Iranian Journal of Orthopedic Surgery

Abstract Introduction: Carpal tunnel syndrome (CTS) represents the most prevalent form of compressive neuropathy. Although electrodiagnostic assessments (EMG–NCV) are routinely used for diagnosis and demonstrate good accuracy, they are invasive procedures and can sometimes produce false‑negative outcomes. In recent years, high‑resolution ultrasonography has gained attention as a noninvasive, widely available, and cost‑efficient diagnostic option. The purpose of this study was to investigate the usefulness of sonographic evaluation in diagnosing CTS and to examine how its findings relate to clinical symptoms and electrophysiological results.
Materials & Methods: In this cross‑sectional diagnostic study, individuals with a clinical suspicion of carpal tunnel syndrome were assessed. Each participant underwent both EMG–NCV testing and bilateral wrist ultrasonography. Sonographic variables, including the cross‑sectional area (CSA) and the width of the median nerve at various points along the forearm and within the carpal tunnel, were compared among electrodiagnostic severity categories classified as normal, mild, moderate, and severe. The sensitivity and specificity were determined for chosen CSA and nerve‑width cutoff values.
Results & Discussion: 60 patients with the mean age of 49.5±10.4 years and mean BMI of 26.8±3.6 kg/m² being 90% female and 80% with bilateral involvement were studied. Age was not significantly associated with CTS severity (P=0.344), whereas higher BMI correlated with greater severity (P=0.01). Median nerve CSA width increased parallel with disease severity. In the right hand, a CSA cut off of 8.5 mm² at the carpal tunnel yielded 87.5% sensitivity and 81.7% specificity; in the left hand, a CSA cut off of 8 mm² provided 70% sensitivity and 95.5% specificity. Nerve width ≥ 5 mm showed high sensitivity but lower specificity.
Conclusion: Ultrasonography—especially assessing the cross‑sectional area of the median nerve—serves as a dependable, noninvasive, and precise complementary tool alongside EMG–NCV for both identifying and grading the severity of CTS.

Abstract Introduction: Carpal tunnel syndrome (CTS) is a common compressive neuropathy of the upper limb. Given the variable performance of conventional diagnostic approaches, quantitative magnetic resonance imaging may assist clinical decision-making. This study evaluated the diagnostic value of quantitative magnetic resonance imaging metrics.
Materials & Methods: In a cross-sectional diagnostic study of 30 patients at a university center, clinical severity of CTS was assessed using the validated Persian Boston Carpal Tunnel Questionnaire, and electrodiagnostic testing and classified-involvement as mild, moderate, or severe. Wrist magnetic resonance imaging with routine sequences was performed with observer blinding to clinical and electrodiagnostic data. The median nerve cross-sectional area at the distal tunnel outlet, intraneural signal intensity, and the signal intensity ratio of nerve to hypothenar muscle were measured and compared with normal subjects. Analyses used appropriate tests with a significance threshold of p<0.05.
Results & Discussion: The median nerve cross-sectional area was larger in patients than in normal (11.36±1.89 vs 9.70±1.63 mm²; p<0.05). Intraneural signal intensity was higher in patients (597.13±52.95 vs 501.67±40.50; p<0.05). The nerve-to-hypothenar signal intensity ratio was also increased (1.31±0.26 vs 0.80±0.13; p<0.01).
Conclusion: Quantitative magnetic resonance imaging metrics demonstrate significant discriminatory power between patients and normal and may serve as adjuncts in the diagnostic pathway. This pattern accords with the pathobiology of compression (edema and structural change) and supports the utility of quantitative magnetic resonance imaging as a complement to clinical examination and electrodiagnostic testing. Standardization of measurement sites and thresholds, and multicenter prospective studies, are required to translate these findings reliably to practice.

Abstract Introduction: Pillar pain is one of the common sequelae after carpal tunnel release (CTR), presenting as deep pain or tenderness upon pressure on the thenar and hypothenar regions. It potentially interferes with return to work and patient satisfaction. This narrative review was conducted with a focus on the etiology, emerging therapeutic approaches, and a practical management algorithm for pillar pain.
Materials & Methods: A structured search of PubMed and complementary sources was performed from 2018 up to December 2025. Clinical trials, systematic reviews and meta-analyses, cohort studies, and high-quality narrative reviews addressing pillar pain, risk factors, pathophysiology, or post‑CTR treatments were identified and categorized.
Results & Discussion: The evidence suggests that pillar pain is a self‑limiting condition, and approximately half of the patients may experience it, with most cases resolving within 3 to 6 months. The etiology is multifactorial and includes biomechanical alterations of the carpal arch after division of the transverse carpal ligament, soft‑tissue inflammation or scarring, irritation or neuroma of the palmar cutaneous branch of the median nerve, and central mechanisms. Non‑surgical treatment is the mainstay of management and encompasses patient education and reassurance, occupational hand therapy modalities (desensitization, massage, graded exercises), non‑opioid analgesics and anti‑inflammatory medications. In refractory cases, minimally invasive options such as extracorporeal shock wave therapy (ESWT) and photo biomodulation may be used. Emerging evidence on fractional CO₂ laser therapy for treatment‑resistant pillar pain is promising but still limited. From a preventive standpoint, minimally invasive techniques and appropriate choice of skin closure method may influence short‑term pillar pain.
Conclusion: Pillar pain after CTR is usually benign and transient but requires a stepwise, multimodal approach. Combining patient education, targeted rehabilitation, and non‑opioid pain strategies, with selective use of minimally invasive interventions in refractory cases, offer safe and efficacious treatment.

Abstract Abstract
Carpal Tunnel Syndrome (CTS) is the most common idiopathic neuropathic compression syndrome in the upper extremity, with a reported prevalence of 2.7% in the general population. Trigger Finger (TF) is a common upper limb disorder characterized by the painful locking of one or more fingers. A review of the literature, and personal experiences of the authors indicates that the occurrence of Trigger Finger after Carpal Tunnel Syndrome surgery is significantly higher in patients with CTS compared to those without CTS, though this increase in incidence has not definitively been linked to the surgery. In most studies, thumb has been the most commonly involved finger in association with CTS; however, in some cases, the third finger was more common. In contrast, when TF occurs alone, the fourth finger is typically the most frequently affected finger with triggering in the fourth one.

Abstract Background: There are advantages and disadvantages for bilateral simultaneous carpal tunnel release (CTR) surgery and also lack of clinical guidelines about this type of surgery. This study aimed to compare the activity level and level of satisfaction post surgery among people who have undergone unilateral and bilateral simultaneous release surgery.
Methods: This longitudinal descriptive study was conducted on 60 patients with bilateral CTS, who were candidates for surgery based on the inclusion and exclusion criteria of the relevant statistical population. A total of 30 patients who wanted to perform bilateral simultaneous CTR surgeries and 30 patients who wanted to perform unilateral CTR surgery were operated by an orthopaedic specialist. The ADL-IADL questionnaire was completed before the surgery, three and 14 days after the surgery.
Results: The ADL-IADL questionnaire showed no significant difference between the two groups in the dependency score of the samples before surgery, three and 14 days after surgery. In the checklist used to evaluate the satisfaction of the results of the surgery in daily life tasks, 95% of patients expressed high or moderate satisfaction with their surgery, while only 5% expressed neither satisfaction nor dissatisfaction.
Conclusion: According to the results, the ability to perform daily life tasks, especially in observing personal hygiene in patients, who underwent bilateral simultaneous surgery three days after the surgery, did not significantly differ from those who underwent unilateral surgery. Most of the patients who underwent bilateral surgery were satisfied with this type of surgery. Finally, in this study, bilateral simultaneous CTR was suggested for people with bilateral CTS.

Abstract Abstract Background: Carpal tunnel syndrome (CTS) is the most common form of localized peripheral neuropathy. CTS and cervical radiculopathy (CR) often co-occur, known as double crush syndrome (DCS). Aim: This study aimed at determining frequency of CR in patients with CTS referred to electrodiagnosis department of Rasht Imam Reza clinic. Materials and Methods: This was a descriptive cross-sectional study on 117 patients with CTS referred to Imam Reza clinic. The patients’ data were recorded through a questionnaire including electrodiagnosis test results, patients’ demographic data, medical history and disease primary diagnosis and related results, electromyogram (EMG)/nerve conduction velocity (NCV) tests results. NCV test shows CTS type (unilateral and bilateral) as well as its severity, while EMG test determines co-occurrence of CR and CTS, type and severity of DCS. Finally, the data were entered into SPSS 19, and analyzed using statistical tests. Results: Out of 117 patients with primary diagnosis of CTS, 21 patients (17.9%) were male and 96 patients (82.1%) were female, with a mean age of 46.5 years. The highest frequency (41.5%) in patients with CTS belonged to housewives. 48 (41%) patients had bilateral CTS and 69 patients (59%) suffered from unilateral one. DCS prevalence in this study was about 35%. Out of 41 patients with DCS, 25 patients (61%) had unilateral DCS with moderate severity (48.8%) and C7 radiculopathy (70.7%). Using binary logistic regression analysis (method=ENTER) showed that age and body mass index (BMI) were two variables affecting on the simultaneous development of CTS and cervical spines involvement (P<0.0001). Conclusion: Since knowing simultaneous presence of CR and CTS in patients’ therapy is necessary, patients with CTS should be examined for DCS.

Abstract  Background: Some authors suggested using ultrasound in diagnosis of carpal tunnel syndrome (CTS), however the efficacy of ultrasound in determining the severity of disease is unclear. In current study, we aimed to investigate the diagnostic efficacy of ultrasound in determining the severity of CTS in comparison with NCV using measurement of cross-sectional area of median nerve. Methods: In a prospective study, 181 CTS suspected wrists (94 patients) were investigated. The cross-sectional area of the median nerve was measured using ultrasound and the severity of disease was determined based on criteria of El Miedany et al. Based on the NCV, the patients were divided into four groups of normal, mild, moderate or severe CTS. Finally, the mean cross-sectional area was compared between the groups and the kappa agreement coefficient for determining the severity of disease by the two methods was calculated. Results: The mean cross-sectional area increased significantly with increase in disease severity (p < /i>>.001). Conclusions: Determination of cross-sectional area of median nerve with ultrasound can be a useful tool in decision-making about surgical intervention in carpal tunnel syndrome. However, the clinical correlation is mandatory.  

Abstract Background: Carpal tunnel syndrome is the entrapment of median nerve in carpal tunnel, resulting in pain and numbness in hand and fingers. It is the most common cause of nerve entrapment in the upper limb. There are two main treatment protocoles: medical and surgical. Methods: In a cohort study, in 220 patients with carpal tunnel syndromes, splinting was compared with sugery. During a 12 months period, symptoms relief and function improvement were evaluated, using the Levine questionnaire. Results: There was no difference between the two groups at the beginning. In the first and third months of follow-up the symptoms severity was lower in splint group but in the six and twelve month evaluation, the surgical group had less symptoms. Regarding functional improvement, the same results occurred with better results in one and three months for splint group and in six and twelve months for surgical group. Conclusions: Although splinting for carpal tunnel syndrome had superior results in first two months, the improvement with surgery is better maintained into 6-12 months .

Abstract Background: Diagnosis of carpal tunnel syndrome is based on clinical findings and these findings are used to confirm the diagnosis. Sonography is also a noninvasive method for diagnosis of carpal tunnel syndrome. The purpose of this study was to investigate the role of sonography and electrodiagnostic studies in diagnosis of this syndrome. Methods: In a prospective study, 76 hands with diagnosis of carpal tunnel syndrome (study group) were compared with 80 hands (control group) in a training hospital in Kerman-Iran. In both groups the diameter of median nerve was measured by sonography and electrodiagnostic studies were performed only on the study group. The study group, post surgery, was followed up for 6 months and the DASH preoperative functional scoring was compared with post operative scores. Results: The difference between the diameters of the median nerve measured by sonography (p=.0001) and also the difference between before and after-operation Dash Score in the patient group (p=.001) were statistically significant. Sonography was 95% sensitive and 93% specific for the diagnosis of carpal tunnel syndrome. A weak correlation was found between the severity of the disease in electrodiagnostic studies and sonography (p < .01, r=.38). No correlation was proved between the sonographic or electrodiagnostic findings and Dash score before and after the operation (p≥.05). Conclusion: sonography might be a suitable module for the diagnosis of carpal tunnel syndrome, but there were no correlation between its findings or electrodiagnostic findings and functional scores. Whether or not sonography could be substitute for electerodiagnostic tests, will need further investigation.

Abstract Background: Carpal tunnel syndrome is one of the most common compression neuropathies in the upper limb and requires surgery if conservative treatment fails. This article compares the result of regular open incision, midpalmar mini incision and endoscopic technique in carpal tunnel release.Methods: This is a clinical trial study on 53 patients (5 males, 48 females) within one year, who were surgical candidates. The surgery was done by arthroscopy, with regular open incision or with mid palmar small incision. The clinical outcomes were evaluated one week, 4 weeks and 4 months post surgery.Results: Relief and satisfaction were better in the first month in the arthroscopic and mini-incision group. All 3 techniques had similar outcomes after 4 months. In 4-months follow-up, night pain relief, followed by parasthesia relief were the ones with the best improvement. Weakness was the symptom with the least improvement. Longer incision cases were associated with more delay to return to work.Conclusion: Carpal tunnel release with endoscopic and mini incision techniques have a better early satisfaction rates compared to regular open incision, but no difference is seen between the two groups after four months.

Abstract Background: Carpal tunnel syndrome develops by compression of the median nerve within the carpal tunnel. There is no "gold standard" test for a definite diagnosis of this syndrome. Carpal tunnel syndrome is a constellation of signs and symptoms. The aim of this study is to investigate the correlation of the subjective, objective and electrophysiological findings in patients who had carpal tunnel syndrome and underwent carpal tunnel surgery.Methods: A prospective study performed on 103 patients who had carpal tunnel surgery. Subjective evaluation accomplished by two standard questionnaires. Objective findings were comprised of Tinel’s sign, Phalen test, pinch and power grip, and electrophysiologic evaluation. Statistical tests were used to evaluate the data.Results: There was a statistically significant linear correlation between the Tinel's sign and Phalen test. There was a positive correlation between the "means" of the pinch and power grip. There was a positive correlation between average symptom severity scale and functional status scale. In patient with severe electrophysiological findings there was a statistically significant correlation between subjective, objective and electrophysiological findings.Conclusions: It seems that in advanced stages, significant correlation between subjective, objective and electrophysiological findings is present.