SYMPOSIUM ON THE UPPER LIMB
A history of carpal tunnel syndrome
Carpal tunnel syndrome is the commonest entrapment neuropathy seen in ciinical practice.
The history of its aetiology and diagnosis gives an interesting insight into how
the condition has evolved to also hecome the best understood neuropathy.
C
arpal tunnel syndrome as a clinical entity was
popularized by Phalen et al ( 1950). They detailed
the aetiology, diagnosis and treatment of this
now well-recognized condition. However, without
understanding and appreciating the neurophysiological
basis of sensation determined by neurologists during the
late 1700s and early 1800s the clinical diagnosis of carpal
tunnel syndrome would still elude us today.
The evolution of our understanding of the patho-
physiology of carpal tunnel syndrome and the develop-
tnent of clinically useful assessment tools and provoca-
tive tests have occurred together, allowing the contempo-
rary clinician to assess and appreciate the complexities of
this condition (Waylett-Rendall, 1988).
The history of sensory testing
Many of the sensory assessment tools were first reported
in the 19th century and have been modified and refined
in the 20th century.
In 1835 Weber introduced static two-point discrimina-
tion as a test of terminal digital sensibility and in 1852
Valentin was the first to observe and assess vibratory per-
ception. Rumpf, in 1889, introduced the tuning fork for
clinical use and assessment of vibratory perception (Dellon,
1981). Moberg developed the clinical testing techniques
for two-point discrimination used today (Mobei^, 1958,
1962). Dellon (1978) introduced the moving two-point
discrimination test, on the premise that fingertip sensibil-
ity was highly dependent on motion. The observation that
moving two-point discrimination returns much earlier
than static two-point discrimination following nerve lac-
eration made it a more valid assessment of discrimination.
The Disk-Cri mina tor (figure I) was introduced by
MacKinnon and Dellon (1985) making the assessment of
two-point discrimination much easier and more precise,
and facilitating the assessment of nerve recovery.
In 1894 Von Frey developed the first sensory threshold
test. He used horse hairs as monofilaments, and also
Mr NS Waitlle is Specialist Registrar in the Department of Orthopaedics, Basildon
and Thurrock University Hospitals NHS Trust, Nethermayne, Essex SSl6 5Nf,
Dr N Poiugiezb is Specialist Registrar in Trauma and Orthopaedics, Royal
Adelaide Hospital, Adelaide, South Australia, Mr N Ashwood is Consultant
Orthopaedic Surgeon, Burton Hospitals NHS Trust, Queen's Hospital, Burton-on-
Trent, Stafforeishire, and Dr GI Bain is Consultant Orthopaedic Surgeon, Royal
Adelaide and Modbury Hospitals, Adelaide, Australia
Correspondence to: Mr NS Wardle
254
developed a non hand-held apparatus to contain the
monofilament, increasing the accuracy of touch thresh-
old recognition. The horse hair monofilaments were later
replaced with nylon monofilaments (Weinstein, 1962).
These new filaments provided specific measurable thresh-
olds of force relative to a range of progressively applied
pressures. They were initially developed for use in a study
of somatosensory changes in brain-injured adults.
With continued advances in technology, computer-
assisted sensory testing became a reality and has been
described for the evaluation of patients with peripheral
nerve compression (Hardy et al, 1992).
The history of provocation tests
In 1915 Tinel introduced his median nerve percussion
test which in later reports was advocated as a means of
detecting regenerating axon buds as a result of chronic
nerve compression (Henderson, 1948; Dellon, 1984).
In 1951 Phalen described the wrist flexion test, where
the forearm is held upright and the wrist is placed in
passive flexion compressing the median nerve between
the proximal edge of the transverse carpal ligament and
the contents of the carpal tunnel, exacerbating the neural
ischaemia and reproducing carpal tunnel syndrome
symptoms in the hand.
Durkan introduced a carpal compression test in 1991,
which consisted of application of direct pressure on the
area overlying the median nerve in the carpal tunnel
(Durkan, 1991). The test was reported using a rubber
bulb which was connected to a pressure sphygmoma-
nometer. This was compressed with the fingers to
figure ]. The Disk-Criminator, developed hy MatK'mnon and
Dellon in 19SS for two-point distrimination testing, facilitating the
assessment of nerve recovery.
British Journal of Hospital Medicine, May 2008, Vol 69, No 5

1 50 mmHg reproducing the symptoms of carpal tunnel
syndrome in patients. The test has also been described
without using instrumentation, but with the examiner's
thumbs used to exert even pressure over the area (Paley
and McMurtry, 1985).
The history of the electrophysiologicat
assessment of carpal tunnel syndrome
The first determinations of nerve conduction velocity in
humans were performed in 1850 by von Helmhokz.
However, it was not until 1948 when this technique was
applied in patients hy Hodes and associates. It was used
for the determination of motor conduction velocity in the
median, ulnar, peroneal and tibial nerves in normal sub-
jects as well as in patients with peripheral nerve injuries.
In 1949 Dawson and Scott described a method of
examining sensory impulses in human peripheral nerves
by electrically stimtxlating the median or ulnar nerves at
the wrist and recording the afferent action potential
through surface electrodes placed over the nerve in the
forearm.
Evidence of partial denervation confined to the mus-
cles supplied by a particular motor nerve or its branches
is required for an electromyographic diagnosis of a nerve
lesion to be made. The disadvantages of this technique,
as stated by Simpson (1956), are that die technique may
fail to demonstrate early changes which are diagnostic
and that the technique requires extensive needle elec-
trode exploration of the intrinsic muscles of the hand.
With an appreciation of the limitations of electromy-
ography in the diagnosis of focal nerve entrapment
lesions, Simpson began examining patients with a prob-
able diagnosis of carpal tunnel syndrome using surface
electrodes. In 1956 Simpson established the basis for the
electrophysiological diagnosis of carpal tunnel syndrome
and other entrapment neuropathies.
The value of electrophysiological techniques was Increas-
ingly being recognized with Giliiatt and collègues apply-
ing sensory nerve study techniques to patients with
peripheral nerve lesions (Giliiatt and Sears, 1958; Giliiatt
and Willison, 1962). They demonstrated that sensory
nerve conduction abnormalities in carpal mnnel syn-
drome were more sensitive than motor nerve conduction.
Subsequent studies by Buchthal and associates (1974)
supported the exclusion of the distal segment of the
median nerve as it was well recognized that the electro-
physiological abnormalities in carpal tunnel syndrome
were often limited to the wrist-to-palm segment of the
median nerve. This method permitted an increased sen-
sitivity of diagnosis.
Electrophysiological techniques and criteria for the
evaluation of carpal tunnel syndrome have been refined
since their initial conception, allowing a greater sensitiv-
ity and specificity in diagnosis (Buchthal et al, 1974;
Giliiatt and Sears, 1958; Giliiatt and Willison, 1962).
This has allowed the clinician to more effectively grade
and follow the clinical course of this and other entrap-
British Journal of Hospital Medicine, May 2008, Vbl 69, No 5
SYMPOSIUM ON THE UPPER LIMB
ment neuropathies. As a consequence the objective elec-
trophysiological examination of the carpal tunnel syn-
drome patient has become an integral part of the assess-
ment process.
The development of carpal tunnel
syndrome theory
Sir James Paget (1854) was the first to describe chronic
median nerve compression at the wrist. This occurred in
his patient as a consequence of a distal radius fracture
and had resulted in ulcerative changes to the radial three
digits that were only relieved by binding the wrist in a
partlyflexedposition. Since this first description, median
nerve compression at the wrist has stimulated countless
articles, many of which reported alternate pathophysio-
logical explanations for what would later be proven to be
median nerve compression at the wrist.
Acroparaesthesia
Putnam (1880) was the first to report the symptom com-
plex of pain and paraesthesia in the median nerve distri-
bution of the hand. The majority of his patients were
women and had an average age of 35 years. The author
described these symptoms occurring especially at night
or in the morning with relief being brought by shaking
the arm or by rubbing the hands together. Patients
reported sensory symptoms predominating with physical
signs usually absent. In 1893, Schultz also described the
sensory symptoms observed by Putnam in a similar
group of patients, and coined the term acroparaesthesia.
In 1909 the influential James Ramsey Hunt described
thenar atrophy and attributed this to isolated compres-
sion of the motor branch of the median nerve as it passed
beneath the transverse carpal ligament. He called the
condition 'occupation neuritis of the thenar branch of
the median nerve' {Hunt, 1909).
The cervical rib theory
The cervical rib theory that claimed to explain both the
sensory and motor abnormalities that had been observed
was originally proposed by Buzzard in 1902 and sup-
ported strongly by Wilson. They proposed that a cervical
rib was causing brachial plexus compression, specifically
of the G7 root. Wilson publishing a report on the various
manifestations of cervical ribs with anatomical explana-
tions did much to perpetuate the cervical rib theory.
The cervical rib theory was further popularized by
Sargent in 1921 who performed cervical rib excisions on
patients he had observed with thenar atrophy. As a con-
sequence this treatment became popular, even though it
was recognized that thenar atrophy often did not resolve
after such operations (Keen, 1907; Sargent, 1921).
Evolution of carpal tunnel syndrome theory
Blecher reported isolated cases of median nerve com-
pression following distal radius fractures (Blecher,
1908). Marie and Foix (1913) reported the autopsy
255
SYMPOSIUM ON THE UPPER LIMB
findings of an 80-year-old woman with compression of
both median nerves beneath the transverse carpal liga-
ments causing thenar atrophy hilaterally. They also
suggested that early surgical release of the transverse
carpal ligament may prevent the thenar atrophy. Their
work was ignored at the time because of the popularity
of the cervical rib theory.
Other investigators, dissatisfied with the results of tib
excision and at a loss to explain why motor and sensory
symptoms occurred in patients without cervical ribs,
looked further for an explanation. Brouwer (1920)
reported l4 cases of thenar atrophy and considered as the
causal factor the recent phylogenic development of the
thenar musculature, affording vulnerability of the mus-
cles to repeated minor trauma. Lewis and Miller (1922)
reported a number of cases of median nerve compression
following distal radius fractures.
Learmonth, in 1933, reported on what was believed
until recently to be the first surgical release of the trans-
verse carpal ligament, tor post-traumatic median nerve
compression. The operation was performed on a 71-
year-old woman with arthritis of the wrist as a result of a
previous injury. However, Amadio (1992) reported that
the first carpal tunnel release operation had been per-
formed almost 10 years earlier at the Mayo Clinic.
Zabriskie and colleagues (1935) reported three cases of
bilateral thenar atrophy with no accompanying altera-
tions in sensation. However, spontaneous compression
of the median nerve was still unrecognized. Moersch
described an idiopathic syndrome, typically thought to
affect the older age groups, causing motor and sensory
symptoms attributable to compression of the median
nerve (Moersch, 1938). He urged clinicians to recognize
this condition to prevent incorrect diagnoses of more
sinister conditions such as progressive muscular atrophy
or neopiastic growth of the cervical portion of the spinal
cord. He also implicated two different lesions. He
believed that only the sensory symptoms were attributa-
ble to compression of the median nerve beneath the
flexor retinaculum and that the motor disturbances were
attributable to isolated compression of the recurrent
motor branch of the median nerve, this occurring as the
recurrent motor branch emerged from beneath the distal
edge of the transverse carpal ligament. He also suggested,
as Marie and Foix had done, that sectioning of the trans-
verse carpal ligament may bring relief, at least from the
motor disturbances.
Woltman (1941) reported two cases of compression of
the median nerve beneath theflexorretinaculum caused
by encroachment of hyperplastic tissue in acromegaly
and secondary to arthritis of the wrist. In the later case
complete recovery was reported after sectioning of the
transverse carpal ligament by Learmonth.
Zachary (1945) published a review of the literature
on thenar palsy and reported a further two cases of
median neuritis with both motor and sensory symp-
toms. One case was the result of osteoarthritis of both
256
scaphoids following old fractures and the other was
caused by a 20-year-old malunited Colles' fracture. In
both cases the nerve was found to be compressed in the
carpal tunnel with pain and paraesthesia being relieved
within a few days following division of the transverse
carpal ligament.
In 1946 Cannon and Love reported on the first carpal
tunnel release for spontaneous median nerve compres-
sion in the carpal tunnel.
Brain et al (1947) published the first paper describing
in detail the clinical signs, diagnosis and pathophysiology
of spontaneous median nerve compression in the carpal
tunnel. They supported Marie and Foix in recommend-
ing surgical release of the transverse carpal ligament as it
was their opinion that spontaneous recovery did not
occur.
It was Phalen's detailed reports, however, that brought
carpal tunnel syndrome into the mainstream of medical
knowledge (Phalen et al, 1950; Phalen, 1951; Phalen
and Kendrick, 1957). In his address to the American
Society for Surgery of the Hand in January 1949 he
reported in detail the first three cases of spontaneous
compression of the median nerve at the wrist of the
eleven cases that had been seen at the Cleveland Clinic.
These cases were later reported in lUefournalofBoneand
Joint Surgery (Phalen et al, 1950). As a result by the mid-
1960s median nerve compression in the carpal tunnel
had become the most frequently diagnosed, best under-
stood and most easily treated entrapment neuropathy in
medical practice (Phalen, 1966).
Treatment options
Conservative (splintage and injection
therapy)
Phalen and Kendrick (1957) reported the success of
wrist immobilization (wearing a neutral position splint
at night, and at times during the day), originally rec-
ommended by Roaf, in mild cases of short duration. In
the same paper they also reported, for the first time,
treating carpal tunnel syndrome with hydrocortisone
injection into the carpal tunnel. Their series was small,
including 20 patients, but their results of 16 patients
experiencing a remission of symptoms made the treat-
ment popular, even though there was only a short fol-
low-up period.
Subsequent studies of greater numbers have shown
that although initial relief following injection can be seen
in up to 90% of cases, after 1 year the number requiring
decompression can be as high as 67% (Wood, 1980). It
was suggested that, as initially considerable symptomatic
relief can be achieved, the principal value oi steroid
injections lies as a palliative remedy while decompres-
sion is awaited (Wood, 1980). However, greater success
has been demonstrated with steroid injection when
the patients were deemed to have milder symptoms of
shorter duration (Gelberman et al, 1980; Agarwal et al,
2005).
British Journal of Hospital Medicine, May 2008, Vol 69, No 5

open surgical decompression
Scili the most practiced intervention for the relief of car-
pal tunnel syndrome is the open surgical decompression
of the median nerve. The procedure is often performed
under local anaesthesia facilitating this as a day case pro-
cedure (Gibson, 1989, 1990). Despite the frequency with
which this procedure is carried out many cases still suffer
less favourable outcomes as a result of operative or post-
operative complications. Kluge et al (1996) outlined a
series of decompressions and showed that at approaching
1 year postoperation tender scars were found in 19% and
pillar pain in 4%; incomplete relief of primary symptoms
was quoted as 18%.
The technique is widely described but consists of a
longitudinal incision on the palmar aspect of the hand
running in line of the radial border of the ring fmger
{Figure 2). The skin and subcutaneous tissues are incised
{Figure 3), followed by the palmar aponeurosis {Figure
4).
Beneath this layet is the transverse carpal ligament (or
flexor retinaculum), this is 'gritty' under the knife giving
it a distinctive characteristic compared to any previous
structure. Careful dissection through a small part of the
transverse carpal ligament should be made with a small
blade in a longitudinal direction. Once the full depth of
the ligament is reached placing a MacDonald dissector
under this layer gives protection to the underlying nerve
figure 2. Site of incision.
Figure 3. Superficial dissection.
British Journal of Hospital Medicine, May 2008, Vol 69, No 5
SYMPOSIUM ON THE UPPER LIMB
{Figure 5) and allows a knife to be used to completed the
division in the longitudinal axis {Figure 6) distally and
proximally until no bridging remnant can be felt with the
MacDonald {Figure 7).
If a tourniquet has been used this should be deflated
before closure and adequate haemostasis ensured before
interrupted sutures are placed {Figure 8).
Areas of danger to be aware of include avoiding the
palmar cutaneous branch of the median nerve which has
a variable course, and also the motor branch (recurrent)
of the median nerve which supplies the thenar muscles
and usually arises from the anterolateral side of the
median nerve, although the course is again largely varia-
ble. Incising the carpal ligament on its ulnar border helps
minimize the risk of damage to the motor branch,
Incomplete release needs to be avoided so as to exclude
this as a cause of continued or recurrent symptoms.
The suroical revolution:
minimally invasive releases
A refinement of the orientation and alignment of the
incision over the transverse carpal ligament, to protect
the palmar cutaneous branch of the median nerve, is the
only change that the open technique of carpal tunnel
release has undergone since its First application in 1924.
More recently a gteat number of carpal tunnel release
techniques have been developed, some endoscopie and
. Palmar aponeurosis imised.
Figure 5. Division of transverse carpal ligament over a MacDonald
dissector.
257
SYMPOSIUM ON THE UPPER LIMB
Figure 6. Completing the release of the transverse carpel ligament.
figure 7. Rehased iBedîm non« seen at base of wound.
Figure 8. Closure with interrupted sutures.
other limited incision techniques. Endoscopie techniques
were developed in an attempt to reduce the perceived
morbidity that resulted from cutting the skin and the
volar tissues superficial to the transverse carpal ligament,
as occurs with the traditional open technique.
In 1989, Chow was the first to report an endoscopie
technique for release of the transverse carpal ligament.
Chows technique is the two-portal endoscopie tech-
nique, where an incision is made proximal to the distal
wrist flexion crease and a second incision in the palm. A
cannuia which is open on its volar aspect is introduced
and through this opening the transverse carpal ligament
can be viewed as a specialized knife divides it. The tech-
258
nique's use was originally reported in a series of 62
hands in 46 patients, in whom no complications were
reported.
In 1989, Okutsu et al described a single-portal method
of carpal tunnel release, in which the incision was made
proximal to the distal wrist flexion crease. A clear can-
nula is inserted into the carpal tunnel and through this
the transverse carpal ligament is viewed while it is cut
with a specialized knife.
In 1992, Agee et al described another proximal single-
portal technique of carpal tunnel release. Their technique
uses an endoscope with a disposable cannuia which
houses a small retractable knife. When the knife is elevat-
ed the transverse carpal ligament can be divided.
Clinical use of these techniques by other trained sur-
geons resulted in mixed success, some reporting serious
complications. As a result of these observations many
surgeons have attempted to develop a safe way to reduce
postoperative loss of strength and function.
Two new groups of surgeons have resulted. One
group, seeking to reduce postoperative morbidity by
reducing the size of the open carpal tunnel release inci-
sion, has developed limited incision techniques. The
other group of surgeons has modified techniques or
instrumentation, attempting to improve endoscopie
carpal tunnel release. Subsequent revisions to the tech-
niques of both limited incision techniques and endo-
scopie carpal tunnel releases have been made since their
advent and there will undoubtedly be more develop-
ments in the future.
Conclusions
The evolution of carpal tunnel syndrome as a clinical
entity has passed many stages, with confusion regarding
this condition being widespread until the mid-20th cen-
tury. Our knowledge has moved on from the isolated
reports of sensory symptoms in the distribution of the
median nerve of the hand following carpal or distal
radius injury, to the wide acceptance of the cervical rib
theory of causality, to finally the recognition of spontane-
ous median nerve compression within the carpal tunnel.
With the recognition of the syndrome various treat-
ments were attempted including carpal tunnel injection
with steroid, splinting of the wrist, and surgical division
of the transverse carpal ligament. Open carpal tunnel
release became the gold standard for treatment and this
persisted until very recently when the surgical revolution
of minimaily-invasive carpal tunnel release techniques
began introducing a number of endoscopie and limited
incision techniques.
An evaluation of all treatment modalities is currently
occurring with the focus on surgical treatments. The goal
is to provide the patient with carpal tunnel syndrome
with a safe and effective procedure that minimizes the
time taken to return to work and to activities of daily
living along with allowing a rapid return of preoperative
strength.
British Journal of Hospital Medicine, May 2008, Vbl 69, No 5

The contemporary clinician has a substantial advantage
over his predecessors in diagnosing carpal tunnel syn-
drome as knowledge of the condition is now so wide-
spread that many patients approach the doctor with a self
diagnosis of carpal tunnel syndrome. However, even with
all the interest and attention this syndrome has received in
the past century a definitive aetiological explanation for
idiopathic carpal tunnel syndrome still eludes us. BJHM
Conflict of interest: none.
Agarwai V, Singh R, Sachdev A, WidafF, Shekhar S, God D (2005) A
prospective study of the long-term efficacy of local methyl
prednisolone acetate injection in the management of mild carpal
tunnel syndrome. Rhrumatology.(Oxford} 44; 647-50
AgeeJM, McCarroll HR |r,Tonosa RD, Berry DA, S/alxj RM, Pdmer
CA (1992) Endoscopie rdease of rhe carpal tunnel; a randomised
prospective m\Ai\Qcma siuáy. J Hand Surg ¡Am] 17: 987-95
Amadio PC (1992) The Mayo Clinic and carpal tunnel syndrome.
Mayo Gin Pror 67: 42-8
Blecher H (1908) Die Schädigung des nervus medianus als
komplikation de.s t>pischen radiusbniches deatsdic. Zietschrififur
Chirurgie 9i'. 34-45
Brain WR, Wright AD, Wilkinson M (1947) Spontaneous
compres.sion of both median nerves in the carpal tunnel; Six cases
treated surgically. Lancet U 277—82
Brouwer B ( 1920) The significance of phylogenetic and ontogenetic
studies for the neuropathologisi.y Atfi' Mem Dis 51: 113-36
Buchthal F, Rosenfalck A, Trojaborg W (1974) Electrophysiological
findings in entrapment of the median nerve at wrist and elbow. /
Neural Neurosurg Psychiatry 37; 340-60
Buzzard EF (Í902) Uniradicular palsies of the brachial plexus. Brain
25:299-303
Cannon BW, I.ove JG (1946) Tardy median palsy; Median neuritis;
Median thenar neuritis amenable to surgery. Surgery 20; 210-17
Chow JC (1989) Endoscopie release of the carpal ligament: a new
technique for carpal tunnel syndrome. Arthroscopy 5: 19-24
Dawson GD, Scott JW (1949) The recording of nerve action
potentials through skin in tinn. J Neural Neurosurg Psychiatry 12:
259-67
Dellon AL (1978) The moving two-point discrimination test: clinical
evaluation of the quickly adapting fiber/receptor system. J Hand
S¡
Dellon AL (1981) F.valuacion of Sensibility and Re-education of
Sensation in the Hand Williams and Wilkins, Baltimore
Dellon AL (1984) Tind or not T\ne\. J Hand Surg [BrJ 9: 216
Durkan JA (1991) A new diagnostic test for carpal tunnel syndrome./
Bone Joint Surg Am 73; 535-8
Gdberman RH. Aronson D, Weisman MH (1980) Carpal-mnnel
syndrome. Results of a prospective trial of steroid injection and
f,p\\nún^. J Bone Joint Surg Am 62: 1181-4
Gibson M (1989) Carpal tunnel decompression under local
anaesthesia. J Hand Surg [Br] 14: 359
Gibson M (1990) Outpatient carpal tunnel decompression without
tourniquet: a simple local anaesthetic technique. Ann R Colt Surg
Engt 72: ^0%-'-)
Giliiatt RW, Sears TA (1958) Setisory nerve aaion potentials in
patients with peripheral nerve lesions. J NeurolNeurosurg Psychiatry
21: 109-18
Giliiatt RW, Willison RG (1962) Peripheral nerve conduction in
diabetic neurop3iûiy. J Neurol Neurosurg Psychiatry 25: 11-18
Hardy M. Jimenez S, Jabaley M, Horch K (1992) Evaluation of nerve
compression with the Automated Tactile Tester. J Hand Surg [AmJ
17; 838-42
Henderson WR (1948) Clinical assessment of peripheral nerve
injuries: Tinel's test. Läncet20: 801-5
Hodes R, Larrabee MC, German W (1948) The human
elearomyogram in response to nerve stimulation and the conduction
velocity of motor axons. Arch Neurol Psychiatry 60: 340-65
Hum JR (1909) Occupational neuritis of the thenar branch of the
median nerve: a well defined type of atrophy of the hand.
Transactions of the American Neurological Society 3S: 184-91
British Journal of Hospital Medicine, May 2008, Vbl 69, No 5
SYMPOSIUM ON THE UPPER LIMB
Keen WW (1907) The symptomatology, diagnosis and surgical
treatment of cervical ribs. American Journal of Medical Science 133;
173-218
Kluge W Simpson RG, Nicol AC (1996) Late complications after
open carpal tunnel óecompression. J Hand Surg [BrJ 21: 205-7
learmonth JR (1933) The principal of decompression in the
treatment of certain diseases of peripheral nerves. Surg Clin North
Am 13:905-15
Lewis D, Miller EM (1922) Peripheral nerve injuries associated with
fractures. Transactions of the American Surgical Association 40: 489-
580
Mackirmon SE, Dellon AL (1985) Two-point discrimination tester./
Hand Surg [Am] 10; 906-7
Marie P, Foix C (1913) Atrophie isolée de l'eminence thenar d'origine
nevritique: Role du ligament annulaire du carpe dans la patholgenle
de la lesion. Revue Neurology 26; 647-9
Mobeig E (1958) Objective methods for determining the functional
value of sensibility in the hand. //iö«i-_/ö/ni 5«i^ ¿r40-B! 454-76
Moberg E (1962) Criticism and study of methods for examining
sensibility of the hand. Neurology 12: 8-19
Moersch FP (1938) Median thenar neuritis. Proceeding of the Staff
meeting of the Mayo Clinic 220-2
Okutsu 1. Ninomiya S, Takatori Y, Ugawa Y ( ! 989) Endoscopie
management of carpal tunnel synámme. Arthroscopy 3; 11-18
Paget J (1854) Lectures on Sur^cai Pathology. Lindsay and Blakiston,
Philadelphia
Paley D, McMurtty RY (1985) Median nerve compression test in
carpal tunnel syndrome diagnosis reprodtices signs and symptoms
in affected wrist. Orthop Rev 14: 41 1-15
Phalen GS (1951) Spontaneous compression of the median nerve at
the wtist. JAm Med Assoc 145: 1128-33
Phalen GS (1966) The carpal-tun ne I syndrome. Seventeen years'
experience in diagnosis and treatment of six hundred fifty-fotir
hands. J Bone Joint Surg Am iS: 2\\ -28
Phalen GS. Kendrick Jl (1957) Compression neuropathy of the
median nerve in the carpal tunnel./,4w Med Assoc 164; 524-30
PhalenGS, Gardner WJ, La LondeAA (1950) Neuropathy of the
median nerve due to compression beneath the transverse carpal
ligament../ Bone Joint Surg Am 32A: 109-12
Putnam JJ (1880) A series of cases of paraesthesia, mainly of the hand,
of periodical recurrence, and possibly of vaso-motor origin. Archives
of Medicine (New York) 4: 147-62
Sargent P (1921) Lesions of the brachial plexus associated with
rudimentary ribs. Brain 44; 95-124
Simpson JA (1956) Electrical signs in the diagnosis of carpal tunnel
and vehted syndtomes. J Neurol Neurosurg Psychiatry 19; 275-80
Waylett-Rendall J (1988) Sensibility evaluation and rehabilitation.
Orthop Clin North Am 19; 43-56
Weinstein S (1962) Tactile sensitivity of ihe phalanges. Percept Mot
Skills 14: 35\-4
Woltman HW ( 1941 ) Neuritis associated with acromegaly. Archives of
Neurology and Psychiatry 45: 680-2
Wood MR (1980) Hydrocortisone injections for carpal tunnel
syndrome. Hand 12: 62—4
Zabriskie EG, Hare CC, Masselink RJ (1935) Hypenrophic anhritis of
cervical venebrae with thenar muscular attophy occuring in three
sisters. Bulletin of the Neurology Institute of New York 4: 207-20
Zachary RB (1945) Thenar palsy due to compression of the median
nerve in the carp^il tumid. Surg Ciymrnl ()htct8\: 1\\ I"
KEY POINTS
Carpal tunnel syndrome hos evolved as a diognosis since the first reported coses in
the mid-19th century.
Objective electrophysiologicol exomination of the carpal tunnel syndrome patient
has become an integral part af the assessment process.
Open iarpal tunnel release remoins the gold standard for treatment.
Modern surgical techniques have evolved to minimize morbidity associated with
the surgical approach.
Carpal tunnel syndrome has become the most frequently diagnosed, best
understood and most easily treated entropment neuropathy in medicol practice.
259