title: Electrosonodiagnosis in Carpal Tunnel Syndrome: A Proposed Diagnostic Algorithm Based on an Analytic Literature Review.
abstract: Suspected carpal tunnel syndrome (CTS) remains the most common clinical scenario prompting referral for electrodiagnostic (EDx) studies to identify objective correlates of reported subjective symptoms and clinical examination findings. Despite much debate and a rapidly expanding literature, identification of an optimal algorithm for diagnosing focal median mononeuropathy at the wrist (FMMW) associated with CTS signs and symptoms remains elusive. The introduction and rapid dissemination of peripheral nerve ultrasound imaging (PN-USI) of the median nerve has raised new questions regarding the relative value of structural information from PN-USI versus physiological information from EDx in the diagnosis of FMMW, as well as the significance of various clinical signs and symptoms suggestive of CTS. The means by which PN-USI and EDx may be optimally deployed and integrated in the process of diagnosing FMMW remains to be clearly delineated.
  
  
  
  To complete an analytical literature review to guide the formulation of a clinical diagnostic algorithm (CDA) integrating the use of PN-USI and EDx for the optimal detection of FMMW in the context of making a clinical diagnosis of CTS.
  
  
  
  A structured literature review was performed on the MEDLINE medical literature database accessed through PubMed.
  
  
  
  Papers with particular relevance and connection to the goal of formulating the CDA were selected from the identified studies. Studies specifically examining the correlations between systematically documented clinical symptomatology, EDx findings, and PN-USI findings were reviewed for consistent outcomes that could be incorporated into a CDA to guide the integration of these two complementary technologies in the diagnostic process.
  
  
  
  The formulation of the algorithm was limited to measures with established validity that can be readily obtained by means of widely accepted protocols using standard EDx and ultrasound equipment. The formulated algorithm assumes a consistent association between pathophysiology and anatomical deformation of the median nerve, which may not occur in certain situations. It may also not be as accurately applied to patients with CTS with significant comorbid neuromuscular conditions.
  
  
  
  An algorithm has been developed and presented, and illustrated as a flow chart, based on findings reported in the relevant reviewed literature in which PN-USI is proposed as a painless and rapidly performed screening test for FMMW to be completed before subjecting a patient to a systematic EDx testing process.
authors.affiliation: Department of Physical Medicine and Rehabilitation, Virginia Commonwealth University School of Medicine, Richmond, VA; Polytrauma Transitional Rehabilitation Program, Hunter Holmes McGuire VA Medical Center, Bldg 514, Rm 143, 1201 Broad Rock Blvd, Richmond, VA 23249(∗). Electronic address: gary.goldberg@va.gov.
authors.forename: Gary
authors.initials: G
authors.lastname: Goldberg
authors.affiliation: Southwest Spine & Sports, Scottsdale, AZ(†).
authors.forename: Jeffrey M
authors.initials: JM
authors.lastname: Zeckser
authors.affiliation: Integrative Sports and Spine, Scottsdale, AZ(‡).
authors.forename: Revati
authors.initials: R
authors.lastname: Mummaneni
authors.affiliation: iOrthoBiologix, Charlotte, NC(§).
authors.forename: Jason D
authors.initials: JD
authors.lastname: Tucker
mesh_terms: D000465:Algorithms; D002349:Carpal Tunnel Syndrome; D004568:Electrodiagnosis; D006801:Humans; D008475:Median Nerve; D009431:Neural Conduction