BOTOX® (Onabotulinumtoxin A) Injection(s) as a Treatment for Carpal Tunnel Syndrome

This is a pilot study, to assist with determining appropriate BOTOX® (onabotulinumtoxin A)
dosing and injection locations in patients suffering from CTS.

Outcome measures will be obtained at follow-up at 6, 12, and 18 weeks post BOTOX®
(onabotulinumtoxin A) injection and post saline injection using the same scales and
instruments at baseline, namely Levine scale, JAMAR pinch dynamometer, EDX/NCS and NMUS.
These measurements will be used to identify the effectiveness of BOTOX® (onabotulinumtoxin A)
in decreasing thenar muscle strength, appropriate BOTOX® (onabotulinumtoxin A) injection
dosing, and ability to decrease the inflammation, median nerve dysfunction, edema, symptoms
of pain, numbness, and tingling often with associated with CTS.

Inclusion Criteria:

- Patient history: evaluated using the Levine Scale for CTS, a self-administered
questionnaire which assesses the function and severity of CTS.

- Physical Exam: including use of JAMAR pinch dynamometer to quantify initial baseline
strength and confirm decreased pinch strength post injection to verify effective
BOTOX® (onabotulinumtoxin A) injection.

- Electrodiagnostics (EDX): The following criteria would establish CTS through EDX
namely baseline electromyogram (EMG) and nerve conduction studies (NCS): a) median
nerve distal motor latency (DML) >4.3ms or >0.9ms above the ulnar nerve DML b) median
distal sensory latency (DSL) to D-1 >2.9ms or >0.4ms above radial nerve D-1 DSL. c)
median D-2 DSL >3.7ms or >0.4ms above ulnar nerve D-5 DSL (5). d) median mixed nerve
palm-to-wrist latency (at 8cm) >2.2ms or >.3ms above ulnar mixed nerve palm-to-wrist
latency (at 8cm).

- Imaging & Measurements (NMUS): Carpal tunnel images will be obtained in a transverse
plane in both a neutral relaxed position at the level of the pisiform and
longitudinally during neutral and Dynamic Stress Testing (DST) by a A Sonosite M-Turbo
6-13 MHz ultrasound system or another similar system (+ 2% accuracy). Measurements:
Transverse images of the CT will measure the median nerve cross sectional area (CSA)
at the level of the pisiform bone. CSA measurements greater than 11 mm2 are indicative
of CTS. Borderline CSA measurements would require wrist forearm ratio (WFR)
measurements to be a WFR > 1.5. Patients will need to have a CSA >11mm2, (or WFR >1.5)
and show median nerve compression during DST of at least 30% to be included.

Exclusion Criteria:

- Patients with prior carpal tunnel surgery, prior history of BOTOX® (onabotulinumtoxin
A) injection

- Steroid injection two months prior or three months after BOTOX® (onabotulinumtoxin A)
CTS injection, median nerve denervation on needle EMG

- Major limb trauma or surgery, dysphagia

- Neuromuscular junction disorder (ie: Myasthenia gravis or Lambert-Eaton syndrome)

- Currently pregnant or breast feeding

- Patients with severe CTS identified by Levine scale >4, electrodiagnostics, and/or
unable to meet the inclusion criteria as identified above would be excluded as
participants in this study.