'Cuff Sign' a new maneuver for decision-making in patients with carpal tunnel syndrome


1 Department of Neurology, Isfahan University of Medical Sciences, Isfahan, Iran

2 Department of Neurosurgery, Isfahan University of Medical Sciences, Isfahan, Iran

3 Department of Neurology, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran

4 Isfahan Neurosciences Research Center, Isfahan University of Medical Sciences, Isfahan, Iran


Background: Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy that results from compression of the median nerve within the carpal tunnel. In most patients, the diagnosis can be proposed based on patient history and clinical symptoms, with physical findings being attributed only in more severely affected patients. The purpose of this study is to introduce a reliable and accurate method for the proper selection of patients with mild carpal tunnel syndrome (CTS), for surgery.
Materials and Methods: Electerodiagnostic studies are performed before and after placement of the cuff of the sphygmomanometer at the arm (Cuff sign), at a mean arterial pressure, for three minutes. Thirty symptomatic patients with mild findings on electrodiagnostic studies and 49 asymptomatic control hands have been included.
Results: Fifteen patients reported good pain relief on the first postoperative day (50%), which increased to 21 on the fouteenth postoperative day (70%). The sensory latency changes were significantly higher in the pain relief group, both on the first and fourteenth postoperative days.
Conclusion: Considering the fact that cooperation of the patients is not necessary and the double effects of direct pressure and ischemia over the proximal parts of the median nerve leads to prolonged latencies, this test is a useful method for decision-making in patients with severe symptoms of CTS, despite the mild electrodiagnostic findings.


Low HL, Sivasamy VP, Griffiths AP, Redfern RM. Recurrent carpal tunnel syndrome owing to an implantation epidermoid cyst after carpal tunnel decompression: Case report. Neurosurgery 2007;60:E956.  Back to cited text no. 1
MacDermid JC, Wessel J. Clinical diagnosis of carpal tunnel syndrome: A systematic review. J Hand Ther 2004;17:309-19.  Back to cited text no. 2
Sonohata M, Tsuruta T, Mine H, Asami A, Ishii H, Tsunoda K, et al. Clinical characteristics of neuropathic pain in patients with carpal tunnel syndrome. Hand Surg 2014;19:43-8.  Back to cited text no. 3
de Krom MC, Knipschild PG, Kester AD, Thijs CT, Boekkooi PF, Spaans F. Carpal tunnel syndrome: Prevalence in the general population. J Clin Epidemiol 1992;45:373-6.  Back to cited text no. 4
Graham B, Regehr G, Naglie G, Wright JG. Development and validation of diagnostic criteria for carpal tunnel syndrome. J Hand Surg Am 2006;31:919-24.  Back to cited text no. 5
Szabo RM, Slater RR Jr, Farver TB, Stanton DB, Sharman WK. The value of diagnostic testing in carpal tunnel syndrome. J Hand Surg Am 1999;24:704-14.  Back to cited text no. 6
Werner RA, Franzblau A, Gell N, Hartigan AG, Ebersole M, Armstrong TJ. Incidence of carpal tunnel syndrome among automobile assembly workers and assessment of risk factors. J Occup Environ Med 2005;47:1044-50.  Back to cited text no. 7
Atroshi I, Gummesson C, Johnsson R, Ornstein E, Ranstam J, Rosén I. Prevalence of carpal tunnel syndrome in a general population. JAMA 1999;282:153-8.  Back to cited text no. 8
Mondelli M, Giannini F, Giacchi M. Carpal tunnel syndrome incidence in a general population. Neurology 2002;58:289-94.  Back to cited text no. 9
Padua L, Aprile I, Lo Monaco M, Padua R, Pasqualetti P, Nazzaro M, et al. Italian multicentre study of carpal tunnel syndrome: Clinical-neurophysiological picture and diagnostic pathway in 461 patients and differences between the populations enrolled in the northern, central and southern centres. Italian CTS Study Group. Ital J Neurol Sci 1999;20:309-13.  Back to cited text no. 10
Faucett J, Blanc PD, Yelin E. The impact of carpal tunnel syndrome on work status: Implications of job characteristics for staying on the job. J Occup Rehabil 2000;10:55-69.  Back to cited text no. 11
Hennessey WJ, Falco FJ, Braddom RL, Goldberg G. The influence of age on distal latency comparisons in carpal tunnel syndrome. Muscle Nerve 1994;17:1215-7.  Back to cited text no. 12
Nowak M, Noszczyk B. Simple clinical tests in severe carpal tunnel syndrome. Pol Przegl Chir 2012;84:502-8.  Back to cited text no. 13
Katz JN, Larson MG, Fossel AH, Liang MH. Validation of a surveillance case definition of carpal tunnel syndrome. Am J Public Health 1991;81:189-93.  Back to cited text no. 14
Katz JN, Simmons BP. Clinical practice. Carpal tunnel syndrome. N Engl J Med 2002;346:1807-12.  Back to cited text no. 15
Liu F, Watson HK, Carlson L, Lown I, Wollstein R. Use of quantitative abductor pollicis brevis strength testing in patients with carpal tunnel syndrome. Plast Reconstr Surg 2007;119:1277-83.  Back to cited text no. 16
Bergquist ER, Hammert WC. Timing and appropriate use of electrodiagnostic studies. Hand Clin 2013;29:363-70.  Back to cited text no. 17
Hansen PA, Micklesen P, Robinson LR. Clinical utility of the flick maneuver in diagnosing carpal tunnel syndrome. Am J Phys Med Rehabil 2004;83:363-7.  Back to cited text no. 18
Katz JN, Stirrat CR, Larson MG, Fossel AH, Eaton HM, Liang MH. A self-administered hand symptom diagram for the diagnosis and epidemiologic study of carpal tunnel syndrome. J Rheumatol 1990;17:1495-8.  Back to cited text no. 19
Phalen GS. The carpal-tunnel syndrome. Seventeen years' experience in diagnosis and treatment of six hundred fifty-four hands. J Bone Joint Surg Am 1966;48:211-28.  Back to cited text no. 20
Dammers JW, Roos Y, Veering MM, Vermeulen M. Injection with methylprednisolone in patients with the carpal tunnel syndrome: A randomised double blind trial testing three different doses. J Neurol 2006;253:574-7.  Back to cited text no. 21
Rahman KU, Rahman S, Khan A, Khan NA, Khan FU, Khan RA, et al. Assessing the complications and effectiveness of open carpal tunnel release in a tertiary care centre in a developing country. Int J Surg Case Rep 2014;5:209-11.  Back to cited text no. 22
Chammas M. Carpal tunnel syndrome. Chir Main 2014;33:75-94.  Back to cited text no. 23
Nam KP, Gong HS, Bae KJ, Rhee SH, Lee HJ, Baek GH. The effect of patient involvement in surgical decision making for carpal tunnel release on patient-reported outcome. J Hand Surg Am 2014;39:493-8.  Back to cited text no. 24
Bland JD. A neurophysiological grading scale for carpal tunnel syndrome. Muscle Nerve 2000;23:1280-3.  Back to cited text no. 25
Hjermstad MJ, Fayers PM, Haugen DF, Caraceni A, Hanks GW, Loge JH, et al.,; European Palliative Care Research Collaborative (EPCRC). Studies comparing numerical rating scales, verbal rating scales, and visual analogue scales for assessment of pain intensity in adults: A systematic literature review. J Pain Symptom Manage 2011;41:1073-93.  Back to cited text no. 26
Kilmer DD, Davis BA. Electrodiagnosis in carpal tunnel syndrome. Hand Clin 2002;18:243-55.  Back to cited text no. 27
Oliveira JT. Carpal tunnel syndrome: Controversies regarding clinical and electrodiagnosis and its work-relatedness. Arq Neuropsiquiatr 2000;58:1142-8.  Back to cited text no. 28
Gerr F, Letz R. The sensitivity and specificity of tests for carpal tunnel syndrome vary with the comparison subjects. J Hand Surg Br 1998;23:151-5.  Back to cited text no. 29
Stevens JC, Sun S, Beard CM, O'Fallon WM, Kurland LT. Carpal tunnel syndrome in Rochester, Minnesota, 1961 to 1980. Neurology 1988;38:134-8.  Back to cited text no. 30
Werner RA, Franzblau A, Albers JW, Buchele H, Armstrong TJ. Use of screening nerve conduction studies for predicting future carpal tunnel syndrome. Occup Environ Med 1997;54:96-100.  Back to cited text no. 31
Buck AA, Gart JJ. Comparison of a screening test and a reference test in epidemiologic studies. I. Indices of agreement and their relation to prevalence. Am J Epidemiol 1966;83:586-92.  Back to cited text no. 32
Gart JJ, Buck AA. Comparison of a screening test and a reference test in epidemiologic studies. II. A probabilistic model for the comparison of diagnostic tests. Am J Epidemiol 1966;83:593-602.  Back to cited text no. 33
Padua L, Giannini F, Girlanda P, Insola A, Luchetti R, Lo Monaco M, et al. Usefulness of segmental and comparative tests in the electrodiagnosis of carpal tunnel syndrome: The Italian multicenter study. Italian CTS Study Group. Ital J Neurol Sci 1999;20:315-20.  Back to cited text no. 34
Beekman R, Visser LH. Sonography in the diagnosis of carpal tunnel syndrome: A critical review of the literature. Muscle Nerve 2003;27:26-33.  Back to cited text no. 35
Jarvik JG, Yuen E, Kliot M. Diagnosis of carpal tunnel syndrome: Electrodiagnostic and MR imaging evaluation. Neuroimaging Clin N Am 2004;14:93-102.  Back to cited text no. 36