Distal musculoskeletal manifestations in polymyalgia rheumatica: a prospective followup study

OBJECTIVE

To determine the frequency and the characteristics of distal musculoskeletal manifestations in polymyalgia rheumatica (PMR).

METHODS

Prospective followup study of 177 consecutive patients meeting clinical criteria for PMR, diagnosed over a 5-year period in 2 rheumatology secondary referral centers in Italy.

RESULTS

Seventy-nine of the 177 patients (45%) had distal musculoskeletal manifestations. Peripheral arthritis occurred in 45 patients (25%), carpal tunnel syndrome in 24 (14%), distal extremity swelling with pitting edema in 21 (12%), and distal tenosynovitis in 5 (3%). These manifestations were usually associated with PMR proximal symptoms (69%); however, 31% of the episodes represented isolated relapse/recurrence at distal sites. Distal symptoms responded promptly to corticosteroids. No evidence of joint deformities, erosions, or development of rheumatoid arthritis was observed during the followup. The group of patients with peripheral arthritis included a higher proportion of females, had a longer duration of therapy, and had more relapses/ recurrences. Patients who had distal extremity swelling with pitting edema had a higher age at disease onset, a shorter duration of therapy, and lower initial and cumulative prednisone doses.

CONCLUSION

Inflammatory involvement of distal articular and/or tenosynovial structures occurs in approximately half of the cases of PMR. Peripheral arthritis is associated with more severe disease, while distal extremity swelling with pitting edema appears to identify a more benign disease subset.

Prevalence of carpal tunnel syndrome among individuals with Down syndrome

We examined occurrence of carpal tunnel syndrome in 48 patients with Down syndrome clinically and electrophysiologically. In the median nerve the distal latency to the abductor pollicis brevis muscle and the distal sensory nerve conduction velocity to digit II and III were recorded. As a control, we examined the ulner nerve. In the median nerve, a distal latency above 4.3 msec and sensory nerve conduction velocity below 50 m/sec were considered indicative of Carpal tunnel syndrome. Twenty seven patients (56%) had normal findings, 13 (27%) had both prolonged distal motor latency and reduced distal sensory nerve conduction velocity, and 8 patients (17%) had one of these signs, a much higher frequency than expected. Results show that prevalence of electrophysiological carpal tunnel syndrome is high in individuals with Down syndrome.

Predicting acute denervation in carpal tunnel syndrome

OBJECTIVE

To determine which nerve conduction parameters can predict the presence of acute denervation in carpal tunnel syndrome.

SETTING

The electrodiagnostic laboratories of a hospital and a county hospital district.

DESIGN

A retrospective review.

PATIENTS

A total of 1,590 consecutive cases from January 1992 to June 1996, diagnosed as having median neuropathy at the wrist.

MAIN OUTCOME MEASURES

Evidence of acute denervation on needle electromyography of the abductor pollicis brevis and its relationship to patient age, gender, and parameters obtained from nerve conduction studies, including median sensory latency and amplitude, and median motor latency and amplitude.

RESULTS

Logistic regression analysis identified gender, median motor latency, and median motor amplitude (all p < or = .008) as contributing to the prediction of denervation. Needle examination of the cases with a median motor amplitude <7 mV detected 95.3% (141/148) of all cases with denervation and could have spared 52% (708/1,362) of the population from a needle examination of the abductor pollicis brevis.

CONCLUSION

The median motor amplitude can predict the presence of acute denervation in the thenar muscles in median neuropathy at the wrist and possibly eliminate a painful needle examination of the median-innervated thenar muscles in over 50% of the cases.

Combined bilateral submandibular and sublingual swelling, macroglossus, and carpal tunnel syndrome caused by light chain amyloidosis

Three cases of light chain kappa amyloidosis in multiple myeloma patients are described with remarkable involvement of the tongue and swelling of the sublingual and submandibular regions, and without signs of nephropathy despite Bence Jones kappa proteinuria. All three patients had carpal tunnel syndrome at the beginning of their disease course and only moderate gastrointestinal involvement. Primarily for prognostic reasons, amyloidosis should be suspected in such cases, even in the presence of these highly unusual manifestations, and the diagnosis should be confirmed by unambigously-positive biopsies.

Forearm velocity in carpal tunnel syndrome: when is slow too slow?

OBJECTIVE

To correlate the frequency of superimposed processes (SPs) such as radiculopathies, polyneuropathies, and plexopathies with median motor forearm conduction velocity (MMFCV) in patients with carpal tunnel syndrome (CTS).

DESIGN

All cases of diagnosed CTS were retrospectively analyzed for evidence of SPs.

SETTING

Electrophysiology laboratory of a tertiary care center.

PARTICIPANTS

One hundred fifty-five patients (44 men, 111 women), ages 19 to 94, who were referred for and met electrophysiologic criteria for CTS, both with and without MMFCV slowing.

MAIN OUTCOME MEASURE

The frequency of SPs in patients with no, mild, moderate, and severe MMFCV slowing.

RESULTS

A total of 192 arms from 155 patients were studied. Of 14 arms with mild slowing (MMFCV of 47.0 to 49.9 m/sec), 2 (14%) had an SP. Of 15 arms with moderate slowing (MMFCV of 43.0 to 46.9 m/sec), 7 [corrected] (46%) had an SP. Of 9 arms with severe slowing (MMFCV of < 43.0 m/sec), 4 (44%) had an SP. The frequency of SPs for both the moderate and severe groups was significantly higher than that in patients with a normal MMFCV (p < .01); of 154 arms with a normal MMFCV, only 9 (6%) had an SP.

CONCLUSION

In cases of CTS, the finding of moderate to severe slowing of MMFCV (< 47.0 m/sec) should prompt a careful electrophysiologic investigation to exclude an SP.

Soft tissue problems associated with rheumatic disease

Rheumatic disease and associated soft tissue problems encompass a large number of syndromes and account for a high percentage of visits to primary care practitioners. This article describes the symptoms, causes, and treatments for five of the problems most commonly encountered: bursitis, tendinitis, carpal tunnel syndrome, myofascial pain syndrome, and fibromyalgia. Effective management requires a structured history, physical examination, and definitive diagnosis that distinguishes the soft tissue problem from a joint problem and an inflammatory syndrome from a noninflammatory syndrome. The overriding principle is self-management of treatments that focuses on relief of pain, maintenance of function, and avoidance of factors that cause recurrence or exacerbation of the problem. Medications, physical therapies, biomechanical aids, and exercise strategies, along with cognitive-behavioral techniques for the more chronic problems, are all known to decrease symptoms and to assist patients in returning to normal functioning.

Symptoms experienced by patients with carpal tunnel syndrome

BACKGROUND

Patients with carpal tunnel syndrome (CTS) sometimes report sensory symptoms outside the median nerve distribution. This study was designed to provide a more detailed assessment of these symptoms.

METHODS

Patients with clinical suspicion of upper limb neuromuscular lesions were divided into those with electrodiagnostic (EDX) evidence of CTS, and those without. CTS patients with superimposed nerve abnormalities were excluded. Motor and sensory symptoms were assessed in the exclusive CTS patients.

RESULTS

Over 50% of patients with exclusive CTS reported tingling or numbness over the whole hand, ulnar or radial nerve distributions. Some patients reported symptoms proximal to the wrist. Sensory signs did not extend beyond the median nerve distribution. Numbness and nocturnal pain were predictive of positive EDX evidence of CTS.

CONCLUSIONS

Sensory symptoms outside the distribution of the median nerve are common in CTS. For enhanced sensitivity in diagnosis it is useful to be aware of these "atypical" symptoms. Reports of numbness and nocturnal pain are strong indicators of CTS.

Median-ulnar anastomosis to thenar, hypothenar, and first dorsal interosseous muscles: collision technique confirmation

Median-ulnar anastomosis (Martin-Gruber anastomosis; MGA) is traditionally diagnosed based upon changes in compound muscle action potential (CMAP) amplitude following proximal stimulation. We describe a rare patient with a MGA innervating thenar, hypothenar, and first dorsal interosseous muscles. Proximal stimulation, however, evoked CMAPs with striking changes in morphology and area but only minimal amplitude changes, due to concomitant diagnoses of carpal tunnel syndrome and polyneuropathy. Collision studies were therefore required for diagnostic confirmation of the MGA.

The occurrence of Raynaud's phenomenon in a general population: the Framingham Study

The prevalence and predisposing conditions for primary and secondary Raynaud's phenomenon (RP) were examined in The Framingham Study based on 16 years of follow-up of a cohort of 4182 men and women. The association with atypical chest pain and migraine headache was also investigated. Over the 16 years of follow-up there were 130 men and 171 women who developed primary RP. The prevalence in women (9.6%) was somewhat higher than in men (8.1%) and 81.4% of the RP was primary. Secondary RP was equally prevalent in men (18.6%) and women (19.7%). The most common causes of secondary RP were beta-blocker use (34.2%), carpal tunnel syndrome (10.5%) and rheumatoid arthritis (7.2%). Primary RP cases differed from noncases by having lower systolic blood pressure (p < or = 0.001) and diastolic blood pressure (p < 0.0001), and more coronary disease (p = 0.009), smoking (p < or = 0.01) and higher blood sugars (p < or = 0.009). Atypical chest pain was present more often than noted previously in The Framingham Study general population survey, and was equally prevalent in primary and secondary RP and in the two sexes. Associated migraine was more prevalent in women (14.4%) than men (5.0%). Vibrating tool use with associated RP occurred in 14.6%.

[Arterial vascularization of the semilunar bone]

The gross examination of 41 dried lunates and the dissection of 50 minimum injected forearms allowed the author to give a general statement of the blood supply of the lunate. On the volar aspect of the hand, 2 or 3 vessels coming from the ramus carpeus volaris and/or the radial artery run downward and penetrate the bone through a big foramen and several smaller around. On the dorsal aspect, 2 or 3 minute branches arise from the dorsal carpal arch and penetrate the triangular posterior surface of the lunate beneath the carpal joint; more infrequently 2 twigs may be traced along both scaphoid-lunate and triquetrumlunate joints. The interosseous artery sends some conspicuous branches to the posterior margin of the radius and the dorsum of the lunate. The volar group appeared to be the most important contributor to the blood supply and the big volar foramen should be named "hilus" of the lunate. It must be emphasized that the nutrient vessels enter the foramen above the upper margin of the transverse carpal ligament; so, no crowding in the carpal tunnel can be liable for "avascular necrosis" of the lunate.

Carpal tunnel syndrome presenting as sclerodactylia, nail dystrophy and acro-osteolysis in a 60-year-old woman

Skin changes associated with carpal tunnel syndrome have rarely been reported. A 60-year-old patient was referred to our Department of Dermatology for evaluation of an aseptic gangrene of the distal phalanx of the third finger of her left hand, progressive nail dystrophy, sclerodactylia and spontaneous ulcerations. These features were seen on the digits with sensory supply from the median nerve. The patient had hand paresthesias for at least 10 years. No abnormal results were found in biochemical, hematological or immunological determinations. An echo-Doppler study of the upper limbs was normal. An electromyographic study was consistent with a bilateral carpal tunnel syndrome (CTS). Ulcerative and mutilating CTS can occasionally produce sclerodactylia with ulcerative lesions on distal fingers, nail dystrophy and acro-osteolysis as a consequence of mechanical compression of the autonomic fibers of the median nerve. The clinical picture includes Raynaud's phenomenon in some patients. Correct diagnosis is important, since ulcerative and mutilating CTS is a marker of a severe neural lesion, which is amenable to treatment by surgical decompression.

"Phantom" carpal tunnel syndrome

Phantom sensation is ubiquitous among persons who have had amputation; however, if it develops into phantom pain, a thorough clinical investigation must ensue. We illustrate this with the case of a 49-year-old woman, 14 years after traumatic amputation of her left 2nd through 5th fingers, and 10 years after traumatic left transfemoral amputation. She had had phantom sensation in her absent fingers for years and developed progressive pain in her phantom fingers 3 months before presentation. Nerve conduction study revealed a high-normal distal motor latency of the left median nerve and a positive Bactrian test (sensitivity 87%). She was diagnosed with "phantom" carpal tunnel syndrome and treated with a resting wrist splint, decreased weight bearing on the left upper limb, and two corticosteroid carpal tunnel injections with marked improvement. Clinicians should recognize that phantom pain may be referred from a more proximal region and may be amenable to conservative management.

Surgical treatment of carpal tunnel syndrome in patients with peripheral neuropathy

Outcome after carpal tunnel surgery was studied retrospectively in 32 patients with peripheral neuropathy and carpal tunnel syndrome. Nocturnal paresthesias were almost universally relieved, followed in order of responsiveness by pain, numbness, and weakness. Twenty-five of 28 patients said they would have the surgery again if the outcome were the same. Patients with carpal tunnel syndrome and peripheral neuropathy benefit from surgical treatment of carpal tunnel syndrome.

[Simultaneous occurrence of trigger fingers and carpal tunnel syndrome]

We report an unusual case of trigger fingers and carpal tunnel syndrome occurring simultaneously; both conditions were caused by space-occupying fibrosis of the flexor tendon sheath. Following operation the patient was relieved of his symptoms. In case of simultaneously occurring trigger fingers and carpal tunnel syndrome, one should be aware that both conditions can be caused by space-occupying lesions beneath the carpal tunnel. Endoscopic surgery should be avoided in these cases.

[Cervico-omo-brachial pain and disability in a person of advanced age]

A person of advanced age usually has degenerative changes of bone, joint and ligament, which can be causes of cervico-omo-brachial pain and disability. He or she may also suffer from metastatic bone tumor of cervical spine or upper extremity. This article described pathology, signs and symptoms and recent treatment of these diseases. Cervical myelopathy and radiculopathy, which are most common causes of cervico-omo-brachial symptoms, are sometimes accompanied by peripheral entrapment neuropathy such as cubital tunnel syndrome or carpal tunnel syndrome (double crush syndrome). In this complicated situation, decompression of neural tissue in both cervical spine and carpal tunnel are necessary. In treatment for carpal tunnel syndrome, release of transverse carpal ligament under an arthroscope has proven to be useful and has been becoming popular. This minimally invasive surgery is also useful in shoulder surgery such as subacromial decompression in aged patients with rotator cuff tear and removal of calcium deposit in the shoulder joint. Osteoarthritis of the elbow also cause pain or disability of the elbow and the hand. Some metastatic bone tumors are treated by tumor resection and reconstruction with instruments, prosthesis or composite grafts, which are attempted not to cure the disease but to maintain or improve the quality of life of the patient.

Histological prevalence of beta 2-microglobulin amyloidosis in hemodialysis: a prospective post-mortem study

The histological prevalence of beta-2 microglobulin amyloidosis (A beta 2m) was evaluated in a prospective study of joint samples obtained at autopsy in 54 patients on hemodialysis (HD) for 2 to 163 (median 47) months, aged 20 to 80 (median 63) years at HD onset. Carpal tunnel syndrome surgery or radiological signs of A beta 2m were present in 2 and 4% of them, respectively. A control group of 34 patients without end-stage renal disease, autopsied during the same period was used as a reference. The 153 sampled joints (1 to 8, median 2 per patient) were sternoclavicular joints (N = 77), shoulders (N = 35), knees (N = 28), others (N = 13). A beta 2m was diagnosed (positive Congo red with typical birefringence and positive immunostaining of deposits for beta 2m) in 26 of 54 (48%) patients. Prevalence reached respectively 21%, 33%, 50%, 90% and 100% within two years, after 2 to 4 years, 4 to 7 years, 7 to 13 years and more than 13 years HD. The calculated sensitivity of the various joints for A beta 2m detection is significantly higher (P < 0.03) for sternoclavicular joints (97%) and knees (91%) than for shoulders (57%). Multivariate stepwise logistic regression with discriminant analysis identified both HD duration (P = 0.0008) and age at HD onset (P = 0.0093) but not diabetic nephropathy (P = 0.23) or gender (P = 0.25) as independent risk factors for A beta 2m. The probability of joint A beta 2m was quantitated as a function of age and HD duration. In conclusion, A beta 2m may be observed in the large joints early after HD onset. Overall prevalence reaches 48% of the patients on HD for a median of 47 months. It is much higher than that reported on the basis of clinical or radiological evidence. The sternoclavicular and knee joints are more frequently (P < 0.03) involved than the shoulder. The easily accessible sternoclavicular joint therefore appears to be the best site for the early detection of A beta 2m. Both HD duration and age at HD onset, but not diabetic nephropathy, are independent risk factors for A beta 2m.

Coexisting peripheral nerve and cervical cord compression

STUDY DESIGN

The authors investigated the clinical usefulness of recording motor evoked potentials after transcranial magnetic stimulation in coexisting peripheral nerve and cervical cord lesions.

OBJECTIVE

To show that the measurement of central motor conduction time from the abductor policis brevis and the abductor digiti minimi can be used as a good screening method for double lesions involving peripheral nerves and the cervical cord.

SUMMARY OF BACKGROUND DATA

Transcranial magnetic stimulation has been used in the diagnosis of compressive cervical myelopathy. This technique could be useful in the assessment of patients with an entrapment neuropathy and cervical myelopathy.

METHODS

Motor evoked potentials after transcranial magnetic stimulation, compound muscle action potentials, and F waves after supramaximal peripheral nerve stimulation were recorded from the abductor policis brevis and the abductor digiti minimi. The central motor conduction time was calculated by subtracting the peripheral conduction time from the motor evoked potentials latency.

RESULTS

Ten patients with coexisting peripheral nerve and cervical cord lesions were evaluated. Two patients did not show satisfactory improvement after the decompression of the entrapment lesions, and six patients had hyperreflexia of lower limbs. In seven of these patients, the central motor conduction time was prolonged an average of 2.5 standard deviation of the normal value. The remaining two patients had spinal cord compression due to the ossification of the posterior longitudinal ligament. The spinal cord compression was demonstrated by magnetic resonance imaging, but the central motor conduction time was normal. Subjective symptoms improved in these two patients after decompressive surgery at the entrapment site alone.

CONCLUSIONS

Measurement of the central motor conduction time using motor evoked potentials is an ideal diagnostic approach for patients with coexisting entrapment neuropathy and cervical cord compression.

Evaluation of carpal tunnel syndrome in patients with polyneuropathy

The difference between the median nerve latency to the second lumbrical muscle and the ulnar nerve latency to the second interosseous muscle (L-I DIFF) was tested in a prospective study to discriminate whether prolonged distal motor latency of the median nerve in patients with polyneuropathy (PNP) reflects an additional carpal tunnel syndrome (CTS). We investigated 92 patients (107 hands) with CTS, 30 patients (34 hands) with PNP, 22 patients (27 hands) with CTS and coexisting PNP (PNP + CTS), and 77 controls (87 hands). L-I DIFF was significantly prolonged in both the CTS and PNP + CTS patients as compared to PNP patients and controls. It proved to be the most specific test to differentiate between diffuse (PNP) and focal (entrapment) nerve disorder.