Role of Ultrasonography in Severe Distal Median Nerve Neuropathy

Purpose: Electrodiagnostic studies do not differentiate severe lesions of the median nerve in the distal forearm from those within the carpal tunnel when compound muscle action potential over the abductor pollicis brevis and sensory nerve action potential are absent; needle electromyography showing denervation confined to the abductor pollicis brevis is presumed to suggest localization to the carpal tunnel, although the lesion may be in the forearm. Under these circumstances, the patient may undergo carpal tunnel release without benefit. This retrospective study looked at patients with clinical picture of severe carpal tunnel syndrome who had no compound muscle action potential or sensory nerve action potential on median nerve stimulation; the goal was to determine how often ultrasonic imaging pointed to a location other than the carpal tunnel. Methods: Patients with clinical picture of severe carpal tunnel syndrome with no sensory nerve action potential and no compound muscle action potential over the abductor pollicis brevis and second lumbrical underwent ultrasonic imaging; criteria for localization to the carpal tunnel included significant increase in the cross-sectional area of the median nerve at the carpal tunnel inlet and increase in the wrist/forearm cross-sectional area ratio. Results: In 42 of 46 cases, entrapment at the carpal tunnel was confirmed by ultrasonography; in four patients, other causes were located proximal to the carpal tunnel. Conclusions: Ultrasonic imaging is useful not only for confirming entrapment of the median nerve at the carpal tunnel in patients with nonlocalizing electrodiagnostic studies but also in detecting pathology in the forearm, which may mimic severe carpal tunnel syndrome.