The use of transcranial motor-evoked potentials, somatosensory-evoked potentials and free-run electromyography for proper placement of paddle leads in chronic pain.

Introduction: As an alternative to those patients who cannot be performed an awake spinal cord stimulation (SCS) or had been percutaneously implanted with poor pain relief outcomes, neurophysiological monitoring through transcranial motor evoked potentials (MEPs), somatosensory-evoked potentials (SSEPs) and free-run electromyography (EMG) under general anesthesia allows the correct placement of surgical leads and provide objective responses.Methods: An initial series of 15 patients undergoing SCS implantation for chronic pain. Physiologic midline was determined with 32-channel NIM-Eclipse System equipment. During neurophysiological monitoring, MEPs, SSEPs, EMG and CMAPs were recorded.Results: MEPs, SSEPs, and EMG were able to target spinal cord physiological midline during SCS to all patients. Physiologic midline was deviated in 53% patients. No warning events in SSEPs, MEPs, or EMG were recorded in any patient.Conclusions: Bilateral CMAPs recording allows placement of paddle leads in physiological midline, obtaining an accurate coverage, pain relief and avoid unpleasant or ineffective stimulation postoperatively. While these neurophysiological techniques are generally used to provide information on the state of the nervous system and prevent neurological injury risks during SCS, our work has shown that can accurate direct lead placement.

Potentially toxic elements fluxes in 210Pb-dated sediment cores from a large coastal lagoon (southern Gulf of Mexico) under environmental stress.

Terminos Lagoon (TL), in the southern Gulf of Mexico, has been under intensive anthropogenic pressure (e.g., oil-industry development) since the 1970s. Historical changes in flux ratios of potentially toxic elements (PTEs; As, Cd, Cr, Cu, Ni, Pb, V, Zn) were, for the first time, assessed inside TL by using 210Pb-dated sediment cores. Sediments showed minor enrichments for Cd, Ni, Pb, and V. However, according to international benchmarks, the As, Cr, Cu, and Ni concentrations could pose a risk for benthic biota. Sedimentary processes involved in the accumulation of PTEs were identified through a chemometric approach. Increments in PTEs flux ratios concur with the recent (⁓50 years) and extensive land-use changes, particularly the transport and deposit of materials delivered by rivers. These findings are expected to be used in managing this crucial natural resource, the larger Mexican coastal lagoon ecosystem, to mitigate the effects of global change.

Vocal fold immobility with normal LEMG: A range of possibilities.

OBJECTIVE: The objective of this paper is to study the etiology of vocal fold immobility with non-pathological LEMG. METHODS: A retrospective study was performed on patients who presented with vocal fold immobility and underwent LEMG from 2009 to 2017. Those patients with normal LEMG findings were selected. The different causes of vocal fold impairment were studied. RESULTS: Of the 120 patients included in this study, 15 had a normal LEMG recording. The different etiologies of vocal fold immobility were idiopathic, central nervous system damage, iatrogenic, and external compression. CONCLUSIONS: Vocal fold immobility and vocal fold paralysis are not equal terms. Vocal fold immobility with normal LEMG has a heterogeneous group of causes. It is not correct to assume that the major cause of immobility in patients with normal LEMG is always cricoarytenoid joint fixation.

Neurophysiological Findings in Critical COVID-19 Patients With Peripheral Nervous System Manifestations.

INTRODUCTION: Coronavirus disease 2019 patients hospitalized in intensive care units develop neuromuscular manifestations. However, to our knowledge, a study describing the neurophysiological findings in these patients has not been reported. The objective of this study was to diagnose the cause of neuromuscular deficit in severe coronavirus disease 2019 patients, through neurophysiological examination. METHODS: This is a retrospective, observational case series. Data were collected from April 13, 2020, to May 31, 2020. Twenty-two coronavirus disease 2019 patients with generalized neuromuscular deficit during intensive care unit hospitalization were studied. Neurophysiological examinations included motor and sensory peripheral nerve conductions, needle electromyography, F waves, and repetitive nerve stimulation. RESULTS: The subjects were 14 men (63.6%) and eight women, ranged from 35 to 74 years old (58.0, interquartile ranges 50.7-66.2). Intensive care unit hospitalization time ranged from 14 to 82 days (median 37.5, interquartile ranges 22.7-55.0). Through neurophysiological examination, myopathy was diagnosed in 17 patients (77.3%) and polyneuropathy in four (18.2%). Focal neuropathies were diagnosed in 12 patients (54.6%), with a total of 19 affected nerves. Common peroneal nerve lesions at the fibular head (68.4%) and ulnar nerve lesions at the elbow level (21.1%) were the most frequent locations. No significant differences were established between neurophysiological findings and clinical or analytical data. CONCLUSIONS: In critical coronavirus disease 2019 patients with neuromuscular complaints, neurophysiological examination provides an accurate diagnosis-useful to select treatment measures and establish the prognosis of recovery. Neurophysiological findings are similar to those described for critical illness neuromuscular disease, with myopathy being the most frequent diagnosis.

Biogeochemical behaviour of cadmium in sediments and potential biological impact on mangroves under anthropogenic influence: A baseline survey from a protected nature reserve.

Cadmium is a toxic element and its effects are well understood for human health, but its biogeochemical behaviour is still poorly studied and understood in natural ecosystems. This work addresses knowledge gaps concerning its presence, biogeochemical behaviour and impacts in mangrove ecosystems. Through geochemical data and multivariate analysis (i.e., factor and cluster analysis) of data from mangroves of Isla del Carmen, one of the largest extents in Mexico we explored the biogeochemical behaviour of Cd, a potentially toxic element, to identify its anthropogenic sources and interactions with sediments. Pollution indices, including enrichment factor (EF), geo-accumulation index (Igeo), sediment quality guidelines (SQG) and toxicological studies were used to assess the biological impacts of Cd and infer the natural levels tolerated by mangrove trees that form the basis of this natural ecosystem. Our results highlighted that Cd accumulation is driven by interactions between organic matter (OM), sulphur and fine particles; whereas enrichment factor showed values of 6.9 (EF) and 3.5 (EF) associated with point sources and ranged between 2 and 2.9 (EF) in relation to non-point sources. Finally, our geochemical approach revealed that Cd enrichment originates from urban activities and from the poor management of urban residuals.

Accumulation and fluxes of potentially toxic elements in a large coastal lagoon (southern Gulf of Mexico) from 210Pb sediment chronologies.

Three 210Pb-dated sediment cores were used to evaluate the contamination degree and flux ratios of potentially toxic elements (PTEs; As, Cd, Cr, Cu, Ni, Pb, V, and Zn) in seagrass meadows from the northern margin of Términos Lagoon (TL), southern Gulf of Mexico. The sediments displayed minor Cd, Ni, V, and Zn enrichments but moderate to strong enrichment by As. Results from a chemometric analysis revealed that: 1) salinization and grain size, along with 2) the terrigenous inputs are the major factors influencing the PTEs accumulation. The historical trends of PTEs flux ratios nearly follow the large-scale land-use changes around TL, linked to the growth of the Mexican oil industry in the area since the 1970s. Our findings showed the critical role of seagrass meadows as PTEs sinks. This information is useful for decision-makers to develop restoration projects for a vulnerable site within the largest coastal lagoon ecosystem in Mexico.

Vocal fold immobility with normal LEMG: A range of possibilities.

OBJECTIVE: The objective of this paper is to study the etiology of vocal fold immobility with non-pathological LEMG. METHODS: A retrospective study was performed on patients who presented with vocal fold immobility and underwent LEMG from 2009 to 2017. Those patients with normal LEMG findings were selected. The different causes of vocal fold impairment were studied. RESULTS: Of the 120 patients included in this study, 15 had a normal LEMG recording. The different etiologies of vocal fold immobility were idiopathic, central nervous system damage, iatrogenic, and external compression. CONCLUSIONS: Vocal fold immobility and vocal fold paralysis are not equal terms. Vocal fold immobility with normal LEMG has a heterogeneous group of causes. It is not correct to assume that the major cause of immobility in patients with normal LEMG is always cricoarytenoid joint fixation.

Clinical experience with patients with spasmodic dysphonia and primary Meige syndrome. / Experiencia clínica en pacientes con síndrome de Meige primario y disfonía espasmódica.

INTRODUCTION: Meige syndrome (MS) is part of the group of segmental cranial dystonias, which affect more than two cranial muscle groups. Specifically, blepharospasm is associated with another cranial dystonia (oromandibular, cervical or laryngeal). The aim of this paper was to report our experience in patients with spasmodic dysphonia (SD) associated with primary MS. MATERIAL AND METHODS: A retrospective study involving 8 patients between May 2010 and June 2015. Variables recorded were: age, sex, associated dystonia, electromyographic pattern in laryngeal muscles and treatment given. Outcomes after treatment were assessed using GRBAS(i) scale and VHI-30 questionnaire, always provided by the same examiner. RESULTS: Fifty-six patients with MS were treated in the Neurology Department. Eight patients of 56 were diagnosed with SD (prevalence of 14%). All of our patients had adductor SD. The median age was 71years. All the patients were treated with intralaryngeal botulinum toxin under electromyographic control. Clinically relevant improvements were found after treatment on both the GRBAS(i) scale and the VHI-30 questionnaire. CONCLUSION: In the study of SD, we should always rule out an association with MS. From the point of view of otorhinolaryngology, the joint use of the GRBAS(i) scale and the VHI-30 questionnaire are useful, reliable and efficient methods for assessing progress and response to treatment. Laryngeal infiltration under electromyographic control with botulinum toxin is the therapeutic alternative that provides better results. The management of SD associated with MS does not differ from isolated SD.

Inmovilidad de cuerdas vocales con electromiografía laríngea normal: un abanico de posibilidades / Vocal fold immobility with normal LEMG: A range of possibilities

Objective: The objective of this paper is to study the etiology of vocal fold immobility with non-pathological LEMG. Methods: A retrospective study was performed on patients who presented with vocal fold immobility and underwent LEMG from 2009 to 2017. Those patients with normal LEMG findings were selected. The different causes of vocal fold impairment were studied. Results: Of the 120 patients included in this study, 15 had a normal LEMG recording. The different etiologies of vocal fold immobility were idiopathic, central nervous system damage, iatrogenic, and external compression. Conclusions: Vocal fold immobility and vocal fold paralysis are not equal terms. Vocal fold immobility with normal LEMG has a heterogeneous group of causes. It is not correct to assume that the major cause of immobility in patients with normal LEMG is always cricoarytenoid joint fixation. (AU)

Objetivo: El propósito de este artículo es estudiar la etiología de la inmovilidad de las cuerdas vocales con una EMG laríngea no patológica. Métodos: Se ha realizado un estudio retrospectivo de pacientes con inmovilidad de cuerdas vocales a los que se les hizo EMG laríngea desde 2009 a 2017. Se seleccionaron los pacientes con EMG laríngea normal. Se estudiaron las diferentes causas de inmovilidad de las cuerdas vocales. Resultados: De los 120 pacientes incluidos en el estudio, 15 tuvieron un resultado de EMG laríngea normal. Las diferentes etiologías de inmovilidad de las cuerdas vocales fueron idiopáticas, lesiones del sistema nervioso central, causas iatrogénicas y compresión externa. Conclusiones: La inmovilidad de cuerdas vocales y la parálisis de cuerdas vocales no son términos equivalentes. La inmovilidad de cuerdas vocales con EMG laríngea normal tiene un grupo de causas heterogéneo. No es correcto asumir que la principal causa de inmovilidad de cuerdas vocales en pacientes con EMG laríngea normal sea siempre la fijación cricoaritenoidea. (AU)

Laryngeal Electromyography for Prognosis of Vocal Fold Paralysis.

OBJECTIVE: This study aimed to determine the value of laryngeal electromyography in the prognosis of vocal fold paralysis. STUDY DESIGN: This is a retrospective descriptive study. MATERIALS AND METHODS: This study included 80 patients diagnosed with unilateral or bilateral vocal fold paralysis on flexible laryngoscopy between 2002 and 2014 in a tertiary medical center. Laryngeal electromyography using a standardized protocol was performed; the outcome measures were classified and analyzed into two groups according to the degree of injury. Group 1 included patients with mild to moderate injury, and group 2 included patients with severe to complete injury. Prognosis was correlated with vocal fold motion recovery status with a minimum of 6 months of follow-up since the symptoms onset using positive and negative predictive values. RESULTS: Sixty patients showed acute or chronic recurrent laryngeal neuropathy in laryngeal electromyography. Twelve of 41 patients included in group 1 recovered motion, and 30 of 35 patients included in group 2 did not recover, resulting in 88.2% of positive predictive value and 35.7% of negative predictive value. CONCLUSIONS: Our data confirm that laryngeal electromyography is a useful clinical tool in predicting poor recovery in patients with vocal fold paralysis. It allows identification of candidates for early intervention.

Herpes zoster-induced abdominal wall paresis: neurophysiological examination in this unusual complication.

BACKGROUND: Herpes zoster affects essentially sensory fibres with segmental distribution. Abdominal wall paresis is a rare complication. AIMS OF THE STUDY: We present the case of a 72 year-old man with herpes zoster infection in T11-T12 left dermatomes and segmental abdominal wall protrusion. METHODS: Electromyography (EMG) and dermatomal somatosensory evoked potentials (DSEPs) were performed 27 days after symptoms onset. RESULTS: EMG confirmed acute axonal lesion in left external oblique muscle and left paraspinal muscles at T11-T12 level and DSEPs assessed topographic distribution: there was no response in the left side at T12 dermatome. Three months following the onset of shingles, the abdominal wall protrusion had completely resolved. CONCLUSIONS: Neurophysiological examination, including EMG and DSEPs, confirms motor and sensory loss in this unusual post-herpetic complication.

[Laryngeal electromyography in diagnosis and treatment of voice disorders]. / Electromiografía laríngea en el diagnóstico y tratamiento de los trastornos de la voz.

INTRODUCTION AND OBJECTIVES: Laryngeal electromyography, together with clinical evaluation, is a valuable tool in voice disorder management. It assesses the integrity of laryngeal nerves and muscles, contributing to the diagnosis of many diseases, especially laryngeal movement disorders. Our purpose was to describe the experience of the first Spanish series with laryngeal electromyography in evaluating voice disorders. METHODS: A prospective study was designed to evaluate laryngeal movement disorders with laryngeal electromyography. Both the cricothyroid and thyroarytenoid muscles were tested routinely and, in some cases, the posterior cricoarytenoid muscle. The laryngeal electromyography technique and result interpretation were performed by a laryngologist and a neurophysiologist. RESULTS: We included 110 patients, with the most common symptom being dysphonia. Laryngeal electromyography was performed in 85% of cases. Primary diagnosis before electromyography was laryngeal immobility. Positive predictive value for diagnosis in cases of paralysis was 88%. CONCLUSIONS: Laryngeal electromyography is a useful adjunct, together with clinical evaluation, for diagnosis and management of motion abnormalities in the larynx in patients who present with dysphonia.

Experiencia clínica en pacientes con síndrome de Meige primario y disfonía espasmódica / Clinical experience with patients with spasmodic dysphonia and primary Meige síndrome

Introducción: El síndrome de Meige (SM) es considerado una distonía craneal segmentaria que afecta a dos o más músculos craneales. Específicamente, asocia blefaroespasmo a otra distonía craneal (oromandibular, cervical o laríngea). El objetivo de este artículo es presentar nuestra experiencia clínica en pacientes con disfonía espasmódica (DE) asociada a SM primario. Material y métodos: Estudio retrospectivo realizado entre mayo de 2010 y junio de 2015. Incluyó 8 pacientes. Las variables recogidas fueron: sexo, edad, distonías asociadas, electromiografía laríngea y tratamiento. Los resultados clínicos objetivados fueron realizados, siempre por el mismo investigador, con la escala GRBAS(i) y el cuestionario VHI-30. Resultados: Cincuenta y seis pacientes fueron tratados de SM por el servicio de Neurología. Ocho pacientes asociaron DE (prevalencia 14%). El 100% de nuestros pacientes tenían DE aductora. La mediana de edad para la aparición de DE fue de 71años. Todos los pacientes fueron tratados con infiltración intralaríngea de toxina botulínica bajo control electromiográfico. Se objetivó mejoría clínica tanto en la escala GRBAS(i) como en los cuestionarios VHI-30. Conclusión: En el estudio de la DE siempre debe tenerse presente su posible asociación con el SM. Desde el punto de vista otorrinolaringológico, el uso conjunto de la escala GRBAS(i) y los cuestionarios VHI-30 es útil, fiable y eficiente como método para evaluar evolución y respuesta a tratamiento. La infiltración laríngea de toxina botulínica bajo control electromiográfico es la alternativa terapéutica que provee mejores resultados clínicos. El manejo de la DE asociada al SM no difiere del de la DE aislada

Introduction: Meige syndrome (MS) is part of the group of segmental cranial dystonias, which affect more than two cranial muscle groups. Specifically, blepharospasm is associated with another cranial dystonia (oromandibular, cervical or laryngeal). The aim of this paper was to report our experience in patients with spasmodic dysphonia (SD) associated with primary MS. Material and methods: A retrospective study involving 8 patients between May 2010 and June 2015. Variables recorded were: age, sex, associated dystonia, electromyographic pattern in laryngeal muscles and treatment given. Outcomes after treatment were assessed using GRBAS(i) scale and VHI-30 questionnaire, always provided by the same examiner. Results: Fifty-six patients with MS were treated in the Neurology Department. Eight patients of 56 were diagnosed with SD (prevalence of 14%). All of our patients had adductor SD. The median age was 71years. All the patients were treated with intralaryngeal botulinum toxin under electromyographic control. Clinically relevant improvements were found after treatment on both the GRBAS(i) scale and the VHI-30 questionnaire. Conclusion: In the study of SD, we should always rule out an association with MS. From the point of view of otorhinolaryngology, the joint use of the GRBAS(i) scale and the VHI-30 questionnaire are useful, reliable and efficient methods for assessing progress and response to treatment. Laryngeal infiltration under electromyographic control with botulinum toxin is the therapeutic alternative that provides better results. The management of SD associated with MS does not differ from isolated SD

[Validity and usefulness of echography in the carpal tunnel syndrome]. / Validez y utilidad de la ecografía en el síndrome del túnel carpiano.

OBJECTIVE: To evaluate the accuracy and utility of ultrasonography for the diagnosis of carpal tunnel syndrome (CTS). MATERIAL AND METHOD: Prospective and blind study of 75 wrists in 42 consecutive patients with suspected CTS. Electrodiagnostic testing (EDT) was used as gold standard. We measure different ultrasonographic parameters and based on a fitted receiver operating characteristic curve, we estimated post-test probabilities for the proximal, middle and distal cross-sectional area of median nerve. We analyzed interobserver and interreader reliability by 3 different explorers and 2 different readers, cost and the patient discomfort. RESULTS: Mean ultrasound measurements were significantly higher in the EDT positive group. There was a high concordance between sonography and nerve conduction. A cut-off of 9.5 mm(2) resulted in the correct classification of 83% of cases (sensitivity 88% and specificity 67%). Conversely, a cut-off of >14 mm(2) or <7 mm(2) had excellent power to rule in CTS, with a post-test probability of 100% of specificity and sensitivity respectively. The interobserver acquisition ICC was 0.915-0.980, and the inter-reader ICC was 0.912-0.987. Ultrasound cost savings in this study were €J3217.59 (€42.9 per symptomatic wrist) and the discomfort perceived by the patient was significantly lesser 6.3 vs 56 in EDT (P <.0005). CONCLUSIONS: Ultrasound median nerve crosssectional area is reliable and may be used to accurately rule in or rule out CTS. Sonography as a first-line test is cost-effective and is more satisfactory to the patients.

Electromiografía laríngea en el diagnóstico y tratamiento de los trastornos de la voz / Laryngeal electromyography in diagnosis and treatment of voice disorders

Introducción y objetivos: La electromiografía laríngea es una herramienta útil en el diagnóstico y tratamiento de los trastornos de la voz. Proporciona información acerca del estado de los nervios y músculos laríngeos completando la evaluación diagnóstica de un gran número de afecciones, fundamentalmente los trastornos del movimiento laríngeo. Presentamos la primera serie española, hasta donde tenemos referencias, que describe la utilidad de dicha prueba en la valoración de los trastornos de la voz. Métodos: Se diseñó un estudio prospectivo descriptivo mediante la creación de un protocolo de valoración para trastornos del movimiento laríngeo, que incluyera la realización de electromiografía laríngea. Los músculos estudiados fueron ambos cricoaritenoideos y tiroaritenoideos en todos los casos y el cricotiroideo posterior en algunos pacientes. La realización de la prueba y la interpretación de los resultados se realizó de forma conjunta por un especialista en Otorrinolaringología y un especialista en Neurofisiología Clínica. Resultados: Ciento diez pacientes fueron incluidos en el estudio. El síntoma de presentación más frecuente fue la disfonía. Se realizó electromiografía laríngea en un 85% de los casos. La entidad diagnóstica más frecuente fue la inmovilidad laríngea. En el caso de la parálisis laríngea, la electromiografía tuvo un valor predictivo positivo del 88% para el diagnóstico. Conclusiones: La electromiografía laríngea es una herramienta útil utilizada de forma conjunta con la exploración clínica en el diagnóstico y el tratamiento de las alteraciones del movimiento laríngeo que cursan habitualmente con disfonía(AU)

Introduction and objectives: Laryngeal electromyography, together with clinical evaluation, is a valuable tool in voice disorder management. It assesses the integrity of laryngeal nerves and muscles, contributing to the diagnosis of many diseases, especially laryngeal movement disorders. Our purpose was to describe the experience of the first Spanish series with laryngeal electromyography in evaluating voice disorders. Methods: A prospective study was designed to evaluate laryngeal movement disorders with laryngeal electromyography. Both the cricothyroid and thyroarytenoid muscles were tested routinely and, in some cases, the posterior cricoarytenoid muscle. The laryngeal electromyography technique and result interpretation were performed by a laryngologist and a neurophysiologist. Results: We included 110 patients, with the most common symptom being dysphonia. Laryngeal electromyography was performed in 85% of cases. Primary diagnosis before electromyography was laryngeal immobility. Positive predictive value for diagnosis in cases of paralysis was 88%. Conclusions: Laryngeal electromyography is a useful adjunct, together with clinical evaluation, for diagnosis and management of motion abnormalities in the larynx in patients who present with dysphonia(AU)

Validez y utilidad de la ecografía en el síndrome del túnel carpiano / Validity and usefulness of echography in the carpal tunnel syndrome

Objetivo: Evaluar la validez y la utilidad de la ecografía en el síndrome del túnel carpiano (STC). Material y método: Estudio ecográfico ciego y prospectivo en 75 carpos de 42 pacientes consecutivos con sospecha de STC. Se utiliza la electromiografía (EMG) como prueba de referencia. Se miden distintos parámetros ecográficos y mediante curvas ROC se estiman las probabilidades tras la prueba para los diferentes cortes del área de sección transversal del mediano (AST). Se analiza la fiabilidad entre explorador y lector con tres exploradores diferentes y dos lectores. Finalmente se efectúa un estudio de costes y de satisfacción del paciente. Resultados: Las medias de los parámetros ecográficos son significativamente mayores en el grupo con STC. Hay una alta concordancia entre la ecografía y la conducción nerviosa. Un punto de corte del AST en 9,5 mm2 clasifica correctamente el 83% de los casos (sensibilidad del 88% y especificidad del 67%). Un punto de corte mayor de 14 mm2 o menor de 7 mm2 tiene una probabilidad tras la prueba para el STC del 100% de especificidad y sensibilidad respectivamente. Los coeficientes de correlación intraclase (ICC) entre observadores fueron 0,915-0,980, y entre lectores, 0,912-0,987. La ecografía puede resultar más económica y ahorrar en el estudio 3.217,59 euros (42,9 euros por muñeca sintomática). El malestar percibido por los pacientes fue significativamente menor: EVA, 6,3 con ecografía frente a 56 con el EMG (p < 0,0005). Conclusiones: La ecografía es fiable y válida para definir si hay o no STC. La ecografía como prueba de primera línea es coste-efectiva y más satisfactoria para los pacientes (AU)

Objective: To evaluate the accuracy and utility of ultrasonography for the diagnosis of carpal tunnel syndrome (CTS). Material and method: Prospective and blind study of 75 wrists in 42 consecutive patients with suspected CTS. Electrodiagnostic testing (EDT) was used as gold standard. We measure different ultrasonographic parameters and based on a fitted receiver operating characteristic curve, we estimated post-test probabilities for the proximal, middle and distal cross-sectional area of median nerve. We analyzed interobserver and interreader reliability by 3 different explorers and 2 different readers, cost and the patient discomfort. Results: Mean ultrasound measurements were significantly higher in the EDT positive group. There was a high concordance between sonography and nerve conduction. A cut-off of 9.5 mm2 resulted in the correct classification of 83% of cases (sensitivity 88% and specificity 67%). Conversely, a cut-off of >14 mm2 or <7 mm2 had excellent power to rule in CTS, with a post-test probability of 100% of specificity and sensitivity respectively. The interobserver acquisition ICC was 0.915-0.980, and the inter-reader ICC was 0.912-0.987. Ultrasound cost savings in this study were J3217.59 (J42.9 per symptomatic wrist) and the discomfort perceived by the patient was significantly lesser 6.3 vs 56 in EDT (P<.0005). Conclusions: Ultrasound median nerve crosssectional area is reliable and may be used to accurately rule in or rule out CTS. Sonography as a first-line test is cost-effective and is more satisfactory to the patients (AU)