Journal of Clinical Neuroscience 104 (2022) 103–106

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Journal of Clinical Neuroscience

journal homepage: www.journals.elsevier.com/journal-of-clinical-neuroscience

Original Research

Comparison of the modified method and the median sensory-ulnar motor

latency difference in the diagnosis of carpal tunnel syndrome
Hamza Şahin *, Hiba Çalışkan, Muhammet Yusuf Uslusoy
Department of Neurology, Kahramanmaraş Sütçü İmam University, Medical Faculty, Kahramanmaraş, Turkey

A R T I C L E I N F O A B S T R A C T

Keywords: Objectives: This study aimed to compare the modified method and the median sensory-ulnar motor latency dif­
Entrapment neuropathy ference in the diagnosis of carpal tunnel syndrome.
Electromyography Methods: The study recruited the electromyography results of 105 hands of 60 patients who had a complaint of
Hand diagram
carpal tunnel syndrome (CTS) on the hand diagram. The average sensory-ulnar motor delay difference
Median nerve
(MSUMLD) was determined by simple subtraction, and the modified method was calculated based on the results
of the classic method. The modified method and the MSUMLD were compared according to their sensitivity and
specificity in the diagnosis of CTS.
Results: In this study, 54 hands were evaluated with a unilateral nerve conduction study (45 right; 9 left). A total
of 23 hands with CTS and 31 hands without CTS were diagnosed electrophysiologically. The MSUMLD had
91.3% sensitivity and 93.5% specificity; however, the modified method showed 95.7% sensitivity and 96.8%
specificity in the diagnosis of CTS. Moreover, the modified method had 100% sensitivity and specificity in the
diagnosis of moderate CTS.
Conclusions: The modified method may have higher diagnostic accuracy than the MSUMLD for diagnosing CTS.

1. Introduction median sensory-ulnar motor latency difference (MSUMLD) is a new

Carpal tunnel syndrome (CTS) is the most common entrapment
neuropathy of the upper extremity and has an estimated prevalence of
3% in the general population [1–7]. It affects mainly women and over
40 years old people [3]. It is caused by chronic compression of the
median nerve under the transverse carpal ligament. The patients
generally apply to the outpatient clinics with complaints of pain,
numbness, and paresthesia in the distribution of the median nerve [8,9].
CTS is diagnosed based on clinical symptoms and electrodiagnostic
studies.
The routine electrodiagnostic tests are generally used not only to
confirm the diagnosis, but also to rule out the possible causes,
comprising radiculopathy or peripheral neuropathy [3,8,9]. However,
the sensitivity and specificity of these routine tests have some limita­
tions, especially for mild carpal tunnel syndrome. Previous studies have
shown that some patients with mild CTS complaints have normal nerve
conduction studies (NCS) [10,11]. Therefore, more sensitive methods
are needed to raise the diagnostic reliability of the CTS.
Recently various electrodiagnostic methods have been revealed in
different studies to solve the limitations of routine tests [4–6,12]. The
method used in some previous studies, and it is based on the normal the
ulnar nerve motor latency in CTS [3]. In these studies, it is claimed that
the MSUMLD may be the best-calculated parameter for diagnosing mild
CTS [13].
In the present study, we aimed to compare the modified method with
the MSUMLD in supporting the diagnosis of CTS.
2. Materials and methods
2.1. Patients
A total of 60 consecutive patients (105 hands), who had complaints
of CTS or radiculopathy, and applied to the EMG laboratory in two
months period, were recruited in this study. First, all patients were
evaluated according to the self-administered hand diagram. In the group
with CTS complaints (the case group), 80 hands diagnosed with classic
or probable CTS were detected according to the hand diagram. However,
the hands diagnosed with possible or unlikely CTS were not included in
the study. In the group with radiculopathy complaints (the control
group), 25 hands without a CTS diagnosis were found according to the

* Corresponding author.

https://doi.org/10.1016/j.jocn.2022.08.013
Received 16 July 2022; Accepted 16 August 2022
Available online 20 August 2022
0967-5868/© 2022 Elsevier Ltd. All rights reserved.
H. Şahin et al. Journal of Clinical Neuroscience 104 (2022) 103–106

hand diagram. Then, the EMG procedure was applied to these two
groups separately. The threshold values for the sensory velocity and
motor distal latency of the median nerve were estimated using the
average of the electrophysiological parameters (±2 SD) from the control
group. In the case group, 26 hands with insufficient EMG data, advanced
CTS, or ulnar neuropathy were excluded from the study. The study was
concluded with the results of 54 hands. The median sensory-ulnar motor
latency difference (MSUMLD) was determined by simple subtraction
and performed for the case group. The classic method defined below was
accepted as a gold standard measuring method for CTS. The modified
method (adapted by us) and the MSUMLD were compared separately
with the classic method to calculate the sensitivity and specificity of the
CTS diagnosis. This study was designed prospectively and informed
written consent was received from all the patients. The Research Ethics
Committee of the University Hospital, Faculty of Medicine, under the
Declaration of Helsinki (Session No: 2022/14, Decision No: 10, Date:
26.04.2022), approved the study.

2.2. Self-administered hand diagram

The case and control groups completed a self-administered hand

diagram by marking the areas of pain, numbness, tingling, and loss of
sensation on both sides of the hand. Two authors evaluated the hand
diagrams completed by the groups, and according to the results, CTS was
classified into four categories (classic, probable, possible, or unlikely)
[14].

2.3. Nerve conduction studies

The routine electrodiagnostic tests of the median and ulnar nerve

were performed by a 5-channel EMG device (Neurosoft). The filtering
settings were 20 Hz-2 kHz and the skin temperature was at or above
32 ◦ C during the study. Velcro ring electrodes were used for antidromic
sensory recording. The median sensory nerve action potential was
recorded at the digit II (finger)-palm and palm-wrist segments by anti­
dromic stimulation at 7 cm and 14 cm proximal to the active recording
electrode, respectively. The onset-latency and velocity of the median
sensory nerve action potential were obtained separately for each
segment. The median motor compound muscle action potential (CMAP)
was performed according to the belly-tendon principle, and the motor
distal latency was recorded over the midpoint of the abductor pollicis
brevis muscle at 8 cm proximal to it. Median CMAP was obtained over
the wrist and elbow by electrical stimulations along the course of the
median nerve. Ulnar CMAP distal latency was obtained at 8 cm proximal
to the belly of the abductor digiti minimi (ADM) muscle.
According to the classical method.
Fig. 1. Flow chart of patient enrollment CTS = carpal tunnel syndrome, NCS =
1- If median nerve palm-wrist sensory conduction velocity was ≥ 50 nerve conduction study.
cm/msec, it was considered no CTS.
2- If the velocity was < 50 cm/msec, mild CTS was diagnosed.
3- Those with a proximal velocity (pv) lower than the expected prox­
3- If the motor distal latency was > 3.67 msec, moderate CTS was
imal velocity (epv) were considered mild CTS, and those with distal
diagnosed.
latency (dl) higher than the expected distal latency (edl) were
4- If the median nerve had a low amplitude of compound muscle action
diagnosed as moderate CTS.
potential (<5mV), severe CTS was diagnosed.
4- The values of kvelocity and klatency were obtained from a plot study
conducted by us. In this study, the velocity constant (k velocity) cut-
According to the modified method.
off value was found to be “0.236381” with 93% sensitivity and
specificity, and the latency constant (k latency) cut-off value was
1- First, the palm-wrist sensory conduction velocity (proximal velocity
observed “0.025016” with 94% sensitivity and 95% specificity.
= pv), the second digit-palm sensory conduction velocity (distal
velocity = dv), the motor distal latency (dl), and the motor prox­
imal–distal latency difference (pdl) of the median nerve were 2.4. Statistical analysis
calculated by routine nerve conduction studies.
2- Second, the expected median sensory nerve proximal velocity (epv) All data were analyzed using IBM Statistical Package for the Social
and the expected median motor distal latency (edl) were calculated Sciences (SPSS) 26.0 (SPSS Inc., Chicago, IL, USA) program. The Chi-
using the formula “epv = dv*(1- kvelocity)” and the formula “edl = square test for categorical variables and the Mann-Whitney U test for
pdl*(1- klatency)”, respectively. continuous variables were used. Receiver operating characteristic (ROC)

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H. Şahin et al. Journal of Clinical Neuroscience 104 (2022) 103–106

Table 1 the median sensory proximal velocity and the mean value of the median
Comparison of the two groups in terms of the following variables: age, sex, motor distal latency were found 58.41 ± 4.24 cm/msec and 2.97 ± 0.35
stroke risk factors, and thyroid disease. msec, respectively. In the classical method, 2SD of these values were
Variables The group with CTS The group without CTS p used to calculate the thresholds (mild CTS = velocity < 50 cm/msec and
Age (years) 47.26 ± 9.38 42.77 ± 14.28 0.175
moderate CTS = distal latency > 3.67msec).
Sex (m/f) 1/22 9/22 0.032 The cut-off value of the MSUMLD was found to be “0.450” with 94%
DM (%) 21.7% 9.7% 0.269 sensitivity and 91% specificity (AUC = 0.932; p < 0.001) (Fig. 2). The
HTN (%) 21.7% 19.4% 0.546 values of the MSUMLD above “0.450” were determined as diagnostic
CAD (%) 4.3% 6.5% 0.612
criteria for the CTS. Table 2 summarizes the comparison of the modified
HL (%) 13.0% 19.4% 0.717
Smoking (%) 30.4% 22.6% 0.515 method and the MSUMLD via the sensitivity, specificity, and predictive
TD (%) 21.7% 6.5% 0.107 values in the diagnosis of CTS. Moreover, nine mild CTS and 14 mod­
erate CTS were diagnosed by the modified method. In diagnosing mild
CTS = carpal tunnel syndrome, m = male, f = female, DM = diabetes mellitus,
HTN = hypertension, CAD = coronary artery disease, TD = thyroid disease, HL
CTS, the modified method showed a sensitivity of 88.9% and a speci­
= hyperlipidemia. ficity of 96.8%. To diagnose moderate CTS, the modified method had
100% sensitivity and specificity.
curves analysis was performed to determine the cut-off value of the
4. Discussion
median sensory-ulnar motor latency difference. P-value < 0.05 was
assumed to be statistically significant.
According to our results, the modified method had more sensitivity
and specificity in diagnosing CTS than the MSUMLD. Moreover, this new
3. Results
method may diagnose mild and moderate CTS with high sensitivity and
specificity. Previous studies reported that there were significantly higher
All of these 54 hands were evaluated with a unilateral NCS (45 right;
CTS patients in the female population [13]. The present study found that
9 left). However, 26 hands were excluded because of insufficient or
there were more female than male patients diagnosed with CTS.
unexpected results (advanced CTS or ulnar neuropathy). A total of 23
Previous studies showed that the wrist-palm sensory conduction or
hands with CTS and 31 hands without CTS were diagnosed electro­
physiological using the classical method. Furthermore, the CTS group
consisted 11 mild and 12 moderate cases (Fig. 1).
It was found that each of these two groups (with or without CTS) Table 2
Comparison of the modified method and the MSUMLD in the CTS diagnosis.
included 22 women. However, women were detected much more in the
group with CTS than without CTS (95.7% vs 71%, respectively) (X2, p = Modified method MSUMLD
0.032). The mean age of the CTS group was 47.26 ± 9.38 years (range Sensitivity 95.7% 91.3%
18–76 years), and there were no significant differences between the two Specificity 96.8% 93.5%
groups (Mann-Whitney U, p = 0.175). It was also noticed that there were PPV 95.7% 91.3%
NPV 96.8% 93.5%
no differences between the two groups related to any systemic condi­ False positive 4.3% 8.7%
tions such as diabetes, hypertension, coronary artery disease, hyperlip­ False negative 4.3% 8.7%
idemia, smoking, and thyroid disease (X2, p > 0.05) (Table 1).
MSUMLD = median sensory-ulnar motor latency difference, PPV = positive
In the control group, none of the 25 hands were diagnosed with CTS
predictive value, NPV = negative predictive value.
by neither the hand diagram nor NCS. In this group, the mean value of

Fig. 2. The summary of three ROC analyzes.

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H. Şahin et al.
the median-ulnar comparison might be superior to the distal motor and
digit-wrist sensory latency measurements in diagnosing mild CTS cases
[15]. These studies have also claimed that ulnar sensory latency in all
patients with CTS may not be normal [16,17]. However, ulnar motor
latency can be used for detecting CTS. Because the slight pressure of the
ulnar nerve on the wrist usually does not affect the ulnar motor latency.
Therefore, researchers have reported that the MUSMLD may be used as a
reliable test for the early diagnosis of CTS [2]. The sensitivity and
specificity of nerve conducting methods in the diagnosis of CTS vary,
and the variety mainly comes from methodological differences. Bodof­
sky et al. showed that the MSUMLD had 95% sensitivity and 100%
specificity for mild CTS [18]. However, Emad et al. reported that the
sensitivity and specificity of the MSUMLD were lower than the results of
Bodofsky (86% and 70%, respectively) [2]. In our study, the sensitivity
and specificity of the MSUMLD were found at 91.3% and 93.5%,
respectively. However, the new method had 95.7% sensitivity and
96.8% specificity in the diagnosis of CTS.
A self-administered hand diagram is frequently used as a diagnostic
tool for CTS diagnosis, especially in epidemiological studies. This test is
easy to perform and has good sensitivity and specificity (80–96% and 73
%-90%, respectively). However, there are differences in the expression
or perception of CTS symptoms according to the ethnic or culture [19].
Therefore, in our study, just the classic or probable CTS sub-types
diagnosed by the hand diagram were accepted as diagnostic criteria
for clinic CTS.
The clinicians can apply this modified method easily in their daily
EMG routine. They need to know only distal median sensory velocity or
motor latency for calculating their threshold of the CTS. CTS causes a
segmental demyelinating neuropathy. Therefore, distal median sensory
velocity is generally protected. As a result, patients serve as their con­
trols, so there is no need for a standard laboratory threshold value to
diagnose CTS. In addition, the new method can contribute early diag­
nosis of mild or moderate CTS. Moreover, patients are diagnosed more
clearly than the other methods. Thus, patients may be diagnosed before
the operational state of the CTS.
The limitations of this study are its one-centered design and small
study sample size. However, the advantage of this method is that its
results may not be affected by age, height, weight, hand temperature,
and sex. Another benefit of this test is that this method may be easily
applied in different laboratories and countries.
5. Conclusion
According to our results, the modified method may have higher
diagnostic accuracy than the MSUMLD for diagnosing CTS. Moreover, it
requires only a simple calculation of the classic nerve conduction results.
Nevertheless, further prospective studies with a large sample size should
be performed to assess the modified method more clearly.
Declaration of Competing Interest
The authors declare that they have no known competing financial
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Journal of Clinical Neuroscience 104 (2022) 103–106
interests or personal relationships that could have appeared to influence
the work reported in this paper.
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