Musculoskeletal Imaging • Original Research

Campagna et al.
MRI of Carpal Tunnel Syndrome

Musculoskeletal Imaging
Original Research

MRI Assessment of Recurrent

Carpal Tunnel Syndrome After
FOCUS ON:

Open Surgical Release of the

Median Nerve
Raphaël Campagna1 OBJECTIVE. The purpose of this study was to retrospectively determine the accuracy of
Eric Pessis1 MRI in identification of the morphologic features of median nerve dysfunction after surgical
Antoine Feydy 1 release of the median nerve for carpal tunnel syndrome.
Henri Guerini1 MATERIALS AND METHODS. Two blinded readers independently evaluated axial
Dominique Le Viet 2 1.5-T MR images for retinacular regrowth, morphologic characteristics of the median nerve,
and presence of mass effect, fibrosis, and carpal tunnel decompression. All 47 patients (11
Patrick Corlobé2
men, 36 women; mean age, 55 years; range, 27–81 years) had undergone open surgical release
Jean-Luc Drapé1 of the median nerve for carpal tunnel syndrome. Thirty-five patients had electromyographic
Campagna R, Pessis E, Feydy A, et al. evidence of recurrent carpal tunnel syndrome. The other 12 patients did not have electrophys-
iologic evidence of recurrent carpal tunnel syndrome and were the control group.
RESULTS. A statistically significant difference between the recurrent carpal tunnel syn-
drome and control groups was found for fibrosis (p = 0.009), nerve enhancement (p = 0.04),
and median nerve width (p = 0.008) and ratio (p = 0.01) at the pisiform level.
CONCLUSION. MRI may be used in association with electromyography for accurate
postoperative evaluation of the carpal tunnel.

Keywords: carpal tunnel, electromyography, MRI, wrist
DOI:10.2214/AJR.08.1433
Received June 24, 2008; accepted after revision
February 3, 2009.
1 pose a challenging clinical problem. In addi-
Université Paris Descartes, Assistance Publique-
Hôpitaux de Paris, Service de Radiologie B, Hôpital
Cochin, 27 rue du Faubourg Saint Jacques, 75679 Paris
Cedex 14, France. Address correspondence to
R. Campagna (rcampagna@free.fr).
2
Institut de la Main, Paris, France.
AJR 2009; 193:644–650
0361–803X/09/1933–644
© American Roentgen Ray Society
T
he diagnosis of carpal tunnel syn-
drome (CTS) relies on clinical
features and electrophysiologic
data. Although imaging of the
median nerve in the carpal tunnel has received
attention in the literature, the technique has
limited value in the diagnosis of CTS in daily
practice [1, 2]. Surgical release of the median
nerve is frequently needed when conservative
treatment has failed. However, after surgical
release, some patients continue to have symp-
toms. Because failure of nerve decompression
has numerous causes [3–7], including teno-
synovitis of flexor tendons, nerve section, fi-
brosis, extrinsic nerve compression, nerve en-
trapment, and bone fracture, these patients
tion, the occurrence of subjective pain after
surgery is well known [8], and objective evi-
dence of nerve dysfunction must be present
for further surgical exploration. Imaging can
be helpful in the postoperative care of these
patients. We aimed to determine with MRI
the morphologic features of the median nerve
in patients with electrophysiologic (electro-
myographic [EMG]) evidence of recurrent
CTS after surgical release.
Materials and Methods
Our institutional review board approved this
study, and oral informed consent was obtained
from all patients.
Patient Sample
We performed a retrospective study of 47 wrists
of 47 patients (11 men, 36 women; mean age, 55
years; range, 27–81 years) consecutively referred
for MRI by an orthopedic surgeon at our institu-
tion. Because they had upper extremity symptoms
after open surgical release of the median nerve,
the 47 patients had been consecutively referred to
and reexamined by the orthopedic surgeon for
electrophysiologic evidence of CTS. The previous
surgical release had been performed by several or-
thopedic surgeons at other institutions. No patient
received steroid injections or other treatments to
manage chronic pain syndromes before the MRI
examination. During reexaminations, nerve con-
duction studies and needle EMG were used to de-
termine the presence or absence of recurrent CTS
after surgery.
Thirty-five patients had EMG evidence of recur-
rent CTS. The 12 patients without EMG evidence
of recurrent CTS were the control group. The con-
trol group was not a truly disease-free group. The

644 AJR:193, September 2009


patients had undergone MRI because of clinical
and electrophysiologic suspicion of ulnar nerve en-
trapment in Guyon’s tunnel (n = 1), clinical suspi-
cion of tenosynovitis (n = 3), and discrepancy be-
tween normal EMG results and clinical examination
findings (loss of grip strength, scar discomfort) (n =
8). To eliminate false-positive results, we excluded
patients who had undergone EMG or MRI within 6
months after surgery [9].
Imaging
MRI was performed with a 1.5-T MRI unit
(Signa Excite, GE Healthcare) with a dedicated
quadrature wrist coil. All patients were placed in
the MR imager in the prone position with the el-
bow extended overhead and the pronated hand in
the center of the coil. The pulse sequences were an
axial spin-echo T1-weighted sequence (TR/TE,
400/14; section thickness, 4 mm; field of view, 6
cm; acquisition time, 4 minutes 21 seconds; num-
ber of signals acquired, 4; matrix size, 256 × 160;
gap, 0.4 mm), an axial fast spin-echo STIR se-
quence (2,320/14; inversion time, 150 millisec-
onds; echo-train length, 9; section thickness, 4
mm; field of view, 6 cm; acquisition time, 3 min-
utes 36 seconds; number of signals acquired, 4;
matrix size, 256 × 160; gap, 0.4 mm), and an axial
fast spin-echo T1-weighted sequence with fat sup-
pression after IV injection of 0.1 mmol/kg of body
weight of gadoterate dimeglumine (Dotarem,
Guerbet) (600/15; echo-train length, 3; section
thickness, 4 mm; field of view, 6 cm; acquisition
time, 4 minutes 24 seconds; number of signals ac-
quired, 4; matrix, 256 × 160; gap, 0.4 mm). The
mean time between surgery and MRI was 28
months (range, 6–193 months), and the mean time
between MRI and electrophysiologic testing was 3
months (range, 0–24 months).
Electrophysiologic Tests
Electrophysiologic studies included needle EMG
and routine motor and sensory nerve conduction
studies. All studies were performed by the same
electrophysiologist before MRI. The needle elec-
trode was connected to an EMG system (Viking,
Nicolet). The 12 patients in the control group had
normal results of EMG and nerve conduction stud-
ies with the following data: no spontaneous muscu-
lar activity, distal motor latency less than 4.4 milli-
seconds, sensitive conduction velocity greater than
44 m/s, and Kimura centimetric value less than 0.2
ms/cm. Patients with at least one abnormal EMG or
nerve conduction result were included in the recur-
rent CTS group (n = 35) according to previous de-
scriptions [10–13]. Results can vary over the time
owing to environmental and technical factors [14].
In our study, however, all tests were performed by
the same electrophysiologist, and the temperature
AJR:193, September 2009 645
MRI of Carpal Tunnel Syndrome
of the room and the skin was monitored. All electro-
physiologic studies were performed at least 6
months after surgery.
Image Analysis
Two musculoskeletal radiologists (4 and 15
years of experience) blinded to electrophysiologic
results reviewed the images independently and
retrospectively at random using a PACS worksta-
tion (Carestream, Kodak). Discrepancies were re-
solved by consensus.
According to previous MRI descriptions of the
preoperative findings of CTS and known operative
complications [3, 6, 15–19], the following findings
were reviewed. First, regrowth of the flexor reti-
naculum was defined as a continuous, linear area
of low signal intensity superficial to the nerve and
thickened in the area deep in relation to the subcu-
taneous scar (Figs. 1 and 2). Regrowth included
incomplete resection of the retinaculum, the pres-
ence of scar tissue that mimicked retinaculum,
and true regrowth of the retinaculum.
Second, median nerve analysis included the
presence of high signal intensity on fast STIR im-
ages in comparison with thenar muscle signal in-
tensity (Fig. 3). Median nerve measurements were
obtained with an electronic caliper at the proximal
(pisiform) and distal (hook of the hamate) levels.
The cross-sectional area and ratio of width to
height (flattening ratio) were measured in milli-
meters at the two levels (Figs. 4 and 5). Nerve en-
hancement after IV gadolinium injection was con-
sidered high if stronger than thenar muscle
enhancement (Fig. 6B). The shortest distance be-
tween the skin and the volar margin of the median
nerve was measured on axial images with an elec-
tronic caliper at the distal level (Fig. 7).
Third, analysis of mass effect in the carpal tun-
nel included the presence of bursitis (focal fluid
collection > 1 cm in the carpal tunnel), a mass, ac-
cessory muscles or distal progression of the mus-
cle belly, bone fracture or fragment, or flexor ten-
TABLE 1:  Sensitivity, Specificity, and Predictive Values of MRI Signs in
Diagnosis of Recurrent Carpal Tunnel Syndrome
Sensitivity Specificity
Sign (%)
Retinacular regrowth 43
Carpal tunnel mass effect 26
Fibrosis 60
Median nerve enhancement 40
Median nerve high signal intensity 74
Carpal tunnel decompression
Good 20
Insufficient 80
don tenosynovitis (excessive fluid within the
tendon sheath with gadolinium enhancement).
Fourth, the presence of fibrosis was defined by an
extensive area of low signal intensity with an ill-
defined nerve margin on T1-weighted images
(Figs. 6 and 8). Fifth, to assess the quality of car-
pal tunnel decompression, we determined the po-
sition of the median nerve and leading flexor ten-
don. This position was compared with the line
joining the hook of the hamate to the ridge of the
trapezium, according to previous findings [20].
Carpal release was considered successful if the
tendon or nerve was located above the line and if
no tendon or nerve was entirely located under this
line (Fig. 9). In the other cases, carpal tunnel re-
lease was considered insufficient (Fig. 10).
Statistical Analysis
Quantitative variables were reported with the
mean and range (minimum to maximum). Cate-
goric variables were reported as count (percent-
age). Statistical analysis was performed with a
nonparametric test (Mann-Whitney) for quantita-
tive variables and Fisher’s test for categoric vari-
ables. All tests were two sided. A value of p < 0.05
was considered significant. Interrater agreement
was calculated for MRI findings (kappa). All anal-
yses were performed with statistical software
(MedCalc version 8.0, MedCalc Software).
Results
The sensitivity, specificity, and positive
and negative predictive values of MRI signs
are summarized in Table 1. The comparisons
of MRI signs for both groups are summa-
rized in Tables 2 and 3. The findings in the
recurrent CTS and control groups differed
statistically only for presence of fibrosis,
nerve enhancement, volar migration of nerve
and tendon (carpal decompression), and me-
dian nerve width and ratio at the pisiform
level. For the following items, there were no
Positive Predictive Negative Predictive
(%) Value (%) Value (%)
50 71 23
58 64 21
83 92 42
92 94 34
33 77 31
50 54 18
50 82 46
 Campagna et al.

Fig. 1—56-year-old woman with recurrent carpal tunnel syndrome and retinacular
regrowth after surgery. Axial T1-weighted spin-echo MR image (TR/TE, 400/14)
shows retinaculum as stripe of low signal intensity tightened from hook of hamate
to ridge of trapezium (arrows).
Fig. 2—61-year-old woman without electrophysiologic evidence of recurrent
carpal tunnel syndrome (control group) and retinacular section without regrowth
after surgery. Axial T1-weighted spin-echo MR image (TR/TE, 400/14) shows
discontinuous stripe of low signal intensity. Arrows indicate persistent gap of
retinaculum.

Fig. 3—46-year-old man with recurrent carpel tunnel syndrome. Axial T2- Fig. 4—54-year-old woman without electrophysiologic evidence of recurrent
weighted STIR MR image (TR/TE, 2,320/14; inversion time, 150 milliseconds) carpal tunnel syndrome (control group). Axial T1-weighted spin-echo MR image
shows high signal intensity of median nerve (asterisk) relative to hypothenar (TR/TE, 400/14) shows median nerve measurement at pisiform level calculated
muscle signal intensity (arrowhead). Arrows indicate site of retinacular regrowth. with electronic caliper. Median nerve ratio is low (2.63/2.87 = 0.92).

statistically significant differences between

groups: regrowth of the flexor retinaculum;
cross-section area of the median nerve, nerve
fast STIR signal intensity, shortest distance
between skin and volar margin of the nerve,
and nerve measurement at the hamate level;
and mass effect in the carpal tunnel. There Fig. 5—63-year-old man
was no statistical difference between groups with recurrent carpal
tunnel syndrome. Axial
in time between surgery and MRI or between T1-weighted spin-echo
surgery and EMG (p > 0.05). According to MR image (TR/TE, 550/19)
criteria commonly used for interpretation of shows median nerve
measurement at pisiform
values [21], interobserver agreement for all level calculated with
observed features was nearly perfect, sub- electronic caliper. Median
stantial, or moderate, except for direct visu- width and nerve ratio
is high (5.41/2.24 = 2.4).
alization of retinacular regrowth, which had
Flattened appearance of
fair agreement (Table 2). nerve is evident.

646 AJR:193, September 2009

 MRI of Carpal Tunnel Syndrome

A B
Fig. 6—53-year-old woman with recurrent carpal tunnel syndrome and superficial fibrosis of carpal tunnel.
A, Axial T1-weighted spin-echo MR image (TR/TE, 400/14) shows ill-defined area of low signal intensity (asterisk) between palmaris longus tendon (arrowhead) and volar
aspect of median nerve (arrow). Loss of shape of volar margin of median nerve is evident.
B, Axial gadolinium-enhanced fat-suppressed spin-echo T1-weighted MR image (400/14) shows strong enhancement of ill-defined area of low signal intensity (asterisk).
Arrow indicates strong enhancement of median nerve in comparison with hypothenar muscle enhancement (arrowhead).

Discussion
Our study showed that MRI is useful for
detecting signs of nerve dysfunction: gado-
linium-enhanced areas, fibrosis, abnormal
nerve width and ratio, and insufficient carpal
release. It also showed that MRI depicts signs
of nerve dysfunction but cannot replace
electrophysiologic tests. MRI can be per-
formed in association with EMG for patients
with pain after carpal tunnel release.
Complications of carpal tunnel release oc-
cur in 3–19% of cases in large series and ne-
cessitates reexploration of the area for vari-
ous reasons in as many as 12% of cases [22].
In a previous meta-analysis [23], endoscopic
carpal tunnel release was comparable with
open release in rate of irreversible nerve
damage. Consequently, there likely was no
bias in our study sample, all of the patients
having undergone open surgical release. The
rate of recurrence of CTS ranges from 1% to
25% [7]. The common causes of recurrent
CTS after surgery are incomplete resection
or regrowth of the flexor retinaculum, fibrous
proliferation, flexor tenosynovitis, and ex-
trinsic median nerve compression (accessory
muscle belly, cyst) [3–7]. We did not analyze
the failure rate of carpal tunnel surgery be-
cause only patients who underwent postop-
erative EMG and MRI were included.
Physical examination of patients who have
undergone carpal tunnel surgery is especial-
ly difficult because of subjective pain and
scar discomfort, which are frequent after
CTS surgery [8] and must be differentiated
from actual persistent median nerve injury.
We chose our patients only on the basis of
objective results of electrophysiologic tests,
although EMG results sometimes are abnor-
mal for several months. In our study, howev-
er, the mean time between surgery and EMG
was more than 2 years, probably reducing
the number of false-positive cases.
To the best of our knowledge, this report is
the first to describe MRI evidence of postop-
erative changes after systematic IV gadolini-
um injection with a control group. In one
study [24], investigators compared postoper-
ative MRI features in patients with recurrent
CTS with those in controls but without gado-
linium injection. Another set of authors [25]
used gadolinium-enhanced MRI to evaluate
recurrent CTS but in only three patients.
Direct visualization of retinacular regrowth
had only fair agreement and cannot be used to
assess carpal tunnel decompression. The oth-
er MRI features described had acceptable
interobserver agreement and therefore may be
used to assess decompression.
In our study, nerve enhancement was sta-
tistically correlated with recurrent CTS. The
cause of this enhancement remains unclear.
The nerve enhancement we observed might
have been the result of persistent nerve ede-
ma [26, 27] or partial nerve injury, as usually
is found with posttraumatic neuroma [28].
Fig. 7—72-year-old
woman with recurrent
carpal tunnel syndrome.
Axial spin-echo T1-
weighted MR image (TR/
TE, 400/14) at hamate
level (10.45 mm) shows
shortest distance
(arrow) between skin
and volar margin of
median nerve.

AJR:193, September 2009 647

 Campagna et al.

A B
Fig. 8—62-year-old woman with recurrent carpal tunnel syndrome and deep fibrosis of carpal tunnel.
A, Axial spin-echo T1-weighted MR image (TR/TE, 400/14) shows area of low signal intensity (arrowheads) on dorsal aspect of median nerve with mass effect on
displaced flexor tendon (asterisks).
B, Gadolinium-enhanced fat-suppressed axial T1-weighted spin-echo MR image (400/14) shows strong enhancement of ill-defined area (arrowheads). Asterisk indicates
nerve enhancement.

Median nerve signal intensity has been
analyzed previously in patients who have un-
dergone surgery, and reduced median nerve
T2-weighted signal intensity has been found
in patients with good clinical outcome [15,
17, 18, 29]. Our recurrent CTS group had
more median nerves with increased T2-
weighted signal intensity than did the control
group, as was found previously [24]. This
difference, however, was not significant, and
the criteria for T2-weighted signal intensity
of the median nerve could not be used to dif-
ferentiate pathologic and healthy nerves after
surgical release.
The cross-sectional area of the median nerve
at the pisiform level has been described [10, 13]
as the most accurate criterion in the preopera-
tive diagnosis of CTS. We found nerve height
and cross-sectional area at the pisiform and
hamate levels to be not significantly different
between the recurrent CTS and control groups.
These results suggest that these various mea-
surements have limited clinical utility in the
evaluation of postoperative CTS.
The median nerve width and flattening ra-
tio at the pisiform level was higher in the re-
current CTS than in the control group, and
the difference was statistically significant.
This difference has been previously reported
[24] and may be an indirect sign of persistent
nerve compression.
Because interobserver agreement was only
fair for direct visualization of the retinacu-

Fig. 9—49-year-old man without electrophysiologic evidence of recurrent carpal
tunnel syndrome (control group) and with leading flexor tendon and median
nerve position in carpal tunnel after surgical release of nerve. Axial T1-weighted
spin-echo MR image (TR/TE, 400/14) shows nerve (arrowhead) and flexor tendon
(asterisk) above line joining hook of hamate to ridge of trapezium. Carpal tunnel
release was considered successful.
Fig. 10—67-year-old woman with recurrent carpal tunnel syndrome and leading
flexor tendon and median nerve position in postoperative carpal tunnel. Axial
T1-weighted spin-echo MR image (TR/TE, 550/19) shows nerve (arrowhead) and
flexor tendon (asterisk) under line joining hook of hamate to ridge of trapezium.
Carpal tunnel release was considered insufficient.

648 AJR:193, September 2009

 MRI of Carpal Tunnel Syndrome

TABLE 2:  Prevalence of MRI Signs in Wrists With Recurrent Carpal Tunnel were seen in both groups. Synovial cyst was
Syndrome and Controls seen only in the recurrent CTS group and is
a well-known cause of compression. The low
Recurrent Carpal
Tunnel Syndrome Control Interobserver rate of mass effect may explain the absence
Sign (n = 35) (n = 12) pa Agreement (κ) of a significant difference of this feature be-
tween the recurrent CTS and control groups.
Retinacular regrowth 15 (43) 6 (50) 0.6 0.3
Presence of median nerve fibrosis was a
Carpal tunnel mass effect 9 (26) 5 (42) 0.4 relevant sign of recurrent CTS. We found a
Flexor tendons tenosynovitis 3 (8.6) 4 (33.3) 0.92 60% rate of fibrosis in the recurrent CTS
Synovial cyst 3 (8.6) 0 1 group versus 17% in the control group. This
finding is consistent with findings after sur-
Accessory muscles 3 (8.6) 1 (8.3) 0.66
gical revision [22]. The detection of fibrosis
Fibrosis 21 (60) 2 (16.6) 0.009 0.67 is helpful for planning surgical reinterven-
Deep 10 (28) 0 tion, and interposition of a composite graft
Superficial 11 (31) 2 (16.6) around the median nerve has been proposed
[31]. Two patterns of fibrosis were observed
Median nerve enhancement 14 (40) 1 (8.3) 0.04 0.63
in previous surgical studies [22, 32]: superfi-
Median nerve high signal intensity 26 (74) 8 (66.7) 0.19 0.46 cial extensive fibrosis between the palmaris
Carpel tunnel decompression 0.04 1 longus tendon and the volar aspect of the
Good 7 (20) 6 (50) nerve and deep fibrosis on the dorsal aspect
of the median nerve with mass effect on the
Insufficient 28 (80) 6 (50)
adjacent flexor tendon. In our study, deep fi-
Note—Data are numbers with percentage in parentheses. brosis was seen only in the recurrent CTS
aFisher’s test.
group (28%) and was more frequent in our
study than in previous surgical observations
lum, we considered this feature not relevant Although abnormal nerve and tendon migra-
[22, 32]. These results suggest that deep fi-
in the assessment of carpal tunnel decom- tion is related to median nerve dysfunction,
brosis may be more frequent than previously
pression. To quantitatively assess decom- the sensitivity and specificity (50%) of this
expected [22, 32]. Superficial fibrosis was
pression, we determined the position of the MRI finding are too low and cannot be used
found more often in the recurrent CTS group
median nerve and leading flexor tendon rela- in daily practice.
(46% versus 17% in control group). This
tive to the line joining the hook of the hamate We found nine cases of mass effect, in-
finding is consistent with the results of a sur-
to the ridge of the trapezium, as described cluding abnormal muscle belly, synovial
gical study [32] showing a 34% rate of super-
previously [20]. Insufficient carpal release cysts, and tenosynovitis, as described previ-
ficial scar tethering.
was more frequent in the recurrent CTS ously [6, 15, 16, 19, 22, 30]. Abnormal mus-
The mean distance between the skin and
group than in the control group (p = 0.04). cle belly and tenosynovitis were rare but
the volar aspect of the median nerve was the
TABLE 3:  Quantitative MRI Values in Wrists With Recurrent Carpal Tunnel same in our groups. Wu et al. [24] described
Syndrome and in Control Group a more palmar location of the median nerve
in their recurrent CTS group but without a
Recurrent Carpal Tunnel Control significant difference from controls.
Value Syndrome (n = 35) (n = 12) pa
Fibrosis can be detected and median nerve
Mean distance between skin and volar 8.8 (4–20) 8.6 (6–11) 0.9 measurements made without gadolinium in-
margin of median nerve (mm) jection. In our experience, however, in diffi-
Median nerve width (mm) at level of cult cases, injection of gadolinium was help-
Pisiform 6.17 5.04 0.008 ful for detecting fibrosis and measuring the
median nerve in the presence of fibrosis.
Hook of hamate 5.94 5.21 0.08
Moreover, nerve enhancement was statisti-
Median nerve height (mm) at level of cally correlated with EMG dysfunction. Thus
Pisiform 2.63 2.75 0.5 we believe that use of gadolinium injection
Hook of hamate 2.84 3.08 0.5 leads to more accurate diagnosis, especially
in difficult cases, and helps surgeons in the
Median nerve surface (mm2) at level of
planning of reintervention.
Pisiform 12.90 10.88 0.1 Our study had several limitations. The
Hook of hamate 13.16 12.04 0.7 first was the retrospective design and the
Median nerve ratio at level of small number of patients with full electro-
physiologic recovery after surgical treatment
Pisiform 2.42 1.90 0.01
(control group). Further prospective studies
Hook of hamate 2.28 1.87 0.1 with a larger number of patients are needed
aNonparametric test (Mann-Whitney U test). to confirm our results. Second, our patients

AJR:193, September 2009 649


were referred to a tertiary care center, which
does not allow extension of our results to pri-
mary care. Third, the criteria for MRI refer-
ral of patients with previous surgery for CTS
at our institution were determined by our
surgeon, which constitutes inclusion bias in
this retrospective study. The fourth limita-
tion was lack of surgical confirmation of the
MRI findings.
We conclude that MRI with gadolinium en-
hancement can depict signs of median nerve
dysfunction after surgical release of the nerve
and show nerve enlargement at the pisiform
level. Moreover, MRI can be used to detect
the presence of fibrosis and may be helpful in
surgical planning. Thus MRI in association
with EMG can be proposed for accurate post-
operative evaluation of the carpal tunnel.
References
1. Jarvik JG, Yuen E, Haynor DR, et al. MR nerve
imaging in a prospective cohort of patients with
suspected carpal tunnel syndrome. Neurology
2002; 58:1597–1602
2. Radack DM, Schweitzer ME, Taras J. Carpal tun-
nel syndrome: are the MR findings a result of
population selection bias? AJR 1997; 169:1649–
1653
3. Botte MJ, von Schroeder HP, Abrams RA, Gell-
man H. Recurrent carpal tunnel syndrome. Hand
Clin 1996; 12:731–743
4. Hybbinette CH, Mannerfelt L. The carpal tunnel
syndrome: a retrospective study of 400 operated
patients. Acta Orthop Scand 1975; 46:610–620
5. Lo SL, Raskin K, Lester H, Lester B. Carpal tun-
nel syndrome: a historical perspective. Hand Clin
2002; 18:211–217
6. Murphy RX Jr, Chernofsky MA, Osborne MA,
Wolson AH. Magnetic resonance imaging in the
evaluation of persistent carpal tunnel syndrome. J
Hand Surg [Am] 1993; 18:113–120
7. Steyers CM. Recurrent carpal tunnel syndrome.
Hand Clin 2002; 18:339–345
8. Siegmeth AW, Hopkinson-Woolley JA. Standard
open decompression in carpal tunnel syndrome
compared with a modified open technique pre-
serving the superficial skin nerves: a prospective
randomized study. J Hand Surg [Am] 2006;
650 AJR:193, September 2009
Campagna et al.
31:1483–1489
9. Shurr DG, Blair WF, Bassett G. Electromyo-
graphic changes after carpal tunnel release. J
Hand Surg [Am] 1986; 11:876–880
10. El Miedany YM, Aty SA, Ashour S. Ultrasono-
graphy versus nerve conduction study in patients
with carpal tunnel syndrome: substantive or com-
plementary tests? Rheumatology (Oxford) 2004;
43:887–895
11. Kele H, Verheggen R, Bittermann HJ, Reimers
CD. The potential value of ultrasonography in the
evaluation of carpal tunnel syndrome. Neurology
2003; 61:389–391
12. Kimura J. The carpal tunnel syndrome: localiza-
tion of conduction abnormalities within the distal
segment of the median nerve. Brain 1979;
102:619–635
13. Nakamichi K, Tachibana S. Ultrasonographic
measurement of median nerve cross-sectional
area in idiopathic carpal tunnel syndrome: diag-
nostic accuracy. Muscle Nerve 2002; 26:798–803
14. Bleasel AF, Tuck RR. Variability of repeated
nerve conduction studies. Electroencephalogr
Clin Neurophysiol 1991; 81:417–420
15. Allmann KH, Horch R, Uhl M, et al. MR imaging of
the carpal tunnel. Eur J Radiol 1997; 25:141–145
16. Buchberger W. Radiologic imaging of the carpal
tunnel. Eur J Radiol 1997; 25:112–117
17. Cudlip SA, Howe FA, Clifton A, Schwartz MS,
Bell BA. Magnetic resonance neurography stud-
ies of the median nerve before and after carpal
tunnel decompression. J Neurosurg 2002; 96:
1046–1051
18. Horch RE, Allmann KH, Laubenberger J, Langer
M, Stark GB. Median nerve compression can be
detected by magnetic resonance imaging of the
carpal tunnel. Neurosurgery 1997; 41:76–82
19. Mesgarzadeh M, Schneck CD, Bonakdarpour A,
Mitra A, Conaway D. Carpal tunnel: MR imag-
ing. Part II. Carpal tunnel syndrome. Radiology
1989; 171:749–754
20. Netscher D, Mosharrafa A, Lee M, et al. Trans-
verse carpal ligament: its effect on flexor tendon
excursion, morphologic changes of the carpal ca-
nal, and on pinch and grip strengths after open
carpal tunnel release. Plast Reconstr Surg 1997;
100:636–642
21. Landis JR, Koch GG. The measurement of ob-
server agreement for categorical data. Biometrics
1977; 33:159–174
22. Stutz N, Gohritz A, van Schoonhoven J, Lanz U.
Revision surgery after carpal tunnel release: anal-
ysis of the pathology in 200 cases during a 2 year
period. J Hand Surg [Br] 2006; 31:68–71
23. Boeckstyns ME, Sorensen AI. Does endoscopic
carpal tunnel release have a higher rate of compli-
cations than open carpal tunnel release? An anal-
ysis of published series. J Hand Surg [Br] 1999;
24:9–15
24. Wu HT, Schweitzer ME, Culp RW. Potential MR
signs of recurrent carpal tunnel syndrome: initial
experience. J Comput Assist Tomogr 2004; 28:
860–864
25. Silbermann-Hoffman O, Touam C, Miroux F,
Moysan P, Oberlin C, Benacerraf R. Contribution
of magnetic resonance imaging for the diagnosis
of median nerve lesion after endoscopic carpal
tunnel release. Chir Main 1998; 17:291–299
26. Kobayashi S, Baba H, Uchida K, et al. Localiza-
tion and changes of intraneural inflammatory cy-
tokines and inducible-nitric oxide induced by
mechanical compression. J Orthop Res 2005; 23:
771–778
27. Sugimoto H, Miyaji N, Ohsawa T. Carpal tunnel
syndrome: evaluation of median nerve circulation
with dynamic contrast-enhanced MR imaging.
Radiology 1994; 190:459–466
28. Nolte I, Pham M, Bendszus M. Experimental
nerve imaging at 1.5-T. Methods 2007; 43:21–28
29. Allmann KH, Horch R, Gabelmann A, Lauben-
berger J, Stark GB, Langer M. Morphology of the
carpal tunnel: movement studies in patients with
constriction symptoms and healthy probands us-
ing MR tomography [in German]. Unfallchirur-
gie 1996; 22:5–11
30. Schon R, Kraus E, Boller O, Kampe A. Anoma-
lous muscle belly of the flexor digitorum superfi-
cialis associated with carpal tunnel syndrome:
case report. Neurosurgery 1992; 31:969–970
31. De Smet L, Vandeputte G. Pedicled fat flap cover-
age of the median nerve after failed carpal tunnel
decompression. J Hand Surg [Br] 2002; 27:350–
353
32. Frick A, Baumeister RG. Re-intervention after
carpal tunnel release [in German]. Handchir Mik-
rochir Plast Chir 2006; 38:312–316