrasound Med 2008;27:1937.
Kluge S, Kreutziger J, Hennecke B, et al. Inter- and intraobserver reliability of
predened diagnostic levels in high-resolution sonography of the carpal tunnel
syndromea validation study on healthy volunteers. Ultraschall Med
2010;31:437.
Naranjo A, Ojeda S, Mendoza D, et al. What is the diagnostic value of
ultrasonography compared to physical evaluation in patients with idiopathic carpal
tunnel syndrome? Clin Exp Rheumatol 2007;25:8539.
Bayrak IK, Bayrak AO, Tilki HE, et al. Ultrasonography in carpal tunnel syndrome:
comparison with electrophysiological stage and motor unit number estimate. Muscle
Nerve 2007;35:3448.
El Miedany YM, Aty SA, Ashour S. Ultrasonography versus nerve conduction study
in patients with carpal tunnel syndrome: substantive or complementary tests?
Rheumatology 2004;43:88795.
Visser LH, Smidt MH, Lee ML. High-resolution sonography versus EMG in the
diagnosis of carpal tunnel syndrome. J Neurol Neurosurg Psychiatry 2008;79:637.
Carlson H, Colbert A, Frydl J, et al. Current options for nonsurgical management of
carpal tunnel syndrome. Int J Clin Rheumtol 2010;5:12942.
Patijn J, Vallejo R, Janssen M, et al. Carpal tunnel syndrome. Pain Pract
2011;11:297301.
Wilder-Smith EP, Seet RC, Lim EC. Diagnosing carpal tunnel syndromeclinical
criteria and ancillary tests. Nat Clin Pract Neurol 2006;2:36674.
Yesildag A, Kutluhan S, Sengul N, et al. The role of ultrasonographic measurements
of the median nerve in the diagnosis of carpal tunnel syndrome. Clin Radiol
2004;59:91015.
Smith NJ. Nerve conduction studies for carpal tunnel syndrome: essential prelude to
surgery or unnecessary luxury? J Hand Surg Br 2002;27:835.
Swen WA, Jacobs JW, Bussemaker FE, et al. Carpal tunnel sonography by the
rheumatologist versus nerve conduction study by the neurologist. J Rheumatol
2001;28:629.
Kamath V, Stothard J. A clinical questionnaire for the diagnosis of carpal tunnel
syndrome. J Hand Surg Br 2003;28:4559.
Assmus H, Antoniadis G, Bischoff C, et al. (Diagnosis and therapy of carpal tunnel
syndromeguideline of the German Societies of Handsurgery, Neurosurgery,
Neurology, Orthopaedics, Clinical Neurophysiology and Functional Imaging, Plastic,
Reconstructive and Aesthetic Surgery, and Surgery for Traumatology). Handchir
Mikrochir Plast Chir 2007;39 : 27688.

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