ارزیابی ارزش تشخیصی سونوگرافی در مقابل روش‌های الکترودیاگنوستیک در تشخیص سندرم Carpal Tunnel

نوع مقاله : مقاله های پژوهشی

نویسندگان

1 دستیار، گروه نورولوژی، دانشکده‌ی پزشکی، دانشگاه علوم پزشکی اصفهان، اصفهان، ایران

2 استادیار، گروه نورولوژی، دانشکده‌ی پزشکی، دانشگاه علوم پزشکی اصفهان، اصفهان، ایران

چکیده

مقدمه: نوروپاتی عصب Median به علت تحت فشار قرار گرفتن عصب در ناحیه‌ی مچ یا همان سندرم Carpal tunnel (Carpal tunnel syndrome یا CTS)، شایع‌ترین نوروپاتی ناشی از گیر افتادن عصب می‌باشد. CTS شیوع بالایی دارد و عدد تقریبی آن 6/280 در هر 100000 بیمار در سال تخمین زده شده است. تشخیص دقیق این سندرم، به عنوان راهنمای درمان و پیش‌گیری از عوارض و ناتوانی‌های ناشی از آن ضروری است.روش‌ها: مطالعه‌ی حاضر از دی ماه 1392 تا فروردین ماه 1393 بر روی 64 بیماری که با علایم بالینی CTS به طور سرپایی به درمانگاه مرکز آموزشی- درمانی الزهرای (س) اصفهان مراجعه کردند، انجام شد. 54 نفر از این بیماران زن و 10 نفر مرد بودند. تمام بیماران تحت ارزیابی سونوگرافی و بررسی هدایت عصبی قرار گرفتند. مقادیر مختلف سطح مقطع عصب Median و نسبت سطح مقطع در مچ به بازو اندازه‌گیری شد و Cut of point مطلوب برای Wrist to forearm ratio (WFR) جهت تشخیص CTS تعیین شد.یافته‌ها: Cut of point به دست آمده از طریق منحنی Receiver operating characteristic (ROC) برای WFR که حساسیت (Sensitivity) و ویژگی (Specificity) مقبولی داشته باشد، 07/2 بود و سطح زیر منحنی ROC برابر با 8/0 و با انتخاب این Cut of point حساسیت 76 درصد و ویژگی 83 درصد برای تشخیص CTS از طریق سونوگرافی مطرح می‌شود. همچنین، مطالعه‌ی حاضر نشان داد که با انتخاب Cut of point برابر با 07/2 برای WFR در عصب Median ارزش اخباری مثبت (Positive predictive value یا PPV) 95 درصد و ارزش اخباری منفی (Negative predictive value یا NPV)، 45 درصد بود.نتیجه‌گیری: بر طبق سایر مطالعات انجام شده و بررسی مقالات موجود بر این نکته که نسبت سطح مقطع عصب در مچ به بازو شاخص دقیق‌تری است در اغلب موارد اتفاق نظر وجود دارد و این تکنیک زمان قابل توجهی را به روش تشخیصی اضافه نمی‌کند و با توجه به احتمال تفاوت‌های فردی، نژادی و آناتومیک، انتخاب این شاخص به جای سطح مقطع تنها در مچ، منطقی به نظر می‌رسد و با انجام این کار شاخص دقیق‌تری با قرار دادن هر فرد به عنوان شاهد خود به دست خواهد آمد. نتایج اولیه‌ی این مطالعه، حساسیت بالایی برای این شاخص به عنوان شاخص تشخیصی CTS مطرح کرده است. یافته‌های اولیه‌ی این مطالعه، حساسیت بالایی برای WFR نشان داده است، اما مطالعه‌ی بزرگ‌تری با حجم نمونه‌ی بیشتر جهت تأیید این موضوع لازم است.

کلیدواژه‌ها

عنوان مقاله [English]

Comparing the Diagnostic Value of Ultrasonography with Electrodiagnostic Tests in Carpal Tunnel Syndrome

نویسندگان [English]

  • Mohammad Reza Mohaghegh 1
  • Majid Ghasemi 2
  • Keivan Basiri 2
  • Ali Asghar Okhovat 2
  • Bagher Zaki 1
1 Resident, Department of Neurology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
2 Assistant Professor, Department of Neurology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
چکیده [English]

Background: Median neuropathy due to nerve compression in the wrist, or carpal tunnel syndrome (CTS), is the most common entrapment neuropathy. Incidence of CTS is high at an estimated value of 280.6 per 100,000 patients per year. Accurate diagnosis of CTS is essential for treatment and preventing disability and morbidity.Methods: 64 patients with clinical diagnosis of CTS from the out-patient clinic of Alzahra Hospital, Isfahan, Iran were evaluated between January and March 2013. All the patients (54 women and 10 men) underwent nerve conduction study (NCS) and ultrasonography. The cross sectional area of the median nerve at the level of pisiform bone and 12cm proximal to that in elbow was estimated via ultrasonography which were used to calculate wrist/forearm ratio(WFR). The cut-off point value for WFR of median nerve was assessed and sensitivity and specificity of ultrasonography for CTS diagnosis was also determined.Findings: The optimal diagnostic cut-off values of CTS that we obtained by ROC curve was 2.07 and the areas under the ROC curve, was 0.8. This cut-off value had a sensitivity of 76%, specificity of 83%, positive predictive value (PPV) of 95% and negative predictive value (NPV) of 45%.Conclusion: The WFR is a new option in the ultra-sonographic diagnosis of CTS. This technique does not add significant time to routine ultra-sonographic examination .The use of a ratio also helps to omit the variability between populations and anatomic variation. Our initial findings suggest a high sensitivity for this method, but study of a larger population is needed for confirmation.

کلیدواژه‌ها [English]

  • Carpal tunnel syndrome
  • Ultrasonography
  • Cross sectional area

مراجع

  1. Hobson-Webb LD, Massey JM, Juel VC, Sanders DB. The ultrasonographic wrist-to-forearm median nerve area ratio in carpal tunnel syndrome. Clin Neurophysiol 2008; 119(6): 1353-7.
  2. Kang S, Kwon HK, Kim KH, Yun HS. Ultrasonography of median nerve and electrophysiologic severity in carpal tunnel syndrome. Ann Rehabil Med 2012; 36(1): 72-9.
  3. Tsai NW, Lee LH, Huang CR, Chang WN, Wang HC, Lin YJ, et al. The diagnostic value of ultrasonography in carpal tunnel syndrome: a comparison between diabetic and non-diabetic patients. BMC Neurol 2013; 13: 65.
  4. Latinovic R, Gulliford MC, Hughes RA. Incidence of common compressive neuropathies in primary care. J Neurol Neurosurg Psychiatry 2006; 77(2): 263-5.
  5. Jablecki CK, Andary MT, Floeter MK, Miller RG, Quartly CA, Vennix MJ, et al. Practice parameter: Electrodiagnostic studies in carpal tunnel syndrome. Report of the American Association of Electrodiagnostic Medicine, American Academy of Neurology, and the American Academy of Physical Medicine and Rehabilitation. Neurology 2002; 58(11): 1589-92.
  6. Duncan I, Sullivan P, Lomas F. Sonography in the diagnosis of carpal tunnel syndrome. AJR Am J Roentgenol 1999; 173(3): 681-4.
  7. Wiesler ER, Chloros GD, Cartwright MS, Shin HW, Walker FO. Ultrasound in the diagnosis of ulnar neuropathy at the cubital tunnel. J Hand Surg Am 2006; 31(7): 1088-93.
  8. Wong SM, Griffith JF, Hui AC, Lo SK, Fu M, Wong KS. Carpal tunnel syndrome: diagnostic usefulness of sonography. Radiology 2004; 232(1): 93-9.
  9. Yesildag A, Kutluhan S, Sengul N, Koyuncuoglu HR, Oyar O, Guler K, et al. The role of ultrasonographic measurements of the median nerve in the diagnosis of carpal tunnel syndrome. Clin Radiol 2004; 59(10): 910-5.
  10. Ziswiler HR, Reichenbach S, Vogelin E, Bachmann LM, Villiger PM, Juni P. Diagnostic value of sonography in patients with suspected carpal tunnel syndrome: a prospective study. Arthritis Rheum 2005; 52(1): 304-11.
  11. Buchberger W, Schon G, Strasser K, Jungwirth W. High-resolution ultrasonography of the carpal tunnel. J Ultrasound Med 1991; 10(10): 531-7.
  12. Hammer HB, Hovden IA, Haavardsholm EA, Kvien TK. Ultrasonography shows increased cross-sectional area of the median nerve in patients with arthritis and carpal tunnel syndrome. Rheumatology (Oxford) 2006; 45(5): 584-8.
  13. Beekman R, Visser LH. Sonography in the diagnosis of carpal tunnel syndrome: a critical review of the literature. Muscle Nerve 2003; 27(1): 26-33.
  14. Peeters EY, Nieboer KH, Osteaux MM. Sonography of the normal ulnar nerve at Guyon's canal and of the common peroneal nerve dorsal to the fibular head. Journal of Clinical Ultrasound 2004; 32(8): 375-80.
  15. Cartwright MS, Shin HW, Passmore LV, Walker FO. Ultrasonographic findings of the normal ulnar nerve in adults. Arch Phys Med Rehabil 2007; 88(3): 394-6.
  16. Martinoli C, Schenone A, Bianchi S, Mandich P, Caponetto C, Abbruzzese M, et al. Sonography of the median nerve in Charcot-Marie-Tooth disease. AJR Am J Roentgenol 2002; 178(6): 1553-6.
  17. Cho JM, Yoon JS, Kim SJ, Park BK, Lee GH, Jeong JS. Feasibility of ultrasonographic area ratio of median nerve in the diagnosis of carpal tunnel syndrome in Korea. J Korean Acad Rehabil Med 2009; 33(5): 627-31.
  18. Lee CH, Kim TK, Yoon ES, Dhong ES. Correlation of high-resolution ultrasonographic findings with the clinical symptoms and electrodiagnostic data in carpal tunnel syndrome. Ann Plast Surg 2005; 54(1): 20-3.
  19. Cartwright MS, Shin HW, Passmore LV, Walker FO. Ultrasonographic findings of the normal ulnar nerve in adults. Arch Phys Med Rehabil 2007; 88(3): 394-6.
  20. Bayrak IK, Bayrak AO, Tilki HE, Nural MS, Sunter T. Ultrasonography in carpal tunnel syndrome: comparison with electrophysiological stage and motor unit number estimate. Muscle Nerve 2007; 35(3): 344-8.
  21. Padua L, Pazzaglia C, Caliandro P, Granata G, Foschini M, Briani C, et al. Carpal tunnel syndrome: ultrasound, neurophysiology, clinical and patient-oriented assessment. Clin Neurophysiol 2008; 119(9): 2064-9.
  22. Park JY, Park SR, Lee SH, Choi KH. The ultrasonographic findings of the median nerve in the carpaltunnel according to age and sex of normal Korean adults. J Korean Acad Rehabil Med 2008; 32(5): 564-69.
  23. Moran L, Perez M, Esteban A, Bellon J, Arranz B, del Cerro M. Sonographic measurement of cross-sectional area of the median nerve in the diagnosis of carpal tunnel syndrome: correlation with nerve conduction studies. J Clin Ultrasound 2009; 37(3): 125-31.
  24. de Krom MC, de Krom CJ, Spaans F. Carpal tunnel syndrome: diagnosis, treatment, prevention and its relevance to dentistry. Ned Tijdschr Tandheelkd 2009; 116(2): 97-101.
  25. Keberle M, Jenett M, Kenn W, Reiners K, Peter M, Haerten R, et al. Technical advances in ultrasound and MR imaging of carpal tunnel syndrome. Eur Radiol 2000; 10(7): 1043-50.
  26. Koyuncuoglu HR, Kutluhan S, Yesildag A, Oyar O, Guler K, Ozden A. The value of ultrasonographic measurement in carpal tunnel syndrome in patients with negative electrodiagnostic tests. Eur J Radiol 2005; 56(3): 365-9.
  27. Mohammadi A, Afshar AR, Masudi S, Etemadi A. Comparison of high resolution ultrasonography and nerve conduction study in the diagnosis of carpal tunnel syndrome: diagnostic value of median nerve cross-sectional area. Iran J Radiol 2009; 6(3): 147-52.
  28. Polykandriotis E, Premm W, Horch RE. Carpal tunnel syndrome in young adults--an ultrasonographic and neurophysiological study. Minim Invasive Neurosurg 2007; 50(6): 328-34.
  29. Karadag YS, Karadag O, Cicekli E, Ozturk S, Kiraz S, Ozbakir S, et al. Severity of Carpal tunnel syndrome assessed with high frequency ultrasonography. Rheumatol Int 2010; 30(6): 761-5.
  30. Mhoon JT, Juel VC, Hobson-Webb LD. Median nerve ultrasound as a screening tool in carpal tunnel syndrome: correlation of cross-sectional area measures with electrodiagnostic abnormality. Muscle Nerve 2012; 46(6): 871-8.
  31. Kwon BC, Jung KI, Baek GH. Comparison of sonography and electrodiagnostic testing in the diagnosis of carpal tunnel syndrome. J Hand Surg Am 2008; 33(1): 65-71.
  32. Zyluk A, Puchalski P, Nawrot P. The usefulness of ultrasonography in the diagnosis of carpal tunnel syndrome--a review. Chir Narzadow Ruchu Ortop Pol 2010; 75(6): 385-91.
  33. Dejaco C, Stradner M, Zauner D, Seel W, Simmet NE, Klammer A, et al. Ultrasound for diagnosis of carpal tunnel syndrome: comparison of different methods to determine median nerve volume and value of power Doppler sonography. Ann Rheum Dis 2013; 72(12): 1934-9.
  34. Hunderfund AN, Boon AJ, Mandrekar JN, Sorenson EJ. Sonography in carpal tunnel syndrome. Muscle Nerve 2011; 44(4): 485-91.
  35. Abrishamchi F, Zaki B, Basiri K, Ghasemi M, Mohaghegh MR. A comparison of the ultrasonographic median nerve cross-sectional area at the wrist and the wrist-to-forearm ratio in carpal tunnel syndrome. J Res Med Sci 2014; 19(12): 1113-7.
  36. Hassan A, Leep Hunderfund AN, Watson J, Boon AJ, Sorenson EJ. Median nerve ultrasound in diabetic peripheral neuropathy with and without carpal tunnel syndrome. Muscle Nerve 2013; 47(3): 437-9.
  37. Kim LN, Kwon HK, Moon HI, Pyun SB, Lee HJ. Sonography of the median nerve in carpal tunnel syndrome with diabetic neuropathy. Am J Phys Med Rehabil 2014; 93(10): 897-907.
  38. Rahmani M, Ghasemi Esfe AR, Vaziri-Bozorg SM, Mazloumi M, Khalilzadeh O, Kahnouji H. The ultrasonographic correlates of carpal tunnel syndrome in patients with normal electrodiagnostic tests. Radiol Med 2011; 116(3): 489-96.
  39. Chen SF, Huang CR, Tsai NW, Chang CC, Lu CH, Chuang YC, et al. Ultrasonographic assessment of carpal tunnel syndrome of mild and moderate severity in diabetic patients by using an 8-point measurement of median nerve cross-sectional areas. BMC Med Imaging 2012; 12: 15.
  40. Lange J. Carpal tunnel syndrome diagnosed using ultrasound as a first-line exam by the surgeon. J Hand Surg Eur Vol 2013; 38(6): 627-32.
  41. Bueno-Gracia E, Haddad-Garay M, Tricas-Moreno JM, Fanlo-Mazas P, Malo-Urries M, Estebanez-de-Miguel E, et al. Diagnostic validity of ultrasonography in carpal tunnel syndrome. Rev Neurol 2015; 61(1): 1-6.
  42. Deniz FE, Oksuz E, Sarikaya B, Kurt S, Erkorkmaz U, Ulusoy H, et al. Comparison of the diagnostic utility of electromyography, ultrasonography, computed tomography, and magnetic resonance imaging in idiopathic carpal tunnel syndrome determined by clinical findings. Neurosurgery 2012; 70(3): 610-6.
مجله دانشکده پزشکی اصفهان
دوره 34، شماره 370 - شماره پیاپی 370
فروردین و اردیبهشت 1395
صفحه 41-48

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سابقه مقاله

  • تاریخ دریافت: 28 مهر 1394
  • تاریخ بازنگری: 11 آبان 1403
  • تاریخ پذیرش: 17 فروردین 1401

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