In the Name of Allah God, The Most Compassionate, the Most Merciful

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• In the Name of Allah (God), The Most
  Compassionate, the Most Merciful

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High Resolution Ultrasonographic Measurement and
Electrophysiological Study of the Carpal Tunnel
Syndrome in Patients with Rheumatoid Arthritis.

• Rawhya R El-Sherief, Sammer F El-Shayb,
  1Rheumatology Rehabilitation and 2 Neurology ,
  Minia University, Egypt.
• 2009

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Introduction

• Rheumatoid Arthritis (RA) is a systemic
  inflammatory disease of unknown etiology
  characterized by the manner in which it involves
  the joints. RA is also associated with
  vasculopathy, peripheral, autonomic and
  entrapment neuropathy resulting in distal
  sensory, combined sensory and sensorimotor
  neuropathy (Shinoda et al., 2002 ).
• Carpal tunnel syndrome (CTS) is the most common
  form of entrapment neuropathies, and is the
  prototypical injury of the median nerve at the
  wrist which is either an acute or chronic
  compressive lesion.

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Carpal Tunnel Syndrome of RA

• Clinical findings are variable and include
  symptoms of burning pain, tingling, numbness, and
  weakness or atrophy in the hands of the patients
  (Unal et al., 2003).
• Tenosynovial proliferation of the flexor tendons
  which increases pressure in the carpal tunnel may
  be the cause of CTS in patients with RA (Shinoda
  et al., 2002).

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Carpal Tunnel Syndrome of RA

• It is often difficult to diagnose early stage of
  CTS in RA patients in the examination of the
  peripheral neuromuscular system due to similar
  symptoms resulting from pain in the joints, and
  limitations of movement (Sivri and Guler, 1998).

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Carpal Tunnel Syndrome of RA

• However, electrodiagnostic studies clearly show
  the existence of subclinical neuropathies (Aluclu
  et al., 2006).
• Golden standard for the diagnosis is the
  combination of the clinical findings and the
  electrophysiological study (Aluclu et al., 2006).

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Carpal Tunnel Syndrome of RA

• Routine median nerve conduction study is
  valuable. Prolonged terminal latency of motor or
  sensory nerve would be found in most CTS hands.
  If the routine study showed equivocal, more
  sensitive methods are needed.
• Those include segmental sensory conduction study
  across the carpal tunnel (Aluclu et al., 2006).

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Diagnosis of CTS

• The diagnostic criteria for CTS includes a distal
  motor latency more than 4.3 ms motor or sensory
  nerve conduction velocity less than 45m/s and of
  more than 0.5 ms latency difference in
  comparative test (Werner and Andary,2002 ).
• The severity of CTS was assessed through the
  American Academy of Neurology clinical diagnostic
  criteria Stages (Padua et al., 1997)

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Diagnosis of CTS

• Extreme (absence of motor and sensory
  responses)
• Severe (absence of sensory response and abnormal
  distal motor latency)
• Moderate (abnormal digit-wrist sensory nerve
  conduction velocity and abnormal distal motor
  latency)
• Mild (abnormal digit-wrist sensory nerve
  conduction velocity and normal distal motor
  latency)
• Minimal (abnormal comparative tests only)
• Negative (normal findings in all tests).

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Imaging of CTS

• In recent years, imaging technique as MRI and
  sonography have been shown to be of value in
  diagnosis of CTS.
• Both have an advantage over NCS in that they
  provide information about the possible causes of
  CTS as tenosynovitis and synovitis in wrist
• Imaging criteria for MRI and sonography for CTS
  appeared to be the same (Buchberger et al.,1991).

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Aim of the study

• To asses the importance of CTS in RA patients
• To determine frequency of it by means of
  electrodiagnostic studies,
• To describe the ultrasonographic finding of CTS
  and
• To evaluate the diagnostic value of US in
  patients suffering from CTS in comparison with
  the electrodiagnostic study.

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Subjects and Methods

• This study was carried out in the Departments of
  Rheumatology-Rehabilitation at Minia University
  hospital, between March 2008 and January 2009.
• This study include 2 groups
• Twenty healthy volunteers who accepted as control
  group (group 1).

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Subjects and Methods

• Fifty four adult patients, 10 males (18.5), 44
  females (81.5) RA patients (group 11).
• RA was defined according to revised criteria of
  the ACR

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Exclusion criteria

• History of wrist surgery (including carpal tunnel
  injection) or fracture
• Clinical or electrophysiological evidence of an
  accompanying condition that mimics CTS or
  interferes with its evaluation, such as proximal
  median neuropathy, cervical radiculopathy or
  polyneuropathy
• History of underlying disorders associated with
  CTS such as diabetes mellitus, pregnancy,
  acromegaly or hypothyroidism, hepatitis.

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Subjects and Methods

• All patients were subjected to
• A detailed clinical history,
• A careful rheumatological examination and
• Extended neurological evaluation were always
  performed.
• Assessment of disease activity by DAS 28.

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Subjects and Methods

• Assessment of disability by HAQ.
  
• Arabic version of the Boston Carpal Tunnel
  Questionnaire (BCTQ) (Levine et al., 1993 ) .
• was used to evaluates symptoms (11-item) and
  functional status (eight-item).

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Subjects and Methods

• Scores were assigned from 1 point (mildest) to 5
  points (most severe)
• Patients were divided into five groups according
  to their mean score extreme (4.15 points),
  severe (3.14 points), moderate (2.13 points),
  mild (1.12 points) and minimal (0.11 point)

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Investigation

• Investigations to assess the activity included
  the ESR, CBC and RF, X-rays of the hands and
  wrists (AP).
• Investigations to diagnose any secondary cause
  for CTS were done.
• Special investigation
• Electrodignostic tests
• Motor and sensory nerve conduction of median
  nerve,
• Comparative test between median and ulnar nerve.

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Investigation

• High resolution ultrasonography
• Cross sectional area (CSA), flattening ratio (FR)
  of median nerve during passive flexion and
  extension of index finger.
• Bowing of FR, AP dimension of carpal tunnel,
• Transverse sliding of the median nerve at the
  inlet and outlet of tunnel).
• These two investigations were performed blindly
  by two observers.
• Statistical analysis was done by SPSS version 11

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Demographic data of RA patients and control
Results
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Radiological Functional Grades
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Clinical Characteristics of RA patients
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Laboratory characteristics of RA patients
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Frequency of CTS in RA patients
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Frequency of CTS in RA patients
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Frequency of abnormal nerve conduction of rt side
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Frequency of abnormal nerve conduction of lt side
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Frequency of patients complaining of symptoms and
sign of CTS
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Frequency of patients complaining of symptoms and
sign of CTS
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Correlation of clinical features of CTS with
abnormal electrodiagnostic tests in RA patients
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The relation between the abnormal
electrodiagnostic tests in RA patients and the
questionnaire of CTS
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Relationship between patients with CTS and
duration of the disease.
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Correlation of DAS28 with abnormal
electrodiagnostic tests in RA patients
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Comparison between patients groups and control
group as regarded ultrasonographic measurements
in lt side .
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Ultrasonographic measurements in relation to
electrophysiological grades in right side of hand
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Ultrasonographic measurements in relation to
electrophysiological grades in left side of hand
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Diagnostic utility of ultrasonographic
measurement of CTS ROC of CSA (cut off value
6.7mm (0.5/0.8), 9.9mm (0.7/0.9) and 12mm (1/1)
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ROC curve for FR Cut off value of 2.3mm
(0.2/0.7), 2.7mm (0.7/0.9) and 3.3mm (1/1)
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Longitudinal scan showing normal median nerve.
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Transverse scan showing normal median nerve
(hypoechoic and ovoid in shape).
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Transverse scan showing enlarged (swollen) median
nerve.
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Transverse scan showing flattening of the median
nerve.
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Longitudinal scan showing indentation (notching)
of the MN by the FR ant.
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Conclusions

• In this study, the prevalence of CTS in patients
  with RA was 40.7,.
• The accuracy of sonography is similar to that
  for electrodiagnostic tests.
• Sonography is probably preferable because it is
  painless, easily accessible, lower cost and
  shorter examination time.
• High-frequency US examination of the median
  nerve should be strongly considered as a new
  alternative diagnostic modality for the
  evaluation of CTS.

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Conclusions

• As in addition to being of high diagnostic
  accuracy it is able to define the cause of nerve
  compression and aids treatment planning US also
  provides a reliable method for following the
  response to therapy.
• We consider that treatment of CTS by medical
  and/or surgical methods in RA patients will
  decrease complaints and increase life quality

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Recommendation

• We recommend that an ultrasonographic
  measurement for CTS should be performed in all
  patients with RA as routine diagnostic procedure,
  as some cases of RA had subclinical neuropathy (8
  patients).

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Thank you