park1腕管综合征得朝圣诊断的价值课件

The Diagnostic Value of Ultrasonographic Measurement in Carpal Tunnel Syndrome Gi-Young Park1, Jung-Ho Bae2 Department of Rehabilitation Medicine, 1 Catholic University of Daegu School of Medicine, 2 Keimyung University School of Medicine Nanjing Carpal Tunnel Syndrome Nerve Conduction Study Imaging Studies for Diagnosis of CTS Plain radiograph Computed tomography (CT) Magnetic resonance imaging (MRI) Ultrasonography Ultrasonography Transverse sonograms of carpal tunnel of wrist show normal appearance of median nerve (black arrows) and flexor tendons (white arrows). r = radial, u = ulnar Objectives To compare the ultrasonographic measurements in patients with CTS, diagnosed by NCS, to those obtained from control subjects To investigate their correlations with the severity of CTS determined by NCS To evaluate the diagnostic value of the ultrasonographic measurement being the highest correlating with NCS Methods Patients Characteristics CTS1 Controls Age (years)53.8 9.6 (28-78) 49.9 7.8 (28-62) Sex (M/F)10 / 902 / 38 Wrists (M/F)13 / 1154 / 57 Values are mean standard deviation (range). 1. CTS: Carpal tunnel syndrome Exclusion Criteria lSystemic conditions such as diabetes mellitus, thyroid disease, chronic renal failure under hemodialysis, rheumatoid arthritis, and myxedma lOrthopedic conditions such as previous wrist fracture or surgery, and CTS surgery lClinical or electrodiagnostic evidence of an accompanying conditions such as cervical radiculopathy and polyneuropathy lUltrasonographic evidence of the bifid median nerve and mass lesions lNegative NCS. Neurophysiologic Grading Scale for CTS Grade 0 (normal): no neurophysiological abnormalities Grade 1 (very mild): only in two sensitive tests (eg, inching, palm/wrist median/ulnar comparison, ring finger “double peak” Grade 2 (mild): orthodromic sensory conduction velocity form index finger to wrist 4.5 ms and 4.5 ms and 6.5 Grade 6 (extremely severe): surface motor potential from APB 0.2 mV, peak to peak Bland JD. Muscle 23:1280-1283 Ultrasonography SonoAce 9900 (Medison, Korea) 5 - 12 MHz liner transducer One physiatrist Ultrasonographic Measurements Cross-sectional area at 3 levels Distal radioulnar joint, pisiform, and hamate Flattening ratio at 3 levels Distal radioulnar joint, pisiform, and hamate Swelling ratio Palmar displacement of flexor retinaculun at pisiform Cross Sectional Areas Pisiform level Swelling ratio: CSA at the level of the pisiform bone/CSA of the distal radioulnar joint Flattening Ratio Transverse diameter/anteroposterior diameter Palmar Displacement Pisiform level Results Neurophysiologic Grading Scale for CTS Neurophysiologic gradeNumber of cases(%) Grade 1 15( 11.7%) Grade 2 24( 18.8%) Grade 3 58( 45.3%) Grade 4 10( 7.8%) Grade 5 17( 13.3%) Grade 6 4( 3.1%) Total 128(100.0%) Comparison of Cross Sectional Area Values are mean standard deviation(mm2). *p.001 1. CTS: Carpal tunnel syndrome CTS1 Controls Distal radius 11.2 2.9* 7.2 0.8 Pisiform13.1 4.2*7.6 0.9 Hamate10.0 2.8*7.4 0.7 Comparison of Flattening Ratio Values are mean standard deviation. *p.001 1. CTS: Carpal tunnel syndrome CTS1 Controls Distal radius 2.89 0.62* 2.07 0.61 Pisiform 2.80 0.72*2.18 0.42 Hamate 3.08 0.74*2.23 0.52 Comparison of Swelling Ratio and Palmar Displacement Values are mean standard deviation. *p.001 1. CTS: Carpal tunnel syndrome CTS1 Controls Swelling ratio 1.19 0.28* 1.07 0.14 Palmar displacement (mm) 4.40 1.24* 3.16 0.58 Correlation between Ultrasonographic Parameters and Neurophysiologic Grading Scale Ultrasonographic parameterNeurophysiologic grading scale CSA1 Distal radius Pisiform Hamate r=0.350* r=0.529* r=0.256* Flattening ratio Distal radius Pisiform Hamate r=0.108 r=-0.035 r=0.262* Swelling ratio Palmar displacement r=0.359* r=0.265* Values are correlation coefficient. *p.01 1. CSA: cross sectional area Areas Under Receiver Operating Characteristic Curves Ultrasonographic parameterAreas under ROC 1 curves CSA 2 Distal radius Pisiform Hamate 0.93 0.96 0.82 Flattening ratio Distal radius0.84 Swelling ratio Palmar displacement 0.62 0.83 1. ROC: receiver operating characteristic, 2. CSA: cross sectional area Sensitivity and Specificity of Optimal Cut-off Values of Ultrasonographic Measurements Ultrasonographic measurement cuff-off values Sensitivity % Specificity %Area under curve (95% CI) CSA1 at distal radioulnar joint 9 mm2 82.893.40.932 (0.898-0.966) CSA at pisiform 9 mm293.891.80.960 (0.933-0.987) CSA at hamate 9 mm265.691.80.823 (0.765-0.880) Flattening ratio at hamate 2.45 82.075.40.844 (0.785-0.903) Swelling ratio 1.0368.862.30.642 (0.560-0.725) Palmar displacement 3.75 mm 76.690.20.827 (0.768-0.886) 1. CSA: cross sectional area Conclusion Median nerve CSA at the pisiform had the highest correlation with the neurophysiological grading scale among the ultrasonographic measurements Its value being gre