Relevance of EMGs in Diagnosing Carpal Tunnel Syndrome

Several Bloggers have discussed having the problem of feeling pain and discomfort that is radiating into their hands - one, Mike, a patient of the Mayo clinic - had neck surgery then experienced pain in the distributions of median nerve.

EMG test presumably failed to confirm carpal tunnel syndrome (reported as "negative"). But surgery was recommended. I presume to decompress the median nerve at the wrist AKA carpal tunnel release.

First, EMG is the standard test and usually confirms or documents carpal tunnel syndrome - but there are exceptions. It may have been performed before changes takes place in the nerve and muscles. It usually takes 3 to 4 weeks or changes to occur. Every Hand Surgeon has cases in which EMG does not confirm what appears to be a strong clinical case of carpal tunnel syndrome.

If I feel strongly that a patient has carpal tunnel then I discuss the situation with the patient and frequently I have done carpal tunnel release- and there is unfortunately a small number of patients that do not see any improvement.

EMG is not a 100% test- a patient has to discuss the options with his or her doctor. The carpal tunnel release surgery is not a major procedure as an abdominal or thoracic procedure. It's straightforward- and can even be done under local - so it may be worth a try in order to relieve "carpal tunnel symptoms". I stress that I think about the indications long and hard and always have a frank discussion with the patient.

I would be interested in the experience of anyone who has had a negative EMG in the presence of strong clinical suspicion of carpal tunnel syndrome- what happened and how it was resolved- and if surgery was done.

Another problem is scaphoid fractures that don't heal- It is thought the natural progression is painful arthritis- initially localized then more extensive- I would like to know the experience of those known to have scaphoid fractures that have healed and whether they have had problems after they refused or rejected surgical definitive treatment.

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Pain in the Hand: Additional Thoughts

Bloggers have pointed out correctly that cervical radiculopathy and/or thoracic outlet syndrome may be the problem causing pain radiating to the hands - and not carpal tunnel syndrome. That is why anyone with persistent symptoms should first be examined by an experienced doctor, hand specialist, orthopedic specialist or neurologist, or any specialist who deals with these problems on a regular basis.

There are tests which can confirm the diagnosis. The EMG is the definitive test for carpal tunnel syndrome. MRI may also be helpful in documenting other problems.

Anyone who has persistent pain and numbness in the upper extremity should try to perceive or localize where the problem originates - neck, wrist, elbow, etc. I know that pain radiates and it may not be easy to localize the originating site, but if you can, it is very helpful in diagnosing the problem.

Approach to treatment: Rest the hands and wrist - stop the offending activity for at least a short time. If possible, use splints to maintain extension of the wrists especially at night (flexion is thought to increase pressure in the wrists) and use mild anti-inflammatory analgesic medications i.e. Tylenol, Advil, etc.

I am not an advocate of injecting the carpal tunnel with steroids and I do not think massage will help in the long term either. B vitamins as suggested by a commenter may help - I'm neutral about B vitamins.

If there's no relief from rest, restricting activity, use of splints and mild analgesic and anti-inflammatory medications then consider surgical release. If there is persistent unrelieved pain which affects one's ability to function and use the hands, then surgery should be considered.

Surgery is designed to relieve pressure on the median nerve within the carpal tunnel. The thick covering over the carpal tunnel (volar carpal ligament) is opened and I also remove the lining around the nerve and flexor tendons. Most people are limited in the first week after surgery but by the 2nd or 3rd week function is normal.

Some commenters have reported that surgery has not helped. It's difficult to judge - presumably diagnosis was correct, perhaps the procedure was not complete or scar tissue formed, not a common problem. Lastly an individual may have waited too long and permanent damage to the median nerve occurred.

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Carpal Tunnel Syndrome: Specific Characteristics

Several commenters have written about carpal tunnel syndrome and pointed out that carpal tunnel syndrome is not the only condition to cause pain, numbness and weakness in the hand. It is important to consider other entities, which cause similar symptoms. Other possible causes include cervical radiculopathy (nerve damage near the cervical vertebrae), impingement of one or more of the cervical nerve roots which can cause pain and numbness radiating from the neck area and also ulnar nerve compression usually at the elbow (cubital tunnel syndrome). I think it is important again to review some aspects of carpal tunnel syndrome.

Carpal tunnel syndrome is a specific entity. It is compression of the median nerve at the wrist in a closed space called the carpal tunnel. Through that small space course the median nerve and all the flexor tendons. The median nerve supplies sensation to the thumb, index, middle and the thumb side of the fourth finger.

It is thought, but never proven that pressure builds up within that small space and causes compression of the median nerve – the symptoms are activity related and episodic.

Jobs such as packing and typing along with exercise are frequently associated with carpal tunnel syndrome. Individuals usually perform their activity then hours later commonly (at night) they awaken with the hands feeling as if they are asleep and they describe shaking their hands to try to bring back feeling into them.

The ulnar nerve supplies sensation to the fifth finger (pinky) and the pinky side of the fourth finger. The ulnar nerve frequently gets compressed at the elbow in the area known as the “funny bone”. There is a groove between the medial epicondyle of the humerus the bone in the upper arm and the olecranon process of the ulnar bone in the forearm and the nerve is compressed in that area. An EMG test is the definitive test to determine and distinguish between the entities affecting the different nerves and nerve roots whether it is the neck, elbow or wrist area. Compression may also inferred or diagnosed by an MRI.

Other entities noted by several bloggers include the repetitive strain injuries one of the buzz words of the 21st century. They include trigger finger, carpal tunnel syndrome and de Quervain disease (tenosynovitis of the first dorsal compartment on the thumb side of the wrist and tennis elbow).

Specifically, trigger finger is a swelling of the first portion of the flexor tendon sheath in the distal palm at the base of each finger. There is a covering that starts over the flexor tendon and extends almost to the end or distal portion of the finger. This first portion-swelling thickening occurs and prevents the smooth gliding of the flexor tendon hence triggering. Injection of steroid is the first option and then if that fails or it continues to recur after a second injection a surgical release or opening of the first portion of the flexor tendon is performed. I do not wish to minimize it, but it is a very small surgical procedure easily and quickly accomplished.

It is a matter of experience, clinical judgment and findings after careful examination of what should and should not be treated. Perhaps in an individual who has one or more problems they all should be treated, but it is a matter of good judgment about which one should be treated first or which is the main culprit or problem in each individual.

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Carpal Tunnel Syndrome or Arthritis?

A number of commenters in recent weeks have pointed out that they have had carpal tunnel syndrome in addition to other problems such as whiplash injuries or elbow problems or other disease entities, which have caused pain, numbness, and weakness in their hands.

I want to stress the fact that it is possible to have carpal tunnel syndrome and also have other problems. Carpal tunnel syndrome is associated with such entities as arthritis, which can obviously cause pain in the hands and also contribute to or actually be associated with carpal tunnel syndrome. In deciding on treatment, certainly surgical treatment, judgment and experience are important. It is important to document all of these other problems and decide which one is contributing to the difficulty an individual has in using his or her hands.

An EMG is usually the definitive test for documenting the existence of carpal tunnel syndrome. It can be diagnosed clinically, but for documentation and verification EMG testing can document the findings and sometimes indicate severity. The carpal tunnel syndrome or these other disease problems can contribute and it is important to distinguish one from the other and make the best-informed decision.

Another cause of frequent hand and wrist pain is arthritis. Arthritis itself is derived from the Greek word "arthros" meaning joint and "itis" meaning inflammation so it specifically is inflammation of the joints.

There are various kinds of arthritis affecting the joints and they include osteoarthritis also known as degenerative arthritis, rheumatoid arthritis and the arthritis associated with other disease entities such as lupus and psoriasis. These are among the most well known. All have a component which causes inflammation and loss of joint integrity and eventually deformity. Those are the common aspects. The disease process differs. The medical and surgical treatments may also have common and differing approaches for each form of arthritis.

Osteoarthritis is certainly the most common form of arthritis. In some respects it has been considered a normal process of aging or "wear and tear." If we live long enough we will all wear out.

Osteoarthritis specifically involves the destruction of the normal cartilaginous surface, which lines the ends of bones. The composition of the collagen changes and friction follows eventually the cartilage is destroyed. Collagen is the significant component in cartilage.

Photo Credit: Wikimedia Commons

As cartilage is destroyed, prostaglandin synthesis occurs, resulting in an inflammatory reaction. A phenomenon also occurs in which there is new bone formation (sclerosis or subcondral bone formation) in a layer beneath the joint. Increased bone formation results in osteophyte formation on the sides of the joint. These osteophytes are in essence, projections. We may also see bony prominences especially in the distal joints. These are typical of osteoarthritis and they have a specific name -- they are known as Heberden's nodes, named after William Heberden, the man who first described them.

Osteoarthritis is a very common problem. Changes may start as early as the second decade in life and it is estimated that by the time individuals reach 70 years of age at least 85 percent of the population has evidence of arthritis. About 20-25 percent of people with osteoarthritis at age 60 have symptoms. So you see the enormity of the problem. In the 5th, 6th and 7th decades the arthritis really kicks in and as much as 85 percent of the population have arthritis and 20-25 percent have symptoms.

Osteoarthritis is a natural progression of living long, aging and wearing out of the joints cartilage thins or is eroded. Accompanying the erosion is increasing bone formation and density at the end of the bones known as sclerosis. Osteophyte (bony projections) also occur. Hence deformity, pain and stiffness follow. The whole process can occur and be accelerated by a traumatic event.

In the hand the two most common areas affected are the distal interphalangeal joints or end joints and also the basilar joint at the base of the thumb, the first metacarpal joint which is the part of that joint (basilar joint) subluxates or becomes dislocated out of place. An individual compensates and tries to use the other areas of the hand and which results in hyperextension at the MP joint or knuckle and a swan neck deformity of the thumb. These are classic kinds of deformities that are present in osteoarthritis.

The DIP joints as we mentioned before become swollen and irritated with Heberden's nodes. The approach to treatment is first if possible modify the activity. Resting or splinting. I find useful in certain joints. If it is possible to apply Band-aids around the joint to give some support and protection, band-aids are easier than using a large splint. Medication is also important starting with basic anti-inflammatory medicines such as acetaminophen (Tylenol), ibuprofen (Motrin or Advil) as well as aspirin, which is an old standard.

Gentle exercises for stretching and putting joints through their full range of motion, are recommended. Avoid aggressive exercising which may cause a rebound effect. There are also anti-inflammatory analgesic medications known as NSAID's -- nonsteroidal anti-inflammatory medicines prescription doses are available. Rheumatologists have additional potent drugs available.

I am not a big proponent of steroid injections. They might help initially when they are used for soft tissue anti-inflammatory effects. The injection of steroids is not beneficial to the cartilage. Cartilage has no direct blood supply. Nutriments come by way of the diffusion from the neighboring tissues and therefore once the cartilage is injured or destroyed it does not regenerate.

Ultimately there is a surgical approach. These joints can be removed and it is possible to replace them with prosthetic joints. They are very effective in providing some movement. Also especially for the end joints and fingers there is arthrodesis or fusion. Even though there is no movement the painful aspect is removed and the person is able to use the hand more effectively and it is cosmetically acceptable.

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Surgery for Carpal Tunnel Syndrome

Surgical treatment for carpal tunnel syndrome is two-fold and directed at decreasing pressure. First, what is commonly done is to open the thick band over the carpal tunnel also known as carpal tunnel release. The band is called the volar carpal ligament or also referred to as flexor retinaculum.

An analogy would be removing a bottle cap from a bottle of soda. This relieves the pressure. Some surgeons do the procedure through a small scope (endoscopically).

Others, including myself, do an open procedure. A small neat incision is made in the wrist. Under direct visualization, the ligament is opened. It also allows me to take care of the second aspect - the thick lining called the flexor synovium. I remove the flexor synovium lining in the carpal tunnel. I believe the real offender in carpal tunnel syndrome is the flexor synovium -- opening the ligament and removing the lining relieves pressure and creates more space.

Results are quite good and definitive. The incision is small and neat and cosmetically acceptable. The operation is a same day procedure - the individual goes home the same day. The individual can be awake. Medication is injected into the arm to "freeze" the hand and wrist or directly into the wrist area to numb the area. Full recovery is 2 to 4 weeks depending on level of activity.

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Carpal Tunnel Syndrome: Fast Facts

There are 2 classes of wrist pain. First pain occurs immediately such as with a traumatic event in which a bone is broken. The second class occurs over a period of time. Arthritis and Carpal Tunnel Syndrome (CTS) are examples. CTS is the most common cause of chronic pain. Frequently it's considered synonymous with wrist pain but it's a distinct entity.

The carpal tunnel is a closed space or "tunnel" located in the middle of the mid palm side of the wrist. A thick ligamentous band covers the space in front and in the back the space is confined by the wrist bones, the radius and ulna. Coursing through the tunnel or space are the flexor tendons and median nerve. "Too much stuff crammed into a small space".

It is thought that pressure builds up within the small space affecting the median nerve - pressure on the median nerve at the wrist manifests as Carpal Tunnel Syndrome. It has never been proven that it is actually the pressure within the carpal tunnel or even how much pressure it takes. Further repetitive movement, exercising and certain activities are associated with carpal tunnel syndrome, but again no specific time frame or repetitive movement has been documented to cause the problem. We do know by experience and anecdotal evidence that activities such as typing or working on a production line doing repetitive movements are associated with CTS.

Carpal Tunnel Syndrome is a Repetitive Strain Injury (RSI) one of the buzz phrases of the 90's and 21st century.

Typical complaints of those with CTS involve numbness, tingling on the palm side of the thumb , index, middle and thumb side of the ring fingers as well as weakness of grip. People affected by median nerve pressure at the wrist will also describe painful or electric shock-like sensation radiating into the hand or back up the forearm. Not everyone has all the classic symptoms but will have some variation or combination. For instance, only one or two fingers may be numb.

Tapping on the carpal tunnel at the wrist may set off unpleasant shock like sensations into the hand. It indicates the median nerve is irritated or compressed at the wrist. Acutely flexing the wrist and holding it in that position increases the pressure on the nerve , again causing the unpleasant sensations radiating into the hand and forearm.

One factor I consider very important is the thick lining around the median nerve and flexor tendons called synovium. People with Carpal Tunnel Syndrome invariably have a thickened swollen synovium. This again increases the content of the carpal tunnel and also presumably the pressure effects.

Individuals with arthritis, hypothyroidism and pregnancy have a greater incidence of CTS. In these conditions and illnesses the common factor is the swollen linings.

The standard confirmatory test for Carpal Tunnel Syndrome is an electric diagnostic study or (EMG). It is a measure of the electrical activity of the median nerve and the muscles enervated by median nerve. Routine x-rays are not much help. MRI may suggest median nerve compression if the contour of the median nerve is altered which is seen on the MRI.

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