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Digit I, III – Palm, Wrist

Surface Recording Technique, Orthodromic Study
  • Giuliano Gentili
  • Mario Di Napoli
Chapter

Original Settings

Sensitivity was 10 μV/division, sweep speed was 1 ms/division, duration of pulse was 100–200 μs, and the machine used was a one-channel electromyograph DISA 14A30. Low-frequency filter, high-frequency filter, and rate of pulse were not specified.

Position

This study was performed in the supine position.

Recording

Following the orthodromic method [1], signals were recorded at two different points (Figs. 1 and 2): on the palm (R1) and at the wrist (R2). On the palm (R1), the subdermal electrodes (both active and reference electrodes) were inserted well outside the zone of compression in the carpal tunnel, 1.5–2 cm distally to the distal edge of the flexor retinaculum. To record from the palmar nerve of digit I (thumb), the electrode was placed 6 cm from the stimulating cathode (−) at the medial border of the thenar eminence. To record from digit III (middle finger), the electrode was placed 9 cm from the stimulating cathode (−) along a line pointing to the midline of digit III. The remote electrode was placed just below the skin either 2–3 cm proximally or transversely to the near-nerve electrode. At the wrist (R2), the electrode was placed near the nerve, proximally to the distal wrist crease. The remote electrode was placed at a transverse distance of 4–5 cm at the level of the near-nerve electrode. Ground (G) electrode was placed around the proximal phalanx when recording in the palm and at the wrist when recording proximal to the flexor retinaculum (the figure shows the ground electrode placed on the palm).
Fig. 1

Orthodromic sensory nerve action potentials (SNAPs) recorded on the palm (upper trace) and at the wrist (lower trace), stimulation of digit I

Fig. 2

Orthodromic sensory nerve action potentials (SNAPs) recorded on the palm (upper trace) and at the wrist (lower trace), stimulation of digit III

Stimulation

Stimulation was applied separately to two fingers: digit I and digit III. The stimulating electrodes (rings or uninsulated platinum needles) were placed medially and laterally at the proximal end of the distal phalanx of digit I or at the middle phalanx of digit III. The reference ring electrode was placed 2 cm distally from the active electrode. The stimulus was gradually increased until the response was a maximum using 0.1 or 0.2 ms of duration of the current pulse.

Measurements

The short distances over which velocities were calculated required that they be measured as accurately as possible. Measurements of the conduction distance were all made with the hand stretched and placed in a standard position with digit I (thumb) abducted to 60°. The shortest latency was determined from the stimulus onset to the initial positive peak and the longest latency from the stimulus onset to the last separate component of the averaged sensory nerve action potential (SNAP). The sensory nerve conduction velocity (SNCV) over the digit–palm segment was calculated by the conventional method and measured in meter per second (m/s). In calculating SNCV over the palm–wrist segment, the distance was divided by the latency difference between the wrist and the palm. The amplitude of the sensory responses was measured peak to peak (peak to peak amplitude). Skin temperature was controlled (surface temperature of 37–38 °C). Normal values (Table 1) were obtained from 10 control subjects (5 women and 5 men, age range 32–57 years). The authors also studied 22 patients (Table 2) all hospitalized in neurological or neurosurgical wards (16 women and 6 men, age range 32–57 years): 13 patients had clinical signs and symptoms of carpal tunnel syndrome (CTS), 5 of which had both hands affected. In 9 patients, signs and symptoms had lasted for less than half a year, in 3 patients 6 months to 1 and a half years, and in 10 patients from 2 to 30 years.
Table 1

Normal values [1]

Digit I – distance (mm)

Mean ± SD

Digit I–wrist

124 ± 3

Digit I–palm

65 ± 3

Palm–wrist

61 ± 3

Digit III – distance (mm)

Mean ± SD

Digit III–wrist

170 ± 3

Digit III–palm

91 ± 3

Palm–wrist

78 ± 3

Wrist–elbow – distance (mm)

Mean ± SD

Wrist–elbow

212 ± 4

SNCV (m/s)

Mean ± SD

Range

Digit I–wrist

53 ± 5

49–60

Digit III–wrist

60 ± 3.5

54–66

Digit I–palm

53 ± 5

48–56

Digit III–palm

60 ± 3.5

56–65

Palm–wrist

58 ± 3.5

48–66

Wrist–elbow

62 ± 5

61–71

Table 2

Pathological values [1]

Mild CTS – SNCV (m/s)

Limit of normal

Range

Digit I–wrist

≥53

37–53

Digit III–wrist

≥53

44–56

Digit I–palm

≥53

42–60

Digit III–palm

≥53

49–64

Palm–wrist

≥52

35–50

Wrist–elbow

≥55

52–78

Severe CTS – SNCV (m/s)

Limit of normal

Range

Digit I–wrist

≥53

16–36

Digit III–wrist

≥53

19–39

Digit I–palm

≥53

49–50

Digit III–palm

≥53

18–52

Palm–wrist

≥52

13–31

Wrist–elbow

≥55

49–71

Comment

Buchthal and Rosenfalck [1] considered abnormal a sensory NCVs less than 53 m/s from digit III to palm and to wrist and of less than 52 m/s across the flexor retinaculum (p < 0.05). In healthy subjects, the amplitude of the SNAP at the palm evoked by a maximal stimulation to digit III averages 25 μV, about 10 μV higher than at the wrist. In 13 patients (14 hands) with markedly slowed conduction, they found the maximum velocity of conduction slower across the flexor retinaculum than distal to it by 10–30 m/s (in ten nerves). In four nerves, the velocity was as slow from the digit to palm as from the palm to wrist. The minimum velocity to the wrist was about 10 m/s less than to the palm. The temporal dispersion at the palm was slightly greater than in the normal subjects as indicated by a longer time from the positive to the negative peak of the potential. The amplitude of the sensory potential at the wrist was always smaller than in normal, even less than 3 μV. The amplitude at the palm was lower than normal, but it was higher than at the wrist in 9 of 14 nerves. In the remaining 9 patients, the authors described borderline or slightly slowed maximum and normal minimum conduction velocity from the digit to wrist, normal amplitudes of sensory potentials recorded at the wrist and at the palm.
Fig. 3

Orthodromic sensory nerve action potentials (SNAPs) recorded on the palm (upper trace) and at the wrist (lower trace), in moderately severe CTS – grade 3 by Bland’s CTS classification scale [2], stimulation of digit I (left) and digit III (right)

References

  1. 1.
    Buchthal F, Rosenfalck A (1971) Sensory conduction from digit to palm and from palm to wrist in the carpal tunnel syndrome. J Neurol Neurosurg Psychiatry 34:243–252PubMedCentralPubMedCrossRefGoogle Scholar
  2. 2.
    Bland JDP (2000) A neurophysiological grading scale for carpal tunnel syndrome. Muscle Nerve 23:1280–1283PubMedCrossRefGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2015

Authors and Affiliations

  • Giuliano Gentili
    • 1
  • Mario Di Napoli
    • 1
  1. 1.Neurological ServiceS. Camillo de’ Lellis General HospitalRietiItaly

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