Effect of coexistent carpal tunnel abnormality on sensory conduction findings in polyneuropathy

OBJECTIVES

To investigate the change of pattern of sensory conduction findings in polyneuropathy with coexistent carpal tunnel abnormality (CTAbN).

METHODS

We reviewed sensory conduction findings of 46 patients with acute inflammatory demyelinating polyradiculoneuropathy (AIDP) and 66 with diabetic polyneuropathy (DP). Both groups were categorized into those with and without CTAbN according to transcarpal median sensory conduction velocities.

RESULTS

In AIDP, median sensory nerve action potential (SNAP) amplitudes were reduced, whereas sural SNAP amplitudes remained unchanged. Median SNAP amplitude was lowest, and sural/median SNAP amplitude ratio was highest in AIDP with coexistent CTAbN. In DP, both median and sural SNAP amplitudes were reduced. Their sural/median SNAP amplitude ratios remained unchanged. Incidence of abnormal median-normal sural pattern was higher in AIDP than in DP. Nevertheless, these incidences did not alter with coexistent CTAbN. The ulnar SNAP amplitude and sural/ulnar SNAP amplitude ratio were not significantly different between those with and without CTAbN in both AIDP and DP groups.

CONCLUSIONS

Coexistent CTAbN caused further increase of sural/median SNAP amplitude ratio only in AIDP.

Diabetic hands: a study on strength and function

OBJECTIVE

To study hand strength and function in type 2 DM patients.

METHODS

We collected data on hand strength and function, disease duration, glycemic, creatinine and HbA1C levels, degree of pain and stiffness and physical examination in 100 DM patients comparing than with 100 hand osteoarthritis patients and 100 controls.

RESULTS

DM patients had hand strength and function better than osteoarthritis patients and worse than controls. De Quervain tendonitis associated with hand strength (p=0.005); hand function associated with carpal tunnel syndrome (p<0.0001), De Quervain tendinitis (p=0.006), HbA1C level (p=0.005), insulin use (p=0.030), disease duration (p=0.0006), pain (p<0.0001) and stiffness (p<0.0001) in univariated analysis. In multivariated analysis only disease duration and stiffness remain as significant.

CONCLUSION

Hand strength and function are impaired in DM patients. Loss of function associated with stiffness and disease duration; loss of strength associates with De Quervain tendinitis.

Impact of distal median neuropathy on handwriting performance for patients with carpal tunnel syndrome in office and administrative support occupations

PURPOSE

This study investigates the handwriting performance of patients with carpal tunnel syndrome (CTS) and healthy controls in office and administrative support occupations, adopting both biomechanical and functional perspectives. This work also explores how surgical intervention altered the performance of the CTS patients.

METHODS

Fourteen CTS patients and 14 control subjects were recruited to complete a self-reported survey and participate in sensory tests, hand strength, dexterity and handwriting tasks using a custom force acquisition pen along with motion capture technology. Based on the results of these, the sensory measurements, along with functional and biomechanical parameters, were used to determine the differences between the groups and also reveal any improvements that occurred in the CTS group after surgical intervention.

RESULTS

The CTS patients showed significantly poorer hand sensibility and dexterity than the controls, as well as excessive force exertion of the digits and pen tip, and less efficient force adjustment ability during handwriting. After surgery and sensory recovery, the hand dexterity and pen tip force of the CTS patients improved significantly. The force adjustment abilities of the digits also increased, but these changes were not statistically significant.

CONCLUSIONS

This study provides the objective measurements and novel apparatus that can be used to determine impairments in the handwriting abilities of office or administrative workers with CTS. The results can also help clinicians or patients to better understand the sensory-related deficits in sensorimotor control of the hand related to CTS, and thus develop and implement more suitable training or adaptive protocols.

Dermatological and immunological conditions due to nerve lesions

Some syndromes are of interest to both neurologists and dermatologists, because cutaneous involvement may harbinger symptoms of a neurological disease. The aim of this review is to clarify this aspect. The skin, because of its relationships with the peripheral sensory nervous system, autonomic nervous system and central nervous system, constitutes a neuroimmunoendocrine organ. The skin contains numerous neuropeptides released from sensory nerves. Neuropeptides play a precise role in cutaneous physiology and pathophysiology, and in certain skin diseases. A complex dysregulation of neuropeptides is a feature of some diseases of both dermatological and neurological interest (e.g. cutaneous and nerve lesions following herpes zoster infection, cutaneous manifestations of carpal tunnel syndrome, trigeminal trophic syndrome). Dermatologists need to know when a patient should be referred to a neurologist and should consider this option in those presenting with syndromes of unclear etiology.

Carpal tunnel release in patients with diabetes result in poorer outcome in long-term study

BACKGROUND

The aim of this prospective study was to compare the results of surgical decompression of carpal tunnel syndrome (CTS) in patients with diabetes mellitus with those with idiopathic CTS.

METHODS

The results of surgical decompression of CTS in 27 patients with diabetes mellitus were compared with 42 patients with idiopathic CTS. All patients underwent surgical release of transverse carpal ligament by the mini-incision of palm technique. Patient self-administered Boston Questionnaire (BQ) for the assessment of severity of CTS symptoms and hand functional status was evaluated before and 6 months and 10 years after surgery.

RESULTS

After surgical release, all the patients of both groups reported an absence of pain, disappearance or reduction of paresthesia, and improvement in hand function. Six months after surgery, there was a significant improvement of symptomatic and functional BQ scores compared with preoperative state in both groups. Ten years after surgery, there was statistical difference in preoperative and postoperative 10th year functional BQ score between DM (-) and DM (+) (p < 0.01). DM status affected statistically functional BQ score between preoperative and postoperative 10th year.

CONCLUSION

Diabetes mellitus was a risk factor for poor outcome of surgical decompression of CTS. Patients with diabetes had worse surgical outcome compared with patients with idiopathic CTS in long-term follow-up.

The effects of diabetes on symptoms of carpal tunnel syndrome treated with mini-open surgery

This study aimed to evaluate the influence of type II diabetes mellitus (DM) on the postoperative outcomes of mini-open carpal tunnel syndrome (CTS) surgery. A total of 99 hands in 74 patients were included in the study. Of these, 36 patients (54 hands) had type II DM (Group A), and 38 patients (45 hands) had idiopathic CTS (Group B). Mini-open carpal tunnel release surgery was performed on all the hands. The night pain, weakness, paraesthesia, numbness complaints were significantly improved in both groups after surgery. However, thenar atrophy was improved significantly only in group A. Night pain, weakness, paraesthesia, numbness, and pillar pain were significantly worse in Group A than in Group B on postoperative examination. Postoperatively, Tinnel and Phalen tests were positive in 32 hands in Group A and 6 hands in Group B. Persistence of symptoms in diabetic patients was found to be more prevalent compared to non-diabetic controls after mini-open carpal tunnel release.

Anatomical basis of ulnar approach in carpal tunnel injection

BACKGROUND

Local steroid injection may be an effective conservative treatment for carpal tunnel syndrome; however, the use of a blind injection technique can increase the chance of median nerve or ulnar artery injury due to median nerve swelling or the close proximity of the median nerve and ulnar artery around the distal wrist crease.

OBJECTIVES

The purpose of this study is to investigate the relative location of the median nerve and ulnar artery to the palmaris longus (PL) tendon around the wrist in carpal tunnel syndrome.

STUDY DESIGN

An observational study.

SETTING

A university outpatient interventional pain management practice in the Republic of Korea.

METHODS

Thirty hands of 15 patients with carpal tunnel syndrome and 30 hands of 15 healthy subjects were studied. Ultrasonography was performed to determine the relative relationship of the ulnar artery and median nerve to the PL tendon around the wrist.

RESULTS

There were statistically significant differences both in the distance from the medial margin of the PL to the medial end of the median nerve and the distance from the medial end of the median nerve to the lateral end of the ulnar artery at all levels of scanning between the 2 groups.

LIMITATIONS

Limitations include the inclusion of a small number of patients with carpal tunnel syndrome.

CONCLUSION

It is important to recognize the risk of blind local steroid injection for carpal tunnel syndrome, which is most likely a result of swelling and/or flattening of the median nerve around the distal wrist crease. A real time, ultrasound-guided local steroid injection is preferred as a safe and accurate technique in carpal tunnel syndrome treatment.

Incidence of carpal tunnel syndrome in adult patients with mitochondrial disease

Symmetrical polyneuropathy is a common feature of mitochondrial disease. Both axonal and demyelinating types are described, with Schwann cell abnormalities demonstrated on nerve biopsy. Some authors have also suggested an increased incidence of entrapment neuropathy. We identified 738 adult patients with proven mitochondrial disease seen in our centre in the past 25 years. One-hundred sixty seven of these patients had undergone nerve conduction studies as part of their routine clinical care, and the results of these studies were reviewed. We found an incidence rate of carpal tunnel syndrome (CTS) of 50.7 per 100,000 person-years; 32.5 per 100,000 person-years for men and 65.3 per 100,000 person-years for women. One other patient had evidence of ulnar neuropathy at the elbow. The incidence of CTS in mitochondrial disease is similar to published rates for the UK general population. We found no evidence that mitochondrial disease per se increases the risk of entrapment neuropathy. We suggest that the pathophysiological mechanisms for the development of polyneuropathy in mitochondrial disease are quite distinct from the pathophysiology of CTS. Furthermore, it is essential that patients with mitochondrial disease who present with upper limb paraesthesia be referred for neurophysiological testing, so that treatable CTS is not missed.

Risk factors for re-recurrent carpal tunnel syndrome in patients undergoing long-term hemodialysis

The purpose of this study was to evaluate risk factors for re-recurrent carpal tunnel syndrome (CTS) in long-term renal hemodialysis (HD) patients. Fifteen wrists of ten HD patients, follow-up period of minimum seven years after reoperation of CTS, were included in this study. Duration of HD, period from first operation to reoperation, shunt side was involved or not, presence of trigger finger and cervical destructive spondyloarthritis, and operative procedure performed during the reoperation (synovectomy was performed or not) were evaluated. Re-recurrent CTS was identified in four out of 15 wrists (27%). The period from first operation to reoperation, which was 3.8 years in the re-recurrence group and eight years in the no re-recurrence group, and the operative procedure had significant differences (synovectomy groups had no re-recurrence vs. no synovectomy groups had 82% re-recurrence). The results of this study suggested that synovectomy would be necessary for recurrent CTS in HD patients.

[Analysis of clinical outcomes of carpal tunnel syndrome combined with cervical nerve root compression]

OBJECTIVE

To analyze the clinical curative effect of carpal tunnel syndrome (CTS) combined with cervical nerve root compression and to explore the differences between CTS combined with cervical nerve root compression and simple CTS in the clinical manifestations, diagnosis and treatment.

METHODS

From February 2004 to October 2010, 93 cases (120 sides) were selected among the patients (21 males and 72 females) adopted to our department and primarily diagnosed as CTS, of whom 29 had cervical nerve root compression. Neurolysis of peripheral nerve was conducted in the 93 cases, and the mean follow-up period was 16 months.

RESULTS

The results of the improvements of symptoms and signs after operation were evaluated by the British Medical Research Council (BMRC). According to the BMRC scores, we divided the patients into three stages: excellent, good and none. In the 93 patients, 29 were with visible nerve root compression in radiograph or magnetic resonance imaging, in whom the excellent rate was 86.21%, and the good rate 13.79%, meanwhile in the patients without nerve root compression, the excellent rate was 90.63% and the good rate 9.37%.

CONCLUSION

In the case of CTS combined with cervical nerve root compression, our findings are as follows: Firstly, neurolysis of peripheral nerve has an accurate curative effect; Secondly, neurolysis of peripheral nerve may decline the symptoms of nerve root compression; Thirdly, patients with nerve root compression are obviously more common in men, therefore, we should pay attention to the double crash when it comes to the male patient.

[Characterisation of pain in patients with carpal tunnel syndrome according to electromyographic severity criteria]

INTRODUCTION

The symptoms of carpal tunnel syndrome (CTS) vary greatly and can depend on the severity of the clinical symptoms.

AIMS

To characterise the description and self-perception of pain in a sample of patients with CTS and to determine whether that perception of pain differs among the patients on the basis of electrodiagnostic severity criteria.

PATIENTS AND METHODS

The sample consisted of 92 females with CTS, who were classified as having mild, moderate or severe CTS, bearing in mind electrodiagnostic criteria. Different instruments were used in the study: a numerical scale (0-10) to evaluate the intensity of the pain, the McGill questionnaire to classify the descriptors that represent the quality of the pain, and the Boston questionnaire for assessing symptom severity and disability.

RESULTS

The most representative descriptors were the presence of tingling (92%), heaviness (67%) and a feeling of swelling (64%). The women with mild CTS showed a longer history of pain than those with moderate and severe CTS (p < 0.05). There were no significant differences among the intensity of the pain, the disability questionnaire and most of the descriptors on the McGill questionnaire between the different groups of mild, moderate or severe CTS. The women with severe CTS described the pain as being periodic, repetitive and terribly unpleasant more often than those with mild or moderate CTS (p < 0.05).

CONCLUSIONS

The presence of tingling and the feeling of heaviness are the most prevalent symptoms of CTS. There are no great differences in the quality of the pain among cases of mild, moderate or severe CTS.

Predicting the outcome of revision carpal tunnel release

PURPOSE

To test the hypothesis that the result of steroid injection in the carpal tunnel in a patient with recurrent carpal tunnel symptoms would serve as a good predictor of the outcome of later carpal tunnel release (CTR).

METHODS

We conducted a retrospective review of all patients who underwent revision CTR for recurrent or persistent carpal tunnel syndrome over a 2-year period at our institution. A total of 28 wrists in 23 patients met inclusion criteria. We evaluated patients to determine whether preoperative factors or the result of injection predicted the outcome of revision CTR. We used a multivariate logistic regression analysis to predict surgical success when multiple preoperative findings were considered.

RESULTS

Of the 23 wrists that had relief from injection, 20 had symptom improvement with surgery. Although they did not reach statistical significance, the sensitivity and positive predictive value for injection alone predicted outcome of revision CTR in 87%. No patient characteristic or physical examination finding predicted successful revision CTR. Multivariate logistic regression analysis combining preoperative injection results with physical examination findings (numbness and/or motor weakness in median nerve distribution, positive Durkin test, and positive Phalen test) provided a sensitivity of 100% and a specificity of 80%.

CONCLUSIONS

In a small group of patients with recurrent carpal tunnel syndrome, cortisone injection into the carpal tunnel was not, by itself, a statistically significant predictor of successful revision surgery. However, relief from injection as a diagnostic test for predicting successful revision CTR was found to have both a high sensitivity and a positive predictive value. Coupled with the components of the physical examination, injection provides a good screening test to establish surgical success with revision CTR.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

[Vascular changes in severe carpal tunnel syndrome: a differential diagnosis of vasculitis]

Carpal tunnel syndrome may present with skin lesions. This may lead to a differential diagnosis with vasculitis. Sympathetic nervous system perivascular involvement and recurrent injuries secondary to sensory loss are probably part of the mechanism of injury. In this case, we also comment on the pathogenic role of persistent median artery associated with a bifid median nerve.

CARPAL TUNNEL SYNDROME PRESENTING AS A NON-HEALING ULCER

Skin ulceration in carpal tunnel syndrome is rare. A case report of a non-healing ulcer due to carpal tunnel with severe sensorimotor denervation is presented and discussed.

Vibrotactile sense in patients with diabetes and carpal tunnel syndrome

AIM

To evaluate vibration perception thresholds of patients with and without diabetes, before and after surgical carpal tunnel release.

METHODS

In a prospective study, 35 consecutive patients with diabetes and carpal tunnel syndrome were age and gender matched with 31 patients without diabetes having idiopathic carpal tunnel syndrome. Preoperatively, 6, 12 and 52 weeks after surgery, the vibration perception threshold of the index and little finger (median and ulnar nerve, respectively) was measured at seven different frequencies (8, 16, 32, 64, 125, 250 and 500 Hz).

RESULTS

At several frequencies, patients with diabetes and carpal tunnel syndrome demonstrated significantly impaired vibration perception thresholds of both the index and the little finger, before as well as after carpal tunnel release, compared with patients without diabetes with idiopathic carpal tunnel syndrome. After surgery, the overall sensibility index improved for the index finger [patients with diabetes and carpal tunnel syndrome (0.79 to 0.91, P < 0.001), patients without diabetes with idiopathic carpal tunnel syndrome (0.91 to 0.96, P > 0.05)] as well as for the little finger [patients with diabetes and carpal tunnel syndrome (0.82 to 0.90, P < 0.008), patients without diabetes with idiopathic carpal tunnel syndrome (0.95 to 0.99, P < 0.05)]. For the index finger, the sensibility index improved to a significantly higher degree for patients with diabetes and carpal tunnel syndrome not having signs of peripheral neuropathy (0.83 to 0.95, P < 0.001) compared with those with neuropathy (0.74 to 0.84, P < 0.02). Vibration perception threshold correlates with age of both patients with diabetes and carpal tunnel syndrome and patients without diabetes with idiopathic carpal tunnel syndrome, while no relationship was found based on duration of diabetes.

CONCLUSIONS

Vibrotactile sense is significantly impaired in patients with diabetes before and after carpal tunnel release compared with patients without diabetes. However, patients with diabetes obtained significant recovery of vibration perception threshold, particularly those without peripheral neuropathy.

Carpal tunnel syndrome and peripheral polyneuropathy in patients with end stage kidney disease

This study was designed to identify the causes of the development of carpal tunnel syndrome (CTS) associated with end stage kidney disease (ESKD). A total of 112 patients with ESKD, 64 on hemodialysis (HD) and 48 on peritoneal dialysis (PD), were enrolled. The duration of ESKD and dialysis, the site of the arteriovenous (A-V) fistula for HD, laboratory data such as blood urea nitrogen, creatinine, and beta-2-microglobulin were determined. Clinical evaluation of CTS and electrophysiological studies for the diagnosis of CTS and peripheral neuropathy were performed. The electrophysiological studies showed that the frequency of CTS was not different in the HD and PD groups (P = 0.823) and the frequency of CTS was not different in the limb with the A-V fistula compared to the contralateral limb (P = 0.816). The frequency of HD and PD were not related to beta-2-microglobulin levels, an indicator of amyloidosis. The frequency of CTS did not increase as the severity of the peripheral neuropathy and the duration of ESKD and dialysis increased (P = 0.307). The results of this study do not support that microglobulin induced amyloidosis or placement of an A-V fistula are associated with an increase in CTS.