Carpal tunnel syndrome

Carpal tunnel syndrome is the most common entrapment neuropathy, affecting approximately 3 to 6 percent of adults in the general population. Although the cause is not usually determined, it can include trauma, repetitive maneuvers, certain diseases, and pregnancy. Symptoms are related to compression of the median nerve, which results in pain, numbness, and tingling. Physical examination findings, such as hypalgesia, square wrist sign, and a classic or probable pattern on hand symptom diagram, are useful in making the diagnosis. Nerve conduction studies and electromyography can resolve diagnostic uncertainty and can be used to quantify and stratify disease severity. Treatment options are based on disease severity. Six weeks to three months of conservative treatment can be considered in patients with mild disease. Lifestyle modifications, including decreasing repetitive activity and using ergonomic devices, have been traditionally advocated, but have inconsistent evidence to support their effectiveness. Cock-up and neutral wrist splints and oral corticosteroids are considered first-line therapies, with local corticosteroid injections used for refractory symptoms. Nonsteroidal anti-inflammatory drugs, diuretics, and pyridoxine (vitamin B6) have been shown to be no more effective than placebo. Most conservative treatments provide short-term symptom relief, with little evidence supporting long-term benefits. Patients with moderate to severe disease should be considered for surgical evaluation. Open and endoscopic surgical approaches have similar five-year outcomes.

[Lipomatosis of nerve: a clinicopathologic analysis of 15 cases]

OBJECTIVE

To study the clinicopathologic features of lipomatosis of nerve (NLS).

METHODS

The clinical, radiologic and pathologic features were analyzed in 15 cases of NLS.

RESULTS

There were a total of 10 males and 5 females. The age of patients ranged from 4 to 42 years (mean age = 22.4 years). Eleven cases were located in the upper limbs and 4 cases in the lower limbs. The median nerve was the most common involved nerve. The patients typically presented before 30 years of age (often at birth or in early childhood) with a soft and slowly enlarging mass in the limb, with or without accompanying motor and sensory deficits. Some cases also had macrodactyly and carpal tunnel syndrome. MRI showed the presence of fatty tissue between nerve fascicles, resembling coaxial cable in axial plane and assuming a spaghetti-like appearance in coronal plane. On gross examination, the affected nerve was markedly increased in length and diameter. It consisted of a diffusely enlarged greyish-yellow lobulated fusiform beaded mass within the epineural sheath. Histologically, the epineurium was infiltrated by fibrofatty tissue which separated, surrounded and compressed the usually normal-appearing nerve fascicles, resulting in perineural septation of nerve fascicles and microfascicle formation. The infiltration sometimes resulted in concentric arrangement of perineural cells and pseudo-onion bulb-like hypertrophic changes. The perineurial cells might proliferate, with thickening of collagen fibers, degeneration and atrophic changes of nerve bundles. Immunohistochemical study showed that the nerve fibers expressed S-100 protein, neurofilament and CD56 (weak). The endothelial cells and dendritic fibers were highlighted by CD34. The intravascular smooth muscle cells were positive for muscle-specific actin.

CONCLUSIONS

NLS is a rare benign soft tissue tumor of peripheral nerve. The MRI findings are characteristic. A definitive diagnosis can be made with histologic examination of tissue biopsy.

Health-related quality of life in diabetic patients with carpal tunnel syndrome

AIMS

To determine health-related quality of life (HRQL) in diabetic and non-diabetic patients with carpal tunnel syndrome (CTS) before and after surgical treatment.

METHODS

In a prospective study, 35 consecutive diabetic patients with CTS were age and gender matched with 31 non-diabetic patients with idiopathic CTS. At baseline (preoperatively), 6, 12 and 52 weeks after surgical carpal tunnel release, patients completed the generic Short-Form 36 (SF-36) and the disease-specific Boston Carpal Tunnel Questionnaire (BCTQ).

RESULTS

The SF-36 physical component scores at baseline were significantly reduced for diabetic (39+/-7.4) compared with non-diabetic patients (48+/-9.0) (P<0.05). Mixed model analysis demonstrated no differences in post-surgical improvement over time between diabetic and non-diabetic patients. The largest clinical effect was found for bodily pain (effect size 0.8). However, population norms were not reached for the diabetic patients. At baseline, no difference was found in mental component score, which deteriorated over time for diabetic patients. At baseline, BCTQ demonstrated that diabetic patients experienced more pronounced 'numbness in the hand' than non-diabetic patients. Large clinical improvements were found in both symptom severity (effect size 1.98-2.14) and functional status score (effect size 0.89-0.94) for both diabetic and non-diabetic patients, with no difference between the two patient groups.

CONCLUSIONS

HRQL is impaired in diabetic patients with CTS compared with non-diabetic patients with CTS and population norms. However, diabetic patients experience similar symptomatic and functional benefits from carpal tunnel release as do non-diabetic patients.

[Clinical and electrophysiological correlations concerning patients with carpal tunnel syndrome]

BACKGROUND

Carpal tunnel syndrome (CTS) is the most commonly diagnosed nerve entrapment neuropathy. Typical clinical symptoms are pain, paresthesia or sensory deficit in the median nerve. In more severe cases the weakness and atrophy of the thenar muscles are also diagnosed. It is believed that the clinical picture along with the electrophysiological test allows making the diagnosis. However, the findings of the studies assessing the clinical and electrophysiological correlations are quite different.

AIM OF THE STUDY

The aim of this study was to establish the correlations between the assessment of a neurological examination and selected parameters of standard electrophysiological tests.

MATERIAL AND METHODS

In the study of 172 patients (253 nerves) with clinical symptoms of CTS, there were 131 women and 41 men at the age of 19-84 (the average: 51.28 +/- 17 years). All the patients underwent standard electrophysiological tests, according to the guidelines of the American Academy of Neurology, the test assessing the sensory latency at the wrist to the second finger (SL-D2) and the test assessing the motor latency at the wrist to the abductor pollicis brevis (DML-APB) and additional D4M-D4U test.

RESULTS

In the neurological examination the most common findings were the sensory deficits in the median nerve (87%) and the weakness of the thenar muscles (71%). Less common was the atrophy of the thenar muscles (25%). Abnormal results, leading to the electrophysiological diagnosis of CTS, were shown in 194 cases (77%) under the SL-D2 test and in 170 cases (67%) under the DML-APB test. Abnormal D4M-D4U test result was found in 94% of patients. In the group of patients we established a statistically valid correlation between the sensory deficit and the results of the SL-D2 test as well as between the weakness of the thenar muscles and the results of the DML-APB test, which indicates the diagnostic value of these parameters.

CONCLUSIONS

The discrepsancies lie in the different criteria for the selection of patients, the statistical methods applied, the selection of clinical scales as well as neurophysiologic testS.

[Possibilities of orthopaedic treatment of patients with renal failure and its meaning in the continuation of haemodialysis and quality of life improvement]

Good cooperation between the fields of orthopaedic surgery and nephrology creates a possibility of multidirectional surgical treatment of the patients with terminal renal failure despite massive general burden and existing risk. Taking a very difficult decision concerning the multidirectional surgical treatment of these patients may to a very great extent improve their locomotor functions and their life comfort. An example of such a situation is the described case of elbow replacement, vascular surgery procedure, total hip replacement and carpal tunnel release surgery.

Sensorimotor axonal polyneuropathy without hepatic failure in erythropoietic protoporphyria

The erythropoietic porphyrias are primarily manifested by skin sensitivity. They are, unlike many other forms of porphyria, usually not associated with neurologic manifestations. Only a few cases have been reported of neuropathy in patients with erythropoietic porphyrias, all characterized by an acute motor and proximally accentuated neuropathy occurring in the setting of hepatic failure. In this report, we present a patient without hepatic failure who presented with a sensorimotor axonal polyneuropathy before being diagnosed with erythropoietic porphyrias. The presented case expands the forms of neurologic complications that can be seen in this specific form of porphyria.

Evaluation of effectiveness of local insulin injection in non-insulin-dependent diabetic patient with carpal tunnel syndrome

BACKGROUND

Carpal tunnel syndrome (CTS) is the most common type of peripheral nerve entrapment and is a significant cause of morbidity. Carpal tunnel syndrome (CTS) has more incidences in diabetic patients. It has been suggested that insulin has an effect on nerve regeneration similar to that of nerve growth factor (NGF). Therefore, we aimed to evaluate the effectiveness of local insulin injection on the median nerve in patients with non-insulin-dependent diabetes mellitus (NIDDM) who have mild-to-moderate carpal tunnel syndrome (CTS).

MATERIALS AND METHODS

We carried out a prospective, randomized, single-blind, case-controlled study in these patients. We randomly selected 50 patients, 20 of whom had bilateral mild-moderate CTS. Therefore we had 70 hands and categorized them into two groups. At the baseline we injected NPH insulin (10U) directly into the carpal tunnel in group 1, and performed physiotherapy for the other group (group 2). Two weeks later, NPH insulin (10U) was injected into the carpal tunnel again and we continued physiotherapy for group 2. Electrodiagnostic study was performed for these two groups before treatment and 4 weeks after the last injection and physiotherapy. The patients were followed up for 6 weeks.

RESULTS

In both groups decrement of distal motor latency (DML) of the median nerves statistically was significant. In both groups, the increment of the sensory nerve conduction velocity was statistically significant. Also the decrement of pain, paresthesia, numbness, weakness/clumsiness and nocturnal awaking was statistically significant in both groups. But there was no significant difference between the two groups.

CONCLUSION

Local insulin injection is an effective and safe treatment for carpal tunnel syndrome in NIDDM patients as physiotherapy

[Congenital scaphotrapezial synostosis associated with a carpal tunnel syndrome: a case report]

This report describes a case of congenital synostosis between two bones of the wrist scaphoid and trapezium in a nine-year-old girl who presented a severe tunnel carpal syndrome treated two years ago by open surgery. This association has not previously been described.

Pseudoarthrosis in a hypertrophic nonunion of the humerus: a case report

Nonunion of humerus fractures is an extensively reviewed topic in orthopedic literature. The current case describes the successful outcome of a hypertrophic nonunion in a patient who chose not to undergo any intervention when the nonunion was identified and the treatment options were discussed with him. Hence this case report is a good example of the transition of the medical world to the concept of patient-centered decision making having a successful outcome.

Ulnar sensory nerve impairment at the wrist in carpal tunnel syndrome

In previous studies, changes in impulse transmission of ulnar motor axons have been documented in patients with carpal tunnel syndrome (CTS). We examined ulnar sensory conduction in 144 CTS hands. In particular, conduction parameters of the dorsal ulnar cutaneous branch (DUC) running outside Guyon's canal were compared with those of the superficial sensory branches (U4 and U5) passing through the canal. U4 and U5 response amplitudes and U5 conduction velocity were significantly lower than in controls. Conduction parameters of the DUC were similar in both groups. Patients with more severely impaired median conduction had smaller ulnar sensory action potentials. We propose that the ulnar nerve may be subject to compression in Guyon's canal as a consequence of high pressure in the carpal tunnel of CTS patients. This may provide insights into the mechanisms underlying extra-median spread of sensory symptoms in CTS patients.

Proximal pain in patients with carpal tunnel syndrome: a clinical-neurophysiological study

Patients with carpal tunnel syndrome (CTS) usually complain of pain and paresthesia in the hand or wrist, but pain proximally to the wrist has been frequently reported in this condition. This study was aimed at understanding which clinical features are associated with the presence of proximal pain (PP) in the upper limb of CTS patients. We recruited 250 patients with clinical and neurophysiological evidence of CTS. After thorough selection to rule out concomitant upper limb painful conditions, 112 patients (175 hands) were included. PP was defined as the presence of pain in the upper limb proximally to the wrist (neck excluded) in association with sensory complaints in the hand. Patients were asked about the presence and severity of proximal sensory complaints, the distribution of sensory complaints in the hand, and underwent an objective evaluation and neurographic study. Thenar muscle strength was significantly larger, the neurophysiological measures were significantly less severe, and hand paresthesia was significantly greater in patients with PP. The neurographic score and the measures of median nerve damage were inversely correlated with the severity of PP. PP was related to extramedian spread of symptoms in the hand. None of the objective/neurographic variables was related to severity of sensory complaints restricted to the hand. PP may be found in a consistent number of CTS patients. PP may represent a clinical marker of mild median nerve damage. The presence of proximal complaints might be related to peripheral or central nervous system mechanisms.

[Reintervention after endoscopic surgery of the carpal tunnel syndrome]

BACKGROUND

The carpal tunnel syndrome is one of the most frequent peripheric nerve compression syndromes. Almost 15 years ago, the endoscopic surgery of the carpal tunnel was introduced, in order to reduce postoperative pain and to shorten the length of the postoperative inactivity period, especially work absence. In the literature the rate of complications due to the endoscopic carpal tunnel release surgery is reported differently in respect to number and severity. This paper summarizes all reinterventions after endoscopic surgery in a single specialized hand surgery department, which prefers the open approach even for first time interventions.

PATIENTS AND METHOD

A retrospective analysis of all reoperations between 1998 and 2006 is presented. There were 22 reinterventions done on 21 patients. A reoperation was performed if the symptoms of the carpal tunnel syndrome persisted or new pain or sensomotor deficit appeared. There were 8 male and 14 female patients. The age span ranged from 28 to 86 years. The time distance between the first and the second surgery was between 19 days and 36 months.

RESULTS

Most of the intraoperative findings were incomplete releases of the retinaculum (n = 13). In three cases abundant adherences caused the clinical symptoms. Three times pathologies were found in carpal tunnel, which could not be recognized or treated endoscopically: severe bleeding in the synovia, massive synovialitis and a swannoma of the median nerve. In seven patients transsected nerves had to be treated: one complete transsection of the median nerve, two nerves with injured radial fascicles, two nerves with violated ulnar fascicles, one neuroma of the median nerve and one transsection of both branches of the ulnar nerve.

CONCLUSION

In 22 cases the result of the endoscopic release of the carpal tunnel forced to redo the intervention. In seven patients there were important lesions of the neurovascular structures. Since the long-term result of the endoscopic and open surgery of the carpal tunnel is comparable, it should be discussed if endoscopic surgery is justified even with the risk of mutilant complications and which preoperative imaging procedure is required to discover pathologies and anatomical variants.

Hemodialysis-associated amyloidosis with cervical spinal cord compression and incomplete tetraplegia: a case report

STUDY DESIGN

Case report.

OBJECTIVES

To report a rare case of hemodialysis-associated amyloidosis of cervical spinal canal with incomplete tetraplegia in long-term hemodialysis patient.

SETTINGS

Traumatology Clinic, Zagreb; Spinal Unit, Varazdinske Toplice, Croatia.

METHODS

Forty-seven-year-old male patient at long-term hemodialysis treatment developed progressive limbs weakness, graded as C4 ASIA C. Cervical computed tomography myelography showed extreme narrowing of the spinal canal. Decompressive laminectomy with bilateral foraminotomies was performed and histological examination revealed amyloidal deposition.

RESULTS

Rehabilitation program started immediately after surgery with physical and occupational therapy, along with psychological support aiming at restoring full activities of daily living. Three months after surgery, the patient returned to his community, neurologically improved to ASIA E. Hemodialysis program was regularly maintained perioperatively and during the rehabilitation.

CONCLUSION

Vertebral involvement with neurological deterioration in hemodialysis-associated amyloidosis patients prompts for early diagnosis, surgical and rehabilitation management, in this instance with good outcome.Spinal

Effect of low level laser therapy in rheumatoid arthritis patients with carpal tunnel syndrome

OBJECTIVE

the aim of the present study was to evaluate the efficacy of low level laser therapy (LLLT) in patients with rheumatoid arthritis (RA) with carpal tunnel syndrome (CTS).

MATERIAL AND METHODS

a total of 19 patients with the diagnosis of CTS in 19 hands were included and randomly assigned to two treatment groups; LLLT (Group 1) (10 hands) with dosage 1.5 J/ per point and placebo laser therapy group (Group 2) (9 hands). A Galium-Aluminum-Arsenide diode laser device was used as a source of low power laser with a power output of 50 mW and wavelength of 780 nm. All treatments were applied once a day on week days for a total period of 10 days. Clinical assessments were performed at baseline, at the end of the treatment and at month 3. Tinel and Phalen signs were tested in all patients. Patients were evaluated for such clinical parameters as functional status scale (FSS), visual analogue scale (VAS), symptom severity scale (SSS) and grip-strength. However, electrophysiological examination was performed on all hands. Results were given with descriptive statistics and confidence intervals between group means at 3 months adjusted for outcome at baseline and for the difference between unadjusted group proportions.

RESULTS

clinical and electrophysiological parameters were similar at baseline in both groups. Improvements were significantly more pronounced in the LLLT group than placebo group. A comparison between groups showed significant improvements in pain score and functional status scale score. Group mean differences at 3 months adjusted at baseline were found to be statistically significant for pain score and functional status scale score. The 95% significant confidence intervals were [-15 - (-5)] and [-5 - (-2)] respectively. There were no statistically significant differences in other clinical and electrophysiological parameters between groups at 3 months.

CONCLUSIONS

our study results indicate that LLLT and placebo laser therapy seems to be effective for pain and hand function in CTS. We, therefore, suggest that LLLT may be used as a good alternative treatment method in CTS patients with RA.

Ulnar tunnel syndrome

As our understanding of the anatomy of the ulnar tunnel has increased, so too has our ability to clinically predict the specific sites of compression in ulnar tunnel syndrome. Anatomic studies have described in detail the course of the ulnar nerve as it passes through the ulnar tunnel and have helped correlate symptoms with anatomic location. Although the most common cause of compression is from a ganglion, other space-occupying lesions, such as tumors, anomalous muscles, or a thrombosed ulnar artery, are important to consider in the initial evaluation of the patient. While conservative management can sometimes be successful, the mainstay of treatment of this condition remains meticulous surgical exploration and decompression.

Watch out for ‘pins and needles’ in hands—it may be a case of gout

We encountered only three patients of carpal tunnel syndrome (CTS) due to tophaceous gout during 25 years of practice in a 'hand clinic' situated in a large metropolis in West India. In two patients, the CTS was bilateral, a rare occurrence in gout. There was an unwarranted delay (up to 9 years) in the diagnosis of both the ailments. In each case, the site of offending tophus was uniquely different.

Muscle atrophy at diagnosis of carpal and cubital tunnel syndrome

PURPOSE

This study was designed to test the hypothesis that patients with an initial diagnosis of cubital tunnel syndrome are more likely to present with muscle atrophy than patients with an initial diagnosis of carpal tunnel syndrome.

METHODS

A list of patients presenting to the office of a single hand surgeon from January 2000 to June 2005 with an initial diagnosis of isolated, idiopathic carpal tunnel syndrome or cubital tunnel syndrome was generated from billing records. The medical records of 58 patients with cubital tunnel syndrome and 370 patients with carpal tunnel syndrome were reviewed for age, gender, diabetes, and presence of atrophy.

RESULTS

Twenty-three of 58 patients with an initial diagnosis of cubital tunnel syndrome had atrophy compared with only 62 out 370 patients with an initial diagnosis of carpal tunnel syndrome. Multiple logistic regression revealed that age (odds ratio, 1.06; 95% CI, 1.04-1.08) and diagnosis (cubital tunnel patients were more likely than carpal tunnel patients to present with atrophy; odds ratio, 4.5; 95% CI, 2.7-8.6) were factors significantly associated with atrophy at presentation.

CONCLUSIONS

Patients with carpal tunnel syndrome present earlier in the course of their disease than patients with cubital tunnel syndrome. Patients with cubital tunnel syndrome are more likely to present with muscle atrophy, reflecting advanced nerve damage that may not respond to surgery.