ORIGINAL ARTICLE

Changes in Electrophysiological Parameters After Surgery for the

Carpal Tunnel Syndrome
Taghrid El-Hajj, Rania Tohme, and Raja Sawaya

Abstract: Carpal tunnel syndrome is a common condition, affecting mostly

females. Nerve conduction studies are performed routinely for the diagnosis
of carpal tunnel syndrome. Surgical intervention for release of the median
nerve at the carpal tunnel is the treatment of choice. Few studies have looked
at the improvement in the electrophysiological parameters after carpal tunnel
release. This study compared the distal motor and sensory latencies, motor
and sensory amplitudes, and sensory conduction velocities of the median
nerves across the carpal tunnel in patients with the carpal tunnel syndrome
preoperatively and postoperatively at 18 and 42 weeks, respectively. The
results showed improvement in all the studied variables, except the distal
sensory latency, 18 weeks after the surgery, whereas the distal sensory
latency improved only at 42 weeks postoperatively. These findings denote
the differential affection of the sensory and motor fibers in the carpal tunnel
syndrome and confirm the value of nerve conduction studies in the evaluation
of patients who do not improve or who have recurrence of their symptoms
after carpal tunnel release.
Key Words: Carpal tunnel syndrome, Surgical decompression, Electrophysiology, Median nerve, Nerve conduction studies.
(J Clin Neurophysiol 2010;27: 224 226)

arpal tunnel syndrome (CTS) is by far the most common

entrapment neuropathy (Campbell et al., 1999; Dawson, 1993;
de Krom et al., 1992; Stevens et al., 1988; Tanaka et al., 1994,
1995). Patients presented with sensory disturbances in the dermatome are innervated by the median nerve (MN). In severe
entrapment, patients may present with weakness and atrophy of the
muscles of the thenar eminence.
Nerve conduction studies (NCS) are performed to confirm the
diagnosis and define the degree of entrapment of the MN.
Treatment strategies are usually based on the clinical symptoms and degree of abnormalities on the NCS.
There is still controversy in the literature concerning the
correlation between the NCS and the outcome of surgical decompression of the MN (Dhong et al., 2000; Schrijver et al., 2005; You
et al., 1999).
The objective of our study is to assess the changes in the
electrophysiologic parameters of the MN postoperatively and during
a 42-week period in comparison with the preoperative values.

From the Department of Internal Medicine, Division of Neurology, American

University Medical Center, Beirut, Lebanon.
Address correspondence and reprints requests to Raja A. Sawaya, M.D., Associate
Professor of Clinical Medicine, Director Clinical Neurophysiology Laboratory, American University Medical Center, P.O. Box 113 6044/C27, Beirut,
Lebanon; e-mail: rs01@aub.edu.lb.
Copyright 2010 by the American Clinical Neurophysiology Society

ISSN: 0736-0258/10/2703-0224

224

PATIENTS AND METHODS

Eighteen patients (14 women and 4 men), between 26 and 75
years of age, with a mean of 54 years, with the clinical diagnosis of
CTS, were referred for NCS of the MN. These patients did not suffer
from any medical condition that is known to affect the peripheral
nerves, such as diabetes mellitus, thyroid disease, connective tissue
disease, or a malignancy, and were not on any drug that may cause
a focal or generalized neuropathy, such as an antiepileptic drug,
statin, chemotherapy, or antiarrhythmic drug. Patients suspected of
any of the above were not included in this study.
The diagnosis was based on the symptom complex of numbness in the hands in the median dermatome with sparing of the ulnar
dermatome. Symptoms were predominantly numbness and paresthesias rather than pain. Symptoms were worse at night and on wrist
flexion. In some patients, the sensory symptoms were accompanied
by weakness of thumb abduction and evidence for atrophy of the
thenar eminence.
There were no symptoms from the forearm or arm or symptoms
or signs suggestive of cervical root disease or a polyneuropathy.

Electrophysiologic Evaluation
The NCS were performed as classically described in the
literature (Kimura, 1989). The compound muscle action potential of
the median and ulnar nerves was produced with stimulation 2.5 cm
proximal to the wrist crease and recording with surface electrodes
from the abductor pollicis brevis and abductor digit quinti muscles,
respectively. The sensory nerve action potential was recorded antidromically with stimulation of the MN at the wrist and recording
with surface electrodes from the second digit and stimulation of the
ulnar nerve at the wrist and recording from the fifth digit. Values more
than or less than 2SD from the mean were considered abnormal.

Surgical Technique
Carpal tunnel decompression was performed by a group of
surgeons who use the same surgical technique. Short incisions of the
palm are performed just beyond the wrist fold. The transverse carpal
ligament is sectioned in a proximal to distal direction along the ulnar
side, and the division is extended subcutaneously, proximally, and
distally, until complete release of the MN is achieved. The epineurium
is left intact.

Statistical Analysis
Comparison of the distal motor latencies (DML), distal sensory latencies (DSL), motor amplitudes (M-amp), sensory amplitudes (S-amp), and sensory conduction velocities (SCV) was performed preoperatively and at 18 and 42 weeks postoperatively using
the nonparametric Wilcoxon signed ranks test. All analyses were
conducted using SPSS v.16 and a one-tailed P value 0.05 was
considered statistically significant.

RESULTS
A total of 24 hands (12 right and 12 left) were diagnosed to
have CTS and were included in the study. DML ranged from 4.8 to

Journal of Clinical Neurophysiology Volume 27, Number 3, June 2010

Journal of Clinical Neurophysiology Volume 27, Number 3, June 2010

Changes in Electrophysiological Parameters

DISCUSSION

15.1 milliseconds and was absent in one hand. M-amp ranged from
0.3 to 9.7 mV. Sensory responses were absent in 15 hands. When
sensory responses could be elicited, the DSL ranged from 3.3 to 5.9
milliseconds, the S-amp ranged from 4 to 39 V, and the SCV
ranged from 28 to 48 m/s. The changes in these parameters at 18 and
42 weeks postoperatively are detailed in Table 1. Comparison and
statistical evaluation of these parameters during the study period are
detailed in Table 2.
Improvement in DML, M-amp, S-amp, and SCV occurred 18
weeks after the operation. However, improvement in DSL required
more time and was only significant at 42 weeks after the operation.
Electrophysiologic measures 18 weeks after the operation revealed
the absence of DSL, S-amp and SCV in six hands, whereas at 42
weeks after the operation, only one hand had an absent sensory
response.

Our results showed improvement in the DML, M-amp, S-amp,

and SCV 18 weeks postoperatively. However, improvement in DSL
was only significant at 42 weeks postoperatively compared with
the preoperative recordings. The reason behind this finding is that
in most cases of CTS, the sensory fibers are affected more than
the motor fibers, and the myelin sheath more than the axons.
Recovery of the sensory parameters is thus delayed in comparison to the motor values.
Few studies in the literature have looked at the time and
pattern of improvement in the electrophysiologic parameters after
carpal tunnel release.
Ginanneschi et al. (2008) found in their recent series of 16
hands that 1 month after carpal tunnel release, SCV and DML

TABLE 1. Electrophysiologic Parameters of the Median Nerve Preoperatively, at 18- and 42-wk Postoperatively
NCS Preoperation

NCS 18-wk Postoperation

NCS 42-wk Postoperation

DML

M-amp

DSL

S-amp

SCV

DML

M-amp

DSL

S-amp

SCV

DML

M-amp

DSL

S-amp

SCV

5
7.5
7.8
4.1
4.8
7.3
9
9.9
5.2
7.3
8.9
8.5
Absent
15.1
15.1
5.7
5.8
5
5.2
4.9
5.7
7.6
8

9.7
5
4.7
7.8
9.6
0.7
4.1
1.5
8.1
3.7
5.1
6.3
Absent
0.3
0.3
6.7
8.4
9.5
9.6
8.4
7.4
5.1
6.3

3.3
Absent
Absent
3.3
3.9
4.1
Absent
Absent
3.8
Absent
Absent
5.9
Absent
Absent
Absent
Absent
Absent
4.4
4
4.2
Absent
Absent
Absent

39
Absent
Absent
28
9
9
Absent
Absent
18
Absent
Absent
4
Absent
Absent
Absent
Absent
Absent
20
19
12
Absent
Absent
Absent

48
Absent
Absent
44
44
41
Absent
Absent
38
Absent
Absent
28
Absent
Absent
Absent
Absent
Absent
39
40
44
Absent
Absent
Absent

4.3
4.8
5.7
4
4.3
5.6
5.4
6.1
3.3
5
4.7
4.4
5.3
6.3
6.3
4.4
4.7
4.5
4.9
3.9
3.9
4.6
5.5

11.8
9.8
9.5
7.9
9.7
2
5.7
6.9
9.4
5.7
6.8
7.5
4.1
6
5.5
11.2
9.5
11.1
11.3
12.4
10.5
7.1
6.1

3
Absent
Absent
3.3
3.2
3.2
2.9
3.1
2.6
3.9
Absent
3.4
3.9
Absent
Absent
Absent
3.6
4
3.9
3.3
3.3
Absent
Absent

53
Absent
Absent
28
18
10
20
21
39
7
Absent
7
6
Absent
Absent
Absent
27
12
17
31
18
Absent
Absent

53
Absent
Absent
50
55
53
55
45
60
47
Absent
44
40
Absent
Absent
Absent
51
52
49
52
38
Absent
Absent

4.3
4.5
5.2
3.5
4.1
4.5
5.1
5.7
3.8
5.2
4.4
4.1
4.9
5.5
5.1
3.9
4.3
4.2
4.9
3.8
3.8
4.4
5.2

11.9
9
8.8
8.7
10.7
4
7.4
10.2
10.1
7.1
6.3
7.9
6.2
7.5
6.2
10.2
7.9
9.5
9.3
13
10.1
7.9
6.1

2.8
4.7
4.6
2.7
2.8
3.1
2.9
3.2
2.8
3.5
3.6
3.3
3.9
Absent
4.2
2.9
3.1
3.6
4.1
3.1
3.2
3.6
3.9

48
7
8
28
18
10
15
15
34
7
15
9
12
Absent
8.1
11
34
26
20
33
16
14
8

57
34
33
57
57
54
55
50
54
48
49
47
42
Absent
35
60
58
50
48
56
36
46
37

DML, distal motor latency in milliseconds; M-amp, motor amplitude in millivolts; DSL, distal sensory latency in milliseconds; S-amp, sensory amplitude in microvolts; SCV,
sensory conduction velocity in m/s.

TABLE 2. Comparison of Electrophysiologic Parameters Before and After Surgery on the Carpal Tunnel
Time of Measurements (Mean SD)

Parameters

Preoperation

18-wk
Postoperation

42-wk
Postoperation

Preoperation vs. 18-wk

Postoperation

18- vs. 42-wk

Postoperation

Preoperation vs. 42-wk

Postoperation

DML
M-amp
DSL
S-amp
SCV

7.10 3.2
5.83 3.4
1.54 2.1
6.58 10.8
15.25 20.4

4.89 0.8
8.58 3.0
2.42 1.6
14.62 14.4
35.09 23.3

4.48 0.6
9.19 1.9
3.21 0.9
18.60 11.8
49.74 8.1

0.001
0.001
0.091
0.001
0.001

0.004
0.226
0.374
0.033
0.005

0.001
0.001
0.007
0.001
0.001

DML, distal motor latency in milliseconds; M-amp, motor amplitude in millivolts; DSL, distal sensory latency in milliseconds; S-amp, sensory amplitude in microvolts; SCV,
sensory conduction velocity in m/s.

Copyright 2010 by the American Clinical Neurophysiology Society

225

T. El-Hajj et al.

Journal of Clinical Neurophysiology Volume 27, Number 3, June 2010

improved but M-amp was still reduced. However, all parameters had
significantly improved at 6 months postoperatively. This pattern of
improvement in conduction velocities with decreased M-amp was
also reported in other studies (Mondelli et al., 2000).
In their large series, Prick et al. (2003) studied the changes in
latencies in the MN 6 and 12 months postoperatively and found that
both DSL and DML improved at 6 and 12 months, respectively;
however, there was still some slowing in both latencies at 12 months
in 80% of cases.
Shurr et al. (1986) were among the first to study the electrophysiologic changes after carpal tunnel release, and they found that
the MCV and SCV were significantly improved as early as 2 weeks
postoperatively but the DSL and DML did not improve before 3 and
6 months, respectively. The reason is that the CTS compression is in
the distal part of the MN at the carpal tunnel rather than the proximal
part in the forearm.
In their series of 50 patients, Naidu et al. (2003) showed that
the DML and S-amp showed significant improvement at 6 months
but the DSL and SCV remained slow. The explanation for this
finding is in coherence with the interpretation of our results.
The place of median NCV postoperatively is still to be
determined, but there is no doubt that it is important in specific
situations. Because it is difficult to evaluate subjective symptoms
and physical findings after carpal tunnel release, the only objective
way to determine and quantitate objectively the improvement after
decompression is by NCS. This is of utmost importance in patients
who claim no clinical improvement after surgery or who develop
symptoms again after a period of time after decompression. Although several studies have demonstrated a modest correlation
between the clinical improvement and the electrophysiologic testing
after carpal tunnel release (Prick et al., 2003; Schrijver et al., 2005),
NCS can still provide reassurance to patients that their operation was
successful and that there is further potential for clinical improvement over time.
NCS performed postoperatively are also important to determine inadequate decompression of the MN or recurrence of entrapment over time. The latencies after release improve but do not return
to normal in most cases, and one can diagnose the recurrence of MN
entrapment only by comparing pre- and postoperative NCS.

226

Our study is in agreement and complements what has been

published previously. It confirms improvement in MN NCS over time
postoperatively. The improvement is evident first in the least compressed fibers and segment of the MN; that is, the motor fibers and the
proximal SCV. The distal sensory fibers improve more slowly but
recover in most cases by 10 months (42 weeks) postoperatively.
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Copyright 2010 by the American Clinical Neurophysiology Society